Active patient participation in nursing handover is low, even when conducted at the bedside, a new study has revealed.
While some patients involved in the study expressed a preference to participate in nursing handover, others did not want to be involved at all.
Researchers explored the frequency and nature of patient participation in nursing handover, considered an essential tool in the provision of safe patient care, and what strategies both patients and nurses believed could be implemented to enhance patient involvement in the process.
Led by Dr Maryann Street, Senior Research Fellow at Deakin University, the study observed nursing handovers on 10 randomly selected wards at Eastern Health, Victoria, between September and December 2019. Semi-structured interviews with patients and nurses followed.
Eastern Health aims to provide holistic patient-centred care in a safe, respectful and caring environment. The study set out to identify whether these standards were being met by evaluating the quality and efficiency of patient and staff involvement during nursing handover.
Findings from the research, Enhancing active patient participation in nursing handover: A mixed methods study, confirmed a low level of patient participation in nursing handover due to a complex interplay of factors, including patient and nurse preferences and perceptions.
Of the 117 morning-to-afternoon shift nursing handovers observed, one in four were not conducted in the patient’s presence. Results showed 33.3% of patients were active participants in handovers; 46.7% were passive participants; and 20% of patients had no input at all. Active participation was higher among women, surgical patients, and when nurses displayed engagement behaviours such as eye contact, the opportunity to ask questions, or explanations.
A total of 455 nurses and nursing students were observed during the 117 handovers. Of these, the average number of nurses/nursing students involved in the handover was four, and for 28% of handovers, five or six nurses were present. Most handovers took place at the bedside (82.1%), followed by the corridor (22.2%), while 76.9% of handovers were conducted in the patient’s presence.
Researchers note patient participation in nursing handover is important for patient-centred care, shared decision-making, patient safety and a positive healthcare experience. National standards recommend involving patients, carers and families as key participants in clinical handover where possible.
The study identified three major themes from interviews with 33 patients and 20 nurses – ‘Being involved’, ‘Layers of influence’, and ‘Information Exchange’.
The theme ‘Being Involved’, which related to patients’ and nurses’ preference for patient participation in handover, generated three sub-themes – Handover is not for me, I want to be a part of it, and Secret nurses’ business.
Just over half of the patients interviewed felt handover was ‘not for me’. These patients typically deferred to nurses as the professionals whose role they believe includes passing on information about their care. Equally, some patients did not want to take part because of their trust in nurses’ care and communication. Others showed a lack of understanding about what handover entails.
Getting the right information was key for patients who wanted to be a part of nursing handover.
‘I prefer it this way, rather than hearing them [nurses] in the doorway far away and you wondering should there be something that I should know’, one patient said.
Examples of reasons for handover not being conducted at the bedside included nurses being concerned about maintaining patient confidentiality and privacy, or the patient being scheduled for rehabilitation or treatment off the ward.
Interestingly, some nurses considered handover ‘Secret nurses’ business’ due to its complex nature, describing the need to build rapport with patients and selectively share information in front of them.
The study found nurses’ expectations for patient participation in handover also varied considerably. Many patients described handover as an important part of nursing care.
‘The important part is that information is transferred from the earlier shift to the next shift, so that everyone is aware of what’s going on’, a patient said.
‘Not that the patient needs to participate, but the patient has to be aware who are the nurses going to look after [them] this afternoon. But they don’t need to participate, they don’t need to hear our handover’, one nurse suggested.
The second theme, ‘Layers of Influence’, identified a complex interplay of factors that influence patient participation in handover – patients’ perception of nurses; facilitators and barriers; and the presence of others during handover.
Many patients observed the conduct of nurses during handover and spoke of their experience of nursing care throughout the entire shift, with most patients making positive comments such as ‘I couldn’t ask for better care’ or ‘They are very professional, they are very helpful, and understanding’.
Factors identified as facilitators or barriers for active patient participation in handover included the location and timing of the handover; conducting handover in the patient’s presence; nurse familiarity with the patient; and asking direct questions. Barriers to patient participation in nursing handover identified by patients included nurses’ use of medical terminology, acronyms and jargon, or their inability to hear and understand what was being said.
Nurses and patients both said that when asked direct questions, patients were more likely to actively participate in nursing handover: ‘Well, if they asked questions, I definitely would be involved’, one patient said.
In some cases, however, patients felt nurses had ignored them: I think it’s talking as if you’re not in the room’, one patient said.
The study found almost one in five patients had visitors present during handover. If visitors were present, nurses often chose to conduct handover outside the room.
Nurses commonly mentioned the presence of others during handover, which links to issues of privacy and confidentiality. Nurses expressed that maintaining patient confidentiality was a concern for them and a prime reason for stepping out into the corridor.
The final theme identified in the study, ‘Information Exchange’, related to handover being a platform for information exchange between patients and nurses.
Both nurses and patients felt patients had knowledge to share; that handover enables patients the opportunity to gain knowledge; and that good communication is essential during handover.
Many nurses saw value in active patient participation in handover, suggesting it provides an opportunity for clarification of issues by the patient or nurse. Some nurses also expressed an expectation that patients would participate in handover, if able to do so, to demonstrate their willingness to be responsible for their own health.
When it came to communication style and content, both patients and nurses expressed the expectation that nursing handover would include accurate, open, honest, consistent, clear, effective and valuable communication.
‘Usually it brings me up-to-date on everything. If I am hearing the same information that the nurses are getting, it makes me feel pretty good to know we are on the same page’, one patient said.
Researchers say the study adds to the understanding of active patient participation in nursing handover and delivers unique insights into the perspectives of both nurses and patients.
Significantly, patients were able to actively participate in nursing handover when they understood the purpose and timing of handover and had built up rapport with nurses.
“The findings from this study have been disseminated with Eastern Health executives, nurse managers and nursing staff to highlight the importance of involving patients in nursing handover to deliver person centred care,” researchers say.
“Recommendations for strategies to achieve this include: discussing with patients whether they want to be involved in handover at admission and on a daily basis, with consideration for patients’ preferences, clinical condition and circumstances; patient education be given in regard to the purpose and timing of handover and their potential role. Further, co-design workshops have been held with nurses, consumers and researchers to develop a model of nursing handover that enables patients to participate by overcoming some of the barriers identified in this current study”
“The study findings highlight an apparent conflict with the view of some patients who do not want information withheld, and nurses’ concern to protect sensitive information,” authors concluded in the study.
“While many patients want to be active participants in nursing handover, factors restrict the level of participation in practice. This study challenges the assumption that conducting handover at the bedside is sufficient to ensure patient involvement. Nurses valued patient input when this clarified information pertaining to their care. Patients sought to be informed about their treatment and discharge plan. Some nurses felt patient participation in bedside handover may be impractical due to lack of time and concerns about privacy.”
Read the full study here