Communication is concerned with the creation, transmission, interpretation and use of information. There are four basic steps to communication:
- Intent: the sender has information that they wish to communicate to others;
- Transmission: the sender chooses a method to convey the information (e.g. speech, writing, signs);
- Receipt: the receiver hears or sees the information;
- Interpretation: the receiver makes sense of the information that they have received.
However, what is interpreted is often different to what was intended – leading to a communication failure.
Why are good communications important?
Effective communication is important in all organisations when key information must be passed between two or more people, or when a task and its associated responsibilities are handed over to another person or work team. Critical times when good communication must be assured include: at shift handover, between shift and day workers, between different functions of an organisation within a shift (e.g. operations and maintenance; pilots and air traffic control; control room and outside operators) and during process upsets and emergencies. Good communication helps to maintain situation awareness.
What can go wrong?
There are a number of barriers to good communications:
- not realising that we need to communicate information to others
- we hear what we expect to hear
- we often ignore information that conflicts with what we already know or believe
- our view of the communicator (such as credibility or respect) affects our view of the message
- our understanding or belief in a message can be influenced by social or work groups
- the same words mean different things to different people
- we may use words that others do not understand
- our body language may conflict with what we say, leading to confusion
- a lack of concentration may influence our communication or understanding (for example, due to stress or fatigue)
- aspects of the environment may affect the quality of communication, such as a noisy or distracting environment.
Any of the above factors may lead to poor communications, such as missing or inaccurate information and misunderstandings.
There are four key aspects that we can address to improve communications:
- make clear the need to communicate
- provide guidance on what is to be communicated, when, and who to
- train and coach people to communicate effectively
- provide the time, facilities and environment that enable good communication.
A number of simple steps can improve communications:
- use face-to-face communication, as this enables interaction and the use of non-verbal cues
- tailor the message and its delivery to the person(s) receiving and acting on the information
- continue to check that the message is being received correctly, for example by getting feedback from the receiver – make it a two-way communication
- if using verbal communication, tell people what you are going to say, say it, and then tell them what you have said, for example by paraphrasing
- use simple and direct language, with a low ‘reading age’ (word-processing software can check this)
- cut out the transmission of unnecessary information
- use aids such as written records, photographs and illustrations to support spoken words
- repeat the key information using different channels, such as both written and verbal communication
- allow sufficient time for communication, particularly when handing over from one shift or work group to another
- encourage listeners to ask questions, seek confirmation and clarification and repeat-back key information.
Listening is part of good communications!
The old adage that we have two ears but only one mouth and so should listen twice as much as we talk is a useful guideline! A good listener aids communication. The following factors will enable effective listening:
- establish eye contact (but not aggressive staring!)
- smile when appropriate
- give feedback to show that you are interested, such as nodding, smiling, or making a positive noise
- don’t interrupt unnecessarily
- ask open questions (usually starting with what, how, when, where, who, or why)
- ask clarifying questions (such as “could you explain a little more?”)
- avoid jumping to conclusions – don’t assume that you know
- avoid closed questions (those that can be answered with a simple ‘yes’ or ‘no’).
The importance of good conversation – and how to have it
The night before the Challenger Space Shuttle exploded, NASA had a three-hour conference call with a company that knew the Shuttle would fail. Why did NASA not abort the mission? John O’Leary explores what makes for an effective conversation. He lists three myths that can lead to destructive silence, and vital techniques to enable good conversation for groups everywhere.
Communications in focus: Shift handover
The goal of shift handover is the accurate, reliable communication of task-relevant information across shift changes, thereby ensuring continuity of safe and effective working (HSE, 1996).
Many accident analyses cite miscommunication as being among the contributory causes, but more specifically, several studies report an increased rate of accidents at or near shift changeover, with the highest incidence at the commencement of the shift.
Shift handover and incidents: “Do you know what I know?”
The Cullen Report into the Piper Alpha disaster concluded that one of the many factors which contributed to the disaster was failure of transmission of information at shift handover. Specifically, knowledge that a pressure safety valve had been removed and replaced by a blind flange was not communicated between shifts. Lack of this knowledge led to the incoming shift taking actions which initiated the disaster.
The Cullen Report concluded that there were no written procedures for shift handover. Furthermore, the type of information which the lead production operator wrote on his notepad and communicated at shift handover was left to his discretion. There was no predetermined analysis or categorisation of important items to include in the handover and maintenance work was not always included in logs. (See this link for more information on the human factors aspects of maintenance).
The CSB investigation report into the explosion and fire at the BP Texas City refinery in 2005 stated that “Two critical miscommunications occurred among operations personnel on March 23, 2005. . . these lapses in communication were the result of BP management’s lack of emphasis on the importance of communication. BP had no policy for effective shift communication, nor did it enforce formal shift turnover or require logbook/procedural records to ensure communication was clearly and appropriately disseminated among operating crews” (U.S. Chemical Safety and Hazard Investigation Board, CSB , March 2007).
There are many parallels between continuous processing tasks in the oil, gas and chemicals industry and the provision of patient healthcare. Both are delivered on a 24-hour basis by shift workers, who must communicate information on the human or technological systems they monitor and control across shift changes.
In the sentencing remarks following the recent prosecution of Mid Staffordshire NHS Foundation Trust for the avoidable death of a patient, the Hon. Mr Justice Haddon-Cave stated that:
“The hospital management failed to prescribe, monitor and enforce a proper, structured and rigorous system of work for handovers between nursing shifts and to devise and ensure the proper marshalling, updating and checking of medical records and notes. . . Proper systems of handovers and record-keeping in hospitals are obviously vital to ensure the correct and timely marshalling and passing on of patient information to enable the continuous delivery of appropriate medical care to patients and the carrying out of patient care plans”, and
“Patients at Stafford Hospital were clearly exposed to risks to their health and safety arising from inadequate handover and record-keeping procedures”, (Crown Court at Stafford, 28 April 2014).
What does good practice look like?
UK HSE guidance for organisations operating continuous processes is helpful for all organisations:
- effective shift handover communication should be given a high priority
- communication skills should be included in the selection criteria for shift-workers
- the communication skills of existing staff should be assessed and developed
- procedures which specify how to conduct an effective shift handover be provided
- greater reliance to be placed on written communication when 12-hour shifts are in operation, and allow for longer shift handovers
- more effort is needed to brief personnel who have been absent for longer periods.
Where possible, critical tasks and activities (such as maintenance work, patient treatment plans etc.) should be completed within one shift, thereby eliminating the risk of miscommunication of key issues at shift handover.
Where handovers are necessary, they should:
- be conducted face-to-face
- be two-way, with both participants taking joint responsibility for ensuring accurate communication
- use verbal and written means of communication
- be given as much time as necessary to ensure accurate communication.
The video below was produced by The Health Service Executive, Northern Ireland. This training programme on Shift Handover for Nurses and Health Care Assistants first of all shows the existing practice, and then provides an example of what good practice looks like.
If you are planning on reviewing your shift handover arrangements, consider what key information incoming personnel will need; what gaps in ‘mental models’ might exist between incoming and outgoing personnel and what support can be provided to personnel (such as shift logs, whiteboards). It follows that the involvement of end-users will be essential in developing good communication methods.
More information on safety critical communications
Effective shift communication. Extract from HSE publication Reducing error and influencing behaviour (HSG48, ISBN 978 0 7176 2452 2, Second edition, published 1999). Contains a summary of what can go wrong, how to improve communications, and a case study of enhancing shift handover at a UK oil refinery.
Human Factors Briefing Note – Safety-Critical Communications. HSE (2003). Provides case studies, a self-assessment, summary of different communication methods and remedies to communications failures through the three communication stages.
Safety critical communications. Extract from HSE Inspectors Human Factors Toolkit. This 5-page guide outlines areas for HSE Inspectors to review, provides good practice and contains a question set for assessing an organisation’s communications.
Effective shift handover – a literature review. Offshore Technology Report, OTO 96 003, HSE (1996). Relevant theoretical work on effective communication is described and implications for effective communication at shift handover are drawn. The report explores lessons from published incidents, where failures of communication at shift handover were among the contributory causal factors. Various studies and surveys which have sought to understand and improve the process of shift handover are then described. Finally, existing guidance on shift handover is analysed and compared to knowledge which has been identified elsewhere in the review. The report draws conclusions regarding the current state of knowledge and highlights implications for best practice.
Safe communication at shift handover – setting and implementing standards. Lardner, R. (1999). This paper describes a site-wide initiative to improve shift handover communication methods and practice on a UK oil refinery. A model of effective shift handover was derived and used to assess current practice in a large oil refinery and make measurable improvements. The project was undertaken during 1994/95 but still has currency today. The practical approach to assessing standards of handover communication described in this paper will be useful to other industries.
Improving communication at shift handover. The Keil Centre (2006). This audit methodology (based on structured questions, observations and documentary evidence) aims to define good practice and makes recommendations to improve current practice. The document builds on HSE Offshore Technology Report OTO 96 003. The audit methodology and question set will be relevant to a wide range of industries.
Person to person communications model. The Keil Centre (2006). A model of the communications activities of a sender and receiver, including the possible outcomes of the receiver’s evaluation of the message (successful communication, receiver unsure of true meaning, receiver wrongly believes they have achieved successful communication). It also includes an outline of the key features of individual communication media (face-to-face, radio etc).
Human factors aspects of remote operation in process plants, HSE (2002). HSE Contract Research Report 432/2002. The vast majority of process plants are remotely controlled to some degree, and technology is enabling trend towards increasingly remote operation. On larger sites this trend has manifested itself in the construction of central control rooms. The introduction of remote operation has significant effects on the way work is conducted, particularly in areas such as communication between Field Operators and Control Room Operators and information acquisition. Very few sites systematically examined and managed the impact of these changes, such as less opportunity for face-to-face communication, the increased use of radios and the challenges of shift handovers if the Field and Control Room Operators are based in different locations.