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BJA Advance Access originally published online on June 13, 2008
British Journal of Anaesthesia 2008 101(3):332-337; doi:10.1093/bja/aen168
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© The Board of Management and Trustees of the British Journal of Anaesthesia 2008. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room{dagger}

A. F. Smith1,*,{ddagger}, C. Pope2, D. Goodwin3 and M. Mort4

1 Department of Anaesthesia, Royal Lancaster Infirmary, Ashton Road, Lancaster LA1 4RP, UK
2 School of Nursing and Midwifery, University of Southampton, Southampton, UK
3 Centre for Medical Education
4 Institute for Health Research, Lancaster University, Lancaster, UK

* Corresponding author. E-mail: andrew.f.smith{at}mbht.nhs.uk

Accepted for publication May 4, 2008.


   Abstract
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 Abstract
Introduction
 Methods
 Results
 Discussion
 Supplementary data
 Funding
 References
 
Background: We aimed to describe how anaesthetists hand over information and professional responsibility to nurses in the operating theatre recovery room.

Methods: We carried out non-participant practice observation and in-depth interviews with practitioners working in the recovery room of an English hospital and used qualitative methods to analyse the resulting transcripts.

Results: We observed 45 handovers taking place between 17 anaesthetists and 15 nurses in the recovery room of the operating theatre suite. These took place in an environment that is event-driven, time-pressured, and prone to concurrent distractions. Anaesthetists and nurses often had differing expectations of the content and timing of information transfer. The point at which transfer of responsibility for the patient occurred during the handover process was variable and depended not only on the condition of the patient but also on the professional relationship between the nurse and doctor concerned. Handover also provided an ‘audit point’ in care where the patient’s intraoperative progress was reviewed and plans were made for further management. Here, as in the transfer of responsibility, we found evidence that nurses play a greater role in defining the limits of anaesthetists’ practice than might be expected.

Conclusions: Patient handovers in the recovery room are largely informal, but nevertheless show many inherent tensions, both professional and organizational. Although formalized handover procedures are often advocated for the promotion of safety, we suggest that they are likely to work best when the informal elements, and the cultural factors underlying them, are acknowledged.

Keywords: anaesthesia, recovery period; communication; education, continuing; interprofessional relations; postoperative care; recovery, postoperative


   Introduction
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Methods
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Modern hospitals are complex and a patient will be cared for by many different people. Handovers play a key role in ensuring the continuity, quality, and safety of patient care.1 There is a substantial body of research on nurse-to-nurse handovers,2–4 and some recent interest in handovers between doctors,5 6 but little work exploring interprofessional handover. Anaesthesia is regarded as one of the leading specialties in healthcare in terms of safety7 and hence might be expected to yield relevant insights into handover practice. We thus aimed to describe how anaesthetists hand patients over to nurses in the operating theatre recovery room.


   Methods
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 Abstract
 Introduction
 Methods
Results
 Discussion
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 References
 
The approval of the local research ethics committee was granted for the investigation of anaesthetic expertise, of which this paper reports a further part,8 and written informed consent obtained from patients being cared for by the staff being studied. We adopted a qualitative approach, grounded in detailed observation.9 10 Our study site was the main theatre complex of a district hospital in the northern UK. Observation was conducted principally by one investigator (D.G.), but some sessions were conducted in tandem with one of the other researchers (C.P. or M.M.) to allow comparisons and internal validity checks. Detailed contemporaneous notes were taken and transcribed immediately after the session. We also discussed interprofessional working relationships during the interviews conducted with anaesthetists and anaesthetic staff as part of the larger study.8 Our analysis began with individual close readings and annotations of the observational and interview transcripts. Collectively, through discussions and comparison of the various readings of the data, the dimensions and boundaries of the emerging categories were refined.11 We tried to keep to a minimum the influence of the observer on what we were studying by conducting observations over a long period of time (nearly 1 yr) and by using a former anaesthetic nurse from the department being studied, whose presence staff were already familiar with. The decision to analyse interprofessional handover was made post hoc when the accumulated data suggested this was a useful area for study. This is usual in such qualitative work, as is the lack of a predetermined ‘hypothesis’ to test. The research team thus had no particular preconception about this subject.


   Results
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 Abstract
 Introduction
 Methods
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Discussion
 Supplementary data
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 References
 
We observed 45 handovers, of which 35 took place in the recovery room, six in the operating theatre, and two in the theatre corridor leading to the recovery room. The remaining two handovers could not be placed from the transcript. These involved 17 anaesthetists (nine consultants, seven trainees, and one non-consultant career grade) and 15 recovery nurses. Nineteen interviews were conducted8 with anaesthetists, anaesthetic nurse, and recovery nurse. Relevant material was extracted from these data, though the main focus of our inquiry was workplace observation.

Within this study, ‘handing over’ achieved three objectives: it offered an opportunity to convey the anaesthetist’s knowledge of the patient’s perioperative care to the receiving nurse in order to facilitate the patient’s ongoing care; it marked the transition of responsibility from one professional to the other; and it provided an ‘audit point’ in care to review what has been done and plan for further management.

Handover in context
However, none of these processes was as straightforward as they might at first have appeared. The handovers we observed took place in among other activities (Fig. 1), while a patient arrived in the recovery room, monitoring was reconnected and readings initiated, equipment was adjusted, an antibiotic mixed, and the patient's blood glucose estimated. Other activities we witnessed taking place during other handovers included preparing a patient-controlled analgesia machine, signing for controlled drugs, and zeroing the arterial line. The recovery room we observed serves up to four operating theatres where the working pattern is unpredictable and the transfer of patients from theatres may coincide. The anaesthetist arriving with a patient may have to wait for a recovery nurse to become free. Furthermore, many different members of staff were transiently involved in the care of patients in the recovery area, including porters, operating department practitioners, nurses, and surgeons, and there is considerable movement in and out of this space. There were, therefore, a number of obstacles to, and distractions from, the business of safely handing over the care of the patient recovering from anaesthesia.


Figure 1
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  		Fig 1 Extract from observation transcript. A, anaesthetist; RN, recovery nurse; SN, surgical nurse; ODP, operating department practitioner; LMA, laryngeal mask airway (airway maintenance device); BM, glucometer for near-patient testing. Names, where given, have been changed to maintain confidentiality.

 
Handover as knowledge transfer
The length and content of the anaesthetists’ handovers we witnessed varied with the complexity of the patient’s condition and operation. However, they were typically brief, and concerned with the patient's preoperative state, operation performed, analgesics given in the operating theatre, and any problems encountered (see Supplementary data, Appendix 1). An element of familiarity was also seen—anaesthetists often referring to ‘my usual’—a combination of anaesthetic drugs and techniques they favoured, which they expected the recovery staff to know. Although a brief handover might be expected for a straightforward case, we also observed instances where quite complex problems encountered during anaesthesia—for instance, an unexpected prolonged drop in oxygen saturation just before extubation of the trachea—were almost glossed over.

Further, the receiving nurse often sought other information, not always volunteered—for instance, asking the patient’s name (Fig. 1). This not only allowed for verification of the patient’s identity, it also helps the nurse to begin the patient’s reorientation into the social world as he or she regains consciousness. Written documents were used too—the anaesthetist left the intraoperative anaesthetic record for the recovery staff, who then added to it their own recordings of the patient’s vital signs during the recovery period. The patient’s prescription chart and the surgeon’s operation note were also to hand, as indeed were the patient’s casenotes. There was, however, no formal documentation that a handover had taken place.

Handover as transfer of responsibility
We found that the location and timing of transfer of responsibility varied considerably. It did not always coincide with the point of transfer of knowledge described above. Sometimes, the anaesthetist passed on information about the patient while the patient was still in the operating theatre, the recovery nurse having gone into theatre to collect the patient. Sometimes, especially if essential details were missing, the nurse had to return to theatre, often after the anaesthetist had started work on the next patient, to query a monitor reading or ask for further drugs or fluids to be prescribed. Thus, for instance, in Figure 2, the nurse appears to assume responsibility earlier in the encounter than in Figure 1.


Figure 2
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  		Fig 2 Excerpt from observation transcript. A, anaesthetist; RN, recovery nurse; SN, surgical nurse; ODP, operating department practitioner; LMA, laryngeal mask airway (airway maintenance device). Names, where given, have been changed to maintain confidentiality.

 
Handover as audit point
Arrival in the recovery room was a transition point in the patient’s care and afforded an opportunity to review what has been done, check everything was in order, and prepare him or her for onward transfer back to the ward. It consisted of auditing the anaesthetist’s actions in the operating theatre, checking on the patient’s current status, and planning for further care. In one example of checking (Fig. 1), the receiving nurse took the opportunity of appraising the patient for the first time to note the backflow of blood up the drip tubing. She also measured the patient’s ventilatory frequency and blood glucose. Figure 3 shows the nurse checking that postoperative analgesia and fluids are prescribed.


Figure 3
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  		Fig 3 Excerpt from observation transcript. A, anaesthetist; RN, recovery nurse; SN, surgical nurse; ODP, operating department practitioner; LMA, laryngeal mask airway (airway maintenance device). Names, where given, have been changed to maintain confidentiality.

 
Completing the process
We observed that the usual way of completing the handover was for the anaesthetist to ask the recovery nurse if he or she was ‘OK’ or, more commonly, ‘happy’.

‘Happy’ in this context related both to the clinical condition of the patient and the professional relationship between anaesthetist and nurse (see Supplementary data for interview with Recovery sister in Appendix 2). In most instances, the reply would be affirmative. Sometimes (Fig. 3), the nurse was clearly not willing for the anaesthetist to go. Here, as elsewhere, direct contradiction was avoided; her reply, ‘you can go but I'd like someone around’ was interpreted, as she intended, by the anaesthetist as an indication that he should stay. This he did, until the patient woke up, and his second enquiry (‘OK?’) was met with agreement.


   Discussion
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 Abstract
 Introduction
 Methods
 Results
 Discussion
Supplementary data
 Funding
 References
 
Our recovery room observations have revealed a dynamic, rapidly changing environment where staff must care for patients in an ‘at risk’ state, often under considerable time pressure. Anaesthetists’ handovers were typically brief and took place amidst a range of other activities which competed for the receiving nurse’s attention. However, the transfer of information did not automatically lead to transfer of professional responsibility for the patient. How, and at what point, this was accepted depended on individual informal negotiation between nurse and anaesthetist and appeared to involve mutual trust, differing expectations, and the balance of power in the relationship.12 The handover also provided an opportunity to review the patient’s care and plan further actions, but this too had to be delicately handled as the anaesthetist’s practice is ‘laid bare’ during the transfer of information.

The anaesthetist’s responsibilities during recovery room handovers are the subject of guidance from professional organizations.13 14 These stipulate that anaesthetists should formally hand over the patient, stay if there are any problems, leave the patient in a stable and satisfactory condition, and review the patient before discharge from recovery. Previous work on handovers in the recovery room has focused more on whether simple criteria are met15 and we are not aware of any studies documenting the everyday, ‘routine’ handover process. The guidelines do not address the content or conduct of the spoken handover, which seem, like other aspects of communication, to be informally learned as part of the ‘tacit knowledge’ of professional practice.16

More generally, within nursing, four functions of the handover have been identified:3 informational (catching up on patients’ progress and maintaining continuity of care), social (social/emotional support and stress relief), organizational (immediate plans for shift—controlled drugs and prescriptions), and educational (both explicit learning and enculturation). The transfer of responsibility and the audit functions which we have described (which we see as distinct from information transfer) seem to us to be additional to these, and may be more evident in the interprofessional context we were observing.

Interprofessional handovers are not a simple transfer of responsibilities; some responsibilities are indeed transferred, but some are delegated, and others are retained by the anaesthetist (who remains ultimately responsible as long as the patient stays in the recovery room). So, the transfer of responsibility must follow the transfer of knowledge, but transfer of knowledge does not in itself oblige the nurse to accept responsibility for the patient if he or she considers the knowledge in some way incomplete. How this was determined seemed to depend not on any written protocol or procedure but rather on an informal and unspoken arrangement shaped by mutual trust and experience. The point at which this transfer occurred varied. In Figure 1, the anaesthetist appeared to decide that the patient could safely be left with the nurse, whereas our reading of the data (Fig. 2) is that the nurse took a more dominant role throughout, taking it upon herself to declare, unsolicited, when it was ‘OK’ for the anaesthetist to leave. To us, this was visible also in the topography of the situation, as the nurse took up position by the patient’s head as the patient entered her territory in the recovery room (thus controlling the airway), the anaesthetist being relegated to the patient’s side. It is of course also possible that this action reflected the nurse’s personal judgement based on his/her own experience and skills, but we feel that close scrutiny of such encounters by a research team with diverse perspectives can reveal insights into practice which are not evident to those within the speciality. Likewise, the exchange documented in Figure 3 raises the possibility that it may be the nurse who is put in the position of deciding when it is appropriate for the anaesthetist to leave. Here, then it appeared that the responsibility was transferred very early in the encounter.

Wherever possible, the recovery nurse will care completely for the patient, but there are of course tasks that her/his role does not allow and of course the patient's condition can change rapidly. She/he may assess the level of pain and decide upon appropriate analgesia, but a doctor is needed to prescribe the drug. Similarly, nurses usually decide, in straightforward cases, if patients can be discharged from the recovery room without further consultation. One characteristic of safety-sensitive organizations is that everyone, no matter how junior they are, feels free to voice concerns about safety.17 18 Our data suggest to us that nurses may sometimes be manoeuvred into taking the responsibility for setting the boundaries of doctors' safe practice—for instance, in saying when they consider the anaesthetist can return to theatre—and this threatens their ability to voice safety concerns effectively. Paradoxically, they do appear to be influencing medical practice, though not in the explicit fashion one would expect in a fully developed ‘safety culture’. However, as this practice here is variable and informal, it tends to be less visible.

Handovers provide an opportunity to check progress and review care to date. Manias and Street2 have suggested that nurse-to-nurse handovers (observed in an intensive care unit) act to maintain conformity of practice, as a nurse's work during the previous shift is under scrutiny by the colleague taking over. Typically, intraoperative problems were underplayed in the handover. This may simply be because few of them led to problems in the recovery room, but suggest the possibility that anaesthetists' practice is similarly exposed to the recovery nurses' subtle and implicit judgement of what constitutes an acceptable clinical standard. The interview with the senior recovery nurse (see Supplementary data, Appendix 2) attests to the fact that different anaesthetists behave in different ways. Her response to this is not to challenge the unsatisfactory anaesthetist, but to order and organize the recovery nurses in such a way so as to provide a safety ‘buffer’ for those individuals' patients. Whatever the circumstances, the handover process must still be conducted to the satisfaction of both parties, and take place in such a way that neither party ‘loses face’ so that future encounters are not jeopardized.19

The informal and locally negotiated character of the handovers we observed appears to contrast with the closely specified, formalized procedures in other safety-critical settings. Patterson and colleagues20 reviewed data on handovers they had observed in four different industries. They identified 21 strategies aimed at increasing the effectiveness and efficiency of handovers, including attempts to limit interruption and distraction, the use of ‘read back’ to check understanding, and greater use of written documentation. However, there is also some evidence from within healthcare that standardized handovers may not improve recall of spoken information.21

In conclusion, we have shown how, in the safety-sensitive specialty of anaesthesia, informal practices prevail. Although there may be safety gains to be made by greater standardization and reliance on protocol, formalized procedures will work best when they acknowledge the informal elements such as we have identified, and the cultural factors which underlie them. Further research could usefully elucidate this relationship in greater detail.


   Supplementary data
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Supplementary data
Funding
 References
 
The appendices can be found as supplementary data in British Journal of Anaesthesia online.


   Funding
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Supplementary data
 Funding
References
 
The project from which this work arose was funded by the United Kingdom NHS North West Regional R&D Fund (‘The problem of expertise in anaesthesia’, project no RDO 28/3/05).


   Footnotes
 
{dagger} An abstract outlining the ideas elaborated in this paper was presented at the European Association for Communication in Healthcare meeting, Basel, Switzerland, September 2006. Back

{ddagger} Declaration of interest. Professor A.F.S. is the recipient of a personal patient safety research development award from the UK National Institute for Health Research. Back


   References
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 Supplementary data
 Funding
 References
 
1 Arora V, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf (2006) 32:646–55.[Medline]

2 Manias E, Street A. The handover: uncovering the hidden practices of nurses. Intensive Crit Care Nurs (2000) 16:373–83.[CrossRef][Medline]

3 Kerr MP. A qualitative study of shift handover practice and function from a socio-technical perspective. J Adv Nurs (2002) 37:125–34.[CrossRef][Web of Science][Medline]

4 Sherlock C. The patient handover: a study of its form, function and efficiency. Nurs Stand (1995) 9:33–6.[Medline]

5 Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician-to-physician communication in patient handoffs. Acad Med (2005) 80:1094–9.[CrossRef][Web of Science][Medline]

6 Horn J, Bell MDD, Moss E. Handover of responsibility for the anaesthetised patient—opinion and practice. Anaesthesia (2004) 59:658–63.[CrossRef][Web of Science][Medline]

7 Gaba D. Anaesthesiology as a model for patient safety in health care. Br Med J (2000) 320:785–8.[Free Full Text]

8 Smith AF, Goodwin D, Mort M, Pope C. Expertise in practice: an ethnographic study exploring acquisition and use of knowledge in anaesthesia. Br J Anaesth (2003) 91:319–28.[Abstract/Free Full Text]

9 Atkinson P, Coffey A, Delamont S, Loftland J, Loftland L. Handbook of Ethnography. (2001) Thousand Oaks, CA: Sage Publications.

10 Savage J. Ethnography and health care. Br Med J (2000) 321:1400–2.[Free Full Text]

11 Miles MB, Huberman AM. Qualitative Data Analysis. An Expanded Sourcebook (1994) 2nd Edn. Thousand Oaks, CA. 278–9.

12 Strauss A, Schatzman L, Ehrlich D, Bucher R, Sabshin M. The hospital and its negotiated order. In: The Hospital in Modern Society—Freidson E, ed. (1963) New York: Free Press.

13 American Society of Anesthesiologists. Standards for Postanesthesia Care. Available at: www.asahq.org/publicationsAndServices/standards/36.pdf (accessed September 25, 2007).

14 Association of Anaesthetists of Great Britain and Ireland. Immediate Postanaesthetic Recovery (2002) London: AAGBI.

15 Anwari JS. Quality of handover to the postanaesthesia care unit nurse. Anaesthesia (2002) 57:488–93.[Web of Science][Medline]

16 Smith AF, Pope C, Goodwin D, Mort M. Communication between anesthesiologists, patients and the anesthesia team: a descriptive study of induction and emergence. Can J Anaesth (2005) 52:915–20.[Web of Science][Medline]

17 Smith AF, Goodwin D, Mort M, Pope C. Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting. Br J Anaesth (2006) 96:715–21.[Abstract/Free Full Text]

18 Sexton JB, Thomas EJ, Helmreich RL. Error, stress and teamwork in medicine and aviation: cross sectional surveys. Br Med J (2000) 320:745–9.[Abstract/Free Full Text]

19 Goffman E. Interaction Ritual: Essays on Face to Face Behaviour. (1967) New York: Doubleday. 113.

20 Patterson ES, Roth EM, Woods DD, Chow R, Gomes JO. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care (2004) 16:125–32.[Abstract/Free Full Text]

21 Talbot R, Bleetman A. Retention of information by emergency department staff at ambulance handover: do standardised approaches work? Emerg Med J (2007) 24:539–42.[Abstract/Free Full Text]


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