The Art of Effective Handoff Communication Among Medical and Surgery Residents

Abstract

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

The Art of Effective Handoff Communication among Medical and Surgery Residents
Nicholas A. Rattray (VA HSR&D Center for Health Information and Communication,
Roudebush VAMC, Indianapolis, USA)
Mindy E. Flanagan (VA HSR&D Center for Health Information and Communication,
Roudebush VAMC, Indianapolis, USA)
Laura G. Militello (Applied Decision Science, LLC, Dayton, USA)
Paul Barach (Jefferson College of Population Health, Philadelphia, PA, USA; Interdisciplinary
Research Institute for Health Law and Science, Sigmund Freud University, Vienna, Austria.)
Richard M. Frankel (Indiana University School of Medicine, Indianapolis, USA)
Running head: Interaction Complexity in Medical Handoffs
Corresponding author:
Nicholas A. Rattray, Ph.D.
Research Health Scientist, VA HSR&D Center for Health Information and Communication,
Roudebush VAMC, Core Investigator, Regenstrief Institute, Inc., nrattray@iupui.edu, 317-988-
9762
Biographies
Nicholas A. Rattray, Ph.D. is a medical anthropologist with expertise in social determinants of
health, disability, health communication, and implementation science. He is a research scientist
and health services researcher at the Center for Health Communication at Veteran Indiana
Health, Regenstrief Institute, and adjunct faculty in Indiana School of Medicine His current VA
Career Development Award is 5-year study of community reintegration among post-9/11
veterans.
Laura G. Militello, MS, is a cofounder and senior scientist at Applied Decision Science, LLC.
She has been studying decision making in complex settings for over 20 years. Her research
interests include the impact of electronic health records on clinical decision making, strategies
for supporting expertise via technology design and training, and solving real world problems.
Mindy E. Flanagan, PhD, is a research consultant for Health Services Research and Development
at the Roudebush VA Medical Center and senior research scientist at Parkview Health. She has
been conducting health services research since 2005, with focus in handoff communication,
implementation science, health informatics, and mixed methods designs.
Paul Barach, MD, MPH, Maj (ret.) is a cardiac anesthesiologist and surgical intensive care
physician and is affiliated with Jefferson College of Population Health, Philadelphia, PA, USA;
Interdisciplinary Research Institute for Health Law and Science, Sigmund Freud University,
Vienna, Vienna, Austria. Interdisciplinary Research Institute for Law and Science, Sigmund
Freud University, Vienna, Austria. His clinical//research interests include clinical model
development, transitions of care, human factors, performance & quality improvement, and
implementation science.

The Art of Effective Handoff Communication among Medical and Surgery Residents 2
Richard M. Frankel, Ph.D., is Professor of Medicine and Geriatrics at Indiana University School
of Medicine and a senior scientist at the Regenstrief Institute and Indianapolis VA Center
Healthcare Information and Communication (CHIC). He currently directs the IU Division of
General Internal Medicine and Geriatrics Advanced Scholars Program for Internists in Research
and Education (ASPIRE). He has published more than 275 research papers in the area of
physician-patient communication and organizational change.
Acknowledgements: 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 12 -090. 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. We appreciate the efforts of Paige
DeChant, Zamal Franks, and Pam Ebright in data collection and analysis. We thank Dr.
Maddamsetti Rao, Dr. Shakaib Rehman, Dr. Howard Gordon, Christopher Kurtz, Ava Harms,
Angela Kuramoto, Naomi Ashely, and Natalia Skorohod for assistance in recruitment and
logistics, and Rachel Gruber for assistance in preparing this manuscript. We would also like to
thank the VA residents that volunteered to take out of their regular duties to participate in the
study.
Declarations of interest: none
Data Availability: To safeguard the privacy of study participants, the dataset used in the current
study is only available in a de-identified version from the corresponding author upon reasonable
request.

The Art of Effective Handoff Communication among Medical and Surgery Residents 3
Abstract
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” involving 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.
Keywords: health communication, resident handoffs, qualitative research, medical care

The Art of Effective Handoff Communication among Medical and Surgery Residents 4
By day, they are Halstedian heroes—tireless individualists tending to patients with complex
conditions. But by night, as they pass off patient and responsibilities to each other, they morph
into team workers, a role that requires completely different skills. And it’s precisely at the brittle
moment of transition – in the confusing, interstitial space between individual and collective
responsibility – that critical errors occur.
(Mukherjee 2004)
Introduction
This paper describes a study of resident physician handoffs with a focus on the moment
by moment behaviors that constitute a transfer of duties, rights, and responsibilities known as an
end of shift handoff or handover. We move beyond the traditional solution of greater
standardization to reduce variations in handoff accuracy and completeness by focusing on a
number of contextual factors that affect resident interactions during end of shift hospital
handoffs. Drawing on naturalistic observations and corresponding interviews with medical
residents, we analyzed the ways in which handoffs, like any type of conversation, are a highly
choreographed collaboration with each party contributing to their evolution in ways that no
amount of standardization can fully account for or eliminate.
According to Cohen and colleagues (Cohen et al., 2012; Hilligoss, 2014), the exchange of
information during end-of-shift handoffs is an emergent moment co-production built on mutual
influence and tacit assumptions. As such, it is more complex than the purely mechanical
metaphor of a telegram, in which one party independently “transmits” while the other
independently “receives” information. As Mukherjee (2004) suggests, collective and individual
obligations are intertwined in handoff encounters. Residents enter into an interstitial space where
they must adapt to local constraints that include interruptions, time pressures, unanticipated
questions from the receiving resident, changes in patient stability, and prioritization of care tasks.

The Art of Effective Handoff Communication among Medical and Surgery Residents 5
In an extension of our previous work on how residents prepare for and communicate
during end-of-shift handoffs (Militello et al. 2018; 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. Residents who transfer rights, duties, and responsibilities for patients
to one another contribute to a system of distributed cognition based on a mixture of verbal,
electronic and implicit assumptions that support team-based cognition (DeChurch & Mesmer-
Magnus, 2010; Fernandez et al., 2017).
Communication during Handoffs as a Hospital Safety Concern
Handoffs have been defined as “the exchange between health professionals of
information about a patient accompanying either a transfer of control over, or of responsibility
for, the patient” (Cohen & Hilligoss, 2010). Handoffs include transfers between hospitals and
inpatient services, at admission or discharge, and, importantly, at shift changes. Such changes
typically occur as an incoming provider assumes responsibility for an outgoing provider’s
patients (Hesselink et al., 2013). During each handoff, outgoing providers transfer patient
information, optimally in each other’s presence that includes conversational exchanges and may
involve the use of structured forms and other paper or electronic artifacts.
Handoffs and transitions of care have emerged as a major quality and safety concern
globally. A 2010 Joint Commission report found that “miscommunication between caregivers
when responsibility for patients is transferred or handed-off plays a role in an estimated 80
percent of serious preventable adverse events” (Transforming & Healthcare, 2014). In one study,

The Art of Effective Handoff Communication among Medical and Surgery Residents 6
59% of medical and surgical house staff reported harm to patients which arose from poor
handoffs; 12% of those responding regarded the harm as “major” (Kitch et al., 2008). Likewise,
as a result of limitations on duty hours, the number of care transitions and associated handoffs
has increased along with the risk of mistakes and adverse events. (Vidyarthi et al., 2006;
Vidyarthi et al., 2007). While electronic health records (EHR) and integrated delivery systems
are thought to facilitate clinical communication among providers, they also create new sources of
errors (Weir et al., 2003) and may result in sub-optimal rates of face-to-face and telephonic
communication when compared with other industries (Patterson, 2005).
Research in high risk, high reliability settings like medicine and aviation have focused on
the importance of contextual factors for understanding failures and sources of variation
(Eisenburg, Raglia, & Pynes, 2006; Frankel & Saleem 2013; Hilligoss, 2014; Omilion-Hodges &
Swords 2017). In terms of contextual factors that affect handoffs, patient safety risks related to
communication stem in part from the limited amount of time and familiarity residents have with
changing work assignments. In one study, patients admitted to the hospital by a cross-covering
physician (rather than primary physician) had longer inpatient stays and more laboratory tests
performed (Lofgren et al., 1990) underscoring the role of situational factors in creating handoff
outcomes. For example, uncertainty about the patient’s condition at handoff may be a result of an
outgoing provider’s own unfamiliarity with the patient or duty hour restrictions limiting the time
spent discussing each (Duong et al., 2017). Either way, the care process is affected by factors
related to context; not simply to information exchange.
Other contextual factors can influence handoff quality. Distractions, such as ambient
noise, other ongoing conversations, individuals entering or exiting the team room, pager alerts,
phone calls, are all common, with one study observing their occurrence in 78% of handoffs

The Art of Effective Handoff Communication among Medical and Surgery Residents 7
(Hasan et al., 2017). Self- or organizationally imposed time pressures are another source of
uncontrolled variation in handoffs. With a larger number of patients to present and approaching
duty hour restrictions, the amount of time spent on each patient may be decreased (Hasan et al.,
2017; Ong & Coiera, 2011). Similarly, different workflow and responsibilities for day and night
shifts can impact the scope and duration of handoffs having nothing to do with the “facts” that
are communicated and everything to do with the local context and implicit expectations for the
task at hand. For example, Lee and colleagues (2017) found that night to day handoffs included
updates on patient conditions and tasks completed or pending from overnight. Day to night
handoffs, on the other hand, included to-do tasks, contingency plans, explanations for care plans,
and clarifying questions from incoming residents (Lee et al., 2017).
Given the relative paucity of social interaction research on handoffs in the literature, we
chose a discovery-oriented approach for this project. This study aimed to gain insights into key
context-based complexities residents face over a 24-hour shift and the strategies they use to
manage these complexities. Improved understanding of how teams and individuals manage shift
handoffs sheds light on what distinguishes effective handoffs from communication which leads
to medical errors.
Methods
Our study design combined two well-known methods to systematically uncover the
underlying strategies and techniques residents used to enact handoffs that were appropriate for
the time of day, the participants involved, and “stacking” of information in terms of prioritizing
tasks for the incoming resident. The first method was direct real-time observation and recording
of end of shift handoffs. Video-recorded handoffs allowed observation and ratings of non-verbal
behavior, including proximity, posture, eye contact, along with communication quality and

The Art of Effective Handoff Communication among Medical and Surgery Residents 8
setting. The second method entailed cognitive task analysis (CTA) to understand residents “lived
experiences” of handoffs. CTA is useful in understanding how experienced personnel structure
their thinking to make decisions or act in the face of complex task demands (Anonymous, 1998).
The CTA interviews were designed to specifically elicit cognitive strategies that guided the
decisions of residents during handoffs (Militello et al, 2018). Qualitative results are reported
according to COREQ (Tong, Sainsbury, & Craig, 2007).
Data Collection
Data were collected at three geographically distinct VA Medical Centers (VAMCs) over a 14-
month period (April 2015 - June 2016). The three VAMC were 177, 209, and 220 bed facilities.
At each facility, a local physician-investigator and research staff helped identify residents from
medicine and surgery departments to serve as study participants. We included medicine and
surgery departments to ensure that we could examine a generalist and specialist service. At each
study site, it was determined that these two services included a sufficient number of residents that
would be eligible for the study. The selected residents were then asked to identify colleagues
like themselves, a technique known as snowball sampling (Heckathorn, 2011).
All observed handoffs occurred on medicine or surgical wards. All participants were
contacted and consented prior to observing handoff and interviews. Observed handoffs were
video recorded from a tripod mounted camera and separately audio recorded with a high-quality
micro audio recorder. A research assistant was present during the observed handoffs. Audio
recordings were professionally transcribed and deidentified for analysis. Day-to-night and
night-to-day handoffs were observed and used as reference points during the subsequent CTA
interviews. We observed handoffs involving two to five residents. In total, 148 handoffs were

The Art of Effective Handoff Communication among Medical and Surgery Residents 9
video recorded. In some cases, residents were observed multiple times. For the present analysis,
we randomly selected one video per resident, resulting in 64 observed handoffs.
After being recorded, residents participated in a one-hour semi-structured CTA interview,
consisting of an adapted critical decision method interview (Crandall, Klein, and Hoffman,
2006). Participants were asked to recall their last transfer of care and describe 4 to 5 major steps
during that handoff. Cognitive probes were used to explore cues, goals, strategies, and
information needs during each step of the transfer process as well as the use of handoff tools and
training/experience (See online Appendix 1 for the interview guide). The CTA interviews were
audiotaped and transcribed verbatim. Research team members checked the quality of transcripts
by comparing them with recordings to identify and correct inaccuracies. Participants received a
$100.00 gift card for completing the interview. Ethics approval was obtained from the IU
University Institutional Review Board and VA Medical Center Human Subjects board prior to
recruitment.
Data Analysis
Data from video observations and CTA interviews were analyzed using immersion/crystallization
(Borkan, 1999), a qualitative research approach that involves multiple reviews of data (immersion)
without making prior assumptions about what one will find until consensus is reached among analyts
(crystallization). Parallel analyses were conducted by the research team for the videotaped encounters
and the cognitive task interviews.
The videos were coded using a structured coding form (see online Appendix 2). The
video coding scheme was a hybrid that incorporated categories from a previous video
observation study of nursing handoffs (O’Brien, 2015) and categories that emerged from the

The Art of Effective Handoff Communication among Medical and Surgery Residents 10
data. A team of 7 analysts viewed the videos and read transcripts of the recordings from each
study site. The analysts were a diverse group and included a sociologist, an anthropologist, a
psychologist, and other health services researchers with qualitative training. The team then
developed a coding form that included resident year, shift (day, night, or evening),
environment/setting (private, interruptions, use of supporting documents), quality of the
exchange (friendly, facial expressions, familiarity), notetaking behavior, body positioning, active
listening on part of the incoming resident, eye contact, and pace. Additional codes were used to
select excerpts related to themes of “uncertainty,” “communication strategies, and “ownership.”
The videos were then divided among three coders to independently code and were tracked in a
database. Next, a team of three analysts used a database program to code 64 videos. As a quality
check, the entire coding team met and viewed 5 videos together to prevent drift. Any remaining
uncertainties about coding were discussed by the entire coding team until consensus was reached.
For the interview data, codebook development began with team members independently
reviewing a sample of CTA interview transcripts. Team members identified portions of text that were
relevant to adjustments made during a handoff to suit the context and gave it a provisional label in open
coding. The team worked together to reach consensus on a codebook, which included the following
codes: anticipatory management, artifact usage, climate, content, errors, goal statement, post-handoff,
preparation, process, questions, recipient design, setting, suggested improvements, training, and
workarounds. One analyst (MEF) reviewed all remaining transcripts to identify segments relevant to each
coding category, using NVivo qualitative analysis software. For the analysis reported in this manuscript, a
team of 3 analysts (MEF, NAR, LGM) independently reviewed a subset of coded excerpts with content
related to how residents used handoff artifacts, dealt with interruptions and distractions in the setting, how
they adapted to handoffs at different shifts or with different teams, meeting on four occasions to discuss

The Art of Effective Handoff Communication among Medical and Surgery Residents 11
interpretations of the data. Candidate findings were shared with the larger project team to incorporate
more diverse perspectives. These meetings also served as a confirmability audit (Lincoln & Guba,
1985); in which specific transcript case examples for each of the code definitions were discussed to
ensure the dependability of the analysis. In the final stage of immersion-crystallization, the broader
study team triangulated the video observations with interviews (Denzin, 2012; Lincoln and Guha
1985). The triangulation strategy involved examining differences and commonalities in how data was
collected across study sites, training levels, and shifts and explored how observed behavior in videos
complemented or contrasted from reported behavior in the CTA interviews.
Results
Sixty-four videos were analyzed, ranging in length from 1 to 20 minutes. Across the three
sites, 35 residents participated in CTA interviews (see Table 1). Most participants (n=23) were
observed and interviewed, and at the same time; 12 participated in interviews only. On average,
interviews were completed within 3 days of observation (5 on same day, longest: 15 days).
First, our qualitative findings focus on a broad overview of the two types of handoffs
observed in our sample: single and double handoffs. Second, we highlight key factors that
influence complexity including the location of the handoff, the use of artifacts, and handoff type.
Third, we describe strategies residents used to manage complexity including deliberately
reducing interruptions, using artifacts to emphasize rather than replace communication, and
flexibility in adapting to the challenges of different types of handoffs.
Single versus double handoffs
We observed handoffs that included two to five residents. In general, the time duration
and physical space allotted for handoffs varied across teams, between facilities, and time of day.

The Art of Effective Handoff Communication among Medical and Surgery Residents 12
For all types of end of shift handoffs, residents met face to face and engaged in brief
conversations about each patient. At two of the sites, single handoffs were used exclusively as
depicted in the left column of Figure 1. In single handoffs, typically three to seven day teams
handoff to a single night team intern (as known as a “night float”). Twelve hours later, the night
team intern hands off to the day teams. Site number three used a double handoff structure,
depicted in the right column of Figure 1. In this handoff structure, the day team hands off to a
single medicine day team called the cross cover team, covering patients on the unit for the
evening. The medicine day teams rotate responsibility for cross cover. The cross cover team
then performs a handoff to a night team, who manage patients through the night and then handoff
to the medicine day teams in the morning.
Factors that Add Complexity to Handoffs
Examining these different types of handoffs, we identified three factors that influenced
complexity: location, use of artifacts, and handoff type.
Interruptions and location. Not surprisingly, we found that the handoff location greatly
influenced the number and type of interruptions and distractions. In our interviews, residents
reported a preference for private, quiet settings without distractions; however, handoffs were
observed in hallways and at nurses’ stations which often had multiple providers conversing and
audible medical alerts. Only 16% (10/64) of handoffs occurred in a private setting with no other
individuals present except the receiver. The majority of handoffs occurred in the residents’ team
room, which was noisy, disruptive, and crowded with as many as eight teams present especially
around scheduled handoff times. One resident explained:
It is just whatever is convenient for the 2 parties involved in the sign-out [handoff] —
every day is a little different. If things are going crazy and you’ve got a sick patient, you
may do sign-out on the ward because that may be more convenient for the person that’s
managing the patient. Alternatively, if everything is fine with the patients, then you’ll do

The Art of Effective Handoff Communication among Medical and Surgery Residents 13
it in a workroom such as this and ideally a quiet workroom, which doesn’t always
happen.
Another resident described the environment as a problem: “There are places where we hand off
where multiple [patient] handoffs are going on at the same time. It’s a problem because it’s hard
to hear, and it’s hot, and it’s crowded, and there is no place to write.”
Interruption was a common theme in the video observations as well: (28%) 18/64 of
handoffs included a significant distraction in which one or more resident’s attention was drawn
away from the handoff. Most interruptions stemmed from pagers going off and incoming phone
calls. As one resident described, “there are a lot of distractions whether I’m the giver or the
receiver and that can decrease the amount of attention that you’re paying to the person who is
telling you something. Sometimes you might miss information that way [information] that you
don’t realize is important.” Handoffs were described as rushed, which made making meaningful
note-taking difficult. One resident explained how “simple things, like standing” can impair the
ability to “write things down that the person tells you …[I] think it just it makes you rush
through it and I think that can make you miss certain details.” In some instances, handoffs
occurred over the phone because a resident was at the bedside caring for a patient. One resident
noted that “receiving a handoff while actively caring for a patient interfered with being able to
recall patient information later.”
Artifacts. Use and availability of supporting artifacts also influenced handoff complexity. A
printed roster of patients usually guided the handoff discussion to allow residents to discuss
patients in sequence. In all but two handoffs, a printed sheet or the electronic health record were
used as supporting documents. Incoming residents often added hand-written notes to the roster as
each patient was discussed, at times using different colored pens to highlight critical issues and
follow up tasks. Especially “sick” patients’ needs were often prioritized and noted as requiring

The Art of Effective Handoff Communication among Medical and Surgery Residents 14
immediate attention or monitoring. Likewise, outgoing residents sometimes held onto the patient
list, adding their own symbols such as circles, checking boxes, and straining to remember
information that might aid the incoming resident. The electronic health record (EHR) was also a
focus of attention; however, some of the observed handoffs occurred in locations where a
computer workstation was not available. This prevented residents from confirming patient care
or laboratory details in real time. Handoffs without EHR access contained minimal patient
information compared with those that did. The only two handoffs that did not use a paper-based
patient list or EHR were transitions from the night to the day team. For the first of these, a white
board containing a list of patients was used. This handoff was not typical in that it was more of a
case discussion between an outgoing resident (first year) and an incoming resident (second year).
The second handoff was based solely on the outgoing resident’s recall of patient events and lab
values.
Handoff type. We analyzed three types of handoffs: day to night, night to day, and cross
cover to understand how each influenced the complexity of the handoff.
The day to night handoff was the most comprehensive. Handoffs of this type included
details such as patient age, history, and reason for admission. Day teams tried to minimize tasks
for the night teams by anticipating and highlighting patient changes likely to occur during the
upcoming shift. This difference in roles was supported by behaviors of both incoming and
outgoing residents. One resident emphasized the importance of experience in anticipating patient
changes when in the outgoing resident role:
Again, it's an art. It's not something you can pick up right away. It's just after you have
signed out again tons of patients, hundreds of patients over months, and you see what
happens to them overnight, you can say oh, this patient has atrial fibrillation and
sometimes they can become very tachycardic... it's hard to make a perfect sign-out
because it's hard to predict exactly what could potentially happen; you want to be

The Art of Effective Handoff Communication among Medical and Surgery Residents 15
thorough and you want to give a person as much information as they could potentially
need.
At the same time, incoming residents focused on their role and knowing what questions
to ask and when. One resident described how he elicited information from the outgoing resident:
“I ask them; I try to ask them you know who is sick. You know “Who do you want me to
keep an eye out on?” And then you know just kind of as we’re going through, you try to
imagine the anticipatory stuff a little bit. You know, “If they call me about chest pain
you know what do you want me to do? If they call me about pain, what do you want me
to do with that?”
At one facility, a primary concern for day-to-night handoffs was the high volume of
patients. Individual residents reported typically having responsibility for 80-100 patients during a
typical night shift.
In contrast to the more detailed day to night handoffs, night to day handoffs were much
briefer, often a single sentence. These handoffs were less scripted and more based on the
approach favored by individual residents. Night residents did not create new handoff sheets, but
rather physically delivered the night shift sheet to the day team. Documentation of changes by
night residents tended to be constrained by limited time and often took the form of brief hand-
written notes. One resident described the night to day handoff in this way:
“The morning handoff is really slimmed down-- if I’m the night doctor handing off to the
day team, I know that this team knows this patient. They’re the ones that told me about
the patient the night before. … The sign-out really then just consists of feedback on
what I followed up for them, what I did about it, any issues that arose overnight that the
day team would not be aware of-- it’s a much shorter and extremely pertinent sign-out
and not inappropriately so.”
Another resident highlighted that the night shift was exhausting given the number of patients one
was responsible for. As a result, the outgoing resident often could not recall every patient but
focused instead only on the most noteworthy events of the night:

The Art of Effective Handoff Communication among Medical and Surgery Residents 16
“When you’re the night team changing over to the day team--you change over to many
day teams (laugh) and you’re exhausted and it’s morning time and you’re trying to
remember what happened. [During] the morning changeover, you do end up saying
“Nothing, no calls on your patients” and you just (laugh) give them the sheet of paper.”
One challenge with double handoffs was that the cross cover resident was not intimately
familiar with each patient which often resulted in fewer details being passed on to the night
resident. During evening handoffs, cross cover residents behaved as if they had only temporary
responsibility for patients and displayed considerable doubt about how to advance care and
which information was truly essential to communicate. Several residents described the quality of
information transferred from the cross cover resident as “degraded” and similar to “playing
telephone.” One resident stated: “as you can imagine with the telephone type thing, information
is lost… as the receiving person on that double sign-out as an intern several years ago, and I
typically don’t make the 2nd person [cross cover resident] sign out to me except for very big
things because all of the information is lost. In that situation, the information is conveyed on the
piece of paper.” Incoming residents played an active role in these handoffs by asking targeted
questions and referring to available written or electric documentation.
Residents’ Adaptative Responses to Complexity
We observed several patterned behaviors that were used to manage complexity during
handoffs. First, residents described specific techniques they used to deal with distractions: for
example, not checking a pager during the handoff (return pages after the handoff); moving to
another space with less distraction (abandoned nursing station, nurse manager’s room); or
completing all handoff-relevant tasks before beginning the next patient handoff. Second, they
maintained accurate and up-to-date printed lists of patients, augmented with hand-written notes,
that allowed for a rapid transfer of care responsibilities, a skill residents reported acquiring over
time. Third, they learned to adjust their strategies based on handoff type by prioritizing

The Art of Effective Handoff Communication among Medical and Surgery Residents 17
information based on their knowledge of patients and their role in advancing care versus
maintaining a steady state until the day team actively resumed care planning and delivery.
Finally, they paid careful attention to communication context sharing information specific to the
challenges they would face in the type of handoff they were engaged in. To accomplish this goal,
residents adjusted their language to the type of handoff and the handoff receiver.
We offer three examples of how these adaptive behaviors affected the different shift
types. One important strategy across these examples is the use of context-dependent, coded
language that residents used based on similar educational backgrounds and an awareness of their
specific hospital work culture and processes. Examples of such coded language were descriptive
terms such as “frequent flyers” for frequently admitted patients, or terms that describe patient
courses, such as “bounce back,” or “crash and burn.”
The first example is from a day to night handoff lasting nine minutes. Figure 2 is a
screenshot from a video recording of the handoff. The handoff took place in a quiet space and the
residents used the EHR as a communication aid in preparing a high acuity patient for discharge,
a family that may need special consideration, among other more routine aspects of care. The
outgoing resident used coded language, alerting the incoming resident about psychosocial factors
that are not often explicitly stated, but adequately communicated.
In this encounter, two outgoing residents (OR1 and OR2) each handoff three patients to
an incoming resident (IR) seated in front of a computer with the EHR displayed. A male resident
(OR1) begins the process by asking, “Mr. X, he is our sickest patient—do you remember him at
all?” OR1 stands up and looks over the shoulder of IR onto the printed handoff list. OR2 offers
anticipatory guidance and instructions on who to contact in the medical intensive care unit if the
patient were to deteriorate on his shift. Next, a female resident, OR3, who is seated, nearby leans

The Art of Effective Handoff Communication among Medical and Surgery Residents 18
in and begins to transfer three consecutive patients. OR3 introduces one patient by asserting,
“We’re trying our hardest to get this man out of here.” She concisely summarizes two patients by
suggesting “I don’t anticipate you’ll get any calls on this guy.” Four and half minutes into the
encounter, OR2 is interrupted by a landline phone call which he takes after three rings. Having
addressed the caller’s request, the interrupted handoff is resumed. OR1 describes useful
ethnographic information for one patient whose family was “extra touchy.” Likewise, he shares
information about another patient hospitalized with congestive heart failure that had “used some
heroin in the ICU.” During this handoff, the team room was quiet and provided an optimal space
for conversing about each patient. Since the IR remained seated, the outgoing residents leaned in
so that they were shoulder to shoulder examining the handoff artifact together.
Figure 3 depicts one outgoing night resident (OR) handing off four patients to an IR in
just one minute and 58 seconds. This handoff illustrates the more cursory interaction typical of
night to day handoffs, as well as several types of complexity, including time pressure, a noisy
setting, and residents unfamiliar with each other. Substantive discussion occurs for a single
patient, including the OR’s rationale for not taking a specific action during the shift. The IR does
not ask clarifying questions, likely because the IR knows these patients well and expects the OR
to highlight any noteworthy developments that occurred during the night shift.
This handoff occurred in a noisy hallway with buzzing and ringing sounds from telemetry
equipment. Both residents were standing. The IR maintained focus on the shared list of patients,
indicating she was listening attentively as each patient was discussed. To open the discussion, the
OR asked, “Which team are you?” The IR replied,” Hi, I’m Team 6.” For two patients, his only
comment was “nothing here.” For another patient where the day team was concerned about acute
coronary syndrome, the OR discussed how he had evaluated the patient during the night and

The Art of Effective Handoff Communication among Medical and Surgery Residents 19
found him sleeping comfortably. The OR noted that he did not “do Heparin or anything,”
indicating his rationale verbally. In this exchange and across the four patients he shared
information about, the IR said “Okay” but did not ask any clarifying questions.
Figure 4 depicts an observed double handoff involving a cross cover resident handing off
to a night resident. A resident from a second medical team is present but is out of the frame. This
handoff illustrates the flexible, adaptive nature of handoffs as the residents discuss who will hand
off first and inquire about the preferences of the IR. The paper-based patient roster is an important
communication tool in this handoff; the OR verbally explains aspects of care that he did not have
time to document. Frequent use of the word “apparently” signals that the cross cover resident is
sharing second hand information that he cannot personally confirm.
Both participants visible in the frame are male first year residents. The handoff occurs in a
dedicated team room. Behind the two residents is a whiteboard covered with phone numbers and
steps for discharge written in black, red, and blue colored marker. As the IR sits down, the OR
hands him two different pagers. Right before they begin, the OR asks if the resident from the
other Medicine Team would like to go first which he declines. The OR asks, “This the White
Team. How do you like sign-out?” As the OR begins, he has a separate sheet for each patient,
which is folded in half. Hand-written notes are written vertically on the back of a handoff sheet.
As Figure 4 illustrates, the residents are positioned such that they both are viewing the same sheet
of paper. In this encounter of 7 minutes and 9 seconds, the residents discuss nine patients. Two
patients were discharged, and all but one patient was described in a few sentences. In the opening
statement, the OR attempts to summarize which patients he visited:

The Art of Effective Handoff Communication among Medical and Surgery Residents 20
OR: “I did get called on [a patient] once for apparently, his blood pressure was like 190s
or 200s. Apparently, he needed to be on tele to get the Levatol IV, so I just put him on the
tele even though I didn’t note it on here.”
IR: “No problem.”
OR: “[Dr. X’s] patients, I didn’t get called on at all. [Dr. Y’s] patients, I didn’t get
call[ed] on at all.
In this interaction, the OR verbally communicated how he had shifted the patient to
telemetry but had not written any documentation. The IR asked clarifying questions about
patients where management or care had changed but had not yet been formally documented in
the electronic medical record.
Taken together, observational and interview data demonstrate how resident strategically
use artifacts to complement information available through the electronic health record and to
efficiently communication in face-to-face encounters. Residents attune their communication
approach in response to interruptions, noise, and lack of pertinent patient information. Outgoing
residents attempt to choreograph information according to the type of handoff and their
perceptions of incoming residents.
Discussion
Our findings revealed a variety of context sensitive behaviors residents exhibited that
were responsive to the types of handoff they were engaged in (i.e., day-to-night, night-to-day, or
double-handoff), and other factors such as the number of patients and teams involved, patient
acuity, physical setting, availability of technology, and use of artifacts. The triangulation of
video recordings with interviews that captured residents’ perceptions about handoffs produced
novel insights, largely missing in the current handoff literature, linking residents’ mental models
with observations of their behavior. Our findings underscore the need for new models of

The Art of Effective Handoff Communication among Medical and Surgery Residents 21
workflow and a broader appreciation of the contextual factors that inform resident work practices
(Vohra et al., 2007).
Roughly two decades after the Institute of Medicine brought attention to the risks
associated with poor communication during transitions of care, error rates remain high despite
numerous efforts at improvement. Historically, most studies and interventions have been based
on a view of handoffs as a mechanical transfer of information. In contrast, our work is aligned
with the idea that handoffs are a moment by moment co-construction between actors operating in
real time and space, interpreting and adapting to the conversational context as it evolves (Barach
& Phelps, 2013). In essence, resident handoffs are a prime example of interaction in a complex
adaptive system.
By observing and recording handoffs directly, we can reach a deeper and more nuanced
understanding of the constitutive interactional rules, variations, and accommodations, by which
they are accomplished. Because these studies are rooted in real-time interactions, we believe that
the knowledge they generate has direct implications for designing training and new practices and
may help explain why many, if not most, interventions based on secondary or tertiary data have
only had a marginal benefit over time (Hesselink et al., 2012).
Given these findings, in this final section, we make a set of recommendations for further research,
and also provide recommendations for how to improve education/training on handoffs. We note that the
latter is speculative as it is based on our qualitative study. Thus, our research recommendations are
designed to capture key elements of our findings and provide concrete steps for continuing research on
this important topic
Narrative as a risk mitigating strategy. In the mechanical handoff paradigm, narrative
form has little purchase since what is being handed off is bullet points of a care plan containing
limited information, mostly devoid of context Cohen et al., 2012). We now know that residents

The Art of Effective Handoff Communication among Medical and Surgery Residents 22
routinely produce narratives that are highly sensitive to the social, clinical, and temporal context
in which they are produced (Rattray et al. 2019). A well-told narrative description of a patient’s
current and projected needs can make the difference between high quality, safe care and
increased task demands, and risk of delays and errors in patient care. Effective narrative in this
context is a skill that requires judgments about what to include, what to emphasize, how much
detail to exclude, and what can be adequately communicated in the context of particular handoff.
Implications. The most important implication of this study is its relevance for graduate
medical education and the techniques that are currently being used to teach residents about end
of shift handoffs. Current medical practice can be characterized as a laissez faire approach to
educating residents about handoffs. Attending physicians have a limited role in educating about
handoff communication, in part, because they are not on site to witness their enactment.
Likewise, most teaching occurs in the classroom and not at the point of care. Similar to evidence
about medication adherence, direct observation of patient behavior, and in this case resident
behavior, produces high fidelity results on which future educational interventions can be based
(Karumbi & Garner, 2015).
The fact that adverse events connected to handoffs continue to be high suggests that more
needs to be done in terms of curriculum development. We, and others, have identified of a set of
context-specific competencies that residents use to adjust their handoff communication (e.g.,
time of day, patient acuity) and environmental factors (e.g., noise and interruptions). Patterson et
al. (2004) described several distinct competencies: improve handoff update effectiveness and
efficiency; increase access to data; improve coordination with others; enable error detection and
recovery; delay transfer of responsibility during critical activities. Many of these competencies
are based on contextual awareness and emergent properties of social interaction that go beyond

The Art of Effective Handoff Communication among Medical and Surgery Residents 23
the mechanics of information exchange. They are, nonetheless, critical components of effectively
handing off duties and responsibilities from one resident to another.
Having identified several communication competencies and contextually sensitive
influences on handoffs, the next question will be how to build them into a teaching curriculum
that is evidence informed and likely to lead to improvement. One answer to this question may lie
in the use of the methods employed in this study, namely videotaping and cognitive task
interviews to help residents review and learn from the data of their own performance during
handoffs and to get feedback on the mental models they employ in enacting handoffs. Video
review has been used successfully to teach communication and relationship skills in a variety of
contexts, including handoffs (Beckman & Frankel, 1994; Frankel et al. 2012). Likewise,
cognitive task analysis has been used to study workflow and mental models of task performance
but has not been used widely in gathering information and providing feedback to residents on
their handoff interactions (e.g., Militello & Hutton, 1998). A curriculum based on interactional
and cognitive competencies could provide a powerful new pedagogy based on real time
observation and a deeper understanding of the cognitive complexities involved in handoffs.
Another implication from this study is the observation that residents are currently chary
of providing peer feedback to one another on the quality and form of communication during
handoffs (O'Brien et al. 2015). In some ways, this is not surprising as residents and some
practicing physicians fear that providing negative or corrective feedback to colleagues may come
back to haunt them. For example, a recent study of faculty reluctance to report medical students’
unprofessional behavior found that fear of reprisal was the leading cause of failing to report
lapses (Ziring et. al., 2018). Creating safe psychological space where residents can share
feedback for improvement with one another without fear of reprisal will be necessary to bring

The Art of Effective Handoff Communication among Medical and Surgery Residents 24
about the necessary changes to education and practice that many organizations are (Leape et al.,
2012; Nofziger et al. 2010; Williams et al. 2007).
This study has several limitations. First, the sample size for this study was small and may
be unrepresentative of residents at VA and non-VA facilities around the country. We attempted
to address the issue of sample size by enrolling residents at three separate VA facilities in
different areas of the country and using maximum variation sampling. Subsequent studies with
larger populations will be necessary to ensure that the competencies identified in our study are
generic and can be taught at scale. This is one of the few studies that relied on videotaping
handoffs in real time and as such can be considered an early qualitative exploration of a
relatively new approach to understanding the dynamics as well as the mechanics of end of shift
handoffs. Second, the use of videotaping to record handoffs, though useful in providing primary
data, may introduce subtle biases such as residents being “on their best behavior” knowing that a
camera is present. We acknowledge that this possibility exists in our data. At the same time,
growing consensus on the effect of recording devices on behavior of research participants
suggests that individuals may alter behavior initially (in the first minute or so) but then return to
typical behavior (Jordan & Henderson, 1995). Even if residents were on their “best behavior” the
gaps and challenges that were observed and enumerated in the cognitive task interviews provide
a rich description of handoff competencies and challenges. Third, although cognitive task
analysis interviews have been designed to increase the accuracy and rich detail of retrospective
accounts, the focus on decisions, judgments, goals, and cognitive strategies, the retrospective
nature of these interviews may leave out contextual details. Conversely observations provide a
clear view of context and important details such as the number of individuals in an interaction
and outside interruptions, but little insight into practitioner decision making. Using these

The Art of Effective Handoff Communication among Medical and Surgery Residents 25
complementary methods, we obtained a more complete understanding of this complex
information exchange, the settings in which the handoff occur, and the key dimensions that shape
the handoff (i.e., responsibility, uncertainty, and advancing care). Given the complexity of a
multi-site study, there is always a risk of drift in themes and reliable data capture. Throughout
the study, a senior qualitative researcher conducted an ongoing internal quality audit, adapted
from previous studies, to determine whether the data were collected, analyzed, and reported
correctly according to the study protocol. Additionally, double handoffs or cross cover handoffs
were confounded with site as these handoffs were only observed at one site. Finally, there may
have been selection bias of residents participating in the study. Participation in this project was
voluntary and may not fully represent the range of resident types and skills.
Conclusions
End-of-shift resident handoffs are a product of social interactions and prone to errors
stemming from miscommunication and inattention to the complex nature of conversations
occurring in chaotic, distracting environments. Handoffs are typically conceptualized as a
mechanical transfer of information from a sender to a receiver where the quality and accuracy of
technical content is the primary focus, in part, because it is believed that these are the elements
that determine the reliability of the handoff. While conveying accurate and relevant information
is critical to an effective handoff, our findings suggest that physical, interpersonal, and emotional
(cognitive) context not only affect handoff quality, they provide the “housing” for directing and
understanding the information exchanged. Furthermore, the types of complexities residents must
manage change based on the location of the handoff, availability of artifacts, and handoff type.
Residents must flexibly adapt the handoff content and style based on the specific context in
which each handoff occurs.

The Art of Effective Handoff Communication among Medical and Surgery Residents 26
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The Art of Effective Handoff Communication among Medical and Surgery Residents 29
Table 1. Video Observations and Interview by Study Sites
Observations
Interviews
Analyzed Handoff
Videos
PGY1
PGY2
PGY3
Total
Site 1
8
0
8
1
9
Site 2
36
14
3
1
18
Site 3
20
8
0
0
8
Total
64
22
8
2
35
Notes: PGY1 = first year postgraduate training level (intern). PGY2 = second year trainee; PGY3 = Third
year trainee.

The Art of Effective Handoff Communication among Medical and Surgery Residents 30
Table 2. Differences in Setting Between Three Types of the Handoffs
Handoff
Setting
Day to Night
(n=31)
Night to Day
(n=18)
Double
Handoff
(n=15)
Total
Yes
No
Yes
No
Yes
No
Yes
No
Private location
5
26
4
14
1
14
10
54
Interruptions
11
20
0
18
7
8
18
46
Use of artifacts
31
0
16
2
15
0
62
2

The Art of Effective Handoff Communication among Medical and Surgery Residents 31
Figure 1: Patterns of Patient Handoffs at Two VA medical facilities
Note: Each column in this diagram represents a 24-hour cycle of handoffs, with each column depicting a
different model. Icons with multiple people represents handoff encounters that include more than one
outgoing resident giving a handoff. Single icons (e.g., night team intern, evening resident, etc.) indicate
encounters where a single person is giving or receiving a handoff.

The Art of Effective Handoff Communication among Medical and Surgery Residents 32
Figure 2: Day to Night Handoff
Note: This is a screen shot of a handoff encounter observed and video recorded. The incoming resident
(IR) is seated in front of a computer screen. Three outgoing residents (OR1, OR2, OR3) are seated around
the IR; over the course of the handoff, each OR discusses patients that are being handed off.

The Art of Effective Handoff Communication among Medical and Surgery Residents 33
Figure 3. Night to Day Handoff
Note: IR = Incoming Resident; OR = Outgoing Resident.

The Art of Effective Handoff Communication among Medical and Surgery Residents 34
Figure 4. Double Handoff Evening Encounter
Note: IR = Incoming Resident; OR = Outgoing Resident.