The critical care nurse’s perception of handover: A phenomenographic study

Intensive & Critical Care Nursing xxx (xxxx) xxx

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Research article

The critical care nurse’s perception of handover: A phenomenographic study Linn Loefgren Vretare a,b, Agneta Anderzén-Carlsson a,c,⇑ a

Faculty of Health, Science and Technology, Institution for Health, Nursing, Karlstad University, Sweden Neonatal Intensive Care Unit, Akademiska Sjukhuset, Uppsala, Sweden c University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden b

a r t i c l e

i n f o

Article history: Received 5 June 2019 Revised 14 January 2020 Accepted 22 January 2020 Available online xxxx Keywords: Communication Critical care Critical care nursing Nursing care Nursing handover Patient handoff Phenomenography

a b s t r a c t Objective: To describe variations in critical care nurses’ perceptions of handover. Research methodology: Phenomenographic design using individual interviews for data-collection. Setting: The critical care nurses participating in the study were recruited from critical care units in three hospitals in Sweden. Findings: Five descriptive categories were identified: Communication between staff, Opportunity for learning, Patient-centred information gathering as a basis for continuous care, Responsibility for transfers, and Patient safety and quality of care. Conclusion: Nursing handover is a complex phenomenon, which is understood in various ways. Handover is mediated through communication and marks a shift in responsibility. Handover seems to be related to patient safety and quality of care. There is potential for improvement in the quality of nursing handover in clinical praxis, but further research is needed to determine ways of improving quality of handover. Ó 2020 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Implications for Clinical Practice  This study stresses the importance of handover in clinical settings.  This study raises awareness that nurses might have different views of the aim and execution of handover, which are important to discuss in clinical settings.  This study raises awareness of the complexity of interventions in order to improve handover.

Introduction Patients in intensive and critical care are severely ill and require support for vital functions. These patients are often sedated and their communication impaired, meaning patients can be vulnerable because of their inability to protect their integrity and autonomy. Intensive and critical care nurses strive to protect patients’ integrity and autonomy while providing care for their medical concerns. Patients are transferred to critical care units from various ⇑ Corresponding author at: University Health Care Research Center, Örebro University Hospital, House S, 1st Floor, S-701 85 Örebro, Sweden. E-mail address: [email protected] (A. AnderzénCarlsson).

other care settings such as the resuscitation room, surgery or other wards. When a patient is transferred between hospital settings a handover report is given to staff in the new setting (Morton and Fontaine, 2017). In healthcare settings, handover can be delivered in various ways and according to the World Health Organization (WHO) it is enacted through communication (2007). Norman (2002) proposed that any act could be divided into the stages of purpose, execution and evaluation. The most prevalent factors in the current handover literature, however, are content, structure, communication and context. All of these factors are interconnected, as shown below. A literature search yielded international research regarding handover within general nursing, but no literature on critical care nursing. The identified literature reports multiple purposes of

https://doi.org/10.1016/j.iccn.2020.102807 0964-3397/Ó 2020 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article as: L. Loefgren Vretare and A. Anderzén-Carlsson, The critical care nurse’s perception of handover: A phenomenographic study, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2020.102807

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L. Loefgren Vretare, A. Anderzén-Carlsson / Intensive & Critical Care Nursing xxx (xxxx) xxx

handover. According to WHO (2007), the primary purpose of handover is to convey information. However, in nurses’ experience, the conveyance of information is only one purpose. Another is the opportunity for reflection (Randell et al., 2011). Handover also marks the transfer of responsibility for the patient (Smith et al., 2008) and is described as contributing to patient safety (Manser and Foster, 2011). The literature reveals that the execution of handover varies and the content varies depending on the context. Two studies show varying types of content in handover (Johnson et al., 2012; Smith et al., 2008) including identification, clinical history, clinical status, care plan, and goals (Johnson et al., 2012) or preoperative, perioperative, medications given and adverse events (Smith et al., 2008). Three studies suggest that the quality of handovers can result in a lengthy process (Bruton et al., 2016; Drach-Zahavy et al., 2015; Farhan et al., 2016), while one study indicates that handovers are short (Smith et al., 2008). When the quality of a handover is compromised, the focus shifts to identifying contradictory information and any lack of response to deterioration in a patient (Drach-Zahavy et al., 2015). The structure of handovers also varies (Bruton et al., 2016; Farhan et al., 2016; Manias et al., 2016). In a systematic review of the literature, Riesenberg et al. (2009) found that 69.6% of the included articles investigated SBAR [situation, background, assessment, recommendation], but also identified 24 other mnemonics. The context of handovers is considered an important factor (Farhan et al., 2016; Johnson et al., 2012; Keenan et al., 2013). Some studies describe bedside handovers, which enable simultaneous patient monitoring (Bruton et al., 2016; Smith et al., 2008). Poor handovers have been associated with adverse events (Manias et al., 2016), yet handovers often occur in distracting contexts, such as when a clinician interrupts with something unrelated to the handover or equipment alarms sound (Spooner et al., 2015). Handover is mediated through communication and careful listening is thus important (Jenkin et al., 2007). Despite this, relatively few nurses are reported to double-check that the receiver interprets the information correctly (Manias et al., 2016; Rayo et al., 2014). More experienced nurses, however, have been reported to be more likely to double-check received information (Manias et al., 2016). In previous literature, the evaluation of handover is closely linked to staff’s perception. A survey study [n = 707] asked how health care staff experienced providing and receiving handover. Most health care staff reported that they received good handovers, but nurses perceived their own handovers as more efficient (P > 0.01) than those of other professions (Manias et al., 2016). One literature review was intended to explore intervention studies on nursing handover, but no identified research used validated outcome measures (Smeulers et al., 2014). Thus, the properties of good handover remain unknown. There is not yet enough research to establish a causal relationship between patient handover and patient safety (Manser and Foster, 2011), although two interventional studies have suggested there is such a relationship (DeMeester et al., 2013; Randmaa et al., 2014). According to Manias et al. (2016), 41% of health care staff perceived poor patient handover to be associated with adverse events. According to the literature on patient safety, communication is key to patient safety. Adverse events are mostly linked to the communicator, but they are preventable if the receiver double-checks the information (Reynard et al., 2009). Manser and Foster (2011) pointed out that further research is needed to establish valid handover quality and safety. To the best of our knowledge, there are no previous studies on patient handover upon admission to critical care wards. Such studies could be useful for identifying quality and safety improvement areas in

handovers as a basis for future interventions in this setting. This study was undertaken as to explore critical care nurses’ experiences in patient handover, which has not previously been described in literature. The study included various critical care wards at three different hospitals, as previous literature indicate a variation in the experiences of handover and because handover might vary across different wards and hospitals. Methods Objective The aim of the study was to contribute to the research of handover. The objective was to examine variations in critical care nurses’ experiences in patient handovers during transfers to a critical care ward in Sweden. Design We used a retrospective qualitative design with a phenomenographic approach for this study. Data were collected by individual interviews and a phenomenographic analysis was performed. The interviews focused on previously experienced handovers, thus the retrospective design. A phenomenographic approach is consistent with examining the variations in experiencing a phenomenon (Marton and Booth, 1997) and was chosen since literature suggests there are various ways of conceptualising handover. Setting The study was conducted at critical care units in two university hospitals and one county hospital in Sweden. These specific hospitals were chosen out of convenience. However, they are located in three various County councils, which ensures a variation between hospital policies in Sweden, since the County councils are responsible for hospital care. Ethical approval The study was conducted in accordance with the Declaration of Helsinki (World Medical Association, 2018). Prior to data collection, the ethics board of Karlstad University (registration number C2017/749) reviewed the design and decided that the study did not require a formal ethical application to a regional ethical review board since it did not include sensitive personal data. Written informed consent was collected from all participants, who were informed that participation was voluntary and that they could withdraw consent at any time. During the analysis, all data was kept on a computer, where the data was only accessible to the first author. A code list with the participants’ identities was stored separately in a locked cabinet. All data will be stored at Karlstad University for at least 10 years, according to Swedish legislation and local guidelines. Quotes presented in the Findings section were selected with caution of not revealing the identity of any of the participants. Participants A consecutive sample was used, as is in line with the literature (Marton and Booth, 1997). In this study, this meant that every participant who was suggested by the operational managers on each ward was included until saturation was reached. Inclusion criteria were registered nurses specialised in critical care nursing and currently having a clinical employment at one of the participating critical care wards. Specialised education in critical care nursing

Please cite this article as: L. Loefgren Vretare and A. Anderzén-Carlsson, The critical care nurse’s perception of handover: A phenomenographic study, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2020.102807

L. Loefgren Vretare, A. Anderzén-Carlsson / Intensive & Critical Care Nursing xxx (xxxx) xxx

comprises one-year university studies in Sweden, completed after the three-year nursing degree. An informational letter and a request for help in recruiting participants to the study were sent by email to the operation managers of 13 wards at the three included hospitals. The intention was to recruit participants from various hospitals, with different experience, age, and gender, since these variations may generate variations in experiencing handover. Nine participants from seven units volunteered. Table 1 shows background data for the participants. Data collection Interviews were conducted in November and December 2017. The questions in the interview guide were open ended and were followed up to allow participants to develop their thoughts on the phenomenon in accordance with Marton and Booth (1997). The questions were developed through a review of the literature. One of the first questions was ‘‘Can you describe a normal handover?”. Follow-up questions were posed to make the respondents reflect on their experiences. The first author interviewed the participants as part of her master-thesis. She had no previous experience in interviewing or critical care nursing, and she tried to remain neutral while asking questions to elicit participants’ full understanding of the phenomenon (Assaroudi and Heydari, 2016). The interviews were performed in settings chosen by each participant. Both authors listened to the first two interviews before proceeding with the study. The mean time for each interview was 38.5 min (range: 24.2–58.9). The first author transcribed each interview verbatim.

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compared to the individual transcripts, and themes were then condensed into descriptive categories. The transcripts for each descriptive category were placed in a separate document, allowing the author to identify qualitatively separate ways of perceiving and describing the phenomenon in accordance with the chosen phenomenographical methodology (Marton and Booth, 1997). The five descriptive categories fulfil the method’s criteria as they have a logical relation to each other and to the phenomenon and they are as few as possible. Together they describe the outcome space or range of variation in conceptions of the phenomenon (Assaroudi and Heydari, 2016). Trustworthiness The four parts in ensuring trustworthiness of a qualitative study are credibility, transferability, confirmability and dependability (Shenton, 2004). Despite the limited sample size, the authors consider the sample as appropriate with regard to the objective of the study. However, a strategic sample could have increased the credibility. There is no previous literature on the subject, which justifies the small sample size according to Boddy (2016). Data saturation appeared to be reached since there were a finite number of qualitative different understandings of the phenomenon (c.f Barnard et al., 1999). Transferability is hard to obtain using such a small sample (Shenton, 2004). The reader is to judge the transferability. Dependability was ensured by using an interview guide in all interviews and by consistency in the data analysis. By providing quotations in the Findings section confirmability is illustrated.

Data analysis

Findings

The first author read the transcripts and listened to the interviews multiple times. According to Marton and Booth (1997), the primary analysis inevitably starts during the data collection as the researcher tries to understand the participants’ conceptions of the phenomenon of interest. The material was reread and a second-order perspective of each individual interview was summarised. Both authors conducted the analysis of the first two interviews as to ensure credibility since the primary author lacked experience in qualitative studies, whilst the second author is a registered nurse and researcher experienced in qualitative methods. The first author conducted the rest of the analysis, while the second author served as a critical discussion partner during the entire analysis. All second-order perspective comments were summarised in a collective document and labelled according to the aspects of the phenomenon they represented. Those aspects were condensed into collective themes in which their relationships were structured in a meaningful way. All material was then re-structured into different sections according to the themes. The content of each theme was

The analysis resulted in five descriptive categories, which together constitute the outcome space and illustrate the various ways handover is perceived when a patient is admitted to a critical care unit:

Table 1 Participant demographics.

Total group (n = 9) Lowest–highest (mean) Women (n = 5) Lowest–highest (mean) Men (n = 4) Lowest–highest (mean)

Age

Experiences as a critical care nurse (years)

Experiences as a registered nurse (years)

31–63 (44)

1–38 (15)

5–42 (20)

31–63 (47)

2–37 (17)

8–42 (24)

31–63 (40)

1–38 (11)

1. Communication between staff 2. Opportunity for learning 3. Patient-centred information gathering as a basis for continuous care 4. Shift in responsibility 5. Patient safety and quality of care The descriptive categories were related to each other. Communication between staff was considered a framework through which all the other descriptive categories emerged (illustrated in Fig. 1). There were qualitatively different ways of experiencing handover in each descriptive category. It was seen as both an opportunity for learning through communication and a process of gathering information to create a mental image of the patient. The information-gathering process was in turn seen as a foundation for planning and delivering continuous care. This process, summarised as Patient-centred information gathering as a basis for continuous care, is illustrated along the thick grey arrow in Fig. 1. Handover was also viewed as something that affected patient safety and quality of care through the aforementioned process and as key in taking over responsibility for the patient. Communication between staff

5–39 (15)

Communication between staff could be viewed as a framework in which handover occurred and was considered important. Handover was communicated in various ways, usually as a verbal report, but some participants also described it as including a written report. The written handover was sometimes described as a

Please cite this article as: L. Loefgren Vretare and A. Anderzén-Carlsson, The critical care nurse’s perception of handover: A phenomenographic study, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2020.102807

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L. Loefgren Vretare, A. Anderzén-Carlsson / Intensive & Critical Care Nursing xxx (xxxx) xxx

Fig. 1. Outcome space.

specific document designed for handover and sometimes as the patient’s existing medical records. Most verbal handovers were conducted face to face, but some were conducted by telephone. Telephone handovers were considered difficult, but sometimes inevitable when a patient was transferred from another hospital. Written handovers were perceived as permanent communications since critical care nurses could reread them and double-check the information.

‘‘Then, too, it’s sort of important that you’re still neutral and upbeat [. . .] if you’re [. . . to] take the report from the division, and you can’t be negative [. . .] You have to have a positive touch on everything and not be denigrating or something [. . .] I must not let myself think they’re. . . incompetent and don’t understand anything, because then, then it doesn’t work, the communication, so instead you, you have to be appreciative and you have to [. . .] collectively arrive at a good type of report’’. (P3)

‘‘Since we read through everything, and then ask questions based on what we have just read [. . .], then I would say we are better prepared. Because when you get this, somehow it ends up being this – we’ve seen it, seen in various exercises, that when someone whispers something to someone else and the message always has to get passed on [. . .] somewhere along the line things go wrong’’. (P5)

Structure was considered essential to a good handover, since lack of structure was associated with the risk of omitting essential information. The participants stated that they were open to different structures, but they were sometimes unable to comprehend structures different to those used between shifts on their own ward. Generally, external handovers were conceived as less structured than those between shifts on the ward. Handovers when admitting patients from standardised surgeries were the exception and were perceived as very structured, though variable depending on the individual patient.

On the other hand, verbal reports could include information that would not be found in the medical records such as subtle signs of a patient’s response to a specific medication or information that could aid the staff in getting to know the patient as a person. Handover was perceived as a dialogue in which the critical care nurses could ask questions to obtain information they wanted. They reported that they were careful, however, in asking questions since they risked interrupting the intended structure of the handover. ‘‘Then you can ask questions, and then of course it’s good if you, sometimes you can ask questions directly under this search word, but sometimes you can hold your questions until the report is finished and [the reporting person] has a chance to clarify things to avoid disturbing the structure for the person doing the reporting’’. (P3) In some cases, especially when the nurse doing the handover was perceived to be stressed, the handover was experienced more as a one-way-communication. One-way-communication was considered an obstacle to staff communication as neither nurse would be pleased with such a handover. Communication in handover was thought to depend on a number of prerequisites. The participants experienced better communication in handovers that took place in a quiet room with no interruptions and all parties focused on the communication. Most participants described absence of stress as an important prerequisite to good communications between staff, and some adjusted their communications according to the experience of other staff involved in the handover. A good handover was considered finished when both parties were satisfied. Many participants experienced a ‘good approach’ enhanced communications between staff and was associated with a good handover, and a ‘bad approach’ was associated with a bad handover. Some participants described how their own approach was mirrored in the handover. It was conceived as common sense to be open-minded and polite when recieving a handover.

‘‘We have the same structure but still not quite the same way [. . .] so that I would say it’s guaranteed these are extremely different reports’’. (P1) Opportunity for learning Many participants described how practising verbal handover positively affects the quality of the handover. They perceived handover as an opportunity for learning, during which everyone involved could benefit from each other’s knowledge and experience. ‘‘We work on the same level here – doctors, RNAs – everything is, we focus on the patient and how we’re going to, I can just say. . .‘Now what do you mean exactly?’ or [. . .] ‘I don’t really understand the medication instructions’ or. . . doesn’t matter whether I’ve been working here for a long time [. . .] that I dare to ask, and I think that’s really, really great, and I think it’s important in any reporting [. . .] It might be some new operating technique, for example, sometimes, or you’re just, like, ’No, this [. . .]’ Or a new heart valve that maybe doesn’t need as much Waran [blood thinners] – you can ask right away’’ (P4) The participants also perceived handover as an opportunity to ask questions about ways to optimise care. Knowing why patients were treated in a certain way was considered essential to reduce their length of stay. Patient-centred information gathering as a basis for continuous care Handover was perceived as a given, a normal and unquestioned part of the nursing routine. Upon reflection on its meaning, it was described as part of gathering information and a unique opportu-

Please cite this article as: L. Loefgren Vretare and A. Anderzén-Carlsson, The critical care nurse’s perception of handover: A phenomenographic study, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2020.102807

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nity to share what is important for the particular patient. The information gathered resulted in a mental image of the patient, which in turn was a basis for planning and executing continuous care for the patient. Handover and observing the patient’s status were the most important parts of information gathering upon patient admission. What was considered important in the handover varied. Some critical care nurses expected a full oral report, whereas others used multiple sources of information. Some participants thought reading medical records was being part of the handover, while others considered such information gathering as complimentary to the main source of information. Sometimes the critical care nurses received multiple handovers from various professions. ‘‘Then we’re also [. . .] faxing documents . . . from here, with some information we want before they arrive – about entrance roads, relatives, maybe a little about the patient before they went under the anaesthetic – that is still important for a [patient], prior illnesses, or whatever it might be, and then we get it all faxed back to us before the patient arrives [. . .] from the transferring hospital [. . .] and then you also call and talk to, say, to the district ICU nurse’’ (P2) The patient’s status was considered the determining factor for how much information was needed before initiating patient care. The felt need for information diminished with deteriorating patient status and increased when the patient status reached a more acceptable state. ‘‘If it’s a patient who goes into cardiac arrest there and you just bring them in here [. . .] for obvious reasons, so to speak, we don’t have time to talk to each other [. . .] rather, you have to, like, save the patient’’. (P7) The participants expressed an increased need for complimentary information if their mental image was incomplete after assessing the patient’s status. Information was then gathered from, for example patient records, the police, health care facilities, communications with the patient and relatives, and any other available sources. A complete mental image resulted in a prioritised care plan. Handover was an opportunity to prepare, to avoid duplicating work, to facilitate care, to making the correct decisions about priorities, and to take a step forward in the continuous chain of care. ‘‘If you’ve been given a good handover, you don’t have any questions: ’So what actually happened during the operation?’ ‘In terms of operating technique, things went well – we were on top of the haemorrhaging, we replenished the blood loss, we have a good Hb,’ So then I can take my next step. . . but what is my next step? Okay, I’m going to see that I keep this patient stable [. . .] and I’m going to extubate, and this patient is going to feel as comfortable as possible [. . .] That’s what I mean by extra steps - it’s like my next step – you move forward, you progress as if on a set of stairs’’. (P3) Different units focused on different aspects of care, so handovers varied according to the ward’s focus and affected planning for continuous care. ‘‘Otherwise it becomes overwhelming and starting at zero [. . .] if you don’t know anything. That’s the way it goes, but if you get yourself a solid background and how the latest – it doesn’t have to be, you know, how the whole medical chain of events went, but the most recent [. . .] day, the hours [. . .] what has happened, has it gotten steadily worse or did it suddenly get worse – things like that [. . .] make a big difference [. . .] and of course it is, can really be, you know, associated with life and achieving a good report’’. (P8)

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Transferring responsibility Handover was considered key to taking over the responsibility for a patient’s care. A good handover enabled the continuity of care and allowed the critical care nurse to feel more secure about the shift of responsibility. The participants reported that taking over responsibility was facilitated by reducing the pathways of communication, i.e. having direct communication from the personnel currently in charge to those taking over responsibility for the patient. ‘‘It still ends up being a little worse in the handover [. . .], so you can sometimes feel that it would have been better if that nurse had relieved the one who’d been working with the patient in Emergency [. . .] and could go with the patient’’. (P9) When the patient has been cared for by different staff, during surgery perhaps or ambulance transport, some critical care nurses wished all involved professionals could be involved in the handover or that there be multiple handovers with varying perspective and content. ‘‘Then again, it wouldn’t be a bad thing if the surgeon attended the report [. . .] so the team could hear his take on the proceedings, too, because now it’s actually the anaesthesia staff who come and talk about what the surgeon did’’. (P7) Patient safety and quality of care Communication between staff was considered to be strongly linked to patient safety and ensuring no information would be omitted. Handover was seen as an opportunity to quickly identify disease progression, and all participants feared missing out on information that could prevent incorrect decisions. A good handover was acknowledged to take time from the care of the patient, but to enable quick and correct decisions, thus saving time and improving quality of care overall. Incomplete information in the handover meant that the critical care nurse would have to spend more time gathering information than caring for the patient, thus prolonging decision-making, which was associated with prolonging the hospital stay. At the same time, participants said they needed to engage in critical thinking and to double-check certain information to guarantee the patient’s safety. Handover was seen as an opportunity to bring up factors such as personal requests that might not be important from a critical care perspective, but are important and perhaps determining factors for that particular patient. Handover was a way to get to know the patient and to facilitate continuous care and provides the patient a sense of reassurance. ‘‘Handovers create continuity. Maybe you haven’t met, maybe you don’t need [. . .] to have met the patient beforehand, but if you are given a solid handover, the patient will not feel the large break [. . .] If I go in and say hi to the patient when I start my shift [. . .] then the patient will feel that I know everything, that I know everything about what the patient has been through, I understand this complication that has just arisen, I know that they need this much more pain medication’’. (P6) Discussion Patient admission to the critical care ward entailed a shift in responsibility from the previous care setting. This shift could happen directly from one nurse to another, or it could include multiple professionals. The shift could also be between one hospital and another, in which case there was intermediary staff taking care of the physical transfer of the patient. The shift in responsibility has previously been described by nurses as the main purpose of

Please cite this article as: L. Loefgren Vretare and A. Anderzén-Carlsson, The critical care nurse’s perception of handover: A phenomenographic study, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2020.102807

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a handover (Smith et al., 2008), but this contradicts other sources such as WHO (2007), who state that the main purpose is the transfer of information and maintenance of patient safety. Both aspects were identified in the present study. The critical care nurses perceived handover as a unique opportunity to get to know the patient as a person, which is often difficult as many patients are unconscious on admission. Personcentred care is an internationally known framework through which a health professional establishes a therapeutic relationship to a person, emphasising values respect for the person and mutual understanding (Slater et al., 2017). Getting to know the person is considered vital to person-centred care, which places the patient in context and fulfils that person’s best interests (Andersson et al., 2015). Handover can therefore be regarded as a prerequisite to person-centred care in critical care wards. In a previous study, handover was believed to be improved through mode of delivery, standardisation, contextual issues and education (Manias et al., 2016), which accords in essence with the results of this study. Other studies explore the possibility of implementing technology in handover reports (Johnston et al., 2014; Randell et al., 2011), which was mentioned only in connection to electronic patient charts in this study. In this study, the structure of handover was considered an important factor for good communication, as emphasised in previous studies (DeMeester et al., 2013; Graan et al., 2016; Miller et al., 2009; Randmaa et al., 2014; Riesenberg et al., 2009). However, according to the findings in the present study, more aspects need to be considered to improve handover. What actually does improve handover is yet unknown and future research is called for. Nursing handover was seen in this study as an opportunity for learning through shared knowledge and experience, similar to the results of Randell et al. (2011). The participants also considered nursing handover as an opportunity to improve their own performance as nurses. This result has not been mentioned in previous research, however the survey by Manias et al. (2016) found that 99% of health care personnel experienced a need for communication training and only 24% felt that they had received such training. The critical care nurses described learning to emulate their colleagues in the way they hand over patients and emphasised the importance of experience in patient handover. A previous survey found the same result, although more experienced nurses considered handovers more time consuming (O’Connell et al., 2008). This issue should be considered in clinical praxis. Consistent with the results of this study, WHO (2007) states that structured handover reduces the risk of adverse events and hence improves patient safety. Despite this, no causal relationship between structured handovers and patient safety has been established (Manser and Foster, 2011). Patient safety can be perceived either as reducing adverse events or understanding what factors make care successful (Hollnagel et al., 2015). If handover is the key to making decisions for continuous care, then the patient safety and quality of care ought to be improved if that handover provides the correct information. Handover was considered by our participants to take time from patient care, which was also found in previous research (Brown and Sims, 2014; O’Connell et al., 2008). However, the participants also believed that the handover could contribute to fast and accurate decisions about patient care and thus improve both quality of care and patient safety. Handover therefore seems to be a tool for improving quality of care and patient safety that warrants further investigation.

Study limitations Some possible study limitations have been identified. These are the small sample size, the consecutive sampling and the first

author’s limited research experience. However, the latter was compensated for by the supervision from the second author, who has extensive experience of qualitative inquiries. Conclusion Critical care nurses have various perceptions of handover, yet the majority spontaneously identified the verbal report as the handover. Handover occurs through communication, which is affected by a number of prerequisites. The main purpose of handover is a shift in responsibility, which enables continuity of care. In the specific context of critical care wards, it seems that handover might be one way to enable person-centred care. The participants in this study and previous literature suggest a number of aspects of handover that can be improved. However, improving nursing handover is complex, and improvements will probably require focus on more than one aspect. Further research is needed to draw conclusions about what defines the quality of a handover and what interventions can be used for improvement. Handover is of international concern and seems to be related to patient safety and quality of care, thus it is an area of clinical importance and further research is needed to establish this relationship. The next step for future research on handover is likely to investigate what qualities that make up a good handover, which is of importance in order to establish validated outcome measures in interventions with the intention to improve handover. Ethical approval The study was conducted in accordance with the Declaration of Helsinki (World Medical Association, 2018). Prior to the data collection, the ethics board of Karlstad University (registration number C2017/749) reviewed the design and decided that the study did not require a formal ethical application to a regional ethical review board since it did not include any sensitive personal data. Informed consent was collected from all participants, who were informed that participation was voluntary and that they could withdraw consent at any time. Quotes were selected with caution so as not to break confidentiality. Funding source information None. Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgements Special thanks to all participants who shared their thoughts. We would also like to thank everyone who helped us get in contact with the participants. Furthermore, we wish to thank the translator for proofreading the material and translating all quotes. Author contribution Linn Loefgren Vretare: Contributed with the conception and design of the study, collected all data, performed the data analysis, drafting the article and approval of the final draft. Agneta Anderzén-Carlsson: Contributed with supervision and editing of the conception and design of the study, checked that the data collection was sufficient, supervised in the data analysis and did

Please cite this article as: L. Loefgren Vretare and A. Anderzén-Carlsson, The critical care nurse’s perception of handover: A phenomenographic study, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2020.102807

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Please cite this article as: L. Loefgren Vretare and A. Anderzén-Carlsson, The critical care nurse’s perception of handover: A phenomenographic study, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2020.102807