Today, patient care in modern healthcare institutions is very much shaped by a condensed workload in a highly dynamic working environment in which health professionals focus on their specialized field. Continuity of care can only be achieved by the continuous, well-coordinated interaction of the different health professionals within and across shifts. Change of shifts does not compromise continuity from an organizational point of view as long as the actors who take over from their colleagues entirely replace their function [1]. However, continuity may only be ensured if the actors work in a coordinated manner and cooperate across shifts [2]. Due to their asynchronous nature, shifts obstruct an interactive exchange on demand between the different shift teams. Therefore, shifts possess a high risk for jeopardizing continuous coverage [3]. In order to partly overcome this dilemma, information has to be communicated at the shift change in handovers,1 in a consistent manner [4]. Handovers are, therefore, communication scenarios that are often ritualized [e.g. 5]. They are very similar across countries with regard to their content and structure [e.g. 6]. Very often they take place verbally in face-to-face situations [e.g. 7].
Cooperation enabled by handovers requires agreements on how to proceed and should lead to a joint understanding of the care process. This understanding is possible due to a shared knowledge background, which is defined by Clark as “the sum of the partners’ mutual, common or joint knowledge, beliefs and suppositions” [8]. Having such knowledge means that all actors know about a proposition, e.g. a fact about a patient, and at the same time also know that the others know it as well [8]. In order to achieve this level of comprehensive and effective understanding, mutual efforts among all the participants are needed, for which Clark coined the term “grounding” [9]. Hertzum refined this concept speaking of collaborative information seeking that consisted of information seeking, a primarily individual effort, as well as of collaborative grounding, which summarizes the joint efforts. The role of collaborative information seeking hereby was to balance individual and shared understanding [10].
In the context of handovers this highly interactive process of information and knowledge synchronization via questions and answers was called dance of reports [11], which lays the ground for detecting information needs [12] and proper decision-making [13]. The process of grounding also leads to awareness among all stakeholders. According to Kuziemsky and Varpio collaborative care delivery builds on awareness at various levels, namely patient status and goal awareness, team member awareness, deliberation awareness and rationale awareness, and finally environment awareness [14].
Grounding may utilize different communication mechanisms, which vary on a continuum between synchronous, e.g. face-to-face or phone communication, and asynchronous forms of communication. The method of choice for establishing common ground is synchronous communication – preferably in face-to-face situations – because it decreases the costs of establishing common ground [9]. It is also the method preferred by health professionals [e.g. 15]. However, synchronous communication was found to be prone to interruptions that may lead to treatment errors [16], [17]. In order to avoid these drawbacks, one could in principle rely on asynchronous communication methods. The effects are less positive than they may seem. It could be demonstrated that building shared knowledge on the goals and activities of patient care could not be supported by asynchronous means, such as a computer based order entry system [18].
Based on these studies, it remains unclear as to what is the most appropriate approach to effectively support the grounding process in typical synchronous scenarios such as handovers. Existing literature reviews which explored – among others – the current use of electronic handover systems provided only a first insight into the topic due to a lack of proper previous studies [4], [6], [19]. However, they
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demonstrated the importance of handovers,
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showed that handovers are error prone,
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yielded an overview of the problems and barriers including the omission of important information, e.g. rationale of decision, anticipated problems,
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listed strategies including structuring the information according to certain schemata.
By providing an exploratory overview they triggered the need for a new comprehensive and detailed review. This need holds true in general but specifically for integrated electronic systems supporting the communication and grounding process in handovers and their evaluation.
Against this background, the aim of this study is to answer the following research questions:
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Given the fact that collaborative grounding is prone to errors in synchronous communication scenarios, (1a) what are the specific types of errors and gaps in handovers performed by nurses and physicians? (1b) What are their consequences?
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What strategies and instruments for systematizing information and communication in handovers are described in the literature and how are they evaluated?
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What type are the electronic handover instruments that are reported in the literature and what is the role of electronic patient record systems?
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Are any of the strategies and instruments specifically addressing the grounding process?
The combination of answers provided by the literature to these four questions should help identifying the appropriate strategies for building an electronic handover system that helps overcoming the problems of the current practice.