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edication communication between nurses and patients during nursingndovers on medical wards: A critical ethnographic study

ei Liu a,*, Elizabeth Manias b, Marie Gerdtz c

partment of Nursing, Melbourne School of Health Sciences, The University of Melbourne, Level 2, Walter Boas Building, Parkville 3010, Australia

partment of Nursing, Melbourne School of Health Sciences, The University of Melbourne, Australia

partment of Nursing, Melbourne School of Health Sciences, The University of Melbourne, Emergency Medicine, Royal Melbourne Hospital, Australia

T I C L E I N F O

le history:

ived 20 August 2011

ived in revised form 24 January 2012

pted 6 February 2012

ords:

ical ethnography

dover

ication communication

o-recording

A B S T R A C T

Background: Communication is central to safe medication management. Handover is a

routine communication forum where nurses provide details about how patients’

medications are managed. Previous studies have investigated handover processes as

general communication forums without specific focus on medication information

exchange. The effects of social, environmental and organisational contexts on handover

communication and medication safety have not been explored.

Objectives: To examine dominant and submissive forms of communication and power

relations surrounding medication communication among nurses, and between nurses and

patients during handover.

Design: A critical ethnographic approach was utilised to unpack the social and power

struggles embedded in handover practices.

Settings: The study was conducted in two medical wards of a metropolitan teaching

hospital in Melbourne, Australia from January to November 2010.

Participants: All registered nurses employed in the medical wards during the study time

were eligible for participation. Patients were eligible if they were able to communicate

with nurses about how their medications were managed. In total, 76 nurses and 27

patients were recruited for the study after giving written consent for participation.

Methods: Participant observations, field interviews, video-recordings and video reflexive

focus groups were conducted. Fairclough’s critical discourse analytic framework guided

data analysis.

Results: Nurse coordinators’ group handovers in private spaces prioritised organisational

and biomedical discourses, with little emphasis on evaluating the effectiveness of

medication treatment. The ward spatial structure provided an added complexity to how

staff allocation occurred. Handovers involving patients in the public spaces at the bedside

facilitated a partnership model in medication communication. Nurses exercised discretion

during bedside handovers by discussing sensitive information away from the bedside.

Handovers across different wards during patient transfers caused communication

breakdowns because information was not exchanged between bedside nurses.

Conclusions: Nurse coordinators need to relinquish organisational control of the handover

practice and appreciate the contribution of bedside nurses to patient information

exchange. Bedside nurses need to be provided with opportunities to raise questions during

the group handover. Designated meeting spaces need to be provided to reduce

interruptions to the group handover process.

� 2012 Elsevier Ltd. All rights reserved.

Corresponding author. Tel.: +61 0432654288.

E-mail address: wei.liu10@gmail.com (W. Liu).

Contents lists available at SciVerse ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

0-7489/$ – see front matter � 2012 Elsevier Ltd. All rights reserved.

10.1016/j.ijnurstu.2012.02.008

W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941–952942

What is already known about the topic?

� Existing handover literature focuses on nurses’ commu-nication about general clinical issues, which highlightsthe complexities of handover processes.� The interconnectedness of social, environmental and

organisational contexts that impact on handover com-munication and medication safety has not beenexplored.

What this paper adds

� Nursing handovers in private spaces prioritise organisa-tional and biomedical discourses, with a lack of nursingperspectives on care.� Nursing handovers involving patients in public spaces at

the bedside facilitate a partnership model in medicationcommunication.� The use of video-recording provides new insights into

the complexities of nursing handover practices.

1. Introduction

Handover is a routine forum of nursing communicationat change of shifts, when nurses take breaks and followingpatient transfers across ward spaces. This forum aims toensure the continuity of patient care by communicatingrelevant information between nurses (Manias and Street,2000). Handovers can be used by nurses to provideinformation about medication changes and on how thesechanges relate to patient assessment parameters (Maniaset al., 2005). Subsequently, ambiguities and incompletecommunication during handovers can increase the risks ofadverse events. Ambiguities at handover included a lack ofinformation exchange about essential components ofpatient care, such as initial diagnosis, ongoing treatmentand newly prescribed medication orders (Matic et al.,2011).

2. Literature review

Nursing handover is known as a ‘‘transitional space’’where power, containment and responsibility for patientcare are transferred from one nurse to another (Wiltshireand Parker, 1996, p. 29). Strange (1996) highlighted theprotective function of the handover process, arguing thatnurses can maintain a feeling of control by knowing thatpatients have received prescribed medications for theirmedical conditions. The importance of cross-checkingmedication charts between oncoming and offgoing nursesduring handovers has also been featured in the literature(McMurray et al., 2010; Welsh et al., 2010). Duringhandovers, offgoing nurses are required to make inter-pretations of medication charts, observational charts andother documents in different spaces, including bedside andoffice areas (Hagler and Brem, 2008). Chaboyer et al. (2010)highlight the importance of performing a ‘‘safety scan’’ ofinformation relating to the patient, environment anddocuments during bedside handovers (p. 140). However,reinterpretations of this information in a different time andspace can contribute to miscommunication.

Beyond its use as a mode of transferring patientinformation, the handover is a complex ‘‘social space’’where nurses can draw on collegial relationships andestablish disciplinary cohesiveness (Strange, 1996, p. 110).Studies on the complexities of handover processes havefocused on the effects of spatial environments and powerrelations (Manias and Street, 2000), nurses’ institutionalstorytelling during handovers (Bangerter et al., 2011), andnurses’ efforts to reach agreement about patient careduring handovers (Hagler and Brem, 2008). Although thesestudies have identified nursing handover as a complexphenomenon involving social and power struggles, thereare a number of limitations.

Previous studies have mainly addressed handover as ageneral communication forum without considering thehandover content and structure (Matic et al., 2011).Investigators have paid little attention to medicationinformation exchange during handover processes, parti-cularly the potential link between communication pro-blems and medication safety. In addition, pastinvestigators have tended to focus on nurses’ experiencesand perceptions of handovers (Street et al., 2011). Patients’involvement in nursing handovers remains under-researched, and there is a lack of understanding aboutthe effects of social power relations on patient participa-tion in handovers.

There is also limited research on the interconnected-ness of social, environmental and organisational contextsthat impact on communication between nurses andpatients during handovers, although Manias and Street’s(2000) critical ethnography illuminates the effects ofspatial environments on handover processes. For instance,nursing handover occurs in different spaces movingbetween the bedside and a site away from the bedside.While nurses have the ability to control handoverlocations, patients are confined to their designatedhospital bed with little control of space and mobility. Thislack of spatial control might reflect and contribute topatients’ limited opportunities for information exchangewith nurses. Clearly, the spatial aspect of handoverpractices and how power is exercised within that spacerequires further empirical research.

In this paper we aim to examine dominant andsubmissive forms of communication and power relationssurrounding medication communication during nursinghandovers. We define medication communication asinformation exchange about treatment regimens amongnurses, and between nurses and patients. Specifically, wewill explore: who gives and who receives the handover,what discourses are embodied in medication communica-tion during handover, who regulates spatial movementsduring handover, and how language discourses impact onclinical practices and social relations.

3. Methods

3.1. Methodological framework

Critical ethnography was the methodological frame-work selected for this study. This framework involves anexamination of how unnecessary repression and social

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W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941–952 943

qualities affect people’s activities and behaviors (Ham-rsley, 1992). Critical ethnography takes mundanents into consideration and reproduces them in a wayt exposes social processes of power imbalancesomas, 1993). This framework was selected because itouraged participants to think about their practices inerent ways and challenged how handover practicesre conducted.Critical ethnography encourages participants andearchers to engage in collaborative research through

process of reflexivity (Thomas, 1993). Accordingly,ticipants were encouraged to draw upon the researcha to reflect on their own practices and challengequal power relations. The first author of this paper, also

research data collector, reflected on how she affected field and how the field affected her subjectivity during research process.

Research sites and participants

This study examined how nurses communicated withh other during the handover process. However,ients’ involvement in this process and its influencemedication safety was a focal point. This study wasertaken in two medical wards (the General Medicalrd and the Medical Assessment Ward) of a metropolitanching hospital in Melbourne, Australia. The Generaldical Ward delivered care to patients with complexdical issues. The Medical Assessment Ward providedrt-term care to patients who were to be dischargede or admitted to other wards within 48 hours. The two

dical wards were selected to encompass diversectices and maximise transferability of the findings.All registered nurses who worked on the wards during

study period (from January to November 2010) wereible for participation. Patients were eligible if they were

e to communicate competently with nurses aboutdication management. Patients were required to speaklish, to be medically stable and cognitively competent, to be on at least one medication.

In-service meetings were organised with nursing staffach ward to introduce the study and to invite nurses toticipate. Information sheets and consent forms wereributed at the end of each meeting. After obtainingsent from nursing staff, the first author approachedients who were allocated to the nurse under observa-

and provided them with information about the studythe bedside. Written consent was obtained from 76ses and 27 patients. All participants were informed thatir identity would not be disclosed in any way in outputsing from the study. Verbal consent was obtained fromother individuals who interacted with the targetedses and patients at the time of observation. The studys approved by the hospital and university ethics

mittees.Nursing participants were employed in the wards asse unit managers (NUMs), nurse coordinators, clinicalse specialists (CNSs) and staff nurses. NUMs wereponsible for the overall management of the wards.

etimes, they worked as nurse coordinators, coordinat- patient flow and overseeing clinical practices for the

shift. CNSs were given a patient load and regarded asexperts in the field of general medicine. Staff nurses weremainly involved in direct delivery of patient care at thebedside.

3.3. Data collection

Data collection methods included participant observa-tions, field interviews, video-recordings and video reflex-ive focus groups (Table 1). In total, our fieldworkcomprised 290 hours of participant observations, 72 fieldinterviews, 34 hours of video-recordings and 5 reflexivefocus groups. The first author, also an emergency depart-ment (ED) nurse working in the study hospital, collectedthe research data.

3.4. Data analysis

Data analysis began with verbatim transcription of allaudio- and video-recordings by the first author. Thetranscribing process increased the author’s familiaritywith the data through writing down details of audiblesounds and ambiguous conversations (Hutchby andWooffitt, 1998). All authors independently interpretedthe audio and video recordings with their understandingsof the meanings conveyed. Audio, video and written datawere imported to NVivo version 8 (QSR International).Coding was used to identify communication discourses,and to mark the relations between discourse and power, aswell as their articulation through organisational struc-tures. Fairclough’s (1992) three-level critical discourseanalytic framework was used to examine events andactivities that happened during handovers (Table 2).

3.5. Rigor

Four methods were used to ensure rigor of the findings:prolonged engagement, triangulation, thick descriptionand member checking (Polit and Beck, 2006). Details ofthese four methods are provided in Table 3.

4. Results

Handover data were collected when nurses attendedthe change of shift handover and following patienttransfers across different wards. On both wards, the shifthandover involved a two-stage process. Firstly, it beganwith a group report in a closed room, which was the‘‘private’’ space for the handover. Secondly, a detailedindividual handover between offgoing and oncomingnurses was delivered at the bedside, in the corridor or atthe staff station, which were the ‘‘public’’ spaces for thehandover.

In the General Medical Ward, the private room wasdesigned for general meeting purposes. The room was onlyaccessible to permanent staff members with a swipe card.Hence, interruptions to group handovers were minimaldue to the access constraint to the room. Staff participatingin the handover included all oncoming nurses and theoffgoing nurse coordinator, who briefly reported on eachpatient, including changes to patients’ current medication

W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941–952944

regimens or special treatments, such as iron transfusionsand intravenous (IV) antibiotics.

In the Medical Assessment Ward, the private room wasdesigned for many purposes such as staff breaks andeducation. This room was closed temporarily during eachhandover time. However, a closed door did not necessarilyimpose a spatial restriction on staff members. Handoversin the private room were often interrupted by non-

attendees, trying to access the room for different reasonssuch as room cleaning and meal breaks.

4.1. Nurse coordinators’ handover: constructing the order

The nurse coordinators’ group handover occurred at thebeginning and the end of each shift. Ten to fifteen minuteswere allotted for the group handover, although it took

Table 1

Details of data collection methods.

Type of method Role of method Participants Data collection strategies Amount of data

Participant

observations

To gain a general

understanding of

nurses’ medication

communication

patterns on the wards.

Nurses and patients

who consented to

participant

observations

The first author conducted

observations between 07:00 and

21:00 hours by following each

nurse participant for a period of

2–3 hours.

130 hours of observations in

the GMW;

Activities and conversations

relating to medication

management between the nurse

and other nurses or patients

were documented.

160 hours of observations in

the MAW;

Conversations between the

nurse and the first author during

the observation period were

documented.

76 nurses and 27 patients

involved in participant

observations

All observations and

conversations were documented

in the form of field notes.

Field interviews To obtain nursing

participants’

perspective on

communication events

that happened during

observations.

Nurses who consented

to field interviews

The first author carried out semi-

structured interviews in the field

after individual observations.

32 interviews in the GMW;

Nurse participants were asked to

comment on medication

activities that happened during

the observations, and to obtain

greater clarity of events and

activities.

40 interviews in the MAW;

All interviews were audio-

recorded.

Interviews lasting between

10 to 30 minutes;

67 nurses involved in field

interviews

Video-recordings To obtain a full record

of the contexts within

which clinical

communications were

played out.

Nurses and patients

who consented to

video-recordings

The first author operated a hand-

held video camera and filmed

nursing handovers that occurred

during participant observations

when nurses participated in

group handovers, bedside

handovers and following patient

transfers across different wards.

15 hours of video-recordings

in the GMW;

19 hours of video-recordings

in the MAW;

72 nurses and 23 patients

involved in video-recordings

Video reflexive

focus groups

To offer participants

feedback about the

research data and

encourage them to

reflect on handover

practices.

Nurses who consented

to video-reflexivity

The first author edited the raw

video data and produced a

reflexive DVD representing the

recurrent patterns and emergent

themes of handover practices.

2 focus groups in the GMW;

The first author conducted focus

groups in the staff room on each

ward by presenting the reflexive

DVD and facilitating group

discussions. One of the other

authors acted as a facilitator.

3 focus groups in the MAW;

Participants were asked to

comment on communication

issues during handover

practices.

15–20 nurses involved in

each focus group;

All focus groups were video-

recorded by placing the camera

on a stationary tripod with its

lens focused on the first author.

Focus groups lasting between

60 and 90 minutes

loninteto odelnurcoonurnatoffgfrom

Tab

Data

Le

Le

Le

Le

Ada

Tab

Des

Ty

Pr

Tr

Th

M

W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941–952 945

ger when the ward was busy. The group handover wasnded to provide an overview of all patients on the wardncoming nurses. Indeed, it was structured as a one-way

ivery of information from the offgoing to the oncomingse coordinator. It also provided a channel for the nurserdinator to relate medication information to oncomingses. Medical-technical jargon and abbreviations domi-ed the handover. The following is an excerpt by theoing nurse coordinator in the General Medical Ward

a video-recorded handover:

Bed 10, Mr. [name patient] is a bit overloaded [withfluids]. He’s had some stat [orders given immediately]frusemide [a diuretic] and a regular oral dose. Theregistrar pointed out to me his fluid balance chartwasn’t filled in yesterday. So we want a strict [in araised tone] in and out fluid balance [pause], trying tomanage his APO [acute pulmonary edema] and they[indicating doctors] haven’t got the information theyneed, so just be careful with that [scanned all nurses].The patient is also unhappy because he is a privatepatient. He said he was promised all the benefits of aprivate patient here. But actually we have no resources[all laugh] . . . Last night he had his alprazolam [an anti-anxiety medication] after CPAP [a ventilation therapy toprovide continuous positive airway pressure forpatients with breathing difficulty] went on. He wantshis alprazolam and CPAP on at 9 pm because he hasalprazolam to help him cope with CPAP [looking at theoncoming nurse coordinator]. Can we make sure thathappens? They [indicating doctors] need to start to planfor discharge. (Nurse coordinator)

In this group handover, the nurse coordinators sat nextto each other at one side of a rectangular table. Alloncoming nurses sat across the other side of the table, orbehind the nurse coordinators (Fig. 1). Although thehandover was designed as a communication forum, most

le 2

analysis guide developed from Fairclough’s three-level analytic framework.

vel of analysis Focus of analysis Questions guiding analysis

vel 1 The structure and content of the text

were examined in its local domain

What were participants saying? What was body language used?

Who was speaking? Who was silent?

To what extent were competing interests of nurses, patients and the

organisation addressed?

vel 2 The strategic use of the text was

explored in its organisational domain

What social relations were relevant to the construction of the conversation?

How were these social relations made relevant?

What positions did nurses and patient adopt when they were speaking?

Where did the interaction occur and under what circumstances?

vel 3 The discursive practice in the text was

evaluated in its societal domain

What were the clinical consequences of the communication practice?

Did the conversation contribute to the maintenance of the status quo in

clinical practices and social relations, or had the traditional order of

discourses been threatened, therefore contributing to positive social

changes?

What subject positions were taken by the researcher during the research

process?

pted from Fairclough (1992).

le 3

cription of methods to ensure rigor.

pe of method Description of method

olonged

engagement

Prolonged engagement involved the

first author’s frequent visits to the field

and persistent observations of

communication activities on the wards.

iangulation

(method, space

and time

triangulation)

Method triangulation involved the use

of multiple sources of data from

participant observations, field

interviews, video-recordings and

reflexive focus groups.

Space triangulation involved the

collection of data in two different care

settings.

Time triangulation involved the

observations of communication

activities at different time blocks on the

shift.

ick description Thick description was available in the

form of field notes, audio-recordings,

video-recordings and transcripts,

together with the first author’s

subjective journal for personal

reflection.

ember checking Participants were allowed to review the

raw video data in the field if they

wished to do so.

Participants were involved in video

reflexive focus groups by reviewing and

challenging their own practices.Fig. 1. Nurse coordinators’ handover in the private room.

W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941–952946

nurses listened quietly and jotted down pertinent infor-mation on the handover sheet. Little direct eye contact wasmade between the nurse coordinators and other nurses.Nurses also rarely raised any questions.

The offgoing nurse coordinator frequently used non-verbal gestures in her talk, such as a sweep of the eyescanning across the nurses, which met with a discerninglook of the oncoming nurse coordinator. The offgoing nursecoordinator toned down a medical complaint about theincomplete fluid balance chart to a discrete warning (‘‘justbe careful with that’’). Nevertheless, the nurse coordinator’sspecific identification of the complaint from ‘‘the registrar’’might be interpreted as a form of hidden power. The nursecoordinator’s focus of communication was moral, concernedwith the patient’s physical condition and individual needs,organisational, concerned with institutional resources andthe patient’s social dimensions, and interpersonal, con-cerned with nurses’ feelings. In doing so, the nursecoordinator carefully positioned herself within discoursesof nursing professionalism and interdisciplinary relation-ship. The nurse coordinator worked as a messenger betweendoctors and nurses, representing the structured order andorganisation of patient care. The nurse coordinator changedsubjects from ‘‘we’’ to ‘‘they,’’ reinforcing the professionaldivision between nursing and medicine.

The discourse of patient autonomy was raised in thenurse coordinator’s handover. It appeared that the patientarticulated his medication needs to his allocated nurse. Hewas ‘‘promised’’ that his social identity as a private patientwould be maintained in a public hospital. He expected thathe could choose his own medication timing and the nursesshould respect his decision. The social discourse of patientautonomy was in tension with the nursing discourse ofstructured order in relation to administering medications atprescribed times. The nurses’ laughter following the nursecoordinator’s rearticulation about the patient’s individualneeds might be read as a sarcastic message. The patientstruggled with traditionally accepted norms in publichospitals where patients’ routines were moulded by nurses’shift schedules. The competing discourses of patientautonomy and disciplinary norms had undesirable effectsupon patient treatment and nurse–patient relationships.

The organisational discourse of efficiency dominatedthe nurse coordinator’s handover. While certain treatmentsuch as a single dose of frusemide was briefly presented,there was no information conveyed about the effectivenessof medication treatment. It was obvious that thisinformation did not serve the nurse coordinator’s interestin increasing work efficiency on the ward. The purpose ofthe nurse coordinator’s handover might be more than aforum for exercising organisational control. When amedical complaint by the registrar was down-played,nurses felt a sense of support and cohesion from themanagement. Although nurses were mostly silent duringthe handover, their open laughter demonstrated sharedemotions and dominant values of the group.

4.2. Staff allocation: hierarchical nursing power

Nurse coordinators’ control of a structured order was

both wards, staff allocation was conducted by nursecoordinators after the group handover, so oncoming nursesdid not know which patients they would care for beforereceiving handovers. A nurse coordinator commentedabout how nurses worked with each other throughout theshift, which was recorded in the field notes:

We bracketed two nurses’ names together on theallocation, and that’s got the tea [time] on it. That’s theperson you go to if you want a check [for medications]or leave for tea. She has patients right next door to yourpatients. (Nurse coordinator)

The nurse coordinator alluded to a discourse of nursingconvention. It was an accepted norm that nurses had aprofessional obligation of care not only for patients, but forother colleagues. A good example was that nurses oftenhanded over patients’ ongoing intravenous therapy to theircolleagues before going for tea breaks. Although individualnurses might only be seen moving between their allocatedpatients, they often overheard other people’s conversa-tions and were ready to help when the need arose. Withinthe public ward space, nurses required each other to bevisible to call for a helpful hand, so that nurses constantlyfelt being supported and looked after by each other.

The allocation process also demonstrated how nursecoordinators used their knowledge of staff and space tomaintain clinical orders. Due to the way in which bothwards were laid out, it was unavoidable to allocate onenurse on each shift to work in a ‘‘corner area’’ where thenurse had to care for two patients in one corridor, andanother two patients in another corridor. The corner areawas out of the visual sight from the central staff stationwhere staff members were mostly congregated. The spatialdivision created social isolation for both nurses andpatients. Nurse coordinators had to take the spatial factorinto consideration to control organisational orders, asdemonstrated in the following interview data with a nursecoordinator:

The way our ward is shaped, you need to make sureyou’ve got senior staff at the corner because basicallythe person there, I very rarely see unless I havesomething specific to tell them . . . I usually putsomeone who I know can cope and doesn’t ask mesort of junior questions like where they can get aninfusion pump. It’s a very far place to walk. Yeah. I canrely on the girl there. (Nurse coordinator)

The nurse coordinator developed certain familiarity withthe staff and space due to her seniority. This familiarity wasimportant for her to run the shift smoothly because shewished not to be interrupted by too many ‘‘juniorquestions.’’ In deciding who should work at the corner,the nurse coordinator used her experiential knowledge ofthe individual nurses’ skill levels, medical knowledge of thepatients and logistic knowledge of the ward space toconstruct the organisational discourse of order.

The nurse working at the corner was prejudiced by theposition as a socially accepted ‘‘reliable’’ nurse. Nursecoordinators’ clinical gaze was restricted by their own

working priorities and spatial configurations of the wards.

further strengthened through the allocation process. On

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W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941–952 947

y achieved organisational order by assigning inexper-ced nurses to work at the central locations andporting their professional development in the spatialximity.

Bedside handover: being a discreet nurse

After being allocated to a group of patients, oncomingses moved from the private room to the public wardce. The location of undertaking bedside handover washazard. It happened either at the bedside or outsideient rooms in the corridor. Sometimes, nurses sat in thetral station while giving individual reports. Theision about where the individual handover shouldur was jointly made by offgoing and oncoming nurses

based on the severity of patient condition.Although it was not an official hospital policy, double-cking medication charts between offgoing and oncom-

nurses during bedside handovers was required by therd management to prevent medication errors. Duringervations, nurses showed low adherence to this warddard at the bedside because the group report some-

es took too long to finish in the room. Double-checkingdication charts at the bedside was opportunisticending on the individual nurses and adequacy of time.

video-reflexive focus group in the Medical Assessmentrd, nurses emphatically talked about the importance ofble-checking medication charts after viewing videos of nurses calling each other at home after work toify medication orders:

ff nurse 1: I know we are meant to check charts,which I am sorry, it doesn’t alwayshappen because we don’t have time.The group handover is too long.

: Yeah. Double-checking is important.What could be a better way beingheld accountable by our peers thanour boss?

ff nurse 2: You could have your charts in front ofyou while checking the patient’scondition . . . Also we can make sureall medication charts are givenand signed.

Nurses identified time as a salient and dominantourse creating clinical tensions. Time was constructedsocial and professional hierarchy. Although nurserdinators were confronted with time pressures to meetanisational demands, they were afforded more flex-ity and authority to regulate their handover time in them compared with bedside nurses, who on the otherd, had to complete handovers in a less regulated spacehe bedside.Nurses were vigilant of their medication practices. Theyre proactive in preventing incidents by willinglyepting their colleagues’ examination, but not thetitutional surveillance from the nurse coordinators

managers. During bedside handovers, offgoing nursesed on oncoming nurses to check patients’ medication

nurses were bestowed with temporal power to critiqueoffgoing nurses’ work to maintain safety.

Furthermore, bedside handovers provided clinicalspaces for patients to feedback effects of medicationtreatment. The following video excerpt illustrated theexchange of medication information among the oncomingnurse, the offgoing nurse and the patient during a bedsidehandover:

Offgoing nurse: Our lovely [name patient] is here.

Patient: Uh, did I hear that right?

Offgoing nurse: Yeah. We are talking about you[laugh].

Patient: Uh, isn’t that nice [all laughs]?

Offgoing nurse: Your leg swelling is going downwith the tablets [indicatingfrusemide] we give to you,isn’t it?

Patient: Yes, a little bit better everyday.I went to the toilet twicethis morning.

Oncoming nurse: She is 89% [oxygen saturation]on room air [looking at theobservational charts]. How manyliters [of oxygen] she’s on now[turning to the offgoing nurse]?

Patient: Not if I sit up like this. I need itwhen I go to bed. If I lie down,I am out of it [breath].

Oncoming nurse: Do you still have the dressingon your legs? It’s for the blisters,is it?

Patient: Yeah, the skin breaks downbecause of the fluid. It’s notdiabetic ulcers.

Offgoing nurse: She has nausea today, a lot ofnausea, no vomiting. I gave hermetoclopramide [an anti-emetic],and I gave her a wafer ofondansteron [an anti-emetic],a stat dose, because I couldn’tgive her another metoclopramide.[Oncoming nurse: Yeah] It’s [themetoclopramide order] on PRN[orders given as required].

Oncoming nurse: Do you still feel sick?

Patient: No. But I just don’t want to eat.

Offgoing nurse: Yeah, she is not eating much.She said she is feeling dizzy.She is not eating, drinking much,that’s why she is feeling dizzy.So just try to encourage herto drink more because she doesn’twant to eat because of the nausea.If she has pain, encourage her touse oxycodone [an opioid analgesic].

rts and medication administration rates. Oncoming

That’s [the oxycodone order] on PRN.

W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941–952948

This extract demonstrated a three-way communicationduring the bedside handover. The offgoing nurse invitedthe patient into the conversation with an interpersonalgreeting, which was responded warmly by both the patientand oncoming nurse. In doing so, the offgoing nurseconveyed her subjective knowledge of the patient’scondition. Throughout the handover, the patient had beensitting upright in a chair with a table in front of her. Bothnurses sat at the side of the bed, which reduced theirphysical distance with the patient (Fig. 2). The nurses’tentative positioning at the bedside allowed them tomaintain direct eye contact with the patient.

The offgoing nurse presented her evaluation of theeffectiveness of frusemide with a two-part sentence – apositive statement of the treatment effect and a negativequestion to involve the patient into the conversation. Thepatient responded with a positive answer and reinforced itwith a description of her body response to frusemide. Seeingthe observational charts and the patient together at thebedside, the oncoming nurse sought out further informationfrom the offgoing nurse about the patient’s oxygentreatment. The patient addressed the oncoming nurse’sinquiry by articulating her need for oxygen at the particulartime of the day. Then, the oncoming nurse raised a questionabout the patient’s wound condition. The patient demon-strated her knowledge by differentiating the fluid retentioncaused skin breakdown from diabetic ulcers.

The offgoing nurse repeatedly used her clinical assess-ment knowledge (‘‘nausea’’, ‘‘a lot of nausea’’, ‘‘doesn’t wantto eat because of the nausea’’) to validate her decisions to usea PRN medication and take further action for a stat order. Theoffgoing nurse also made references to her own body whendescribing the patient’s feeling of nausea, by pointing to herstomach and demonstrating a dry retching gesture. Herfrequent reference to the patient’s symptoms led to thejointly-held account of the patient’s medication needs, withthe oncoming nurse who subsequently raised a question toevaluate the treatment effect.

The patient responded to the oncoming nurse’s questionwith an incomplete answer (‘‘no, but . . .’’), and the offgoingnurse changed to another topic about the patient’s painmanagement. The offgoing nurse recommended specificmedication interventions by encouraging the patient to usePRN oxycodone for pain by the oncoming nurse. It is possible

what the patient needed in the forthcoming shift. Throughextended contact with the patient throughout the shift, theoffgoing nurse had developed an understanding of thepatient’s treatment regimen.

A striking feature of bedside handovers was nurses’frequent movement between various spaces including thebedside, outside patient rooms, corridors and staff stations.Before approaching a patient at the bedside, offgoing nursesfrequently asked oncoming nurses in the corridor ‘‘do youknow this patient?’’ Previous knowledge of the patientmeant better understanding of the medical history andtreatment regimen. If oncoming nurses indicated that theyknew the patient from the previous shift, the handovermoved to the bedside immediately. It was important fornurses to have some basic information about the patientbefore approaching the bedside space where professionalknowledge was contested by the patient’s own under-standing of illness.

Nurses were mindful about the issue of confidentialityassociated with bedside handovers. Curtains were drawnwhen private information was discussed in a sharedbedroom. Nurses often moved from the bedside if thecontent of handovers was sensitive. The power exercisedby nurses during bedside handovers took the form of a‘‘tyranny of discretion.’’ Nurses were very discrete aboutwhat they said in front of patients, as indicated from thefollowing video excerpt:

[Bedside]

Offgoing nurse: She [indicating the patient] justcame back from dialysis. Sheis on heparin [an anti-coagulant]infusion. Her APTT [activated partialthromboplastin time, an indicatorused to monitor the effects withheparin treatment] was 50[seconds] yesterday. So sheis on 50mls [infusion rate]per hour now.

[Moving from the bedside]

[Offgoing nurse gave the oncoming nurse a sidewayglance and both walked out of the room]

[Corridor]

Oncoming nurse: Secret [whispers]?

[Moving to the staff station]

Oncoming nurse: There was confusion in themorning that we were told tostop the infusion.

Oncoming nurse: The doctor said or?

Offgoing nurse: It’s [name doctor]. When we hadhandover, [name nurse coordinator]said you can never stop theheparin infusion. This is a hugeRiskman [an on-line electronicincident report system]. So wecalled [name doctor] and hecame down. He charted againand now it’s running again.

Fig. 2. Bedside handover.

that the offgoing nurse might have been trying to preempt

occpretreabedoncobjdiawitbodwhvercollof cmopub

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W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941–952 949

This excerpt illustrated dynamic spatial movement thaturred during the bedside handover. The offgoing nursesented clinical objects about the patient’s dialysistment, heparin infusion and pathology results at theside. Seeing the patient at the bedside offered theoming nurse with opportunities not only to accumulateective data relevant to the patient’s conditions after thelysis, but also to develop interpersonal connectionsh the patient. The offgoing nurse’s non-verbal cues andy gestures were captured as a fascinating moment

ere initiation of subtle movement occurred. This non-bal gesture was picked up immediately by hereague, indicating nurses’ routine use of versatile meansommunication. With an eye glance and a smooth bodyvement, the bedside handover was repositioned to alic corridor where a ‘‘secret’’ whisper followed (Fig. 3).

It was obvious that the purpose of space shifting was to the ‘‘confusion about the heparin infusion.’’ Theoing nurse considered this medication information as

ppropriate to be shared with the patient. There was ase that the doctor made a clinical decision that coulde led to a ‘‘huge’’ medication incident report. The nurserdinator stopped the reporting chain and maintainedical order by calling the doctor back to the ward torite the chart. During the handover in the staff station,

offgoing nurse indicated the nurse coordinator’srcise of experiential knowledge and authoritativeer by asking the doctor to correct the medication

er. However, it appeared that the nurse coordinator’sfessional boundary was blurred at one level for notorting the incident when it had already happened att time. The power exercised by the nurse coordinator, in positioning to control the order, could have hadificant effects upon patient safety and institutional

icies such as medication incident reporting.There was little spatial control by patients duringside handovers. Patients were confined to theirpital beds while nurses moving between spaces duringdover processes. In reflecting on nurses’ exercise oftrol over spaces, a nurse stated that ‘‘We talk aboutes in the station when we want to brainstorm each

er. We go to bedside when we need to. We have nevered what patients want.’’ Nurses not only regulated the

interactions, but also shaped the spatial orientation duringhandover processes.

4.4. Handover across ward spaces: disjunctions of medication

communication

On both wards, it was nurse coordinators’ responsibility togive and receive a handover to or from another ward (Fig. 4).Both wards frequently admitted patients from the ED throughtelephone communication. The information was relayed tobedside nurses from nurse coordinators afterwards.

The NUM of the Medical Assessment Ward explainedthe importance of controlling handovers by recalling anevent that occurred on her shift when she took the nursecoordinator’s role, ‘‘The ED rang through to the back[station] where a graduate [nurse] took the handover. Halfof the information was missed. The patient came up withan ED drug chart.’’ In this context, a new graduate nurseunintentionally received a handover from another ward.Normally this type of handover was undertaken by nursecoordinators, who did not accept patients into ward careuntil all aspects of verbal handover and documentationwere completed by ED nurses. An important part ofdocumentation required in the handover was inpatientmedication charts. Different from medication charts usedin the ED, an inpatient medication chart had to be writtenby admission doctors prior to patient transfers to thewards. The ED nurses had to ensure the completeness ofthis medical documentation. Nurse coordinators exercisedclinical examination of ED nurses for medication chartomissions through the handover process.

Handover across wards through the telephone by nursecoordinators was not without defects. The completeness ofan inpatient medication chart did not guarantee allrelevant information was communicated effectively.Information was not exchanged between bedside nurses.In the following interview excerpt, a graduate nurse wasperturbed by the medication information gap thatoccurred during patient transfers:

I don’t know why we are not allowed to take ahandover. It would be really good if we could talk tothem [ED nurses] . . . I had one [patient], she was from

3. An offgoing nurse used a hand gesture indicating a spatial

ement. Fig. 4. A nurse coordinator receiving handover from another ward.

W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941–952950

the rehabilitation centre, went to ED. It was a funnytime of the day. She hasn’t had any oral meds. It’scardiac, anti-hypertensive stuff. I was like, OK, what amI going to do? I didn’t receive the handover. So I rang upthe ED nurse and she assumed that the patient probablyhad them all in the morning. But I cannot assume that.Then they [nurses from the rehabilitation] said no, theyhaven’t given anything because she had gone beforethey started early meds. That took probably two hoursto sort out. (Staff nurse)

This example demonstrated communication break-downs regarding medication information during patienttransfers across the hospital and ward spaces. The graduatenurse questioned the organisational practice of nursecoordinators receiving handovers from another ward. Inquerying the particular time of the day when the patienthad not had her regular medications, the graduate nursedid not accept the usual medication time schedule on themedication chart. The graduate nurse contacted the EDnurse, trying to clarify the information. When uncertaintypersisted, the graduate nurse sought out further toinvestigate the situation. She was contingently positionedin competing discourses of patient safety, organisationalpractice and clinical efficiency.

Because ward nurses had not communicated first-handmedication information with ED nurses, they gleanedmessages from progress notes and medication charts.Information on progress notes amounted to little morethan the name of the stat dose medication and the time itwas administered in the ED. Evaluation of medicationtreatment in written documents was strikingly minimal.The telephone handover across wards during patienttransfers resulted in a disjunction in the flow of detailedmedication knowledge, shaping what nurses could knowin the confined ward spaces and affecting continuity ofpatient management.

Medication communication during nursing handoverswas shaped by social relationships and organisationalstructures. Nurse coordinators’ control over group hand-over, staff allocation and handover across wards werestrengthened by the organisational discourse of order. Bychallenging the nurse coordinators’ telephone handoveracross wards, nurses opposed organisational dominanceand brought about possibilities for change through powerstruggles.

5. Discussion

Nursing handovers on medical wards occurred indifferent spatial locations, affecting communication pro-cesses and social relationships in a number of ways. Nursecoordinators’ handovers in private spaces strengthenedorganisational control and nursing hierarchies. Bedsidenurses’ handovers involving patients in public spaces atthe bedside enhanced patient-centered medication com-munication. Telephone handover following patient trans-fers across different wards created communicationbarriers between bedside nurses.

Nurse coordinators’ group handovers prioritised orga-nisational discourses of order and efficiency, with little

emphasis on evaluating effectiveness of medications.Nurse coordinators drew heavily on medical discoursesin terms of diagnosis, procedures and investigations(Payne et al., 2000). While the nurse coordinator’s hand-over was shaped by the organisational structure, thehandover practice itself contributed to the constitution ofthe organisational structure which shaped the practice.There is a dialectic relationship between social structureand social practice (Fairclough, 1992). In this situation, theorganisational structure was both a condition for, and aneffect of the nurse coordinators’ practice.

Nurses tended to perceive their role as undertaking andrecording patient assessment parameters, distancingthemselves from involvement in patient treatment deci-sion-making. This role reflects and reinforces traditionalpower relations that privilege medical practices overnursing practices (Bail et al., 2009) and subordinatepsychosocial aspects of patient care to biomedicaldiscourses (Lally, 1999). There was little evidence of thenursing voice during group handovers to dispute structuralhierarchies and medical dominance.

Nurse coordinators’ handovers were conducted in aprivate room, distant from busy clinical environments.This private space enabled nurse coordinators to give animpression of control to oncoming nurses who wereunable to view their patients (Manias and Street, 2000).However, nurse coordinators’ work conducted behind a‘‘closed door’’ did not privilege nursing with higher statusin comparison to other work conducted on the ‘‘open floor’’(Spain, 1992, p. 206). The temporary private spaceconverted from a multi-functional room was vulnerable,subjecting nurses to constant interruptions from domesticstaff and other health professionals. Nurses’ professionalstatus was not automatically improved when they entereda private room. The same physical space was useddifferently by people from different status and occupations(Street, 1992). In this context, the multi-functional roomwas used by nurses as a private meeting space. However,for other staff members, the multi-functional room was acommunal space for meal breaks.

Paradoxically, interruptions or questions from nursesparticipating in the group handovers were rare. Traditionalcultural routines marked out the relations and powerdifferentials between nurse coordinators and bedsidenurses, and the behaviors associated with each person(Ainsworth and Hardy, 2004). In this situation, only nursecoordinators were allowed to talk, whereas bedside nurseswere expected to listen. Bedside nurses’ social position ofbeing cooperative and accepting nurse coordinators’reports has been well documented (Manias and Street,2000; Payne et al., 2000). Nurses in this study also took aphysical position of lower level to nurse coordinators bysitting behind them during group handovers, perpetuatingthe traditional nursing hierarchy.

Staff allocation took place after handovers according tonurses’ skill levels and patients’ personal needs (Farnelland Dawson, 2006). Nurse coordinators exercised theirhierarchical power by subordinating individual nurses’issue of spatial isolation at a corner space. Allocated intothe corner space on the wards, experienced nurses wereprivileged with more control over their own work and less

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W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941–952 951

veillance from nurse coordinators at one level. Yet, fromcial perspective, experienced nurses’ individual knowl-e was subjugated to maintain the ward structuraler.During beside handovers, nurses were positioned instant vie for time and patient safety. Nurses relayed ante awareness of ‘‘error wisdom’’ (Reason, 2004, p.28) bying on each other to double-check medication charts at

change of shift. This finding differs from Manias andet’s (2000) report on nurses’ expressions of fear andiety during bedside handovers, supporting nurses’egial solidarity in resistance to organisational power

scrutiny. It appeared that nurses in this studyoured the professional discourse of safety, even at

cost of being scrutinised by their colleagues.By involving patients at the bedside, nurses challenged

traditional discourse of unidirectional informationivery and emphasised patient-centred medication

munication. Bedside handovers provided patientsh opportunities to feedback the effect on treatment.

ever, promoting patient-centred medication commu-ation was not without challenges. Nurses were oftenitioned in competing discourses of patient autonomy

organisational efficiency. Nevertheless, this studywed evidence of patients’ involvement in medicationrmation exchange at the bedside, refuting previousm on patients’ lack of interest in bedside handoverticipation (Chaboyer et al., 2010) and nurses’ dom-nce in inhibiting patient involvement during bedsidedovers (Parker, 1996).

Although this study demonstrated patient involvementhe bedside, it was notable that nurses controlled thetial movement during handovers. Nurses approached

patients’ bedside space when they needed to speakut patients. They moved away from this space when theients’ presence was considered inappropriate. Thenny of discretion that manifested during bedsidedovers was characterised by nurses discreetly asses-

g the appropriateness of information (Chaboyer et al.,0) and strategically utilising body language (Bangerterl., 2011).

By undertaking handovers on behalf of bedside nursesing patient transfers, nurse coordinators consolidatedir control of the ward, the patients and the staff.

munication inefficiencies occurred due to the lack ofdication information exchange between bedsideses. On reflection, bedside nurses contested theinant convention of the nurse coordinators’ handover.

power struggle moved nurses beyond the traditionalordinate role of passively following organisationalctices.Using a critical ethnographic approach, nurses’ move-nts within ward spaces and the ways in which thesevements affected handover processes and patient–se relations were examined. At the same time, reflexivelysis enabled critical understandings of how thesevements could be challenged. Video-recording allowedanalysis of verbal interactions and non-verbal cues suchhysical position, eye contact and body gestures. Mostortantly, video-recording enabled participants to

ect on ritualistic events, contribute to critical analysis

of social relations and practices, and uncover dominantand submissive forms of communication.

The study has some limitations. In an attempt toexplore the complexity of power relations during nursinghandovers, nurses were invited from different levels of thestructural hierarchy to participate in the study. As a result,nurses who were less confident in their communicationskills might have been unintentionally excluded fromparticipating in the video-recording. However, we noticedthat some nurses who agreed to participate were initiallyhesitant and lacking in confidence because this was a newexperience for them. They soon accepted the process andbecame unconcerned about being observed. Therefore, wewere convinced that nurses’ practices had not beenaffected by the observation process.

The first author’s subjectivity during the video-record-ing is worth mentioning. While nurses discussed sensitiveinformation away from the patient’s bedside, they did nothide this information from the author and her camera lens,which can be attributed to the author’s subject positions ofbeing a nurse and a researcher. As a nurse, she wasexpected to share clinical and social understandings withthe participants. As a researcher, she was expected by theparticipants to critically explore handover practices withher camera. The first author’s insider position enabled herto maintain closeness to the field and the participants.However, this insider position also created pragmaticissues. On many occasions, the first author found herselffluctuating between the nursing role and the observer roleduring fieldwork. When the wards were busy, the firstauthor sometimes felt compelled to act as a nurse byoffering to help. The first author dealt with this issue byassisting occasionally with aspects of nursing care thatwere not related to the research such as retrieving bedlinens for nurses and making tea or coffee for patients.Therefore, we were confident that our reporting of findingswas not affected by the first author’s activities.

6. Conclusion

This study has highlighted contextual influences ofward environments on medication communication duringnursing handovers. Because nurses spend most of theirtime at the patient bedside, they should have a profoundinfluence on patient care and decision-making. Nursecoordinators need to relinquish organisational control ofthe handover practice and appreciate the contribution ofbedside nurses to patient information exchange, in thegroup handover and following patient transfers acrossdifferent wards. Bedside nurses need to be provided withopportunities to raise questions during the group hand-over. The duration of group handovers need to bestructured to ensure sufficient time for nurses to performdouble-checking medication charts and to involve patientsin information exchange during bedside handovers.

This study demonstrated the effects of space limitationson communication processes. Nurses need to be providedwith designated meeting spaces to reduce interruptions tothe group handover process. Nurse coordinators need togive clinical and moral support to bedside nurses who areallocated to work in isolated clinical areas. Nurses can also

W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941–952952

support each other in having a profound influence onpatient care and decision-making by addressing commu-nication difficulties and organisational constraints affect-ing their handover practice. In addition, hospital architectsneed to consider the potential difficulties confronted bybedside nurses in their daily work, incorporating nurses’voices into future hospital design.

Acknowledgements

This paper is based on a study that was funded by anAustralian Research Council Discovery Grant [grantnumber DP0879002]. The authors would like to thankthe nurses and patients who volunteered their time toparticipate in this study. The authors’ thanks also go to theanonymous reviewers who helped to strengthen thispaper.

Contributions

W. Liu took a total responsibility of works, related tothis study, such as data collection/analysis and drafting ofthe manuscript, besides getting herself involved with E.Manias and M. Gerdtz to do study design, data interpreta-tion, critical revisions of manuscript and final decision tosubmit for publication.

Conflict of interest

None declared.

Funding

This PhD research project has been sponsored by anAustralian Research Council Discovery Grant from 2009 to2012.

Ethical approval

Ethical approval was given by the Mental HealthResearch and Ethics Committee of Melbourne Health,Australia (Project No. 2009.639).

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