METHODS IN QUALITATIVE RESEARCH

Assignment

METHODS USED IN QUALITATIVE RESEARCH

In order to achieve credible and trustworthy results from qualitative studies, the methodology must be designed very carefully. That is, you must consider the process of conducting qualitative research to address your research question. Important considerations include selecting the research question, collecting data, engaging in data analysis and management, and selecting appropriate
interpretive techniques.

For this Assignment, be sure to view this week’s Qualitative Research Design PowerPoint webinar and pay close attention to its content on the basic elements of qualitative research methods (e.g., sample selection, data collection, plans for interpretive analysis). Then, review the two research studies presented in this week’s resources for this assignment.

Note

: While not a required resource, you might find the definitions in the Encyclopedia of Nursing Research helpful for this assignment.

This assignment involves identifying and describing different elements of the research method used in the Tobiano, Ting, Ryan, Jenkinson, Scott, & Marshall (2019) article.

· Focus on the research design, sample selection, data collection methods, and plan for data analysis as discussed in the Tobiano, Ting, Ryan, Jenkinson, Scott, & Marshall (2019) article.

· Identify at least two strengths and two weaknesses of the article’s research method based on trustworthiness. You must provide support for your explanation with citations from additional sources.

· Use the Journal Club Template for Qualitative Research located in this week’s resources. Note: Assignments will not be accepted unless the required template is used.

· The template includes an area for each element discussed in the study.

· Be brief, paraphrase and summarize each of the elements clearly on the form.

RESOURCES

· Tobiano, G., Ting, C., Ryan, C., Jenkinson, K., Scott, L., & Marshall, A.P. (2019).

Front-line nurses’ perceptions of intra-hospital handover Links to an external site.

.
Journal of Clinical Nursing, 29, 2231–2238.

http://doi.org/10.1111/jocn.15214

Once this is complete, save your file and submit the Journal Club Template for Qualitative Research to the submission link. Note that you must use the template provided.

NURS_3150_Week_4_Assignment_Rubric

15 pts

5 pts

NURS_3150_Week_4_Assignment_Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeResearch Design	15 to >13.0 pts Excellent Student provided a fully developed explanation of the research design with insightful analysis of concepts and related issues. 13 to >11.0 pts Proficient Student provided a developed discussion of the research design with reasonable analysis of concepts and related issues. 11 to >10.0 pts Basic Student provided a minimally developed discussion of the research design with limited analysis of concepts and related issues. 10 to >0 pts Needs Improvement Student provided an under-developed discussion of the research design with little or no analysis of concepts and related issues.			1 5 pts
This criterion is linked to a Learning OutcomeSample Selection	15 to >13.0 pts Excellent Student provided a fully developed explanation of the sample selection with insightful analysis of concepts and related issues. 13 to >11.0 pts Proficient Student provided a developed explanation of the sample selection with insightful analysis of concepts and related issues. 11 to >10.0 pts Basic Student provided a minimally developed explanation of the sample selection with insightful analysis of concepts and related issues. 10 to >0 pts Needs Improvement Student provided an under-developed explanation of the sample selection with insightful analysis of concepts and related issues.
This criterion is linked to a Learning OutcomeData Collection Methods	15 to >13.0 pts Excellent Student provided a fully developed explanation of the data collection methods with insightful analysis of concepts and related issues. 13 to >11.0 pts Proficient Student provided a developed explanation of the data collection methods with insightful analysis of concepts and related issues. 11 to >10.0 pts Basic Student provided a minimally developed explanation of the data collection methods with insightful analysis of concepts and related issues. 10 to >0 pts Needs Improvement Student provided an under-developed explanation of the data collection methods with insightful analysis of concepts and related issues.
This criterion is linked to a Learning OutcomePlan for Data Analysis	15 to >13.0 pts Excellent Student provided a fully developed explanation of the plan for data analysis with insightful analysis of concepts and related issues. 13 to >11.0 pts Proficient Student provided a developed explanation of the plan for data analysis with insightful analysis of concepts and related issues. 11 to >10.0 pts Basic Student provided a minimally developed explanation of the plan for data analysis with insightful analysis of concepts and related issues. 10 to >0 pts Needs Improvement Student provided an under-developed explanation of the plan for data analysis with insightful analysis of concepts and related issues.
This criterion is linked to a Learning OutcomeIdentifies and describes the strengths and weaknesses of the research method used based on the elements of trustworthiness.	25 to >22.0 pts Excellent Student provided a fully developed discussion of at least two strengths and two weaknesses of the research methods based on the elements of trustworthiness. 22 to >19.0 pts Proficient Student provided a developed discussion of at least two strengths and two weaknesses of the research methods based on the elements of trustworthiness. 19 to >17.0 pts Basic Student provided a minimally developed discussion of at least two strengths and two weaknesses of the research methods based on the elements of trustworthiness. 17 to >0 pts Needs Improvement Student provided an under-developed discussion of at least two strengths and two weaknesses of the research methods based on the elements of trustworthiness.	25 pts
This criterion is linked to a Learning OutcomeProfessional Writing: Clarity, Flow, and Organization	5 to >4.0 pts Excellent Content is free from spelling, punctuation, and grammar/syntax errors. Writing demonstrates very well-formed sentence and paragraph structure. Content presented is completely clear, logical, and well-organized. 4 to >3.5 pts Proficient Content contains minor spelling, punctuation, and/or grammar/syntax errors. Writing demonstrates appropriate sentence and paragraph structure. Content presented is mostly clear, logical, and well-organized. 3.5 to >3.0 pts Basic Content contains moderate spelling, punctuation, and/or grammar/syntax errors. Writing demonstrates adequate sentence and paragraph structure and may require some editing. Content presented is adequately clear, logical, and/or organized, but could benefit from additional editing/revision. 3 to >0 pts Needs Improvement Content contains significant spelling, punctuation, and/or grammar/syntax errors. Writing does not demonstrate adequate sentence and paragraph structure and requires additional editing/proofreading. Key sections of presented content lack clarity, logical flow, and/or organization.		5 pts
This criterion is linked to a Learning OutcomeProfessional Writing: Context, Audience, Purpose, and Tone	5 to >4.0 pts Excellent Content clearly demonstrates awareness of context, audience, and purpose. Tone is highly professional, scholarly, and free from bias, and style is appropriate for the professional setting/workplace context. 4 to >3.5 pts Proficient Content demonstrates satisfactory awareness of context, audience, and purpose. Tone is adequately professional, scholarly, and/or free from bias, and style is consistent with the professional setting/workplace context. 3.5 to >2.0 pts Basic Content demonstrates basic awareness of context, audience, and purpose. Tone is somewhat professional, scholarly, and/or free from bias, and style is mostly consistent with the professional setting/workplace context. 2 to >0 pts Needs Improvement Content minimally or does not demonstrate awareness of context, audience, and/or purpose. Writing is not reflective of professional/scholarly tone and/or is not free of bias. Style is inconsistent with the professional setting/workplace context and reflects the need for additional editing.
This criterion is linked to a Learning OutcomeAPA Attributions and Formatting: cover page, title of paper on second page, level headings, Times New Roman 12 font, 1″ margins, and page numbers. APA References: Uses in-text citations appropriately and format correctly. Paraphrases to avoid plagiarizing the source.	5 to >4.0 pts Excellent Demonstrates fully developed APA formatting with no errors in the template provided. 4 to >3.5 pts Proficient Demonstrates developed APA formatting with few formatting errors in the template provided. 3.5 to >3.0 pts Basic Demonstrates minimally developed APA formatting with several formatting errors in the template provided. 3 to >0 pts Needs Improvement Demonstrates limited APA formatting with multiple formatting errors or fails to use the template provided.
Total Points: 100

Title of the Paper in Full Goes Here

Student Name Here

Program Name or Degree Name, Walden University

Course Number, Section, and Title

(Example: NURS 0000 Section 01, Title of Course)

Instructor Name

Month, Day, Year

(enter the date submitted to instructor)

Journal Club Template for Qualitative Research Article

The purpose of this assignment is to describe the research design and methodology. Please discuss the research design, the sample selection, the data collection methods and the plans for data analysis. Please do not focus on or include the results of the study. The use of this template is required. Any other format will not be accepted. Each section should be fully developed and written in your own words. Avoid quoting the article’s content. The article should be cited within the response in APA format. At the end, include this article in the reference section using APA format. Any other resources used should also be cited and referenced appropriately.

Research Design
Sample Selection
Data Collection Methods
Plans for Data Analysis
Strengths (include two strengths)
Weaknesses (include two weaknesses)

References

List references in alphabetical order and in APA format. References should be published within the last
five years. In your paper, be sure every reference entry matches a citation, and every citation refers to an item in the reference list.

1 | INTRODUC TION

Miscommunication during handover results in adverse events
with 60%–80% of communication failures (including hando-
ver) contributing to clinical incidents in America (The Joint
Commission, 2013). Emergency department (ED) handovers can

occur within the department and between admitting clinical
units. In Australia, approximately 2.5 million people who present
to EDs are admitted to hospital annually, and each transfer from
the ED to an inpatient unit (IPU) provides opportunity for mis-
communication jeopardising patient safety (Australian Institue of
Health & Welfare, 2018). In recognition of the potential impact

Received: 13 September 2019 | Revised: 15 December 2019 | Accepted: 3 February 2020

DOI: 10.1111/jocn.15214

O R I G I N A L A R T I C L E

Front-line nurses’ perceptions of intra-hospital handover

Georgia Tobiano BN, PhD, Nurse Researcher1 | Christine Ting BN, MN, Clinical Nurse
(Research)1 | Christine Ryan BHSC(Nurs), MNurs(ClinLead), Quality Improvement Lead
(Clinical Handover)1 | Kim Jenkinson BN, MHLM, Acting Quality Improvement Lead (Clinical
Handover)1 | Lucie Scott BA in Healthcare Acute and Critical Care, Clinical Nurse Consultant
(Children’s Emergency), Advanced Diploma Adult Nursing1 | Andrea P. Marshall BN, PhD,
Professor of Acute and Complex Care1,2

1Gold Coast Health, Southport, QLD,
Australia
2School of Nursing and Midwifery, Menzies
Health Institute Queensland, Griffith
University, Southport, QLD, Australia

Correspondence
Georgia Tobiano, Gold Coast Health, 1
Hospital Blvd, Southport, QLD 4215,
Australia.
Email: georgia.tobiano@health.qld.gov.au

Funding information
Gold Coast Hospital and Health Service
Study Education and Research Trust
Account.

Abstract
Aim and objective: To explore nurses’ perceptions of factors that help or hinder intra-
hospital handover.
Background: Miscommunication during clinical handover is a leading cause of clini-
cal incidents in hospitals. Intra-hospital nursing handover between the emergency
department and inpatient unit is particularly complex.
Design: A descriptive, qualitative study. This research adheres to the consolidated
criteria for reporting qualitative research.
Methods: Forty-nine nurses participated in group interviews, which were analysed
using inductive content analysis.
Results: Three categories emerged: (a) “lacking clear responsibilities for who provides
handover”; (b) “strategies to ensure continuity of information”; and (c) “strained rela-
tionships during handover.”
Conclusions: Intra-hospital handover requires clear processes, to promote high-qual-
ity information sharing. Ensuring these processes are broad and acceptable across
units may ensure nurses’ needs are met. Relational continuity between nurses is an
important consideration when improving intra-hospital handover.
Relevance to clinical practice: Nursing managers are optimally positioned to enhance
intra-hospital handover, by liaising and enforcing standardisation of processes across
units. Nurse managers could promote intra-unit activities that foster front-line nurses’
communication with each other, to encourage problem-solving and partnerships.

K E Y W O R D S

communication, inpatients, nursing staff, patient handoff, patient transfer methods

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mailto:

https://orcid.org/0000-0001-5437-0777

https://orcid.org/0000-0001-7692-403X

mailto:georgia.tobiano@health.qld.gov.au

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that poor handovers can have on patient safety, there have been
major policies released and standards created to enhance com-
munication safety. For instance, the World Health Organization’s
“High 5s” action plan highlights recommendations for implement-
ing and evaluating standardised patient safety solutions for com-
munication during patient handover (World Health Organization,
2006); today, the problem of inadequate handover communica-
tion persists (Trossman, 2019).

2 | BACKGROUND

Nurses may not communicate efficiently during handover. In a study
of over 22,000 nurses across 600 European hospitals, research-
ers found that 21%–61% of nurses were dissatisfied with handover
(dependent of country of origin) (Meißner et al., 2007). Reasons
for nurse dissatisfaction include receiving insufficient information
(Meißner et al., 2007) and finding handover communication difficult
to follow (Street et al., 2011). These findings suggest that nurses’
handover communication is an area requiring improvement.

Effective communication during intra-hospital nursing hando-
vers is particularly challenging because of differences related to
specific work areas. One example is handover between the ED and
IPU nurses when a patient is admitted to hospital from the ED.
Nurses across settings view different information as important; ED
staff strive for information about medical condition and immediate
care needs (Pun, Matthiessen, Murray, & Slade, 2015), while IPU
nurses are more focused on personal information about the patient
including longer-term care needs and providing explanations to
patients to increase their knowledge (Johnsson, Wagman, Boman,
& Pennbrant, 2018). Additionally, ED nurses face different work
pressures including the need to discharge patients within a set time
(Sullivan et al., 2016), making their communication process with pa-
tients time-pressured and lacking an interpersonal approach (Pun
et al., 2015). Despite these challenges, nurses across units are re-
quired to work interdependently.

To facilitate communication between nurses, protocols have
been suggested as a strategy to standardise the handover process
and content (Riesenberg, Leisch, & Cunningham, 2010). Protocols
may include checklists to guide handover content required. These
checklists sometimes use the “SBAR” pneumonic as a technique to
set expectations for content around the topics “situation,” “back-
ground,” “assessment” and “recommendation” (Haig, Sutton, &
Whittington, 2006; Marshall et al., 2018). Using standardised proto-
cols means a more complete handover can be achieved by increasing
the rate of information exchanged to over 80% (Yang & Zhang, 2016).
Moreover, a systematic review demonstrated that standardised pro-
tocols improve intra-hospital handover, without significantly chang-
ing the duration (Gardiner, Marshall, & Gillespie, 2015).

There is a clear tension between emerging evidence for stan-
dardised handover protocols and the fact that clinical handover is
heavily influenced by contextual issues. Handover is a sociotechnical
activity, meaning many factors such as teamwork, technology and

organisational issues influence the handover process and outcomes
(Holden et al., 2013). The factors that influence the handover and
transfer of patients from the ED to IPUs is not well studied (Gonzalez
et al., 2018) and presents a significant area for improvement for
the nursing workforce and a challenge for nursing management.
For interventions aimed at improving handover to be successful, a
clear understanding of contextual factors influencing intra-hospi-
tal handover is required. Without this evidence, efforts to improve
intra-hospital handover are at risk of being misdirected and may
achieve suboptimal outcomes.

3 | METHODS

3.1 | Design

A descriptive qualitative study, as described by Elliot and Timulak
(2005), was selected because it allows understanding of the aspects
of the phenomenon of intra-hospital handover. Elliot and Timulak
(2005) provide guidance on the methodological practices required
for a descriptive, qualitative study. See Appendix S1 for adherence
to the consolidated criteria for reporting qualitative research.

3.2 | Aim

To explore nurses’ perceptions of factors that help or hinder ED to
IPU intra-hospital handover.

3.3 | Data collection

This study took place at a public tertiary level teaching hospital,
located in Queensland, Australia. The participating settings were
the ED and four surgical IPUs. Surgical IPUs were purposefully se-
lected, as direct transfers from ED to surgical IPUs occurred more
frequently at this site. All registered or enrolled nurses, working reg-
ularly in the participating ED and IPUs, were invited to participate.
On a day of data collection, the first and second listed researcher
and the clinical facilitator on the unit invited all nurses on the shift
to participate. Interested nurses were informed in a verbal and writ-
ten manner about the purpose of the study and provided informed

What does this paper contribute to the wider global
clinical community?

• Our study confirms the importance of standardising
handover processes to enhance intra-hospital handover.

• The degree of relational co-ordination between nurses
may underpin the success of improving intra-hospital
handover.

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consent and demographic data prior to interviews. Ethics approval
was gained from the hospital.

Elliot and Timulak (2005) recommend semi-structured in-
terviews for qualitative inquiry; thus, semi-structured, group
interviews were used for data collection. Two group interviews
occurred per IPU, and two groups occurred in ED. The size of each
group ranged from four to six participants; four participants were
the minimum participants required for sufficient group interaction
(Polit & Beck, 2008). Interviews were conducted from January–
February 2017 in a space designated for meetings or education
sessions. Group interviews were audio-recorded, with two re-
searchers present; the first listed researcher led interviews; the
other researcher managed equipment and note-taking. We con-
tinued interviews until data saturation occurred, which was when
the team judged that no new information was emerging from in-
terviews (Polit & Beck, 2008).

The interview questions were open-ended and guided by par-
ticipant responses, changing the ordering of questioning to suit the
topics raised, and probes were used to elicit more comprehensive
details. Examples of questions were “What do you normally do in an
ED to IPU handover?” and “Thinking about the context where you
work, what helps you to conduct an effective handover?”

3.4 | Data analysis

Interviews were transcribed verbatim by a professional transcrip-
tion service, and transcripts were uploaded into NVivo software
(QSR International Pty Ltd., 2018). Interview data were analysed
using inductive content analysis, as guided by Elo and Kyngäs
(2008). This approach was selected because qualitative research
does not use pre-existing categories for sorting data (Elliot &
Timulak, 2005). The first listed researcher labelled transcripts
line-by-line in NVivo, producing codes (Elo & Kyngäs, 2008). The
codes were read through many times, and then, select codes were
grouped together under the same heading to form subcategories
based on codes that “belonged” together (Elo & Kyngäs, 2008).
Finally, subcategories were investigated to determine which “be-
longed” together. Select subcategories were grouped together
under the same headings which were higher-order categories (Elo
& Kyngäs, 2008). The process was iterative with the researcher
constantly referring to raw data to check emerging subcatego-
ries and categories, and using flow diagrams to assist in the for-
mation of subcategories and categories. The final subcategories
and categories were decided with team input; they were engaged
throughout analysis to read emerging subcategories and catego-
ries to confirm or disconfirm findings.

3.5 | Rigour

The enhance credibility, the same PhD-trained researcher
conducted all interviews. The researcher had experience in

interviewing, ensuring the interview process was consistent, and
questions were asked in a way that elicited in-depth responses
(i.e., re-ordered and re-phrased as required) (Krefting, 1991). This
researcher spent enough time interviewing participants to identify
reappearing patterns in the interviews (Krefting, 1991). To make
the findings confirmable, the researcher analysing data was reflec-
tive. Immediately after interviews occurred, an audio recording of
the interview was listened to by the lead researcher, who under-
took initial analysis completing a contact summary form (Miles,
Huberman, & Saldaña, 2014). This allowed the researcher to iden-
tify gaps in knowledge and reflect on her interview techniques.
In addition, throughout the analysis process notes were kept on
any emerging or striking findings and thoughts. The interviewer
was known by some participants; thus, reflecting on each inter-
view made her aware of any biases prior to subsequent interviews.
The process of data analysis was made dependable by having IPU
and ED nurses review and interpret emerging categories (Krefting,
1991).

TA B L E 1 Demographic characteristics of sample

Characteristics IPU nurses (n = 38)
ED nurses
(n = 11)

Gender

Female 37 (97.4%) 8 (72.7%)

Male 1 (2.6%) 3 (27.3%)

Hours worked at hospital

Full-time 4 (10.5%) 1 (9.1%)

Part-time 24 (89.5%) 10 (90.9%)

Position in nursing

Clinical nurse 6 (15.8%) 4 (36.4%)

Registered nurse 28 (73.7%) 7 (63.6%)

Other 4 (10.5%) 0 (0.0%)

Work as team leader

Yes 22 (57.9%) 10 (90.9%)

Age (years)

25–35 26 (68.5%) 8 (72.8%)

36–45 2 (5.3%) 1 (9.1%)

46–55 7 (18.4%) 1 (9.1%)

>56 3 (7.9%) 1 (9.1%)

Number of years in nursing profession (years)

<5 12 (31.6%) 6 (54.5%)

6–10 19 (50.0%) 4 (36.4%)

11–20 5 (13.2%) 1 (9.1%)

>21 2 (5.3%) 0 (0.0%)

Number of years in current nursing unit (years)

<5 27 (71.1%) 8 (72.7%)

6–10 8 (21.1%) 3 (27.3%)

11–20 3 (7.9%) 0 (0.0%)

>21 0 (0.0%) 0 (0.0%)

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4 | RESULTS

A sample of 49 nurses participated in the study (Table 1). Interviews
lasted an average of 20 min.

At the time of interviews, there was no hospital protocol for how
to conduct intra-hospital handover. Nurses spoke about the com-
plexity of the process of ED to IPU handovers. Nurses described two
information handovers that could occur (See Figure 1): (a) phone-to-
phone information exchange while the patient was in ED (hereafter
called handover one) and (b) face-to-face information exchange on
the IPU (hereafter called handover two).

Three categories emerged regarding nurses’ perceptions of
factors that helped or hindered ED to IPU handover, as described
below. The composition of each group can be seen in Table 2.

4.1 | Lacking clear responsibilities for who
provides handover

There was no clear responsibility for who should transfer the pa-
tient from ED to IPU, effecting the perceived quality of handover
two. Nurses reported three staff that may transfer the patient: an
ED nurse either providing or not providing care for the patient:
“Sometimes you’re just pulled in because the nurse is busy that
was looking after that patient … you’re just asked can you take this
patient upstairs…which is the truth and so you’re looking through
their notes” (Focus Group [FG] 2), or “…the patient just comes with
a wardie (orderly)…” (FG 9). Nurses were unable to describe con-
sistent ways of determining who should accompany the patient to

the IPU, suggesting it could be based on patients’ acute illness (FG
4), the presence of intravenous fluid (FG 9), scoring systems based
on vital signs (FG 7) or ED nurses’ clinical judgement, which could
be challenged by IPU nurses. Lack of clear responsibility resulted
in lack of task significance, as ED nurses questioned if it should be
their role to transfer patients, if handover two added information
and viewed the task as a poor use of their time: “If you count the
lost man-hours that we can lose in transferring patients and put
it back to here, it would make us a lot more functional, as a unit.”
(FG 6).

In turn, processes for handover two on the IPU were unclear. In
cases where an orderly transferred the patient, there was no infor-
mation transfer: “…they pop them in the room, they bring the notes
out here, dump them on the desk and go…we don’t really get any
face-to-face handover…” (FG 9). If an ED nurse not caring for a pa-
tient transferred the patient, IPU nurses were concerned that they
“do not usually know much at all” about the patient (FG 8). If the ED
nurse caring for the patient transferred the patient, it was still un-
clear what face-to-face information was expected, given handover
one had occurred. For IPU nurses, they stated that the information
they desired at this point was “Any changes. Rather than asking the
same information again.” (FG 10). However, ED nurses experienced
that the IPU nurse accepting the patient were not always informed of
handover one, requesting another full information exchange: “Every
time I’ve been up (to the IPU)… ‘I don’t know anything’. That’s what
they’ll (IPU nurses) say, and I’ll say, ‘I’ve handed over to your team’”
(FG 6) This resulted in ED nurses “repeating the information that you
said on the phone because the team leader upstairs hasn’t conveyed
that information…” (FG 2).

F I G U R E 1 Perceived handover process

(May be ED bedside nurse or other ED
nurse)

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4.2 | Strategies to ensure continuity of information

Nurses described strategies to manage the quality of information
transferred, such as using “chart biopsy”; the process of carefully stud-
ying the patient’s electronic medical record (EMR) during handover
one. IPU nurses prepared for handover one by reading EMR prior to
receiving the phone handover, while ED nurses reported undertaking
chart biopsy to gain information about the patient, sometimes reading
these notes while giving handover: “If we’ve got EMR open and they’ve
got the EMR open, that’s what we’re getting.” (FG 1). For IPU nurses,
this caused some frustration as ED nurses were viewed to verbally pro-
vide the same information as IPU nurses had read.

Both ward and ED nurses stated that IPU nurses’ role was
prompting information from ED nurses, to ensure the most com-
prehensive handover: “each ward… they’ll ask specific things that
are important to them.” (FG 2). IPU nurses stated they prompted
information about patient assessments and recommendations,
as it was identified that patient information about situation and
background was available in the EMR: “We’re having to prompt
to ask, do they have an IV? Do they have [IV] access?” (FG 7). On
two IPUs, nurses had created checklists to assist nurses’ prompt-
ing behaviours.

A desired strategy to ensure continuity of information was to
have the ED nurse providing care for the patient be involved in at
least one information exchange, as they were viewed to have infor-
mation ward nurses required:

A lot of the time it’s the in-charge of a section that hands
the patient over but [they] have no idea …what’s wrong
with them. They just literally are reading off a screen, and
they don’t actually physically know the patient…from the
desk here, he looks pretty old, and I think he walks with
a stick. Should it just be the nurse that’s actually been
allocated to that patient that [sic] actually hands the pa-
tient over …?

(FG 4)

While ED nurses stated they encouraged the ED bedside nurse
to do handover one, it was not always possible due to contextual
pressures. “…we’re trying to get a practice of the actual person
who’s looking after the patient handover, but a lot of times in re-
suscitation (area) it’s too busy and we just have time constraints…”
(FG 6).

4.3 | Strained relationships during handover

The relationship between the sender (ED) and receiver (IPU) was
tense, and this appeared to be influenced by ward nurses’ infor-
mation needs not being met. Both IPU and ED nurses understood
that the IPU nurse receiver desired certain information related to
patient “assessments” and “recommendations” such as patients’ mo-
bility status, diet, medications, falls risk, plan and mood. However,
IPU nurses suggested that this information was often not shared or
prioritised by ED nurses: “…the important stuff for us is to know the
plan and …how they mobilise and whether they’re a falls risk, which
often isn’t the priority downstairs.” (FG 8).

Emergency department nurses shared contextual pressures that
made them unable to meet IPU nurses’ information needs. IPU and
ED nurses recognised that pressures in ED meant ED nurses did not
prioritise comprehensive assessment for these other nonimmediate
issues: “but we have time constraints here and we have an infinite
number that [sic] come through the door, whereas the ward nurses
have a certain number” (FG 6). Because of time constraints, ED and
IPU nurses believed that ED nurses, both those caring and not caring
for the patient, had incomplete information about patients: “I think
the main issues we have with handovers from ED is not so much
we’re not getting the information, it’s that they don’t know the pa-
tient they’re handing over…” (FG 10).

The inability to meet IPU nurses’ needs resulted in a strained
relationship between the nurses working in the two settings, and
nurses desired a better relationship: “…creates a lot of animosity
and I think it probably goes two ways, because they don’t under-
stand why that’s [information] important for us to know.” (FG 1). IPU
nurses worried that when they prompted more information from ED
nurses, it could strain the relationship further. There was a desire for
transparency about information known by ED nurses and a sense
of distrust based on previous experiences: “…the patient gets here
and it’s a very different picture to what you get told on the phone.”
(FG 7).

5 | DISCUSSION

In our study, nurses described no clear process for ED to IPU
handover due to a lack of clarity for who should transfer patients
and what content to transmit once the patient was on the IPU.
Nurses used strategies to improve co-ordination such as using
EMR and prompting to enhance communication. Overall, nurses
across ED and IPUs expressed a struggle to collaborate because

TA B L E 2 Interview group characteristics

Unit Group ID
Number of
participants

Emergency department 2 5

6 6

Surgical IPU 1 1 5

5 4a

Surgical IPU 2 3 6

10 5

Surgical IPU 3 4 5

9 4

Surgical IPU 4 7 6

8 4

aOne nurse participated in two group interviews.

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2236 | TOBIANO eT Al.

IPU nurses’ expectations could not be met, and in turn, relation-
ships were strained.

Our study suggests that clearer ED to IPU handover processes
are required. Development of a handover standard operating pro-
tocol (SOP) may assist with process issues such as who transfers
the patient. Similar to previous work, nurses consider patient acuity
and safety as a driving factor when preparing for patient transfer
(Bergman, Pettersson, Chaboyer, Carlström, & Ringdal, 2019). SOPs
can guide nurses’ decision-making for transfers, prompting them to
assess predetermined patient risk factors prior to transfer and en-
sure the transfer team has the right level of knowledge and skills
(Alamanou & Brokalaki, 2014). Similar to other research, some IPUs
had developed checklists for standardised content and prompted
specific information when receiving handover (Bergs et al., 2018).
This finding suggests that IPUs may be seeking specialised infor-
mation, promoting a “functional” approach to task division and
meaning similar activities are brought together in one IPU (Pless,
Van Hootegem, & Dessers, 2017). This approach commonly creates
“siloed” IPUs where each IPU desires specific information relative
to their IPU, which may create challenges for ED staff providing in-
formation to a range of settings (Gittell, Godfrey, & Thistlethwaite,
2013). Broader approaches to communication from ED to a range
of IPUs could be achieved by creating a checklist that works across
all IPUs, promoting a process-orientated approach where each unit
prompts and expects similar content. Many organisational rede-
sign models to improve communication, such as Care Pathways,
Lean Thinking, Relational Co-ordination and Modern Sociotechnical
Design, all demand that there is a shift from functional task division,
to process-orientated task division (Pless et al., 2017).

However, moving towards a process-orientated approach during
handover could be challenging in the ED environment due to the or-
ganisational issues identified in this study. For a process-orientated
approach to occur, ED nurses would require a broader knowledge of
their patient. In other ED settings, nurses have expressed frustra-
tion when ED nurses lack knowledge of patients’ social or functional
status, influenced by hectic ED work conditions where efficient pa-
tient flow is prioritised (Bergs et al., 2018), and staff feel they lack
the capacity to spend time knowing their patient in-depth (Sujan,
Spurgeon, & Inada-Kim, 2014). The quality of intra-hospital hando-
ver may be enhanced by nurses increasing time spent collating and
organising information before handover (Clarke et al., 2012). In one
study, nurses wore bright coloured vests indicating “do not to dis-
turb” and had a private designated space for handover preparation,
giving nurses permission to claim space and time for this important
activity (Clarke et al., 2012).

Similar to our study, nurses often create strategies to deal with
their tensions (Sujan et al., 2014), and further developing these strat-
egies could enhance collaboration. Using EMR to prepare for han-
dover is a common nursing strategy (Ernst, McComb, & Ley, 2018),
with EMR viewed as an electronic member of the team for hando-
ver (Ernst et al., 2018). However, using EMR for handover could be
problematic as the documentation focuses on biomedical knowledge
from doctors’ notes (Bergs et al., 2018), may not be complete in ED

settings (Manias, Gerdtz, Williams, & Dooley, 2015) and can be per-
ceived as inaccurate (Sujan, Spurgeon, & Cooke, 2015). However,
current EMR documentation may not be fit-for-purpose. An elec-
tronic handover platform was developed for physicians which in-
cluded a standardised information dashboard where information
was actively input for handover across units (Nelson et al., 2017).
When electronic systems are specifically designed for handover be-
tween units, healthcare professionals’ perceptions of satisfaction,
efficiency and trust between healthcare professionals can improve
(Nelson et al., 2017). With the international move towards EMR, it
may be important to consider electronic sources when developing
handover checklists, as paper-based checklists are not always ad-
hered to in practice (Marshall et al., 2018).

In our study, there were issues with co-ordination across ED and
IPUs, creating relational discontinuity amongst nurses. Teamwork
across units is perceived as having the largest effect on successful
intra-hospital handovers (Richter, McAlearney, & Pennell, 2016)
and creates relational discontinuity (Calleja, Aitken, & Cooke, 2016;
Havens, Vasey, Gittell, & Lin, 2010). Phone communication has been
identified as an impediment to building relationships during hando-
ver, with healthcare professionals expressing that their roles and re-
sponsibilities were undervalued on both sides, and it can enhance
antagonism between settings as there is no sense of the context
on the other unit (Nelson et al., 2017). Nurses have reported poor
relationships during handover with nurses being grumpy, rude, dis-
missive and stressed during phone-to-phone handover (Bergs et al.,
2018). It would be important to foster face-to-face communication
practices across units and undertake activities to build teamwork
and reconcile issues through negotiation and adaptive forms of be-
haviour (Sujan et al., 2014).

Our findings may suggest that a relational co-ordination ap-
proach to intra-hospital handover could be advantageous, a strategy
used to address low-quality nontechnical skills such as communica-
tion, teamwork and task management (Pless et al., 2017). Relational
co-ordination supports centralised co-ordination of tasks at the
meso-level, whereby leaders that sit across units take responsibil-
ity for ensuring standardisation of the task (Pless et al., 2017). This
approach is supported by fixed formal procedures such as handover
SOPs. However, at the micro-level ED and IPU nurses require flex-
ibility and communication across their boundaries to improve rela-
tional co-ordination. Relational co-ordination approaches promote
proactive conflict resolution and face-to-face communication at the
micro-level (Pless et al., 2017). Having these opportunities would
allow nurses to openly discuss the tension they face on their units
together and provide the flexibility to make trade-offs around their
handover practice.

5.1 | Limitations

First, we were unable to separate senior and junior nurses in our
sample during interviews because of staffs’ workload constraints;
however, on commencement of interviews, we identified who was

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senior and junior and tailored probing questions to each group. Given
junior and senior nurses had different roles in the handover process,
they comfortably shared their different experiences. Second, focus
groups may have resulted in less in-depth findings when compared
to one-on-one interviews; however, the experienced interviewer
used techniques to gain rich data. Third, this study was conducted at
a single site; thus, the experiences identified may not be consistent
with nurses’ experiences at other types of hospitals, in other con-
texts. Though our findings are not intended for generalisation, we
have provided dense descriptions of the context, sample and hos-
pital processes, allowing others to judge applicability for their own
setting.

6 | CONCLUSION

At one hospital, intra-hospital handover was challenging due to un-
clear processes and poor relationships across units. Nurses dealt
with this tension by using strategies such as prompting information
and reading EMR, but ultimately relationships were strained. Due
to the siloed and specialised nature of IPUs, exploring strategies to
ensure information transfer processes are standardised, broad and
process-orientated could be required. However, this is not enough.
Front-line nurses need support to enhance relational co-ordination;
without this, there may be little in improvement in nurses’ percep-
tions of the quality of nursing handover.

7 | RELE VANCE TO CLINIC AL PR AC TICE

Improvement in intra-hospital handover is challenging because multi-
ple hospital units are involved. A meso-level leader could liaise across
units and standardise handover processes using SOPs. Within SOPs,
checklists could support standardisation consisting of broad content
that is acceptable to end-users across varying units, which could be
incorporated into EMR. Acknowledging handover as a high-risk task
and giving nurses permission to spend time preparing for handover
may also facilitate high-quality handover (Clarke et al., 2012).

Teamwork between units also requires attention. Relational
co-ordination frameworks may assist in devising strategies to pro-
mote collaboration across units. At the micro-level more frequent,
timely, accurate and problem-solving face-to-face communication
between units may be required. For instance, translational simula-
tion (Brazil, Purdy, Alexander, & Matulich, 2019) and nursing rounds
(Tobiano et al., 2019) have been shown to enhance comradery
across units (Rosenbaum, 2019). Promoting more opportunities for
secondment in other units could also enhance relationships (Dryden
& Rice, 2008).

ACKNOWLEDG EMENTS
Thank you to the nurses who very willingly facilitated and partici-
pated in group interviews. Thank you to Gai Meade and Emma Wells
who were note keepers during some interviews.

CONFLIC T OF INTERE S T
All authors have no conflicts of interest to declare.

AUTHOR CONTRIBUTION
All authors meet the following criteria: made substantial contribu-
tions to the conception and design, or acquisition, analysis and in-
terpretation of data; drafted the manuscript or revised it critically
for important intellectual content; approved the final version to be
published, agreed to take public responsibility for appropriate por-
tions of the content; and are accountable for all aspects of the work
in ensuring that questions related to the accuracy or integrity of any
part of the work are appropriately investigated and resolved.

ORCID
Georgia Tobiano https://orcid.org/0000-0001-5437-0777
Andrea P. Marshall https://orcid.org/0000-0001-7692-403X

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How to cite this article: Tobiano G, Ting C, Ryan C, Jenkinson
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