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Patients experiences of bedside handover: findings from a meta‐ synthesis. Bressan, Valentina; Cadorin, Lucia; Stevanin, Simone; Palese, Alvisa School of Nursing, Department of Medical Sciences, University of Udine, Udine Italy Continuing Education Centre, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano – Pordenone Italy Agency for Health and Social Care, Veneto Region Italy Scandinavian Journal of Caring Sciences (SCAND J CARING SCI), Sep2019; 33(3): 556-568. (13p) Article - research, systematic review, tables/charts, meta synthesis English Patient Attitudes -- Evaluation Shift Reports Hand Off (Patient Safety) Human; Meta Synthesis; Quality Assessment; Thematic Analysis; Qualitative Studies; PubMed; CINAHL Database; Psycinfo; Nursing Care; Patient Rights; Consumer Participation; Nurses; Patient Safety; Systematic Review; Clinical Assessment Tools; Male; Female; Middle Age; Aged; Aged, 80 and Over; Adult; Emotions Background: Bedside shift reports have been recently recommended to ensure handovers. However, no evidence summarising studies designed to determine the qualitative approaches capable of better understanding patient experience have been published to date. Aim: The aim of this study was to acquire a deeper understanding of the experiences of patients regarding bedside shift reports. Data sources and review methods: A systematic review of qualitative studies followed by a meta‐ synthesis method based upon Sandelowski's and Barroso's guidelines was performed. Four databases were systematically explored (PubMed, CINAHL, Scopus and PsycINFO) without any limitation in time and up to the 31 August 2018. A total of 10 studies were included and evaluated in their methodological quality; then, a thematic synthesis was developed to synthetize the findings.
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Results: Three major themes reflect patients' experience regarding the bedside shift reports: (i) 'Being involved'; (ii) 'Being the centre of nursing care processes'; and (iii) 'Experiencing critical issues'. Patients are supportive of bedside shift reports as a right, as an opportunity to be involved, and of being in the centre of the nursing care process. By designing and implementing bedside shift reports, nurses also have an opportunity to increase patient safety and to provide concrete proof of the advancements achieved by the nursing profession in recent years. Conclusions: The bedside shift reports experience has been little studied to date from the perspective of patients. According to the findings, implementation of the bedside shift reports should include providing education to nurses with regard to the preferences and expectations of patients, as well as the critical issues that they can experience during the bedside shift reports. Presenting the bedside shift reports method, asking patient consent, discussing potential critical issues and the degree of involvement preferred at hospital admission, is strongly recommended. Continental Europe; Core Nursing; Europe; Nursing; Peer Reviewed Evidence-Based Practice Critical Appraisal Skills Programme (CASP) 0283-9318 NLM UID: 8804206 20190913 20200831 10.1111/scs.12673 138540679 CINAHL Plus with Full Text
Patients experiences of bedside handover: findings from a meta‐synthesis
Background: Bedside shift reports have been recently recommended to ensure handovers. However, no evidence summarising studies designed to determine the qualitative approaches capable of better understanding patient experience have been published to date. Aim: The aim of this study was to acquire a deeper understanding of the experiences of patients regarding bedside shift reports. Data sources and review methods: A systematic review of qualitative studies followed by a meta‐synthesis method based
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upon Sandelowski's and Barroso's guidelines was performed. Four databases were systematically explored (PubMed, CINAHL, Scopus and PsycINFO) without any limitation in time and up to the 31 August 2018. A total of 10 studies were included and evaluated in their methodological quality; then, a thematic synthesis was developed to synthetize the findings. Results: Three major themes reflect patients' experience regarding the bedside shift reports: (i) 'Being involved'; (ii) 'Being the centre of nursing care processes'; and (iii) 'Experiencing critical issues'. Patients are supportive of bedside shift reports as a right, as an opportunity to be involved, and of being in the centre of the nursing care process. By designing and implementing bedside shift reports, nurses also have an opportunity to increase patient safety and to provide concrete proof of the advancements achieved by the nursing profession in recent years. Conclusions: The bedside shift reports experience has been little studied to date from the perspective of patients. According to the findings, implementation of the bedside shift reports should include providing education to nurses with regard to the preferences and expectations of patients, as well as the critical issues that they can experience during the bedside shift reports. Presenting the bedside shift reports method, asking patient consent, discussing potential critical issues and the degree of involvement preferred at hospital admission, is strongly recommended.
Keywords: bedside handover; bedside shift report; literature review; meta‐synthesis; nursing; patient experience; systematic qualitative review; thematic synthesis
Introduction Shift handover has been defined as the process of transferring authority and responsibility of a patient between two or more healthcare professionals [ 1]. It is considered a basic component of healthcare organisations due to its influence on the quality of care and consequent patient safety and clinical outcomes [ 2]. Different shift handover methods have been documented to date, and above all, bedside shift reports (BSRs) have been considered as one of the best due to their capacity to increase patient safety, their centred care approach [[ 3]], satisfaction for both patients and nurses, and decreased miscommunication, errors [[ 5]], and costs [[ 6]].
The BSR occurs when the handover shift report between the off‐going nurse and the incoming nurse takes place at the patient bedside [ 3]; it requires a face‐to‐face interaction between two or more nurses, involving the patient as an active member of the process [ 8]. Even if currently no BSR gold standard has been defined, its key components have been identified in the following elements: (i) participants in the process and their role (e.g., nurses, other staff members, patients' relatives); (ii) where and when the BSR occurs (e.g., in the patient's room, in a dedicated meeting room); (iii) the nature of the information shared (e.g., patient's medical history, nursing care plan) and how (e.g., verbally, through a checklist, mnemonics) [Forde et al. [ 9]. Moreover, according to Chaboyer et al. [10] five steps are required to guarantee a good BSR practice: the first step is preparatory, and usually includes staff and patient's allocation and an update of patient's information and care documents. In the second step, outgoing nurse(s) introduce oncoming staff and patients; then, in the third step, information is exchanged through
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different strategies, such as face‐to‐face communication, patients' care records, staff questions and clarifications answers to patients. In fact, in order to improve the quality and the accuracy of handover contents, patients should be invited to comment or to ask questions during the fourth step of the BSR process; in the fifth and final step, a safety check of patients' conditions, environment and equipment should be performed by oncoming nurses [10].
To date, several reviews and primary studies have documented the advantages and implications of the BSR on the quality of care and patients' involvement [e.g., Mardis et al. [ 6]; Tobiano et al. [11]; Ford and Heyman [12]; Whitty et al. [13]]. However, despite the documented positive outcomes of the BSR, clinical nurses have been reported to not always adopt it as a standard method to transfer clinical data for different reasons, including the fear of threatening confidentiality [[14]], of speaking in front of patients, and/or the increased time required to perform shift reports [18]. Furthermore, the available evidence has been derived from quantitative studies [e.g., Sand‐Jecklin and Sherman [16]; Wakefield et al. [17]]; only a few qualitative studies have investigated patients' BSR experiences. Exploring and better understanding patients' feelings and thoughts [19] regarding the BSR can help identify the principles that should be considered in designing and implementing the BSR in an attempt to respectfully consider the preferences and values of the patients and their relatives. Thus, a meta‐synthesis was designed to identify and summarise qualitative studies that have explored to date patients' experience of the BSR.
The review
Aim The aim of this study was to acquire a deeper understanding of the experiences of patients regarding the BSR. The main research question was as follows: 'What is the experience of patients involved in hospital BSRs?'
Design A systematic review [20] followed by a meta‐synthesis [21] was adopted to analytically summarise the findings of qualitative studies available in the field. As reported by Sandelowski and Barroso [21], the meta‐synthesis represents an interpretative integration of results that emerge from qualitative studies, allowing a novel interpretation and exploration of a phenomenon through the lens of the participants directly involved. According to Thomas and Harden [22], the methodology synthesis adopted in this study was based on thematic synthesis. The methods and findings have been reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines as well [23].
Search methods The pre‐planned review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement [24], and the Sandelowski and Barroso qualitative research synthesis process [21]. Inclusion criteria were applied in the selection of (i) primary qualitative
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studies, (ii) studies which explored the perceptions and experiences of adult (>18 years) patients regarding BSR(s), (iii) studies published in English and (iv) studies with abstracts available. Moreover, qualitative data from mixed‐method studies were included, if distinguished; in addition, to guarantee that all relevant studies were included, no limitations in time have been applied on all potential studies published before 31 August 2018 were considered.
PubMed, CINAHL, Scopus and PsycINFO databases were searched by two authors in August 2018. The keywords and MeSH terms 'patient experience', 'bedside handover' and 'qualitative research' were included and combined using Boolean operators. The search terms were also modified and explored in the databases to ensure that all possible combinations were considered. A manual search was also performed by two researchers by accessing the reference lists of the selected studies. To determine the eligibility of all potentially relevant studies, the same researchers independently scanned all titles and abstracts.
Search outcomes Database searches yielded 749 studies during the initial phase of the search. After removing duplicates and screening the titles and abstracts, 52 full‐text studies were assessed and seven met the inclusion criteria. The reference lists of the selected studies were reviewed, and three additional papers were found; therefore, a total of 10 studies were included. The review process including study identification, inclusion and exclusion, according to the PRISMA guidelines [24], is reported in Fig. .
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Flow chart of the search strategy and results.
Quality appraisal To evaluate the methodological quality of the included studies [22], all members of the research team used the Critical Appraisal Skills Programme (CASP) [25] in the initial stage and then agreed upon the findings. In the case of studies performed by members of the research team, the evaluation was performed by other researchers.
The 10 appraisal items of the CASP allow researchers to detect the logical and rational flow of the research process, how ethical issues are addressed, and the value of the research contributions. At the end of the evaluation process, the score is one of three options, 1 (Yes), 0.5 (Unclear) and 0 (No) [26], resulting in a maximum score of 10, with higher scores suggesting a higher study quality. The evaluation of study quality was judged as high, medium or low according to the scores obtained by each study [25].
Data abstraction and synthesis A researcher extracted the data and populated a grid reporting the study design, the participants' characteristics, the data collection methods and the analytical strategy used; the main findings of each study were also extracted (Table ). The extraction process was then checked independently by a second researcher and disagreements were discussed.
Description of included studies
Author, year, country
Study aim(s) Participants and setting
Study designData collection method
Key findings
Bruton et al. (2016) 37 UK
To understand the purpose, impact and experience of nurse‐to‐ nurse handover from both patient and staff perspectives and the perceived differences between nurse handover and medical ward rounds
Eight patients (gender and age not reported) 1 medical and 1 surgical ward
Qualitative study
Observation, semi‐ structured interviews
Patients felt reassured when staff clearly knew about them, while they felt insecure if the nurse did not appear to know about their care or treatments Patients' views and experience of involvement in handover varied: some felt involved in the handover, some would to be more involved, others wanted to hear the handover on their condition but not be involved, and some thought involvement could be a distraction for the nurses
Lupieri et al.
To describe the experiences of
14 patients (female = 28%;
Qualitative descriptive
Semi‐ structured
Four themes emerged: (1) discovering a new nursing
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(2015) 31 Italy
postoperative cardio‐ thoracic surgical patients experiencing nursing bedside handover
range age = 49– 86 years) 1 cardio‐ thoracic intensive care unit
study interviews identity (2) being apparently engaged in a bedside handover (3) experiencing the paradox of confidentiality (4) having the situation under control
Lu et al. (2014) 35 Australia
To explore patients' perceptions of bedside handover
30 patients (female = 73%; age not reported); acute medical, acute surgical, and maternity wards
Qualitative descriptive study
In‐depth semi‐ structured interviews
Four themes emerged: (1) a more effective and personalised approach (2) being empowered and contributing to error minimisation (3) privacy, confidentiality and sensitive topics (4) training need and avoidance of using technical jargon
Bradley & Mott (2013) 36 Australia
To study empirically the process and outcomes of nursing bedside handover implementation
Nine inpatients (gender and age not reported) 3 acute rural hospital wards
Mixed‐ method: quantitative (quasi‐ experimental), qualitative (ethnography)
Ethnographic interview, observations journaling
Patients preferred the bedside handover method to the traditional closed‐door office handover approach: they know who is looking after them and they are involved in discussion related to their care Patients felt empowerment linked with being active in their care
Jeffs et al. (2013) 30 Canada
To explore patients' experiences and perceptions associated with implementation of bedside nursing handover
45 patients (female = 66%; age not reported) surgery 29%; obstetrics and gynaecology, 27%; nephrology 27%; general respirology, 18%
Qualitative study
Interviews Three themes emerged: (1) creating a space for personal connection (2) 'bumping up to speed' (3) varying preferences
Kerr et al. (2013) 38 Australia
To explore the perspectives of patients regarding bedside
30 patients (female = 60%; age not
Qualitative descriptive study
Semi‐ structured interviews
Two themes emerged: (1) patients perceive that participating in bedside handover
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handover by nurses in the emergency department
reported) 1 tertiary urban emergency department
enhances individual care: it provides the opportunity for patients to clarify discrepancies and to contribute further information during the handover process, and is valued by patients; patients are reassured about the competence of nurses and continuum of care after hearing handover conversations (2) maintaining privacy and confidentiality during bedside handover is important for patients: preference was expressed for handover to be conducted in the emergency department cubicle area to protect privacy of patient information and for discretion to be used with sensitive or new information
Staggers et al. (2013) 34 USA
(1) To determine inpatient oncology patients' perceptions about participation in shift change handoffs (2) To elicit patients' information priorities and identify tools to support future patient‐provider handoffs
20 patients (female = 50%; range age 28– 85 years; mean 58.4 years) 1 general surgery ward of a large oncological centre
Exploratory descriptive study
Naturalistic observations, interviews, fields note, artefact (tool) capture
Three themes and 15 categories emerged: (1) depend upon how sick I am (level of participation by patients, frequency of patients' participation, location of nurses' handoff, negotiation with patients after handoff, patients' barriers to participating) (2) I want to know everything (information needs of patients, preferences of patients, patient's discharge information needs, patient tools, shared electronic health record information) (3) my life is in their hands (take care of me, being a good patient, perceptions of the nurses' role, perceptions of care)
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McMurray et al. (2010) 32 Australia
To interpret patients' perceptions of shift‐to‐ shift bedside handover in nursing
10 patients (female = 60%; range age 52– 74; median age 68 years) 2 medical units
Descriptive case study
Semi‐ structured interviews
Four themes emerged: (1) acknowledging patients as partners (2) amending inaccuracies (3) passive engagement (4) handover as interaction
Greaves (1999) 29 UK
To explore how patients, perceive the practice of nursing bedside handover
Four patients (gender and age not reported) hospital setting
Qualitative study
Semi‐ structured interviews
Four themes emerged: (1) patients desire to be involved and access information (2) importance of confidentiality (3) need for continuity of information passed from nurse to nurse (4) neglect the patient presence during handover
Cahill (1998) 33 UK
(1) To capture, describe and provide an analysis of patients' perceptions of the bedside handover (2) To illuminate which elements patients, express either satisfaction or dissatisfaction with
10 patients (gender and age not reported) surgical care setting
Grounded theory
In‐depth interviews
Three categories emerged: (1) maintaining professional dominance where patients identified a division between themselves and nurses (2) establishing professional sharing; for patient's bedside handover represented a forum for debriefing and nurse‐to‐nurse interaction (3) managing patient safety
1 Only qualitative data were extracted.
The findings of each study were analysed, and a thematic matrix was built by extracting, coding and analysing the data as themes or categories, and developing new potential themes [21]. This was performed through the three stages requested by the thematic synthesis approach as suggested by Thomas and Harden [22]: (i) the free line‐by‐line coding studies' findings; (ii) the organisation of codes into associated areas to settle 'descriptive' themes; and (iii) the development of the 'analytical' themes. The new themes were derived inductively [27], and the process was performed manually by involving all members of the research team; each step was then discussed by researchers to reach an inter‐coder agreement. For each theme, when needed, sub‐themes were also developed following the same process.
To detect possible inconsistencies, theme and sub‐themes were analysed repeatedly and summarised [28]. Then, emerged themes and sub‐themes were evaluated in their occurrence by calculating the intra‐
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study intensity and the inter‐study frequency effect size to avoid under or overweighed themes and/or sub‐themes [21].
Results
Studies included Ten studies published between 1998 and 2016 were included (Table ), one of which a mixed‐method study. Four studies were performed in Australia, three in the UK, and the remaining in Canada, Italy and the United States. The designs (e.g., qualitative study, qualitative descriptive study, grounded theory, ethnography) and settings varied across studies, while data collection methods were similar and based mainly upon observation and semi‐structured/in‐depth interviews. Patients involved in studies ranged from four [29] to 45 [30] and the total sample participants included in all studies were 180.
Quality evaluation of the selected studies The CASP evaluation revealed that the majority of studies were of high quality (Table ). All of them described research aims that were appropriate with the research methodology used; the recruited strategies and data collection methodologies were also clearly reported. A few studies reported the researchers' role during data collection [[30]], and two described ethical issues too briefly [[33]]. Clear statements of findings were presented in all studies.
Quality assessment of included studies using the Critical Appraisal Screening Programme
Bruton et al. 37
Lupieri et al. 31
Lu et al. 35
Bradley & Mott 36
Jeffs et al. 30
Kerr et al. 38
Staggers et al. 34
McMurray et al. 32
Greaves 29
Cahill 33
Item 1. Was there a clear statement of the aims of the research?
Y Y Y Y Y Y Y Y Y Y
Item 2. Is a qualitative methodology appropriate?
Y Y Y Y Y Y Y Y Y Y
Item 3. Was the research design appropriate to address the aims of the research?
Y Y Y Y Y Y Y Y Y Y
Item 4. Was the recruitment strategy appropriate to the aims of the research?
Y Y Y Y Y Y Y Y Y Y
Item 5. Was the data collected in a way that addressed the research issue?
U Y Y Y Y Y Y Y Y Y
Item 6. Has the relationship between researcher and
N Y U N Y N N U N N
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participants been adequately considered? Item 7. Have ethical issues been taken into consideration?
Y Y Y Y Y Y U Y Y U
Item 8. Was the data analysis sufficiently rigorous?
U Y Y Y Y Y Y Y U Y
Item 9. Is there a clear statement of findings?
Y Y Y Y Y Y Y Y Y Y
Item 10. Was this research valuable?
Y Y Y Y Y Y Y Y Y Y
Overall score 8 10 9.5 9 10 9 8.5 9.5 8.5 8.5 Overall Level of Quality Moderate
to High High High High High High Moderate
to High High Moderate
to High Moderate to High
2 Y = Yes ( 1); N = No (0); U = Unclear (0.5).
Synthesis of findings Three major themes emerged from the selected studies as reflecting the experience of patients involved in hospital BSRs: (i) 'Being involved', (ii) 'Being the centre of nursing care processes' and (iii) 'Experiencing critical issues'. The themes were divided into several sub‐themes of meaningful units (Table ).
Intra‐study intensity and inter‐study frequency effect sizes of sub‐themes/themes
Themes 1. Being involved
2. Being the centre of nursing care processes
3. Experiencing critical issues
Intra‐study intensity effect size, % (n/N)
Sub‐themes 1.1 Being involved is a right
1.3 Being involved is a controversial experience
1.4 Being involved at different degrees of intensity
2.1 Experiencing a sense of safety
2.2 Being in contact with nurses
2.3 Experiencing nurse's effectiveness
Bruton et al. 37
✓ ✓ ✓ 66 (2/3)
Lupieri et al. 31
✓ ✓ ✓ ✓ 66 (2/3)
Lu et al. 35 ✓ ✓ ✓ 100 (3/3)
Bradley & Mott 36
✓ ✓ 66 (2/3)
Jeffs et al. 30 ✓ ✓ ✓ ✓ ✓ ✓ 100 (3/3)
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Kerr et al. 38 ✓ ✓ ✓ ✓ ✓ ✓ 100 (3/3)
Stagger et al. 34
✓ ✓ ✓ ✓ ✓ 100 (3/3)
McMurray et al. 32
✓ ✓ ✓ ✓ ✓ ✓ 100 (3/3)
Greaves 29 ✓ ✓ ✓ 100 (3/3)
Cahill 33 ✓ ✓ ✓ ✓ ✓ ✓ 100 (3/3)
Inter‐study frequency effect size, % (n/N)
60 (6/10) 60 (6/10) 50 (5/10) 80 (8/10) 80 (8/10) 30 (3/10) 80 (8/10)
3 Representation of sub‐themes in single studies: number of findings in each study/total number of findings across studies.
4 Individual report contribution to sub‐themes: number of studies containing findings/total number of findings across studies.
Theme 1: 'Being involved' The major theme and sub‐themes that emerged were in regards to the perception of being involved in the care process as a right; however, patients differed in their experience when directly involved in the BSR, suggesting that the degree of their involvement should be tailored according to their preferences and expectations as well as to their self‐confidence in considering themselves ready to hold an active role in the BSR.
Being involved is a right Being a member of the BSR process for patients means to be informed, to have the opportunity to increase their confidence in terms of their clinical conditions, and to develop a sense of control with respect to the care received [[30], [35]]. For patients involved in the BSR, it also represents an opportunity to ask questions, to provide data regarding their care, and to verify the information passed between nurses during shift changes [[30], [36]]. Furthermore, when data regarding rehabilitation programs, follow‐ups or the planned discharge day are shared during the BSR, patients can be better prepared and empowered when these events occur [[30], [32], [34]].
Being involved is a controversial experience In addition to the right of being involved, patients' desire to be an active partner of the BSR process varied as well as the quality of the involvement [[30], [37]]. Many patients reported a desire to be involved in daily BSRs [30], and in some cases, they wanted be more involved [37]; nevertheless, others did not
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consider it necessary to participate in every BSR as they were believed to be redundant [30]. Furthermore, some patients preferred participating as passive listeners [[30], [32]] as they felt inadequate in their ability to understand their clinical condition [33], resulting in a preference to take part in the handover discussion only when invited by nurses [38].
Being involved at different degree of intensity The degree of patients' involvement and what data they wanted to listen to and discuss were influenced by their clinical conditions, preferences, and when the BSR occurred during the day. Some patients preferred to participate at minimum twice a day, at the beginning and end of the day [[30], [33]], because hearing one's own clinical story repeatedly [33] and/or being frequently woken, caused frustration [[30], [34]].
Patients expect nurses to play a role in advocacy, thus taking the responsibility to protect them by being a mediator for when it is appropriate to receive upsetting information [[33], [38]].
Theme 2: 'Being in the centre of nursing care process' For many patients, the BSR is an opportunity to develop a sense of security that their care continuity is guaranteed, as well as an opportunity to acknowledge that their physical and psychological safety is ensured. Furthermore, the BSR represents an opportunity to create a partnership with nurses, to be connected with them, and to feel as though they consider the patient as the centre of their care processes: as a consequence, patients have an opportunity to enhance their consideration towards nurses and their competences.
Experiencing a sense of safety The majority of patients are reassured when they feel that nurses clearly know their clinical conditions and treatments as it can be appreciated during the BSR [[29], [37]]. The same happens when patients, listening to the BSR, understand that the continuity of care is guaranteed, and that appropriate information is transferred among professionals [[31], [33], [38]]. The BSR also represents an opportunity for patients to detect possible data inconsistencies, as well as mistakes and misunderstandings, and to provide further information and follow the care process [[31], [35], [38]].
Being in contact with nurses For many participants, the BSR represents an opportunity to create a deeper connection and a sort of 'alliance' with nurses. Patients feel nurses take care of them and perceive that nursing care is tailored based on their needs [[30]]; in addition, the BSR allows patients to increase their knowledge regarding the value of care offered by nurses and to spend more time with them [[30], [33], [36]]. In some cases, these interactions also create a sense of mutual support [33], increasing the comfort of patients involved in the process [[33], [37]].
Experiencing nurse's effectiveness
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Being involved in the BSR helps patients see nurses in a different light, identifying their role, competences and professionalism [31]. Some patients also perceive that the BSR helps nurses improve the quality of care [33]. However, professional behaviour can make a difference in developing a sense of trust among patients [[31], [35]]: for example, when patients appreciate that during the BSR their data are appropriately discussed [[31], [35]] or when nurses manage bad clinical news in a professional manner [35].
Theme 3: 'Experiencing critical issues' One of the most critical points reported by patients is the use of professional jargon during the BSR, because it can create negative feelings such as anxiety [[33], [37]] and barriers between patients and nurses [[31], [33], [35]].
Another cause of concern was the confidentiality of information shared during BSRs: for some patients, the benefits of the BSR are superior to the confidentiality issues [[29], [31]]; on the other hand, sharing sensitive information requires discretion (e.g., data regarding sexual preferences, clinical conditions, mental diseases, addictions) and therefore a good reason to avoid being involved in the BSR when a hospital room is shared with other patients [[35], [38]]. Nurses' behaviour, such as loud speech during BSRs, use of the patient's full name and speaking freely about their clinical condition in front of others [[30], [38]], have been reported as the main reasons of concern. Furthermore, the presence of relatives and visitors during the BSR is not always supported by patients [38] for similar reasons.
Another cause of concern during the BSR has been reported regarding the professionals' relationship observed between carers which should be positive; for example, when students are criticised or provided with negative feedback in front of patients, this is also perceived negatively by patients [33].
Discussion
Discussion of the studies included In the last 20 years, patient participation has been highlighted as the central paradigm in healthcare setting and BSR as a concrete example (Malfait et al. [39]) as documented in the retrieved studies published mainly from 2013. However, although handovers were initiated at the end of the 1970s [e.g., Feeley [40]], only in recent years they have been recommended in the form of the BSR [41], while patients' experiences regarding this method of handover is still little studied.
As showed by the included studies, the topic has been primarily researched in Australian and British contexts, while limited in other countries; for example, across Europe, only one Italian study [31] has been published, suggesting the need to explore patients' experiences in other countries to determine how in different contexts where rights, culture and practices regarding patient care participation can affect the perceptions of patients regarding the BSR [[41]].
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The included studies were mainly performed in single hospitals, in medical and surgical units; despite the importance in understanding the patient experience at each nursing change, only a few patients have been involved to date, suggesting that more research is necessary. Moreover, data regarding patients' characteristics in addition to age and gender have been largely missing, suggesting that further studies involving patients with different clinical conditions at different stages of life and with different in‐hospital lengths of stay, are also needed. Furthermore, given that BSR implementation can be critical due to infringement of patient's privacy and confidentiality, thus triggering ethical and/or legal issues especially in some vulnerable conditions (e.g., palliative care, mental health care, infection disease care), further research on practical solutions, on frameworks capable of involve effectively patients, as well as on strategies aimed at protecting patients while implementing BRS, are strongly suggested (Malfait et al., [39]).
Different study designs and methodologies were used, and many were based upon a qualitative descriptive approach that does not follow particular disciplinary or methodologic rules; thus, mainly reporting a comprehensive summary of the BSR experience [43]. Finally, according to the CASP evaluation [25], the quality of the included studies is high, suggesting that more attention on how ethical issues and data collection have been handled, is needed.
Discussion of the themes emerged
Theme 1: 'Being involved' Patients feel more confident when they are directly involved in the BSR, because they receive more information about their treatments and they can participate in the decision‐making process regarding their care [11]. However, findings of our meta‐synthesis suggest that some patients prefer being passive participants [[30], [32]], especially when they feel unable to understand their health conditions or when their cooperation is limited due to illness [42]. Furthermore, patients and nurses may give different meanings of the concept of being active during the BSR [44] and it is sometimes difficult to understand if the passive role played by patients is a consequence of the lack of information regarding their expected role or if it is related to personal traits [45]. In a few studies, patients highlighted the nurses' role and responsibility to protect them as mediators [[33], [38]].
However, when patients are treated with respect and provided with clear information, their involvement in the BSR increased [45]. On the contrary, when nurses do not support them, patients are more concerned about their health and care [45] and their anxiety increased [[33], [38]]. Patients' personality traits, age and/or cultural barriers can also influence their participation in bedside handovers [[43], [45]], indicating that further research is needed to better explore how individual factors can affect patients desire to be involved in the BSR.
Theme 2: 'Being in the centre of nursing care process' The BSR has been recommended due to its ability to prevent errors and misunderstandings, thus
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improving patient outcome and safety [[ 7], [17], [46]]. Findings of our meta‐synthesis confirmed that being involved in the BSR increased the perception of safety, according to the active role played by patients in verifying information, detecting accuracies, and – when necessary – providing missing data [31]. Moreover, the BSR also represents an opportunity for patients to spend time with nurses, to better understand how they work in a team [[30], [33], [36]], and to recognise their advancements in the professional competencies [31]. Ensuring safety has been reported as a priority in the nursing agenda, suggesting that the BSR can be a strategy to prevent failures in the nursing care process. At the same time, the BSR can also increase the proportion of time that nurses spend at the bedside. Direct nursing care has been recently reported as decreased due to lack of resources, the occurrence of non‐nursing tasks and the complexity of healthcare work environments [47], thus detaching nurses from patients. More contact with patients through the BSR can in turn result in an increased appreciation of the nursing profession by citizens. In countries such as Italy where several advancements of the nursing profession have been achieved rapidly in recent years, the nursing profession can be still perceived in its traditional role and not in its actual degree of professionalism [48].
However, a nurse's behaviour during the BSR plays an important role in achieving these outcomes [45], suggesting the need to provide appropriate training on the BSR [15]. As reported by Lockwood [49], when evidence‐based education is lacking, the risks of compromising the quality of the BSR are present, increasing issues in terms of patients' safety and trust. Conversely, when the BSR is considered a structured strategy [[32], [50]], performed in positive environments by well‐trained nurses [[35], [41]], BSR outcomes can increase [11].
Theme 3: 'Experiencing critical issues' In addition to the benefits, some critical issues have also emerged [46], such as the use of medical jargon, the potential violation of patients' confidentiality and negative relationships among professionals involved in the process.
The use of medical language, talking over patients, or ignoring their requests are behaviours that can negatively influence patients' participation in the BSR [44]. In the literature, the use of technical jargon has been reported as one of the most common barriers [e.g., Kerr et al. [38]; Stagger et al. [34]]. Our findings confirm how unfamiliar language can limit patients' understanding of data shared during handover, thus affecting their active participation [35]. Nurses must speak clearly, adjust information, and appropriately educate patients [41] when conducting the BSR.
Confidentiality represents another cause of concern in line with previous studies and reviews [e.g., Evans et al. [51]; Tobiano et al. [11]]; however, according to our findings, nurses have been reported to be more concerned with confidentiality compared with patients [[31]]. Specifically, Lupieri et al. [31] reported that when patients are involved in the BSR, a lack of privacy is a 'calculated risk'; on the other hand, other studies have underlined that the need to share sensitive information represents a cause of concern for patients, thus affecting their participation [[35], [38]]. Patients appreciate when nurses adopt strategies to
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protect their sensitive data [35]: engaging patients in the BSR also means providing them with instruments to control the flow of information shared at the bedside and guaranteeing a safe environment. Therefore, discussing these issues at hospital admission, as well as if they can share data also in the presence of relatives [[35], [38]], and obtaining their informed consent, should be considered a basic step in the implementation process of BSR.
Limitations of the study This meta‐synthesis has several limitations. According to the inclusion criteria of the study, only qualitative primary studies published in indexed journals, and written in English have been selected; therefore, grey literature and dissertations were not searched, and this may have introduced an information bias. Primary studies include heterogeneous samples of patients, expressing different professional and healthcare service setting and cultures, thus affecting the transferability of findings to other contexts. The study designs and analytic strategies used were also different across studies, and this could affect the reliability of the data synthesis performed.
Conclusions This meta‐synthesis of qualitative studies was designed to better understand patients' experience of bedside handovers to support effective implementation of the BSR.
Patients are supportive of the BSR because it represents a right, and an opportunity to be involved and of being in the centre of the nursing care process by participating in care decisions. By designing and implementing BSRs, nurses also have the opportunity to increase patient safety and to provide concrete proof of the advancements achieved by the nursing profession in recent years. However, an effective BSR handover should ensure a variable degree of involvement according to the preferences of the patient, which can be assessed at hospital admission, when the BSR method should be explained. Moreover, issues regarding confidentiality should be discussed with the patient, avoiding the use of medical language, thus ensuring complete understanding and involvement in the handover process.
Our findings suggest the inclusion of patients' experiences and perceptions in educational programs designed to implement effective BSRs. Communication skills should also be promoted among nurses aimed at ensuring a full assessment of patients' preferences and expectations regarding BSRs, ensuring a tailored approach. Enhancing communication skills can also prevent confidentiality issues, the use of professional jargon and negative behaviour that can occur during the handover.
Future studies should be focused on the influence of cultural and personal traits and ethnic diversity in patients' BSR experience, as well as explore the benefits of the participation of family members or other caregivers in the BSR. Discovering sub‐groups of patients who are at risk of negative experiences of BSRs aimed at guiding clinical nurses with more evidence regarding their appropriate implementation in terms of frequency (number of BSRs in a day), duration and number of professionals to involve (only two or more, e.g., with nursing students and nurses' aides) is also strongly suggested.
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Conflict of interest None.
Authors' contributions Authors participated equally in study conception, data collection, and analysis, as well as drafting of the manuscript.
Ethical approval Not applicable.
Funding None.
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~~~~~~~~ By Valentina Bressan; Lucia Cadorin; Simone Stevanin and Alvisa Palese
Reported by Author; Author; Author; Author
This article is copyrighted. All rights reserved. Source: Scandinavian Journal of Caring Sciences