ORIGINAL ARTICLE

Transferring 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 to

Alicia 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 PeriAnesth

another 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 Nurses

THETRANSFEROFAPATIENT’SCARE from one

health 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 Queen’s 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 1-13

processes 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 O’Byrne 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 Nurses

1089-9472/$36.00

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

1

2 MCMULLAN, PARUSH, AND MOMTAHAN

The 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 master’s 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 patient’s 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 master’s 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 communication

approaches 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 master’s thesis, 2009).17 The communica-

tion events observed from nursing shift reports

(T. Foster-Hunt, unpublished master’s 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 master’s thesis, 2009). Further-

more, during synchronous interactions, health

care providers are given an opportunity to discuss

or question a fellow colleague’s 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 3

from 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

master’s 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. As

such, 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 team’s 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,

unpublishedmaster’s 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 MOMTAHAN

hospital 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 by

the 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 keeping purposes, a number identified

each handoff, and the patient name was only re-

corded (on a separate piece of paper) for the pur-

pose of tracking the patient up to the point of

observing the handoff in the PACU. No identifying

information for patients was retained on the tran-

scripts of the handoffs. Patients were informed

that at any point during the observation periodthey had the right to withdraw from the study

with no penalty or risk of loss of quality and safety

of care. Any patient at the hospital whowas at least

18 years with the intended destination of the PACU

postoperatively and who was able to sign a con-

sent form or had a guardian who could sign a con-

sent form on their behalf were eligible to be

included in the study. The study hospital is oneof the four hospitals that were recently amalgam-

ated to form one entity and are now considered

campuses of the larger hospital group. Observa-

tions took place at a large campus that provides

neurology (interventional, vascular, and spine),

gynecology, general, and orthopaedic surgery to

adults only.

Health Care Workers

Health care staff members who worked in the

PACU and OR were passively consented for partic-

ipation in this study. Passive consent was deemed

appropriate because of the fact that the researchers

were unaware as to how many of the nursing and

anesthesiology staff would actually be under obser-vation. Passive consent is a common procedure for

research in this specific teaching hospital. As such,

all staff memberswhowere involvedwith handoffs

and who did not dissent to participate in the study

were observed. Information sessions were held

before the start of the study at both anesthesia

rounds and nursing in-services. Neither of the staff

declinedparticipation nor did they request that anyhandoff observation data be removed from the data

analysis. The observed sample of health care staff

included at least one PACU nurse and one anesthe-

siologist per handoff but on average included four

to five staff members, such as additional nurses

who assisted the primary nurse assigned to the pa-

tient bed and/or a more junior anesthesiologist

SYNCHRONOUS BIDISCIPLINARY COMMUNICATION 5

who accompanied the anesthesiologist assigned to

the case for learning purposes. For some handoffs,

there was an orderly present, but they were there

to bring clean blankets and if needed, to help

move equipment; they were not involved in thecommunication exchanges. There were 35 nurses

on staff in the PACU with an average age of 50.4

and an average of 20.6 years of service at the hospi-

tal. The hospital did not provide demographic in-

formation on the anesthesiology staff. In the

study hospital, the anesthesiologist was respon-

sible for giving the handoff report, and therefore,

it was rare that surgical staff were primary partici-pants. Participation in this study was voluntary,

and participants received no benefits or rewards

personally.

Materials

CODING. The SBAR30,33 (Situation, Background,

Assessment, Recommendation) checklist model

is a conceptual skeleton specifically developed

for multidisciplinary patient-related information

sharing and communication. It is especially useful

for handoffs.33,34 The paper tool cues staff to the

important pieces of information that should be

shared among the team concerning variousmedical information categories. For our

purposes, the ‘‘Background’’ checklist of the

SBAR protocol was used to assist in the coding

process because it includes medical terminology

and categorizations of medical information.33

DATA AND MEASURES. Conversation analysis,

(C. Kramer, unpublishedmaster’s thesis, 2009) 35-37

a technique used to understand team commu-

nication in command and control environments,

guided the mapping and description of commu-

nication patterns. Using the method of conver-sation analysis, the full transcripts of each handoff

were segmented into utterances, and the resulting

unit of analysis was each utterance produced by a

nurse or physician in the PACU. Utterances were

not always between multiple staff members; they

could be an announcement to the team, for

example, ‘‘Fentanyl is in.’’ The verbatim example

below shows a sequence of utterances between anurse and an anesthesiologist (belonging to the

content category of future care plan).

Nurse to Anesthesiologist: ‘‘What about giving

her a Tylenol suppository?’’

Anesthesiologist to Nurse: ‘‘I would sooner do that

than give Fentanyl.’’

Analysis of the number of utterances best

described the volume of communication observed.To understand the content of conversations, utter-

ances were then grouped as discussions. Discus-

sions were defined as instances of conversations

(that included utterances) concerning a specific

topic (eg, administering pain medication). The

aforementioned example of two utterances would

have been identified as one discussion.

Information Content Categories

Once the full transcripts of communication

exchanges were broken down by utterances, the

researchers coded information according to its

content, such as medical history, current medica-

tions and dosages, treatments, and future care

plans for medication and treatments. This processresulted in a hierarchy of main categories (Table 1;

eg, patient status, future care plan, etc) and subcat-

egories (eg, dosages, type of medication, etc) of

medical information. The categories of informa-

tion that emerged were referred to as information

content categories. The frequency of these cate-

gories was calculated by counting each time a spe-

cific content category (as described in Table 1)discussed throughout the duration of the handoff.

These counts were then summed across the

observed handoffs. The coding process was aided

using SBAR,30,33 and categories identified in earlier

qualitative handoff observation research (T. Foster-

Hunt, unpublished master’s thesis, 2009). A group

of four senior nurses from the PACU and one staff

anesthesiologist then verified the coded informa-tion content categories for accuracy. These

specific information items that are conveyed be-

tween health care workerswere essential in outlin-

ing the structure and patterns of patient care

handoffs. Furthermore, these details might give

insight into how efficient and effective the hand-

offs are in terms of receiving and disseminating

relevant patient information, and ultimately howvulnerable handoffs may be to information loss.

Verbal Behavior Types

The researchers were interested in the features/

types of communication (ie, verbal behavior types)

between nurses and physicians involved in the

Table 1. Information Content Categories, Descriptions, and Examples

Content Description Examples

History Medical history, hemodynamic information

(blood pressure, temperature, etc),

allergies, and comorbidities

‘‘Any allergies?’’

� ‘‘Yes, she’s allergic to Codeine.’’

Intraoperative events Any patient-relevant event that occurred in

the operating room (eg, pain medications

administered, blood loss, treatments,

vitals, etc)

‘‘I gave 100 of Fentanyl in the room.’’

Patient status Any patient-relevant information (see

aforementioned examples)

communicated at the time of the handoff

‘‘Can we give Tylenol for the arm pain.’’

� ‘‘Yes, I would sooner do that now than

give Fentanyl.’’

Future care plan Any relevant information for the future care

of the patient. This involved future care in

the recovery room or the surgical unit

‘‘She’s on Metoprolol and I want her to get

her next regular dose.’’

Other This category combined all other categories

of information discussed in handoffs and

mainly consisted of information deemed

as ‘‘patient demographics’’ within the

specific context of care

‘‘Patient is 45 years of age.’’

6 MCMULLAN, PARUSH, AND MOMTAHAN

handoff as well as if there was clear verbal commu-

nication between the professions. Each utterance

was coded into a specific category of verbal

behavior (eg, questions, reports, replies; Table 2).

The categories used in this study (and their descrip-

tions) were initially developed by Parush et al36,37

using conversation analysis during observational

research of a similar naturewithin a hospital setting.

Information Flow/Dissemination ofInformation

The researchers captured the specific health care

workers who transferred specific information(eg, nurse). In addition, the coding process identi-

fied which types of verbal behaviors (eg, ques-

tions, report, replies, etc) were most common

for specific health care workers.

Results

Information Content Categories

There were a total of 942 utterances observed for

more than 40 handoff observations (mean 5 24.54per handoff, mode 5 23, minimum 5 11, and

maximum 5 50) categorized into 725 discussions.

Of the 725 instances of discussing medical topics

across the 40 handoffs, most information exchanged

concerned five general content categories: history,

intraoperative events, patient status, future care

plan, and other (Table 1). Eight subcategories that

individually consisted only of single utterances per

patient handoff per subcategory and that were not

common to most handoffs were combined to create

the ‘‘other’’ category. This includedpatient age (3.4%

of utterances), condition (1.9%), name of surgical

procedure (6.3%), duration of procedure (0.7%),type of anesthesia (4.6%), preoperative events

(1.7%), discharge from PACU information (3.2%),

and miscellaneous information (eg, social ex-

changes: 4.8%).With the exceptionofmiscellaneous

information, all these subcategories were a ‘‘proac-

tive report’’ by an anesthesiologist at the very begin-

ning of the handoff.

The four most frequently discussed single-subject

content categories (history, intraoperative events,

patient status, and future care plan) combined ac-

counted for 73% of the topics of information ex-

changes (Figure 1). This indicates that most

information sharing in OR-PACU handoffs focuses

on these specific types of medical information.

Overall, proportions of communications werefairly even among the four categories, although

future care plan was discussed slightly less often.

The next step in the analysis was to further inves-

tigate handoff content to uncover whether there

were any patterns in the types of verbal interac-

tions (eg, questions, replies, report giving).

Table 2. Verbal Behavior Categories, Descriptions, and Examples

High-Level Category Subcategory Example

Seeking information

One person requires information from another Question: Requesting information known (or

assumed to be known) by another person, such

as a numerical value or current state of affairs

‘‘What did the patient get for nausea and vomiting?’’

Clarify: Asking for further information to elucidate

a previously provided response

‘‘What did you say to give him now for pain?

Fentanyl or Hydromorph?’’

Anticipate: Asking a question in which the answer

is already expected, desired, or implied

‘‘Ready to turn?’’

Proactive information/report

Providing information without being prompted.

Solely an anesthesiologist verbal behavior

‘‘This is patient X, 68 years of age, no past history to

report.’’

Responsive information

Providing information in response to another

type of communication

Reply: Providing previously unknown information

needed by the requester‘‘What time did he get his first dose of antibiotics?’’

� ‘‘10. Sorry, 9:30.’’

Confirm: Acknowledging that a request was made

and indicating themanner that it will be acted on‘‘Let’s put the patient on their side.’’

� ‘‘Okay.’’

Read-back: Repeating verbatim the words of the

requester‘‘You got the temp I gave you? 36.3.’’

� ‘‘36.3.’’

Offering information

Information offered without having been

requested or sought by another. Information

sharing that is not a part of the report from the

anesthesiologist

Announce: Offering information to other members

about the current state of affairs without being

asked

‘‘There’s no need for antibiotics.’’

Plan: Similar to announcements, but indicative of

future events

‘‘She is onMetoprolol so we’ll need to give her next

dose in 2 hours.’’

Concern raising: Alerting the team to current or

possible problems

‘‘I think there is something wrong with the stent.’’

Brief: Bringing someone ‘‘up to speed’’ ‘‘This patient has a history of airway issues, has a

latex allergy and was consented for epidural.’’

Requesting/commanding

Expressing a need, a want, or an order for

something other than information

For objects: Asking for a tool or a piece of

equipment

‘‘More saline please.’’

For actions: Directing another to do something ‘‘Administer morphine.’’

Educating

Instructing, guiding, or quizzing. Coach/teach: Assisting during a situation where

that person was not yet proficient

(Continued)

SYNCHRONOUS

BID

ISCIPLIN

ARY

COMMUNICATIO

N7

Table

2.Continued

High-LevelCategory

Subcategory

Example

‘‘Doyo

uwan

tto

givehim

someIV

Toradolordo

youwan

tto

waituntilhe’saw

akean

dgive

Celebrex?’’

Commenting

Extendingapreviouscommunicationwithout

providingnew

inform

ationto

thesituation

Discu

ss/explain:Case-relevan

tcommunication

usedto

elaborate

onapreviouslymentioned

topic

‘‘Alsosincethisonedoesn’twork

withourunit,w

e

can

’tuse

it.’’

Other:Caserelevan

tinform

ationbutnotnew

or

needed

‘‘Ishould

bewearinggloves.’’

Irrelevan

t

Contentan

dintenthad

nothingto

dowiththe

currentcaseorotherpatients

Joke:N

onserious,orsarcasticnature,light-hearted,

laughable

conversation

‘‘How

comeyo

ugetso

much

vacationtimedoc?I

neverleavethisplace!’’

�‘‘hah

a.’’

Socialize:Case-irrelevan

t,person-oriented

conversation

‘‘Did

youhaveagoodweekend?’’

Figure 1. Frequencies of observed discussions

involving specific information content categories.

8 MCMULLAN, PARUSH, AND MOMTAHAN

Verbal Behavior Types

The analysis identified eight categories (Table 2):

seeking information, responsive information, of-

fering information, proactive information/report,

requesting/commanding, educating, comments,

and irrelevant information. Each of these cate-

gories consisted of several subcategories (17

different subcategories in total). Offering informa-

tion and proactive information/report wereincluded as two separate types based on the

outcome of the analysis of the captured data. Offer-

ing information involved medical staff providing

more opinion-based information (eg, ‘‘I think

he’ll be okay’’), whereas proactive information/

report involved a physician providing information

that was part of the critical report and directly rele-

vant for the patient’s postoperative care (eg, ‘‘Hehas no allergies’’). The categorizations were

initially developed by Parush et al.36,37

Verbal Behavior Types and InformationContent Categories

A subsequent analysis mapped out which verbal

behavior types (Table 2) were most frequently

associated with specific content categories in the

handoffs. The analysis (Figure 2) focused on thefour most frequently discussed content categories

(Figure 1). Report giving was a more frequent ver-

bal behavior for the content categories of patient

history (42.6% of utterances) and intraoperative

events (39.7% of utterances). In contrast, the

frequency of report giving decreased when

Figure 2. Frequencies of verbal behavior types as a function of the information content category and relative to

the total number of utterances.

Figure 3. The frequency of questions and replies

by speaker (anesthetist or registered nurse) for the in-

formation content category of patient status relative

to the total number of utterances for that verbal

behavior type.

SYNCHRONOUS BIDISCIPLINARY COMMUNICATION 9

discussing patient status (8.5% of utterances) and

future care plan (9.2% of utterances).

Seeking information was more frequent when dis-

cussing patient status (46.6% of utterances) andfuture care plan (29.5% of utterances). In contrast,

the frequency of these verbal types was lower for

intraoperative events (18.9% of utterances) and pa-

tient history (5.3% of utterances). It appears that a

low proportion of report giving is associated with

a high proportion of seeking information. The

latter is more visible for patient status and future

care plan information categories (Figure 2).

Responsive information was most frequent when

communication dealt with patient status (50% of

utterances) and future care plan (28.5% of utter-

ances). This trend corresponds with seeking infor-

mation being the most frequent verbal behavior

for these two categories. This pattern is also indic-

ative of a dialog-oriented communication betweennurses and physicians.

Offering information was also most frequent for

patient status (30.2% of utterances) and future

care plan (31.9% of utterances). Seeking informa-

tion, responsive information, and offering infor-

mation were less frequent for history and

intraoperative events most likely because reportgiving accounted for 79% and 62% of utterances,

respectively. This finding might suggest that

patient status and future care plan require more

interactive points of information transfer as they

are composed of interactive verbal behavior

types.

Seeking Information and Speaker

The next step in the analysis was to identify whichhealth care workers were associated most with

askingquestions, because themost frequent subcat-

egory of verbal behavior types was ‘‘questions’’

within the verbal behavior type ‘‘seeking

information.’’ The analysis focused on the patient

status and future care plan categories because these

were more frequently associated with information-

seeking behaviors. The analysis indicated thatnurses asked most questions in both content cate-

gories (74.4% for patient status and 78.6% for future

care plan; Figures 3 and 4). For both information

categories, the nurses asked significantly more

questions and the anesthesiologists had

significantly more replies. It appears that the

nurses might have been leading the information

Figure 4. The frequency of questions and replies

by speaker (anesthetist or registered nurse) for the

information content category of future care plan rela-

tive to the total number of utterances for that verbal

behavior type.

10 MCMULLAN, PARUSH, AND MOMTAHAN

sharing during communications concerned withthese two specific information categories.

Discussion

The aim of this study was to uncover patterns of

communication and information exchange during

handoffs within a postoperative care team. A dis-

cussion of the findings follows along with sugges-

tions for future research and practical implications.

Interactive Verbal Communication

The relations between the verbal behaviors and

content categories (Figure 2) revealed that patient

status and future care plan categories had the high-

est proportion of interactive information exchange,

especially with regard to questions and responses.

Furthermore, the speaker analysis (Figures 3 and

4) showed that in the aforementioned categories,

nurses asked most questions and consequently,anesthesiologists provided most responses. This

result is likely indicative of bidisciplinary

interactive verbal communication, which has

been suggested in previous research as a potential

strategy for combating information loss.18 It is

worth noting that it may be possible that the Haw-

thorne effect influenced the proactivity of nurses

in relation to the frequency of questions posed toanesthesiologists concerning the patient. It would

be fruitful for future investigations to follow the pa-

tient’s care to the next stage of recovery (eg, admis-

sion to a patient unit) to uncover whether this type

of interactive verbal communication is associated

with improved information transfer.

Transactive Memory and InformationSeeking

One potential explanation for the proportion ofquestions by nurses during discussions concern-

ing the patient’s status and future care plan is

provided by transactive memory theory. Memory

systems are transactive because of the

communications or transactions among team

members that are used to encode, store, and

retrieve information.38,39 The theory posits that

a team that is highly comfortable with theirmembers is also more likely to be aware of the

members’ knowledge/ability/expertise, and as a

result, they communicate information more

effectively.39,40 Perhaps as a result of nurses

and physicians not being formally educated

together, nurses are not confident that the

anesthesiologists will proactively provide them

with the information that is particularly relevantfor their care of the patient in the recovery

room. Consequently, the nurses are upfront

and ask the questions. Future research

should investigate the potential benefits of

handoff education for nurses and physicians

collaboratively.

Focus on Retrospective Information Sharing

The four most common content categories dis-cussed in observed handoffs were history, intrao-

perative events, patient status, and future care

plan. Of those categories, history and intraopera-

tive events primarily comprises retrospective pa-

tient information, and only future care plan is

primarily prospectively oriented. Reporting by

anesthesiologists was more common for the two

retrospective categories and decreased in thefuture care plan category (Figure 2). This result

suggests that a large proportion of communica-

tion in handoffs in the PACU focused on sharing

past information and replicates previous research

within various health care environments.22-24

Research by Dowding41 found that nurses were

more likely to recall prospective information

when receiving a verbal report of patient informa-tion. The implication of this and our observations

suggests that perhaps it should be standardized

for anesthesiologists to proactively verbally pro-

vide nurses with future care plan patient informa-

tion during the handoff (regardless of whether it

is also noted in the patient chart).

SYNCHRONOUS BIDISCIPLINARY COMMUNICATION 11

Practical Implications

Past research has shown that in order for clinicians

to feel comfortable voicing their concerns andquestions, there has to be an explicit safety culture

present.30 The results of this study point toward

the presence of such a culture, as nurses posed a

fair number of questions that were matched by

anesthesiologist and fellow nurse replies. This

study cannot confirm whether or not the ‘‘power

distance’’ referred to in the literature29,42 was a

barrier to effective communication within thecontext of the PACU. However, the volume of

verbal behaviors and discussions concerning

patient details speaks to the open lines of

communication between physicians and nurses

in this specific hospital environment.

Within the context of the hospital unit of observa-

tion, nurses were more senior and seemedcomfortable enough with surgically related hand-

offs to know which questions to ask to capture

the information they needed from anesthesiolo-

gists. However, this may not always be the case

in other hospital units where verbal handoffs are

not so common and/or nurses are not as experi-

enced. Although the rate of replies matched that

of the questions, overall, the high frequency ofquestions especially with regard to the future

care plan indicates that nurses were seeking out

this information and not relying on or assuming

the anesthesiologist would provide it. There are

two potential explanations for this finding.

Perhaps because of the unit size (35 nurses and a

maximum of 12 nursing staff working during a

day shift, 6 in the evening, and 4 at night) andseniority of the nurses, this particular team is

well acquainted and thus familiar with each other’s

communication styles. This could result in the an-

esthesiologists becoming more confident that

nurses will ask for any additional information

theywould like to receive verbally (as all critical in-

formation should be provided in the patient docu-

mentation). Recent research43 revealed thatclinicians preferred verbal information exchange

because they felt that documentation was either

not updated or inefficient for information retrieval.

The other possibility is that because of differences

in nursing and physician cultures, the difference in

the education both types of staff receive (and sepa-

rately), and the difference in status/authority,

nurses might be expecting that there will be a

lower level of collaboration and thus, are actively

seeking out information. In a study concerning

collaboration among critical care nurses and physi-

cians, results indicated that 73% of physicians

rated collaboration and communication withnurses as high or very high. Comparatively, only

33% of nurses rated collaboration and communica-

tion with physicians as high or very high.44 These

results point to a discrepancy in perceptions of

nurse/physician teamwork culture. An informa-

tion checklist specific to the PACU (eg, a format

similar to that of the SBAR30,33 protocol) might

help in ensuring that both nurses andanesthesiologists involved in the handoff feel

content with the information exchanged. The

research would suggest that even by offering

general information regardless of the presence of

specific details pertaining to a certain topic (eg,

‘‘No intraoperative complications to report’’), the

clinician giving the handoff could help to

minimize the potential for perceived informationloss on the receiving end. This should be

practiced as a standard of information exchange

during handoffs.

Limitations

There are a few limitations to the presentstudy; most are inherent to qualitative research

conducted within a health care environment.

Because of the hospital’s requirement to consent

patients preobservation, in addition to the limited

number of patients whose care would provide a

point of observation, the researcher was unable

to preselect handoffs based on the specific anes-

thesiologist assigned to the case. Therefore,several observations involved the same anesthesi-

ologist giving the report and the assumption of in-

dependence of sampling was violated. Limited

staff numbers would also not have allowed for

the observation of different people every handoff.

Observations were completed in one hospital unit

only. Although approval was granted in a surgicalunit, the organizational structure of the PACU

meant that patients could come out of the OR

with very short notice and therefore, to capture

the handoff, the researcher had to remain in the

PACU. It is possible that different perioperative

hospital units might require different types of

patient-relevant handoff information to provide

the appropriate care.

12 MCMULLAN, PARUSH, AND MOMTAHAN

Despite the limitations, the findings are repre-

sentative of other similar hospital settings.

Furthermore, previous in-hospital communica-

tion research (C. Kramer, unpublished master’s

thesis, 2009) 12,36,37 has observed similarscenarios and produced useful findings that

have been applicable across health care settings.

Conclusion

In this qualitative observational study, the most

frequently occurring verbal behavior was questions

and theirmatched replies.Questionswereprimarily

posed by nurses and were answered by a fellow

nurse or an anesthesiologist. The highest rate ofquestions and replies occurred in the patient status

and future care plan information content categories

and were between nurses (questions) and anes-

thesiologists (replies). Most handoff communica-

tions involved retrospective information sharing; a

similar finding to that of earlier research in varioushealth care settings.22-24 These findings demon-

strate an interactive communication style between

nurses and anesthesiologists during handoffs

from the OR to the PACU in this hospital. Future

research is necessary to provide a definitive

answer as to why PACU nurses asked such a high

frequency of questions to the anesthesiologists.

It would also be beneficial to uncover the impactof primarily sharing retrospective medical infor-

mation on patient care by following the transfer

of information further along in the care process.

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