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International Journal of Nursing Practice 2014; 20: 250–257
RESEARCH PAPER
Towards patient-centred care: Perspectives of nurses and midwives regarding shift-to-shift bedside handover Debra Kerr RN BN MBL GradCert ClinResMeth GradCert Tertiary Ed PhD Senior Lecturer, Honours Coordinator, Victoria University, St Albans, Victoria, Australia
Sai Lu MBBS PhD Lecturer, Victoria University, St Albans, Victoria, Australia
Louise McKinlay BN Manager, Centre of Education, Western Health, Footscray, Victoria, Australia
Accepted for publication January 2013 Kerr D, Lu S, McKinlay L. International Journal of Nursing Practice 2014; 20: 250–257 Towards patient-centred care: Perspectives of nurses and midwives regarding shift-to-shift bedside handover The aim of this descriptive qualitative study was to explore perspectives of nurses and midwives towards the introduction of shift-to-shift bedside handover. Semistructured interviews with nurses (n = 20) and midwives (n = 10) occurred 12 months after the introduction of bedside handover. Data were analyzed using thematic content analysis. Two main themes were identified: enhanced individual patient care and documentation, along with improved patient–clinician partnerships; and protection of confidentiality and privacy. The newly introduced bedside handover model improved efficiency and accuracy of the handover process and led to the provision of safe, high-quality care. Development of ward-specific tools and relevant educational resources, along with clinical support, are identified as the facilitators to ensure the new model can be successfully integrated into normal clinical practice. Key words: bedside handover, hospital care, midwife, nurse–patient partnership, patient-centred care.
INTRODUCTION Correspondence: Debra Kerr, Victoria University, Building 4, Room 4C211, McKechnie St, St Albans, Vic. 3021, Australia. Email: [email protected] Support: An internal university grant of AUD$25 000 supported the conduct of this study. Contributions Conception and design: DK, SL, LM; Analysis and Interpretation of data: DK, SL, LM; Drafting the article: DK, SL, LM; Final approval of the version to be published: DK, SL, LM. © 2013 Wiley Publishing Asia Pty Ltd
Effective communication of health-care information from one health-care professional to another, normally achieved by handover, is pivotal to ensuring patient care continuity and safety.1 As a result of handover, there is a transfer of professional responsibility and accountability in aspects of care for an individual or group of patients.2 In the inpatient setting, nurses and midwives conduct handover to convey pertinent patient information to staff on an incoming shift. Unfortunately, handover is considered a ‘high-risk activity that can be associated with serious doi:10.1111/ijn.12138
Bedside handover—professional opinions
adverse events due to poor communication and inaccurate or lacking information’.3 Ineffective handover is known to account for almost 70% of all sentinel events reported in the USA.4 Breakdown in communication between healthcare professionals was also identified as one of the major contributors to nearly one-quarter of adverse events in the states of Victoria5 and Western Australia.6 Analysis of 25 000 to 30 000 preventable adverse events in Australia found that 11% were due to communication issues.7 In a nursing study, Sexton et al.8 found that communication during handover contributed to confusion and did not clarify issues about patient status, treatments and management. Numerous barriers to effective handover have been acknowledged including informal structure,9,10 unnecessary content,10 lengthy duration11 and lack of confidence.12 There have been efforts at a national and international level to improve the quality of clinical handover by healthcare professionals.1,13,14 Known strategies for enhancing the effectiveness of handover include focus on patient safety,15 standardization,13 effective leadership,16 skilful communication15,17 and updated documentation.18 Attempts to address system-based problems that may impact on health-care outcomes have led to research in alternative modes of handover. Handover performed at the bedside, frequently referred to as ‘bedside handover’ (BHO), is one of them. According to McMurray et al.,19 BHO is based on patient-centred care, which is fostered by communication of relevant and timely information to enhance care planning in collaboration with the patient. In their opinion, patient input has the potential to ‘reduce care fragmentation, miscommunication-related adverse events, readmissions, duplication of services and enhance satisfaction and continuity of care’.19 (p. 2580). The involvement of patients and their respective families in the process of health care is recognized as an important aspect of care. According to a World Health Organization report,1 the patient and their respective family are likely to be the only constant variable during a hospital episode, who have the potential to ensure continuity of care. There is growing evidence of support from the patient’s perspective for BHO.20–23 In Australia, nurses’ opinions about BHO have been reported in two separate papers. McMurray et al.19 identified five themes including ‘being part of the big picture’, ‘linking the project to standardisation initiatives’, ‘reassurance on safety and quality’, ‘smoothing out logistical difficulties’ and ‘learning to listen’. Chaboyer et al.24
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reported key issues including improved accuracy in communication between nurses and promotion of patientcentred care. In Arizona (USA), Anderson and Mangino20 investigated the impact of BHO in an adult acute care unit. They reported increased accountability, interpersonal satisfaction and receipt of important information for registered nursing staff. In an action research study, Webster25 found that 12 months after implementation, nursing staff favoured BHO compared with the ‘traditional’ model. Nurses preferred the focus towards meaningful and relevant nursing needs, including nursing documentation, rather than medical information. BHO was introduced in the organization in which this study was conducted in August 2010 as part of a structured program that included ward-based coordination by a project manager in an 8-week period, development of ward-specific tools and individual education sessions. There are few in-depth studies on the experiences and opinions of clinicians towards BHO, in particular in the maternity context. The aim of this study was to explore perspectives of nurses and midwives towards the introduction of BHO in the clinical setting.
METHODS Design Data collection and analysis were informed by a qualitative descriptive method.26,27 Using qualitative description, accounts of the phenomena are usually captured by structured interviews or focus groups, and further analysis aims to gain knowledge of professionals’ experience with a topic. The purpose of this study was to explore the subjective experiences and viewpoints of the nurse and midwife participants. Data collection and analysis focused on the perceived benefits and limitations of BHO and impact on patient-centred care from their perspective.
Sample A purposive sample included nurses and midwives employed on one of the three wards in which BHO was introduced. A broad sample was sought to gain wide variation of opinion to maximize insight into the issue.26 The study was promoted verbally via ward in-service meetings and an information form was distributed to all staff. To be eligible, nurses and midwives were required to be permanently employed in each respective ward prior to the introduction of BHO. Those who were keen to participate approached the research assistant and provided written consent prior to the interview. © 2013 Wiley Publishing Asia Pty Ltd
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Table 1 Interview schedule23,24 Were you in favour of the introduction of bedside handover? What do you think about nurses and midwives undertaking shift-to-shift handover at the bedside? From your perspective, what are some of the benefits of bedside handover? What are some of the limitations of bedside handover? Did the introduction of bedside handover have an impact on your nursing or midwifery practice? Do you think that a patient has a role in bedside handover? If yes, how do you currently include the patient’s input or opinions in handover? What do you think the role of a patient could be in the bedside handover (i.e. how do you think they should/could participate)? How do you deal with the presence of family members? What role do you think family members might have in bedside handover? Do you think that bedside handover compromises the patient’s privacy or confidentiality? What strategies do you have for maintaining patient privacy in multiple bed rooms? Are there topics you think should be excluded from the bedside handover? If so, what are they? Is there any extra information you think should be included in the bedside handover? Overall, how do you think that bedside handover could be improved?
Procedure
Data analysis
Taped semistructured interviews were conducted in August 2011, approximately 12 months after the introduction of BHO in each ward. An open-ended interview schedule (Table 1), based on previous case study research,23,24 was used. Questions included risks, benefits, and limitations of BHO. In addition, opinion was sought regarding the perceived impact on patient-centred care and how to improve BHO practice. In contrast to other qualitative methods that strive for thick description (ethnography), theory development (grounded theory) or interpretation (phenomenology), in qualitative descriptive methods, the researcher aims to describe the experience in the participants’ own language. Hence, the interview schedule was slightly more structured than is usually found in other qualitative methods.26 Issues raised in the interview could be further explored and probed at that time by the interviewer. The one-on-one taped interview was performed in a private office of each ward at a mutually agreeable time. Data were collected by one trained research assistant, a registered nurse. Interviews lasted approximately 30 min in duration.
After taped interviews were transcribed, thematic content analysis was performed as described by Smith and Osborn.28 First, the whole transcript was read and reread several times to gain a general sense of the overall accounts. Second, transcripts were examined using lineby-line analysis. Notes indicating striking issues were made in the margins as a form of coding, with the development of themes to reflect the researcher’s interpretation of the data. Third, themes were clustered together and redeveloped as main themes and subthemes. Themes not supported by sufficient data were omitted. In the final stage, themes and subthemes were tabulated in a summary table after careful scrutiny for clarity and order. This process was followed by a second researcher who independently identified themes and subthemes. After a period of time to allow for reflection and re-examination of the transcripts, a consensus meeting was held with all investigators to reach a joint thematic framework regarding the themes and subthemes. Trustworthiness of the data was maintained by appropriate sample selection and an audit trail to demonstrate systematic documentation, data collection and analysis.
Ethical considerations Ethics approval was obtained from the institutional ethics panel. Emphasis was placed on voluntary participation; hence, all participants gave written informed consent. In addition, data were managed in a confidential manner. © 2013 Wiley Publishing Asia Pty Ltd
RESULTS There were 30 participants in this study: 25 women and 5 men. For the medical and surgical wards, 20 nurses were interviewed; and for the maternity ward, 10 midwives
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Table 2 Employment categories Employment category
n
%
Enrolled Nurse Registered Nurse Midwife Clinical Nurse Specialist—Registered Nurse Clinical Nurse Specialist—Midwife Associate Nurse Unit Manager—Registered Nurse Associate Nurse Unit Manager—Midwife Total
3 13 7 2 2 2 1 30
10.0 43.3 23.3 6.7 6.7 6.7 3.3
were interviewed. Employment categories for the participants ranged from enrolled nurse to unit manager, as shown in Table 2. Two main themes emerged from the data: ‘Enhanced care and documentation’ and ‘Discretion to protect confidentiality and privacy’.
Theme 1: Enhanced care and documentation Overall, nurses and midwives believed that the standard of care and documentation had improved as a direct result of BHO, articulated in three subthemes: ‘Enhanced Continuity of Care’, ‘Improved Nursing and Midwifery Documentation’ and ‘Strengthened Healthcare Partnership’. There was a general consensus that BHO enabled early visualization of patients and their charts as well as detailed and focused information transfer. All of these facilitated better clinical judgements and decision-making that ultimately led to ‘Enhanced Continuity of Care’. Visualization of patients and their charts at the beginning of the shift was seen as an ideal opportunity to confirm whether certain clinical tasks had been completed: . . . just having a good look at your patient at the beginning of your shift. So you have an idea of everyone’s status right at the beginning as opposed to starting a shift and then getting caught up with doing other stuff and then it might be an hour or so before you actually lay eyes on your patient to find that they are acutely unwell (RN5). . . . you can check the charts with the person who’s looked after the patient before you. So if there are any problems you can sort them out straight away (RN8). Explicit and detailed information received during individual BHO provided nurses and midwives of the
oncoming shift provision of adequate information to deliver continued care. Participants valued the opportunity to view the charts at shift commencement to confirm that certain activities had been completed such as medications administered and documented appropriately and fluid balance charts kept up to date. This allowed them to thoroughly plan for the forthcoming shift: . . . you get a lot more detailed information about your set of patients which is really helpful in terms of understanding what they’ve done for the day and what needs to be done . . . it helps you better care (RN11). I think the positives are you get a lot more detailed information about your set of patients which is really helpful in terms of understanding what they’ve done for the day and what needs to be done (RN3). Many participants reported that they were paying more attention to completion of their nursing or midwifery responsibilities and documentation before handover commenced to prevent embarrassment due to identification of incomplete documentation. They considered that this had resulted in improved nursing and midwifery documentation. . . . it does motivate you more to make sure you get everything done so that handover does sort of follow through more smoothly . . . it obviously goes more smoothly if you’ve tried to at least do as many things as you can, so that when you go through the charts you can say, ‘I’ve done this, I’ve given this’ (RN16). . . . it makes people more accountable . . . so you actually work a bit more efficiently because you know when you’ve got to do that handover that that paperwork is going to be checked and you want to make sure it’s accurate (M9). In general, nurses and midwives believed BHO led to better communication. They expressed that they had more confidence in the process of this new type of handover practice as there was an opportunity to ask questions and clarify issues.
I think it has reduced the number of errors or missed medication . . . and it provides an opportunity to pick up things (RN5). © 2013 Wiley Publishing Asia Pty Ltd
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. . . better than the handover in the office because you find out more things and then you can query things . . . (RN17). Interestingly, in comparison with BHO, some nurses reflected on their inability to concentrate during the traditional mode of handover, which used to involve a large number of patients. . . . I know that it is very hard to concentrate on 20 patients at the general handover. It’s much easier to concentrate on just the four that you know you are going to give complete care to (RN2). Previous handover was long and not relevant to the group as a whole. The whole group didn’t need to know a lot of information that was being hand over. A lot of important information was being left out (RN5). Participants expressed the view that BHO helped to strengthen the health-care partnership between the nurse or midwife and the patient. By clarifying their own condition and plan, patients can assist nurses and midwives to provide quality care with accurate information and up-to-date information. I think it gives the patient an opportunity to speak up . . . like something that they may not have thought was relevant, [or] they might not have wanted to bother anybody . . . It gives them an opportunity to contribute to their care . . . they know better than anybody how they are feeling (R5). . . . often they’ll bring up little things that they may not have done otherwise, because they feel safe discussing them with you and reviewing things that they may not have done otherwise (M9). Handover at the bedside was also seen as opportunity for visitors (e.g. family, next of kin) to provide additional information about the patient and/or their condition; in particular, patients with cognitive or neurological impairment who are unable to communicate effectively, patients who are for palliative care, and for those patients who do not speak English. In particular, the ability of visitors to translate was seen as major advantage of BHO. Moreover, some participants raised concerns that not all patients use the opportunity to be involved in the handover conversation, and this was a missed opportunity. Recommendations were made for the patient to be educated on hospital admission about the BHO process: © 2013 Wiley Publishing Asia Pty Ltd
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I think that they should be more involved. I think that they should speak up and say ‘oh yeah well actually . . . this happened’ or ‘I didn’t tell the nurse this shift but this was going on’ . . . I think they . . . need . . . education about the handover process as well (RN6).
Theme 2: Discretion to protect confidentiality and privacy Participants of this study outlined ways in which they used discretion to protect patient’s confidentiality and privacy. Two subthemes were identified: ‘Concerns about privacy and confidentiality’ and ‘Strategies to prevent disclosure of private and sensitive information’. There were ‘Concerns about privacy and confidentiality’ of patient information disclosed during BHO, especially that of a private (e.g. palliative care, cancer diagnosis) or sensitive (e.g. blood-borne virus infection, drug and alcohol history) nature. Specifically, concerns were raised that other patients and visitors in the same room can hear patient information. Participants described the way in which they applied various strategies to ensure discretion to protect their confidentiality and privacy. I feel there’s a privacy issue, saying everything out loud. I try to speak quietly but curtains aren’t soundproof. I don’t like that . . . I had a patient with [cancer] that’s not aware . . . So you have to step out into the hallway afterwards . . . then you’ve got to whisper it . . . I feel that it’s such private information, I don’t want to just whisper it out in the hallway, I wish there was a better way I could do that (RN18). In the maternity ward, specific issues were raised about BHO. Usually during the events of celebration, maternity patients tend to receive more visitors compared with other areas of the hospital. In the view of participants, this compounded issues of confidentiality and privacy and handover interruptions. Some of the information we deal with in maternity is more sensitive than in other settings. We’re talking about their . . . genital tracts, we’re talking about their breasts. We’re talking about sexually transmitted infections and drug use (M8). Participants discussed their strategies for managing issues of confidentiality and privacy including pointing at important information in the patient’s chart, speaking
Bedside handover—professional opinions
quietly, disclosing sensitive or private information outside the patient’s room, and asking visitors to leave.
DISCUSSION This study has identified that standards of patient care and nursing and midwifery documentation, in addition to continuity of care, improved after the introduction of BHO. Opportunities for the patient to be included in handover strengthened clinician–patient partnerships. Over time, there is a belief that the quality of BHO improved with added confidence and practice, which could be further supported with additional training and standardized tools. Nurses and midwives remain concerned, however, about how to deal with private and sensitive information. Participants in this study believed that early visualization of the patient enabled them to provide a more comprehensive assessment of their patient. Being able to read charts and documentation at the commencement of the shift leads to the identification of missing information or clarification of nursing or midwifery care for the staff involved. As a consequence, the handover practice becomes less subjective and more data-driven with pertinent information exchanged that is reliable and valid. Our findings are similar to Chaboyer et al.24 who reported that nurses perceived improved accuracy and service delivery improvements after the introduction of BHO. Anderson and Mangino20 also found increased accountability by nursing staff attributed directly to BHO reporting. In their study, they also reported increased physician satisfaction with more informed nurses. Nurses and midwives of this study identified that BHO provides an opportunity for patients to contribute to their care. First, the patient and their next of kin can clarify and provide additional information. This has the potential to enhance nursing care and documentation, which may lead to improvements in clinical outcomes and reduction of adverse outcomes. Second, BHO provided an opportunity for patients to communicate their needs. This information aids the nurse and midwife in planning for the forthcoming shift. Although the concept of involving patients in their health care has been widely accepted in the clinical arena, it is not generally implemented in handover practice. This study further confirmed a notion that BHO provides a real platform for patients’ participation.
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Recently, there has been a swell of support for inclusion of the patient in handover practice. In Australia, NSW Health29 strongly advocate that clinical handover is in front of the patient. Dufault et al.30 recommend bedside rounds that include the patient. In a study comparing nurse and patient perceptions of clinical decision-making, Florin et al.31 found that nurses do not successfully involve patients in decisions regarding their care. They recommend careful assessment of patient preferences regarding their willingness to participate in decision-making. This strategy is in alignment with recommendations by McMurray et al.23 that while some patients appreciate the inclusive approach of handover, others prefer passive engagement. In a mixed methods study, Chin et al.32 explored 30 women’s perceptions of safety and quality of maternity clinical handover. Handover provided positive reassurance to women of clinician awareness of their information, teamwork, care and communication. Concerns about confidentiality and privacy of patient information were raised by participants of this study. To deal with these concerns, various strategies are implemented by nurses and midwives. However, some research suggests that patients are less concerned than nurses regarding this issue. In a small study of 10 patients, McMurray et al.19 found that patients were more concerned about mixed gender accommodation than sensitivity of information in a four-bed room. This study was limited to three ward settings and a purposive sample of 30 participants. Therefore, findings will not be generalized. Nevertheless, the findings may still be transferable to similar clinical settings considering that comparable findings have been reported in Australia.19,24 Despite favourable attitudes regarding enhanced patient care in acute and maternity settings, this study did not measure for improvements in patient care. This is an area in need of further research. In conclusion, nurses and midwives of this study perceived enhanced patient care, and nursing and midwifery documentation, and strengthened clinician–patient partnerships after the introduction of BHO. The study has highlighted the importance of specific training to enable confident and competent delivery of handover practice. Further work is required to evaluate whether patient outcomes are improved as a result of the introduction of BHO. Evidence of enhanced patient care may encourage endorsement of BHO as the preferred handover practice in other clinical settings in the future. © 2013 Wiley Publishing Asia Pty Ltd
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ACKNOWLEDGEMENTS The authors would like to acknowledge the clinicians who participated in this study and Victoria University for funding this project. Sincere thanks are extended to Leanne Rhodes who recruited all participants and conducted the interviews, and to the Unit Managers (Jenny Tenni, Justine Mizen, Carla McCarthy) who supported the study.
REFERENCES 1 World Health Organisation. Communication during patient handovers. Patient Safety Solutions 2007; 1: 1–4. 2 Junior Doctors Committee, National Patient Safety Agency, Modernisation Agency. Safe Handover: Safe Patients. Guidance on Clinical Handover for Clinicians and Managers. London: British Medical Association, 2006. 3 Haig KM, Sutton S, Whittington J. SBAR: A shared mental model for improving communication between clinicians. Joint Commission Journal on Quality and Patient Safety 2006; 32: 167–175. 4 The Joint Commission. Joint Commission on Accreditation of Healthcare Organisations (JCAHO), 2003. Available from URL: http://www.jointcommission.org/SentinelEvents/ Statistics. Accessed 21 September 2012. 5 Department of Human Services Victoria. Sentinel event program: Annual report 2006–07. Melbourne: State of Victoria, Department of Human Services, 2007. 6 Department of Health Western Australia (WA Health). Delivering safer health care in Western Australia: WA Sentinel Event Report 2006–2007. Perth: Department of Health, 2007. 7 Zinn C. 14 000 preventable deaths in Australia. British Medical Journal 1995; 310: 1487. 8 Sexton A, Chan C, Elliott M, Stuart J, Jayasuriya R, Crookes P. Nursing handovers: Do we really need them? Journal of Nursing Management 2004; 12: 37–42. 9 Benson E, Rippen-Sisler C, Jabusch K, Keast S. Improving nursing shift-to-shift report. Journal of Nursing Care Quality 2007; 22: 80–84. 10 Davies S, Priestly MJ. A reflective evaluation of patient handover practices. Nursing Standard 2006; 20: 49–52. 11 Baldwin L, McGinnis C. A computer-generated shift report. Nursing Management 1994; 25: 61–64. 12 Evans AM, Pereira DA, Parker JM. Discourses of anxiety in nursing practice: A psychoanalytic case study of the change-of-shift handover ritual. Nursing Inquiry 2008; 15: 40–48. 13 Australian Commission On Safety and Quality In Health Care. The Ossie Guide to Clinical Handover Improvement, 1st edn. Sydney, Australia: ACSQHC, 2010.
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14 Haikerwal M, Dobb G, Ahmed T. Safe Handover: Safe patients. AMA Clinical Handover Guide. Guidance on Clinical Handover for Clinicians and Managers. Australia: Australian Medical Association Ltd, 2006; 1–47. 15 Arora VM, Johnson JK, Meltzer DO, Humphrey HJ. A theoretical framework and competency-based approach to improving handoffs. Quality and Safety in Health Care 2008; 17: 11–14. 16 Catchpole KR, de Leval MR, McEwan A et al. Patient handover from surgery to intensive care: Using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatric Anesthesia 2007; 17: 470–478. 17 Simpson K. Perinatal patient safety: Handling handoffs safely. American Journal of Maternal/Child Nursing 2005; 30: 152. 18 Wilson R. Reducing Risk by Moving Clinical Handover to the Bedside, 2008. Available from URL: http://www .archi.net.au/resources/safety/clinical/clinical-handover. Accessed 20 May 2011. 19 McMurray A, Chaboyer W, Wallis M, Fetherston C. Implementing bedside handover: Strategies for change management. Journal of Clinical Nursing 2010; 19: 2580– 2589. 20 Anderson CD, Mangino RR. Nurse shift report: Who says you can’t talk in front of the patient? Nursing Administration Quarterly 2006; 30: 112–122. 21 Cahill J. Patient’s perceptions of bedside handovers. Journal of Clinical Nursing 1998; 7: 351–359. 22 Kassean HK, Jagoo ZB. Managing change in the nursing handover from traditional to bedside handover—a case study from Mauritius. BMC Nursing 2005; 4: 1–6. 23 McMurray A, Chaboyer W, Wallis M, Johnson J, Gehrke T. Patients’ perspectives of bedside nursing handover. Collegian 2011; 18: 19–26. 24 Chaboyer W, McMurray A, Wallis M. Bedside nursing handover: A case study. International Journal of Nursing Practice 2010; 16: 27–34. 25 Webster J. Practitioner-centred research: An evaluation of the implementation of the bedside hand-over. Journal of Advanced Nursing 1999; 30: 1375–1382. 26 Neergaard MA, Olesen F, Andersen RS, Sondergaard J. Qualitative description—the poor cousin of health research? BMC Medical Research Methodology 2009; 9: 52. 27 Sandelowski M. Whatever happened to qualitative description? Research in Nursing & Health 2000; 23: 334– 340. 28 Smith J, Osborn M. Interpretative phenomenological analysis. In: Smith JA (ed.). Qualitative Psychology. A Practical Guide to Research Methods, 2nd edn. London: Sage, 2008; 51–80. 29 NSW Department of Health. Implementation Toolkit: Standard Key Principles for Clinical Handover, 2011. Available from
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URL: http://www.archi.net.au/documents/resources/ qs/clinical/clinical-handover/implementation-toolkit.pdf. Accessed 8 November 2011. 30 Dufault M, Duquette CE, Ehmann J et al. Translating an evidence-based protocol for nurse-to-nurse shift handoffs. Worldviews on Evidence Based Nursing 2010; 7: 59–75.
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31 Florin J, Ehrenberg A, Ehnfors M. Patient participation in clinical decision-making in nursing: A comparative study of nurses’ and patients’ perceptions. Journal of Clinical Nursing 2006; 15: 1498–1508. 32 Chin GS, Warren N, Kornman L, Cameron P. Patients’ perceptions of safety and quality of maternity clinical handover. BMC Pregnancy and Childbirth 2011; 11: 58.
© 2013 Wiley Publishing Asia Pty Ltd
International Journal of Nursing Practice 2014; 20: 250–257
RESEARCH PAPER
Towards patient-centred care: Perspectives of nurses and midwives regarding shift-to-shift bedside handover Debra Kerr RN BN MBL GradCert ClinResMeth GradCert Tertiary Ed PhD Senior Lecturer, Honours Coordinator, Victoria University, St Albans, Victoria, Australia
Sai Lu MBBS PhD Lecturer, Victoria University, St Albans, Victoria, Australia
Louise McKinlay BN Manager, Centre of Education, Western Health, Footscray, Victoria, Australia
Accepted for publication January 2013 Kerr D, Lu S, McKinlay L. International Journal of Nursing Practice 2014; 20: 250–257 Towards patient-centred care: Perspectives of nurses and midwives regarding shift-to-shift bedside handover The aim of this descriptive qualitative study was to explore perspectives of nurses and midwives towards the introduction of shift-to-shift bedside handover. Semistructured interviews with nurses (n = 20) and midwives (n = 10) occurred 12 months after the introduction of bedside handover. Data were analyzed using thematic content analysis. Two main themes were identified: enhanced individual patient care and documentation, along with improved patient–clinician partnerships; and protection of confidentiality and privacy. The newly introduced bedside handover model improved efficiency and accuracy of the handover process and led to the provision of safe, high-quality care. Development of ward-specific tools and relevant educational resources, along with clinical support, are identified as the facilitators to ensure the new model can be successfully integrated into normal clinical practice. Key words: bedside handover, hospital care, midwife, nurse–patient partnership, patient-centred care.
INTRODUCTION Correspondence: Debra Kerr, Victoria University, Building 4, Room 4C211, McKechnie St, St Albans, Vic. 3021, Australia. Email: [email protected] Support: An internal university grant of AUD$25 000 supported the conduct of this study. Contributions Conception and design: DK, SL, LM; Analysis and Interpretation of data: DK, SL, LM; Drafting the article: DK, SL, LM; Final approval of the version to be published: DK, SL, LM. © 2013 Wiley Publishing Asia Pty Ltd
Effective communication of health-care information from one health-care professional to another, normally achieved by handover, is pivotal to ensuring patient care continuity and safety.1 As a result of handover, there is a transfer of professional responsibility and accountability in aspects of care for an individual or group of patients.2 In the inpatient setting, nurses and midwives conduct handover to convey pertinent patient information to staff on an incoming shift. Unfortunately, handover is considered a ‘high-risk activity that can be associated with serious doi:10.1111/ijn.12138
Bedside handover—professional opinions
adverse events due to poor communication and inaccurate or lacking information’.3 Ineffective handover is known to account for almost 70% of all sentinel events reported in the USA.4 Breakdown in communication between healthcare professionals was also identified as one of the major contributors to nearly one-quarter of adverse events in the states of Victoria5 and Western Australia.6 Analysis of 25 000 to 30 000 preventable adverse events in Australia found that 11% were due to communication issues.7 In a nursing study, Sexton et al.8 found that communication during handover contributed to confusion and did not clarify issues about patient status, treatments and management. Numerous barriers to effective handover have been acknowledged including informal structure,9,10 unnecessary content,10 lengthy duration11 and lack of confidence.12 There have been efforts at a national and international level to improve the quality of clinical handover by healthcare professionals.1,13,14 Known strategies for enhancing the effectiveness of handover include focus on patient safety,15 standardization,13 effective leadership,16 skilful communication15,17 and updated documentation.18 Attempts to address system-based problems that may impact on health-care outcomes have led to research in alternative modes of handover. Handover performed at the bedside, frequently referred to as ‘bedside handover’ (BHO), is one of them. According to McMurray et al.,19 BHO is based on patient-centred care, which is fostered by communication of relevant and timely information to enhance care planning in collaboration with the patient. In their opinion, patient input has the potential to ‘reduce care fragmentation, miscommunication-related adverse events, readmissions, duplication of services and enhance satisfaction and continuity of care’.19 (p. 2580). The involvement of patients and their respective families in the process of health care is recognized as an important aspect of care. According to a World Health Organization report,1 the patient and their respective family are likely to be the only constant variable during a hospital episode, who have the potential to ensure continuity of care. There is growing evidence of support from the patient’s perspective for BHO.20–23 In Australia, nurses’ opinions about BHO have been reported in two separate papers. McMurray et al.19 identified five themes including ‘being part of the big picture’, ‘linking the project to standardisation initiatives’, ‘reassurance on safety and quality’, ‘smoothing out logistical difficulties’ and ‘learning to listen’. Chaboyer et al.24
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reported key issues including improved accuracy in communication between nurses and promotion of patientcentred care. In Arizona (USA), Anderson and Mangino20 investigated the impact of BHO in an adult acute care unit. They reported increased accountability, interpersonal satisfaction and receipt of important information for registered nursing staff. In an action research study, Webster25 found that 12 months after implementation, nursing staff favoured BHO compared with the ‘traditional’ model. Nurses preferred the focus towards meaningful and relevant nursing needs, including nursing documentation, rather than medical information. BHO was introduced in the organization in which this study was conducted in August 2010 as part of a structured program that included ward-based coordination by a project manager in an 8-week period, development of ward-specific tools and individual education sessions. There are few in-depth studies on the experiences and opinions of clinicians towards BHO, in particular in the maternity context. The aim of this study was to explore perspectives of nurses and midwives towards the introduction of BHO in the clinical setting.
METHODS Design Data collection and analysis were informed by a qualitative descriptive method.26,27 Using qualitative description, accounts of the phenomena are usually captured by structured interviews or focus groups, and further analysis aims to gain knowledge of professionals’ experience with a topic. The purpose of this study was to explore the subjective experiences and viewpoints of the nurse and midwife participants. Data collection and analysis focused on the perceived benefits and limitations of BHO and impact on patient-centred care from their perspective.
Sample A purposive sample included nurses and midwives employed on one of the three wards in which BHO was introduced. A broad sample was sought to gain wide variation of opinion to maximize insight into the issue.26 The study was promoted verbally via ward in-service meetings and an information form was distributed to all staff. To be eligible, nurses and midwives were required to be permanently employed in each respective ward prior to the introduction of BHO. Those who were keen to participate approached the research assistant and provided written consent prior to the interview. © 2013 Wiley Publishing Asia Pty Ltd
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Table 1 Interview schedule23,24 Were you in favour of the introduction of bedside handover? What do you think about nurses and midwives undertaking shift-to-shift handover at the bedside? From your perspective, what are some of the benefits of bedside handover? What are some of the limitations of bedside handover? Did the introduction of bedside handover have an impact on your nursing or midwifery practice? Do you think that a patient has a role in bedside handover? If yes, how do you currently include the patient’s input or opinions in handover? What do you think the role of a patient could be in the bedside handover (i.e. how do you think they should/could participate)? How do you deal with the presence of family members? What role do you think family members might have in bedside handover? Do you think that bedside handover compromises the patient’s privacy or confidentiality? What strategies do you have for maintaining patient privacy in multiple bed rooms? Are there topics you think should be excluded from the bedside handover? If so, what are they? Is there any extra information you think should be included in the bedside handover? Overall, how do you think that bedside handover could be improved?
Procedure
Data analysis
Taped semistructured interviews were conducted in August 2011, approximately 12 months after the introduction of BHO in each ward. An open-ended interview schedule (Table 1), based on previous case study research,23,24 was used. Questions included risks, benefits, and limitations of BHO. In addition, opinion was sought regarding the perceived impact on patient-centred care and how to improve BHO practice. In contrast to other qualitative methods that strive for thick description (ethnography), theory development (grounded theory) or interpretation (phenomenology), in qualitative descriptive methods, the researcher aims to describe the experience in the participants’ own language. Hence, the interview schedule was slightly more structured than is usually found in other qualitative methods.26 Issues raised in the interview could be further explored and probed at that time by the interviewer. The one-on-one taped interview was performed in a private office of each ward at a mutually agreeable time. Data were collected by one trained research assistant, a registered nurse. Interviews lasted approximately 30 min in duration.
After taped interviews were transcribed, thematic content analysis was performed as described by Smith and Osborn.28 First, the whole transcript was read and reread several times to gain a general sense of the overall accounts. Second, transcripts were examined using lineby-line analysis. Notes indicating striking issues were made in the margins as a form of coding, with the development of themes to reflect the researcher’s interpretation of the data. Third, themes were clustered together and redeveloped as main themes and subthemes. Themes not supported by sufficient data were omitted. In the final stage, themes and subthemes were tabulated in a summary table after careful scrutiny for clarity and order. This process was followed by a second researcher who independently identified themes and subthemes. After a period of time to allow for reflection and re-examination of the transcripts, a consensus meeting was held with all investigators to reach a joint thematic framework regarding the themes and subthemes. Trustworthiness of the data was maintained by appropriate sample selection and an audit trail to demonstrate systematic documentation, data collection and analysis.
Ethical considerations Ethics approval was obtained from the institutional ethics panel. Emphasis was placed on voluntary participation; hence, all participants gave written informed consent. In addition, data were managed in a confidential manner. © 2013 Wiley Publishing Asia Pty Ltd
RESULTS There were 30 participants in this study: 25 women and 5 men. For the medical and surgical wards, 20 nurses were interviewed; and for the maternity ward, 10 midwives
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Table 2 Employment categories Employment category
n
%
Enrolled Nurse Registered Nurse Midwife Clinical Nurse Specialist—Registered Nurse Clinical Nurse Specialist—Midwife Associate Nurse Unit Manager—Registered Nurse Associate Nurse Unit Manager—Midwife Total
3 13 7 2 2 2 1 30
10.0 43.3 23.3 6.7 6.7 6.7 3.3
were interviewed. Employment categories for the participants ranged from enrolled nurse to unit manager, as shown in Table 2. Two main themes emerged from the data: ‘Enhanced care and documentation’ and ‘Discretion to protect confidentiality and privacy’.
Theme 1: Enhanced care and documentation Overall, nurses and midwives believed that the standard of care and documentation had improved as a direct result of BHO, articulated in three subthemes: ‘Enhanced Continuity of Care’, ‘Improved Nursing and Midwifery Documentation’ and ‘Strengthened Healthcare Partnership’. There was a general consensus that BHO enabled early visualization of patients and their charts as well as detailed and focused information transfer. All of these facilitated better clinical judgements and decision-making that ultimately led to ‘Enhanced Continuity of Care’. Visualization of patients and their charts at the beginning of the shift was seen as an ideal opportunity to confirm whether certain clinical tasks had been completed: . . . just having a good look at your patient at the beginning of your shift. So you have an idea of everyone’s status right at the beginning as opposed to starting a shift and then getting caught up with doing other stuff and then it might be an hour or so before you actually lay eyes on your patient to find that they are acutely unwell (RN5). . . . you can check the charts with the person who’s looked after the patient before you. So if there are any problems you can sort them out straight away (RN8). Explicit and detailed information received during individual BHO provided nurses and midwives of the
oncoming shift provision of adequate information to deliver continued care. Participants valued the opportunity to view the charts at shift commencement to confirm that certain activities had been completed such as medications administered and documented appropriately and fluid balance charts kept up to date. This allowed them to thoroughly plan for the forthcoming shift: . . . you get a lot more detailed information about your set of patients which is really helpful in terms of understanding what they’ve done for the day and what needs to be done . . . it helps you better care (RN11). I think the positives are you get a lot more detailed information about your set of patients which is really helpful in terms of understanding what they’ve done for the day and what needs to be done (RN3). Many participants reported that they were paying more attention to completion of their nursing or midwifery responsibilities and documentation before handover commenced to prevent embarrassment due to identification of incomplete documentation. They considered that this had resulted in improved nursing and midwifery documentation. . . . it does motivate you more to make sure you get everything done so that handover does sort of follow through more smoothly . . . it obviously goes more smoothly if you’ve tried to at least do as many things as you can, so that when you go through the charts you can say, ‘I’ve done this, I’ve given this’ (RN16). . . . it makes people more accountable . . . so you actually work a bit more efficiently because you know when you’ve got to do that handover that that paperwork is going to be checked and you want to make sure it’s accurate (M9). In general, nurses and midwives believed BHO led to better communication. They expressed that they had more confidence in the process of this new type of handover practice as there was an opportunity to ask questions and clarify issues.
I think it has reduced the number of errors or missed medication . . . and it provides an opportunity to pick up things (RN5). © 2013 Wiley Publishing Asia Pty Ltd
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. . . better than the handover in the office because you find out more things and then you can query things . . . (RN17). Interestingly, in comparison with BHO, some nurses reflected on their inability to concentrate during the traditional mode of handover, which used to involve a large number of patients. . . . I know that it is very hard to concentrate on 20 patients at the general handover. It’s much easier to concentrate on just the four that you know you are going to give complete care to (RN2). Previous handover was long and not relevant to the group as a whole. The whole group didn’t need to know a lot of information that was being hand over. A lot of important information was being left out (RN5). Participants expressed the view that BHO helped to strengthen the health-care partnership between the nurse or midwife and the patient. By clarifying their own condition and plan, patients can assist nurses and midwives to provide quality care with accurate information and up-to-date information. I think it gives the patient an opportunity to speak up . . . like something that they may not have thought was relevant, [or] they might not have wanted to bother anybody . . . It gives them an opportunity to contribute to their care . . . they know better than anybody how they are feeling (R5). . . . often they’ll bring up little things that they may not have done otherwise, because they feel safe discussing them with you and reviewing things that they may not have done otherwise (M9). Handover at the bedside was also seen as opportunity for visitors (e.g. family, next of kin) to provide additional information about the patient and/or their condition; in particular, patients with cognitive or neurological impairment who are unable to communicate effectively, patients who are for palliative care, and for those patients who do not speak English. In particular, the ability of visitors to translate was seen as major advantage of BHO. Moreover, some participants raised concerns that not all patients use the opportunity to be involved in the handover conversation, and this was a missed opportunity. Recommendations were made for the patient to be educated on hospital admission about the BHO process: © 2013 Wiley Publishing Asia Pty Ltd
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I think that they should be more involved. I think that they should speak up and say ‘oh yeah well actually . . . this happened’ or ‘I didn’t tell the nurse this shift but this was going on’ . . . I think they . . . need . . . education about the handover process as well (RN6).
Theme 2: Discretion to protect confidentiality and privacy Participants of this study outlined ways in which they used discretion to protect patient’s confidentiality and privacy. Two subthemes were identified: ‘Concerns about privacy and confidentiality’ and ‘Strategies to prevent disclosure of private and sensitive information’. There were ‘Concerns about privacy and confidentiality’ of patient information disclosed during BHO, especially that of a private (e.g. palliative care, cancer diagnosis) or sensitive (e.g. blood-borne virus infection, drug and alcohol history) nature. Specifically, concerns were raised that other patients and visitors in the same room can hear patient information. Participants described the way in which they applied various strategies to ensure discretion to protect their confidentiality and privacy. I feel there’s a privacy issue, saying everything out loud. I try to speak quietly but curtains aren’t soundproof. I don’t like that . . . I had a patient with [cancer] that’s not aware . . . So you have to step out into the hallway afterwards . . . then you’ve got to whisper it . . . I feel that it’s such private information, I don’t want to just whisper it out in the hallway, I wish there was a better way I could do that (RN18). In the maternity ward, specific issues were raised about BHO. Usually during the events of celebration, maternity patients tend to receive more visitors compared with other areas of the hospital. In the view of participants, this compounded issues of confidentiality and privacy and handover interruptions. Some of the information we deal with in maternity is more sensitive than in other settings. We’re talking about their . . . genital tracts, we’re talking about their breasts. We’re talking about sexually transmitted infections and drug use (M8). Participants discussed their strategies for managing issues of confidentiality and privacy including pointing at important information in the patient’s chart, speaking
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quietly, disclosing sensitive or private information outside the patient’s room, and asking visitors to leave.
DISCUSSION This study has identified that standards of patient care and nursing and midwifery documentation, in addition to continuity of care, improved after the introduction of BHO. Opportunities for the patient to be included in handover strengthened clinician–patient partnerships. Over time, there is a belief that the quality of BHO improved with added confidence and practice, which could be further supported with additional training and standardized tools. Nurses and midwives remain concerned, however, about how to deal with private and sensitive information. Participants in this study believed that early visualization of the patient enabled them to provide a more comprehensive assessment of their patient. Being able to read charts and documentation at the commencement of the shift leads to the identification of missing information or clarification of nursing or midwifery care for the staff involved. As a consequence, the handover practice becomes less subjective and more data-driven with pertinent information exchanged that is reliable and valid. Our findings are similar to Chaboyer et al.24 who reported that nurses perceived improved accuracy and service delivery improvements after the introduction of BHO. Anderson and Mangino20 also found increased accountability by nursing staff attributed directly to BHO reporting. In their study, they also reported increased physician satisfaction with more informed nurses. Nurses and midwives of this study identified that BHO provides an opportunity for patients to contribute to their care. First, the patient and their next of kin can clarify and provide additional information. This has the potential to enhance nursing care and documentation, which may lead to improvements in clinical outcomes and reduction of adverse outcomes. Second, BHO provided an opportunity for patients to communicate their needs. This information aids the nurse and midwife in planning for the forthcoming shift. Although the concept of involving patients in their health care has been widely accepted in the clinical arena, it is not generally implemented in handover practice. This study further confirmed a notion that BHO provides a real platform for patients’ participation.
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Recently, there has been a swell of support for inclusion of the patient in handover practice. In Australia, NSW Health29 strongly advocate that clinical handover is in front of the patient. Dufault et al.30 recommend bedside rounds that include the patient. In a study comparing nurse and patient perceptions of clinical decision-making, Florin et al.31 found that nurses do not successfully involve patients in decisions regarding their care. They recommend careful assessment of patient preferences regarding their willingness to participate in decision-making. This strategy is in alignment with recommendations by McMurray et al.23 that while some patients appreciate the inclusive approach of handover, others prefer passive engagement. In a mixed methods study, Chin et al.32 explored 30 women’s perceptions of safety and quality of maternity clinical handover. Handover provided positive reassurance to women of clinician awareness of their information, teamwork, care and communication. Concerns about confidentiality and privacy of patient information were raised by participants of this study. To deal with these concerns, various strategies are implemented by nurses and midwives. However, some research suggests that patients are less concerned than nurses regarding this issue. In a small study of 10 patients, McMurray et al.19 found that patients were more concerned about mixed gender accommodation than sensitivity of information in a four-bed room. This study was limited to three ward settings and a purposive sample of 30 participants. Therefore, findings will not be generalized. Nevertheless, the findings may still be transferable to similar clinical settings considering that comparable findings have been reported in Australia.19,24 Despite favourable attitudes regarding enhanced patient care in acute and maternity settings, this study did not measure for improvements in patient care. This is an area in need of further research. In conclusion, nurses and midwives of this study perceived enhanced patient care, and nursing and midwifery documentation, and strengthened clinician–patient partnerships after the introduction of BHO. The study has highlighted the importance of specific training to enable confident and competent delivery of handover practice. Further work is required to evaluate whether patient outcomes are improved as a result of the introduction of BHO. Evidence of enhanced patient care may encourage endorsement of BHO as the preferred handover practice in other clinical settings in the future. © 2013 Wiley Publishing Asia Pty Ltd
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ACKNOWLEDGEMENTS The authors would like to acknowledge the clinicians who participated in this study and Victoria University for funding this project. Sincere thanks are extended to Leanne Rhodes who recruited all participants and conducted the interviews, and to the Unit Managers (Jenny Tenni, Justine Mizen, Carla McCarthy) who supported the study.
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