Week 4_METHODS USED IN QUALITATIVE RESEARCH

J Clin Nurs. 2020;29:2231–2238. wileyonlinelibrary.com/journal/jocn  |  2231© 2020 John Wiley & Sons Ltd

1  | INTRODUC TION

Miscommunication during handover results in adverse events with 60%–80% of communication failures (including hando- ver) contributing to clinical incidents in America (The Joint Commission, 2013). Emergency department (ED) handovers can

occur within the department and between admitting clinical units. In Australia, approximately 2.5 million people who present to EDs are admitted to hospital annually, and each transfer from the ED to an inpatient unit (IPU) provides opportunity for mis- communication jeopardising patient safety (Australian Institue of Health & Welfare, 2018). In recognition of the potential impact

Received: 13 September 2019  |  Revised: 15 December 2019  |  Accepted: 3 February 2020

DOI: 10.1111/jocn.15214

O R I G I N A L A R T I C L E

Front-line nurses' perceptions of intra-hospital handover

Georgia Tobiano BN, PhD, Nurse Researcher1  | Christine Ting BN, MN, Clinical Nurse (Research)1 | Christine Ryan BHSC(Nurs), MNurs(ClinLead), Quality Improvement Lead (Clinical Handover)1 | Kim Jenkinson BN, MHLM, Acting Quality Improvement Lead (Clinical Handover)1 | Lucie Scott BA in Healthcare Acute and Critical Care, Clinical Nurse Consultant (Children's Emergency), Advanced Diploma Adult Nursing1 | Andrea P. Marshall BN, PhD, Professor of Acute and Complex Care1,2

1Gold Coast Health, Southport, QLD, Australia 2School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia

Correspondence Georgia Tobiano, Gold Coast Health, 1 Hospital Blvd, Southport, QLD 4215, Australia. Email: [email protected]

Funding information Gold Coast Hospital and Health Service Study Education and Research Trust Account.

Abstract Aim and objective: To explore nurses' perceptions of factors that help or hinder intra- hospital handover. Background: Miscommunication during clinical handover is a leading cause of clini- cal incidents in hospitals. Intra-hospital nursing handover between the emergency department and inpatient unit is particularly complex. Design: A descriptive, qualitative study. This research adheres to the consolidated criteria for reporting qualitative research. Methods: Forty-nine nurses participated in group interviews, which were analysed using inductive content analysis. Results: Three categories emerged: (a) “lacking clear responsibilities for who provides handover”; (b) “strategies to ensure continuity of information”; and (c) “strained rela- tionships during handover.” Conclusions: Intra-hospital handover requires clear processes, to promote high-qual- ity information sharing. Ensuring these processes are broad and acceptable across units may ensure nurses' needs are met. Relational continuity between nurses is an important consideration when improving intra-hospital handover. Relevance to clinical practice: Nursing managers are optimally positioned to enhance intra-hospital handover, by liaising and enforcing standardisation of processes across units. Nurse managers could promote intra-unit activities that foster front-line nurses' communication with each other, to encourage problem-solving and partnerships.

K E Y W O R D S

communication, inpatients, nursing staff, patient handoff, patient transfer methods

2232  |     TOBIANO eT Al.

that poor handovers can have on patient safety, there have been major policies released and standards created to enhance com- munication safety. For instance, the World Health Organization's “High 5s” action plan highlights recommendations for implement- ing and evaluating standardised patient safety solutions for com- munication during patient handover (World Health Organization, 2006); today, the problem of inadequate handover communica- tion persists (Trossman, 2019).

2  | BACKGROUND

Nurses may not communicate efficiently during handover. In a study of over 22,000 nurses across 600 European hospitals, research- ers found that 21%–61% of nurses were dissatisfied with handover (dependent of country of origin) (Meißner et al., 2007). Reasons for nurse dissatisfaction include receiving insufficient information (Meißner et al., 2007) and finding handover communication difficult to follow (Street et al., 2011). These findings suggest that nurses' handover communication is an area requiring improvement.

Effective communication during intra-hospital nursing hando- vers is particularly challenging because of differences related to specific work areas. One example is handover between the ED and IPU nurses when a patient is admitted to hospital from the ED. Nurses across settings view different information as important; ED staff strive for information about medical condition and immediate care needs (Pun, Matthiessen, Murray, & Slade, 2015), while IPU nurses are more focused on personal information about the patient including longer-term care needs and providing explanations to patients to increase their knowledge (Johnsson, Wagman, Boman, & Pennbrant, 2018). Additionally, ED nurses face different work pressures including the need to discharge patients within a set time (Sullivan et al., 2016), making their communication process with pa- tients time-pressured and lacking an interpersonal approach (Pun et al., 2015). Despite these challenges, nurses across units are re- quired to work interdependently.

To facilitate communication between nurses, protocols have been suggested as a strategy to standardise the handover process and content (Riesenberg, Leisch, & Cunningham, 2010). Protocols may include checklists to guide handover content required. These checklists sometimes use the “SBAR” pneumonic as a technique to set expectations for content around the topics “situation,” “back- ground,” “assessment” and “recommendation” (Haig, Sutton, & Whittington, 2006; Marshall et al., 2018). Using standardised proto- cols means a more complete handover can be achieved by increasing the rate of information exchanged to over 80% (Yang & Zhang, 2016). Moreover, a systematic review demonstrated that standardised pro- tocols improve intra-hospital handover, without significantly chang- ing the duration (Gardiner, Marshall, & Gillespie, 2015).

There is a clear tension between emerging evidence for stan- dardised handover protocols and the fact that clinical handover is heavily influenced by contextual issues. Handover is a sociotechnical activity, meaning many factors such as teamwork, technology and

organisational issues influence the handover process and outcomes (Holden et al., 2013). The factors that influence the handover and transfer of patients from the ED to IPUs is not well studied (Gonzalez et al., 2018) and presents a significant area for improvement for the nursing workforce and a challenge for nursing management. For interventions aimed at improving handover to be successful, a clear understanding of contextual factors influencing intra-hospi- tal handover is required. Without this evidence, efforts to improve intra-hospital handover are at risk of being misdirected and may achieve suboptimal outcomes.

3  | METHODS

3.1 | Design

A descriptive qualitative study, as described by Elliot and Timulak (2005), was selected because it allows understanding of the aspects of the phenomenon of intra-hospital handover. Elliot and Timulak (2005) provide guidance on the methodological practices required for a descriptive, qualitative study. See Appendix S1 for adherence to the consolidated criteria for reporting qualitative research.

3.2 | Aim

To explore nurses' perceptions of factors that help or hinder ED to IPU intra-hospital handover.

3.3 | Data collection

This study took place at a public tertiary level teaching hospital, located in Queensland, Australia. The participating settings were the ED and four surgical IPUs. Surgical IPUs were purposefully se- lected, as direct transfers from ED to surgical IPUs occurred more frequently at this site. All registered or enrolled nurses, working reg- ularly in the participating ED and IPUs, were invited to participate. On a day of data collection, the first and second listed researcher and the clinical facilitator on the unit invited all nurses on the shift to participate. Interested nurses were informed in a verbal and writ- ten manner about the purpose of the study and provided informed

What does this paper contribute to the wider global clinical community?

• Our study confirms the importance of standardising handover processes to enhance intra-hospital handover.

• The degree of relational co-ordination between nurses may underpin the success of improving intra-hospital handover.

13652702, 2020, 13-14, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/jocn.15214 by U

niversity of M iam

i, W iley O

nline L ibrary on [23/09/2023]. See the T

erm s and C

onditions (https://onlinelibrary.w iley.com

/term s-and-conditions) on W

iley O nline L

ibrary for rules of use; O A

articles are governed by the applicable C reative C

om m

ons L icense

     |  2233TOBIANO eT Al.

consent and demographic data prior to interviews. Ethics approval was gained from the hospital.

Elliot and Timulak (2005) recommend semi-structured in- terviews for qualitative inquiry; thus, semi-structured, group interviews were used for data collection. Two group interviews occurred per IPU, and two groups occurred in ED. The size of each group ranged from four to six participants; four participants were the minimum participants required for sufficient group interaction (Polit & Beck, 2008). Interviews were conducted from January– February 2017 in a space designated for meetings or education sessions. Group interviews were audio-recorded, with two re- searchers present; the first listed researcher led interviews; the other researcher managed equipment and note-taking. We con- tinued interviews until data saturation occurred, which was when the team judged that no new information was emerging from in- terviews (Polit & Beck, 2008).

The interview questions were open-ended and guided by par- ticipant responses, changing the ordering of questioning to suit the topics raised, and probes were used to elicit more comprehensive details. Examples of questions were “What do you normally do in an ED to IPU handover?” and “Thinking about the context where you work, what helps you to conduct an effective handover?”

3.4 | Data analysis

Interviews were transcribed verbatim by a professional transcrip- tion service, and transcripts were uploaded into NVivo software (QSR International Pty Ltd., 2018). Interview data were analysed using inductive content analysis, as guided by Elo and Kyngäs (2008). This approach was selected because qualitative research does not use pre-existing categories for sorting data (Elliot & Timulak, 2005). The first listed researcher labelled transcripts line-by-line in NVivo, producing codes (Elo & Kyngäs, 2008). The codes were read through many times, and then, select codes were grouped together under the same heading to form subcategories based on codes that “belonged” together (Elo & Kyngäs, 2008). Finally, subcategories were investigated to determine which “be- longed” together. Select subcategories were grouped together under the same headings which were higher-order categories (Elo & Kyngäs, 2008). The process was iterative with the researcher constantly referring to raw data to check emerging subcatego- ries and categories, and using flow diagrams to assist in the for- mation of subcategories and categories. The final subcategories and categories were decided with team input; they were engaged throughout analysis to read emerging subcategories and catego- ries to confirm or disconfirm findings.

3.5 | Rigour

The enhance credibility, the same PhD-trained researcher conducted all interviews. The researcher had experience in

interviewing, ensuring the interview process was consistent, and questions were asked in a way that elicited in-depth responses (i.e., re-ordered and re-phrased as required) (Krefting, 1991). This researcher spent enough time interviewing participants to identify reappearing patterns in the interviews (Krefting, 1991). To make the findings confirmable, the researcher analysing data was reflec- tive. Immediately after interviews occurred, an audio recording of the interview was listened to by the lead researcher, who under- took initial analysis completing a contact summary form (Miles, Huberman, & Saldaña, 2014). This allowed the researcher to iden- tify gaps in knowledge and reflect on her interview techniques. In addition, throughout the analysis process notes were kept on any emerging or striking findings and thoughts. The interviewer was known by some participants; thus, reflecting on each inter- view made her aware of any biases prior to subsequent interviews. The process of data analysis was made dependable by having IPU and ED nurses review and interpret emerging categories (Krefting, 1991).

TA B L E 1   Demographic characteristics of sample

Characteristics IPU nurses (n = 38) ED nurses (n = 11)

Gender

Female 37 (97.4%) 8 (72.7%)

Male 1 (2.6%) 3 (27.3%)

Hours worked at hospital

Full-time 4 (10.5%) 1 (9.1%)

Part-time 24 (89.5%) 10 (90.9%)

Position in nursing

Clinical nurse 6 (15.8%) 4 (36.4%)

Registered nurse 28 (73.7%) 7 (63.6%)

Other 4 (10.5%) 0 (0.0%)

Work as team leader

Yes 22 (57.9%) 10 (90.9%)

Age (years)

25–35 26 (68.5%) 8 (72.8%)

36–45 2 (5.3%) 1 (9.1%)

46–55 7 (18.4%) 1 (9.1%)

>56 3 (7.9%) 1 (9.1%)

Number of years in nursing profession (years)

<5 12 (31.6%) 6 (54.5%)

6–10 19 (50.0%) 4 (36.4%)

11–20 5 (13.2%) 1 (9.1%)

>21 2 (5.3%) 0 (0.0%)

Number of years in current nursing unit (years)

<5 27 (71.1%) 8 (72.7%)

6–10 8 (21.1%) 3 (27.3%)

11–20 3 (7.9%) 0 (0.0%)

>21 0 (0.0%) 0 (0.0%)

13652702, 2020, 13-14, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/jocn.15214 by U

niversity of M iam

i, W iley O

nline L ibrary on [23/09/2023]. See the T

erm s and C

onditions (https://onlinelibrary.w iley.com

/term s-and-conditions) on W

iley O nline L

ibrary for rules of use; O A

articles are governed by the applicable C reative C

om m

ons L icense

2234  |     TOBIANO eT Al.

4  | RESULTS

A sample of 49 nurses participated in the study (Table 1). Interviews lasted an average of 20 min.

At the time of interviews, there was no hospital protocol for how to conduct intra-hospital handover. Nurses spoke about the com- plexity of the process of ED to IPU handovers. Nurses described two information handovers that could occur (See Figure 1): (a) phone-to- phone information exchange while the patient was in ED (hereafter called handover one) and (b) face-to-face information exchange on the IPU (hereafter called handover two).

Three categories emerged regarding nurses' perceptions of factors that helped or hindered ED to IPU handover, as described below. The composition of each group can be seen in Table 2.

4.1 | Lacking clear responsibilities for who provides handover

There was no clear responsibility for who should transfer the pa- tient from ED to IPU, effecting the perceived quality of handover two. Nurses reported three staff that may transfer the patient: an ED nurse either providing or not providing care for the patient: “Sometimes you're just pulled in because the nurse is busy that was looking after that patient … you're just asked can you take this patient upstairs…which is the truth and so you're looking through their notes” (Focus Group [FG] 2), or “…the patient just comes with a wardie (orderly)…” (FG 9). Nurses were unable to describe con- sistent ways of determining who should accompany the patient to

the IPU, suggesting it could be based on patients' acute illness (FG 4), the presence of intravenous fluid (FG 9), scoring systems based on vital signs (FG 7) or ED nurses' clinical judgement, which could be challenged by IPU nurses. Lack of clear responsibility resulted in lack of task significance, as ED nurses questioned if it should be their role to transfer patients, if handover two added information and viewed the task as a poor use of their time: “If you count the lost man-hours that we can lose in transferring patients and put it back to here, it would make us a lot more functional, as a unit.” (FG 6).

In turn, processes for handover two on the IPU were unclear. In cases where an orderly transferred the patient, there was no infor- mation transfer: “…they pop them in the room, they bring the notes out here, dump them on the desk and go…we don't really get any face-to-face handover…” (FG 9). If an ED nurse not caring for a pa- tient transferred the patient, IPU nurses were concerned that they “do not usually know much at all” about the patient (FG 8). If the ED nurse caring for the patient transferred the patient, it was still un- clear what face-to-face information was expected, given handover one had occurred. For IPU nurses, they stated that the information they desired at this point was “Any changes. Rather than asking the same information again.” (FG 10). However, ED nurses experienced that the IPU nurse accepting the patient were not always informed of handover one, requesting another full information exchange: “Every time I've been up (to the IPU)… ‘I don't know anything’. That's what they'll (IPU nurses) say, and I'll say, ‘I've handed over to your team’” (FG 6) This resulted in ED nurses “repeating the information that you said on the phone because the team leader upstairs hasn't conveyed that information…” (FG 2).

F I G U R E 1   Perceived handover process

(May be ED bedside nurse or other ED nurse)

13652702, 2020, 13-14, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/jocn.15214 by U

niversity of M iam

i, W iley O

nline L ibrary on [23/09/2023]. See the T

erm s and C

onditions (https://onlinelibrary.w iley.com

/term s-and-conditions) on W

iley O nline L

ibrary for rules of use; O A

articles are governed by the applicable C reative C

om m

ons L icense

     |  2235TOBIANO eT Al.

4.2 | Strategies to ensure continuity of information

Nurses described strategies to manage the quality of information transferred, such as using “chart biopsy”; the process of carefully stud- ying the patient's electronic medical record (EMR) during handover one. IPU nurses prepared for handover one by reading EMR prior to receiving the phone handover, while ED nurses reported undertaking chart biopsy to gain information about the patient, sometimes reading these notes while giving handover: “If we've got EMR open and they've got the EMR open, that's what we're getting.” (FG 1). For IPU nurses, this caused some frustration as ED nurses were viewed to verbally pro- vide the same information as IPU nurses had read.

Both ward and ED nurses stated that IPU nurses' role was prompting information from ED nurses, to ensure the most com- prehensive handover: “each ward… they'll ask specific things that are important to them.” (FG 2). IPU nurses stated they prompted information about patient assessments and recommendations, as it was identified that patient information about situation and background was available in the EMR: “We're having to prompt to ask, do they have an IV? Do they have [IV] access?” (FG 7). On two IPUs, nurses had created checklists to assist nurses' prompt- ing behaviours.

A desired strategy to ensure continuity of information was to have the ED nurse providing care for the patient be involved in at least one information exchange, as they were viewed to have infor- mation ward nurses required:

A lot of the time it's the in-charge of a section that hands the patient over but [they] have no idea …what's wrong with them. They just literally are reading off a screen, and they don't actually physically know the patient…from the desk here, he looks pretty old, and I think he walks with a stick. Should it just be the nurse that's actually been allocated to that patient that [sic] actually hands the pa- tient over …?

(FG 4)

While ED nurses stated they encouraged the ED bedside nurse to do handover one, it was not always possible due to contextual pressures. “…we're trying to get a practice of the actual person who's looking after the patient handover, but a lot of times in re- suscitation (area) it's too busy and we just have time constraints…” (FG 6).

4.3 | Strained relationships during handover

The relationship between the sender (ED) and receiver (IPU) was tense, and this appeared to be influenced by ward nurses' infor- mation needs not being met. Both IPU and ED nurses understood that the IPU nurse receiver desired certain information related to patient “assessments” and “recommendations” such as patients' mo- bility status, diet, medications, falls risk, plan and mood. However, IPU nurses suggested that this information was often not shared or prioritised by ED nurses: “…the important stuff for us is to know the plan and …how they mobilise and whether they're a falls risk, which often isn't the priority downstairs.” (FG 8).

Emergency department nurses shared contextual pressures that made them unable to meet IPU nurses' information needs. IPU and ED nurses recognised that pressures in ED meant ED nurses did not prioritise comprehensive assessment for these other nonimmediate issues: “but we have time constraints here and we have an infinite number that [sic] come through the door, whereas the ward nurses have a certain number” (FG 6). Because of time constraints, ED and IPU nurses believed that ED nurses, both those caring and not caring for the patient, had incomplete information about patients: “I think the main issues we have with handovers from ED is not so much we're not getting the information, it's that they don't know the pa- tient they're handing over…” (FG 10).

The inability to meet IPU nurses' needs resulted in a strained relationship between the nurses working in the two settings, and nurses desired a better relationship: “…creates a lot of animosity and I think it probably goes two ways, because they don't under- stand why that's [information] important for us to know.” (FG 1). IPU nurses worried that when they prompted more information from ED nurses, it could strain the relationship further. There was a desire for transparency about information known by ED nurses and a sense of distrust based on previous experiences: “…the patient gets here and it's a very different picture to what you get told on the phone.” (FG 7).

5  | DISCUSSION

In our study, nurses described no clear process for ED to IPU handover due to a lack of clarity for who should transfer patients and what content to transmit once the patient was on the IPU. Nurses used strategies to improve co-ordination such as using EMR and prompting to enhance communication. Overall, nurses across ED and IPUs expressed a struggle to collaborate because

TA B L E 2   Interview group characteristics

Unit Group ID Number of participants

Emergency department 2 5

6 6

Surgical IPU 1 1 5

5 4a 

Surgical IPU 2 3 6

10 5

Surgical IPU 3 4 5

9 4

Surgical IPU 4 7 6

8 4

aOne nurse participated in two group interviews.

13652702, 2020, 13-14, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/jocn.15214 by U

niversity of M iam

i, W iley O

nline L ibrary on [23/09/2023]. See the T

erm s and C

onditions (https://onlinelibrary.w iley.com

/term s-and-conditions) on W

iley O nline L

ibrary for rules of use; O A

articles are governed by the applicable C reative C

om m

ons L icense

2236  |     TOBIANO eT Al.

IPU nurses' expectations could not be met, and in turn, relation- ships were strained.

Our study suggests that clearer ED to IPU handover processes are required. Development of a handover standard operating pro- tocol (SOP) may assist with process issues such as who transfers the patient. Similar to previous work, nurses consider patient acuity and safety as a driving factor when preparing for patient transfer (Bergman, Pettersson, Chaboyer, Carlström, & Ringdal, 2019). SOPs can guide nurses' decision-making for transfers, prompting them to assess predetermined patient risk factors prior to transfer and en- sure the transfer team has the right level of knowledge and skills (Alamanou & Brokalaki, 2014). Similar to other research, some IPUs had developed checklists for standardised content and prompted specific information when receiving handover (Bergs et al., 2018). This finding suggests that IPUs may be seeking specialised infor- mation, promoting a “functional” approach to task division and meaning similar activities are brought together in one IPU (Pless, Van Hootegem, & Dessers, 2017). This approach commonly creates “siloed” IPUs where each IPU desires specific information relative to their IPU, which may create challenges for ED staff providing in- formation to a range of settings (Gittell, Godfrey, & Thistlethwaite, 2013). Broader approaches to communication from ED to a range of IPUs could be achieved by creating a checklist that works across all IPUs, promoting a process-orientated approach where each unit prompts and expects similar content. Many organisational rede- sign models to improve communication, such as Care Pathways, Lean Thinking, Relational Co-ordination and Modern Sociotechnical Design, all demand that there is a shift from functional task division, to process-orientated task division (Pless et al., 2017).

However, moving towards a process-orientated approach during handover could be challenging in the ED environment due to the or- ganisational issues identified in this study. For a process-orientated approach to occur, ED nurses would require a broader knowledge of their patient. In other ED settings, nurses have expressed frustra- tion when ED nurses lack knowledge of patients' social or functional status, influenced by hectic ED work conditions where efficient pa- tient flow is prioritised (Bergs et al., 2018), and staff feel they lack the capacity to spend time knowing their patient in-depth (Sujan, Spurgeon, & Inada-Kim, 2014). The quality of intra-hospital hando- ver may be enhanced by nurses increasing time spent collating and organising information before handover (Clarke et al., 2012). In one study, nurses wore bright coloured vests indicating “do not to dis- turb” and had a private designated space for handover preparation, giving nurses permission to claim space and time for this important activity (Clarke et al., 2012).

Similar to our study, nurses often create strategies to deal with their tensions (Sujan et al., 2014), and further developing these strat- egies could enhance collaboration. Using EMR to prepare for han- dover is a common nursing strategy (Ernst, McComb, & Ley, 2018), with EMR viewed as an electronic member of the team for hando- ver (Ernst et al., 2018). However, using EMR for handover could be problematic as the documentation focuses on biomedical knowledge from doctors' notes (Bergs et al., 2018), may not be complete in ED

settings (Manias, Gerdtz, Williams, & Dooley, 2015) and can be per- ceived as inaccurate (Sujan, Spurgeon, & Cooke, 2015). However, current EMR documentation may not be fit-for-purpose. An elec- tronic handover platform was developed for physicians which in- cluded a standardised information dashboard where information was actively input for handover across units (Nelson et al., 2017). When electronic systems are specifically designed for handover be- tween units, healthcare professionals' perceptions of satisfaction, efficiency and trust between healthcare professionals can improve (Nelson et al., 2017). With the international move towards EMR, it may be important to consider electronic sources when developing handover checklists, as paper-based checklists are not always ad- hered to in practice (Marshall et al., 2018).

In our study, there were issues with co-ordination across ED and IPUs, creating relational discontinuity amongst nurses. Teamwork across units is perceived as having the largest effect on successful intra-hospital handovers (Richter, McAlearney, & Pennell, 2016) and creates relational discontinuity (Calleja, Aitken, & Cooke, 2016; Havens, Vasey, Gittell, & Lin, 2010). Phone communication has been identified as an impediment to building relationships during hando- ver, with healthcare professionals expressing that their roles and re- sponsibilities were undervalued on both sides, and it can enhance antagonism between settings as there is no sense of the context on the other unit (Nelson et al., 2017). Nurses have reported poor relationships during handover with nurses being grumpy, rude, dis- missive and stressed during phone-to-phone handover (Bergs et al., 2018). It would be important to foster face-to-face communication practices across units and undertake activities to build teamwork and reconcile issues through negotiation and adaptive forms of be- haviour (Sujan et al., 2014).

Our findings may suggest that a relational co-ordination ap- proach to intra-hospital handover could be advantageous, a strategy used to address low-quality nontechnical skills such as communica- tion, teamwork and task management (Pless et al., 2017). Relational co-ordination supports centralised co-ordination of tasks at the meso-level, whereby leaders that sit across units take responsibil- ity for ensuring standardisation of the task (Pless et al., 2017). This approach is supported by fixed formal procedures such as handover SOPs. However, at the micro-level ED and IPU nurses require flex- ibility and communication across their boundaries to improve rela- tional co-ordination. Relational co-ordination approaches promote proactive conflict resolution and face-to-face communication at the micro-level (Pless et al., 2017). Having these opportunities would allow nurses to openly discuss the tension they face on their units together and provide the flexibility to make trade-offs around their handover practice.

5.1 | Limitations

First, we were unable to separate senior and junior nurses in our sample during interviews because of staffs' workload constraints; however, on commencement of interviews, we identified who was

13652702, 2020, 13-14, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/jocn.15214 by U

niversity of M iam

i, W iley O

nline L ibrary on [23/09/2023]. See the T

erm s and C

onditions (https://onlinelibrary.w iley.com

/term s-and-conditions) on W

iley O nline L

ibrary for rules of use; O A

articles are governed by the applicable C reative C

om m

ons L icense

     |  2237TOBIANO eT Al.

senior and junior and tailored probing questions to each group. Given junior and senior nurses had different roles in the handover process, they comfortably shared their different experiences. Second, focus groups may have resulted in less in-depth findings when compared to one-on-one interviews; however, the experienced interviewer used techniques to gain rich data. Third, this study was conducted at a single site; thus, the experiences identified may not be consistent with nurses' experiences at other types of hospitals, in other con- texts. Though our findings are not intended for generalisation, we have provided dense descriptions of the context, sample and hos- pital processes, allowing others to judge applicability for their own setting.

6  | CONCLUSION

At one hospital, intra-hospital handover was challenging due to un- clear processes and poor relationships across units. Nurses dealt with this tension by using strategies such as prompting information and reading EMR, but ultimately relationships were strained. Due to the siloed and specialised nature of IPUs, exploring strategies to ensure information transfer processes are standardised, broad and process-orientated could be required. However, this is not enough. Front-line nurses need support to enhance relational co-ordination; without this, there may be little in improvement in nurses' percep- tions of the quality of nursing handover.

7  | RELE VANCE TO CLINIC AL PR AC TICE

Improvement in intra-hospital handover is challenging because multi- ple hospital units are involved. A meso-level leader could liaise across units and standardise handover processes using SOPs. Within SOPs, checklists could support standardisation consisting of broad content that is acceptable to end-users across varying units, which could be incorporated into EMR. Acknowledging handover as a high-risk task and giving nurses permission to spend time preparing for handover may also facilitate high-quality handover (Clarke et al., 2012).

Teamwork between units also requires attention. Relational co-ordination frameworks may assist in devising strategies to pro- mote collaboration across units. At the micro-level more frequent, timely, accurate and problem-solving face-to-face communication between units may be required. For instance, translational simula- tion (Brazil, Purdy, Alexander, & Matulich, 2019) and nursing rounds (Tobiano et al., 2019) have been shown to enhance comradery across units (Rosenbaum, 2019). Promoting more opportunities for secondment in other units could also enhance relationships (Dryden & Rice, 2008).

ACKNOWLEDG EMENTS Thank you to the nurses who very willingly facilitated and partici- pated in group interviews. Thank you to Gai Meade and Emma Wells who were note keepers during some interviews.

CONFLIC T OF INTERE S T All authors have no conflicts of interest to declare.

AUTHOR CONTRIBUTION All authors meet the following criteria: made substantial contribu- tions to the conception and design, or acquisition, analysis and in- terpretation of data; drafted the manuscript or revised it critically for important intellectual content; approved the final version to be published, agreed to take public responsibility for appropriate por- tions of the content; and are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

ORCID Georgia Tobiano https://orcid.org/0000-0001-5437-0777 Andrea P. Marshall https://orcid.org/0000-0001-7692-403X

R E FE R E N C E S Alamanou, D. G., & Brokalaki, H. (2014). Intrahospital transport policies:

The contribution of the nurse. Health Science Journal, 8(2), 166–178. Australian Institue of Health and Welfare (2018). Emergency department

care 2017–18: Australian hospital statistics. Retrieved from https:// www.aihw.gov.au/repor ts/hospi tals/emerg ency-depar tment -care-2017-18/data

Bergman, L., Pettersson, M., Chaboyer, W., Carlström, E., & Ringdal, M. (2019). Improving quality and safety during intrahospital transport of critically ill patients: A critical incident study. Australian Critical Care, 32, 8–9. https://doi.org/10.1016/j.aucc.2018.12.003

Bergs, J., Lambrechts, F., Mulleneers, I., Lenaerts, K., Hauquier, C., Proesmans, G., … Vandijck, D. (2018). A tailored interven- tion to improving the quality of intrahospital nursing handover. International Emergency Nursing, 36, 7–15. https://doi.org/10.1016/j. ienj.2017.07.005

Brazil, V., Purdy, E., Alexander, C., & Matulich, J. (2019). Improving the relational aspects of trauma care through translational simulation. Advances in Simulation, 4(1), 10. https://doi.org/10.1186/s4107 7-019-0100-2

Calleja, P., Aitken, L., & Cooke, M. (2016). Staff perceptions of best prac- tice for information transfer about multitrauma patients on discharge from the emergency department: A focus group study. Journal of Clinical Nursing, 25(19–20), 2863–2873. https://doi.org/10.1111/ jocn.13334

Clarke, D., Werestiuk, K., Schoffner, A., Gerard, J., Swan, K., Jackson, B., … Probizanski, S. (2012). Achieving the ‘perfect handoff’ in patient trans- fers: Building teamwork and trust. Journal of Nursing Management, 20(5), 592–598. https://doi.org/10.1111/j.1365-2834.2012.01400.x

Dryden, H., & Rice, A. M. (2008). Using guidelines to support second- ment: A personal experience: Using guidelines to support second- ment. Journal of Nursing Management, 16(1), 65–71. https://doi. org/10.1111/j.1365-2934.2007.00794.x

Elliot, R., & Timulak, L. (2005). Descriptive and interpretive approaches to qualitative research. In J. Miles, & P. Gilbert (Eds.), A handbook of research methods for clinical and health psychology (pp. 147–159). Oxford, UK: Oxford University Press.

Elo, S., & Kyngäs, H. (2008). The qualitative content analysis pro- cess. Journal of Advanced Nursing, 62(1), 107–115. https://doi. org/10.1111/j.1365-2648.2007.04569.x

Ernst, K. M., McComb, S. A., & Ley, C. (2018). Nurse-to-nurse shift hand- offs on medical–surgical units: A process within the flow of nursing care. Journal of Clinical Nursing, 27(5–6), e1189–e1201. https://doi. org/10.1111/jocn.14254

13652702, 2020, 13-14, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/jocn.15214 by U

niversity of M iam

i, W iley O

nline L ibrary on [23/09/2023]. See the T

erm s and C

onditions (https://onlinelibrary.w iley.com

/term s-and-conditions) on W

iley O nline L

ibrary for rules of use; O A

articles are governed by the applicable C reative C

om m

ons L icense

2238  |     TOBIANO eT Al.

Gardiner, T. M., Marshall, A. P., & Gillespie, B. M. (2015). Clinical hando- ver of the critically ill postoperative patient: An integrative review. Australian Critical Care, 28(4), 226–234. https://doi.org/10.1016/j. aucc.2015.02.001

Gittell, J. H., Godfrey, M., & Thistlethwaite, J. (2013). Interprofessional collaborative practice and relational coordination: Improving health- care through relationships. Journal of Interprofessional Care, 27(3), 210–213. https://doi.org/10.3109/13561 820.2012.730564

Gonzalez, C. E., Brito-Dellan, N., Banala, S. R., Rubio, D., Ait Aiss, M., Rice, T. W., … Escalante, C. P. (2018). Handoff tool enabling standard- ized transitions between the emergency department and the hos- pitalist inpatient service at a major cancer center. American Journal of Medical Quality, 33(6), 629–636. https://doi.org/10.1177/10628 60618 776096

Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. The Joint Commission Journal on Quality and Patient Safety, 32(3), 167–175. https://doi.org/10.1016/S1553 -7250(06)32022 -3

Havens, D. S., Vasey, J., Gittell, J. H., & Lin, W.-T. (2010). Relational coor- dination among nurses and other providers: Impact on the quality of patient care. Journal of Nursing Management, 18(8), 926–937. https:// doi.org/10.1111/j.1365-2834.2010.01138.x

Holden, R. J., Carayon, P., Gurses, A. P., Hoonakker, P., Hundt, A. S., Ozok, A. A., & Rivera-Rodriguez, A. J. (2013). SEIPS 2.0: A human factors framework for studying and improving the work of healthcare pro- fessionals and patients. Ergonomics, 56(11), 1669–1686. https://doi. org/10.1080/00140 139.2013.838643

Johnsson, A., Wagman, P., Boman, Å., & Pennbrant, S. (2018). What are they talking about? Content of the communication exchanges be- tween nurses, patients and relatives in a department of medicine for older people—An ethnographic study. Journal of Clinical Nursing, 27(7–8), e1651–e1659. https://doi.org/10.1111/jocn.14315

Krefting, L. (1991). Rigor in qualitative research: The assessment of trustworthiness. The American Journal of Occupational Therapy, 45(3), 214–222. https://doi.org/10.5014/ajot.45.3.214

Manias, E., Gerdtz, M., Williams, A., & Dooley, M. (2015). Complexities of medicines safety: Communicating about managing medicines at transition points of care across emergency departments and med- ical wards. Journal of Clinical Nursing, 24(1–2), 69–80. https://doi. org/10.1111/jocn.12685

Marshall, A. P., Tobiano, G., Murphy, N., Comadira, G., Willis, N., Gardiner, T., … Gillespie, B. M. (2018). Handover from operating theatre to the intensive care unit: A quality improvement study. Australian Critical Care, 32(3), 229–236. https://doi.org/10.1016/j. aucc.2018.03.009

Meißner, A., Hasselhorn, H. M., Estryn-Behar, M., Nézet, O., Pokorski, J., & Gould, D. (2007). Nurses' perception of shift handovers in Europe – Results from the European nurses' early exit study. Journal of Advanced Nursing, 57(5), 535–542. https://doi.org/10.1111/j.1365-2648.2006.04144.x

Miles, M. B., Huberman, A. M., & Saldaña, J. (2014). Qualitative data analysis: A methods sourcebook (3rd ed.). Thousand Oaks, CA: SAGE Publications Inc.

Nelson, P., Bell, A. J., Nathanson, L., Sanchez, L. D., Fisher, J., & Anderson, P. D. (2017). Ethnographic analysis on the use of the electronic medical record for clinical handoff. Internal and Emergency Medicine, 12(8), 1265–1272. https://doi.org/10.1007/ s1173 9-016-1567-7

Pless, S., Van Hootegem, G., & Dessers, E. (2017). Making care orga- nizations great again? A comparison of care pathways, lean think- ing, relational coordination, and modern sociotechnical design. International Journal of Care Coordination, 20(3), 64–75. https://doi. org/10.1177/20534 34517 725529

Polit, D., & Beck, C. T. (2008). Nursing research: Generating and assess- ing evidence for nursing practice (8th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Pun, J. K. H., Matthiessen, C. M. I. M., Murray, K. A., & Slade, D. (2015). Factors affecting communication in emergency departments: Doctors and nurses' perceptions of communication in a trilingual ED in Hong Kong. International Journal of Emergency Medicine, 8, 1–12. https://doi.org/10.1186/s1224 5-015-0095-y

QSR International Pty Ltd. (2018). NVivo qualitative data analysis soft- ware; Version 12.

Richter, J. P., McAlearney, A. S., & Pennell, M. L. (2016). The influence of organizational factors on patient safety: Examining successful hand- offs in health care. Health Care Management Review, 41(1), 32–41. https://doi.org/10.1097/HMR.00000 00000 000033

Riesenberg, L. A., Leisch, J., & Cunningham, J. M. (2010). Nursing handoffs: A systematic review of the literature. American Journal of Nursing, 110(4), 24–34. https://doi.org/10.1097/01.NAJ.00003 70154.79857.09

Rosenbaum, L. (2019). Cursed by knowledge — Building a culture of psy- chological safety. New England Journal of Medicine, 380(8), 786–790. https://doi.org/10.1056/NEJMm s1813429

Street, M., Eustace, P., Livingston, P. M., Craike, M. J., Kent, B., & Patterson, D. (2011). Communication at the bedside to enhance pa- tient care: A survey of nurses' experience and perspective of hando- ver. International Journal of Nursing Practice, 17(2), 133–140. https:// doi.org/10.1111/j.1440-172X.2011.01918.x

Sujan, M., Spurgeon, P., & Cooke, M. (2015). The role of dynamic trade- offs in creating safety—A qualitative study of handover across care boundaries in emergency care. Reliability Engineering and System Safety, 141, 54–62. https://doi.org/10.1016/j.ress.2015.03.006

Sujan, M., Spurgeon, P., & Inada-Kim, M. (2014). Clinical handover within the emergency care pathway and the potential risks of clinical handover fail- ure (ECHO): Primary research. Southampton, UK: NIHR Journals Library. Retrieved from https://www.ncbi.nlm.nih.gov/books /NBK25 9597/

Sullivan, C., Staib, A., Khanna, S., Good, N. M., Boyle, J., Cattell, R., … Scott, I. A. (2016). The National Emergency Access Target (NEAT) and the 4-hour rule: Time to review the target. Medical Journal of Australia, 204(9), 354–354. https://doi.org/10.5694/mja15.01177

The Joint Commission (2013). Sentinel event data: Root causes by the event type: 2004-June 2013. Retrieved from http://www.medle ague.com/wp-conte nt/uploa ds/2013/11/Root_Causes_by_Event_ Type_2004-2Q2013.pdf

Tobiano, G., Murphy, N., Grealish, L., Hervey, L., Aitken, L. M., & Marshall, A. P. (2019). Effectiveness of nursing rounds in the Intensive Care Unit on workplace learning. Intensive and Critical Care Nursing, 53, 92–99. https://doi.org/10.1016/j.iccn.2019.03.003

Trossman, S. (2019). Consistent, quality communication. American Nurse Today, 14, 28–30.

World Health Organization (2006). Action on patient safety - High 5s. Retrieved from http://www.who.int/patie ntsaf ety/imple menta tion/ solut ions/high5 s/en/

Yang, J.-G., & Zhang, J. (2016). Improving the postoperative handover process in the intensive care unit of a tertiary teaching hospital. Journal of Clinical Nursing, 25(7–8), 1062–1072. https://doi.org/10.1111/jocn.13115

SUPPORTING INFORMATION Additional supporting information may be found online in the Supporting Information section.

How to cite this article: Tobiano G, Ting C, Ryan C, Jenkinson K, Scott L, Marshall AP. Front-line nurses' perceptions of intra-hospital handover. J Clin Nurs. 2020;29:2231–2238. https://doi.org/10.1111/jocn.15214

13652702, 2020, 13-14, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/jocn.15214 by U

niversity of M iam

i, W iley O

nline L ibrary on [23/09/2023]. See the T

erm s and C

onditions (https://onlinelibrary.w iley.com

/term s-and-conditions) on W

iley O nline L

ibrary for rules of use; O A

articles are governed by the applicable C reative C

om m

ons L icense