Challenges for conducting and teaching handovers as collaborative conversations: an interview study at teaching ICUs

Case characteristics

– Diagnostic uncertainty

– Complexity

– Treatment progress

Individual characteristics

– Experience

– Familiarity with patient

– Handover preferences (own and others’)

– Treatment preferences (own and others’)

– Orientation towards personal agenda (e. g., appearing competent or selling a point of view)

– Weariness

Group characteristics

– Group size

– Distribution of experience

– Familiarity with patient

– Organizational values/culture regarding handover utility

– Social safety (e. g., ability to ask questions)

Workflow characteristics

– Formally available time

– Time of handover

– Number of patients to hand over

– Urgency of patient care and overall workload

– Opportunities to discuss patients at other times during the shift

An appropriate amount of detail to illustrate or support the story must be communicated

‘Your assessment of the case, especially the difficult ones, should be supported with arguments and findings so that your colleagues can reflect and fully understand the problem.’ Intensivist, hospital 3

‘I think it’s challenging, being concise to keep everybody focused but at the same time adding enough detail so people will understand why things happened the way they did.’ Intensivist, hospital 1

‘In many situations, you don’t need the details such as respiration rate and support settings if you provide the right context and a good summary. […] For instance, if a patient who has had heart surgery […] keeps bleeding, and a lot is required to keep pressures up, you’ll be illustrating the gravity of the situation with some numbers.’ Intensivist, hospital 1

‘I know generally what kind of handover to expect from my colleagues. A concise handover from one; from another a handover with details that I personally do not think are relevant, or with considerations I would not mention […] One person has lots of confidence, the other has less, and that seeps through in their handovers.’ Intensivist, hospital 1

‘What I find important may not be what my colleague finds important. So I recommend [residents] to do one thing. The next day my colleague instructs them otherwise. For [residents] it is very hard knowing when you are doing it right. And that is the point, you never can.’ Intensivist 4, hospital 1

‘We hand over 20 to 24 patients […]. That means I cannot memorize 10 details per patient, I only have a limited number of mental slots per patient available.’ Intensivist 6, hospital 1

Handovers must be adapted to receiver experience to an appropriate extent

‘The receiver determines how you hand over. […] When I hand over to a staff member, […] I outline the patient in more abstract terms. When the receiver is less experienced, I provide the same outline, only with more explanations of the how’s and why’s, and the pitfalls along the way. For instance, I could point out that ventilation problems of a patient with COPD are not resolved simply by increasing ventilation pressures, as you normally would. I do this to prevent the development of unnecessary problems or harmful events.’ Fellow, hospital 1

‘As a resident it’s nice to know the daily ins and outs, as I will need to handle those things. A supervisor is more interested in the overall goals and long-term plans.’ Resident, hospital 1

Doubts, suspicions and considerations must be communicated to an appropriate extent

‘[Omitting suspicions] can be dangerous: If there’s a suspicion of internal bleeding in the stomach but this is not communicated across the shift, and your colleague finds a thrombotic leg and starts anticoagulants, the patient might die.’ Intensivist 1, hospital 2

‘If you don’t communicate your uncertainties, where you’re at in making sense of the situation, chances are that your colleague will spend another 4 to 6 hours before reaching the same level of understanding that you had. So tell them, ‘I don’t know. I’ve considered this and this, it’s not improving’.’ Fellow 2, hospital 1

‘I do report if I’m not sure of something. I’d nuance the strength of my diagnosis. […] But I wouldn’t express too many of my suspicions as I might bias someone towards a certain direction, which may not be wise since it’s only my perspective.’ Fellow 1, hospital 1

‘It’s especially dangerous when handovers consist of overly ‘polished’ reports and justifications; to appear more competent, to avoid discussions, or to ‘sell’ a point-of-view. ’ Intensivist 3, hospital 1

‘An experienced sender knows exactly how to control a handover, what to tell and what not to in order to start or avoid a discussion. […] If one presents himself being so certain, it’s difficult for the audience to wonder ‘what if it’s not …?’ […] The real art of handing over is to have a vision, but not to push your point too heavily.’ Fellow 2, hospital 1

There must be ample opportunity to reflect and debate

‘I think it’s good to discuss certain patients with the new team: ‘couldn’t this be the problem, or this, or should we try this, or this?’ I know not everybody’s a big fan of this.’ Intensivist 2, hospital 2

‘Since we frequently do our shifts alone, the handover offers a good opportunity to test your plans or diagnoses with a colleague, and you can discuss your decisions for the complex cases.’ Intensivist 2, hospital 3

‘Discussions are about the things of importance: about starting or stopping an intervention, ‘have you considered this or this?’. It’s not about prescribing aspirin, it should be about the things that could make a difference. ’ Intensivist 2, hospital 2

‘It is often the staff members who initiate a dialogue: ‘why have we done this, should we try this as well?’ […] But it leaves me thinking: ‘we’ve gone through this already during the multidisciplinary rounds’. […] A fresh perspective could be good, but often it’s too much, nothing new comes up and discussions drift away from what is immediately important.’ Resident 1, hospital 2

‘I still find it difficult to balance the desire to address things that could have been done differently, and the desire to have someone going home with the feeling they have […] done a good day of work.’ Intensivist 3, hospital 1

‘I have had times [as a resident] in which I felt others were accusing me of poor judgment, for instance, when they asked me why I chose option A rather than B. I immediately assumed they felt I should have gone for option B. […] I think the problem is for the most part the recipient of the question, who is tired and feels vulnerable after a long shift.’ Intensivist 4, hospital 1

There must be ample opportunity to incorporate teaching

‘If the case is so complex that discussions are needed, the educational aims of the handover are set aside. If the patient will benefit from the discussions being held, this becomes more important than ensuring the lesser experienced resident entirely gets it.’ Fellow, hospital 1

Sure, you must never be afraid [to ask questions]. That is very important as a young resident, when everything is new. You might doubt, ‘is it okay to do so?’, but asking questions is never wrong. Resident 1, hospital 2

‘Sure sometimes things are not always clear to me, like ‘why is this person given this type of antibiotics and not this one?’ Or ‘why was this chosen and not that?’ But I will not always ask. Often, you can look things up. It depends on the atmosphere and the time pressure.’ Resident 3, hospital 2

‘We are limited: depending on how many patients we have, we need all the time we have to go by all patients. But if there is time, and there is a problem where more than one person can learn from […] than the handover might be the best time to offer some teaching. Provided that you stay within the time slot.’ Intensivist 7, hospital 1

There must be ample opportunity to incorporate organizational learning and strengthening of shared values

‘I wanted others to learn from my experience and said ‘that is why we want such patients going straight to the OR and not to us first.’ […] I wanted to make sure we all agree that we cannot let things like this happen again. But, although I think that we as a team should discuss such things, you could also question whether the handover is the right time. It can be distracting, and if you’re not careful, it will take up a lot of time.’ Intensivist 3, hospital 1

‘Because I think communication should always lead to doing the right thing. That means we must incorporate learning into our communication. If we do this structurally, we will reach a higher level as a team, and patients will profit from this. If you use communication only to manage care […] you will only be putting out fires.’ Fellow 1, hospital 1