ORIGINAL RESEARCH: EMPIRICAL RESEARCH –

QUANTITATIVE

Nursing handovers as resilient points of care: linking handover

strategies to treatment errors in the patient care in the following shift
Anat Drach-Zahavy & Nadim Hadid

Accepted for publication 28 November 2014

Correspondence to A. Drach-Zahavy: D R A C H - Z A H A V Y A . & H A D I D N . ( 2 0 1 5 ) Nursing handovers as resilient points

e-mail: anatdz@research.haifa.ac.il of care: linking handover strategies to treatment errors in the patient care in the
following shift. Journal of Advanced Nursing 00(0), 000–000. doi: 10.1111/
Anat Drach-Zahavy PhD
jan.12615
Associate Professor
Department of Nursing, University of Haifa,
Israel Abstract
Aim. To examine the relation between the strategies the nurses employ during
Nadim Hadid MA RN handover and the number and types of treatment errors in patient care in the
Research Student following shift.
Ziv Medical Center, Haifa, Israel Background. Patient handover has repeatedly been declared an area of
considerable vulnerability to patient safety. This study examined factors that
affect treatment errors in patient care, including the use of handover strategies
from high reliability organizations.
Design. Prospective study.
Method. Data were collected in 2012–2013 from 200 randomly selected
handovers in five internal wards. Handover strategies previously adopted from
High Reliability Organizations were assessed via observations; treatment errors –
dosage discrepancy, order postponed, no documentation – captured from the
patient’s files and demographical data were collected via questionnaires.
Findings. On average, in nearly one-fifth of the patient’s files, medication dosage
given was inaccurate; in nearly one-third a care order was fulfilled late; and in
nearly half, documentation was partially missing. Rate of use of handover
strategies previously adopted from high reliability organizations varied
substantially. Results of negative binomial regression analysis revealed that face-
to-face verbal update with interactive questioning, update from practitioners
other than the outgoing, topics initiated by incoming and outgoing team,
including the latter’s stance on care plans and writing a summary prior to
handover, were significantly and negatively linked to number of treatment errors
(P < 0
05).
Conclusions. Nursing handover is an opportunity for nurses to prevent errors and
unsafe practice by implementing more risk-aware handover strategies.
Implications for facilitating the use of such strategies are discussed.

Keywords: errors, handover, handover strategies, nursing, resilience

© 2015 John Wiley & Sons Ltd 1

A. Drach-Zahavy and N. Hadid
Why is this research needed?
 Patient handover has repeatedly been declared an area of
considerable vulnerability to patient safety.
 Previous research has focused on assessing the content and
processes of the handover, whereas only scant research has
linked handover content and processes to patient’s safety.
What are the key findings?
 In nearly a fifth to a half of the patient’s files some devia-
tion from the prescribed treatment was found.
 Rate of use of handover strategies previously adopted from
High Reliability Organizations varied substantially.
 Face-to-face verbal update with interactive questioning;
update from practitioners other than the outgoing; topics
initiated by incoming as well as outgoing team, including
the latter’s stance on care plans and writing a summary
prior to handover – all were significantly and negatively
linked to fewer treatment errors.
How should the findings be used to influence policy/
practice/research/education?
 Training interventions should be developed to ensure that
incoming nurses play a more active role in handovers,
speak up and make sure they receive the information they
need.
 Nurses should be taught how to facilitate shared decision-
making with team members and patients alike.
 Checklists and structured aids can remind nurses to check
the medical technologies devices during handover.
Introduction
Since the publication of the influential report To Err is
Human (Kohn et al. 1999), researchers and practitioners
have intensified their interest in patient safety. More
research and a greater regulatory effort have been applied
to structuring nursing handovers in an attempt to improve
the patient’s continuity of care (e.g. Riesenberg et al.
2010). A nursing handover is the exchange of information
between nurses about a patient, involving transfer of con-
trol over or responsibility for that patient (e.g. Hilligoss &
Cohen 2011). Most previous research has assessed the com-
pleteness and accuracy of the handover content or the ade-
quacy of the handover processes (e.g. Riesenberg et al.
2010, Manser & Foster 2011). But only scant research has
linked the handover’s content and processes to its handover
outcomes in patient safety (Riesenberg et al. 2010). This
study addresses this gap in the literature by investigating
the relation of the handover strategies applied by nurses to
2 © 2015 John Wiley & Sons Ltd
the number and types of treatment errors in patient care in
the following shift.
Background
Patient handover, namely the transfer of information
regarding a patient, and the shift of control and responsibil-
ity for the patient, from the departing healthcare provider
(or team of providers) to the receiving one(s) (e.g. Cohen &
Hilligoss 2010), has been repeatedly declared an area of
considerable vulnerability to patient safety (e.g. Thomas
et al. 2013). Research has identified handovers as a risky
time in the care process, when information may be lost, dis-
torted or misinterpreted (Borowitz et al. 2008, Owen et al.
2009, Philibert 2009). So not surprisingly, in the last dec-
ade extra research and regulatory efforts have been devoted
to handovers to learn how to structure these crucial
moments of discontinuity to facilitate patient safety (e.g.
Chaboyer et al. 2010, Riesenberg et al. 2010, Payne et al.
2012). Most interventions aim to standardize the hand-
over’s order and content (Farhan et al. 2012, Payne et al.
2012). Standardization, according to recent research, will
reduce communication errors during handovers, because the
‘rules’ for interaction (e.g. function, process, content and
timing and who is directly or indirectly included in the con-
versation) are imposed, hence more resistant to variation
(Patterson 2008). Checklists, mnemonics and minimum
data sets define the topics to be covered and list them in a
specific order (Talbot & Bleetman 2007, Hill & Nyce
2010, Manser & Foster 2011). A recent systematic review
of handovers identified 24 different mnemonics – ‘SBAR’
(Situation, Background, Assessment, Recommendation)
(Haig et al. 2006) being recommended most frequently
(Riesenberg et al. 2010). Still, these studies have not yielded
a reliable body of direct evidence that handover standardi-
zation produces distinct gains in measured patient out-
comes, such as reducing falls, length of stay or mistakes
made during patient care (Patterson & Wears 2010, Hilli-
goss & Cohen 2011, Manser & Foster 2011, Scott et al.
2012). Also apparent is a fundamental lack of recommen-
dations on how much content standardization and content
ordering is desirable or even possible (Cohen & Hilligoss
2010).
Acknowledging these potential disadvantages of standard-
ized handovers, several authors have recently advocated
integrating resilient strategies and strategies from High
Reliability Organizations (HRO: organizations that have
succeeded in avoiding catastrophes in an environment
where normal accidents can be expected due to risk factors
and complexity (Weick & Sutcliffe 2007), into handovers
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE
(e.g. Patterson & Wears 2010). These authors argue that,
although standardization certainly has merit, handovers
provide an important ‘audit-point’ essential for potential
recovery from failure. So it might be constructive to inte-
grate elements of resilience into the handover practice (e.g.
Jeffcott et al. 2009, Hill & Nyce 2010, Patterson & Wears
2010, Hilligoss & Cohen 2011). At the simplest level,
handover carries opportunities for correcting errors by such
actions as running a safety scan of functioning equipment,
double-checking a medication dosage and/or a lab value
(Hilligoss & Cohen 2011). Beyond simple error correction,
the resilience perspective suggests that handovers might
convey opportunities to detect and ‘bounce back’ from
unexpected events through systematic application of intui-
tion, anticipation and foresight skills (Weick & Sutcliffe
2007, Jeffcott et al. 2009). Communication during hand-
over can also afford new perspectives on a patient’s situa-
tion through the outgoing team’s refreshed attention to him
or her while preparing for the handover, or of the incoming
team’s ‘fresh perspective and rested mind’ (Patterson et al.
2007, Hilligoss & Cohen 2011).
Assessing handover quality
Previous research has typically assessed handover quality by
three types of measures: its content, process or outcomes
(Cheung et al. 2010, Manser & Foster 2011). The first cat-
egory – handover content – has been mostly descriptive,
concentrating on the completeness and accuracy of informa-
tion (Arora et al. 2005, Berkenstadt et al. 2008, Horwitz
et al. 2009a,b). These studies typically showed verbal hand-
over to be incomplete compared with the information avail-
able in the patient’s record (Lamond 2000, Arora et al.
2007) or compared with a pre-defined handover protocol
(Catchpole et al. 2007). Moreover, this line of research
ignores the dispute over the definition of which items
should be included in such a list (Riesenberg et al. 2010,
Manser & Foster 2011) and whether assessing a small num-
ber of highly relevant items in the handover may be more
effective than looking at a larger number of less relevant
items (Philibert 2009).
The second category – the handover process–assesses its
environmental aspects (e.g. interruptions, workload) or its
behavioural aspects (e.g. preparation for the handover, using
written memos, shared decision-making and verbal face-to-
face reports) (Apker et al. 2010, Chaboyer et al. 2010,
Manser et al. 2010, Manser & Foster 2011). Research in
this area exceeds information transmission, to identify
through surveys or structured observations the processes
vital for the quality of the handover. For example, Manser
et al. (2010) developed a structured observation sheet and
© 2015 John Wiley & Sons Ltd
Handover strategies
identified three categories of processes: information transfer,
shared understanding and working atmosphere, to predict
perceived handover quality. However, most of these studies
relied on the subjective perceptions of the healthcare staff in
assessing the quality of the handover.
The final category – outcome measures – usually assesses
staff’s perceptions of or satisfaction with the handover
(Borowitz et al. 2008, O’Connell et al. 2008, Chaboyer
et al. 2010, Farhan et al. 2012, Klim et al. 2013), provid-
ers’ confidence (Payne et al. 2012) or perceived near- miss
on-call (e.g. Payne et al. 2012). To date, most studies have
relied on subjective outcome measures of handovers and
only few have attempted to link handover content or pro-
cess characteristics with objective outcome measures (except
Arora et al. 2005, Borowitz et al. 2008, Thomas et al.
2013). Handover outcome measures could also benefit from
measurement of objective criteria, such as treatment errors
in the following shift (Riesenberg et al. 2010, Manser &
Foster 2011). Human errors pertain to unintentional
actions; deviation from expectations, namely actions that
took the task or system beyond its acceptable limits; or
undesirable actions, namely deviation from a set of rules or
an external observer (Reason 1990). Although such devia-
tions in themselves do not necessarily produce adverse
consequences (i.e. patient’s harm) – if they are minor or
detected and put right early, they create conditions that
make such consequences more likely to occur (Fogarty &
McKeon 2006). In sum, an accurate understanding of how
an effective handover affects patient’s safety and reduces
errors is still lacking.
The study
Aim
The main aim of this study was to narrow this gap in
research by examining the relation between the strategies
nurses employ during handover and the number and types
of treatment errors in patient care in the following shift.
Design
The study took a mixed-method prospective approach,
combining observations, surveys and pooling data from
patients’ charts for data collection.
Sample and procedure
Data were collected during 2012–2013. Two hundred
handovers were sampled as follows: Before the handover,
3
A. Drach-Zahavy and N. Hadid
five patients were randomly selected for inclusion in the
study, based on a list of all patients hospitalized in the
ward: three ‘complex’ patients with Charlson Comorbidity
Index (CCI) (CCI ≥ 3) and two ‘simple cases’ with
(CCI < 2). During the handover, transfer of information on
these patients was observed and demographical data of
incoming and outgoing nurses involved in the handover and
context information, were collected. Near the end of the
shift following the handover a research assistant, who was
a senior nurse (near completion of his MA degree) and an
expert in risk management, extracted from the patient’s
chart data that might indicate errors.
The study was conducted in five nursing internal wards.
Hospital policy was to place patients evenly among wards,
so that wards were about the same in their mix of illnesses
and complexities. The five wards applied a face-to-face,
bedside, verbal handover process three times a day. No
standardized template was in use when the study was con-
ducted. Each outgoing nurse handed the information about
the patients under her or his care to her or his incoming
counterpart (approximately, six patients per nurse).
Data collection
Outcome measures
The outcome measure in this study was treatment errors,
defined here as ‘deviations from prescribed care’ as found
from a check of the patient’s chart in the shift after hand-
over. It was first checked for any care order given before
the handover (e.g. starting new medication, terminating
medication usage, screening, lab tests, change in nutrition,
physiotherapy). Based on Warrick et al. (2011), three
measures were then extracted from the patient’s chart on a
dichotomous scale (1 = yes; 0 = no): (1) Late/non-executed
care order – namely whether the nursing/medical order had
or had not been performed as prescribed and on time; (2)
Missing documentation – in the patients’ files on the execu-
tion of care orders; (3) Dosage discrepancy – as against the
medication order, namely the nurse had administered the
wrong dosage. The total number of errors in the three
measures was then calculated.
Observation sheet
The observation sheet listed eight of the ten HRO handover
strategies identified as employed to various degrees by
nurses, adapted from Patterson et al. (2005). Three of them
(‘limit initiation of operation during update,’ ‘incoming
receives primary access to the most up-to-date information’
and ‘make it clear to others at a glance which personnel are
responsible for which duties at a particular time’) were
4 © 2015 John Wiley & Sons Ltd
observed in 100 per cent of the handovers, hence were
analysed no further. One strategy (‘outgoing has knowledge
about prior shift activities’) was also customary in all hand-
overs, so it was replaced by ‘departing are present at physi-
cians’ rounds.’ Another strategy (‘read back to ensure that
information was accurately received’), only rarely observed
by Patterson et al. (2005), was not observed at all in our
sample. A strategy that was prevalent to some degree in
our sample (‘incoming checks medical equipment’) was
added. Observers were instructed to mark ‘yes’ when the
strategy was observed and ‘no’ when it was not. Percent-
ages using each strategy are presented in Table 1.
Ethical consideration
The study was approved by the Medical Ethical Review
Board of the medical centre.
Rigor
Several steps were taken to validate the observation sheet.
First, the tool was reviewed by five nurse specialists for
content validity and slight changes in the wording of the
strategies were made. Secondly, a pilot study of 30 hand-
overs was conducted to test the observation sheet. Observ-
ers noted that the strategies were clear, easy to measure
and representative of nursing handover. Two graduate stu-
dents, nurses by profession, participated as observers. The
ward’s nurses perceived their presence as natural, which
might prevent bias, yet the observers’ objectivity could be
relied on and they were familiar with the best practices of
handover strategies. To ensure inter-rater reliability and the
observations’ validity the observers received 12 hours of
extensive training. This covered: (a) observation techniques
in research; (b) a thorough study of the handover process;
and (c) participation in periodic meetings during the
observation period when categorization dilemmas were dis-
cussed and resolved by the group consensus technique
(Kappa = 0
88), indicating a good inter-rater reliability.
Data analysis
Descriptive statistics to summarize the data were used.
Error rates of handovers that used the strategies were com-
pared with those that did not by the Chi-square (v2) test.
The number of errors was regressed on the eight handover
strategies and the control variables. Since our dependent
variable was a count of occurring events that had only non-
negative integer values, we used the negative binomial
regression model, a generalized form of Poisson regression.
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE Handover strategies

Table 1 Handover strategies, their frequencies and links to treatment errors.

Dosage discrepancy Late- or non-executed order No documentation

Strategy observed Strategy observed Strategy observed

% % %

Strategy (% observed) Yes No v2 P Yes No v2 P Yes No v2 P

(1) Face-to-face verbal update with interactive 12% 33% 5
14 0
037 9% 24% 3
88 0
046 26% 40% 1
66 0
376
questioning (55%)
(2) Update from practitioners other than the 9% 48% 14
07 0
008 7% 32% 8
93 0
007 26% 35% 0
84 0
538
outgoing (57%)
(3) Limit interruptions during update (77%) 5% 26% 5
15 0
043 14% 46% 7
77 0
005 19% 43% 4
40 0
042
(4) Topics initiated by incoming and outgoing 25% 54% 5
31 0
028 25% 51% 3
10 0
045 57% 42% 1
66 0
658
(51%)
(5) Include outgoing team’s stance on care plans 14% 24% 1
28 0
835 24% 47% 3
70 0
042 34% 32% 0
18 0
439
(70%)
(6) Outgoing writes summary prior to handover 11% 24% 0
91 0
587 33% 42% 0
27 0
584 11% 18% 0
29 0
328
(9%)
(7) Outgoing participated in medical rounds 0% 34% 18
25 0
001 0% 24% 13
01 0
007 29% 33% 0
25 0
743
(67%)
(8) Incoming check medical equipment (35%) 0% 35% 6
59 0
032 12% 34% 3
82 0
038 0% 25% 4
14 0
041

This approach was suitable because the variance of our
dependent variable exceeded its mean, indicating over dis-
persion in the data (Long 1997). The control variables
(department, nurse’s tenure, complexity of the patient’s
condition) were entered in step 1. The main effect terms of
the handover strategies were entered in step 2.
Results
Characteristics of the sample
Two hundred bedside handovers were observed in five
medical wards. Mean handover time was 73
45 seconds (SD
18
16) and 50
56 seconds (SD 13
76) for complex and non-
complex patients, respectively. Ninety per cent of the
incoming nurses and 80% of the outgoing nurses were
women. Ages of the incoming nurses were 24-58 years
(mean 39, SD 10
44) and of the outgoing nurses 25–
60 years (mean 44, SD 10
88). Average unit tenure of the
incoming nurses was 15 years (SD 11
49) and of the outgo-
ing nurses 19 years (SD 11
90).
Treatment deviations
Documentation drawn from the patient’s chart in the shift
following handover, showed dosage discrepancies in 23%
of the handovers; an example is half of a prescribed dosage
being provided. Delayed or not-executed care orders were
found in 52% of the handovers, for example, a prescribed
antibiotic that had to be taken after the meal was given
before the meal or not at all. In 33% of the handovers
documentation was absent from the files, for example, exe-
cution of an order for a lab test, change in diet, or physio-
therapy given by the physician.
Table 1 presents the percentages of treatment deviations
(as documented in the shift following handovers) in hand-
overs that observed strategies compared with handovers
that did not. The table shows that ‘limit interruptions dur-
ing update’ was observed in 77% of the handovers; and
‘incoming check of medical equipment’ in 35% of the
handovers. Significantly fewer dosage discrepancies, late- or
non-executed care orders and documentation errors were
found in handovers that applied these given strategies than
in handovers that did not. Next, ‘face-to-face verbal update
with interactive questioning’ was observed in 55% of the
handovers; ‘update from practitioners other than outgoing’
was applied in 57% of the handovers; ‘topics initiated by
incoming and outgoing’ in 51%; and ‘outgoing participated
in medical rounds’ was applied in 67% of the handovers.
In all these cases, significantly fewer dosage discrepancies
and late- or non-executed care orders were found in hand-
overs that applied the given strategy than in handovers that
did not. However, no statistically significant differences in
missing documentation were found between handovers that
did and did not use the strategy. The strategy of ‘including
outgoing team’s stance on care plans’ was used in 70% of
the handover; significantly fewer late- or non-executed care
orders were found in handovers that applied the given strat-
egy than in handovers that did not. Finally, the strategy of
‘outgoing written summary prior to handover’, used only in

© 2015 John Wiley & Sons Ltd 5

A. Drach-Zahavy and N. Hadid

9% of the observed handovers, was not significantly related
to treatment deviations of any kind.
The results of the negative binomial regression analysis
for predicting number of treatment errors, from handover
strategies and control variables, are presented in Table 2.
Model 1 includes only the control variables, while Model
2 adds the explanatory variables of handover strategies. It
significantly improves model fit over Model 1: the likeli-
hood ratio test statistic of improvement in model fit is
10
57, significant at P < 0
01. As for the control variables,
a significant difference in the treatment errors among
wards was found (B = 0
606, P < 0
05). However, the
departing nurse’s tenure, and the patient’s complexity
score, was not linked to the number of treatment errors
(P > 0
05).
Among the handover strategies, ‘face-to-face verbal
update with interactive questioning’ (B = 0
842,
P < 0
05); ‘update from practitioners other than the outgo-
ing’ (b = 0
721, P < 0
01); ‘topics initiated by incoming
as well as outgoing’ (b = 0
801, P < 0
01); ‘include out-
going team’s stance on care plans’ (b = 0
742, P < 0
01);
and ‘outgoing writes summary prior to handover’
(b = 0
432, P < 0
05) were significantly and negatively
linked to the number of treatment errors. No significant
links were found between the remaining three strategies
and the number of treatment errors.
Discussion
This study took a resilience perspective, arguing that
although a nursing handover is certainly a vulnerable point
of care it also presents opportunities to identify, correct and
‘bounce back’ from errors, with obvious positive conse-
quences for patient’s safety (Jeffcott et al. 2009, Cohen &
Hilligoss 2010, Hill & Nyce 2010). The findings demon-
strated, in accordance with Reason’s (2004) three-bucket
model, that a nursing handover provides an opening for
frontline nurses to prevent errors and unsafe practice, if
they adopt more risk-aware and ‘error-wise’ handover strat-
egies. Our findings thus contribute to current handover
research in several aspects.
First, in line with previous research, our findings show
that a nursing handover is a point of vulnerability. On aver-
age, in nearly one-fifth of any handover, some sort of devia-
tion from ‘accurate dosage’ of medication occurred; in
nearly one-third a care order was executed late or not at
all; and in nearly half of the handovers documentation was
partially missing. As mentioned earlier, although these
treatment errors in themselves do not necessarily produce
adverse consequences (i.e. patient’s harm), they create con-
ditions that make such consequences more likely (Fogarty
& McKeon 2006). Our evidence thus augments previous
findings reporting some sort of distorted communication,
ranging from 19
8% (Thomas et al. 2013)–30% (Arora
et al. 2005) and 31% (Borowitz et al. 2008), depending on
definition, type and assessment of the errors, as a result of
poor handover strategies.
Second, handover strategies previously adopted from high
reliability organizations (HRO) (Patterson et al. 2005, Phili-
bert 2009) were shown to vary substantially in their rate of
use. Some were rarely used (e.g. ‘outgoing written summary
prior to handover’, ‘incoming check of medical equip-
ment’); others were used moderately (e.g. ‘topics initiated
by incoming and outgoing’, ‘face-to-face verbal update with

Table 2 Negative binomial regression analysis for predicting number of treatment errors (N = 200).
Model 1: controls Model 2: direct effects

Variables B SE B SE

Departing nurse’s tenure 0
010 0
02 0
275 0
03

Patient’s complexity score 0
115 0
28 0
162 1
04
Ward 0
606* 0
43 0
822** 0
27
Face-to-face verbal update with interactive questioning 0
842* 1
45
Update from practitioners other than the outgoing 0
721** 0
79
Limit interruptions during update 0
136 0
62
Topics initiated by incoming and outgoing 0
801** 0
81
Include outgoing team’s stance on care plans 0
742** 0
35
Outgoing writes summary prior to handover 0
432* 0
40
Outgoing participated in medical round 0
117 0
73
Incoming check medical equipment 0
363 1
32
Log likelihood D – 10
57**
d.f. 3 11

*P < 0
05; **P < 0
01.

6 © 2015 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE
interactive questioning’, ‘updates from practitioners others
than the outgoing nurse’); while still others strategies were
used regularly. These findings are similar to previous find-
ings on HRO handover strategies of residents and nurses
(Patterson et al. 2005, Philibert 2009).
But perhaps our most interesting finding concerns the
links found between the handover strategies nurses
employed and treatment errors. This result reflects the
recent dual focus of safety science on both system design
and system resilience (Leape & Berwick 2005, Thomas
et al. 2013). System design refers to standardized
approaches, aiming to simplify and streamline clinical
handover, providing nurses with a firm grasp of what is to
be conveyed during handover and how it is to be done
(Spooner et al. 2013). Two of our strategies – ‘limit inter-
ruptions during update and outgoing writes summary prior
to handover’ – could be viewed as such an approach. Only
the latter was linked to the number of treatment errors.
However, as our findings demonstrate, flexibility and resil-
ience elements exercised alongside standardized procedures
will help ensure patient safety and the overall quality of the
handover.
Three of the observed strategies concern substituting the
info-centric approach with a more user-centric approach,
emphasizing not only the departing nurse’s responsibility
for handing over complete information but also the receiv-
ing nurse’s needs for clarification, discussion and appraisal
of the patient’s current condition (Scott et al. 2012). Our
findings indicate that the strategies of ‘face-to-face verbal
update with interactive questioning’, ‘topics initiated by
incoming as well as outgoing’ and ‘include outgoing team’s
stance on care plans’ were linked to decreased treat-
ment errors. Providing more than facts, then, seems to be
essential in maintaining patient safety and continuity of
care! Apparently, communicating not only retrospective
objective information on patient’s background, physical
state and procedures already performed, but also on care
options, predictions of the patient’s prognosis and anticipa-
tions of ‘what could possibly go wrong,’ was linked to
fewer errors. This type of information is often not included
in handovers and is increasingly difficult to find in the med-
ical records (Borowitz et al. 2008, Philibert 2009, Manser
et al. 2013). These findings are consistent with previous
research, demonstrating that the benefits of face-to-face ver-
bal handover are more fully reaped when nurses perceive it
as an opportunity for interactive discussion (e.g. Patterson
et al. 2005, Scott et al. 2012, Manser et al. 2013). Still,
our findings elaborated previous findings by showing links
not only with subjective appraisal of the handover’s quality
but also with fewer errors as indicated from the patients’
© 2015 John Wiley & Sons Ltd
Handover strategies
files in the shift following the handover. One possible
explanation for these findings is that the emphasis on the
active role of both the incoming and the outgoing teams
facilitates safety through the development of team situa-
tional awareness (Patterson et al. 2005, Hilligoss & Cohen
2011). Situational awareness refers to the departing and
receiving nursing teams maintaining the ‘big picture’ and
thinking ahead to plan and discuss contingencies. This
ongoing dialogue, which keeps members of the team up-to-
date with what is happening and how they will respond if
the situation changes, is a key factor in patient safety
(Leonard et al. 2004, Patterson et al. 2005). Indeed, Boro-
witz et al. (2008) found that residents commented on the
importance of including contingency plans, and the ratio-
nale for the plan of care during handovers, so that if
changes are needed during an on-call shift there is a clear
context for how best to make those changes.
Two additional strategies–‘update from others than the
incomings and outgoing participated in medical rounds’ are
embedded in a team interaction perspective on handovers
(Patterson & Wears 2010). This perspective draws from
team research to posit that considering multiple viewpoints
during the handover (e.g. by the head nurse, the patient,
the caring physician) in evaluating the patient’s condition
can have several benefits (Richard et al. 2004, Singh &
Point 2006, Shore et al. 2009). First, diverse views reflect
qualitative differences that equip teams with a broader
range of approaches to patient evaluation. Different per-
spectives and knowledge form the core of the ‘value-in-
diversity’ hypothesis (McLeod et al. 1996) – a value that is
deemed especially advantageous for developing a thorough
understanding of the patient’s condition and maintaining
patient safety (Weller et al. 2014). Second, exposure to
diverse opinions also decreases the likelihood of cognitive
bias that might occur when the incoming nurse inappropri-
ately applies default assumptions of the outgoing nurse’s
approach (Nemeth & Owens 1996). Third and closely
related to the last two benefits, diverse perspectives on the
patient’s situation can contribute identifying, correcting or
‘bouncing back’ from errors (Patterson et al. 2007, Hilli-
goss & Cohen 2011). Our findings accordingly indicate that
the strategy update from others than outgoing nurse was
linked to decreased treatment errors. This finding is in line
with previous studies demonstrating that updating by more
informants such as the head nurse and other caregivers
(Borowitz et al. 2008, Hilligoss & Cohen 2011, Scott et al.
2012) and patient involvement (e.g. Davis et al. 2007,
Drach-Zahavy & Shilman 2015), may enhance the nurse’s
familiarity with the patient, facilitate the development of a
more complex view of his or her condition and contribute
7
A. Drach-Zahavy and N. Hadid
to improving patient safety. Surprisingly, no link was found
between the strategy of ‘outgoing participated in medical
rounds’ and fewer errors. Perhaps the mere participation of
the nurse in the medical round does not guarantee that she
will provide novel information on the patient during the
handover.
Our findings could not support the importance of assur-
ing the integrity of the medical technological devices, such
as actual checking of the mechanical ventilators, syringes
and monitoring system alarms, checking that infusion
orders were consistent with the medications infused into
the patient and reviewing medication charts. Perhaps this is
because this strategy was rarely observed. Several authors
have emphasized the gap between the rare use of these
strategies and their benefit to handover quality and reduced
errors, advocating teaching nurses to apply these strategies
(Spooner et al. 2013, Thomas et al. 2013). For example,
Perren et al. found that about two-thirds of ICU-to-ward
handover reports contained at least one error that was dis-
covered by nurses trained to check the medical technologi-
cal devices (Perren et al. 2008).
Limitations and suggestions for further research
This study has several limitations. The first limitation
pertains to the limited sample size of 200 handovers in
five wards. Because of the variability between wards and
hospitals in handover strategies, the findings might be lim-
ited in generalization. However, given that the handover
strategies were observed in other studies (Patterson et al.
2005, Philibert 2009), these findings do enhance the sparse
existing literature by demonstrating links between indica-
tors of the handover’s processes and its outcomes (Manser
& Foster 2011). Second, our findings showed differences
among wards in treatment errors. Although the hospital’s
policy was to distribute patients evenly among wards, with
a relatively equal mix of illnesses and complexities, other
factors, such as staffing or ward climate regarding patient’s
safety, could account for these differences. Third, our
observational approach to measuring a handover’s strate-
gies might be subject to bias, as participants may behave
differently in the presence of an observer. Roter (1989)
concluded that the ‘good impression bias’ that stems from
the presence of the observer is minimal, as individuals typ-
ically quickly become accustomed to the observer’s pres-
ence and tend to behave naturally. Moreover, the
employment rate of the different strategies observed in this
study is consistent with previous research (Patterson et al.
2005, Philibert 2009), thus strengthening confidence in the
findings. Finally, it is plausible that the use of handover
8 © 2015 John Wiley & Sons Ltd
strategies and fewer treatment deviations are both influ-
enced by common organizational factors such as safety
climate (Zohar 2002); these impacts should be examined
in future studies.
Practical implications
Our study presents opportunities for interventions aimed to
improve communication during handover. The findings,
which support the association between specific handover
strategies, errors and handover quality, suggest the integra-
tion of flexibility alongside standardized procedures. First,
to ensure that incoming nurses play a more active role in
handovers, training interventions should be developed
aimed at teaching incoming nurses strategies to speak up
and make sure that they receive the information they need
(Weinger et al. 2010, Manser et al. 2013). A more radical
option might be to structure handovers differently, by
allowing the incoming nurse to lead the handover through
a three-stage process: reading the written report, receiving
an impression of the patient and asking the outgoing nurse
for additional information. Second, the finding that inclu-
sion of the team’s stance on care plans is important is not
new, but has been previously indicated in several standard-
ized handover formats such as SBAR, albeit with limited
success (Hilligoss & Cohen 2011, Manser et al. 2013).
Therefore, team-building interventions focusing on under-
standing the respective work roles and their interdependen-
cies (Blickensderfer et al. 1993), developing trust among
the team and highlighting the importance of team situa-
tional awareness (Patterson & Wears 2010), seem most
appropriate. Third, to facilitate checking the medical tech-
nology devices, structuring aids should support the team
communication process during handover by providing
room for assessments. For example, special time during
handover could be devoted to checking the reliability of the
medical equipment and reading written reports and notes,
preferably while the outgoing nurses are still on the ward
or can be reached by email or telephone. Obviously, it is
imperative that nurses be aware of these opportunities for
cross-checking. Fourth, although bedside face-to-face hand-
over allows patient involvement, previous research has
showed that nurses seldom invite it (Patterson et al. 2005,
Cheung et al. 2010). Targeting the participation of the
patient and his or her family in the handover could be
achieved by teaching nurse’s communication strategies and
encouraging behaviours during handover such as calling the
patient by name, being authentic, avoiding professional
jargon and responding to patients’ needs (Muething et al.
2007).
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE
Funding
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
Author contributions
All authors agreed on the final version and meet at least
one of the following criteria [recommended by the IC-MJE
(http://www.icjme.org/ethical_1author.html)]:
 substantial contributions to conception and design,
acquisition of data, or analysis and interpretation of
data;
 drafting the article or revising it critically for impor-
tant intellectual conent.
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