De la transmission d’informations cliniques au partage de savoir lors de relèves infirmières

Abstract

The transmission of information concerning a patient at the hospital is governed on the one hand by the computerized patient's file, and on the other hand by the nurses' and/or multiprofessional's handovers. As a real challenge for the quality of healthcare, these oral and written transmissions are a very specific concern of healthcare institutions. Psychiatry, marked by orality (Barett, 1997), differs from the world of somatic care by this specificity. Nursing practice primarily uses relational care and uses a thought activity in the service of collective intelligence (Merkling, 2007). The CIPSY study (PSYchiatric Nurses Interaction Skills) conducted in collaboration between the Vinatier Hospital and the ICAR laboratory (CNRS, Lyon 2 University, ENS of Lyon) has the main objective of determining the language repertoire of the two production formats (oral and written) during nurses' handovers and written transmissions, using qualitative and quantitative analyses. In this article, we propose to conduct an interactional and multimodal analysis of oral nurses' handovers in psychiatric institutions, which has emerged as a possible place to "know" and "learn" among health professionals. Although the main objective of a nurses' handover is to transmit and share the up-to-date information on the different patients present in the unit, we have been able to identify exchanges during which participants can "complement professional knowledge" or "help the partner see more clearly" (Grosjean &Lacoste, 1999: 112). Indeed, as the authors have shown, "the role of interaction is not only to convey one way, it is to answer the questions and solicitations of others and integrate their reactions, it is to build a discourse thanks to the collaboration of many" (Grosjean & Lacoste, ibid.). Our analysis is based on four excerpts from the CIPSY project. The study includes multi-view audiovisual recordings of the three handovers on five consecutive Mondays of the same psychiatric unit: one at 6:30 a.m., one at 2:00 p.m. and one at 9:45 p.m. Added to these is the week's medical meeting, also known as the "weekly staff" which takes place at 9:00 a.m. The choice was only on Mondays because, for an adult psychiatry service and as the first day of the week, these are particularly rich handovers, since they are abundant of clinical events that happened during the weekend. The special feature of this day is also the weekly staff which exceptionally brings together nurses and nursing assistants in the morning, one or two psychiatrists, the psychologist, the health manager, the occupational therapist, the assistant students (nurses and externals). This original audiovisual corpus, with a total duration of 14 hours 30 minutes, depicts 38 health professionals, and concerns 40 patients put on the agenda of these meetings. Oral data are transcribed and coded in the ELAN software, written data (observations extracted from the patient record) are imported and encoded in the CLAN software. The coding grid of oral and written data is common to facilitate their comparison. It has been co-constructed with the recorded participants, and experts about care in order to stick to the problems of the service and to confront it with the knowledge of nursing experts. The methodology of fieldwork, corpus collection and analysis in which the CIPSY project takes part is developed in interactional linguistics and conversational analysis. This methodology aims to capture audio and video data in order to make available, and therefore analysable, linguistic, multimodal and situational details (gazes, gestures, movements, actions, objects, bodily framework) relevant to recorded interaction (Groupe ICOR, 2006). It also allows us to observe precisely the evolution in time and space of activity and social interactions that co-construct between participants. In this article, we propose to question the pre-established organization of nurses' handovers in a psychiatric unit and to identify moments that modify the planned interactional sequence of a meeting to bring a more didactic aspect to the current conversation. Indeed, the handovers follow a similar process. A particular nurse designates themself or is designated to list the clinical updated information of each patient, according to an order established by the room numbers. We will also use the concept of "super speaker" to define this central role in the succession. Other participants, on the other hand, can write down on a handover sheet what is said by the nurse in charge of the meeting. However, in four excerpts from the corpus, the didactic dimension is more present in the discourse of professionals and temporarily suspends the expected progression of the current transmission. We have identified two sequences with different didactic dimensions: the first is the repair of a multimodal transition between two patients (extracts 1 and 2), the second is the sharing of professional knowledge to colleagues (extracts 3 and 4). In an interactional and multimodal approach, we will describe the resources mobilized by the participants to support their discourse in these specific sequences. In particular, we will analyze the co-participants' management of an error in the transition from one patient to another, the suspension by a co-participant of the transition to another patient to finish taking notes on his sheet, the adjustment of the nurse in charge of the handoff to this suspension, or the emergence of exchanges of shared knowledge about the profession and the possible impact of these moments of regulation or shared knowledge on the effectiveness of the succession. The results of these fine analyses highlight specific skills of daily nursing exercise. Indeed, we have seen that, during succession meetings, the patient's clinical news, in other words "knowing" it, is not the only concern of caregivers. While there is a strong tendency to describe only the psychological and somatic state of the patient, a didactic dimension appears quite frequently, in relation to nurses' work and skills, and no longer directly with patients' information. From a multimodal point of view, the results of the analyses show in particular that these more didactic moments are detectable by specific postures. In the "knowing" sequences, the note taking on their sheet by caregivers is a central activity and can modify the progression of transmissions, while in the didactic phases of "learning", the gazes are oriented more to the speaker who transmits knowledge and skills, stopping the writing activity. Future analyses of these successions will illustrate the richness of nurses' daily work. The conversational analysis here finds a new and contributing field of exploration to the quality of care.

Keywords

• handover
• nurse
• multimodal interaction
• informing
• upskilling