A Novel Model of Patient Handover in Emergency Medicine-Addressing Hidden Tensions in Culture.

Introduction: Clinical handover (or handoff), the transfer of patient care between providers, is essential in Emergency Medicine. Poor communication during handover can threaten patient safety. Existing literature views handover as an information transfer; little research has examined the human interaction within handover and how it affects patient safety. We sought a more nuanced understanding of handover to improve this critical aspect of Emergency Medicine care. Methods: We used constructivist grounded theory to explore handover as a social phenomenon. We invited staff emergency physicians in an academic, tertiary care hospital to participate in semi-structured interviews, which were recorded, de-identified, and transcribed. The research team analyzed the transcripts in multiple progressively interpretive analytical stages: initial, focused, and theoretical. Cultural-Historical Activity Theory (CHAT) provided a framework for our data analysis. CHAT situates an individual's action into an activity system in which components interact, producing tensions. We sought to attain theoretical sufficiency by revising the interview guide and recruiting participants for specific insights. Results: We interviewed sixteen (16) participants. During handover, the object was for the incoming physician (IP) to accept the handover plan from the outgoing physician (OP). We identified a rule requiring minimal handover plans that were realistic and dichotomous. The divisions of labor were tasks. During the interaction, emotional reactions such as judgment or compassion, and behavioral reactions such as pushback or acceptance could have resulted. There were unintended consequences from the handover process that impacted members' self-worth and generated threats to patient safety. Conclusions: We built a novel and more nuanced framework of handover in the emergency department that involves multiple interactions and tensions. Using this new model, emergency departments should adjust their handover processes to enhance group dynamics and patient safety.