From standardization to resilience: Strategies that nurses develop during handovers
Rambam Health Care Campus, Israel
: J Nurs Patient Care
Background: Nursing handover represents one of the basics of classical nursing practice. Recently, however, several authors have expressed dissatisfaction with the nursing handover process, arguing that much of the information transferred is either corrupted or lost during the handover, with obvious detrimental consequences for the quality of care. Hence, research and practice yearn for studies that enlighten our understanding of the ways to improve nursing handover. Two main theoretical approaches have been suggested for investigating nursing handover: Standardization and resilience. Standardization calls for consistency in the processes and contents of nursing handover. In comparison, resilience is a more proactive approach, which focuses on nurses' anticipation of changes, constant attention, course corrections, reassessment, monitoring and feedback. This research focuses on the latter approach. Research aims: The main aim of the current study was to understand the process of nursing handover from the perspective of the nurses participating in the handover. More specifically, our aim was twofold: First, to identify the goals of handover from the perspective of the participating nurses; and second, to identify the cognitive, emotional and behavioral strategies nurses use when receiving and handing over shifts, which allow them to manage the information in the best manner for the benefit of the patient's care and safety. Methods: This research employed qualitative methods. Fourteen nurses, males and females, who worked at Rambam Medical Center in Haifa, Israel, participated in the study. Sampling strategy assured that participants would represent nurses from different clinical fields, seniority, roles and clinical experience. Research participants were interviewed individually through semi-constructed in-depth interviews. All interviews were recorded and later transcribed. Data analysis was done through content analysis. Findings: Content analysis revealed three major themes. The first referred to the goals of nursing handover. This theme focused on the declared versus the actual goals of the handover prevalent in the ward. While all the participants emphasized the importance of the declared goals, they at the same time described how these goals were informally shaped to create goals "in practice", which had better, conform to the nursing handover. The second theme referred to the ward's personal and interpersonal factors influencing the nursing handover. This theme related to personal factors such as the nurses' seniority and reputation, interpersonal factors such as trust among staff, and handover characteristics such as work load and interruptions. These factors were often involved in the handover process, turning the handover goals into attainable ones. The third theme referred to the strategies which the nurses develop and operate to bridge the gap between declared and actual goals, and thus to better respond to the goals of the nursing handover, as they perceive it. This theme is divided into two subthemes: (1) handing over strategies and (2) receiving strategies. Discussion: The findings of the present research are pioneering in terms of identifying the handover strategies, which nurses develop to strike a balance between efficiency and workload, on the one hand, and maintaining the quality and safety of care, on the other hand. Nine forecasting strategies were mapped. Nurse Handover strategies focused on recalling strategies aimed at recalling what the nurses perceived as the crucial information for handover. Strategies for receiving shifts focused on identifying "red warning lights" that enable receiving nurses to optimize care and to mark those cases, which require further inquiry, to develop an improved care map. These strategies are discussed in line with theories that relate to practical and professional knowledge development. In line with this body of theories, it seems that these strategies, which were developed based on nurses' clinical knowledge, experience, clinical judgment, and intuition, enable nurses to develop the ability to foresee negative events. Nevertheless, like all heuristics, they are vulnerable to error. Conclusions and implications: The present research have important theoretical and practical implications. The research identified nine forecasting strategies that are employed by nurses during the handover were mapped. Future research should examine the effectiveness of these forecasting strategies in preventing errors, on the one hand, and on maintaining the quality of care, on the other hand, so that they could be recommended for comprehensive practice. Furthermore, similar research can be conducted in other medical centers and on larger populations of nurses to hear more voices and identify more strategies. Furthermore, the findings of the present research have important implications for nursing practice. First, they emphasize the importance of verbal, faceto- face nursing handover at the patient's bedside. Under these circumstances, nurses can compare the different sources of information (e.g., the information provided at the handover with personal impressions from the patient, along with written records), which allow them to turn on "red warning lights" in case of inadequacy. Second, the findings highlight the gap between the information nurses wish to receive and the information they wish to hand over. While the handing over nurses emphasized the importance of standardized pattern for delivering information, the receiving nurses were not interested in consistent and complete information; they wished only to receive the most crucial information. Hence, it is recommended to consider changing the pattern of nursing handover, so that it is less constructed, thus enabling the receiving nurses to pose questions to the conveying personnel. Third, the research findings imply that the lack of common mental models among nurses regarding the information that must be transferred during the handover creates a lack of trust and lowers the credibility of the conveyed information. Fourth, our research emphasizes the importance of nurses' practical knowledge and experience. Therefore, one needs to invest more in improving nurses' theoretical knowledge for their practice to be more evidence based.