E. Data Analysis

To test the feasibility of the dramaturgical approach, a framework was adapted exploring the perspectives of the actors and audience, the script, the staging and the overall performance (Canary et al., 2008; Crea, 2017; Henderson, 2005).  Delineation of roles within the handover (Preves & Stephenson, 2009; Schell, 2016) identified the following ‘actors’: lead, major support, support, and bit actors. The perceived director was involved in the leading and facilitation of the handover (Goffman, 1959).  The audience was defined as observers or those actors minimally involved in the main discussion (Canary et al., 2008; Hays & Weinert, 2006). Other factors considered in the analysis included scripting, staging, and performance analysis (Hays & Weinert, 2006).

We scrutinised the data using a deductive thematic content analysis based on dramaturgy criteria (Elo & Kyngäs, 2008).  The usefulness of voice-occupied time (VOT) was appraised and VOT was defined as the total time a participant spoke during the entire handover divided by the total duration of the handover, expressed as a percentage. The utility of a timeline considered the dynamics connected to scene development. Lastly, the trustworthiness of the qualitative data analysis protocol was audited (Elo et al., 2014).

III. RESULTS

The following data were used to assess the feasibility, functionality and quality of the dramaturgical process. For full data details, please refer to Figshare (2020).

A. Actors and Audience

The handover involved 15 participants (Table 1).

Table 1: Roles and number of participants and observers present in handover.

The VOT analysis (see Table 2) was useful in quantifying participation as aligned with perceived roles. The participant with the highest VOT was deemed to be the lead actor, while the second highest VOT was classified as the major supporting actor.  Participants with VOTs of greater than 5% were defined as supporting actors, and participants who had VOTs of less than 5% were judged to be bit actors and audience. Accordingly, the lead consultant (the initial director) (P13) and the senior registrar (P3), who each had more than 15% of the VOT, were judged to be the lead and major support actors respectively. Eight (53%) of the participants were identified to be present as bit actors or audience. 

Figure 2: Timeline of acts, scenes and selected events

3) Additional observations: Multiple data collection methods enhanced the dramaturgical method, through clarifying inaudible audio data. Entrances and exits did not always prompt comments on the audio recording, but were noted from the video recordings. A critical incident occurred when the lead consultant established an educational role and used the whiteboard for teaching – the impact of this would not have been so apparent without a video recording. 

IV. DISCUSSION

The studied handover was attended by multiple professionals and students, and had several purposes, focussing on the safe exchange of knowledge and responsibility for a group of patients with variable clinical conditions and acuity (Australian Medical Association Limited, 2006; Hilligoss & Cohen, 2011). We argued that the dramaturgical approach would be a valuable method for analysing the dynamics of this handover. To evaluate the effectiveness of this research approach, we focussed on the feasibility, functionality and quality of the dramaturgy approach.

A. Feasibility

The dramaturgical perspective argues that individuals “play different roles as ‘actors’ and engage in ‘performances’ in order to shape their ‘definition of the situation’” (Canary et al., 2008, p. 155). We applied the metaphor of ‘life as drama’ to this handover. The findings and information gleaned from this handover demonstrated that a dramaturgy approach embedded within a case study methodology can be applied to a complex team handover.

Obtaining consent from all handover attendees in a manner that did not impact on the handover itself required significant pre-planning by the research team and cooperation from the department. In their systematic review, Flory and Emanuel (2004) examined methods for improving the consent process and for increasing participant understanding. One recommendation centred on employing significant person-to-person contact as an optimal method to improve understanding. To avoid undue power dynamics, a senior consultant at this hospital involved in the study was not involved in the administrative process, and this prevented any direct involvement in the recruitment and data collection processes, thus minimising inducement and conflict of interest.  

Patients are often particularly vulnerable in this type of research, as they may not fully understand their legal or ethical rights (Sankar et al., 2003). We were cognisant of this when considering our research design. To maintain confidentiality of patients, we de-identified patient details, using a numbering system and only referred to patients by their number code to minimise release of personal medical information. 

We established that the dramaturgical approach was able to feasibly capture both verbal and non-verbal elements of the discourse. To capture this wide range of information, we used multiple methods of data collection creating greater accuracy of the handover.  Other studies have used different research approaches. Using grounded theory and content analysis, Behara et al. (2005) studied five North American Emergency Departments using ethnographic observations, and emphasised the active participation of handover members in co-construction of their understanding about the patients who were considered in the handover. The use of ethnographic observation has some resonance with this study, although, in this study, we created an ‘a priori’ framework for analysis using the dramaturgical components.  The dramaturgical method allowed us to structure our analysis. Several researchers (Donnelly et al., 2019; Ooi et al., 2020) have used inductive techniques to analyse semi-structured interview data, and these studies provided useful perceptions of team handovers in New Zealand hospitals. The advantage of using interviews is that professionals interviewed have time to reflect on the salient aspects of the handover; however, a disadvantage is that the interviewees can censor and forget key elements of the process.

B. Functionality

In this section, we address the second research question focussed on describing the functional dynamics of the handover. 

We found that dramaturgical methods provided a useful lens to analyse the way the actors and their roles interacted with the staging. For example, the handover was clearly orchestrated by designated and perceived roles of the lead actor (P13) and the major support actor (P3). Our method of utilising VOT allowed us to evaluate the reasons why some actors within the handover participated more or less, with findings clearly showing that the handover was directed by P13, until she left the room and then P3 became the dominant driver of the performance. This finding is consistent with the work of Donnelly, who described the critical nature of the team handover leader’s role in ensuring safe and equitable outcomes for patients by “running meetings smoothly and respectfully” (Donnelly et al., 2019, p. 611). 

The interruption caused by the critical case in Scene 9 highlighted the importance of patient safety and care in handover function (Australian Medical Association Limited, 2006), which took priority over ensuring equal voice contribution of the handover attendees. The impact of handover members having differing levels of clinical experience within a team has been noted as an important contributor to handover dynamics (Behara et al., 2005; Hilligoss & Cohen, 2011). We documented a degree of audience segregation (Canary et al., 2008; Murphy, 2009) within the handover, in that, within specific scenes, some actors were markedly involved, whilst others, particularly the bit actors, were effectively the audience and were relatively uninvolved unless prompted by the director or major support actor.    

The video analysis permitted us to regard this handover as more akin to an unscripted improvisation (Sawyer, 2004; Schryer et al., 2003) based on the handover sheet. Hilligoss and Cohen (2011, p. 95) have described handovers as “routines grounded in human memory for habits”, and the handover sheet provided a routine document to be worked through. The dramaturgical framework allowed us to visually consider the layout of the room (or stage) (Goffman, 1959; Murphy, 2009).  Kinahan (2017), in her qualitative analysis of seating positions within an educational context, reported that different seating positions likely yield different outcomes. The horseshoe-formation structure used in this handover likely promoted more participant engagement. 

Lastly, the dramaturgical approach allowed us to segment the analysis in terms of acts and scenes (Henderson, 2005). This was useful as it allowed us to determine if there were specific activity patterns or key events arising within this handover.  Hilligoss and Cohen (2011, p. 95) stated that research “examines how micro patterns of activity in [handover] are embedded in, shaped by, and ultimately produce effects on the larger system of hospital activities”. The handover had a prologue in which members had a brief period of social contact, an important element of handover (Hilligoss & Cohen, 2011; Nugus et al., 2017) which initiates formalising the community of practice (Bradley et al., 2018; Egan & Jaye, 2009). 

The functionality of the dramaturgical approach can be easily demonstrated within Acts 2 and 3. Act 2 centred on discussion regarding two patients who presented diagnostic uncertainty, and provided the platform for opportunistic teaching, with significant emphasis and time spent on these patients. However, it was clear from our analysis that these teaching moments resulted in a single focus when all team members were effectively engaged through use of directed questioning.  The importance of learning within handover has been described (Hilligoss & Cohen, 2011; Ooi et al., 2020; Paradis & Sutkin, 2017). Specifically, the use of brief opportunistic learning related to appropriate patients has been suggested as a useful strategy within handover (Bradley et al., 2018; Ooi et al., 2020). Nonetheless, it was unclear to the researchers whether the teaching initiatives seen in this handover represent typical behaviour, or whether participant activity may have been influenced by the study itself (Paradis & Sutkin, 2017). Act 2 revealed a subsequent shift from a focus on education to patient care, demonstrating that patients continued to receive emergency treatment when required.  This reflected an understanding that the participation of the team at handover did not compromise the ongoing provision of medical care for other patients (Australian Medical Association Limited, 2006).  

A further change in focus was observed in Act 3, with a focus on the requirement to discuss briefly the remaining 28 patients on the sheet. Our analysis demonstrated a shift to much briefer discussions, reflecting the need to work in a timely manner. This suggested a shift in the handover from a community of practice with at least partly an educational focus to that of a formal work group (Egan & Jaye, 2009; Wenger & Snyder, 1999). The need to pace the handover and to balance the conflicting functions has been noted in other studies (Donnelly et al., 2019; Horsky et al., 2015).

C. Quality Appraisal of the Research Methodology

The dramaturgical approach created a formalised structure from which authentic workplace activity could be identified.  In comparison to other qualitative methods, the advantages were the rich, untainted data obtained. The findings of semi structured interviews conducted with the participants involved in this handover are published in a further report (Ooi et al., 2020) and builds on other existing findings published to date within other specialties (Donnelly et al., 2019). The findings of the Ooi et al study were informative as they allowed probing, using semi-structured interviews, into the perceptions of the handover participants after the handover had taken place. These findings are useful in the understanding participants’ views on team dynamics, modes of communication, and the opportunities for learning. Similarly using an interview approach to gathering data, Bradley et al. (2018) was able to develop a set of themes that could be used to describe the handover process, namely informal learning (comprising opportunistic learning, implicit learning, and reflective learning) and formal and deliberative learning. Gathering data using the interview approach enables a deliberative process whereby the participants have time to reflect on their educational and clinical experience associated with the handover. Nevertheless, as aforementioned, it also allows participants to censor their thoughts and memories of the handover (Knox & Burkard, 2009) and may not capture the authoritative complexity of what has occurred in a multifaceted meeting. Therefore, the dramaturgical process could be viewed as authentic ‘in the moment’ research whilst an interview perspective is memory driven, retrospective and reflective.

The optimal approach is to use the dramaturgical system to capture the objective evidence of what actually happened in the handover, and then to use interview data to consider how the participants frame their reflections of what happened. Using both systems would be highly informative in terms of illustrating congruity or incongruity between what happened, what participants thought had happened, and participants’ consequential deliberations regarding their educational and clinical experiences. Using both research systems would benefit handovers, as they would complement each other. To gather data from a larger sample source, using a self-report questionnaire may be valuable once the theoretical domains are established. However, it is acknowledged that designing and developing a questionnaire that is fit for purpose takes careful planning and a rigorous research process (Rattray & Jones, 2007).

A major limitation of the dramaturgical approach taken was the presence of the observers, cameras and audio recording devices and the knowledge of being observed. The Hawthorne effect has been noted as an important aspect of studies as it infers that the perception of special attention may influence behaviour (Paradis & Sutkin, 2017). The research team was uncertain whether the strong emphasis within this handover on teaching reflected the usual practice of the paediatricians involved, but acknowledged that some of the handover participants were aware that two of the researchers were involved in previous research in this area (Ooi et al., 2020), which could have contributed to conciliatory behaviour. One further area of concern was conflict of interest or undue influence.  The handover we studied occurred within a hospital at which one of the researchers is both Clinical Director and a paediatrician, and where two others are previous or current members of the paediatric team. None of these three doctors was present in the room during the study, but we acknowledge a potential conflict of interest, which could have altered participants’ behaviour. However, we felt that we had instigated safeguards to minimise this influence, such as having two independent observers within the handover and asking an administrator to contact handover participants with regards to participation and consent. In addition, we also believe in the professionalism of the participants as their main concern in the handover was the authentic transfer of patient information to ensure optimal patient care. It is likely that a mixed-methods approach would be the optimal method for describing the explicit and implicit nature of the handover process.

Our system of analysis created a triangulation method drawing information from the video and audio recordings taken from differing angles, the subsequent transcription of the audio recording, and the notes from two independent observers (medical student and medical educationalist). We were also able to collect data on the room layout (Figure 1) and the handover sheet.  We found the data from the video source invaluable in identifying which participants were speaking and in detecting dialogue that was not clearly audible from the audio recording. Once the transcript was agreed on, we found analysis of the video sources and the recordings of the two observers critical to understanding the dynamics within the handover. The video allowed us to identify non-verbal behaviours such as the entrances and exits of staff where this was not otherwise referenced in the audio recording. An entire sequence of teaching occurred when one participant used the whiteboard, and this would not have been appreciated from use of the audio source only. Rees et al., 2013) used video and audio recordings to collect data relating to bedside teaching of medical students, but did not use a structured method of analysis; nonetheless, they found the video useful in capturing linguistic and para-linguistic information, although they noted the difficulty in capturing subtle non‐verbal communication (e.g. smiles). 

V. CONCLUSION

This feasibility study has demonstrated that a dramaturgical method had immense utility when analysing the complexity of a paediatric handover meeting. A discussion as to its functionality, benefits and limitations is also provided and we believe that this approach has generated a deep understanding of this handover’s dynamics and highlighted key aspects of the handover’s function, with implications for educational and organisational research. 

Further studies could be designed relating to the dramaturgical method.  These could be directed to other team handovers in either paediatric or other specialties, and in different health systems to broaden the understanding of processes that occur within these complex meetings.  Examples of other such meetings are Multi-Disciplinary patient related meetings, ward rounds, radiology meetings and educational meetings such as Grand Rounds and workshops. Further research could be broadened to include semi-structured interviews of handover participants to gain further understanding of handover members’ reactions to the handovers they have participated in. 

Notes on Contributors

Stephen Bradly is a consultant paediatrician (MBChB, FRACP, MClinEd), Clinical Lead, Medical Education, Lakes District Health Board, New Zealand. He reviewed the literature, co-designed the study, analysed the transcripts and co-wrote the manuscript. 

Aaron Ooi is a registrar and teaching fellow (MBChB, DipPaed, PGDipClinEd), Waikato District Health Board, New Zealand. He reviewed the literature, co-designed the study, analysed the transcripts and co-wrote the manuscript.

Kerry Stafford is a senior house officer (BMBS), Department of Paediatrics, Christchurch Hospital, Canterbury District Health Board, New Zealand. She reviewed the literature, co-designed the study, analysed the transcripts and contributed to the manuscript.

Shuvayon Mukherjee was a fifth year medical student (BSc) at the time of the study, University of Auckland, New Zealand and on clinical attachment at the Department of Paediatrics, Rotorua Hospital, Lakes District Health Board. He reviewed the literature, co-designed the study, conducted the interviews, analysed the transcripts and contributed to the manuscript. 

Marcus A. Henning is an associate professor (BA, MA, MBus, PhD), Centre for Medical and Health Sciences Education, University of Auckland, New Zealand. He reviewed the literature, co-designed the study, conducted the interviews, analysed the transcripts and co-wrote the manuscript. He is the corresponding author for this manuscript*.

Ethical Approval

Ethics approval was obtained from the University of Auckland Human Participants Ethics Committee (UAHPEC) on 26 June 2018.  The reference protocol number is 121483.

Data Availability

The anonymised data set is available on https://figshare.com/s/2985a2e3047594816d88 Figshare (2020), with URL details below. 

Due to the nature of the video and audio recording containing identifying information, these have not been made public. Requests for these can be directed to the corresponding author if required.  

Acknowledgement

We wish to thank the participants in the handover that we studied, who graciously allowed our observation of them working hard to provide excellent care for their patients. We are also grateful to Brenda Flood, who efficiently and capably transcribed the handover. 

Funding

A grant to meet the cost of transcription was received from the Stolwyk Trust, Lakes District Health Board.

Declaration of Interest

The authors declare no conflicts of interest. 

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*Marcus A. Henning
The University of Auckland,
Private Bag 92019,
Auckland 1142,
New Zealand,
Contact No: 0064 923 7392
Email: m.henning@auckland.ac.nz