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An exploration of shift-to-shift clinical handover and clinical handover improvement using a user-centred approach at the Royal Hobart Hospital, Tasmania, Australia

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Wong, MC (2011) An exploration of shift-to-shift clinical handover and clinical handover improvement using a user-centred approach at the Royal Hobart Hospital, Tasmania, Australia. PhD thesis, University of Tasmania.

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Abstract

This research explores shift-to-shift clinical handover and clinical handover improvement at the Royal Hobart Hospital’s Department of General Internal Medicine using a user-centred approach and highlights the outcomes associated with using this approach. This research presents findings that contribute to an improved understanding of shift-to-shift clinical handover and to the role that an electronic tool can play in clinical handover improvement. Clinical handover involves the transfer of information, professional responsibility and accountability for patient care from one clinical team to another either temporarily or permanently. With changes in doctors’ working hours and an increasing demand for flexible work practices, the need for mechanisms to support effective and efficient handover processes for transferring information, responsibility and accountability has become recognised as increasingly important for the delivery of high quality safe health care. Clinical handover has been identified as a high risk scenario for patient safety with dangers of discontinuity of care, medical errors, adverse events and the potential for legal claims of malpractice. With the emergence of debates on ehealth, a role for information systems has been promoted but there remains limited evidence on the impact of these systems on clinical handover. More broadly however, it is evident that the experiences of information systems in health care has not always been successful and that there might be consequences to patient safety after their implementation. In this context, one set of approaches for improving the uptake and use of information systems recommends acquiring a detailed understanding of users needs through direct user engagement. These user-centred approaches have been proven successful in the development and implementation of ehealth systems. Based in the Department of General Internal Medicine the user-centred approach led to the conduct of a case study grounded in clinician (particularly interns and registrars) experiences, attitudes and insights towards clinical handover. The methodology used in this research adopted a subjective ontology and an interpretive epistemology. The research strategy involved a three phased approach. Phase One involved the use of thirty-eight observation sessions and seventeen semi-structured interviews with three clinician groups - interns, registrars and consultants, to facilitate an in-depth understanding of clinical handover and clinical handover improvement within the Department of General Internal Medicine and also build rapport and trust with the participants. Phase Two involved the use of two focus groups with one group consisting of six interns and the other consisting of five registrars to validate the results obtained from Phase One before moving forward with design of the electronic tool. All participants were then invited to participate in four design workshops to work through the requirements of the electronic tool. Phase Three consisted of ten further observation sessions and fourteen semi-structured interviews three months after the introduction of the electronic tool to further explore the participant’s understanding, expectations and experiences of clinical handover after involving them in the clinical handover improvement initiative. The data collected through all three phases were analysed using open axial and selective coding drawing on the principles of grounded theory. After analysing the data independently in each phase, the data were then analysed and interpreted across the three phases to allow for the key findings to emerge. These key findings were then interpreted and discussed based on the researcher’s understanding of the data and in relation to the available literature. The key findings that emerged are as follows:  Clinical handover is a complex, dynamic and evolving clinical system and its status needs to be viewed from a contextual, clinical and user perspective.  A formal education and training program with established standards is imperative for clinical handover improvement.  Clinical handover culture is important in clinical handover improvement and the development of a clinical handover culture requires an incremental approach.  The understanding of clinical handover amongst clinicians varies and this variability in understanding significantly influences the behaviours of clinicians during clinical handover and practice of clinical handover.  The strongest personal attributes that influence clinical handover and clinical handover improvement are cultural background and individual personalities.  Various factors affect clinical handover but it is the nature of these factors and their interrelationships that influence team dynamics which in turn influence clinical handover and clinical handover improvement.  There is a significant difference between perceived and actual handover. This difference has a significant impact on clinical handover especially in the development of electronic tools.  Clinical handover serves various different functions and these functions change after the introduction of electronic clinical handover support tool.  An over-arching user-centred approach is important to engage all users before conducting user-requirements for electronic clinical handover support tool design and implementation.  While a user-centred approach is extremely useful, there are many challenges associated with this approach in clinical handover improvement and quality and safety initiatives.  If an electronic tool is to be introduced for clinical handover improvement, it is imperative to mandate the use of the electronic tool for all clinical handover sessions. This research has made a number of contributions at substantive, methodological and theoretical levels. At a substantive level, it has contributed to the understanding of clinical handover and clinical handover improvement and provided guidance on how an Information systems researcher can conduct research in a clinical setting. This research has made a significant contribution to clinical handover improvement through the use of a user-centred approach as this approach has since been developed further and incorporated as the national guidelines for clinical handover improvement (OSSIE guide). This research has also informed further work conducted in the utilisation of electronic tools in clinical handover which has since been developed into the national guidelines for safe use of electronic tools in clinical handover (SafeTECH). At a methodological level, this research has illustrated the importance of using an over-arching user-centred approach within a multi-snapshot case study to understand clinical handover and clinical handover improvement. This research has suggested that the use of a user-centred approach within a multi-snapshot case study is very important in obtaining a clear understanding of clinical practice which is not clearly defined from the users’ perspective. This research has also contributed at a methodological level by demonstrating that the use of qualitative research techniques drawing on the principles of grounded theory to generate an understanding of a clinical process which is not clearly defined is highly valuable. At a theoretical level, this research has developed a conceptual understanding of clinical handover from three perspectives: a contextual perspective, clinical perspective and a user perspective. This conceptual understanding of clinical handover opens up new areas for future research.

Item Type: Thesis (PhD)
Keywords: clinical handover improvement, user-centered approach, qualitative research
Additional Information: Copyright © the Author
Date Deposited: 14 Dec 2011 00:31
Last Modified: 18 Nov 2014 04:26
URI: http://eprints.utas.edu.au/id/eprint/12523
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