TOPIC transfer of information, accountability and responsibility for



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The primary aim of the project is to reduce the adverse
patient outcome without disturbing the continuity of care with higher quality
of care.


A clinical handover is the transfer of information, accountability
and responsibility for a patient or group of patients. A standardisation of key
principles for clinical handover will aid effective, concise and complete
communication in all clinical situations and facilitate care delivery.Traditionally
handovers have occurred in different ways and can vary depending upon the
caregivers roles, hierarchies, circumstances and traditions (Athwal, Fields
& Wagnell. 2009). Inadequate communication handovers have been identified
as the basic cause in sentinel events (Adamski, 2007; Patterson & Wears,
2010).  The different unit culture and
contexts and resulting lack of collaboration and cohesion between nurses to
create increased risk for adverse events (Behara et al., 2005).

A typical handover involves the exchange of important
information such as patients engagement, medications and discharge plans from
one nurse to another. Handover is a common tradition among nurses however
standard and effective handover and information communication skills are not
taught formally taught during nursing academic education; rather nurses learn
such skills during their daily practice and form more experienced nurses.



Different countries have started to implement strategies
to reduce the working hours of healthcare professionals (Australian Medical
Association, 2006b, Australian Medical Association, 2006a, British Medical
Association. 2004). In 2004, Sexton, Chan, Elliot, Stuart & Crookes
understook a study to investigate the value and content of nurse to nurse shift
report because of criticisms related to time expenditure, content, accuracy,
and usefulness of shift report within the role of modern nursing. There were 23
handovers were audio taped in a medical ward in Sydney, Australia hospital.
Then the audio was analyzed and classified according to the location in medical
record. The results demonstrated that 84.6% of the information discussed in the
report could be found in existing documentation structures. 9.5% of time the
information was not relevant to patients care were discussed. Actual
information exchanged was not in current documentation was only 5.9%.

In 2002 Kerr, reports that there is a structured handover
method the quality of care is promoted and nurses will have a full understanding
and knowledge about the patients.

The importance of having a structured handover process
stating that it will lead to an improvement in the quality of care delivered
were discussed by Glen in 1998.


A study was conducted in 2011 at a hospital located in
Mashad, Iran. The population consisted of ICU nurses having bsc degree with 6
months of work experience. The study sample size was of 55 nurses. The main aim
for this study was to improve the nursing handover styles







Discourse analysis does not seem to be the choice of
method of many texts in the literature search. One discourse analysis on
nursing handover looked at anxiety in nursing practice (Evans et al., 2008).
However there are many research articles that integrate components of discourse
as language in use. Language in use can stand alone or be made significant by
the related social interaction. Many researches had shown mixed views of nurses
towards beside clinical handover. Handover is a predominant practice in healthcare
and problems such as medication errors and delays in treatment can arise from
poor communication during handover. Perceptions and experiences of bedside
clinical handover and to lay a foundation to improve future bedside clinical
handover processes. In this study i would like to explore nurses perceptions of
bedside clinical handover.


According to McNamara 1999; Interviews are particularly
useful for getting the story behind a participants experience. The interviewer can
pursue in depth information around the topic. Group interview is a semi
structured interview which involves a moderator leading a discussion between
small groups of respondents in a specific topic. An interpretive, descriptive,
qualitative research approach was used to gain an insight into nurses
understanding and their perception. Group interview with semi structured
questions were conducted with nurses. The inclusion criteria for this study
were registered nurse with one year of clinical experience in hospital, nurses
who are involed in bedside handover and nurses who had participated earlier in
bedside handover. There were mainly 7 question in the interview been conducted.
The questions were mainly based on the existing perception and knowledge of
nurses regarding their view about bedside clinical handover.


Nurses from different background were chosen for this
study. The demographic data of the nurses were also included such as their
gender, age, grade and work experience.  Four
groups with five nurses in each group. The interview was held in a private room
to ensure privacy. Each group were interviewed for 30 minutes to an hour. Non verbal
clues such as body language and expressions were also taken into
considerations. A member from the research team sat in all the interview to
provide guidelines. In this study nurses described that some patients
verbalized not to be involved in the clinical handovers conducted at bedside as
they would prefer to do other thing such as rest or attend to visitors and
family members.


This research has mainly focused on bedside clinical
handover importance. In this study the group of nurses were given privacy and
the information was not disclosed in front of patients and their family
members. This survey had deliberately not included patients so that the privacy
and dignity of patient shall be maintained. Apart from this the study do not
have any ethical issues as we have not particularly discussed about the medical
condition or any other topic which would effect the confidentiality of the


The participants were all from one ward of an acute
tertiary hospital and it only reflected on the perception of that clinical
area. The ward mainly received patients with higher socio economic background
and therefore the expectations regarding to participation in clinical handover
is different from other wards. Findings from quantitative study would be not
generalized to other settings.


A total 20 nurses participated in this interview. Majority
of the participation were 95% of female nurses with an average of 10 years of
work experience. Some nurse felt that there were frequent interruptions and
distractions from the patient and surrounding because of which the important
information was missed out during handovers. They felt that with no interruptions
and distractions the handover would be holistic.

Whereas some other nurses perception was they were viewed
as unprofessional by the patients and family members while conducting nursing
handover. Nurses even felt that instead of giving handover they had to do small
task in between said by the patients and relatives. Some nurses also mentioned
that they tend to giggle and laugh during handover but they felt as if they
were exposing themselves to patients and family members and they were
susceptible to negative impressions from patients and their family members.

This provided insight into nurses perceptions of bedside
handover and the challenges faced by the nurses during bedside handover. Nurses
identified both the advantages and disadvantages of bedside clinical handover
from nurses point of view. This was illustrated by lack of consistency in the
nurses perception of bedside clinical handover.






Patient confidentiality can be compromised. In
semi private rooms there would be other patients and relatives who would also
be listening to all the confidential information of the patient in the cubicle.Request of secrecy. Some of the patients or
family members request nurses not to reveal certain information due to their
personal reasons where in this would be the most important information that
needs to be passed on to incoming nurse on shift. Misinterpretation of information. During bedside
handover the other patients and relatives would hear the diagnosis of this
patient and they would start fearing unnecessarily and would create a
misunderstanding among other patients.Disturbance during bedside handover. Nurses felt
that in between the handover there would be interruptions and distraction by
patient relative regarding updating the status of patient condition and their
treatment plans because they could see nurse in the room. Time consuming. While bedside clinical
handover there would be patient involvement their doubts and questions were
inevitable thus delay the process of handover which leads to delayed patient
care and their treatment.


In order to bring the change initiated requires a
direction and power of leadership. By the work of Swansburg and Swansburg who
argued that “Transformational leaders are seen in healthcare organizations as a
commitment to excellence.” To bring about a change in a hospital setting is a
huge task as it is about the change in the attitude and behaviour of the staff
in a difficult environment in order to gain their co-operation.

The first step would be to create awareness among the
people who were going to be affected by this new improvements that would include
the staff nurses, ward managers, patients and their family members. This would
help in improving the handover system. Discussion among nurses in the ward
which will lead to more information about the new handover system. Problems faced
during handover should be brought up in the meeting by the nurses should be
taken into consideration and solved at managerial level with better
improvements and put in practice. Different communication channels to be used
such as personal contact with nurses to understand their point of view. Initially
the ward managers would act as mentor for other nurses who are been experienced
in this particular areas to encourage the nurses and support them in their difficult
situation. Time to time revising and practicing would become an ease to put
into daily habit of practice. Initially they would be supervised by their
seniors and later on once they are confident enough they can carry out their
work through self confidence.

Planning and implementation should be done very carefully
to minimize the adverse effects on the change. To deal with the conflict a
flexible and humanistic approach has to be taken in consideration. The suggestions
been put forward by the team members 
should be treated with respect and dignity. Feedbacks should be
constructive according to the level of performance. If the nurses were doing
really well appraisal to be given to them so that they would strive more harder
to put in their efforts as the famous proverb says “No pain No gain.”





For any strategy to workout it needs to be evolved. For that
particular evolution we need to make changes and upgradation. Inspite of
innovation and upgradation it could be uncertain to expect good luck into the
survival and expansion of business. Incremental change is a type of change
where change is implemented slowly over a specified period of time (De Wit and
Meyer, 2010). So as to improve the nursing handover we need to implement the
things over a period of time which would give enough time for the individual to
understand and get into the process in a systematic manner. In the same way
there are many different theoretical and models of change. One of the best and
popular cornerstone models for bringing up an organisational change was
developed by Kurt Lewin in 1940 and it is still considered and holds it to be
very true till today. His model is known as Unfreeze- Change- Refreeze which is
referred to be the important three stages of change process. Being a social
scientist he explained beautifully using changing shape of a block of ice. But as
the main aim of this project is to improve the nursing clinical handover which
goes hand in hand with leadership and management of change related to bedside
handover, this project also implies with the ADKAR theory of change.


This model
is created by Prosci founder Jeff Hiatt, it is a goal oriented change
management model which guides an individual and to make changes changes in an
organization. ADKAR is an acronym that brings out an achievement for a change
to be successfull that is :

A: Awareness;
D: Desire; K: Knowledge; A: Ability; R: Reinforcement

Change is a
complex process and moreover it is inevitable. Change is a difficult process in
any organization. It is required to start from a basic level starting from the
new thinking, new models and new frameworks for smooth functioning of the
desired change without hampering the surrounding. This model can be used in a
wide range to bring out the change process in an organization. When this type
of model is been used for a change it allows the leaders and the change
management teams to aim on their change that will make an individual change as
to achieve the results of the organization. ADKAR can give us a clear goal and
outcome for change in the management. It gives a systematic framework so that
everyone in the organization can use and it would be easy to understand and
describe the matter. As the problems included from both the nurses and the
patients side which would likely to be changed as patients have trust on nurses
and the management would be implementing change without compromising patients
treatment and care and as well as the integrity and financial status of the
hospital is maintained. Therefore ADKAR model would be a key for a change in
improving nursing handover.

Phase 1:  Awareness

In this
scenario, firstly the leader should identify the problems faced by the
organization depending upon the nature and depth of the problem and how badly
the organization is been affected should be calculated. The leader will then
find out the root cause of this problem and take into considerations and try to
improve that particular area. From this study the awareness for the need of
change would be explained by taking presentations in the meeting and the
importance of change would be explained in the managerial level. So that each
and every individual will discuss the topics held in the meeting with their
ward colleagues. Based on this the reaction could be vague but at the same time
they would ask for how would it be implemented? How soon we can put in

Phase 2:

In this
there should be a set desired goal. There should be willingness and approval from
the other members of the hospital, its not only a leaders job to change. Each and
every individual of the organization is equally responsible in their own
possible ways. There should be equal participation and motivation to reach to
that particular goal which has to be achieved in such a period of time. All the
participants engagement is very essential throughout the process. A good team
work would boost the energy of the participant to reach the desired aim. In this
patient should be focused about the adverse effects and risking a patient life
as well as to put nurses profession at risk.

Phase 3:

Firstly the
persisting knowledge would be assessed so that we are aware the nurses point of
view and how they look into it and how things are been carried out on a daily
basis. Then we would identify which are the lacking sources and then improve
them on that basis. Implementing new skills and behaviour would not be easily
accepted by everyone. So starting from the improvement and then gradually
introducing new skills would make sense to them and they would put into
practice. Adequate training should be provided to get the best out from them. On
duty training should be given in a practical manner while handing over. In this
a leader would lead the group and train the other colleagues.

Phase 4:

In this only
theoretical knowledge is not required. The ability to perform towards change is
also necessary. To bridge the gap between the knowledge and the ability the
employees should be trained in such a area by giving a scenario so that they
can make mistakes and questions would arise. By this they will understand their
mistakes and would not repeat this in future. To realize the change, staffs
also need time. When the ability is achieved, changes take place and we can see
the demonstrated new behaviours in practice.


Phase 5: Reinforcement

Human brains
are weired for thse same habit and psychologically we are programmed to revert
back to old habits been used for a longer period of time. Hence monitoring the
change is sustained or not. And if not, where it has stopped so that we can
reinforce and push into a start again. If there is positive attitude and result
rewarding the employees for making the change and demonstrating is important. If
most of the employees are reverting back to same method after a particular
period of time, check whether they require more training and reinforce them to
continue working in the new manner.


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