Clinical handover improvement for safer patient care : exploring the practical aspects of organisational processes and the theoretical aspects of the safety value alignment model

This PhD thesis is a synthesis of research work, and analysis and reflections from 7 out of a series of 18 publications from 2005-2013, with the aim of answering the following research questions: 1. What are the understanding and practices of clinical handover from the perspective of clinicians? 2. What interventions are required to improve clinical handover from the perspective of clinicians? 3. What are the essential elements of clinical handover improvement? Clinical handover, defined as "the transfer of responsibility and accountability of patient care from one team of healthcare professionals to the other", is an essential part of clinical practice for delivering safe and high quality patient care. Poor clinical handover has been associated with medical errors, adverse clinical events, medico-legal claims and patient complaints. With the increasing emphasis on reduction in working hours of healthcare professionals to reduce fatigue, clinical handover has become increasingly important in order to deliver safe patient care. While the literature has provided guidance on how to improve clinical handover, there remains a lack of clear understanding of clinical handover practices and a lack of a conceptual understanding of different strategies and interventions to improve clinical handover, especially from the perspective of clinicians across different clinical practice areas, institutions and professional boundaries. This thesis is written based on the PhD candidate's published work in clinical handover improvement. It is the product of analysis and reflections of a selection of 7 publications based on research projects in the field of clinical handover improvement from 2005-2013, after the PhD candidate's involvement in local, regional and national clinical handover improvement programs. This thesis provides a synthesis and review of these 7 key publications. Through this process, five key findings are described and discussed. This thesis then provides an analysis and reflection of these publications to develop a conceptual model to understand strategies and interventions aimed at improving clinical handover. This thesis firstly explores and reflects on the current literature in the field of clinical handover improvement. An analysis of current literature categorises the literature into three fields: safety and clinical handover, standardisation of clinical handover practices and engagement of clinicians to improve clinical handover. This thesis then provides detailed clinical and research context for primary data collection and data analysis utilised in the research project. This research project was conducted in two parts. The first part of the research project started in October 2005 and was conducted at the Department of General Internal Medicine, Royal Hobart Hospital. The first part of the research project aimed to understand clinical handover and clinical handover improvement among medical practitioners with the ultimate aim of developing an electronic tool to support clinical handover. Data collection involved observations, interviews and clinical handover notes analysis. Data analysis involved open, axial and selective coding applying grounded theory principles. This part of the research formed the foundation for the second part of the research project to take place. The second part of the research project was conducted between 2007 and 2009. It was also conducted at the Royal Hobart Hospital, Tasmania, Australia but across 6 clinical settings: Medical and nursing handover at the Department of General Internal Medicine, Department of Emergency Medicine and Department of General Surgery. Data collection techniques used were the same as the first part of the research project. It involved observations, interviews and clinical handover notes analysis. All collected data were analysed using open, axial and selective coding techniques, applying grounded theory principles. Both the first and the second part of the research project produced publications which are included in this thesis