"Mr Smith's been our problem child today…": anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs.

Background: Tools and procedures designed to improve end-of-shift handoffs through standardisation of processes and reliance on technology may miss contextually sensitive information about anticipated events that emerges during face-to-face handoff interactions. Such information, what we refer to as anticipatory management communication (AMC), is necessary to ensure timely and safe patient care, but has been little studied and understood.

Objective: To investigate AMC and the role it plays in nursing and medicine handoffs.

Research Design: Qualitative thematic analysis based on audio recordings of nurse-to-nurse, medical resident-to-resident and surgical intern-to-intern handoffs.

Subjects: 27 nurse handoff dyads and 18 medical resident and surgical intern handoff dyads at one VA Medical Center.

Results: Heads-up information was the most frequent type of AMC across all handoff dyads (N=257; 108 resident and 149 nursing). Indirect instructions AMC was used in a little over half the resident handoff dyads, but occurred in all nursing dyads (292 instances). Direct instructions AMC occurred in roughly equal proportion across all dyads but at a modest frequency (N=45; 28 resident and 17 nursing). Direct (if/then) contingency AMC occurred in resident handoffs more frequently than in nursing handoffs (N=32; 30 resident and 2 nursing).

Conclusions: The different frequencies for types of AMC likely reflect differences in how residents and nurses work and disparate professional cultures. But, verbal communication in both groups included important information unlikely to be captured in written handoff tools or the electronic medical record, underscoring the importance of direct communication to ensure safe handoffs.