EFFECTIVE COMMUNICATION DURING POSTOPERATIVE HANDOVER · EFFECTIVE COMMUNICATION DURING...

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27.04.2011 Tanja Manser, Industrial Psychology & Human Factors EFFECTIVE COMMUNICATION DURING POSTOPERATIVE HANDOVER This research was funded by the European Commission, Marie Curie Intra-European Fellowship (PIEF- GA-2009-236668) and carried out in collaboration with Aberdeen Royal Infirmary (Dr. Rona Patey & Dr. Paul Holder), the Industrial Psychology Research Group (Prof. Rhona Flin), University of Aberdeen, and Simon Foster, Organizational and Occupational Sciences, ETH Zurich.

Transcript of EFFECTIVE COMMUNICATION DURING POSTOPERATIVE HANDOVER · EFFECTIVE COMMUNICATION DURING...

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Tanja Manser, Industrial Psychology & Human Factors

EFFECTIVE COMMUNICATION DURING POSTOPERATIVE HANDOVER This research was funded by the European Commission, Marie Curie Intra-European Fellowship (PIEF-GA-2009-236668) and carried out in collaboration with Aberdeen Royal Infirmary (Dr. Rona Patey & Dr. Paul Holder), the Industrial Psychology Research Group (Prof. Rhona Flin), University of Aberdeen, and Simon Foster, Organizational and Occupational Sciences, ETH Zurich.

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  Mechanism for transferring information, responsibility & authority

  Contributes to informational, relational & management continuity (Haggerty et al., 2003)

  Important “audit-point” essential for potential recovery from failure (Clancy, 2006; Perry, 2004)

  Ideally “a moment of shared cognition” (Perry, 2004)

  Related to organizational learning (Haggerty et al., 2003; Patterson et al., 2004)   Training, socialization, encouraging / maintaining group cohesion

Patient handover

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  Status quo impedes good practice necessary to maintain high standards of clinical care (BMA, NPSA & NHS Modernisation Agency, 2005; Harvey et al., 2007)   Lack of training on effective communication & team

coordination   Lack of formal systems for patient handover

  Patient handover as key process to investigate in order to improve patient safety (Australian Council for Safety and

Quality in Health Care, 2005; Committee on quality of health care in America, 2001)

  Human factors research as integral part (Harvey et al., 2007)

Patient handover as a research priority

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  In contrast to other high-risk industries, patient handover has seldom been studied (Patterson, et al. 2004)

  Most studies focus on shift handover

  Few studies investigate patient handover at postoperative care transitions to recovery or ICU (Horn & Jacobi, 2006; Catchpole et al.,

2007; Smith et al., 2008; Nagpal et al., 2010; Thieme Groen et al., 2010)

  take place in an environment that is event-driven, time pressured, and prone to concurrent distractions

  while the patient is in an “at risk” state (Smith et al., 2008)

Studies of patient handover

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  Observational studies (Catchpole et al., 2007; Thieme Groen et al., 2010)

  Ideosyncratic handover practices   Information transfer often unstructured and

not supported by documentation  Concurrent clinical tasks

  Development of standardised protocols (Catchpole et al., 2007; Nagpal et al., 2010)

  Evaluation of standardized handover protocols   Improvements in quality of handover* and in teamwork

without increasing handover duration (Catchpole et al., 2007)

* Operationalised as adherence to protocols

Postoperative patient handover

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  Research gap:   Little in-depth information on the specific teamwork

activities and their effects on handover quality

  Research questions:  What is the current practice in postoperative handover ?  Which factors influence handover practice

(e.g. clinical setting, level of training)?  Which characteristics of current handover practice are

related to positive assessments of handover quality?

Research gap & questions

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Methodological approach

  Unit of analysis  Patient handover at care transitions after surgery

  Interview study   Semi-structured interviews   Ethnographic observations

  Observation study   Structured observations  Assessment of handover quality

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  Interview topics   Participant's clinical experience   Goal structure   Factors influencing the quality and safety of patient handover   Task structure   Team structure / Leadership   Information needs   Decision making / Shared cognition   Feedback and education

  27 participants: 5 anaesthetists, 5 theatre nurses, 5 recovery room nurses, 5 ICU nurses, 5 ICU physicians, 2 surgeons

  Transcription and qualitative analysis (i.e. emergent themes)

Interview study

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  “Anaesthesia isn’t black and white so I think it’s easier to handover verbally. I would much prefer a verbal handover than a written handover.” (Anaesthesia consultant)

  “I just try to make sure it’s maybe not too technical from the point of view of the whole patient story, it’s maybe how they’ve been in theatre and highlighting anything particular that I want them to know really at the end of the day. (..) So I think they have quite a lot of information coming in. I try to keep it reasonably brief (..) I try to tell them things outwith the standard. (..) That’s what is asked for by the nurses. They want to know what’s going to happen with the patient (..) anything I can predict that might happen.” (Anaesthesia consultant)

  “I just want to ascertain what they’ve had in theatre any complications that they’re expected to have during their time in the recovery room and what our plan is for when the patient is in recovery. Just to make sure that the patient has a safe transition from theatre to recovery and there’re no gaps in information. Make sure of the important things are handed over to me. I want to know what their observations have been like in theatre and what their expectations are for the recovery room.” (Recovery room nurse)

Handover as information transfer

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Transfer of responsibility for a patient

I take that bit where I say “Are you happy

with everything” and they say “Yes”, I take that as the end point of the handover. I’m now officially handing the patient over to you

and you’re taking prime responsibility for their care from that point onwards but I’ll be there as a backup. When the anaesthetist walks out of the door,

then it’s my patient and I will take responsibility for the patient.

If the anaesthetist and the scrub nurse come through with a patient,

the idea is that, until they’ve given handover to a recovery nurse, they’re responsible.

(…) there tends to be a point at which the theatre nurse (…) will share

the information and then from that point forward, the responsibility is ours (...) but, in real terms, you assume responsibility for the patient as soon as they come

in the door.

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  “I certainly don’t feel I transfer the responsibility. Even if I’m... Certainly to a nurse or to a junior surgeon, I would never feel I was transferring responsibility. To a colleague, a consultant anaesthetist, to a degree you’re transferring responsibility. But it’s one of those things... If you’ve been involved with a patient, you have a sense of responsibility even quite far down the line.” (Anaesthesia consultant)

  “I suppose in theory it should be exactly the same but I feel more comfortable usually taking a patient into ITU because both the nursing staff and the medical staff there are used to dealing with things that happen acutely. (..) So I think I’d probably give ITU responsibility a bit earlier, particularly if they know the patient. (..) Whereas I know that, in Recovery, I can’t suddenly give responsibility for the patient to the nurse because they’re trained totally differently and they won’t be able to deal with all the problems that come up, whereas intensive care will. I’m quite happy to give responsibility back to them. Get out of there as fast as possible.” (Anaesthesia consultant)

Handover as transfer of responsibility

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  “I guess it’s whoever’s been the main person looking after the patient as well throughout the operation, whoever has developed the most understanding of the patient, it would make sense.

  Occasionally, the person who’s in charge may ... occasionally you have a problem where they (consultant anaesthetists) pitch up just at the end so they’ll come through to recovery with you and (…), they’ll do the handover but not having been there for most of the time which is sometimes when the dangerous bits happen, they’ll say “Oh yes, his blood pressure’s been fine the whole way through” and you’re like “No, actually it’s been too high the whole way through”.

  (...) so you may just stick around waiting for the other person to leave so that you can give a bit more information because you don’t want to embarrass them by saying “Actually that’s totally wrong” in front of somebody else unless it’s something very serious, very tactfully say “Well, yes, the blood pressure was fine but then it was really weird, during the operation it was really high all the time. So, if it’s high here, I think we should do X, Y, or Z”.

  It’s something we’re not very good at, especially when there’s two anaesthetists working, we’re not very good at working out who’s in charge“

(Anaesthesia trainee)

Who should hand over?

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  Structured observation of 117 handovers   50 theatre to recovery room   25 theatre to cardiac ITU   42 recovery room to ward (40 matching cases)

  Audio recording of subset for reliability analysis   Participants

  31 anaesthetists, 36 scrub nurses, 21 recovery room nurses, 12 cardiac ITU nurses, 31 ward nurses

 Maximum of 5 observations per clinician to avoid bias   Quantitative analysis

(i.e. relative amount of time per category)

Observation study

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  Mostly routine handovers

Situational handover characteristics

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Situational handover characteristics

  Similar for all clinical settings

  In line with interview data

  Tendency of receiving clinicians to rate complexity and uncertainty lower

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Handover observation system

  Development of observation categories   Literature review, Interviews, Ethnographic observations

  Second-by-second coding of handover activity

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Handover activity Ti

me

spen

t on

hand

over

act

iviti

es

in %

of

hand

over

dur

atio

n

75 72

198

7

70 63 58 86

34 34 18 43 5 5 4 5

0

50

100

150

200

250

Overall Theatre to recovery (n=50)

Theatre to Cardiac ITU (n=25)

Recovery to ward (n=42)

Clinical work (% of t) HO Com (% of t) HO Doc (% of t) Soc Com (% of t)

  Significant difference between settings for   Clinical work (ANOVA with setting = factor, p < 0.001, Eta² = 0.91)

  HO communication (ANOVA with setting = factor, p < 0.001, Eta² = 0.44)

  Concurrent activities (ANOVA with setting = factor. p < 0.001, Eta² = 0.80)

Concurrent A. 1.84, ±0.57

Concurrent A. 1.41, ±0.14

Concurrent A. 2.78, ±0.40

Concurrent A. 1.73, ±0.25

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Handover communication

  Time spent on subcategories of handover communication in % of handover duration across clinical settings and handover roles

22.15 (±8.8) 2.62 (±2.9) 0.23 (±1.4) 19.74 (±12.3) 9.13 (±5.8) 12.79 (±5.2) 2.92 (±2.8)

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Handover communication

  Time spent on subcategories of handover communication in % of handover duration across clinical settings comparing handover roles

  Transferring clinician(s): Information giving, Assessment and Planning & decision making

  Receiving clinician(s): Acknowledgement and Information seeking

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Handover communication

Theatre to recovery

Recovery to ward

Theatre to Cardiac ITU

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Clinical work & handover communication

Kendall tau correlations between Clinical work (Setup/Patient care) and handover communication for the three clinical settings. ͣIn setting 2 “Information verifying" did not occur * p < 0.05, ** p < 0.01, *** p < 0.001

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  Literature claims problems with trainee handover – but often only includes data on trainee handover

  What is different?  Trainee handovers take longer

(277.9 sec; ±111 vs. 222.7sec; ±70.5, p<0.05, Eta²=0.08)*  Receiving staff’s ratings of handover quality slightly

lower for trainees (3.2; ±0.94 vs. 3.5; ±0.73, n.s.)*  Differences in handover communication?

* Due to sample size only calculated for Theatre to recovery handovers.

Trainee vs. consultant handover

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Trainee vs. consultant handover

Handovers from theatre to recovery by trainee (n=12) or consultant level anaesthetists (n=38)

Information giving Information seeking Information verifying

Planning & Decision making Acknowledgement Handover organisation

Assessment

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Trainee vs. consultant handover

Handovers from theatre to CITU by trainee (n=4) or consultant level anaesthetists (n=21)

Information giving Information seeking Information verifying

Planning & Decision making Acknowledgement Handover organisation

Assessment

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Ratings of handover quality

  Rating by   transferring and   receiving clinician(s)

  Analysis   Item quality   Factor structure  Predictive validity   Link to handover

activities Manser et al., 2010 QSHC

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Factor structure of handover quality

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Patient care information

Shared understanding

Handover organisation

Conduct

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Factors predicting handover quality

Patient care information r = 0.45, p < 0.001

Shared understanding r = 0.32, p < 0.001

Handover organisation r = 0.37, p < 0.001

Conduct r = -0.13, p < 0.05

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Differences between clinical settings

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  Overall handover quality  Across clinical settings higher receiver rating when:

  More Assessment (r = .312; p ≤ 0.001)

  Less Information seeking by receiver (r = -.327; p ≤ 0.001)

 No relationship for Information giving (r = .118; ns) and Planning & decision making (r = .095; ns)

  Assessment (but not information giving and planning and decision making) negatively correlated with information seeking

Assessments are key to handover quality ratings

* Correlation analysis of handover activities with quality judgments of the receiving staff across all settings

What makes a „good handover“?*

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Handover communication

Patient care information

Handover organisation

Shared understanding

Conduct

Information giving

Information seeking r = -.205*

Information verifying

Assessment r = .224** r = .359** r =.193* r = -.298**

Planning & decision making

Acknowledgement r =.251**

Handover organisation r = -.182*

What makes a „good handover“?

* Significant at 0.05 level ** Significant at 0.01 level

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  It’s more than facts and figures  Assessments are key to high handover quality ratings  Compensatory information seeking behaviour of

receiving staff

  Implications for handover standardisation efforts   Implications for education / training of handover   Research challenges

 Ethics – especially for ITU admissions  Complexity of handover in different settings

Discussion