The Invisible Work of Transfer Center Nurses: A Qualitative Study of Strategies to Overcome Communication Challenges

Abstract

Aims:

To explore the role of transfer center nurses and how they facilitate communication between referring and accepting providers during calls about interhospital transfers, including their strategies to overcome communication challenges.

Design:

A qualitative interview study.

Methods:

We conducted semi-structured interviews with 17 transfer center nurses at one tertiary medical center from March to August 2019, asking participants to describe their work. We performed content analysis, applying codes based on the Relational Coordination Framework and generating emergent codes, then organized codes within higher-order concepts. We followed the COREQ checklist.

Results:

Transfer center nurses employed multiple strategies to mitigate communication challenges. When referring providers had misconceptions about the transfer center nurse’s role and accepting hospital’s processes, the nurses informed referring providers why sharing information with them was necessary. If providers expressed frustrations or lacked understanding about their counterpart’s caseload, the nurses managed providers’ emotions by letting them “vent,” explaining the other provider’s situational context, and describing the hospital’s capabilities. Some nurses also mediated conflict and sought to break the tension if providers debated about the best course of action. When providers struggled to share complete and accurate information, the nurses hunted down details and ‘filled in the blanks.’

Conclusion:

Transfer center nurses perform invisible work throughout the lifespan of interhospital transfers. Nurses’ expert knowledge of the transfer process and hospitals’ capabilities can enhance provider communication. Meanwhile, providers’ lack of knowledge of the nurse’s role can impede respectful and efficient transfer conversations. Interventions to support and optimize the transfer center nurses’ critical work are needed.

Impact:

This study describes how transfer center nurses facilitate communication and overcome challenges during calls about interhospital transfers. An intervention that supports this critical work has the potential to benefit nurses, providers, and patients through ensuring accurate and complete information exchange in an effective, efficient manner that respects all parties.

INTRODUCTION

Patients who are transferred between acute care hospitals tend to have worse outcomes than patients who are directly admitted (Hernandez-Boussard et al., 2017; Mueller, Zheng, et al., 2019; Philip et al., 2020; Sokol-Hessner et al., 2016). While patient-related factors and institutional resources contribute to these poor outcomes, other interorganizational and interprofessional influences have been less thoroughly examined (Hernandez-Boussard et al., 2017; Mueller, Fiskio, et al., 2019; Mueller, Zheng, et al., 2019; Ozdemir et al., 2016; Philip et al., 2020; Sokol-Hessner et al., 2016). Improving patient handoffs, including standardizing documentation and verbal communication during transitions of care within the same institution, has improved patient outcomes; however, a similar association is less established for patients transferred between acute care hospitals (BMA Junior Doctors Committee NMA, 2006; Holly & Poletick, 2014; Meyer et al., 2010; Payne et al., 2012; Starmer et al., 2014; Tobiano et al., 2020). Therefore, understanding challenges during calls about interhospital transfers is a critical first step to improving communication processes and optimizing care of patients transferred between acute care facilities.

BACKGROUND

Transfer centers are centralized departments at accepting hospitals that serve as a contact point for referring providers at other healthcare facilities who may want to transfer a patient for reasons such as specialty services or a higher level of care. These centers play an integral role in coordinating the care of transferred patients and the communication between providers at referring and accepting hospitals. Studies have shown that the communication between the referring provider, the accepting provider, and the staff at the accepting hospital’s transfer center typically follows the sequence depicted in Figure 1 (Alagoz et al., 2022; Herrigel et al., 2016; Newton & Fralic, 2015; Pagali et al., 2022). Although not all transfer centers are staffed by nurses, we will refer to transfer center staff as transfer center nurses (TCNs) to reflect our participant population. First, a referring provider (RP), often an emergency medicine physician, calls the transfer center and requests a transfer through the TCN. The TCN collects initial information from the RP, such as the diagnosis, and pages the specialty-appropriate on-call accepting provider (AP). Second, the TCN talks to the AP individually, summarizing what they heard from the RP. Third, the TCN connects the AP and RP so they can discuss the patient and reach a decision about whether to transfer. The TCN stays on the line during this three-way call. After a decision is made, the TCN coordinates logistics of the transfer (e.g., securing transportation, bed assignments, and insurance approval, if applicable) (Amedee et al., 2012; Herrigel et al., 2016; Hulefeld, 2009; Newton & Fralic, 2015; Pagali et al., 2022).

Figure 1.

Diagram of the sequence of conversations during calls about interhospital transfers

Aside from the TCNs’ roles and tasks described above, which have been gleaned through surveys and observational studies (Herrigel et al., 2016; Newton & Fralic, 2015; Pagali et al., 2022), the nuances of how TCNs facilitate communication and address challenges during conversations about transfers is not well understood. To our knowledge, no studies to date have included interviews with TCNs or other transfer center staff about communication challenges or strategies to overcome them. From the TCN or provider perspective, there have only been interviews or surveys with physicians, which revealed issues with disorganized chains of communication and unreliable information exchange (Mueller et al., 2021; Mueller & Schnipper, 2019). A call has been made for further study on fundamental issues in the interhospital transfer process as well as standardization of information exchange during transfers through interventions such as communication tools (Gupta & Mueller, 2015).

Our research, grounded by the Relational Coordination Framework, aims to understand challenges during conversations about transfers and improve outcomes of transferred patients through optimizing communication (Alagoz et al., 2022). The framework has been used widely in healthcare to assess organizational performance and coordination of work roles and systems (Alagoz et al., 2022; Gittell, 2002, 2006, 2009; Gittell et al., 2010). Studies have shown that improved communication and higher levels of relational coordination are frequently associated with better patient outcomes (Gittell et al., 2000; Havens et al., 2010; Payne et al., 2012; Starmer et al., 2014). Relational coordination is defined as a “mutually reinforcing process of communicating and relating for the purpose of task integration” (Bolton et al., 2021). In contrast to administrative coordination processes such as scheduling, the Relational Coordination Framework focuses on shared knowledge about each person’s work, mutual respect for each person’s role, and shared goals as essential components that affect relationships and communication, which in turn influence teamwork and coordination. In the framework, TCNs represent boundary spanners, defined as people whose role is to coordinate others’ work. TCNs’ insights into these processes can inform the development of interventions to improve interhospital transfer decision making and handoffs for optimal patient care. In this paper, we describe the TCNs’ role, particularly their strategies to address challenges in provider communication, from their own perspective. We also make suggestions for future interventions that might help mitigate these challenges.

THE STUDY

Aims

The aim of this study was to explore the role of the TCN and how they facilitate communication between referring and accepting providers during calls about interhospital transfers. The research questions were:

1. How do transfer center nurses describe their role facilitating communication about interhospital transfers?

2. How do transfer center nurses describe challenges to communication during calls about interhospital transfers?

3. How do transfer center nurses overcome communication challenges?

Design and Setting

The research described here is part of a larger study about interhospital transfers of emergency general surgery patients (Alagoz et al., 2022). Because of the TCN’s pivotal role and their daily management of interhospital transfers, we interviewed TCNs first, followed by RPs and APs. We anticipated that TCNs would sensitize us to new topics or concepts to explore in subsequent interviews with providers. Thus, we conducted semi-structured qualitative interviews with TCNs at a single tertiary academic hospital in the United States. The hospital accepts more than 350 emergency general surgery transfers annually from over 70 referring facilities within and outside the state (Philip et al., 2019). Qualitative interviews are the best way to capture the nuances of participants’ perspectives on communication challenges during interhospital transfers and are particularly appropriate due to the lack of published qualitative studies that include transfer center staff members. The study adheres to the consolidated criteria for reporting qualitative research (COREQ) (Supplemental File 1) (Tong et al., 2007).

Participants

Two former TCNs and all 23 current TCNs at one transfer center were invited via email to participate in 2019. Both former TCNs and 15 of the 23 current TCNs participated. Of the eight invited TCNs who did not participate, one declined, five did not respond to the study invitation, and two agreed to participate but did not follow through with scheduling interviews. We did not glean any new information or themes from analysis of the last several interviews and thus did not pursue additional interviews with the remaining TCNs.

Participant demographic information is displayed in Table 1. Their experience working in the transfer center ranged from 4 months to 17 years and their experience with direct patient care ranged from 5 to 35 years. We also included multiple participants who worked second and/or third shift to capture the broadest range of transfer experiences.

Table 1.

Characteristics of Transfer Center Nurse Participants

Characteristic	n (%)
Female	13 (76.5)
Highest nursing degree
BSN or higher	12 (70.6)
ADN and/or LPN	5 (29.4)
Years at the transfer center (median, range)	4 (0.3–17)
Shift†
Day	11 (64.7)
Evening	12 (70.6)
Night	3 (17.6)
Experience in direct patient care settings†‡	17 (100)
Inpatient and/or ICU	15 (88.2)
ED and/or outpatient	10 (58.8)

BSN, Bachelor of Science in Nursing; ADN, Associate Degree in Nursing; LPN, Licensed Practical Nurse; ICU, Intensive Care Unit; ED, Emergency Department

^†Categories are not mutually exclusive

^‡Categories collapsed to preserve anonymity

Data collection

The development of our semi-structured interview guide was informed by synthesis of the scientific literature, clinical experience, observations of TCNs fielding transfer calls, and elements of the Relational Coordination Framework. A group of peer qualitative researchers external to the research team, including an expert qualitative methodologist, helped with organization and question wording. We piloted the interview guide (see Supplemental File 2) with a trauma nurse practitioner (who is not counted as a participant) and two former TCNs (who are counted as participants) before interviewing current TCNs. We refined the guide iteratively after the pilot interviews and as interviews progressed to improve question flow and clarity.

Trained, masters-level qualitative interviewers (NA and MCS) conducted interviews in person in a private room from March to August 2019. Interviews lasted about 60 minutes and were followed by a brief demographic survey. We asked TCNs to describe what happens when they coordinate calls between RPs and APs, what challenges they experience and observe, and how they facilitate communication during calls regarding transfers. The interviewers asked follow-up probes and clarifying questions based on participant responses, rather than adhering to strict question wording and order. We did not have prior relationships with participants, conduct repeat interviews, or give participants copies of their transcripts. Interviews were audio recorded, transcribed verbatim, de-identified, and imported into NVivo 12 (QSR International) for coding and analysis.

Ethical considerations

A university Institutional Review Board approved the study and granted exempt status. Participants were provided with written information about the study and given the opportunity to ask questions. Participation was voluntary and identifying information was removed from transcripts to ensure confidentiality. All participants provided verbal consent for participation and were paid $100.

Data analysis and rigor

Strategies for ensuring trustworthiness and rigor were built into the research study design and analysis processes. We followed the criteria created by Lincoln and Guba, known as credibility, dependability, confirmability, and transferability (Lincoln & Guba, 1986). To ensure transferability and dependability, we have clearly described our theoretical grounding, selection and characteristics of the participants, institutional context, and data collection and data analysis processes so that readers can assess whether findings are applicable to their specific contexts and repeat the study if desired. Additional strategies for trustworthiness and data analysis are described below.

The research team was composed of five women from different disciplinary backgrounds to reduce biased interpretations and ensure credibility during analysis (acute care surgeon [AMI], qualitative scientist [EA], sociologist [MCS], and two health services researchers [NA, SFT]). The Principal Investigator (AMI) had seven years of experience participating in transfer calls as an AP and brought important contextual knowledge and insight to the analysis discussions. The qualitative scientist (EA) had more than ten years of experience designing and conducting qualitative studies, and all other team members had multiple years of experience collecting and analyzing qualitative data, strengthening the study’s dependability.

We analyzed the data using deductive qualitative content analysis (Kyngäs et al., 2020). To develop our codebook, five team members (MCS, EA, NA, SFT, AMI) read through the first several interview transcripts and took extensive margin notes about our observations, including our thoughts about passages that fit Relational Coordination Framework concepts and emergent themes that were not accounted for by the framework. As we discussed our notes for specific data excerpts, we grouped similar observations into concepts or themes (e.g., ‘working behind the scenes,’ ‘taking initiative outside the norm,’ and ‘strategies to diffuse tension’). The codebook was composed of all Relational Coordination Framework concepts and any inductive themes in the data that were not captured by the framework. As the codebook was applied to subsequent transcripts during team meetings, code definitions were adjusted and new codes were added as needed, and adjusted/new codes were applied retroactively to earlier transcripts. Once the codebook was finalized with 43 codes and sub-codes total, we used NVivo to manage and code all interview transcripts. Three or more team members coded each remaining transcript separately, merged their NVivo files, and compared coding agreement during biweekly team meetings to ensure codes were applied consistently. We discussed discrepancies and reached consensus for each transcript. To establish confirmability, we created memos throughout analysis to track our thoughts, findings, analytical decisions, and new questions.

For this paper, we examined all data associated with codes relating to TCNs’ work (i.e., ‘working behind the scenes,’ ‘triage,’ ‘taking initiative outside the norm,’ ‘strategies for successful communication,’ ‘strategies for diffusing tension,’ ‘process improvement,’ ‘content and amount of information,’ and ‘reactions or emotions of TCNs’). Some Relational Coordination Framework themes were prominent in these TCN-specific codes, so we also examined data under specific framework codes (‘accurate communication,’ ‘problem-solving communication,’ ‘shared knowledge,’ and ‘timeliness’) and catalogued data that were specifically relevant to TCN work. We created data matrices and organized quotes into new categories and sub-categories of TCN work, performing constant comparisons to discern patterns and develop higher-level concepts (Creswell & Miller, 2000; Miles & Huberman, 1994). Examples of these concepts included setting the stage during initial call with RP and AP, ensuring information completeness and accuracy before and during the three-way call, and mediating disagreement. These findings were presented to a group of peer qualitative researchers external to the research team at both early and late stages of higher level analysis to check interpretations and further establish credibility (Creswell & Miller, 2000). The results section reflects extensive analysis agreed upon by all authors. Participant quotes have been included from a wide variety of participants to support credibility, and lightly edited for readability (e.g., removed filler words).

FINDINGS

Overview of results

Although TCNs did discuss what goes well during transfer calls, our analysis focuses on their role in facilitating communication, specifically regarding the challenges they experienced and their strategies to prevent, mitigate, or solve these challenges. We maintained this focus on challenges because the results of this work are intended to inform interventions to improve interhospital transfers. Our results, tables, and figures are organized by each conversation that occurs during the process to discuss a transfer. First, we summarize themes in the TCN’s initial conversation with the RP. Then, we describe themes in the conversation between the TCN and AP. Finally, we identify themes in the three-way call between the RP, AP, and TCN. Within each sub-section, we present the challenges encountered, followed by the strategies utilized in response.

Transfer center nurses’ conversations with referring providers

Familiarize referring providers with transfer center roles and processes

During conversations with RPs, TCNs faced challenges when RPs were unfamiliar with the TCNs’ role (Figure 2).

Figure 2.

Challenges experienced by transfer center nurses during conversations with referring providers

“Initially when the call comes in they think that we’re like secretaries so they’re just like ‘I don’t need to tell you this’…it happens occasionally where they like treat you like you have no medical background and no business asking for information about the patient” (TCN 22).

Some RPs attempted to bypass TCNs and only share information with APs. In these cases, TCNs were on the receiving end of RPs’ impatience or dismissiveness.

“It’s very common in other facilities and smaller systems, where physicians don’t treat everybody with respect. And so, it starts on the phone call where the physician is exasperated that they’re being asked to give information. They really just wanna talk to [the AP]” (TCN 11).

TCNs also said RPs think they know which specialty they need to talk to, but that RPs can be unaware of the accepting hospital’s specialties and sub-specialties. TCNs noted that, especially in urgent situations, RPs tended to rush the initial conversation or did not share information that TCNs needed, potentially leading to incorrect triage and delays.

TCNs used several strategies to inform RPs about transfer center processes and why sharing information before connecting to APs was necessary (Table 2). TCNs told RPs that their role is to ask questions to make sure they page the correct specialty and explained that the APs that treat a particular condition may differ at referring and accepting hospitals. Some TCNs described apologizing to RPs and appealing to protocol to convince RPs to share information.

Table 2.

Strategies utilized by transfer center nurses during conversations with referring providers

Strategy	Exemplary quotes
Familiarize referring providers with transfer center roles and processes	“We would know when we got new docs … I’d be like, ‘you’ve got to understand, we’ve got 300 doctors on call tonight, I’ve got 10 different surgeons, I’ve got to get you the right one, so I’ve got to ask you some questions, I want to make sure that you get the right one right away.’” (TCN 5)
	“The only thing you can really do is say ‘this [answering my questions] is going to help us figure out bed-wise what we have available for you and our provider.’ Sometimes that helps, sometimes it doesn’t.” (TCN 22)
Hunt down complete or accurate information	“If I don’t see [images] pretty quickly and I have a minute, I will call them back and say, ‘I’m still waiting on the images, and I can’t call my surgeon until I have those,’ so that they understand it’s not just the delay to be a delay.” (TCN 27)
	“If you’re really stuck, you circle back and call and ask to speak to the nurse that’s taking care of the patient.” (TCN 6)

“I am sorry, I know it takes a couple extra minutes, but our protocol is we have a snapshot of the patient and the clinical information” (TCN 6).

Hunt down complete or accurate information

TCNs shared challenges regarding information RPs provided. RPs sometimes gave incorrect patient information (Figure 2), did not send images quickly, or gave accurate information but left out important facts. TCNs noted that inaccurate or incomplete information may lead to triaging the patient incorrectly or even discussing the wrong patient.

TCNs used strategies to ensure they obtained accurate, complete information about the patient by confirming specifics, such as date of birth and name spelling, and asking RPs to send images before they explain the patient situation. They informed RPs about the importance of sending images digitally when possible and before connecting with the AP. TCNs also alerted RPs when images had not been received (Table 2) and helped RPs and their radiology departments troubleshoot if system-related problems occurred during the process. TCNs saw these strategies as key to ensuring the conversation between providers went smoothly and efficiently.

TCNs also described digging deeper for patient details if the RP’s information was incomplete. Some mentioned that RPs do not always volunteer important social details about patients, such as housing insecurity or drug use. TCNs asked more questions if they suspected there was additional information that would affect the conversation between RPs and APs.

“If you ask the questions, you get the answers, but nobody’s going to offer it… you can get kind of these subtle questions in to say, ‘are we going to have to worry about drug or alcohol withdrawals, or any indication of that?’ You would try to just slip those questions in with your clinical questions to get that information” (TCN 5).

When RPs were not forthcoming or too busy, some TCNs sought out other sources, such as the nurse at the referring hospital, to get information (Table 2).

Transfer center nurses’ conversations with accepting providers

Assess how much information to give accepting providers

During conversations with APs, TCNs were challenged by APs’ varying preferences regarding how much information they desired and whether they wanted to view images prior to conversing with the RP (Figure 3). APs’ preferences ranged from a couple sentences to a full history depending on their approach and the patient’s clinical issue. This caused TCNs to have uncertainty about how much information to relay to the AP before connecting them with RPs. In addition, TCNs were conflicted about whether to share only facts with APs or also include their impressions or professional opinions about the transfer request. Some said they shared their suspicions about the completeness of the information being provided or the reason behind the transfer request, while others said they withheld their opinion to avoid clouding APs’ judgment.

Figure 3.

Challenges experienced by transfer center nurses during conversations with accepting providers

TCNs addressed this challenge by learning the preferences of each AP (Table 3). If TCNs were unsure whether APs wanted to see images before connecting to RPs, they paged the APs and asked their preference. They then tailored their approach in subsequent conversations.

Table 3.

Strategies utilized by transfer center nurses during conversations with accepting providers

Strategy	Exemplary quotes
Assess how much information to give accepting providers	“I’ve asked for the images… Do you want me to re-page you when the images are here, or do you want to take the call right now?” (TCN 12)
Inform accepting providers about referring hospital capabilities	“If I had more information, I would share it, I would just say, ‘I got a call from [TOWN] and they haven’t had a surgeon for three months, they’re still recruiting.’” (TCN 5)

“You get to know the personalities. Some doctors will always accept a patient with or without a scan, and some will not even talk to the referring until they actually see images” (TCN 18).

Inform accepting providers about referring hospital capabilities

Another challenge TCNs described was APs’ lack of awareness of the referring hospitals’ capabilities and capacity (Figure 3). TCNs said an understanding of each referring hospital’s resources (e.g., hospital size, imaging capabilities, etc.) is critical because this information can influence decisions surrounding the transfer.

TCNs described overcoming this challenge by informing APs about referring hospitals’ resources before connecting them to RPs (Table 3). TCNs learned this contextual information from individual conversations with RPs or from fielding calls from the same referring hospital over time. Information TCNs shared with APs included the referring hospital’s surgical staffing, bed shortages, and availability of imaging and/or specialty services. Per the TCNs, providing this information helped APs make transfer decisions and saved time during the three-way call with RPs.

Transfer center nurses’ three-way calls with referring providers and accepting providers

Prevent conflict through informational and emotional support

TCNs anticipated challenges, such as friction or impatience between RPs and APs, during three-way calls (Figure 4). Conflict often stemmed from competing clinical demands causing delays in connecting the providers (e.g., APs operating and unable to answer pages immediately, RPs busy in the emergency department and unable to wait on hold for APs). TCNs also identified providers’ lack of understanding about their counterpart’s caseload as an issue. For example, TCNs described some APs becoming frustrated by transfer requests because they felt the referring hospital should be able to care for the patient.

Figure 4.

Challenges experienced by transfer center nurses during 3-way calls with referring and accepting providers

TCNs sought to prevent tension or conflict by helping providers understand the context in which the conversation would take place before connecting (Table 4). For example, TCNs explained to RPs that APs were in the OR and unable to view images. Another TCN described “coddling” RPs so they would not get upset.

Table 4.

Strategies utilized by transfer center nurses before and during three-way calls with referring and accepting providers

Strategy	Exemplary quotes
Prevent conflict through informational and emotional support	“Sometimes I find that our surgeons are maybe frustrated by receiving a call that doesn’t seem appropriate, and so I will let them vent to me. [Laughs]…. And I’m like, ‘Okay, get it all out. Are you done? Okay, now let’s go.’” (TCN 27)
	“They have a generally happy tone over the phone, like everybody’s all getting along, but then off the phone, like when they’re not talking to each other, it’s a little bit more like exasperation… we’re kind of the shoulders for a lot of doctors venting frustration.” (TCN 8)
Mediate conflict	“If they’re going back and forth we may interrupt and say, ‘Excuse me’ or ‘Can I get something else?’ just to sort of break the monotony and let them refocus. [Laughs] So I interrupt like, ‘Oh, by the way, can I get those vitals?’.… or, there have been times when we’ve had to say, ‘you know, this is a recorded line.’” (TCN 18)
	“Sometimes just a little practical talk goes a long ways…You just have to say, ‘Are you a little tired tonight, doctor?’…sometimes just give them a little hint.” (TCN 16)
Ensure complete information and solidify the plan for next steps	“We often interrupt while the doctors are talking to say, ‘Could we hear a set of vitals? Or could you send the images?’ if our physician forgets to do that.” (TCN 11) “I’m just like, ‘excuse me doctors I just want you to know we do have a waitlist’ or ‘we’re at capacity and there may be a delay for a bed.’ And I need both of them to know that because if it’s a situation where that’s not appropriate then we need to come up with a different plan.” (TCN 19)

“[The AP is] in an intense operation so they can’t come to the phone, so we just ask that you be a little understanding and patient” (TCN 18).

TCNs checked with RPs about the urgency of the situation and told them when to expect APs’ return call to reassure them. Some TCNs also described the RP’s current situation or mood to the AP.

“I try to let [the AP] know if the referring provider is seeming stressed out, or is behaving in a way that is kind of short with me… so they know ahead of time what they’re dealing with” (TCN 24).

Sharing this information enabled the providers to enter into the three-way conversation with a better understanding of each other’s situational context. Fortunately, TCNs said that providers were usually understanding of the other’s circumstance.

TCNs also prevented friction by helping providers process their emotions before connecting the providers (Table 4). TCNs described letting providers “vent” before talking to the other provider to help them act more cordially with each other. One nurse explained “they take out their frustration before they get on the phone with them” (TCN 19). Although providers were cordial with each other once connected, TCNs reported being the target of impatience.

“I’m kind of the middle man, and if there is going to be dismissive or disrespectful behavior, it often comes to us more than from to provider to provider…they’re more likely to be disrespectful to me as the [TCN] than they are to another physician” (TCN 24).

TCNs generally said they did not take this behavior personally and tried to “move on” and “let it roll off” (TCN 8).

Mediate conflict

Once providers were connected, TCNs faced challenges when providers were not on the same page about how to manage the patient, which led to TCNs feeling stuck or unsure regarding what to do with the encounter. A common conflict was RPs and APs disagreeing about the necessity of transfer, with the conversations sometimes getting heated (Figure 4). While some TCNs described consistently feeling more aligned with APs’ decisions, others felt conflicted because RPs are their “customer.”

TCNs had varied strategies and approaches when providers lacked consensus about what to do with the patient. Several nurses did not view mediation as part of their role and did not participate in discussions unless asked.

“I don’t get involved if they’re disagreeing about the need to transfer…That’s above my paygrade [laughs]” (TCN 19).

TCNs who did engage to help providers find common ground used strategies such as asking clarifying questions to diffuse tension or redirect providers’ focus, or making suggestions about potential compromises (Table 4).

“Sometimes, you might jump in and just try to diffuse it by asking ‘Could we do this with this patient to find us some middle ground?’ Or sometimes-re-asking a question that’s been asked before to just break the cycle” (TCN 6).

Some TCNs also suggested getting another service involved or sending the patient to the ED for further workup before admittance. If debates got too heated, TCNs reminded providers that they were on a recorded line, suggested ending the call and reconnecting at a later time, or alluded to involving leadership support. When APs did not accept a patient for transfer, TCNs smoothed tensions over by reassuring RPs that they could call back if they still needed help.

Ensure complete information and solidify the plan for next steps

TCNs described challenges with incomplete or inaccurate information being shared between providers during three-way calls. This could lead to assigning the wrong level of care or the patient arriving sicker than anticipated. Providers also lacked knowledge about current bed availability. Even when RPs and APs reached consensus to transfer patients, they sometimes had trouble putting the plan into action and only had a vague idea of what follows (Figure 4).

TCNs addressed these challenges by interjecting or clarifying information when needed (Table 4). TCNs “filled in the blanks” (TCN 1) if providers asked about details from the electronic health record, or if RPs forgot to share something with APs that RPs told the TCN before the three-way conversation, such as lab results.

“If you found anything that needed clarification, you might interrupt or add to it. If something that the referring had told you, but they weren’t telling our provider, if the referring had said, ‘Well, I did an X-ray and I got these results’ and they went on about something else, you might break in and say, ‘And what were the results of the CAT scan that you told me about?’” (TCN 1).

Sometimes, TCNs interrupted to ask for necessary information, because RPs were more likely to answer queries with APs on the phone or because APs forgot to ask (Table 4). Finally, TCNs shared updates about bed and transport availability, which informed the transfer logistics.

TCNs also recounted helping providers finalize and activate the transfer plan by prompting them to clarify next steps and details, such as whether the patient will come to the ED or be directly admitted and with what level of care.

“So then I’ll just go in and clarify, ‘So, Doctor So-and-so, you’re saying this? Is that what you understand [SURGEON]? Is this what your plan is?’ Like, clarify what the plan is. ‘Do you think that this patient needs to come over for surgery today? Or Monday? Do you think that general care is good, or should this patient go to IMC because of blood pressure?’ So, just to clarify the vagueness” (TCN 8).

TCNs also informed RPs that medical acceptance does not necessarily mean that the patient can be transferred immediately. For direct admissions, insurance must be approved prior to transfer in addition to having an available, staffed bed. Furthermore, TCNs described coordinating and communicating with multiple parties prior to the patient being transferred and arranging many details of the transfer, including paging out for a bed at the accepting hospital, obtaining administrative approval, as appropriate, and communicating with the referring hospital about bed status, transport, and outstanding information (e.g., face sheets, images). Often, beds are not available immediately, so it could be several hours or sometimes days before patients can be transferred. If the TCN was informed by the referring hospital that the patient’s condition changed during this time, TCNs paged APs to see if another three-way conversation or a change in level of care was needed.

DISCUSSION

Using a qualitative approach, our study demonstrates the role TCNs play in facilitating communication throughout the lifespan of an interhospital transfer, including performing invisible work. Invisible work is a concept used in social science literature that includes activities that may be unseen, unrecognized, undervalued, or taken for granted by others (Allen, 2014; Devault, 2014; Hatton, 2017). TCNs adopted strategies to facilitate communication and overcome challenges, from the initial conversations with RPs, to speaking with APs, and three-way calls with both providers. The strategies TCNs described included: (1) hunting down and conveying complete and accurate information, (2) informing providers about the transfer center’s processes and each other’s hospital resources and clinical context, (3) managing providers’ emotions, (4) mediating conflict, and (5) getting providers on the same page about the patient and the clinical plan. As one TCN said about their role, “the Access Center functions to just keep it magical, that when the patient arrives, everything is smooth and nobody sees that there is any kind of hiccups behind the scenes” (TCN 8).

These results reinforce the importance of shared knowledge and mutual respect for optimal communication and teamwork as explained by the Relational Coordination Framework. In particular, TCNs encountered challenges when RPs lacked knowledge about the TCN’s role and accepting hospital’s transfer processes. This lack of knowledge sometimes contributed to a lack of respect for the TCN’s role and an unwillingness to share essential information, which delayed timely triage and effective communication. Conversely, TCNs’ in-depth and vast knowledge of the transfer process and hospital capabilities, developed through repetitive contact with RPs and referring hospitals, clearly enhances their ability to facilitate communication between providers.

RPs’ lack of knowledge about the TCNs’ role, a substantial communication challenge that TCNs described, may be due to inconsistencies in transfer processes across hospitals. A survey of 32 tertiary care centers in the US found that interhospital transfer processes and the backgrounds of transfer center staff vary widely. According to the authors, “the level of transfer center involvement in the verbal and written handoff is inconsistent” (Herrigel et al., 2016). In fact, 16% of the institutions surveyed did not require a three-way recorded conversation facilitated by the transfer center. In addition to inconsistencies in processes, variation exists in the staffing of transfer centers. While most transfer centers at tertiary hospitals are staffed by registered nurses, potentially with critical care experience, or emergency medical technicians, approximately 22% of centers are staffed by nonclinical personnel (Herrigel et al., 2016). Another study of 10 transfer centers concluded that a transfer center staffing model containing both clerical staff for support tasks and clinical staff for clinical issues seemed to be the preferred model (Newton & Fralic, 2015). Since some transfer centers are staffed by individuals without a clinical background, this may contribute to RPs’ hesitancy to give information to the transfer center staff rather than being connected directly with APs. However, even nonclinical transfer center staff need information when initially taking the call to select the specialty-appropriate on-call AP.

Our study also illuminates the emotional labor TCNs devote to preventing communication challenges and facilitating respectful and cordial conversations between providers (Grandey & Gabriel, 2015; Wharton, 2009). Emotional labor, which has been more widely documented in nurse-patient interactions, is often invisible and not documented as an official job requirement (Gray & Smith, 2009; Hatton, 2017; Smith, 2012; Wharton, 2009). Despite this, TCNs spent considerable effort anticipating negative feelings of RPs and APs and worked diligently to prevent tension during conversations. TCNs described managing providers’ emotions by letting providers “vent” their frustrations before connecting them and sharing the clinical and emotional context of each provider with the other to promote empathy, while keeping their own emotions to themselves. This emotional labor helped lay the groundwork for successful transfer conversations by improving the shared knowledge and mutual respect between providers so that they could communicate effectively about transfer requests.

Nurses’ invisible work organizing, coordinating, and communicating is often the ‘glue’ that holds healthcare systems together (Allen, 2014). Studies of relational coordination in healthcare settings have cited nurses and case managers as classic examples of “boundary spanners,” or people who facilitate integration of work across different settings (Gittell, 2002; Gittell & Weiss, 2004). While the Relational Coordination Framework has primarily been applied to coordination within organizations rather than between organizations, some studies have demonstrated that boundary spanners can greatly enhance interorganizational coordination (Gebo & Bond, 2020; Gittell & Weiss, 2004). For example, case managers at one hospital helped improve coordination of care with a rehabilitation hospital to which patients were discharged after surgery because they coordinated care among internal and external providers (Gittell & Weiss, 2004). As dedicated boundary spanners, TCNs bring valuable contextual and institutional knowledge to the conversations that providers frequently lack, facilitating the process by which transfers occur. In this way, they streamline the communication and logistics of interorganizational work and may impact intermediate or process outcomes, such as provider job satisfaction. However, the role of boundary spanners in improving organizational outcomes in healthcare is mixed, with some studies demonstrating a positive effect and others showing no effect or a negative result (Bolton et al., 2021; Gebo & Bond, 2020; Gittell & Weiss, 2004). More research studies are needed to understand how to best support relational coordination, including boundary spanner roles between healthcare organizations, particularly during interhospital transfers for vulnerable populations, including those requiring urgent or emergent surgery.

We have identified interventions that could support and optimize the critical work of TCNs in the future. Transfer center nurses and administrators should be empowered by hospital leadership in working with their facility and referring facilities to ensure that all providers transferring patients are familiar with the transfer center processes, including the role and expertise of TCNs, and expectations surrounding communication with the staff. This may help reduce the burden on TCNs to educate providers during calls, resulting in more respectful and efficient conversations about transfers. This increase in shared knowledge and mutual respect may prevent burnout and increase job satisfaction of TCNs (Gittell et al., 2020; Havens et al., 2018). TCNs and APs could also collaborate to determine what questions TCNs should ask RPs during their initial conversation. This could reduce TCN uncertainty about how much information they should convey during their calls with APs. If not already implemented, transfer centers may also consider tailoring training for staff with clinical and nonclinical backgrounds. Additionally, providing staff with training on how to address particularly challenging situations, such as mediating provider conflicts, may empower staff to intervene and help providers reach consensus when conversations get heated.

Strengths and Limitations

Our study had several strengths, including an experienced, qualified research team; a novel participant population which fills a crucial gap in understanding challenges during interhospital transfers and the role TCNs play in facilitating communication and overcoming challenges; and the extensive number of TCNs interviewed to ensure the breadth of experiences was captured. Our study also has some limitations. This study was conducted at a single-site academic tertiary medical center in the Midwest US. Unlike our center, not all transfer centers are staffed by nurses. Therefore, our findings may not be generalizable to hospitals that use a different staffing model or hospitals outside the US. Second, given the intentional qualitative design of our study, we cannot quantify how frequently these challenges occurred. Third, TCNs are not privy to what happens to patients after they are transferred. Therefore, they may not see the downstream effects of challenging or seemingly successful communication and thus may not know which of their strategies are impactful on patient outcomes. Finally, APs and RPs may have different perspectives on communication challenges during conversations surrounding transfers. While we are currently completing analysis of AP and RP interviews, presenting results from all three perspectives in a single paper would minimize the richness of the data we obtained from the TCNs.

CONCLUSION

Our findings suggest that TCNs perform a wide breadth of invisible work to help conversations about interhospital transfers go smoothly. The Relational Coordination Framework and its dimensions of shared knowledge, mutual respect, and shared goals provide a useful conceptual model upon which to analyze the interactions that occur during interhospital transfer. Nurses’ expert knowledge of the transfer process and hospitals’ capabilities can enhance provider communication. Meanwhile, providers’ lack of knowledge of the transfer center nurse’s role can impede respectful and efficient transfer conversations. Higher levels of relational coordination and communication have been shown to be associated with better patient outcomes (Gittell et al., 2000; Havens et al., 2010; Payne et al., 2012; Starmer et al., 2014). Therefore, improving relational coordination along the dimensions of shared knowledge, shared goals, and mutual respect has the potential to lead to better communication about and outcomes of patients who are transferred between hospitals.

The results of this study, along with our interviews of RPs and APs, have illuminated targets for intervention and potential strategies for preventing or mitigating challenges during conversations about interhospital transfers. We will use these data to inform our development of interventions to support and optimize the TCNs’ critical work. We are currently conducting stakeholder engagement panels to create tools to facilitate communication during the transfer process. We will pilot test these interventions in the near future. If successful, these interventions will be implemented through large scale trials to study the association between communication and transfer processes as well as patient outcomes.

Patient or public contribution:

This study was designed to capture the perspectives and experiences of transfer center nurses themselves through interviews. Therefore, it was not conducted using input or suggestions from the public or the patient population served by the organization.