Pilot for Bedside Nursing Handovers in a Medical Ward

Topic

To Pilot the use of a bedside nursing handovers in a medical ward: A pilot study using service improvement methodology.

Aim

The aim of this proposal is to improve the communication between professionals through the use of bedside handovers and service improvement will be planned and piloted through the use of Six-stage framework which was formulated by National Health Service (NHS) for Innovation and Improvement, (2010).

There is major improvement work in the process through nursing in general, patient safety and experience, quality and transparency. Furthermore, NHS believes an approach to initiating a safety-first culture into all the corners of nursing (The Quality Improvement Guide, 2013).  NHS Institute for Innovation and Improvement, (NHSIII, 2010) suggested that Service development pursues to constantly adjust and improve methods or pathways which benefit patients, families, and support the clinical excellence, this can be achieved through using the mapping process and to achieve the best goals, a firm structure must act as pillars that uphold the project and keeps it stable during the trial period (The Quality Improvement Guide, 2013).

Rationale

The reason for choosing this topic is because there is evidence that poor communication between professionals’ increases risks or in danger the patient’s wellbeing. The National Institute for Health and Care Excellence (NICE, 2017) poor communication in the process of clinical handovers can produce terrible risks to the patients. This was supported by the Department of Health (DOH, 2013) who stated that poor handovers have been a contributing factor in many circumstances which resulted in risk or harm to patients through insufficient information passed on. For example, the negligence incidents at the Staffordshire hospital in 2013, which resulted in the death of patients and also poor nursing handover was one of the identified triggers. NICE, (2017) suggested that effective handovers can help to improve responsibility between professionals, helps in risks assessment and identifying complications at the early stages and it makes provision of care much easier.

Background

In nursing practice, effective bedside handovers have been identified as an essential tool in a clinical environment and good communication is of paramount importance in the developing therapeutic relationship and teamwork (Edwards, 2010). Nevertheless, Bach and Grant (2009) emphasise that communication in clinical practice is built on an exchange of information which individuals pass on to each other through verbal or non-verbal methods. The main purpose of bedside handover is to receive or provide an accurate patient’s medical history, treatment plan and current condition (Johnson and Cowin,2013). According to Boyd and Dare, (2014) all practitioners are encouraged to work with other professionals collaboratively in order to safeguard and promote high standards of care.

In addition, Jonhson and Cowin (2013) suggested that clinical bedside handover is the transference of professional accountability or duty of care for all aspects of the patient’s care which is shared among the Multi-disciplinary team (MDT) and poor handovers are acknowledged as the most contributing factor in severe adverse situations or a major cause of poor patient care. In respect to the National Institute for Health and Care Excellence (NICE, 2017), clinical evidence explains that handovers are used effectively or successfully by professionals to fulfill the provision of care. However, an attempt was made by DOH, (2013)  to improve the quality of handovers from the traditional method of office handover to bedside-handover which is person-centred. However, some of the NHS hospitals are still using the office-based handovers.

Search Strategy

The research information was obtained by using different research methods and databases. The first attempt at gathering information was through the University website using the library catalogue and typing the chosen topic title. The author typed handovers in NHS hospitals and came out with 824 articles but some of the articles were not relevant to the chosen topic. The second attempt was to use the University of Wolverhampton electronic resources and selecting the databases.

The author chose precise databases because they provide wide and an extensive range of literature that is greatly recommended by the Royal College of Nursing (RCN, 2015).

An EBSCO host database was used and selected CINAHL plus full text, therefore by typing the chosen topic bedside handovers, there were 77 articles found which was reduced by selecting articles published between 2009 – 2018 and the outcome was 67 articles then continued with the same wording Bedside handovers and selecting nursing journals, and then 12 articles were found. Looking at 12 articles, 9 journals were considered because of how the articles were published and the background experience and knowledge of the researchers.

Critical approach

The selected articles had five themes developed and highlighted such as clinical bedside handover, office-based handover, and person-centred care, breach of confidentiality and effective communication. However, bedside handover was the most discussed theme and relevant to the chosen topic. The literature review highlighted a greater number of service improvement approaches that was applied to some of the healthcare sectors and the most service improvement method or strategy that have been implemented in healthcare was adopted to maximise the benefits for stakeholders (Pallesen, 2014). Furthermore, the literature review discovered that among all the chosen articles, there are 2 types of handovers which are office based handover and bedside handover.

Anderson et al (2012), who identified bedside handover as a way of improving person-centered care through therapeutic relationship and it empowers patients to participate fully in their care. Despite the identified benefits, Anderson et al (2014) suggested that the effectiveness of the practice model for bedside handover involves patients’ participation. Kerry et al (2014) suggested that the involvement of patients in person-centred care being provided needs nurses to have skills, knowledge including therapeutic building skills.  Conversely, Choboyer et al (2010), acknowledged that not every type of nursing handover is effectual in regards to patient outcomes or nursing outcomes, professionals are still in search of approaches to optimise handovers together with patients involvement, and improving the accurateness of handover.

Kerr et al (2014a) selected 22 nurses from different wards, who use bedside-handover to participate in the interviews and findings that bedside-handover enhance accuracy, accountability, and efficiency of the clinical handovers which are patient-centred care and promotes high standards of care. Nevertheless, in Kerr et al. (2014a), some of the patients were principally excluded from participating in the research due to communication barriers; patients, not English speakers or have mental capacity issues. This was supported by Saunders et al (2012), who acknowledged that poor health literacy can cause communication barriers, individuals lacking an understanding of information and can cause difficulties clinical making decisions.

Findings

The study from Johnson and Cowin (2013), who interviewed about 200 participants and the outcome of results showed that bedside handover might perhaps have a pessimistic effect on teamwork in clinical exercise. This was supported by Roslan and Lim (2016), who stated that when conducting bedside handovers, nurses identified several difficulties encountered during handover, especially when it is visiting hours. Furthermore, they raised concerns of the potential breach of confidentiality, as bedside handovers are done in the shared bay where patients and families could hear the handover, consequently resulting in a probable breach of confidentiality (Roslan and Lim (2016). This causes other staff to have negative thoughts about the bedside handovers. However, other staff recommended bedside handover as a method which reduces adverse events in clinical settings, time-consuming, and enables nurses to build up a therapeutic relationship with their patients (Johnson and Cowin, 2013). Following the study by Lu et al (2014), there was a direct observation method of 25 bedside-handovers which the researcher assessed based on impact, time efficiency and quality of the handover. However, it was recognised that the results could not provide a legal description of the interruptions on the ward because of the limitation of the sample, as the handovers were not including weekend and evening handovers.

Pallesen (2014) suggested that a varied sample might have enabled the authors to find an additional trend, frequencies and it has been noted that participants were not fully informed about the aim of the proposed change, therefore, the reliability of the data was not accepted ( Street et al,2011). There was a very good substantial amount of literature collected which reveals the success of bedside-handover in the promotion of high standards of care. To begin with, bedside handover may be able to endorse patient-centered care because it encourages full patient involvement; moreover, another advantage is that it enables direct verbal contributions of patients to the care being provided and being informed of improvements (Kerr et al 2014). This concurs with Anderson et al (2012) who acknowledged that during bedside handovers patients must speak out of any further concerns, misconceptions and provide valuable feedback. The study by Kerr et al (2014a), stated that there was evidence which highlighted that patients were valued, appreciated, empowered and given an opportunity to contribute during bedside handover, as well as enhanced their experience.

Furthermore, through this active involvement, the patient gained a better understanding of their wellbeing which strengthens the patient’s responsibility for their recovery (Kerr et al. (2014b).This concurs with Anderson et al. (2012), who stated that patients have the capability of promoting their safety and can reduce the adverse events which occur because of miscommunication during handovers. Conversely, Johnson and Cowin (2013), reported that some of the patients are uncomfortable with the pressure of the full participation in relation to bedside-handover, and most of the patients preferred to be passively engaged through observing only but not enthusiastically participating in the handover. Bradley and Mott (2014) suggested that practitioners must provide individualised care by bearing in mind of each patient’s preferences when implementing bedside-handovers, in the case that full participation may perhaps not be the choice of all patients. Furthermore, felt uncomfortable and ashamed because of their poor understanding of their health, this was outlined by service users who are non -English speakers (Lu et al. 2014). The article from Johnson and Cowin (2013), argued that patient participation in bedside handover may not at all times bring patient-centered care or improve the standards of care as some nurses were lacking concentration and not giving patients the opportunity to talk during bedside handovers.

By so doing this can cause oppressive and traumatise the patients, especially to those with learning difficulties or mental health issues. Lu et al (2014) also identified some failing in nurses to utilise some of the skills like non-verbal communication skills or therapeutic relationship to guarantee positive and full patient participation throughout bedside handovers. Focusing on Anderson et al, (2012) research study, it is noted that bedside handover can create a negative impact on nurses’ capability to ventilate their feelings and thoughts. Sand-Jecklin and Sherman (2014), there are some nurses who acknowledged that being well-informed about each and every patient’s well-being or condition improves decision making, bring forth the effective and secured care process. In addition, Kerr et al. (2014) bedside-handover have been recognised as a process which increases accountability among practitioners in clinical practice and it promotes constructive situational awareness. Johnson and Cowin, (2013) in this study some nurses complained of feeling tremendously nervous whilst handing over and this will affect the nurses’ confidence and performance.

Nevertheless, Koberich (2014) pointed out that most nurses preferred the usual office-based handover because it enables practitioners to exchange information, in a confidential way, quite suitable environment for open discussions. It is formerly noted that the literature determines the efficiency of bedside-handover in the provision of patient care (Koberich, 2014). Conversely, it appears that there is a lack of comprehensible formal guidelines in relation to the proposal of bedside-handover in the wards. By so doing, Lu et al (2012) acknowledged that professionals are unable to put into practice the bedside-handover efficiently in an approach that safeguards patient safety and minimise the risk associated with poor communication errors. Johnson and Cowin (2013) pointed out that formal guidelines could conclude in the introduction of additional consistent and clear approaches for assessing the effectiveness and excellence bedside handovers.

Confidentiality issues within bedside handovers

According to NMC (2015), professionals have a challenge in regards to maintaining confidential information or sharing information about ill health which can be sensitive. Healthcare professionals are encouraged to respect privacy and confidentiality as they have a legal and ethical responsibility to certify that patients’ information is shared in a proper conduct which safeguards the patient’s right to confidentiality and privacy (NMC, 2015). According to Polit and Beck (2006), participants must be given a full explanation of the aim of the proposed change and seek consent before involving them, respect for participates considers two ethical considerations and the ethical theory comprises of issues concerning informed consent and confidentiality.

There are concerns raised by Johnson and Cowin, (2013) study, that bedside handover is frequently done during visiting times and visitors will hear the handovers, by so doing, this increases the anxiety levels, distress levels, embarrassment, and humiliation. However, Anderson et al (2012), nurses stated that when bedside-handover is being conducted, they have to lower voices or closing curtains to sustain privacy when discussing responsive information. Conversely,  Lu et al (2012) acknowledged that bedside curtains will not prevent information to be heard by others and this makes patients feel vulnerable as their information is being passed at the bedside. Most of the ward nurses were concerned about the breach of confidentiality during bedside handovers (Anderson et al (2012).In comparison to other countries, it has been noted that in Singapore acute medical ward, bedside handovers has been effective and resolute the conversion of essential information and the stability of quality of care, however, confidentiality was still an issue Anderson et al (2012).

Johnson and Cowin (2013) it is reported that the breach of confidentiality increase dissatisfaction, negative impact to a therapeutic relationship and this can ultimately result in patients declining treatment and this can bring a pessimistic impact on the well-being of patients’.The Breach of confidentiality is a very serious matter in our day to day nursing. However, at some point patients will end up focusing on their own health and recovery, as a result, they will view confidentiality issues from bedside handovers as an inconsequential concern (Street et al (2012).Roslan and Lim (2016), suggesting that implementing bedside-handover, professionals are to apply additional strategies, such as a written handover sheet and making sure that disclosing confidential information away from the bedside and discuss this in office handovers to maintain patient privacy.

Anderson et al (2012), argued that bedside-handover is time efficiency handover as compared to other ways of handing over for instant office-based handovers, which takes a longer period of time and further noted that if the handover is extremely long, it causes risk of unnecessary information being exposed. According to Johnson and Cowin, (2013), there is no way bedside handovers can improve the standards of care exclusive to patient participation or staff training which brings alertness to patient-centered care strategies. Moreover, bedside-handover is more effective, objective, and dispassionate and it allows the exchange of more significant, reliable, precise information and also promoting patient safety throughout the improved team working. Kerr et al (2014).Furthermore, the effective team plays an essential role in enhancing high-quality care and holistic care. By implementing bedside-handover this can increase of consistency and solidarity that improve the effectiveness of the multidisciplinary team as established in the study of (Anderson et al, 2012).

Define and Scope

Planned change is identified as a planned application of awareness, knowledge or skills from the clinical leaders, Furthermore, a change requires the change agent to be the skilled enough in decision making, problem-solving, and communication skills (Choboyer et al, 2010). According to Gage (2013), the proposed change has to be gradually introduced and change agent to be constantly aware of the opinion and concerns of stakeholders about the proposed change, identify resistant forces and identifying strategies to prevent them. Martin (2006), suggests that a comprehensible presentation of the idea and reason for the change may motivate or empower the majority of the stakeholders to be supportive and the participation will bring success to the proposed change. The main expected goal is for Nurses and other professionals to improve their communication about patients’ medical conditions and consider a way of handing over that does not put patient’s health at risk. Gage (2013) noted that experience from practice area and research proves that nurses fail to handover appropriately due to lack of standardised handover processes.

Therefore, the change agent willfully give a good explanation of the proposed change and make sure all the staff understood the reasons for the changes and assure them of training to improve handover skills and improve confidence, clinical auditing and feedbacks from the stakeholders involves giving information about practice and performance as part to constrain quality of care (NHSIII, 2010).To achieve a successful change there must be a clear consistent communication that describes the effective vision of the proposed change which can bring clarification to confusion (NHSIII, 2010). Therefore, the change agent will find ways to overcome conflicts, for example, educating stakeholders about the change beforehand, having informal discussions with the multi-disciplinary team about the proposed change and how to implement it. By so doing the change agent will give stakeholders opportunity to ventilate feelings and thoughts and give chance for them to ask questions. The change agent will introduce the models and tools which will be used to achieve a successful change.

Stakeholder involvement

Taylor and Randall (2007) defined Stakeholders as any individual or group of individuals who have a substantial interest in the deliverance of care or any individual who might be affected by the decisions made or planned changes. Stakeholders comprise of patients, carers, staff, public members, trade unions, Ministers and community groups. However, in this proposed change, Hospital managers, ward manager, matrons, nurses, doctors, healthcare assistants, and administration team will be involved as stakeholders. Moreover, hearing service users’ opinions, experiences, and evaluating the patient experience help professionals to check any development or improvement of the services (Taylor and Randall, 2007). As a leader, it is important to consider our stakeholders when formulating individual projects or activities, communicate with stakeholders in order to meet their needs accordingly. For the project proposal to become successful, the full engagement and consultation with the Stakeholders are of paramount importance as they are essential members in the Multidisciplinary team (MDT) and the author will be identified as the change agent or project manager in this proposed change.

Gage (2013) stated that Project Manager is responsible of identifying senior members in the organisation who have the responsibility that might be affected by the proposed project outcomes, and they have a duty to support Project Manager in championing throughout the project. Cameron and Green (2015) acknowledged that for change to be successfully accomplished, MDT must communicate effectively and share their opinions because teamwork is essential as MDT bring diverse knowledge and ideas in order to accomplish the desired outcome. By so doing, the author as the change agent will liaise with hospital managers and ward managers of the medical ward ensuring that doctors, nurses, and healthcare support workers of the imposed change and the training that might be needed. The trial of bedside hand over will be set for a period of 3 months with a review of every month. The change agent will formulate questionnaires and have face to face interviews with stakeholders as they are individuals to be affected by the change. This was supported by Cameron and Green (2015) stipulate that stakeholders are the individuals who are at the center and likely to be affected and they influence the project outcome. The involvement of stakeholders would be more beneficial when they assist in achieving the goal rather than oppose the idea (Cameron and Green, 2015).

Measuring and Understanding

According to the Department of Health (2017), stated that good communication is of paramount importance in healthcare provision, networks between hospital staff, family, also communication is a benefit in decision making and service improvement. In the past the handover was done in office whereby, the change agent noticed that some of the information about patients was not accurate for example the recording of fluid balance charts and intervention charts, whereas, after implementing the change it was noted that bedside handovers are effective as they empower patients to participate fully in their care and it reduces mistakes on documentation. The change agent will monitor the implementation of bedside handovers and auditing at the end of the month. According to NICE(2017), clinical audits have been identified as quality improvement procedure that focuses on improving patients’ care and which result through a systematic review against unambiguous criteria and the implementation of the proposed change.

The change agent and ward managers have got a duty to perform clinical audits, checking on the progress of the set goals and identifying any barriers to achieve the goals. Furthermore, the use of questionnaires was used to monitor the stakeholders’ opinions. The change agent will target a small acute ward to use for a trial.

Design and plan

Rolland (2012) suggested that a change for service improvement has to be implemented gradually. Furthermore, the change agent and management must be aware of staffs’ reaction and concerns about the proposed change. The change agent should be tolerant, compassionate and have an understanding of staff feelings (Rolland, 2012). Staff will be given the opportunity to ventilate feelings, thoughts and identified barriers to the proposed change then formulate strategies to conquer them. It is noted by Kerry et al (2014) that in most of the studies, lack of training, understanding, and confidence in performing bedside handover has been an issue in most of the nurses. Therefore, development and education training programme is needed for the medical ward staff to improve the handover process. Staff will be encouraged to attend training focusing on handovers and effective communication as it is the main goal of the service improvement.

Gage (2013) suggested that the goals and precise objectives of the proposed change should be clarified to the stakeholders and set out the required things to achieve goals and set a time of achievement. The change agent planned to give a 3 months trial of bedside handover only in one ward to start with then consider other wards if this is successfully implemented. After the trial, the change agent will have a meeting with the hospital directors, managers and staff to review the outcomes of the trial and set an action plan which will have SMART goals.  According to Hutchfield (2010), SMART stands for specific, measurable, achievable, realistic and timely manner. In addition, Tschirky (2011) suggested that an action plan is a procedure for formulating steps which can be used in achieving the goals of the proposal.

Piloting and implementation

Rolland (2012) identified change agent as project manager and a change agent is needed in service improvement when implementing change and they act as a catalyst. Change agents can be anyone from internal or external organisations who know the company’s operational procedures, politics and company history (Mansfield, 2011). Change agent requires certain qualities such as the ability to establish, to listen, and maintain flexible relationships with staff as well as being aware of individual strengths and weakness. However, un-organised change strategy and poor management or poor leadership might result into resistance and conflict to the change, however, the level of this resistance might be more established within the individual (Wright, 1994).In addition, this can be argued that the possibility of resistance and conflict can happen regardless of the use of suitable strategies and the communication method (Hunt and Pearson, 2001).

Service Improvement Models

There are different types of models to use in service improvement. The change agent chose to use Kurt Lewins’ model (1951)because it is easy to follow through its stages. Kurt Lewins’ model has got 3 stages, unfreezing, moving and refreezing stage. The first stage is unfreezing; this is where the change process begins. The change agent will give a clear rationale of the need for change and making sure all stakeholder will have a good understanding of the benefits of the change proposal (Lewins’ model,1951). The second stage is the moving stage, which is the actual changes that will take the team to a further level, identifying problems which the change agent will formulate the critical mass for the change. The change agent will be aware of the values and attitudes of the stakeholders, discussing the barriers and identifying solutions (Lewins’ model,1951). This is where the change agent will support the stakeholders to reduce resistance to the change. The final stage of the change model is refreezing which arise when behaviour turns into an element of the daily activities. Furthermore, it involves institutionalising or stabilising the proposed change by establishing the training needs and other processes (Lewin, 1951).

Rolland (2012) suggested that this final stage identifies the change as a new behaviour and without the refreezing stage; the proposed change can possibly go back to your old ways back. The change agent has to motivate staff and communicate effectively with all the stakeholders.  Lewin (1951) identified a tool which can work effectively with the model. Force field analysis is a tool that takes into consideration obstacles and empowering factors to each change. Lewin’s force field tool enables the change agent to understand the forces that are controlling the proposed change or those opposing the change and to consider actions which are effective in the change process (Lewin, 1951) .furthermore, this tool helps the change agent to have an overview of the obstructions and the positive factors, which will enhance change process. In service improvement, change agent uses different approaches. The most common and effective approach is Plan Do Study Act (PDSA). According to the Institute for Healthcare Improvement (IHI, 2018), PDSA model was set for service improvement and it provides a framework for emerging, testing the plan and applying the changes that lead to improvement. Conversely, PDSA does not substitute the models which are already in place but it strengthens the change proposal (IHI, 2018).

PLAN

This is where the change agent will organise meetings with the management first, followed by meetings with all the stakeholders and this is done through the support of the hospital managers, ward managers, and the IT department. The IT department will assist in creating online training, log in details and passwords.

Do

The online training will educate stakeholders by showing videos of different types of handovers, showing scenarios with advantages and disadvantages. The stakeholders will be given time to discuss the videos and bring suggestions and questions in relation to what they have observed. By so doing this will bring a better understanding of the change and minimise conflicts (IHI, 2018).

Study and ACT

The PDSA approach permits the project to be on trial on a small scale and then when approved, it will be introduced to a wider area. Therefore, the change agent will implement bedside handover in one medical ward for 3 months, and then expand to other wards if it is successful. IHI (2018) suggested that by applying PDSA, this enables aims and goals to be monitored, checking the efficiency and assessing forum anticipated problems that might arise to destruct the project.

Leadership and management

Rolland (2012) acknowledged that Leadership is the main key and it plays a vital role in change management. Mathews and Whelan (2010) highlighted that a strategic leader consists of 3 characteristics such as team building, creativity and the sense of direction. Moreover, Leadership style plays a fundamental role in the management of the proposed change, and it is known as an approach in which the purpose of leadership is approved(Rolland,2012). According to Smith (2011), it is important for nurses to have good leadership styles and be transformational. The transformational leadership styles enable professionals to identify the need for a change, areas for improvement and helps in team building (Smith, 2011). This was supported by Rolland (2012) stated that the change agent must have an understanding of feelings of the team, their views of change, be non-judgmental, be able to avoid criticism and be sympathetic. By so doing this will create constructive reinforcement and formulate ownership of the change among the stakeholders resulting in stakeholders believing that the innovation for the change was brought in action by them (Hunt and Pearson, (2001).

The change agent must encourage weekly team meetings for staff to discuss the improvements and changes. Staff to be given an opportunity to discuss the challenges they are facing and give suggestions. Ward managers to have weekly reviews on the progress of bedside handovers and monitor the time taken by office handovers, time being taken by bedside handovers and how in-depth or effective these 2 handovers are. Therefore, the change agent will set up a timescale of 3 months period observing the benefits of bedside handover and comparing with those of office-based handover. Then they will review this in managers meeting.

The managerial style, the change agent will use will be focusing on promoting teamwork between staff, motivating staff to perform at the high level of standards, and encouraging optimistic self-esteem, empowering staff to be fully involved and committed in the new development or proposed change.

Quality Assurance

Quality assurance is done through the use of clinical governance, which was identified as a structure or culture that ensures healthcare sectors are delivering good quality of care and ensures that change agent and stakeholders are participating competently and safely in the management of proposed change using the  Quality Assurance framework which was published in 2017(NHSII, 2017). clinical audit tools are the essential instruments used to the review progress and appraisal is the heart of quality improvement. Tschirky (2011) suggested that quality assurance is for maintaining high standards of care, measuring the effectiveness and identify weaknesses of the proposed change. Therefore the change agent will assure stakeholders and patients about the benefits of the proposed change. The evaluation of the proposed change was carried out using 2 mechanisms namely questionnaires and face to face interviews. The use of questionnaires and interviews focused on staff and patients from both morning and evening shift bedside handovers on weekly bases to monitor effectiveness and ensure validity.

A humanistic approach was implemented in solving conflicts, and staffs’ resistance was not undervalued. Furthermore, constructive feedback and suggestions from stakeholders were treated with respect and dignity; this is in line with Webster (2016). There is also a formative evaluation which can be used throughout the change process; this is done through team meetings in order to monitor the effectiveness and management of the change process (NHSII, 2017). By so doing this will give staff the opportunity to reflect on their practice, develop new ideas for change or development. Nevertheless, a summative evaluation is essential and this includes clinical auditing of the bedside handovers and weighing its effectiveness and staff training is important to professional development and obstacles can be prevented by bullet-proofing which is a technique that helps in identifying and planning for the obstacles (NHSII, 2017).

Conclusion

In conclusion, the studies showed that change can be done effectively through stakeholders’ involvement, considerations of staff training and good management or leadership. The importance of communication between health care professionals in regards to bedside handovers has been highlighted and the use of the Six-stage framework in the process of service improvement has been outlined. For future professional development, the author noted that professionals must improve their communication regarding patients’ health in order to minimise risk. The author acknowledged the importance of patients and family’s involvement in the provision of care and the effectiveness of the change process can be done through team meetings and reflecting on practice.

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Appendices

Author and date	Aim of study	Study type and information	Findings	Strengths and limitations
Johnson and Cowin (2013)	exploring  perceptions and experiences of nursing in regards to bedside handover	Focused on 200  participants using a methodology approach -Qualitative research	– A standardised guidance was formulated and implemented in a way to safeguard patient through bedside-handover.	-Purposive sampling was used on a focus group  and methodology created a sensible  discussion and reliable data collected
Lu et al. (2014)	To outline views and experiences  patients and impact of bedside-handover	Descriptive approach was used to interview 30 participates from 3 acute medical wards.   Qualitative research	Education and training is requires for  effective communication and Patient involvement can bring quality of care which is person centred	The approach used was well structured and certify reliability of retrieved data
Kerr et al. (2014a)	–Focused on A &E department investigating patients’ views on bedside handover.	–   It was done through interviews with 22 participants – Thematic descriptive and a Qualitative study,	Bedside-handover gives patients had opportunity to be fully involved in the care which was person centred.	Non English speaking patients or mental ill patients  were excluded   Seriously ill patients not included due to capacity
Koberich (2014)   Street et al (2011),	focused on  the bedside-handover in cardiovascular surgical ward and to hear the opinions of patients and staff   Focused on verification of effectiveness and efficiency of bedside handover which promotes patient-centred care	– The information was used through questionnaires and it is a qualitative research   Methodology approach with questionnaires by 400 ward nurses, 105 family members or carers, and 200 patients	-There was no evidence to suggest that bedside handover brings impact on patient centred care   The bedside handover promotes patient-centred care ,it is very effective and efficiency	There were issues with method used for data collection as there was incomplete information and data missing.   There is good number of participates involved which include patients, family and staff, all completed questionnaires.
Anderson et al. (2012),	– To explore the triggers of disturbances while conducting bedside handover in a Critical medical Unit.	-. The Researchers monitored about  20  bedside handovers in the different shift patterns	There is a lot of Interruptions caused by busy environment, medical equipment alarms, and visitors which results in loss of information which cause adverse health measures.	-The method of data collection focused only on handovers during the weekdays only which makes the findings to be questionable.
Choboyer et al (2010),	To outline the family’s experiences and opinions about bedside handover in rehabilitation wards.	Mixed methods were used to interview 154 patients  in  cardio-surgical wards and the study is a qualitative research	Family and patient involvement prevent incidence of miscommunication during bedside handovers.	Depth interviews produced  of reliable data and  family and patients had opportunity to share their opinions
Sand- Jecklin and Sherman (2014)	To find out strategies which can make bedside-handover improve patient care outcomes and increase staff fulfilment.	A methodology survey was used which includes   nurses, patients and family.	Effective bedside handovers can reduce errors, unpleasant events, patient risks and can enhance staff development and experiences.	There was transferability of data issues as unwell patients were not included and it focused only on  surgical ward nurses.
Kerr et al.(2014b)	The focus was on practitioners experiences on the bedside handovers.	a qualitative approach conducted   by interviewing  30 practitioners	The bedside handover can  enable  practitioners to provide patient centred care, however education and training is required to staff	Transferability of data was an issue due to small sample size and type of sampling method used

 

 

Database	Search Term	results	Keywords	Inclusion or Exclusion on Criteria	results	Remaining   Articles	Notes
Step 1   University of Wolverhampton Library catalogue	Handovers in nhs hospitals	824   articles	Handovers in nhs hospitals	Articles with full text	824   articles	still a large number of articles of interest	Most of the articles were not relevant to chosen topic
Step2   electronic resources EBSCO-and selected CINAHL plus full text	Handovers in NHS hospitals	77   articles	Bedside handovers in hospitals	Limited the search by published date   2009-2018	67   articles	articles were reduced and still of interest	Upto date articles are more recommended
Step 3   Continued with same wording and articles with full text	Bedside handovers in hospital	67   articles	Bedside handovers	Selected nursing journals	32   articles	Articles were relevant to chosen topic	Some articles focused on other countries not Uk
Step 4   Articles were limited by choosing English language	Bedside handovers in hospital	31   articles	No changes to key words	Limited the search by selecting publisher	12   articles	Remaining articles related to clinical handovers in hospitals	Among 12 articles there were 9 with well experienced researchers
Step 5   Looked at the way the articles were published and academic back ground of the researchers	Bedside handovers in hospital	9   articles	No changes to key words	Continued focusing on English language articles	9   articles	Remaining articles were on my choice	The Articles had both the search term and key words used