13Patient voice: including the patient in mental health handovers

John Walsh, Nayia Cominos and Jon Jureidini

13.1Introduction

In the previous chapter we described the interprofessional team-based care that characterized the mental health care in our research site, a metropolitan teaching hospital in Australia. We identified different handover communication strategies – preservative and generative – and described how clinicians moved between these strategies according to the needs, purpose and constraints of the different events in managing care for their mental health patients in both the emergency department and acute wards. In detailing the complementarity of preservative and generative handover strategies we noted that the interprofessional interactions through which each patient’s care is managed across the meeting cycle sits well with the Australian clinical handover standard’s focus on the ‘process’ of handover.

In this chapter we consider the Australian clinical handover standard’s emphasis on ‘patient involvement in clinical handover’ and explore how this requirement sits with the care model at our research site. As we noted in the previous chapter, patients were not physically present in the mental health handover meetings. However, in this chapter we argue that the clinicians did represent patients by quoting their words and referencing their thoughts and dispositions. We label this ‘patient voice’ and discuss examples of when and how clinicians used this in talking about patients in our data.

13.2Patient voice

The Australian clinical handover standard makes patient involvement in handover a clear requirement. Specifically, the third of the three criteria to achieve the Australian clinical handover standard is:

Working from this criterion, one Australian health department specifically identifies ‘Establishing mechanisms to involve a patient and, where relevant, their carer in clinical handover’ as a developmental priority (South Australian Health 2012: 6).

In the area of mental health, this requirement has not been fully incorporated into the standard ways of operating. Formal processes are in place to include patients and carers in care and management plans, such as debriefing by nurses and doctors following ward rounds, and planned family meetings during the patient’s stay and prior to discharge. In addition, there are semi-formal processes where patients and visiting carers interact frequently with nursing staff, asking questions and making requests with regard to care plans. Patients and carers may request a consultation with a doctor outside formal therapeutic consultations, and clinicians report that patients and carers often avail themselves of this opportunity.

Mental health patients and their carers, however, were physically excluded from all of the handovers we analyzed. Even when patients were transferred from the emergency department to the acute open ward, although they were introduced to the ward clinicians, the handover proper took place, away from the patient, in the nursing station.

When questioned, as part of the ECCHo national survey, mental health clinicians expressed ambivalence about including mental health patients and carers in handover. Opinion was equally divided between effective (34%) and less effective (30%), with 20% unable to judge. Clinicians noted that while patient or carers could be ‘very effective in planning particular goals and outcomes’ and ‘invaluable for collateral (information from sources other than the patient)’, there was also possibility of the ‘misconstrual of information’ by patients or carers, and that the complexity of family/ carer relationships with the patient was frequently a factor contributing to the pathology of the patient.

The data confirmed this dilemma. On the one hand, in many instances family members provided precious collateral to assist in the assessment process, for example, ‘I talked to the parents, um, they said [the patient] was fine in terms of the warning symptoms, and his mother has been concerned about an increase in suicidal ideation.’ On the other hand, the data showed that managing patient and carer relationships both within families and in relation to mental health treatment plans was complex. In Text 13.1, extracts from an extended discussion in an acute ward round, the family was divided on how to manage the patient Annie, and the clinicians were being careful to avoid exacerbating this conflict.

Text 13.1: ‘Annie’

Resistance to including patients in handover meetings was also due in part to mental health clinicians’ reservations about the capacity of an acutely mentally ill patient to have meaningful participation in handover. Perhaps it also reflected an adherence to traditional models of care, where clinicians feel that confidentiality and the freedom to speak about the patient are only possible in handover away from the patient.

Although patients were not participants in handover meetings, we noted the consistent representation of the patient’s words in clinical meetings. We label this ‘patient voice’ and describe below how it is evoked at different points in handovers to inform and shape the optimal care plan for the patient. While patient voice may or may not constitute patient participation in handover in terms that satisfy the Australian clinical handover standard, our data shows that clinicians used the voice of the patient to represent the patient’s wishes and needs in handover. In the following sections we exemplify and discuss patient voice in our data, suggesting that through this communicative strategy, clinicians acknowledged the voice of the patient as a key source of information and understanding in piecing together the most coherent narrative.

13.3Identifying patient voice

To capture what we call ‘patient voice’ in our mental health data we have adapted a framework developed by linguists Martin and White (2005). Their framework identifies two ways of including someone else’s words in a text or conversation: acknowledging, when there is no explicit judgement about the person or what is being said, and distancing, where there is some implied doubt. We saw evidence of both in our data.

13.3.1Acknowledging

13.3.2Distancing

Distancing in this context does not necessarily mean that the patient’s version of events is regarded as being untruthful or deceitful; it is rather a clinician’s way of acknowledging the symptoms of psychiatric patients in crisis. A fundamental aspect of the clinicians’ work is to determine which elements of the patient’s verbalizations and perceptions are credible and which are not; hence the process of verification and cross-checking between versions of the patient’s story and collateral from other sources, such as family, colleagues and allied health professionals. In mental health, the patient’s verbalizations and perceptions also have a diagnostic function, indicating the ways in which the patient is thinking. Again this highlights the importance of the handover as a process, where there is time to gather collateral and to engage with clinician colleagues to collaboratively build up knowledge.

13.4The frequency of patient voice

Using the acknowledging and distancing classification system described above, we analyzed a representative corpus of 24 handover meetings (nine hours of recordings) from the emergency department and acute ward teams, which had comparable handover meeting types, i.e. shift handovers, intake meetings and ward rounds. Of the 4,223 turns in total, approximately 10% contained evocations of patient voice. Of the 70 patients being handed over, patient voice was evoked for 55 of them (78%). If the figure of 10% of turns with patient voice appears low, one explanation was the high acuity of the majority of patients in the emergency department and on the mental health wards. It was not unusual that a patient was either recovering from an overdose or sedation, or was in a state of mental confusion, so that their capacity for spoken interaction was severely compromised.

Numerically, the emergency department team clinicians evoked patient voice more frequently than the clinicians on the acute ward team; we attribute this in large part to the difference in the length and function of the intake meetings. The emergency department team intake meetings lasted up to 40 minutes, and functioned as ‘mini’ ward rounds, with numerous assessment reports and clinical exchanges about new and incoming patients. In contrast, the acute ward intake meetings were short (5 to 10 minutes), used as a briefing update on medical and administrative tasks.

Figure 13.1 below shows the frequency of patient voice evocation in the emergency department team meetings and the acute ward meetings.

Fig. 13.1: Comparison of the frequency of patient voice evocation between the emergency department and acute ward teams

Figure 13.1 shows distinct variation in the distribution of patient voice in the meetings of both teams. The percentage of evocations was relatively constant across the four emergency department team meetings: 10%, 12%, 15% and 8%. In contrast, there was significant variation between meetings of the acute ward teams. The intake meetings and ward rounds averaged 6% and 5%, respectively, while the evocation of patient voice in shift handovers ranged between 16% and 27%. These differences could be attributed to the purpose of the meetings, the cycle of meetings and the amount of face-to-face contact between the clinicians and the patient.

The three emergency department morning meetings took place daily from 0700 to 1030 and were driven by the urgency and space constraints of the emergency department. There was continuous seeking and feeding back of information about and to the patients to reach a decision about the next stage in the patient’s management and care. During the three-and-a-half hour window, patients could be seen several times for assessment and consultation, which explained the higher number of evocations of patient voice. In contrast, the acute ward team meetings were part of a longerterm therapeutic cycle, with a week-long gap between ward rounds. This resulted in a longer delay between patient consultation and reporting back to the whole team, but more numerous debriefing communications, containing patient voice evocations, outside scheduled handover meetings.

The acute ward team shift changes showed the highest frequency of patient voice evocation. This was linked to the duration, regularity and immediacy of communication between the patient and the clinician. Nursing shifts lasted 12 hours, and the nurses observed and interacted with patients on innumerable occasions during that period. They cared for the patients’ physical as well as psychological needs, washing their clothes, feeding them, accompanying them to appointments and attending family meetings with them and on their behalf.

Another influence on the frequency in the evocation of patient voice was the institutionalized division of labor between nurses and doctors. Buus (2006: 1090– 1091) argues that a central purpose of nursing handover is to ‘predict patient behavior and the present condition’ and that ‘therefore their experiences are everyday and concrete’. He contrasts this with doctors, whose work is relatively ‘more conceptual … construing case presentations and records, creating images of longer trajectories of the patient’s treatment and health, often with the diagnosis as the narrative plot’. These different roles were reflected in our data. In shift handovers, acute ward nurses handed over detailed information about conversations and incidents with patients, using this information to illustrate the state of mind of the patient and to help the oncoming nurse understand and anticipate potential issues and concerns. Only the acute ward team leader participated in the acute ward rounds, and the emphasis was on the longer term treatment and discharge plan for the patient.

In the emergency department team, the direct care of the patient was the responsibility of a specially employed nurse. This meant that the emergency department mental health team nurses were more focused on assessment and had a more medical role. This accounts for the higher evocation of patient voice in the ward rounds and for the fact that the handover information about the patient was more conceptual and diagnosis oriented.

13.5Forms of patient voice

Patient voice was most usually evoked through reported speech, for example, ‘She told me she had been unwell for some time’. When reporting the patient’s words clinicians most commonly used ‘neutral’ verbs, such as said, mentioned, stated, asked. This seemed to be a strategy to reduce personal bias or interpretation when handing over the information. This was confirmed in interviews with the clinicians. As one nurse put it, ‘it’s important that the information I bring to the team is as objective as possible, so that we make proper, evidence-based clinical judgements’.

Another way of evoking patient voice was to repeat excerpts of a dialogue with the patient, ‘acting out’ the patient’s part. This strategy seemed to have a number of functions in handover. One was to emphasize a clinical aspect of the patient’s presentation, for example:

In this instance, it seems that the meaning of the patient’s words were less relevant in the diagnostic process than what the flow of words indicated about the way in which the patient was thinking – to demonstrate the patient’s cognitive processes. In other examples, however, the credibility of the information seemed to be of greater importance, as in this example, where the nurse had been asked if the patient had been taking his medication:

A variation on this was when a clinician was handing over a patient to another service, and wanted the receiving clinician to understand the patient’s role in the process of arriving at the current management plan. In this example, the two clinicians move between reporting what the patient said, and playing out the patient’s role.

Less frequently, clinicians evoked patient voice when describing the quality of the communication with the patient and the patient’s thoughts and feelings. To describe the quality of the communication, clinicians used evaluative verbs such as complain, threaten and grateful, and added emphasis with expressions such as keep talking, keep asking, insisting, really grateful, such as in these examples:

From a diagnostic perspective, this type of speech is consistent with the medical literature on mental health, and in the linguistic analysis of mental illness by Fine (2006) and Rochester and Martin (1979). The literature suggests that repetition and reiteration of a thought or phrase characterize the discourse of mental health patients. It would seem that in these instances, the clinicians are using evaluative language to stress the patient’s clinical state, and that a summary of the gist of the patient’s words is sufficient.

We noted a number of instances where clinicians also used evaluative terms to describe the patient’s feelings, such as concerned, worried, regretful, and summarized the patient’s thoughts with expressions such as ‘It’s his idea that he’s unsteady on his feet’,’ ‘His thinking is that he won’t get better’, ‘He has thoughts of harming himself’.

The patient’s understanding of their illness and the clinician’s understanding how the illness affects the patient’s ‘interactions with the world, is another important clinical diagnostic criterion used by mental health clinicians (Marková and Berrios 1992). Patient voice could demonstrate insight or the lack of it, for example:

‘These expressions seemed to have the dual clinical function of providing clinical information about the patient’s illness, and identifying potentially problematic beliefs that could have an impact on the care plan.

Distancing formulations were rare. We found only one example where the verb claim was used, during award round when the team leader said ‘she has claimed [one of the nurses] is trying to give her AIDS’. When interviewed, the team leader explained that it was her way of explaining that the patient was still very unwell, as the patient’s perception was quite obviously untrue.

Occasionally clinicians included an adverbial expression that indicated some contentiousness with regard to the patient’s words, as in this example: ‘He reportedly told his wife that um, aliens were sucking his blood out of him.’ In this instance the clinician was repeating evidence in the patient’s health records on the database from another credible source, a psychiatric registrar. The clinician explained that he was not discrediting the patient. Rather, he was emphasizing that he was relying on another clinician’s assessment that the patient had been experiencing hallucinations. In contrast, when a clinician said ‘she understandably can’t see any way out’, rather than distancing himself from the patient’s statement, the clinician was appealing to the group’s understanding that this was a credible possibility, thereby legitimizing the patient’s perspective.

These examples of distancing were notable because most often when patients described improbable events, the clinicians did not use a sarcastic tone or mocking gestures. For example, ‘He told his wife that aliens were sucking his blood ‘and ‘She’s talking about wolves and red planes and people on the roof’. Apart from this being part of professional ethical behavior, this was very likely due to the fact that patients frequently were involved in difficult, unpredictable situations through confusion and drug use, and were often victims of violence or abuse. Two typical examples follow:

That said, there were occasional smiles when the consultant would say, ‘so I’d say it’s quite likely they’ll be confirming her to come in’, when a clinician reported a particularly unlikely set of events as recounted by the patient, or when nurses ‘debriefed’ following a difficult shift. Even then, we did not observe any instances of mockery of or disrespect towards patients; on the contrary we observed many instances of empathy and understanding. For example:

Another way of showing that there was doubt about information was when a clinician followed the patient’s assertion with a contradictory statement, for example:

This was to be expected in the mental health context, as the clinician’s understanding of the patient’s situation evolved as the patient spent time in the hospital. Frequently an assertion made by the patient prior to the intake meeting would be confirmed or contradicted in the ward round, following a full assessment by the registrar, and/ or by the arrival of collateral from external sources, such as family, friends, and allied health professionals.

Sometimes clinicians explicitly acknowledged that they could not evoke patient voice. This suggests that the expectation or norm is that the patient should be cited during handover. If the clinician was unable to report back on what the patient said or was unsure of what the patient meant, they generally offered an explanation. For example:

Alternatively, a clinician would state explicitly that they did not know: ‘I think that’s what she said’ or ‘I didn’t think to ask’.

We also noted rare instances of what we called ‘negative’ attribution, when a clinician referred to what a patient had not said. This occurred when the clinician receiving handover queried an aspect of the patient’s history, for example, whether the patient had been abused as a child. The giver of the handover replied with an expression such as ‘not that she reported’ or ‘not that he disclosed to me’. This seemed to represent the patient as being unforthcoming, or withholding information and implied that the emphasis was somehow on the patient to provide the information. It may also have been a strategy used by the clinician to avoid admitting they hadn’t asked the question, or to dismiss a possible alternative explanation for the patient’s behavior.

13.6The function of patient voice in effective clinical handover

In addition to describing the patient’s symptoms and exemplifying different pathologies, patient voice was evoked to inform their care plan. The following excerpts show how a patient’s therapeutic concerns were raised and managed in three handovers over two days. The patient, Michael, presented with anger management issues, self-harm and depression. During the emergency department mental health ward round, the emergency department registered medical officer who had made the initial assessment noted that: ‘Michael [was] seeing a psychologist [recommended by his GP] for quite a few months, but stopped seeing [him] about three months ago because he thinks it doesn’t help.’ Two days later, the psychiatry registrar undertook a full assessment with Michael. Then, during handover to the post-discharge mental health therapist, the issue was discussed again, transcribed in Text 13.2 below.

Text 13.2: ‘Michael’

In the telephone handover to Michael’s general practitioner an hour later, the psychiatry registrar explicitly spoke of this issue, explaining that ‘the PD therapist will continue to see him, and then he’ll be able to make recommendations of psychologists and longer-term treatment, as well’. Michael’s issue with the previous psychologist was consistently raised in the handover meetings, and an adapted treatment plan was developed to accommodate Michael’s concerns.

Patients’ personal concerns, such as the care of family or pets, were also frequently raised in handovers. The example below is typical. The night nurse was on duty when the patient, Greg, presented at the emergency department the previous evening:

The day nurses were informed of and dealt with the care of Greg’s dog, and the night nurse considered the issue of sufficient significance to Greg to verify that it had been followed up when coming on duty the next day.

13.7Discussion

The preceding examples demonstrate that although patient voice may comprise only 10% of the utterances in mental health handover, it is a significant element in clinical handover in mental health. The representation of the patient’s thoughts, words and feelings were a feature of all the handover interactions we observed, and we saw that this informs and shapes the care plan for the patient.

Patient voice has particular importance in mental health handovers due, in large part to the nature of mental illness. Psychiatric pathologies are largely ‘invisible’ to blood tests and X-rays, so their diagnosis is dependent on bringing together clinical observation (‘she looks upset’), the patient’s qualitative, subjective description of their experience (‘she says she’s feeling upset’), and other’s understandings or knowledge of the patient (‘her mother says she’s been unhappy for some time’). The work of the clinicians is often painstaking, as they piece together a jigsaw of information from diverse sources – carers, family, police, allied health professionals, case notes – to address the questions: Why does the patient suffer from these problems at this point in time? What is the best care plan for this patient?

Adding to the complexity is the fact that the clinicians need to understand the patient’s meaning-making when the mind itself is compromised. The clinician must meet the patient ‘where s/he is’ to listen to the patient and hear what the patient says. This explains the diversity of forms used to evoke patient voice and the different functions these evocations imply.

Patient voice was evoked in a variety of ways, from quoting the patient’s words verbatim or in reported speech, to describing the feelings and thoughts that the patient had confided during their interactions with the clinicians on the team. The most frequent forms were neutral acknowledgement, in which information was presented with minimal subjectivity on the part of the clinicians, consistent with the evidence-based methodology of clinical diagnosis. This highlighted the rarer evaluative evocations of patient voice. Distancing formulations were infrequent and used only when there was clear incongruence between the patient’s perceptions and those of other, credible sources. This was most frequently realized through the juxtaposition of conflicting statements and without negative comments about the patient. Patient voice was also included to communicate the patient’s concerns, such as the care of family or pets, or their response to other clinicians and types of therapy. The addition of this qualitative, personalized information about the patient, and the clinician’s emphasis on certain aspects of the patient’s communication, created a rich narrative. All the clinicians interviewed agreed that the patient’s voice was a vital element in reaching an accurate understanding of the patient and his or her situation, and that this permitted the generation of new knowledge to inform the patient’s care and management.

While all clinicians considered it their professional responsibility to represent the patient as objectively and respectfully as possible in handover, they expressed mixed views on the manner and extent to which patient voice should be included. When interviewed, some clinicians thought that it was important to reproduce as much as possible of what the patient said so that it could be interpreted by others. Others argued that in instances when a patient was psychotic or deranged and their conversation was fragmented and repetitive, an accurate summary that included some of the patient’s own words could suffice. When we spoke to medical students, they confirmed that the role and ways in which patient voice could be evoked in handover was not explicitly taught.

13.8Conclusion

There is no immediate plan to include mental health patients in clinical handover at the research site. In the meantime, we suggest that the inclusion of patient voice offers one means of ‘involving patients in their own care, asking questions, and being an active participant in decision-making’, and that this ‘contributes to a reduction in the risk of the patient experiencing an adverse event’. (ACSQHC 2012: 24)

Our data show that, in the absence of the patient’s physical presence at handover, the inclusion of the patient’s words, verbatim or reported, permits the patient to ‘speak’ to the whole team and aid the team in reaching an optimal care and management plan for that patient. The evocation of patient voice functioned to provide evidence of pathologies, provide examples of clinical observations, show changes in the patient’s perceptions, and give personalized information about the patient’s intimate concerns. The patient’s voice added to the narrative, and influenced the subsequent care plan. The data also showed that clinicians ‘mediated’ the patient’s voice, to add emphasis or to summarize the patient’s words, and that while this added depth to the team’s understanding of the patient’s circumstances, it could be problematic if the clinician’s evaluation was incorrect or flawed.

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.

Irrespective of the directives of the Australian clinical handover standard, we argue, that considering patient voice more broadly, speaking for the patient rather than about the patient offers a significant qualitative improvement in the representation of the patient in mental health handover. Given its benefit to mental health patients, we argue that a clarification of the role and importance of patient voice is necessary, and merits inclusion in medical clinical handover communication in other disciplines. As Eggins and Slade (chapter 6) have noted, the cultural shift in medical communication to include patients as ‘active partners and co-producers in their care … improves clinical outcomes’, but there are many situations where the patient cannot be physically included in handover – they may be semi-conscious, intubated, sedated, suffering from dementia or feel intimidated by the hospital context. Patient voice, mediated by clinicians and/ or carers offers a means to take into consideration both clinical informational content, such as a description of the events leading up to the presentation, social support and medical history, and personal interactional content, the patient’s perspective of their symptoms, and their needs and desires. Its explicit inclusion in the handover process ensures that clinicians have all the available information to make an informed and compassionate decision with regard to the patient’s care and management plan.

Finding a balance between a potentially objectifying clinical assessment, for example, ‘the patient is depressed’, and an empathic understanding of what the patient is going through, such as ‘this person is really miserable because his girlfriend died’ is a skill that clinicians develop over many years, and is a largely intuitive, implicit process. We suggest that the explicit teaching of language skills to include patient voice is to the benefit of both patients and clinicians, and reflects a genuinely patientcentered model of care. We propose that health policy and protocols formally recognize the importance of patient voice in clinical handover interactions. We also suggest training modules to teach clinicians practical strategies and techniques so that they develop the competence and confidence to accurately and respectfully represent the patient and carer’s words in clinical communications.