Recognition and Management of Uncertainty in the Transitions of Patient Care

Purpose Effective patient-care handovers between interns must be comprehensive enough to allow the receiving intern to construct a complete mental model of the patient’s current status, future care plan, and anticipated clinical events. Recipients of an effective handover should feel that no essential content has been omitted, and there is little uncertainty about that content, to be able to care effectively for their patients during a given shift. The purpose of this study was to determine the degree to which receiving interns, supervisory residents (SR) and nurses perceived missing handover content and intern uncertainty about that content. We also examined consequences of, and intern responses to, missing content and/or uncertainty. Methods Over a 3-month period in 2012, 9 night-shift interns, their 13 supervisory residents (SRs), and the nurses caring for their patients completed anonymous, constructed quantitative, and free-text surveys on 3 patients-cases per night, for 3 nights per week. The responses of these three parties with regard to intern missing patient information (content) and intern uncertainty (lack of understanding, relevance or contextual meaning) were triangulated and analyzed using McNemar’s Test for correlated proportions. Cross-covering SR responses were compared to primary-team SR responses to assess the influence of cross-coverage using Fisher’s exact test. The type of content missing, the perceived implications or consequences of that missing content, the nature of intern uncertainty and the actions taken in response to that uncertainty were reviewed by non-study participant faculty and residents; themes and exemplar responses were independently derived and reported. Results Data for 82 complete survey sets was collected during the study period. Handover content was considered missing by interns and/or their supervisory residents 33% of the time. Supervisory residents and interns agreed on the presence or absence of missing content 74% of the time. When they disagreed, interns were 3.2 times more likely to report missing content than their supervisory residents (McNemar’s Test, p = 0.013). Content was considered missing by interns and/or nurses 30% of the time. Nurses and interns agreed on the presence or absence of missing content 77% of the time. When they disagreed, interns were 5 times more likely to report missing content than nurses (McNemar’s Test p = 0.004). Uncertainty was reported by interns and/or their supervisory residents 39% of the time. Supervisory residents and interns agreed on the presence or absence of uncertainty 73% of the time. When they disagreed, interns were 4.5 times more likely to be uncertain than their supervisory residents reported they were (McNemar Test p = 0.002). There was no difference in the rate of uncertainty-reporting nor in the rate of resource-seeking between primary team and cross-covering supervisory residents (Fisher’s exact test p = 0.56 and p = 0.38 respectively). When interns recognized uncertainty, their recognition was prompted during the handover 48% of the time and during patient-care activities 39% of the time. Supervisory residents noticed intern uncertainty during handovers 40% of the time and during patient-care activities 40% of the time. Conclusion Supervisory residents and nurses were frequently unaware that interns felt they were missing handover content. Intern uncertainty about the nature of handover content also went underappreciated by supervisory residents and nurses, resulting in a suboptimal shared mental model of the team’s patients