Empowering nurses through action research for developing a new nursing handover program in a pediatric ward in Iran

Abstract

This study aimed at developing a new nursing handover program in pediatric wards in Iran through action research. Nursing handover is the handover of patient information among nurses between shifts. The participants, including 12 nurses, 2 assistants, a head nurse, and academic researchers as facilitators, worked through two cycles of reflection and action for change over a period of 20 months from 2012 to 2014. The data were collected and analyzed using the concurrent mixed method. Reflection on actions in two cycles resulted in designing and implementing action plans for change, learning in both participants and facilitators, and improvement in nurses' satisfaction with the new nursing handover program. Furthermore, the quantitative data showed a significant decrease in time and cost of nursing handover. This study resulted in the participants' deep understanding about the principles of nursing handover in real world, applicable knowledge through action for change, and reflection on it. Finally, the nurses could establish the foundation of sustainable nursing handover successfully.

Keywords

Action research nursing handover empowerment learning

Introduction

The Joint Commission on Accreditation for Hospital Organizations (JCAHO) stated that failure in communication is a major reason for medical errors in hospitals (Raines & Mull, 2007). In fact, preciseness and clarity in information exchange are very important for a qualitative and safe care. Nursing handover is a prevalent and strong vehicle for exchanging patient information and planning tasks that should be done, priorities, and concerns (Rushton, 2010). The aim of nursing handover is to transfer accountability from one provider to other providers. Other advantages are teaching new nurses, socializing, improving staff's cohesiveness and learning, and helping to know the situation of the ward (Athwal, Fields, & Wagnell, 2009; Chaboyer, 2011; Thomas, 2009; Welsh, Flanagan, & Ebright, 2010). During nursing handover, errors in communications could lead to errors in patients' care; therefore, JCAHO assigned standardization of handover as one of patient safety goals in 2006 (Baker, 2010; Schroeder, 2006). Ineffective handover could lead to major errors in patient safety, ineffective communications, inefficient working environment, lack of coordination, replication and duplication in care, delay in treatment, waste of time, and contradictory recommendations (Chaboyer, 2011; Rushton, 2010).

The role of nurses and families has changed in pediatric wards recently. Previously, all responsibilities were done by professional nurses, but now complete involvement of family is highly supported (Sabet, Moattari, Nikbakht, Momennasab, & Yektatalab, 2015). Studies showed that patients valued having access to information and considered themselves an important part in maintaining accuracy that improves safety and quality (McMurray, Chaboyer, Wallis, Johnson, & Gehrke, 2011; Sabet et al., 2015). Nursing handover in pediatric wards is a time when different information related to families and children and their coping mechanisms is exchanged. This process is a risk for labeling and discrimination among families (consideration of a patient based on a characteristic or class rather than individual merit and lack of attention to other patients). Words and tones of speech that nurses use can have a profound influence on the perceptions of other nurses, which can lead to some preconceptions, labeling (words such as dysfunctional, manipulative, dirty, or crazy), isolation, and avoidance from families (families may not have the opportunity to learn the skill or to connect with the right resources). When families' stress and coping mechanisms are misinterpreted by nurses and these preconceptions and personal judgments are exchanged during various shifts, family-centered care will be compromised (Hutchfield, 1999; Ryan & Steinmiller, 2004).

Considering the importance of nursing handover, improving this process has been addressed by many researchers and some evidence of the impact of this enhancement has been reported. Cases of such evidence have been reported as decreased hospital cost and nursing handover time, decrease in bed falls and bed sore, and increase in patients', nurses', and physicians' satisfaction (Burke & McLaughlin, 2013; Lawrence, Tomolo, Garlisi, & Aron, 2008; Welsh et al., 2010). Since participation and innovation are of utmost importance for improving nursing handover, we tried to use an action research approach to solve the challenges of everyday life. Action research is defined as a group or cycles of actions done by staff in an organization or society to solve problems. In this approach, all beneficiaries and stakeholders in an organization participate in designing, collecting, analyzing, evaluating, and disseminating the result. This approach is a useful method for organizational and professional changes that promote empowerment and authority in staff, and its use has been on the rise (Coghlan & Brannick, 2010; Coghlan & Casey, 2000). In this cooperative research approach, both researchers and beneficiaries participate in the research process and review and re-write the aims of the study frequently, but power is equal among all participants during the process. It is emancipatory and critical and helps people eliminate the tensions of irrational, non-productive, unfair, and unsatisfactory social structures that may lead to limitations in personal growth (Kemmis & Taggart, 2013). This approach is also practical; i.e. all participants try to diagnose the problems, recommend possible solutions, and review the results. Additionally, it is empowering since it helps participants fight with limitations of life and learning simultaneously (Iman, 2012; Iman & Gerusi, 2006; Reason & Bradbury, 2006). Action research is a useful approach for developing innovation, improving healthcare, developing knowledge, understanding in practitioners, and involvement in users and staff (Green & Thorogood, 2009). Although there is a rich body of literature on nursing handovers, most studies have focused on other research methods and have not considered the elements that address nurses' needs effectively (Benson, Rippin-Sisler, Jabusch, & Keast, 2007; McMurray, chabayor, Wallis, & Fetherson, 2010; Ortega & Parsh, 2013). Since nursing handover is context-based (situation may vary from one area to another in relation to number of patients, dependency, staffing level, and the model of care delivery of each ward), it should be ensured that accurate information is frequently collected and communicated at each step of the process (McMurray et al., 2010; Sabet, Moattari, Nikbakht, Momennasab, & Yektatalab, 2014a).

The author's stance (first author) is that this research approach can be fundamental because it seeks to bring together action and reflection, theory and practice, and participation. In fact, the goal of action research is to involve nurses and help them plan, act, observe, and reflect more carefully and systematically. Thus, this study aims at developing a new nursing handover program in pediatric ward through action research. We hope to develop a model that can be transferred to other contexts in other care institutions.

Pediatric ward was selected since communications, participations of families, and safety are really crucial during nursing handover in this context.

Iran, the home of one of the most ancient world civilizations, is a large country with a population of approximately 70 million. More than 98% of the population is Muslim. Iran modern nursing emerged under the situation that Iran was the field of great social and political developments. A review of the Iran contemporary history shows how the response to a social need, and at a critical juncture in the history of the country, would lead to the quantitative and qualitative development of nursing as an academic discipline (Farsi, Dehghan-Nayeri, Negarandeh, & Broomand, 2010). In the 14th year, since the first PhD program officially began, the number of schools that offer PhD programs in nursing has grown to 12 which improved in many field such as research (Heydari & Fatemi, 2015). Nursing research is disseminated through regular research conferences held annually in various parts of Iran. University nursing faculty members are heavily involved in research with quantitative and qualitative method, which is becoming an important part of their roles (Nasrabadi, Lipson, & Emami, 2004). In Iran, nurses make up a significant portion of the employees in the healthcare system that most of them are women. But there is no sex segregation in working environment. Woman and man in the Islamic legal system enjoy equal rights and responsibilities in most instances due to their similarity in terms of human nature. Certainly, difference in rights and responsibilities does not indicate preference of one gender over the other; rather mainly pointing to distinct legal titles to which each woman and man is entitled proportionate to the specific roles that are not interchangeable, in the family (Approval of The Supreme Council of the Cultural Revolution, 2004). So, conducting qualitative research such as action research in this country and in this culture is applicable as other researchers in Iran did it successfully (Mirzabeygi, Basiri, & Yadegarnia, 2001).

Methodology

Participants

The participants, including 12 nurses, 2 assistants, a head nurse, and academic researchers as facilitators, were actively involved in developing a standardized nursing handover process. All the nurses, except for two assistants, had bachelor's degrees. The mean age of the nurses was 34.3 years and their mean working experience was 8.2 years. All the participants were female. These nurses had the role of action researchers. They were involved in thinking, planning, and executing actions that would help understand the situation and change their actions. All of them were guided to set up an action plan and reflect on them in focus group sessions. A matron (the woman in charge of nursing who is responsible for all nurses and strategies of the hospital and serves as a leader) and a clinical supervisor (serves as clinical expert with good leadership skills) were actively involved in this research, too. They supported nurses, provided resources, and revised action plans based on philosophy, vision, and mission of the hospital. The academic researchers included two professors (second and third authors), two assistant professors (third and fourth authors), and a PhD candidate (first author) that led the research as facilitators and outside consultants. As outside consultants, they began by gathering information about the problems, concerns, and challenges from the group members. They also guided the participants and the research process and provided educational resources as the change agent. Physicians, parents, and patients were also actively involved in this process and participated in writing and revising the acting plans. Families and physicians were asked about an ideal nursing handover, their expectations and role in this process, and their ideas were taken in to account too.

Data collection

The participants with the help of the academic researchers as facilitators gathered multiple sources of data, such as observations, interviews, focus group sessions, and questionnaires. Observations were non-interventional and semi-structured, focusing on the key events and activities during handovers. Field notes were written immediately after each observation by the first and second authors. Also the first and third authors conducted nine in-depth interviews with the nurses who were selected through purposeful sampling. Sampling was continued until reaching data saturation point. The inclusion criteria were availability and willingness to complete the interview. A guide was prepared for covering key questions with prompt to encourage responses during the interviews. All the interviews were conducted and recorded in a quiet location and each lasted for 30–45 minutes. Furthermore, focus group sessions were held for reflection on action in both cycles. These sessions lasted for about 90 minutes, and the participants were informed about the time and place of the sessions in advance. The participants were asked to reflect and talk about their experiences fluently while the conversations were recorded.

A questionnaire was also used to assess the nurses' perception about the new nursing handover program. This questionnaire was developed based on literature review and the participants' views (Searson, 2000). The content validity of the questionnaire was assessed using Waltz and Bausell index, and its reliability was confirmed by test re-test method (0.79). Approximately all the participants were actively involved in data gathering during the cycles.

Data analysis

The data were collected and analyzed by first and third authors with the help of the participants using the concurrent mixed method. Besides, inductive content analyses were recruited for analyzing the qualitative data. The interviews, observations, and field notes were transcribed after each section of data collection. At first, the data were approached by being repeatedly read as a whole before being read word by word to achieve immersion and finally to derive codes. Then, the codes were organized and grouped into meaningful clusters. For the purpose of abstraction, the relationships between the categories were identified (Elo & Kyngas, 2007; Helen & Carpenter, 2007). MaxQDA software was used to analyze the qualitative data. In addition, the quantitative data, including nurses' satisfaction and handover time and cost, were analyzed by chi-square test and analysis of variance using the SPSS statistical software.

Ethical considerations

The Ethics Committee of Shiraz University of Medical Sciences, Shiraz, Iran approved the project. Before the study, the participants were informed about the study objectives and procedures and voluntary nature of their participation. They were also reassured about the confidentiality of their information. On top of that, written informed consent forms were signed by all the participants. Since action research has an emergent nature and the role of researchers and participants will change during the cycles, this form was progressively refined and procedural consent was obtained (Winter & Munn-Giddings, 2001). It should be noted that we tried to consider all stakeholders and listened to all minorities' and majorities' voices.

An eight-step research process

The context

From 2012 to 2014, the staff and academic researchers as facilitators started the research in a pediatric ward of Namazi Hospital, Shiraz, South of Iran. Namazi is a public, educational, specialty hospital. Its pediatric ward has 20 beds that admits children between 1 month and 18 years of age with neurology or nephrology defects. In this ward, nursing is based on total patient care and each nurse is responsible for five patients. In total patient care model, nurses are responsible for planning, organizing, and performing all care for their assigned group of patients during the assigned shift (Harkness & Dincher, 1992). In this ward, there are four rooms for 20 children and the presence of parents is mandatory during hospitalization.

This action research included eight steps in two action reflection cycles. Although the inquiry process applied in this project appears to be linear, it actually followed a spiral of steps each of which was composed of a circle of planning, action, reflection, and evaluation of the actions results (Figure 1).

Figure 1.

The eight-step research process.

Observation (step 1)

The first step lasted for about four months, and the facilitators and participants analyzed the situation carefully and discovered the challenges of nursing handover. Analysis of multiple data sources indicated that nursing handover in this ward had many challenges that needed to be modified. The findings showed that nursing handover practices were not holistic since the contents of reports were unstructured and not holistic. Besides, the nurses' ethical and practical involvement was low and the process was not patient-centered. Literature suggests that the content of nursing handover should be holistic containing information, such as physical, psychosocial, spiritual, medical, nursing care, and family needs, at the same time (Rushton, 2010). However, nursing handovers in the study ward lacked such holistic approaches and medical and physical needs were dominant.

Furthermore, nursing handovers in this ward were poorly managed. Time and space management during handovers was poor, as well. In our study, the nurses had to allocate some time for checking the equipment (such as emergency box and necessary utensil related to the ward), leading to a decrease in the time allocated to patients due to priority of checking the equipment because of economic considerations. This is because some equipment is scarce and expensive, and hospitals expect nurses to maintain them as well as possible. Moreover, too many interruptions during handovers lead to inattention and prolongation of the process. Also, there was not a quiet room for handovers that resulted in many interruptions during handovers, which in turn decreased the quality and accuracy of handovers.

Plan for change (step 2)

After analyzing the situation and identifying the challenges, the participants and facilitators took part in two focus group sessions and reflected on challenges, designed operational plans, and prioritized them. Based on the challenges, the participants and facilitators designed an operational plan. In this operational plan, they defined main and specific goals, possible strategies and participants, funding resources, time frame, and evaluation tools for each problem. At first, the participants and academic researchers as facilitators tried to provide facilities and substructures, such a quiet room, job descriptions of staff during handover, forms of nursing handover, and audit tools. Furthermore, the nurses participated in two workshops for empowerment in nursing handover. Literature review in action research has an emergent nature and should be done repeatedly during each step of the research (Craig, 2009). Since choosing the appropriate educational content between the varied literatures is time-consuming and needs sufficient knowledge of English language, the facilitators accepted to prepare educational course contents based on the challenges of nursing handover in this ward. All the participants were encouraged to take part actively in the learning process. They learned about the principles of a standardized nursing handover, ethical and legal issues related to nursing handover, basics of family-centered care, time management skills, communication skills such as verbal and non-verbal behaviors, and listening, writing, and speaking skills which are necessary for nursing handover. Advanced teaching methods, such as role playing, films, brain storming, and lectures, were used in these workshops. For example, the nurses watched a short film without sound and the leader asked them to talk about the film based on non-verbal behaviors. Then, they watched it with sound. Finally, they captured the importance of paying attention to non-verbal behaviors during nursing handover and discussed about it in group sessions. In the role playing session, six nurses sat near each other in a row. The first nurse whispered a small part of nursing handover excerpts to next nurse, the next nurse did it too, and the process continued to the last nurse. The last nurse said this excerpt aloud. Surprisingly, it was completely different from the first nursing handover excerpt. Finally, they discussed about the verbal behaviors and the importance of clarity and voice in speech. This step lasted for about four months.

Action for change (step 3)

The third phase resulted in implementing action plan and immersing in action for change for about two months. In this phase, we encountered some resistance to change and it proved to be hard to accommodate with the new nursing handover program. For instance, it was hard for the nurses to apply nursing handover forms or participate families during bedside handover. They did not communicate with families and children and resistant to participate them in nursing handover. However, the head nurse and facilitators encouraged the nurses to implement the actions and provided them with supportive and constructive feedbacks. One method that helps us to decrease the resistance of nurses was to make them participate in planning and evaluating. The key is to understand the true nature of resistance and modify it.

Evaluation (step 4)

At the end of the first cycle, evaluation was done collaboratively. The participants had a conversation about their experiences during the program and especially focused on the process of action research. Feedbacks and notes from meeting and teaching opportunities were presented to the participants both orally and in writing.

Reflection (step 5)

In the first cycle, knowledge of the participants and facilitators increased, helping them to find subsequent solutions. On the basis of the lessons learned from action in the first cycle, the second cycle started as the participants reflected on group sessions. In fact, there were some weaknesses that needed to be reflected and confronted in group sessions. Like the previous cycle, this cycle consisted of reflection, plan for change, action, and evaluation that lasted for about six months. One important step in action research is reflection. Reflection refers to thinking about thinking in which events, experiences, challenges, or opportunities are reviewed and revised in order to promote a deeper understanding of the context. This understanding can lead to solutions, ideas, improvement, and change. The literature indicates that reflection is a way for personal and professional development, increases commitment to improve quality of care and eliminates the gaps between practice and theory. Reflection is, in fact, seeing issues through different lenses and perspectives and helps people think about their experiences and learning. Learning through experiences is the heart of reflection (Coghlan & Brannick, 2010; Moattari & Abedi, 2008; Moattari, Abedi, Amini, & Fathi Azar, 2003). Before each meeting, the facilitator set up the room providing opportunities for the nurses to get involved in discussions. Gibbs' model of reflection was used to encourage the participants to reflect. Gibbs identified a series of six steps to aid reflective practice. These steps make up a cycle that can be applied over and over. Gibbs model incorporates all the core skills of reflection. Arguably, it is focused on reflection on action. In practice, however, it could be used to focus on reflection in and before action (Bulman & Schutz, 2013).

Planning (step 6)

During the sixth phase, another operational plan was designed and limitations of the first action plan were resolved. The facilitators supported the nurses to write and revise their action plans by giving them feedbacks and suggestions. Also, the matron and supervisors of the hospital reviewed the nurses' action plans and offered specific comments regarding the philosophy of the hospitals. In addition, a meeting was held with the physicians of the ward and their comments were considered in this step.

Action for change (step 7)

In this phase, the participants implemented the new action plans for about three months (Box 1). Fortunately, the participants' resistance was considerably lower compared to the previous cycle, and all the participants tried hard to implement their action plans and reflect on them at the same time. The parents (14 ones) also participated in this phase. They were interviewed about family-centered care approaches in nursing handover by the fourth author. They were asked about an ideal nursing handover and their expectations and role in this process, and their ideas were taken in to account too. As a result, in new nursing handover, they were actively participated in nursing handover and help nurses to plan for new shift.

Box 1.

New nursing handover.

In this regard, one of the mothers said, “I expect nurses to explain about my child's condition during nursing handover and involve me in this process. I really like to learn something about my child's disease.” One other mother also maintained, “I really want nurses to introduce themselves in any shift, I should know who is responsible for my child care, even a smile during nursing handover in the new shift is enough for me.”

Evaluation (step 8)

Finally, in the eighth phase, the facilitators and participants evaluated the results and celebrated the new nursing handover program with all the participants, supervisors, and research team after 20 months.

Findings

Qualitative data analysis in the first cycle revealed various challenges in handover practices in nursing; therefore, it seems essential to modify these challenges. Data analysis resulted in identification of two themes that explain challenges of nursing handover practices: “non-holistic approach” and “poor management during nursing handover.” Reflection on actions in the two cycles resulted in designing and implementing action plans for change and learning in both participants and facilitators (Boxes 2 and 3).

Box 2.

Nurses' reflection about new nursing handover.

With the new nursing handover program, I really can manage time, plan for patients, and prioritized them. Furthermore, I can collaborate with and help other nurses do their tasks during the shift. I have become more responsible, and I try to decrease personal judgments and preconceptions about patients and their families. During reports, I try to manage time by abstracting and listening carefully (Nurse 4).

Box 3.

Researcher's reflection during the research.

Today is the 3rd of June. I was reading an article about the role of nursing assistants in nursing handover and found that we can participate them during nursing handover. Thus, I decided to hold a session with nursing assistants and the head nurse, and talked about this new idea. I think we can improve team cooperation in that ward in this way.

The quantitative data analysis in the first and second cycles showed a significant decrease in the time of nursing handover (Chart 1). According to the results, nursing handovers in this ward lasted for about 47 minutes, most of which being allocated to checking the utensils and verbal reports in a crowded and noisy station. After the program, however, the nurses could manage nursing handover time and allocate more time to bedside handover. In this method, nurses could allocate more time to communicate with patients and their families and assess them carefully as it is illustrated in Box 1.

Chart 1.

Time of nursing handover before and after the program.

In this research, the cost of the nursing handover was calculated by combining the number of nurses with the amount of time each nurse spent for the report process. The cost was calculated before and after the program by the last author. It should also be mentioned that US Dollar (USD) was used in order to facilitate international comparison. Based on the report by the Central Bank of Iran, 12260 Rails (IRR) was considered as the exchange rate in 2012 (1 USD ∼ 12260 IRR). Quantitative data analysis before and after the intervention showed that this research saved $309,641 (Table 1).

Table 1.

Cost of nursing handover before and after the program.

Program	Cost (USD)
Before	339152
After	29511
Difference	−309641

Also, reflection of nurses in the eighth phase showed significant improvement in nurses' perception about new nursing handover. The vital views that were the most representative voices of nurses have been presented in Table 2.

Table 2.

Summaries of the nurses' perceptions about the new nursing handover program.

In comparison to the traditional nursing handover:
1—Are you less or more concentrated?
Much less concentrated	Less concentrated	No change	More concentrated	Much more concentrated
			8	4
2—Are you less or more involved in nursing handover?
Much less involved	Less involved	No change	More involved	Much more involved
			7	5
3—How has time management changed during nursing handover? I have …
Much less management	Less management	No change	Better management	Much better management
			7	5
4—Are you more or less informed about patient conditions?
Much less informed	Less informed	No change	More informed	Much more informed
			7	5
5—Are contents of nursing handover more or less holistic (physical, psychosocial, families, … information)?
Much less holistic	Less holistic	No change	More holistic	Much more holistic
			7	5
6—Do information exchanges focus on nursing and care or other paradigms? They focus on …
Much less nursing	Medical paradigm completely	No change	Nursing and care paradigm	Nursing and care paradigm completely
			12
7—Are you less or more capable of planning for patients' care?
Much more capable	Less capable	No change	More capable	Much more capable
			5	7
8—Are patients more or less informed about their plans?
Much less informed	Less informed	No change	More informed	Much more informed
		3	6	3
9—Is care delivery enhanced or hindered?
Much hindered	Hindered	No change	Enhanced	Much enhanced
			12
10—Is nurse / patient relationship better or worse?
Much worse	Worse	No change	Better	Much better
			8	4
11—“I am comfortable with the new nursing handover”
Strongly disagree	Disagree	No idea	Agree	Strongly agree
			8	4

Discussion

In this action research, we focused on establishing a sustainable nursing handover with the help of the participants based on the characteristics of the context. Knowing the contextual factors in the environment was a key factor in implementing changes successfully. In other words, establishing a sustainable change entails having sufficient insights about the context (Sabet, Moattari, Nikbakht, Momennasab, & Yektatalab, 2014b). In this research, high involvement of the participants, reflection on action, and criticizing the previous actions caused them to know the challenges of nursing handover in practice more deeply.

Our first aim was to understand the challenges of nursing handover in this ward. The results of qualitative and quantitative data analyses showed that nursing handover in this ward had many challenges that needed to be confronted. Analysis of multiple sources of data showed that these challenges were “non-holistic approach” and “poor management.”

The results of this study pointed to poor time and space management during nursing handover. Baldwin and McGinnis (1994) also reported that prolonged verbal reports led to nurses' inability to prioritize patients' needs (Baldwin & McGinnis, 1994). Another challenge was allocation of space. Locating an area far from interruptions and observing patients' confidentiality and privacy are essential aspects of handovers, and the best option depends upon the context (Yurkovich & Smyer, 1998). Similar results were also obtained by Welsh et al. (2010). Their analysis showed that inadequate information, inconsistent quality, limited opportunity to ask questions, equipment malfunction, and insufficient time to generate reports and interruptions limited handovers (Welsh et al., 2010).

Based on the challenges, the participants reflected on their experiences and designed an operational plan, prioritized the plan, implemented action plan, and immersed in action for change for about four months. In planning, we paid attention to the latest recommendations of the literature and research, but applying these recommendations completely depended on the capabilities and substructures of the ward as well as the participants' willingness and acceptance, so that the changes become sustainable. This was one of the strengths of our action research. Other strengths of our study were empowerment of the participants based on the challenges known in the context, high involvement of the participants in these workshops, and their reflections on the actions.

At the end of the first cycle, evaluation was done. On the basis of the lessons learned from action and reflection in the previous cycle, the second cycle started as the participants reflected in group sessions. After that, another operational plan was designed and implemented. Finally, the facilitators and participants evaluated the results. The results showed that the new nursing handover program increased the nurses' satisfaction and decreased the time and cost of the handover significantly.

Nurses' satisfactions

In all health systems, nurses are the largest human sources that have a substantial role in the quality of care. Therefore, their satisfaction and efficacy affects success of the organization profoundly (Curtis, 2007; Dehaghani, Akhormeh, & Mehrabi, 2012; Jahangir & Shokrpour, 2009). Nurses in their profession have a lot of challenges that need to be modified. Recognizing these challenges and finding possible solutions by nurses decrease the challenges and, as a result, these solutions become more acceptable and sustainable. One solution for these kinds of challenges is using action research that has a contextual, group, participatory, and self-evaluation nature and improves collaboration, self-esteem, satisfaction, and power in nurses (Brydon-Miller, Greenwood, & Maguire, 2013; Crozier, Moore, & Kite, 2012; Yang et al., 2013). In the present study, analysis of the nurses’ reflection showed that they were satisfied with the new nursing handover program (Table 2). In fact, approximately, all the nurses were comfortable with the new system. Searson (2000) conducted an action research that introduced bedside handover using a similar tool for assessing nursing perspective. In that study, nine nurses reported that they were comfortable with the new system (Searson, 2000).

Decrease in time

The results of observations revealed that duration of nursing handover decreased significantly after the program and the nurses could allocate more time to bedside handover (Chart 1). Evans, Grunawalt, McClish, Wood, and Friese (2012) in Michigan Hospital decreased the time of handover from 45 minutes to 29 minutes. It is noteworthy that they introduced bedside handover in their wards but introducing bedside handover was not possible in this ward because of the facilities, number of rooms, and participants' acceptance. Yet, different researches have emphasized the importance of bedside nursing handover (Chaboyer, Johnson, & Wallis, 2009; Johnson & Cowin, 2012; McMurray et al., 2011; Tobiano, Chabayor, & McMurray, 2012). Also, Carins et al. (2013) implemented bedside nursing handover program in Pennsylvania Hospital and could reduce nursing handover from 6194 minutes to 5281 minutes for a period (Cairns, Dudjak, Hoffmann, & Lorenz, 2013).

Decrease in cost

A key consideration in determining whether an intervention should be provided in a given hospital setting is whether the effects of a program justify the costs and benefits of providing that program (Donaldson, Currie, & Mitton, 2002; Morris, Devin, & Parkin, 2007). According to Table 1, compared to pre-intervention strategies, post-intervention strategies reduced the costs by $309,641. Athwal et al. (2009) in a hospital in San Diego standardized nursing handover and could save $8000 (Athwal et al., 2009). We expect that our findings will give the nurse managers a deeper perception to confront the challenges of the nursing handover in their wards. In addition, the finding can serve to create a framework for developing this new nursing handover to other wards. Finally, we hope this research helps other action researchers to convey similar studies. We hope to develop a model based upon our experience which will be transferable to other curriculum development initiatives and contribute in theory development.

Our learning

One important part of action research is talking about our learning (Coghlan & Brannick, 2010). As a PhD candidate, this study was like a voyage in which I encountered different challenges and opportunities and earned many benefits. In reality, this was a voyage for change and learning. I learned that learning is living, reflecting on experiences, and changing the behaviors. Also, learning is not limited to a specific time, but it is a dynamic and continual process that is related to all moments of our lives. One of the best lessons action research gave me was that “I am responsible for my life, and I can change it as I wish, but I learned that I can never change others as I would like to.”

Moreover, being actively involved in the research process brings different kinds of knowledge for participants (Reason & Bradbury, 2008; Yorks & Sharoff, 2001). Our participants acquired experimental knowledge by being actively involved in designing and implementing the action plans in practice. Additionally, reflecting on challenges of nursing handover in terms of abstract meaning, themes, and subthemes brought them propositional knowledge, and they acquired practical knowledge of a standardized nursing handover by implementing and experiencing it successfully. One instance of nurses' learning has been described in Box 3.

Validity

Based on the principles of validity in action research proposed by Herr and Anderson (2005), we tried to improve validity through five criteria of process, outcome, democratic, catalytic, and dialogic validity. Using two cycles of action and reflection, high involvement of stakeholders, triangulation, ongoing seeing of the challenges and resolving them based on situational analysis, considering the facilities, acceptance of participants and contextual factors, causing deep understanding and learning in both participants and facilitators, reflections on experiences, disseminating the results, and having critical discussions with other researchers were some strategies for improving validity in our study. Furthermore, prolonged engagement, varied experiences, peer checking, and triangulation were strategies for improving the trustworthiness of the study (Helen & Carpenter, 2007; Polit, Bech, & Hungler, 2006).

Generalizability

Stick (1986) introduced two kinds of generalizability known as formalistic and naturalistic generalizability. Formalistic generalizability is related to experimental research, while naturalistic generalizability is related to research that brings direct experiment and learning, which is more sustainable. The results of this kind of research cannot be generalized but can be transferred from the sending context to the receiving context, which is known as trans-contextual credibility. This means that the participants who conduct the study and the immediate society next to the research context will be informed about the study and its results; as a result, knowledge will be shared with and transferred to immediate societies. This is a milestone in action researches (Herr & Anderson, 2005). We also experienced this kind of transferability in our research, such a way that other wards in the hospital tried to know and learn about our new nursing handover, as well. Overall, this new nursing handover process is recommended to be transferred to other contexts (other pediatric wards) by taking their capabilities and weaknesses into account.

Conclusion

Close collaboration of the nurses and facilitators led to development of a standardized nursing handover. This research identified two challenges of nursing handover in practice. Nurses in a collaborative work succeeded to implement the recommended solutions and prioritized and implemented them in the first cycle. On the basis of the lessons learned from action and reflection in the previous cycle, the second cycle started as the participants reflected in group sessions. This study resulted in improving nurses' satisfaction and decreasing the time and cost of nursing handover. Furthermore, it resulted in deep understanding of the participants about the principles of nursing handover in real world and applicable knowledge through action for change and reflection on it. In this program, the participants learned the principles of nursing handover practically. Understanding the advantages of the new system caused them to want more improvement although some organizational barriers, such as lack of facilities and nurses' workload, restricted their progress. Finally, the nurses could lay the foundation of establishing sustainable nursing handover successfully. Yet, continuity of moving in these paths needs trying to overcome the barriers and supporting nursing profession.

Footnotes

Acknowledgements

The authors would like to thank the Research Vice-chancellor of Shiraz University of Medical Sciences for approval and supervision of this research project. They also would like to appreciate the nurses who participated in this study. Thanks also go to Ms A Keivanshekouh at the Research Improvement Center of Shiraz University of Medical Sciences for improving the use of English in the manuscript. This paper was a part of a PhD dissertation. The author would also like to thank Dr. Svante Lifvergren for leading the review process of this article. We welcome and invite your comments and reactions at our action research community's interactive ARJ blog housed at AR+ .

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: This work was supported by Research Vice-chancellor of Shiraz University of Medical Sciences (Grant No. 916217).

Author biographies

Raheleh S Sarvestani is an Assistant Professor of Nursing, Fasa University of Medical sciences, Fasa, Iran and Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.

Marzieh Moattari is a Professor of Nursing, Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran.

Alireza N Nasrabadi is a Professor of Nursing, Department of Nursing, College of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran.

Marzieh Momennasab is a Associate professor of Nursing, Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran.

Shahrzad Yektatalab is an Assistant Professor of Nursing, Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran.

Abdosaleh Jafari is an Instructor of Health Human Resources Research Centre, School of Management and Medical Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.

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