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Implications for practice and research
Structured handover tools, clear explicit language and active communication can minimise risk for mis-communication or gaps in medication-related content of handover.
Research must shift from current reliance on verbal handover communication to examine complementary strategies to increase the reliability of handover information used to transfer responsibility and accountability for ongoing patient care.
Medication and communication errors during clinical handover are well recognised as significant contributors to preventable patient harm worldwide. This study by Braaf et al addresses the link between 2 of the 10 patient safety issues given prominence in the National Safety and Quality Health Service Standards1 introduced into the Australian health system in 2011: medication safety and clinical handover.
This qualitative exploratory study investigated the ‘what’ and ‘how’ of medication information communication during clinical handover interactions using a substantial sample of nurses across a range of high acuity specialty practice settings in a single health service. Data collection was between 2011 and 2013 which correlated with the early stages of implementing the NSQHSS into Australian hospitals. The naturalistic approach to data collection involved participant observation of handover events in ‘real time’ and captured actual behaviours as they occurred within the context of the complex environmental, contextual and interpersonal influences impacting medication communication during handover that cannot be replicated outside clinical settings. This approach enhanced the credibility, dependability and transferability of findings. Credibility and dependability were further enhanced by data saturation and rigorous qualitative analyses that included analyst triangulation by three independent researchers. Use of Manias' Medication Communication Model2 to underpin analysis provided theoretical triangulation, but may also be a limitation of the study.
During 131 hours of data collection, 45 observations of 37 nurses captured data on 185 separate handover interactions. Analyses revealed consistent gaps in the medication information communicated at handover. These gaps were attributed to aspects of the handover approach employed, including non-structured verbal content, health professionals' prioritising of information, focus on partial details of patients’ medication regimens, processes for auditing the medication administration record, a lack of verbal communication about details of and specific medication content and lack of interactive questions about medications at handover.
This study makes a valuable contribution to current understanding about the relationship between handover communication and preventing harms. This study examined both what (content) and how (processes) medication communication occurred at handover. Rather than focusing entirely on verbal exchanges, this study's most important contribution is to understanding non-verbal content and processes used to communicate patient medication information during handover. It therefore addresses a gap in current handover research that frequently omits examination of such practices often useful to build resilience and mitigate harm.
Using Manias' conceptual model2 to underpin analysis enabled the authors to position their findings in relation to understanding medication communication. However, a broader relevance is evident when findings are considered in relation to elements of a handover conceptual model: information or content; transfer of responsibility and/or accountability; and the system/context in which it occurs.3 Consistent with previous research, this study revealed handover content was conveyed in multiple ways, was often unstructured, information gaps were common and seldom involved family. Findings supported previous suggestions that handover communication is enhanced by using both verbal and non-verbal communication, two-way face-to-face communication at the patient bedside, written support tools and standardisation.4 Opportunities to improve delegation processes include interactive questioning, confirmation of intentions or recommendations for ongoing care and a focus on patient charts.4 ,5 A range of organisational, cultural and environmental factors that impacted handover performance were also identified.
Research may need to shift from its current reliance on verbal handover communication to explore how complementary strategies, for example, using structured tools (eg, Situation, Background, Assessment, Recommendation (SBAR)) with key patient care documents, can support consistent handover structure, highlight information important for the safety of ongoing care and explicit verification of salient information. Given the increasing pressures of time and resources, research is needed to assist nurses in making decisions about the content, amount and priority of information given at handover.
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