“All the ward’s a stage”: a qualitative study of the experience of direct observation of handoffs

  • Kathleen Huth
  • Sarah Schwartz
  • Shelly-Anne Li
  • Natalie Weiser
  • Sanjay Mahant
  • Christopher P. Landrigan
  • Nancy D. Spector
  • Amy J. Starmer
  • Daniel C. West
  • Maitreya Coffey
  • Zia BismillaEmail author


Direct observation of clinical skills is central to assessment in a competency-based medical education model, yet little is known about how direct observation is experienced by trainees and observers. The objective of the study is to explore how direct observation was experienced by residents and faculty in the context of the I-PASS Handoff Study. In this multi-center qualitative study, we conducted focus groups and semi-structured interviews of residents and faculty members at eight tertiary pediatric centers in North America that implemented the I-PASS Handoff Bundle. We employed qualitative thematic analysis to interpret the data. Barriers to and strategies for direct observation were described relating to the observer, trainee, and clinical environment. Residents and faculty described a mutual awareness that residents change their performance of handoffs when observed, in contrast to their usual behavior in a clinical setting. Changes in handoff performance may depend on the nature of the observer or ‘audience’. Direct observation also highlighted the importance of handoffs to participants, recognized as a clinical activity that warrants feedback and assessment. Dramaturgical theory can be used to understand our finding of ‘front-stage’ (observed) versus ‘backstage’ (unobserved) handoffs as distinct performances, tailored to an “audience”. Educators must be cognizant of changes in performance of routine clinical activities when using direct observation to assess clinical competence.


Direct observation Dramaturgy Handoff Pediatrics Residency education 



We thank all resident and faculty participants, the I-PASS site leads, and the I-PASS Executive Council for their contributions to this research. We acknowledge Physician Services Incorporated (#11-28) and the US Department of Health and Human Services (R18 AE000029) for financial support of this study.

Compliance with ethical standards


The study was supported by funding from: (1) improving resident handoff in teaching hospitals: understanding implementation and effectiveness of a handoff bundle. Coffey M, Starmer A, Mahant S, Matlow A, Bismilla Z, Landrigan C. Physician Services Incorporated Health Research Grant. ($154,820 2011–2013). (2) Building Effective Resident Hand Off Practices To Improve Patient Safety. Landrigan C et al. U.S. Dept. of Health and Human Services (ARRA funding) ($3,000,000—2010–2013)

Conflict of interest

Drs. Landrigan, West, Spector and Starmer have consulted with and hold equity in the I-PASS Patient Safety Institute, which seeks to train institutions in best handoff practices and aid in their implementation. Drs. Starmer, Spector, and West reported receiving honoraria and travel reimbursement from multiple academic and professional organizations for delivering lectures on handoffs and patient safety. Dr. Landrigan has been supported in part by the Children’s Hospital Association for his work as an Executive Council member of the Pediatric Research in Inpatient Settings (PRIS) network. In addition, Dr. Landrigan has received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety, and has served as an expert witness in cases regarding patient safety and sleep deprivation.

Ethical approval

The study was approved by the Hospital for Sick Children Research Ethics Board.


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Copyright information

© Springer Nature B.V. 2018

Authors and Affiliations

  • Kathleen Huth
    • 1
  • Sarah Schwartz
    • 2
    • 3
  • Shelly-Anne Li
    • 2
  • Natalie Weiser
    • 2
  • Sanjay Mahant
    • 2
    • 3
  • Christopher P. Landrigan
    • 1
    • 4
  • Nancy D. Spector
    • 5
  • Amy J. Starmer
    • 1
  • Daniel C. West
    • 6
    • 7
  • Maitreya Coffey
    • 2
    • 3
    • 8
  • Zia Bismilla
    • 2
    • 3
    Email author
  1. 1.Department of PediatricsBoston Children’s Hospital and Harvard Medical SchoolBostonUSA
  2. 2.The Hospital for Sick ChildrenTorontoCanada
  3. 3.Department of PaediatricsUniversity of TorontoTorontoCanada
  4. 4.Division of Sleep and Circadian DisordersBrigham and Women’s HospitalBostonUSA
  5. 5.Office of Faculty Development and the Executive Leadership in Academic Medicine ProgramDrexel University College of MedicinePhiladelphiaUSA
  6. 6.Department of PediatricsUniversity of CaliforniaSan FranciscoUSA
  7. 7.UCSF Benioff Children’s HospitalsSan FranciscoUSA
  8. 8.Solutions for Patient SafetyCincinnatiUSA

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