Intensive and Critical Care Nursing (2016) 35, 28—37

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ORIGINAL ARTICLE

Cardio-thoracic surgical patients’

experience on bedside nursing handovers:
Findings from a qualitative study
Giulia Lupieri a,∗, Chiara Creatti b, Alvisa Palese a

a
School of Nursing, Department of Medical and Biological Sciences, Udine University, Italy
b
Cardiosurgery ICU, Azienda Ospedaliero-Universitaria ‘S. Maria della Misericordia’, Udine, Italy

Accepted 3 December 2015

KEYWORDS
Bedside handovers;
Cardio-thoracic unit;
Intensive care unit;
Patients experience;
Qualitative study
Summary The purpose of this study was to describe the experiences of postoperative cardio-
thoracic surgical patients experiencing nursing bedside handover. A descriptive qualitative
approach was undertaken. A purposeful sampling technique was adopted, including 14 patients
who went through cardio-thoracic surgery and witnessed at least two bedside handovers. The
study was performed in a Cardio-thoracic ICU localised in a Joint Commission International
accredited Academic Hospital in north-eastern Italy from August to November 2014. The expe-
rience of patients participating at the bedside handover is based on four main themes: (1)
‘discovering a new nursing identity’, (2) ‘being apparently engaged in a bedside handover’, (3)
‘experiencing the paradox of confidentiality’ and (4) ‘having the situation under control’. With
the handover performed at the bedside in a postoperative setting, two interconnected poten-
tial effects may be achieved with regard to patients, nurses and the nursing profession. Nurses
have a great opportunity to express their closeness to patients and to promote awareness of the
important growth that nursing has achieved over the years as a profession and discipline. There-
fore, patients may better perceive nursing competence and feel safer during the postoperative
care pathway. They can appreciate nurses’ humanity in caring and trust their competence and
professionalism.
© 2016 Elsevier Ltd. All rights reserved.

∗ Corresponding author. Tel.: +39 0432 590926.

E-mail address: alvisa.palese@uniud.it (G. Lupieri).

http://dx.doi.org/10.1016/j.iccn.2015.12.001
0964-3397/© 2016 Elsevier Ltd. All rights reserved.
Cardio-thoracic surgical patients’ experience on bedside nursing handovers 29

Implications for Clinical Practice

• Cardio-surgical patients appreciate bedside handovers, allowing them to be more informed about their postoperative
pathway, to feel safer and to be aware of nurses’ expertise in taking care of them.
• Participating in the bedside handovers allows cardio-thoracic surgical patients to check on transferred data and to
have the situation under control, which may, in turn, decrease stress.
• Confidentiality is not an issue for patients, but clinical nurses might continue using discretion when reporting sensitive
data.
• Bedside handovers should be rethought as a process, based on a framework that allows patients in critical condition to
be involved progressively, through different stages from informative to shared decision-making when their condition
and their willingness to actively participate in the process, is expressed.

Introduction delivery; it is traditionally carried out as a one-way con-

Change of shift reporting is peculiar to the health-care pro-
fessions. It differs from the common concept of shift work
because it does not simply entail staff turnover; it implies a
careful transmission of information concerning a patient’s
condition and care plan, through which the transfer of
responsibility to the oncoming nurse occurs (Bulfone et al.,
2012; Benaglio et al., 2006). Aiming to improve the effec-
tiveness of the handover, providing a nurse-to-nurse shift
report at the patient’s bedside is recommended (Chaboyer
et al., 2009). Bedside handover leads to a patient-centred
approach, allows the patient direct access to health infor-
mation and decision-making, promotes the nurse—patient
relationship, enables nurses to assess the patient’s condi-
tion and the environment while receiving the information,
and to prioritise nursing care and related workloads more
effectively (Anderson and Mangino, 2006).
Recently, increased attention has been documented with
regard to the perceptions of patients experiencing nurs-
ing bedside handovers at the hospital level (Jeffs et al.,
2014; Kerr et al., 2013a), in surgical and medical units
(Anderson and Mangino, 2006; Ford et al., 2014), in pae-
diatric settings (Friesen et al., 2013), stroke units (Laws
and Amato, 2010) and in emergency departments (Farhan
et al., 2012; Shendell-Falik et al., 2007). However, up to
date no data has been reported with regard to the per-
ceptions of postoperative cardio-thoracic surgical patients
who have specific clinical and psychological needs, such as
increased clinical instability and the occurrence of depres-
sive and anxiety symptoms (Szczepanska-Gieracha et al.,
2012) that may increase their vulnerability. Therefore, the
purpose of this study was to describe the experiences of
postoperative cardio-thoracic surgical patients experiencing
nursing bedside handover.
Background
The challenge for nursing staff is to provide an effective
shift-to-shift report, promoting the patient’s care process
and safety (Laws and Amato, 2010). An effective handover
should ensure a systematic approach and efficient commu-
nication concerning the patient’s problem(s), treatment(s)
and plan of care (Klim et al., 2013). Handover method
and setting may vary according to the unit model of care
versation among nurses away from the patient’s room, thus
preventing patients’ involvement. Inadequacies of the tradi-
tional handover have been widely documented: its content is
often inappropriate with a lack of patient-centred informa-
tion (Sexton et al., 2004) and structure (Klim et al., 2013);
it may be repetitive and time-consuming, due to interrup-
tions (Laws and Amato, 2010). As it implies interpreting data
without the presence of the patient, it is vulnerable to mis-
communication and loss of relevant information, resulting in
decreased patient safety (Lu et al., 2014; Riesenberg et al.,
2010).
In acute settings, major weaknesses in traditional han-
dovers have been recognised, including subjectivity, missed
information and lack of patients’ involvement (Kerr et al.,
2011). In medical/surgical units, information shared during
a traditional handover is often inaccurate and the setting in
which it is performed may be cluttered, often making nurses
perceive an overall sense of ‘something missing’ (Radtke,
2013). In addition, some questions cannot be answered once
the nurse from the previous shift has gone. All of the above-
mentioned issues can affect patient safety (Anderson and
Mangino, 2006).
Aiming to improve patient safety, the bedside nursing
report has recently been considered the gold standard, given
that it may (a) enhance patient participation, (b) strengthen
the nurse—patient relationship as well as nurse—caregiver
interaction and (c) increase the cohesiveness of the team
(Kerr et al., 2013; Radtke, 2013).
With bedside handover, patients feel they are not con-
sidered as bed numbers or a medical diagnosis (Lu et al.,
2014; Tobiano et al., 2012; Wakefield et al., 2012). Instead,
they perceive to be informed about the care plan on a
daily basis (Maxson et al., 2012) and to have the oppor-
tunity to verify the accuracy of the information shared by
nurses (Bradley and Mott, 2013; Chaboyer et al., 2009). A
patient may check and clarify information related to his/her
status, identifying and correcting any potential and actual
error (Jeffs et al., 2013). When family members are also
involved, bedside handover makes them feel safer and more
compliant in following treatment advices (Anderson and
Mangino, 2006); family members also feel more included and
confident, achieving a clear perspective on their relative’s
clinical condition (Tobiano et al., 2012).
Bedside handover also increases cooperation between
healthcare professionals (Anderson and Mangino, 2006).
30
Nurses are more informed about patients’ conditions (Kelly,
2005), so that the risk of inaccuracies can be minimised
(McMurray et al., 2010); they might succeed in better man-
aging their problems and delegating care activities to nurse
assistants. Moreover, the oncoming nurse is better able to
prioritise the shift work since all patients are met at the
beginning of the shift (Anderson and Mangino, 2006; Jeffs
et al., 2013; Sand-Jecklin and Sherman, 2013).
In addition, conducting the report in front of the patient
significantly decreases call light usage (Cairns et al., 2013),
as well as patient falls, and medication errors (Sand-Jecklin
and Sherman, 2013). As a result of bedside handover, the
standards of care and documentation may improve (Kerr
et al., 2014).
However, three main barriers have been reported with
regard to bedside handover implementation: the increased
time spent at the bedside, the risk to threaten confi-
dentiality and increased interruptions. Since a traditional
shift-to-shift report, managed in a nurses’ private room,
embodies both an occasion for distraction and profes-
sional socialisation, staff might be resistant to bedside
handover (Wakefield et al., 2012). Baker (2010) suggests
nurses’ bedside reports take from three to five minutes with
each patient and may reduce end-of-shift overtime. Cairns
et al. (2013) have reported that the total number of extra
minutes a nurse worked between the bedside report pre-
implementation and post-implementation phases decreased
10 minutes per day and 61 hours on an annual basis, resulting
in a reduction of 23% of the salary budget for the ward. Simi-
larly, Anderson and Mangino (2006) have reported a decrease
in nurse overtime due to bedside handover implementation.
The second barrier regards the privacy violation which
may occur when patients share a room with other patient(s)
(Radtke, 2013). In this case, speaking in a low voice
(Chaboyer et al., 2009) or establishing a post-report time
on an as-needed-basis to talk about sensitive issues away
from the patient’s bedside (Laws and Amato, 2010) are rec-
ommended.
The third barrier, which may also affect the handover
duration, regards the interruptions that may be determined
by nurses, other healthcare professionals such as physicians
and medical devices such as intravenous pumps alarms,
which may lead to loss of critical information and result in
adverse patient events in ICU settings (Spooner et al., 2015).
Despite the increased relevance, detailed studies reflect-
ing patients’ perceptions and their insights about bedside
handover remain limited in the ICU settings in particular (Lu
et al., 2014).
Methods
Study design
A qualitative descriptive study design (Polit and Tatano
Beck, 2014) was undertaken to explore the postoperative
cardio-thoracic surgical patient experience of nurses’ bed-
side handovers. Qualitative approaches are recommended
when a new perspective is needed for practice (Polit and
Tatano Beck, 2014; Streubert and Carpenter, 2009) as in
the field of ICU patients’ experience of bedside handovers
(Lu et al., 2014). The Consolidated Criteria for Reporting
G. Lupieri et al.
Qualitative Research (COREQ) (Tong et al., 2007) was used
to report the findings.
Setting
The study was performed in a Cardio-thoracic ICU localised
in a Joint Commission International accredited Academic
Hospital in north-eastern Italy, from August to November
2014. The unit was based on a primary nursing delivery
model of care (Bulfone et al., 2012). There were 10 beds
and two patients on average were admitted on a daily basis,
arranged into two rooms with four beds each and two indi-
vidual rooms; patients’ length of stay (LOS) was from three
to four days on average.
In the study period, Registered Nurses’ (RNs) regular shift
schedules started with a morning shift (from 7.00 am to
2.00 pm), followed by an afternoon shift (from 2.00 pm to
9.00 pm), night shift the next day (from 9.00 pm to 7.00 am)
and then two days off.
The bedside nursing handover was introduced 14 years
before the study. Nursing handovers were usually carried out
at patients’ bedsides at every change of shift (at 7.00 am, at
2.00 pm and at 9.00 pm). As the nurse-to-patient ratio was
1:2 and nurses cared for two patients, bedside handovers
lasted from 10 to 15 minutes on average. The time spent for
handovers was not paid for those nurses who finished their
shift work while it was paid for the ones starting the shift.
All information verbally reported were routinely included
also in written format (Lamond, 2000). There was no stan-
dardisation of the verbal handover (Nagpal et al., 2013);
therefore, each RN was free to report and share the relevant
information to the next nurse.
Participants
A purposeful sampling technique (Polit and Tatano Beck,
2014), including patients who went through cardio-thoracic
surgery and had consciously witnessed at least two bedside
handovers, was adopted. In order to be included, patients
were required to be >18 years old, capable of communicat-
ing in Italian, cognitively competent and clinically stable;
they had to express their willingness to participate, and then
to sign an informed consent as evidence. Those patients
not reporting the above-mentioned criteria, intubated or
sedated, were excluded.
The recruitment process was conducted by a clinical RN
responsible for the nursing care of the eligible patients dur-
ing the entire research period. The recruitment process
ended after having achieved data saturation as the point in
data collection when the full range of themes was obtained
from the participants and no new information related to the
research question emerged while interviewing further par-
ticipants (Polit and Tatano Beck, 2014). The saturation point
was assessed independently by two researchers (GL, AP).
Data collection instrument and process
Background information regarding age, gender, main diagno-
sis, type of surgery and postoperative day of the interview,
were collected from the nursing records.
Cardio-thoracic surgical patients’ experience on bedside nursing handovers
Table 1 Semi-structured interview.
How many bedside nursing handovers have you witnessed
during your hospitalisation?
What were your feelings in that situation? What is your
experience with bedside nursing handovers?
From your perspective, what are the positive and negative
aspects of your participation in nursing handover?
Is there any handover that worried you or, on the contrary,
relieved you? Can you share your experience?
What do you think about your confidential issues that might
be conveyed in front of other patients during the bedside
handovers?
Thinking about your experience, do you have any
suggestion to improve bedside nursing handovers?
Then, a six open-ended questions semi-structured inter-
view was used as a guide to collect data for all patients as
reported in Table 1; it focused on the issues under scrutiny,
aiming to reduce the risk of tiring patients at the same
time. With respect to the qualitative approach undertaken
(Polit and Tatano Beck, 2014), patients were encouraged
to speak freely, reporting their experience in depth. The
same researcher conducted the interviews, using strate-
gies to encourage patients to share their experience; the
researcher was not involved in the care of patients; she was
trained and supervised to conduct the interviews.
Since patients were not able to move from their beds
due to their critical conditions, interviews were handled at
their bedsides after the 2.00 pm change of shift. When inter-
viewing those admitted to multiple bed rooms, the interview
waited until the patient was alone, for example when the
other patients were out of the room for diagnostic or sur-
gical reasons. The majority of the patients (10/14) were
interviewed when they were alone.
Each interview was audio-recorded and transcribed ver-
batim afterwards; they lasted from 2.5 to 20.45 minutes.
Data analysis and rigour
Data were analysed reading the transcriptions carefully and
repeatedly, to link the common themes in each participant’s
experience and to extrapolate their essence in order to
frame a complete description of the experience (Polit and
Tatano Beck, 2014; Thorne, 1997). Thereafter, in accordance
with the descriptive qualitative approach (Polit and Tatano
Beck, 2014) assumed by the study, the following steps were
taken:
Bracketing: to prevent any misconception, the
researchers’ opinions and personal convictions were
discussed and bracketed in a preliminary fashion (Polit
and Tatano Beck, 2014; Streubert and Carpenter, 2009).
Researchers shared their beliefs with regard to the bedside
handovers.
Analysing: researchers re-read the transcriptions, iden-
tified the transitions and units of the experience, detected
meanings by relating constituents to each other and to
the whole, reflected on the constituents in the con-
crete language of the participant, and transformed the
31
concrete language into the language or concepts of science
(researchers’ words) (Streubert and Carpenter, 2009).
Describing: researchers integrated and summarised the
insights into a descriptive structure (themes) describing the
meaning of the experience (Polit and Tatano Beck, 2014;
Streubert and Carpenter, 2009). Examples of the patient’s
words were included with an indication of the interview (e.g.
Pt 01) to which they related.
In order to obtain credible and consistent findings, each
aforementioned phase was conducted simultaneously; in
addition, each phase was performed by the researchers
independently, who then worked closely together in theme
triangulation. Researchers have considered with care the
need to set aside their personal biases, avoiding personal
judgement, as well as opinions (Streubert and Carpenter,
2009).
Ethical issues
Research ethics approval was granted by the Internal Review
Board composed by University and Academic Hospital mem-
bers. All participants were informed about the aims of the
study, the voluntary nature of the participation, and about
the maintenance of confidentiality. Each participant signed
a written consent form prior to the interview. In order to
assure anonymity, patients were de-identified using num-
bers (e.g., Pt 10, Patient 10) instead of their actual names
when transcribing the recorded interviews.
Findings
A total of 14 patients participated, 10 males and four
females, aged between 49 and 86 years. Among these, five
patients went through heart valve surgery and four patients
had Coronary Artery Bypass Graft (CABG) surgery. Interviews
mainly occurred during the second postoperative day (nine
interviews), and the remaining ones took place between the
third and the fourth postoperative day.
Data analysis revealed that the experiences of patients
witnessing the bedside handover was based on four main
themes: (1) ‘discovering a new nursing identity’, (2) ‘being
apparently engaged in a bedside handover’, (3) ‘experi-
encing the paradox of confidentiality’ and (4) ‘having the
situation under control’.
Discovering a new nursing identity
Thanks to bedside handover, patients experienced the
opportunity to perceive the nursing profession in a new light,
becoming aware of the knowledge, competence, and pro-
fessionalism achieved by the nursing profession in recent
years:
‘‘Professionally speaking, I think each person [nurse] I
met here really matches up with it’’. (Pt 01)
‘‘Professionalism is remarkable here, I have no com-
plaints!. (Pt 07)
Patients felt extremely satisfied by the bedside handover,
by the cooperation perceived by the members of the nursing
team, and by their readiness in responding to their needs.
32
What they appreciated most was nurses’ humanity dur-
ing the process of sharing information at the bedside, an
essential feature for every healthcare professional:
‘‘I think that, as usual, human beings make the differ-
ence. I mean, for me the most important thing is to rely
on a high-levelled staff, both defined by professionalism
and humanity.’’ (Pt 01)
‘‘I think the way they behave is the right one and they do
it with professionalism and humanity, so there’s nothing
else they should do; in addition, everything is organised
in the proper way.’’ (Pt 03)
Nurses’ kindness, carefulness, attention and hand touch-
ing during the handover made patients feel comfortable
with putting themselves in nurses’ care. Patients were very
confident about nurses’ competence, because they had the
opportunity to meet them at the beginning of the shift
change, and to trust them:
‘‘I wasn’t worried at all, I put myself in their hands, I
had no concerns.’’ (Pt 13)
Even the lack of interest showed by a patient’s words hid
his faith in the nursing team:
‘‘We put ourselves in their hands, that’s why I don’t
care too much; they are the ones who should be wor-
ried about doing their job in the appropriate way, I’m
only the patient.’’ (Pt 08)
The opportunity to listen to the nurses’ handovers reas-
sured patients that all the relevant information regarding
their condition were conveyed and that transition of care
was maintained between shifts; they perceived that nurses
had accumulated sufficient knowledge about their situation
and care plan to care for them competently:
‘‘This morning, during the change of shift, he told her
‘this is Mr. F.’, he explained everything to her and then
they talked to each other; it was amazing!’’ (Pt 04)
‘‘To me it’s positive that they inform each other, because
the oncoming nurse has of course to know his patient.
What’s more, they do it near the bed and not in a pri-
vate room as they used to do a long time ago, when they
went away with the medical record leaving you there. . .
alone. . . it is very positive.’’ (Pt 07)
Nevertheless, sometimes it was hard for patients to dis-
tinguish between the various healthcare professionals who
surrounded them; they often confused nurses with doctors,
‘‘I saw two doctors running here and there, coming here
to ask me if I needed something, if I was ok or not, and
then they let me phone to my wife. . . so kind of them!’’
(Pt 04)
‘‘I felt very relieved because the doctor looking after
me was ever-present and satisfied anything I needed, she
explained me every single thing she did, every medica-
tion she gave me, every single examination prescribed
by the doctor. . .’’ (Pt 05)
In fact, in Italian health-care work processes, physicians
are used to having meetings at the bedside while clinical
G. Lupieri et al.
nurses are used to having meeting handovers in a specific
room, away from patients.
Being apparently engaged in a bedside
handover
Even if the majority of participants considered bedside han-
dovers as positive and effective, they would prefer to be
more involved during the process, as nurses often talked to
each other neglecting the patient was listening to them:
‘‘They don’t tell you anything; I get that they have to
talk to one another, but they should involve the patient
if there’s something concerning him.’’ (Pt 07)
‘‘They should have answered my questions. . . well, they
answered actually. . . but they generally don’t pay too
much attention to the fact that the patient is listening
and would like to know something while they report.’’
(Pt 14)
Patients’ participation was limited, thus suggesting only
an apparent engagement in the handover process. Patients
would also prefer to receive more information about their
functional recovery during the handover process, as data
with regard to their functional independence/dependence
were shared between nurses.
In addition, the professional vocabulary used by nurses
was easily understood by young patients, while it was harder
for older patients to comprehend the content of the conver-
sation:
‘‘Maybe it is more difficult for the elderly to approach
a participative handover.’’ (Pt 05)
‘‘I heard only something, the rest was technical matter.’’
(Pt 08)
The use of medical jargon excluded patients from the
conversation, even if they were the ones concerned. It
seemed that patients were not always well informed about
their situation, although they believed they had the right
to know their condition and care plan; listening to the han-
dover embodied the occasion to receive all the information
they were longing for:
‘‘It is positive indeed, because if the patient listens to
what they say about the surgery, he is aware of what he
has to deal with.’’ (Pt 01)
‘‘I would be satisfied in any case, because the best aspect
of being documented is the knowledge.’’ (Pt 10)
‘‘They talked about the surgery and the values; since
they were all good, it was more than positive to hear
them talk.’’ (Pt 11)
However, being informed was not always perceived as
positive; when bad news occurred, listening to nurses talking
about it could make patients feel more worried and anxious:
‘‘Of course I was worried!’’ (Pt 02)
‘‘You know, patients are nervous when they are told
there isn’t good news. . .’’ (Pt 02)
Cardio-thoracic surgical patients’ experience on bedside nursing handovers
Patients generally felt gratified by gaining knowledge,
but nurses had to deliver it with professionalism, sensitivity
and humanity, especially in the case of bad news.
‘‘The positive is always positive, while the negative gets
you down; you perceive there’s something wrong. . .’’ (Pt
11)
Experiencing the paradox of confidentiality
Patients have reported that assuring their privacy during
the experience of hospitalisation is very important; how-
ever, when asked if bedside handover compromised their
privacy, most of the participants stated that the discussion
of their medical-related issues in front of other patients did
not concern them:
‘‘Nurses don’t speak aloud; they use the right tone of
voice. They talk to each other and don’t broadcast what
they say.’’ (Pt 03)
‘‘They don’t let people not involved in the conversation
listen to what they say; I would have criticised them if
that had happened!’’ (Pt 10)
Privacy was maintained by nurses speaking softly, and
sometimes nobody occupied the patient’s nearest bed. A few
thought that bedside handover did not fully protect privacy
and confidentiality, but since all patients were in the same
situation, they believed none of them would be interested
in the conversation:
‘‘We are all sick, I met them here but I will never meet
them again, so it doesn’t bother me at all.’’ (Pt 07)
‘‘There is so much talk about privacy but they don’t pay
too much attention to protecting it! In any case your bed
neighbours are in the same situation, so I don’t think they
care too much about your information.’’ (Pt 11)
Lack of privacy was an existing problem but it did not
represent a significant concern for patients, since the ben-
efits of listening to the report were more important than
preserving confidentiality. Only one of the participants was
worried about lack of privacy, and he thought that nurses
should do their best to protect it:
‘‘Privacy is an essential feature and medical data is sen-
sitive information that should be protected.’’ (Pt 05)
Nevertheless, no violation of privacy occurred during
the bedside handovers based upon the experience of the
patients involved.
Having the situation under control
The majority of patients expressed satisfaction about par-
ticipating at bedside nursing handovers, as it gave them the
opportunity to verify the completeness of the information
conveyed to the oncoming nurse:
‘‘I would prefer nursing handover to be handled at the
patient’s bedside, but of course you have to consider
the organisation of each ward, maybe they do it because
of convenience, I don’t know; the intensive care unit is
obviously a special ward, it is clear that it’s better to do
33
it in front of the patient, so he can listen to it. . . yes I
would prefer it.’’ (Pt 01)
‘‘To me it was perfect, I don’t know what they should
do to improve it. . . the ones who found some deficiency
should suggest some improvements, I didn’t find any.’’
(Pt 04)
Some of them also asserted that, if they had the chance
to choose the nursing handover approach, they would cer-
tainly choose the one at the bedside, because listening to
what nurses said was crucial:
‘‘To me it’s better here, at least you can understand
what’s going on.’’ (Pt 08)
‘‘It’s better where you can listen to the handover.’’ (Pt
14)
Several feelings arose from hearing the reports, a sense
of safety and protection above all. Bedside reports reassured
patients that everything was under control, particularly dur-
ing the change of shift:
‘‘I felt protected, safe.’’ (Pt 04)
‘‘It provides you a sense of safety, also in your mind,
so you feel better, even if you have some pain you feel
better. . . when someone tells you ‘everything went OK,
I fixed it’, you can stand the pain!’’ (Pt 07)
Another feeling that emerged was the sense of relief,
provided not only by the awareness that the recovery was
positive, but also by the possibility of checking the accuracy
of transmitted information:
‘‘They told me that everything was okay, that everything
went fine, that there was no need to be worried, so I felt
reassured. . .’’ (Pt 06)
‘‘It’s good! It means they care about you.’’ (Pt 09)
‘‘If they talked to each other about my situation and
on what I was supposed to do, I had nothing to worry
about!’’ (Pt 10)
Discussion
We have conducted a qualitative study exploring ICU
patients’ experiences with regard to bedside handover. Pre-
viously, different approaches have been used in the field
(e.g. case study) by authors (e.g., McMurray et al., 2011) in
different contexts.
Participants have emphasised the professionalism and
humanity characterising nurses’ presence at the bedside,
which made them feel safe. Given that in Italian units nurs-
ing handovers are mainly managed away from patients’
bedside in closed rooms (Bulfone et al., 2012), in-hospital
patients may have less chances to acquire an overall idea
of the nursing profession advancements achieved in recent
year.
After having witnessed nursing handovers at the bedside,
patients have reported their surprise at the perception of
a new nursing identity, which results in a greater close-
ness between nurses and patients. Furthermore, Grant and
Colello (2009) have reported that patients became more
conscious of nurses’ professionalism and caring complexity
34
by being involved in bedside handovers. However, there is
the risk for nurses to be confused with physicians during
bedside handovers, since they wear the same uniform and
physicians typically undertake rounds. Therefore, it is rec-
ommended for nurses to make clear their role at the bedside
and the purpose of the bedside handover to patients.
Patients witnessing bedside handovers have reported the
experience of being transferred from the hands of the nurse
who ended the shift into new hands, those of the nurse tak-
ing over the responsibility of patient care for the next shift.
Patients have appreciated the accumulation of knowledge
over time in the transition process from one nursing shift to
another. The literature has already reported the complexity
of the transition experience of patients from one context to
another and from one clinical condition to another (Beach
et al., 2012), but it has not documented the complexity of
the transition from one nurse to another.
Patients, however, have reported perceiving themselves
as spectators at the bedside handover and they have also
reported not being engaged during the process; thus, nurses
have not always opened the conversation with patients who
wanted to receive information on their functional recovery.
In addition, patients have reported the need to express their
feelings and concerns, or to be reassured when the clinical
trajectory was not positive.
Patients want to be more involved in healthcare
decisions, or at least to be informed about the possi-
ble alternatives available (Anderson and Mangino, 2006).
Patients appreciate being considered as partners, since they
are the experts on themselves, and they have the right to
be updated on their condition and to participate in the clin-
ical decision making (McMurray et al., 2011; Cahill, 1996).
However, Lu et al. (2014) have highlighted that although the
concept of patients’ involvement in healthcare processes is
generally accepted, it is not always implemented in daily
practice, especially during nursing handovers. As already
suggested in the literature (Anderson and Mangino, 2006;
McMurray et al., 2011; Timonen and Sihvonen, 2000), bed-
side reports remain a one-sided conversation, with patients
excluded from the process or barely included in the discus-
sion. However, as reported recently by Manias and Watson
(2014), patients’ lack of involvement may be determined by
several factors, including patients who were asleep at the
time of the handover, hard of hearing, comatose and those
who had no desire for clinical handover to take place at their
bedside.
Even though the level of involvement is still low, Anderson
and Mangino (2006) have reported that what patients most
appreciated was to be informed. In our study, having the
chance to listen to the handover allowed patients to be
aware of nurses’ expectations and care plan including infor-
mation that would not have been shared in the case of a
traditional handover managed in a private nurses’ room.
On the other hand, some patients asserted that listening
to nurses reporting bad news on their condition was a cause
for anxiety. However, rather than thinking it necessary to
avoid bedside nursing handovers, they preferred nurses to
use sensitivity instead. The use of medical jargon has also
limited patients’ understanding of the handover. Timonen
and Sihvonen (2000) have already suggested using a language
that is familiar to patients in order to establish a relationship
of trust and to involve them in the conversation.
G. Lupieri et al.
Patients believe that the privacy of confidential infor-
mation and its protection against unauthorised disclosure
(MESH database, 1980) is important and should be
respected. However, paradoxically, they have reported that
confidentiality rights are violated when nurses speak about
them elsewhere, while they are not when nurses share
information regarding each patient in front of him/her
and roommates. Recently, Olausson et al. (2013) have doc-
umented that hospital rooms, especially in critical care
settings, are perceived as a lived in and extended place
and space; they can promote a margin of trust and secu-
rity. Patients in neighbouring beds, who have shared the
same experience, were therefore not perceived as threat-
ening confidentiality, as reported in previous studies (Kelly,
2005; McMurray et al., 2011; Timonen and Sihvonen, 2000).
Since they were all in the same situation, there was no
interest in paying attention to what nurses said about
the other patients. However, the American Institute of
Architects (2006) has recommended single-room occupancy
as the minimum standard for a range of healthcare facili-
ties, increasing patients’ privacy and control over personal
information and providing an opportunity to discuss freely
their needs with family and staff members (Chaudhury et al.,
2005). In addition, given that the ICU architectural design
may also affect nurses’ well-being, work satisfaction and the
provision of sensitive care, there is need to involve nurses
in the process of designing ICU settings (Olausson et al.,
2014).
Confidentiality issues are usually recognised as a barrier
to bedside handover implementation (Bulfone et al., 2012),
especially when several patients share the room, but nurses’
sensitivity and attention could make the difference. In their
recent integrative review of literature, Anderson et al.
(2015) have reported that concerns regarding patient pri-
vacy are more a problem for nurses than patients. Patients
think that any lack of privacy due to bedside handover is
outweighed by advantages, such as acquiring information
on their condition and improving the accuracy of communi-
cation (Friesen et al., 2013; Tobiano et al., 2012).
As previously documented by McMurray et al. (2011), par-
ticipants have appreciated the opportunity to check on the
accuracy of the information transmitted. In accordance with
Baker’s (2010) and Laws and Amato’s (2010) findings, our
patients were reassured by bedside handover. They were
also able to verify that everything was done in the proper
way reassuring them that the situation was under control.
Having the control of a situation is an opportunity to impact
on one’s life aspect and to exert mastery over it, reducing
stress, a crucial aspect in cardio-thoracic surgical patients.
The more informed and involved patients are, the less likely
to be anxious are they (Anderson and Mangino, 2006).
Limitations
Our study has involved patients receiving a visit by nurses
three times per day, for the purpose of bedside handover.
The handover was not standardised in format (McMurray
et al., 2010), since every nurse has reported the information
in a different manner. Nurses performing bedside handovers
were not paid for the time devoted to the round after their
shift had finished, and this may have affected the quality
Cardio-thoracic surgical patients’ experience on bedside nursing handovers
of their handover and the amount of time they spent on it,
influencing also the patient experience.
Therefore, patients may be exposed to different modali-
ties, thus eliciting different experiences. In addition, there
were only two nurses involved in the bedside handover:
sometimes several members of the multidisciplinary team
have been reported to attend the handover (Chaboyer
et al., 2009). Future studies should consider perceptions
with regard to ‘crowded’ handovers.
In accordance with its aims, the study was performed
in a single cardio-thoracic ICU, with a homogeneous cul-
tural group of Italian patients and nurses: therefore, more
variability in the purposeful sampling is suggested in future
studies. Participants were adult/elderly patients typically
cared for by the cardio-thoracic ICU, which entailed a short
stay, in discomfort and tiredness. For this reason, the inter-
views were short and performed after at least the second
postoperative day and with at least two bedside handovers
experienced. However, this may have affected the depth of
the shared experience.
In addition, patients’ disclosure of information may have
been prevented by the limited auditory privacy due to
interviews being conducted in shared rooms. In fact, when
personal conversations are overheard by other patients,
important information may be withheld (Larsen et al.,
2014). Researchers have considered this risk with care, con-
ducting the majority of the interviews when patients were
alone. In the future, more interviews should involve patients
in ICU, who have experienced multiple bedside handovers
performed in different settings and by different nurses, in
single rooms if possible.
Finally, in accordance with Twinn (1997), in the pro-
cess of manuscript preparation, the translation process
from Italian to English language was performed with care
by researchers. Since both authors and participants were
Italian and interviews were conducted in Italian, English
translation performed was reviewed by an authorised trans-
lator in order to assure its accuracy. Only one translator
was involved to maximise the reliability of the study as
suggested by Twinn (1997). However, the process of transla-
tion performed may have affected the real meaning of the
experience as shared by patients.
Conclusions
The purpose of this study was to describe the experiences of
postoperative cardio-thoracic surgical patients experiencing
bedside handovers. No previous research to our knowl-
edge has described cardio-surgical patient bedside handover
experiences as reported in the ICU.
In accordance with previous studies conducted in other
fields, our patients were supportive of bedside handovers, as
they allowed them to be more informed about their health
status, to feel safer and to be aware of nurses’ expertise
in taking care of them. They had the opportunity to check
on transferred data and to be informed about their clinical
condition, which would be difficult in the case of traditional
handovers. Overall, patients were not worried about privacy
issues, but nurses should continue using discretion when
reporting sensitive data. Participation in the handover was
perceived as limited by patients and from the findings, in ICU
35
cardio-surgical settings, the bedside handover might follow
an informative strategy rather than a patient involvement
one. Bedside handovers should be rethought as a process,
based on a framework that allows patients in critical con-
dition to be involved progressively, through different stages
from informative to shared decision-making, when their con-
dition and their willingness to actively participate in the
process is expressed.
With the handover performed at the bedside in postop-
erative settings, two interconnected potential effects may
be achieved with regard to patients and the nursing pro-
fession. Nurses have the great opportunity to express their
closeness to patients and to promote awareness of the
important growth that the nursing profession has achieved
over the years. Therefore, patients may perceive greater
nursing competence and feel safer during the postopera-
tive care pathway. They can appreciate nurses’ humanity
in caring as well as their competence and professionalism,
resulting in augmented trust. Therefore, intensity of stress
due to the lack of information and uncertainty of the situa-
tion may be reduced and patient safety may increase.
Healthcare services too should consider implementing
bedside handovers in other settings due to several positive
outcomes, such as greater patient involvement and satis-
faction, increased accuracy of the information transmitted
resulting in increased patient safety, reduced period of
missed surveillance, nurses’ overtime diminution and better
teamwork and staff relationships. Moreover, more atten-
tion should be paid to improving communication between
staff members, who might avoid medical jargon in order to
involve the patient in the conversation and consider him or
her as a resource in designing and implementing the conti-
nuity of nursing care. Besides, the influence of conducting
handover after the cessation of the nurses’ shift report on
the quality of the care provided, should be imperative in
future research.
Authors’ contributions
Mrs Lupieri and Mrs Palese conceived the study design and
develop the research protocol. Mrs Lupieri and Mrs Cereatti
provided the data collection process; Mrs Lupieri, Cereatti
and Palese performed the data analysis. Mrs Lupieri and Mrs
Palese prepared the manuscript. All authors approved the
final manuscript.
Funding
The authors have no sources of funding to declare.
Conflict of interest
The authors have no conflict of interest to declare.
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