Measuring content overlap during handoff communication using distributional semantics: An exploratory study

Linguistic dissection of nursing handoffs: Implications for patient safety in varied-acuity hospital settings

AIM

This study examines the intricate language and communication patterns of nurse-to-nurse handoffs across three units with varying patient acuity levels and nurse-patient ratios, seeking to identify linguistic factors that may affect the quality of information transfer and patient outcomes.

DESIGN

A mixed-methods cross-sectional design.

METHODS

This study used the Nurse-to-Nurse Transition of Care Communication Model to explore the content and meaning of language in nursing handoffs within a large academic medical centre. Data were collected on three units through digital audio recordings of 20 handoffs between June and September 2022, which were transcribed and analysed using the Linguistic Inquiry Word Count programme. Trustworthiness was established by adhering to COREQ and STROBE guidelines for qualitative and quantitative research, respectively.

RESULTS

Analysis revealed a preference for casual, narrative language across all units, with ICU nurses demonstrating a higher confidence and leadership in communication. Cognitive processes such as insight and causation were found to be underrepresented, indicating a potential area for miscommunication. Communication motives driven by affiliation were more pronounced in ICU settings, suggesting a strong collaborative nature. No significant differences were observed among the units post multiple testing adjustments. Speech dysfluencies were most pronounced in ICU handoffs, reflecting possible stress and cognitive overload.

CONCLUSION

The study highlights the need for improved communication strategies such as interventions to enhance language clarity and incorporating technological tools into handoff processes to mitigate potential miscommunications and errors. The findings advance nursing science by highlighting the critical role of nuanced language in varied-acuity hospital settings and the necessity for structured nurse education in handoff communication and standardized handoff procedures.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

This study underscores the critical role of language in nurse-to-nurse handoffs. It calls for enhanced communication strategies, technology integration and training to reduce medical errors, improving patient outcomes in high-acuity hospital settings.

PATIENT OR PUBLIC CONTRIBUTION

Nurses only.

Comparison of a Nurse-Nurse Handoff Mnemonic With Real-World Handoffs

BACKGROUND

Communication failures, including clinical handoff or clinical handover errors, contribute to 80% of all serious preventable adverse events each year. The N-PAS, N = Nurse, P = Patient Summary, A = Action Plan, and S = Synthesis, is a flexible standardized clinical handoff tool for nurses.

PURPOSE

The purpose of this study was to determine the proportion of N-PAS core components present in real-world patient handoffs.

METHODS

A mixed-methods design was used to analyze secondary data. Patient handoffs (n = 138) were transcribed into statements and then independently coded by 2 research assistants.

RESULTS

Of all handoff statements, 63.2% were coded as Patient Summary and 13.6% were coded as Action Plan, whereas Synthesis was not coded in any handoffs. Three new Patient Summary elements and 1 new Action Plan element were identified.

CONCLUSION

Patient Summary and Action Plan are critical data reported during clinical handoff. A handoff synthesis is a critical step to include in handoff training.

Nurse competencies for transitions of care: Implications for education and practice

Although there are a number of transitions of care initiatives that address specific needs as patients move across healthcare settings, adverse events still occur during handoffs. Transitions of care create periods of vulnerability for populations with complex needs that include communication gaps, medication changes, and poorly coordinated treatment plans, often without involving patients and their families. This paper outlines what nurses need to know to provide for safe transitions of care across the healthcare continuum. The theoretical basis for transitions of care at the macro level, examples of nurse-led models for transitions of care, and key activities and implications for nursing education and practice are described. A holistic framework for effective transitions of care across healthcare settings can guide nursing educators in the development of specific nursing competencies for transitions of care.

Information tools for care coordination in patient handover: Is an electronic medical record enough to support nurses?

BACKGROUND

Effectiveness of end-of-shift patient handover between nurses may be impacted by poor communication. This can be improved with the use of information tools, either electronic or paper-based. Few studies have investigated the activities that support patient handover, and fewer have explored how several of these tools used together affects the handover process.

PURPOSE

The aim of this study was to understand coordination challenges in end-of-shift patient handover between nurses and the influence of multiple information tools used in that context.

METHODOLOGY

A qualitative methodology to investigate phenomena in an acute care hospital in the United States was used in this study. Semistructured interviews were used to elicit insights from 16 nurses. Data were analyzed by coding three types of task dependencies (prerequisite, simultaneous, and shared) and three information tools (electronic medical records [EMRs], Kardex, and printouts of EMR data).

RESULTS

In preparation for a handover, nurses were burdened by ensuring that information in the EMR was correct and complete. A one-sheet Kardex was the tool nurses in the study preferred, because the essential information was at hand and it provided structure to the communication. Printouts of EMR data were often physically cumbersome and not useful in their current form, although they may be useful for communicating anomalous data.

CONCLUSION

This study provides insights regarding the challenges of care coordination in end-of-shift patient handover between nurses and the usages of a variety of information tools in preparation for handover, as well as the actual handover process.

PRACTICE IMPLICATIONS

Multiple interrelated information tools may be used to support patient handover. Health leaders should focus efforts on further advancing protocols for end-of-shift nurse handovers. Health system designers should design information tools to align them with their defined purpose in the handover process. Future work should consider both the information needs of nurses and the goal of improving nurse workflows.

Association between paediatric intraoperative anaesthesia handover and adverse postoperative outcomes

OBJECTIVE

To determine whether intraoperative handover of patient care from one anaesthesia clinician to another was associated with an increased risk of adverse postoperative outcomes during paediatric surgeries.

DESIGN, SETTING AND PARTICIPANTS

A retrospective, population-based cohort study (1 April 2013-1 June 2018) at an academic medical centre.

EXPOSURE

Intraoperative handover of care between pairs of anaesthesia clinicians from one care provider to another compared with no handover of anaesthesia care.

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite of all-cause mortality and major postoperative morbidity within 30 days after surgery. Secondary outcomes included individual components of the primary outcome and 30-day hospital readmission. Inverse probability of exposure weighting using propensity scores for intraoperative handovers was calculated. Weighted logistic regression was used to determine the association between intraoperative anaesthesia handovers and outcomes.

RESULTS

78 321 paediatric surgical cases (n=5411 with handovers) were included for analysis. Patients were predominantly male (56.5%) with a median age of 6.56 (IQR: 2.65-12.53) years and a median anaesthesia duration of 76 (IQR: 55-126) min. In the weighted sample, the odds of the primary outcome (OR: 0.92; 95% CI 0.75 to 1.13; p=0.43), any morbidity (OR: 0.93; 95% CI 0.75 to 1.16; p=0.515), all-cause mortality (OR: 0.8; 95% CI 0.37 to 1.73; p=0.565) or 30-day readmission following surgery (OR: 0.99; 95% CI 0.84 to 1.18; p=0.95) did not significantly differ among surgeries with and without handovers.

CONCLUSIONS

Among paediatric patients undergoing surgery, intraoperative anaesthesia handovers were not associated with adverse postoperative outcomes, after accounting for relevant covariates. These findings provide a preliminary perspective on the role of intraoperative handovers as a care-neutral event, with implications for improving safety.

Listening and question-asking behaviors in resident and nurse handoff conversations: a prospective observational study

OBJECTIVE

To characterize interactivity during resident and nurse handoffs by investigating listening and question-asking behaviors during conversations.

MATERIALS AND METHODS

Resident (n = 149) and nurse (n = 126) handoffs in an inpatient medicine unit were audio-recorded. Handoffs were coded based on listening behaviors (active and passive), question types (patient status, coordination of care, clinical reasoning, and framing and alignment), and question responses. Comparisons between residents and nurses for listening and question-asking behaviors were performed using the Wilcoxon rank-sum tests. A Poisson regression model was used to investigate differences in the question-asking behaviors between residents and nurses, and the association between listening and question-asking behaviors.

RESULTS

There were no significant differences between residents and nurses in their active (18% resident vs 39% nurse handoffs) or passive (88% resident vs 81% nurse handoffs) listening behaviors. Question-asking was common in resident and nurse handoffs (87% vs 98%) and focused primarily on patient status, co-ordination, and framing and alignment. Nurses asked significantly more questions than residents (Mresident = 2.06 and Mnurse = 5.52) by a factor of 1.76 (P < 0.001). Unit increase in listening behaviors was associated with an increase in the number of questions during resident and nurse handoffs by 7% and 12%, respectively.

DISCUSSION AND CONCLUSION

As suggested by the Joint Commission, question-asking behaviors were common across resident and nurse handoffs, playing a critical role in supporting resilience in communication and collaborative cross-checks during conversations. The role of listening in initiating question-asking behaviors is discussed.

Perceptions and Experiences of Hospital Nurses During Transition to an Electronic Handover Informatics System

An effective patient transfer, or handover, among healthcare professionals can help prevent communication-related medical errors, and a reliable electronic handover informatics system can standardize the handoff process. Adapting to a new handover system may cause stress for nurses. This descriptive qualitative study aimed to explore the perceptions and transition experiences of hospital nurses in adopting and adapting to a new handover informatics system. Thirty-eight nurses at a medical center in Taiwan participated in the study from December 2016 to January 2017. The researcher conducted five focus group interviews and analyzed all responses using content analysis. Results showed three major themes: "Perceptions of challenges and barriers related to the transition to a new handover informatics system," "Perceptions of benefits and strategies to the transition to a new handover informatics system," and "Suggestions for successful implementation of a new handover informatics system." Five subthemes emerged from the first theme, and six subthemes emerged from the second theme. The results of this study could enhance our understanding of nurses' perceptions and experiences with transition to a new handover informatics system and could provide a reference for hospitals to develop individualized strategies to facilitate the implementation of a handover informatics system.

'This is our liver patient…': use of narratives during resident and nurse handoff conversations

OBJECTIVE

Handoffs are often framed as the co-construction of a shared understanding relying on narrative storytelling. We investigated how narratives are constructed and used during resident and nurse handoff conversations.

METHOD

We audio-recorded resident (n=149) and nurse (n=126) handoffs in an inpatient medicine unit. Qualitative analysis using grounded theory was conducted to identify and characterise the structure of resident and nursing handoff narratives.

RESULTS

Handoff conversations among both residents and nurses used three types of narratives: narratives on creating clinical imagery, narratives on coordinating care continuity and narratives on integrating contextual aspects of care. Clinical imagery narratives were common during patient introductions: residents used a top-down approach relying on overarching patient clinical situations (eg, 'a liver patient'), whereas nurses used a bottom-up approach using patient-specific identifying information. Narratives on the coordination of care continuity for residents focused on managing internal and external coordination activities, whereas nurse narratives focused on internal coordination, emphasising their role as an interface between patients and their physicians. Both resident and nurse narratives on the contextual aspects of care had considerable focus on highlighting 'heads up' anticipatory information and personal patient information; such information was often not present in patient charts, but was important for ensuring effective care management.

DISCUSSION

The presence of narrative structures highlights the need for new perspectives for the design of handoff tools that allow for both informational and cognitive support and shared awareness among conversational partners during handoff conversations. We discuss the implications of the use of narratives for patient safety and describe specific design considerations for supporting narrative interactions during handoffs.

A graph-based approach for characterizing resident and nurse handoff conversations

Prior research has used a variety of qualitative and quantitative approaches for studying handoff communication. Due to the dynamic and interactive nature of handoffs, characterizing the structure and content of these conversations is challenging. In this paper, we use a graph-based approach to characterize handoff communication as a conversation network. Conversation networks were used to compare the structural properties of resident-resident and nurse-nurse handoff communication. Resident (n = 149) and nurse (n = 126) handoff conversations from general medicine units were coded using a previously validated clinical content framework. The coded conversations were then translated into separate resident and nurse conversation networks, and were compared using 11 network measures. Transition probabilities were used to identify commonly repeating sub-networks within resident and nurse conversations. There were significant differences between resident and nurse conversation networks in 10 of the 11 network measures. There were also significant differences in the structure of conversations: compared to resident conversations, nurse conversations were focused on fewer clinical content categories and had more branching and switching between clinical content categories; however, there were clinically-relevant organic relationships in the order of presentation of clinical content among both resident and nurse handoff conversations. We discuss the potential for using graph-based approach as an alternative method for characterizing interactive conversations and also suggest future directions for using network-based approaches for analyzing handoff conversations.

Comparative assessment of content overlap between written documentation and verbal communication: an observational study of resident sign-outs

Objective

Effective sign-outs involve verbal communication supported by written or electronic documentation. We investigated the clinical content overlap between sign-out documentation and face-to-face verbal sign-out communication.

Methods

We audio-recorded resident verbal sign-out communication and collected electronically completed ("written") sign-out documentation on 44 sign-outs in a General Medicine service. A content analysis framework with nine sign-out elements was used to qualitatively code both written and verbal sign-out content. A content overlap framework based on the comparative analysis between written and verbal sign-out content characterized how much written content was verbally communicated. Using this framework, we computed the full, partial, and no overlap between written and verbal content.

Results

We found high a high degree of full overlap on patient identifying information [name (present in 100% of sign-outs), age (96%), and gender (87%)], past medical history [hematology (100%), renal (100%), cardiology (79%), and GI (67%)], and tasks to-do (97%); lesser degree of overlap for active problems (46%), anticipatory guidance (46%), medications/treatments (15%), pending labs/studies/procedures (7%); and no overlap for code status (<1%), allergies (0%) and medical record number (0%).

Discussion and Conclusion

Three core functions of sign-outs are transfer of information, responsibility, and accountability. The overlap-highlighting what written content was communicated-characterizes how these functions manifest during sign-outs. Transfer of information varied with patient identifying information being explicitly communicated and remaining content being inconsistently communicated. Transfer of responsibility was explicit, with all pending and future tasks being communicated. Transfer of accountability was limited, with limited discussion of written contingency plans.

Impact of an electronic handoff documentation tool on team shared mental models in pediatric critical care

OBJECTIVE

To examine the impact of the implementation of an electronic handoff tool (the Handoff Tool) on shared mental models (SMM) within patient care teams as measured by content overlap and discrepancies in verbal handoff presentations given by different clinicians caring for the same patient.

MATERIALS AND METHODS

Researchers observed, recorded, and transcribed verbal handoffs given by different members of patient care teams in a pediatric intensive care unit. The transcripts were qualitatively coded and analyzed for content overlap scores and the number of discrepancies in handoffs of different team members before and after the implementation of the tool.

RESULTS

Content overlap scores did not change post-implementation. The average number of discrepancies nearly doubled following the implementation (from 0.76 discrepancies per handoff group pre-implementation to 1.17 discrepancies per handoff group post-implementation); however, this change was not statistically significant (p=0.37). Discrepancies classified as related to dosage of treatment or procedure and to patients' symptoms increased in frequency post-implementation.

DISCUSSION

The results suggest that the Handoff Tool did not have the desired positive impact on SMM within patient care teams. Future electronic tools for facilitating team handoff may need longer implementation times, complementary changes to handoff process and structure, and improved designs that integrate a common core of shared information with discipline-specific records.

CONCLUSION

While electronic handoff tools provide great opportunities to improve communication and facilitate the formation of shared mental models within patient care teams, further work is necessary to realize their full potential.