Implementing structured model of clinical handover (SHARED ...

cnssciedupresscom Clinical Nursing Studies 2019 Vol 7 No 1

ORIGINAL ARTICLE

Implementing structured model of clinical handover(SHARED) Its influence on nursesrsquo satisfaction

Sohair Mabrouk Mohammed Sanaa Moustafa Safanlowast

Nursing Administration Faculty of Nursing Menoufia University Egypt

Received October 8 2018 Accepted November 8 2018 Online Published November 19 2018DOI 105430cnsv7n1p71 URL httpsdoiorg105430cnsv7n1p71

ABSTRACT

Objective Clinical handover is acting an important role which nurses are usually involved numerous times in daily working forproviding patient care In spite of the importance of clinical handover there is no standardized handover practice in our healthcaresettings This study aimed to explore the effect of implementing a structured model of clinical handover (SHARED) and itsinfluence on nursesrsquo satisfactionMethods Design The quasi-experimental design was utilized Settings Conducted at Menoufia University Hospitals at inpatientdepartmentsunits Subjects A convenient sample of 167 staff nurses who had at least a year of experience and accept toparticipate in this study Tools Tool I Handover Knowledge Questionnaire Tool II clinical handover questionnaire and Tool IIInursesrsquo satisfaction questionnaireResults Nursesrsquo levels of total knowledge regarding practices of the current clinical handover were poor at pre-implementationand improved after implementation of the structured model as SHARED Additionally there was an improvement of clinicalhandover attitude after implementation of a SHARED framework among studied subjects and had a good level of attitude thanpre-implementation phasesConclusions There was the highest level of nursesrsquo satisfaction regarding clinical handover practice at the post-implementationof SHARD model than pre-implementationRecommendations Ongoing educational sessions for nurses and periodic refresher training courses should be provided in orderto keep nurses updating knowledge and practice regarding structured and standardized handover models

Key Words Structured model Clinical shift handover Nurses satisfaction

1 INTRODUCTION

On a day-to-day function in each healthcare setting the obli-gation for the care of patients is reassigned among healthcarepersonnel The announcement of client information to thefollowing caregiver can be recognized as ldquohandoverrdquo Han-dover is an important process during which clinicians shareinformation as well as exchange authority and main account-ability for patient care The assignment of care requests thehandover of information about the nature of the patientrsquos

complaint and full requirements for more exploration andtreatment[1]

The handover includes that patient information responsi-bility and authority is moved from one of caregivers to ad-vancing or new staff Three factors that anticipate handoverquality are recognized information transfer mutual under-standing and at work atmosphere Within nursing the givingof the report has been factually recognized and is acceptedas a part of the nursing tradition and culture[2] A systematic

lowastCorrespondence Sanaa Moustafa Safan Email sanaa_safanyahoocom Address Nursing Administration Faculty of Nursing MenoufiaUniversity Egypt

Published by Sciedu Press 71

review of the current information to define handover featuresand the ensuing effect on safety results was conducted Han-dover results were defined as every activity that happens afterachievement of the handover or related to patients who arehanded off for their treatment[3]

Clinical handover methods need to be designed and doc-umented This safeguards that all members identify thepurpose of the handover the vital information and docu-mentation they need to communicate Handover involvesthe transmission of standard information between clinicianswithin a discipline from one discipline to another and be-tween wards or departments within a health facility Han-dover should happen at the change of the shift from oneward to another ward or department at patient relocation toanother facility on patient discharge and when a patientrsquoscondition merits it[4] Poor communication handovers haveresulted in adverse actions delays in treatment severancesthat influence efficiencies and effectiveness and low patientand healthcare worker satisfaction[5]

Standardizing the process to safeguard exact and relevantinformation interchange through the occasion for illustrativedemands has been identified as a vital for improving patientsafety So far there is a lack of a standardization processThe lack of a standardization process for ldquohandoversrdquo makesit hard to control[3] Obstacles and organizers to clinical han-dovers are well-known However indicators for the greatestpractice are not obvious There is some research availableto inform on that issue Nurse reports have been known as aldquoritualrdquo that includes difficult cognitively powerful actionsthat are predisposed by the setting and culture of the unitwhere the nurse is working[3]

So the structured model of clinical handover (SHARED)framework for clinical handover outlines and explains theessential components of clinical handover These compo-nents are essential for the provision of safe and effectivehealthcare The SHARED framework assists clinicians toparticipate in comprehensive appropriate and safe clinicalcommunication irrespective of clinical[6] Components areimportant for the providing of harmless and effective health-care This structured model announced in August 2011and previously reported by Klim et al[7] contains the sub-sequent features (1) a systematic method (2) conducted atthe bedside (3) involvement of the patient andor relative(4) showing of patient charts during handover and (5) apreliminary group handover for general information aboutunbalanced patients and overall status of the departmentThe model also highlights nursing care requirements andthe treatment and disposition plan and includes stimuli forsignificant nursing care basics (medication chart vital signsfluid balance vital signs) The notepads individual forms in

a pad for single use were planned to provide prompts for thenurse to inform the nurse-in-charge or treating doctor of thedeteriorating patient[8]

This SHARED framework contained five attributes for cur-rent clinical handover The first attribute is called face toface communication and is the good means for safeguard-ing responsibility that patient care is handed over correctlyFace communication helps handover to be collaborating anda double way process where the occasion for questioningand confirmation is allowed between the giver and receiverof the information A second attribute is the allocation ofenough time for the handover and communication of up-to-date information is essential[9] A third attribute is thevital use of a shared language and a standardized methodmainly for sharing critical information The correction ofusing common language and a standardized method ldquounderroutine conditionsrdquo helps ldquohealth specialists to regularizeand form their communication in an approach that confirmsbetter understandingrdquo mainly when time pressure and ur-gency applies precise and reliable information exchange tosafeguard patient safety A fourth attribute called forms andchecklists are very important as they can be approved fromcaregiver to receiver and trailed in a patientrsquos chart Andthe fifth attribute is called place of the narrative understand-ing and representation of a clinical situation in combinationwith a formalized method and minimum data set for clinicalcommunication[10]

Nurses referred to bedside clinical handover as the best meth-ods of communication between nurses patients and fam-ily members Bedside clinical handover allowing nursesto check their patients and explain any doubts to confirmthe continuity of care Nursersquos needs handover to be in astructured manner to see the patient and transfer of the im-portant patient information during handover to the incomingnurses[11]

11 Significance of the studyPatient handovers comprise a process of transitory infor-mation responsibility and mechanism from sender to thereceiver during care transitions Useless handovers havesevere significant outcomes in wrong treatments delays indiagnosis longer patient stays medication errors patientfalls and patient deaths Nowadays essential components ofnurse-nurse handovers have not been known and a lack ofidentification is significant in moving towards a standardizedmethod for nurse-nurse handovers Moreover during clini-cal supervision it was observed that the handover processwas done randomly (not follow a systematic approach ormethod) there were no formal and standardized methods oftransferring patient information and reports were subjective

72 ISSN 2324-7940 E-ISSN 2324-7959

(semi-structured format based on the patient sheet) So thisstudy was conducted out to explore the effect of implement-ing a SHARED and its influence on nurses satisfaction

12 Aim of the studyThis study aimed to explore the effect of implementing aSHARED and its influence on nurses satisfaction

13 Research hypotheses(1) There will be an insufficient knowledge and improper

attitude regarding clinical handover among the studysubjects

(2) There will be an improvement of clinical handoverknowledge and attitude post implementation of thestructured model among studied subjects

(3) There will be an increased level of staff nursesrsquo satis-faction after implementing a SHARED

2 METHODS21 DesignThe quasi-experimental research design was utilized

22 SettingThe study was conducted at Menoufia University Hospitalsat inpatient departmentsunits (Hemodialysis Medicine On-cology and Obstetric units)

23 SubjectsA convenient sample of 167 staff nurses who had at least ayear of experience and accepted to participate in the studyfrom above-mentioned departments at Menoufia UniversityHospital

24 ToolsTo achieve the purpose of this study the following tools wereused

Tool I Clinical Handover Knowledge Questionnaire Thistool consisted of two parts

Part I Contains socio-demographic characteristics of thestudy subjects such as age qualification years of experienceand department

Part II Clinical Handover Knowledge Questionnaire wasdeveloped by the researchers after reviewing the related lit-erature[11] to assess their knowledge about actual handoverpractices It included 15 multiple-choice questions Han-dover definition and related concepts (3 questions) impor-tance and benefits of handover (3 questions) componentsof handover and communication competence (3 questions)methods and structure of handover (3 questions) and han-dover communication tools (3 questions) With scoring (one)

for the right answer and (zero) for the incorrect answer Withscoring that nursesrsquo level of knowledge was determined asfollow high knowledge level gt 75 moderate knowledgelevel ranged from 60-75 and low knowledge level lt 60

Tool II The clinical handover attitude questionnaire Thistool was adapted from Kerr et al[8] Orsquoconnell et al[13]

It consisted of 21 items to assess nurses attitude of prac-ticing clinical handover through a three-point Likert scale(1) disagree (2) neutral and (3) agree Items such as ldquoInfor-mation was presented in a systematic and organized wayrdquoand ldquoThe way in which information was provided to me waseasy to followrdquo were asked Data were collected throughtwo phases pre and post implementation of the SHAREDWith scoring as follows 60 and more were considered thegood attitude of practicing clinical handover and less than60 were considered the poor attitude of practicing clinicalhandover

Tool III Nursesrsquo satisfaction questionnaire was used to as-sess nursesrsquo satisfaction related to the handover process(prior and after implementation of a structured model ofhandover) This questionnaire has of 23 items related tothree dimensions of nurses satisfaction The first dimensioncalled prior to clinical handover (7 items) The second di-mension is called during hander over (13 items) and the thirddimension called after handover (3 items)

25 Scoring systemThe respondents were asked to indicate their satisfactionor dissatisfaction with the questionnaire statements usingscale (1-unsatisfied and 2-satisfied) Therefore the maximumpossible scores were 46 With scoring as follows 70 andmore were considered satisfied became unsatisfied if theyhad less than 70 This tool carried out before and afterimplementation of structured model (SHARED)

26 The validity of the instrumentsTools were tested to assess face and content validity throughexpertsrsquo opinions which were assessed through a group offive experts in the field of nursing administration They werealso asked to judge the items for suitability fullness andclarity

27 Reliability of the instrumentsTest-retest reliability was realistic by the researcher for test-ing the internal consistency of the tool It was done by givingthe same tools to the same applicants under similar circum-stances on two or more times Scores from recurrent testingwere compared The Cronbachrsquos coefficient alpha for the han-dover knowledge questionnaire was 094 clinical handoverquestionnaire was 079 and nurse satisfaction questionnaire

was 095

28 Pilot studyA pilot study was carried out on 10 of the study subjects(17) who were not included in the main study subject poolin order to test the clarity validity and reliability Nec-essary modifications and clarifications of some questionswere made to have more appropriate tools for data collectionSome questions and items were omitted added or rephrasedand then the final forms were developed The average timeneeded to be completed

29 FieldworkPreparation of data collection tools was carried out over aperiod of four months from the first of April to the end of July2016 An oral consent was taken from study subjects Thequestionnaires were distributed during nursersquos work hours(morning and afternoon shifts) at the available hospital aftertwo or three hours of her starting shift to confirm that patientcare was provided The data collected through 3 daysweekthe nurses were taken according to their units workload Theusual time required to complete the questionnaires the firsttool ranged between (15-20 minutes) the second tool rangedbetween (10-15 minutes) and the third tool (10-20 minutes)

210 Administrative and ethical considerationsWritten approval from the Medical and Nursing Directorsof Menoufiya University Hospitals to conduct the study wasobtained prior starting data collection from the nurses Theresearcher announced herself to them clarified the objectivesof the study and informed them that their information wouldbe confidential and used for the single purpose of the studyAdditionally each subject was informed about the right to ac-cept or refuse to participate in the study Their verbal consentwas taken

211 Statistical analysisThe data collected were analyzed by SPSS version 20 onIBM compatible computer Quantitative data were expressedas mean and standard deviation and analyzed by applyingstudent t-test for comparison of two groups of normally dis-tributed variables Qualitative data were stated as number andpercentage and analyzed by applying chi-square test pairedsamples test was applied for comparison between the quan-titative data at interval for the same group at two sessionsMcNemar tests were used in the present study for comparingdifferences in proportions when values are resulting frompaired (non independent) groups Significance was adoptedat p lt 05 for interpretation of results of tests of significance

212 ProcedureBefore implementing the structured handover model theresearcher done assessment of the actual handover carriedout by nurses and identifies the positive and negative pointto assess need for standardized handover through clinicalhandover knowledge questionnaire The process was carriedout by the nurse-in-charge of the leaving shift to those on theincoming shift Shift-to-shift nursing handover commonlyoccurs two times per day morning and afternoon Primarydata advocated that there were problems with the compre-hensiveness of nursing documentation and various parts ofthe nursing care In another study nurses stated that previoushandover structures threatened continuity of care Thus theSHARED structured of nursing handover was establishedand introduced as a deliberate approach to improve the qual-ity of clinical handover nursing practice and documentationin the organization in which this study was conducted Thenotepads stimulated nurses to use a standardized approachto supplying the handover which caused stress on nursingcare needs the treatment and disposition plan and stimulifor vital nursing care components (medication chart vitalsigns fluid balance vital signs)

The structured model called the SHARED provided a stan-dardized method that cleared the lowest dataset Improve-ments in accuracy and appropriateness of information werenoted[12] (see Table 1)

3 RESULTSTable 2 presents socio-demographic characteristics of thestudied subjects As indicated in this table the mean age ofstudied nurses were (316 plusmn 648) and the majority of thestudied subjects (958) were from 20 to less than 40 yearsold Furthermore the majority of subjects (724) had from10-20 years of clinical experience with a mean of approx-imately 11 years (113 plusmn 665) Regarding qualificationsthe highest percentage of the studied subjects (413) haddiploma in nursing And also the majority of subjects(383) were from the department of medicine

Table 3 illustrates distribution of nursesrsquo levels of clinicalhandover knowledge pre and post-implementation phases Itwas observed that levels of studied subjectsrsquo total knowledgewere significantly improved from post-implementation to preat p le 05 And also level of clinical hand over knowledgewas low (766) pre-implementation of SHARED Other-wise the level of clinical hand over knowledge was high(748) post-implementation of SHARED

Table 4 indicates the knowledge of studied subjects about thehandover process pre and post-implementation of the modelAs shown in the table a method of handover changed at pre

74 ISSN 2324-7940 E-ISSN 2324-7959

amp post-implementation of the model and all nurses usedthe oral and written method Handover takes more time 16-20 pre-implementation but after the implementation phaseit takes less time Regarding the site of handover carriedout at nurse room and counter (station) at the study phases

incomplete sentence Additionally there was a significantimprovement of handover process after implementation ofthe model

Table 1 SHARED handover structured model

S Situation

Reason for admissionphone callchange in condition diagnosis specific information

H History

Medicalsurgicalpsychosocialrecent treatmentresponses and events

A Assessment

Resultsblood testsX-rays scansobservationsseverity of condition

R Risk

Allergiesinfection controlliteracyculturaldrugsskin integritymobilityfalls

E Expectation

Expected outcomes plan of care timeframes discharge plan escalation

D Documentation

Progress notes care path relevant electronic health recorddatabase

Table 2 Distribution of socio-demographic characteristicsof studied subjects (n = 167)

Socio-demographic characteristics No

lt 20 years 0 000

20-30 years 80 479

30-40 years 80 479

ge 40 years 7 42

Mean plusmn SD 316 plusmn 648

Years of experience

lt 5 years 20 120

5-10 years 26 156

10-20 years 121 724

Qualification

Bachelor degree in nursing 32 192

Diploma 69 413

Associated degree in nursing 66 395

Departmentsunits

Medicine 64 383

Hemodialysis 33 198

Obestetric 44 263

Oncology 26 156

Table 5 displays handover attitude throughout pre and post-implementation phases among studied subjects The tableindicated that statistically significant improvement of thestudied subjects regarding the most items of clinical han-dover pre and post-implementation phases at p le 05 Andalso nurses reported that finding information in a systematicand organized way (pre 323 post 538 p lt 001) andusing effective communication skills during handover (pre425 post 778 p lt 001)

Table 6 displays handover attitude throughout pre and post-implementation phases among studied subjects The tableindicated the statistically significant improvement of the stud-ied subjects regarding the most items of clinical handover preand post-implementation phases at p le 05 And also nursesreported that information received was up to date (pre 00post 778 p lt 001) and that during handover discussionspatients had the opportunity to participate andor listen (pre12 post 312 p lt 001) As a result of handover I havea clear understanding of the plan for the patients (pre 15post 653 p lt 001) at an increased rate after implemen-tation of the structured handover approaches Respondentswere less likely to report that ldquoobservations of the importantvital signs are repeatedly absent from nursing handoverrdquo (pre653 post 342 p lt 001) after implementation of thestructured handover approach

Figure 1 shows handover attitude throughout pre and post-implementation phases among studied subjects It was ob-served that there was an improvement of clinical handoverattitude post-implementation of SHARED framework amongstudied subjects (7480) and had a good level of clinicalhandover attitude (3440) than pre-implementation phases

Table 7 shows mean score of nurse satisfaction about clini-cal handover practice pre and post-implementation phasesAs indicated from the table there was highly statisticallysignificant difference in relation to the mean score of nurseSatisfaction of clinical handover throughout the study phasesThe mean score (331 plusmn 421) during the handover processwas improved at the post-implementation of structured model(SHARED framework) than pre-phase Respectively the totalmean score (582 plusmn 321) of nurse satisfaction was improvedat the post than pre-implementation of a SHARED

Table 3 Distribution of nursesrsquo levels of clinical handover knowledge pre and post implementation phases (n = 167)

Studied variables Pre-implementation Post-implementation

McNemar test p value No No

Knowledge of handover 886 001

High 29 174 125 748

Moderate 10 60 34 204

Low 128 766 8 48

Note Highly significant

Table 4 Levels of knowledge of studied subjects about clinical handover practice (process) pre and post-implementation ofthe model (n = 167)

Method of handover -- --

Oral and written 167 1000 167 1000

Oral 000 000 000 000

Witten 000 000 000 000

Sound recorded 000 000 000 000

Time of handover 158 001

10-15 26 156 140 838

16-20 139 832 27 162

21-30 2 120 0 000

Site of handover 143 002

Beside patients 26 263 11 660

Nurses counter(station) 44 198 47 281

Nurse room 33 156 19 114

Nurse room and counter(station) 64 383 90 539

Highly significant

Table 5 Nursesrsquo handover attitude throughout pre and post-implementation phases among studied subject (n = 167)

Handover Attitude Items

Studied staff nurses McNemar

test p value Pre-implementation No () Post-implementation No ()

Agree Neutral Disagree Agree Neutral Disagree

1 During handover I provided with sufficient

information about patients in my care 78 (467)

( 429)

(71) 104 595

2 During handover I provided with suitable

information about all patients in the unit 53 (317)

(324) 0230 892

3 Handover was too lengthy 28 (168) 85

(497) 137 001

4 Information was presented in a systematic and

organized way 54 (323)

(156) 184 001

5 Important information was not given to me 42 (251) 75

(288) 0090 957

6 During patient handover I was given irrelevant

andor inappropriate information 33 (198)

(365) -- --

7 The charts were available during handover to

clarify information provided to me 42 (251)

(15) 280 001

8 Handover includes chart eg drug chart vital

signs 92 (551)

(000) 001 912

9 Ways of provided information to me was easy to

follow 57 (341)

(311) 980 007

10 During handover excessive noise can lead to

unable to keep my mind focused 52 (311)

(413) -- --

11 Using effective communication skills during

handover 71 (425)

(180) 1380 001

76 ISSN 2324-7940 E-ISSN 2324-7959

Studied staff nurses

McNemar

12 Handover was disturbed by patients and

health professionals

(251) 287 001

13 Receiving information was up to date 0

(059) 2173 001

14 Handover was done at front of the patient 29

(532) 476 001

15 During handover discussionsrsquo patients

had the opportunity to participate andor

listen

(413) 657 001

16 Further Information I had to seek about my

patients take from a nurse or

nurse-in-charge after the handover

(665) 330 001

17 I can ask any questions about things I did

not understand during handover

(647) 304 001

18 I have a clear understanding the plan for

the patients as a handover outcome

(000) 1669 001

19 During handover I received adequate

information about nursing care

(377) 734 001

20 Observations of important vital sign 109

(000) 324 001

21 During handover vital information is often

not given eg allergy unavailable

(83) 176 001

Highly significant

Figure 1 Total of handover attitude throughout pre and post-implementation phases among studied subjects

Table 7 Mean score of nurse satisfaction about clinical handover practice pre and post-implementation phases (n = 167)

Studied variables Pre-implementation

(Mean plusmn SD)

Post-implementation

(Mean plusmn SD) Paired t-test p value

Prior handover process 121 plusmn 088 142 plusmn 055 261 001

During handover process 250 plusmn 351 331 plusmn 421 191 001

After handover process 659 plusmn 181 832 plusmn 122 102 001

Total mean satisfaction 438 plusmn 520 582 plusmn 321 304 001

Figure 2 Total nurse satisfaction of handover pre and post-implementation phase

Table 8 Relation between socio-demographic characteristics and nurses clinical handover post intervention (n = 167)

Socio-demographic

Clinical handover

χ2 p value Good (N = 125) Poor (N = 42)

Age 259 274

lt 20 years 0 000 0 000

20-30 years 58 464 22 524

30-40 years 60 480 20 476

ge 40 years 7 560 0 000

Years of experience 802 001

lt 5 years 0 000 20 476

5-10 years 15 120 11 262

10-20 years 110 880 11 262

Qualification 333 001

Bachelor 17 136 15 357

Diploma 43 344 26 619

Nursing institute 65 520 1 240

Departments 156 001

Medicine 56 448 8 190

Hemodialysis 18 144 15 357

Obstetric 35 280 9 214

Oncology 16 128 10 239

Figure 2 illustrates total nurse satisfaction of clinical han-dover pre and post-implementation phase This figure re-vealed that there was the highest level of nursesrsquo satisfac-tion at the post (862) than pre (653) implementation ofSHARD model regarding clinical handover practice

Table 8 indicates relation between socio-demographic char-acteristics and clinical handover post-intervention It was

observed that there was a highly statistically significant rela-tion between socio-demographic characteristics except forage and clinical handover post-intervention The highestrelation of nurses (880) attitude of clinical handover post-intervention which has 10-20 years of experience with quali-fication as nursing institute especially working at MedicineDepartment

78 ISSN 2324-7940 E-ISSN 2324-7959

Table 9 Relation between socio-demographic characteristics and nurse satisfaction regarding clinical handover postintervention (n = 167)

Socio-demographic

characteristics of studied

nurses

Satisfaction of hand over

χ2 p value Satisfied (N = 144) Not satisfied (N = 23)

Age 375 153

lt 20 0 000 0 000

20-30 65 451 15 652

30-40 72 500 8 348

ge 40 7 490 0 000

lt 5 10 690 10 435

5-10 15 104 11 478

10-20 119 826 2 870

Bachelor 24 167 8 348

Diploma 61 424 8 348

Departments 161 658

Medicine 56 389 8 348

Oncology 24 167 2 870

Table 9 shows relation between socio-demographic charac-teristics and satisfaction regarding clinical handover post-intervention As indicated from the table there was a highlystatistically significant relationship between satisfaction ofclinical handover post-intervention and years of experienceexcept for age qualification and departments with no statis-tically significant differences

4 DISCUSSIONProvision of safe and proper health care is very importantto patientsrsquo health At this time a wide range of safetyissues has confronted the healthcare distribution and there-fore many individual and managerial strategies have beenestablished for supporting patient safety[14] Intended com-munication processes have been established as a standardindications for good practice for handovers is not knownThe intent of the patient handover is to provide for continuityof care to address changes in patient condition and to trackand to communicate patient response to the care that is beingprovided[15] Therefore this study aimed to explore the ef-fect of implementing a SHARED and its influence on nursesrsquosatisfaction

Before discussing the results attention to socio-demographic

characteristics of the studied subjects should be reviewedThe mean age of studied nurses were (316 plusmn 648) and themajority of the studied subjects (958) were from 20 to 40years old Furthermore the majority of subjects (724) hadfrom 10-20 years of experience with the mean (113 plusmn 665)of 11 years Regarding qualifications the highest percentageof the studied subjects (413) had a diploma in nursingThe majority of subjects (383) were from the MedicineDepartment

The present study indicated that regarding levels of knowl-edge about handover practices pre and post implementationphases among studied subject It was observed that levelsof studied subjectsrsquo total knowledge were significantly im-proved post than pre-implementation phases at p le 05 Itwas observed that levels of studied subjectsrsquo total knowledgewas significantly improved post-implementation than pre-implementation at p le 005 And also the level of clinicalhandover knowledge was low (766) pre-implementationof a structured model of clinical handover (SHARED) Oth-erwise the level of clinical handover knowledge was high(748) post-implementation using the SHARED This re-sult was not similar to those[16 17] who found that using amnemonic did not improve information retaining by emer-

gency department staff (566 data retaining using unstruc-tured handovers vs 492 using structured handovers) orinformation recall Adding a handover was not improvedby an intervention to enhance paramedic communicationskills[18]

The study finding revealed that the method of handovershowed no changed at pre amp post-implementation of thestructured model and all nurses used oral and written methodThese results were not congruent with Delrue[15] who foundthat the frequent method which the RNrsquos used was a verbalreport byways of the telephone at 8148 Percentage ofusing the electronic medical record was 4444 and Emer-gency Department admission handovers ldquoSBARrdquo tool (37)only being used

Concerning the time of handover it takes more time (16-20minutes pre-implementation) but after the implementationit takes less time from nursing staff This result was similarto Kerr[8] who stated that the current handover practices weretime-consuming required patient participation and varied instyles In spite of these undesirable perceptions it was alsowell-known that 82 of the staff (153 RNs from 23 wards)stated they wanted the modification of the handover styleused in the current practice

Additionally there was a statistically significant improve-ment of studied nurses concerning the most items of clinicalhandover pre to post-implementation of structured clinicalhandover at p le 05 Nurses reported that receiving infor-mation was up to date (pre 00 post 778 p lt 001)This result was similar to Delrue[15] who stated that updatedthe organizationrsquos work depends on the policy of handoverscommunication that had written in 2007

Additionally nurses reported that ldquoduring handover discus-sionsrdquo patients had the opportunity to participate andorlisten (pre 12 post 312 p lt 001) Studied subjectswere less able to report that ldquoobservations of important vi-tal sign are repeatedly absent from nursing handoverrdquo (pre653 post 342 p lt 001) after structured handovermethods had been implemented This result is in the sameline with Kerr[8] who indicated that during handover discus-sions patients had the opportunity to participate and listen(pre 422 post 807 p lt 001) at an improved afterstructured handover methods had been implemented Studiedsubjects were less able to report that observations of impor-tant vital signs are repeatedly absent from nursing handover(pre 500 post 322 p = 022) after implementation ofthe structured handover approach

The finding of the present study revealed that using effec-tive communication skillsrsquo during handover (pre 425

post 778 p lt 001) This result was congruent withSmeulers[19] who stated that communication gaps duringhandover can cause several problems such as medication er-rors in appropriate treatment diagnoses and delays of careomission

Concerning total attitude of clinical handover pre and post-implementation phase among studied subjects it was ob-served that there was an improvement of nurse clinical han-dover post-implementation of SHARED framework amongstudied subjects (7480) and had a good level than pre(3440) implementation phases This result was in thesame line with Kerr[8] who stated that nursing care activitiesdocumentation and communication of vital information tonurses on the receiving shift were improved after implemen-tation of a new handover model (SBAR)

Regarding implementation of structured model (SHAREDframework) on nursersquos satisfaction the finding revealed thatthere was the highest level of nurse satisfaction (862)at the post than pre (653) implementation phase Thisresult was not similar to Johnson[20] who stated that an inte-grated system has been applied with progressive outcomesof improved nurse satisfaction with handover nurses wereactually knowledgeable about all patients had improved pa-tient assignments and better patient information for all healthspecialists With bedside handoff additional benefits wereengaging the patient in care collaboration and completing avisual safety assessment of the patient environment

Furthermore relationships between socio-demographic char-acteristics and nurse of clinical handover post-interventionshowed that the highest relation between nurses (880) ofclinical handover post-intervention which had 11-20 years ofexperience with qualification as nursing institute especiallyworking at Medicine department This result was in the sameline with OrsquoConnell[13] who stated that there were alterationsin perceptions recognized on the basis of years of experienceand worked hours number It is exciting to note some differ-ence between the nursing staff from the ED and the in-patientunits especially the years of experience and the maximumlevel of education accomplished The in-patient staff statedthat the highest percentage of inexperience with 6471 hav-ing five years or less experience as an RN in a comparisonto 25 of the studying staff of Emergency Department Ad-ditionally in-patient nursing staff had the highest percentageof staff prepared at the baccalaureate level with 5294 incomparison to 20 of Emergency Department staff

5 CONCLUSIONS

According to the results of the present study it was con-cluded that nursesrsquo levels of total knowledge regarding

80 ISSN 2324-7940 E-ISSN 2324-7959

practices of the current clinical handover were poor at pre-implementation and improved after implementation of struc-tured model as SHARED Additionally there was an im-provement of clinical handover attitude post-implementationof SHARED framework among studied subjects and had agood level of attitude than pre-implementation phases Alsothere was highest level of nursesrsquo satisfaction at the post thanpre-implementation of SHARD model regarding clinical han-dover practice

Recommendationsbull Replication of the study on a large probability sample

from different settings is required to allow generaliz-ability of the findings

bull Ongoing educational sessions for nurses and periodicrefresher training courses should be provided in or-

der to keep nurses updating knowledge and practiceregarding the structured and standardized model

bull Adoption of the standardized and structured modelas a practice guideline for conducting handover forvarious categories of nurses in different settings

bull Developing periodic follow-up is required to providemore information on the lasting impact of the model

bull Strict observation of nursesrsquo performance on utiliza-tion of structured and standardized model and correc-tion of poor practices from their supervisors

bull Hospital management policy should be implemented aSHARED structure in documentation system

CONFLICTS OF INTEREST DISCLOSUREThe authors declare they have no conflicts of interest

REFERENCES[1] Athwal P Fields W Wagnell E Standardization of change-of-

shift report Journal of Nursing Care Quality 2009 24 143PMid 19287253 httpsdoiorg10109701NCQ00003474512879438

[2] Foster S Manser T The effects of patient handoff characteristicson subsequent care A systematic review and areas for future re-search Academic Medicine 2012 87 1105-1124 PMid 22722354httpsdoiorg101097ACM0b013e31825cfa69

[3] Staggers N Clark L Blaz JW et al Why patient summaries in elec-tronic health records do not provide the cognitive support necessaryfor nursesrsquo handoffs on medical and surgical units Insights frominterviews and observations Health Informatics Journal 2011 17209-223 PMid 21937463 httpsdoiorg1011771460458211405809

[4] Performance Quality and Rural Health Victorian Government De-partment of Health June 2014

[5] Patterson E Wears R Patient handoffs Standardized and reliablemeasurement tools remain elusive Joint Commission Journal onQuality amp Patient Safety 2010 36 52-61 httpsdoiorg101016S1553-7250(10)36011-9

[6] Australian Medical Association Canberra AMA 2006 Safe han-dover safe patients Guidance on clinical handover for cliniciansand managers In Pascoe H Gill SD Hughes A McCall-White MClinical handover An audit from Australia Australas Med J 2014Sep 30 7(9) 363-71 PMid 25324901

[7] Klim S Kelly AM Kerr D et al Developing a framework for nursinghandover in the emergency department An individualised and sys-tematic approach Journal of Clinical Nursing 2013 22 2233-2243PMid 23829405 httpsdoiorg101111jocn12274

[8] Kerr D Klim S Mckay K et al Attitudes of emergency departmentpatients about handover at the bedside Journal of Clinical Nursing2016

[9] Australian Institute of Health and Welfare Safe handover Safe pa-tients guidelines on clinical handover for clinicians and managers2006 Available from httpwwwamacomauwebnsfdocWEEN-6XFDKNpdf

[10] Australian Commission on Safety and Quality in Health Care (Ac-sqhc) Windows into Safety and Quality in Health Care ACSQHCSydney 2008 Available from httpwwwsafetyandqualitygovauwpcontentuploads200801Windows-into-Safety-and-Quality-in-Health-Care-2008-FINALpdf

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82 ISSN 2324-7940 E-ISSN 2324-7959

Introduction

Significance of the study
Aim of the study
Research hypotheses
Methods
Design
Setting
Subjects
Tools
Scoring system
The validity of the instruments
Reliability of the instruments
Pilot study
Fieldwork
Administrative and Ethical Considerations
Statistical analysis
Procedure
Results
Discussion
Conclusions