Table of Contents
Type: Discussion Chapter | Subject: Nursing | Level: Masters | Word Count: ~3000 words
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This chapter should discuss the key findings from your mixed-methods study of nurse-to-nurse shift handover communication on an acute medical ward, interpreting them in relation to the patient safety and communication literature, before setting out the study’s limitations and implications for practice.
Note: this is a single chapter presented as reference material; the full dissertation would include the remaining chapters.
This chapter discusses the key findings presented in Chapter Four, which examined nurse-to-nurse shift handover communication on a 32-bed acute medical ward at a fictional NHS teaching hospital, Aldermoor Foundation Trust. The study was designed to address two research questions: how do registered nurses on the ward currently experience and enact shift handover, and what factors appear to influence the completeness and safety of the information transferred? The study used a mixed-methods design comprising a cross-sectional survey of registered nurses (n = 52), semi-structured interviews with a purposive sub-sample of ten nurses of varying seniority, and a structured review of forty anonymised incident reports coded as handover-related over a twelve-month period. Four principal findings emerged from the analysis: inconsistent application of the SBAR (Situation, Background, Assessment, Recommendation) handover tool despite its formal adoption three years earlier; frequent omission of medication-related information during verbal handover; a reluctance among junior and newly qualified nurses to seek clarification from more senior colleagues during handover; and a persistent reliance on informal, unrecorded ‘corridor’ handovers as a workaround to time pressure. This chapter interprets each finding in relation to the existing evidence base on clinical handover and patient safety, offers a systems-level synthesis of how the four findings relate to one another, and considers the strengths and limitations of the study before setting out its implications for nursing practice at ward level. Where possible, the quantitative findings are triangulated against the interview and incident data to strengthen the interpretive claims made in this chapter, rather than being discussed as three separate strands of evidence.
The finding that SBAR was used consistently by fewer than half of surveyed nurses (44.2 per cent reporting ‘always’ or ‘almost always’ following the structure), despite formal trust policy requiring its use, is consistent with a substantial body of implementation literature indicating that structured handover tools are frequently adopted in name but not reliably embedded in routine practice (Randmaa et al., 2014). It is worth noting that Randmaa et al.’s (2014) original study was conducted in a Swedish anaesthetic clinic rather than an acute medical ward, and the present findings suggest that the implementation challenges the tool faces are not confined to the perioperative setting in which much of the existing SBAR evaluation literature originates, but extend to general ward nursing with its own distinct time pressures and staffing patterns. Interview participants attributed inconsistent use principally to time pressure and to a perception, among more experienced nurses in particular, that the structure was ‘unnecessary’ for colleagues who already knew the patients. This pattern mirrors Müller et al.’s (2018) systematic review finding that structured handover tools show measurable short-term improvements in information transfer immediately following training, but that adherence typically declines over time in the absence of ongoing audit and reinforcement, a phenomenon the review terms ‘implementation decay’. A further nuance evident in the interview data was that adherence appeared to vary by shift type as well as by seniority: night handovers, conducted with fewer staff present, were described as more likely to depart from the structure than day handovers, even among nurses who reported using SBAR consistently by day. Notably, two of the four most experienced interviewees reported consistent use, attributing this to having witnessed a handover-related incident before the tool’s introduction, suggesting that direct exposure to the consequences of poor handover, rather than seniority as a blunt proxy, may better explain adherence. The present findings extend this observation by suggesting that decay was not uniform across seniority bands: newly qualified nurses in the interview sample reported using SBAR more consistently than nurses with over ten years’ post-registration experience, who more often described ‘adapting’ the structure informally. This is broadly consistent with Street et al.’s (2011) contention that experienced clinicians are more likely to substitute standardised tools with tacit, experience-based communication routines that are efficient for the individual but harder for colleagues, and for the organisation, to audit and standardise.
Medication-related omissions were identified in eleven of the forty reviewed incident reports as a contributing factor, and eighteen survey respondents (34.6 per cent) reported having personally identified a medication discrepancy that they attributed to incomplete handover information within the preceding six months. This finding can usefully be interpreted through Endsley’s (1995) model of situation awareness, which distinguishes between the perception of relevant information, its comprehension, and the projection of its future implications for patient status. Interview accounts suggest that omissions typically occurred not because information was entirely absent from the patient record, but because it was not verbally foregrounded at the point of handover, meaning the incoming nurse’s situation awareness at Endsley’s first level, perception, was incomplete regardless of what was documented elsewhere. This is consistent with Wong, Yee and Turner’s (2008) argument that verbal handover functions as the primary real-time mechanism for establishing shared situation awareness across a nursing team, and that written documentation alone, however complete, cannot substitute for this function during a fast-paced shift change. One incident report reviewed, anonymised for the purposes of this discussion, described a recent dose change to an anticoagulant that had been recorded correctly in the electronic patient record but was not verbally mentioned during a busy evening handover; the incoming nurse administered the previous, higher dose the following morning before the discrepancy was identified during a routine medicines round. While this single case cannot be generalised, it illustrates concretely how the information-loss pattern identified at the aggregate level in the incident data can translate into an actual near-miss at the level of an individual patient. The present findings therefore support the view that medication safety during handover depends less on the existence of accurate records and more on reliable verbal practices for surfacing high-risk information, a distinction the SBAR tool is explicitly designed to support through its ‘Recommendation’ component but which, as noted above, was not consistently followed by ward staff. Closer examination of the eleven medication-related incidents suggests that omissions clustered around a small number of high-risk drug classes: anticoagulants and insulin together accounted for seven cases, categories in which a single missed dose adjustment can have serious clinical consequences. This concentration is consistent with Vincent and Amalberti’s (2016) observation that safety failures in complex systems tend to cluster around a small number of high-risk, time-critical tasks rather than being distributed evenly, implying that verbal handover emphasis might usefully prioritise such medications rather than attempting equal verbal coverage of every prescribed item.
A recurring theme in the interview data was the reluctance of junior and newly qualified nurses to interrupt handover to ask for clarification, particularly when the nurse leading handover was senior or perceived as ‘busy’. Several interviewees described withholding questions during handover and instead attempting to locate the information independently afterwards, a pattern that delays, rather than prevents, information loss and adds to individual workload. This finding aligns closely with Edmondson’s (1999) concept of psychological safety, defined as a shared belief that a team is safe for interpersonal risk-taking such as asking questions or admitting uncertainty. Where psychological safety is low, as the interview data suggest was the case on this ward for less senior staff, individuals rationally avoid behaviours, such as questioning a senior colleague’s handover, that carry perceived social risk even when those behaviours would improve patient safety. This interpretation is consistent with Okuyama, Wagner and Bijnen’s (2014) review of speaking-up behaviour in healthcare, which found that hierarchical gradient was one of the most consistently reported barriers to staff raising safety concerns across clinical settings internationally. The present findings suggest this dynamic operates not only around overt safety concerns, the focus of most existing speaking-up literature, but also around the more routine act of seeking clarification during a structured communication process, indicating that psychological safety may be a relevant explanatory factor for handover quality more broadly than previously emphasised in the ward-based handover literature specifically. This pattern was not universal, however: two interviewees described a specific senior colleague who routinely paused after each patient summary to invite questions, and both reported feeling more comfortable seeking clarification during that colleague’s handovers than during others. This exception suggests that psychological safety on the ward was not a fixed team-wide property but was, at least in part, locally produced by individual senior nurses’ handover behaviour, indicating a modifiable behavioural target for intervention rather than a more diffuse cultural problem.
Finally, both the survey and interview data point to a persistent practice of supplementing, or in some cases substituting, formal handover with brief informal exchanges in corridors or at the nurses’ station, particularly during periods of short staffing. Twenty-nine survey respondents (55.8 per cent) reported that this occurred ‘often’ or ‘very often’ on the ward. Interview participants generally did not describe this practice as problematic; several framed it as a pragmatic and even efficient response to time pressure. This normalisation of an informal workaround, despite its documented association with information loss elsewhere in the same findings, is consistent with Vaughan’s (1996) concept of the normalisation of deviance, whereby a practice that departs from formal protocol becomes accepted as routine within a work group because it has not, to date, been observed to cause visible harm. Debono et al.’s (2013) review of workarounds in nursing practice similarly found that such practices are rarely recognised by staff as deviations from safe practice, precisely because they typically succeed in the short term, reinforcing their continued use. The present study’s finding that corridor handovers were common despite the ward’s own incident data showing an association between incomplete handover and medication discrepancies illustrates this disconnect between individual staff perception and the aggregate pattern visible only at ward or organisational level. Notably, several interviewees who described corridor handovers as unproblematic were the same individuals who, earlier in their interviews, described SBAR as unnecessary once colleagues ‘already knew the patients’, suggesting that the two findings discussed so far in this chapter are not independent but are underpinned by a shared, informally held belief among more experienced staff that personal familiarity with patients can substitute for structured, recorded communication, a belief the incident data reviewed for this study do not support. Survey data further indicated that reported frequency of corridor handovers was significantly associated with respondents’ self-reported perception of being short-staffed on the shift in question, with nurses rating their shift as short-staffed more than twice as likely to report frequent informal handover. While not establishing causation given the cross-sectional design, this association supports the interpretation that corridor handovers function as a response to situational pressure rather than a general disregard for formal process.
Taken individually, each of the four findings discussed above might be read as a discrete, locally correctable problem: retrain staff on SBAR, remind staff to document medication changes, encourage junior nurses to speak up, discourage corridor handovers. Reason’s (2000) model of organisational accidents suggests a more integrated reading. Reason distinguishes between active failures, the immediate, often individual actions or omissions that directly precede an adverse event, and latent conditions, the more distant organisational and design weaknesses, such as time pressure, staffing levels, training gaps and cultural norms, that create the conditions in which active failures become likely. Read through this lens, the specific instances of incomplete SBAR use, omitted medication information and unspoken questions identified in this study are best understood as active failures whose underlying latent conditions are largely shared: chronic time pressure, an informal cultural tolerance for departing from protocol under pressure, and a hierarchical team culture that inhibits the cross-checking behaviour that might otherwise catch individual omissions before they reach the next shift.
This systems reading has an important implication for how the findings should be acted upon. Reason’s (2000) central argument is that interventions targeted solely at active failures, for example disciplinary responses to individual missed handover items, are unlikely to produce durable improvement because they leave the underlying latent conditions untouched, and similar active failures will recur under the same pressures with different individuals. The World Health Organization’s (2007) patient safety guidance on handover communication makes a closely related point, recommending that handover improvement initiatives address structural and cultural conditions, protected time, standardised tools embedded in routine workflow, and a culture that supports questioning, rather than relying on individual staff vigilance or memory alone. The four findings of this study, considered together through this systems lens, therefore point toward a shared set of underlying latent conditions rather than four unrelated local problems, a synthesis that directly informs the practice implications proposed later in this chapter. Reason’s (1990) earlier and more widely known ‘Swiss cheese’ model of accident causation offers a useful shorthand here: each latent condition, time pressure, cultural tolerance of departure from protocol, and hierarchical inhibition of questioning, can be understood as a defensive layer with its own characteristic weaknesses. An adverse event such as the anticoagulant error described above occurs not because a single layer fails completely but because the holes in several layers momentarily align: a busy shift reduces the time available for full SBAR handover, ward culture treats the shortcut as acceptable rather than a departure to be flagged, and hesitancy to question a senior colleague removes the final opportunity to catch the gap before it reaches the patient.
This study has several strengths, including its mixed-methods design, which allowed the quantitative survey findings to be contextualised and explained through interview accounts, and its use of incident report data to triangulate self-reported perceptions against a documented outcome measure. The researcher’s own clinical background as a registered nurse facilitated rapport with interview participants and an informed interpretation of ward-specific terminology, although this proximity to the setting also required deliberate reflexive practice, including a reflective log maintained throughout data collection, to guard against the researcher’s own assumptions about handover practice shaping the interview questioning or the coding of qualitative data. Nonetheless, several limitations should be acknowledged when interpreting the findings. First, the study was conducted on a single ward within a single fictional trust, and the findings, particularly regarding the specific balance of contributing factors, cannot be assumed to generalise to wards with different staffing models, patient acuity or handover practices. Second, the interview sample was self-selecting, and nurses who volunteered to participate may have held stronger views, in either direction, about handover practice than non-participants, introducing a possible volunteer bias. Third, survey items asking nurses to self-report their own SBAR adherence and their awareness of medication discrepancies are subject to social desirability and recall bias; actual adherence, as distinct from self-reported adherence, was not independently observed. Fourth, the cross-sectional design captures a single point in time and cannot establish whether the patterns identified have been stable or are recently emerging, for example following a specific staffing change. Future research using direct observation of handover practice, rather than self-report alone, would help to address the second and third of these limitations. A further limitation concerns the incident data specifically: as with most healthcare reporting systems, reporting is voluntary and likely subject to under-reporting, so the forty reviewed reports should be read as a partial rather than complete record of handover-related safety events, and the true incidence of medication-related omissions attributable to handover is plausibly higher than the incident data alone suggest.
Despite these limitations, the findings carry several plausible implications for ward-level practice, which the systems perspective set out above suggests should be pursued together rather than in isolation. The gap between formal SBAR policy and actual use suggests that one-off training at the point of tool introduction is unlikely to be sufficient; periodic audit and feedback, an approach with some supporting evidence in the wider implementation literature (Müller et al., 2018), may help to counter the implementation decay observed here, for example through a named handover safety champion conducting brief monthly spot-checks against the SBAR structure with non-punitive, developmental feedback to the team. The association between hierarchical culture and reluctance to seek clarification suggests that interventions aimed solely at handover structure may be of limited value unless accompanied by attention to team psychological safety, for example through senior staff visibly modelling openness to being questioned during handover and explicitly inviting clarification questions at the close of each handover episode, rather than treating the absence of questions as evidence that the handover was complete. Finally, the normalisation of corridor handovers as a workaround for time pressure suggests that protecting dedicated, uninterrupted handover time through a rostering change, for example a short planned overlap between outgoing and incoming shifts that is not simultaneously used for other clinical tasks, may be a necessary precondition for any communication-tool intervention to succeed, since a well-designed tool cannot compensate for insufficient time to use it properly. Ward leadership sign-off and visible commitment to protecting this time would likely be required for such a change to be sustained beyond an initial pilot period. It is worth briefly setting aside an alternative intervention common in the wider literature: replacing verbal handover with a structured electronic tool integrated into the patient record. Staggers and Blaz’s (2013) integrative review found that such tools can improve the completeness of transferred information but do not, alone, address interpersonal barriers such as reluctance to question a senior colleague, and may in some settings reduce the face-to-face interaction through which situation awareness is established. The recommendations above are therefore deliberately framed around behavioural and organisational change rather than technology procurement.
This chapter has discussed the study’s four principal findings, inconsistent SBAR use, medication-related information loss, hierarchical barriers to seeking clarification, and the normalisation of informal handover workarounds, in relation to the existing literature on structured communication tools, situation awareness, psychological safety and the normalisation of deviance, before drawing on Reason’s (2000) systems model to argue that these four findings share common underlying latent conditions rather than representing four unrelated local problems. The study’s strengths and limitations have been considered, and several linked practice implications have been identified, centred on protected handover time, structured audit and feedback, and leadership behaviours that support psychological safety.
Taken as a whole, this discussion suggests that improving handover communication on this ward, and plausibly on comparable acute wards elsewhere, is unlikely to be achieved through a single isolated intervention, whether a further round of SBAR training, a reminder about medication documentation, or an exhortation to junior staff to speak up. Instead, the findings point toward the need for a coordinated set of changes addressing the shared latent conditions of time pressure, informal cultural norms and hierarchical communication patterns identified across all four findings. Chapter Six draws these findings and their implications together to present the study’s overall conclusions and recommendations.
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