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VIEWPOINT
The limits of checklists: handoff
and narrative thinking
Brian Hilligoss,1 Susan D Moffatt-Bruce2
1
Division of Health Services
Management and Policy, College
of Public Health, The Ohio State
University, Columbus, Ohio, USA
2
Department of Surgery, The
Ohio State University Wexner
Medical Center, The Ohio State
University, Columbus, Ohio, USA
Correspondence to
Professor Brian Hilligoss, College
of Public Health, The Ohio State
University, 224 Cunz Hall,
1841 Neil Avenue, Columbus,
OH 43210-1351, USA;
bhilligoss@cph.osu.edu
Received 26 November 2013
Revised 22 February 2014
Accepted 9 March 2014
Published Online First
2 April 2014
To cite: Hilligoss B, MoffattBruce SD. BMJ Qual Saf
2014;23:528–533.
528
ABSTRACT
Concerns about the role of communication failures
in adverse events coupled with the success of
checklists in addressing safety hazards have
engendered a movement to apply structured tools
to a wide variety of clinical communication
practices. While standardised, structured
approaches are appropriate for certain activities,
their usefulness diminishes considerably for
practices that entail constructing rich
understandings of complex situations and the
handling of ambiguities and unpredictable
variation. Drawing on a prominent social science
theory of cognition, this article distinguishes
between two radically different modes of human
thought, each with its own strengths and
weaknesses. The paradigmatic mode organises
context-free knowledge into categorical hierarchies
that emphasise member-to-category relations in
order to apply universal truth conditions. The
narrative mode, on the other hand, organises
context-sensitive knowledge into temporal plots
that emphasise part-to-whole relations in order to
develop meaningful, holistic understandings of
particular events or identities. Both modes are
crucial to human cognition but are appropriate
responses for different kinds of tasks and
situations. Many communication-intensive
practices in which patient cases are
communicated, such as handoffs, rely heavily on
the narrative mode, yet most interventions assume
the paradigmatic mode. Improving the safety and
effectiveness of these practices, therefore,
necessitates greater attention to narrative thinking.
INTRODUCTION
The identification of communication
failure among the most common root
causes of adverse events1 ignited a movement to improve communication-intensive
practices in healthcare. Among these practices, the handoff has received considerable attention, due to concerns that poor
communication threatens patient quality
of care and safety during transitions of
care. Researchers have cited variability in
practice, fallible human memory, omission
of important information and distractions
in the physical environment among the
many factors that compromise effective
communication during handoff.2
Efforts to improve handoff communication and other patient safety challenges
have been heavily influenced by the
remarkable success of checklists in reducing central line infections3 and surgeryrelated complications and mortality.4
Researchers have implemented checklists,
mnemonics (eg, SBAR) and similar tools in
order to reduce practice variations and
standardise transmission of information.2 5
While many of these efforts certainly led
to improvements, checklists are by no
means cure-alls nor replacements for critical thinking,6–8 and it is vital we understand their limits.
For example, the remarkable successes of
the Michigan Keystone program3 and the
Matching Michigan project9 both entailed
far more than implementation of ‘simple
checklists’. A host of social and organisational changes accompanied those implementation efforts, and without the
attendant changes, it is highly unlikely that
the checklists alone would have produced
the significant reductions in infections and
mortality.6 10 11 Similarly, checklists, once
implemented, may engender a ‘false sense
of safety’ if levels of compliance drop and
other safety practices have been replaced
by the checklists.12
But beyond these implementation and
sustainability concerns, the usefulness of a
checklist is further constrained by the type
of cognitive challenge it is best suited to
address. The success of checklists stems
largely from their abilities to outline
step-by-step instructions for technical procedures for which the particulars of
context are immaterial, reliance on human
memory is a known problem and variations
in those procedures are undesirable.7
Similarly, mnemonics work by prescribing
and sequencing broad categories to be
covered during information exchange. But
the usefulness of checklists and mnemonics
Hilligoss B, et al. BMJ Qual Saf 2014;23:528–533. doi:10.1136/bmjqs-2013-002705
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Viewpoint
alone—indeed, even the appropriateness of relying on
such highly structured tools—diminishes when the activities in question involve ambiguous, unfolding, complex
situations. In other words, checklists are most appropriate for simple or complicated problems, not complex
ones.
Glouberman and Zimmerman13 distinguish between
simple, complicated and complex problems. Simple
problems (eg, baking a cake) require little expertise
and can be addressed using highly standardised, formulaic solutions. A complicated problem (eg, sending
a rocket to the moon) arises from multiple causes and
involves multiple parts, but it can be solved by breaking it down and managing it piece by piece.13 In contrast, a complex problem (eg, raising a child) also
involves multiple causes and parts, but complexity
emerges out of the interaction of the parts, such that
one must deal with the whole rather than the individual parts. Inserting a central line is a complicated task
that can be broken down and outlined in a checklist;
whereas understanding the clinical course of a specific
patient is a complex and evolving task, in which one
must grasp a holistic sense of the interdependencies of
biological, pharmacological, social and other interacting processes. Distinguishing between complicated
and complex tasks is important because social science
theory and research suggest that humans rely on different modes of thought when dealing with these different types of problems. Specifically, humans
frequently rely on paradigmatic thought when dealing
with simple and complicated problems, but narrative
thought becomes most important when dealing with
complex problems.
PARADIGMATIC AND NARRATIVE
MODES OF THOUGHT
Cognitive psychologist Jerome Bruner identified two
distinct modes of thought—the paradigmatic (also,
‘logico-scientific’) and the narrative—each with its own
unique way of ordering experience and constructing
knowledge.14 Neither is superior to the other, nor are
Table 1
they alternatives for one another. Each contributes to
the richness of human cognition by providing strengths
suited to different kinds of cognitive challenges. We all
depend on both modes in our everyday existence.
Table 1 provides a comparison.
The paradigmatic mode of thinking organises
knowledge into hierarchical categories, classifying
phenomena according to categorical memberships.14 15
Its quest is to identify and apply universal truth conditions. Thus, it is context-free, dealing in generalisations. The particulars of circumstance are irrelevant in
the paradigmatic mode. Instead, the phenomenon (eg,
event or entity) is abstracted from context and
matched to its appropriate position within the categorical hierarchy.15 The paradigmatic mode is procedural, technical, rigid and easily reproducible, deftly
handling all phenomena that fit neatly into its categorical scheme. Its usefulness breaks down, however, in
the face of ambiguity and unpredictable variability,
which make categorising phenomena difficult if not
impossible. The paradigmatic mode is materialised in
taxonomies, lists and standard operating procedures.
We evaluate the products of paradigmatic thinking on
their verity—their ability to withstand falsification.14
By contrast, the narrative mode of thinking organises knowledge temporally into a plot, linking specific events into a unified whole by emphasising
consequential connections among them.14 Its quest is
to connect disparate events and information into a
meaningful whole—in short, to make sense of a situation. As such, it is highly sensitive to context, dealing
in the particular. The narrative mode is adept at handling anomaly, uncertainty and unpredictable variability, which it readily incorporates into its unfolding
plot.14 The narrative mode materialises in the form of
stories. It is the means by which we establish identities
(our own and those of others) and make sense of the
continual stream of experience we call life. Finally, the
narrative mode aids comprehension16 and appears to
be a crucial means by which we organise, retain and
recall memories.17 We judge the products of narrative
Comparison of the paradigmatic and narrative modes of thought
Paradigmatic mode
Narrative mode
Mode of production
To identify or adhere to universal truth conditions
Categorical: emphasising relations such as
member-to-category and instance to general class
Logic: propositions and timeless abstractions (eg,
‘if X then Y’)
Extensive: sacrifices specificity and detail for generality
Context-free
Low: cannot easily accommodate variability,
contingency, anomaly, and uncertainty
Systematic abstraction
Criteria for evaluation
Tools
Verification: proof against falsification
Taxonomies, lists, and standard operating procedures
To connect disparate events and information into a meaningful whole
Temporal: emphasising consequential connections between specific
events or ideas. Part-to-whole relations
Plot: temporal sequences, involving interconnected actions and
intentionality (eg, ‘The king died and then the queen died of grief’)
Intensive: sacrifices generality for deep understanding of specifics
Context-sensitive
High: can easily accommodate variability, contingency, anomaly, and
uncertainty
Situated interaction, relying on the inter-subjective experience of
narrator and audience
Verisimilitude: true based on (conceivable) experience
Stories
Quest
Organising scheme
Causal device
Focus
Handling of context
Flexibility
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thinking by their verisimilitude, or conformance to
what we take to be lifelike.15 16 18
Each mode of thought is exercised daily in the clinical arena,19 and many tasks may draw on both
modes. The checklist for central line insertions provides a stellar example of the paradigmatic mode in
action.3 Checklists work because a generalised knowledgebase exists to categorise the practice, irrespective
of context. The singularity of the particular patient
matters little: the steps required to ensure a sterile
insertion do not vary from one instance to the next.
In the controlled environment of an intensive care
unit, no stories are needed to accomplish the insertion
—only a careful adherence to a predefined, well
understood procedure. In fact, variation or divergence
from standard procedures in such cases can lead to
complications and poor patient outcomes.
On the other hand, the act of communicating a
patient plan of care—such as when handing off responsibility at shift change or transferring the patient to a
different unit—draws heavily on the narrative mode of
thinking. Unlike the central line example, telling a
patient’s story entails focusing on the particulars of the
case at hand—rather than abstract generalisations—
and attending to uncertainties and ambiguities.
Narrative is central to the practice of medicine.20–22
It is the means by which patients inform doctors of
symptoms and doctors inform patients of disease, diagnosis, treatment and prognosis processes. Narrative is
the cognitive structure of the case report.21 It is
through stories that errors, near misses and adverse
events are processed—by both clinicians and patients
—and held up as examples to galvanise support for
learning and system change.23 24 In the following
section, using the example of handoff, we explore in
greater depth why communicating a patient’s care
necessarily involves the narrative mode.
HANDOFF AND THE NARRATIVE MODE
Many handoffs include elements of paradigmatic
thinking, such as when details about the case are presented in standardised, categorical formats. For
example, in box 1 a nurse presents a patient by listing
values corresponding to general vital sign categories.
This sample handoff excerpt and others provided
below are modified from actual handoffs we have
observed.
While the paradigmatic mode can provide an overall
structure to the conversation, or at least to portions of
Box 1
Handoff paradigmatic mode example
Nurse: He’s alert and oriented, Blood pressure was 145
over 97 initially; however, his heart rate is 129 sinus
tach. Afebrile on 90% room air. Really a nice guy. He
really wants to eat.
530
it, the complexities of many cases require narrative
thinking to be employed as well.20 21 Explicit attention
to the role of narrative, however, is largely missing
from current research focused on improving the
safety of communication-intensive practices such as
handoffs. Admittedly, some commonly used improvement approaches, such as collaborative crosschecking25 and crew resource management,26 employ
practices that touch on the narrative mode of cognition, but even these approaches leave many aspects of
narrative thinking underexplored. In the following sections, we discuss four aspects of handoffs that demonstrate why the narrative mode is crucial.
The singularity of the case is most important
First, every patient case is unique in ways that bear
directly on understanding it.20 21 In fact, one of the
most crucial functions of handoff may be to highlight
what is unique about the case or care plan. For this
reason, the narrative mode is essential to activities
involving the communication of patient cases. Even
where standardised patient stories may be established,
handoffs will necessarily entail careful attention to the
ways in which the present case deviates from those
standardised ones.27 It is the singularity of the case—
the particular details of this patient—that holds the
most informative clues, not only for understanding
the patient, but also for anticipating the future trajectory of illness and for the selection of approaches to
care that are most likely to provide benefit.20 To be
certain, generalised knowledge of disease and treatment are essential, but knowing how best to apply
that knowledge to a specific case often demands a
rich understanding of the case itself.21 In short, generalised knowledge must be adapted to the specific
details of the present case through narration. Box 2
provides an example of a physician in a critical care
unit using the narrative mode to relate specific details
in the unfolding story of one patient.
Understandings of patients must be co-constructed
Second, comprehending a singular patient case involves
constructing a coherent, holistic understanding of that
Box 2 Handoff narrative example 1
Physician: He was brought to the Emergency Department
when his family found him coughing up some bright red
blood. In the ED, GI did try to scope him initially and
ended up having to intubate him to complete the scope,
and they saw an oesophageal ulcer with a visible vessel,
and they squirted some epinephrine in there. They were
able to evacuate about 80% of the clot, but they wanted
him to remain intubated, come up to the ICU, and then
they want to re-scope him tomorrow.
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case: a whole that is greater than the sum of its parts.28
The tendency to think of handoffs as information transmissions has led to a focus on identifying the necessary
pieces of information to be transmitted and on measuring the accuracy and completeness of transmission and
reception.2 27 Such an approach presumes the paradigmatic mode of thinking: generalised categories to be
applied to all or subsets of cases. What the information
transmission perspective overlooks, however, is the
work entailed in assembling those various pieces of
information into a coherent, meaningful whole. Here
again, it is the singularity of the case that matters most.
Even if it is possible to identify a required set of categories of information to be covered during the communication, a holistic understanding of the case does not
automatically arise from reception of various pieces of
information about the case, nor are the interconnections
among that information objectively apparent.
Understanding is the product of co-construction.28 It is
only by the narrative mode that a holistic understanding
of a specific series of events and other details can be
constructed. The process of that construction is known
as emplotment,29 and it emphasises the active role of
the narrator in building the plot.20
In narrating stories, we do not simply relate events in
chronological order.29 Instead, we posit connections
between those events, including causality, by ordering
our stories in particular ways, supplying details at specific points in the narration where their significance to
other details can be asserted.16 The novelist E M Forster
famously explained: ‘“The king died and then the
queen died” is a story. “The king died, and then the
queen died of grief ” is a plot.’30 By adding the simple
preposition ‘of grief ’ at a key point, the narrator asserts
a relationship between the two events, shaping the audience’s understanding of each of those events. Thus,
emplotment is crucial to the construction of meaning
and identity, the arguing of causality and the demonstration of human intentions. Clinicians engage in emplotment frequently. As Charon20 notes, ‘Diagnosis itself is
the effort to impose a plot onto seemingly disconnected
events or states of affairs.’ When we recognise the narrative mode is crucial to handoff, our attention is turned
not only to the specific pieces of information to be
included in the telling, but also to the way in which the
various details of the patient’s case are fitted together
into a plot.
For example, through an interaction of questions
and answers, the two residents in the handoff in box
3 engage in narrative thinking as they co-construct an
understanding of one aspect of a patient’s treatment.
In addition, we see emplotment in this example as
well, as Resident 2 explains the intentions that guided
the choices and sequencing of medications administered. Emplotment is also illustrated in the handoff in
box 2, when the physician describes the related,
unfolding events in a patient’s admission to the critical
care unit.
Hilligoss B, et al. BMJ Qual Saf 2014;23:528–533. doi:10.1136/bmjqs-2013-002705
Box 3 Handoff narrative example 2
During handoff, two residents discuss medications for an
insulin-dependent diabetic patient with a history of gastroparesis and chronic kidney disease who ‘isn’t very compliant with her medications’.
Resident 1: Does she have an antiemetic that she likes?
Resident 2: She likes Phenergan.
Resident 1: Oh, so Phenergan does work for her? Tried
Compazine or anything like that?
Resident 2: Not yet. So, she has Phenergan and Regalan at
home, and those are the two she likes. Compazine is what I
would go to next. Zofran I don’t think does a single thing for
her. I just figured: try the Phenergan because she likes it,
and then I tried the Regalan, because I figured with gastroparesis, the body would like it.
Resident 1: Sure, sure.
Ambiguity and uncertainty must be accommodated
Third, narrations of patient cases often occur while
other relevant activities are still unfolding, and therefore, while understandings of those cases are still evolving. Consequently, in telling and interpreting patient
stories, clinicians must deal with ambiguities, uncertainties and emerging contingencies. Whereas the rigidity of
checklists, modelled on the generalised knowledge that
is central to the paradigmatic mode of thinking, cannot
readily incorporate unexpected variation and ambiguity,
the flexible structure of narrative easily stretches to
accommodate the emergent and unpredictable. In fact,
emplotment is an act of imposing order on what might
otherwise be disorderly and of conjecturing where
insufficient information produces uncertainties or
inconclusive data gives rise to ambiguities.14 If the narrative mode has a weakness of which we should be
aware, it is likely the fact that it can so easily accommodate equivocality, including to the point that one might
over-rationalise or underemphasise some ambiguity,
thereby presenting an inaccurate or overly simplistic
understanding of the case.16 This danger arises not from
an inherent flaw in narrative thinking, but rather from
the way such thinking may be practiced as individuals
deal with norms and expectations. For example, where
doctors feel pressured to appear knowledgeable and
confident, they may be more likely to tell stories in ways
that downplay uncertainties. The solution, then, lies not
in faulting the narrative mode of thinking, but rather in
adjusting the socio-cultural norms that shape behaviours. In box 4, a physician uses narrative thinking to
acknowledge uncertainties and open up thinking to possibilities beyond the accepted diagnosis.
Patient stories must be adapted for the audience
Finally, handoff situations vary in terms of the relative
status and experience of the involved parties, their
prior knowledge of the patient, and the extent and
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quality of their existing relationship.2 31 Effective
handoff communication—and by extension, effective
co-construction of understanding—demands adaptation to these factors.
There are many different ways to tell the same story,
but the ‘best’ narration is one that is adapted to this
inter-subjectivity of narrator and audience. Events may
be sequenced differently as a way of emphasising different details, asserting different ideas or arguing different
interconnections. If narrators are to create in their audiences the understandings they hope to create, however,
they must attend to the perspectives of their audience
and let these perspectives shape the narrating. When
individuals engage in perspective-taking,28 32 they
attempt to see matters from another’s point of view and
to understand what that person might be thinking.
Gaining insight into another’s perspective enables more
effective communication because speakers can better
interpret their audiences’ emerging understanding,
anticipate needs and adjust communication accordingly.
Perspective-taking highlights the fact that effective narration entails sensitivity to context and complex,
nuanced social interactions that cannot be neatly predefined by a checklist. The failure to consider another’s
point of view may contribute to ineffective communication during handoff,33 and a few researchers have begun
exploring the influence of various perspective-taking
practices on these interactions.34 35
All of this suggests that the narrative mode may be
highly important in handoffs involving parties who
are particularly inexperienced or to a clinician who
has had no prior experience with the specific patient.
In such instances, more work is often required to
make explicit links between events or among details.
For example, the detailed narrative relayed in box 2 is
necessary insofar as the receiving party is unfamiliar
with the details surrounding the patient’s admission.
By considering the perspective of the receiving party,
the speaker is able to predict what may be the most
appropriate level of details to provide.
CONCLUSION
Storytelling has been fundamental to human communication since at least the beginning of recorded history, as
our ancestors’ drawings on cave walls would attest. Far
from being merely a tool for entertainment, narrative is
Box 4
Handoff narrative example 3
Physician: She’s had frequent bouts of pneumonia in the
past, and it’s usually the same findings on chest X-ray,
but this is worse than previous X-rays have been. So,
part of me says this may actually not be pneumonia at
all, and some other process is really driving all of this—
that we’re just watching things get progressively worse
and worse and calling it pneumonia.
532
integral to the way we make sense of unfolding situations, form identities, address the unique aspects of particular situations, and cope with contingencies and
ambiguities. The narrative mode of thinking is not inferior to the paradigmatic mode14; it is complementary.
Both modes are crucial to many clinical tasks, particularly handoffs. We have focused on the narrative mode
only because it has been largely overlooked in reported
handoff improvement efforts. If the narrative mode is
more chaotic, less predictable and less amenable to
standardisation than the paradigmatic mode, that is
because its chief task is to cope with the complexity of
an evolving, unpredictable world that is never perfectly
knowable.16 As our social world and care models grow
increasingly complex, the importance of the narrative
mode will likewise increase.
Where checklists and mnemonics are used to structure
communication-intensive practices, it is highly likely that
clinicians are still engaged in the narrative mode as they
co-construct understandings of unfolding cases. While
the checklists and mnemonics used in such scenarios
would guard against forgetting particular details, it is not
likely that such tools offer any assistance with the challenging work of crafting plots and co-constructing
useful, holistic understandings of patients. For example,
Hu et al36 have shown that during complex, unanticipated situations in the operating room, which is heavily
governed by the checklist mentality, human resilience is
what rescues the provider and patient. Resilience is the
ability to adapt to and absorb variations and disturbances, particularly those that fall outside of what the
system has been designed to accommodate.37 We argue
that it is the narrative mode of thought that is most
essential to such resilience. Therefore, to build more
resilient systems of care, we must supplement current
improvement efforts with approaches that honour the
strengths and challenges of narrative thinking. What
such approaches might look like, we can only speculate
since we are not aware of any research that has
attempted to examine how different narrative practices
shape comprehension or effectiveness of handoff. A
starting place might be simply to pay closer attention to
how specific patient stories are being narrated and to
encourage clinicians to examine what it is about certain
narratives that make them easier or more difficult to
comprehend. In the meantime, research into the narrative structure of effective handoffs would deepen our
understanding of how transitions of care might be
further improved.
To be clear, we are not arguing against the value of
checklists but urging caution relative to simplistic applications of such approaches.6 7 Indeed, when incorporated into a multi-dimensional, inter-professional patient
safety programme, checklists can be an effective piece of
the solution.38 They are not, however, the holy grail of
communication. Our argument, then, is that we need to
differentiate between complicated tasks that draw primarily on the paradigmatic mode of thought and
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complex tasks that draw on the narrative mode and then
fashion interventions accordingly, recognising that many
activities involve both types of tasks. The nearly complete absence in the recent communication patient safety
literature of any discussion of the role of narrative thinking and the paucity of interventions shaped to address
the unique demands of narrative tasks suggests that we
are missing opportunities to intervene effectively. We
may even run the risk of making matters worse.
Acknowledgements The authors acknowledge the helpful
feedback from Dr Vineet Arora.
Contributors BH developed and drafted the initial manuscript.
SDM-B helped refine the ideas and contributed to the revisions
of the manuscript.
Competing interests None.
Provenance and peer review Not commissioned; externally
peer reviewed.
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Downloaded from qualitysafety.bmj.com on June 12, 2014 - Published by group.bmj.com
The limits of checklists: handoff and
narrative thinking
Brian Hilligoss and Susan D Moffatt-Bruce
BMJ Qual Saf 2014 23: 528-533 originally published online April 2,
2014
doi: 10.1136/bmjqs-2013-002705
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