An Analysis of Clinical Handover Miscommunication Using a Language and Social Psychology Approach

The Challenges of Handover

Handover does not occur in isolation from other aspects of patient care and treatment. However, the interconnectedness of handover is sometimes ignored. Handover is a recorded point in the patient’s journey, and its aim is the assessment of the patient’s condition at that point. If the handover is not conducted well, patients are vulnerable to clinical deteriorations including adverse events. Handover processes vary and can occur across a number of situations. These include, but are not limited to, shift-to-shift handovers (including nursing handovers and night doctor to day medical staff handovers), postoperative handovers, hospital department to ward transfers, and hospital to hospital handovers. The sharing of patient information is the one common denominator across these diverse handover contexts.

Slade, Manias, and Watson (in press) have noted constraints to handover that add to the complexity of this communication process. These constraints include demographic considerations. For example, people are living longer than before. Older patients present with more complex health comorbidities and chronic illnesses. Handover for these patients is time consuming and detailed. There are also physical constraints on handover. Many handovers occur in public spaces such as emergency departments or at the bedside, with noise and ongoing interruptions. Noise can affect the cognitive abilities of the health providers to function effectively (Haka et al., 2009) causing vital patient information to be missed (Siu, Suh, Mukherjee, Oleynikov, & Stergiou, 2010). There are organizational constraints. For example, ensuring that the right health professionals are all together for the handover is a difficult task, as is the challenge of allocating enough time to conduct a thorough handover (see Watson et al., 2014). There are also cultural constraints. Health providers from different ethnic backgrounds may have communication difficulties during handover. Issues such as linguistic barriers and racial prejudice are just some of the problems involved (Penner, Albrecht, Orom, Coleman, & Underwood, 2010).

In some settings, handovers are particularly problematic because of the contextual environment involved (see Braaf, Manias, Finch, Riley, & Munro, 2012). Following the United Kingdom, the Australian Federal Government has introduced targets whereby patients must be moved from the emergency department to another environment within 4 hours (National Health Performance Authority, 2012). Because of these targets, safety and quality concerns can occur, with inadequate or incomplete handover information communicated as patients are hurried through the emergency department (Lowthian et al., 2012). Hospitals are “hierarchical and complex socio-technical systems” (Watson, Hewett, & Gallois, 2012, p. 293). This fact is often not considered when targets are set that can lead to increased stress and increased miscommunication.

In sum, effective and timely communication is critical to efficient and safe handover. The large number of handovers and their associated complexity create situations where communication problems occur. Miscommunication is caused by the use of inaccurate, poorly organized, or misleading data, and mistimed or delayed information. Miscommunication at handover can negatively affect continuity of care and increase the risk of adverse events and patient harm (Beach et al., 2003).

Communication Skills Training as a Solution

A human factors approach has often been taken to address problems in communication. Leonard, Graham, and Bonacum (2004) recommended using tools to assist structuring dialogue between clinicians about a patient’s status. They promoted a method that incorporated four steps: Situation, Background, Assessment, and Recommendation (SBAR). Various derivations of SBAR have been developed, such as ISBAR, ISBARR, and iSoBAR (Porteous, Stewart-Wynne, Connolly, & Crommelin, 2009). More recently, mnemonics such as PRIMARY (Koch et al., 2014) have been used for handover educational purposes. As recognized in the human factors literature, tools alone will not remove the conflicts and underlying tensions that exist in the hospital system. The LSP perspective provides researchers with an additional theoretical framework to examine the contexts that exist around communication and associated problems in handover practices.

The LSP Approach to Handover

Leonard et al. (2004) noted three main contributors to ineffective communication in the hospital system. First, doctors and nurses are trained separately and learn different communication styles. Second, power and status differentials between professional groups can constrain lower status groups from speaking out, and third, there is often a culture of blame in hospitals which means problems and errors are not reported. In this article, we view hospitals as complex social systems where there are cultural differences between professions.

Coupland et al. (1991) developed an integrative model of levels of analysis of “miscommunication.” The model addresses six levels of miscommunication that range from everyday slips of the tongue to miscommunication social structural levels that may reflect power imbalances. Levels I and II are where miscommunication is either not recognized or let pass. The need to repair the miscommunication is either not relevant or not appropriate as the matters are trivial, such as slips of the tongue. At Level III miscommunication is attributed to either poor skills or an inclination not to effectively communicate. Repair takes the form of communication skills training that will “fix” these deficit communicators. Level IV refers to how individuals try to strategically negotiate their communication behaviour to achieve goals. It relates to choices about how interactants present themselves to achieve their outcomes. Such strategies may result in harmless deceptions to save face and maintain a certain persona. Repair occurs when strategies do not enhance cooperative relations and new ways are sought to achieve desired goals. At Level V miscommunication is attributed at the group level. Behaviour is seen as stereotypical of the way particular groups behave (high-status groups, for example), and repair occurs through learning the cultural norms and accommodation. Finally, at Level VI the systems within which individuals exist create miscommunication. Individuals unknowingly support miscommunication and only social change brought about by outside intervention will redress the problem and repair miscommunication.

In this article, we use Levels III, V, and VI of Coupland et al.’s (1991) model to articulate how miscommunication plays out in clinical handovers. We chose these levels because they most clearly relate to the communication issues acknowledged in handover literature and LSP research. Recently, Robertson et al. (2014) noted that although communication competence was the largest problem, hospital infrastructure and busy wards (both Level VI) were also causes of adverse events. We recognize (as did Coupland et al., 1991) that the divisions between the levels are artificial and there will be overlap. Nevertheless, this model provides a base from which to explore handover communication in more depth.

Our overarching research question was whether health providers’ perceptions of handover could be mapped to Coupland et al.’s model with particular reference to Levels III, V, and VI. Given the literature on communication skills training, we expected that health professionals would focus on skills training to fix communication deficits.

We were also interested in what health professionals say about handover and communication. We, therefore, asked two research questions.

Research Question 2 examined clinicians’ awareness of the systemic structure within which they work and how it perpetuates miscommunication.

Method

Results

Question 1: What Are the Major Barriers to Engaging Senior Staff as Effective Role Models?

Closed Item Responses

In response to this item, a quarter (25.9%) of the sample indicated that there were no barriers, as shown in Figure 1. While findings should be interpreted in the context of the sample largely consisting of highly experienced health professionals, a significant difference associated with seniority level was found for only one item. This was for the most common response (40.5%), that senior personnel were too busy to provide feedback about handover to junior clinicians. Junior respondents (59.2%) believed time pressures to be a barrier compared with 36.2% of senior personnel, χ²(1, N = 286) = 13.89, p < .001, Cohen’s w = 0.22. More than a quarter of the sample indicated that senior staff did not see handover training as their responsibility (26.9%), and that they are more focused on clinical priorities (17.8%). In terms of skills and communication competence, 26.6% of respondents indicated that senior staff may not have sufficient handover skills themselves or the communication skills necessary to provide effective feedback and adequately mentor junior staff in handover skills (17.7%). While not statistically significant, the trend on the two skill-based barriers was for experienced personnel to be more critical of the communication and handover skills of their cohort than junior respondents.

OPEN IN VIEWER

Figure 1.

Barriers to engaging senior staff as role models.

Open-Ended Comments ¹

Fifty-four participants answered the question about barriers. Some included more than one level in their response. There were 13 comments about skills (Level III) and 24 comments about group differentiation issues (Level V). Participants also made 23 references to systemic issues (Level VI). The following comment by a nurse reflected a skills focus: “There are [sic] no organizational accepted handover standard or tool in current use” (Nurse). Often when skills were mentioned, it was with reference to group differences. “Doctors do not appear to have any visible structure to handover processes to the outside observer” (Nurse). Another participant stated, “Again dependent on personalities. Nursing is better at feedback than medical” (Nurse). With respect to group differentiation, there were several comments that reflected conflict: “Staff don’t like receiving negative (but constructive) feedback from other disciplines (i.e., doctor to nurse, anaesthetist to surgeon, etc.)” (Doctor), while another doctor stated that “Senior staff have been beaten into submission and are too scared and too tired to give genuine feedback as they will be involved in harassment and bullying cases if they do.” In a similar vein, a nurse stated, “Senior staff are demoralized and minimalized.” However, the main topic that reflected system issues concerned time. References to time constraints include the following: “Workloads impede on available time” (Nurse), “Rushed, assumes the junior knows all, how to access every service in the universe, then walks off” (Doctor).

Question 2: What Aspect of Clinical Handovers do Junior Health Professionals Find Most Difficult?

Closed Item Responses

This item examined what aspect of clinical handover health professionals believed junior staff found most difficult. All bar one item can be classified as Level III, skill or communication deficiencies (“checking recipient understanding of information” is defined as Level V because of the group focus). Figure 2 rank orders the critical skill components of handover in descending order of perceived difficulty. According to the responses, the most challenging handover skill for junior staff to master was checking the recipient has understood the information. All participants rated information collection as the least difficult task requirement; however, senior personnel (Mean Rank = 316.22, n = 495) believed this to be more of a problem than junior personnel (Mean Rank = 276.94, n = 121), U = 26128.5, z = −2.335, p = .020.

OPEN IN VIEWER

Figure 2.

Challenges for junior health professionals (total sample).

Open-Ended Comments

Thirty-six participants completed this item. Typical comments (22) concerned junior professionals not having the skills to gather relevant patient information (Level III). The following was representative of responses about skills: “Knowing which parts of the handover are relevant and/or needing to be emphasized” (Allied Health). Inexperience was the basis for most of these comments. One respondent combined skills with group differentiation (Level III and V). “Doctor handwriting is always a problem to decipher the plan of care” (Nurse). There were also 11 comments that addressed group differentiation directly (Level V). One health professional said, “When senior-staff are rude to more junior staff communication is made even more hazardous—an ED consultant last week was extremely rude to one of my junior staff” (Allied Health). Another allied health professional noted that “junior staff never check the recipient response especially if its to a senior staff member” (Allied Health). Similarly, one participant responded about junior staff that “they don’t want to seem that they are stupid so don’t ask questions they should” (Nurse). There was one comment that may reflect system issues (Level VI); “Organization culture of bullying impacts on the handover environment” (Nurse). Comments from two other respondents also implied system issues: “So many people involved information everywhere” (Allied Health) and “Handover to GP at discharge—junior staff are often burdened with the responsibility for discharge summaries for patients they have not had direct responsibility, for example, uncompleted summaries from the previous rotation” (Allied Health).

Discussion

Handover is a critical aspect of patient care (Manias et al., 2008). Communication competency training is viewed as an important part of handover improvement. Yet, despite training, communication continues to be a major problem in handover (Robertson et al., 2014). In this article, we introduced complexity as an overlooked aspect that contributes to ineffective handover. We also emphasized that hospitals as hierarchical, intergroup systems can negatively influence communication effectiveness. We invoked the LSP framework to address these aspects of handover. This approach recognises how professional identities and cultural norms influence communication efficacy. From this perspective, we argue that focusing only on individuals is insufficient to understand miscommunication. The problem with a purely human factors approach is that the environmental context and people’s identities, motivations, and cognitions are not seen as relevant (see Hulscher et al., 2013; Morello et al., 2013), we argue that they are.

We applied LSP with Coupland et al.’s (1991) model of integrative levels of analysis of miscommunication to investigate health professionals’ perceptions of handover across three specific survey items. Their model provides a theoretically grounded framework to understand the communication problems associated with handover and to highlight the group dynamics and the social structure of the system as pressing communication problems.

The suggestion made by many participants that a standardized handover tool would solve the problems of handover complexity seems unrealistic given the issues associated with group conflict and time constraints. While standardization may assist clinicians, there are other issues that a single tool will not fix. The focus on a standardized tool as the solution to handover problems supports Coupland et al.’s (1991) suggestion that individuals directly concerned with miscommunication (in this instance health professionals) are not able to objectively observe the systemic issues of their workplace (Level VI).

We also confirmed that clinicians are aware of the need for skills training at the individual and team level to fix miscommunication. This finding supported Hypothesis 1: Health professionals discuss communication skills deficits at handover. There were numerous survey responses discussing training and tools to improve communication. However, the clinicians’ open responses also revealed evidence of Levels V and some VI issues. Both these higher levels issues were seen as the status quo.

Clinicians’ responses to the closed options regarding barriers to senior staff role modelling handover cited being too busy more than other options. When they elaborated on the barriers in their open responses, they focused on group conflict and time constraints. The comments indicated that health professionals worked in a potential minefield where professional group differentiation and seniority divided rather than united staff. The comments suggest a culture that is not functioning but which is accepted as the status quo. The changes would need to come from outside the hospital environment for social change to occur.

Item 2 sought clinicians’ perceptions about what junior staff find most difficult. The closed responses all emphasized information and indicated that checking understanding was a major problem. The open responses highlighted communication competency, but many comments related to group differentiation, often portrayed negatively. Participants implied the existence of a hierarchical hospital culture that constrained junior staff in ways that meant they did not openly engage with their senior colleagues.

Many participants responded to Item 3 about how to improve handover. Standardizing tools and improving processes and skills were dominant themes. Interwoven with these comments was recognition that role modelling and training by proficient staff is needed. There was acknowledgement that different health disciplines did not always communicate effectively and differing opinions at handover were not handled well. It was also noted that more interprofessional contact would help relations between the different disciplines. Indeed, the existence of a “silo” mentality between health professions was clearly demonstrated (see Kreindler, Dowd, Dana Star, & Gottschalk, 2012). There was a general consensus that multidisciplinary teams need to work together but the ability to ensure this happened regularly and effectively was restricted.

Interpretation of our data using Coupland et al.’s (1991) model does confirm their proposition that miscommunication in handover is predominately viewed by participants working in the system as both a skills and group differentiation issue (Levels III and V, respectively). There was acceptance of the systemic issues that negatively affected handover (Level VI), and this finding suggests that outside researchers in close collaboration with hospital personnel are needed to change the system.

There are limitations to this article. While the number of participants was high, many were senior staff and it would be valuable to obtain more junior staff opinions. Junior staff may see the systemic issues more clearly because they are not yet acculturated. We would also like to see how hospital management view these problems, but they were not in evidence in this study. The strength of this article is that the data provide a valuable vehicle for examining miscommunication using a mixed methods approach.

Conclusion

One aim of this article was to demonstrate the value of the LSP perspective and argue that to improve handover communication we need to go beyond a skills-only approach (Level III). To achieve this, there needs to be a heightening of clinicians’ awareness of the role their group memberships play in everyday interactions (Level V). Social change must occur but according to Coupland et al.’s (1991) model requires an additional outside influence. The response data indicated that the status quo was accepted, which supports this view. Researchers can begin social change by making clinicians, managers, and policy makers aware of the system within which they operate (Level VI). While the involvement of interdisciplinary scholars in the medical research environment is not without its challenges (see Albert, Paradis, & Kuper, 2015), the potential of such collaboration to refocus attention and implement change should not be undervalued. One recent example of the viability of innovative interdisciplinary approaches is examined in Hor, Iedema, and Manias (2014). Looking at how the built environment in an intensive care unit influences safe communications, they used a video-reflexive, ethnographic approach to enable clinicians to review their practices and work with researchers to formulate strategies for improvement. Through the lens of different discipline perspectives we can apply innovative approaches to improving miscommunication in handover.

This article has demonstrated issues of miscommunication and ineffective handover as described by health professionals. These data are mapped into an appropriate theoretical model that recognizes the complexity of health systems and the relationships of those who work within it. Whilst tools and simple handover checklists have been used to improve handover, this research identifies that they are not sufficient on their own. A broader improvement response supported by handover communication research is urgently needed.