International Journal of Nursing Studies 49 (2012) 941952

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International Journal of Nursing Studies

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Medication communication between nurses and patients during nursing

handovers on medical wards: A critical ethnographic study
Wei Liu a,*, Elizabeth Manias b, Marie Gerdtz c
a
Department of Nursing, Melbourne School of Health Sciences, The University of Melbourne, Level 2, Walter Boas Building, Parkville 3010, Australia
b
Department of Nursing, Melbourne School of Health Sciences, The University of Melbourne, Australia
c
Department of Nursing, Melbourne School of Health Sciences, The University of Melbourne, Emergency Medicine, Royal Melbourne Hospital, Australia

A R T I C L E I N F O A B S T R A C T

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

Received 20 August 2011 routine communication forum where nurses provide details about how patients
Received in revised form 24 January 2012 medications are managed. Previous studies have investigated handover processes as
Accepted 6 February 2012 general communication forums without specic focus on medication information
exchange. The effects of social, environmental and organisational contexts on handover
Keywords: communication and medication safety have not been explored.
Critical ethnography Objectives: To examine dominant and submissive forms of communication and power
Handover
relations surrounding medication communication among nurses, and between nurses and
Medication communication
patients during handover.
Video-recording
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, eld interviews, video-recordings and video reexive
focus groups were conducted. Faircloughs 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).

0020-7489/$ see front matter 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2012.02.008
942 W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941952
What is already known about the topic?
 Existing handover literature focuses on nurses commu-
nication about general clinical issues, which highlights
the complexities of handover processes.
 The interconnectedness of social, environmental and
organisational contexts that impact on handover com-
munication and medication safety has not been
explored.
What this paper adds
 Nursing handovers in private spaces prioritise organisa-
tional and biomedical discourses, with a lack of nursing
perspectives on care.
 Nursing handovers involving patients in public spaces at
the bedside facilitate a partnership model in medication
communication.
 The use of video-recording provides new insights into
the complexities of nursing handover practices.
1. Introduction
Handover is a routine forum of nursing communication
at change of shifts, when nurses take breaks and following
patient transfers across ward spaces. This forum aims to
ensure the continuity of patient care by communicating
relevant information between nurses (Manias and Street,
2000). Handovers can be used by nurses to provide
information about medication changes and on how these
changes relate to patient assessment parameters (Manias
et al., 2005). Subsequently, ambiguities and incomplete
communication during handovers can increase the risks of
adverse events. Ambiguities at handover included a lack of
information exchange about essential components of
patient care, such as initial diagnosis, ongoing treatment
and 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 patient
care are transferred from one nurse to another (Wiltshire
and Parker, 1996, p. 29). Strange (1996) highlighted the
protective function of the handover process, arguing that
nurses can maintain a feeling of control by knowing that
patients have received prescribed medications for their
medical conditions. The importance of cross-checking
medication charts between oncoming and offgoing nurses
during handovers has also been featured in the literature
(McMurray et al., 2010; Welsh et al., 2010). During
handovers, offgoing nurses are required to make inter-
pretations of medication charts, observational charts and
other documents in different spaces, including bedside and
ofce areas (Hagler and Brem, 2008). Chaboyer et al. (2010)
highlight the importance of performing a safety scan of
information relating to the patient, environment and
documents during bedside handovers (p. 140). However,
reinterpretations of this information in a different time and
space can contribute to miscommunication.
Beyond its use as a mode of transferring patient
information, the handover is a complex social space
where nurses can draw on collegial relationships and
establish disciplinary cohesiveness (Strange, 1996, p. 110).
Studies on the complexities of handover processes have
focused on the effects of spatial environments and power
relations (Manias and Street, 2000), nurses institutional
storytelling during handovers (Bangerter et al., 2011), and
nurses efforts to reach agreement about patient care
during handovers (Hagler and Brem, 2008). Although these
studies have identied nursing handover as a complex
phenomenon involving social and power struggles, there
are a number of limitations.
Previous studies have mainly addressed handover as a
general communication forum without considering the
handover content and structure (Matic et al., 2011).
Investigators have paid little attention to medication
information exchange during handover processes, parti-
cularly the potential link between communication pro-
blems and medication safety. In addition, past
investigators have tended to focus on nurses experiences
and perceptions of handovers (Street et al., 2011). Patients
involvement in nursing handovers remains under-
researched, and there is a lack of understanding about
the 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 contexts
that impact on communication between nurses and
patients during handovers, although Manias and Streets
(2000) critical ethnography illuminates the effects of
spatial environments on handover processes. For instance,
nursing handover occurs in different spaces moving
between the bedside and a site away from the bedside.
While nurses have the ability to control handover
locations, patients are conned to their designated
hospital bed with little control of space and mobility. This
lack of spatial control might reect and contribute to
patients limited opportunities for information exchange
with nurses. Clearly, the spatial aspect of handover
practices and how power is exercised within that space
requires further empirical research.
In this paper we aim to examine dominant and
submissive forms of communication and power relations
surrounding medication communication during nursing
handovers. We dene medication communication as
information exchange about treatment regimens among
nurses, and between nurses and patients. Specically, we
will explore: who gives and who receives the handover,
what discourses are embodied in medication communica-
tion during handover, who regulates spatial movements
during handover, and how language discourses impact on
clinical practices and social relations.
3. Methods
3.1. Methodological framework
Critical ethnography was the methodological frame-
work selected for this study. This framework involves an
examination of how unnecessary repression and social
 W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941952
inequalities affect peoples activities and behaviors (Ham-
mersley, 1992). Critical ethnography takes mundane
events into consideration and reproduces them in a way
that exposes social processes of power imbalances
(Thomas, 1993). This framework was selected because it
encouraged participants to think about their practices in
different ways and challenged how handover practices
were conducted.
Critical ethnography encourages participants and
researchers to engage in collaborative research through
the process of reexivity (Thomas, 1993). Accordingly,
participants were encouraged to draw upon the research
data to reect on their own practices and challenge
unequal power relations. The rst author of this paper, also
the research data collector, reected on how she affected
the eld and how the eld affected her subjectivity during
the research process.
3.2. Research sites and participants
This study examined how nurses communicated with
each other during the handover process. However,
patients involvement in this process and its inuence
on medication safety was a focal point. This study was
undertaken in two medical wards (the General Medical
Ward and the Medical Assessment Ward) of a metropolitan
teaching hospital in Melbourne, Australia. The General
Medical Ward delivered care to patients with complex
medical issues. The Medical Assessment Ward provided
short-term care to patients who were to be discharged
home or admitted to other wards within 48 hours. The two
medical wards were selected to encompass diverse
practices and maximise transferability of the ndings.
All registered nurses who worked on the wards during
the study period (from January to November 2010) were
eligible for participation. Patients were eligible if they were
able to communicate competently with nurses about
medication management. Patients were required to speak
English, to be medically stable and cognitively competent,
and to be on at least one medication.
In-service meetings were organised with nursing staff
in each ward to introduce the study and to invite nurses to
participate. Information sheets and consent forms were
distributed at the end of each meeting. After obtaining
consent from nursing staff, the rst author approached
patients who were allocated to the nurse under observa-
tion and provided them with information about the study
at the bedside. Written consent was obtained from 76
nurses and 27 patients. All participants were informed that
their identity would not be disclosed in any way in outputs
arising from the study. Verbal consent was obtained from
all other individuals who interacted with the targeted
nurses and patients at the time of observation. The study
was approved by the hospital and university ethics
committees.
Nursing participants were employed in the wards as
nurse unit managers (NUMs), nurse coordinators, clinical
nurse specialists (CNSs) and staff nurses. NUMs were
responsible for the overall management of the wards.
Sometimes, they worked as nurse coordinators, coordinat-
ing patient ow and overseeing clinical practices for the
943
shift. CNSs were given a patient load and regarded as
experts in the eld of general medicine. Staff nurses were
mainly involved in direct delivery of patient care at the
bedside.
3.3. Data collection
Data collection methods included participant observa-
tions, eld interviews, video-recordings and video reex-
ive focus groups (Table 1). In total, our eldwork
comprised 290 hours of participant observations, 72 eld
interviews, 34 hours of video-recordings and 5 reexive
focus groups. The rst author, also an emergency depart-
ment (ED) nurse working in the study hospital, collected
the research data.
3.4. Data analysis
Data analysis began with verbatim transcription of all
audio- and video-recordings by the rst author. The
transcribing process increased the authors familiarity
with the data through writing down details of audible
sounds and ambiguous conversations (Hutchby and
Wooftt, 1998). All authors independently interpreted
the audio and video recordings with their understandings
of the meanings conveyed. Audio, video and written data
were imported to NVivo version 8 (QSR International).
Coding was used to identify communication discourses,
and to mark the relations between discourse and power, as
well as their articulation through organisational struc-
tures. Faircloughs (1992) three-level critical discourse
analytic framework was used to examine events and
activities that happened during handovers (Table 2).
3.5. Rigor
Four methods were used to ensure rigor of the ndings:
prolonged engagement, triangulation, thick description
and member checking (Polit and Beck, 2006). Details of
these four methods are provided in Table 3.
4. Results
Handover data were collected when nurses attended
the change of shift handover and following patient
transfers across different wards. On both wards, the shift
handover involved a two-stage process. Firstly, it began
with a group report in a closed room, which was the
private space for the handover. Secondly, a detailed
individual handover between offgoing and oncoming
nurses was delivered at the bedside, in the corridor or at
the staff station, which were the public spaces for the
handover.
In the General Medical Ward, the private room was
designed for general meeting purposes. The room was only
accessible to permanent staff members with a swipe card.
Hence, interruptions to group handovers were minimal
due to the access constraint to the room. Staff participating
in the handover included all oncoming nurses and the
offgoing nurse coordinator, who briey reported on each
patient, including changes to patients current medication
944 W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941952

Table 1
Details of data collection methods.

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

Participant To gain a general
observations understanding of
nurses medication participant
communication
patterns on the wards.
Nurses and patients
who consented to
21:00 hours by following each
observations
The rst author conducted 130 hours of observations in
observations between 07:00 and the GMW;
nurse participant for a period of
23 hours.
Activities and conversations 160 hours of observations in
relating to medication the MAW;
management between the nurse
and other nurses or patients
were documented.
Conversations between the 76 nurses and 27 patients
nurse and the rst author during involved in participant
the observation period were observations
documented.
All observations and
conversations were documented
in the form of eld notes.

Field interviews To obtain nursing
participants to eld interviews
perspective on
communication events
that happened during
observations.
Nurses who consented
structured interviews in the eld
The rst author carried out semi- 32 interviews in the GMW;
after individual observations.
Nurse participants were asked to 40 interviews in the MAW;
comment on medication
activities that happened during
the observations, and to obtain
greater clarity of events and
activities.
All interviews were audio- Interviews lasting between
recorded. 10 to 30 minutes;
67 nurses involved in eld
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 rst author operated a hand-
held video camera and lmed
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 reexive To offer participants Nurses who consented
focus groups feedback about the
research data and
encourage them to
reect on handover
practices.
The rst author edited the raw 2 focus groups in the GMW;
to video-reexivity video data and produced a
reexive DVD representing the
recurrent patterns and emergent
themes of handover practices.
The rst author conducted focus 3 focus groups in the MAW;
groups in the staff room on each
ward by presenting the reexive
DVD and facilitating group
discussions. One of the other
authors acted as a facilitator.
Participants were asked to 1520 nurses involved in
comment on communication each focus group;
issues during handover
practices.
All focus groups were video- Focus groups lasting between
recorded by placing the camera 60 and 90 minutes
on a stationary tripod with its
lens focused on the rst author.

regimens or special treatments, such as iron transfusions
and intravenous (IV) antibiotics.
In the Medical Assessment Ward, the private room was
designed for many purposes such as staff breaks and
education. This room was closed temporarily during each
handover time. However, a closed door did not necessarily
impose a spatial restriction on staff members. Handovers
in the private room were often interrupted by non-
attendees, trying to access the room for different reasons
such as room cleaning and meal breaks.
4.1. Nurse coordinators handover: constructing the order
The nurse coordinators group handover occurred at the
beginning and the end of each shift. Ten to fteen minutes
were allotted for the group handover, although it took
 W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941952 945

Table 2
Data analysis guide developed from Faircloughs three-level analytic framework.

Level of analysis Focus of analysis Questions guiding analysis

Level 1 The structure and content of the text What were participants saying? What was body language used?
were examined in its local domain Who was speaking? Who was silent?
To what extent were competing interests of nurses, patients and the
organisation addressed?

Level 2 The strategic use of the text was What social relations were relevant to the construction of the conversation?
explored in its organisational domain 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?

Level 3 The discursive practice in the text was What were the clinical consequences of the communication practice?
evaluated in its societal domain 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?
Adapted from Fairclough (1992).

longer when the ward was busy. The group handover was Bed 10, Mr. [name patient] is a bit overloaded [with
intended to provide an overview of all patients on the ward uids]. Hes had some stat [orders given immediately]
to oncoming nurses. Indeed, it was structured as a one-way frusemide [a diuretic] and a regular oral dose. The
delivery of information from the offgoing to the oncoming registrar pointed out to me his uid balance chart
nurse coordinator. It also provided a channel for the nurse wasnt lled in yesterday. So we want a strict [in a
coordinator to relate medication information to oncoming raised tone] in and out uid balance [pause], trying to
nurses. Medical-technical jargon and abbreviations domi- manage his APO [acute pulmonary edema] and they
nated the handover. The following is an excerpt by the [indicating doctors] havent got the information they
offgoing nurse coordinator in the General Medical Ward need, so just be careful with that [scanned all nurses].
from a video-recorded handover: The patient is also unhappy because he is a private
patient. He said he was promised all the benets of a
private patient here. But actually we have no resources
[all laugh] . . . Last night he had his alprazolam [an anti-
Table 3
anxiety medication] after CPAP [a ventilation therapy to
Description of methods to ensure rigor. provide continuous positive airway pressure for
patients with breathing difculty] went on. He wants
Type of method Description of method
his alprazolam and CPAP on at 9 pm because he has
Prolonged Prolonged engagement involved the alprazolam to help him cope with CPAP [looking at the
engagement rst authors frequent visits to the eld
oncoming nurse coordinator]. Can we make sure that
and persistent observations of
communication activities on the wards.
happens? They [indicating doctors] need to start to plan
for discharge. (Nurse coordinator)
Triangulation Method triangulation involved the use
(method, space of multiple sources of data from In this group handover, the nurse coordinators sat next
and time participant observations, eld to each other at one side of a rectangular table. All
triangulation) interviews, video-recordings and
oncoming nurses sat across the other side of the table, or
reexive focus groups.
Space triangulation involved the behind the nurse coordinators (Fig. 1). Although the
collection of data in two different care handover was designed as a communication forum, most
settings.
Time triangulation involved the
observations of communication
activities at different time blocks on the
shift.

Thick description Thick description was available in the

form of eld notes, audio-recordings,
video-recordings and transcripts,
together with the rst authors
subjective journal for personal
reection.

Member checking Participants were allowed to review the

raw video data in the eld if they
wished to do so.
Participants were involved in video
reexive focus groups by reviewing and
challenging their own practices.
Fig. 1. Nurse coordinators handover in the private room.
946 W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941952
nurses listened quietly and jotted down pertinent infor-
mation on the handover sheet. Little direct eye contact was
made 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 eye
scanning across the nurses, which met with a discerning
look of the oncoming nurse coordinator. The offgoing nurse
coordinator toned down a medical complaint about the
incomplete uid balance chart to a discrete warning (just
be careful with that). Nevertheless, the nurse coordinators
specic identication of the complaint from the registrar
might be interpreted as a form of hidden power. The nurse
coordinators focus of communication was moral, concerned
with the patients physical condition and individual needs,
organisational, concerned with institutional resources and
the patients social dimensions, and interpersonal, con-
cerned with nurses feelings. In doing so, the nurse
coordinator carefully positioned herself within discourses
of nursing professionalism and interdisciplinary relation-
ship. The nurse coordinator worked as a messenger between
doctors and nurses, representing the structured order and
organisation of patient care. The nurse coordinator changed
subjects from we to they, reinforcing the professional
division between nursing and medicine.
The discourse of patient autonomy was raised in the
nurse coordinators handover. It appeared that the patient
articulated his medication needs to his allocated nurse. He
was promised that his social identity as a private patient
would be maintained in a public hospital. He expected that
he could choose his own medication timing and the nurses
should respect his decision. The social discourse of patient
autonomy was in tension with the nursing discourse of
structured order in relation to administering medications at
prescribed times. The nurses laughter following the nurse
coordinators rearticulation about the patients individual
needs might be read as a sarcastic message. The patient
struggled with traditionally accepted norms in public
hospitals where patients routines were moulded by nurses
shift schedules. The competing discourses of patient
autonomy and disciplinary norms had undesirable effects
upon patient treatment and nursepatient relationships.
The organisational discourse of efciency dominated
the nurse coordinators handover. While certain treatment
such as a single dose of frusemide was briey presented,
there was no information conveyed about the effectiveness
of medication treatment. It was obvious that this
information did not serve the nurse coordinators interest
in increasing work efciency on the ward. The purpose of
the nurse coordinators handover might be more than a
forum for exercising organisational control. When a
medical complaint by the registrar was down-played,
nurses felt a sense of support and cohesion from the
management. Although nurses were mostly silent during
the handover, their open laughter demonstrated shared
emotions and dominant values of the group.
4.2. Staff allocation: hierarchical nursing power
Nurse coordinators control of a structured order was
further strengthened through the allocation process. On
both wards, staff allocation was conducted by nurse
coordinators after the group handover, so oncoming nurses
did not know which patients they would care for before
receiving handovers. A nurse coordinator commented
about how nurses worked with each other throughout the
shift, which was recorded in the eld notes:
We bracketed two nurses names together on the
allocation, and thats got the tea [time] on it. Thats the
person you go to if you want a check [for medications]
or leave for tea. She has patients right next door to your
patients. (Nurse coordinator)
The nurse coordinator alluded to a discourse of nursing
convention. It was an accepted norm that nurses had a
professional obligation of care not only for patients, but for
other colleagues. A good example was that nurses often
handed over patients ongoing intravenous therapy to their
colleagues before going for tea breaks. Although individual
nurses might only be seen moving between their allocated
patients, they often overheard other peoples conversa-
tions and were ready to help when the need arose. Within
the public ward space, nurses required each other to be
visible to call for a helpful hand, so that nurses constantly
felt being supported and looked after by each other.
The allocation process also demonstrated how nurse
coordinators used their knowledge of staff and space to
maintain clinical orders. Due to the way in which both
wards were laid out, it was unavoidable to allocate one
nurse on each shift to work in a corner area where the
nurse had to care for two patients in one corridor, and
another two patients in another corridor. The corner area
was out of the visual sight from the central staff station
where staff members were mostly congregated. The spatial
division created social isolation for both nurses and
patients. Nurse coordinators had to take the spatial factor
into consideration to control organisational orders, as
demonstrated in the following interview data with a nurse
coordinator:
The way our ward is shaped, you need to make sure
youve got senior staff at the corner because basically
the person there, I very rarely see unless I have
something specic to tell them . . . I usually put
someone who I know can cope and doesnt ask me
sort of junior questions like where they can get an
infusion pump. Its a very far place to walk. Yeah. I can
rely on the girl there. (Nurse coordinator)
The nurse coordinator developed certain familiarity with
the staff and space due to her seniority. This familiarity was
important for her to run the shift smoothly because she
wished not to be interrupted by too many junior
questions. In deciding who should work at the corner,
the nurse coordinator used her experiential knowledge of
the individual nurses skill levels, medical knowledge of the
patients and logistic knowledge of the ward space to
construct the organisational discourse of order.
The nurse working at the corner was prejudiced by the
position as a socially accepted reliable nurse. Nurse
coordinators clinical gaze was restricted by their own
working priorities and spatial congurations of the wards.
 W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941952 947

They achieved organisational order by assigning inexper- nurses were bestowed with temporal power to critique
ienced nurses to work at the central locations and offgoing nurses work to maintain safety.
supporting their professional development in the spatial Furthermore, bedside handovers provided clinical
proximity. spaces for patients to feedback effects of medication
treatment. The following video excerpt illustrated the
4.3. Bedside handover: being a discreet nurse exchange of medication information among the oncoming
nurse, the offgoing nurse and the patient during a bedside
After being allocated to a group of patients, oncoming handover:
nurses moved from the private room to the public ward
space. The location of undertaking bedside handover was
Offgoing nurse: Our lovely [name patient] is here.
haphazard. It happened either at the bedside or outside
patient rooms in the corridor. Sometimes, nurses sat in the Patient: Uh, did I hear that right?
central station while giving individual reports. The Offgoing nurse: Yeah. We are talking about you
decision about where the individual handover should [laugh].
occur was jointly made by offgoing and oncoming nurses Patient: Uh, isnt that nice [all laughs]?
and based on the severity of patient condition.
Offgoing nurse: Your leg swelling is going down
Although it was not an ofcial hospital policy, double-
with the tablets [indicating
checking medication charts between offgoing and oncom-
frusemide] we give to you,
ing nurses during bedside handovers was required by the
isnt it?
ward management to prevent medication errors. During
observations, nurses showed low adherence to this ward Patient: Yes, a little bit better everyday.
standard at the bedside because the group report some- I went to the toilet twice
times took too long to nish in the room. Double-checking this morning.
medication charts at the bedside was opportunistic Oncoming nurse: She is 89% [oxygen saturation]
depending on the individual nurses and adequacy of time. on room air [looking at the
In a video-reexive focus group in the Medical Assessment observational charts]. How many
Ward, nurses emphatically talked about the importance of liters [of oxygen] shes on now
double-checking medication charts after viewing video [turning to the offgoing nurse]?
clips of nurses calling each other at home after work to Patient: Not if I sit up like this. I need it
clarify medication orders: when I go to bed. If I lie down,
I am out of it [breath].
Staff nurse 1: I know we are meant to check charts,
Oncoming nurse: Do you still have the dressing
which I am sorry, it doesnt always
on your legs? Its for the blisters,
happen because we dont have time.
is it?
The group handover is too long.
Patient: Yeah, the skin breaks down
CNS: Yeah. Double-checking is important.
because of the uid. Its not
What could be a better way being
diabetic ulcers.
held accountable by our peers than
our boss? Offgoing nurse: She has nausea today, a lot of
nausea, no vomiting. I gave her
Staff nurse 2: You could have your charts in front of
metoclopramide [an anti-emetic],
you while checking the patients
and I gave her a wafer of
condition . . . Also we can make sure
ondansteron [an anti-emetic],
all medication charts are given
a stat dose, because I couldnt
and signed.
give her another metoclopramide.
Nurses identied time as a salient and dominant [Oncoming nurse: Yeah] Its [the
discourse creating clinical tensions. Time was constructed metoclopramide order] on PRN
by social and professional hierarchy. Although nurse [orders given as required].
coordinators were confronted with time pressures to meet Oncoming nurse: Do you still feel sick?
organisational demands, they were afforded more ex-
Patient: No. But I just dont want to eat.
ibility and authority to regulate their handover time in the
room compared with bedside nurses, who on the other Offgoing nurse: Yeah, she is not eating much.
hand, had to complete handovers in a less regulated space She said she is feeling dizzy.
at the bedside. She is not eating, drinking much,
Nurses were vigilant of their medication practices. They thats why she is feeling dizzy.
were proactive in preventing incidents by willingly So just try to encourage her
accepting their colleagues examination, but not the to drink more because she doesnt
institutional surveillance from the nurse coordinators want to eat because of the nausea.
and managers. During bedside handovers, offgoing nurses If she has pain, encourage her to
relied on oncoming nurses to check patients medication use oxycodone [an opioid analgesic].
charts and medication administration rates. Oncoming Thats [the oxycodone order] on PRN.
948 W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941952

what the patient needed in the forthcoming shift. Through

extended contact with the patient throughout the shift, the
offgoing nurse had developed an understanding of the
patients treatment regimen.
A striking feature of bedside handovers was nurses
frequent movement between various spaces including the
bedside, outside patient rooms, corridors and staff stations.
Before approaching a patient at the bedside, offgoing nurses
frequently asked oncoming nurses in the corridor do you
know this patient? Previous knowledge of the patient
meant better understanding of the medical history and
treatment regimen. If oncoming nurses indicated that they
knew the patient from the previous shift, the handover
moved to the bedside immediately. It was important for
Fig. 2. Bedside handover.
nurses to have some basic information about the patient
before approaching the bedside space where professional
This extract demonstrated a three-way communication knowledge was contested by the patients own under-
during the bedside handover. The offgoing nurse invited standing of illness.
the patient into the conversation with an interpersonal Nurses were mindful about the issue of condentiality
greeting, which was responded warmly by both the patient associated with bedside handovers. Curtains were drawn
and oncoming nurse. In doing so, the offgoing nurse when private information was discussed in a shared
conveyed her subjective knowledge of the patients bedroom. Nurses often moved from the bedside if the
condition. Throughout the handover, the patient had been content of handovers was sensitive. The power exercised
sitting upright in a chair with a table in front of her. Both by nurses during bedside handovers took the form of a
nurses sat at the side of the bed, which reduced their tyranny of discretion. Nurses were very discrete about
physical distance with the patient (Fig. 2). The nurses what they said in front of patients, as indicated from the
tentative positioning at the bedside allowed them to following video excerpt:
maintain direct eye contact with the patient.
[Bedside]
The offgoing nurse presented her evaluation of the
effectiveness of frusemide with a two-part sentence a Offgoing nurse: She [indicating the patient] just
positive statement of the treatment effect and a negative came back from dialysis. She
question to involve the patient into the conversation. The is on heparin [an anti-coagulant]
patient responded with a positive answer and reinforced it infusion. Her APTT [activated partial
with a description of her body response to frusemide. Seeing thromboplastin time, an indicator
the observational charts and the patient together at the used to monitor the effects with
bedside, the oncoming nurse sought out further information heparin treatment] was 50
from the offgoing nurse about the patients oxygen [seconds] yesterday. So she
treatment. The patient addressed the oncoming nurses is on 50mls [infusion rate]
inquiry by articulating her need for oxygen at the particular per hour now.
time of the day. Then, the oncoming nurse raised a question [Moving from the bedside]
about the patients wound condition. The patient demon- [Offgoing nurse gave the oncoming nurse a sideway
strated her knowledge by differentiating the uid retention glance and both walked out of the room]
caused skin breakdown from diabetic ulcers.
[Corridor]
The offgoing nurse repeatedly used her clinical assess-
ment knowledge (nausea, a lot of nausea, doesnt want Oncoming nurse: Secret [whispers]?
to eat because of the nausea) to validate her decisions to use [Moving to the staff station]
a PRN medication and take further action for a stat order. The Oncoming nurse: There was confusion in the
offgoing nurse also made references to her own body when morning that we were told to
describing the patients feeling of nausea, by pointing to her stop the infusion.
stomach and demonstrating a dry retching gesture. Her
Oncoming nurse: The doctor said or?
frequent reference to the patients symptoms led to the
jointly-held account of the patients medication needs, with Offgoing nurse: Its [name doctor]. When we had
the oncoming nurse who subsequently raised a question to handover, [name nurse coordinator]
evaluate the treatment effect. said you can never stop the
The patient responded to the oncoming nurses question heparin infusion. This is a huge
with an incomplete answer (no, but . . .), and the offgoing Riskman [an on-line electronic
nurse changed to another topic about the patients pain incident report system]. So we
management. The offgoing nurse recommended specic called [name doctor] and he
medication interventions by encouraging the patient to use came down. He charted again
PRN oxycodone for pain by the oncoming nurse. It is possible and now its running again.
that the offgoing nurse might have been trying to preempt
 W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941952
This excerpt illustrated dynamic spatial movement that
occurred during the bedside handover. The offgoing nurse
presented clinical objects about the patients dialysis
treatment, heparin infusion and pathology results at the
bedside. Seeing the patient at the bedside offered the
oncoming nurse with opportunities not only to accumulate
objective data relevant to the patients conditions after the
dialysis, but also to develop interpersonal connections
with the patient. The offgoing nurses non-verbal cues and
body gestures were captured as a fascinating moment
where initiation of subtle movement occurred. This non-
verbal gesture was picked up immediately by her
colleague, indicating nurses routine use of versatile means
of communication. With an eye glance and a smooth body
movement, the bedside handover was repositioned to a
public corridor where a secret whisper followed (Fig. 3).
It was obvious that the purpose of space shifting was
due to the confusion about the heparin infusion. The
offgoing nurse considered this medication information as
inappropriate to be shared with the patient. There was a
sense that the doctor made a clinical decision that could
have led to a huge medication incident report. The nurse
coordinator stopped the reporting chain and maintained
clinical order by calling the doctor back to the ward to
rewrite the chart. During the handover in the staff station,
the offgoing nurse indicated the nurse coordinators
exercise of experiential knowledge and authoritative
power by asking the doctor to correct the medication
order. However, it appeared that the nurse coordinators
professional boundary was blurred at one level for not
reporting the incident when it had already happened at
that time. The power exercised by the nurse coordinator, in
her positioning to control the order, could have had
signicant effects upon patient safety and institutional
policies such as medication incident reporting.
There was little spatial control by patients during
bedside handovers. Patients were conned to their
hospital beds while nurses moving between spaces during
handover processes. In reecting on nurses exercise of
control over spaces, a nurse stated that We talk about
issues in the station when we want to brainstorm each
other. We go to bedside when we need to. We have never
asked what patients want. Nurses not only regulated the
Fig. 3. An offgoing nurse used a hand gesture indicating a spatial
movement.
949
interactions, but also shaped the spatial orientation during
handover processes.
4.4. Handover across ward spaces: disjunctions of medication
communication
On both wards, it was nurse coordinators responsibility to
give and receive a handover to or from another ward (Fig. 4).
Both wards frequently admitted patients from the ED through
telephone communication. The information was relayed to
bedside nurses from nurse coordinators afterwards.
The NUM of the Medical Assessment Ward explained
the importance of controlling handovers by recalling an
event that occurred on her shift when she took the nurse
coordinators role, The ED rang through to the back
[station] where a graduate [nurse] took the handover. Half
of the information was missed. The patient came up with
an ED drug chart. In this context, a new graduate nurse
unintentionally received a handover from another ward.
Normally this type of handover was undertaken by nurse
coordinators, who did not accept patients into ward care
until all aspects of verbal handover and documentation
were completed by ED nurses. An important part of
documentation required in the handover was inpatient
medication charts. Different from medication charts used
in the ED, an inpatient medication chart had to be written
by admission doctors prior to patient transfers to the
wards. The ED nurses had to ensure the completeness of
this medical documentation. Nurse coordinators exercised
clinical examination of ED nurses for medication chart
omissions through the handover process.
Handover across wards through the telephone by nurse
coordinators was not without defects. The completeness of
an inpatient medication chart did not guarantee all
relevant information was communicated effectively.
Information was not exchanged between bedside nurses.
In the following interview excerpt, a graduate nurse was
perturbed by the medication information gap that
occurred during patient transfers:
I dont know why we are not allowed to take a
handover. It would be really good if we could talk to
them [ED nurses] . . . I had one [patient], she was from
Fig. 4. A nurse coordinator receiving handover from another ward.
950 W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941952
the rehabilitation centre, went to ED. It was a funny
time of the day. She hasnt had any oral meds. Its
cardiac, anti-hypertensive stuff. I was like, OK, what am
I going to do? I didnt receive the handover. So I rang up
the ED nurse and she assumed that the patient probably
had them all in the morning. But I cannot assume that.
Then they [nurses from the rehabilitation] said no, they
havent given anything because she had gone before
they started early meds. That took probably two hours
to sort out. (Staff nurse)
This example demonstrated communication break-
downs regarding medication information during patient
transfers across the hospital and ward spaces. The graduate
nurse questioned the organisational practice of nurse
coordinators receiving handovers from another ward. In
querying the particular time of the day when the patient
had not had her regular medications, the graduate nurse
did not accept the usual medication time schedule on the
medication chart. The graduate nurse contacted the ED
nurse, trying to clarify the information. When uncertainty
persisted, the graduate nurse sought out further to
investigate the situation. She was contingently positioned
in competing discourses of patient safety, organisational
practice and clinical efciency.
Because ward nurses had not communicated rst-hand
medication information with ED nurses, they gleaned
messages from progress notes and medication charts.
Information on progress notes amounted to little more
than the name of the stat dose medication and the time it
was administered in the ED. Evaluation of medication
treatment in written documents was strikingly minimal.
The telephone handover across wards during patient
transfers resulted in a disjunction in the ow of detailed
medication knowledge, shaping what nurses could know
in the conned ward spaces and affecting continuity of
patient management.
Medication communication during nursing handovers
was shaped by social relationships and organisational
structures. Nurse coordinators control over group hand-
over, staff allocation and handover across wards were
strengthened by the organisational discourse of order. By
challenging the nurse coordinators telephone handover
across wards, nurses opposed organisational dominance
and brought about possibilities for change through power
struggles.
5. Discussion
Nursing handovers on medical wards occurred in
different spatial locations, affecting communication pro-
cesses and social relationships in a number of ways. Nurse
coordinators handovers in private spaces strengthened
organisational control and nursing hierarchies. Bedside
nurses handovers involving patients in public spaces at
the bedside enhanced patient-centered medication com-
munication. Telephone handover following patient trans-
fers across different wards created communication
barriers between bedside nurses.
Nurse coordinators group handovers prioritised orga-
nisational discourses of order and efciency, with little
emphasis on evaluating effectiveness of medications.
Nurse coordinators drew heavily on medical discourses
in terms of diagnosis, procedures and investigations
(Payne et al., 2000). While the nurse coordinators hand-
over was shaped by the organisational structure, the
handover practice itself contributed to the constitution of
the organisational structure which shaped the practice.
There is a dialectic relationship between social structure
and social practice (Fairclough, 1992). In this situation, the
organisational structure was both a condition for, and an
effect of the nurse coordinators practice.
Nurses tended to perceive their role as undertaking and
recording patient assessment parameters, distancing
themselves from involvement in patient treatment deci-
sion-making. This role reects and reinforces traditional
power relations that privilege medical practices over
nursing practices (Bail et al., 2009) and subordinate
psychosocial aspects of patient care to biomedical
discourses (Lally, 1999). There was little evidence of the
nursing voice during group handovers to dispute structural
hierarchies and medical dominance.
Nurse coordinators handovers were conducted in a
private room, distant from busy clinical environments.
This private space enabled nurse coordinators to give an
impression of control to oncoming nurses who were
unable to view their patients (Manias and Street, 2000).
However, nurse coordinators work conducted behind a
closed door did not privilege nursing with higher status
in comparison to other work conducted on the open oor
(Spain, 1992, p. 206). The temporary private space
converted from a multi-functional room was vulnerable,
subjecting nurses to constant interruptions from domestic
staff and other health professionals. Nurses professional
status was not automatically improved when they entered
a private room. The same physical space was used
differently by people from different status and occupations
(Street, 1992). In this context, the multi-functional room
was used by nurses as a private meeting space. However,
for other staff members, the multi-functional room was a
communal space for meal breaks.
Paradoxically, interruptions or questions from nurses
participating in the group handovers were rare. Traditional
cultural routines marked out the relations and power
differentials between nurse coordinators and bedside
nurses, and the behaviors associated with each person
(Ainsworth and Hardy, 2004). In this situation, only nurse
coordinators were allowed to talk, whereas bedside nurses
were expected to listen. Bedside nurses social position of
being cooperative and accepting nurse coordinators
reports has been well documented (Manias and Street,
2000; Payne et al., 2000). Nurses in this study also took a
physical position of lower level to nurse coordinators by
sitting behind them during group handovers, perpetuating
the traditional nursing hierarchy.
Staff allocation took place after handovers according to
nurses skill levels and patients personal needs (Farnell
and Dawson, 2006). Nurse coordinators exercised their
hierarchical power by subordinating individual nurses
issue of spatial isolation at a corner space. Allocated into
the corner space on the wards, experienced nurses were
privileged with more control over their own work and less
 W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941952
surveillance from nurse coordinators at one level. Yet, from
a social perspective, experienced nurses individual knowl-
edge was subjugated to maintain the ward structural
order.
During beside handovers, nurses were positioned in
constant vie for time and patient safety. Nurses relayed an
acute awareness of error wisdom (Reason, 2004, p.28) by
relying on each other to double-check medication charts at
the change of shift. This nding differs from Manias and
Streets (2000) report on nurses expressions of fear and
anxiety during bedside handovers, supporting nurses
collegial solidarity in resistance to organisational power
and scrutiny. It appeared that nurses in this study
honoured the professional discourse of safety, even at
the cost of being scrutinised by their colleagues.
By involving patients at the bedside, nurses challenged
the traditional discourse of unidirectional information
delivery and emphasised patient-centred medication
communication. Bedside handovers provided patients
with opportunities to feedback the effect on treatment.
However, promoting patient-centred medication commu-
nication was not without challenges. Nurses were often
positioned in competing discourses of patient autonomy
and organisational efciency. Nevertheless, this study
showed evidence of patients involvement in medication
information exchange at the bedside, refuting previous
claim on patients lack of interest in bedside handover
participation (Chaboyer et al., 2010) and nurses dom-
inance in inhibiting patient involvement during bedside
handovers (Parker, 1996).
Although this study demonstrated patient involvement
at the bedside, it was notable that nurses controlled the
spatial movement during handovers. Nurses approached
the patients bedside space when they needed to speak
about patients. They moved away from this space when the
patients presence was considered inappropriate. The
tyranny of discretion that manifested during bedside
handovers was characterised by nurses discreetly asses-
sing the appropriateness of information (Chaboyer et al.,
2010) and strategically utilising body language (Bangerter
et al., 2011).
By undertaking handovers on behalf of bedside nurses
during patient transfers, nurse coordinators consolidated
their control of the ward, the patients and the staff.
Communication inefciencies occurred due to the lack of
medication information exchange between bedside
nurses. On reection, bedside nurses contested the
dominant convention of the nurse coordinators handover.
The power struggle moved nurses beyond the traditional
subordinate role of passively following organisational
practices.
Using a critical ethnographic approach, nurses move-
ments within ward spaces and the ways in which these
movements affected handover processes and patient
nurse relations were examined. At the same time, reexive
analysis enabled critical understandings of how these
movements could be challenged. Video-recording allowed
for analysis of verbal interactions and non-verbal cues such
as physical position, eye contact and body gestures. Most
importantly, video-recording enabled participants to
reect on ritualistic events, contribute to critical analysis
951
of social relations and practices, and uncover dominant
and submissive forms of communication.
The study has some limitations. In an attempt to
explore the complexity of power relations during nursing
handovers, nurses were invited from different levels of the
structural hierarchy to participate in the study. As a result,
nurses who were less condent in their communication
skills might have been unintentionally excluded from
participating in the video-recording. However, we noticed
that some nurses who agreed to participate were initially
hesitant and lacking in condence because this was a new
experience for them. They soon accepted the process and
became unconcerned about being observed. Therefore, we
were convinced that nurses practices had not been
affected by the observation process.
The rst authors subjectivity during the video-record-
ing is worth mentioning. While nurses discussed sensitive
information away from the patients bedside, they did not
hide this information from the author and her camera lens,
which can be attributed to the authors subject positions of
being a nurse and a researcher. As a nurse, she was
expected to share clinical and social understandings with
the participants. As a researcher, she was expected by the
participants to critically explore handover practices with
her camera. The rst authors insider position enabled her
to maintain closeness to the eld and the participants.
However, this insider position also created pragmatic
issues. On many occasions, the rst author found herself
uctuating between the nursing role and the observer role
during eldwork. When the wards were busy, the rst
author sometimes felt compelled to act as a nurse by
offering to help. The rst author dealt with this issue by
assisting occasionally with aspects of nursing care that
were not related to the research such as retrieving bed
linens for nurses and making tea or coffee for patients.
Therefore, we were condent that our reporting of ndings
was not affected by the rst authors activities.
6. Conclusion
This study has highlighted contextual inuences of
ward environments on medication communication during
nursing handovers. Because nurses spend most of their
time at the patient bedside, they should have a profound
inuence on patient care and decision-making. Nurse
coordinators need to relinquish organisational control of
the handover practice and appreciate the contribution of
bedside nurses to patient information exchange, in the
group handover and following patient transfers across
different wards. Bedside nurses need to be provided with
opportunities to raise questions during the group hand-
over. The duration of group handovers need to be
structured to ensure sufcient time for nurses to perform
double-checking medication charts and to involve patients
in information exchange during bedside handovers.
This study demonstrated the effects of space limitations
on communication processes. Nurses need to be provided
with designated meeting spaces to reduce interruptions to
the group handover process. Nurse coordinators need to
give clinical and moral support to bedside nurses who are
allocated to work in isolated clinical areas. Nurses can also
952 W. Liu et al. / International Journal of Nursing Studies 49 (2012) 941952
support each other in having a profound inuence on
patient care and decision-making by addressing commu-
nication difculties and organisational constraints affect-
ing their handover practice. In addition, hospital architects
need to consider the potential difculties confronted by
bedside nurses in their daily work, incorporating nurses
voices into future hospital design.
Acknowledgements
This paper is based on a study that was funded by an
Australian Research Council Discovery Grant [grant
number DP0879002]. The authors would like to thank
the nurses and patients who volunteered their time to
participate in this study. The authors thanks also go to the
anonymous reviewers who helped to strengthen this
paper.
Contributions
W. Liu took a total responsibility of works, related to
this study, such as data collection/analysis and drafting of
the manuscript, besides getting herself involved with E.
Manias and M. Gerdtz to do study design, data interpreta-
tion, critical revisions of manuscript and nal decision to
submit for publication.
Conict of interest
None declared.
Funding
This PhD research project has been sponsored by an
Australian Research Council Discovery Grant from 2009 to
2012.
Ethical approval
Ethical approval was given by the Mental Health
Research and Ethics Committee of Melbourne Health,
Australia (Project No. 2009.639).
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