Nursing

Module5-JNCQ-D-20-00290.pdf

Barriers to and Facilitators of Bedside Nursing Handover

A Systematic Review and Meta-synthesis Marco Clari, PhD, RN; Alessio Conti, PhD, RN; Daniela Chiarini, RN; Barbara Martin, MSc; Valerio Dimonte, MSc, RN; Sara Campagna, PhD, RN

ABSTRACT Background: Bedside nursing handover (BNH) has been recognized as a contributor to patient-centered care. However, concerns about its effectiveness suggest that contextual factors should be considered before and after BNH implementation. Purpose: This review aimed to identify, evaluate, and synthetize the qualitative literature on the barriers to and facilitators of BNH as experienced by nurses and patients. Methods: The Joanna Briggs Institute meta-aggregation method was applied. A systematic search was per- formed to identify qualitative studies published from inception to June 30, 2020. Two independent researchers assessed methodological quality and extracted data. Results: Twenty-four articles were included, comprising 161 findings, and 5 synthesized findings emerged with a moderate level of confidence. Conclusions: BNH ensures patient safety and increases satisfaction and recognition among patients and nurses. This evidence on the barriers to and facilitators of BNH could help health care providers who have implemented or plan to implement this practice. Keywords: implementation science, meta-aggregation method, patient handoff, quality of health care, systematic review

The term “handover” refers to a routine nursing activity during which information,

professional responsibility, and accountability for the care of patients are transferred due to a transition in care.1 Handovers can be performed in different ways2 and occur up to 3 times per day across different settings when patients are admitted, transferred, or discharged from or within health care providers. This process is complex and has been widely recognized as a time-consuming, potentially risk-laden activity, representing a challenge in clinical practice

Author Affiliations: Department of Public Health and Pediatrics, University of Torino, Torino, Italy (Drs Clari, Conti, and Campagna and Ms Martin and Mr Dimonte); and Department of Surgery, Città della Salute e della Scienza University Hospital, Torino, Italy (Ms Chiarini).

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com).

Correspondence: Alessio Conti, PhD, RN, Department of Public Health and Pediatrics, University of Torino Via Santena 5 bis, 10126 Torino, Italy ([email protected]).

Accepted for publication: February 15, 2021

Published ahead of print: April 12, 2021

DOI: 10.1097/NCQ.0000000000000564

and management.3,4 Because handovers are recurrent and potentially lead to patient harm,4

ensuring safety and quality in this process has recently become a health care priority.5 Conse- quently, greater focus has been placed on the handover process, specifically on the promising characteristics of bedside nursing handover (BNH).

The value of moving handovers to patients’ bedsides through BNH has gradually gained recognition in acute care hospitals,6-8 because it allows patients to interact; thus, it maximizes the proficiency of care delivery while minimizing communication problems.9 Unlike nonbedside handover processes, nurses are not taken away from patients’ beds during BNH, which can result in a more efficient use of their time.1,2

Although previous studies have presented BNH as a necessary practice that contributes to patient-centered care,10 conflicting evidence exists on the long-term effectiveness of BNH.11

This suggests that contextual factors (eg, social processes, resources, and organization policies) should be considered before and after BNH is implemented.

Although BNH has been promoted emphat- ically to improve patient safety, many existing

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reviews that described this process were not sys- tematic; instead they used narrative approaches. These reviews focused on the impact of BNH on patients and providers,12,13 the issues related to implementation, the tools needed to assess BNH in practice,14 the content of the information shared,15 and patient participation during the process.10 Two systematic reviews summarized the qualitative literature on patients’, families’, and nurses’ experiences of BNH.16,17 Despite the need for evidence on the contextual factors rel- evant to BNH, no review has focused on which of these factors should be considered before and after the implementation of BNH to ensure opti- mal results. Indeed, implementing nontraditional handover processes in real-life settings may rep- resent a challenge for health care providers.18

Therefore, it seems necessary to identify el- ements that support or hinder BNH from an end user perspective. Qualitative research can improve our understanding of which elements patients and nurses consider relevant in applying BNH, and the synthesis of these elements might represent useful evidence that can be applied in the clinical context. Thus, this systematic review aimed to identify, evaluate, and synthetize the qualitative literature on the barriers to and fa- cilitators of BNH as experienced by nurses and patients.

METHODS This systematic review and meta-synthesis was conducted following the Joanna Briggs Institute (JBI) method of meta-aggregation,19 and pre- sented following the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidelines.20 Meta-aggregation is a well-consolidated, rigorous method for produc- ing evidence to inform clinical decision-making. It retains the conventions and requirements of qualitative approaches by implementing a quan- titative review process that conforms to the meta-analytic process.19 Two researchers, 1 with clinical experience and 1 with methodological experience, completed the process independently.

Search strategy The literature search strategy combined elec- tronic and manual searches,19 involving an expert librarian. A preliminary search was per- formed to strengthen the search sensitivity and to identify additional suitable keywords and index terms referring to the review question. A system-

atic search was then performed in the PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Scopus, Em- base, and Web of Science databases, applying a combination of thesaurus terms and free key- words with Boolean operators, consistent with the Participants, phenomenon of Interest, and Context (PICo) model.19 A manual search of the reference lists of all included articles was also performed to identify any additional articles. Duplicates were identified through a citation manager software and removed. The complete search strategy is reported in Supplemental Dig- ital Content Table 1 (available at: http://links. lww.com/JNCQ/A852). The inclusion and ex- clusion criteria are presented in Supplemental Digital Content Figure 1 (available at: http:// links.lww.com/JNCQ/A853).

Assessment of methodological quality The methodological quality of eligible articles was appraised with the 10-item JBI Qualita- tive Assessment and Review Instrument (QARI) critical appraisal tool.19 Each item was scored as “yes” (fulfilled), “no” (not fulfilled), or “un- clear.” The researchers agreed to include only eligible articles that attained a score of at least 60% (see Supplemental Digital Content Table 2, available at: http://links.lww.com/JNCQ/A854).

Data extraction The following data were extracted from each included article: study methodology, data collec- tion method, phenomenon of interest, geograph- ical/cultural setting, participants, data analysis, and conclusions. Findings were independently extracted as reported in the original articles.19

The JBI-QARI software was used to analyze and classify findings as unequivocal (ie, supported by data beyond any doubt) or credible (ie, plausible considering the data and the theoretical frame- work). Findings for which no connection was identified between the data and the findings were classified as unsupported and excluded.19

Data synthesis Unequivocal and credible findings were aggre- gated and synthesized into categories based on homogeneity in meaning.19 Consistent with the JBI approach, a minimum of 2 findings were re- quired to create a category. All researchers inde- pendently appraised the categories created, and disagreements were solved through discussion.

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The final set of synthesized findings was created by aggregating all obtained categories.19

Assessment of level of confidence The ConQual approach was applied to assess the level of confidence of each synthesized finding. Developed to assist clinical decision-making, this assessment method ranks the level of confidence of qualitative evidence as high, moderate, low, and very low. The type of study, as well as its dependability and credibility, can contribute to a reduction in the level of confidence.21

RESULTS A description of the search outcome is presented in Supplemental Digital Content Figure 1 (avail- able at: http://links.lww.com/JNCQ/A853). A total of 24 articles, published between January 1, 1998, and June 30, 2020, were included in the review.22-45 The details of the included stud- ies are reported in Supplemental Digital Content Table 3 (available at: http://links.lww.com/ JNCQ/A855).

A total of 161 findings were extracted from the included articles; no findings were excluded due to a lack of quality. Findings were aggregated into 5 synthesized findings, composed of 23 cat- egories depicting barriers to and facilitators of BNH. They are reported in Supplemental Digital Content Table 4 (available at: http://links.lww. com/JNCQ/A856), with some illustrative quotes.

Humanize care and ensure safety, but may cause stress and feelings of inadequacy BNH enhanced patients’ awareness of and their connection with nurses, and allowed them to participate in their own care.22,24,31 Patient in- volvement during BNH provided an opportunity for them to spend more time with nurses, thereby promoting dialogue.22,27,30,32,43 Furthermore, pa- tients described that the personalized approach of BNH ensured tailored care delivery,24,36 in which the person came first.24,37,43 The rela- tionship between nurses and patients became a partnership during BNH. Patients and nurses could acquire further clarifications and provide additional information, which helped to ensure quality of care.39,40,42,43

During BNH, patients observed and listened to the information transmitted, which increased their confidence in the care.32,40,43 This interac- tive partnership ensured the right of negotiation between patients and nurses, and decreased

anxiety and perceived isolation, thus preserv- ing their physical and emotional security.33,34,40

Active participation during BNH involved pa- tients directly in their care process, keeping them informed of their progress and ensuring that the clinical information they received was personalized.23,26,28,33,37,43 BNH also allowed pa- tients to complain about inadequate care,25

and allowed nurses to verify the complete- ness of the information collected during BNH so that prompt adjustments could be made if needed.23,28,29,32,35,39,41-44 Nurses also reported having to improve the quality of written records to avoid embarrassing situations in front of patients.33

Patients often reported refusing to dialogue with nurses during BNH, as they felt they could not contribute meaningfully because they lacked the appropriate knowledge.23 The more complex the clinical decisions became, the less patients wanted participate in BNH, preferring instead to take on a passive role.23,40,42 Indeed, patients with complex health problems described BNH as an activity that was performed by professionals and did not require their presence.44 Nurses had conflicting opinions about the importance of pa- tient involvement during BNH.45 Their rationale for excluding patients from this process was re- lated to patients’ lack of expertise and the fatigue nurses experienced when they failed to succeed in the time-consuming task of understanding pa- tients’ needs.34 Such failures led nurses to be superficial and shorten BNH,23,34,43 resulting in patients feeling excluded and in negative patient perceptions of the process.37

Optimize organization of care but may lead to overtime and transmission of redundant information Through BNH, nurses could perform compre- hensive clinical assessments of patients rapidly and prioritize care activities.22,24,27,29,35,39 The continuous flow of information ensured a con- stant control of care,24,26,27 while the use of technological supports facilitated the transmis- sion and regular updating of data.28 The head nurse was a fundamental reference point, ensur- ing that the data were processed and forwarded by all staff members.38 Through BNH, patients reported that they became aware of the organiza- tional patterns in the hospital.25,27,35 They would call nurses less because they were more aware of the nurses’ schedules and did not want to risk

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interrupting them.35,43 Patients were also able to evaluate available staff resources, and wondered whether BNH needed to be repeated daily, but expressed their willingness to remain involved.23

Nurses who had to work overtime often felt the need to rush to complete all their tasks, including BNH.27,35,44 Moreover, tech- nological supports were sometimes seen as time-consuming tools.28 Some nurses even ac- knowledged stopping BNH with patients who had more complex issues.35 Patients whose BNH was performed with nurses who were working overtime were sometimes frustrated, because these nurses were perceived to be absent, hasty, superficial, and not engaged in the therapeutic relationship.34 Nurses claimed that distrac- tions, noises, and interruptions were inevitable during BNH, and that these could lead to omissions.28,31,41,45 In their opinion, the old han- dover methods, for which nurses sat around a table, entailed less risk of losing information.28,31,44 If nurses expressed their dissatisfaction with discontinuity of care during BNH, patients sometimes felt less considered in the organization of care.26,42 The need to repeat the same information at every shift could overwhelm both nurses and patients. Both par- ties failed to recognize the need to perform BNH regularly, and in some cases considered it a waste of time.30,31 Nurses considered that repeating information could lead to the poten- tially dangerous loss or omission of necessary clinical details, especially if there were frequent overlapping shifts or interruptions.39

Can lead to lack of confidentiality but shared decision-making may reduce these concerns in patients Privacy violations were always considered prob- lematic during BNH.26 Patients described a paradox of confidentiality37; they considered re- spect for privacy to be fundamental, but they were not concerned about it during BNH.36,37

Simple strategies were used to maintain confi- dentiality during BNH, such as asking patients if they wanted to have caregivers present.28,31

Maintaining a private setting provided further confidentiality during BNH,31,34 as did agree- ments between nurses and patients concerning what information could be communicated in front of others.32,42,44

Nurses described the management of confi- dential information as an additional complexity

of BNH.28,33,35 They were particularly concerned about the privacy violations that could oc- cur due to the presence of other patients or caregivers.27,28,31,35,38,44 The greatest challenge was to pass relevant information to incoming colleagues while maintaining confidentiality.41,45

Patients perceived their medical data as sensi- tive and considered information about sexually transmitted diseases or addiction problems to be discriminatory. They thought that such issues should be treated with great care and should not be discussed during BNH.32,36,42-44 As pa- tients also often confused BNH and medical examinations,36 they renounced BNH when they believed it was affecting their privacy.42

Promote clear, interactive communication but may lead to uncertainty and discomfort The mutual exchange of information between patients and nurses made for interactive com- munication during BNH.30,40 Dialogues between staff and patients were described as friendly and included humor and gratitude.25 It was empha- sized that, to ensure a reasonable exchange of information, communication should take place in a cordial and friendly context and leave the appropriate space for emotions.23,24 BNH of- fered nurses and patients the opportunity to ask questions and receive answers.25,35,42 Be- cause of BNH, nurses were obligated to translate clinical information into more comprehensible language, so that patients could understand changes in their health status.25,30,42 This was valuable in ensuring patient safety and ensuring their right to receive transparent information.42

Nurses described that BNH facilitated commu- nication between professionals because it is a structured method.31,38 BNH promoted the use of specialized language, which in turn reassured patients of nurses’ competence.28,29 The structure of BNH also facilitated its execution and pro- vided a guide for less experienced colleagues and students.28,39

Although BNH is a structured method, nurses expressed a sense of uncertainty as to the level of detail they should use during this process.24

In particular, they felt that they could not answer patients’ questions during BNH and complained about the confusion this might create.35 Such concerns about communication were particularly prevalent among less expe- rienced nurses.28 The scientific language that BNH requires left some patients feeling excluded

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from the process.36 They perceived BNH as an excuse for the staff to exercise control and as- sert their authority over them.23,36,37 In addition, language barriers sometimes limited nurses’ un- derstanding of specific information, which in some cases led patients to exhibit discriminatory behaviours.31

Promote professionalism and emotional exchanges among nurses but may contribute to decreased sense of collegiality and security Nurses described BNH as a means to provide insight into the nursing profession in front of patients.22,24 Nurses claimed that BNH encour- aged them to give further explanations of clinical information and use appropriate language con- fidently, which patients and nursing students perceived as nurses’ professionalism.23,37 Com- pared to traditional methods, BNH gave nurses a greater sense of responsibility and constituted a valuable tool for students to understand the im- portance of patients having an active role during nursing practice.23 Nurses reported that observ- ing colleagues during BNH offered them both the opportunity to learn from and teach each other, reinforcing the relationships among staff involved in planning and care.28,35 In addition to its professional influence, BNH offered nurses the time to deal with and calm their anxiety, and lighten their emotional burden.23 These benefi- cial effects were also evident to patients, who rec- ognized BNH as a tool for professional and emo- tional debriefing among health care providers.23

BNH was not always warmly accepted by all nursing staff; some described that the re- placement of nonbedside handover methods substantially limited collegiality.38 They referred explicitly to the free expression that nonbedside handover methods afforded them, methods that were devoted to sharing concerns and reducing frustrations among colleagues.38,45 When BNH was applied in contexts where nurses were less skilled and cared for a small number of patients, BNH especially provoked calls for a return to previous handover methods.27,31,38 BNH some- times led to feelings of uncertainty in nurses, especially if they felt judged by patients or expe- rienced colleagues during the process.23,35 Nurses described interacting with and being questioned in front of the patient without having enough information as an anxiety-generating barrier that contributed to embarrassing situations.35,44

Sometimes nurses reported that practicing an intellectual task like BNH, which included no technical element, caused them embarrassment, because patients did not consider BNH a neces- sary process, but as a chat between the staff that was inconsistent with care.44

The 5 synthesized findings had a moderate ev- idence quality score due to the downgrading of 1 level in a credibility criterion (see Supplemen- tal Digital Content Table 5, available at: http:// links.lww.com/JNCQ/A857).

DISCUSSION This systematic review provided qualitative evi- dence of the experiences of patients and nurses regarding barriers to and facilitators of BNH. These findings could deepen our knowledge about the barriers and facilitators that are rec- ognized by nurses and patients. Moreover, the moderate level of confidence of the synthesized findings suggests that they are suitable for incor- poration into clinical practice.

The active role of patients in BNH distin- guishes this method from conventional medical models; it recognizes that nurses have different identities, and patients considered BNH as an opportunity to spend time with nurses.7 The in- volvement of patients and families is promoted in BNH,16 and when patients and families were in- volved in BNH, they reported feeling recognized as care partners. They also said they under- stood the medical condition better, and became more aware of both the care provided and future treatment plans.16 This involvement helped pa- tients develop closer relationships with staff and contributed to the humanization of care. BNH has been recommended as a method that main- tains relational continuity, individualizes care, and provides a patient-centered approach that allows patients to be part of their care process, thus ensuring safety.1,12 Indeed, patient involve- ment has gained increasing relevance in clinical settings, and is now recognized as essential to the provision of safe care.46 However, some patients and nurses had negative reflections on BNH. The use of medical jargon and talking over patients have already been described as things to avoid to keep patients from feeling excluded and to promote their involvement in BNH.10 Although some patients described this behavior as reassur- ing, as it signals a high level of competence, it might amplify the vulnerability of patients, espe- cially those without linguistic proficiency.47

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BNH enables early patient assessment and has been found to promote the prioritization of care rather than the performance of routine activities or preestablished tasks.10,15 In this regard, evi- dence has shown that starting nursing shifts with rounds before performing handovers increased the amount of time spent directly with patients, ensured that their needs were addressed, and al- lowed them to participate meaningfully in the handover without requiring additional care.8 Al- though nurses in the included studies expressed concerns about having to work overtime, BNH has actually been found to decrease the time spent on handovers,13,14 leading to reduced over- time costs and discharge times, and generating cost savings for the organization.48 Findings from the included articles highlighted that BNH requires considerable effort from nurses, but in contrast to traditional approaches, it does not move them away from the patient’s bed and can result in a more efficient use of their time. This results in a continuity of care that depends on the accuracy and completeness of the informa- tion conveyed.1

BNH seemed to improve staff satisfaction and enhance the working environment, playing a fundamental role in the improvement of team collaboration.48 In particular, the findings of the present review supported emerging evidence that BNH can improve communication between colleagues and patients and provide an opportu- nity to further strengthen their relationships.10,12

Moreover, BNH can enable a mutual exchange of information and emotions, creating a cli- mate that supports the emotional well-being of staff and improves quality of care and safety.49

Addressing confidentiality concerns is essen- tial in the implementation of BNH, as such con- cerns can generate anxiety in nurses and become an obstacle to effective communication.12,14

Some strategies that could be employed by nurses to address privacy concerns have been identified in this review. They include approaches that have already been outlined, such as moving close to patients and other nurses, speaking quietly at the bedside, discussing sensitive information in a pri- vate area, pointing at written information, and pulling curtains closed in patients’ rooms.50 In these ways, behaviors that do not promote ef- fective communication, such as those connected to a lack of confidence, fear of being judged by colleagues and patients, a negative opinion

about the relevance of information supplied by patients, and the time required to communicate, should be limited.12,13

The findings of this review acknowledged the impact BNH can have on professionalism. Dur- ing BNH, nurses are close to patients for a con- siderable amount of time, which leads patients to have an increased knowledge of and trust in staff members.51 Nurses experienced increased professional satisfaction with BNH, and BNH has already been shown to enhance the quality of the nursing process and nurses’ accountabil- ity, teamwork, and prioritization abilities.7 This systematic review has implications for nursing practice and for research on contextual factors that should be considered when implementing the BNH, as shown in Supplemental Digital Con- tent Table 6 (available at: http://links.lww.com/ JNCQ/A858).

Our meta-synthesis has some limitations. The review of 6 literature databases and the re- striction to studies published in English and Italian could have excluded relevant articles that offer further results or examined different con- texts and cultural perspectives. The majority of our findings came from studies performed in high-income countries with different health care systems and different social considerations when it comes to nurses, which may limit the general- izability of our findings. Furthermore, we cannot exclude the possibility that bias has occurred in the research and selection of studies, which was carried out by 2 independent researchers. Despite the aforementioned limitations, this review was conducted following the JBI meta-aggregative approach,24 which ensures the highest rigor, and it is the first meta-synthesis to describe the barri- ers to and facilitators of BNH.

CONCLUSIONS This meta-synthesis provided qualitative evi- dence on the barriers to and facilitators of BNH. The identified findings, derived from the expe- riences of patients and nurses, encompass areas related to the humanization of care, patient safety, health care management, and profession- alism. Health care providers should consider these barriers and facilitators before implement- ing BNH and when adapting BNH in their facility after implementation, in order to design processes that will offer safer care for patients and their families, and ensure increased satisfac- tion and social recognition.

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