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Effective Communication in Clinical Handover

Book Description

Based on detailed multi-disciplinary analyses of more than 800 recorded handover interactions, audits of written handover documentation, interviews and survey responses, the contributing authors identify features of effective and ineffective clinical handovers in diverse hospital contexts. The authors then translate their descriptive findings into practical protocols, communication strategies and checklists that clinicians, managers and policy makers can apply to improve the safety and quality of clinical handovers. All the contributors are affiliated with the International Research Centre for Communication in Healthcare (IRCCH), an international multidisciplinary organisation of over 90 healthcare professionals from more than 17 countries committed to improving improving communication in healthcare systems around the world.

'The authors have created a new and tightly woven systems safety net that will, if implemented, significantly reduce the occurrence of errors resulting from cumulative communication failures.' -H. Esterbrook Longmaid III, MD, FACR, President of Medical Staff, Beth Israel Deaconess-Milton Hospital, Milton, MA USA

'Uncommonly valuable for the rigorous, original communication research it reports and for the careful translation of the research findings into practical strategies that actually improve clinical handovers in the real world of practice.' -Professor Suzanne Kurtz, Washington State University

'This clear, plain English book is an outstanding resource for the training of all involved in healthcare.' -Elizabeth Trickett, (Former) Director of Safety and Quality, ACT Health, Australia

Table of Contents

  1. Cover
  2. Title Page
  3. Copyright Page
  4. Preface
  5. Acknowledgements
  6. Contents
  7. Contributors
  8. Transcription conventions
  9. Section 1
  10. Background: safety, quality and communication in clinical handover
    1. 1 Effective communication in clinical handover: challenges and risks
      1. 1.1 Setting the scene
      2. 1.2 Communication in clinical handovers
      3. 1.3 Recognizing the role of communication in clinical handover
      4. 1.4 Impact of organizational and institutional factors
        1. 1.4.1 Physical constraints
        2. 1.4.2 Rostering and scheduling
        3. 1.4.3 Cultural diversity
        4. 1.4.4 Employment conditions
        5. 1.4.5 Interdisciplinary boundaries
        6. 1.4.6 Hierarchical barriers
        7. 1.4.7 Lack of clinical handover training
      5. 1.5 Communicative risk factors in actual handover delivery
        1. 1.5.1 Lack of structure
        2. 1.5.2 Lack of adequate explanations about process
        3. 1.5.3 Lack of patient involvement
        4. 1.5.4 Excessive reliance on memory without reference to written documentation
        5. 1.5.5 Poor quality of written medical records
      6. 1.6 Responses designed to improve clinical handover communication
        1. 1.6.1 Structural handover tools: ‘SBAR’
        2. 1.6.2 Flexible standardization and the minimum dataset
        3. 1.6.3 Patient-centered care and bedside handover
      7. 1.7 Gaps in clinical handover research and understanding
        1. 1.7.1 Lack of empirical evidence of actual communication in handover
        2. 1.7.2 Under-theorization of patient-centered care
        3. 1.7.3 Lack of evidence and evaluation of standardization
        4. 1.7.4 Lack of clarity about ‘flexible standardization’ and the minimum dataset
        5. 1.7.5 Unclear allocation of responsibility for behavioral change
      8. 1.8 The ECCHo project: an interdisciplinary language-based approach to communication in clinical handover
        1. 1.8.1 ECCHo research framework
        2. 1.8.2 ECCHo as a mixed methods translational research project
        3. 1.8.3 Methods
        4. 1.8.4 Translational research process
      9. 1.9 Outline of this book
    2. 2 Clinicians’ voices: what healthcare professionals say about handover practice
      1. 2.1 Setting the scene
      2. 2.2 Investigating clinicians’ perspectives on clinical handover
        1. 2.2.1 In-depth interviews
        2. 2.2.2 The survey data
      3. 2.3 Adverse events associated with poor handover practice
      4. 2.4 Issues and challenges in handover practices: the clinicians’ views
        1. 2.4.1 Omission of significant information
        2. 2.4.2 Changes and omissions in information across multiple shift-change handovers
        3. 2.4.3 Lack of direct patient care by clinician handing over
        4. 2.4.4 Lack of interaction in handovers
        5. 2.4.5 Over-reliance on memory and lack of adequate written records
        6. 2.4.6 Lack of mentoring of junior clinicians
      5. 2.5 Clinicians’ responses to handover policy directions
        1. 2.5.1 Clinicians’ use and evaluations of structured communication tools
        2. 2.5.2 Adoption and perceived effectiveness of patient-centered handovers
      6. 2.6 Clinicians’ suggestions to improve clinical handover
        1. 2.6.1 Handover context
        2. 2.6.2 Handover delivery
        3. 2.6.3 General suggestions
      7. 2.7 The need for education and training in handover communication
      8. 2.8 Conclusion
  11. Section 2
  12. Changing staff: clinical handovers at shift changes
    1. 3 Emergency department medical handovers as teaching and learning opportunities
      1. 3.1 A morning round in the emergency department
      2. 3.2 Factors at play during emergency department medical handovers
      3. 3.3 Clinical handover during ward rounds in the emergency department – a view from the literature
      4. 3.4 The theory of practice – another way to see the practice of clinical handover
      5. 3.5 Our research site, aims and methods
      6. 3.6 Challenges to effective handover in public hospital emergency departments
      7. 3.7 Emergency department medical handover practice – doings, sayings and relatings
      8. 3.8 Clinician perspectives on handover practice
      9. 3.9 Discussion
      10. 3.10 Conclusion
    2. 4 Strengthening medical handover communication in emergency departments
      1. 4.1 Introduction
      2. 4.2 The unique features of the emergency department hospital environment
        1. 4.2.1 The high demand for emergency department services
        2. 4.2.2 The wide range of patients who visit emergency departments in Australian hospitals
        3. 4.2.3 The number of critical and acute unscheduled patients who present at Australian emergency departments
        4. 4.2.4 Most emergency department patients are undifferentiated
        5. 4.2.5 Time and safety are closely connected in emergency departments
        6. 4.2.6 Emergency departments are characterized by high levels of noise and constant interruptions
      3. 4.3 The communication challenges of hospital emergency departments
        1. 4.3.1 Episodic care
        2. 4.3.2 Challenges to building alliances between emergency department team members
        3. 4.3.3 Poor access to clinical information
        4. 4.3.4 Second language issues and poor health literacy
        5. 4.3.5 Different grades of experience and applied knowledge
        6. 4.3.6 Medical hierarchy of responsibility
        7. 4.3.7 High safety stakes
      4. 4.4 Five key principles of clinical handover practice
        1. 4.4.1 Patient safety is at the center of clinical handover practice
        2. 4.4.2 The transfer of responsibility and accountability is a core function of clinical handover
        3. 4.4.3 Clinical handover is an organizational process
        4. 4.4.4 Clinical handover depends on teamwork
        5. 4.4.5 Clinical handover combines action, talk and relationships
      5. 4.5 Five key principles of clinical handover communication
        1. 4.5.1 Patient safety must be the focus of clinical handover communication
        2. 4.5.2 The transfer of responsibility and accountability for ongoing patient care must be made explicit during clinical handover
        3. 4.5.3 Clinical handover participants must make team decisions about how each patient’s continuity of care is organized
        4. 4.5.4 Clinical handover participants must actively share and discuss patient information with other team members during handover
        5. 4.5.5 Clinical handover participants must negotiate both the informational and the interpersonal or interactional dimensions of clinical handover
          1. 4.5.5.1 Informational aspects of clinical handover
          2. 4.5.5.2 Interpersonal aspects of clinical handover
      6. 4.6 Communication strategies to strengthen clinical handover
        1. 4.6.1 Informational communication strategies: how to facilitate the exchange of information during clinical handover
          1. 4.6.1.1 Prepare for clinical handover
          2. 4.6.1.2 Manage the context
          3. 4.6.1.3 Use a consistent framework to transfer information
          4. 4.6.1.4 Make sure the information framework is logical
          5. 4.6.1.5 Use signposts to structure information at the sentence level
          6. 4.6.1.6 Explain your reasoning
          7. 4.6.1.7 Maximize the effectiveness of your information delivery
          8. 4.6.1.8 Don’t assume knowledge
          9. 4.6.1.9 Avoid using vague terms
          10. 4.6.1.10 Provide your listeners with clear information distinctions
          11. 4.6.1.11 Be aware that newcomers may not be familiar with medical terminology
        2. 4.6.2 Interpersonal communication strategies: how to facilitate the relationship between speaker and listener during clinical handover
          1. 4.6.2.1 Establish rapport with team members
          2. 4.6.2.2 Make it clear who is responsible for outstanding tasks
          3. 4.6.2.3 Indicate to the speaker when you want to add information
          4. 4.6.2.4 Indicate to the speaker when you want to confirm information or ask a question
          5. 4.6.2.5 Ask the speaker to clarify or provide further information
          6. 4.6.2.6 Find out information you do not know with WH-questions
          7. 4.6.2.7 Explain why you are asking
          8. 4.6.2.8 Confirm information with yes/no questions
          9. 4.6.2.9 Clarify information with assumptive questions
      7. 4.7 Conclusion
    3. 5 Resource: transferring patient information to the emergency department medical team during clinical handover
      1. 5.1 How to transfer patient information to the emergency department medical team during clinical handover
      2. 5.2 Establishing and building a positive relationship with patients and with emergency department team members during clinical handover
    4. 6 Communication in bedside nursing handovers
      1. 6.1 Introduction
      2. 6.2 Setting the scene
      3. 6.3 Background: research questions and data
      4. 6.4 Summary of interactional and information issues in bedside handovers
        1. 6.4.1 Interactional issues
        2. 6.4.2 Informational issues
      5. 6.5 Interactional issues in bedside handovers
      6. 6.6 Informational issues in bedside handovers
        1. 6.6.1 Structure and protocols
        2. 6.6.2 Redefining the ‘minimum dataset’
        3. 6.6.3 Unstated assumptions: responsibility and accountability
      7. 6.7 Conclusion: improving quality and safety in bedside handover
    5. 7 Resource: communicating effectively in bedside nursing handovers
      1. 7.1 Introduction
      2. 7.2 Training design
        1. 7.2.1 Dimensions of a good bedside handover
        2. 7.2.2 Interactional dimensions of bedside handover: the CARE communication protocol
        3. 7.2.3 Informational dimensions
        4. 7.2.4 Use of transcribed examples from actual handovers
        5. 7.2.5 Information structure on ward sheets
      3. 7.3 Conclusion: changing practice through targeted training
  13. Section 3
  14. Changing sites: clinical handovers when patients move
    1. 8 Clinical handover in context: risks and protections across a hospital patient’s journey
      1. 8.1 Setting the scene
      2. 8.2 Good – but there are gaps
      3. 8.3 The paradox of clinical handover: a risk-minimizing and risk-creating event
      4. 8.4 Clinical handover as a risk repair and educational resource
      5. 8.5 Handover as a safety risk: poor and poor communication
      6. 8.6 Summary of barriers to safe and effective handovers
        1. 8.6.1 Attitudes to interactivity and assertiveness in the hospital context
        2. 8.6.2 Deference to role hierarchy or discipline boundaries, in particular junior with more senior doctors and nurses with doctors
        3. 8.6.3 The persistence of an outdated attitude that excludes patients and carers from the handover
        4. 8.6.4 Lack of confidence or skills in communicating in spontaneous, fast-paced, multi-party, patient-inclusive interactions
      7. 8.7 Strategies to maximize the safety benefits of clinical handover
        1. 8.7.1 Organizational strategies
        2. 8.7.2 Communication strategies
        3. 8.7.3 Mentoring and leadership strategies
      8. 8.8 Conclusion
    2. 9 Interhospital transfer of rural patients: an audit of ‘patient expect’ documentation
      1. 9.1 Setting the scene
      2. 9.2 Background: research question, approach and data
        1. 9.2.1 Research approach and sample
        2. 9.2.2 iSoBAR for interhospital transfer and audit
        3. 9.2.3 Qualities of the ‘patient expect’ call
      3. 9.3 Identify
        1. 9.3.1 Patient identification
        2. 9.3.2 Clinician identification
        3. 9.3.3 Determining clinical responsibility and accountability
        4. 9.3.4 Diffusion of personal responsibility and accountability
        5. 9.3.5 Delegation of responsibility and accountability
      4. 9.4 Situation and Observations
      5. 9.5 Background
      6. 9.6 Agreed plan
      7. 9.7 Readback
        1. 9.7.1 Compliance
        2. 9.7.2 Accessibility
        3. 9.7.3 Readability
        4. 9.7.4 Endurability
      8. 9.8 Summary: expanding the concept of written clinical communication
  15. Section 4
  16. Changing disciplines: clinical handovers in interprofessional teams
    1. 10 iSoBar: An innovative framework and checklist for clinical rounds in an interprofessional student training ward
      1. 10.1 Setting the scene
      2. 10.2 Background: research question, approach and data collection
        1. 10.2.1 Mnemonics and checklists
        2. 10.2.2 iSoBAR for ward rounds
      3. 10.3 Research site and approach
      4. 10.4 Results
        1. 10.4.1 Setting the scene
      5. 10.5 Summary
        1. 10.5.1 Informational recommendations
        2. 10.5.2 Interactional recommendations
    2. 11 Resource: interprofessional ward round handovers
      1. 11.1 Better bedside communication
        1. 11.1.1 For better bedside communication
      2. 11.2 Informational structures: i-S-o-B-A-R
      3. 11.3 Preparation
        1. 11.3.1 Time management
        2. 11.3.2 Team composition
        3. 11.3.3 Organization
      4. 11.4 Guidance on following the steps in the iSoBAR protocol
        1. 11.4.2 S is for Situation
        2. 11.4.3 O is for Observations
        3. 11.4.4 B is for Background
        4. 11.4.5 A is for Agree to a Plan (Actions)
        5. 11.4.6 R is for Readback
      5. 11.5 Summary of resources
    3. 12 Maintaining and generating knowledge in interprofessional mental health handovers
      1. 12.1 Introduction
      2. 12.2 Language and communication
      3. 12.3 Successful teamwork communication: polite, respectful and inclusive
      4. 12.4 Participation and turn-taking in meetings
      5. 12.5 Preservative handover exchanges
      6. 12.6 Generative handover exchanges
      7. 12.7 Generative handover interactional strategies
        1. 12.7.1 Clarification
        2. 12.7.2 Repair
        3. 12.7.3 Challenge
        4. 12.7.4 Pedagogic scaffolding
        5. 12.7.5 Referencing
        6. 12.7.6 Evaluation
        7. 12.7.7 Elaboration, abstraction and integration
        8. 12.7.8 Summary of generative communication strategies
      8. 12.8 Conclusion
    4. 13 Patient voice: including the patient in mental health handovers
      1. 13.1 Introduction
      2. 13.2 Patient voice
      3. 13.3 Identifying patient voice
        1. 13.3.1 Acknowledging
        2. 13.3.2 Distancing
      4. 13.4 The frequency of patient voice
      5. 13.5 Forms of patient voice
      6. 13.6 The function of patient voice in effective clinical handover
      7. 13.7 Discussion
      8. 13.8 Conclusion
    5. 14 Resource: mental health clinical handover audit tool (mCHAT)
      1. 14.1 Introduction
      2. 14.2 How to use the mCHAT
      3. 14.3 Handover environment
      4. 14.4 Handover organization
      5. 14.5 Informational process and outcomes
        1. 14.5.1 Informational process
        2. 14.5.2 Informational outcomes
      6. 14.6 Interactional practices
        1. 14.6.1 Team leader’s communication
        2. 14.6.2 Team members’ communication
      7. 14.7 Collating and reflecting on the audit results
  17. Section 5
  18. Integrating ECCHo outcomes
    1. 15 iCARE3: an integrated translational model of effective clinical handover communication
      1. 15.1 Setting the scene
      2. 15.2 Accumulating problems as systemic risks in clinical handover
      3. 15.3 Interpreting risk: applying a systems approach to clinical handover
      4. 15.4 Identifying types of communication risks in clinical handover
        1. 15.4.1 Latent factors and active errors in clinical handover
      5. 15.5 Managing communication risks: the iCARE3 model
      6. 15.6 Contextual constraints in iCARE3: participants, scheduling, environment and resources
        1. 15.6.1 Communicative context 1: Involving all relevant participants
        2. 15.6.2 Communicative context 2: Scheduling
        3. 15.6.3 Communicative context 3: Environment
        4. 15.6.4 Communicative context 4: Resources
        5. 15.6.5 Context and handover: summary
      7. 15.7 Effective information is structured information: iSoBAR in iCARE3
        1. 15.7.1 CARE-1 Information quality: Concise, Accurate, Reasoned, Explicit
      8. 15.8 Handover as an interactive event: recipient design and iCARE3
        1. 15.8.1 CARE-2 in spoken handovers: Connect, Ask, Respond, Empathize
        2. 15.8.2 CARE-3 in written handovers: Compliant, Accessible, Readable, Enduring
      9. 15.9 iCARE3 as a response to accumulating risks across the patient’s journey
      10. 15.10 Clinical handover assessment and risk matrix (CHARM)
      11. 15.11 CHARM questions
        1. 15.11.1 Purpose of handover
        2. 15.11.2 Assessing contextual risks
          1. 15.11.2.1 Participants
          2. 15.11.2.2 Scheduling
          3. 15.11.2.3 Environment
          4. 15.11.2.4 Resources
        3. 15.11.3 Assessing informational risks
        4. 15.11.4 Assessing interactional risks
      12. 15.12 Conclusion
  19. References
  20. Index
  21. Footnotes