ORIGINAL REPORTS

Establishing a Conceptual Framework for Handoffs Using Communication Theory Matthew Mohorek, BS and Travis P. Webb, MD Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin BACKGROUND: A significant consequence of the 2003 Accreditation Council for Graduate Medical Education duty hour restrictions has been the dramatic increase in patient care handoffs. Ineffective handoffs have been identified as the third most common cause of medical error. However, research into health care handoffs lacks a unifying foundational structure. We sought to identify a conceptual framework that could be used to critically analyze handoffs. METHODS: A scholarly review focusing on communication

theory as a possible conceptual framework for handoffs was conducted. A PubMed search of published handoff research was also performed, and the literature was analyzed and matched to the most relevant theory for health care handoff models. RESULTS: The Shannon-Weaver Linear Model of Communication was identified as the most appropriate conceptual framework for health care handoffs. The Linear Model describes communication as a linear process. A source encodes a message into a signal, the signal is sent through a channel, and the signal is decoded back into a message at the destination, all in the presence of internal and external noise. The Linear Model identifies 3 separate instances in handoff communication where error occurs: the transmitter (message encoding), channel, and receiver (signal decoding). CONCLUSIONS: The Linear Model of Communication is a suitable conceptual framework for handoff research and provides a structured approach for describing handoff variables. We propose the Linear Model should be used as a foundation for further research into interventions to C 2015 improve health care handoffs. ( J Surg 72:402-409. J Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: handoffs, transition of care, communica-

tion, framework COMPETENCIES: Interpersonal and Skills, Professionalism, Patient Care

Communication

Correspondence: Inquiries to Travis P. Webb, MD, MHPE, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226; fax: (414) 8058641; e-mail: [email protected]

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INTRODUCTION In 2003, the Accreditation Council for Graduate Medical Education mandated resident duty hour restrictions, hoping to reduce sleep loss and fatigue, improve resident education, and improve patient safety. Although the restrictions were successful in achieving some goals, unintended consequences have occurred. One of the consequences included the number of breaks in the continuity of care of patients. Each break must be accompanied by a handoff in which patient information is transferred from one health provider to another. Since the implementation of duty hour restrictions in 2003, resident handoffs have increased by 40%.1 The increase in handoff frequency is concerning because a poor handoff may lead to adverse events.2 Medical error because of a poor handoff is the third most common reason for adverse events leading to patient harm.3 Physicians themselves are wary of handoffs; only 47% of residents in a study felt that their current handoff practice was adequate to ensure patient safety.4 Furthermore, 59% of residents surveyed suggest that one or more of their patients had been harmed by a poor handoff.5 The increased dependence and harm associated with poor handoffs has led to an explosion in handoff research over the last decade. Despite the volume of published studies, much of the research has lacked a clear foundation for exploration of the topic. Consequently, there is no enough research to warrant evidence-based handoff strategies.6 Handoff clarification studies explaining how and why an intervention works are needed rather than descriptive and justification studies explaining what intervention was done and whether the intervention worked, respectively.6 Clarification studies, unlike descriptive or justification studies, “employ each step in the scientific method, starting with observations (typically building on prior research) and models or theories, making predictions, and testing these predictions. Confirmation of predictions supports the proposed model, whereas results contrary to predictions can be just as enlightening.”7 Currently, a foundation for handoff research is absent from the health care literature. It is this article’s goal to propose a foundation for handoff research. A conceptual framework is proposed to clarify the

Journal of Surgical Education  & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.11.002

nature of the problem and guide the development of questions and solutions.8 By analyzing handoffs through the lens of a conceptual framework, researchers can build on previous handoff research and eventually develop evidencebased handoff strategies.

IDENTIFYING AN APPROPRIATE CONCEPTUAL FRAMEWORK After an extensive literature search and dialogue with practicing clinicians, communication theory was chosen as the most appropriate foundation to study handoffs. Specifically, the Linear Model of Communication was chosen as the framework for handoffs. At its core, the handoff is a linear transmission of information from one person to another (the essence of the Linear Model). Our literature search supported this choice; each handoff study could be analyzed through a lens of communication theory using principles developed by the Linear Model. Throughout this article, with the ultimate goal of creating a conceptual framework for handoffs, we show that the handoff can be analyzed with this model. First, we describe the model. Then, we analyze handoffs using Linear Model terminology. Finally, we demonstrate how the Linear Model establishes 3 error zones where problems inevitably arise during handoffs. Throughout the discussion we provide solutions (from handoff literature and our own) to eliminate these error zones.

The Linear Model describes communication starting with a source. The source has a message intended for a destination. To do so, a transmitter encodes the message into a signal, which is then conveyed through a channel. A receiver decodes the signal back into a message for the destination. The result is message transfer from the source to the destination. At every point in this sequence, noise is present and acts to corrupt the message. Internal noise (including physiological, psychological, and semantic noise) corrupts the encoding/decoding of messages/signals. External noise corrupts signals present in channels. According to the Linear Model, the effectiveness of communication is limited only by the ability to accurately encode/decode and the amount of noise present. The Figure demonstrates the Linear Model. The Linear Model accurately reflects handoff communication. To illustrate, physician A and B demonstrate handoff communication with the Linear Model: physician A’s brain (source) has patient information (message) for physician B’s brain (destination). Physician A encodes the patient information into language (signal) by using his brain and vocal cords (transmitter). Language is conveyed through the air via sound waves (channel). Physician B’s ears and brain (receiver) decodes language back into patient information for physician B’s brain (destination). Table 2 takes Linear Model terminology and applies it to the handoff. The utility of the Linear Model is its ability to identify where error occurs during handoffs. It highlights 3 separate error zones in the communication process. The 3 error zones are encoding error, transmission error, and decoding error.

ENCODING ERROR

THE LINEAR MODEL OF COMMUNICATION The Linear Model of Communication was developed by Claude Elwood Shannon and Warren Weaver in 1949 and later supplemented by Melvin DeFleur in 1970.9 It was intended as a mathematical model of communication but was quickly adapted for the social sciences. Shannon and Weaver developed the vocabulary that underlies the Linear Model of Communication, which includes source, message, transmitter, encoding, signal, channel, noise, receiver, decoding, and destination. Table 1 defines important terms.

According to the Linear Model, a source’s message is encoded by a transmitter into a signal. During a handoff, this process amounts to a physician converting his/her thoughts into words. Encoding is the first error zone. Encoding error arises during a handoff because of lack of experience or the presence of internal noise or both.

LACK OF EXPERIENCE Encoding error may occur because the transmitter lacks the experience or knowledge to properly encode a message into

TABLE 1. Linear Model of Communication Terms Term Source Message Transmitter Encoding Signal Channel Noise Receiver Decoding Destination

Definition Responsible for producing the message The bit of information that is intended to be communicated Responsible for turning the message into a signal so that it can be sent through a channel The process of a transmitter turning a message into a signal The message in a form that can be conveyed through a channel Medium over which the signal is sent Anything that can degrade message quality from source to destination Responsible for turning the signal back into a message so that it can reach its destination The process of a receiver turning a signal back into a message The place the source intends the message to be sent

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FIGURE. The Linear Model of communication.

a signal. A physician may be an ineffective communicator or lack training on handoffs. Regardless of the reason, lack of experience causes encoding error that corrupts messages during handoffs. There are solutions to improve a physician’s lack of experience in encoding messages. Educational interventions and use of structured handoff formats are 2 ways to improve an encoding error of this type. Several educational interventions to improve handoffs have been studied. Gakhar and Spencer10 investigated the effect of a didactic/interactive curriculum on handoffs. Similarly, Chu et al.11 investigated whether handoffs improved after combining didactic sessions and practicum experiences. Farnan et al.12 studied the success of a 1-week interactive workshop on handoffs. The use of observed structured clinical examination13 and 2-hour teaching interventions14 were also researched. Web-based learning is an approach much appreciated by residents because of the flexibility it provides for study time.15 Devoge et al.16 and DeRienzo et al.17 separately investigated whether web learning was a viable option for handoff education. Filichia et al.18 developed a handoff computer simulation program that was both web-based and interactive. In studies where handoff quality was measured, researchers overwhelmingly found improvement after educational intervention. This is evidence that educational interventions can help to decrease encoding error. The use of structured handoff formats should also improve the handoff process. In 2006, the Joint Commission recognized the importance of adding structure to 404

handoffs. In national patient safety goal 2e, they included the need to “Implement a standardized approach to handoff communications, including an opportunity to ask and respond to questions,” in an effort to decrease adverse hospital events.19 The most commonly used structured handoff formats in literature include formal-standardized handoff protocols, written and electronic checklists, and mnemonics. Formal-standardized handoffs are common in handoff literature. Specific protocols include clarifications of who should be present for the handoff/who is responsible for the patient, the order in which patient information is transferred, and specific opportunities for questions to be asked. Many studies look at handoff success before and after protocol implementation. Most of the studies show improvement after implementation,20-24 but the reasons TABLE 2. Association of Linear Model to Health Care Handoff Term Source Message Transmitter Encoding Signal Channel Noise Receiver Decoding Destination

Handoff Example Physician 1’s brain Patient information Physician 1’s brain and vocal cords Physician 1 converts thoughts into words Spoken word Air (sound waves) Internal and external noise examples Physician 2’s ears and brain Physician 2 converts words back into thoughts Physician 2’s brain

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are never included. The Linear Model suggests that these protocols work by promoting accurate message encoding even if physicians lack the proper handoff knowledge/ experience. Similar to formal-standardized handoff protocols, written and electronic checklists are commonly implemented as a means to improve handoff structure. According to published literature, written checklists improve handoff communication.25,26 Presently, electronic checklists are getting more attention, and multiple studies27-30 show that they improve handoff quality as well. We found that 2 studies29,30 go as far to say that electronic checklists are superior to their paper-based counterparts. However, researchers fail to answer why the implementation of these checklists are successful. As has been stated previously, the structured handoff facilitates message encoding for physicians who lack proper handoff knowledge/experience. The last way to improve handoff structure is to implement a specific mnemonic as a guide for communication. Riesenberg et al.31 wrote a review solely on handoff mnemonics and found 46 articles with 24 different mnemonics. Situation, Background, Assessment, and Recommendation (SBAR) was the most studied at 69.6%.31 SBAR was developed by the US military as a means to standardize communication during situational debriefings32 but has recently been adapted to facilitate communication in the health care setting. According to some studies, SBAR implementation can improve handoffs.33 However, Wentworth et al.34 found SBAR to be an effective mnemonic only when implemented in an electronic format. Other mnemonics that have been studied include SIGNOUT,35 DeMIST,36 MIST/ASHICE,37 and I PASS the BATON,38 but their effect on handoff quality is still not clear. Current literature cannot definitively conclude whether mnemonics improve handoffs, but the Linear Model predicts that they would, because they provide a structure to improve encoding for physicians who lack proper handoff knowledge/ experience.

INTERNAL NOISE: PHYSICAL AND PSYCHOLOGICAL The second reason encoding error occurs is because the transmitter is distracted by internal noise. Internal noise can manifest as physiological, psychological, and semantic noise. Physiological noise includes any distraction that originates from the body and causes encoding error. Psychological noise is any distraction that occurs from preconceived notions brought into a conversation. Semantic noise occurs when the receiver does not decode a word or expression used as a signal by the transmitter to the same message. We classify semantic noise as decoding error and as such can be found within that heading. Examples of physiological noise include sleepiness, hunger, thirst, necessity to void, and pain. These are distractions

that physicians encounter constantly but can cause major encoding error during handoffs. Despite the obvious implications of physiological noise on handoffs, there exists no literature investigating its effects. Solutions to control this noise are sparse as well. Examples of psychological noise include hierarchy barriers and personal relationship barriers. Both of these examples can generate enough noise to interfere with encoding. Differences in power or status between 2 communicators can easily disrupt information exchange.39 The hierarchal structure that exists amongst doctors is a form of psychological noise that can interfere with message encoding. Multiple studies and reviews have found that communication barriers exist between attending physicians and residents.33,40-42 A study even concludes that these hierarchy barriers lead to direct patient harm.40 Although many have identified hierarchy as a barrier to effective handoffs, few provide a solution to the problem. Physicians agree that medicine cannot do away with hierarchy; most residents and attending physicians find it necessary.40 An idea to overcome hierarchy barriers then is to implement the “Two Challenge Rule.” In aviation, the Two Challenge Rule states that, “A subordinate is empowered to take control if a pilot is clearly challenged twice about an unsafe situation during a flight without a satisfactory reply.”43 Perhaps this challenge rule can be modified to address hierarchy barriers that cause psychological noise during handoffs. Until this internal noise is addressed, it will continue to corrupt encoding. Beyond hierarchy issues, some physicians have incompatible personality traits, communications styles, or both. Although personal relationships may rarely interfere with physician day-to-day operations, incompatible relationships during a handoff create errors in encoding when incompatibility leads to noise. This conclusion is supported by a study that found that residents believe the most important factor impeding communication was comfort with the attending physician and their personality.40 Although not cited in literature, team-building exercises (discussed later in the review) are a potential solution to overcome this noise.

TRANSMISSION ERROR The second error zone during handoff communication is signal transmission. The signal must travel from the transmitter to the receiver via a channel. However, throughout the channel the signal is bombarded by external noise that corrupts it, leading to transmission error. To prevent transmission error, external noise must be limited.

EXTERNAL NOISE External noise from the environment dramatically affects handoff communication quality. Nagpal et al.44 found that

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work environment was the most reported cause of information transfer and communication failure. Chen et al.45 divided handoff distractions into 2 categories: distractions that are nonessential and essential to patient care. Nonessential distractions include extraneous staff distractions, irrelevant side conversations between handoff personnel, and Television/radio/computer background noise. Essential distractions include phone/beeper interruptions, clarification/learning interruptions, overhead pages, and monitor alarms. Regardless of classification, all environmental noise degrades signal transmission. Nonessential distractions are stressed as a key barrier to effective handoff communication in many studies.43,45-49 Despite this, literature that analyzes the effect of nonessential distractions on handoffs is rare. However, a study effectively showed that after creating a handoff environment with a closed door, assigned seating, smaller room, and methods to minimize side conversations, handoff satisfaction increased.48 Another way to decrease nonessential distractions could be through implementation of sterile cockpit methodology. The sterile cockpit is a concept developed by the aviation industry that prevents any aircraft personnel from engaging in activity that could distract performance of duties or interfere with the proper conduct of those duties.49 In aviation, the sterile cockpit has helped to limit nonessential and non–flight-related conversations during crucial times. Although not yet tested, some researchers have proposed that sterile cockpit methodology would help to improve handoff quality.45,47,49,50 Other solutions to nonessential distractions include moving handoffs away from the middle of the day to reduce care disruptions46 and to ensure optimal lighting.43 Finally, proper channel selection can help to limit external noise. A face-to-face handoff is preferred to a telephone or e-mail handoff because it ensures that, “Facial expression, posture, gesture, smell, proximity, and eye contact—is available to participants to help interpret and ‘make sense’ of the information being exchanged.”51 All these solutions can help to limit the external noise associated with unessential distractions. Because it is directly related to patient care, external noise taking the form of essential distractions is more difficult to overcome. For example, pager beeps cannot be avoided. A study reported only 2% of handoffs being beep free.4 Dracup Morris52 acknowledge the chaotic environment of the handoff but encourage limiting these essential distractions as much as possible. Currently, few solutions have been proposed and none have been tested. A proposed solution to eliminate essential distractions is to designate “protected time” in a physician’s schedule where essential interruptions cannot occur.4 Whether essential or nonessential, distractions in the environment work to corrupt signal transmission. If signal transmission is corrupted, the receiver cannot accurately decode the signal back into a message. By limiting external 406

noise, transmission error can be eliminated, leading to better handoff communication.

DECODING ERROR The last error zone identified by the Linear Model is decoding error. This is where the receiver decodes the signal back into the message at the destination. Reasons for decoding error are identical to the previously discussed reasons for encoding error. The first is that the receiver lacks proper knowledge/ experience to decode the signal and the second is that internal noise (physical and psychological) exists, which prevents effective decoding. Solutions to both these issues are discussed in the encoding section. However, with decoding, there is an additional form of internal noise, that is, semantic noise.

INTERNAL NOISE: SEMANTIC NOISE Semantic noise occurs when a word or an expression used as a signal by the transmitter is not decoded to the same message by the receiver. It occurs because of differing mental models, culture, race, gender, age, educational background, and language preference. Unlike psychological and physiological noise, semantic noise only manifests as noise for the receiver. However, both the transmitter and the receiver can work to limit semantic noise. Possible strategies include standardizing vocabulary, improving listening skills, taking notes, improving teamwork skills, and instituting read-backs. Any of these strategies can limit semantic noise and improve signal decoding. Standardizing vocabulary is a logical solution to limiting semantic noise. Kanki et al.53 proved that standardizing vocabulary reduces error in aviation, and similar success is presumed with handoffs. Vocabulary standardization would be especially useful to limit handoff error between 2 physicians who speak different first languages. Solet et al.,43 supporters of vocabulary standardization, argue that colloquialisms should be avoided, linguistic checks and balances should occur, and only the most common medical abbreviations should be used. By limiting semantic noise, the Linear Model helps us conclude that vocabulary standardization is a probable method to decrease decoding error. Improving receiver listening skills is another way to limit semantic noise and can be used to improve handoff communication.42,46,54 Using the HEAR checklist, Greenstein et al.54 investigated which listening skills are used during handoffs and found that passive listening techniques (nodding and eye contact) were used only approximately 50% of the time. Furthermore, active listening techniques (read-backs and note-taking) were being used even less, approximately 25%. No research has investigated the effect of listening skills on handoff quality, but the Linear Model makes us believe that improving receiver listening skills could decrease semantic noise and reduce decoding error.

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Encouragement of note-taking itself is another way to decrease semantic noise. Note-taking can improve communication because the transient messages sent to the destination are made permanent, even if the destination forgets the message. Implementing effective note-taking procedures is part of the problem. While studying implementation, Donnelley et al.55 discovered that an e-mail that contained standardized note-taking instructions and asked/reminded physicians to write notes during handoffs increased note-taking tendencies from 0% to 86%. Although no one has investigated whether note-taking actually does improve the quality of handoffs, the Linear Model leads us to conclude that doing so would decrease semantic noise and decoding error. The Institute of Medicine suggests that patient safety can be improved by using teamwork training in health care. By decreasing semantic noise, teamwork training should be an effective way to improve handoffs as well. When the source and the destination function as a team, signal decoding is more accurate because of mutual understanding between both the team members. An issue that arises when researchers study teamwork’s effect on handoffs is how to measure the level of teamwork. Symons et al.56 studied handoffs using 2 validated teamwork scales: the Observational Teamwork Assessment for Surgery and the Manser scale. Their study found that the scales showed concurrent validity and concluded that there are teamwork scales available that can accurately assess teamwork during handoffs. The scales also indicate that the quality of teamwork varied widely among physicians. Research that proves a relationship between teamwork and handoff quality is still needed, but again, the Linear Model suggests that teamwork would be an effective method to decrease semantic noise and reduce decoding error. The last solution to decrease semantic noise is by implementing read-backs.52,54,57 High-risk industries including commercial aviation, submarine, and nuclear technology use read-backs to ensure mutual understanding.57 Read-backs are a type of verification process that occur during communication to ensure that the message at the destination is identical to the message at the source. If miscommunication occurs at any point in the communication process, an effective readback identifies the error, and the source can resend the appropriate message. A study by Prabhakar et al.57 concluded that most physicians believe standardized read-backs are an effective tool for reducing and preventing adverse events. Beyond preventing decoding error, read-backs are useful for determining if a message was corrupted at any error zone of the Linear Model. In that way, read-backs serve as a “safety valve” for accurate handoff communication.

to explain why messages deteriorate at every step in communication. The model, when used as a framework, allows researchers to identify 3 separate error zones where messages are corrupted. The model not only serves as a framework for handoffs but can also be used to classify the currently disjointed research on handoffs as well. The fact that most of the research fits within the Linear Model’s parameters also lends support to the conclusion that the Linear Model is a suitable framework for handoffs. Therefore, it is recommended that handoff research from this point forward should be studied with the Linear Model as a conceptual framework, as it provides an organized approach to a complex and important health care problem.

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Establishing a conceptual framework for handoffs using communication theory.

A significant consequence of the 2003 Accreditation Council for Graduate Medical Education duty hour restrictions has been the dramatic increase in pa...
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