“Workin' on Our Night Moves”: How Residents Prepare for Shift Handoffs


      Poor-quality handoffs have been associated with serious patient consequences. Researchers and educators have answered the call with efforts to increase system safety and resilience by supporting handoffs using increased communication standardization. The focus on strategies for formalizing the content and delivery of patient handoffs has considerable intuitive appeal; however, broader conceptual framing is required to both improve the process and develop and implement effective measures of handoff quality.


      Cognitive task interviews were conducted with internal medicine and surgery residents at three geographically diverse US Department of Veterans Affairs medical centers. Thirty-five residents participated in semistructured interviews using a recent handoff as a prompt for in-depth discussion of goals, strategies, and information needs. Transcribed interview data were analyzed using thematic analysis.


      Six cognitive tasks emerged during handoff preparation: (1) communicating status and care plan for each patient; (2) specifying tasks for the incoming night shift; (3) anticipating questions and problems likely to arise during the night shift; (4) streamlining patient care task load for the incoming resident; (5) prioritizing problems by acuity across the patient census, and (6) ensuring accurate and current documentation.


      Our study advances the understanding of the influence of the cognitive tasks residents engage in as they prepare to hand off patients from day shift to night shift. Cognitive preparation for the handoff includes activities critical to effective coordination yet easily overlooked because they are not readily observable. The cognitive activities identified point to strategies for cognitive support via improved technology, organizational interventions, and enhanced training.
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      Laura G. Militello, MA, is Senior Scientist, Applied Decision Science, LLC, Kettering, Ohio.


      Nicholas A. Rattray, PhD, is Research Health Scientist, US Department of Veterans Affairs, Health Services Research and Development Service, Center for Health Information and Communication (VA HSR&D CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, and Adjunct Assistant Professor, Department of Anthropology, Indiana University–Purdue University Indianapolis.


      Mindy E. Flanagan, PhD, is Senior Research Consultant with Health Services Research and Development Service, Richard L. Roudebush VA Medical Center, Indianapolis and Senior Research Scientist with Parkview Health, Fort Wayne, IN; and Zamal Franks, BA, is Program Specialist, VA HSR&D CHIC.


      Shakaib Rehman, MD, is Associate Chief of Staff for Education, Phoenix VA Healthcare System, and Professor, Department of Biomedical Informatics, University of Arizona College of Medicine, Phoenix.


      Howard S. Gordon, MD, is Staff Physician, Jesse Brown VAMC, Center of Innovation for Complex Chronic Healthcare, and Professor of Medicine, University of Illinois at Chicago.


      Paul Barach, MD, MPH, is Clinical Professor, Children's Hospital of Michigan, Wayne State University School of Medicine.


      Richard M. Frankel, PhD, is Senior Scientist, VA HSR&D CHIC, and Professor of Medicine and Geriatrics, Indiana University School of Medicine.