ORIGINAL ARTICLE

Human Factors in Clinical Shift Handover Communication

Review of reliability and resilience principles applied to Change of Shift Report
Wrae Hill BSc.RRT
Corporate Director of Quality Improvement and Patient Safety,
Interior Health Region of British Columbia, Kelowna , British Columbia
Dr. James Nyce PhD
Cultural anthropologist,
Ball State University, Indiana and Leonardo da Vinci Center for Complexity & Systems Thinking,
University of Lund, Sweden

ABSTRACT
It is rare that the skill of clinical handover (change of shift
report, CoSR) is formally taught or evaluated in any of the
health professions, much less evaluated (in situ) in multidisciplinary care settings. Clinical handover is complex,
cognitively taxing and clinical risks are linked to lack of
clarity. The research is clear that there is room to improve
and that it is a risky time for patients.
What is unclear is what varied anticipatory techniques
healthcare practitioners already use to develop their intuition
and foresight so that they can prospectively manage and cope
with ambiguity and uncertainty, and how they use their
discretionary space in practice.
Both reliability and resilience principles are important to
develop effective CoSR. Handoff strategies from higher
reliability (HR) industries indicate that the three most
important features of effective handovers are ;
Two way face-to-face communication,
written support tools and
Content in handover which captures intention.
These recommendations align with the recommendations
of most healthcare handover research in the last 15 years
While there is ample research describing the problem of
handover in patient safety, much of the research is of poor
quality and proposes simplistic normative solutions such as
'SBAR'.
While standardization and minimum data sets may have
their place, we still need to learn how clinicians create;
foresight, coping strategies and recovery strategies so that
they can better manage efficiency and thoroughness
tradeoffs (ETTO). Resilience Engineering (RE) principles
will help us establish and better describe these prospective,
adaptive and predictive capacities.
Future research should evaluate; first - what techniques
clinicians already use to create foresight during CoSR and,
second- Whether patient safety (preventable adverse events)
is associated with the degree of prospective / anticipatory
communication in the preceding CoSR.

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RSUM
Il est rare que les aptitudes de relve clinique (rapport de relve
de quart) soient formellement enseignes ou values chez les
professions de la sant, et encore moins values (sur place) dans
des environnements de soins multidisciplinaires. La relve clinique
est complexe, puisante au plan cognitif et le manque de clart
comporte des risques cliniques. Les recherches montrent clairement quil y a place lamlioration et quil sagit dun moment
qui prsente des risques pour les patients.
On ne sait pas clairement quelles sont les diffrentes techniques
d'anticipation dj appliques par les professionnels de la sant pour
dvelopper leur intuition et leur clairvoyance afin dtre en mesure
de grer de manire prospective lambigit et lincertitude et de
composer avec ces lments et de quelle faon ils utilisent leur espace
discrtionnaire en pratique.
Les principes de fiabilit et de rsilience sont galement
importants dans la production des rapports de relve. Les stratgies
de transfert appliques dans les industries haut coefficient de
fiabilit indiquent que les trois lments les plus importants
dun transfert efficace sont :
la communication bidirectionnelle en personne;
les outils de soutien crits;
le contenu du transfert qui saisit lintention.
Ces recommandations sont conformes celles tablies dans la
plupart des tudes sur la relve de quart menes dans le secteur
de la sant au cours des quinze dernires annes. Bien que de
nombreux travaux dcrivent les problmes de scurit du patient
lis au transfert, la plus grande partie de la recherche est de
mauvaise qualit et propose des solutions normatives simplistes,
comme SBAR .
Bien que la standardisation et les ensembles de donnes
minimums puissent avoir leur place, nous devons encore comprendre comment les cliniciens crent les stratgies de prvision,
de compensation et de rcupration afin de mieux grer les
compromis en matire d'efficacit et dintgralit. Les principes
dingnierie de la rsilience nous aideront tablir et mieux
dcrire ces capacits prospectives, adaptatives et prdictives.
Les prochaines recherches devraient valuer dabord les
techniques adoptes par les cliniciens pour tablir une prdiction
durant les rapports de relve, puis dterminer sil existe un lien
entre la scurit des patients (vnements ngatifs vitables) et le
degr de communication prospective / anticipative durant le
processus de relve prcdent.

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Revue canadienne de la thrapie respiratoire

INTRODUCTION
Patient transfers from one care giver to another are an area
of high safety consequence (Shendell-Falik 2007) and
effective clinical handover is a national patient safety goal
in the USA , Australia and now Canada (JCAHO 2009,
Wong 2008, Accreditation Canada 2008)
Change of shift report (CoSR) is ubiquitous in healthcare.
Hospital inpatient care practitioners such as resident
Physicians, Nurses and Respiratory therapists do this every
shift, (sometimes several times a 'shift') yet it is exceedingly
rare that this skill is even taught or evaluated in any of the
health professions, much less evaluated (in situ) in multidisciplinary care settings. The research that exists on the
subject is clear that there is substantial room for improvement
and that change of shift , and patient care `handovers` are
risky for patients. What is still unclear is what varied
techniques practitioners already use to prospectively manage
this challenge and which might be the most effective and
safe. This review examines the international clinical
handover, or Change of Shift Report (CoSR) literature
from a reliability and resilience engineering perspective to
determine, to what extent these principles are used in healthcare CoSR, and specifically if clinical practitioners can (or do)
use anticipatory techniques to create foresight (and patient
safety) during change of shift report (CoSR) in hospitals.
HOW FORESEEABLE IS PATIENT SAFETY ?
When patients entrust themselves to our care, we make two
implicit, but key professional and organizational promiseswe promise to do everything possible to help patients, to
provide good care; and, we promise not to harm them.
(Reinertsen & Clancy, 2006) The Canadian Adverse
Events Study in 2004, confirmed as other countries have
done, that healthcare is neither inherently safe nor highly
reliable. This retrospective multicenter study found an
overall adverse event (AE) rate of 7.5%, of which 37% were
judged to be potentially preventable and 21% were purportedly related to the cause of unexpected death.
Extrapolating for 2.5 million annual hospitalizations, the
study estimated that 9,000-24,000 preventable deaths
occur from adverse events per year in Canada. (Baker,
Norton, Flintoff, Blais, Brown & Cox, 2004) This study
makes the inference that these adverse events, [judged in
hindsight] may have been foreseeable and therefore preventable. This may not actually be the case because, with
retrospective knowledge of the outcome it is far too easy to
suggest (or judge) what a practitioner could have or should
have done. (Dekker 2006a p.39-44). It is very important
to determine what makes sense to practitioners [from their
lens], in real time, given their limited available cues.
(Dekker 2006a p45-55)
During recent years the significance of the concept of
human error has changed considerably.... It is concluded
that errors cannot be studied as a separate category of
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behavior fragments; the object of study should be

cognitive control of behavior in complex environments.
(Rasmussen 2003)
Rene Amalberti described five systemic barriers currently
preventing health care from becoming an ultrasafe system:
i) the need to limit the discretion of workers, ii) the need
to reduce worker autonomy, iii) the need to make the transition from a craftsmanship mindset to that of equivalent
actors, iv) the need for system-level (senior leadership) arbitration to optimize safety strategies, and v) the need for
simplification. Amalberti (2005)
Based on the emerging science of resilience, Amalbertis
first two purported barriers (discretion / autonomy) may
not be barriers at all when we consider that practitioners
[when coping with complexity and uncertainty] may actually
need to use their autonomy and discretionary space to create
safety.
CHANGE OF SHIFT REPORT IN THE INTENSIVE
CARE UNIT AN EXAMPLE
A Registered Respiratory Therapist (RRT) is receiving
fifteen -thirty minute change of shift report (CoSR) in an
Intensive care unit (ICU) for his eight to ten patients, [most of
whom are on life support]. In this short time period which
includes multiple interruptions, he will conduct a rapid head
to toe review of organ system problems and ongoing treatment
for all of his patients and interact with several different
colleagues. He feels that the first CoSR in his set of four shifts
is the most risky because many of his patients are new to him.
There is no standard process for this, everyone does it differently.
With experience he has developed his own habit of asking both
the Registered Nurses (RN) and Registered Respiratory
Therapist (RRT);What should I be most worried about
tonight and why ? Other colleagues have their own techniques
as well.
HIGH RELIABILITY PERSPECTIVE
Much of the Canadian healthcare improvement activity in
the last decade has taken a systems reliability perspective,
by looking into (and attempting to borrow from) domains
such as; manufacturing and especially commercial aviation
that seem to embody the desired high reliability organizational (HRO) characteristics, yet The Healthcare System
has not yet achieved the status of being a high reliability or
resilient industry (Amalberti, Auroy, Berwick & Barach,
2005 ;Wachter& Pronovost, 2006)
Following the lead of anaesthesiologists who adopted a
systems model in the 1980s, healthcare practitioners now
look to other industries for lessons in safety. (Reason 2008)
High Reliability Organizations (HROs) are complex
organizations which are engaged in high hazard activities,
yet have fewer than expected accidents. They embody five
characteristics which Weick & Sutcliff (2001) coin as

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mindfulness such as ; i) preoccupation with failure, ii) reluctance to simplify interpretations, iii) sensitivity to operations, iv) commitment to resilience and v) deference to
expertise. Within HROs, the commitment to resilience
means that they develop capabilities to detect, contain and
bounce back from those errors that are part of the indeterminate world. (Weick & Sutcliffe 2001 p.14) Resilience
(in HROs) involves a combination of techniques to keep
errors small and involves local improvisation and
workarounds. It also requires a deep knowledge of technology, the system, ones coworkers, ones self and the raw
materials available. (Weick & Sutcliffe 2001 p.14-15)
Herein lies both a similarity and a distinction between
resilience in HRO and Resilience Engineering concepts.
Although there is some overlap these are distinct ideas...
Healthcare`s variability, diversity, limited resources, specialization and ad hoc teams mean that HRO characteristics
such as redundancy and extensive training are simply not
achievable. (Jeffcott 2009a p.257).
Intensive care unit (ICU) care coordination unfolds as
non linear sequence (Miller 2009)
Modern healthcare has been characterized as a complex
adaptive system (CAS) where relationships are critical, are
generally non-linear, and lead to unpredictable dynamics
(Anderson 2005 p.670) A key to understanding the system
as an integrated whole lies in understanding the patterns of
relationships among its agents (Anderson 2005 p.672)
RESILIENCE ENGINEERING PERSPECTIVE
Resilience involves anticipation and is an active process
which may be a better match for healthcare settings than
the principles for high reliability because it more effectively
addresses the unique complexities of healthcare (Jeffcott
2009). The emerging concept of resilience moves the
focus away from What went wrong? to Why does it go
right?, and goes beyond simplistic reactions to error-making
toward valuing a proactive focus on error prevention and
recovery (Hollnagel, Nemeth, Dekker 2008). The concept
of resilience in practice may not be new, but our appreciation of it as a technique to; create foresight, cope with
complexity and effectively rescue patients is just emerging.
MANAGING EFFICIENCY THOROUGHNESS TRADEOFFS (ETTO)
Clinicians must actively manage the balance between
efficiency and thoroughness (ETTO), usually favoring
efficiency. (Hollnagel 2009) ..The predominant explanations
that psychologists and engineers attribute performance
failures to, is a mismatch between demand and capacity,
but that they curiously neglect the fundamental fact that
everything takes time, and takes place in time. (Hollnagel
2009 p.26) In addition to the time needed at each stage, is

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the time needed to make the decision and carry out the
action, plus the uncertainty of adapting to new information
or interruptions. (Hollnagel 2009 p.26-27)
FIGURE 1: Efficiency - Thoroughness Tradeoffs (ETTO) Hollnagel

An interruption or other unexpected event may demand

our attention so that the current activity is completed
prematurely, suspended or not finished at all. Ebright
(2003) reported that nurses experienced numerous
interruptions while providing care on surgical units. In a
three-hour block of time, the number of interruptions
ranged from 7 to 31 with a mean of 19. Interruptions were
caused by various individuals, including clinicians and
patients, and often occurred while nurses primarily were
focused on other activities.
At change of shift report (CoSR) for example, a healthcare
worker may develop individual strategies in an attempt to
cope with ambiguous cues, data overload and interruptions
under severe time constraint. He/ she may even attempt to
create foresight by asking a more general anticipatory
question. Practicing resilience in this way can help us
manage the efficiency-thoroughness trade off (Sheps, S.B.
2009) Clinicians experience clinical successes far more than
clinical failures, while using essentially the same tactics to
get through their day. A resilience perspective looks at how
clinicians create success, or dynamic stability by modifying
their tactics to the constantly evolving clinical situation.
Safety is never the only goal and that people must reconcile
competing goals to meet safety and production pressures James
Reason 2008
Ideally, resilient clinicians will frequently monitor and
revise their risk tolerances given the systems capabilities.
They assess, reassess and use resources proactively in the
face of anticipated or realized disruptions. They dynamically
balance and proactively manage production pressures such
as; changing patient acuity, interruptions, time constraint
and conflicting priorities in order that they effectively
balance efficiency-thoroughness tradeoffs.
While some processes are linear (such as a surgical safety
checklist) resilient clinicians understand that interactive
healthcare systems cannot be viewed as simplistic

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machines, or assembly lines. Resilient systems of care

require anticipation of changes, constant attention, course
corrections, reassessment, monitoring and feedback. Like a
bicycle, a healthcare system is dynamically stable only when
receiving constant inputs and feedback from practitioners.
INTUITION
Intuition is a sacred gift. Rationality its faithful servant
Einstein (nd)
Intuition depends on the use of experience to recognize
key patterns that indicate the dynamics of the situation.
(Klein 1999 p.31) Intuition has a basis in biology, in that
healthy subjects experience an emotional reaction to
anticipated consequences of good or bad decisions. A study
involving neonatal nurses in 1993, showed how NICU
nurses picked up subtle and ambiguous cues to diagnose
early stages of neonatal sepsis before any definitive lab
diagnosis, yet they could not describe how they knew.
The cues were different for each nurse and each nurse relied
on his or her patterns of previous experience. Almost half
of the cues were not recognized in the medical literature,
and some were the opposite of sepsis cues in adults.
(Klein 1999 p.40)
EXPERTISE
An expert has made all the mistakes that can be made in a
very narrow field Niels Bohr (18851962)
Cognitive science seeks to understand the nature of
human intelligence and how it works. Expertise can be
divided into three broad categories ; Social, Cognitive and
Physical. Cognition is described as macro-cognition (planning & detection) and micro-cognition (puzzle solving).
Macro cognition is usually tested in real world settings,
such as Intensive care units or OR theaters.
Macro-cognition tends to focus on cognitive functions
such as decision making embedded in several tasks, sensemaking and situational assessment, and problem detection,
and on the processes that support these phenomena such as
attention management, mental stimulation and storyboarding, and developing mental models. (FarringtonDarby & Wilson 2006 p.24)
The cognitive psychological characteristics of experts
include having greater skill in ;
Producing inferences when monitoring ambiguous
cues, by making meaning and assessing implications
of actions.
Anticipation and processing cues preventatively to
make better predictions,
Taking a wide range of global and local data into
account in diagnosis,
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Encoding new information quickly and completely and

Assessing and applying strategies.
(Summarized from Cellier et al in FarringtonDarby & Wilson 2006 p.10 Table 1)
ANTICIPATION
Practitioners who sense problems earlier seem to maintain
a higher self consciousness about their beliefs and their
validity. They have institutional support for their doubtfulness, and are able to attend closely to the proximal issues
and actively challenge interpretations (Weick & Sutcliffe
2001 p.159) Anaesthesiologists as a group are skilled at
anticipation and are often focused on advanced preparation
for what could possibly go wrong here ? Future research
should determine if other practitioners such as ICU nurses
& Respiratory Therapists similarly tuned to anticipate
problems.
The past seems incredible, the future implausible
David Woods
FORESIGHT
Often, what are seen as clear warnings with the benefit of
hindsight after the fact, were discounted before the fact
(Woods 2009) In Failures of Foresight, David Woods says;
Foresight is fragile and extra investments in safety are
most important when least affordable.
Foresight is difficult to establish in dynamic or cyclical
tradeoffs of efficiency thoroughness. This requires
personal or organizational self reflection to critically
evaluate their own adaptive capacity in order to
recognise when brittleness is on the rise.
Assessment of resilience is an emerging area of study.
Creation of foresight relies on resilience and anticipation.
Rather than assessing adherence to policy, it looks for
gaps between work as imagined and work as performed
and how practitioners anticipate bottlenecks in order
to prepare for the unexpected, prospectively.
Finally, foresight is created by managing system
resilience. (Woods 2009)
USE OF DISCRETIONARY SPACE TO CREATE SAFETY
Safety is the presence of something, not the absence of something Sidney Dekker
RESILIENT RECOVERY - NOT FOLLOWING A RULE
SAVES A LIFE IN ICU
A woman in her mid 50s had had a successful lobe resection
for lung cancer, and was in the ICU the day after surgery. Mid
day, after ambulating for the first time since surgery, she
suddenly collapsed in the ICU hallway from what is quickly
determined to be a massive cardio-pulmonary embolus (clot).
By chance the patients family, surgeon, intensivist, nurse
practitioner, ICU nurse were all present in the ICU. The

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definitive treatment is immediate cardio-thoracic surgery on

cardiopulmonary bypass which is not available at this hospital.
Despite its absolute contraindication in post operative
patients, a decision was quickly taken (with familial consent)
by the Intensivist to administer Tenectaplase, a potent drug
intended dissolve the clot(s). This expectedly resulted in massive
post operative bleeding which was successfully managed,
despite considerable risks and challenges. Rapid effective teamwork had saved this patients life. She was able to return to her
family (well) within several weeks. (White 2009)
This recent local case of resilient recovery demonstrates
how the Intensivist and her team used their discretionary
space to dynamically manage clinical tradeoffs resulting
from the precipitous increase in patient acuity, severe time
constraint and conflicting priorities of life saving thrombolysis vs. life threatening blood loss. The choice to give a
drug which was normally contraindicated (Tenectaplase)
was a lifesaving decision albeit with significant predictable
side effects. This example also illustrates recognizable features
of discretionary space and resilient recovery from the
perspectives of both high reliability and resilience engineering.
The situation represents an unanticipated, emergent,
dynamic, non-linear, complex and time constrained
process. An important feature of resilience, illustrated clearly
by this case is to not allow too much constraint by way of
rigid policy.
In complex socio-technical settings such as healthcare, the
conditions of work never completely match what has been
specified or prescribed through rules, procedures or regulations
(the fundamental basis for high reliability in many hazardous
industries), thus individuals normally adjust their
performance to meet existing demands... (Reason 2008,
Dekker 2008, Hollnagel 2009 in Sheps & Cardiff 2009)
The right [or wrong ] call is often decided by the outcome,
in hindsight. It is very important to remind ourselves that,
had this resuscitation been unsuccessful, it is conceivable
that a well intentioned patient safety report might have
been filed indicating that a contributor to the patients
death was the administration (counter to hospital formulary)
of a contraindicated thrombolytic on post op day one. The
report would have (undoubtedly) not contained all of
the detail of the complexity and tradeoffs experienced in
real time.
SUMMARY OF LITERATURE ON HEALTHCARE
CHANGE OF SHIFT REPORT (COSR)
Change of shift handover is most successful when there
is; i) multidisciplinary rounding, and care decisions are
made collaboratively, ii) continuity of care is increased by
decreasing frequency of handovers if possible. (ASQC

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2005) Change of shift handover is most risky when there

are absences of training and processes and when there are ;
i) no structured processes, ii) during weekend handover, iii)
when there is information overload (dangers of overly long
handovers) and when iv) verbal handover only. All risks are
linked to lack of clarity. Decreased continuity of care is
associated with; cross coverage, night float systems and
reduced resident duty hours. Diffusion of responsibility
and interruptions were cited as contributors to adverse
events. Critical success factors include; minimum data sets,
standard operating protocols (SOPs), education and training,
electronic tools and reflective learning/implementation
methods. (ACSQHC 2008)
REVIEW METHOD FOR RELIABILITY &
RESILIENCE PERSPECTIVES
Hill (2010) synthesized the literature in three systematic
reviews (ASQC 2005, ACSQHC 2008, Reisenberg 2009)
and further reviewed a group of twenty four more recent
papers from 2007 2009 that focused exclusively on clinical shift to shift handover in hospitals. These papers were
reviewed and coded for reliability & resilience perspectives.
(See table 1).The papers were reviewed to determine the
number and type of clinical participants and the number
of CoSR interactions studied. This group of 24 papers in
( Hill 2010) included a systematic review of handoff
mnemonics , mixed methods studies involving Physician
teams, methods review papers, 9 peer reviewed articles of
qualitative CoSR work, 1 book chapter, 11 editorial reviews
and 2 news articles.
The quality of studies are generally poor but two papers
(Horwitz/Philibert) stood out. 58% of authors adopted
reliability (HRO) characteristics such as; recommending
standard processes, education and minimum data sets.
Resilience engineering (RE) perspectives were demonstrated
by 50% of authors who suggested participant participation
in CoSR tool creation and 70% suggested that anticipatory
questions / feedback should be incorporated. No authors
explicitly looked at the creation of foresight, coping and
ETTO Management The SBAR mnemonic is gaining
popularity but is (as yet ) not proven to improve communication during CoSR.
Parke &Mishkin 2005 reviewed safety critical best
practices in shift handover communication, specifically
with the Mars exploration rover (MER) surface operations.
In this review, they said that in dynamic industries, (such
as off shore & on-shore oil rigs, air traffic control), errors
and accidents occur disproportionately after shift handover (Parke &Mishkin 2005)
Based on reviews from Nuclear power generation, Air
traffic control, Offshore oil, Spacecraft mission control,
and aviation maintenance, the three most important ele-

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TABLE 1 - Review of recent papers on CoSR from reliability and resilience perspectives
Reliability Coding

Resilience Coding (after Jeffcott 2009 )

Calls for
Standardization
Minimum data sets
More training
More measures
SBAR format (or another mnemonics)

CoSR format may help practitioners bridge gaps by ;

Preventing something bad happening, Foresight (FS)
Preventing something bad becoming worse, Coping (CO)
Allowing recovery from something bad once it`s
occurred, Recovery (RE)
Managing Efficiencythoroughness tradeoffs (ETTO)
Encouraging anticipatory questions (AN)
Prospectively, systematically Utilizing Intuition/
experience (IE)

ments of effective handovers are; i) Two way communication (preferably face-to- face), ii) Face-to-face handovers
with written support and iii) Content in handover which
captures intention. (Parke &Mishkin 2005)
CRITICAL (HUMAN) FACTORS IN CHANGE OF
SHIFT REPORT (COSR)
Face to face, two way communication
Face to face, two way communication may ensure a
shared mental model. It allows an oncoming worker to
ask questions and to rephrase the material to be handed
over. It enables gestures, eye contact, tones of voice,
degrees of confidence and other redundant, rich
aspects of personal communication to be utilized in
conveying different mental models (Hopkin1980 and
Lardner 1992 in Parke & Miskin 2005)
Face-to-Face Handovers with Written Support
A checklist or a logbook/chart is helpful when reviewed
together by both oncoming and off going staff.
Written material introduces redundancy in the verbal
handover and allows a-priori agreement on key data
(minimum data sets). (Parke & Miskin 2005 p.2)
Content of Handover Captures Intention
Handover works best if communication captures
problems; hypotheses, and intention, rather than simply
lists of occurrences. Perception and memories are
organized by hierarchical goal representations and
these representations in turn drive narrative comprehension, memory and planning. Structure and
function are important, and well intentioned work can
go wrong. Further, shift handover errors have been
attributed to listing work completed (hindsight) rather
than giving a predictive diagnosis of the situation
(foresight). (Parke & Miskin 2005 p.2)

Canadian Journal of Respiratory Therapy

Revue canadienne de la thrapie respiratoire

SIMILARITIES BETWEEN CURBSIDE

CONSULTATION AND COSR
Its interesting that we dont really think about something we
do all the time Two physicians talking about curbside
consultations (Pereley 2006 p.138)
The informal, non-scripted, open ended nature of clinical
handover report (CoSR) has many similarities to the physicians curbside consultations. Pereley studied informal physician-to-physician consultation in the USA and found that
physicians use this collegial method many times per shift.
Colleagues are familiar, reliable, immediately available,
inexpensive and they give concise, organized answers
(Pereley 2006 p. 137).
Most of them said there were no rules, they just knew
how to do it (Pereley 2006 p.141)
In curbside consultations, the novice is encouraged to ask
questions of the more experienced practitioner in private,
hallway conversations a context that allows for issues like
self doubt that seldom appear in more formal consultations
or rounds. The key similarities with Clinical handover are
the concepts of ; i) collegial support , ii) reciprocity and ii)
professional validation of your original course of action.
SUMMARY
It is rare that the skills related to clinical handover (change
of shift report) are formally taught or evaluated in any of
the health professions, much less evaluated (in situ) in
multi-disciplinary care settings. Clinical handover is
complex, cognitively taxing and clinical risks in a ward can
be linked to lack of clarity or miss-communication. The
research is clear that there is room to improve and that it is
a risky time for patients. What is unclear is what varied
anticipatory techniques healthcare practitioners already use
to develop their intuition and foresight so that they can
prospectively manage and cope with ambiguity and uncertainty,
and how they use their discretionary space in practice.

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We are not yet demonstrating the cognitive psychological

characteristics of experts, with respect to CoSR. Both
reliability and resilience principles are important to develop
effective Change of Shift Report (CoSR) methods and
handoff strategies from higher reliability (HR) industries
indicate that the three most important features of effective
handovers are ; i) Two way face-to-face communication, ii)
written support tools and iii) Content in handover which
captures intention. (Parke &Mishkin 2005) These recommendations reflect the conclusions of most healthcare handover research reviewed, yet much of the research is of poor
quality and proposes mechanistic, normative solutions
such as 'SBAR'. While standardization and minimum data

sets may have their place, we still need to learn how clinicians create; i) foresight ii) coping strategies, iii) recovery
strategies so that they can better manage efficiency and
thoroughness tradeoffs (ETTO).
Future qualitative research on CoSR should take into
account a practitioners perspectives, resilience, lived experience and micro-situation assessments in real time.
Methods to achieve this might include individual interviews
of; Nurses, Physicians & Respiratory Therapists in both
ICU and Med-Surgical settings to determine from the
practitioners/perspective how they manage efficiencythoroughness tradeoffs during CoSR, and develop skills to;
foresee, cope and adapt to changes they may later experience.

REFERENCES
Accreditation Canada (2008) Qmentum Accreditation Program,
Required Organizational Practice; Patient Safety - Communication;
Accreditation Canada 05/29/2008 http://www.accreditation.ca/
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Horwitz, L,I,.Moin,T.,Krumholz,H..,Wang,L.,Bradley,E.H. (2009)

What are covering doctors are told about their patients? Analysis of
sign-out among internal medicine house staff. Quality and Safety in
Health Care 18:248-255

ASQC (2005) - Clinical Handover and Patient Safety Literature

Review Report Australian Council for Safety and Quality in
Healthcare downloaded June 20.2009 from
http://www.health.gov.au/internet/safety/publishing.nsf/
Content/AA1369AD4AC5FC2ACA2571BF0081CD95/$File/
clinhovrlitrev.pdf
ACSQHC (2008) The Evidenced-based Literature Review prepared by
eHealth Services Research Group for the Australian Commission
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%20on%20Pilot%20Study%20TASDept.pdf

ABOUT THE AUTHORS

CORRESPONDING AUTHOR

CO AUTHOR

Wrae Hill BSc.RRT is a Registered Respiratory Therapist

employed as the Corporate Director of Quality Improvement
and Patient Safety in the Interior Health region of British
Columbia. Wrae is also a MSc. student in Human Factors
and Systems Safety at the Leonardo da Vinci Center for
Complexity & Systems thinking, at the University of
Lund, Sweden. Wrae can be contacted at 250-870-5893,
1815 Kirschner Rd. Kelowna British Columbia, V1Y 4N7
or by email at wrae.hill@interiorhealth.ca

James M. Nyce, an associate professor in the Department of

Anthropology, Ball State University, studies how information
technologies emerge and are used in complex workplaces
and organizations. A docent at Linkping University,
Sweden, Nyce is also visiting professor in Lund Universitys
Masters Program in Human Factors. Dr. Nyce can be
contacted at Ball State University in Muncie, Indiana at
765-789-8793, or by email at jnyce@rocketmail.com

APPENDIX 1
CANADIAN HANDOVER STANDARDS

Accreditation Canadas relevant goal in Patient Safety,

Area 2: Communication is to Improve the effectiveness
and coordination of communication among care/service
providers and with the recipients of care/service across the
continuum.
The tests for compliance include ;
1) The team uses mechanisms for timely transfer of
information at transition points that result in proper
information transfer,
2) Staff is aware of the organizational mechanisms used
to transfer information, and

Canadian Journal of Respiratory Therapy

Revue canadienne de la thrapie respiratoire

3) There is documented evidence that timely transfer of

information has occurred.
Accreditation Canada 2008 Qmentum Accreditation
Program, Required Organizational Practice; Patient Safety Communication; http://www.accreditation.ca/
uploadedFiles/information%20transfer.pdf?n=1212

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