ABSTRACT & COMMENTARY
Questions Asked During Handovers Provide Insights into Ways to Improve Communication Skills
By Leslie A. Hoffman, RN, PhD
Professor Emeritus, Nursing and Clinical & Translational Science, University of Pittsburgh
SYNOPSIS: Interactive questioning, defined as how communication occurs during handovers, differed in ways that influenced message clarity when comparisons were made between those with more training (attending physicians, nurse practitioners) and less training (residents, staff nurses).
Rayo MF, et al. Interactive questioning in critical care during handovers: A transcript analysis of communication behaviours by physicians, nurses and nurse practitioners. BMJ Qual Saf 2014;23:483-489.
Most (89%) interventions designed to improve handover communication, including those endorsed by The Joint Commission, focus on promoting use of a structured format, e.g., SBAR (Situation, Background, Assessment, Recommendations).1 Although such tools assist in organizing information, they do not address a more important aspect of the exchange, i.e., how to ensure clarity and understanding. This study had two goals — to determine if communication patterns could be objectively analyzed for type and content, and to analyze communication styles of clinicians with more (attending physicians, nurse practitioners) and less training (residents, staff nurses). A total of 133 handover observations were conducted during randomly selected shift changes in three medical ICUs affiliated with an academic medical center. During these observations, a research team member categorized comments in real time using a digital Echo pen and notebook. Statements were coded as: 1) explain (declarative statement that conveyed information); 2) clarify (request to repeat information to confirm understanding); 3) collaborative cross-check (challenge to accuracy or appropriateness of information regarding the diagnosis, management plan, or prognosis); 4) read-back (verbatim repeat of statement); and 5) disagree (aggressively question statement).
Clinicians with less training (residents, staff nurses) were less likely to ask clarifying questions (P = 0.04), perform collaborative cross-checks (P < 0.001), or disagree (P = 0.04). However, they interrupted the clinician sharing information an average of three times a minute vs one time a minute for more experienced practitioners (P < 0.001). During the study, the research team recorded 96 cross-checks when the incoming clinician questioned appropriateness of the management plan. Resident and attending physicians were more likely to engage in statements that questioned actions or indicated disagreement than nurse practitioners or staff nurses. Overall, 45% of physician or resident statements fell into this category compared with 22% for nurse practitioners or staff nurses.
COMMENTARY
When providing care, we are challenged to share our management plan and perceptions in a manner that clearly and accurately conveys what has been done and what should follow. Patient handovers have repeatedly been identified as a time when accurate and clear understanding is essential. Restrictions on resident duty hours have amplified challenges associated with patient handovers, as they increase the number of times this process occurs. As noted by the authors, most attempts to improve communication during handovers have focused on how to organize the process, based on the assumption that a more structured approach will ensure better outcomes. While logical, better structure does not guarantee better communication. This study, one of few to identify specific strategies that practitioners can use to improve communication practices, provides a number of examples — fewer interruptions, greater use of clarifying questions, and cross-checks to ensure the accuracy and appropriateness of the information being shared. More assertive cross-checks also appear to be beneficial, as they were used more frequently by those with more training.
In addition, clinicians should be more assertive when they perceive what they are hearing is incorrect or not indicated. Using simulation, training could be structured to assess types of interruptions and the number of cross-checks and to clarify questions asked during scenarios when there are obvious and less than obvious problems with the management plan. While prior studies have identified problems associated with handover communication, few have attempted to identify objective measures that could be used to train less experienced or less assertive individuals to communicate more clearly and accurately and rate their ability to perform this skill. This study identifies ways to accomplish this goal.
REFERENCE
- Abraham J, et al. A systematic review of the literature on handoff tools: Implications for research and practice. J Am Med Inform Assoc 2014;21:154-162.
