Establishing a conceptual framework for handoffs using communication theory

Theoretical Frameworks in Medical Education: Using a Systematic Review of Ophthalmology Education Research to Create a Theory of Change Model

BACKGROUND

Theoretical frameworks provide a lens to examine questions and interpret results; however, they are underutilized in medical education.

OBJECTIVE

To systematically evaluate the use of theoretical frameworks in ophthalmic medical education and present a theory of change model to guide educational initiatives.

METHODS

Six electronic databases were searched for peer-reviewed, English-language studies published between 2016 and 2021 on ophthalmic educational initiatives employing a theoretical framework. Quality of studies was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach; risk of bias was evaluated using the Medical Education Research Study Quality Instrument (MERSQI) and the Accreditation Council for Graduate Medical Education (ACGME) guidelines for evaluation of assessment methods. Abstracted components of the included studies were used to develop a theory of change model.

RESULTS

The literature search yielded 1661 studies: 666 were duplicates, 834 studies were excluded after abstract review, and 132 after full-text review; 29 studies (19.2%) employing a theoretical framework were included. The theories used most frequently were the Dreyfus model of skill acquisition and Messick's contemporary validity framework. GRADE ratings were predominantly "low," the average MERSQI score was 10.04, and the ACGME recommendation for all assessment development studies was the lowest recommendation. The theory of change model outlined how educators can select, apply, and evaluate theory-based interventions.

CONCLUSIONS

Few ophthalmic medical education studies employed a theoretical framework; their overall rigor was low as assessed by GRADE, MERSQI, and ACGME guidelines. A theory of change model can guide integration of theoretical frameworks into educational initiatives.

Standardized Work Rounds Enhance Teaming, Comprehensiveness, Shared Mental Model Development, and Achievement Rate of End-of-Shift Goals

OBJECTIVES

To determine the impact of standardized PICU work rounds on the frequency of ideal teaming behaviors, rounds comprehensiveness, shared mental model index development, and rate of completed end-of-shift goals.

DESIGN

A single-center, pre-post, prospective cohort study.

SETTING

A 259-bed, quaternary, pediatric referral center.

PATIENTS

Children 0-18 years old from November 2018 to January 2020.

INTERVENTIONS

Standardized, bedside, nurse-led PICU work rounds, emphasizing ideal teaming behaviors using a collaboratively developed rounding script and quality/safety checklist.

MEASUREMENTS AND MAIN RESULTS

Study data were collected by direct observation and immediate postrounds participant questionnaire data. Primary outcomes were frequency of observed ideal teaming behaviors, rounds comprehensiveness, efficiency (rounds content divided by duration), shared mental model index (congruence among rounds participants regarding key healthcare data and planning), rounds face validity, and achievement rate of rounds-established, end-of-shift goals. During study, 154 encounters were observed (50 preintervention, 52 after Plan-Do-Study-Act cycle 1, and 52 after Plan-Do-Study-Act cycle 2). We observed improvements in overall shared mental model index (24-87%), rounds comprehensiveness (72-98%), and ideal teaming behaviors (including closed-loop communication: 82-100%; responsibility delegation: 74-100%; interdependence behaviors: 26-98%, all p < 0.01) by the end of study. Nursing presentations accounted for 3.6 ± 1.5 minutes of rounds and rounds duration was unchanged postintervention (11 ± 5 min preintervention and 11 ± 4 min after Plan-Do-Study-Act cycle 2, p > 0.99). Face validity, assessed using questionnaire data from 953 participants, revealed positive attitudes regarding efficiency, clarity, and participant self-value. Greatest enhancements in self-value were noted among advanced practice providers and respiratory therapists. On exploratory modeling, we noted associations between ideal teaming behaviors, rounds comprehensiveness, and shared mental model index. Similarly, we noted a positive association between the shared mental model index and the rate of achieved rounds-established, end-of-shift goals (odds ratio, 8.9; 95% CI, 1.7-46; p < 0.01).

CONCLUSIONS

Standardization of PICU work rounds may encourage ideal teaming behaviors, enhance rounds comprehensiveness, strengthen the congruence of participant shared mental model, and affect the rate of achieved goals established during rounds without compromising workplace efficiency.

Failure Mode and Effect Analysis: Engineering Safer Neurocritical Care Transitions

BACKGROUND/OBJECTIVE

Inter-hospital patient transfers for neurocritical care are increasingly common due to increased regionalization for acute care, including stroke and intracerebral hemorrhage. This process of transfer is uniquely vulnerable to errors and risk given numerous handoffs involving multiple providers, from several disciplines, located at different institutions. We present failure mode and effect analysis (FMEA) as a systems engineering methodology that can be applied to neurocritical care transitions to reduce failures in communication and improve patient safety. Specifically, we describe our local implementation of FMEA to improve the safety of inter-hospital transfer for patients with intracerebral and subarachnoid hemorrhage as evidence of success.

METHODS

We describe the conceptual basis for and specific use-case example for each formal step of the FMEA process. We assembled a multi-disciplinary team, developed a process map of all components required for successful transfer, and identified "failure modes" or errors that hinder completion of each subprocess. A risk or hazard analysis was conducted for each failure mode, and ones of highest impact on patient safety and outcomes were identified and prioritized for implementation. Interventions were then developed and implemented into an action plan to redesign the process. Importantly, a comprehensive evaluation method was established to monitor outcomes and reimplement interventions to provide for continual improvement.

RESULTS

This intervention was associated with significant reductions in emergency department (ED) throughput (ED length of stay from 300 to 149 min, (p < .01), and improvements in inter-disciplinary communication (increase from pre-intervention (10%) to post- (64%) of inter-hospital transfers where the neurological intensive care unit and ED attendings discussed care for the patient prior to their arrival).

CONCLUSIONS

Application of the FMEA approach yielded meaningful and sustained process change for patients with neurocritical care needs. Utilization of FMEA as a change instrument for quality improvement is a powerful tool for programs looking to improve timely communication, resource utilization, and ultimately patient safety.

Noise and turn-taking impact postanesthesia care unit handoff efficiency

Background

Optimal handoffs are pivotal for patient safety, yet some of the underlying communication mechanisms which support effective handoffs remain to be understood. As handoffs are conversations between providers, understanding communication mechanisms is necessary to improve handoff protocol development. The objective of this study was to characterize communication variables influencing the efficiency of handoffs in the postanesthesia care unit.

Methods

We conducted a single-center, observational study of handoffs over a three-week period in June/July of 2017. We recorded 96 handoffs between the cardiac operating room and postanesthesia care unit. We defined and measured efficiency by dividing the count of unique, nonrepetitive pieces of information by duration of the handoff conversation. Furthermore, we calculated and measured two communication variables: turn-taking and noise. We utilized West and Zimmerman’s Syntactic Scale to analyze turn taking by segregating noise into three subcategories: environmental noise caused by equipment, environmental noise caused by staff, and third-party interruptions. Finally, we recorded and measured the frequency and duration of noise and turn-taking during the handoff events.

Results

Due to technical issues, we transcribed and analyzed a total of 85 observations. Providers passed an average of 31.68 unique pieces of information during each handoff with the average length being 1 min and 46 s. Overlaps was the most common type of turn-taking behavior. Activity noise was the most common type of noise. Activity noise took place an average of 3.64 times per handoff and lasted an average of 9.83 s. Turn-taking accounted for 15.6% of variance in handoff efficiency. Together, noise and turn-taking accounted for 25.2% of the variance in handoff efficiency.

Conclusion

Because turn-taking and noise account for over a quarter the variance in handoff efficiency, recommendations include providing quiet locations for handoffs to take place. Additionally, we recommend that receivers provide input in any handoff interventional studies as their involvement would decrease the need to interrupt or clarify information from the sender.

A Longitudinal and Sustainability Assessment of Pediatric Interfacility Transport Handover Standardization

Introduction:

Standardization of interfacility transport handover is associated with improved shared mental model development, efficiency, and teaming. We sought to build upon previously published data by evaluating 1-year follow-up data, assessing face-validity, and describing sustainability.

Methods:

We performed a pre-post, retrospective cohort study in a stand-alone, tertiary, pediatric referral center for children 0–18 years of age transported to our pediatric intensive care unit, neonatal intensive care unit, or emergency department from October 2016 to November 2017. Handover was standardized using multidisciplinary checklists, didactics, and simulation. Data were collected for three 8-week periods (preintervention, postintervention, and 1-year follow-up). Outcomes included shared mental model index (shared mental model congruence expressed as an index, percent congruence regarding healthcare data), teaming data (efficiency, attendance, interruptions, interdependence), and face validity (5-point, Likert scale questionnaires). Statistics included 1-way analysis of variance, Kruskal-Wallis, chi-square, and descriptive statistics.

Results:

One hundred forty-eight handovers (50 preintervention, 50 postintervention, and 48 at 1-year) were observed in the emergency department (41%), pediatric intensive care unit (45%), and neonatal intensive care unit (14%). No differences were noted in demographics, diagnoses, PIM-3-ROM, length of stay, mortality, ventilation, or vasoactive use. Sustained improvements were observed in shared mental model congruence expressed as an index (38% to 82%), physician attendance (76% to 92%), punctuality (91.5% to 97.5%), interruptions (40% to 10%), provision of anticipatory guidance (42% to 85%), and handover summarization (42% to 85%, all P < 0.01). Efficiency was maintained throughout (mean duration 4.5 ± 2.1 minutes). Face validity data revealed handover satisfaction, effective communication, and perceived professionalism.

Conclusions:

Enhancements in teaming, shared mental model development, and face validity were achieved and sustained 1-year following handover standardization with only minimal reeducation during the study period.

Barriers to effective, safe communication and workflow between nurses and non-consultant hospital doctors during out-of-hours

Objective

This study aimed to evaluate the nature and type of communication and workflow arrangements between nurses and doctors out-of-hours (OOH). Effective communication and workflow arrangements between nurses and doctors are essential to minimize risk in hospital settings, particularly in the out-of-hour's period. Timely patient flow is a priority for all healthcare organizations and the quality of communication and workflow arrangements influences patient safety.

Design

Qualitative descriptive design and data collection methods included focus groups and individual interviews.

Setting

A 500 bed tertiary referral acute hospital in Ireland.

Participants

Junior and senior Non-Consultant Hospital Doctors, staff nurses and nurse managers.

Results

Both nurses and doctors acknowledged the importance of good interdisciplinary communication and collaborative working, in sustaining effective workflow and enabling a supportive working environment and patient safety. Indeed, issues of safety and missed care OOH were found to be primarily due to difficulties of communication and workflow. Medical workflow OOH is often dependent on cues and communication to/from nursing. However, communication systems and, in particular the bleep system, considered central to the process of communication between doctors and nurses OOH, can contribute to workflow challenges and increased staff stress. It was reported as commonplace for routine work, that should be completed during normal hours, to fall into OOH when resources were most limited, further compounding risk to patient safety.

Conclusion

Enhancement of communication strategies between nurses and doctors has the potential to remove barriers to effective decision-making and patient flow.

A Critique of the Shannon-Weaver Theory of Communication and Its Implications for Nursing

With the Joint Commission's revelation that as much as 65%-70% of the time miscommunication has been discovered to be the root cause of many sentinel events, it may be time to examine a communication theory to support practice improvement efforts. Effective communication has been shown to decrease medical errors, improve patient satisfaction, and increase adherence to treatment plans leading to better health outcomes; yet very few studies have examined communication theories and their applicability to practice. This article will examine the Shannon-Weaver Communication Theory as one theory that may support future studies examining the teach-back communication method as a means to improving patient health literacy leading to improvements in clinical practice.

Standardization of Pediatric Interfacility Transport Handover: Measuring the Development of a Shared Mental Model

OBJECTIVES

To determine if standardization of pediatric interfacility transport handover is associated with the development of a prototypical shared mental model between healthcare providers.

DESIGN

A single center, prepost, retrospective cohort study.

SETTINGS

A 259-bed, tertiary care, pediatric referral center.

PATIENTS

Children 0 to 18 years old transferred to our critical care units or emergency center from October 2016 to February 2017.

INTERVENTIONS

Standardization of interfacility handover using a multidisciplinary checklist, didactic teaching, and simulation conducted midway through the study period.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was a shared mental model index defined as percent congruence among handover participants regarding key patient healthcare data including patient identification, diagnoses, transport interventions, immediate postadmission care plans, and anticipatory guidance for ongoing care. Secondary outcomes were handover comprehensiveness and teaming metrics such as efficiency, attendance, interruption frequency, and team member inclusion. During the study period, 100 transport handovers were observed of which 50 were preintervention and 50 post. A majority of handovers represented transfers to the emergency center (41%) or PICU (45%). There were no observable differences between prepost intervention cohorts by general characteristics, admission diagnoses, or severity of illness metrics including Pediatric Index of Mortality-3-Risk of Mortality, length of stay, mortality, frequency of invasive and noninvasive ventilation, and vasoactive use. The shared mental model index increased from 38% to 78% following standardization of handover. Attendance (76% vs 94%), punctuality (91.5% vs 98%), attention (82% vs 92%), summarization (42% vs 72%), and provision of anticipatory guidance (42% vs 58%) also improved. Efficiency was unchanged with a mean handover duration of 4 minutes in both cohorts.

CONCLUSIONS

Considerable enhancements in handover quality, team participation, and the development of a shared mental model after standardization of interfacility transport handover were noted. These findings were achieved without compromising handover efficiency.

Standardization of Postoperative Transitions of Care to the Pediatric Intensive Care Unit Enhances Efficiency and Handover Comprehensiveness

Introduction:

To determine the impact of standardization of postoperative transitions of care to the pediatric intensive care unit on handover efficiency and the quality of healthcare data exchange.

Methods:

This was a prospective, pre–post observational study after standardization of postoperative transitions in a 44-bed pediatric intensive care unit in a 313-bed tertiary care pediatric hospital from April to July 2015. Standardization was completed using a multidisciplinary handover checklist. Primary outcomes were efficiency expressed as mean handover duration and the comprehensiveness of healthcare data exchange.

Results:

Forty-seven postoperative transitions were observed of which 23 were preintervention and 24 were postintervention. After standardization, efficiency improved from 10.5 ± 5.4 to 7.8 ± 2.7 minutes (P < 0.05). Healthcare data exchanged between surgical, anesthesia, and critical care providers were more robust including intraoperative, historical, and anticipatory guidance (all P < 0.05). After intervention, attendance through completion of handover for surgical services increased from 13% to 88% (P < 0.05).

Conclusions:

Standardization of postoperative transitions improved efficiency, healthcare data exchange, and anticipatory planning. Future research is required to link standardization of transitions to improved patient outcomes and measure the development of shared mental models.

Evaluating handoffs in the context of a communication framework

BACKGROUND

The implementation of mandated restrictions in resident duty hours has led to increased handoffs for patient care and thus more opportunities for errors during transitions of care. Much of the current handoff literature is empiric, with experts recommending the study of handoffs within an established framework.

METHODS

A prospective, single-institution study was conducted evaluating the process of handoffs for the care of surgical patients in the context of a published communication framework. Evaluation tools for the source, receiver, and observer were developed to identify factors impacting the handoff process, and inter-rater correlations were assessed. Data analysis was generated with Pearson/Spearman correlations and multivariate linear regressions. Rater consistency was assessed with intraclass correlations.

RESULTS

A total of 126 handoffs were observed. Evaluations were completed by 1 observer (N = 126), 2 observers (N = 23), 2 receivers (N = 39), 1 receiver (N = 82), and 1 source (N = 78). An average (±standard deviation) service handoff included 9.2 (±4.6) patients, lasted 9.1 (±5.4) minutes, and had 4.7 (±3.4) distractions recorded by the observer. The source and receiver(s) recognized distractions in >67% of handoffs, with the most common internal and external distractions being fatigue (60% of handoffs) and extraneous staff entering/exiting the room (31%), respectively. Teams with more patients spent less time per individual patient handoff (r = -0.298; P = .001). Statistically significant intraclass correlations (P ≤ .05) were moderate between observers (r ≥ 0.4) but not receivers (r < 0.4). Intraclass correlation values between different types of raters were inconsistent (P > .05). The quality of the handoff process was affected negatively by presence of active electronic devices (β = -0.565; P = .005), number of teaching discussions (β = -0.417; P = .048), and a sense of hierarchy between source and receiver (β = -0.309; P = .002).

CONCLUSION

Studying the handoff process within an established framework highlights factors that impair communication. Internal and external distractions are common during handoffs and along with the working relationship between the source and receiver impact the quality of the handoff process. This information allows further study and targeted interventions of the handoff process to improve overall effectiveness and patient safety of the handoff.