12Maintaining and generating knowledge in interprofessional mental health handovers
John Walsh, Nayia Cominos and Jon Jureidini
12.1Introduction
This chapter provides a detailed study of mental health clinical handover communication in hospital D, a large public teaching hospital in Australia. We draw on data collected from two of the hospital’s mental health teams: the mental health team in the emergency department team and an acute ward team. The role of the mental health clinicians in the emergency department team was to advise emergency department medical staff on the disposition of mental health patients and to develop a patient management/ care plan to the next point of care. The emergency department handled approximately 220 to 250 mental health patient presentations per month, representing 5% of total patient presentations. The acute ward was an open ward for patients suffering from acute mental illness. Patients could be admitted for two weeks up to several months depending on the progress of their condition. The role of clinicians in the acute ward team was to provide therapeutic care for these patients until they were well enough to be discharged to a general practitioner, community team or back to their families. Both teams undertook their patient management tasks through daily and weekly meeting cycles of 12-hour shift changes, intake meetings which updated the team on incoming and current patients, and ward rounds, which were reviews of all patients in their care. These meetings had both diagnostic and therapeutic functions. Both teams were interprofessional, containing mental health doctors, nurses, trainee clinicians and allied health professionals, ranging from medical students to consulting psychiatrists.
Between February 2012 and July 2013, we collected data from scheduled handover meetings within and between the teams, resulting in a corpus of 180 audio and audiovisual recordings of 137 clinicians handing over 127 patients, 18 individual interviews with clinicians and management, 76 responses to the ECCHo national online questionnaire and over 500 pages of observation notes and written artefacts, such as handover lists, clinicians’ notes and database notes.
We analyzed our data to identify clinical handover processes and to explore how these are expressed in clinical communication in a context where each patient’s care is managed across a series of team meetings. From the perspective of the clinicians and from our observations we argue that the processes of handover worked successfully in this particular context.
We view clinical communication as integrally connected to team membership and our analysis therefore explores who talks in team meetings and how team members talk to each other, noting how these interactions reflect variables of leadership, status and power.
In this chapter we pay particular attention to the Australian clinical handover standard’s focus on the ‘processes of clinical handover’. We argue that in contexts like the one we studied, in which interdisciplinary teams of clinicians discuss the same patient over the course of several meetings, handover is better understood as a process rather than as a moment-in-time event. We argue that we need to introduce a distinction between two types of handover communication strategies: ‘preservative’ and ‘generative’. By ‘preservative’ handover strategies we refer to the relatively routinized, predictable and typically brief exchanges that clinicians used to pass on known information, often adhering to structured handover protocols like iSBAR. These preservative strategies were an effective means for clinicians to communicate established information rapidly and succinctly when time was short and new or newly gathered personnel needed to be brought up to speed.
However, clinicians in our data more frequently used less formal, highly interactive and less predictable interactional strategies to probe, clarify, reformulate and uncover ‘new’ information. We argue that these generative strategies were an appropriate and effective way for clinicians to communicate as they collaborated to develop an explanatory narrative about patients across several meetings. We argue that both types of handover strategies are useful and necessary in ensuring the continuity of collaborative and clinically sound mental health care for patients.
12.2Language and communication
One of the innovations of the ECCHo project has been to foreground and make explicit the language of the participating clinicians as they communicate with each other in executing their professional duties. In order to do this, we work with the systemic functional linguistic model of language. Systemic functional linguistics is a theory of how language works, derived from analyzing how we use language ‘to live life’. A key principle in this approach is that the meanings we make in communicating with one another are tied to both the context of that communication (in our case, the teams) and their expression in the words and grammar of the speakers (the language used by our mental health clinicians) (Halliday, 1994). The model also recognizes that in every act of communication participants are simultaneously exchanging information and negotiating interpersonal roles and relationships.
In tracking the different teams across a number of their meetings, we saw that each team’s distinct purpose and function shaped their meetings, providing an overall structure to their communication. For example, acute ward patients were part of an ongoing treatment plan, so the purpose of acute ward shift change meetings was to update the oncoming nurse about a known patient. In the emergency department, the night-to-day shift change was used to begin the construction of a narrative about each patient ‘in transit’, so the shift-change communication was more exploratory and diagnostic.
In addition to identifying a structure, we analyzed two other key contextual dimensions that impacted on the language used by the clinicians. Firstly, we analyzed the topic or content of the communication: what topics were spoken about, by whom, in what ways and at which meeting(s). Secondly, we analyzed the interpersonal or relational aspects of communication, for example relations of intimacy, solidarity and power between participants. Figure 12.1 below shows the relationship between the different dimensions of the context of the mental health teams and the language patterns on which they had most impact in our data.
For the informational dimension, over each meeting and across the cycle of meetings, we identified and tracked participants’ vocabulary choices and analyzed how they described and identified patients in the clinical process of developing a patient narrative. For example, we analyzed how the clinicians named the patient’s illness and how they recounted the patient’s history, current mental state and medication. In doing this we noted examples of what linguists refer to as nominalization. This is the process through which we talk about ‘goings on’ and qualities as if they were‘things’. For example, instead of saying she is depressed (a quality) we may refer to her depression (a thing). The significance nominalizing in the healthcare context is that once a clinician normalizes a patient’s illness, the tendency is for other clinicians to accept that label. In doing so, they implicitly accept the diagnosis it presumes. Subsequent interactions then potentially presuppose that the patient has a named illness – depression – rather than keeping diagnosis open as long as possible.
To explore clinicians’ roles and their relationships with one another, we analyzed how the team members supported or challenged each other as they took turns in the communication process. Finally, we looked at the language participants used to integrate the voice of the patient in their meetings.
12.3Successful teamwork communication: polite, respectful and inclusive
From the communication patterns of the clinicians in the three teams we concluded that there was an overall sense of harmony, with team members working together successfully to engage in and fulfil their organizational brief. The teams created an environment in which the members engaged with their work and with each other willingly and without resentment. Individual team members understood their roles and both they and their colleagues deemed they executed them successfully. Seniority and authority were for the most part implicit, understood and enacted without direct reference.
One obvious contributing factor to harmony is that of respectful behavior, expressed through the politeness team members showed one another in their interactions. For example, team members adhered strongly to the order of the patients to be discussed, providing the space for the giver of information to speak uninterrupted for an extended period.
12.4Participation and turn-taking in meetings
In interviews we conducted before collecting our data, clinicians commented that they were encouraged, and encouraged their colleagues, to participate in team meetings. The meetings were inclusive, in that members were made to feel that their contributions would be valued and that contributing was an important aspect of the harmonious functioning of the team. Interviewees felt that this respect for one another encouraged a democratic environment in which all the participants felt supported to contribute.
Our analysis of turn-taking in the meeting data supported these comments, providing a quantitative picture of which clinicians contributed to the communication and the degree to which the ‘air’ was shared by the members of the team. Figures 12.2 and 12.3 compare turn-taking by roles in the emergency department and acute ward team meetings.
As Figs. 12.2 and 12.3 show, in the nurse-to-nurse shift-changes in the emergency department and acute ward, the turn-taking was shared almost equally between the givers and receivers of handover. However, in the interprofessional ward rounds in both teams, while team members spoke less than the senior clinicians, all the members of the teams contributed to the discussion. At 65% to 70% of all turns, the combined input of participants other than the senior clinician was considerable. The senior clinicians did take a more central leadership role in the ward round meetings, but they displayed trust in the judgements of the nurses by treating their contributions seriously, incorporating their information about and evaluations of the patient.
Fig. 12.2: Comparison of turn-taking in the emergency department team
Fig. 12.3: Comparison of turn-taking in the acute ward team
The turn-taking in the intake meetings varied between teams according to the purpose of the meetings. This was particularly noticeable with respect to the senior clinicians in ward rounds and intake meetings, as Tab. 12.1 shows.
Tab. 12.1: Comparison of percentage of senior clinician turns in intake meetings and ward rounds
Intake meetings in the ward were task-oriented, and this was reflected in the nursing team leaders dominating with 58% of the turns. In the emergency department, the senior nurse and psychiatrist shared the majority of turns (42% and 39%, respectively), but in these meetings, the psychiatrist tended to respond with acknowledging feedback such as, ‘Mmm’ or ‘OK’, taking a supporting rather than dominating role. This was the reverse in the emergency department ward round, where the psychiatrist took 30% of the turns, while the senior nurse took 14%. The psychiatrist’s turns were more extended, putting together the different elements of the narrative to articulate a formulation that would determine the management and care plan for the patient.
The analysis of turn-taking gave a clearer picture of who participated, at what juncture and for what purpose in the different team meetings. This reinforced clinicians’ anecdotal claims that both teams exhibited democratic qualities. What turn-taking did not provide, however, was any insight into just what participants said when they had the turn. What did they talk about? How were their contributions received? Did other participants extend, elaborate on, query, challenge, reject or ignore what they had said? To look more closely at these interactional patterns, we analyzed the types of dialogic exchanges between participants.
12.5Preservative handover exchanges
Discourse analysts Martin and Rose (2007) propose that in highly institutionalized settings there are likely to be routinized exchanges between participants. The exchanges are typically brief and are conventionalized. That is, clinicians generally talk through a predictable sequence of identifiable stages. In a clinical context, protocols like iSBAR are intended to help participants produce just such predictable sequences of exchanges in performing clinical handover. The iSBAR mnemonic is a prompt for a series of mandated communication steps in handover. The aim of such structured protocols is to ensure that the minimum dataset of information is exchanged intact in a time-efficient way. This primary intent for handovers to preserve information is linked to efforts to limit the iatrogenic harm that evidence suggests can occur if important information is not handed over. This preservative approach to handover is consistent with the notion that each handover is a discrete event, rather than one step in a process of ongoing communication about the patient and his/her care.
We did find examples of these staged, routinized or what we call ‘preservative’ handover sequences in our data, most commonly in shift-change handovers. These sequences were brief, contained relevant clinical information, and were structured to follow the stages of the iSBAR mnemonic, although we found some variation in the order in which each of the iSBAR elements was given. See for example Tabs. 12.2 and 12.3 below, where nurses hand over at the end of their shifts.
Tab. 12.2: iSBAR stages in an acute ward shift change
| iSBAR stage | Talk |
| i | OK. So, room 2, [pointing to chart]. Patient [full name], |
| S | |
| B | She’s also got a long history of uh bipolar affective disorder. She had a recent admission to the acute ward in the context of a manic episode … by medication non-compliance … and illegal substance use. |
| S | … and she’s had some PRN medication prior to coming up here, about an hour ago, she had a couple of loraz, two milligrams of lorazepam, |
| A | … with good effect, so it’s um, seems that that’s actually been helpful. |
| R | And her Webster pack’s there for you. |
Tab. 12.3: iSBAR stages in an emergency department shift change handover
| iSBAR stage | Talk |
| i | [pointing on handover sheet] Alex? Do you know him? He’s the real, the real tall fellow with all the tats. Looks kind of intimidating but generally he’s OK. |
| S | Brou – brought here by the police in handcuffs… we’ve just given him another ten and two, ten minutes ago. |
| B | He just uses a lot of amphetamines and he comes here pretty charged up. Apparently he tried to jump off a roof but he’s now denying he’s suicidal. |
| A | Traditionally he settles down very quickly. |
| R | but, I would expect he could be have a brief admission tomorrow maybe. |
We also found examples of iSBAR-structured routinized sequences in the longer interprofessional team meetings. However, we noted that the emphasis on particular elements in iSBAR varied, depending on the meeting. Assessment, for example, was more extensive and detailed in the interprofessional ward rounds, when the clinician was reporting back to the team after a full patient assessment, than in the nurse to nurse shift handovers, where a short summary was sufficient for the oncoming team. This was related to the purpose of the meeting – the function of ward rounds was diagnostic, to determine longer-term care and management, whereas the nurses receiving the shift handover prioritized those elements which would affect their direct care that day. As with the shift-change handovers in Tabs. 12.2 and 12.3 above, we noted that these iSBAR-structured moments fulfilled a preservative function. Their purpose was to provide the group with the information known about the patient at that time.
12.6Generative handover exchanges
However, in the meetings after such moments, the type of communication typically changed, becoming less formal, more interactive and less predictable in terms of who would take a turn and what they would do when they did. That is, participants frequently communicated through the more dialogic and less formalized exchanges that Martin and Rose (2007) also identify in institutional settings. In the healthcare setting, our findings align with the work of Buus (2006) who analyzed the structure of nursing shift handover meetings in a number of contexts, noting that participants moved through formal and informal and less or more interactive phases.
For example, once the registrar had summarized the patient’s known history and assessment, there was typically a moment’s pause. Then the most senior clinician would often ask a question. This signaled the beginning of the less formal more interactive phase. These exchanges were interactive and un-routinized, and all team members had the possibility of contributing. Consider Text 12.1 where the night and day nurses discuss Bob, a recently admitted patient:
Text 12.1
68Night nurse giving handover: Alright. Uh. Bob Noatty. He apparently yesterday walked in front of traffic. He’s got a, it says history of anxiety disorder. I reviewed him, last night, and, I mean he’s got complex post traumatic stress disorder and he was sexually abused when he was, between ten and a half and twelve, and um has never had any counseling for that. Um. And is, yeah just not coping. It seems to be all triggered again by um, couple of weeks ago he started some counseling for job preparation? So they’ve sent him to a counsellor for some reason or other, and uh, they must have touched on that. It sounds as if they have. And yesterday was his second appointment with that person. Um, yeah so, he’s, had the appointment with the counselor again yesterday morning, and um, then gone and walked in front of traffic, try and kill himself.
69Day nurse: Didn’t get hit by the car == ( )
70Night nurse: == didn’t get hit, no. But I mean he’s not, did – have you spoken to him?
71Day nurse: I just saw him he looks pretty...
72Night nurse: He’s pretty unhappy.
73Day nurse: Yeah he didn’t look (great to me)
74Night nurse: He’s, he’s pretty, he’s messed up. Now he’s also got an alcohol and a drug problem. The last two weeks he’s been drinking a bottle of s – spirits every day? And he’s also been using an awful lot of, uh, ice.=
75Day nurse: =mm. Yeah, he was saying
76Night nurse: And that’s not ice in his whisky, that’s [smiles] yeah so I mean he’s, using up to four points of ice in a session, but the session might last two days. Cause he can’t sleep, (after it). Um. So anyway yeah he he’s a bit messed up. Yeah we probably need to get him seen by um drug and alcohol lady as well. The other thing is I was gonna give him the uh, contact details for [name of counseling service]? I just thought you c’d just look them up on the internet, and just give him the contact numbers, just there’s a bit of a blurb, so, if one of you could do that, that’s where you get specific counseling for ( ) sexual abuse. He was quite keen about that. Talking to someone who actually knew what they were talking about.
Participants would ask questions, float ideas and seek clarification or challenge previous understandings. This process of verbalizing the mental work of handover is designed to lead to a common conceptualization and understanding of the patient and the factors influencing his/her current situation. We refer to this kind of talk as ‘generative’ handover exchanges as the talk created new information and understandings about the patient, rather than exchanging known information.
Our attention was thus drawn to the capacity of these exchanges – and the meetings in which they occurred – to generate information and understanding about the patient and between team members. At each successive meeting information about the patient was brought back to the team and was gradually shaped into a coherent narrative, such as for patient Mary-Jane. Table 12.4 shows the information offered about Mary-Jane at two of the meetings where her care was discussed. In the shift handover, the night nurse provides the required information in some detail. The presentation by the psychiatry registrar in the ward round three hours later is informed by a full psychiatric assessment. It has become a detailed narrative organized chronologically and logically. A new factor in the patient’s situation has been introduced – the patient’s relationship with her mother – which has a significant positive impact on the patient’s care plan.
The narrative about Mary-Jane captured in Tab. 12.4, however rich and complete, was the point of departure for the clinical work of diagnosis, that is, the deconstruction, re-shaping and interpretation of the story from a clinical perspective to arrive at a formulation that determined the onward journey of the patient.
Tab. 12.4: Initial presentation of information about patient Mary-Jane at the two emergency department meetings
| Emergency department shift handover | Emergency department ward round |
| Night nurse: Well, she’s presented with suicidal ideas, ( ), and uh a recent trigger I think is her boyfriend broke up with her. They’d been together for 14 months or so. They lived together at her mum’s place. She’s feeling quite, upset about that. Her history is that her father left, you know, before she can remember, when she was about 14, I think. Which is that wasn’t very nice at that stage but they’re getting on much better. The down side is that uh, her mother hooked up with a guy and, when she was about 6, he sexually abused her, for some time … And um, yeah she’s had like, childhood counseling that sort of thing but, hasn’t had any adult counseling about the abuse. And, I think [CPC coughs] I think she’s just in crisis at the moment just speaking to the mum very briefly, sounds like it’s been the same underlying depression, she got a poor self-esteem, and she herself feels that it stems from that. | Psychiatric registrar: So um. Just so you’re aware, she’s an 18 year old, woman who’s was um, sexually abused by her step-dad when she was six and um, he was convicted and I think ( ) um. Then, and she also never met her biological father until she was um 14 basically she was told that she was, it was like a one-night stand relationship between mum and dad and mum was actually with the step-dad at the time. Um, so basically this time she, um, more the boyfriend broke up with her two weeks, um, ago so, she’s got this chronic, um, mood swing sensitivity to rejection and feeling of emptiness and insomnia and so on for a long time but they all sort of got worse over the last two weeks in the context of the break up. Yesterday texted the boyfriend, he ignored her, told him that she was going to hang herself, he called mum. Mum went to see her at work, she was working at the market, um, yesterday, and basically uh she told mum to go away, and then mum asked her to come home afterwards so she came home then mum brought her here. Um basically um, we’ve talked to mum. Um, she’s not quite sure what she, um wants either. She’s agreed that um, well she’s not sure whether she should come in and so on, but Mary-Jane was sort of, wanting to go home, yeah, and she agreed for, to see you guys, um. Sheee, I think there’s a dynamic between her and mum that’s a bit worrying though, because when we went to see mum, she sort of closed up more. Yeah, didn’t talk much more and, yeah she’s ‘ve - mm, very ambivalent, yeah in terms of ==the relationship between her and her mum, I think so … Um, you know she said mum’s really supportive when we talked to her and so on |
In our analysis we saw that within this particular model of care the handover process created the potential for both preservative and generative handover communication. Although the two modes of communication tended to associate with particular contextual variables, this was not an either/or but a more/less correlation.
In other words, in some events, such as shift-change handovers, preservative communication dominated. This was a functional response to the contextual need to efficiently ensure continuity of care when personnel changed.
In other events, such as the ward rounds or intake meetings, generative communication dominated, although as we have seen there would also be moments of preservative communication. In these less time-pressured, diagnostic phases, rather than a one-way report from one clinician to another, the context supported a more interactive discussion, with all team members potentially contributing their understanding and knowledge of the patient in the shared interests of developing a coherent explanatory narrative about the patient. This sometimes resulted in ‘light-bulb’ moments, when one of the participants recognized a pattern or the significance of a piece of information that was not evident to the others. Thus a significant increase in understanding or diagnosis could be generated through the more interactive communication choices/patterns.
We now exemplify and discuss the different interactive strategies that constituted this more generative style of handover communication.
12.7Generative handover interactional strategies
12.7.1Clarification
The most frequent type of dialogic move that generated new information was clarification, that is, prompts for more information, clarifying questions and factual corrections. Two typical examples were during a shift change where the incoming clinician asked, ‘Has he had many um depressive episodes or … is this the first?’, and again, ‘the counselor that he saw … he’s just a work counselor? These contributions had the important clinical function of minimizing risk through error or omission. In the second example, not only did the nurse give more precision about the type of counsellor the patient had seen, but by adding ‘just’ he offered a judgement on the quality or capacity of the counselor to deal with the patient’s mental health issues. This suggestion was developed in subsequent meetings and was later understood as an important contributor to the patient’s presentation.
12.7.2Repair
The dialogic exchanges during handover created the opportunity to correct information. The most frequent type of repair was self-repair, as in this example where a registrar is reporting on a patient at a ward round:
‘So she’ll need a medical, thorough medical work up because she has some um other co-morbidities. So she’s had renal toxicity secondary to – I shouldn’t keep saying that. She doesn’t have renal toxicity; she’s had renal problems secondary to Lithium toxicity in the past.’ [speaker’s emphasis]
Less frequent was repair by colleagues. This was said directly to the person, stated without criticism and received without comment by the person corrected, as in this exchange:
Registrar: … late last year, the brother took her to the [name of other metropolitan hospital], I think=
Medical student: =It was a friend that took her to the [name of other metropolitan hospital]
Registrar: Oh yeah, and …
Collective repair was also evident, as in this example from an emergency department team ward round:
12Day nurse: Did we see who brought her [the patient] in?==
13Senior nurse: ==Ah [looking at notes]
14Day nurse: Was it the community =
15Senior nurse: = I don’t know, I wasn’t=
16Day nurse: Team?
17Direct care nurse: == No, the police brought her in, she, she started a ruckus outside a, um, a pub.
Repair was possible because the whole team shared responsibility for the patient, all team members were encouraged to participate in handover and there was no stigma attached to making an error; the focus was on retrieving the correct information. This element of generative handover was another effective strategy for risk management through which errors were identified and rectified before they led to adverse outcomes.
12.7.3Challenge
Receiving clinicians sometimes challenged the application of the procedures involved in handover. For example, a nurse receiving a patient transferred from the emergency department to an acute ward asked, ‘I thought they had to get to a certain level [of physical recovery] before they were moved out of an ED.’ The nurse used this statement to indicate that in her professional evaluation the patient had not reached the required level of physical recovery (‘I thought’), and affirm the correct procedure (‘they had to’). In keeping with the medical discourse convention of not directly criticizing colleagues, the nurse uses the generalized ‘they’, rather than the name of the clinicians involved. These challenges offered insight into the day-to-day tensions involved in implementing procedures across teams.
Receiving clinicians also sometimes challenged the use of terms that implied attitudes or positions. While this did not necessarily contribute to new understanding of the particular patient, it offered an alternative understanding of the way in which the causes of mental illness were understood. For example, a nurse receiving a handover about an abuse victim challenged the use of the term ‘child pornography’:
130Day nurse [receiving handover]: It’s not pornography at all.
131Night nurse: Yeah
132Day nurse: Yeah but we we, we reduce uh by the language we use
133Night nurse: Mm
134Day nurse: we reduce what it actually is, it’s not pornography.
135Night nurse: Mm
136Day nurse: It’s not. It’s child sexual abuse.
137Night nurse: Yeah. ‘Cause == it’s ( ) there’s no choice there
138Day nurse: == do you know what I mean? Well, ah, pornography, we give it tacit approval by the t – it’s an adult term by ==consenting adults
When the day nurse substituted ‘child sexual abuse’ for the term ‘child pornography’, her colleague endorsed the change, showing her understanding of the reason behind the challenge, ‘cause there’s no choice there’. This is in turn was affirmed by the day nurse ‘it’s an adult term by consenting adults’ (who can choose). The nurses demonstrated awareness of the role of language in shaping the representation of the patient and the patient’s circumstances. We observed clinicians to be attentive to this kind of semantic precision, both with regard to technical mental health terminology and when citing patients or other sources.
12.7.4Pedagogic scaffolding
The participating hospital was a teaching hospital and all the interprofessional handovers included clinicians in training. We noted numerous occasions when more senior clinicians corrected and interacted with more junior clinicians to help them develop better clinical communication. Following a rambling presentation by the registered medical officer, the psychiatrist asked him to articulate his understanding of what it was that the patient wanted:
15Registered medical officer [giving handover]: … And uh GP that he – ah he – sometimes sees the GP, but he doesn’t trust his GP as much, because he thinks that ah his GP doesn’t really help him with all his problems, in terms of the depression and things like that. And uh but otherwise, he doesn’t you know show any see – significant features of the depression or anything. Yeah. My thought is whether you know we can actually follow him up ( ) community or. He feel [sic] more comfortable to be in a hospital for couple of days, to have you know treatment. Yeah.
16Psychiatrist: What does he want?
17Registered medical officer [giving handover]: Well he said he’ll be more comfortable to be, you know, staying in a hospital –
18Psychiatrist: But what does he expect?
The psychiatrist began by asking a direct question ‘What does he want?’ When the registered medical officer gave a vague response, the psychiatrist paraphrased the question ‘But what does he expect?’ The change from ‘want’ to ‘expect’ obliged the registered medical officer to move beyond representing the patient as a passive comfort seeker to having a stake in the outcome of the treatment.
Senior clinicians occasionally asked the group of trainees to confirm or provide information about doses of particular medications. There were also a number of instances where receiving clinicians volunteered additional information about current clinical practice in the team, for example, ‘Last week we were using it [a medication], like for the guy that had opiate withdrawal’.
12.7.5Referencing
Sometimes a contribution made explicit reference to general clinical knowledge to illustrate an aspect of the patient’s presentation. For example, in a handover about a distressed adolescent, the nurse mentioned that the patient had previously attempted suicide by hanging. The senior nurse present drew attention to this, ‘[nods] so, pretty violent == for a girl’. By contrasting ‘violent’ and ‘girl’, the senior nurse reinforced the norms around suicide by hanging (usually men) while emphasizing the gravity of the patient’s attempt.
12.7.6Evaluation
The use of emotionally charged language to describe a patient’s situation emphasized the ‘personal’ in each patient’s case. The inclusion of words carrying a high level of evaluative or emotional weight, such as ‘she’s really suffering’, counterbalanced the depersonalizing effect of technical language. For example, ‘[She’s] had a history of what sounds like dysthymic type of um presentation over the years.’ While the more affective language did not necessarily contribute significant information or analytical content to the understanding, it impacted on how the clinical or technical information was received and dealt with, for example:
145Night nurse [giving handover]: Yeah, geez it goes on and on. She can’t go to her house that she, done up and made a nice place for herself because her children are stalking her out there. Even her daughter has threatened to slit her throat if she sold the house. And um,
146Day nurse: God!
The night nurse described the patient’s status as a victim through the cumulative effects of repetition, ‘it goes on and on’, and vocabulary with strong negative connotations, ‘threaten’, ‘stalking’, ‘slit’, contrasting them with the patient’s positive efforts to ‘[make] a nice place for herself’. In adding ‘even’ to ‘her daughter’, the night nurse emphasized the apparent aberration of the family situation. The exclamation by the day nurse acknowledged the emotional difficulty of the situation and showed empathy with the patient. In the subsequent intake meeting, the day nurse drew attention to this social aspect of the patient’s situation, ‘I think this is massive social work territory isn’t it?’, following up with the recommendation of a particular social worker, ‘I think this is, her [social worker] territory; she’s pretty good at handling these sorts of situations … she’s the expert …’ By adding evaluative weight, the clinician ensured that an experienced and specialized social worker would be included in the care plan.
12.7.7Elaboration, abstraction and integration
Receiving clinicians also identified new ways of making sense of the presentation through the elaboration, consolidation and abstraction of information. In the following example, the acute ward team leader is handing over a well-known patient to the night nurse. The night nurse shows understanding of the information and elaborates on it to make sense of the patient’s behavior during the day:
| 32 | Team leader: | She was shouting [a lot, today]… She looks a bit irritated == |
| [giving handover] | ||
| 33 | Night nurse 1: | == Yeah |
| 34 | Night nurse 2: | == mm. |
| 35 | Team leader: | I’m not sure what it’s about really == |
| 36 | Night nurse 2: | == It’s probably about having no say, feeling she has no say. |
Integration, drawing together information and describing it under one heading or term, resulting in abstraction was evident, as in this example during a shift change in the emergency department:
| 44 | Night nurse giving handover: | Well, she’s presented with suicidal ideas, ( ), and uh a recent trigger I think is her boyfriend broke up with her. They’d been together for 14 months or so. They lived together at her mum’s place. She’s feeling quite, upset about that. Her history is that her father left, you know, before she can remember, when she was about six, I think. |
| 45 | Day nurse: | Mm |
| […] | ||
| 67 | Senior nurse: | OK. And so the, the, boyfriend’s left or, is he going to be ==crushing down a fragile person== |
| [...] | ||
| 94 | Night nurse: | == but it will be the (trigger), you know, |
| 95 | Senior nurse: | Yep |
| 96 | Night nurse: | As a result of the, I think, from the loss of the father when she was younger |
| 97 | Senior nurse: | Mm, mm |
| 98 | Night nurse: | And you know, yeah. |
| 99 | Day nurse: | == retraumatized with the loss of the boyfriend |
| 100 | Night nurse: | Mm. |
The night nurse gave the first report of the patient, and noted the relationship between the patient and her boyfriend as the precipitant of the presentation: ‘her boyfriend broke up with her’. The senior nurse reiterated this following further information about the patient, elaborating and linking it to the patient’s fragility. At the end of the interaction the night nurse and the day nurse reconstructed this in clinical terms, linking the father and the boyfriend’s leaving, ‘from the loss of the father … retraumatized with the loss of the boyfriend’, making a clinical connection between the precipitant to the presentation and the history of trauma and abandonment. This was expressed in language through the process of nominalization, which involves speakers changing the actions (leaving/breaking up) into an abstract thing (loss). This subtle shift in the use of language has the effect of creating an entity with the result that as an entity it can be potentially presupposed as a clinical fact. Here we see the nurses actively engaged in shaping the content of the handover to increase clinical understandings and develop a more logical and coherent patient narrative.
The emergency department shift changes often demonstrated teamwork, with participants pooling information and making sense of it in ways that are generally regarded as more characteristic of ward rounds or case conferences. In the following example the team was uncertain about the suicidal intent of a patient who had taken an overdose. This concern was made explicit not by the nurse handing over but by one of the recipients. Information was then elicited that might not otherwise have been handed over:
| 104 | Senior nurse: | I don’t suppose we know, if it was a recreational overdose. He’s too out of it. |
| 105 | Night nurse giving handover: | Um, don’t know, but it was a whole bottle-full. |
| 106 | Day nurse: | He went for a drive afterwards didn’t he. |
| 107 | Night nurse: | Yeah, and, oh that’s right, he had a l– low, speed, collision. Twenty kilometers an hour or something. |
| 108 | Day nurse: | But yeah no-one’s, sure. |
| 109 | Senior nurse: | Mm. |
| 110 | Night nurse: | Mm. |
| 111 | Day nurse: | He’d – ah something on (the database) said he’d thought of suicide that morning. |
In this setting, as is common in psychiatric teams, the senior clinician, psychiatrist or senior nurse have not always seen or personally assessed the patient. The initial assessment is commonly delegated to junior clinicians such as the psychiatry registrar and medical students. During their assessment report, the senior clinician uses the information to generate new ideas or introduce more sophisticated explanations for behavior. In the following interaction the registrar reported back to the team during the ward round. She had noted something about the relationship between a girl and her mother but did not expand on it or make use of it in her formulation. The psychiatrist provided an explanation, drawing together the previous information about the patient and this new information:
12.7.8Summary of generative communication strategies
These examples of dialogic exchanges from meetings of the different teams were a clear indication that the communication between clinicians constituted more than preserving information. The communication potentially generated new information. We propose that this process of generative handover is a powerful means of increasing the pool of information and understanding about patients and their presentations. From a clinical perspective, we concluded that generative handover increased the likelihood of optimal patient care by:
–allowing the whole team to share and have access to the best knowledge available at that time about the patient, with a consequent reduction in error through missed information
–allowing clinicians to organize and shape information to create a richer clinical profile of the patient, so patient care and management plans are optimized
–offering possibilities of professional development in situ for clinicians of all levels
–valuing the contribution of each team member and encouraging a more active and democratic engagement in the handover process.
As we indicated earlier, generative communication strategies were also evident in the more routinized meetings, such as shift changes, but were more prevalent in the less formalized, more discursive meetings. While the experience and expertise of the clinicians was a significant factor in generative handover, we argue that such handover is more likely under particular organizational arrangements. These include a model of care that establishes handover as a process, where there are well-established interprofessional teams of clinicians who are focused on the care of the same patients over an extended period of time. While such conditions may be resource intensive, they are likely to be efficient in terms of risk minimization. Not unimportantly they are also likely to be more professionally rewarding for the clinical teams. Clinicians are challenged and challenge each other to consider each patient as a forensic case, a mentally unwell person for whom they have professional care and about whom they aim to generate the most accurate understanding and the most beneficial care. The process of exchanging information that needs to be preserved is very important but it is only part of the clinical work evident within these teams.
12.8Conclusion
The model of care within the local health network that was the site of our research facilitated a collaborative and successful interprofessional team-based approach. In mental health, the care of the patient was given over to different, interprofessional teams of clinicians at different stages or points in the patient journey. These teams took on specific functions in providing optimal care to the patient. Each team met over a cycle of daily and in some cases weekly meetings, often communicating about the same patient(s) in these meetings. Across these meetings, each iteration of the patient’s narrative gained in clinical precision and coherence as clinicians consulted with the patient, gathered collateral and then, as a team, shaped the information. The purpose of the narrative was to develop a sufficient understanding of the patient to arrive at a formulation, defined as ‘an explanatory hypothesis to provide a structure to further management’ (Royal Australian and New Zealand College of Psychiatrists 2012).
In this chapter we have argued that our data pointed to handover as a process, in keeping with the national standard’s criterion of ‘processes of handover’. Clinicians met to talk about the same patients over a number of meetings, which contributed to the shaping of a patient narrative and led to a formulation. In this model of care we saw participants employing both ‘preservative’ communication/exchange strategies – which tended to be brief, routinized, highly predictable sequences of turns – and ‘generative’ strategies – longer, highly interactive and less predictable. We noted that while both types of strategies occurred across the handover events in a patient’s care, the generative strategies dominated in many of them, with preservative strategies employed in events or at stages when the need was to summarize known information efficiently and accurately, for example at shift-change handovers. At such times clinicians’ use of the iSBAR handover protocol was an appropriate functional response to the context.
However, we presented examples to show that the generative communication strategies – involving clarification, elaboration, scaffolding, etc. – were more likely to lead to new information and insights that enabled the team to agree on a diagnosis and management plan for the patient. We noted that these complementary handover communication strategies contributed to the successful operation of the teams and enhanced the management of risk.
The mental health teams moved between preservative and generative handover strategies because their purposes required it. In a model of care where handover is a process, and where clinicians work in teams, developing a coherent story about their patients will often mean that handovers need to both present known information (preservative strategies) and generate new information (generative strategies). Preservative strategies allowed participants to ‘cover the bases’, so that all members of the teamworked from the same understanding of the patient. To arrive at a rich patient narrative, however, the team needed to negotiate and renegotiate their understanding. This interaction generated new knowledge, which fulfilled the purpose of the meetings: to arrive at an optimal patient care and management plan. An integration of both handover strategies was necessary in this context, and both served to create a successful communication process.
Our clinicians recognized the value of this type of handover communication and considered that the redundancy built into the model of care of the research hospital offered a context conducive to such communication. They also argued, however, that explicit training in these skills would permit this handover communication in other contexts, with different models of care.
In the following chapter we consider the Australian national standard’s emphasis on ‘patient involvement in clinical handover’ and describe how this requirement sits with mental health care, particularly in the care model at our research site, and how clinicians sought to include the patient’s voice although the patient could not be physically present at the handovers.