Team Communication During Patient Handover
From the Operating Room: More Than Facts and
Figures
Tanja Manser, University of Fribourg, Fribourg, Switzerland,
Simon Foster, ETH Zurich, Zurich, Switzerland, Rhona Flin, University of
Aberdeen, Aberdeen, United Kingdom, and Rona Patey, Aberdeen Royal
Infirmary, Aberdeen, United Kingdom
Objective: This study was aimed at examining team
communication during postoperative handover and its
relationship to clinicians’ self-ratings of handover quality.
Background: Adverse events can often be traced back
to inadequate communication during patient handover.
Research and improvement efforts have mostly focused
on the information transfer function of patient handover.
However, the specific mechanisms between handover
communication processes among teams of transferring
and receiving clinicians and handover quality are poorly
understood.
Method: We conducted a prospective, cross-sectional
observation study using a taxonomy for handover behaviors
developed on the basis of established approaches for
analyzing teamwork in health care. Immediately after the
observation, transferring and receiving clinicians rated the
quality of the handover using a structured tool for handover
quality assessment. Handover communication during 117
handovers in three postoperative settings and its relationship
to clinicians’ self-ratings of handover quality were analyzed
with the use of correlation analyses and analyses of variance.
Results: We identified significantly different patterns of
handover communication between clinical settings and across
handover roles. Assessments provided during handover were
related to higher ratings of handover quality overall and
to all four dimensions of handover quality identified in this
study. If assessment was lacking, we observed compensatory
information seeking by the receiving team.
Conclusion: Handover quality is more than the
correct, complete transmission of patient information.
Assessments, including predictions or anticipated problems,
are critical to the quality of postoperative handover.
Application: The identification of communication
behaviors related to high-quality handovers is necessary to
effectively support the design and evaluation of handover
improvement efforts.
Keywords: communication process, handover, observa-
tion study, team cognition, teamwork, patient safety, oper-
ating room, recovery room, anesthesia
Address correspondence to Tanja Manser, University of
Fribourg, Rue P.-A. de Faucigny 2, CH-1700 Fribourg;
e-mail: tanja.manser@unifr.ch.
HUMAN FACTORS
Vol. 55, No. 1, February 2013, pp. 138-156
DOI:10.1177/0018720812451594
Copyright © 2012, Human Factors and Ergonomics Society.
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Introduction
Patient care is an inherently communicative
activity. It is therefore not surprising that com-
munication errors are frequently found to con-
tribute to adverse events (Bogenstätter et al.,
2009; Catchpole, Giddings, et al., 2007;
Greenberg et al., 2007; Lingard et al., 2004;
Manser & Foster, 2011). Communication pro-
cesses are particularly vulnerable at organiza-
tional interfaces, such as handovers from the
operating room. Thus, handover research with a
human factors focus has been identified as key to
improving patient safety (Australian Council for
Safety and Quality in Health Care, 2005;
Committee on Quality of Health Care in America,
2001; Harvey, Schuster, Durso, Matthews, &
Surabattula, 2007). Although research on patient
handover is rapidly growing, systematic studies
of handover practices and their relationship to
indicators of handover quality remain sparse
(Manser & Foster, 2011; Riesenberg, Leitzsch,
Massucci, et al., 2009). This is in stark contrast
to other industries in which handover has
received considerable attention from human fac-
tors research (Patterson, Roth, Woods, Chow, &
Gomes, 2004).
Patient handover has been defined as the
transfer of professional responsibility and
accountability for some or all aspects of care for
a patient, or groups of patients, to another per-
son or professional group on a temporary or
permanent basis (British Medical Association,
National Patient Safety Agency, & NHS
Modernisation Agency, 2005). The primary
goal of any handover is the accurate transfer of
information necessary for continuing safe
patient care. This goal has led to the dominant
view of patient handover as one-way transmis-
sion of information (Patterson & Wears, 2010;
Wears & Perry, 2010). This focus often neglects
Postoperative Handover Communication 139
the multiple functions of handover (e.g., train-
ing, socialization, building and maintaining
trustful relationships and clarification of roles;
Haggerty et al., 2003; Patterson et al., 2004),
the active role of the receiving clinicians in
shaping effective communication processes
(Foster & Manser, 2012), and most importantly,
that patient handover is a team activity (Manser
& Foster, 2011).
Patient Handover as a Team
Activity
Salas, Dickinson, Converse, and Tannenbaum
(1992) define team as a “distinguishable set of
two or more people who interact dynamically,
interdependently, and adaptively toward a com-
mon and valued goal/object/mission, who have
each been assigned specific roles or functions
to perform, and who have a limited life span of
membership” (p. 4). By this definition, patient
handover clearly is a team activity beyond
information transmission (Manser & Foster,
2011).
This notion is supported by research concep-
tualizing patient handover as an episode of
shared cognition and sensemaking between cli-
nicians (Perry, 2004) that provides opportuni-
ties for collaborative cross-checking (Patterson
et al., 2004; Patterson, Woods, Cook, & Render,
2007). Shared cognition enables team members
to have more accurate expectations and a com-
patible approach for task performance (Cannon-
Bowers & Salas, 2001). From this perspective,
handovers are important “audit points” that are
essential for potential recovery from failure
(Clancy, 2006; Perry, 2004; Smith, Pope,
Goodwin, & Mort, 2008), and it can be assumed
that team performance decreases and errors
increase when team cognition “fails.”
Patient handover is a complex cognitive task.
Effective handover should contribute to a broad
knowledge base that helps individual team mem-
bers to better understand the priorities for patient
treatment, to anticipate future events, and to plan
accordingly. Clinicians’ mental models of a
patient’s condition, including the rationale for
treatment decisions, uncertainties, and anticipa-
tions of problems, have to travel with the patient
across care transitions. However, research shows
that handovers often fail to optimally support
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receiving clinicians’ anticipation and planning.
In a survey study, 31% of residents indicated that
something had happened during a shift that the
handover had not prepared them for (Borowitz,
Waggoner-Fountain, Bass, & Sledd, 2008).
In various complex work environments, a
team cognition approach has been employed
for the understanding of multiple elements of
effective teamwork (e.g., team knowledge,
communication, and coordination). It has been
argued that team cognition is best defined and
measured at the team level, particularly empha-
sizing team member interactions (Gorman,
Cooke, & Winner, 2006), and that this emphasis
allows for diagnosing deficiencies and design-
ing targeted interventions. However, patient
handover has rarely if ever been studied with
the application of this approach.
Handover Communication
Research on patient handover highlights the
idiosyncratic nature of clinicians’ handover prac-
tices. However, specific team process behaviors,
such as communication, that have been linked
theoretically and empirically to team perfor-
mance (Burtscher, Wacker, Grote, & Manser,
2010; Foushee, 1984; Stout, Salas, & Carson,
1994) have rarely been studied for patient hando-
ver. Instead, most studies, especially those on
postoperative handover, focus on the transfer of
accurate, complete information.
For example, observers of postoperative
handovers have found that a considerable pro-
portion of critical information (e.g., allergies,
comorbidities, intraoperative problems, postop-
erative plan) was not communicated (Nagpal,
Vats, Ahmed, Vincent, & Moorthy, 2010;
Schwilk, Gravenstein, Blessing, & Friesdorf,
1994). This finding is in line with research
assessing recovery nurses’ perceptions of hando-
ver quality (Anwari, 2002). Only one third of
handovers attained maximum scores for quality
of verbal information. In 14% of handovers,
anesthetists failed to communicate any of the
five required information elements and gave all
five in only 33%.
Smith et al. (2008) found that anesthetists and
recovery nurses often had different expectations
concerning content and timing of information
transfer. Furthermore, handover communication
140 February 2013 - Human Factors
was observed to be largely informal, and intraop-
erative problems were frequently underreported.
Some authors highlight safety-relevant aspects
beyond information transfer, such as negotiation
of responsibility and voicing of concerns by
receivers (Smith et al., 2008; Smith & Mishra,
2010).
Based on the evidence on information loss
and idiosyncratic handover practices, suggested
improvements focus on standardization of con-
tent and sometimes on handover structure
(Catchpole, De Leval, et al., 2007; Manser &
Foster, 2011). A notable exception is one com-
plex, multicomponent intervention (Weinger
et al., 2010). Most interventions have been evalu-
ated only on the basis of adherence to protocols
and error rates. The effectiveness of handover
standardization still has to be established in sys-
tematic outcome studies, and the specific mecha-
nisms behind these connections have to be
understood (Foster & Manser, in press). This goal
requires an improved understanding of the com-
munication process. Detailed analyses of the
actual handover communication process are rare.
For example, Apker et al. (2010) coded handover
communication between emergency physicians
and hospitalists. These handovers were dominated
by information giving, whereas information seek-
ing occurred only sporadically and information
verifying was almost absent. Another study
showed that handover content changed as a func-
tion of uni- versus multiprofessionality (Miller et
al., 2009). Specifically, in handovers involving
nurses and physicians, patient goals emerged as a
means for integrating the different professional
perspectives.
Objective and Research Questions
Despite initial promising studies, knowledge
of the role of team communication in handover
quality is very limited. Empirical results linking
detailed analyses of handover communication
processes with measures of handover quality,
and ultimately, with patient outcomes, are
urgently needed for the future development of
effective interventions.
In this study, we aim at advancing handover
research by linking detailed descriptions of team
communication processes with handover quality
ratings. This link will allow for identifying
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performance critical communication behaviors
and will improve our understanding of the team
processes supporting effective patient handover.
To achieve this goal, we (a) developed and applied
a method for the structured observation of hando-
ver activities, particularly, communication, and
(b) related these observations to clinicians’ self-
ratings of handover quality.
Although the limited knowledge on hando-
ver communication processes did not allow for
the formulation of specific hypotheses, we
expected differences in the distribution of com-
munication behaviors for transferring and
receiving clinicians, for transferring consultants
versus trainees, and between different postop-
erative handover settings.
Method
Research Setting
Our study focused on postoperative patient
handover, specifically from operating room
(OR) to either recovery room (RR) or intensive
care unit (ICU). Patients undergoing surgery
are especially vulnerable to handover errors
because of the number of transitions occurring
throughout their care. Although communication
during the pre- and intraoperative phases has
received considerable attention in recent years
(Lingard, Reznick, Espin, Regehr, & DeVito,
2002; Manser, 2009), almost no in-depth
information is available on the communication
processes during postoperative handover
(Catchpole, De Leval et al., 2007; Nagpal et al.,
2010; Smith et al., 2008). Postoperative hando-
vers are critical episodes because they take
place in an environment that is event driven,
time pressured, and prone to concurrent distrac-
tions while the patient is in an “at-risk” state
(Smith et al., 2008) and because they involve
clinicians across professional groups, each with
his or her own skill set and priorities (Nagpal
et al., 2010).
Procedure
Participants. Participants were clinicians
involved in postoperative handovers from one
large Scottish teaching hospital. We obtained
approval from the North of Scotland Research
Ethics Committee (Protocol-No. 10/S0801/14)
Postoperative Handover Communication 141
and the School of Psychology, University of
Aberdeen (PEC-No.1112091345). All potential
clinical participants were informed about the
study goals. Written informed consent was
obtained from clinicians at the start of their shift
and from the patients involved in this study at
preoperative assessment.
Data collection. All data were collected
between July and August 2010 and included a
broad spectrum of surgical specialties. We
intended to observe 50 handovers from OR to
RR (OR-RR), 50 from RR nurse to ward nurse
(RR-W), and 25 from OR to cardiac ICU (OR-
CICU). To minimize the influence of individual
handover styles reported in the handover litera-
ture (Raduma-Tomas, Flin, Yule, & Williams,
2011; Riesenberg, Leitzsch, Massucci, et al.,
2009), we observed a maximum of 5 handovers
per transferring OR clinician. Because we did
not have ethics committee approval for collect-
ing experience levels of nurses, no such restric-
tion was applied for receiving clinicians.
Measures
Observation of handover communication.
Prior to formal data collection, the observer, a
researcher with extensive experience in observ-
ing clinicians (TM), spent several weeks in all
three clinical settings. This time allowed her to
become familiar with the patient care processes
and the clinicians to become accustomed to the
presence of the observer.
Observations focused on the handover per-
formed verbally at the bedside immediately
after patient arrival into the RR or CICU or at
arrival of the ward nurse to the RR and ended
when the handover was complete. The observer
recorded all handover activities and who per-
formed these activities (i.e., work role) using a
PDA-based data recorder that logged start and
end times (Held & Manser, 2005). This method,
which allows for recording of concurrent activi-
ties, had been successfully applied in previous
studies involving observation of health care
teams (Manser, Howard, & Gaba, 2008; for
details, see Appendix A). A subset of 10 audio-
recorded handovers was transcribed to assess
rater reliability.
Taxonomy of handover activities. We coded
observations using a structured taxonomy of
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handover activities that we developed on the
basis of a review of existing systems for assess-
ing handover practices (Apker et al., 2010;
Catchpole, De Leval, et al., 2007), descriptions
of clinicians’ handover behavior (Lawrence,
Tomolo, Garlisi, & Aron, 2008; Smith et al.,
2008; Wears, Perry, Shapiro, Beach, & Behara,
2003), interviews, and field notes. A prototype
was piloted for a period of 2 weeks and was
refined with a focus on completeness and
usability.
The final observation system comprised 31
descriptive codes allowing for continuous cod-
ing of handover behavior (Table 1). The major-
ity of codes describe handover communication
with the main categories: information giving,
information seeking, information verification,
acknowledgment, assessment, planning and
decision making, and handover management.
Additionally, we coded use of patient documen-
tation, social communication, clinical tasks, and
interruptions (i.e., when it occurred, the source,
and duration).
Handover quality assessment. In this study,
we aimed to link handover behaviors to hando-
ver quality. Thus we used a recently developed
structured handover assessment tool (Manser,
Foster, Gisin, Jaeckel, & Ummenhofer, 2010;
see Appendix B) consisting of 21 items rated on
a 4-point scale (yes = 4, rather yes = 3, rather
no = 2, no = 1). Of these items, 16 describe
patient handover in terms of information trans-
fer and teamwork, and a single item assesses
overall handover quality. Additionally, 4 items
(i.e., time pressure of transferring and receiving
team, case complexity and uncertainty) were
collected as control variables. Immediately
after handover completion, all clinicians
involved rated handover quality using this tool.
Because team composition was quite variable,
only the ratings of the main transferrer and
receiver were used in the data analysis.
Data Analysis
Observational data were prepared for sta-
tistical analysis in PASW Statistics (Version
17; SPSS) with the use of customized soft-
ware (Held & Manser, 2005). The proportion
of time spent on each observation category
was calculated in relation to handover duration
142 February 2013 - Human Factors
Table 1: Observation Categories for Clinicians’ Behavior During Postoperative Patient Handover
Handover Behavior
Information giving
 
Information seeking
 
 
Information verification
 
 
Acknowledgement
Assessment
 
 
 
 
Planning and decision making
 
 
 
 
Handover management
 
 
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Coding Category Operational Definition
Patient presentation Statements that convey patient identifiers,
medical history, and current issues of
concern
Procedure Statements about procedures that have
already been performed (diagnostic,
surgical, medication)
Request for information Asking for specific information (e.g., results
of scans, timing of events)
Request for explanation Asking for explanations/elaborations
Clarification Seeking clarification of preceding
statements
Read-back Statements paraphrasing or restating
information given
Summary Summarizing the gist of what has been said
Cross-checking Using another source of information to
confirm verbal statements (e.g., patient
chart, patient)
Acknowledgement General acknowledgement of information
Clinical impression Identification of the current clinical
impression, naming the problem and
underlying reasons
Prognosis Statements about the patient’s future
condition based on completed or
proposed treatments
Treatment Statements evaluating the current treatment
of the patient, including medication
Uncertainty Statements about missing information or
unexplained events
Overall assessment Statements referring to the overall
assessment of the case
Goals Formulating patient care goals
Treatment (options) Discussion about treatment options
including potential risks
Treatment (tasks) Identifying tasks to be done by receiving
team
Responsibilities Statements about who will be responsible
for certain tasks
Context information Statements about logistic or procedural
issues
Establishment of roles Identifying/confirming who will take
responsibility for the patient
Minimization of Dealing with interruptions prospectively/
interruptions reactively
Inviting team members Explicitly inviting team members to provide
to provide information information from their perspective
(continued)
Postoperative Handover Communication 143
Table 1: (continued)
Handover Behavior Coding Category
  Inviting interactive
questioning
  Confirmation of
completeness
  Transfer of
responsibility
Use of documentation Reading notes
  Making notes
  Refer to notes
Social communication Social communication
Clinical tasks Setup
  Patient care tasks
overall, for transferring and receiving clini-
cians, and for the three handover settings.
Note that the overall time on handover activ-
ity exceeded handover duration because we
observed a team activity wherein multiple
activities occurred simultaneously. All aggre-
gate data are shown as mean with standard
deviations in parentheses. Comparisons of
communication behaviors between handover
settings and handover roles were calculated
with MANOVA to test for an overall differ-
ence in several communication behaviors and
with ANOVA for single communication
behaviors. In addition, we used the F test of
the equality of two variances to compare the
variances of different groups.
We investigated the relationships between
the relative amount of handover time spent on
specific handover behaviors and quality ratings
using Pearson correlations.
Differences between consultants and trainees
in the distribution of communication behaviors
during OR-RR and OR-CICU handovers were
analyzed qualitatively because of limited sam-
ple size and statistical power.
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Operational Definition
Explicitly inviting team members to ask
questions
Ensuring that the receiving team has all
information they need (verbal/written)
Statements explicitly referring to
responsibility for the patient
Reading patient documentation
Completing patient documentation during
handover
Referring to patient documentation to
support the handover
Greetings and introductions, chat, other
communication not related to the patient
handover
Connecting monitoring, ventilation,
infusions, etc.
All patient care activities not related to
setup
Results
A total of 117 patient handovers were observed
at three postoperative care transitions: OR-RR
(n = 50, 3.9 min ± 1.4), RR-W (n = 42, 3.0 min ±
1.9), and OR-CICU (n = 25, 6.0 min ± 2.9). A total
of 21 recovery room nurses, 31 anesthetists, 36
OR nurses, 31 ward nurses, and 12 CICU nurses
participated in this study. For the anesthetists,
most OR-RR handovers were consultant led (n =
38), and 12 were performed by a trainee. All but 4
OR-CICU handovers were performed by consul-
tants. Of the 31 transferring anesthetists, 23 were
observed more than once. Of those who were
studied repeatedly, the number of observations
was 2.7 ± 1.3 (median = 3). Only three transfer-
ring clinicians were observed five times.
None of the observed handovers was con-
ducted with an identical team of transferring
and receiving clinicians. Thus, the dependency
in our data and the potential for bias from indi-
vidual handover styles are very limited.
Character of the observed handovers. Across
the clinical settings, participating clinicians judged
most handovers as routine with low levels of case
144 February 2013 - Human Factors

Figure 1. Box-and-whisker plots of handover communication across all three handover settings
(percentage of handover time spent on the seven communication categories). Each plot shows the
interquartile range (box), the median (thick horizontal line), the values falling at the first quartile
minus 1.5 times the interquartile range or at the third quartile plus 1.5 times the interquartile range
(lower and upper whiskers), and outliers (separate points).

complexity (1.7 ± 1.0), uncertainty (1.4 ± 0.7), and
time pressure for the transferring (1.3 ± 0.7) and
receiving clinicians (1.3 ± 0.6).
Coding reliability for handover communica-
tion. Comparison of codings from 10 handover
transcripts by the main observer and a second
coder (a psychologist experienced in coding
verbal data obtained in acute care settings)
yielded a Cohen’s Kappa of .84, and compari-
son of the main observer’s transcript and live
codings yielded a Cohen’s Kappa of .76, sug-
gesting good rater reliability (Landis & Koch,
1977). Although the content categories of the
newly developed coding system were the focus
of our reliability analysis, the comparison of
live versus transcript coding showed excellent
agreement (.96) for unitizing (i.e., identification
of relevant coding units).
Distribution of Handover
Communication Behaviors
Overall, handover communication accounted
for 70% ± 19% of the handover duration. This
finding was significantly different between set-
tings (ANOVA), F(2, 114) = 44.4, p < .001, η² =
.44, with handover communication taking up
63% ± 13% of OR-RR handover time, 58% ±
18% for OR-CICU handovers, and 86% ± 13%
for RR-W handovers.
The distribution of handover communication
showed four dominant communication behav-
iors: information giving, followed by assess-
ment, acknowledgement, and planning and
decision making (Figure 1).
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When compared between settings (with
ANOVA), significantly more time was spent on
information seeking, F(2, 114) = 15.7, p < .001,
η² = .22, during OR-CICU handovers; on assess-
ment, F(2, 114) = 112.1, p < .001, η² = .66, and
acknowledgement, F(2, 114) = 19.8, p < .001, η² =
.26, during RR-W handovers; and on handover
management, F(2, 114) = 11.2, p < .001, η² = .17,
during OR-RR handovers.
Handover roles. Handover communication
accounted for 53% ± 16% of handover duration
for transferring clinicians and for 14% ± 6% for
receivers. The dominant communication behav-
iors (Figure 2) differed significantly between
transferring and receiving clinicians (MANOVA),
F(7, 226) = 191.8, p < .001, η² = .86. ANOVA
showed that transferring clinicians’ handover
communication focused on information giving,
F(1, 232) = 585.3, p < .001, η² = .72; assessment,
F(1, 232) = 196.4, p < .001, η² = .46; planning and
decision making, F(1, 232) = 266.9, p < .001, η² =
.54; and handover management, F(1, 232) = 50.2,
p < .001, η² = .18; whereas receiving clinicians’
handover communication was characterized by
acknowledgement, F(1, 232) = 341.3, p < .001, η²
= .60, and information seeking, F(1, 232) = 61.4,
p < .001, η² = .21.
Handover communication of consultant and
trainee anesthetists. Figure 3 gives an over-
view of communication behaviors during
OR-RR and OR-CICU handovers by consul-
tants versus trainees. Because of limited sam-
ple size, we performed a qualitative comparison
of handover communication patterns. Although
Postoperative Handover Communication 145

Figure 2. Box-and-whisker plots of handover communication of the transferring and receiving

clinicians across all three handover settings (percentage of handover time spent on the seven
communication categories). Each plot shows the interquartile range (box), the median (thick
horizontal line), the values falling at the first quartile minus 1.5 times the interquartile range
or at the third quartile plus 1.5 times the interquartile range (lower and upper whiskers), and
outliers (separate points).

there appeared to be no difference between Clinicians’ Self-Ratings of

trainee and consultant handovers for informa-
tion giving (i.e., the transfer of the medical
facts about patient and procedure), the qualita-
tive analysis suggests that more time was spent
on assessment and planning and decision mak-
ing during consultant handovers. Also, infor-
mation seeking tended to be more prominent
during trainee handovers. These differences
were more pronounced during OR-CICU
handovers (Figure 3). As can also be seen from
Figure 3, consultants’ handover communica-
tion appeared more variable than trainees’ in
both clinical settings.
Handover Quality
Overall, ratings of handover quality were
rather positive, with means ranging from 3.1 to
3.9. We identified four dimensions of handover
quality: discussion of patient care information,
handover organization, establishing a shared
understanding, and conduct (see Appendix C).
Relationships Between
Communication Behaviors and
Handover Quality Ratings
To answer the question, What makes a “good
handover”? we correlated the transferring and

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146 February 2013 - Human Factors

Figure 3. Box-and-whisker plots of handover communication during handovers from operating room (OR)
to recovery room (RR) by consultants (n = 38) and trainees (n = 12) and during handovers from OR to cardiac
intensive care unit (CICU) by consultants (n = 21) and trainees (n = 4) (percentage of handover time spent on the
communication categories). Each plot shows the interquartile range (box), the median (thick horizontal line), the
values falling at the first quartile minus 1.5 times the interquartile range or at the third quartile plus 1.5 times the
interquartile range (lower and upper whiskers), and outliers (separate points).
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Postoperative Handover Communication 147

Table 2: Relationships Between Receiving Clinicians’ Ratings of Handover Quality and the Proportion
of Handover Duration Spent on the Various Communication Behaviors (Across All Three Handover
Settings)

Dimensions of Handover Quality  

Patient Care Handover Shared Under-

Handover Activity Information Organization standing Conduct Overall Quality

Information giving –.26* .22 –.08 .23 –.04

Information seeking –.23 –.33** .09 .05 –.36**
Information verifying .12 .05 .07 –.12 .00
Assessment .27* .23* .12 –.38** .30**
Planning and decision .14 .03 .12 .03 .04
making
Acknowledgment –.02 .25* –.07 –.34** .08
Handover management –.02 -.23* –.12 .18 –.05
*p < .05. **p < .01.

Table 3: Relationships Between Transferring Clinicians’ Ratings of Handover Quality and the
Proportion of Handover Duration Spent on the Various Communication Behaviors (Across All Three
Handover Settings)

Dimensions of Self-Rated Handover Quality  

Patient Care Handover Shared Under-

Handover activity Information Organization standing Conduct Overall Quality

Information giving –.09 –.04 –.11 –.13 –.10

Information seeking .12 –.12 –.09 .06 .00
Information verifying –.14 .16 .02 –.06 –.08
Assessment .15 .41** .27** –.20 .14
Planning and decision .09 –.09 .09 –.18 –.17
making
Acknowledgment .02 .21* .32** –.04 .15
Handover management .09 –.14 –.04 .00 .00

*p < .05. **p < .01.

receiving clinicians’ self-ratings of handover significantly related to three dimensions for

quality across settings with the relative amount
of handover time spent on the various commu-
nication behaviors.
Higher receiver ratings of overall handover
quality were related to more assessments and less
information seeking (Table 2). No significant rela-
tionships were found for transferring clinicians’
ratings of overall handover quality (Table 3).
When we broke this analysis down into the four
dimensions of handover quality, assessment was
receiver ratings and to two dimensions for transfer-
rer ratings. Quality ratings of handover organiza-
tion were positively related to assessment and
acknowledgement for both clinician groups. These
two communication behaviors were also positively
correlated with ratings of shared understanding for
transferring clinicians and negatively correlated
with ratings of conduct for receiving clinicians.
The negative correlations of receiving clini-
cians’ quality ratings of patient care information

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148 February 2013 - Human Factors
with information seeking and of ratings of
handover organization with information seeking
and handover management suggest that these
behaviors may be compensatory. Interestingly,
receiving clinicians’ quality ratings of patient
care information were negatively related to
information giving.
Discussion
In this study, we were able to establish a first
empirical link between team communication
during postoperative handovers and clinicians’
self-ratings of handover quality. More specifi-
cally, we found that assessment was associated
with higher ratings of overall handover quality
by the receiving clinicians and correlated with
all four dimensions of handover quality identi-
fied in this study. Interestingly, no clear picture
emerged regarding communication behaviors
and transferring clinicians’ ratings of handover
quality. This variation in what transferring cli-
nicians think makes a good handover corre-
sponds to the large variability in handover
communication found in this study and is in line
with research indicating idiosyncratic handover
practices (Raduma-Tomas et al., 2011; Riesenberg,
Leitzsch, Massucci, et al., 2009). That assessment
was not correlated to transferring clinicians’ qual-
ity ratings may also be interpreted as a lack of
understanding what the receiving team needs and
values (Carroll, Williams, & Gallivan, in press;
Smith et al., 2008).
From a methodological point of view, the
observation system we have developed is sensi-
tive enough to distinguish handover roles (i.e.,
transferring and receiving) and different hando-
ver settings. This system is a methodological
contribution because detailed descriptions of
handover communication can improve the
understanding of the mechanisms underlying
effective team performance and, thus, is a foun-
dation for designing handover interventions and
evaluating their effectiveness.
More Than Facts and Figures
The finding that assessment was positively
related to handover quality is consistent with
previous research on coordination in anesthesia
crews that identified provision of situation
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assessments as a performance-critical aspect dur-
ing a simulated medical crisis (Manser, Harrison,
Gaba, & Howard, 2009). Research in nonclinical
settings has also highlighted the importance of
verbalizing situation assessments to maintain
good coordination (Salas, Prince, & Baker, 1995)
and the performance-enhancing effects of discuss-
ing threats and errors (Sexton, 1999).
Providing information on the patient history,
comorbidities, procedures already performed,
and so on helps the receiving team to get clear
about facts and figures. This aspect of handover
communication is the focus of many studies and
interventions aimed at assuring completeness
and accuracy of information transfer. However,
providing assessments is about more than that.
It is also about feelings and hunches, options,
predictions, anticipations, and uncertainties and
thus is in essence the fullest range of what is
known about the patient. This tacit knowledge
about a patient is rarely documented, and unless
verbalized during handover, this information
will not be available to the clinicians continuing
to care for that patient.
We found the receiving team to show more
information-seeking behaviors, such as request-
ing explanations for certain parameters and ask-
ing for predictions or anticipated problems, if
assessments were not provided by the transfer-
ring team. This finding further highlights the
importance of assessments and the active role
of the receiving team in assuring handover qual-
ity. It is in contrast to the implicit assumption in
the literature that information transfer during
handover is a one-way street (Manser & Foster,
2011). Handover studies in nonclinical settings
have previously stressed the importance of inter-
active handover strategies, such as a “question-
and-answer period,” to detect errors in assessments
and plans (Patterson et al., 2004; Patterson &
Woods, 2001).
The relevance of assessment is further sup-
ported by our exploratory analyses indicating
that consultant anesthetists spent more time on
assessments than do trainees, particularly dur-
ing OR-CICU handover. For cardiac cases,
trainees stated that they felt less confident in
predicting the course of the patient’s recovery
and about the expectations of the receiving
Postoperative Handover Communication 149
clinicians. These qualitative findings point at
a need to systematically investigate expert-
novice differences in handover communication
to identify training needs with a focus on ver-
balizing assessments.
Implications for Handover
Improvement Efforts
The findings presented here have practical
implications for effectively supporting
and training health care teams. First, they
support the connection between specific com-
munication behaviors and handover quality.
Assessments seem to play a central role in
assuring handover quality, and it does not suf-
fice to standardize the handover content to
assure completeness of information transmis-
sion. Instead, structuring aids should support
the team communication process during hando-
ver by providing room for assessments. This
recommendation is in line with the frequently
applied communication format SBAR (situa-
tion, background, assessment, recommenda-
tion; Haig, Sutton, & Whittington, 2006) that
clearly acknowledges the importance of assess-
ments, as do some other handover structures
(e.g., Catchpole, De Leval, et al., 2007).
Another aspect highlighted by SBAR is rec-
ommendation, which corresponds to planning
and decision making in our study. We did
not find a significant relationship of planning
and decision making with handover quality.
However, our qualitative comparison of consul-
tant versus trainee handovers showed that dur-
ing consultant handovers in CICU, more time
was spent on assessment and on planning and
decision making. Empirical examinations of the
communication formats recommended in the
literature and of their effects on patient care are
rare and not conclusive (Foster & Manser, in
press; Riesenberg, Leitzsch, & Little, 2009).
Observational studies, such as the one presented
in this article, could support the evaluation of
such interventions.
Second, our results highlight the active role
of the receiving clinician in assuring handover
quality and thus emphasize a view of patient
handover as a team activity. This finding has
implications for the design of handover formats
that encourage interactive questioning and
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discussion. Also, training interventions can help
the receiving clinicians to develop strategies to
speak up and assure that they get the informa-
tion they need, especially during physician-to-
nurse handovers (Weinger et al., 2010).
Finally, differences in the handover commu-
nication behaviors associated with higher
handover quality ratings of transferring versus
receiving clinicians’ (see Tables 2 and 3) point
at a need to establish a shared understanding of
the receivers’ needs. Cross-training has been
shown to improve team performance through
increasing interpositional knowledge (i.e., pro-
moting understanding of other team members’
roles and responsibilities; Cooke et al., 2003;
Marks, Sabella, Burke, & Zaccaro, 2002). For
patient handover, a training intervention focusing
on an understanding of the respective work roles
and their interdependencies (Blickensderfer,
Stout, Cannon-Bowers, & Salas, 1993), high-
lighting a teamwork orientation, and targeting
specific communication behaviors aligned with
the handover role (Volpe, Cannon-Bowers,
Salas, & Spector, 1996) seems most appropriate
(e.g., Weinger et al., 2010). However, a recent
study demonstrated differences in the expecta-
tions of transferring and receiving clinicians
even during shift handovers within the same
professional group (Carroll et al., in press),
indicating the need to understand more about
the working conditions and the specific pres-
sures associated with different roles.
Limitations
This study has limitations, some of which
were a consequence of observing professionals
in their actual work environment, which is also a
strength of this study. Particularly, the fact that
this study was a prospective observational field
study limited the sample size and thus reduced
the statistical power. Also, the study design did
not allow for control of factors potentially influ-
encing handover practices (e.g., information
passed on before the actual handover), and we
did not consider the actual content of the hando-
ver communication. Another critical aspect is the
potential dependency of our data, given that
individual participants were studied multiple
times. Without ethics committee approval to
collect identifying information on individual
150 February 2013 - Human Factors
receivers, assessment of the effects of their
demographic attributes on handover quality was
precluded. Countermeasures were taken when
collecting and analyzing our data. Although 23
transferring anesthetists were observed multiple
times (mean = 2.7 ± 1.3; median = 3; only three
transferring clinicians were observed five times),
the composition of the entire handover team was
unique for all observations. Furthermore, an
additional analysis of only the first handover
from each transferring clinician showed similar
(albeit nonsignificant) patterns of results.
The statistical analyses performed in this ini-
tial study do not allow for causal interpretation
of the relationships identified. Our aim was to
uncover potential relationships rather than to
test a specific hypothesis on individual relation-
ships. Therefore, we have analyzed our data
without multiplicity adjustment on the basis of
recommendations by Bender and Lange (2001)
for exploratory studies. Our exploratory results
may inform future hypothesis-based empiric
research. Also, future studies with much larger
sample sizes will allow researchers to use hier-
archical linear modeling to explore influences
at the level of hospitals, units, or teams.
Because there are no validated standardized
measures for handover quality (Patterson &
Wears, 2010), we assessed handover quality
using structured clinician self-ratings by the
transferring and receiving clinicians (Manser et
al., 2010). Handover quality ratings were all
rather high, making statistical analysis difficult.
The fact that these were self-ratings and that cli-
nicians had not received any training in how to
use the rating scale may have affected results.
However, we believe that this restricted range
issue is not an effect of the rating scale itself,
but rather, it reflects the fact that clinicians’ sub-
jective perception of the handover is very posi-
tive (e.g., they may be used to a practice that an
outside observer judges as suboptimal). Having
an independent external rater would have been
valuable, as self-assessments are often inaccu-
rate (Davis et al., 2006), but a second observer
was not possible for practical reasons. We used
a trained observer with years of experience, but
it was impossible for her to both attend to the
coding task and reliably rate the handover
quality.
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Because we did not have ethics committee
approval for videotaping of handovers, inter-
coder reliability for handover communication
could be assessed only on the basis of handover
transcripts, which is different from live coding.
Reliability analysis of live versus transcript
coding showed slightly lower but good intra-
rater agreement. Together with the excellent
unitizing reliability (i.e., identification of rele-
vant coding units), these results indicate that the
observation system can reliably be used to code
the handover communication process.
Finally, our results derive from a single hos-
pital. However, we included three types of
patient handover (i.e., handover to RR, to
CICU, and to the ward), providing some evi-
dence that the observation categories are appli-
cable in different postoperative settings and
that our results may generalize to postopera-
tive handovers in other hospitals. A systematic
investigation of the external validity would
require a much broader application in a variety
of handover settings across multiple hospitals.
These studies should also include possible
confounds (e.g., patient complexity, surgical
specialty, and duration) not included in this
study.
Conclusion
In line with previous research (Burtscher,
Kolbe, Wacker, & Manser, 2011; Cooke,
Gorman, Duran, & Taylor, 2007), our study
illustrates that the underlying mechanisms of
team performance in a complex cognitive task
can be better understood if one considers asso-
ciated team processes, such as communication
and coordination. Without this knowledge,
standardization efforts may be premature.
Detailed descriptions of communication pro-
cesses related to high-quality handovers will
further the understanding of this safety-critical
task and support the design and evaluation of
handover improvement efforts.
Appendix A
Procedure for Recording
Observational Data
Observing a complex activity, such as patient
handover, in the clinical work environment
Postoperative Handover Communication 151
without the benefits of video recording requires
a highly trained observer and adequate techno-
logical support for the data recording. The
PDA-based data recorder used in this study
(FIT-System) has successfully been applied in
previous studies involving observation of clini-
cians (Manser, Harrison, Gaba, & Howard,
2009; Manser, Howard, & Gaba, 2008) and is
described in detail by Held and Manser (2005).
In the following, we provide information on (a)
recording of start and end times of handover
activities, (b) recording of concurrent handover
activities, and (c) calculation of the relative
amount of time spent on the various handover
activities.
Recording of start and end times of hando-
ver activities. The observer recorded all
handover activities and who performed
these activities (i.e., work role) by acti-
vating buttons on the interface of the
FIT-System that automatically logs start
and end times for each event. This system
allows for continuous coding of behav-
ioral processes.
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Recording of concurrent handover activities. For
recording concurrent events (i.e., handover
activities of different clinicians or multiple
handover activities performed by a single
clinician simultaneously), an additional func-
tion of the FIT-System allows for entering
these events sequentially and then activat-
ing a delimiter for processing these events in
“packages” of concurrent events.
Calculation of the relative amount of time
spent on the various handover activities.
Because patient handover is a team activity
and multiple handover activities may occur
simultaneously, the overall time on hando-
ver activity can exceed handover duration.
Overall handover activity was defined
as the combined duration of all handover
activities in relation to the handover dura-
tion. The relative amount of each observa-
tion category was defined as the time spent
on a certain category in relation to overall
handover activity. For example, if a nurse
spent 50 s of a 1-min 40-s handover on
information giving, his or her information
giving score would be 50%.
152 February 2013 - Human Factors

Appendix B

Note: Ratings on the 4-point scale were coded as yes = 4, rather yes = 3, rather no = 2, and no = 1. All negatively
keyed items (i.e., when agreement would actually indicate lower quality) were recoded prior to data analysis with
the use of standard SPSS procedures for item transformation.

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Postoperative Handover Communication 153

Appendix C Dimensions of Perceived

Dimensionality of Handover
Quality Ratings
We analyzed ratings of handover quality
using factor analysis to establish the dimension-
ality of the rating tool. To allow for comparison
of transferrer and receiver ratings of handover
quality, we calculated a common factors struc-
ture across raters and settings. We performed
multiple regression analysis to test for the pre-
dictive validity of these dimensions for overall
handover quality.
Handover Quality
We assessed the dimensions of the quality
ratings using exploratory factor analysis (prin-
cipal component analysis) with varimax rota-
tion. Preliminary checks (Field, 2005) showed
good sampling adequacy (n = 183), as indi-
cated by a Kaiser-Meyer-Olkin-criteria of
0.80. Also, the range of intercorrelations
between the items (i.e., neither too low nor too
high) was shown to be adequate, as indicated
by a significant Bartlett test of sphericity (p =

Table C1: Four Factors of Handover Quality

Factor

Items 1 2 3 4

Priorities for further treatment were addressed .84  

Possible risks and complications were discussed .79  
The person handing over the patient .70  
communicated her or his assessment of the
patient clearly
All relevant information was selected and .66 .42  
communicated
Not enough time was allowed for the handover .72  
(R)
The handover followed a logical structure .70  
Documentation was complete .54 .39  
It was easy to establish good contact at the .54  
beginning of the handover
The team jointly assured that the handover was .81  
complete
Questions and ambiguities were resolved (active .58  
inquiry by the person taking on responsibility
for the patient)
The patient’s experience was considered .44 .46  
carefully during handover
There were tensions within the team during .75
handover (R)
The person handing over the patient .40 .32 –.62
continuously used the available documentation
(patient chart, etc.) to structure the handover
Variance explained in % 20.0 16.5 13.3 8.8

Note. Rotated factor loadings smaller than 0.3 not shown. R = reverse-coded item. The item “The patient’s experi-
ence was considered carefully during handover” could not be assigned to a single factor and was excluded from
further analysis.

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154 February 2013 - Human Factors
.000) and a determinant of the intercorrelation
matrix of 0.045.
Factor Solution
Factor analysis revealed four eigenvalues
greater than 1, determining the number of fac-
tors extracted together with the loading pattern
(Table C1). The four factors account for 58.5%
of the variance in the items.
Factor 1 (discussion of patient care informa-
tion) deals with transmitting the relevant clini-
cal information and highlighting risks and
priorities to the receiving team (i.e., selecting
and communicating all relevant information,
communicating an assessment of the patient,
addressing priorities for further treatment, and
discussing possible risks and complications).
Factor 2 (handover organization) focuses on
aspects that may support effective communica-
tion between clinicians (i.e., allowing for
enough time, following a logical structure, hav-
ing complete patient documentation, and estab-
lishing good contact at the beginning of the
handover). Factor 3 (establishing a shared
understanding) deals with the means for estab-
lishing a shared understanding between trans-
ferring and receiving clinicians through active
clarification of questions and ambiguities and
assuring completeness of the handover. Factor 4
(conduct) deals with the atmosphere within the
team of clinicians involved in a handover (i.e.,
tensions) and with the continuous use of avail-
able documentation.
Predictive Validity of Dimensions
of Perceived Handover Quality
We calculated factor scores from the solu-
tion of the factor analysis using the regression
method (Field, 2005). Multiple regression
analysis showed that three of the four factors
identified in this study have good predictive
validity for the perceived overall handover
quality. Discussion of patient care information
showed the highest correlation with overall
handover quality (β = 0.46, p < .001), followed
by handover organization (β = 0.33, p < .001)
and establishing a shared understanding (β =
0.28, p < .001). Conduct was not significantly
correlated with overall handover quality (β =
0.03, ns).
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Acknowledgments
This research was funded by the European
Commission, Marie Curie Intra-European Fellowship
(Grant No. PIEF-GA-2009-236668). We thank the
participating clinicians for their support in conduct-
ing this study.
Key Points
•• The methodological approach of this study
advances the state-of-the-art of handover research
by (a) developing and applying a method for
structured observation of handover activities
based on existing research on effective teamwork
in health care and (b) relating these observations
to clinicians’ self-ratings of handover quality.
•• Assessment is a communication behavior associ-
ated with higher handover quality ratings. If there
is a lack of assessment, the receiving team can
compensate by showing more information-seek-
ing behavior, such as requesting explanations and
asking for predictions or anticipated problems.
•• In recommendations for handover practice and
training interventions, one needs to consider more
than just accuracy and completeness of informa-
tion transfer but also to give due attention to cli-
nicians’ assessments and acknowledge the active
role of the receiving clinicians in shaping the
handover communication process.
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Tanja Manser is a Swiss National Science Foundation
professor of industrial psychology and human fac-
tors at the University of Fribourg. She received her
PhD in psychology in 2002 from the University of
Zurich, Switzerland.
Simon Foster is a PhD student at the Center for
Organizational and Occupational Sciences, ETH
Zurich. He received his MSc in psychology in 2008
from the University of Bern, Switzerland.
Rhona Flin is a professor of applied psychology at
the University of Aberdeen. She received her PhD in
psychology in 1983 from the University of Aberdeen,
Scotland.
Rona Patey is a consultant anaesthetist for NHS
Grampian and the head of the Division of Medical
and Dental Education at the University of Aberdeen.
She graduated MB ChB from the University of
Aberdeen in 1982, received her FRCA in 1987, and
completed an M Ed with the Open University in
2005.
Date received: June 1, 2011
Date accepted: May 17, 2012