Findings

Data revealed that the information handed over varied from nurse to nurse, and that the
handover process was influenced by many contextual. patient and nurse factors. Some of the
contextual factors were the time available to conduct handover and the pace of the ward at the
time. Additionally, patient information that was handed over varied due to the nurse's
knowledge levelsmof the individual patient's condition and their personal understanding of
the patient. Nurses who had returned from days off, and agency or casual nurses who had
only worked on the ward for a short period, had limited information about the patients and
were unlikely to be able to handover information in a substantial way. Consequently,
information handed over tended to be incomplete. The increasing use of agency and casual
nurses and the large numbers of nurses involved in each patient's care exacerbated
the problem. It seemed that due to the changing context of practice, nurses felt more
comfortable communicating: infcnuation verbally. However, this information was more
prone to being lost when held and handed over in the oral culture. The following excerpts
from interviews illustrate these points.
Ill('(/IJ sOllle oJ I/.ll' pcople [mulC5] 1 lPo,.k (pith
Ilrc sldflilJ~ offfind some illo:perituad, ... like slartifl!
l offdt coon/i/llltiltg /lnd Ihry mill rillxr boud oper
loo llIudJ J<!IJorllldlioH or cist' somdiml's lIJcy dOli'I
hi/lid OPl''' wOllgl,. Ana Ifml you htlllt' SOUlt' propit', /
kllOIP 11,1ms Ollt' lady [rrIerl'il/51 10 a colll'dgut'], s/,l'
Il'dS 11 !ollely lady, /'lll slJC rcally, yOll (lWIt' oul [of
ththlludol'l.'r room]lIIra you rl'dlly I,dd, s/il/ 110 itlcd
of ll'/JIII '.lI1d IJllppwt'd, l'tTl/HSC you I1lmosl !lot lIlt
16 CnllcMiilJl Vul R No I }OOO
hislory oJ l/lhat's harrmcd, or whats going to happ,,_
Tbry t"d to fo"" on tb,fact tbat of all tb,
thillgs that thO' did that day ... 50 this has bttll a
major fVt'JIt oJ the day, like melanlll, tJ1t'l1 1/11115 IVI)al
thry'lI Jocus 011. Ytah, and Ihry'lI jorget to tell yOIl
Ihe ntdoscopy happelltd yl.'5/trday.
The findings revealed that regardless of
the type of handover that was used there
were consistent gaps in information due to
a number of reasons.
"Ntl/l admissioll, don't know /IIuch I1bout him,
bes jusI COIUC up from casualty. l've 110t dOfle Ihe
ohs."
"[SIatl.'5 his a!1e mid IIltdical diagnosis] ... IJt IJas
alcohol p"oHc1Us, Ilefds a sputum. We dOll't knoll'
Il'IJtrt IJt is 510illg to, I)/It tht social UJorktr ;5
invo!lletl."
"[SldtCS his l1!1t mrd lIIl'diml diagJlosisJ ... sorry
1dOll'l k"oll" IJtS come from mlOl/m Ulard mrd the
pmo1r (pho /lookcd him ill did Hot bt01P (pIJ"t opem·
tioll JJt llJl15 coming injOI:"
Additionally, the fragmented c communication
between nurses and doctors added
to this problem.
No, you'pe gal to dJlIse I/JCIlI [referrill~ to the
doe/ors], sOmttimfs you jj"d Ollt fr01l1 II)t Pflliwl,
1/,0' SIlY "01" rill going '}oIIlt' ill IIJr 1Il0nrillu" t/nd
t/lllls lhc first lilUe you'Pt' Ildl!ll/1y 1,Ct'tJ lold.
There were many instances where nurses'
knowledge about the patient remained
"uncertain". fvloreover, lllln;es' acceptance
of uncertainty and "not knowing specifics
about palierlt care" left them vlllner"ble as

The findings revealed that regardless of

the type of handover that was used there
were consistent gaps in information due to
a number of reasons.

felling she didn’t really know what was going on

Another problem with handover was related to the type of information given. For
example, some nurses used this time togive an account of the activities they had performed on
a shift. This information had little relevance to other nurses who weremore interested in the
patient's progress and future care.
They dont look at the patient on a continum, ypu know, they don’t sort of look at what
happened maybe yesterday. So they dont give you any of the it had the potential to lead to
undesirable outcomes.
He came ill lasl WWiHg.

Th0' dOIl'1 look at Iht patitllt 011 a cOlltilluum, you hlOW, tl,ty dOll't ~ort oJ look at
tVI,allwpptlltd maybt yesttrday. SO I/J0' don't givtyou allY oj the it had the potential to lead to
undesirable outcomes. He came ill lasl WWiHg. [SIt/ItS Iht raliwls agt m,d ""dical diagllOsis]
be; a NIDDM, fdl m,d jractured IJis ril,s, [givts tlJ mtdical trtdtmwtbe '}Odn011 Ihe prtvious
ward] ... 110 ditl he Cel/lIlol swallow, IIl1so-gasfric luht rt-iJlmied, jteds w;l/ hI.' comillg lip,
dopa mint i,rjusioll 20 IIlI per hOllr, also IVfluids, "1.'5 dthydraltd OIlCt juds slmt IV call stop,
his unue ot/tpul is Vtry poor, two /'ourly ml.'t1surmlwl, SIlClio'lill! l PRN, 1)( Iluds luaps and
luaps oj moull) cart his lIlouth looks Vtry bad. Ht gol vtry agi/altd whtl1 1passed the nasa-
gastric lubt, I don't kllOll' he seens cOlljustd. Oxygtll sats artfil1t, oxygw COI1tillllOllS milh
tJJt Hudson mask, CVP rtadillgs art ceased. Hes 1101 jorilltubalioll if be armis. [AnolherI'll/m
asks a qlltS/ion:} "W/1al, do Ult jllstgivthim cardiac massagd' [The sl1ifl coordinalor allswm..]
"[ aptcl 50." [The handovtr COlltiIlUtd.] As a consequence of receiving inadequate handovers,
many nurses spent considerable time chasing accurate information from a number of sources.
This time-consuming exercise reduced the time available to deliver care. Overall, analyses of
the data indicated that each type of handover had particular strengths and limitations, however,
no one type of handover was appraised as being more effective.

TihliS 1Lrraidliil:oolf1lal lface to lfaCiS handovers OD1l 11:ihle

oihfoce wiStre appralsed as !beong Uen9l11:lhly. time
COI11JSIUIMOI11J9I al11Jd ofteD1l cOI11J11:a1oll1ingj subjective
lPa1LOiSl11J'IJ: ol11J1totrmatioll1l. e-aowiSvetr. 11:lhiis type of
ihlall1ldloviSlr served another purpose as they
WiStre IUIsedl SlS a1111J avenue 11:0 eu:clhlSlll1l9le
o01l11.oll.ma1l:ioll1l.idle!bll.ie1i. all1lidl as a time il'Otr sociat
cihloil:cihlail: fdhla11: was em011:DOl11JalUy ClImll sociallUy
omlP0tr1l:al11J'IJ: lfol1' 111JIl1ltrses.

time available to conduct handover and the

pace of the ward at the time. Additionally,
patient information that was handed over
varied due to the nurse's knowledge levels
of the individual patient's condition and
their personal understanding of the patient.
Nurses who had returned from days off, and
agency or casual nurses who had only
worked on the ward for a short period, had
limited information about the patients and

were unlikely to be able to handover information

in a substantial way. Consequently,
information handed over tended to be
incomplete. The increasing use of agency
and casual nurses and the large numbers of
nurses involved in each patient's care exacerbated
the problem. It seemed that due to
the changing context of practice, nurses felt
more comfortable communicating: infcnuation
verbally. However, this information
was more prone to being lost when held
and handed over in the oral culture. The
following excerpts from interviews illustrate
these points.
f Ill('(/IJ sOllle oJ I/.ll' pcople [mulC5] 1 lPo,.k (pith
Ilrc sldflilJ~ offfind some illo:perituad, ... like slartifl!
l offdt coon/i/llltiltg /lnd Ihry mill rillxr boud oper
loo llIudJ J<!IJorllldlioH or cist' somdiml's lIJcy dOli'I
hi/lid OPl''' wOllgl,. Ana Ifml you htlllt' SOUlt' propit', /
kllOIP 11,1ms Ollt' lady [rrIerl'il/51 10 a colll'dgut'], s/,l'
Il'dS 11 !ollely lady, /'lll slJC rcally, yOll (lWIt' oul [of
ththlludol'l.'r room]lIIra you rl'dlly I,dd, s/il/ 110 itlcd
of ll'/JIII '.lI1d IJllppwt'd, l'tTl/HSC you I1lmosl !lot lIlt
hislory oJ l/lhat's harrmcd, or whats going to happ,,_
Tbry t"d to fo"" on tb,fact tbat of all tb,
thillgs that thO' did that day ... 50 this has bttll a
major fVt'JIt oJ the day, like melanlll, tJ1t'l1 1/11115 IVI)al
thry'lI Jocus 011. Ytah, and Ihry'lI jorget to tell yOIl
Ihe ntdoscopy happelltd yl.'5/trday.
The findings revealed that regardless of
the type of handover that was used there
were consistent gaps in information due to
a number of reasons.
"Ntl/l admissioll, don't know /IIuch I1bout him,
bes jusI COIUC up from casualty. l've 110t dOfle Ihe
ohs."
"[SIatl.'5 his a!1e mid IIltdical diagnosis] ... IJt IJas
alcohol p"oHc1Us, Ilefds a sputum. We dOll't knoll'
Il'IJtrt IJt is 510illg to, I)/It tht social UJorktr ;5
invo!lletl. "
"[SldtCS his l1!1t mrd lIIl'diml diagJlosisJ ... sorry
1dOll'l k"oll" IJtS come from mlOl/m Ulard mrd the
pmo1r (pho /lookcd him ill did Hot bt01P (pIJ"t opem·
tioll JJt llJl15 coming injOI:"
Additionally, the fragmented communication
between nurses and doctors added
to this problem.
No, you'pe gal to dJlIse I/JCIlI [referrill~ to the
doe/ors], sOmttimfs you jj"d Ollt fr01l1 II)t Pflliwl,
1/,0' SIlY "01" rill going '}oIIlt' ill IIJr 1Il0nrillu" t/nd
t/lllls lhc first lilUe you'Pt' Ildl!ll/1y 1,Ct'tJ lold.
There were many instances where nurses'
knowledge about the patient remained
"uncertain". fvloreover, lllln;es' acceptance
of uncertainty and "not knowing specifics
about palierlt care" left them vlllner"ble as

Face to face handovers

in the office
The traditional face to face handovers in
the office were appraised as being lengthy,
time consuming and often containing subjective
patient information. However, this
type of handover served another purpose as
they were used as an avenue to exchange
information, debrief, and as a time for social
chitchat that was emotionally and socially
important for nurses. New staff, especially
new graduates, found this type of handover
useful as they used it as an opportunity to
confirm information and were often given
an impromptu educational session.
AllotJm unrseasks her 11 qUl.'5lioll 'Dots s/)tgtl
up for /m S/'OIPtO' The a.m. co-ordilll1tor mlSIPm
'Yl.'5'. Furl/uro:pllliHS howslu is alllbuldliJlg. Wil/,hold
ber meals, sbe is !'l1villg double /lIeals, s/,tsays
I/,eJl1mily 1Jrill~ /Jcr ill mCl/ls fllld tlmJ she rats our
meals l1S wdl. Num 3 Sl1ys '51)(5 Pl'ry IJUIl!1ry', tlJt
lUll. co-ordinalor t'xplaills wlJy s/Jt is hUlIgry
hmwseshe is 011 sleroids.
Individual nurses also had different
approaches to handing over patient information.
Some methods were thought to he
less helpful and retarded the communication
process.
Aud if II)ty USt /l s/Jecl oj PIIPtJ' IIJty lIs1wily
rcad dOIPIt Iwd follolP l/ formlll IIUtl it IMS somr
slruclufe. 1f t/,cy dOIl'1 IIsr 11 sl)ul oJpc/prr Iwd
they're hmhliug ollr/" off the lOp oj dId/" helld, 1/)(11 it
seetlls 10 llld/llia /'lefr. lhcfr mid CllClyll'lJl.'l"C. Quill.'
Jmnkly, ... IP/ml il twds la (pmldn"tre, dJere alld
weryllll,m 1don 'I mm 10 be able 10 remew/m' it
[patient details] at al/.
This type of handover was important as
it provided an avenue for the transference
of information within the oral culture.
There were many patient care issues that
were held in nurses' minds and only handed
over verbally. These included either
confidential issues or instances of mismanaging
care. An excerpt from the field notes
illustrates this point.
TIJis patieut was all alcol,olic alld they IPm
(messing "illl Jar lI'ifhdrall'aJs. He was prescribed
1.1(I/;UIll iJ he IPas displaying certain wUIJdrallJal
siglls. TI,e ll11m handed over tlJat Ihis palit,lt called
a 1St year RN dJal night and said Ihat "he had
IUdrd an explosioll" Ihe nurse instantly gave him
5111gs oJ Valilllu as si" thouglJt tl'at he was !pithdmming
alld hallucinating. Apparently, tl}(re was
all explosion at a nearby vwue alld tht patiellt was
nothallucinating at all. Several days later the HurS(S
continued to hand this over alld ,,,tVe a little chuckle
at 1/" same time. BtSides signing 11" medicatioll chart
this episode IPas notdoclllllellted.
A summary of the strengths and weaknesses
of verbal office handovers is listed in
Table 1.

TABELLLL
Tape recorded handovers
Due to the rostering system and lack of
shift overlap time, tape-recorded handovers
were introduced to communicate
patient information. While this type of
handover had practical benefits, as no face
to face contact is required, it also hindered
communication, as its use tended to modify
and alter the efficacy of the handover
process. More specifically, nurses found
that they tended to handover information
in a more impersonal way, focusing on
tasks rather than on patient progress. This
type of handover tended to be brtefer and
did not reveal fully the patient's overall
condition. Additionally, some nurses used
abbreviations that were not understood by
other staff. Due to the time lapse between
recording the information and listening to
the handover some patient information was
out of date. A nurse's account of the effectiveness
of handover provides an example
of the problem.
Tbey do it all llJpe [refnring la tbe I,mtdoper]
dud Iht limildtioJl 1suppose, especially if you lire
comillg all 1111 aJtemooll shifl, tI'lll's ttlpea at J I.]0·
12.00 o'clock md 1Jilld tbt maiH Ihillgs an: really
hllppmiug aroulld r.oo o'e/ock, after 11I1IrJJ, so thlll
aoes/l't get l'llllaed over all tJJe tllpe dJld if they dOIl't
sec yOll - verbally yOll don't gd it at ,,11, mId it's
lIs11dlly lJy Iril11 alld error thlll you fiutl it 0111. I
kllOl/l myself, it's slld, a rush "Oh, fpe gal to I,mldOllet"
on the t"pt", ,p/,erws it wOllld he /Jeller to do it
vcrIJ'llly, 1tlJillk yOll remelll"n more ,PfJCJI YOl/'rt /lot
so flIs/Jtd.

On some occasions, nurses would have

to replay the tape in order to determine
what was said. However, if the message was
not clear it was difficult to confirm or deny
information, as the person handing over
may not have been accessible. The following
taped handover is an example of an
unclear message.
PAT/ENT C] [states the patients name,
age, medical diagnosis] borderliHe sleep apllOtil,
ambulanl, self-care, IV bllllgtd, iJhe is IlIIllletl Jast
JJim Jrom ! 2.00lIIidnigl" md call the lealll.
Within this context, it was difficult to
determine with certainty what "unwell"
meant, and the nursing response that was
expected if the patient was unwell after
12.00 midnight. In addition, as these handovers
did not provide an opportunity for
nurses to clarify patient details or fill in the
gaps in information, some knowledge about
patient care got lost. This occurred more
frequently with agency nurses as they often
did not return to the ward.
The at/m Jrustrating tl,illg linked to that [tl'e
tape-recorded /Jmdover] is somdimes tlJe staff t!1ember
oJtm iSI1" lime allY mort to Jilld out IIll,al's gOlle on,
50 YOll're somdimes losl and have 10 spelld a lot oJ
time Jillding out thal i'ifonnatioll Ihat's lost tl'at was11
't 011 11" tape ... but oJtell inJonnation isjust losl.
For a summary of the strengths and limitations
of the tape recorded handovers see
Table I.

TABLE 1: STRENGTHS AND LIMITATIONS OF THE THREE TYPES OF HANDOVER

Strengths Limitations
Verbal Office • Collective narrative (less gaps • More story like (prone to being
Handovers in information) subjective and judgmental}
• Opportunity for staff to debrief e Tirne consuming
• Opportunity to clarify informa- • Some information is
tion (learning opportunity superfluous
especially for new staff) • Some nurses switch off -
especially when the
information is subjective
Tape Recorded • Does not require shift overlap • Information can be out of date
Handovers • Less time consuming • Difficult to clarify information
• It is more factual • Cannot check patient and/or
• Some nurses like this documentation
matter-of-fact approach • No teaching opportunity
• Acts as a filter (some nurses
are awkward and are cautious
tape recording information)
• Some information is not handed
over and is not processed
formally or informally
Face to Face • Involve the patient • Public forum - difficult to dis-
Bedside Handovers (individualised care) cuss personal patient issues
• Check the charts and • Confidential information is
medications sometimes revealed
• Remedy errors • Time consuming:
• Assess patients and clarify - Nurses prone to being
information at time of interrupted by ward issues
handover - Some patients like to chat

Face to face handover

at the bedside
Face to face handovers at the bedside were
introduced in many wards to try to overcome
the weaknesses of the traditional
office andtape-recorded handovers. This
type of handover seemed useful, as nurses
were able to check documentation and clarify
information with the patients and each
other.
As this IW1dover is cOllducted at the bedside, 11)(
patimts lislell in all the IWldovers. QlIile oJI(II tlJe
IlllrSe asks the patiel1llPhal /,as I,appaltd. For example,
have yOIl had YOllr X-ray loday] Has Ihe doclor
seal YOII] Whal did he say] ... Ouceagaill Ihere
is emplwsis all tlu medication clwrt IOI'ich is
reviewed, alld drugs that are nolsiglled offare looked
at and the lIurse lookillg after the patialt, if sI" isstill
all duty, is asked toclarify wlJell"r shthas give" t"e
drug or 1I01.
While handovers that were conducted
at the bedside involved the patient in discussing
their care, it also posed specific
problems, as it was difficult for nurses to
handover personal and confidential information
in front them.
11,e nurses qualify thillgs u,jl/J edelJ other ie. does
he call yOIl wlml he needs a bottle ordoes he w(/himself.
This nllrse had berfl Oil days offalld the patimt
IPas quite sick allhe lime. Because rbe IJaJldover5 are
conducted at 11" bedside ifthm is allY private alld
awkward illJonnatioll to halldover the nurse points to
Im writttH »cres 011 her I,a"dover sheet Jor I/Je other

HUtSI' 10 mill. For (xl/mp/t, 11,"5 rlltifHIll'd5 " IlIlmic

r!errmiuc dHJlIIWhd d 10/ oJ (fl(OllrogelUcul md tl.l(
HUfSt' did /lol/pl/lll to 51ly 11J1l1 0111 aloud.
Additionally. nurses were constantly
interrupted during the handover. This
made these t ype s of ha ndover-s very
lengthy.
Dud"!} lI'tfield ol'Stn)flliOH !,triod, f obstn)l'd cl
nurse btiH!J illtl'rruplrd six tiJllfS, ill /1 tllleJIly-minult
period, [I'Mlc tryiJl!J 10 /JrIl1dovcr ill I!JC IPard arm.
Time ifllerruptiollS uvrc I/ue 10 /hcfollomirl!J rmsous.
lIisilors mkiu!Jassislmlrt for tlJtir rr/ali/1t5; " sludwt
llUrst askifl!J a/Joul pa/itut care, on II#tllCy nurse
!JOill!J offduty alld IJlTlldiu!J O[Ier Ihekeys; 1/ Pl/tieu!
(IIC/P admissioll) [Pho arrillcd from tile Clllcr'ilCHCY
depl/fhl1f11t dud thc orderly Ilecdhlg Ilssislmlcc 10 se/Ill'
tlJf Pllliwl; ptllirlll /Jells ri"gillgcOllstdnlly.
For a summary of the strengths and limitations
of the face to face bedside handove-
s see Table I.
Discussion
To answer the question of which is the
most appropriate type of handover, one
must first reflect on the handover's purpose.
In this study, handovcrs were used fJS
torurns to communicate patient information,
to provide staff with avenues to infermally
debrief, clarify and exchange patient
information. New staff including graduates
found these informal educational sessions
very helpful. This finding is supported by
Parker, Cardner and Wiltshire (1992) who
state t hat talking to other nurses and
debriefing is;;111 important aspect of nursing
practice that is difficult to achieve in
patient areas and occurs within the context
of the verbal office handover.
Regardless of the type of handover
method used, their efficacy as a communication
medium is questionable. Specifically,
the results have highlighted a number of
problems with each type of handovcr, and
there does not appear to be one method
that is more effective. The findings of this
study confirm what many authors state:
that the traditional verbal handovcrs conducted
in the office 'Ire lengthy and rime
consuming. Furthermore, they are often
lacking in structure and concentrate on the
nurses' tasks rather than the patients' needs
(\X'illiall1s 1~)9~, Mclvcuna 1~)97, Crcavcs
18 C(lllq.~i;lfl Vul x N(l.~ 2001
1999, Webster 1999).
The results of the current study support
the literature identifying the positive
aspects of the bedside handover, those
being its immediacy and inclusiveness,
allowing patients to participate in the
problem solving process (McKenna 1997).

develop ward specific pro forma to

structure handovers focusing on patient
progress rather than on tasks;
• use tape-recorded handovers as a last
resort and then only as an adjunct to
other verbal communication methods;
• include doctors in the handover process
for a brief period, this will enhance
communication and accuracy of patient
care information;
• think creatively and combine the
strengths from the different styles of
handover to develop a communication
strategy that meets the needs of individual
patients and ward situations.
The findings of this study revealed that
handcver is more than just a forum for
communicating patient care. It is also used
as a place where nurses can debrief, clarify
information and update knowledge. Given
the pressure cooker conditions under
which nurses work these supportive and
debriefing forums are necessary and need
to be scheduled as part of a ward routine.
They are important for quality patient care
and nurses' well being. Achieving the multiple
goals of handovcr presents researchers
and clinicians with a challenging task. It is
necessary to explore and evaluate more
creative ways of conducting handover, so
that an important aspect of nursing practice
does not get classified as just another
ritual.