Clinical Nursing Research2015, Vol. 24(3) 234 –252© The .docx

Clinical Nursing Research
2015, Vol. 24(3) 234 –252
© The Author(s) 2014
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DOI: 10.1177/1054773813508134
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Article
Challenges of Nursing
Handover: A Qualitative
Study
Raheleh Sabet Sarvestani, RN, MSN1,
Marzieh Moattari, PhD, MD, RN1,
Alireza Nikbakht Nasrabadi, PhD, MD, RN2,
Marzieh Momennasab, PhD, MD, RN1, and
Shahrzad Yektatalab, PhD, MD, RN1
Abstract
The aim of this study was to explore the challenges of nursing
handover
process during shift rotation in hospitals. The research had a
descriptive
exploratory design with a qualitative content analysis approach.
To conduct
the study, three pediatric wards were selected at first. Data were
gathered

through a 4-month observation of nursing handovers by
recording the oral
conversations of nurses during the process and semistructured
interviews.
Then, qualitative content analysis was used for data analysis.
Two major
themes and five subthemes emerged through the data analysis.
The first
and the second themes were a nonholistic approach and poor
management,
respectively. In general, applying a holistic approach and
managing handover
situations are recommended for nursing managers to overcome
handover
challenges. Future focus could be on addressing handover
challenges through
an action research study.
Keywords
handover, nursing, content analysis
1Shiraz University of Medical Sciences, Iran
2Tehran University of Medical Sciences, Iran
Corresponding Author:
Marzieh Moattari, Department of Nursing, School of Nursing
and Midwifery, Shiraz University
of Medical Sciences, Shiraz, Iran.
Email: [email protected]
508134 CNRXXX10.1177/1054773813508134Clinical Nursing
ResearchSarvestani et al.
research-article2013
http://crossmark.crossref.org/dialog/?doi=10.1177%2F10547738
13508134&domain=pdf&date_stamp=2013-12-03

Sarvestani et al. 235
Introduction
The nursing change of shift report or handover is a valuable
opportunity to
transfer responsibility and accountability from one nurse to
another in most
hospital wards (Lamond, 2000). It is actually a substantial part
of a nurse’s
duty, and each nurse should allocate 38% of his or her working
hours in a
hospital ward every day to fulfill the handover process (Spanke
& Thomas,
2010). Therefore, handover is a fundamental component of
nursing care for a
nurse to pass on patients’ care plan, practices, information, and
priorities to
the next (Rushton, 2010). Moreover, handover is an opportunity
for nurses’
group cohesion, professional socialization, education,
interaction, and emo-
tional support (Griffin, 2010; Payne, Hardey, & Coleman,
2000). Thus,
handover should be accurate, complete, specific, relevant,
timely, up to date,
subjective, and objective. However, cases of handover that are
inaccurate,
incomplete, and biased may lead to many errors, mislead
nursing practices,
and increase patient complications (Rushton, 2010; Strople &
Ottani, 2006).
A key component in patient safety and care quality is accurate
communi-

cation during handover (Chaboyer, 2011). The Joint
Commission on
Accreditation of Health Care Organizations (JCAHO) has
established stan-
dardizing handover as a priority for improving patient safety
since 2006
(Chaboyer, 2011; Schroeder, 2006). However, a review of
literature reflects
limited research and articles addressing handover, while most of
them high-
lighted the importance of nursing handover and prioritized it for
patient
safety (Baker, 2010; Blouin, 2011; Schroeder, 2006; Scott,
2012; Welsh,
Flanagan, & Ebright, 2010).
Although there are controversies about the efficacy of handover
practices,
some articles highlight the importance of oral shift report that
could not be
substituted by any other method because handover is the only
place where
different aspects of professional nursing care are identified
(Gordon &
Findley, 2011; Manias & Street, 2000; Scovell, 2010);
otherwise, other stud-
ies question its efficacy and report that there is no need to have
an oral shift
report because most of the discussed information could be
located within
nursing documentation, and, therefore, such a practice is time-
consuming
(Manias & Street, 2000; Sexton et al., 2004).
In practice, the complexity of patients’ conditions, lack of
organization,

and different interruptions during handover prolong the
reporting process
(Spanke & Thomas, 2010). In a large scale study of 10
European countries,
Meiβner et al. (2007) explored the nurses’ perception of
handover and the
reason for dissatisfaction among them. She found that 22% to
61% of nurses
were dissatisfied due to “too many disturbances,” “lack of
time,” and “work
organizational factors” (Meiβner et al., 2007).
236 Clinical Nursing Research 24(3)
In general, the goal of nursing handover is the transfer of
relevant infor-
mation and continuity of patient care; however, there is no
agreement about
its content and the related literature recommends different
templates for pre-
senting data (Johnson, Jefferies, & Nicholls, 2012). According
to Schroeder
(2006), the specific component of shift report should include
PACE (Patient
problems, Assessment/Action, Continuing/Changes, Evaluation;
Schroeder,
2006), and other researchers have suggested other templates
such as SBAR
(Situation, Background, Assessment, and Recommendations;
Raines & Mull,
2007). Regarding all such guidelines, the content of handover
must contain
short- and long-term goals. It should also be broad and specific
enough to

meet the patients’ needs. Furthermore, it should contain
information such as
medical and nursing care and physical, psychosocial, spiritual,
and family
needs at the same time (Rushton, 2010).
A body of literature reflects four modes of handover: the verbal
handover
in station, tape recording, written handover, and handover at
bedside. In prac-
tice, the method of handover depends on the patient, the shift
(day, evening,
or night shift), and the model of service delivery (team vs. case
method;
Johnson & Cowin, 2012). Nevertheless, many studies have
confirmed the
efficacy of bedside handovers. (Chaboyer, 2011; Chaboyer,
Johnson, &
Wallis, 2009; Mott & Bradley, 2010; Webster, 1999) For
example, Mott and
Bradley (2010) conducted an action research in three rural
South Australian
hospitals and incorporated bedside handover reports. She found
that bedside
handover was better than office reports in terms of ease and
time efficiency.
Interestingly, level of satisfaction increased among nurses and
patients, and
patients were more involved in their care; it also decreased the
rate of errors
(Mott & Bradley, 2010).
The role of nurses and families has changed recently in
pediatric wards;
previously, all responsibilities were done by professional
nurses, but now,

complete involvement of family is highly supported (Hutchfield,
1999;
Mikkelsen & Frederiksen, 2011). The words nurses use in
describing a family
during shift report can affect how other nurses approach a
family. Although
the goal of shift report is to exchange objective data, value
judgments and
labels often accompany these data. These labels can limit the
opportunity of
families to learn the skills needed to manage the problems and
meet their
essential needs and decrease their involvement. So, applying a
standard
handover is essential in pediatric wards (Ryan & Steinmiller,
2004).
The first step in standardizing handover and introduction of an
alternative
model is to improve our understanding of current practices.
Although some
studies have been conducted in several countries, the handover
practices have
not been well studied in the Iranian health system because the
context is dif-
ferent. Because situational analysis is the first step in changing
the program,
exploring the current conditions of handover is important.
Hence, the aim of
this study was to explore the challenges of handover practices
in Iran to pro-

vide an opportunity for a better understanding of the situation
and help
improve the current practices.
Method
Design
The study was conducted using a descriptive exploratory
qualitative design
with a content analysis approach. Content analysis is a way to
analyze writ-
ten, verbal, or visual information. It actually serves as an action
guide and
aims at providing valid insights from data to attain a broad and
complete
description of a phenomenon (Cole, 1988). In this research, an
inductive
approach of content analysis was used. In this method,
categories are derived
from data during data analysis, which help to attain a richer
understanding of
a phenomenon. Another approach we used during the analysis
was summa-
tive content analysis. This approach is fundamentally different
from the pre-
vious one in that rather than analyzing the data as a whole, the
text is often
approached as a single word or in relation to a particular
content and word
frequency is calculated manually or by a computer (Hsieh &
Shannon, 2005).
Data Collection
Three pediatric wards in Shiraz in the south of Iran were

selected. We gath-
ered multiple sources of data such as observations, interviews,
and record-
ings of oral shift reports. During 4 months of observation
period, 14 handovers
(5 in the morning, 5 in the evening, and 4 at night) were
observed and tape-
recorded. Observations were noninterventional and
semistructured, focusing
on the key events and activities during handovers. Field notes
were written
immediately after each observation. Then, the records were
transcribed ver-
batim and a sample of 130 patient reports was subjected to
summative con-
tent analysis. A coding framework was used to calculate the
type and
frequency of information exchanged during nursing handovers.
Word fre-
quencies of oral shift reports were calculated manually. In
addition, nine in-
depth interviews were conducted with the nurses, who were
selected through
a purposeful sampling. We continue sampling until we have
reached satura-
tion. The inclusion criteria were availability and willingness to
complete the
interview. A guide was prepared for covering key questions that
were general
with prompt to encourage responses during the interviews.
Examples of
interview questions include the following:

Can you describe today’s handover, what are the problems with
the hando-
ver? How do you deal with these problems? Can you provide
any examples?
Would you like to make see any changes? If so, what would
they be? All
interviews were conducted and recorded in a quiet location, and
each lasted
between 30 min and 45 min.
Ethics
The ethics committee of the university approved the project.
Before each
interview, the participants were informed of the aim and method
of the study
and that their participation was voluntary. Besides, they were
told that they
could leave the study at any time they wished. Confidentiality
was ensured so
that no names were mentioned. On top of that, a form was
signed by the par-
ticipants saying that they were informed and consented to the
study.
Analysis
Inductive and summative content analyses were used to explore
the chal-
lenges of nursing handover practices. Content analysis may be
used in an
inductive or deductive way. However, while in inductive
content analysis, the
categories are derived from the data, in deductive content
analysis, the data

are categorized according to previous knowledge or theory (Elo
& Kyngas,
2007). The oral shift report-taped handovers, interviews,
observations, and
field notes were transcribed after each section of data
collection. At first, data
were approached by being read as a whole repeatedly before
being read word
by word to achieve immersion and finally to derive codes. Then,
we orga-
nized and grouped the codes into meaningful clusters. For the
purpose of
abstraction, the relationships between categories were
identified, and two
major themes emerged. The researcher returned to the codes and
reconsid-
ered them to check whether the themes fit the data again. A
second researcher
read the categories and themes for further refinement.
MAXqda2 software
was used for data analysis.
Trustworthiness
The procedures that were used to improve trustworthiness were
as follow:
Coding and categories were sending back to the participant for
possible
revision. A team-based approach (composed of four qualified
nurses in
qualitative research) to analyze data was established to check
the credibil-
ity. It showed a good level of agreement in interpretation, and
some dis-
agreements were resolved through discussion. Prolonged

engagement,
varied experiences, peer checking, and triangulation were other
strategies
for improving the trustworthiness of the study (Helen &
Carpenter, 2007;
Polit, Bech, & Hungler, 2006).
Findings
All the nurses were female with a mean age of 30.1 ± 6.8 years
and mean
experience of 6.9 ± 5.6 years, and all have bachelor’s degree in
nursing.
Data analysis resulted in identification of two major themes and
five sub-
themes. The first theme was a nonholistic approach, and the
second one was
poor management. These are presented in Table 1 and are
explained in the
following section.
Nonholistic Approach
The first theme emerged from data included nonholistic
approaches in nurs-
ing handover practices. The subthemes were
nonholistic/unstructured con-
tent, low nurses ethical and practical involvement, and non-
patient-centered
approach, which are explained separately in the following

section.
Nonholistic/unstructured content. Summative content analysis
of 130 patients
in the oral shift report showed that the contents of nursing
handovers were not
holistic. The total frequency with which information was
mentioned in nurs-
ing handover can be seen in Table 2. This table illustrates that
medical plans
and physical dimensions are more dominant, and nursing care
plans and other
aspects of patient care such as psychosocial, functional,
spiritual, and family
needs are almost unheard-of. In addition, as can be seen in the
following shift
report, the focus was on medical plans and physical dimensions
so that the
reports were not holistic:
Table 1. Main Themes and Related Subthemes Emerged From
Analysis of Current
Nursing Handover Practices.
1. Nonholistic approach
a. Nonholistic/unstructured content
b. Low nurses’ ethical and practical involvement
c. Non-patient-centered approach
2. Poor management
a. Poor time and space management
b. Poor task management

Table 2. Frequency of Information Presented in Patients’
Report.
Information Frequency %
General information
Name 130 100
Age 25 19.2
Diagnosis 54 41.5
Contextual information 21 16.1
Date of admission 11 8.4
Medical history 29 22.3
Physical status
Respiratory function 10 7.6
Consciousness 7 5.3
Discomfort 11 8.4
Urine 16 12.3
Diet 37 28.4
Vomiting 10 7.6
Bleeding 11 8.4
Physical measures
Blood pressure 22 16.9
Temperature 33 25.3
Fluid input 32 24.6
Weight 16 12.3
Nursing intervention
Patient care need 37 52
Nursing care plan 28.4 40
Medical treatment
Consultations 25 19.2
Medications 72 55.3
Surgical intervention 8 6.1
Tests 57 43.8
Plan of care 46 35.3
Doctor orders 16 12.3
Global judgments

Patient condition 17 13
About care 9 6.9
Psychology/personality 9 6.9
Colleagues 28 21.5
Management issues
Patient transfer 12 9.2
Admission 3 2.3
Discharge 17 13
General 30 23
(continued)
X, X was well too, she didn’t have any convulsion, the
physician changed the
Phenobarbital and Dilantin to PO ones. She didn’t have any
sample to send to
laboratory; we didn’t have any problems with her.
Furthermore, analysis of tape records represented that nursing
handover
did not have a structured content. Different presentation styles,
irregular
body, and incomplete wrap up and narration are the categories
emerging from
data analysis. The following excerpt illustrates that the
unstructured content
of the report leads to missing information:
Incharge: Miss X, Do you know her?! Head nurse: Yes.
Incharge: X was well
too, she is NPO for MRI; she had Doppler Sono yesterday, and
its result is in her

file. She is ok and doesn’t have any problem. Next patient Y,
Head nurse: Does
previous patient have EEG for today? Incharge: Oh, yes of
course, I forgot to
mention it.
Nurses’ low ethical and practical involvement. Another
subtheme pertaining to
nonholistic approach is nurses’ low ethical and practical
involvement. Data
obtained from multiple sources indicated that in spite of the
case method car-
ing system, the nurses did not have an active role in the
handover process and
those in charge are the only individuals who have the whole
responsibility.
The following field note and interview showed low practical
involvement of
nurses during handover processes:
Observation 4: One evening, after checking the emergency and
narcotic boxes,
two Incharge sat on chairs in the station and oral shift report
started while other
nurses were preparing medications or speaking with each other
in the station.
In another case, one of the head nurses in the interview stated
that
Table 2. (continued)
Information Frequency %
Family
Care need 15 11.5

Comprehensions 8 6.1
Functional status 5 3.8
Psychological 3 2.3
Social 1 0.7
Spiritual 0 0
In the handover process, all of the responsibilities are for the
one In charge and
other nurses don’t have an active role in this process, and speak
with each other or
do other things, while they must have an active role and listen
to reports carefully
to be informed about patients’ conditions.
In addition, data from observation and tape records showed that
nursing
handovers were not completely ethics-based. Labeling patients,
prejudg-
ments, and inattention to patient and their families’ demands
were the catego-
ries that emerged from the data. The following excerpts
illustrate that nurses
labeled patients and had prejudgment about patients and their
families:
Visitor of X made us nervous; she has a mental problem. She
came every 30
minutes to the station and asked different questions about her
child.
X is a 2-year-old girl that was transferred here from ICU
yesterday; she was opium

poisoned. The nurse of the new shift said: Definitely her family
gave her the
opium, didn’t they?!
Summative content analysis, as shown in Table 2, also shows
that fre-
quency of prejudgments about patients, families, and colleagues
were high in
nursing handover contents.
Non-patient-centered approach. The findings showed that
nursing handovers
are non-patient-centered. Observations revealed that the average
time taken
for handover was 41 min for each shift, only 9 min of which
was allocated to
bedside handover (42 s for each patient on average).
Observation 8: In the second room, the nurses entered while
speaking with each
other; one of them approached the patient and assessed the IV
sheets and its date.
Then without saying anything she went to another patient. This
took 50 seconds.
As you see, we categorized these subthemes—
nonholistic/unstructured
content, nurses’ low ethical and practical involvement, and non-
patient-cen-
tered approach—in one group and subsequently labeled it as
nonholistic
approach.
Poor Management
The second theme that emerged from the data is poor

management during
nursing handover practices. Subthemes were poor time and
space manage-
ment and poor task management.
Poor task management. Data obtained from multiple sources in
this research
showed that nurses encountered task overlap and work overload
during
handover processes.
One. of the head nurses in the interview said,
Job description is not clear during handover processes, so
during this process
nurses should do many tasks simultaneously such as checking
the equipment and
utensils, preparing medications, answering telephones,
responding to visitors,
completing the notes of patients or doing other stuff such as
discharging or
admitting new patients.
Poor time and space management. Data from interviews and
several field obser-
vations also suggested that the time and space of handovers
were not well man-
aged. Poor time management, hasty reports, too many
interruptions, crowded
stations, and no seats to participate in handovers were the
categories.

The results of observations showed that handover lasts for about
41 min,
but time management of the process is not appropriate; at first,
they check the
equipment such as emergency trolley, the narcotics box, and
other utensils for
about 12 min. Then they listen to the oral shift report in the
station for about
26 min and then have a round in patient rooms for about 9 min,
approxi-
mately 42 s for each patient. These data suggest that time
management was
poor, and in this regard, a nurse said,
We should check the equipment carefully because if something
is lost, we must
pay for it, so it takes a long time to check them; as a result, we
report in a hurry and
many important things might be missed.
Or another nurse in the interview said,
We don’t have a place for handover; in the station there are
many people such as
medical and nursing students, physicians and other nurses.
When we are reporting,
we should answer phone calls, questions from families and
physicians and in the
meanwhile focus our mind to report, and it is impossible. There
are many
distractors that lead to inattention.
As can be seen, we categorized these subthemes—poor task
management and
poor time/space management—in one group and labeled it as
poor management.

Discussion
The aim of this study was to explore challenges of nursing
handover practices
in Iran. The findings indicate that there are various challenges
in handover
practices in nursing, and, therefore, it seems essential to explore
these chal-
lenges in our health system. Data analysis resulted in
identification of two
themes that explain challenges of nursing handover practices,
namely, non-
holistic approach and poor management during nursing
handover.
Findings showed that nursing handover practices were not
holistic
because the contents of report were not holistic and structured.
The nurses’
ethical and practical involvement was low and non-patient-
centered.
Literature suggests that the content of handover should contain
information
such as physical, psychosocial, spiritual, medical, and nursing
care and
family needs at the same time (Rushton, 2010). However,
nursing hando-
vers in the studied wards lack such holistic approaches, and
medical and
physical needs are dominant. This fact is confirmed by other

studies in our
country. Irajpour, Alavi, Abdoli, and Saberizafarghandi (2012)
and
Yektatalab, Kave, Sharif, Fallahi Khoshknab, and Petramfar
(2012), in two
qualitative studies, showed that health care in Iran is based on
“Medical
Paradigm” in which professionals treat the clients as biological
entities,
that is, they pay all their attention to meet the clients’
biological deficits and
needs, thereby neglecting many aspects of care such as
educating patients.
According to Moattari, Ebrahimi, Sharifi, and Rouzbeh (2012),
ensuring
adequate access to education for all patients is a clear challenge
(Moattari
et al., 2012).Other Findings showed that health professionals
who follow
medical approach may neglect the clients’ nonbiological (i.e.,
psychoso-
cial) needs and problems (Irajpour et al., 2012; Yektatalab et
al., 2012). In
addition, Momennasab, Moattari, Abbaszade, and Shamshiri
(2012) high-
lighted the importance of attention to spiritual needs of patients
in a reli-
gious context such as the Iranian society (Momennasab et al.,
2012).
Medical paradigm in our country is dominant and leads to
medical oriented
approach in nursing practices even in nursing handovers
(Hagbaghery,
Salsali, & Ahmadi, 2004). In Addition, Ekman and Segesten
(1995) stated
that “nurses receive deputed power of medical control and little

attention is
paid to nursing needs during handover” (Ekman & Segesten,
1995,
pp. 1006-1011). Nikbakht, Juliene, and Emami (2004)
highlighted this
medical oriented paradigm and explained that it could be due to
the patriar-
chal social structure in Iran, because the most respected health
care pro-
vider is an experienced, male physician (Nikbakht et al., 2004).
Emami and Nikbakht, in a qualitative study in 2007, showed
that nurses in
Iran work based on task-orientated approach. This appears to be
due to nursing
curriculum in Iran whose focus is on a biomedical and task-
orientated approach.
Therefore, it affects how nurses prioritize their working tasks
(Emami &
Nikbakht, 2007). As Nikbakht et al. (2004) suggested, schools
of nursing must
prepare students to deal with the consequences of conflicting
models by
helping the faculty revise the curriculum to reflect a creative
and culturally
based philosophical perspective (Nikbakht et al., 2004).
Our findings showed that the current handover practices do not
have an
organized structure, and this is one of the challenges that lead
to many prob-

lems such as lack of concentrations and missing or forgetting
important infor-
mation, while structural contents of the report allow meaningful
organization
of large amounts of data (Yurkovich & Smyer, 1998). Dowding
(2000) con-
ducted an experimental study to assess the effects of changing
the style and
content of the nurses’ report on nurses’ ability to plan patient
care. Results
indicated that such type of report had a significant effect on
nurses’ ability in
planning patient care, accuracy of information and the ability to
recall the
information they heard (Dowding, 2000). Therefore, providing a
template for
presenting patient information may increase the quality,
accuracy, and speed
of handovers. Analyses of multiple sources of data showed that
handover
process is not a collective action. Moreover, nurses’ ethical and
practical
involvement was low, and they had an inactive role in this
process. Inadequate
nursing staff may cause this situation in nursing handovers in
Iran because
some of the nurses should check and prepare the medications,
some of them
should listen to oral shift reports, and others should go to
patients’ rooms for
monitoring IV sites and sheets. Furthermore, the nurses know
that the ones in
charge have the whole responsibility and should listen to the
reports carefully
to transfer the important information to other nurses, so they do
not partici-

pate in this process actively. Yektatalab, Kave, Sharif, Fallahi
Khoshknab,
and Petramfar (2011) believed that this impaired care is due to
nursing short-
age, lack of competent nurses, high workload, lack of job
security, and low
salaries in Iran (Yektatalab et al., 2011).
While literature and studies emphasize the collective function
of hando-
vers (Ekman & Segesten, 1995; Scovell, 2010; Strople & Ottani,
2006), this
process was not so in the studied wards. Handovers provide an
opportunity
for professional communication, supporting role socialization
and develop-
ment of a cohesive group process (Yurkovich & Smyer, 1998).
Unfortunately,
studies in our country show that teamwork in our society and
health care
system are poor and need to be improved (Mojdeh,
Memarzadeh, Abdar
Isfahan, & Gholi Pour, 2009; Tafreshi, Pazargadi, & Abed
Saeedi, 2007). In
addition, Meiβner et al., 2007 found that “poor support from
colleagues” was
a reason for dissatisfaction during shift handover in Europeans
nurses
(Meiβner et al., 2007).
However, we found that handovers can become vehicles for
gossiping
and labeling each other, with the potential for undermining the
relation-
ships and trust among nurses during handovers. This finding is
consistent

with the result of Payne et al. (2000) indicating that these
judgments are
frequent in handovers (Payne et al., 2000). Code of ethics in
Iran was for-
mulated in 2010, but to achieve more, it seems essential that we
compile
codes of nursing ethics at different levels of nursing practices
such as nurs-
ing handovers and educate nurses in workshops and seminars
(Sanjari,
Zahedi, & Larijani, 2008). The American Nurse Association
code of ethics
for nurses recommends the value of a guide to nursing handover
(American
Nurses Association, 2001); however, because Iran is an Islamic
country,
and gossiping, labeling, and prejudgments are taboos based on
teachings of
the religion, it is undoubtedly necessary to provide a national
code based on
our sociocultural norms in this field. Nursing in Iran is
perceived as a holy
and honorable job, so Islamic principles provide a promising
guide to ethi-
cal codes of nursing taking Iranian culture and religion
(Larijani, Zahedi, &
Malek-Afzali, 2005; Nikbakht, Emami, & Parsayekta, 2003;
Sanjari et al.,
2008).
Another important aspect of the holistic approach in nursing

handover is
patient-centered care. Our study showed that patient
participation was low
and they were mostly passive onlookers, while the findings of
McMurray,
Chaboyer, Wallis, Johnson, and Gehrke’s (2011), which
examined patient
perspective of nursing handover in Queensland hospitals,
showed that
patients valued having access to information and considered
themselves an
important part in maintaining accuracy that improves safety and
quality
(McMurray et al., 2011). Nowadays, patients desire to move
from a parent
model of care to a collaborative model of care, especially in
pediatric wards
that focus on family-centered care (Anderson & Mangino, 2006;
Hutchfield,
1999; Mikkelsen & Frederiksen, 2011). Like many Asian
countries, Iran is a
family-oriented society, so family members express concern
about the
patient’s problem and provide support for their loved ones
(Moattari,
Hashemi, & Dabbaghmanesh, 2013). The results of our study
showed that
patients’ and families’ participation is ignored. Vasli, Salsali,
and Tatarpoor
(2012), in a qualitative study in Iran, assessed the perspectives
of nurses on
barriers of parental participation in pediatric wards. Four main
themes
emerged as barriers of parental participation in pediatric care,
namely, mutual
motivation and interest in parties, lack of support for nurses,

nursing short-
ages, nurses’ workload, and poor teamwork between nurses and
physicians,
confidence in the nursing profession, and finally undefined role
for mothers
(Vasli et al., 2012). Timonen and Sihvonen (2000) interviewed
families and
found that main reason for them not participating during
handover were lack
of encouragement, nurses concentrating on their papers, using
special lan-
guage, and lack of time (Timonen & Sihvonen, 2000). Thus, we
should con-
sider these findings to improve and strengthen parental
participation during
handovers.
Another theme that emerged from our data was poor
management. Based
on the results of this study, time and space management during
handovers
is poor. Baldwin and McGinnis (1994) reported that prolonged
verbal
reports lead to nurses’ inability to prioritize patient needs
(Baldwin &
McGinnis, 1994). In our study, nurses had to allocate some time
for check-
ing the equipment, so the time allocated for patients decreased
due to the
priority of checking the equipment due to economic
considerations. It is
actually because some equipment is rare and expensive, and

hospitals
expect nurses to maintain them as well as possible.
Furthermore, too many
interruptions during handovers lead to inattention and
prolonging the
process as well.
Another challenge was allocation of space. Locating an area far
from
interruptions and patient’s confidentiality and privacy is an
essential aspect
of handovers, and the best option depends on the context
(Yurkovich &
Smyer, 1998). In these wards, there was not a quiet room for
handovers, lead-
ing to many interruptions during handovers, which in turn
decrease the qual-
ity and accuracy of handover. In addition, Nikbakht and Emami
(2006) found
that institutional circumstances are an issue for nurses in Iran.
Welsh et al.
(2010) found the same result as the current study. Their analysis
showed that
inadequate information, inconsistence quality, limited
opportunity to ask
questions, equipment malfunction, insufficient time to generate
reports, and
interruptions limited handovers (Welsh et al., 2010).
Task overlap was another problem that interfered with
handovers. During
handovers, the nurses should do many tasks simultaneously.
Task overlap
leads to inattention that will cause many errors during oral shift
reports. Lack
of definite job description for nurses during handovers in our

health system is
the key reason for such task overlap. Mayor, Bangerter, and
Aribot (2012)
found that mean handover duration per patient increased with
increasing task
uncertainty, and they recommended that redesigning of
handover procedure
should take task uncertainty into account (Mayor et al., 2012).
A qualitative
study conducted by Nikbakht et al. (2003) supported the finding
that work
pressures, insufficient time, and lack of resources hindered
nurses from doing
their work (Nikbakht et al., 2003).
However, our study has some limitations that should be
considered. The
study took place in pediatric wards, so there are limitations for
generalizing
our findings to other clinical settings. Thus, it is recommended
that further
studies be conducted in other wards. Furthermore, although we
had field
observations, we may miss other challenges although we have
reached satu-
ration. Despite these limitations, the findings captured a good
picture of the
current situation to better understand the current nursing
handover practices
and provide a foundation to plan and implement appropriate
change.

Conclusion
Qualitative and quantitative analyses are ways to reach a better
understanding
of the challenges of nursing handovers. In general, analysis of
multiple sources
of data indicated that nursing handover process had many
challenges that need
to be modified. Applying a holistic approach (designing a
holistic content,
encouraging nurses’ participation, and involving patients) and
managing the
handover process (determining job description and allocating
specific time and
space) are some strategies for improvement. The findings of the
present study
challenge nursing managers to develop new strategies that can
improve nursing
handovers, which can in turn facilitate changes that increase the
nurses’ level of
work satisfaction; as a result, these can lead to a higher level of
patient safety
with a higher quality of care. Nursing handover is a skill that
requires education
and practice, so, in this regard, in service education is highly
recommended.
Because standardization of handover practices completely
depends on the con-
text (culture, philosophy, needs, facilities, priorities, and
economic consider-
ations in each organization are different), future focus could be
on addressing
handover challenges through an action research study in which
the identified
problems will be addressed by including those who are part of
the process to act

on their own behalf to solve real-world problems.
Acknowledgment
The authors would like to thank the deputy chancellor for
research of Shiraz University
of Medical Sciences for the approval, supervision, and funding
of this research proj-
ect. The authors would like to thank those who helped them
carry out this study and
the nurses who participated in this study. The authors would
also like to thank Dr.
Nasrin Shokrpour at the Center for Development of Clinical
Research of Nemazee
Hospital for editorial assistance.
Authors’ Note
R.S.S. was responsible for the study conception and design.
R.S.S. performed the data
collection. R.S.S. and M. Moattari performed the data analysis.
R.S.S., M.
Momennasab, S.H.Y., and A.N.N. were responsible for drafting
the manuscript.
R.S.S., M. Moattari, M. Momennasab, S.H.Y., and A.N.N. made
critical revisions to
the article for important intellectual content. M. Moattari
obtained funding. M.
Moattari, M. Momennasab, S.H.Y., and A.N.N. gave
administrative, technical, or
material support. M. Moattari and A.N.N. supervised the study.
This paper is a part of
PhD dissertation of Raheleh Sabet Sarvestani.
Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with
respect to the research,
authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial
support for the research,
authorship, and/or publication of this article: Vice chancellor of
Research in Shiraz
University of Medical Sciences (Grant Number: 916217).
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Author Biographies
Raheleh Sabet Sarvestani is a PhD student of nursing, Student
Research Committee,
Shiraz University of Medical Sciences, Shiraz, Iran.
Marzieh Moattari is a professor of nursing, Department of

Nursing, College of
Nursing and Midwifery, Shiraz University of Medical Sciences,
Shiraz, Iran.
Alireza Nikbakht Nasrabadi is a professor of nursing,
Department of Nursing,
College of Nursing and Midwifery, Tehran University of
Medical Sciences, Iran.
Marzieh Momennasab is an assistant professor of nursing,
College of Nursing and Midwifery, Shiraz University of
Medical Sciences, Shiraz,
Iran.
Shahrzad Yektatalab is an assistant professor of nursing,
College of Nursing and Midwifery, Shiraz University of
Medical Sciences, Shiraz,
Iran.

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