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1 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 11 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? 16 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. 17 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 20 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 22 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 24 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 52 40 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. 29 “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 41 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.” 50 Conclusion 51 In general, analysis of multiple sources of data indicated that nursing handover process had many challenges that need to be modified. 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