Table 1

Protocol development and assessment using video-reflexive ethnography—method specification

Phase	Process		Purpose
Phase 1	Focus groups	Protocol development	These groups were used to elicit perspectives on and aspects of handover communication. A researcher (CB) held a total of 10 pre-intervention focus groups with ED clinicians from both participating hospitals and with paramedics from Ambulance NSW. Focus groups lasted between 30 and 60 min and had between 6 and 10 participants. Issues thus identified oriented the subsequent filming and footage analysis.
Phase 2	Filming and analysis of in situ practice		Consent was obtained from all participants prior to filming of handovers. In total, 73 pre-intervention handovers were filmed across both sites. Each filmed handover was formally analysed using categories proposed by ED clinicians (doctors and nurses) and paramedics: quality of information content (including triage category), speed of delivery, number of questions, frequency and type of repeated information and degree of mutual eye contact (between paramedic and ED staff).
Phase 3	Reflexive focus groups		Groups of ED clinicians (doctors and nurses) and paramedics were shown five exemplars of practice enabling them to reflect and comment on their own practices. These groups were also shown our analytical results. These cues enabled the groups to form and articulate views about what is essential information needing to be communicated, critical process steps to be included, and context characteristics to be maintained. A total of nine reflexive focus groups were held, six with ED clinicians and three with paramedics. These sessions lasted on average from 60 min to 90 min.
Phase 4	Protocol design		Results obtained through formal video analysis were combined with comments obtained from pre- and post-intervention focus groups and all this was tabled in meetings with selected stakeholders from both sites: members of Ambulance NSW, NSW Department of Health, the Ministerial Task Force on Emergency Care, and the research team. These stakeholders' discussions led to adoption of a handover protocol that encompassed a mnemonic for topic standardisation as well as instructions on the delivery and context management of handovers.
Phase 5	Protocol implementation	Protocol assessment	ED clinicians were informed about the new protocol during in-service times and medical teaching sessions. Paramedics were educated during times of hospital bed-block (when having to wait outside the hospital) and were also given on-the-spot training before attending a new job. In total, 368 participants were reached using these methods over a 5-week period: 108 ED clinicians and 260 paramedics. Each participant was also given a pocket-sized plastic card with the mnemonic for additional reinforcement.
Phase 6	Protocol trial	Protocol assessment	Assessment was done in two ways: 64 post-intervention handovers were filmed and analysed, and the results were compared with those of the pre-intervention handovers (Phase 2). Additional results were obtained from a five-question survey completed by ED triage nurses. This survey was provided on an e-tablet feeding data directly into an electronic database. The survey consisted of five questions addressing the quality of the information given during handover, the structure of the information, the duration of the handover, relevance of the handover and the need for questions. Each question allowed one of four answers: strongly agree, agree, disagree and strongly disagree. The survey tablets could be accessed at the point of triage for periods of 2 months at both sites. In total, 416 pre- and post-intervention surveys were completed.