From Protocol to Practice

Abstract

Shift handovers in intensive care units (ICUs) are critical for patient safety, yet notable discrepancies persist between formal protocols (Work-as-Imagined, WAI) and real-world practices (Work-as-Done, WAD). Standardized frameworks such as SBAR and I-PASS aim to structure information transfer, but physicians often adapt these to manage interruptions, time constraints, and dynamic patient conditions. This pilot study explores the relationship between empirical work practices and interaction design for efficient, transparent handover processes. The study used the Functional Resonance Analysis Method (FRAM) to model ICU shift handovers from the perspective of physicians. Interviews were conducted with ICU physicians from multiple countries to identify key risks, adaptive strategies, and areas where protocols are not followed. Workflow variability, interdependencies, and interruptions during shift handovers were modeled using FRAM, revealing key risks such as communication gaps, inconsistent documentation, technology failures, and workload pressures. The analysis exposed a clear gap between formal procedures and real-world practices. By visualizing these adaptations, the study enhances transparency into how physicians modify protocols under real conditions, offering insights for designing more visible, accountable, and coordinated handover processes. This transparency reveals how design for information visibility and accountability can improve communication and coordination between members. The findings contribute to Human Work Interaction Design (HWID) by translating empirical insights into design-oriented knowledge that bridges the gap between Work-as-Imagined and Work-as-Done. This study underscores the need to balance procedural compliance with adaptive practice in designing transparent, human-centered systems for ICU shift handovers.