Download Challenges of Nursing Handover

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Challenges of Nursing Handover:
A Qualitative Study
2
Raheleh Sabet Sarvestani
PhD student of nursing
Dr. Marzieh Moattari
Professor of Nursing
Dr Alireza Nikbakht Nasrabadi
Professor of Nursing
Dr. Maryam Momennasab
Associate professor of Nursing
Dr. Shahrzad Yaktatalab
Associate professor of Nursing
3
The nursing change of shift report or handover is a valuable
opportunity to transfer responsibility and accountability from
one nurse to another in most hospital wards
4
Therefore, handover is a fundamental component of nursing
care for a nurse to pass on patients' care plan , practices,
information and priorities to the next
Moreover, handover is an opportunity for nurses’ group
cohesion, professional socialization, education, interaction
and emotional support
5
Thus, handover should be accurate, complete, specific,
relevant, timely, up to date, subjective and objective.
However, cases of handover that are inaccurate, incomplete
and biased may lead to many errors, mislead nursing practices
and increase patient complications
6
A key component in patient safety and care quality is accurate
communication during handover
7
The role of nurses and families has changed recently in pediatric
wards; previously all responsibilities were done by professional
nurses but now complete involvement of family is highly
supported
8
The words nurses use in describing a family during shift report
can affect how other nurses approach a family.
Although the goal of shift report is to exchange objective data,
value judgments and labels often accompany theses data.
These labels can limit the opportunity of families to learn the
skills needed to manage the problems and met their essential
needs and decreased their involvement.
So, applying a standard handover is essential in pediatric wards
9
Hence, the aim of this study was to explore the challenges of
handover practices in Iran in order to provide an opportunity
for better understanding of the situation and help improve the
current practices.
10
Method
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The study was conducted using a descriptive exploratory
qualitative design with a content analysis approach.
Three pediatric wards in Shiraz in the South of Iran
were selected.
We gathered multiple sources of data such as
observations, interviews and recordings of oral shift
reports.
12
During four months of observation period, fourteen handovers
(five in the morning, five in the evening and four at night) were
observed and tape-recorded.
Observations were non-interventional and semi-structured,
focusing on the key events and activities during handovers.
Field notes were written immediately after each observation.
13
A sample of 130 patient reports was subjected to summative
content analysis. A coding framework was used to calculate the
type and frequency of information exchanged during nursing
handovers.
Word frequencies of oral shift reports were calculated
manually.
Also, nine in-depth interviews were conducted with the nurses,
who were selected through a purposeful sampling. We continue
sampling until we have14 reached saturation.
Interview guide :
 Can you describe today’s handover,
 what are the problems with the handover?
 How do you deal with these problems?
 Can you provide any examples?
 Would you like to make see any changes?
 If so, what would they be?
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Ethics:
The ethics committee of University approved the project.
Before each interview, the participants were informed of the
aim and method of the study and that their participation was
voluntary.
Besides, they were told that they could leave the study at any
time they wished. Confidentiality was ensured so that no
names were mentioned. On top of that, a form was signed by
the participants saying that they were informed and consented
to the study.
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Analysis
Inductive and summative content analysis was used to explore
the challenges of nursing handover practices.
Content analysis may be used in an inductive or deductive way.
However, while in inductive content analysis the categories are
derived from the data in deductive content analysis the data
are were categorized according to previous knowledge or
theory
18
Another approach we used during analysis was
summative content analysis.
This approach is fundamentally different from the previous
one in that rather than analyzing the data as a whole, the text
is often approached as a single word or in relation to a
particular content, and word frequency is calculated
manually or by a computer
19
The researcher returned to the codes and reconsidered
them to check if the themes fit the data again. A second
researcher read the categories and themes for further
refinement.
MAXqda2 software was used for data analysis.
MAXQDA 2007
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Coding and categories were sending back to the participant for
possible revision.
A team-based approach to analyze data was established to check
the credibility.
It showed a good level of agreement in interpretation and some
disagreements were resolved through discussion.
Prolonged engagement, varied experiences, peer checking and
triangulation
21
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‫شماره‬
‫سمت‬
‫سن‬
‫جنس‬
‫تحصیالت‬
‫سابقو کار‬
‫‪1‬‬
‫پرستار‬
‫‪45‬‬
‫مونث‬
‫لیسانس‬
‫‪12‬‬
‫‪2‬‬
‫پرستار‬
‫‪35‬‬
‫مونث‬
‫لیسانس‬
‫‪4‬‬
‫‪3‬‬
‫پرستار‬
‫‪40‬‬
‫مونث‬
‫لیسانس‬
‫‪14‬‬
‫‪4‬‬
‫پرستار‬
‫‪26‬‬
‫مونث‬
‫لیسانس‬
‫‪1‬‬
‫‪5‬‬
‫پرستار‬
‫‪45‬‬
‫مونث‬
‫لیسانس‬
‫‪17‬‬
‫‪6‬‬
‫سر پرستار‬
‫‪37‬‬
‫مونث‬
‫لیسانس‬
‫‪13‬‬
‫‪7‬‬
‫پرستار‬
‫‪30‬‬
‫مونث‬
‫لیسانس‬
‫‪7‬‬
‫‪8‬‬
‫پرستار‬
‫‪45‬‬
‫مونث‬
‫لیسانس‬
‫‪16‬‬
‫‪9‬‬
‫پرستار‬
‫‪30‬‬
‫مونث‬
‫لیسانس‬
‫‪4.5‬‬
‫‪10‬‬
‫پرستار‬
‫‪35‬‬
‫مونث‬
‫لیسانس‬
‫‪8‬‬
‫‪11‬‬
‫پرستار‬
‫‪28‬‬
‫مونث‬
‫لیسانس‬
‫‪2‬‬
‫‪12‬‬
‫پرستار‬
‫‪26‬‬
‫مونث‬
‫لیسانس‬
‫‪2‬‬
‫‪13‬‬
‫پرستار‬
‫‪26‬‬
‫مونث‬
‫لیسانس‬
‫‪1‬‬
‫‪14‬‬
‫بهیار‬
‫‪22‬‬
‫‪23‬‬
‫مونث‬
‫دیپلم‬
‫‪2‬‬
Table 1: Main themes and related subthemes:
1- Non holistic approach
a)-Non holistic/ unstructured content
b)- Low nurses’ ethical and practical involvement
c)-Non Patient-centered approach
2-Poor management
a)-Poor time and space management
b)-Poor task management
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Non-holistic/unstructured content
Summative content analysis of 130 patients in the oral shift
report showed that the contents of nursing handovers were
not holistic.
The focus was on medical plans and physical dimensions so
the reports were not holistic.
25
Information
General information
Name
Age
Diagnosis
Contextual information
Date of admission
Medical history
frequency
130
25
54
21
11
29
Percent
Information
frequency
percent
100
19.2
41.5
16.1
8.4
22.3
Medical treatment
Consultations
Medications
Surgical intervention
Tests
Plan of care
Doctor orders
25
72
8
57
46
16
19.2
55.3
6.1
43.8
35.3
12.3
Global judgments
Patient condition
About care
Psychology/personality
Colleagues
17
9
9
28
13
6.9
6.9
21.5
12
3
17
30
9.2
2.3
13
23
15
8
11.5
6.1
5
3
1
0
3.8
2.3
0.7
0
Physical status
Respiratory function
Consciousness
Discomfort
Urine
Diet
Vomiting
Bleeding
10
7
11
16
37
10
11
7.6
5.3
8.4
12.3
28.4
7.6
8.4
Physical measures
Blood pressure
Temperature
Fluid input
Weight
22
33
32
16
16.9
25.3
24.6
12.3
Nursing intervention
Patient care need
Nursing care plan
37
28.4
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Management issues
Patient transfer
Admission
Discharge
General
Family
Care need
comprehensions
26
Functional status
Psychological
Social
Spiritual
27
Literature suggests that the content of handover should
contain information such as physical, psychosocial, spiritual,
medical, as well as nursing care and family needs at the same
time
28
Furthermore analysis of tape records represented that
nursing handover did not have a structured content.
Different presentation styles, irregular body and incomplete
wrap up and narration are the categories emerging from data
analysis.
The following excerpt illustrates that the unstructured
content of the report lead to missing information.
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“X, X was well too, she didn’t have any convulsion, the
physician changed the Phenobarbital and Dilantin to PO
ones. She didn’t have any sample to send to laboratory; we
didn’t have any problems with her”
30
“Incharge: Miss X, Do you know her?! Head nurse: yes.
Incharge: X was well too, she is NPO for MRI; she had Doppler
Sono yesterday, and its result is in her file. She is ok and doesn’t
have any problem.” Next patient Y,
Head nurse: Does previous
patient have EEG for today? Incharge: Oh, yes of course, I forgot
to mention it.”
31
Therefore, providing a template for presenting patient
information may increase the quality, accuracy and speed of
handovers.
32
Analyses of multiple sources of data showed that handover
process is not a collective action.
Inadequate nursing staff may cause this situation in nursing
handovers in Iran since some of the nurses should check and
prepare the medications, some of them should listen to oral
shift reports, and others should go to patients’ rooms for
monitoring IV sites and sheets.
33
Observation 4:
One evening, after checking the emergency and narcotic boxes,
two Incharge sat on chairs in the station and oral shift report
started while other nurses were preparing medications or
speaking with each other in the station.
34
Handovers provide an opportunity for professional
communication, supporting role socialization and development
of a cohesive group process.
35
Also data from observation and tape records showed that
nursing handovers were not completely ethics-based.
Labeling patients, pre- judgments and inattention to patient and
their families’ demands were the categories that emerged from
the data.
36
“Visitor of X made us nervous; she has a mental problem. She came
every 30 minutes to the station and asked different questions about
her child.”
“X is a 2-year-old girl that was transferred here from ICU yesterday;
she was opium poisoned. The nurse of the new shift said: Definitely
her family gave her the opium, didn’t they?!”
37
Code of ethics in Iran was formulated in 2010, but in order to
achieve more, it seems essential that we compile codes of
nursing ethics at different levels of nursing practices such as
nursing handovers and educate nurses in workshops and
seminars
The American Nurse Association code of ethics for nurses
recommends the value of a guide to nursing handover
38
The findings showed that nursing handovers are not patientcentered.
39
Observation 8:
In the second room, the nurses entered while speaking with each
other; one of them approached the patient and assessed the IV
sheets and its date. Then without saying anything she went to
another patient. This took 50 seconds.
40
Our study showed that patient participation was low and they
were mostly passive onlookers, while the findings of Mc Murry
et al.’s (2011) which examined patient perspective of nursing
handover in Queensland hospitals showed that patients valued
having access to information, and they considered themselves
an important part in maintaining accuracy that improves safety
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and quality.
Nowadays, patients desire to move from a parent model of
care to a collaborative model of care especially in pediatric
wards that focus on family-centered care
Like many Asian countries, Iran is a family-oriented society, so
family members express concern about the patient’s problem
and provide support for their loved ones ,the results of our
study showed that patients and family’s participation is
ignored.
42
Timonen et al 2000 interviewed with families and found that
main reason for not participating during handover were lack of
encouragement, nurses concentrating on their papers, using
special language and lack of time
Thus, we should consider these findings to improve and
strengthen parental participation during handovers
43
Poor management
The second theme that emerged from the data is poor
management during nursing handover practices.
Subthemes were poor time and space management and poor
task management.
44
Poor time management, hasty reports, too many interruptions,
crowded stations, and no seats to participate in handovers were
the categories.
45
46
These data suggest that time management was poor and in this
regard a nurse said:
“We should check the equipment carefully because if something is
lost, we must pay for it, so it takes a long time to check them; as a
result, we report in a hurry and many important things might be
missed”
47
Another challenge was allocation of space.
Locating an area far from interruptions and patient’s
confidentiality and privacy is an essential aspect of handovers
and the best option depends upon the context .
48
A nurse in the interview said:
“We don’t have a place for handover; in the station there are
many people such as medical & nursing students, physicians and
other nurses. When we are reporting, we should answer phone
calls, questions from families and physicians and in the
meanwhile focus our mind to report, and it is impossible. There
are many distractors that lead to inattention”
49
Poor task management
Data obtained from multiple sources in this research showed
that nurses encountered task overlap and work overload during
handover processes.
One of the head nurses in the interview said:
“Job description is not clear during handover processes, so
during this process nurses should do many tasks simultaneously
such as checking the equipment and utensils, preparing
medications, answering telephones, responding to visitors,
completing the notes of patients or doing other stuff such as
discharging or admitting new patients.”
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Conclusion
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In general, analysis of multiple sources of data indicated that
nursing handover process had many challenges that need to
be modified.
Applying a holistic approach (designing a holistic content,
encouraging nurses’ participation and involving patients) and
managing the handover process (determining job description,
and allocating specific time and space) are some strategies for
improvement.
52
The findings of the present study challenge nursing managers
to develop new strategies that can improve nursing handovers
which can in turn facilitate changes that increase the nurses’
level of work satisfaction; as a result these can lead to a higher
level of patient safety with a higher quality of care.
Nursing handover is a skill that requires education and
practice, so in this regard, in service education is highly
recommended.
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Enjoy your life today
because yesterday
had gone and
tomarrow may never
come.
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