The qualitative article critique written paper
Selection of an article for critique:
for this assignment you will have in this order:
Selection of an article for critique:
for this assignment you will have in this order:
-One cover page
-A reaction paper summary up to 10 pages (to be written collaboratively).
-One copy of the article
-Grading will be as follows:
-Title (5 points)
-Does the title clearly and concisely describe the study?
-Is the population/sample included in the title?
-
-A reaction paper summary up to 10 pages (to be written collaboratively).
-One copy of the article
-Grading will be as follows:
-Title (5 points)
-Does the title clearly and concisely describe the study?
-Is the population/sample included in the title?
-
Please do the assign as following: the article is under the instructions.
a) Abstract (5 points)
1- Is an abstract included in the article?
2- Does the abstract include a statement of the problem, purpose, and/or hypothesis?
3- Does the abstract briefly summarize the design, methodology, results, and conclusions?
4- Is the abstract adequate? Why or why not?
1- Is an abstract included in the article?
2- Does the abstract include a statement of the problem, purpose, and/or hypothesis?
3- Does the abstract briefly summarize the design, methodology, results, and conclusions?
4- Is the abstract adequate? Why or why not?
b) Confidence in the Findings (5 points)
1- What are the qualifications and reputation of the investigator/s?
2- What evidence is there in this report that they are qualified to conduct this study?
3- Is this article published in a referred journal?
1- What are the qualifications and reputation of the investigator/s?
2- What evidence is there in this report that they are qualified to conduct this study?
3- Is this article published in a referred journal?
c) Theoretical Framework/Conceptual Framework (10 points)
1- Is a theoretical or conceptual framework described? If not, does the absence detract from the significance of the research?
2- Does the research problem flow naturally from the conceptual framework?
1- Is a theoretical or conceptual framework described? If not, does the absence detract from the significance of the research?
2- Does the research problem flow naturally from the conceptual framework?
d) Protection of Human Rights (5 points)
1- Is there evidence of an independent ethics review by a board (IRB) or a committee?
2- Has the study been designed to minimize risk and maximize benefits to participants?
3- Is there an indication that participants gave voluntary, informed consent?
4- Is there evidence in the study that individuals can be identified?
1- Is there evidence of an independent ethics review by a board (IRB) or a committee?
2- Has the study been designed to minimize risk and maximize benefits to participants?
3- Is there an indication that participants gave voluntary, informed consent?
4- Is there evidence in the study that individuals can be identified?
e) The Problem (10 points)
1- Was the problem statement introduced promptly?
2- Is the problem significant to nursing and is the significance described?
3- Has the purpose for conducting the research been explained?
4- What are the research variables and how are they measured/operationalized?
5- Will an answer to the problem provide insight into clinical applicability of the problem?
1- Was the problem statement introduced promptly?
2- Is the problem significant to nursing and is the significance described?
3- Has the purpose for conducting the research been explained?
4- What are the research variables and how are they measured/operationalized?
5- Will an answer to the problem provide insight into clinical applicability of the problem?
f) Research Questions/Hypotheses (10 points)
1- Are research questions or hypotheses formally stated? If no, should they be included?
2- Do the research questions and hypotheses naturally flow from the research problem and theoretical framework?
3- Does each research question or hypothesis contain at least two variables?
4- Are the research questions or hypotheses worded clearly and objectively? Is a prediction evident?
5- If there is not a research question or hypothesis, write one for the study and explain why your hypothesis or research question fits the study.
1- Are research questions or hypotheses formally stated? If no, should they be included?
2- Do the research questions and hypotheses naturally flow from the research problem and theoretical framework?
3- Does each research question or hypothesis contain at least two variables?
4- Are the research questions or hypotheses worded clearly and objectively? Is a prediction evident?
5- If there is not a research question or hypothesis, write one for the study and explain why your hypothesis or research question fits the study.
g) Review of the Literature (10 points):
1- Is the review comprehensive, logical and relevant to the problem?
2- is the relationship to the research purpose evident?
3- Does it include recent research?
4- Can a case be made for conducting this study based on the review?
1- Is the review comprehensive, logical and relevant to the problem?
2- is the relationship to the research purpose evident?
3- Does it include recent research?
4- Can a case be made for conducting this study based on the review?
h) Research Design (5 points):
1- What design has been used for the study?
2- Is the design appropriate for the research question and the purpose of the research?
3- Has enough information been given to permit replication?
i) Sampling (10 points):
1- Is the target population carefully described?
2- Are sample selection procedures clearly defined?
3-Does the sampling method fit the research design?
4-Are potential sample biases described?
5- Is the sample sufficiently large?
6- Did the author/authors use power analysis to document that the study size was adequate or inadequate?
7- How was sample size justified?
8- To whom can study results be generalized?
1- What design has been used for the study?
2- Is the design appropriate for the research question and the purpose of the research?
3- Has enough information been given to permit replication?
i) Sampling (10 points):
1- Is the target population carefully described?
2- Are sample selection procedures clearly defined?
3-Does the sampling method fit the research design?
4-Are potential sample biases described?
5- Is the sample sufficiently large?
6- Did the author/authors use power analysis to document that the study size was adequate or inadequate?
7- How was sample size justified?
8- To whom can study results be generalized?
j) Data Collection (10 points):
1- Describe the instruments used for data collection.
2- Has rationale been given for the selection of instruments?
3- Are instruments congruent with the research question?
4- Are instruments suitable for use with the study sample?
5- Have procedures for testing the reliability and validity of instruments been described? Are results sufficient to indicate their use?
1- Describe the instruments used for data collection.
2- Has rationale been given for the selection of instruments?
3- Are instruments congruent with the research question?
4- Are instruments suitable for use with the study sample?
5- Have procedures for testing the reliability and validity of instruments been described? Are results sufficient to indicate their use?
k) Qualitative Analysis (5 points):
1- Is the link between the analysis and the findings logical and clear?
2- Is the statistical result presented clearly both in the text as well as in numerical presentation?
3- Are graphic displays clear and simple?
1- Is the link between the analysis and the findings logical and clear?
2- Is the statistical result presented clearly both in the text as well as in numerical presentation?
3- Are graphic displays clear and simple?
l) Conclusions and Recommendations (10 points):
1- What are the assumptions and limitations of the study? Are they listed or do you have to infer what they are?
2- Are results of data analysis clearly explained in reference to research questions, hypothesis and theoretical framework?
3- What recommendations for nursing practice and future research studies have been made? Are these recommendations supported by the data?
1- What are the assumptions and limitations of the study? Are they listed or do you have to infer what they are?
2- Are results of data analysis clearly explained in reference to research questions, hypothesis and theoretical framework?
3- What recommendations for nursing practice and future research studies have been made? Are these recommendations supported by the data?
ARTICLE
Article
Challenges of Nursing
Handover: A Qualitative
Study
Raheleh Sabet Sarvestani, RN, MSN1,
Marzieh Moattari, PhD, MD, RN1,
Alireza Nikbakht Nasrabadi, PhD, MD, RN2,
Marzieh Momennasab, PhD, MD, RN1, and
Shahrzad Yektatalab, PhD, MD, RN1
Abstract
The aim of this study was to explore the challenges of nursing handover
process during shift rotation in hospitals. The research had a descriptive
exploratory design with a qualitative content analysis approach. To conduct
the study, three pediatric wards were selected at first. Data were gathered
through a 4-month observation of nursing handovers by recording the oral
conversations of nurses during the process and semistructured interviews.
Then, qualitative content analysis was used for data analysis. Two major
themes and five subthemes emerged through the data analysis. The first
and the second themes were a nonholistic approach and poor management,
respectively. In general, applying a holistic approach and managing handover
situations are recommended for nursing managers to overcome handover
challenges. Future focus could be on addressing handover challenges through
an action research study.
Keywords
handover, nursing, content analysis
1Shiraz University of Medical Sciences, Iran
2Tehran University of Medical Sciences, Iran
Corresponding Author:
Marzieh Moattari, Department of Nursing, School of Nursing and Midwifery, Shiraz University
of Medical Sciences, Shiraz, Iran.
Email: Moattari@yahoo.com
508134 CNRXXX10.1177/1054773813508134Clinical Nursing ResearchSarvestani et al.
research-article2013
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Sarvestani et al. 235
Introduction
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 (Lamond, 2000). It is actually a substantial part of a nurse’s
duty, and each nurse should allocate 38% of his or her working hours in a
hospital ward every day to fulfill the handover process (Spanke & Thomas,
2010). 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 (Rushton, 2010). Moreover, handover is an opportunity for nurses’
group cohesion, professional socialization, education, interaction, and emotional
support (Griffin, 2010; Payne, Hardey, & Coleman, 2000). 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 (Rushton, 2010; Strople & Ottani, 2006).
A key component in patient safety and care quality is accurate communication
during handover (Chaboyer, 2011). The Joint Commission on
Accreditation of Health Care Organizations (JCAHO) has established standardizing
handover as a priority for improving patient safety since 2006
(Chaboyer, 2011; Schroeder, 2006). However, a review of literature reflects
limited research and articles addressing handover, while most of them highlighted
the importance of nursing handover and prioritized it for patient
safety (Baker, 2010; Blouin, 2011; Schroeder, 2006; Scott, 2012; Welsh,
Flanagan, & Ebright, 2010).
Although there are controversies about the efficacy of handover practices,
some articles highlight the importance of oral shift report that could not be
substituted by any other method because handover is the only place where
different aspects of professional nursing care are identified (Gordon &
Findley, 2011; Manias & Street, 2000; Scovell, 2010); otherwise, other studies
question its efficacy and report that there is no need to have an oral shift
report because most of the discussed information could be located within
nursing documentation, and, therefore, such a practice is time-consuming
(Manias & Street, 2000; Sexton et al., 2004).
In practice, the complexity of patients’ conditions, lack of organization,
and different interruptions during handover prolong the reporting process
(Spanke & Thomas, 2010). In a large scale study of 10 European countries,
Meiβner et al. (2007) explored the nurses’ perception of handover and the
reason for dissatisfaction among them. She found that 22% to 61% of nurses
were dissatisfied due to “too many disturbances,” “lack of time,” and “work
organizational factors” (Meiβner et al., 2007).
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236 Clinical Nursing Research 24(3)
In general, the goal of nursing handover is the transfer of relevant information
and continuity of patient care; however, there is no agreement about
its content and the related literature recommends different templates for presenting
data (Johnson, Jefferies, & Nicholls, 2012). According to Schroeder
(2006), the specific component of shift report should include PACE (Patient
problems, Assessment/Action, Continuing/Changes, Evaluation; Schroeder,
2006), and other researchers have suggested other templates such as SBAR
(Situation, Background, Assessment, and Recommendations; Raines & Mull,
2007). Regarding all such guidelines, the content of handover must contain
short- and long-term goals. It should also be broad and specific enough to
meet the patients’ needs. Furthermore, it should contain information such as
medical and nursing care and physical, psychosocial, spiritual, and family
needs at the same time (Rushton, 2010).
A body of literature reflects four modes of handover: the verbal handover
in station, tape recording, written handover, and handover at bedside. In practice,
the method of handover depends on the patient, the shift (day, evening,
or night shift), and the model of service delivery (team vs. case method;
Johnson & Cowin, 2012). Nevertheless, many studies have confirmed the
efficacy of bedside handovers. (Chaboyer, 2011; Chaboyer, Johnson, &
Wallis, 2009; Mott & Bradley, 2010; Webster, 1999) For example, Mott and
Bradley (2010) conducted an action research in three rural South Australian
hospitals and incorporated bedside handover reports. She found that bedside
handover was better than office reports in terms of ease and time efficiency.
Interestingly, level of satisfaction increased among nurses and patients, and
patients were more involved in their care; it also decreased the rate of errors
(Mott & Bradley, 2010).
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 (Hutchfield, 1999;
Mikkelsen & Frederiksen, 2011). 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 these data. These labels can limit the opportunity of
families to learn the skills needed to manage the problems and meet their
essential needs and decrease their involvement. So, applying a standard
handover is essential in pediatric wards (Ryan & Steinmiller, 2004).
The first step in standardizing handover and introduction of an alternative
model is to improve our understanding of current practices. Although some
studies have been conducted in several countries, the handover practices have
not been well studied in the Iranian health system because the context is different.
Because situational analysis is the first step in changing the program,
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Sarvestani et al. 237
exploring the current conditions of handover is important. Hence, the aim of
this study was to explore the challenges of handover practices in Iran to provide
an opportunity for a better understanding of the situation and help
improve the current practices.
Method
Design
The study was conducted using a descriptive exploratory qualitative design
with a content analysis approach. Content analysis is a way to analyze written,
verbal, or visual information. It actually serves as an action guide and
aims at providing valid insights from data to attain a broad and complete
description of a phenomenon (Cole, 1988). In this research, an inductive
approach of content analysis was used. In this method, categories are derived
from data during data analysis, which help to attain a richer understanding of
a phenomenon. Another approach we used during the 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 (Hsieh & Shannon, 2005).
Data Collection
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. During 4 months of observation period, 14 handovers
(5 in the morning, 5 in the evening, and 4 at night) were observed and taperecorded.
Observations were noninterventional and semistructured, focusing
on the key events and activities during handovers. Field notes were written
immediately after each observation. Then, the records were transcribed verbatim
and 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. In addition, nine indepth
interviews were conducted with the nurses, who were selected through
a purposeful sampling. We continue sampling until we have reached saturation.
The inclusion criteria were availability and willingness to complete the
interview. A guide was prepared for covering key questions that were general
with prompt to encourage responses during the interviews. Examples of
interview questions include the following:
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238 Clinical Nursing Research 24(3)
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? All
interviews were conducted and recorded in a quiet location, and each lasted
between 30 min and 45 min.
Ethics
The ethics committee of the 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.
Analysis
Inductive and summative content analyses were 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 categorized according to previous knowledge or theory (Elo & Kyngas,
2007). The oral shift report-taped handovers, interviews, observations, and
field notes were transcribed after each section of data collection. At first, data
were approached by being read as a whole repeatedly before being read word
by word to achieve immersion and finally to derive codes. Then, we organized
and grouped the codes into meaningful clusters. For the purpose of
abstraction, the relationships between categories were identified, and two
major themes emerged. The researcher returned to the codes and reconsidered
them to check whether the themes fit the data again. A second researcher
read the categories and themes for further refinement. MAXqda2 software
was used for data analysis.
Trustworthiness
The procedures that were used to improve trustworthiness were as follow:
Coding and categories were sending back to the participant for possible
revision. A team-based approach (composed of four qualified nurses in
qualitative research) 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,
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Sarvestani et al. 239
varied experiences, peer checking, and triangulation were other strategies
for improving the trustworthiness of the study (Helen & Carpenter, 2007;
Polit, Bech, & Hungler, 2006).
Findings
All the nurses were female with a mean age of 30.1 ± 6.8 years and mean
experience of 6.9 ± 5.6 years, and all have bachelor’s degree in nursing.
Data analysis resulted in identification of two major themes and five subthemes.
The first theme was a nonholistic approach, and the second one was
poor management. These are presented in Table 1 and are explained in the
following section.
Nonholistic Approach
The first theme emerged from data included nonholistic approaches in nursing
handover practices. The subthemes were nonholistic/unstructured content,
low nurses ethical and practical involvement, and non-patient-centered
approach, which are explained separately in the following section.
Nonholistic/unstructured content. Summative content analysis of 130 patients
in the oral shift report showed that the contents of nursing handovers were not
holistic. The total frequency with which information was mentioned in nursing
handover can be seen in Table 2. This table illustrates that medical plans
and physical dimensions are more dominant, and nursing care plans and other
aspects of patient care such as psychosocial, functional, spiritual, and family
needs are almost unheard-of. In addition, as can be seen in the following shift
report, the focus was on medical plans and physical dimensions so that the
reports were not holistic:
Table 1. Main Themes and Related Subthemes Emerged From Analysis of Current
Nursing Handover Practices.
1. Nonholistic approach
a. Nonholistic/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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240 Clinical Nursing Research 24(3)
Table 2. Frequency of Information Presented in Patients’ Report.
Information Frequency %
General information
Name 130 100
Age 25 19.2
Diagnosis 54 41.5
Contextual information 21 16.1
Date of admission 11 8.4
Medical history 29 22.3
Physical status
Respiratory function 10 7.6
Consciousness 7 5.3
Discomfort 11 8.4
Urine 16 12.3
Diet 37 28.4
Vomiting 10 7.6
Bleeding 11 8.4
Physical measures
Blood pressure 22 16.9
Temperature 33 25.3
Fluid input 32 24.6
Weight 16 12.3
Nursing intervention
Patient care need 37 52
Nursing care plan 28.4 40
Medical treatment
Consultations 25 19.2
Medications 72 55.3
Surgical intervention 8 6.1
Tests 57 43.8
Plan of care 46 35.3
Doctor orders 16 12.3
Global judgments
Patient condition 17 13
About care 9 6.9
Psychology/personality 9 6.9
Colleagues 28 21.5
Management issues
Patient transfer 12 9.2
Admission 3 2.3
Discharge 17 13
General 30 23
(continued)
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Sarvestani et al. 241
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.
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 leads to missing information:
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.
Nurses’ low ethical and practical involvement. Another subtheme pertaining to
nonholistic approach is nurses’ low ethical and practical involvement. Data
obtained from multiple sources indicated that in spite of the case method caring
system, the nurses did not have an active role in the handover process and
those in charge are the only individuals who have the whole responsibility.
The following field note and interview showed low practical involvement of
nurses during handover processes:
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.
In another case, one of the head nurses in the interview stated that
Table 2. (continued)
Information Frequency %
Family
Care need 15 11.5
Comprehensions 8 6.1
Functional status 5 3.8
Psychological 3 2.3
Social 1 0.7
Spiritual 0 0
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242 Clinical Nursing Research 24(3)
In the handover process, all of the responsibilities are for the one In charge and
other nurses don’t have an active role in this process, and speak with each other or
do other things, while they must have an active role and listen to reports carefully
to be informed about patients’ conditions.
In addition, data from observation and tape records showed that nursing
handovers were not completely ethics-based. Labeling patients, prejudgments,
and inattention to patient and their families’ demands were the categories
that emerged from the data. The following excerpts illustrate that nurses
labeled patients and had prejudgment about patients and their families:
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?!
Summative content analysis, as shown in Table 2, also shows that frequency
of prejudgments about patients, families, and colleagues were high in
nursing handover contents.
Non-patient-centered approach. The findings showed that nursing handovers
are non-patient-centered. Observations revealed that the average time taken
for handover was 41 min for each shift, only 9 min of which was allocated to
bedside handover (42 s for each patient on average).
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.
As you see, we categorized these subthemes—nonholistic/unstructured
content, nurses’ low ethical and practical involvement, and non-patient-centered
approach—in one group and subsequently labeled it as nonholistic
approach.
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.
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Sarvestani et al. 243
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.
Poor time and space management. Data from interviews and several field observations
also suggested that the time and space of handovers were not well managed.
Poor time management, hasty reports, too many interruptions, crowded
stations, and no seats to participate in handovers were the categories.
The results of observations showed that handover lasts for about 41 min,
but time management of the process is not appropriate; at first, they check the
equipment such as emergency trolley, the narcotics box, and other utensils for
about 12 min. Then they listen to the oral shift report in the station for about
26 min and then have a round in patient rooms for about 9 min, approximately
42 s for each patient. 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.
Or another nurse in the interview said,
We don’t have a place for handover; in the station there are many people such as
medical and 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.
As can be seen, we categorized these subthemes—poor task management and
poor time/space management—in one group and labeled it as poor management.
Discussion
The aim of this study was to explore challenges of nursing handover practices
in Iran. The findings indicate that there are various challenges in handover
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244 Clinical Nursing Research 24(3)
practices in nursing, and, therefore, it seems essential to explore these challenges
in our health system. Data analysis resulted in identification of two
themes that explain challenges of nursing handover practices, namely, nonholistic
approach and poor management during nursing handover.
Findings showed that nursing handover practices were not holistic
because the contents of report were not holistic and structured. The nurses’
ethical and practical involvement was low and non-patient-centered.
Literature suggests that the content of handover should contain information
such as physical, psychosocial, spiritual, medical, and nursing care and
family needs at the same time (Rushton, 2010). However, nursing handovers
in the studied wards lack such holistic approaches, and medical and
physical needs are dominant. This fact is confirmed by other studies in our
country. Irajpour, Alavi, Abdoli, and Saberizafarghandi (2012) and
Yektatalab, Kave, Sharif, Fallahi Khoshknab, and Petramfar (2012), in two
qualitative studies, showed that health care in Iran is based on “Medical
Paradigm” in which professionals treat the clients as biological entities,
that is, they pay all their attention to meet the clients’ biological deficits and
needs, thereby neglecting many aspects of care such as educating patients.
According to Moattari, Ebrahimi, Sharifi, and Rouzbeh (2012), ensuring
adequate access to education for all patients is a clear challenge (Moattari
et al., 2012).Other Findings showed that health professionals who follow
medical approach may neglect the clients’ nonbiological (i.e., psychosocial)
needs and problems (Irajpour et al., 2012; Yektatalab et al., 2012). In
addition, Momennasab, Moattari, Abbaszade, and Shamshiri (2012) highlighted
the importance of attention to spiritual needs of patients in a religious
context such as the Iranian society (Momennasab et al., 2012).
Medical paradigm in our country is dominant and leads to medical oriented
approach in nursing practices even in nursing handovers (Hagbaghery,
Salsali, & Ahmadi, 2004). In Addition, Ekman and Segesten (1995) stated
that “nurses receive deputed power of medical control and little attention is
paid to nursing needs during handover” (Ekman & Segesten, 1995,
pp. 1006-1011). Nikbakht, Juliene, and Emami (2004) highlighted this
medical oriented paradigm and explained that it could be due to the patriarchal
social structure in Iran, because the most respected health care provider
is an experienced, male physician (Nikbakht et al., 2004).
Emami and Nikbakht, in a qualitative study in 2007, showed that nurses in
Iran work based on task-orientated approach. This appears to be due to nursing
curriculum in Iran whose focus is on a biomedical and task-orientated approach.
Therefore, it affects how nurses prioritize their working tasks (Emami &
Nikbakht, 2007). As Nikbakht et al. (2004) suggested, schools of nursing must
prepare students to deal with the consequences of conflicting models by
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Sarvestani et al. 245
helping the faculty revise the curriculum to reflect a creative and culturally
based philosophical perspective (Nikbakht et al., 2004).
Our findings showed that the current handover practices do not have an
organized structure, and this is one of the challenges that lead to many problems
such as lack of concentrations and missing or forgetting important information,
while structural contents of the report allow meaningful organization
of large amounts of data (Yurkovich & Smyer, 1998). Dowding (2000) conducted
an experimental study to assess the effects of changing the style and
content of the nurses’ report on nurses’ ability to plan patient care. Results
indicated that such type of report had a significant effect on nurses’ ability in
planning patient care, accuracy of information and the ability to recall the
information they heard (Dowding, 2000). Therefore, providing a template for
presenting patient information may increase the quality, accuracy, and speed
of handovers. Analyses of multiple sources of data showed that handover
process is not a collective action. Moreover, nurses’ ethical and practical
involvement was low, and they had an inactive role in this process. Inadequate
nursing staff may cause this situation in nursing handovers in Iran because
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. Furthermore, the nurses know that the ones in
charge have the whole responsibility and should listen to the reports carefully
to transfer the important information to other nurses, so they do not participate
in this process actively. Yektatalab, Kave, Sharif, Fallahi Khoshknab,
and Petramfar (2011) believed that this impaired care is due to nursing shortage,
lack of competent nurses, high workload, lack of job security, and low
salaries in Iran (Yektatalab et al., 2011).
While literature and studies emphasize the collective function of handovers
(Ekman & Segesten, 1995; Scovell, 2010; Strople & Ottani, 2006), this
process was not so in the studied wards. Handovers provide an opportunity
for professional communication, supporting role socialization and development
of a cohesive group process (Yurkovich & Smyer, 1998). Unfortunately,
studies in our country show that teamwork in our society and health care
system are poor and need to be improved (Mojdeh, Memarzadeh, Abdar
Isfahan, & Gholi Pour, 2009; Tafreshi, Pazargadi, & Abed Saeedi, 2007). In
addition, Meiβner et al., 2007 found that “poor support from colleagues” was
a reason for dissatisfaction during shift handover in Europeans nurses
(Meiβner et al., 2007).
However, we found that handovers can become vehicles for gossiping
and labeling each other, with the potential for undermining the relationships
and trust among nurses during handovers. This finding is consistent
with the result of Payne et al. (2000) indicating that these judgments are
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246 Clinical Nursing Research 24(3)
frequent in handovers (Payne et al., 2000). Code of ethics in Iran was formulated
in 2010, but 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 (Sanjari,
Zahedi, & Larijani, 2008). The American Nurse Association code of ethics
for nurses recommends the value of a guide to nursing handover (American
Nurses Association, 2001); however, because Iran is an Islamic country,
and gossiping, labeling, and prejudgments are taboos based on teachings of
the religion, it is undoubtedly necessary to provide a national code based on
our sociocultural norms in this field. Nursing in Iran is perceived as a holy
and honorable job, so Islamic principles provide a promising guide to ethical
codes of nursing taking Iranian culture and religion (Larijani, Zahedi, &
Malek-Afzali, 2005; Nikbakht, Emami, & Parsayekta, 2003; Sanjari et al.,
2008).
Another important aspect of the holistic approach in nursing handover is
patient-centered care. Our study showed that patient participation was low
and they were mostly passive onlookers, while the findings of McMurray,
Chaboyer, Wallis, Johnson, and Gehrke’s (2011), which examined patient
perspective of nursing handover in Queensland hospitals, showed that
patients valued having access to information and considered themselves an
important part in maintaining accuracy that improves safety and quality
(McMurray et al., 2011). 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 (Anderson & Mangino, 2006; Hutchfield,
1999; Mikkelsen & Frederiksen, 2011). 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 (Moattari,
Hashemi, & Dabbaghmanesh, 2013). The results of our study showed that
patients’ and families’ participation is ignored. Vasli, Salsali, and Tatarpoor
(2012), in a qualitative study in Iran, assessed the perspectives of nurses on
barriers of parental participation in pediatric wards. Four main themes
emerged as barriers of parental participation in pediatric care, namely, mutual
motivation and interest in parties, lack of support for nurses, nursing shortages,
nurses’ workload, and poor teamwork between nurses and physicians,
confidence in the nursing profession, and finally undefined role for mothers
(Vasli et al., 2012). Timonen and Sihvonen (2000) interviewed families and
found that main reason for them not participating during handover were lack
of encouragement, nurses concentrating on their papers, using special language,
and lack of time (Timonen & Sihvonen, 2000). Thus, we should consider
these findings to improve and strengthen parental participation during
handovers.
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Sarvestani et al. 247
Another theme that emerged from our data was poor management. Based
on the results of this study, time and space management during handovers
is poor. Baldwin and McGinnis (1994) reported that prolonged verbal
reports lead to nurses’ inability to prioritize patient needs (Baldwin &
McGinnis, 1994). In our study, nurses had to allocate some time for checking
the equipment, so the time allocated for patients decreased due to the
priority of checking the equipment due to economic considerations. It is
actually because some equipment is rare and expensive, and hospitals
expect nurses to maintain them as well as possible. Furthermore, too many
interruptions during handovers lead to inattention and prolonging the
process as well.
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 on the context (Yurkovich &
Smyer, 1998). In these wards, there was not a quiet room for handovers, leading
to many interruptions during handovers, which in turn decrease the quality
and accuracy of handover. In addition, Nikbakht and Emami (2006) found
that institutional circumstances are an issue for nurses in Iran. Welsh et al.
(2010) found the same result as the current study. Their analysis showed that
inadequate information, inconsistence quality, limited opportunity to ask
questions, equipment malfunction, insufficient time to generate reports, and
interruptions limited handovers (Welsh et al., 2010).
Task overlap was another problem that interfered with handovers. During
handovers, the nurses should do many tasks simultaneously. Task overlap
leads to inattention that will cause many errors during oral shift reports. Lack
of definite job description for nurses during handovers in our health system is
the key reason for such task overlap. Mayor, Bangerter, and Aribot (2012)
found that mean handover duration per patient increased with increasing task
uncertainty, and they recommended that redesigning of handover procedure
should take task uncertainty into account (Mayor et al., 2012). A qualitative
study conducted by Nikbakht et al. (2003) supported the finding that work
pressures, insufficient time, and lack of resources hindered nurses from doing
their work (Nikbakht et al., 2003).
However, our study has some limitations that should be considered. The
study took place in pediatric wards, so there are limitations for generalizing
our findings to other clinical settings. Thus, it is recommended that further
studies be conducted in other wards. Furthermore, although we had field
observations, we may miss other challenges although we have reached saturation.
Despite these limitations, the findings captured a good picture of the
current situation to better understand the current nursing handover practices
and provide a foundation to plan and implement appropriate change.
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248 Clinical Nursing Research 24(3)
Conclusion
Qualitative and quantitative analyses are ways to reach a better understanding
of the challenges of nursing handovers. 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. 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.
Because standardization of handover practices completely depends on the context
(culture, philosophy, needs, facilities, priorities, and economic considerations
in each organization are different), future focus could be on addressing
handover challenges through an action research study in which the identified
problems will be addressed by including those who are part of the process to act
on their own behalf to solve real-world problems.
Acknowledgment
The authors would like to thank the deputy chancellor for research of Shiraz University
of Medical Sciences for the approval, supervision, and funding of this research project.
The authors would like to thank those who helped them carry out this study and
the nurses who participated in this study. The authors would also like to thank Dr.
Nasrin Shokrpour at the Center for Development of Clinical Research of Nemazee
Hospital for editorial assistance.
Authors’ Note
R.S.S. was responsible for the study conception and design. R.S.S. performed the data
collection. R.S.S. and M. Moattari performed the data analysis. R.S.S., M.
Momennasab, S.H.Y., and A.N.N. were responsible for drafting the manuscript.
R.S.S., M. Moattari, M. Momennasab, S.H.Y., and A.N.N. made critical revisions to
the article for important intellectual content. M. Moattari obtained funding. M.
Moattari, M. Momennasab, S.H.Y., and A.N.N. gave administrative, technical, or
material support. M. Moattari and A.N.N. supervised the study. This paper is a part of
PhD dissertation of Raheleh Sabet Sarvestani.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
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Sarvestani et al. 249
Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: Vice chancellor of Research in Shiraz
University of Medical Sciences (Grant Number: 916217).
References
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Anderson, C. D., & Mangino, R. R. (2006). Nurse shift report: Who says you can’t
talk in front of the patient? Nursing Administration Quarterly, 30, 112-122.
Baker, S. J. (2010). Bedside shift report improves patient safety and nurse accountability.
Journal of Emergency Nursing, 36, 355-358. doi:10.1016/j.jen.2010.03.009
Baldwin, L., & McGinnis, C. (1994). A computer-generated shift report. Nursing
Management, 25(9), 61-64.
Blouin, A. S. (2011). Improving hand-off communications: New solutions
for nurses. Journal of Nursing Care Quality, 26, 97-100. doi:10.1097/
NCQ.0b013e31820d4f57
Chaboyer, W. (2011). Clinical handover. Retrieved from http://www.health.qld.gov.
au/psq/handover/docs/ch_presentation2.pdf
Chaboyer, W., Johnson, J., & Wallis, M. (2009). Bedside handover quality improvement
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Cole, F. L. (1988). Content analysis: Process and application. Clinical Nurse
Article
Challenges of Nursing
Handover: A Qualitative
Study
Raheleh Sabet Sarvestani, RN, MSN1,
Marzieh Moattari, PhD, MD, RN1,
Alireza Nikbakht Nasrabadi, PhD, MD, RN2,
Marzieh Momennasab, PhD, MD, RN1, and
Shahrzad Yektatalab, PhD, MD, RN1
Abstract
The aim of this study was to explore the challenges of nursing handover
process during shift rotation in hospitals. The research had a descriptive
exploratory design with a qualitative content analysis approach. To conduct
the study, three pediatric wards were selected at first. Data were gathered
through a 4-month observation of nursing handovers by recording the oral
conversations of nurses during the process and semistructured interviews.
Then, qualitative content analysis was used for data analysis. Two major
themes and five subthemes emerged through the data analysis. The first
and the second themes were a nonholistic approach and poor management,
respectively. In general, applying a holistic approach and managing handover
situations are recommended for nursing managers to overcome handover
challenges. Future focus could be on addressing handover challenges through
an action research study.
Keywords
handover, nursing, content analysis
1Shiraz University of Medical Sciences, Iran
2Tehran University of Medical Sciences, Iran
Corresponding Author:
Marzieh Moattari, Department of Nursing, School of Nursing and Midwifery, Shiraz University
of Medical Sciences, Shiraz, Iran.
Email: Moattari@yahoo.com
508134 CNRXXX10.1177/1054773813508134Clinical Nursing ResearchSarvestani et al.
research-article2013
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Sarvestani et al. 235
Introduction
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 (Lamond, 2000). It is actually a substantial part of a nurse’s
duty, and each nurse should allocate 38% of his or her working hours in a
hospital ward every day to fulfill the handover process (Spanke & Thomas,
2010). 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 (Rushton, 2010). Moreover, handover is an opportunity for nurses’
group cohesion, professional socialization, education, interaction, and emotional
support (Griffin, 2010; Payne, Hardey, & Coleman, 2000). 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 (Rushton, 2010; Strople & Ottani, 2006).
A key component in patient safety and care quality is accurate communication
during handover (Chaboyer, 2011). The Joint Commission on
Accreditation of Health Care Organizations (JCAHO) has established standardizing
handover as a priority for improving patient safety since 2006
(Chaboyer, 2011; Schroeder, 2006). However, a review of literature reflects
limited research and articles addressing handover, while most of them highlighted
the importance of nursing handover and prioritized it for patient
safety (Baker, 2010; Blouin, 2011; Schroeder, 2006; Scott, 2012; Welsh,
Flanagan, & Ebright, 2010).
Although there are controversies about the efficacy of handover practices,
some articles highlight the importance of oral shift report that could not be
substituted by any other method because handover is the only place where
different aspects of professional nursing care are identified (Gordon &
Findley, 2011; Manias & Street, 2000; Scovell, 2010); otherwise, other studies
question its efficacy and report that there is no need to have an oral shift
report because most of the discussed information could be located within
nursing documentation, and, therefore, such a practice is time-consuming
(Manias & Street, 2000; Sexton et al., 2004).
In practice, the complexity of patients’ conditions, lack of organization,
and different interruptions during handover prolong the reporting process
(Spanke & Thomas, 2010). In a large scale study of 10 European countries,
Meiβner et al. (2007) explored the nurses’ perception of handover and the
reason for dissatisfaction among them. She found that 22% to 61% of nurses
were dissatisfied due to “too many disturbances,” “lack of time,” and “work
organizational factors” (Meiβner et al., 2007).
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236 Clinical Nursing Research 24(3)
In general, the goal of nursing handover is the transfer of relevant information
and continuity of patient care; however, there is no agreement about
its content and the related literature recommends different templates for presenting
data (Johnson, Jefferies, & Nicholls, 2012). According to Schroeder
(2006), the specific component of shift report should include PACE (Patient
problems, Assessment/Action, Continuing/Changes, Evaluation; Schroeder,
2006), and other researchers have suggested other templates such as SBAR
(Situation, Background, Assessment, and Recommendations; Raines & Mull,
2007). Regarding all such guidelines, the content of handover must contain
short- and long-term goals. It should also be broad and specific enough to
meet the patients’ needs. Furthermore, it should contain information such as
medical and nursing care and physical, psychosocial, spiritual, and family
needs at the same time (Rushton, 2010).
A body of literature reflects four modes of handover: the verbal handover
in station, tape recording, written handover, and handover at bedside. In practice,
the method of handover depends on the patient, the shift (day, evening,
or night shift), and the model of service delivery (team vs. case method;
Johnson & Cowin, 2012). Nevertheless, many studies have confirmed the
efficacy of bedside handovers. (Chaboyer, 2011; Chaboyer, Johnson, &
Wallis, 2009; Mott & Bradley, 2010; Webster, 1999) For example, Mott and
Bradley (2010) conducted an action research in three rural South Australian
hospitals and incorporated bedside handover reports. She found that bedside
handover was better than office reports in terms of ease and time efficiency.
Interestingly, level of satisfaction increased among nurses and patients, and
patients were more involved in their care; it also decreased the rate of errors
(Mott & Bradley, 2010).
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 (Hutchfield, 1999;
Mikkelsen & Frederiksen, 2011). 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 these data. These labels can limit the opportunity of
families to learn the skills needed to manage the problems and meet their
essential needs and decrease their involvement. So, applying a standard
handover is essential in pediatric wards (Ryan & Steinmiller, 2004).
The first step in standardizing handover and introduction of an alternative
model is to improve our understanding of current practices. Although some
studies have been conducted in several countries, the handover practices have
not been well studied in the Iranian health system because the context is different.
Because situational analysis is the first step in changing the program,
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Sarvestani et al. 237
exploring the current conditions of handover is important. Hence, the aim of
this study was to explore the challenges of handover practices in Iran to provide
an opportunity for a better understanding of the situation and help
improve the current practices.
Method
Design
The study was conducted using a descriptive exploratory qualitative design
with a content analysis approach. Content analysis is a way to analyze written,
verbal, or visual information. It actually serves as an action guide and
aims at providing valid insights from data to attain a broad and complete
description of a phenomenon (Cole, 1988). In this research, an inductive
approach of content analysis was used. In this method, categories are derived
from data during data analysis, which help to attain a richer understanding of
a phenomenon. Another approach we used during the 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 (Hsieh & Shannon, 2005).
Data Collection
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. During 4 months of observation period, 14 handovers
(5 in the morning, 5 in the evening, and 4 at night) were observed and taperecorded.
Observations were noninterventional and semistructured, focusing
on the key events and activities during handovers. Field notes were written
immediately after each observation. Then, the records were transcribed verbatim
and 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. In addition, nine indepth
interviews were conducted with the nurses, who were selected through
a purposeful sampling. We continue sampling until we have reached saturation.
The inclusion criteria were availability and willingness to complete the
interview. A guide was prepared for covering key questions that were general
with prompt to encourage responses during the interviews. Examples of
interview questions include the following:
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238 Clinical Nursing Research 24(3)
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? All
interviews were conducted and recorded in a quiet location, and each lasted
between 30 min and 45 min.
Ethics
The ethics committee of the 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.
Analysis
Inductive and summative content analyses were 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 categorized according to previous knowledge or theory (Elo & Kyngas,
2007). The oral shift report-taped handovers, interviews, observations, and
field notes were transcribed after each section of data collection. At first, data
were approached by being read as a whole repeatedly before being read word
by word to achieve immersion and finally to derive codes. Then, we organized
and grouped the codes into meaningful clusters. For the purpose of
abstraction, the relationships between categories were identified, and two
major themes emerged. The researcher returned to the codes and reconsidered
them to check whether the themes fit the data again. A second researcher
read the categories and themes for further refinement. MAXqda2 software
was used for data analysis.
Trustworthiness
The procedures that were used to improve trustworthiness were as follow:
Coding and categories were sending back to the participant for possible
revision. A team-based approach (composed of four qualified nurses in
qualitative research) 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,
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Sarvestani et al. 239
varied experiences, peer checking, and triangulation were other strategies
for improving the trustworthiness of the study (Helen & Carpenter, 2007;
Polit, Bech, & Hungler, 2006).
Findings
All the nurses were female with a mean age of 30.1 ± 6.8 years and mean
experience of 6.9 ± 5.6 years, and all have bachelor’s degree in nursing.
Data analysis resulted in identification of two major themes and five subthemes.
The first theme was a nonholistic approach, and the second one was
poor management. These are presented in Table 1 and are explained in the
following section.
Nonholistic Approach
The first theme emerged from data included nonholistic approaches in nursing
handover practices. The subthemes were nonholistic/unstructured content,
low nurses ethical and practical involvement, and non-patient-centered
approach, which are explained separately in the following section.
Nonholistic/unstructured content. Summative content analysis of 130 patients
in the oral shift report showed that the contents of nursing handovers were not
holistic. The total frequency with which information was mentioned in nursing
handover can be seen in Table 2. This table illustrates that medical plans
and physical dimensions are more dominant, and nursing care plans and other
aspects of patient care such as psychosocial, functional, spiritual, and family
needs are almost unheard-of. In addition, as can be seen in the following shift
report, the focus was on medical plans and physical dimensions so that the
reports were not holistic:
Table 1. Main Themes and Related Subthemes Emerged From Analysis of Current
Nursing Handover Practices.
1. Nonholistic approach
a. Nonholistic/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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240 Clinical Nursing Research 24(3)
Table 2. Frequency of Information Presented in Patients’ Report.
Information Frequency %
General information
Name 130 100
Age 25 19.2
Diagnosis 54 41.5
Contextual information 21 16.1
Date of admission 11 8.4
Medical history 29 22.3
Physical status
Respiratory function 10 7.6
Consciousness 7 5.3
Discomfort 11 8.4
Urine 16 12.3
Diet 37 28.4
Vomiting 10 7.6
Bleeding 11 8.4
Physical measures
Blood pressure 22 16.9
Temperature 33 25.3
Fluid input 32 24.6
Weight 16 12.3
Nursing intervention
Patient care need 37 52
Nursing care plan 28.4 40
Medical treatment
Consultations 25 19.2
Medications 72 55.3
Surgical intervention 8 6.1
Tests 57 43.8
Plan of care 46 35.3
Doctor orders 16 12.3
Global judgments
Patient condition 17 13
About care 9 6.9
Psychology/personality 9 6.9
Colleagues 28 21.5
Management issues
Patient transfer 12 9.2
Admission 3 2.3
Discharge 17 13
General 30 23
(continued)
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Sarvestani et al. 241
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.
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 leads to missing information:
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.
Nurses’ low ethical and practical involvement. Another subtheme pertaining to
nonholistic approach is nurses’ low ethical and practical involvement. Data
obtained from multiple sources indicated that in spite of the case method caring
system, the nurses did not have an active role in the handover process and
those in charge are the only individuals who have the whole responsibility.
The following field note and interview showed low practical involvement of
nurses during handover processes:
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.
In another case, one of the head nurses in the interview stated that
Table 2. (continued)
Information Frequency %
Family
Care need 15 11.5
Comprehensions 8 6.1
Functional status 5 3.8
Psychological 3 2.3
Social 1 0.7
Spiritual 0 0
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242 Clinical Nursing Research 24(3)
In the handover process, all of the responsibilities are for the one In charge and
other nurses don’t have an active role in this process, and speak with each other or
do other things, while they must have an active role and listen to reports carefully
to be informed about patients’ conditions.
In addition, data from observation and tape records showed that nursing
handovers were not completely ethics-based. Labeling patients, prejudgments,
and inattention to patient and their families’ demands were the categories
that emerged from the data. The following excerpts illustrate that nurses
labeled patients and had prejudgment about patients and their families:
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?!
Summative content analysis, as shown in Table 2, also shows that frequency
of prejudgments about patients, families, and colleagues were high in
nursing handover contents.
Non-patient-centered approach. The findings showed that nursing handovers
are non-patient-centered. Observations revealed that the average time taken
for handover was 41 min for each shift, only 9 min of which was allocated to
bedside handover (42 s for each patient on average).
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.
As you see, we categorized these subthemes—nonholistic/unstructured
content, nurses’ low ethical and practical involvement, and non-patient-centered
approach—in one group and subsequently labeled it as nonholistic
approach.
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.
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Sarvestani et al. 243
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.
Poor time and space management. Data from interviews and several field observations
also suggested that the time and space of handovers were not well managed.
Poor time management, hasty reports, too many interruptions, crowded
stations, and no seats to participate in handovers were the categories.
The results of observations showed that handover lasts for about 41 min,
but time management of the process is not appropriate; at first, they check the
equipment such as emergency trolley, the narcotics box, and other utensils for
about 12 min. Then they listen to the oral shift report in the station for about
26 min and then have a round in patient rooms for about 9 min, approximately
42 s for each patient. 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.
Or another nurse in the interview said,
We don’t have a place for handover; in the station there are many people such as
medical and 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.
As can be seen, we categorized these subthemes—poor task management and
poor time/space management—in one group and labeled it as poor management.
Discussion
The aim of this study was to explore challenges of nursing handover practices
in Iran. The findings indicate that there are various challenges in handover
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244 Clinical Nursing Research 24(3)
practices in nursing, and, therefore, it seems essential to explore these challenges
in our health system. Data analysis resulted in identification of two
themes that explain challenges of nursing handover practices, namely, nonholistic
approach and poor management during nursing handover.
Findings showed that nursing handover practices were not holistic
because the contents of report were not holistic and structured. The nurses’
ethical and practical involvement was low and non-patient-centered.
Literature suggests that the content of handover should contain information
such as physical, psychosocial, spiritual, medical, and nursing care and
family needs at the same time (Rushton, 2010). However, nursing handovers
in the studied wards lack such holistic approaches, and medical and
physical needs are dominant. This fact is confirmed by other studies in our
country. Irajpour, Alavi, Abdoli, and Saberizafarghandi (2012) and
Yektatalab, Kave, Sharif, Fallahi Khoshknab, and Petramfar (2012), in two
qualitative studies, showed that health care in Iran is based on “Medical
Paradigm” in which professionals treat the clients as biological entities,
that is, they pay all their attention to meet the clients’ biological deficits and
needs, thereby neglecting many aspects of care such as educating patients.
According to Moattari, Ebrahimi, Sharifi, and Rouzbeh (2012), ensuring
adequate access to education for all patients is a clear challenge (Moattari
et al., 2012).Other Findings showed that health professionals who follow
medical approach may neglect the clients’ nonbiological (i.e., psychosocial)
needs and problems (Irajpour et al., 2012; Yektatalab et al., 2012). In
addition, Momennasab, Moattari, Abbaszade, and Shamshiri (2012) highlighted
the importance of attention to spiritual needs of patients in a religious
context such as the Iranian society (Momennasab et al., 2012).
Medical paradigm in our country is dominant and leads to medical oriented
approach in nursing practices even in nursing handovers (Hagbaghery,
Salsali, & Ahmadi, 2004). In Addition, Ekman and Segesten (1995) stated
that “nurses receive deputed power of medical control and little attention is
paid to nursing needs during handover” (Ekman & Segesten, 1995,
pp. 1006-1011). Nikbakht, Juliene, and Emami (2004) highlighted this
medical oriented paradigm and explained that it could be due to the patriarchal
social structure in Iran, because the most respected health care provider
is an experienced, male physician (Nikbakht et al., 2004).
Emami and Nikbakht, in a qualitative study in 2007, showed that nurses in
Iran work based on task-orientated approach. This appears to be due to nursing
curriculum in Iran whose focus is on a biomedical and task-orientated approach.
Therefore, it affects how nurses prioritize their working tasks (Emami &
Nikbakht, 2007). As Nikbakht et al. (2004) suggested, schools of nursing must
prepare students to deal with the consequences of conflicting models by
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Sarvestani et al. 245
helping the faculty revise the curriculum to reflect a creative and culturally
based philosophical perspective (Nikbakht et al., 2004).
Our findings showed that the current handover practices do not have an
organized structure, and this is one of the challenges that lead to many problems
such as lack of concentrations and missing or forgetting important information,
while structural contents of the report allow meaningful organization
of large amounts of data (Yurkovich & Smyer, 1998). Dowding (2000) conducted
an experimental study to assess the effects of changing the style and
content of the nurses’ report on nurses’ ability to plan patient care. Results
indicated that such type of report had a significant effect on nurses’ ability in
planning patient care, accuracy of information and the ability to recall the
information they heard (Dowding, 2000). Therefore, providing a template for
presenting patient information may increase the quality, accuracy, and speed
of handovers. Analyses of multiple sources of data showed that handover
process is not a collective action. Moreover, nurses’ ethical and practical
involvement was low, and they had an inactive role in this process. Inadequate
nursing staff may cause this situation in nursing handovers in Iran because
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. Furthermore, the nurses know that the ones in
charge have the whole responsibility and should listen to the reports carefully
to transfer the important information to other nurses, so they do not participate
in this process actively. Yektatalab, Kave, Sharif, Fallahi Khoshknab,
and Petramfar (2011) believed that this impaired care is due to nursing shortage,
lack of competent nurses, high workload, lack of job security, and low
salaries in Iran (Yektatalab et al., 2011).
While literature and studies emphasize the collective function of handovers
(Ekman & Segesten, 1995; Scovell, 2010; Strople & Ottani, 2006), this
process was not so in the studied wards. Handovers provide an opportunity
for professional communication, supporting role socialization and development
of a cohesive group process (Yurkovich & Smyer, 1998). Unfortunately,
studies in our country show that teamwork in our society and health care
system are poor and need to be improved (Mojdeh, Memarzadeh, Abdar
Isfahan, & Gholi Pour, 2009; Tafreshi, Pazargadi, & Abed Saeedi, 2007). In
addition, Meiβner et al., 2007 found that “poor support from colleagues” was
a reason for dissatisfaction during shift handover in Europeans nurses
(Meiβner et al., 2007).
However, we found that handovers can become vehicles for gossiping
and labeling each other, with the potential for undermining the relationships
and trust among nurses during handovers. This finding is consistent
with the result of Payne et al. (2000) indicating that these judgments are
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246 Clinical Nursing Research 24(3)
frequent in handovers (Payne et al., 2000). Code of ethics in Iran was formulated
in 2010, but 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 (Sanjari,
Zahedi, & Larijani, 2008). The American Nurse Association code of ethics
for nurses recommends the value of a guide to nursing handover (American
Nurses Association, 2001); however, because Iran is an Islamic country,
and gossiping, labeling, and prejudgments are taboos based on teachings of
the religion, it is undoubtedly necessary to provide a national code based on
our sociocultural norms in this field. Nursing in Iran is perceived as a holy
and honorable job, so Islamic principles provide a promising guide to ethical
codes of nursing taking Iranian culture and religion (Larijani, Zahedi, &
Malek-Afzali, 2005; Nikbakht, Emami, & Parsayekta, 2003; Sanjari et al.,
2008).
Another important aspect of the holistic approach in nursing handover is
patient-centered care. Our study showed that patient participation was low
and they were mostly passive onlookers, while the findings of McMurray,
Chaboyer, Wallis, Johnson, and Gehrke’s (2011), which examined patient
perspective of nursing handover in Queensland hospitals, showed that
patients valued having access to information and considered themselves an
important part in maintaining accuracy that improves safety and quality
(McMurray et al., 2011). 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 (Anderson & Mangino, 2006; Hutchfield,
1999; Mikkelsen & Frederiksen, 2011). 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 (Moattari,
Hashemi, & Dabbaghmanesh, 2013). The results of our study showed that
patients’ and families’ participation is ignored. Vasli, Salsali, and Tatarpoor
(2012), in a qualitative study in Iran, assessed the perspectives of nurses on
barriers of parental participation in pediatric wards. Four main themes
emerged as barriers of parental participation in pediatric care, namely, mutual
motivation and interest in parties, lack of support for nurses, nursing shortages,
nurses’ workload, and poor teamwork between nurses and physicians,
confidence in the nursing profession, and finally undefined role for mothers
(Vasli et al., 2012). Timonen and Sihvonen (2000) interviewed families and
found that main reason for them not participating during handover were lack
of encouragement, nurses concentrating on their papers, using special language,
and lack of time (Timonen & Sihvonen, 2000). Thus, we should consider
these findings to improve and strengthen parental participation during
handovers.
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Sarvestani et al. 247
Another theme that emerged from our data was poor management. Based
on the results of this study, time and space management during handovers
is poor. Baldwin and McGinnis (1994) reported that prolonged verbal
reports lead to nurses’ inability to prioritize patient needs (Baldwin &
McGinnis, 1994). In our study, nurses had to allocate some time for checking
the equipment, so the time allocated for patients decreased due to the
priority of checking the equipment due to economic considerations. It is
actually because some equipment is rare and expensive, and hospitals
expect nurses to maintain them as well as possible. Furthermore, too many
interruptions during handovers lead to inattention and prolonging the
process as well.
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 on the context (Yurkovich &
Smyer, 1998). In these wards, there was not a quiet room for handovers, leading
to many interruptions during handovers, which in turn decrease the quality
and accuracy of handover. In addition, Nikbakht and Emami (2006) found
that institutional circumstances are an issue for nurses in Iran. Welsh et al.
(2010) found the same result as the current study. Their analysis showed that
inadequate information, inconsistence quality, limited opportunity to ask
questions, equipment malfunction, insufficient time to generate reports, and
interruptions limited handovers (Welsh et al., 2010).
Task overlap was another problem that interfered with handovers. During
handovers, the nurses should do many tasks simultaneously. Task overlap
leads to inattention that will cause many errors during oral shift reports. Lack
of definite job description for nurses during handovers in our health system is
the key reason for such task overlap. Mayor, Bangerter, and Aribot (2012)
found that mean handover duration per patient increased with increasing task
uncertainty, and they recommended that redesigning of handover procedure
should take task uncertainty into account (Mayor et al., 2012). A qualitative
study conducted by Nikbakht et al. (2003) supported the finding that work
pressures, insufficient time, and lack of resources hindered nurses from doing
their work (Nikbakht et al., 2003).
However, our study has some limitations that should be considered. The
study took place in pediatric wards, so there are limitations for generalizing
our findings to other clinical settings. Thus, it is recommended that further
studies be conducted in other wards. Furthermore, although we had field
observations, we may miss other challenges although we have reached saturation.
Despite these limitations, the findings captured a good picture of the
current situation to better understand the current nursing handover practices
and provide a foundation to plan and implement appropriate change.
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248 Clinical Nursing Research 24(3)
Conclusion
Qualitative and quantitative analyses are ways to reach a better understanding
of the challenges of nursing handovers. 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. 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.
Because standardization of handover practices completely depends on the context
(culture, philosophy, needs, facilities, priorities, and economic considerations
in each organization are different), future focus could be on addressing
handover challenges through an action research study in which the identified
problems will be addressed by including those who are part of the process to act
on their own behalf to solve real-world problems.
Acknowledgment
The authors would like to thank the deputy chancellor for research of Shiraz University
of Medical Sciences for the approval, supervision, and funding of this research project.
The authors would like to thank those who helped them carry out this study and
the nurses who participated in this study. The authors would also like to thank Dr.
Nasrin Shokrpour at the Center for Development of Clinical Research of Nemazee
Hospital for editorial assistance.
Authors’ Note
R.S.S. was responsible for the study conception and design. R.S.S. performed the data
collection. R.S.S. and M. Moattari performed the data analysis. R.S.S., M.
Momennasab, S.H.Y., and A.N.N. were responsible for drafting the manuscript.
R.S.S., M. Moattari, M. Momennasab, S.H.Y., and A.N.N. made critical revisions to
the article for important intellectual content. M. Moattari obtained funding. M.
Moattari, M. Momennasab, S.H.Y., and A.N.N. gave administrative, technical, or
material support. M. Moattari and A.N.N. supervised the study. This paper is a part of
PhD dissertation of Raheleh Sabet Sarvestani.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
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Sarvestani et al. 249
Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: Vice chancellor of Research in Shiraz
University of Medical Sciences (Grant Number: 916217).
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