Medication communication between nurses and patients during nursing handovers on medical wards: A critical ethnographic study

Background: Communication is central to safe medication management. Handover is a routine communication forum where nurses provide details about how patients' medications are managed. Previous studies have investigated handover processes as general communication forums without specific focus on medication information exchange. The effects of social, environmental and organisational contexts on handover communication and medication safety have not been explored. Objectives: To examine dominant and submissive forms of communication and power relations surrounding medication communication among nurses, and between nurses and patients during handover. Design: A critical ethnographic approach was utilised to unpack the social and power struggles embedded in handover practices. Settings: The study was conducted in two medical wards of a metropolitan teaching hospital in Melbourne, Australia from January to November 2010. Participants: All registered nurses employed in the medical wards during the study time were eligible for participation. Patients were eligible if they were able to communicate with nurses about how their medications were managed. In total, 76 nurses and 27 patients were recruited for the study after giving written consent for participation. Methods: Participant observations, field interviews, video-recordings and video reflexive focus groups were conducted. Fairclough's critical discourse analytic framework guided data analysis. Results: Nurse coordinators' group handovers in private spaces prioritised organisational and biomedical discourses, with little emphasis on evaluating the effectiveness of medication treatment. The ward spatial structure provided an added complexity to how staff allocation occurred. Handovers involving patients in the public spaces at the bedside facilitated a partnership model in medication communication. Nurses exercised discretion during bedside handovers by discussing sensitive information away from the bedside. Handovers across different wards during patient transfers caused communication breakdowns because information was not exchanged between bedside nurses. Conclusions: Nurse coordinators need to relinquish organisational control of the handover practice and appreciate the contribution of bedside nurses to patient information exchange. Bedside nurses need to be provided with opportunities to raise questions during the group handover. Designated meeting spaces need to be provided to reduce interruptions to the group handover process.