The qualitative article critique written paper
\nSelection of an article for critique:
\nfor this assignment you will have in this order:<\/p>\n
-One cover page
\n-A reaction paper summary up to 10 pages (to be written collaboratively).
\n-One copy of the article
\n-Grading will be as follows:
\n-Title (5 points)
\n-Does the title clearly and concisely describe the study?
\n-Is the population\/sample included in the title?<\/p>\n
Please do the assign as following: the article is under the instructions.<\/p>\n
a) Abstract (5 points)
\n1- Is an abstract included in the article?
\n2- Does the abstract include a statement of the problem, purpose, and\/or hypothesis?
\n3- Does the abstract briefly summarize the design, methodology, results, and conclusions?
\n4- Is the abstract adequate? Why or why not?<\/p>\n
b) Confidence in the Findings (5 points)
\n1- What are the qualifications and reputation of the investigator\/s?
\n2- What evidence is there in this report that they are qualified to conduct this study?
\n3- Is this article published in a referred journal?<\/p>\n
c) Theoretical Framework\/Conceptual Framework (10 points)
\n1- Is a theoretical or conceptual framework described? If not, does the absence detract from the significance of the research?
\n2- Does the research problem flow naturally from the conceptual framework?<\/p>\n
d) Protection of Human Rights (5 points)
\n1- Is there evidence of an independent ethics review by a board (IRB) or a committee?
\n2- Has the study been designed to minimize risk and maximize benefits to participants?
\n3- Is there an indication that participants gave voluntary, informed consent?
\n4- Is there evidence in the study that individuals can be identified?<\/p>\n
e) The Problem (10 points)
\n1- Was the problem statement introduced promptly?
\n2- Is the problem significant to nursing and is the significance described?
\n3- Has the purpose for conducting the research been explained?
\n4- What are the research variables and how are they measured\/operationalized?
\n5- Will an answer to the problem provide insight into clinical applicability of the problem?<\/p>\n
f) Research Questions\/Hypotheses (10 points)
\n1- Are research questions or hypotheses formally stated? If no, should they be included?
\n2- Do the research questions and hypotheses naturally flow from the research problem and theoretical framework?
\n3- Does each research question or hypothesis contain at least two variables?
\n4- Are the research questions or hypotheses worded clearly and objectively? Is a prediction evident?
\n5- If there is not a research question or hypothesis, write one for the study and explain why your hypothesis or research question fits the study.<\/p>\n
g) Review of the Literature (10 points):
\n1- Is the review comprehensive, logical and relevant to the problem?
\n2- is the relationship to the research purpose evident?
\n3- Does it include recent research?
\n4- Can a case be made for conducting this study based on the review?<\/p>\n
h) Research Design (5 points):
\n1- What design has been used for the study?
\n2- Is the design appropriate for the research question and the purpose of the research?
\n3- Has enough information been given to permit replication?
\ni) Sampling (10 points):
\n1- Is the target population carefully described?
\n2- Are sample selection procedures clearly defined?
\n3-Does the sampling method fit the research design?
\n4-Are potential sample biases described?
\n5- Is the sample sufficiently large?
\n6- Did the author\/authors use power analysis to document that the study size was adequate or inadequate?
\n7- How was sample size justified?
\n8- To whom can study results be generalized?<\/p>\n
j) Data Collection (10 points):
\n1- Describe the instruments used for data collection.
\n2- Has rationale been given for the selection of instruments?
\n3- Are instruments congruent with the research question?
\n4- Are instruments suitable for use with the study sample?
\n5- Have procedures for testing the reliability and validity of instruments been described? Are results sufficient to indicate their use?<\/p>\n
k) Qualitative Analysis (5 points):
\n1- Is the link between the analysis and the findings logical and clear?
\n2- Is the statistical result presented clearly both in the text as well as in numerical presentation?
\n3- Are graphic displays clear and simple?<\/p>\n
l) Conclusions and Recommendations (10 points):
\n1- What are the assumptions and limitations of the study? Are they listed or do you have to infer what they are?
\n2- Are results of data analysis clearly explained in reference to research questions, hypothesis and theoretical framework?
\n3- What recommendations for nursing practice and future research studies have been made? Are these recommendations supported by the data?<\/p>\n
ARTICLE
\nArticle
\nChallenges of Nursing
\nHandover: A Qualitative
\nStudy
\nRaheleh Sabet Sarvestani, RN, MSN1,
\nMarzieh Moattari, PhD, MD, RN1,
\nAlireza Nikbakht Nasrabadi, PhD, MD, RN2,
\nMarzieh Momennasab, PhD, MD, RN1, and
\nShahrzad Yektatalab, PhD, MD, RN1
\nAbstract
\nThe aim of this study was to explore the challenges of nursing handover
\nprocess during shift rotation in hospitals. The research had a descriptive
\nexploratory design with a qualitative content analysis approach. To conduct
\nthe study, three pediatric wards were selected at first. Data were gathered
\nthrough a 4-month observation of nursing handovers by recording the oral
\nconversations of nurses during the process and semistructured interviews.
\nThen, qualitative content analysis was used for data analysis. Two major
\nthemes and five subthemes emerged through the data analysis. The first
\nand the second themes were a nonholistic approach and poor management,
\nrespectively. In general, applying a holistic approach and managing handover
\nsituations are recommended for nursing managers to overcome handover
\nchallenges. Future focus could be on addressing handover challenges through
\nan action research study.
\nKeywords
\nhandover, nursing, content analysis
\n1Shiraz University of Medical Sciences, Iran
\n2Tehran University of Medical Sciences, Iran
\nCorresponding Author:
\nMarzieh Moattari, Department of Nursing, School of Nursing and Midwifery, Shiraz University
\nof Medical Sciences, Shiraz, Iran.
\nEmail: Moattari@yahoo.com
\n508134 CNRXXX10.1177\/1054773813508134Clinical Nursing ResearchSarvestani et al.
\nresearch-article2013
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\nSarvestani et al. 235
\nIntroduction
\nThe nursing change of shift report or handover is a valuable opportunity to
\ntransfer responsibility and accountability from one nurse to another in most
\nhospital wards (Lamond, 2000). It is actually a substantial part of a nurse\u2019s
\nduty, and each nurse should allocate 38% of his or her working hours in a
\nhospital ward every day to fulfill the handover process (Spanke & Thomas,
\n2010). Therefore, handover is a fundamental component of nursing care for a
\nnurse to pass on patients\u2019 care plan, practices, information, and priorities to
\nthe next (Rushton, 2010). Moreover, handover is an opportunity for nurses\u2019
\ngroup cohesion, professional socialization, education, interaction, and emotional
\nsupport (Griffin, 2010; Payne, Hardey, & Coleman, 2000). Thus,
\nhandover should be accurate, complete, specific, relevant, timely, up to date,
\nsubjective, and objective. However, cases of handover that are inaccurate,
\nincomplete, and biased may lead to many errors, mislead nursing practices,
\nand increase patient complications (Rushton, 2010; Strople & Ottani, 2006).
\nA key component in patient safety and care quality is accurate communication
\nduring handover (Chaboyer, 2011). The Joint Commission on
\nAccreditation of Health Care Organizations (JCAHO) has established standardizing
\nhandover as a priority for improving patient safety since 2006
\n(Chaboyer, 2011; Schroeder, 2006). However, a review of literature reflects
\nlimited research and articles addressing handover, while most of them highlighted
\nthe importance of nursing handover and prioritized it for patient
\nsafety (Baker, 2010; Blouin, 2011; Schroeder, 2006; Scott, 2012; Welsh,
\nFlanagan, & Ebright, 2010).
\nAlthough there are controversies about the efficacy of handover practices,
\nsome articles highlight the importance of oral shift report that could not be
\nsubstituted by any other method because handover is the only place where
\ndifferent aspects of professional nursing care are identified (Gordon &
\nFindley, 2011; Manias & Street, 2000; Scovell, 2010); otherwise, other studies
\nquestion its efficacy and report that there is no need to have an oral shift
\nreport because most of the discussed information could be located within
\nnursing documentation, and, therefore, such a practice is time-consuming
\n(Manias & Street, 2000; Sexton et al., 2004).
\nIn practice, the complexity of patients\u2019 conditions, lack of organization,
\nand different interruptions during handover prolong the reporting process
\n(Spanke & Thomas, 2010). In a large scale study of 10 European countries,
\nMei\u03b2ner et al. (2007) explored the nurses\u2019 perception of handover and the
\nreason for dissatisfaction among them. She found that 22% to 61% of nurses
\nwere dissatisfied due to \u201ctoo many disturbances,\u201d \u201clack of time,\u201d and \u201cwork
\norganizational factors\u201d (Mei\u03b2ner et al., 2007).
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\n236 Clinical Nursing Research 24(3)
\nIn general, the goal of nursing handover is the transfer of relevant information
\nand continuity of patient care; however, there is no agreement about
\nits content and the related literature recommends different templates for presenting
\ndata (Johnson, Jefferies, & Nicholls, 2012). According to Schroeder
\n(2006), the specific component of shift report should include PACE (Patient
\nproblems, Assessment\/Action, Continuing\/Changes, Evaluation; Schroeder,
\n2006), and other researchers have suggested other templates such as SBAR
\n(Situation, Background, Assessment, and Recommendations; Raines & Mull,
\n2007). Regarding all such guidelines, the content of handover must contain
\nshort- and long-term goals. It should also be broad and specific enough to
\nmeet the patients\u2019 needs. Furthermore, it should contain information such as
\nmedical and nursing care and physical, psychosocial, spiritual, and family
\nneeds at the same time (Rushton, 2010).
\nA body of literature reflects four modes of handover: the verbal handover
\nin station, tape recording, written handover, and handover at bedside. In practice,
\nthe method of handover depends on the patient, the shift (day, evening,
\nor night shift), and the model of service delivery (team vs. case method;
\nJohnson & Cowin, 2012). Nevertheless, many studies have confirmed the
\nefficacy of bedside handovers. (Chaboyer, 2011; Chaboyer, Johnson, &
\nWallis, 2009; Mott & Bradley, 2010; Webster, 1999) For example, Mott and
\nBradley (2010) conducted an action research in three rural South Australian
\nhospitals and incorporated bedside handover reports. She found that bedside
\nhandover was better than office reports in terms of ease and time efficiency.
\nInterestingly, level of satisfaction increased among nurses and patients, and
\npatients were more involved in their care; it also decreased the rate of errors
\n(Mott & Bradley, 2010).
\nThe role of nurses and families has changed recently in pediatric wards;
\npreviously, all responsibilities were done by professional nurses, but now,
\ncomplete involvement of family is highly supported (Hutchfield, 1999;
\nMikkelsen & Frederiksen, 2011). The words nurses use in describing a family
\nduring shift report can affect how other nurses approach a family. Although
\nthe goal of shift report is to exchange objective data, value judgments and
\nlabels often accompany these data. These labels can limit the opportunity of
\nfamilies to learn the skills needed to manage the problems and meet their
\nessential needs and decrease their involvement. So, applying a standard
\nhandover is essential in pediatric wards (Ryan & Steinmiller, 2004).
\nThe first step in standardizing handover and introduction of an alternative
\nmodel is to improve our understanding of current practices. Although some
\nstudies have been conducted in several countries, the handover practices have
\nnot been well studied in the Iranian health system because the context is different.
\nBecause situational analysis is the first step in changing the program,
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\nSarvestani et al. 237
\nexploring the current conditions of handover is important. Hence, the aim of
\nthis study was to explore the challenges of handover practices in Iran to provide
\nan opportunity for a better understanding of the situation and help
\nimprove the current practices.
\nMethod
\nDesign
\nThe study was conducted using a descriptive exploratory qualitative design
\nwith a content analysis approach. Content analysis is a way to analyze written,
\nverbal, or visual information. It actually serves as an action guide and
\naims at providing valid insights from data to attain a broad and complete
\ndescription of a phenomenon (Cole, 1988). In this research, an inductive
\napproach of content analysis was used. In this method, categories are derived
\nfrom data during data analysis, which help to attain a richer understanding of
\na phenomenon. Another approach we used during the analysis was summative
\ncontent analysis. This approach is fundamentally different from the previous
\none in that rather than analyzing the data as a whole, the text is often
\napproached as a single word or in relation to a particular content and word
\nfrequency is calculated manually or by a computer (Hsieh & Shannon, 2005).
\nData Collection
\nThree pediatric wards in Shiraz in the south of Iran were selected. We gathered
\nmultiple sources of data such as observations, interviews, and recordings
\nof oral shift reports. During 4 months of observation period, 14 handovers
\n(5 in the morning, 5 in the evening, and 4 at night) were observed and taperecorded.
\nObservations were noninterventional and semistructured, focusing
\non the key events and activities during handovers. Field notes were written
\nimmediately after each observation. Then, the records were transcribed verbatim
\nand a sample of 130 patient reports was subjected to summative content
\nanalysis. A coding framework was used to calculate the type and
\nfrequency of information exchanged during nursing handovers. Word frequencies
\nof oral shift reports were calculated manually. In addition, nine indepth
\ninterviews were conducted with the nurses, who were selected through
\na purposeful sampling. We continue sampling until we have reached saturation.
\nThe inclusion criteria were availability and willingness to complete the
\ninterview. A guide was prepared for covering key questions that were general
\nwith prompt to encourage responses during the interviews. Examples of
\ninterview questions include the following:
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\n238 Clinical Nursing Research 24(3)
\nCan you describe today\u2019s handover, what are the problems with the handover?
\nHow do you deal with these problems? Can you provide any examples?
\nWould you like to make see any changes? If so, what would they be? All
\ninterviews were conducted and recorded in a quiet location, and each lasted
\nbetween 30 min and 45 min.
\nEthics
\nThe ethics committee of the university approved the project. Before each
\ninterview, the participants were informed of the aim and method of the study
\nand that their participation was voluntary. Besides, they were told that they
\ncould leave the study at any time they wished. Confidentiality was ensured so
\nthat no names were mentioned. On top of that, a form was signed by the participants
\nsaying that they were informed and consented to the study.
\nAnalysis
\nInductive and summative content analyses were used to explore the challenges
\nof nursing handover practices. Content analysis may be used in an
\ninductive or deductive way. However, while in inductive content analysis, the
\ncategories are derived from the data, in deductive content analysis, the data
\nare categorized according to previous knowledge or theory (Elo & Kyngas,
\n2007). The oral shift report-taped handovers, interviews, observations, and
\nfield notes were transcribed after each section of data collection. At first, data
\nwere approached by being read as a whole repeatedly before being read word
\nby word to achieve immersion and finally to derive codes. Then, we organized
\nand grouped the codes into meaningful clusters. For the purpose of
\nabstraction, the relationships between categories were identified, and two
\nmajor themes emerged. The researcher returned to the codes and reconsidered
\nthem to check whether the themes fit the data again. A second researcher
\nread the categories and themes for further refinement. MAXqda2 software
\nwas used for data analysis.
\nTrustworthiness
\nThe procedures that were used to improve trustworthiness were as follow:
\nCoding and categories were sending back to the participant for possible
\nrevision. A team-based approach (composed of four qualified nurses in
\nqualitative research) to analyze data was established to check the credibility.
\nIt showed a good level of agreement in interpretation, and some disagreements
\nwere resolved through discussion. Prolonged engagement,
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\nSarvestani et al. 239
\nvaried experiences, peer checking, and triangulation were other strategies
\nfor improving the trustworthiness of the study (Helen & Carpenter, 2007;
\nPolit, Bech, & Hungler, 2006).
\nFindings
\nAll the nurses were female with a mean age of 30.1 \u00b1 6.8 years and mean
\nexperience of 6.9 \u00b1 5.6 years, and all have bachelor\u2019s degree in nursing.
\nData analysis resulted in identification of two major themes and five subthemes.
\nThe first theme was a nonholistic approach, and the second one was
\npoor management. These are presented in Table 1 and are explained in the
\nfollowing section.
\nNonholistic Approach
\nThe first theme emerged from data included nonholistic approaches in nursing
\nhandover practices. The subthemes were nonholistic\/unstructured content,
\nlow nurses ethical and practical involvement, and non-patient-centered
\napproach, which are explained separately in the following section.
\nNonholistic\/unstructured content. Summative content analysis of 130 patients
\nin the oral shift report showed that the contents of nursing handovers were not
\nholistic. The total frequency with which information was mentioned in nursing
\nhandover can be seen in Table 2. This table illustrates that medical plans
\nand physical dimensions are more dominant, and nursing care plans and other
\naspects of patient care such as psychosocial, functional, spiritual, and family
\nneeds are almost unheard-of. In addition, as can be seen in the following shift
\nreport, the focus was on medical plans and physical dimensions so that the
\nreports were not holistic:
\nTable 1. Main Themes and Related Subthemes Emerged From Analysis of Current
\nNursing Handover Practices.
\n1. Nonholistic approach
\na. Nonholistic\/unstructured content
\nb. Low nurses\u2019 ethical and practical involvement
\nc. Non-patient-centered approach
\n2. Poor management
\na. Poor time and space management
\nb. Poor task management
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\n240 Clinical Nursing Research 24(3)
\nTable 2. Frequency of Information Presented in Patients\u2019 Report.
\nInformation Frequency %
\nGeneral information
\nName 130 100
\nAge 25 19.2
\nDiagnosis 54 41.5
\nContextual information 21 16.1
\nDate of admission 11 8.4
\nMedical history 29 22.3
\nPhysical status
\nRespiratory function 10 7.6
\nConsciousness 7 5.3
\nDiscomfort 11 8.4
\nUrine 16 12.3
\nDiet 37 28.4
\nVomiting 10 7.6
\nBleeding 11 8.4
\nPhysical measures
\nBlood pressure 22 16.9
\nTemperature 33 25.3
\nFluid input 32 24.6
\nWeight 16 12.3
\nNursing intervention
\nPatient care need 37 52
\nNursing care plan 28.4 40
\nMedical treatment
\nConsultations 25 19.2
\nMedications 72 55.3
\nSurgical intervention 8 6.1
\nTests 57 43.8
\nPlan of care 46 35.3
\nDoctor orders 16 12.3
\nGlobal judgments
\nPatient condition 17 13
\nAbout care 9 6.9
\nPsychology\/personality 9 6.9
\nColleagues 28 21.5
\nManagement issues
\nPatient transfer 12 9.2
\nAdmission 3 2.3
\nDischarge 17 13
\nGeneral 30 23
\n(continued)
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\nSarvestani et al. 241
\nX, X was well too, she didn\u2019t have any convulsion, the physician changed the
\nPhenobarbital and Dilantin to PO ones. She didn\u2019t have any sample to send to
\nlaboratory; we didn\u2019t have any problems with her.
\nFurthermore, analysis of tape records represented that nursing handover
\ndid not have a structured content. Different presentation styles, irregular
\nbody, and incomplete wrap up and narration are the categories emerging from
\ndata analysis. The following excerpt illustrates that the unstructured content
\nof the report leads to missing information:
\nIncharge: Miss X, Do you know her?! Head nurse: Yes. Incharge: X was well
\ntoo, she is NPO for MRI; she had Doppler Sono yesterday, and its result is in her
\nfile. She is ok and doesn\u2019t have any problem. Next patient Y, Head nurse: Does
\nprevious patient have EEG for today? Incharge: Oh, yes of course, I forgot to
\nmention it.
\nNurses\u2019 low ethical and practical involvement. Another subtheme pertaining to
\nnonholistic approach is nurses\u2019 low ethical and practical involvement. Data
\nobtained from multiple sources indicated that in spite of the case method caring
\nsystem, the nurses did not have an active role in the handover process and
\nthose in charge are the only individuals who have the whole responsibility.
\nThe following field note and interview showed low practical involvement of
\nnurses during handover processes:
\nObservation 4: One evening, after checking the emergency and narcotic boxes,
\ntwo Incharge sat on chairs in the station and oral shift report started while other
\nnurses were preparing medications or speaking with each other in the station.
\nIn another case, one of the head nurses in the interview stated that
\nTable 2. (continued)
\nInformation Frequency %
\nFamily
\nCare need 15 11.5
\nComprehensions 8 6.1
\nFunctional status 5 3.8
\nPsychological 3 2.3
\nSocial 1 0.7
\nSpiritual 0 0
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\n242 Clinical Nursing Research 24(3)
\nIn the handover process, all of the responsibilities are for the one In charge and
\nother nurses don\u2019t have an active role in this process, and speak with each other or
\ndo other things, while they must have an active role and listen to reports carefully
\nto be informed about patients\u2019 conditions.
\nIn addition, data from observation and tape records showed that nursing
\nhandovers were not completely ethics-based. Labeling patients, prejudgments,
\nand inattention to patient and their families\u2019 demands were the categories
\nthat emerged from the data. The following excerpts illustrate that nurses
\nlabeled patients and had prejudgment about patients and their families:
\nVisitor of X made us nervous; she has a mental problem. She came every 30
\nminutes to the station and asked different questions about her child.
\nX is a 2-year-old girl that was transferred here from ICU yesterday; she was opium
\npoisoned. The nurse of the new shift said: Definitely her family gave her the
\nopium, didn\u2019t they?!
\nSummative content analysis, as shown in Table 2, also shows that frequency
\nof prejudgments about patients, families, and colleagues were high in
\nnursing handover contents.
\nNon-patient-centered approach. The findings showed that nursing handovers
\nare non-patient-centered. Observations revealed that the average time taken
\nfor handover was 41 min for each shift, only 9 min of which was allocated to
\nbedside handover (42 s for each patient on average).
\nObservation 8: In the second room, the nurses entered while speaking with each
\nother; one of them approached the patient and assessed the IV sheets and its date.
\nThen without saying anything she went to another patient. This took 50 seconds.
\nAs you see, we categorized these subthemes\u2014nonholistic\/unstructured
\ncontent, nurses\u2019 low ethical and practical involvement, and non-patient-centered
\napproach\u2014in one group and subsequently labeled it as nonholistic
\napproach.
\nPoor Management
\nThe second theme that emerged from the data is poor management during
\nnursing handover practices. Subthemes were poor time and space management
\nand poor task management.
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\nSarvestani et al. 243
\nPoor task management. Data obtained from multiple sources in this research
\nshowed that nurses encountered task overlap and work overload during
\nhandover processes.
\nOne. of the head nurses in the interview said,
\nJob description is not clear during handover processes, so during this process
\nnurses should do many tasks simultaneously such as checking the equipment and
\nutensils, preparing medications, answering telephones, responding to visitors,
\ncompleting the notes of patients or doing other stuff such as discharging or
\nadmitting new patients.
\nPoor time and space management. Data from interviews and several field observations
\nalso suggested that the time and space of handovers were not well managed.
\nPoor time management, hasty reports, too many interruptions, crowded
\nstations, and no seats to participate in handovers were the categories.
\nThe results of observations showed that handover lasts for about 41 min,
\nbut time management of the process is not appropriate; at first, they check the
\nequipment such as emergency trolley, the narcotics box, and other utensils for
\nabout 12 min. Then they listen to the oral shift report in the station for about
\n26 min and then have a round in patient rooms for about 9 min, approximately
\n42 s for each patient. These data suggest that time management was
\npoor, and in this regard, a nurse said,
\nWe should check the equipment carefully because if something is lost, we must
\npay for it, so it takes a long time to check them; as a result, we report in a hurry and
\nmany important things might be missed.
\nOr another nurse in the interview said,
\nWe don\u2019t have a place for handover; in the station there are many people such as
\nmedical and nursing students, physicians and other nurses. When we are reporting,
\nwe should answer phone calls, questions from families and physicians and in the
\nmeanwhile focus our mind to report, and it is impossible. There are many
\ndistractors that lead to inattention.
\nAs can be seen, we categorized these subthemes\u2014poor task management and
\npoor time\/space management\u2014in one group and labeled it as poor management.
\nDiscussion
\nThe aim of this study was to explore challenges of nursing handover practices
\nin Iran. The findings indicate that there are various challenges in handover
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\n244 Clinical Nursing Research 24(3)
\npractices in nursing, and, therefore, it seems essential to explore these challenges
\nin our health system. Data analysis resulted in identification of two
\nthemes that explain challenges of nursing handover practices, namely, nonholistic
\napproach and poor management during nursing handover.
\nFindings showed that nursing handover practices were not holistic
\nbecause the contents of report were not holistic and structured. The nurses\u2019
\nethical and practical involvement was low and non-patient-centered.
\nLiterature suggests that the content of handover should contain information
\nsuch as physical, psychosocial, spiritual, medical, and nursing care and
\nfamily needs at the same time (Rushton, 2010). However, nursing handovers
\nin the studied wards lack such holistic approaches, and medical and
\nphysical needs are dominant. This fact is confirmed by other studies in our
\ncountry. Irajpour, Alavi, Abdoli, and Saberizafarghandi (2012) and
\nYektatalab, Kave, Sharif, Fallahi Khoshknab, and Petramfar (2012), in two
\nqualitative studies, showed that health care in Iran is based on \u201cMedical
\nParadigm\u201d in which professionals treat the clients as biological entities,
\nthat is, they pay all their attention to meet the clients\u2019 biological deficits and
\nneeds, thereby neglecting many aspects of care such as educating patients.
\nAccording to Moattari, Ebrahimi, Sharifi, and Rouzbeh (2012), ensuring
\nadequate access to education for all patients is a clear challenge (Moattari
\net al., 2012).Other Findings showed that health professionals who follow
\nmedical approach may neglect the clients\u2019 nonbiological (i.e., psychosocial)
\nneeds and problems (Irajpour et al., 2012; Yektatalab et al., 2012). In
\naddition, Momennasab, Moattari, Abbaszade, and Shamshiri (2012) highlighted
\nthe importance of attention to spiritual needs of patients in a religious
\ncontext such as the Iranian society (Momennasab et al., 2012).
\nMedical paradigm in our country is dominant and leads to medical oriented
\napproach in nursing practices even in nursing handovers (Hagbaghery,
\nSalsali, & Ahmadi, 2004). In Addition, Ekman and Segesten (1995) stated
\nthat \u201cnurses receive deputed power of medical control and little attention is
\npaid to nursing needs during handover\u201d (Ekman & Segesten, 1995,
\npp. 1006-1011). Nikbakht, Juliene, and Emami (2004) highlighted this
\nmedical oriented paradigm and explained that it could be due to the patriarchal
\nsocial structure in Iran, because the most respected health care provider
\nis an experienced, male physician (Nikbakht et al., 2004).
\nEmami and Nikbakht, in a qualitative study in 2007, showed that nurses in
\nIran work based on task-orientated approach. This appears to be due to nursing
\ncurriculum in Iran whose focus is on a biomedical and task-orientated approach.
\nTherefore, it affects how nurses prioritize their working tasks (Emami &
\nNikbakht, 2007). As Nikbakht et al. (2004) suggested, schools of nursing must
\nprepare students to deal with the consequences of conflicting models by
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\nSarvestani et al. 245
\nhelping the faculty revise the curriculum to reflect a creative and culturally
\nbased philosophical perspective (Nikbakht et al., 2004).
\nOur findings showed that the current handover practices do not have an
\norganized structure, and this is one of the challenges that lead to many problems
\nsuch as lack of concentrations and missing or forgetting important information,
\nwhile structural contents of the report allow meaningful organization
\nof large amounts of data (Yurkovich & Smyer, 1998). Dowding (2000) conducted
\nan experimental study to assess the effects of changing the style and
\ncontent of the nurses\u2019 report on nurses\u2019 ability to plan patient care. Results
\nindicated that such type of report had a significant effect on nurses\u2019 ability in
\nplanning patient care, accuracy of information and the ability to recall the
\ninformation they heard (Dowding, 2000). Therefore, providing a template for
\npresenting patient information may increase the quality, accuracy, and speed
\nof handovers. Analyses of multiple sources of data showed that handover
\nprocess is not a collective action. Moreover, nurses\u2019 ethical and practical
\ninvolvement was low, and they had an inactive role in this process. Inadequate
\nnursing staff may cause this situation in nursing handovers in Iran because
\nsome of the nurses should check and prepare the medications, some of them
\nshould listen to oral shift reports, and others should go to patients\u2019 rooms for
\nmonitoring IV sites and sheets. Furthermore, the nurses know that the ones in
\ncharge have the whole responsibility and should listen to the reports carefully
\nto transfer the important information to other nurses, so they do not participate
\nin this process actively. Yektatalab, Kave, Sharif, Fallahi Khoshknab,
\nand Petramfar (2011) believed that this impaired care is due to nursing shortage,
\nlack of competent nurses, high workload, lack of job security, and low
\nsalaries in Iran (Yektatalab et al., 2011).
\nWhile literature and studies emphasize the collective function of handovers
\n(Ekman & Segesten, 1995; Scovell, 2010; Strople & Ottani, 2006), this
\nprocess was not so in the studied wards. Handovers provide an opportunity
\nfor professional communication, supporting role socialization and development
\nof a cohesive group process (Yurkovich & Smyer, 1998). Unfortunately,
\nstudies in our country show that teamwork in our society and health care
\nsystem are poor and need to be improved (Mojdeh, Memarzadeh, Abdar
\nIsfahan, & Gholi Pour, 2009; Tafreshi, Pazargadi, & Abed Saeedi, 2007). In
\naddition, Mei\u03b2ner et al., 2007 found that \u201cpoor support from colleagues\u201d was
\na reason for dissatisfaction during shift handover in Europeans nurses
\n(Mei\u03b2ner et al., 2007).
\nHowever, we found that handovers can become vehicles for gossiping
\nand labeling each other, with the potential for undermining the relationships
\nand trust among nurses during handovers. This finding is consistent
\nwith the result of Payne et al. (2000) indicating that these judgments are
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\n246 Clinical Nursing Research 24(3)
\nfrequent in handovers (Payne et al., 2000). Code of ethics in Iran was formulated
\nin 2010, but to achieve more, it seems essential that we compile
\ncodes of nursing ethics at different levels of nursing practices such as nursing
\nhandovers and educate nurses in workshops and seminars (Sanjari,
\nZahedi, & Larijani, 2008). The American Nurse Association code of ethics
\nfor nurses recommends the value of a guide to nursing handover (American
\nNurses Association, 2001); however, because Iran is an Islamic country,
\nand gossiping, labeling, and prejudgments are taboos based on teachings of
\nthe religion, it is undoubtedly necessary to provide a national code based on
\nour sociocultural norms in this field. Nursing in Iran is perceived as a holy
\nand honorable job, so Islamic principles provide a promising guide to ethical
\ncodes of nursing taking Iranian culture and religion (Larijani, Zahedi, &
\nMalek-Afzali, 2005; Nikbakht, Emami, & Parsayekta, 2003; Sanjari et al.,
\n2008).
\nAnother important aspect of the holistic approach in nursing handover is
\npatient-centered care. Our study showed that patient participation was low
\nand they were mostly passive onlookers, while the findings of McMurray,
\nChaboyer, Wallis, Johnson, and Gehrke\u2019s (2011), which examined patient
\nperspective of nursing handover in Queensland hospitals, showed that
\npatients valued having access to information and considered themselves an
\nimportant part in maintaining accuracy that improves safety and quality
\n(McMurray et al., 2011). Nowadays, patients desire to move from a parent
\nmodel of care to a collaborative model of care, especially in pediatric wards
\nthat focus on family-centered care (Anderson & Mangino, 2006; Hutchfield,
\n1999; Mikkelsen & Frederiksen, 2011). Like many Asian countries, Iran is a
\nfamily-oriented society, so family members express concern about the
\npatient\u2019s problem and provide support for their loved ones (Moattari,
\nHashemi, & Dabbaghmanesh, 2013). The results of our study showed that
\npatients\u2019 and families\u2019 participation is ignored. Vasli, Salsali, and Tatarpoor
\n(2012), in a qualitative study in Iran, assessed the perspectives of nurses on
\nbarriers of parental participation in pediatric wards. Four main themes
\nemerged as barriers of parental participation in pediatric care, namely, mutual
\nmotivation and interest in parties, lack of support for nurses, nursing shortages,
\nnurses\u2019 workload, and poor teamwork between nurses and physicians,
\nconfidence in the nursing profession, and finally undefined role for mothers
\n(Vasli et al., 2012). Timonen and Sihvonen (2000) interviewed families and
\nfound that main reason for them not participating during handover were lack
\nof encouragement, nurses concentrating on their papers, using special language,
\nand lack of time (Timonen & Sihvonen, 2000). Thus, we should consider
\nthese findings to improve and strengthen parental participation during
\nhandovers.
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\nSarvestani et al. 247
\nAnother theme that emerged from our data was poor management. Based
\non the results of this study, time and space management during handovers
\nis poor. Baldwin and McGinnis (1994) reported that prolonged verbal
\nreports lead to nurses\u2019 inability to prioritize patient needs (Baldwin &
\nMcGinnis, 1994). In our study, nurses had to allocate some time for checking
\nthe equipment, so the time allocated for patients decreased due to the
\npriority of checking the equipment due to economic considerations. It is
\nactually because some equipment is rare and expensive, and hospitals
\nexpect nurses to maintain them as well as possible. Furthermore, too many
\ninterruptions during handovers lead to inattention and prolonging the
\nprocess as well.
\nAnother challenge was allocation of space. Locating an area far from
\ninterruptions and patient\u2019s confidentiality and privacy is an essential aspect
\nof handovers, and the best option depends on the context (Yurkovich &
\nSmyer, 1998). In these wards, there was not a quiet room for handovers, leading
\nto many interruptions during handovers, which in turn decrease the quality
\nand accuracy of handover. In addition, Nikbakht and Emami (2006) found
\nthat institutional circumstances are an issue for nurses in Iran. Welsh et al.
\n(2010) found the same result as the current study. Their analysis showed that
\ninadequate information, inconsistence quality, limited opportunity to ask
\nquestions, equipment malfunction, insufficient time to generate reports, and
\ninterruptions limited handovers (Welsh et al., 2010).
\nTask overlap was another problem that interfered with handovers. During
\nhandovers, the nurses should do many tasks simultaneously. Task overlap
\nleads to inattention that will cause many errors during oral shift reports. Lack
\nof definite job description for nurses during handovers in our health system is
\nthe key reason for such task overlap. Mayor, Bangerter, and Aribot (2012)
\nfound that mean handover duration per patient increased with increasing task
\nuncertainty, and they recommended that redesigning of handover procedure
\nshould take task uncertainty into account (Mayor et al., 2012). A qualitative
\nstudy conducted by Nikbakht et al. (2003) supported the finding that work
\npressures, insufficient time, and lack of resources hindered nurses from doing
\ntheir work (Nikbakht et al., 2003).
\nHowever, our study has some limitations that should be considered. The
\nstudy took place in pediatric wards, so there are limitations for generalizing
\nour findings to other clinical settings. Thus, it is recommended that further
\nstudies be conducted in other wards. Furthermore, although we had field
\nobservations, we may miss other challenges although we have reached saturation.
\nDespite these limitations, the findings captured a good picture of the
\ncurrent situation to better understand the current nursing handover practices
\nand provide a foundation to plan and implement appropriate change.
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\n248 Clinical Nursing Research 24(3)
\nConclusion
\nQualitative and quantitative analyses are ways to reach a better understanding
\nof the challenges of nursing handovers. In general, analysis of multiple sources
\nof data indicated that nursing handover process had many challenges that need
\nto be modified. Applying a holistic approach (designing a holistic content,
\nencouraging nurses\u2019 participation, and involving patients) and managing the
\nhandover process (determining job description and allocating specific time and
\nspace) are some strategies for improvement. The findings of the present study
\nchallenge nursing managers to develop new strategies that can improve nursing
\nhandovers, which can in turn facilitate changes that increase the nurses\u2019 level of
\nwork satisfaction; as a result, these can lead to a higher level of patient safety
\nwith a higher quality of care. Nursing handover is a skill that requires education
\nand practice, so, in this regard, in service education is highly recommended.
\nBecause standardization of handover practices completely depends on the context
\n(culture, philosophy, needs, facilities, priorities, and economic considerations
\nin each organization are different), future focus could be on addressing
\nhandover challenges through an action research study in which the identified
\nproblems will be addressed by including those who are part of the process to act
\non their own behalf to solve real-world problems.
\nAcknowledgment
\nThe authors would like to thank the deputy chancellor for research of Shiraz University
\nof Medical Sciences for the approval, supervision, and funding of this research project.
\nThe authors would like to thank those who helped them carry out this study and
\nthe nurses who participated in this study. The authors would also like to thank Dr.
\nNasrin Shokrpour at the Center for Development of Clinical Research of Nemazee
\nHospital for editorial assistance.
\nAuthors\u2019 Note
\nR.S.S. was responsible for the study conception and design. R.S.S. performed the data
\ncollection. R.S.S. and M. Moattari performed the data analysis. R.S.S., M.
\nMomennasab, S.H.Y., and A.N.N. were responsible for drafting the manuscript.
\nR.S.S., M. Moattari, M. Momennasab, S.H.Y., and A.N.N. made critical revisions to
\nthe article for important intellectual content. M. Moattari obtained funding. M.
\nMoattari, M. Momennasab, S.H.Y., and A.N.N. gave administrative, technical, or
\nmaterial support. M. Moattari and A.N.N. supervised the study. This paper is a part of
\nPhD dissertation of Raheleh Sabet Sarvestani.
\nDeclaration of Conflicting Interests
\nThe author(s) declared no potential conflicts of interest with respect to the research,
\nauthorship, and\/or publication of this article.
\nDownloaded from cnr.sagepub.com
\nSarvestani et al. 249
\nFunding
\nThe author(s) disclosed receipt of the following financial support for the research,
\nauthorship, and\/or publication of this article: Vice chancellor of Research in Shiraz
\nUniversity of Medical Sciences (Grant Number: 916217).
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\nCole, F. L. (1988). Content analysis: Process and application. Clinical Nurse<\/p>\n","protected":false},"excerpt":{"rendered":"
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