The importance of person-centred care has been consistently emphasised throughout my nursing degree course.
However, during clinical placement, I often found this focus hard to see. This was demonstrated particularly in how nurses conducted patient handovers.
In class, our lecturers emphasised the importance of participation by patients and their whānau, and we discussed what patient-centred care would look like, including the benefits of bedside nursing handovers. Despite this, I have yet to witness a bedside handover.
All handovers I observed on clinical placement occurred privately between staff members in the nurses’ station, without the patient’s involvement. Anecdotally, this also appears to be the experience of many of my fellow student cohort.
In at least one emergency department, reported anecdotally, a combined handover method is used, where the co-ordinator provides an update on all patients, after which the nurse conducts a bedside handover. While this approach was effective, time constraints could lead to rushed bedside handovers, compromising their quality.
The irregularities in handover practice in New Zealand, and lack of patient involvement in non-bedside handovers, led me to investigate the literature to answer this question: Do bedside handovers achieve better patient outcomes than non-bedside handovers?
Continuity of care
The New Zealand Nurses Organisation defines patient handover as the exchange of information between health-care team members to ensure continuity of care can be provided to the patient.1
Patient handovers typically occur during shift changes or when a patient is transferred to a different unit, ward, or health-care facility.1 Often, handovers occur in staffrooms or conference rooms when the next shift begins, and do not involve the patient or whānau members.2
During the handover process, incorrect information is frequently passed on because patient participation and perspective are often missing.2 Many errors can be attributed to the provision of incorrect or unreliable information given during handovers.2
. . . handovers typically lack patient involvement, meaning the patient loses a valuable chance to ask questions, discuss their care and provide their input.
In contrast, bedside handovers are a person-centred approach involving the patient, which helps prevent information-sharing errors and results in better patient outcomes and care.2
Working in partnership
The Nursing Council Code of Conduct sets standards for all nurses working in New Zealand to meet and apply to their practice.3 One of the standards is to work in partnership with the health consumer, ensuring that they have the opportunity to express their views and preferences.
This can be accomplished through collaboration with the patient, showing empathy, providing sufficient information regarding their care, ensuring that communication with the patient meets their needs and is readily understood, and respecting and upholding their preferences where possible.4
Patient participation is a key concept underpinning person-centred care.4 However handovers typically lack patient involvement, meaning the patient loses a valuable chance to ask questions, discuss their care and provide their input.
This is because patients’ care discussions are typically conducted away from the patient in the nurses’ station, and are based on information and documentation acquired during previous shifts.4
Using bedside handovers
One study I looked at investigated what was the best available evidence on patient involvement in, and experiences of, clinical handover conducted at the bedside.5
The study found that the involvement and two-way communication that occurred during bedside handover — as opposed to the traditional nurse-to-nurse-only communication that occurs at shift change — improved patient safety and increased patient satisfaction. It allowed the patient to share ideas and needs about their care which meant the patient was better prepared for discharge.5
The validity of information about the patient’s care could also be determined, and information was less likely to be missed.
However, the use of bedside handover is affected by factors such as the need for confidentiality — which could be hard to maintain where others in the ward could hear the conversation — and staff resistance to altering existing handover procedures.
The use of medical jargon and patients’ willingness to be involved also played a role in patients’ perceptions of bedside handovers. But this study found that patients were generally interested in being involved in bedside handovers; however each patient should be able to determine the extent of their involvement.5
Overall, according to this research, bedside handovers have been shown to enhance the quality of care provided to patients.5
Does handover education help?
An Australian study, based in two geriatric and rehabilitation wards, used an education intervention — which put forward a standardised bedside nursing handover method — to investigate whether bedside handover would enhance patient safety.6
Nursing staff, inpatients and family members received teaching materials on bedside handover, including information on the SBAR communication method (situation, background, assessment, and recommendation), an example video, written materials, and a bedside flowchart.6 The participants were surveyed before and after the intervention.
Before the intervention, patient handover occurred only in the staffroom through written and verbal information transfers. Despite the organisation’s earlier use of SBAR, the information conveyed from nurse to nurse varied significantly.6
After the intervention, the study found the nurses believed bedside handover standardisation improved patient safety, and patient and nurse satisfaction with the process had improved. The intervention ensured shift handover best practices and guidelines were achieved. Some patient injuries, such as falls and pressure injuries, were reduced, and there were fewer medication errors.
However, the improvements were not substantial, due to the modest number of instances reported.6 Other limitations to the study included the fact that the sample size was small, and from a single hospital.6
Patient satisfaction
A Swedish study aimed to assess patient satisfaction two years after the introduction of person-centred handovers and to discover what patients considered to be individualised treatment.7
The participants were 90 adult patients on an inpatient oncology ward at the Karolinska University Hospital in Sweden. The survey found that two years after the introduction of person-centred handover, there was a significant improvement in the provision of information by nurses.
However, differing methodologies make it hard to draw comparisons to other studies. This study did not directly measure patient involvement in information exchange, so a higher result did not necessarily mean patients actively participated in their care.7
The survey found that two years after the introduction of person-centred handover, there was a significant improvement in the provision of information by nurses.
Overall, this study demonstrated improvements in information provision and exchange between nurses and patients. However, long-term and randomised studies are necessary for a more complete understanding. Nevertheless, this study recommended the use of person-centred handover in oncological inpatient settings because it can improve patient outcomes.7
What helps, and what hinders
Another systematic review and meta-analysis compared findings from 24 qualitative studies on bedside nursing handover and explained what facilitated its use and what were the barriers to implementing it.8
Barriers the studies found included lack of time, with some nurses feeling rushed to complete the bedside nursing handover, which patients took negatively and interpreted it to mean the nurse lacked interest in the therapeutic relationship.
Nurses worried that patient enquiries and the time needed to express and repeat information without medical terminology could lead to errors and lost information during handovers, which could be unsafe.8
However, it was found that nurses who used bedside nursing handover, used easily understood terms which allowed patients to better understand their medical condition and instilled confidence in the nurses’ abilities.
Nurses were concerned about the ability to maintain confidentiality during bedside nursing handover in a shared room, and there was uncertainty around how much information nurses should provide during such handovers.8
It was found that participation in bedside handover decreased when the complexity of the patient’s illness increased. Some nurses did not like bedside nursing handover as they felt less free to communicate concerns with colleagues.
The study drew no conclusions on which handover method was recommended, only emphasising facilitators and barriers that needed consideration before an organisation implemented bedside nursing handover.8
WHO strategies
The World Health Organization (WHO) outlined strategies to improve communication during patient handovers to guide health professionals’ practice and ensure patient safety, in a guide issued in 2007.9 It cited Australian data which said 11 percent of the 25,000 to 30,000 preventable events that caused disability in Australian hospitals in 1992 were related to communication breakdown.9
Among its recommendations to reduce errors and improve communication were:
- use of standardised handover approaches, such as the SBAR technique
- allowing enough time for providing the necessary information
- limiting exchanges of information to only those needed to care for the patient
- making it easy for other healthcare providers to access the patient’s information and records if necessary
- communication between healthcare organisations.9
The WHO recommended patient and family participation in the handover process, stating that the patient and family played a crucial role in ensuring continuity of care. It was also important to ensure the patient had access to their medical records and that the patient was aware of the nurse caring for them on a particular shift, so they could ask questions or share concerns with the appropriate staff member.9
A crucial aspect of patient engagement was keeping patients and their families informed so they were aware of the next steps in their care and could participate more actively.
Factors standing in the way of implementing these recommendations could include staff opposition to change, lack of training and time, cost, language and cultural differences, low health literacy, staffing shortages, leadership failures, lack of technology infrastructure and insufficient accepted research or data.9
Recommendations
Current handover practices in this country usually occur away from the patient.6 Although I could not find a standardised nationwide handover policy, the Nursing Council’s Code of Conduct includes the principle of participation and states that the involvement of health consumers must be facilitated.3
It could be argued that handovers that occur without the patient’s presence do not adhere to the principle of participation because they fail to provide the patient the opportunity to hear and input any concerns or correct any information in the handover process.
Each health organisation must evaluate their specific bedside implementation barriers and facilitators.8 It seems many New Zealand organisations have not yet implemented bedside nursing handovers, but by not doing so, they prevent nurses from achieving an essential principle in their practice and potentially lowering the quality of care provided to patients.
Barriers to the implementation of bedside handovers include staff resistance to change, insufficient time, and insufficient research.8,9
Bedside handovers are associated with fewer patient injuries and errors than non-bedside handovers.5,6,9 Therefore, instituting this practice could save time and improve health outcomes by reducing the number of errors requiring time and staff to correct.
Based on the literature summarised above, bedside handovers are the recommended practice.7,9 However there are few studies conducted over the long-term that could assess if a change in practice offered sustained results.6,7
The findings of some of the studies could be questioned, due to the small sample size and the possibility of observation bias.6 Further randomised studies need to be undertaken that have a higher reliability, without bias.7
Each of the studies I looked at recognised there were barriers to implementing bedside handover, but they all described its positive effects on patient care.
Although the safety solutions proposed by the WHO9 are not recent, the organisation is globally recognised for its health promotion recommendations. It could be argued that its recommedations on handover practices have not been updated because the information is still applicable 16 years after the initial publication.
Each of the studies I looked at recognised there were barriers to implementing bedside handover, but they all described its positive effects on patient care. The reduced patient injuries from the use of bedside handover,6,9 could result in fewer hospitalisations, and because patients do not sustain additional illnesses or injuries, they may return to good health more quickly. This points to bedside handovers being a possible solution to improving patient outcomes.
The more involved and knowledgeable the patient and family are, the better it is for the patient because it ensures the continuity of care.5,9 Ultimately patients are better prepared for discharge.5,9
Do bedside handovers achieve better patient outcomes than non-bedside handovers? My literature search found that bedside handovers were not the most commonly used handover method.
However, the research showed that bedside handover equates to fewer patient injuries, and greater patient participation and satisfaction, despite not all studies directly concluding that it was the recommended practice.
More research needed
There is a need for further research to gain more understanding of the benefits of bedside handover. Research has shown that bedside handovers result in positive patient outcomes, provided the specific barriers and facilitators applicable to each facility or organisation are first considered.
Due to the positive aspects of bedside handover, it is possible to conclude that bedside handovers result in better patient outcomes than non-bedside handovers.
Acknowledgements: I would like to thank Dr Thomas Harding, one of my lecturers at NorthTec Te Pukenga, for his encouragement and help in preparing this article for publication. I would also like to thank another of my nursing lecturers, Linda Christian, for inspiring me to get an article published in Kaitiaki. Thank you both very much for all you have taught me.
Nicole Simonson has just completed the final year of her bachelor of nursing course, and is sitting state finals.
* This article was reviewed by Ben Ross, RN, MN(clinical), who is the charge nurse manager education, in the workforce practice and development unit, Te Whatu Ora — Capital, Coast and Hutt Valley.
References
- New Zealand Nurses Organisation. (n.d.). Position statement: Patient handover – emergency department.
- Levett-Jones, T. (2022). The clinical placement: An essential guide for nursing students (5th ed.). Elsevier.
- Nursing Council of New Zealand. (2012). Code of conduct.
- Bond, G., Christiaan, J., Kessell, M., Ma’asi, M., McCulloch, S., Tea, S., & Hodgson, K. (2021). How well is patient-centred care applied in practice? Kai Tiaki Nursing New Zealand, 27(1), 32-34.
- Porritt, K. (2022). Bedside clinical handover: Patient experience and involvement. JBI evidence summary.
- Hada, A., Coyer, F., & Jack, L. (2018). Nursing bedside clinical handover: A pilot study testing a ward-based education intervention to improve patient outcomes. Journal of Australasian Rehabilitation Nurses Association, 21(1), 9-18.
- Kullberg, A., Sharp, L., Johansson, H., Brandberg, Y., & Bergenmar, M. (2019). Improved patient satisfaction 2 years after introducing person-centred handover in an oncological inpatient care setting. Journal of Clinical Nursing, 28(17-18), 3262-3270.
- Clari, M., Conti, A., Chiarini, D., Martin, B., Dimonte, V., & Campagna, S. (2021). Barriers to and facilitators of bedside nursing handover: A systematic review and meta-synthesis. Journal of Nursing Care Quality, 36(4), E51-E58.
- World Health Organisation. (2007, May). Communication during patient handover.