Communication as Sequences: Evaluating the Structure and Content of Patient Handoff Communication

Handoff communication is a threat to patient safety as they are a source for medical errors. However, there is limited research exploring the nuanced process of handoff communication. Using the theoretical foundations of handoffs, symbolic interactionism framework and sensemaking theories, I conducted a comparative evaluation of handoff communication practices among residents and nurses, focusing on their interactive structure, conversational content, and supporting functions. Using audio-recorded handoff communication of residents (n=149) and nurses (n=126) in a medicine unit, I used a mixed-methods approach for coding and analysis of conversations. Open-ended qualitative coding was used to characterize clinical narratives, social and contextual aspects of care within the conversations. Structured coding was used to segment conversational content, and code clinical content, listening behaviors, questions and responses, anticipatory management strategies, and communication breakdowns. Comparative analysis between resident and nurse handoff communication was conducted using Wilcoxon rank-sum tests, Poisson regression, and zero-inflated Poisson regression. Graph-based analysis was used to generate conversation networks and investigate the structure of exchanged clinical content. Nurse conversations had significantly more conversational turns, asked more questions, and had fewer instances of anticipatory management discussions, compared to residents. There were no differences in listening behaviors or communication breakdowns. However, increased listening had marginally more pronounced effects on question-asking behaviors among nurses than residents; breakdowns were marginally less likely with increased turns but increased with more questions. Compared to resident conversation networks, nurse networks were more focused, and had more branching and switching between clinical content categories. Resident and nurse conversation networks showed significant chunking, where organically-related clinical content were presented together. Qualitative analysis showed the symbolic use of language to create a narrative “patient imagery,” management of dependencies, and discussion of socio-contextual aspects of care, with inherent differences between residents and nurses. These findings highlight the underexplored functions of handoffs and inherent differences between residents’ and nurses’ use of stereotypical narratives, transfer of accountability, resilience in communication, and social interactions. Conceptualizing handoffs as a collaborative sensemaking activity, I propose the development of shared visual aids for handoffs and provide design considerations. Contributions to the fields of communication and informatics are discussed.