Between standardisation and resilience: Nurses' emergent risk management strategies during handovers

Aims and objectives: In this study, we aimed to understand how nurses manage handovers at shift change and to identify the working strategies they employ to maintain patients' safety. Background: Nursing handovers at shift change are potentially hazardous for patients' quality of care. The nurses on the outgoing and incoming shifts need accurate understanding of the patient's current state, under circumstances that are frequently turbulent and time constrained. Design: Qualitative study. Method: Eighteen nurses working in a central Israeli hospital participated in the study. Data were collected through in-depth semi-structured interviews, conducted over a 10-month period in 2011-2012. The interviews were tape-recorded and transcribed verbatim. Content analysis method was used. Results: We revealed three interrelated themes: (1) Adaptation of declared handover goals to goals, which better fit the day-to-day routine of the ward; (2) Contextual turbulent circumstances, and (3) Strategies to optimise care for patients. Nurses on the outgoing shift developed organising strategies, ensuring efficient transmission of all important information; nurses on the incoming shift used cross-checking strategies to verify the accuracy of the received information. Conclusion: A nursing handover is both vulnerable and resilient, given its imposed constraints. The handover should be restructured, assuring resilience in patients' care while also limiting the risk for vulnerability. Relevance to clinical practice: Handover should be restructured so that it creates opportunities to cross-check the information against as many sources of information as possible. During handover, special time should be devoted to reading written reports and notes, preferably when the outgoing nurses are still on the ward or are accessible via e-mail or telephone. Team discussions should focus on achieving agreement about the order and manner of delivering concise information and facilitating shared understanding and trust among nurses.