Handover performance in a health care
setting: a literature review
Master thesis, Msc Supply Chain Management
University of Groningen, Faculty of Economics and Business
June 20
th, 2016
Name: YUE DU
Student number: S2954974
Email: y.du.4@student.rug.nl
Supervisor: Prof. dr. Jan de Vries
Co-assessor: Prof. dr. J. Wijngaard
drs. ing. H.L. (Henk) Faber
Preface
Abstract
Background: During a medical process, different steps are combined to form a medical process chain. Clinical handover is the interface between these care steps within or between healthcare organizations. The performance of the complicated clinical handover plays a key role in the continuity between different departments in hospitals. However, current research on this field is still scarce. Therefore, further studies concentrating on the clinical handover performance is of great necessity. Main aim: The main aim of this study is to present an overall analysis of the clinical handover performance by conducting an in-depth exploration of its influential factors and how these factors can affect the performance.
Method: This study has been undertaken as a literature review to summarize and analyze the main findings explored from existing papers.
Result: In total, 17 papers met the inclusion criteria and were included in this review. 12 factors that can affect the clinical handover performance were identified and further analyzed in detail. Findings show that the completeness, efficiency and effectiveness of clinical handover performance can be affected by the identified factors.
Limitations and recommendations: Limitation of this study is mainly related to the limited number of cited papers because of time constraints, and therefore the conclusion of this study is not universal. More papers can be included and analyzed in the future. Also, a need for taxonomy of the factors is identified.
Content
Abstract ... 3
1.Introduction ... 5
2. Theoretical background ... 7
2.1 Clinical handover ... 7
2.2 Clinical handover performance ... 9
2.3 The Conceptual model ... 12
3.Methodology ... 13
3.1 Research design overview ... 13
3.2 Paper selection... 14
3.3 Content extraction and taxonomy ... 16
3.4 Quality assessment ... 17
4. Result ... 19
4.1 Study demographics ... 19
4.2 Category 1: Factors that influence the information transmission performance: 21 4.3 Category 2: Factors that influence the responsibility and accountability transmission performance ... 22
4.4 Category 3: Factors that influence the power transmission performance ... 24
4.5 Result for the quality assessment ... 25
5. Discussion ... 26
6. Conclusion ... 29
Appendix ... 31
1. Introduction
During a medical process, different steps are combined to form a medical process chain. Clinical handover is the interface between these care steps within or between healthcare organizations. The Australian Commission on Quality and Safety in Health Care has identified clinical handover as one of its top priorities (Priority Area 5) for work in 2007-2008(Ming Chao Wong, Kwang Chien Yee ,Paul Turner,2008). However, research shows that a large number of healthcare adverse events are associated with clinical handover: Retrospective reviews of malpractice claims showed that 20% to 24% of medical errors resulted from clinical handover errors; Cases also showed that 43% of the clinical communication breakdowns involved handovers; A review of 146 surgical errors found that 41 (28%) were associated with handovers (Jeffcott, S. A., Evans, S. M., Cameron, P. A., Chin, G. S. M., & Ibrahim, J. E, 2009). As a result, studies concerning the clinical handover topic are of great necessity in order to explore the main reasons behind these adverse events and further improve the overall healthcare performance.
Realizing the importance of clinical handover, different experts have conducted a series of studies. An increasing number of articles focusing on various aspects of the clinical handover process have been published: Clinical information sharing in handover process (Rached, M., Bahroun, Z., & Campagne, J. P, 2015; Bond, S. D., Carlson, K. A., Meloy, M. G., Russo, J. E., & Tanner, R. J, 2007; Smeulers, M., Lucas, C., & Vermeulen, H., 2014); Communication errors happened in inefficient handovers(Iacono, M. V., 2009; Manser, T., & Foster, S., 2011; Poot, E. P., Bruijne, M. C., Wouters, M. G., Groot, C. J., & Wagner, C., 2014); Responsibility handover in a health care setting (Thomas, M. J., Schultz, T. J., Hannaford, N., & Runciman, W. B., 2013; Pezzolesi, C., Schifano, F., Pickles, J., Randell, W., Hussain, Z., Muir, H., & Dhillon, S., 2010; Wayne, J. D., Tyagi, R., Reinhardt, G., Rooney, D., Makoul, G., Chopra, S., & DaRosa, D. A., 2008) etc. In 2008, the EHSRG clinical handover team wrote a peer-reviewed article regarding the field of clinical handover. This article highlighted the complexity of the clinical handover process and the need to consider the interaction between people, technology, and the environment when developing interventions to improve clinical handover performance (Yee et al., 2008). Although it is recognized by many authors that the performance of the complicated clinical handover plays a key role in the continuity between different departments in hospitals (Smeulers et al., 2014), relevant studies are still limited and fragmented (Stoyanov, S., Boshuizen, H., Groene, O., Van der Klink, M., Kicken, W., Drachsler, H., & Barach, P, 2012). The main reason for the scant research is that the clinical handover performance is typically determined by various influential factors. Existing studies mainly focus on one or two influential dimensions, which cause limitations on their results. It is discussed by Botti(2009) that in complex clinical handover situations, factors such as culture, behavior, environment, etc. can all affect the performance of clinical handover process. However, a systematical multi-faced study regarding those factors has not yet been researched (Botti,2009). Therefore, integrating and analyzing interventions of the performance of clinical handover remains a critical issue. This study aims to solve this issue by presenting a comprehensive view of this field, which is also the main focus of this study.
overall analysis of the clinical handover performance. This study will conduct an in-depth exploration of its influential factors and how these factors can affect the performance. One comprehensive review of the related published literature will be chosen as the methodology to achieve this goal. By reviewing and filtering relevant handover materials, all related influential factors will be extracted and analyzed in detail. From a practical perspective, the framework provided can help healthcare managers have a better overview of the various interventions of clinical handover performance, and thus help them to improve the performance from different perspectives. Also, the result of this literature review will enrich the existing theoretical knowledge of the clinical handover field by providing a comprehensive summary of clinical handover performance and its influential factors.
Based on all statements elaborated above, this study introduces the following Research Questions:
RQ1:What are the identified factors that can influence the clinical handover performance?
RQ2:In what way do the identified factors influence the clinical handover performance?
2. Theoretical background
The theoretical foundation of the study is divided into two parts. In the first part, an overview of the clinical handover is presented, including a summary table of the existing clinical handover definition, which can help enhance the understanding of clinical handover. In the second part, studies of the clinical handover performance are introduced to build a basis for this research.
2.1 Clinical handover
What is clinical handover? Although an increasing number of articles referring to this topic can be found in different journals, seldom does literature give a formal definition of this phrase(Abraham, J., & Reddy, M. C., 2010). From a broad perspective, Vidyarthi (2006), who focuses on the challenging aspects of clinical handovers in his article, defines clinical handover as ‘the transfer of information and professional responsibility and accountability between individuals and teams.’ Similarly, another article with the core idea of improving overall patient handoff conditions, describes the phrase as ‘the process of transferring primary authority and responsibility for providing clinical care to a patient from one departing caregiver to one oncoming caregiver.’(Erik Van Eaton, M.D. T, 2010). Clinical handover has also been defined narrowly when the authors study only one specific handover aspect: From a nurse-to-patient perspective, clinical handover is ‘a routine communication forum where nurses provide details about how patients’ medications are managed’.( Liu, W., Manias, E., & Gerdtz, M., 2012) Likewise, articles studying the handover from ambulance to emergency department consider clinical handover as ‘the transfer of information concerning a single patient to the connected doctor or nurse as well as team building, teaching and group cohesion.’(Farhan, M., Brown, R., Woloshynowych, M., & Vincent, C., 2012) Currently, a universally recognized definition about clinical handover does not exist.(Ming Chao Wong et al., 2008) One reason for this is that the clinical handovers involve a complex set of dynamic processes that need to be taken into account (Yee et al., 2006; Wong, M. C., Yee, K. C., & Turner, P., 2008; Yonge, 2008). It is understandable that different articles analyzing different handover process topics will give dissimilar definitions for clinical handover.
Definition of clinical handover
Literature Definitions of the term ‘Clinical Handover’
Key elements identified in the definition
C.care et al., 2001
The transfer of information
and professional
responsibility and accountability between individuals and teams
Information, responsibility and accountability transmission
Erik Van Eaton et al., 2010
The process of transferring primary power and responsibility for providing clinical care to a patient from one departing caregiver to one oncoming caregiver.
Power and responsibility transmission
Wei Liu, et al., 2012
A routine communication forum where nurses provide details about how patients’ medications are managed
Communication forum
Maisse Farhan,2011
The transfer of information concerning a single patient to the connected doctor or nurse as well as team building, teaching and group cohesion.
Information transmission
Chambers, 2001
The transfer of power from one person or group of people to another Power transmission Oakbrook Terrace, 2007 Real-time process of passing patient-specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient’s care
Information transmission
Randell et al., 2011
A process that involves the passing and acceptance of responsibility for some or all aspects of care for a patient, or group of patients, and the sharing of relevant information
Responsibility and information transmission
Toccafondi et al., 2012
The transfers of responsibility and accountability for a patient from one care giver to another
Responsibility and accountability transmission
Philip et al., 2012
Any transition in patient management between stages in a care pathway or between teams dealing with continuing or concurrent care activities.
The National Patient Safety Agency
The transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis
Responsibility and accountability transmission
Table 1: Samples of definitions of the term ‘clinical handover’
According to all the definitions listed above, it can be concluded that a majority of the authors consider clinical handover as a transition process within the health care sector (Bomba, D. T., & Prakash, R., 2005). Transition can be defined as the process and outcome of the interactions between human and environment. It may associate with more than one person and depends on the context and the situation. Transition is not an event, but rather the ‘inner reorientation and self-redefinition’ that people go through in order to incorporate change (Bridges, 2004).
Additionally, key elements that need to be included in the clinical handover process are also explicitly recognized from the definitions. To summarize, the following three elements can be identified:
(1) information transmission
(2) responsibility and accountability transmission (3) power transmission
Therefore ,it can be concluded that the clinical handover is a transition process in terms of information; responsibility and accountability and power. This finding provides the direction for the following clinical handover performance analysis.
2.2 Clinical handover performance
transferred’. Based on this result, this study classified the clinical handover performance as: information transmission performance, responsibility and accountability transmission performance, and power transmission performance. This classification supports the analysis of clinical handover performance in a systematical way.
Information transmission performance
Information transmission happens frequently during the clinical handover process (Philip Scott, 2012). It is the procedure during which all related information is shared and spread in the clinical handover process. It takes place between work shifts and is exchanged both internally and externally between staff and residents within the clinics (Lyhne, S., Georgiou, A., Marks, A., Tariq, A., & Westbrook, J. I., 2012). For the best performance of clinical handover, the information transmission must be complete, accurate and adequately communicated (Philip Scott, 2012). In a health care setting, the media for information transmission lies in different formats of communication (Tucker, A., Brandling, J., & Fox, P., 2009), thus the effectiveness and efficiency of the information transmission in a health care sector can be determined by the effectiveness and efficiency of communication transmission (Smeulers et al.,2014). According to Jeffcott, the information transmission in a health care setting is completed through either verbal communication or written communication (Jeffcott et al., 2009).Verbal communication in a health care sector means face-to-face communication or communication through phone and video chat(Benham-Hutchins et al., 2010). It is the most commonly used form of communication in a health care sector (L.I.Horwitz,2009). As information transmission in this kind of communication happens through direct verbal exchange between people, it is affected by various human factors including the presence of hospital staff, talking habits, presentation skills, etc.(L.I. Horwitz, 2009).Verbal communication also has been found to be preferred by most clinicians and patients(80%) (S.K. Muni, 2015). In contrast, written communication is a means of communication that happens without speaking. Written communication relies on media support like written paper charts and/or electronic records (Benham-Hutchins, M. M., & Effken, J. A., 2010). For instance, nurses use notes written on paper towels or scraps of paper to help them remember patients current conditions; Doctors use e-mails and messages to communicate with patients regarding their conditions regularly and conveniently, etc.( Welsh, C. A., Flanagan, M. E., & Ebright, P., 2010)Because of time constraints and widely dispersed patients(I. Philibert, 2009), direct human contact between clinical staff and patients cannot always occur. With the increasing development of communication technology, written communication is more frequently used as a method to transfer information in health care sectors. In this case, factors such as the choices of media types, current communication technology level, and writing skills can all influence the performance of information transmission(Jeffcott et al., 2009).
Both communication methods are built to ensure sufficient information transmission in clinical handover, It was deemed that all information needs to be provided in a prioritized, clear, concise and chronological manner to ensure a smooth clinical handover process (Smeulers et al., 2014).
Responsibility and accountability transmission performance
transmission needs to guarantee that patients’ satisfaction and safety are ensured after the patients have been transferred to another responsible party (Wayne et al., 2009). Where and when the transfer occurs can be dynamic. The transmission of responsibility and accountability can happen between teams, at points of resident transition (e.g. to another setting) or between different levels of care (Lyhne et al., 2012); Also, differing perceptions are given about when ‘complete transfer’ of responsibility and accountability actually occurr, either by the end of the handover communication(Wilson et al., 2007) or at the actual commencement of work(Chin et al., 2012). Some clinical staff feel that their responsibility and accountability is ongoing even after they have handed it over to the staff on the following shift (Chin et al., 2012). The placement diversity and time discontinuity can lead to complex performance of responsibility and accountability transmission. Hence, the means of analyzing the clinical responsibility and accountability as well as its influential factors in an organized fashion, is currently being studied.
Although used synonymously, responsibility and accountability are discrete concepts (Emanuel EJ, Emanuel, LL, 1996). Responsibility is a personal attribute that can be delegated whereas accountability represents an organizational attribute, which is often mandated and cannot be delegated (Emanuel et al., 1996). In this case, both individual and team factors in a health care sector can influence the performance of responsibility and accountability transmission. Individual factors mainly focus on the human factors. Generic human factors relevant to clinical handover include elements of teamwork; situation awareness; leadership; communication; trust; etc. (Pezzolesi, C., Schifano, F., Pickles, J., Randell, W., Hussain, Z., Muir, H., & Dhillon, S, 2010). As for team factors, professional skills, management decisions as well as supporting facilities can be of importance (Botti et al., 2009). Different expertise level, clinical policy, responsibility allocation, resource allocation and capacity management can all bring different results of responsibility and accountability transmission(Linda L et al., 2014 ).
Power transmission performance
In a health care sector, different staff members all have their own obligations and duties, and accordingly hold different levels of power (Vidyarthi et al., 2006). A power owner is the person who acts as the main leader of one clinical step and who can make the final decision during one handover step.(Vidyarthi et al., 2006) The power transmission between clinical handover steps can be described as the changing of power owners. During a handover process, the power owner changes from one caregiver to another. The power owners in a health care sector are not only experts who are at high levels of hierarchy (for example, health care managers, nurse coordinators and attending physicians), but can also be low level staffing such as bed-side nurses. Also, power transmission in a health care sector not only crosses those at comparable levels of experience, expertise, and equivalent levels of a hierarchy (for example, attending physician to attending physician), but can also cross differential levels of staffing, such as from a primary caregiver to an on-call provider; handover across specialties (from an anesthesiologist to a post-anesthesia recovery room nurse); handover across settings(from the Emergency Department(ED) to the intensive care unit(ICU)); handover between professional health care providers and family caregivers (discharging from a hospital setting to an in-home setting),etc. (Van Eaton, 2010).
there is tight senior control in all levels of staffs because of the hierarchy system. High level staff members always think they should make every decision in the work without sharing power to low level staff members. Sutcliffe (2004) reported that power control can be a barrier to shared discussion and clarification requests, and it can cause problems with difficult upward channels of communication (junior staff often lack the chances to speak up), role ambiguities, and conflict (Sutcliffe et al., 2004). All problems can lead to an inefficient clinical handover process performance. Power ambiguity is another factor that many authors suggested to affect the power transmission performance (Riesenberg, L. A., Leisch, J., & Cunningham, J. M., 2010; Gardiner et al., 2015; Farhan et al., 2012; Agarwal et al., 2012; Kapadia & Addison, 2011; Klim et al., 2013; Lyhne et al., 2012). At present, most health care sectors do not have a uniform policy or procedure regarding handover power allocation (Riesenberg et al., 2009). Therefore the decision-makers are always those people who stand on the upper level in clinical hierarchy systems (health care managers, nurse coordinators and attending physicians etc.), although decisions can theoretically be made by low level staff members themselves. Hence, authors highly recommend standardized handover policies defining individual power, to give working staff adequate clarity of the scope of their power for efficient performance (Farhan et al., 2012; Cohen et al., 2010).
2.3 The Conceptual model
Based on the theoretical background, one conceptual model is shown in Figure 1. The main aim of this study is to present an overall analysis of the clinical handover performance in terms of its influential factors and how these factors affect the performance. As shown in the figure, the clinical handover performance is analyzed from three perspectives: information transmission performance, responsibilities & accountability transmission performance and power transmission performance. Therefore, in terms of RQ1, this study explored and listed all factors that can affect the clinical information transmission performance, responsibility and accountability transmission performance and power transmission performance. In terms of RQ2, the way in which these factors affect the performance will be measured from multiple assessment perspectives (for example, the completeness, effectiveness or efficiency of clinical handover performance).
In the following Chapters, data will be presented through a comprehensive literature review and further analysis will be given.
RQ2
RQ2 RQ1
Figure 1: the conceptual model
3 Methodology
The chosen methodology and detailed research steps are introduced in this Chapter. An overall research design plan is first given, followed by all the steps this study carried out.
3.1 Research design overview
This study was conducted as a literature review based on the original guidelines proposed by Fink(1998). In general, literature reviews have two goals: Firstly, they summarize existing state of knowledge by summarizing patterns and subjects. Secondly, they identify the conceptual content of one field and contribute to theory development (Harland CM et al., 2006). Fink(1998) wrote in his article that: ‘A literature review is a systematic, explicit, and reproducible design for identifying, evaluating, and interpreting the existing body of recorded documents’. Because the main aim of this study is to conduct an in-depth exploration to identify, evaluate and interpret the factors that can affect handover performance, a literature review appeared to be the most appropriate approach. By reviewing and filtering relevant handover materials from all cited resources, useful data was extracted and generated for further analysis.
The whole study was conducted using the adapted process model proposed by Mayring (2003), who considered that the literature review should be divided into three steps:
1. Paper selection: As the first step of literature review, paper selection means published literature related to the topic was selected as the data source of this study. In the first round of paper selection, all relevant papers were collected by online key words searching through different channels. Afterwards, the yielded papers were further filtered using detailed exclusion criteria. Finally, the remaining papers that met all the criteria were included in this study and analyzed in detail.
2. Content extraction and taxonomy: After confirming all the qualified papers that could be included in this study, for the next step, the content of these cited papers were analyzed. In order to present the result in a systematical way, useful content was extracted from the cited papers and further organized into different categories. This provided a clear logic for further analysis and evaluation.
3. Result evaluation: As the last step of the literature review, the presented result was analyzed and discussed based on the established categories. This allowed identification of relevant issues and interpretation of results.
Figure 2: visualized methodology overview
3.2 Paper selection
Initial searchIn total, 105 papers were initially cited in this study. The papers selected in this study were cited by using online key words searching. In order to enlarge the searching field, key words used in this study not only included ‘handover’, ‘clinical handover’ but also included words like ‘handoff’, ‘patient transfer’, ‘clinical interface’, etc. A detailed form showing all the key words used in this study is given in table 2 below.
Table 2: Key words used in the searching
This thesis primarily used Google Scholar as the main searching engine and the gateway for various database including ScienceDirect, Wiley Online, EBSCOhost and Web of science. In total, 105 articles were yielded by key word searching. Furthermore, when scanning the content of target articles, some identified articles in reference lists of those cited papers were also selected and searched. Table 3 below shows the detailed number of articles found through each channel.
Key words used in the searching
Key words used
clinical handover, clinical handoff, interface in hospitals ,patient transfer, clinical handover definition; clinical handoff definition; clinical handover concept; clinical handoff concept
handover process ;handoff process
handover performance ; handoff performance
handover influential factors, interventions of clinical handover
Channel used Cited papers
ScienceDirect 63
EBSCOhost 4
Web of science 14
Paper selection
Initial literature collection by key words searching through different channels
Further literature filtering using exclusion criteria
Content extraction and
taxonomy
Useful content of the cited literature was extracted and further categorized for a systematical review
The result of the literature review was presented and interpreted. Further issues were identified. Result
Table 3: Channel used in the searching
The yielded 105 papers were published in different journals, Table 4 below presents a detailed summary of the number of papers found in each Journal.
Journal No. of Papers Journal No. of Papers American Journal of Medical Quality
5 International Journal of Production Research
1
Anesthesia and Analgesia 2 Joint Commission Journal on Quality and Patient Safety
1
Australian Critical Care 5 Journal for healthcare quality : official publication of the National Association
for Healthcare Quality
5
Australian Health Review 3 Journal of Clinical Nursing 6
BMJ quality & safety 3 Journal of Evaluation in Clinical Practice
2
Critical care medicine 1 Journal of health services research & policy
4
Current opinion in anesthesiology
1 Journal of Hospital Medicine 3
EMA - Emergency Medicine Australasia
6 Journal of hospital medicine (Online) 1
Emerald insight 11 Journal of Paranesthesia Nursing 1
Emergency medicine journal : EMJ
3 Journal of Surgical Education 1
Health Services and Delivery Research
2 Journal of the American Medical Informatics Association : JAMIA
3
Injury 1 Medical Education 1
Internal and Emergency Medicine
6 Nursing in Critical Care 2
International Journal for Quality in Health Care
10 Nursing management (Harrow, London, England : 1994) 1 International Journal of Clinical Leadership 1 Nursing Outlook 1 International Journal of Evidence-Based Healthcare
3 Quality & safety in health care 6
International Journal of Human-Computer
Interaction
1 The Medical journal of Australia 6
Work 1
Table 4: Journals cited in the searching
Wiley Online, 22
Emerald, 2
Paper exclusion
Although initially 105 papers were cited using the key words searching criteria elaborated above, many papers were not qualified after further analysis. Therefore it is particularly important to define clear boundaries to delimitate the research. In this context, five important notes are made:
1. Language: Only materials written in English were included in the research
2. Year: Studies published before 1990 were not taken into consideration to ensure the timeliness
3. Origin: Only literature published in formal Journals was considered. Media discussion and notifications were not included; Similar articles with duplications were removed.
4. Subject: This study aimed at presenting an overall analysis of the clinical handover performance by conducting an exploration of its influential factors. Papers with abstracts clearly unrelated or unconsolidated to this research subject were not considered; Papers with vague descriptions of the factors were removed. 5. Qualification: Non-empirical studies that included the authors’ assumptions or
personal views without supporting data were excluded.
Finally, 17 papers were identified to be eligible for detailed full-page analysis and were included in the framework. In order to show the whole procedure of literature exclusion in a more visualized way, one commonly used diagram called PRISMA is given in Figure 3 below (Moher D, 2009). In which the whole process is divided into four phases: Identifying, Screening, Selecting and Including. All related literature is included in the reference list which is listed at the end of this thesis.
3.3 Content extraction and taxonomy
In total, 17 qualified papers were included in this study, for the next step, the content of these cited papers was analyzed. Because not all the information provided in the cited papers was useful to this study, only relevant content was extracted from the cited papers for further analysis. Based on the main aim of this study, content related to the influential factors of clinical handover performance and how these factors can
affect the performance was extracted from the 17 cited papers. One detailed form can
be found in Appendix 1, showing respectively all the relevant extracted content from the 17 cited papers.
Because the 17 papers analyzed different influential factors respectively. It is disorganized to present all the factors and their influences all together. In this case, the 17 papers were categorized in order to give the result in a systematical way. Based on the extracted content, it was found that all papers discussed at least one aspect of clinical handover performance, namely: information transmission performance, responsibility and accountability transmission performance and power transmission performance. Therefore, the categories were designed from these three perspectives: Category1: Papers with content analyzing factors that can influence the information transmission performance
Category2: Papers with content analyzing factors that can influence the responsibility and accountability transmission performance.
Category3: Papers with content analyzing factors that can influence the power transmission performance
All cited papers from different searching channels (N=105) Duplications removed (N=74) Papers related to performance of clinical handover and its influenced factors (N=32)
Full-Paper assessed after identification for appropriateness (N=23)
Non-English removed. Old studies removed (>1990). Media discussion and notifications removed
Paper removed after screening the titles and abstracts
Paper removed after reviewing introduction Paper included in detailed synthesis (N= 17) Id e n ti fi cat io n Sc re e n in g El ig ib ili ty In cl u d e d
Paper with vague descriptions of the factors removed; Non empirical studies removed.
could be classified into more than one category. The three categories provided a clear logic for further analysis and evaluation in this study. The final results of this literature review were presented using these three categories.
Figure 3 : PRISMA flow diagram
3.4 Quality assessment
It was important to ensure the quality of all cited papers in this study to ensure the validity and reliability of the result. Firstly, the chosen papers in this study were all from top journals written by highly-educated authors as listed above, and this to some extent ensured the quality of the sources included. In order to further prove the validity and reliability of the selected papers, this thesis followed the Quality Checklist suggested by Kitchenham and Charters. This checklist aims to check the overall validity issues related with the various phases in the selected papers. Six quality related questions needed to be answered to assess the validity and reliability of all selected papers. The questions are shown as following:
Q1:Are the study objectives in the selected papers clearly stated? Q2:Are the variables used in the selected papers adequately measured? Q3:Are the measures used in the selected papers fully defined?
Q6:Are all study questions in the selected papers answered?
4 Result
The result section is divided into two parts. In the first part, basic information of the cited papers is presented and analyzed, (including the paper numbers, authors, publication year, published Journal, related methodology and category etc.) in order to give the demographics of the study. In the second part, the results for the content extraction are given in terms of the three categories. All cited factors and their influences are systematically presented in the second part .
4.1 Study demographics
The whole study identified 105 articles in total. Finally 17 papers met the inclusion criteria and were included in this review after full-text screening. In this study, each included paper was assigned a unique identification number as ‘PNX’ (Paper Number X, for instance, PN1, PN2, PN3…) for reference. Table 5 below gives an overview of the basic information of all 17 cited papers.
Paper number(
PN)
Main
Author Published year Published Journal Methodology Category
1 Liu, W 2012 International journal of nursing studies 290 hours of participant observations,72 field interviews, 34 hours of video-recordings 1
2 Sujan 2014 Book ： Clinical
handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO): primary research. A multidisciplinary qualitative research approach: semi-structured interviews and observations 1，2 3 Abraham 2010 International journal of medical informatics Qualitative data collection techniques including observations and interviews 1，2，3
4 Manser 2011 Best practice & research Clinical anesthesiology Literature review 1,2 5 Jensen 2013 Acta Anaesthesiologica Scandinavica Literature review 1,2,3
6 Thomas 2013 Journal for
Healthcare Quality An analysis of incident reports 1
7 Philibert 2009 Quality and Safety
in Health Care, combining qualitative
interviews and surveys
1,3
Review questionnaire, observations and interviews
9 Jeffcott 2009 Quality and Safety
in Health Care A fully literature review 2,3
10 Welsh 2010 Nursing outlook a qualitative,
descriptive pilot study with semi-structured
interviews
1,2
11 Botti 2009 Med J Australia Mixed qualitative interviews, questionnaires observations and surveys
1,2
12 Burton 2010 Journal of hospital medicine
a qualitative study by observation and survey
1,2,3
13 Patterson 2010 The joint
commission journal on quality and patient safety A literature review 1,2,3 14 Dawson 2013 Emergency Medicine Australasia A literature review 1,2 15 Pezzolesi 2012 International journal for quality in health care Mixed methods include a literature review, and consultations with a panel of experts 1,2,3 16 Riesenberg 2009 Academic
Medicine A systematic review thorough, of English-language articles 1 17 Ye 2007 Emergency Medicine Australasia A mixed qualitative study with observation and survey 1,2
Table 5:Basic information of the cited papers
From the table, it can be seen that the oldest study was conducted in 2005 (PN8). 2 studies were conducted between 2005 and 2008(12%); 11 studies were published between 2009 and 2012(65%) and 4 studies were conducted after 2013 (24%). Because most of the studies were published after 2009 (15 out of 17, 88%), this ensured the timeliness of this study. All selected papers were journal papers except one from a book chapter (PN2). All cited papers came from different Journals except PN14 and PN17 were both published in Journal ‘Emergency Medicine Australasia’, as well as PN7 and PN9 both published in Journal ‘Quality and Safety in Health Care’. For the methodology part, all selected papers used a qualitative research approach. The related methodology includes observation(7/17,41%),survey(4/17,24%),interviews(8/17,47%),questionnaires(2/17,1 2%) and literature review. (7/17,41%)
of clinical handover performance and thus were classified into all three categories.(PN3,5,12,13,15); Nine papers analyzed two perspectives of clinical handover performance and were classified into two categories(PN2,4,7,8,9,10,11,14,17). The remaining three papers [PN1,6,16] analyzed only one specific type of clinical handover performance and were classified into one category.
4.2 Category 1: Factors that influence the information
transmission performance:
Papers in Category 1 analyzed factors that can influence the information transmission performance. In total, 16 papers were classified into this category.[PN1-8,10-17] A high degree of consistency was found, in that all related studies highlighted the importance of communication during clinical information transmission. Verbal communication is regarded as the most frequent and significant form of information transmission based on the argument of [PN2] and [PN7]. Verbal communication means face-to-face communication or communication through phone and video to exchange information. In this way, information transmission happens through direct verbal exchange between people. Based on an interview result reported in [PN7], interviewees showed a preference for verbal, interactive handover. However, [PN2] pointed out that verbal communication relies on memory and the sender may filter information depending on perceived importance, and therefore verbal communication may be unstructured and confusing, leading to fragmental information transmission, which hampers the effectiveness of information transmission performance. Moreover, the completeness of information transfer is also affected by verbal communication. For instance, [PN5] identified that although face-to-face conversation is preferred by most respondents, a lack of ‘active listening’ and absent-mindedness during the conversation can lead to information loss. In addition, a reporting analysis in [PN16] presented that during verbal conversation, language barriers can also affect the effectiveness of information transmission.
As another communication form reported in [PN5,6,8,10,13,16], it is obvious that written communication also plays an important role in clinical information transmission process. Written communication happens through media support such as written paper charts and/or electronic records. With the increasing development of communication technology, written communication is more frequently used as a method to transfer information in health care sectors. [PN10] conducted a polite study to analyze the written communication during clinical handover and found that the formulization of written communication remains a problem that can influence the effectiveness of information transmission. Because there is a lack of handover protocols to standardize the written format and content, both too much and too little written communication occurred during clinical handover. Written communication happened based on nurses’ own writing preferences, and this led to misinterpretations or wrong statements of information, as well as information loss or unnecessary information accumulation[PN10]
Clinical hierarchy system was identified in 2/17(12%) papers as another factor that
talk ,speak out and ask questions. Residents are not likely to hand off work to more senior residents, because rigid restriction on residents’ actions prohibits such behavior. This is reported in [PN1] and [PN16] to hamper the completeness of information transmission.
4/17 papers(24%) identified Information technology(IT) as a factor in this category[PN3,4,5,17]. [PN3] and [PN4] both reported that hospitals use the electronic medical record(EMR) system to support their handover work. This system collects handover information in different departments together and stores the information in an electronic format. A systematical report review given in [PN4] shown EMR-based handover can help reduce the information loss, handover duration and human typing errors, and thus enhancing the completeness, efficiency and effectiveness of information transmission performance. Also, IT systems were reported to help formulate the handover process.[PN4,PN5] A survey in [PN17] shown that the majority of professionals preferred a formal centralized process, facilitated by IT, to better transfer information [PN17], as they believed formulization improved their working efficiency.
The completeness of information transmission can be hindered by the far distance between two departments reported in [PN5][PN7]and[PN8].Communication breakdowns regarding medication information happen during patient transfers across the hospital and ward spaces. One survey in [PN7] showed that patients are normally dispersed across different departments and locations in an institution, and as a result, residents have to walk significant distances to have face to face contact with patients. Residents often responded that the far distance was an inconvenience and information gaps always happened during the handover transmission, leading to a low efficiency of work. In addition to the distance, [PN12][PN13] presented that a large and quiet working space away from main traffic area can support handover conversation free of distraction, which can increase the accuracy of handover performance. In contrast, factors such as noise, lighting and crowding are potential threats to high-quality handover performance for residents [PN4][PN14][PN16]. [PN4] concluded all these negative factors as environmental distractions and argued that these distractions can hamper the effectiveness of information transmission performance.
One interesting and unexpected finding in this literature review is that nurses’
self-interest was reported in 2/17(12%) papers as a factor to influence the information
transmission performance.[PN3,14] According to one interview finding with a clinical staff reported in [PN3], nurses are able to “hide beds” in their departments by blocking the available bed information to other departments. The report summarized that different clinical staff members may have different motivations and private needs, which this study named self-interest. However, deliberate information blocking can largely hinder the completeness of information transferred and lead to discontinuity in the handover process.
4.3 Category 2: Factors that influence the responsibility and
accountability transmission performance
All papers in Category 2 analyzed factors that can influence the responsibility and accountability transmission performance. In total , 14 papers were classified into this category.[PN2,3,4,5,7,8,9,10,11,12,13,14,15,17]
sector, authority is allocated to different departments based on department functions. There should be explicit handover protocol to determine the authority allocation in a health care setting to clarify individuals’ responsibility[PN13]. However, a common phenomenon was identified in three cited papers, that at present, there are few guidelines for who is responsible for what transfer process and how the transfer of responsibility for the patient actually took place[PN5][PN7][PN9]. The ambiguous responsibility allocation can result in responsibility loss, which damages the completeness of responsibility and accountability transmission performance.
Whether responsibility and accountability transmission in a health care sector is effectively completed depends highly on the professional skills of professionals. As stated in [PN7], good professional diagnostic skills can raise clinicians’ decision-making accuracy and task management ability. For example, an advanced understanding of clinical conditions and likely contingencies allows the physicians to prepare well for the upcoming tasks, and thus taking their full responsibility .
11/17(65%) papers identified teamwork as an influential factor in this category.
[PN2,4,5,7,8,9,10,11,13,14,15]
Research conceptualized patient handover as a team-based activity. Teamwork in clinical handover gathers different functions of different departments. The effectiveness of both patient care and patient transfer activities depend heavily on smooth collaboration between the sending and receiving clinical departments. [PN3] One important characteristic of teamwork analyzed in several papers was trust ([PN2][PN7][PN9][PN11][PN14]). Staffs from different departments and organizations have to work together and trust one another in order to avoid duplication and to provide best possible care[PN7]. Low trust in a team can lead to a lack of confidence in one physician’s judgement on the information provided by another physician. A physician may check the provided information again by himself/herself, and this action largely affects the efficiency of responsibility and accountability transmission between two parties [PN14]. In addition, working teams in a health care sector need responsible leaders to direct the handover process [PN9][PN15]. As clinical handover is a transition process that happens between different departments, the main leader is also changed during the process. The leader of one responsible team holds the main power and command, so he/she needs to direct the handover process[PN9][PN15] and make the final decision to ensure every team member performs his/her responsibility and accountability effectively.
As stated by Philibert,(2009), clinical handover is time-constrained. Therefore timeliness is important for the clinical handover[PN7,10,12]. During the time-constrained clinical handover, clinicians’ responsibility and accountability can be truncated or omitted, as there is not enough time to manage every step well[PN7]. During the interviews in [PN10], it was reported that because of time constraints, handover nurses who receive the patients always have limited opportunities or are even unable to have contact with the former nurses during a handover process. As a result, some important but subsidiary handover steps may be ignored, which can harm the completeness of clinical responsibility and accountability transmission performance. Also, it was reported in [PN12] that inconsistent start time, prolonged duration of handoff, and excessive time waiting for former reports can all hinder the efficiency of responsibility and accountability transmission performance.
hospitals[PN14],clinical handover has been pointed out to be ‘ mostly unstructured, informal and error prone’, and the majority of
doctors noted that there is no standard or formal procedure for clinical handover[PN8][PN9][PN17]. In this case, responsibility and accountability may be omitted during transmission.
Department goal was the last factor identified in 3/17(18%) papers that can affect
the responsibility and accountability transmission performance.[PN2,3,13] The professionals in different departments hold different goals and will take different approaches to treat patients. The investigation result presented in[PN3] shown that while the ED (Emergency Department) pays more attention to an expeditious diagnostic evaluation and steps for immediate pain relief, inpatient departments such as NSD (Nutritional Service Department) focus on therapeutic care and longer term treatment. Consequently, when patients are transferred between the two departments, the main goal of the received department may be ignored by the former department, and this can lead to information or treatment gap. In this case, the completeness of responsibility and accountability transmission performance can be hampered.
4.4 Category 3: Factors that influence the power transmission
performance
All papers in Category 3 analyzed factors that can influence the power transmission performance. In total ,7 papers were classified into this category[PN3][PN5][PN7][PN9][PN12][PN13][PN15]
.
Clinical hierarchy system was the only factor that identified in 7/17 (38%) papers as
an important factor affecting power transmission performance in a health care sector.
Although hierarchy systems are commonly used in most clinics, both high level staff and low level staff should have their own authority. However, because of the clinical hierarchy system, high level staff members always believe that they should control every step in the handover process and make each decision by themselves [PN1,3,10]. It was reported in paper [PN1] and [PN10] that tight senior control was a commonly seen phenomenon in one health care setting as a result of the clinical hierarchy system . Low level nurses in the study are always bounded by high level nurses, only following the instructions from nurse coordinators, even though situation showed low level nurses can make decisions themselves. It seems that the accuracy of power transmission is difficult to be ensured. One solution for this problem lies in a need for explicit handover protocols to clearly identify the authority allocation in a health care team [PN13][PN15], instead of solely following the clinical hierarchy system. Moreover, it was cited in [PN3] that patient transfers between clinical departments depend on the bed assignment decisions made by the IPA (Inpatient Access Department)who are non-clinical staff. However, because of the hierarchical power structure in the hospital, the clinical staff have overall control in most patient care activities, and they still believe that they should have the unlimited power in any cases dealing with patient care including patient transfer. Therefore, conflicts often occur when deciding who should hold the decision-making power of patient transfer.
Identified factors (number of papers analyzed this factor)
The way in which clinical handover performance is affected
Information transmission performance
Completeness Efficiency Effectiveness
Communication(13) √ √ Clinical hierarchy system(2) √ IT(4) √ √ √ Distance(3) √ √ Environment distraction(5) √ Self-interest(2) √ Responsibility and accountability transmission performance authority allocation(4) √ Professional skills(5) √ √ Teamwork(11) √ √ Timeliness(2) √ √ handover structure(4) √ Department goal(3) √ √ Power transmission performance Clinical hierarchy system(7) √ Table 6: Summary of the result
4.5 Result for the quality assessment
The quality assessment result is shown in table 7 below based on the quality criteria detailed in section 3.5. Based on the result, most of the papers (12 out of 17) are of “very good” quality. Also, no paper scoring below 3 is included in this study.
Quality assessment result
Quality score Quality level No. of studies
0-2 Poor 0
2-3 Borderline 0
3-4 Fair 3
4-5 Good 3
6 Very good 12
5 Discussion
The main aim of this study is to present an overall analysis of the clinical handover performance by conducting an in-depth exploration of its influential factors and how these factors affect the performance. Based on the results of a comprehensive literature review, a summary form is given indicating all the identified factors and their corresponding influences. The form is given in table 6 above in the end of last section. From table 6, it can be concluded that although various factors were identified from different cited papers, one consistency is found , the influences of the identified factors on the clinical handover performance can all be concluded from three dimensions, namely: completeness, effectiveness or efficiency. This finding is in accordance with the theory of Neely(1995) who stated that completeness, effectiveness and efficiency are the three dimensions from which performance is always assessed.
In total 17 papers were cited in this literature review, 16 papers were cited under Category 1 with findings of 6 identified factors; 14 papers were cited under Category 2 with findings of 6 identified factors; 7 papers were cited under Category 3 with the finding of only 1 identified factor. Table 8 below presents a summary of all identified factors that can affect the clinical handover performance and the number of related papers concluded from cited literature.
Category 1 Category 2 Category 3
Identified factors (number of papers analyzed this factor)
Communication(13) authority allocation(4)
Clinical hierarchy system(7) Clinical hierarchy system(2) Professional
skills(5)
IT(4) Teamwork(11)
Distance(3) Timeliness(2) Environment distraction(5) handover
structure(4) Self-interest(2) Department goal(3)
Total number of involved papers
16 14 7
Table 8: Summary of identified factors with paper numbers
abundant studies on communication(13/17) and environmental factors(8/17), although the other four factors are also identified in this study as affecting the completeness, effectiveness and efficiency of information transmission performance, the number of cited papers is much less than the former two. With only 4 studies claiming that
Information technology(IT) [PN3,4,5,17]can influence the completeness, effectiveness and efficiency of information transmission, and 2 claiming that the clinical hierarchy
system[PN1,16]
and self-interest[PN3,14] can influence the completeness of information. The low number of cited literature impacts the validity of the given conclusion of this study. This finding shows that most existing research studying the clinical information transmission performance only focuses on prevailing areas (communication, environmental factors, etc.). Other important but less recognized factors (Information technology, clinical hierarchy system, self-interest, timeliness,
etc.) are seldom analyzed specifically.
A rich number of papers were also found analyzing the second category (Papers with content analyzing factors that can influence the responsibility and accountability transmission performance)(14/17). This result appears to be a bit surprising as fewer works were predicted to be cited before the study. The reason for this prediction is that the responsibility and accountability transmission performance is demonstrated by many authors to require more definitional and developmental work(Wayne et al., 2008; Lyhne et al., 2012), which shows a shortage of former analysis in this area. Among all identified factors, teamwork is most frequently reported, 11/17 papers pointed out that teamwork in a health care sector can enhance the effectiveness and efficiency of the clinical responsibility and accountability transmission performance through high trust and stable leadership. This view is in accordance with the statement of Pezzolesi (2013) that team factors like leadership and trust are of importance to the entirety of the clinician’s work. However, similar to Category 1, excluding teamwork, other factors were far less identified in published papers. Only 5 papers claim that
professional skills[PN5,7,8,10,15] can affect the effectiveness and efficiency of responsibility and accountability transmission performance; 4 papers claim authority
allocation[PN5,7,9,13], 4 papers claim handover structure[PN8,9,14,17], and 3 papers claim
department goal[PN2,3,13] can affect the completeness of responsibility and accountability transmission performance. Only 2 papers were found stating that
timeliness[PN7,12] can affect the completeness and efficiency of responsibility and accountability transmission performance. The small amount of cited papers again challenges the result validity. In addition, although 14 papers were identified in this Category, the main aims of these papers are scattered. Related aims included exploring the whole clinical handover process(PN8,10); analyzing one typical type of handover(PN2,10,13,18), or presenting as a literature review to summarize the overall clinical handover performance(PN4,5,9,14,15). The responsibility and accountability transmission performance is always found to be only one study dimension in these studies. Seldom are papers cited that carry the specific aim of analyzing clinical responsibility and accountability transmission performance. This finding is interesting, as it again reinforces the statement by many authors, stating that clinical responsibility and accountability transmission requires more definitional and developmental work, as was presented at the beginning of this paragraph.(Wayne et al., 2008，Lyhne et al.,2012) Consequently, the lack of in-depth studies highlights a need for more focus in this field.
of papers found in Category 3 (Papers with content analyzing factors that can influence the power transmission performance) were rare (only 7 papers in all 17 identified papers (7/17)). The clinical hierarchy system is the only factor identified under this category. Based on the results, the effectiveness of power transmission performance is mainly affected by the clinical hierarchy system through tight senior control and strong hierarchy awareness. This finding is in accordance with the statement of Sutcliffe that power gradients can lead to conflicts and redundant control. (Sutcliffe et al., 2004). Because of the extremely scarce and concentrated findings, this study can only conclude that, in general, power transmission performance in a health care sector can be affected solely by the clinical hierarchy system. However, it is believed that this conclusion could be partial and subjective because of the limited number of cited papers.
During the literature review process, this study found that one problem was frequently identified by many papers: A lack of taxonomy for the diverse influential factors(Smeulers et al., 2014; Stoyanov et al., 2012; Iacono, M. V., 2009; Manser et al., 2011; Poot et al., 2014). One detailed taxonomy would greatly assist researchers to cite and analyze the factors without repeating the work. However, the great heterogeneity of existing handover settings and types increases the difficulty of this job. When extracting the useful contents from all cited papers, this study found it greatly complicated to identify and group all the related factors because of the huge difference in backgrounds and topics between different papers. In this case, one suggestion is that a taxonomy for all factors based on factor types or functions can be created in the future research. Some existing theories include the claims of Mari Bott, who considered that the factors can be classified into either Organizational Factors or
Human Factors. Another theory by Botti (2010) claims that the classification can be
conducted from three perspectives named Organizational Perspective, Cultural
Perspective and Behavioral Perspective. Future work can be conducted using these
6 Conclusion
The main aim of this thesis is to present an overall analysis of the clinical handover performance by conducting an in-depth exploration of its influential factors and how these factors affect the performance. Based on the result of a definition exploration of the term ‘clinical handover’, the clinical handover performance in this study was analyzed from three perspectives, namely: clinical information transmission
performance, clinical responsibility and accountability transmission performance,
and clinical power transmission performance. Using the methodology of a comprehensive literature review, 12 total factors that affect the clinical handover performance are summarized after a detailed analysis of the chosen papers(RQ1). Specifically, 6 factors were identified to affect the information transmission performance(communication, clinical hierarchy system, IT, distance, environment
distraction and self-interest), 6 factors were identified to affect the responsibility and
accountability performance(authority allocation, professional skills, teamwork,
timeliness, handover structure and department goal) and 1 factor was identified to
affect the power transmission performance(clinical hierarchy system)(one factor named clinical hierarchy system was found affecting both information transmission performance and power transmission performance) .Based on a detailed analysis of the way in which all 12 identified factors influence the clinical handover performance(RQ2), it can be concluded that the completeness, effectiveness and efficiency of clinical handover performance can be affected by the identified factors. Detailed analysis of the influences was presented in section 4.
Although different factors were cited from different studies. Great heterogeneity was found in the number of cited papers. Among all 16 papers analyzing clinical information transmission performance, 13 papers studied how communication during clinical handover affects the information transmission while only 2 papers studied the factor self-interest. Similarly, in terms of responsibility and accountability transmission performance, 11/17 papers studied the factor teamwork, but only 3/17 papers analyzed the factor timeliness. The high differentiation exposes the narrow scope of present studies on clinical handover performance. This highlights the first limitation of contemporary research. Another limitation found during the literature review is the scarce research on the performance of power transmission during clinical handover. The clinical hierarchy system may lead to extreme power centralization which can hinder the effectiveness of power transmission performance, and this requires more attention from future researchers. Moreover, a lack of taxonomy for the diverse influential factors was identified as the third shortage of the existing studies. The irregular and multitudinous factors present difficulty for future researchers to cite and analyze their needed factors for further study.
The limitation of this thesis is mainly related to the limited number of cited papers. In this study, only 17 papers were included in the detailed analysis because of the time constraints, and therefore the results of this study can be limited in scope. Secondly, 7 out of 17 cited papers in this study used a research method of literature review, which hinders the research validity, as the data extracted from these papers is second-hand. Also, experimental studies cited in this area are rare. More papers combining different aspects of qualitative and quantitative research methods can be included in the research in the future.
