Teaching and assessing ED handoffs: A qualitative study exploring resident, attending, and nurse perceptions

Introduction: The Accreditation Council for Graduate Medical Education requires that residency programs ensure resident competency in performing safe, effective handoffs. Understanding resident, attending, and nurse perceptions of the key elements of a safe and effective emergency department (ED) handoff is a crucial step to developing feasible, acceptable educational interventions to teach and assess this fundamental competency. The aim of our study was to identify the essential themes of ED-based handoffs and to explore the key cultural and interprofessional themes that may be barriers to developing and implementing successful ED-based educational handoff interventions. Methods: Using a grounded theory approach and constructivist/interpretivist research paradigm, we analyzed data from three primary and one confirmatory focus groups (FGs) at an urban, academic ED. FG protocols were developed using open-ended questions that sought to understand what participants felt were the crucial elements of ED handoffs. ED residents, attendings, a physician assistant, and nurses participated in the FGs. FGs were observed, hand-transcribed, audiorecorded and subsequently transcribed. We analyzed data using an iterative process of theme and subtheme identification. Saturation was reached during the third FG, and the fourth confirmatory group reinforced the identified themes. Two team members analyzed the transcripts separately and identified the same major themes. Results: ED providers identified that crucial elements of ED handoff include the following: 1) Culture (provider buy-in, openness to change, shared expectations of sign-out goals); 2) Time (brevity, interruptions, waiting); 3) Environment (physical location, ED factors); 4) Process (standardization, information order, tools). Conclusion: Key participants in the ED handoff process perceive that the crucial elements of intershift handoffs involve the themes of culture, time, environment, and process. Attention to these themes may improve the feasibility and acceptance of educational interventions that aim to teach and assess handoff competency.