Transferring Patient Care: Patterns of Synchronous Bidisciplinary Communication Between Physicians and Nurses During Handoffs in a Critical Care Unit

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  • ORIGINAL ARTICLETransferring Patient Care: Patterns ofSynchronous Bidisciplinary CommunicationBetween Physicians and Nurses During

    Handoffs in a Critical Care UnitAlicia McMullan, MA, Avi Parush, PhD, Kathryn Momtahan, PhD, RN

    Purpose: The transfer of patient care from one health care worker toAlicia McMullan

    Canada. Miss Mc

    experimental psyc

    University of Otta

    Carleton Universit

    is a professor of ps

    at Carleton Unive

    adjunct professor i

    sity in Ontario, Ca

    TheOttawaHospit

    is currently the lead

    and an adjunct pr

    Carleton Universit

    Journal of PeriAnesthanother involves communication in high-pressure contexts that are often

    vulnerable to error. This research project captured current practices for

    handoffs during the critical care stage of surgical recovery in a hospital

    setting. The objective was to characterize information flow during transfer

    and identify patterns of communication between nurses and physicians.Design and Methods: Observations were used to document communica-

    tion exchanges. The data were analyzed qualitatively according to the

    types of information exchanged and verbal behavior types.Findings: Reporting and questions were the most common verbal behav-

    iors, and retrospective medical information was the focus of information

    exchange. The communication was highly interactive when discussing

    patient status and future care plans. Nurses proactively asked questions

    to capture a large proportion of the information they needed.Conclusions: Findings reflect positive and constructive patterns of

    communication during handoffs in the observed hospital unit.

    Keywords: communication, handoffs, patient safety. 2014 by American Society of PeriAnesthesia NursesTHETRANSFEROFAPATIENTSCARE from onehealth care worker to another or from one area of

    care to another involves communication in high-

    pressure contexts that are often vulnerable to

    error. Errors in information sharing among clinical

    staff during handoffs have been shown to lead toadverse health events.1-4 Although there is a

    growing awareness of the need for high-quality, MA, Ottawa University, Ottawa, Ontario,

    Mullan is currently a PhD candidate in

    hology in the School of Psychology at The

    wa in Ontario, Canada; Avi Parush, PhD,

    y, Ottawa, Ontario, Canada. Dr Avi Parush

    ychology in the Department of Psychology

    rsity, Ottawa, Ontario, Canada and an

    n the School of Nursing at Queens Univer-

    nada; and Kathryn Momtahan, PhD, RN,

    al, Ottawa, Ontario, Canada. DrMomtahan

    of nursing researchat TheOttawaHospital

    ofessor in the Department of Psychology at

    y in Ottawa, Ontario, Canada.

    esia Nursing, Vol -, No - (-), 2014: pp 1-13processes during this critical, yet susceptible point

    in the care system,4-6 the current literature does

    not conclusively identify where communication

    failures typically occur.7

    According to OByrne et al,8 the patient handoff isone of the most important points in the health care

    process for the exchange of critical information.Conflict of interest: None to report.

    This project was funded by The Canadian Patient Safety

    Institute in partnership with The Ottawa Hospital.

    Address correspondence to Alicia McMullan, The University

    of Ottawa, 55 Laurier Avenue East, Desmarais 6140, Ottawa,

    Ontario, Canada K1N6N5; e-mail address: alleymcmullan@

    gmail.com.

    2014 by American Society of PeriAnesthesia Nurses1089-9472/$36.00

    http://dx.doi.org/10.1016/j.jopan.2014.05.009

    1

    Delta:1_given nameDelta:1_surnameDelta:1_given namemailto:alleymcmullan@gmail.commailto:alleymcmullan@gmail.comhttp://dx.doi.org/10.1016/j.jopan.2014.05.009

  • 2 MCMULLAN, PARUSH, AND MOMTAHANThe moment a handoff to a different health care

    worker occurs, there is an implied risk of

    information loss. Moreover, with a transfer to a

    different hospital unit, there is an additional risk

    because of a new environment that may havedifferent interactions and procedures.9,10

    Therefore, although handoffs are a necessary

    component of patient care, they can increase

    susceptibility to medical error through poor

    transfer of information, differential authority, and

    diffused responsibility for patient care.10

    The purpose of this research project was to cap-ture current practices for handoffs during the crit-

    ical care stage of recovery after surgery in a

    hospital setting. Specifically, the objective was to

    characterize information flow during transfer and

    identify patterns of communication between

    nurses and physicians. This was accomplished by

    documenting the verbal communications involved

    in transferring a patient from the operating room(OR) to the postanesthesia care unit (PACU).

    The Significances of Communication Duringthe Patient Care Handoff

    The consequences of communication errors can

    be significant for both the patient and the health

    care worker. A recent study of postoperative carerevealed that the patient outcome was directly

    related to communication and care coordina-

    tion.11 The search for missing information or clari-

    fication of treatment orders can lead to delays in

    care and/or adverse events (T. Foster-Hunt, unpub-

    lished masters thesis, 2009).10 The negative con-

    sequences of such gaps in communication have

    consequences for all involved as the workloadand stress of the health care workers increase

    along with risks to the patients quality of care.

    Poor communication concerning patient-relevant

    details during a handoff can also lead to inconsis-

    tencies in care, which have been identified as a

    threatening factor to patient safety.11

    To develop effective communication solutions inhealth care, several research studies (T. Foster-

    Hunt, unpublished masters thesis, 2009)11-16

    have investigated the communication modes

    used in health care settings and evaluated these

    in terms of their facilitation of performance

    during patient care. Depending on the environ-

    mental circumstances, different communicationapproaches can provide different benefits and

    consequences to effective health care.

    Synchronous Communication

    Synchronous communication occurs when a hand-

    off is carried out in real time, most commonly in a

    face-to-face manner.11,12 In a study by Coiera and

    Tombs,13 synchronous communication was identi-

    fied as the most preferred means of communica-

    tion throughout the hospital under study, and

    this finding has been confirmed by subsequent

    research studies.14-16 There were several reasonslisted and among them was the desire for the

    social facilitation of the face-to-face interactions,

    the ability to clarify and ask questions with imme-

    diate responses, and the ability to confirm the

    transfer of responsibility for the patient.15 In two

    recent studies of patient handoffs in the emer-

    gency department and during nursing shift

    reports, researchers found that face-to-face com-munications were the most frequent means of

    information exchange (T. Foster-Hunt, unpub-

    lished masters thesis, 2009).17 The communica-

    tion events observed from nursing shift reports

    (T. Foster-Hunt, unpublished masters thesis,

    2009) were highly interactive, and it was docu-

    mented that additional requests for information

    increased as a function of the level of organizationof the handoff (disorganized to highly organized).

    The author hypothesized that this finding may

    imply that better organized handoffs offer more

    opportunities to expand on the information pro-

    vided. Patterson et al18 have suggested, through

    observation and analysis, that verbal exchanges

    could be a potential strategy for combating infor-

    mation loss if they can maintain an interactivenature. This idea was supported by the research

    on shift report mentioned previously (T. Foster-

    Hunt, unpublished masters thesis, 2009). Further-

    more, during synchronous interactions, health

    care providers are given an opportunity to discuss

    or question a fellow colleagues point of view, and

    this can sometimes lead to new ideas or patient

    care solutions.19

    Problems Associated With SynchronousCommunication

    The shortcoming of synchronous communication

    is mainly found in its interruptive nature. When

    conversing with an individual, it is easy to divert

  • SYNCHRONOUS BIDISCIPLINARY COMMUNICATION 3from the topic because there is an opportunity

    given for questions to be asked, other medical in-

    terruptions can take place, unrelated conversa-

    tions can distract, and/or other external

    distractions can occur.17 Interruptions during thehandoff process create a problem for the flow of

    communication and can lead to medical error. In

    interruption-driven environments, the cognitive

    resources of health care workers are taxed as

    they work to absorb and communicate informa-

    tion,20 and even seconds taken away from the pri-

    mary action can result in memory failure.21

    Synchronous verbal handoffs have also been criti-

    cized for their orientation toward retrospective pa-

    tient information. Research has demonstrated a

    tendency for health care workers to focus on

    sharing past information that can typically be

    found in the patient chart (eg, what medications

    were administered in the OR) versus sharing pro-

    spective information (eg, what medications togive over the recovery period).22 This is a concern

    because empirical evidence points to the benefits

    of prospective information sharing for improved

    recall and retention of information, along with

    the facilitation of care plans.22-24 The challenges

    of synchronous communication can increase

    when handoffs are completed between different

    health care disciplines.

    Multidisciplinary Communication and Care

    Multidisciplinary communication involves verbal

    and nonverbal interactions between various health

    care disciplines (eg, from anesthesia provider to

    nurse, nurse to physician, emergency room physi-

    cian to surgeon, nurse to orderly). The communica-tion serves multidisciplinary collaboration, also

    referred to as multidisciplinary teamwork, with

    health care workers from various disciplines com-

    ing to a mutual agreement for the purpose of

    achieving mutual goals (C. Kramer, unpublished

    masters thesis, 2009).25 This communication also

    involves a combination of skills and attitudes.26,27

    All interactions that are shared regarding thepatient(s), such as relaying drug information,

    participating in patient rounds, treatments, or

    giving shift reports, are included in this dynamic

    form of communication. These interactions are

    critical for the coordination of patient care

    because each discipline brings a slightly different

    picture of the patient care plan to the table. Assuch, successful collaboration or teamwork

    should occur in an environment of mutual

    understanding and respect, where each individual

    is free to divulge their concerns. In turn, the

    successful integration of the teams assets andmedical knowledge should facilitate increasingly

    synchronized care. However, factors such as

    hierarchies associated with different disciplines

    may result in ineffective communication in a

    multidisciplinary health care context.

    In a literature review of the dynamics among multi-

    disciplinary collaboration, nurses reported thatthey felt undervalued, were not directly involved

    in decision making, were interrupted, and were re-

    minded of the power distance between them-

    selves and the physicians (T. Foster-Hunt,

    unpublishedmasters thesis, 2009). The power dis-

    tance refers to a situation where a subordinate staff

    member may not want to speak up about their con-

    cerns or question the authority of their supe-rior.8,28-30 In medicine, a by-product of this

    power distance is limited direct communication

    between nurses and physicians.

    The present study focused on the specific patterns

    of synchronous bidisciplinary communication be-

    tween nurses and physicians during handoffs in a

    critical care unit of a large teaching hospital. Theresearch goal was to provide insight into the pat-

    terns of communication in the handoff process

    during this high-intensity care transition point.

    Method

    The current investigation was a qualitative obser-

    vational study of handoff instances that took place

    within the natural environment of a hospital unit.

    Specifically, the study focused on synchronous

    communications and processes in handoffs be-

    tween anesthesiologists from the OR to nurses in

    the PACU. This study design was used to providea detailed description of handoff communication

    within its natural setting. The researcher was un-

    able to control the observational environment,

    and as a by-product of this research reality, patient

    cases were observed based on predetermined

    criteria that included age (181) and the destina-tion of the patient postoperatively (ie, the PACU).

    The primary participants were the nursing andmedical personnel involved in the handoff, but

    because of the observational nature of the study,

  • 4 MCMULLAN, PARUSH, AND MOMTAHANhospital patients were also within the observed

    environment.

    Through the observation of staff, data were

    collected over a 4-month period on the variousparameters of team communication and the

    overall transfer of information during handoffs

    in the PACU. These parameters included verbal

    interactions (eg, questions, replies), content of

    communication (eg, future care plan, patient

    history, medications administered), and the

    composition of the care team (eg, nurse, anesthe-

    siologist). The researcher observing handoffs wasexternal to the hospital and therefore, was not

    familiar to the participants. During the course of

    each handoff, the researcher stood within close

    proximity to the activity, while also maintaining

    enough of a distance so that movement around

    the patient and medical attention necessary to

    make the patient transfer were not disrupted.

    Only the handoffs (N 5 40) were recorded bythe researcher using freeform paper notes to docu-

    ment all the details of the communications and

    individuals involved in the communications. The

    notes were verified and supplemented by an audio

    recorder that provided full transcripts of the

    exchanges.

    Study Sample

    An important requirement of qualitative research

    is to obtain a sample size that can provide quality

    information to answer the research questions.31,32

    Before observations, a sample of around 50

    observations was deemed large enough to

    establish the types of information being

    conveyed during handoffs.12 At the point of 40observations, data saturation was reached as no

    new data (medical information categories; see

    findings) emerged. Past research has demonstrated

    that once new data are not discovered and obser-

    vations display recurring themes, the researchers

    can be fairly certain that data saturation has been

    achieved.31

    Patients

    The study received ethics approval from both the

    hospital and the university research ethics boards.

    A nurse in the preanesthesia care unit provided pa-

    tients with a brief study overview and asked

    patients if they were willing to be approached bythe researcher. If the patient agreed, the researcher

    approached them to answer any questions and to

    ask if they would be willing to have their handoff

    observed and audio recorded. Patients who agreed

    were asked to sign a consent form. For data entryand record...

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