In most cases, participants did not spontaneously connect the transfer of responsibility and accountability as a function or role of clinical handover. Clinicians spontaneously reported the primary function of handover being information transfer, patient care and/or continuity of care in all but one interview and one focus group. In the one focus group where it was not spontaneously reported, logistical management of resources, beds and staff and, accountability were thought immediately associated with the functions and roles of handover. In one interview, the transfer of responsibility and accountability was spontaneously reported as the primary role of handover above any other function and role.
In total were 7 clinicians in this study who spontaneously identified the transfer of responsibility and/or accountability as one of the roles or functions of handover. However, when asked specifically about this function, the other clinicians agreed that it was indeed connected to handover. Once introduced to this concept, they spoke about the transfer of responsibility and accountability in terms of complete transfer as well as shared and ongoing personal responsibility and accountability (box 1
Box 1. Example quotations about transfer of responsibility and accountability
- Complete transfer of responsibility and accountability
- So I'm the one looking after her, I decide to stay, yeah, and some other midwife comes in, well you're right, there's never anything officially said, but, I would assume I'm still the one responsible and if that happens with me coming into a room, I would assume that they were responsible…Well, till they leave.
- (Senior midwife)
- [describing when responsibility and accountability has been transferred] When you have communicated your concerns about the patient, when you've communicated any, any issue, any management or issues that have come up whether it be from the patient perspective or from the clinician's perspective and when you feel that when you're satisfied that the team that's taking over um, understands what your proposed plan of management was, whether they agree with it or, or not um, and have enough information to be able to make sound clinical judgements with what they're going to do.
- (Junior obstetric doctor (Level 2 Registrar))
- When the handover's completed…And if we don't know about a patient, then it's hard to take responsibility for what goes on, um, and equally can't provide care.
- (Consultant obstetrician)
- …You are accountable for the information transferred as well as received…You can't literally handover all sixty babies on the floor of nursery so there will be anticipated problems that may occur in the next shift, so from a reviewer perspective you want to handover what has been done and what problems that you might anticipate in nursery or in obstetric deliveries. The role of handover is for that safe anticipation of a patient's journey.
- (Consultant paediatrician)
- Shared responsibility and accountability
- There's a couple of hours where that's not clear because you're both there and although we have um, you know, like an education time after handover and the afternoon staff go to that and so technically the morning staff still cover that woman until whenever. In my own practice if I get handed to at two thirty, before I do anything um, I make sure that I've seen what I'm responsible for and if I'm able to I go to education sessions then but I like to look at, you know, exactly what I'm taking up before I let that other person go.
- I believe I am transferring partial responsibility for the patient because that personal responsibility has not passed. Occasionally I continue to take part in the management especially if I am MFM [Maternal Fetal Medicine] Registrar or know her from the ward, I know that I will be looking after this patient postpartum and I always ask what has happened to her. But I think my responsibility, if I finished night duty, I hand over patient to the morning staff and continuity to the staff. I still have responsibility for what I have done, what I made. It is difficult what you mean, responsibility on a legal point of view, mental point of view, moral point of view?…Legally I feel responsibility but I hand over, morally I feel responsible as well, can I say shared responsibility?
- (Junior obstetric doctor (registrar))
- Ongoing responsibility and accountability
- [on the timing of transferring responsibility and accountability] When you decide to go home. Sometimes you'll stay until four o'clock [thirty minutes after the official end of morning shift] and there's still no birth and you're thinking it's time I went and you walk.
- (Senior midwife)
- Definitely especially if I have been with the patient full time and this patient is in 2nd stage is very close to delivery after 20 hours, especially labour related handover and I handover someone who is almost fully dilated, occasionally I feel that I carry full responsibility and next day I found something had happened, it was a difficult delivery, I feel responsible that I should have partly done something for this patient.
- (Junior obstetric doctor (registrar))
- [speaking about being paged after handover] But if they have told you that there is no one else around, the patient is having late decels [signifying non-reassuring fetal monitoring], I guess you can't do much, at least you have taken the call and given them some basic instructions and what to do and although they are basic and the midwives may have already done them first it always helps to re-iterate things.
- (Junior obstetric doctor (Level 2 registrar))
- I guess for me, within our department, it is if you are rostered on you are responsible, and when you are not on that responsibility is transferred to the next person. It's really that time base thing, although there is often, often do carry that responsibility say if I have got a patient that I have been particularly involved with needing to make sure she is okay even if I am not on. And that probably provides more confusion, 'cause what's [Doctor's Name] ringing when she's not on.
- (Consultant physician (haematologist))
Complete transfer of responsibility and accountability
Complete transfer of care was marked by some as corresponding to the end of the handover communication (which may be part of an organisational protocol), by rostered time of duty, actual commencement of work or by the clinician leaving the workplace at the end of the shift. Although it was highlighted by a few that this happens regardless of the communication, some clinicians stressed that they were responsible and accountable for delivering the information required for a safe transition of care and that it be understood by the on-coming team.
Midwives had first a group ward or birth suite handover followed by allocations of patients and finally an individual one-to-one handover. Some midwives, specifically mentioned that the complete transfer of care was marked by the end of the one-to-one handover with the off-coming midwife of their allocated patients.
The importance of seniority was also mentioned by some clinicians. This was discussed in terms of responsibility and accountability being transferred once handover was given to a clinician of similar or of greater seniority than the handing-over clinician.
Shared responsibility and accountability
For some clinicians, responsibility and accountability was felt not to be handed over completely at the clinical handover communication. At times where there was a regular overlap of rostered shift time for the off-coming and on-coming clinicians (30 min for the obstetric doctors and up to 2 h in the case of midwives handing over in the middle of the day), this was seen either as a period of shared or blurred responsibility and accountability until the off-coming clinician went home. Having this overlap in rostered shifts allowed for handover communication to take place and for the midwives, the opportunity for a group to have education sessions while being covered by others on the ward.
Some clinicians still felt ties to the patient due to their own extensive personal clinical knowledge of the patient, their role within the continuity of care of the patient in the hospital or their extensive direct involvement in the patient's care. One clinician even expressed this as the division of legal and moral responsibility for a patient's care. In this case, both can be handed over at a shift change, but this clinician felt that they morally had ongoing responsibility for a patient.
Ongoing personal responsibility and accountability
Some clinicians felt an ongoing personal responsibility and accountability for patients despite having given a handover to the on-coming staff. Examples of this were in the case of incomplete handover and personal professional attachment to the patient's clinical well-being and care. This was acknowledged by one clinician, a physician, as potentially causing confusion.
Some clinicians felt responsible and accountable for the information that they gave at handover including ensuring tasks that were handed over were understood. Some also felt that if after handover the on-coming clinician was unavailable for an emergency, the off-coming clinician had a duty of care to help if they could if paged. If the clinician did not handover everything required for assumed patient care, some clinicians felt that they were still responsible and accountable for the patient until they handed over the information; even if this meant calling up the ward, after they had left, to handover.
One clinician noted that despite handing over care, if the outcome of a labour was a difficult delivery following the handover, they felt responsible for the outcome. This illustrated the ambiguous relationship between management decisions prior to handover that potentially result in adverse outcomes following handover. Although the transfer of information at this time point can be defined, less obvious to the clinician was where their responsibility and accountability lies in the continuum of care resulting in the health of the mother and baby following birth. This could happen whether or not the outcome was within the clinician's control.
Both midwives and obstetric doctors spoke of ongoing responsibility and accountability of patients in labour following an official handover. This occurred in the public and privately insured healthcare systems. Some of these clinicians who had direct care of the patient during this time chose and felt responsible and accountable for the patient until after the birth had been completed; even if this meant working past the end of their rostered shift. This enabled continuity of clinician throughout this key time of transition to motherhood. This practice was acknowledged as an accepted but not necessarily an expected practice by other clinicians.
One clinician in particular reflected on how it was difficult for clinicians to leave the workplace and that learning to hand over care and leave was important for clinician longevity within the workforce.
Defining who is responsible
A few clinicians commented about who was responsible for patient care (box 2
). They spoke about defining work and responsibilities within the on-coming team. They also described a person's clinical area and expertise defining their work and responsibilities. One anaesthetic doctor described it is a matter of ownership: responsibility and accountability for a patient being equated with the ownership of the care of the patient and associated issues.
Box 2. Example quotations about defining who is responsible
- Defining roles and responsibilities
- …It's now, I'm leaving, and it's not your responsibility. So I guess it's also depending on how workload is shared I think you do need to define who will be responsible for checking progress, or a result or reviewing a patient, and that's a shared responsibility.
- (Consultant physician (haematologist))
- …Very recent times we have moved to having very set times that you have of responsibility for something, which makes it much easier for someone to just “oh it's really my responsibility today”, in to move on, and I think that you see in all levels, I mean you see it where residents, maybe less so with the registrars, because I think a lot of them are a little bit more aware of the fact that they've made his, they have made the transition, they have the responsibility…But the problem is everybody kind of, reaches that point where they're not really involved, and is there's no single person who has that ownership over the patient for the problems that arise, so, I don't know how that's going to change though.
- (Junior anaesthetic doctor (Senior registrar/fellow))
- Seniority defining responsibility
- Sure, the minute I'm assuming the handing over is to a team who are starting a shift, so within that team there will be a pecking order of accountability and responsibility, and I would therefore assume that if it's the morning handover and your handing over from the night shift to the morning shift it will be a registrar, nurse manager , the relevant midwives who will be each – the departing person will be replaced by an incoming person who will have the same level of accountability and responsibility.
- (Consultant obstetrician)
One junior obstetric doctor felt that the allocation of responsibility was to the most senior person on the shift: the consultant. He felt that although the consultant obstetrician was responsible, he saw that person as separate from the team and the role of the consultant was to provide expert opinion at a distance.