Background: Transfers of care, also known as handovers, remain a substantial patient safety risk. Although research on handovers has been done since the 1980s, the science is incomplete. Surprisingly few interventions have been rigorously evaluated and, of those that have, few have resulted in long-term positive change. Researchers, both in medicine and other high reliability industries, agree that face-to-face handovers are the most reliable. It is not clear, however, what the term face-to-face means in actual practice. Objectives: We studied the use of non-verbal behaviours, including gesture, posture, bodily orientation, facial expression, eye contact and physical distance, in the delivery of information during face-toface handovers. Methods: To address this question and study the role of non-verbal behaviour on the quality and accuracy of handovers, we videotaped 52 nursing, medicine and surgery handovers covering 238 patients. Videotapes were analysed using immersion/crystallisation methods of qualitative data analysis. A team of six researchers met weekly for 18 months to view videos together using a consensus-building approach. Consensus was achieved on verbal, non-verbal, and physical themes and patterns observed in the data. Results: We observed four patterns of non-verbal behaviour (NVB) during handovers: (1) joint focus of attention; (2) 'the poker hand'; (3) parallel play and (4) kerbside consultation. In terms of safety, joint focus of attention was deemed to have the best potential for high quality and reliability; however, it occurred infrequently, creating opportunities for education and improvement. Conclusions: Attention to patterns of NVB in face-toface handovers coupled with education and practice can improve quality and reliability.

Background Tools and procedures designed to improve end-of-shift handoffs through standardisation of processes and reliance on technology may miss contextually sensitive information about anticipated events that emerges during face-to-face handoff interactions. Such information, what we refer to as anticipatory management communication (AMC), is necessary to ensure timely and safe patient care, but has been little studied and understood. Objective To investigate AMC and the role it plays in nursing and medicine handoffs. Research design Qualitative thematic analysis based on audio recordings of nurse-to-nurse, medical resident-to-resident and surgical internto-intern handoffs. Subjects 27 nurse handoff dyads and 18 medical resident and surgical intern handoff dyads at one VA Medical Center. Results Heads-up information was the most frequent type of AMC across all handoff dyads (N=257; 108 resident and 149 nursing). Indirect instructions AMC was used in a little over half the resident handoff dyads, but occurred in all nursing dyads (292 instances). Direct instructions AMC occurred in roughly equal proportion across all dyads but at a modest frequency (N=45; 28 resident and 17 nursing). Direct (if/then) contingency AMC occurred in resident handoffs more frequently than in nursing handoffs (N=32; 30 resident and 2 nursing). Conclusions The different frequencies for types of AMC likely reflect differences in how residents and nurses work and disparate professional cultures. But, verbal communication in both groups included important information unlikely to be captured in written handoff tools or the

Increasing staff education needs, limited staff development resources, and retention of valuable staff are issues facing healthcare providers today. This article describes the use of project management methodology to design and implement a Train-the-Trainer (TTT) program. This TTT program describes how to enlist leadership support for staff presentation of educational offerings. The TTT program was designed to retain employees through staff development and meet the educational needs of the healthcare system.

Background Shift change handoffs are known to be a point of vulnerability in the quality, safety and outcomes of healthcare. Despite numerous efforts to improve handoff reliability, few interventions have produced lasting change. Although the opportunity to ask questions during patient handoff has been required by some regulatory bodies, the function of questions during handoff has been less well explored and understood. Objective To investigate questions and the functions they serve in nursing and medicine handoffs.Research design Qualitative thematic analysis based on audio recordings of nurse-to-nurse, medical resident-to-resident and surgical internto-intern handoffs. Subjects Twenty-seven nurse handoff dyads and 18 medical resident and surgical intern handoff dyads at one VA Medical Center. Results Our analysis revealed that the vast majority of questions were asked by the Incoming Providers. Although topics varied widely, the bulk of Incoming Provider questions requested information that would best help them understand individual patient conditions and plan accordingly. Other question types sought consensus on clinical reasoning or framing and alignment between the two professionals. Conclusions Handoffs are a type of socially constructed work. Questions emerge with some frequency in virtually all handoffs but not in a linear or predictable way. Instead, they arise in the moment, as necessary, and without preplanning. A checklist cannot model this process element because it is a static memory aid and questions occur in a relational context that is emergent. Studying the different functions of

Electronic clinical handover is feasible and practical within the Irish healthcare system. In addition, it was found in our study to be attractive and effective to physicians without increasing their workload.