ArticlePDF Available

Abstract and Figures

Background Handoff education is both formal and informal and varies widely across medical school and residency training programs. Despite many efforts to improve clinical handoffs, little evidence has shown meaningful improvement. The objective of this study was to identify residents’ perspectives and develop a deeper understanding on the necessary training to conduct safe and effective patient handoffs. Methods A qualitative study focused on the analysis of cognitive task interviews targeting end-of-shift handoff experiences with 35 residents from three geographically dispersed VA facilities. The interview data were analyzed using an iterative, consensus-based team approach. Researchers discussed and agreed on code definitions and corresponding case examples. Grounded theory was used to analyze the transcripts. Results Although some residents report receiving formal training in conducting handoffs (e.g., medical school coursework, resident boot camp/workshops, and handoff debriefing), many residents reported that they were only partially prepared for enacting them as interns. Experiential, practice-based learning (i.e., giving handoffs, covering night shift to match common issues to handoff content) was identified as the most suited and beneficial for delivering effective handoff training. Six skills were described as critical to learning effective handoffs: identifying pertinent information, providing anticipatory guidance, applying acquired clinical knowledge, being concise, incorporating delivery strategies, and appreciating the styles/preferences of handoff recipients. Conclusions Residents identified the immersive performance and the experience of covering night shifts as the most important aspects of learning to execute effective handoffs. Formal education alone can miss the critical role of real-time sense-making throughout the process of handing off from one trainee to another. Interventions targeting senior resident mentoring and night shift could positively influence the cognitive and performance capacity for safe, effective handoffs. Electronic supplementary material The online version of this article (10.1186/s12909-018-1350-8) contains supplementary material, which is available to authorized users.
Content may be subject to copyright.
R E S E A R C H A R T I C L E Open Access
Content counts, but context makes the
difference in developing expertise: a
qualitative study of how residents learn
end of shift handoffs
Nicholas A. Rattray
, Patricia Ebright
, Mindy E. Flanagan
, Laura G. Militello
, Paul Barach
, Zamal Franks
Shakaib U. Rehman
, Howard S. Gordon
and Richard M. Frankel
Background: Handoff education is both formal and informal and varies widely across medical school and residency
training programs. Despite many efforts to improve clinical handoffs, little evidence has shown meaningful improvement.
The objective of this study was to identify residentsperspectives and develop a deeper understanding on the necessary
training to conduct safe and effective patient handoffs.
Methods: A qualitative study focused on the analysis of cognitive task interviews targeting end-of-shift handoff
experiences with 35 residents from three geographically dispersed VA facilities. The interview data were analyzed using an
iterative, consensus-based team approach. Researchers discussed and agreed on code definitions and corresponding case
examples. Grounded theory was used to analyze the transcripts.
Results: Although some residents report receiving formal training in conducting handoffs (e.g., medical school
coursework, resident boot camp/workshops, and handoff debriefing), many residents reported that they were only
partially prepared for enacting them as interns. Experiential, practice-based learning (i.e., giving handoffs, covering night
shift to match common issues to handoff content) was identified as the most suited and beneficial for delivering effective
handoff training. Six skills were described as critical to learning effective handoffs: identifying pertinent information,
providing anticipatory guidance, applying acquired clinical knowledge, being concise, incorporating delivery strategies,
and appreciating the styles/preferences of handoff recipients.
Conclusions: Residents identified the immersive performance and the experience of covering night shifts as the most
important aspects of learning to execute effective handoffs. Formal education alone can miss the critical role of real-time
sense-making throughout the process of handing off from one trainee to another. Interventions targeting senior resident
mentoring and night shift could positively influence the cognitive and performance capacity for safe, effective handoffs.
Keywords: Communication, Resident handoffs, Qualitative research, Resident training, Continuing education, Quality of
care, Patient safety
* Correspondence:
VA HSR&D Center for Health Information and Communication, Roudebush
VAMC, Indianapolis, USA
Department of Anthropology, Indiana University-Purdue University
Indianapolis, Indianapolis, USA
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (, which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
( applies to the data made available in this article, unless otherwise stated.
Rattray et al. BMC Medical Education (2018) 18:249
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
End-of-shift patient handoffs, also known as transfers-
of-care or sign-outs, pose a substantial patient safety risk
and an opportunity for quality improvement. These transi-
tions lead to unwanted variation in handoffs and have
been associated with delays in diagnosis and treatments
[1], duplication of tests or treatment and patient discom-
fort [2], inappropriate care and less functional training for
health care personnel [3], medication errors and failure to
follow a patientscodestatus[4], and longer hospital stays
and increased laboratory testing [5,6]. The Accreditation
Council for Graduate Medical Education (ACGME) re-
quires teaching hospitals to develop residentscompetency
in communicating with team members during the handoff
process [7]. Proposed curricula for medical students and
residents in end-of-shift handoffs [8], as well as interven-
tions that improve transfer processes, have resulted in
meager changes in practice and growing awareness
that one size of training does not fit all kinds of
handoffs [9,10]. Training for end-of-shift handoff com-
petency is infrequently included in formal medical educa-
tion and, where it is, the content and structure of the
training varies widely [11]. Instead, end-of-shift handoffs
are typically learned on the job,from interns or resi-
dents, who likely learned them in the same manner [12].
The clash between formal training and local practice cul-
ture (i.e., the way things are done around here) may con-
tribute to the considerable variation observed in handoff
effectiveness [1316].
Handoffs are a complex form of social interaction that
occur in microsystems,[17] defined as groups of clini-
cians and staff with a shared clinical purpose and legal
responsibility to provide care. Formal onboarding
training-- the action or process of integrating a new em-
ployee into an organization for new physicians in train-
ing, is accompanied by informally acquired knowledge
and expectations about the day-to-day operation of the
microsystem. Differences in local culture have been
identified as a major contributor to variations in individ-
ual and the microsystem performance and may, in part,
explain why interventions that call for rigid adherence to
uniform standards have been unsuccessful [18].
Recent literature suggests a change in the conceptualization
of handoffs from a mechanical transfer of accurate and
complete patient information, to a highly nuanced, con-
textually sensitive and emergent social-technical commu-
nication event [18,19]. To date, developers of handoff
improvement strategies have paid little attention to the
complexities of workflow. Competing cognitive, linguistic,
technical and physical demands influence the success of a
handoff, but are not routinely considered part of the edu-
cational process for leaning and improvement [20,21].
Identifying and enhancing the capacity of clinicians to
make sense (clinical sensemaking) of these complexities in
patient care is crucial [22]. A sense-making approach that
focuses on the motivation of clinicians who are jointly
responsible for patient care, rather than focusing solely on
errors or root causes, may contribute to the development
and implementation of effective and sustainable interven-
tions [23].
The objective of this study was to gain insights into
residentsperspectives on the local cultural assumptions
and contextual factors that shape their knowledge about,
and skills of enacting effective handoffs. In this paper,
we report our findings related to the formal, and import-
antly, the hiddenor informal curriculum that residents
reported being exposed to in developing these skills.
Setting and participants
We conducted a prospective, multi-method, qualitative
study. Data collection included semi-structured cognitive
task interviews with medicine and surgery residents at
three geographically dispersed VA Medical Centers
(VAMCs). Site investigators and chief residents supplied
names of potential residents to recruit for a cognitive
task interview and to have their handoffs videotaped. Re-
cruited participants were then asked to provide add-
itional names of peers who might be open to
participating, a form of snowball sampling [24]. Research
assistants met with interested providers, informed them
about the study, and obtained their written consent to
participate. Residents received a $100.00 gift card for
participation in the interview. Ethics approval was ob-
tained from the Indiana University Institutional Review
Board and VAMC Research and Development Human
Subjects board.
Data collection
Data were collected from individual Cognitive Task Ana-
lysis (CTA) interviews. This method extends the critical de-
cision method of Klein, Calderwood, & Macgregor [25],
later adapted by Militello and Hutton, and generally in-
cludes a combination of observations and semi-structured
interviews [26]. CTA enables elicitation of factors that ex-
perienced professional face while engaging in complex clin-
ical tasks [2730]. Specifically, participants are asked to
recall their last handoff and describe 4 to 5 major steps in
ing/experience, cues, goals, strategies, and information
needs and tools used during each step of the handoff
process. An interview guide is included as Additional file 1.
The CTA interviews were conducted in a quiet location
in the hospital, audio-recorded and transcribed verbatim
according to a standardized format. Team members veri-
fied that the recordings matched the transcripts an d cor-
rected any transcription inaccuracies.
Rattray et al. BMC Medical Education (2018) 18:249 Page 2 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Data analysis
Interview data were analyzed using a grounded theory ap-
proach to explore key social processes and structures [31].
The interviews were coded using qualitative software
NVivo [32]. Emerging codes were circulated among au-
thors and the list of codes was developed into a
code-book during face-to-face meetings, conference calls,
and email correspondence. Regular conference calls were
held to refine the codebook as other codes emerged dur-
ing the analysis process. In building the inventory of
codes, portions of the text and provisional codes were
compared and differences reconciled in a series of iterative
consensus-building meetings until thematic saturation
was reached (e.g., no new codes emerged) [33].
One member of the data analysis team was responsible
for updating and maintaining a master file of the consen-
sus coded transcripts (NR). Iterative reviews using the
constant comparative method, resulted in assignment of
codes to mutually exclusive categories. We report here on
the findings related to training and experiencethat were
derived from the interviews; study findings on how resi-
dents prepare for handoffs have been published elsewhere
[34]. A confirmability audit to ensure dependability of the
training and experience category analysis was conducted
to match code definitions with transcript case examples.
Participant demographics
A total of 35 residents were interviewed. Demographics are
summarized in Table 1. Data analysis resulted in 2 main
themes that emerged: (i) formal and (ii) informal training
experiences and three main skills as described below.
Formal training experiences
Formal training strategies included: medical school cur-
riculum (e.g., handoff class, handoff practice, simulation,
observation opportunities); resident/ intern orientation
handoff boot camp/workshops; and debriefing handoffs
to identify necessary information to be included.
Informal training experiences
Informal, on-the-jobtraining experiences were reported
as having a stronger influence on actual practices than
formal instruction. Residents described three specific
handoff-related types of skills: 1) acquiring and applying
knowledge to anticipate patient needs and tasks; 2) align-
ing information needs to work tasks (content and
amount); and 3) adapting to the handoff to the setting and
context (see Table 2for a summary of skills and exemplar
quotations). We have broken down each of these types
into two specific skills.
Skill 1: Acquire and apply knowledge to anticipate patient
needs and tasks
Residents recognized that acquiring specific and targeted
clinical knowledge continued during residency and influ-
enced their ability to communicate anticipatory guidance
and tasks for the upcoming shift during handoffs.
Skill 1a. Apply newly acquired clinical knowledge
Residents reported that the quality of their handoffs im-
proved over time as their clinical understanding of pa-
tient disease trajectories and medical treatments
expanded. Continued learning resulted from month-long
rotations on different medical wards and exposure to a
variety of cases. Learning also occurred informally when
senior residents intervened(i.e. ask a question, inter-
rupt to clarify, etc.) during challenging handoffs. One
resident (P101) described this type of learning as follows:
When you first start residency like your senior resident
is always there with you when youre signing out to kind
of jump in when the night person asks you a question…”
Additionally, residents developed a better understanding
of the implicit language of handoffs: I think there is a
lot of hidden language in sign out, the way you describe
a patient to somebody else,[and] in the way that words
are constructed and the sign out itself is constructed.
Skill 1b. Provide anticipatory guidance and assign
tasks Anticipatory guidance was reported to provide in-
coming residents with an early guide to issues that might
arise during the next shift. Typically, this type of informa-
tion included relaying past patient responses to medication
or procedures, and communicating clinical trajectories, po-
tential or desired outcomes and care needs.For example,
anticipatory guidance might include how a patient
responded to a specific diuretic dose, how his vital signs
varied, reactions and follow-up plans, patient triaging, an-
ticipating nursing questions, tasks to complete, using base-
line status for comparison, and alternate care plans if
certain conditions occurred during the night shift.
Residents also adopted a simple binary vocabulary for
indicating the acuity of a patients condition, sickor
not sick.”“Sickreferred to patients who could decom-
pensate during the upcoming shift, while not sickre-
ferred to patients who only needed routine monitoring.
The ability to offer anticipatory guidance improved with
Table 1 Interviews analyzed by care providers breakdown by
study site
PGY1 PGY2 PGY3 Total
Medical Surgical Medical Surgical Medical Surgical
Site 1 0 0 7 1 1 0 9
Site 2 12 2 1 2 0 1 18
Site 3 8 0 0 0 0 0 8
Total 20 2 8 3 1 1 35
Rattray et al. BMC Medical Education (2018) 18:249 Page 3 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
continued clinical experience and explicit feedback on
previous handoffs.
Skill 2: Align information needs to work tasks
Residents consistently noted that including the rightin-
formation in the rightamount was a key and new skill
developed to give organized, clear handoffs. One resi-
dent (P103) explained that: It takes a lot of practice
after youve done these sign-outs for months on end, you
know the important points to hit on.
Skill 2a. Identify pertinent information Residents de-
scribed the skill of providing patient information as one
that best informs the receiver of what they will need to
do during their upcoming shift.Communicating pertin-
ent information was contrasted with mechanically recit-
ing a problem list. For example, residents discussed how
to convey patient acuity by interpreting aspects of seem-
ingly routine updates, such as mental status exam: I will
ask them those same [mental health] questions overnight,
and if things are off at all, like thats gonna tip me off to
do more, or if its exactly the same, Ill worry about it
less. (P118).
One striking example of on-the-job learning emerged
as residents completed night shift rotations. Prior to
staffing overnight shifts, classroom learning had sug-
gested handoffs were standardized, whether from day to
night or night to day. Yet, during night floatrotations,
which refer to when residents cover the night shift, they
typically monitored and intervened with patients only
when necessary. One resident (P129) described the ex-
periential learning process: When you experience the
night float you start knowing what is important, what
is not important. So when you put yourself in the call
teams shoes and then as night float, and you know
whats important and whats not important.
Skill 2b. Be concise Residents valued concision and de-
scribed streamlining the amount of information they in-
cluded in their handoffs. In this way, they could focus
only on items of critical importance. Economy of actions
was achieved by limiting detailed descriptions of contin-
gency plans, the amount of background information,
and the problem list to 12 of the most pressing prob-
lems. Compared to start of their internship year, by the
end residents reported they had mastered the skill of
giving concise handoffs. For example, one resident
(P117) stated, July 1, its like every detail ever and like
no consolidation or paring down of anything. Its just like
verbal diarrhea, and youre like, I dontknowwhatto
make of this,I feel like Sherlock Holmes.July 1 repre-
sents the beginning of residency training in North
America. More concise handoffs translated into more ef-
fective care by making information actionable during the
upcoming shift.
Rather than following a list of prescribed elements
learned in didactic sessions, practice had taught them to
focus on, and prioritize, the most important and time
sensitive information: They teach us [that] you need to
give a whole hospital course, a whole history of present
illness leading up to this hospitalization, then you go,
Im gonna make sure that I cover all of my bases by talk-
ing about everything.When you do that, sign-outs take
an hour long…” (P111).
Table 2 Training and experience themes, experiential learning skills and representative quotes related to end-of-shift handoffs
Skill Sub-skill Representative quote(s)
Acquire and apply knowledge to
anticipate patient needs and tasks
Apply newly acquired
clinical knowledge
When you become an intern and now youre in a residency, you learn a lot
more about whats important because your knowledge is growing as a doctor.
Provide anticipatory
guidance and assign tasks
“…Giving them recommendations based on potential scenarios…”
I think now that as I got more experience, I am able to anticipate what problems
I see might happen with a patient a little bit better. So, if I foresee that
something would go wrong with a patient, I like to tell the cross-cover person
you know like Hey, watch out for this guy to go into alcohol withdrawal and if
he does, do this.’”
Align information needs to work
tasks (content and amount)
Identify pertinent
Whats important for someone whos going to take care of this patient for 14 h
needs to know…”
I think it just takes a lot of practice and being on both ends, like receiving and
providing to kind of see where the benefits of providing certain pieces of
information are, so I think everybody just kind of has to experience it…”
Be concise “…Concise is important because there are things. There is a lot. Time doesnt
stand still for handoffs. Youll be getting pages as youre getting handoffs…”
Adapting handoffs to the setting
and context
Incorporate helpful
delivery strategies
“…I really dont stand during a sign out. If Im going to give a sign out to a
person, I like to sit down and have then sit next to me so we make sure they
dont feel that Im rushing them, and then give a thorough sign out without…”
Appreciate othersstyles/
preferences for handoff
“…I mean you kind of can read people and when like theyre shutting down.
When theyre not listening and theyre writing something else or looking at their
phone or like those are kinds of ways.
Rattray et al. BMC Medical Education (2018) 18:249 Page 4 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Skill 3: Adapting handoffs to the setting and context
Another critical skill related to concision by eliminating
redundancy without omitting important information was
making adaptations in delivery strategies and accommo-
dating to incoming residents preferences and background.
Skill 3a. Incorporate helpful delivery strategies Resi-
dents described several different strategies they incorpo-
rated into their handoffs including acclimating to noisy
environments and providing thorough paper-based back
up information. One resident (P125) emphasized the im-
portance of painting a picture or relaying a weird story
to help the incoming resident remember individual pa-
tients. Some strategies were taught by senior residents
during handoffs; others learned by observing how col-
leagues handled the process. Helpful handoff strategies
varied considerably and were not formally taught. Tips,
tricks and shortcuts described by residents did not have
the force of institutional authority, or formal rules, regu-
lations and procedures, but rather, they were part of the
informal curriculum of resident education.
Skill 3b. Appreciate othersstyles/preferences for
handoffs Residents learned from their experience to iden-
tify and adjust to other resident preferences for giving and
receiving information. For example, residents described
variations in the preferred level of detail to be included in
a handoff based on previous experiences with other resi-
dents. Some also reported adapting their handoffs based
on the receiversreputationor behavioral cues. In both
cases, adaptations were based on implicit assumptions
about an incoming residentspreferences:Some people
are very detail oriented; some people are big picture ori-
ented; some people like to talk and are social during their
sign-outs; some people are not.(P111) In terms of behav-
ioral cues, some incoming residents used nonverbal cues
to indicate that a handoff was too long by diverting atten-
tion elsewhere and not listening.
Our findings indicate that critical skills for enacting ef-
fective patient handoffs were mostly learned informally
through observation and experience. Study participants
described how immersion in the local microsystem cul-
ture was the best teacher in terms of mastering skills.
Our analysis uncovered six skills viewed by residents
as critical to handoff quality: identifying pertinent infor-
mation, providing anticipatory guidance, applying ac-
quired clinical knowledge, being concise, incorporating
delivery strategies, and appreciating styles/preferences
for handoffs. Our findings also highlight the dynamic
cognitive work required to enact safe and effective hand-
offs and the importance of shared goals, shared know-
ledge, and mutual respect between providers. These
relational dynamicscan in turn predict higher levels of
quality [35]. These skills require a high level of interper-
sonal knowledge and sense-making that is critical for ac-
curate assessment of patient status and care needs, care
planning, interpersonal and setting-specific issues, and
handoff content [22,23]. Sense-making is the integration
of both tacit and explicit knowledge of a situation and is
a basis for social action [23]. Our findings demonstrate
how residents use sense-making activities to coordinate
complex actions like the transfer of rights, duties and re-
sponsibilities between providers involved in end of shift
handoffs. Too great a focus on content alone can miss
the critical role of sense-making and interpretation that
housethe handoff process. Attempts to design effective
handoff interventions should balance the urge to
standardize with explicating the role of self and situation
awareness in handoff interactions [36].
Interestingly, residents did not focus on handoff me-
chanics, content, or preferred formats. Instead, practical
concerns relating to informal organizational culture and
experience and how it influenced their workflow made
up the bulk of their comments. Our findings suggest
that the ability to detect nuanced messages and adapt
accordingly is a subtle interpersonal skill that emerges
only when a resident has mastered the mechanics of
handing off complex patients. Perhaps, only then does
the resident have the cognitive resources to attend to
the recipients skills, attention level, and real-time reac-
tions to the information being conveyed. Residents also
reported being less willing to confront each other about
handoff defects and inefficiencies which may explain
resident self-reported high ratings of their handoffs [4].
Skill acquisition is difficult in the absence of feedback
[37,38]; a goal for future improvement interventions.
Safety of patients may also be compromised by a false
sense of confidence that emerges when handoff strat-
egies are not rigorously assessed [35].
We have several suggestions for improving handovers
based on experiential learning pedagogy. First, changing
attitudes may be enhanced through establishing collab-
orative learning meetings between medical students, in-
terns and residents to better understand each others
perspectives, competencies (knowledge, skills, and infer-
ences) and expectations [39]. Simulated handoff cases in
which ambiguous or incomplete information is commu-
nicated could be used to stimulate discussion about
sense-making and the tacit (unspoken) rules of social
interaction. Direct feedback by incoming resident or by
independent monitor during handoff may be greatly
beneficial especially during early months of internship or
junior residency.
Second, we suggest providing point-of-care education
programs that connect best practices with patient safety
and efficiency goals [40]. In this way, the hospital
Rattray et al. BMC Medical Education (2018) 18:249 Page 5 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
providers may better understand how their own thinking
and actions impact quality and safety [41]. One approach,
used successfully in infection control, is video-reflexive eth-
nography in which clinicians view video footage of their ac-
tions to identify vulnerabilities for spreading infection. This
approach allows participants to understand the conse-
quences of their actual behaviors (including those that seem
irrelevant), question their habits of practice, and expand re-
assessment to behaviors outside the video footage (e.g., re-
duced infections [42] improved handoff communication
[43]). Incorporating a video-reflexive session for resident
handoffs might reveal non-verbal behaviors, speech pace,
and other habits that seemingly are unrelated to effective
Third, both classroom and on-the-job mentoring could
be enriched by the use of stories or vignettesthat are
meaningful and memorable to residents, because they
demonstrate the direct link between handoff processes
and their effects on patient care [44]. Incorporating stories
and connections is one scaffolding technique for making
handoff curricula salient for learners because they demon-
strate the direct link between handoff processes and their
effects on patient care [41]. In addition, as shown in this
study, enacting actual handoffs was viewed as the most ef-
fective learning method for developing mastery. Medical
students and trainees need liveopportunities to learn
how to conduct handoffs safely and receive feedback.
The study has several limitations. First, data were ana-
lyzed and compared at three VA sites with distinct local
cultures. Nevertheless, the emergence of the same skills
across sites increases the credibility and trustworthiness
of the findings. We made all efforts to ensure methodo-
logical rigor and validity across the study sites by using a
standardized codebook, meeting and talking frequently,
sharing and comparing our results. Second the data re-
flect participant reportsabout their experiences and
could be subject to response bias [45]. Cognitive task ana-
lysis is a non-judgmental process that, in principle, re-
duces, but does not eliminate unwanted bias. Third, the
modest number of participants may not be representative
of all medical residentshandoff education or practice.
Our findings underscore the complex social structure of
end-of-shift handoffs with implications for handoff train-
ing curricula and efforts to improve effectiveness [46].
The use of individual interviews provided invaluable in-
sights into the subtleties of decision-making, and the
underlying shared values, beliefs, assumptions, and norms
of that characterize the handoff process. While complex
and difficult to define, focusing on sense making and con-
textual features of handoffs can potentially help residents
develop the expertise needed to ensure and safety across
care transitions [47].
Additional file
Additional file 1: Interview Guide. This appendix outlines the interview
guide used in conducting CTA interviews. (DOCX 21 kb)
ACGME: The Accreditation Council for Graduate Medical Education (ACGME);
CTA: Cognitive Task Analysis; VA: Veterans Affairs; VAMCs: VA Medical Centers
We appreciate the efforts of Paige DeChant in data collection and analysis,
and Dr. Maddamsetti Rao, Christopher Kurtz, Ava Harms, Angela Kuramoto,
Naomi Ashlely, and Natalia Skorohod for assistance in recruitment and
logistics. We would also like to thank the VA residents that volunteered to
take out of their regular duties to participate in the study.
The research was funded by the Center for Health Information and
Communication, Department of Veterans Affairs (VA), Veterans Health
Administration, Health Services Research and Development Service (CIN 13
416), Project No. IIR 12090. The funder had no role in the design of this
study and did not have any role during its execution, analyses, interpretation
of the data, or decision to submit results.
Availability of data and materials
Upon request, the co-authors will consider requests for the final dataset.
These requests for access will be reviewed by the Richard L Roudebush VA
Medical Center R&D Committee and Associate Chief of Staff (ACOS) for Re-
search and addressed within a reasonable timeframe. The limited dataset will
include deidentified data relevant to the specific request.
All authors were involved in the design of this research, participated in
manuscript development, and critically revised the manuscript for its
intellectual content. RMF obtained study funding and directed the study. PE,
MEF, LGM, PB, NAR, ZF, and RMF participated in data analysis. NAR, PE, PM,
RMF, and MEF drafted the manuscript, and NAR, PE, PM, RMF, MEF, LGM, ZF,
SUR, and HSG have read, revised, and approved the final version.
Ethics approval and consent to participate
Site investigators and chief residents supplied names of potential residents to
recruit for a cognitive task interview and to have their handoffs videotaped.
Recruited participants were then asked to provide additional names of peers who
informed them about the study, and obtained their written consent to participate.
Ethics approval was obtained from the Indiana University Institutional Review
Board and VAMC Research and Development Human Subjects board.
Consent for publication
Not applicable.
Competing interests
Each of the authors declares that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
VA HSR&D Center for Health Information and Communication, Roudebush
VAMC, Indianapolis, USA.
Department of Anthropology, Indiana
University-Purdue University Indianapolis, Indianapolis, USA.
Institute, Inc., Indianapolis, USA.
Indiana University School of Nursing,
Indianapolis, USA.
Applied Decision Science, LLC, Dayton, USA.
Wayne State
University School of Medicine, Detroit, USA.
Phoenix VA Healthcare Systems,
Phoenix, USA.
University of Arizona College of Medicine-Phoenix, Phoenix,
VA HSR&D Center of Innovation for Complex Chronic Healthcare, Jesse
Brown VAMC, Chicago, USA.
University of Illinois at Chicago, Chicago, USA.
Indiana University School of Medicine, Indianapolis, USA.
Rattray et al. BMC Medical Education (2018) 18:249 Page 6 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Received: 7 February 2018 Accepted: 15 October 2018
1. Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern
Med. 2005;142(5):3528.
2. Hesselink G, Schoonhoven L, Barach P, Spijker A, Gademan P, Kalkman C, et
al. Improving patient handovers from hospital to primary care: a systematic
review. Ann Intern Med. 2012;157(6):41728.
3. Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of
inadequate sign-out for patient care. Arch Intern Med. 2008;168(16):175560.
4. Arora V, Johnson J. A model for building a standardized hand-off protocol.
Jt Comm J Qual Patient Saf. 2006;32(11):64655.
5. Toccafondi G, Albolino S, Tartaglia R, Guidi S, Molisso A, Venneri F, et
al. The collaborative communication model for patient handover at the
interface between high-acuity and low-acuity care. BMJ Qual Saf. 2012;
21(Suppl 1):i5866.
6. Lofgren RP, Gottlieb D, Williams RA, Rich EC. Post-call transfer of resident
responsibility: its effect on patient care. J Gen Intern Med. 1990;5(6):5015.
7. ACGME Common Program Requirements
PFAssets/ProgramRequirements/CPRs_2017-07-01.pdf Accessed 30 Jan 2018.
8. Drachsler H, Kicken W, van der Klink M, Stoyanov S, Boshuizen HP, Barach P.
The handover toolbox: a knowledge exchange and training platform for
improving patient care. BMJ Qual Saf. 2012;21(Suppl 1):i11420.
9. Kicken W, Van der Klink M, Barach P, Boshuizen HP. Handover training: does
one size fit all? The merits of mass customisation. BMJ Qual Saf. 2012;
21(Suppl 1):i848.
10. Keebler JR, Lazzara EH, Patzer BS, Palmer EM, Plummer JP, Smith DC, et al.
Meta-analyses of the effects of standardized handoff protocols on patient,
provider, and organizational outcomes. Hum Factors. 2016;58(8):1187205.
11. Horwitz LI, Krumholz HM, Green ML, Huot SJ. Transfers of patient care
between house staff on internal medicine wards: a national survey. Arch
Intern Med. 2006;166(11):11737.
12. Babu MA, Nahed BV, Heary RF. Investigating the scope of resident patient
care handoffs within neurosurgery. PLoS One. 2012;7(7):e41810.
13. Carroll JS, Williams M, Gallivan TM. The ins and outs of change of shift
handoffs between nurses: a communication challenge. BMJ Qual Saf. 2012;
14. Borowitz SM, Waggoner-Fountain LA, Bass EJ, JM DV. Advances in patient
safety resident sign-out: a precarious exchange of critical information in a
fast-paced world. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors.
Advances in patient safety. Rockville: Agency for Healthcare Research and
Quality (US); 2008.
15. Volpp KG, Grande D. Residentssuggestions for reducing errors in teaching
hospitals. N Engl J Med. 2003;348(9):8515.
16. Frankel RM, Flanagan M, Ebright P, Bergman A, O'Brien CM, Franks Z, et al.
Context, culture and (non-verbal) communication affect handover quality.
BMJ Qual Saf. 2012;21(Suppl 1):i1218.
17. Mohr J, Batalden P, Barach P. Integrating patient safety into the clinical
microsystem. Qual Saf Health Care. 2004;13(Suppl 2):ii348.
18. Cohen MD, Hilligoss B, Kajdacsy-Balla Amaral AC. A handoff is not a telegram:
an understanding of the patient is co-constructed. Crit Care. 2012;16(1):303.
19. Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals:
deficiencies identified in an extensive review. Qual Saf Health Care. 2010;
20. Lilford RJ, Chilton PJ, Hemming K, Girling AJ, Taylor CA, Barach P. Evaluating
policy and service interventions: framework to guide selection and
interpretation of study end points. BMJ. 2010;341:c4413.
21. Johnson JK, Farnan JM, Barach P, Hesselink G, Wollersheim H, Pijnenborg L,
Kalkman C, Arora VM. Searching for the missing pieces between the
hospital and primary care: mapping the patient process during care
transitions. BMJ Qual Saf. 2012;21(Suppl 1):i97105.
22. Barach P, Phelps G. Clinical sensemaking: a systematic approach to reduce
the impact of normalised deviance in the medical profession. J Royal Soc
Med. 2013;106(10):38790.
23. Weick KE, Sutcliffe KM, Obstfeld D. Organizing and the process of
Sensemaking. Organ Sci. 2005;16(4):40921.
24. Heckathorn DD. Snowball versus respondent-driven sampling. Sociol
Methodol. 2011;41(1):35566.
25. Klein GA, Calderwood R, MacGregor D. Critical decision method for eliciting
knowledge. IEEE Trans Syst Man Cybern. 1989;19(3):46272.
26. Militello L, Hutton R. Applied cognitive task analysis (ACTA): a practitioners toolkit
for understanding cognitive task demands. Ergonomics. 1998;41(11):161841.
27. Christensen RE, Fetters MD, Green LA. Opening the black box: cognitive
strategies in family practice. Ann Fam Med. 2005;3(2):14450.
28. Patterson MD, Militello LG, Bunger A, Taylor RG, Wheeler DS, Klein G, Geis GL.
Leveraging the critical decision method to develop simulation-based training
for early recognition of sepsis. J Cogn Eng Decis Mak. 2016;10(1):3656.
29. Crandall B, Calderwood R. Clinical assessment skills of experienced neonatal
intensive care nurses: national center for nursing research. Natl Inst of
Health. 1989.
30. Dominguez CO, Hutton R, Flach JM, McKellar DP. Perception-action
coupling in endoscopic surgery: a cognitive-task analysis approach. 1995.
31. Glaser B. Discovery of grounded theory: strategies for qualitative research.
London: Routledge; 2017.
32. NVivo qualitative data analysis software. In., vol. Version 10. QSR
International Pty Ltd. ; 2012.
33. Walker JL. Research column. The use of saturation in qualitative research.
Can J Cardiovasc Nurs. 2012;22(2):37-46.
34. Militello LG, et al. Workinon our night moves: how residents prepare for
shift handoffs. Jt Comm J Qual Patient Saf. 2018;44(8):48593.
35. Gittell JH. Relational coordination: coordinating work through relationships
of shared goals, shared knowledge and mutual respect. In: Kyriakidou O,
Ozbilgin MF. Relational perspectives in organizational studies. Cheltenham:
Edward Elgar; 2006.
36. Patterson ES, Wears RL. Patient handoffs: standardized and reliable measurement
tools remain elusive. Jt Comm J Qual Patient Saf. 2010;36(2):5261.
37. Shanteau J. Competence in experts: the role of task characteristics. Organ
Behav Hum Decis Process. 1992;53(2):25266.
38. Hoffman RR, Ward P, Feltovich PJ, DiBello L, Fiore SM, Andrews DH.
Accelerated expertise: training for high proficiency in a complex world.
London: Psychology Press; 2013.
39. Stoyanov S, Boshuizen H, Groene O, van der Klink M, Kicken W, Drachsler H,
Barach P. Mapping and assessing clinical handover training interventions.
BMJ Qual Saf. 2012;21(Suppl 1):i507.
40. Riesenberg LA, Leitzsch J, Little BW. Systematic review of handoff
mnemonics literature. Am J Med Qual. 2009;24(3):196204.
41. Clarke CM, Persaud DD. Leading clinical handover improvement: a change
strategy to implement best practices in the acute care setting. J Patient Saf.
42. Iedema R, Hor S-Y, Wyer M, Gilbert GL, Jorm C, Hooker C, O'Sullivan MVN.
An innovative approach to strengthening health professionalsinfection
control and limiting hospital-acquired infection: video-reflexive
ethnography. BMJ Innov. 2015;1(4):15762.
43. Calaman S, Hepps JH, Bismilla Z, Carraccio C, Englander R, Feraco A, et al. The
creation of standard-setting videos to support faculty observations of learner
performance and entrustment decisions. Acad Med. 2016;91(2):2049.
44. Weick KE, Sutcliffe KM. Managing the unexpected: resilient performance in
an age of uncertainty. San Francisco: Jossey-Bass; 2007.
45. Orne MT. On the social psychology of the psychological experiment: with
particular reference to demand characteristics and their implications. Am
Psychol. 1962;17(11):77683.
46. Grol R, Grimshaw J. From best evidence to best practice: effective
implementation of change in patientscare. Lancet. 2003;362(9391):122530.
47. Shekelle PG, Pronovost PJ, Wachter RM, Taylor SL, Dy SM, Foy R, et al.
Advancing the science of patient safety. Ann Intern Med. 2011;154(10):6936.
Rattray et al. BMC Medical Education (2018) 18:249 Page 7 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
... These best practices are actionable and are summarized in Table 4. Though similar lists of best practices and handoff protocols are available in the literature, very few have been generated from the perspectives of residents and fellows, and none have represented such a wide range of specialties. [35][36][37][38][39][40] Systems-level recommendations include providing means for reducing distractions, improving resources (such as space and computers), and protecting housestaff time. As for oversight, respondents recommended that a fellow or attending be present during higher stakes sign-outs such as those in the intensive care unit or emergency department. ...
Full-text available
Background: Safe and effective physician-to-physician patient handoffs are integral to patient safety. Unfortunately, poor handoffs continue to be a major cause of medical errors. Developing a better understanding of challenges faced by health care providers is critical to address this continued patient safety threat. This study addresses the gap in the literature exploring broad, cross-specialty trainee perspectives around handoffs and provides a set of trainee-informed best practices for both training programs and institutions. Methods: Using a constructivist paradigm, the authors conducted an explanatory-sequential mixed method study to investigate trainees’ experiences with patient handoffs across Stanford Health Care, a large academic medical center. The authors designed and administered a survey instrument including Likert-style and open-ended questions to solicit information about trainee experiences from multiple specialties. The authors performed a thematic analysis of open-ended responses. Results: 687/1138 (60.4%) of residents and fellows responded to the survey, representing 46 training programs. There was wide variability in handoff content and process, most notably code status not being consistently mentioned a third of the time for patients who were not full code. Supervision and feedback about handoffs were inconsistently provided. Trainees identified multiple health-systems level issues that complicated handoffs and suggested solutions to these threats. Our thematic analysis identified five important aspects of handoffs: 1) handoff elements, 2) health-systems-level factors, 3) impact of the handoff, 4) agency (duty), and 5) blame and shame. Conclusions: Health systems, interpersonal, and intrapersonal issues affect handoff communication. The authors propose an expanded theoretical framework for effective patient handoffs and provide a set of best practices that training programs and sponsoring institutions should implement to protect patient safety. Cultural and health-systems issues must be prioritized and addressed, as an undercurrent of blame and shame permeates the clinical environment.
... Creating a learning culture that emphasizes patient safety should be made high priority. 43,44 ...
Background: The World Health Organization (WHO) Patient Safety Curriculum Guide defines learning objectives for patient safety. Current implementation in healthcare education is insufficient. Possible explanations may be obsolescence and/or a shift in needs. We investigated whether overarching topics and specific learning objectives of the WHO Patient Safety Curriculum Guide are still up-to-date, their attributed importance, and their perceived difficulty to achieve. Methods: Experts on patient safety and medical education from 3 European countries were asked to suggest learning objectives concerning patient safety using group concept mapping. Following 3 successive steps, experts rated ideas by importance and difficulty to achieve. Correlation analyses investigated the relationship between those. Overarching topics of the learning goals (clusters) were identified with multivariate analysis. Results: A total of 119 statements about intended learning objectives on patient safety were generated, of which 86 remained for sorting and rating. Based on multivariate analyses, 10 overarching topics (clusters) emerged. Both the learning objectives and the overarching topics showed high correspondence with the WHO Patient Safety Curriculum Guide. Strong correlations emerged between importance and difficulty ratings for learning objectives and overarching topics. Conclusions: The WHO Patient Safety Curriculum Guide's learning goals are still relevant and up-to-date. Remarkably, learning objectives categorized as highly important are also perceived as difficult to achieve. In summary, the insufficient implementation in medical curricula cannot be attributed to the content of the learning goals. The future focus should be on how the WHO learning goals can be implemented in existing curricular courses.
... In an extension of our previous work on how residents prepare for and communicate during end-of-shift handoffs Frankel et al. 2012;Rattray et al, 2018, Rattray et al. 2019, this study focused on integrated findings from cognitive task interviews with an analysis of video recorded handoff encounters. We argue that three types of handoffs-day to night, night to day, and double handoffs-involve distinct characteristics and are sensitive to different contextual clues. ...
Full-text available
End-of-shift handoffs occur when physicians transfer care responsibilities from one shift to another. Typically viewed as a straightforward exchange of information, we argue that several contextually relevant factors shape the communication behaviors of outgoing and incoming residents during handoffs. Digital recordings and transcripts of resident handoffs in medicine and surgery were made at three VA Medical Centers. They were triangulated with cognitive task interviews that elicited residents’ reconstructions of their work practices. Analyses revealed clear distinctions among “day-to-night,” “night-to-day,” and “double handoffs” that involve transitions between day and night teams. Although residents preferred handing off in dedicated, quiet spaces, few (16%) occurred in such settings; 28% contained significant interruptions. The quality handoff artifacts (notes and forms) influenced interactions, especially in cases where multiple residents from different teams were involved, requiring incoming residents to adjust “on the fly.” This study demonstrated that there are multiple contextual factors that affect, and are affected by, handoff interactions. The findings suggest that handoffs are less like the delivery of a telegram (unidirectional) and more like complex adaptive systems (products of interactional co-construction). Teaching communication practices based on interaction complexity may reduce errors and adverse outcomes for hospitalized patients.
Full-text available
Objetivo: Conhecer as práticas de transferência de responsabilidade entre plantonistas nas unidades de terapia intensiva da Aliança Mundial para a Segurança do Paciente garantia da segurança do paciente através de uma revisão do tipo integrativa. Metodologia: A pesquisa caracteriza-se como Revisão Integrativa da Literatura – RIL, este método permite inferir resultados a partir de múltiplos estudos publicados anteriormente. Resultados: Após todo o procedimento metodológico, a busca resultou em um total de 59 artigos. Desses, 24 foram encontrados na base de dados PubMed, 33 na plataforma Google Acadêmico, e 02 no LILACS as demais plataformas não apresentaram resultados que estivessem de acordo com os critérios de seleção. Portanto, 54 destes não estavam de acordo com os critérios de elegibilidade do presente estudo. Conclusão: Apesar deste estudo ter um enfoque multiprofissional, notou-se que a maior parte do conteúdo publicado está relacionado às práticas da equipe de enfermagem, havendo uma lacuna de conteúdo específico da equipe médica e de outros profissionais. Logo, sugere-se a investigadores e estudiosos que voltem seus olhares para este assunto, especialmente aos pertencentes ao âmbito da medicina, a fim de proporcionar melhores possibilidades de prover uma assistência profissional livre de riscos e danos à segurança de pacientes e contribuir para a produção científica nesta área.
Full-text available
Objective: The overall purpose was to understand the effects of handoff protocols using meta-analytic approaches. Background: Standardized protocols have been required by the Joint Commission, but meta-analytic integration of handoff protocol research has not been conducted. Method: The primary outcomes investigated were handoff information passed during transitions of care, patient outcomes, provider outcomes, and organizational outcomes. Sources included Medline, SAGE, Embase, PsycINFO, and PubMed, searched from the earliest date available through March 30th, 2015. Initially 4,556 articles were identified, with 4,520 removed. This process left a final set of 36 articles, all which included pre-/postintervention designs implemented in live clinical/hospital settings. We also conducted a moderation analysis based on the number of items contained in each protocol to understand if the length of a protocol led to systematic changes in effect sizes of the outcome variables. Results: Meta-analyses were conducted on 34,527 pre- and 30,072 postintervention data points. Results indicate positive effects on all four outcomes: handoff information (g = .71, 95% confidence interval [CI] [.63, .79]), patient outcomes (g = .53, 95% CI [.41, .65]), provider outcomes (g = .51, 95% CI [.41, .60]), and organizational outcomes (g = .29, 95% CI [.23, .35]). We found protocols to be effective, but there is significant publication bias and heterogeneity in the literature. Due to publication bias, we further searched the gray literature through and found another 347 articles, although none were relevant to this research. Our moderation analysis demonstrates that for handoff information, protocols using 12 or more items led to a significantly higher proportion of information passed compared with protocols using 11 or fewer items. Further, there were numerous negative outcomes found throughout this meta-analysis, with trends demonstrating that protocols can increase the time for handover and the rate of errors of omission. Conclusions: These results demonstrate that handoff protocols tend to improve results on multiple levels, including handoff information passed and patient, provider, and organizational outcomes. These findings come with the caveat that publication bias exists in the literature on handoffs. Instances where protocols can lead to negative outcomes are also discussed. Application: Significant effects were found for protocols across provider types, regardless of expertise or area of clinical focus. It also appears that more thorough protocols lead to more information being passed, especially when those protocols consist of 12 or more items. Given these findings, publication bias is an apparent feature of this literature base. Recommendations to reduce the apparent publication bias in the field include changing the way articles are screened and published.
Full-text available
Training hour reductions for resident physicians have resulted in fewer opportunities for novices to manage critically ill patients. Our goals were (a) to understand differences in how novices and experts notice and interpret clinical cues using sepsis as an exemplar and (b) to develop simulations that replicate clinical cues to facilitate acquisition of expertise. Researchers conducted 14 critical decision method (CDM) interviews with four novices (interns), four senior trainees (senior residents), and six faculty (expert) physicians. We interviewed across a spectrum of experience to better assess for experience-based differences in sepsis recognition. Investigators analyzed transcribed interviews using a card sort technique. Experts described more hypothesis testing and violated expectations than novices. Expert–novice differences in sepsis recognition informed the design and future piloting of training scenarios that require novices to seek, interpret, and act on relevant cues.
Most writing on sociological method has been concerned with how accurate facts can be obtained and how theory can thereby be more rigorously tested. In The Discovery of Grounded Theory, Barney Glaser and Anselm Strauss address the equally Important enterprise of how the discovery of theory from data-systematically obtained and analyzed in social research-can be furthered. The discovery of theory from data-grounded theory-is a major task confronting sociology, for such a theory fits empirical situations, and is understandable to sociologists and laymen alike. Most important, it provides relevant predictions, explanations, interpretations, and applications. In Part I of the book, "Generation Theory by Comparative Analysis," the authors present a strategy whereby sociologists can facilitate the discovery of grounded theory, both substantive and formal. This strategy involves the systematic choice and study of several comparison groups. In Part II, The Flexible Use of Data," the generation of theory from qualitative, especially documentary, and quantitative data Is considered. In Part III, "Implications of Grounded Theory," Glaser and Strauss examine the credibility of grounded theory. The Discovery of Grounded Theory is directed toward improving social scientists' capacity for generating theory that will be relevant to their research. While aimed primarily at sociologists, it will be useful to anyone Interested In studying social phenomena-political, educational, economic, industrial- especially If their studies are based on qualitative data. © 1999 by Barney G. Glaser and Frances Strauss. All rights reserved.
Background: Poor-quality handoffs have been associated with serious patient consequences. Researchers and educators have answered the call with efforts to increase system safety and resilience by supporting handoffs using increased communication standardization. The focus on strategies for formalizing the content and delivery of patient handoffs has considerable intuitive appeal; however, broader conceptual framing is required to both improve the process and develop and implement effective measures of handoff quality. Methods: Cognitive task interviews were conducted with internal medicine and surgery residents at three geographically diverse US Department of Veterans Affairs medical centers. Thirty-five residents participated in semistructured interviews using a recent handoff as a prompt for in-depth discussion of goals, strategies, and information needs. Transcribed interview data were analyzed using thematic analysis. Results: Six cognitive tasks emerged during handoff preparation: (1) communicating status and care plan for each patient; (2) specifying tasks for the incoming night shift; (3) anticipating questions and problems likely to arise during the night shift; (4) streamlining patient care task load for the incoming resident; (5) prioritizing problems by acuity across the patient census, and (6) ensuring accurate and current documentation. Conclusion: Our study advances the understanding of the influence of the cognitive tasks residents engage in as they prepare to hand off patients from day shift to night shift. Cognitive preparation for the handoff includes activities critical to effective coordination yet easily overlooked because they are not readily observable. The cognitive activities identified point to strategies for cognitive support via improved technology, organizational interventions, and enhanced training.
Background: Evidence shows that suboptimum handovers at hospitaldischarge lead to increased rehospitalizations and decreased quality of health care. Purpose: To systematically review interventions that aim to improve patient discharge from hospital to primary care. Data Sources: PubMed, CINAHL, PsycInfo, the Cochrane Library,and EMBASE were searched for studies published between January 1990 and March 2011. Study Selection: Randomized, controlled trials of interventions that aimed to improve handovers between hospital and primary care providers at hospital discharge. Data Extraction: Two reviewers independently abstracted data on study objectives, setting and design, intervention characteristics,and outcomes. Studies were categorized according to methodological quality, sample size, intervention characteristics, outcome, statistical significance, and direction of effects. Data Synthesis: Of the 36 included studies, 25 (69.4%) had statistically significant effects in favor of the intervention group and 34 (94.4%) described multicomponent interventions. Effective interventions included medication reconciliation; electronic tools to facilitate quick, clear, and structured summary generation; discharge planning; shared involvement in follow-up by hospital and community care providers; use of electronic discharge notifications; and Web-based access to discharge information for general practitioners. Statistically significant effects were mostly found in reducing hospital use (for example, rehospitalizations), improvement of continuity of care (for example, accurate discharge information), and improvement of patient status after discharge (for example,satisfaction). Limitations: Heterogeneity of the interventions and study characteristics made meta-analysis impossible. Most studies had diffuse aims and poor descriptions of the specific intervention components. Conclusion: Many interventions have positive effects on patient care. However, given the complexity of interventions and outcome measures, the literature does not permit firm conclusions about which interventions have these effects.
Speed in acquiring the knowledge and skills to perform tasks is crucial. Yet, it still ordinarily takes many years to achieve high proficiency in countless jobs and professions, in government, business, industry, and throughout the private sector. There would be great advantages if regimens of training could be established that could accelerate the achievement of high levels of proficiency. This book discusses the construct of ‘accelerated learning.’ it includes a review of the research literature on learning acquisition and retention, focus on establishing what works, and why. This includes several demonstrations of accelerated learning, with specific ideas, plans and roadmaps for doing so. The impetus for the book was a tasking from the Defense Science and Technology Advisory Group, which is the top level Science and Technology policy-making panel in the Department of Defense. However, the book uses both military and non-military exemplar case studies.
Entrustable professional activities (EPAs) provide a framework to standardize medical education outcomes and advance competency-based assessment. Direct observation of performance plays a central role in entrustment decisions; however, data obtained from these observations are often insufficient to draw valid high-stakes conclusions. One approach to enhancing the reliability and validity of these assessments is to create videos that establish performance standards to train faculty observers. Little is known about how to create videos that can serve as standards for assessment of EPAs.The authors report their experience developing videos that represent five levels of performance for an EPA for patient handoffs. The authors describe a process that begins with mapping the EPA to the critical competencies needed to make an entrustment decision. Each competency is then defined by five milestones (behavioral descriptors of performance at five advancing levels). Integration of the milestones at each level across competencies enabled the creation of clinical vignettes that were converted into video scripts and ultimately videos. Each video represented a performance standard from novice to expert. The process included multiple assessments by experts to guide iterative improvements, provide evidence of content validity, and ensure that the authors successfully translated behavioral descriptions and vignettes into videos that represented the intended performance level for a learner. The steps outlined are generalizable to other EPAs, serving as a guide for others to develop videos to train faculty. This process provides the level of content validity evidence necessary to support using videos as standards for high-stakes entrustment decisions.