Communication in Verbal Hand-Over Reports: Nurses´ Experiences from
In-Patients Hospital Units in Saudi Arabia - Qualitative Study

(	Haniha Alyamany Correspondence: Haniha Alyamany Email: alyamany-haniha@hotmail.com

Abstract Background: Nurses as professionals provide care for patients in many areas of health care, from disease prevention to curative care. Nurses are communicating with each other and with other health care workers, in order to provide good nursing care for the patients. Communication between health care team workers requires competence and awareness of communication skills, for the safety and the well-being of the patients. Any failure in communications between health care team workers can directly or indirectly affect the patient negatively. The area of verbal hand-over reporting is considered as an important part of health care. Verbal handover reporting enables the exchange of patient information, and handing over nursing care responsibilities from one shift to another shift. Communication between nurses is a very important part in daily nursing care practice and can affect the quality of care, especially if there is miscommunication between the nurses which can affect patient safety. Aim: To describe nurses` experiences of communication during verbal hand-over reporting, on in-patient units. Method: Qualitative, semi-structured open ended interviews were carried out with ten participants. Content analysis method is used to analyse the data in this study. Result: The result of this study was shown according to the main themes which were selected. Three themes were identified from the data as a result of the nurse's experiences during communicating the verbal hand-over reporting: Advantages of verbal communication in nursing hand-over reporting, challenges of verbal communication in nursing hand-over reporting, and the impact of verbal hand-over reporting on nursing care were studied. Conclusion: The hand-over verbal communication experienced between the nurses had many advantages which can be connected with nurses´ satisfaction in providing high quality care and that this reflects positively in patient's satisfaction and safety. The points considered as challenges are related and connected to; miscommunication, misunderstanding, incomplete patient data and language issues. The advantages and challenges shown in the result section of this study are important factors to be taken into consideration, for further research in the area of communication in hand-over reporting. Further research in the field can lead to improved safety and quality of care for patients in hospitals in Saudi Arabia. Keywords: Hand-over report, nursing communication, verbal hand-over reporting, nursing shift reporting

Introduction
Nurses constitute the largest group of health care providers in most countries in the world. Nurses as professionals provide care for patients in many areas of health care, from disease prevention to curative care (Oulton, 2006). Although nurses are the largest group of health care providers, many hospitals have a shortage of professional nurses which can in turn affect patients' care. As a result of this, many countries throughout the world are striving to improve staffing levels of professional nurses in their hospitals (Buchan & Calman, 2004). Saudi Arabia is one such country which has a shortage of nursing staff. The government is now working intensively in the area of nurse education and nursing practice to improve the situation. Saudi Arabia started its own health education programmes in Riyadh in 1958. The main goal was to increase the number of trained Saudi national nurses working within the health care services (Almalki, FitzGerald, Clark, 2011). The Ministry of Health has shown that Saudi Arabian nationals represent less than one quarter of the workforce in the health care sector in Saudi Arabia (MOH 2008; WHO, 2006). Even though there is an increase in the number of graduated Saudi nurses, the majority of the nurses in Saudi Arabia are recruited from abroad, in order to cover the shortage of nurses. There are therefore many challenges faced in these multi-cultural workplaces, which include clashes of beliefs and value systems which can be different from the Saudi culture (Mebrouk, 2008). There are even challenges in the areas of communication within the health care facilities. English is the official recognised language used in the health care sector in Saudi Arabia. Most of the nurses working in the services, both Saudi and non-Saudi, have English as a second or even as a third language. This can lead to gaps in communication between nurses and patients, since most of the patients are Saudi nationals and are native Arabic speakers (Simson, Butler, Al-Somali & Courtney, 2006).

Background

Nursing
Nursing entails providing care to; promote health, prevent illness, to recuperate health, and eliminate patients´ suffering. In addition nurses have the responsibilities to provide care with respect for the individual and provide equality in the care given for the patients and their families (International Council of Nurses, 2006).

Nursing care is a way of enabling patients and empowering them, also by having communication skills with patients and other health care worker to be able to give the right information (Lewis, Heitkemper, Dirksen, O`Brien Bucher, 2007). The information received regarding the patients status through nurses or other health care providers is used to provide the high quality care and to solve patients' health problems. Therefore the good assessment by nurses can provide the correct information regarding the patients, that help nurses in having the full pictures of the patients' condition between the health care providers (Lewis, Heitkemper, Dirksen, O`Brien Bucher, 2007;Mayor, Bangerter & Aribot, 2011).

Nurses play an important role in ensuring patient safety. Nurses and health care providers are making the clinical diagnosis and taking the discussions, planning the care and treatment for the patients. Moreover, they are providing the care and intervention regarding the information they get about the patients. Therefore communication between the nurses is considered as a very important part in the care, because any incomplete information can cause harm for the patients' (Schuster & Nykolyn, 2010). To ensure safety and quality of care for the patients, nurses are exchanging information between them and other health workers staff. The clinical hand-over between nurses regarding the patients' assessment, diagnosis; and treatment that constitutes the hand-over, helps the nurses to achieve the patients' satisfaction and safety (S.M. Borowitz, Waggoner-Fountain, Bass, 2008). Patient safety is the way of providing safe care for the patients, which includes the prevention of medical errors and reaches the widespread support, and maintains safe practice by health care workers (Leape, Berwick, 2005).

In-patient unit
An in-patient unit is the area where the patients are admitted to in the hospital. These patients are often coming to the unit directly from the Emergency department or from other clinics, to receive treatment and care given by health care professionals. The in-patient units are categorized according to specialties and if they are medical units or surgical units (Evashwik, 2005; Williams & Hopper, 2011).

Communication
The word communication comes from the Latin which is communicatio and that means the combined or alternate interchange and the comminico means division (Levinson & Chamumeton, 1999). People are communicating to exchange and share their ideas between each other and to find out what the other person is thinking and feeling which can build an intimacy to share and find solutions for their problems (McCarthy, 2011). Communications is used as a process of exchanging messages between two or more people, sender and receiver (McCarthy, 2011). Communication is considered as a primary need for the human being (Levinson & Chamumeton, 1999). Human communication is the way of sharing knowledge and experiences between people. Moreover communication is a basic ingredient of social behaviour. There are several forms of communication; language is one of these forms. Language as a form of communication for human beings include: speech, writing, gestures and broadcasting. Interpersonal communication is the way of sharing the message between people which help in exchanging the meaning of this message between them (West, Turner, 2011). Moreover interpersonal communication can allow the person to gain knowledge and understanding about the individual. Therefore it is important in communication that there is clarity in the expression in order to receive the people's needs through the communication (Cypress, 2011).

In communication a message has two parts, expressing verbal message of the sender which includes thought and feeling. Non-verbal is a message expressed through body language. In communication, verbal messages are sent through words, voice tone and rate of speech. Non-verbal communication includes messages sent by body language through for example facial expressions. Between the sender and receiver in communication there will be both verbal and non-verbal messages to transfer feelings and thoughts. Moreover each person in the communication will be the sender and receiver (Littlejohn & Foss, 2008).

The most usual activities in human life for people are the ability to talk and being understood. Communication is an important activity to human life; communication is considered as central to social life. In addition to this peoples' lives can be affected by the way of communication between people. Communication is an important term used in the English language; many schools have defined the term communication: one definition is "the process that links discontinuous parts of the living world to one another" (LittleJohan, Foss, 2008, P. 3). Some definitions of communication mentioned the message sent from the person to the message received by the other one; many meanings are included in the definitions about communication success, effectiveness, or accuracy. Communication is connected to the meaning of success, because it is successfully sending the ideas between the people. Communication as a concept has no right or wrong meaning, it is dependent on the kind and prospect of the communication (Littlejohn, Foss, 2008). The fundamental unit in communication is made up of three parts; sender, receiver, and a message sent during the specific context. The message which is transferring the information from the sender to the receiver can be, in words as speech, like saying something or doing something like smiling. Therefore every message in the communication has content which can have meaning. In addition to this communication between two persons it has reason or history with a goal or future plan that can be affected by their previous experiences for each individual (Ellis, Gates & Kenworthy, 2003).

Communication is the main part of the human daily life and it's more important when it comes to health care. Communication in health care can mean the difference between life and death. In the nursing profession, communication is recognized as a main theoretical ingredient (Cypress, 2011). The relationship between health workers and how they receive the responsibilities of care relies on the quality of communication. Good communication in health care depends on many factors such as; the gender of the clients, the age, the level of education of the client and the health situation and their ability to communicate (Levinson & Chamumeton, 1999).

History of communication as an academic subject
Communication was established as an academic subject after the First World War; it was promoted as a subject by the philosophers of the twentieth century. The development of communication helps the society to improve and have big social change. In the middle of the twentieth century communication became an important academic subject because of the notice it was given about what it can accomplish. Communication as an academic subject was incorporated in many university departments as a subject in areas such as; Science, Arts, Mathematics, Literature, Business, and Political Science. Communication is a major concept right across the university curriculum, because it is a social activity between people and social processes which is an important factor in society. Moreover communication is considered as a factor which can make changes in different cultures in society. Communication provides the right way of understanding of human interaction (Littlejohn & Foss, 2008).

Forms of communication
Communication is a composition of verbal and non-verbal attitudes integrated for sharing information; it also has a general meaning which is meta-communication. The information which is being exchanged is between individuals and it is also a way of carrying the information between the individual; it's the complete meaning of communication (Arnold & Boggs, 2007; Taylor, Lillis & LeMone, 2005).

Meta-communication
Meta-communication is the mixing of verbal and non-verbal behaviour involved in the process of sharing information. It includes the exchanging of the information, culture, native language and body language with verbal and non-verbal communication (Arnold & Boggs, 2007).
Meta-communication is used to describe the factors that can affect the message during communication. Meta-communication is about how the person can explain the meaning of the message through both verbal and non-verbal communication. This can be shown in nursing communication during verbal communication which can also show respect for the patients through eyes contact, and body language such as head nodding. In meta-communication the people who communicate can transfer the positive and negative expressions. Therefore meta-communication can be used as a method to control the way of communication (Arnold & Boggs, 2007).

Verbal communication
The way of exchanging information by using words which include: both the methods of speaking and written words. This type of communication is dependent on the language which is the way of prescribing the use of words that can allow people to share information between them. Nurses are using this form of communication when they are providing care to patients or their families and when they are giving oral reports to nurses and health care workers (Taylor, Lillis & LeMone, 2005).

Non-verbal communication
Transmission of information between people without using words is regarded as non-verbal communication. The usual term for this form is body language communication, which helps in finding the meaning which others cannot express in their words. Non-verbal communication can add more meaning to the verbal communication which can be show in the face of the person all the expressions that they want to show to others. Nurses must be aware of other kinds of communication to be able to cover all the patients needs (Taylor, Lillis & LeMone, 2005). There is another communication method which is by telephone or other electronic means and that method of communication has reduced the effect of gestures and other non verbal communication (Riley, 2012).

Health care worker communication in hospital settings
Health workers` communication skills are the execution of specific tasks and attitude to obtaining things like patients' history or exploring some diagnosis and prognosis, or giving some medical instructions. Communication between the health team workers requires competence and awareness of communication skills, because they need to send clear messages between them which are related to the well-being of the patients. Failure in communications between health care team workers can affect patient safety (Duffy, Gordon, Whelan, Cole-Kelly, & Franel, 2004).

Communication is a very important part in the health field and can affect the quality of care if there is miscommunication between the health care workers. Communication between health workers includes health promotions, disease prevention and patients' assessment, diagnosis and treatment and even includes informal information. Moreover there is another area of communication for the health care worker which is communication with the patients and their families. There is evidence that the communication with patients directly or indirectly between the health care providers, affects patients' satisfaction (Servellen, 2009).

Communication skills in nursing
The nurses communicate all the time with patients, their families and other members of the health care team (Riley, 2012). It is very important that the health care providers and nurses have good communication skills. Moreover, they should have the ability to be good listeners and encourage each other in the health team to provide effective communication in order to collaborate to provide high quality care to the patients (Schuster & Nykolyn, 2010). In addition communication and other factors such as leadership, and teamwork contribute toward patient safety. The most important of these factors is communication which is considered an important factor because effective communication completes the care from these other factors (Greenberg, Regenbogen, Studdert, et al. 2007).

Hand-over reporting
The term hand-over refers to reporting; it is the transmutation and exchanging of information between the professional health care workers either during change of shift duty or transferring of patients within the hospital or to other hospitals (O'Connell & Penney, 2001; Hohenhaus et al, 2006). The information which nurses are communicating with each other, during the change of shift, which relates to the patients, is called nursing hand-over report (Mitton & Donaldson, 2004). This is used for either controlling the patients´ situation or handling information regarding the nurses´ responsibilities for the patients' care. There are four types of nursing hand-over reporting; the hand-over in the nursing station, hand-over at the bedside of the patient, tape-recorded and written handover. The nursing handover is continually changing and is not restricted to one method, to achieve the best outcomes for the patients. Moreover the method of the handover between nurses depends on the number of patients in the unit. If the unit has a large number of patients in general the hand-over will take a long time, whereas if the patient numbers are small the nurses, are in general, giving the handover report in a short time (O'Connell & Penney, 2001; Hohenhaus et al, 2006).

Nurses are gathering information about patients during the shift exchange duty by different sources; they are taking the information from the last shift of nurses directly, or from the indirect dealing with other team workers, such as physiotherapist, managers and administration, pharmacies. The nurses are also gathering the patients' information through the patients themselves or from the patient's files, to collect the complete pictures about the patients (Llan, et al. 2012; Lyhne, Georgiou, Marks, Tariq, & Westbrook, 2012). Nurses provide the care to the patients twenty four hours; every shift nurses are handling the responsibilities of patient care. Hand-over is the way exchange of important information about the patients, such as clinical information of any new signs and symptoms, medical information, such as the disease's prognosis, important social information which is related to the patients' satisfaction and wishes and daily nursing diagnosis and assessment with physicians orders and medications ( Lyhne, Georgiou, Marks, Tariq, & Westbrook, 2012). The clinical hand-over report is considered as a basic tool of transferring the responsibilities and accountabilities surrounding the patient care from the nurses (and other health care workers) during their shift of duty (Johnson, Arora, Bacha, & Barach, 2011). There are many stages for the handover process between the nurses, such as the information which was gathered by the nurses, the preparation for the handover document and the handover meeting. Moreover the stages of handover are in process during changing of the shift between nurses and most of the hospital have three shift duties, which is eight hours on duty (Lyhne, Georgiou, Marks, Tariq, & Westbrook, 2012).

Communication during patient hand-overs
There are different ways of communicating during hand-over reporting between the nurses. Some nurses are discussing each patient's case, others provide an update of necessary information about their patient's conditions (McCloughen, O'Brien, Gillies & McSherry, 2008). Hand-over reporting is considered as a routine forum of daily nursing communication during changing of the shift, or if nurses are taking their break or during transferring the patients to another ward. That communication between nurses regarding the patients is aiming to continue the patients' care by exchanging patients information about any change in the patients care or treatment (Manias, Aitken, Duning, 2005). The hand-over communication is covering all aspects of the patients' care, including the social needs of the patients regarding their wishes of involving their family or not, also the psychological needs to be supported by nurses or other health care workers (Randell, Wilson, Woodward, 2011).

In some hand-over situations the topic of communication and discussing between the nurses depends on the patients' situation and condition. Some cases, such as serious cases the discussion about information of the patients can cause harm to the patients (Kowalsky, Nemeth, Brandwijk, & Cook, 2004; Arora, Johnson, Lovinger, Humphry, & Melter, 2005). According to Lamond, (2000), in many studies they have mentioned that certain main issues regarding the patients cannot be documented by written hand-over documentation. Therefore nurses need to summarize the important patient information to find good ways of communication to hand-over the information to the next shift. It's important that the nurses are able to judge the patients' information priorities relating to the patients' conditions and situations. Moreover the hand-over communication between the nurses is not considered only as the patients complications and their serious situation it should also consider the features, thought and suspicions regarding the patients' situations and conditions including the patients' wishes regarding their care as well as considering the patients' safety. Nurses should be aware that handover is the meaning of transferring the responsibilities between them during the exchange of duty (Strople & Ottani, 2006). The handover between nurses includes important issues about the patients such as current clinical condition and the general judgment and evaluation regarding the patients, which helps the nurses to become familiar with the patient's sense and needs (Randell, Wilson, Woodward, 2011).

According to Pthier, Monteiro, Mooktiar & Shaw, (2005), the way of verbal communication during the hand-over can affect the patients' information which is transferred over to another shift especially if the unit has a high number of patients. The environment and the place of hand-over can affect the exchanging of information during the hand-over .Therefore nurses should have the ability to select a suitable place for their hand-over communication (Manias and Street's, 2000). Moreover the time of the group nursing hand-over has to be structured to allow the nurses to be able to do a double check of the patients' charts and medication that allows nurses to involve patients during the exchange of their information in the bedside hand-over (Liu, Manias & Gerdtz, 2012)

Methods used in nursing verbal hand-over reports
The communication between the health care workers is very important part in the care of the patients. This means effective communication is important between the nurses. Communication errors occur in health care and may be related to severe consequences. Certain health care errors can lead to unnecessary suffering and cost money and may even lead to death (Sutcliffe, Lewton, & Rosenthal, 2004). Moreover it can create other issues that affect the patients' satisfaction and affect the period of the patients' hospitalization (Pronovost et al., 2003). Therefore the health care professionals are looking for a way that can help in reducing communication error. There are many methods or models that can be used between health care workers to be able to cover the entire patient's information and having effective communication, such as briefings, debriefings, SBAR, Situation, Background, Assessment, Recommendation, assertive language, critical language, common, language, closed communication loops, active listening and callouts. All these methods are used as model of communication, in general for all health care workers, some are used only for a group of health care workers and some only in special situations, like explaining unprofessional behavior (Lo, 2011). The most useful method was used in health care settings and mentioned in the literature as a useful method and is used between health care workers during the communication, is a SBAR method which is related to Situation, Background, Assessment, Recommendation and it is used as a standardized tool in America (Doucette, 2006). The SBAR tool was used in 2003 at Kaiser Permanente to organize the conversation between the physicians and nurses (Thomas et al., 2009). From that time the SBAR was used as a protocol between the health worker´s communication in various healthcare settings. Moreover, the SBAR tool improved communication in the way of having a protocol for the communication between the health workers and having a common language and anticipation of what the communication will be (Haig et al., 2006; Hohenhaus, Powell, & Hohenhaus, 2006).

The SBAR as a tool is successful because it provides a standard way of communication between the health care workers during the usual stressful situation and environment, because the health care workers are facing situations that need rapid communication and exchanging a lot of information while they are under stress. Therefore that stressful situation can make them miss communication or give a wrong message. Therefore the SBAR method solved these problems between the health care workers (Woodhall et al., 2008).

SBAR protocol of communication is structured after four ingredients. The first one is the Situation which includes the name of the sender and the current patients' problems. Then there is the Background which includes all the patients' data from admission such as diagnosis and prognosis and the patients' history. Then there is Assessment which includes the subjective and objective data such as vital signs or pain complaints and the area of communication because it includes any changes in the patient. The last ingredient is Recommendation which regards the action, which are the suggestions given by the sender. Moreover the SBAR includes the nurse's chart about the patients' medications and laboratory tests (Woodhall et al., 2008)

Types of hand-over
Hand-overs between nurses have many different methods to transfer the information between nurses. These types include the verbal communication, recorded hand-over, bedside hand-over report and written hand-over (O'Connell, Kelly & MacDonald, 2008; Scovell, 2010).

Written hand-over
The written report is considered a legal report with the nurse depending on the information which is written including the written report nurses have on the verbal hand-over report either for the bedside or ward office hand-over (Scovell, 2010). The written hand-over may be as documented handwriting or as computerized word access. Moreover nurses during the verbal hand-over are using either a piece of paper or they have files for every patient, to use during communicating in the verbal hand-over report to remind then about the important information about the patient (Hardey, Payne & Coleman, 2000). The nurses have nursing documentation about all the updated information about the patients to allow nurses who are coming in the next shift to have a full picture about what happened to the patients during the last shift (Sexton et al, 2004)

Verbal hand-over
The nurses are communicating during their exchange the end of the duty to hand-over their patients' information. Nurses are using verbal communication which is face to face gathering information between them. There is another way of gathering the verbal hand-over information between the nurses which is by telephone. In non verbal hand-over, nurses are exchanging the information through email and message systems and through fax for external contact (Lyhne, Georgiou, Marks, Tariq, & Westbrook, 2012). The topic of the hand-over communication includes discussion of the medical status of the patients such as reasons for admission, the needs of treatment and care, and how nurses can organize the work. However the main important issues in verbal hand-over communication is the discussion regarding the patients health status; nurses are handing-over the patients feelings regarding their fairness' and patients' social needs (Mayor, Bangerter & Aribot, 2011). There are many studies that have focused on the affect of environment around the nurses during hand-over and nurses, during the exchange the patients' information need to have a good environment to be able to get a clear hand-over to provide good patient care (Hagler and Berm, 2008).

Research Problem
Communication between nurses during hand-over is considered as an important factor which can affect the patients` care and safety. In many studies they identified that there are differences between what is written in the patients' document and what is reported verbally during the shift hand-over. The lack of communication between nurses during the hand-over can affect the patients negatively and interfere with patient safety (Sexton, Chan, Elliot, Stuart, Jayasuriya & Crookes 2004). Therefore the author is going to explore the nursing experiences of hand-over reporting in an in-patient unit setting where the official working language is English. The English language is often the second or third language spoken by the nurses. The author aims to discover issues which may have impact on the improvement of care and increase patient safety.

Aim
To describe nurses` experiences of communication during verbal hand-over reporting, on in-patient units

Method

Qualitative method
Qualitative research is used to analyse the narrative data such as interview or dialogue (Polit & Beck, 2008). The qualitative content analysis used in nursing research is applied to the difference of the data and to interpreting the various aspects of the data. Qualitative research depends on the narrative data or observations and the researcher will have the text written. Although there is written text most of the time it includes many meanings and there are different levels of the interpretation of the text (Graneheim & Lundman, 2004).

Content analysis has been used for a long time with communication, journalism, sociology, psychology and it is used in nursing research also (Elo & Kyngas, 2007). Qualitative content analysis is defined as "a research method for subjective interpretation of text data through the systematic classification process of coding and identifying themes or patterns" (Hsieh & Shannon, 2005, P. 1278).

Qualitative interviews with the content analysis method are used in this study investigating communication during verbal handover report: nurses' experiences from in-patient hospital units in Saudi Arabia. The data of this study was analysed by using the Graneheim & Lundman, 2004 step of qualitative content analysis in nursing research. To obtain more details the interviews were tape-recorded in order to assess the verbal interaction during the interview. The tape-recorded interviews provide accurate detail which cannot be obtained from the memory or by taking notes (Liamputtong & Ezz, 2005). Consent forms were obtained before starting the interviews and the participants in this study were given written information about the research time before the interview. The participants were gathered as a result of sending application forms to their hospitals' nursing education and research unit. The participating nurses in this study fulfilled the inclusion criteria and were approved by the head nurses of each in patient units. Then the researcher explained to all nurses in that unit during their shift exchange, briefly about the aim of the study and the interview question and the tape-recorded and that all the information would be handled in confidence (Kvale & Brinkmann, 2009).

Data collection
The author applied to four hospitals in Saudi Arabia to conduct the research. There is one hospital who agreed to do the research directly, without having other specific demands, i.e. such as paying money or having a supervisor from their hospital only. After the ethical committee agreement and education and research units' agreement, the proposal was submitted to the in-patient units in that hospital, which included both medical and surgical wards. The head nurses of these units selected the nurses who were involved in the study. In August, 2012, the author started face to face interviews with staff nurses working at a large hospital in the Jeddah region in Saudi Arabia, with both medical and surgical units. A semi- structured interview with open ended questions was used during the interviews, which can help the participants to explain their experiences during their verbal handover communication report see Appendix (I). The interviews were held at a time which suited the nurses, in the nurses` workplace; the time of each interview was individual, with a range of between fifteen to thirty minutes (Kvale & Brinkmann, 2009).

Participants
Ten nurses participated in this study; all of the participants came from different countries in Asia; the age group ranged between 25 years to 55 years of age, and were both male and female. All of the participants had English as second language and for some of them English was their third language. The interview was carried out and a tape- recorder was used to record the interviews for all of the ten participants. All the participants agreed that the interview could be recorded. The tape- recorder was checked before every interview to avoid any technical problems. The author was satisfied with the information that was taken from the ten participants. After six participants the data started to repeat itself; this is confirmed by Kvale & Brinkmann, (2009) as a means of knowing that your data is complete. The inclusion criteria regarding the participants were covered by all the participants' years' experiences except one of the participants who had less than three years' experience. The interview was carried out in a conference room in the education department and research unit in the same hospital. All the participants who met the study inclusion criteria were selected by the head nurse of each in-patient unit. Written information regarding the study was given to the participants before the interview (Kvale & Brinkmann, 2009).

Inclusion criteria
• Between eight to ten participants from four hospitals in Saudi Arabia.
" Nurses who work in adult in-patient units will be interviewed.
• The participants should have three or more year's experience working in Saudi Arabian Hospitals. According to Benner (2001), after three years of clinical experiences nurses can be regarded as experts in their field,
• Nurses who speak English in their working practice and are communicating in multi- national teams.

Interview guide
In this study an interview guide was used. According to Kvale & Brinkmann, (2009) the structure of the interview questions is built close to a conversation, but carried out in a professional way in the form of an interview. The questions include a specific approach and style of questioning. All the interview questions are attached in Appendix II.

Data analysis
In order to analyze the data the Graneheim & Lundman, (2004) the article was used by the author to gain an understanding in the way of analyzing the interview text data in the qualitative content analysis method. Then the author listened to the recorded interviews many times and made the data description into a document, and the author read the documented interview many times, to understand the entire contents. The author analyzed the data manually according to the Graneheim & Lundman, (2004), content analysis method. All the data was extracted after interviews by verbatim transcriptions. The quotations were taken from the descriptive data randomly going through the entire interview answering of the questions. After that each sentence and paragraph was read several times, and all main ideas were coded to the specific meaning. For the words, sentences and paragraphs the meaning units were used. For meaning units condensed meaning units were used. Then the statements were used to condense the meaning unit interpretation of the underlying meaning according to the general ideas. Then all sub-themes were summarized to give meaningful themes of the data, which will be used in the finding of the research example of the data analysis as shown in Table one. All the process of the research data analysis was done under the supervision of the research supervisor.

Content analysis
Content analysis was used according to Graneheim & Lundman, 2004, method of analysing and the steps of analysing the data were kept in a schedule shown in Table 1 as an example of the data analysis.


Click here for Table 1: Example of meaning units, condensed meaning units, sub-themes, and theme for the content analyses of the data of nurses' experience of communication in handover report (Graneheim & Lundman, 2004).

Ethical Considerations
In this study the ethical issue which is related to professional nursing practice will be considered during the research for the good of the patients, and avoiding harm. In addition to that the responsibility of the researcher is to protect the participant from any unnecessary risk during participation in the study. That also includes any mental or physical discomfort. All nurses who participated in this study were unnamed and all the information regarding them or the patients was handled respecting their privacy and autonomy. A code was used to name the participants during the analysis so that the researcher can get the benefit from the participants' experiences. All the participants were informed before the interview regarding the study and the consent for their participation was taken before starting the interviews; moreover the participants were informed that they can stop the interview at any time if they don't want to complete it. All the patients' information will be handled as privacy information (Speziale & Carpenter, 2007).

The study was carried after the approvals were obtained from the unit of biomedical ethics research committee in the participating Hospital and from the nursing education and research unit see Appendix (IV). The participants' information was handled according to the international council of nurses' code of ethics (International Council of Nurses, 2010). All the participants were informed that they can withdraw at any time from the study and they have the right to refuse that the interview was tape recorded. The author is responsible for all the recorded data to be kept confidentiality and secured for the next five years in order to be asked to review the data (Bankert & Amdur, 2006)

Result
The results of this study are shown according to the main themes which were selected. Three themes were identified from the data: Advantages of verbal communication in nursing hand-over reporting, Challenges of verbal communication in nursing hand-over reporting, and the impact of verbal hand-over reporting on nursing care. The participants during the interview were using the word endorsement or endorse instead of hand-over and they mean hand-over.

Advantages of verbal communication in nursing hand-over reporting

Provide comprehensive communication
The hand-over communication between the nurses is used as an easy way of providing clear information and communication between the nurses on in-patient units. Verbal hand-over communication reporting helps the nurses to communicate and exchange the patient's information in a comprehensive way to be able to have clear patient data.

"In each hand-over I need to endorse these patients everything in each my shift"

"This while communication, this SBAR is very easy one by one, we can receive the endorsement, all the patient's data we will get it"

"They are physically giving us the full picture of what was going to the patients"

A compliment to the written report
The nurses were aware that there is a specific way to communicate, to be able to have good communication during hand-over. They were able to differentiate between what they are going to communicate in the verbal report and in the written report. They were also aware about the method used during the communication in the hand-over, which helps them not to miss any information or waste their time with unimportant information.

"It should be different the verbal hand-over from the document"

"This is very nice (SBAR), it is nice for all the patient data"

"We are endorsing this one endorsing together with our focus"

Clarify information
During the communication in the verbal hand-over report nurses are clarifying information about the patients. Moreover they have the ability to ask the last shift nurses about any doubts or questions they made have.

"You understand the way she endorse to you is very clear crystal clear"

"We are getting more information sometimes"

"Sometimes this verbal I like this verbal handover or endorsement, because you will know what are what is the, lacking one that she did not do and what is that... she did like that I like it too much"

"If we will have any doubts we will ask them now, so we will clarify that one, so we are not in doubt we know already the patient. If we doesn't know we will ask the one she will endorsing"

Holistic view
The verbal hand-over communication is a means of informing the nurse about what has happened during the last shift. Through this form of communication the nurse gains a clearer view about the patient´s condition and situation.

"Verbal hand-over when you, when coming shift endorse and you are the nurse that will receive, this will give you a better picture of the patients"

"You are not only imagination so physically you have the first view what is going on"

"Usually our hand-over, our endorsing to another staff it will be at the bed-side, so that we can see what the condition of the patients is; patient is ok stable or deteriorating"

Reminder to the nurse
Nurses are using the verbal hand-over communication as a reminder for them. Sometimes they are writing small notes during the verbal hand-over or they are depending on their memory to remember what was happening to the patients in the last shift. These notes help them not to need to go every now and then to the patient's files to check for any previous information.

"If you are telling me something about the patient's condition it is happen it's done it is easy, so already in my mind"

"Communication verbal endorsement I like personally, because it will remember, remind you to do what is important"

Updating the nursing information
The verbal hand-over communication helps nurses in updating their patient's data and knowing more about their patients' conditions. Nurses do two shifts duties and when they are outgoing, or incoming they have to hand-over the entire important and updated patient's information to the other shift. During the day patients are having many procedures and the patient's condition prognosis will change. Therefore the communication during the verbal hand-over can update the nursing knowledge or information about what happened all the day to the patients.

"Every shift will get the endorsement so that endorsement place whatever things we did for the patients also if any new things also we used to endorse the next shift"

"If I am reading from the file or something like that maybe I will not get as much about the patients'"

Method of communication
In order to communicate and transfer the patient's data during their hand-over report the nurses are using a specific method to cover all important aspects of patient care during the communication. They are aware of this method, step by step, in order to provide the clear picture about the patients to the next shift.

"It is very nice the SBAR. It nice for all the patient data we will receive, so the patient clinical complains, chief complain, relevant history, past history then the implementation, the recommendation what the important to solve patients condition the problems. It helps for us to make the patient comfortable"

"We are practicing SBAR so easy for us to yes its very helpful for all the history we will get while endorsement"

"This while communication this SBAR is very easy, one by one we can receive the endorsement all the patient data will get it"

"This is very nice the SBAR, it is nice for all the patient data"

Challenges of handover verbal communication

Time consuming
The handover communication can increase the workload on the nurses. Due to the amount of patients on the unit it can take a long time to carry out the verbal hand-over between the shifts. Moreover if there are critical cases or new admissions which need to have more explanation from the nurse to give the clear picture about that patient.

"If the situation is busy we are having really hard time to endorse the patient"

"If the patient is so critical, like for example in my shift I just... you know assist the patients intubation like this is very, very long endorsement"

"Some patient unstable patient with ventilator tracheostomy like that it will take more time; it is according to the patient's condition"

Language issues
Most of the nurses come from different countries and have different levels of English; there are difficulties in understanding the different dialects and pronunciations when communicating through English during the hand-over report. Nurses sometimes have difficulty in understanding some of the pronunciation of other nurses if they have not the same nationality.

"Their pronunciation is different the language is really different sometimes the way of endorsing"

"During the hand over the first time I receive from another shift. I have difficulty with the diction of different; we are working in multi nationality setting multi cultural setting"

Communication breakdown
In hand-over communication it is possible to have miscommunication or misunderstandings between the nurses. Nurses can explain something specific about the patient`s condition but their colleague gets another understanding about this thing. This can in turn affect the patient's care, if the misunderstanding is not recognized.

"When they fail to endorse then you will sometimes be surprise there is thing to be done to the patient but they did not endorse to me"

"It is possible to have communication error"

"Some people if I am telling something and you are listening something maybe when you listen you are getting something else but I mean something else"

Incomplete patient data
Nurses during the verbal handover communication can miss some important information or the other nurses who received the information can miss something because they are only relying on the verbalized information. Therefore nurses can take incomplete data about the patients during the verbal communication.

"Verbal handover sometime report maybe they missing because we are giving without file, maybe it will be something missing"

"Some people they are very lazy and if some people they are easily forgetting things, some people they are not very much interested in things so there will be error will happen so there is chance to get error"

"If I am not endorsing properly about my patient of course the other nurses cannot follow what she needs to do for the patients so there will be error"

The impact of verbal handover report on nursing care

Effective nursing care
The clear hand-over communication assists the nurse to provide effective nursing care. Because the nurses have all the patients' information and know about the patients' condition during the previous hours so they have obtained a full picture about what was the care that had been given to the patients. Moreover, they have clear pictures about what is the patients' needs that have to be covered by provide good care to attend those needs.

"How you can provide effective nursing care if the endorsement is not clear, it should be clear"

"We will get the endorsement we know our care of this patient, what care is and what we will do"

Managing the care
After the nurses have received their hand-over reporting (endorsement) regarding the patients. it helps them to prioritize. Therefore having enough knowledge about their patients' condition during communicating in the hand-over report can give the nurse the confidence to provide the care. Moreover, verbal hand-over prepares nurses for their shift by providing the complete information and knowing about the patients conditions before starting the shift. This enables the nurses to have the ability to organize their care due to the information they get about the patients. This helps them prioritize the care depending on the patient's situations.

"Communication verbal endorsement I like personally, because it will remind you to do what is important"

"That is the important thing when we communicating the good picture of the patient, so I can manage myself"

"We will receive the endorsement again so we can prioritize the work"

"Verbal handover if verbal also we writing it down know what ever to be done and we can cheek in between whatever is remaining and we prioritizing the work"

Provide high quality of care
Hand-over communication helps the nurses in improving their work and provides care which incorporates patients' wishes with high quality care. Therefore nurses are communicating during the hand-over report to gain a clear picture about the patients in their units.

"From the effective communication and giving a right data about the patient, and what happened in her shift that can provide an effective intervention and effective nursing care"

"we have to give them explain to the next staff that will easy, and we can give if we know about the patients details we can give good nursing care for the patient"

"Verbal handover is very important for me because it is giving clear picture a better picture to provide this good nursing care"

Making care-plan
The proper hand-over report helps the nurses to uphold care-plans because they will know all the patients' conditions and which case is serious and that helps them in providing nursing care plans. Nurses receiving the verbal hand-over report are making a plan for each patient that helps them in achieving their care-plan by the end of their duty

"If I am endorsing properly of course the other people who is getting from me she knows what to do for the patient if she is aware about her nursing care she will best this is what I feel"

"After the endorsement we will get the, our patient ideas, know she is for what? so we will prepare according to the procedures"

"If I am endorsing properly of course the people who is getting from me she knows what to do for the patient if she is aware about her nursing care, she will do best, this what I feel"

"Handover prepare you, because you know what is your next action your next legal and your next quality intervention to be done for the patient for optimum health you what it to achieve for the patient"

"Definately handover prepares you, because you know what is your next action your next legal and your next quality intervention to be done for the patient from optimum health want it to achieve for the patient"

Patient safety
Verbal handover communication can reduce the errors that can accrue due to the lack of patients' information being available. The nurses can ask during hand-over about specific things related to the patients, and if the patients received any emergency medication or has some special care due to their conditions or situations. Even though all the emergency medication, etc. is documented in the patient's file, nurses need to underline these important things. Moreover, hand-over can help the nurses in taking the precaution for any cases that need to be isolated or need special care due to their case or condition.

"If you get infected patient' to our ward also we have to get information so that we can take proper precaution for the patient"

"It is really important when you will be communicating, when you will have verbal communication, because you will prevent error, medication error anything any error that is very important"

"If some patient with some complicating some disease also while transferring also we have to take precaution and we have to inform them also"

Feeling satisfaction about knowledge obtained
After giving and receiving the verbal hand-over report the nurses having identified all relevant areas of knowledge about their patients, can feel relaxed and satisfied that they have a clear picture about the patients and their care.

"For me I am taking the endorsement with highlight and when I finish my endorsement .It will be easy for me to just follow the patient care"

Nursing care recommendation
During the verbal hand-over communication nurses can suggest or recommend to other nurses something for the patient's care which can make the patients more satisfied or more comfortable.

"Better suggestion Expectation that is important to solve the patient chief complain and all"

Patient's satisfaction
When the nurses have a clear and complete picture about their patients this helps in providing the right care for the patients, moreover in verbal hand-over nurses can discuss special things about the patients which cannot be written in the patients' file which can better help the nurses reach the patients' satisfaction.

"The patient is center here they are the one they are the rezone why we are having this work and their illness we have to provide good quality care"

"Communication for us, those who are experience here, I can talk Arabic also to a patient there will be good communication between me and my patient"

"Also with that communication patient can express their feeling and we can for the patient, we can tell them also and it is not only medication, so our tender loving care also, that will relive their agony"

Discussion

Method
The method used in the study is qualitative method; semi-structured open ended questions were used to be able to explain any doubt of misunderstanding the interview question, or if the answers of the participants needed more clarification (Kvale & Brinkmann, 2009). The interviews were carried out with ten participants from one hospital in Saudi Arabia. The proposal was sent to four hospitals in Saudi Arabia to do the research in conjunction with them. The proposal submission time was during an official holiday period, which made it challenging to apply to do the research in the hospitals, because most of the employees were on vacation.
One of the hospitals requested that they provide a supervisor from their hospital to supervise the work and that it be voluntary, as it is not mandatory for any senior nurses in that hospital to supervise in any study. Therefore this hospital was excluded from doing the research with them because there was no one who would volunteer to be supervisor for collecting the data in their hospital since I already had my university supervisor. In another hospital they requested a fee to conduct the research in their hospital, which made the author exclude it. In the the third hospital all the applications were posted to them, but there was no reply. The fourth hospital which the data was collected from, agreed to participate when the formal application for the ethical approval and education and research department was completed.

The interviews were carried out after all the applications for approval were finalized. From every department on in-patients units two or three participants agreed to take part in the interviews. The author made a schedule for the participants to do the interview during their working shift. The interview was carried out in the education and research department conference room, so nurses took permission from their head nurse of their department to do the interview, which may have made some of the participants feel stressed to finish the interview.

No pilot study was carried out due to the time limitation to collect the data. After the first two participants were interviewed, they found the interview questions clear for them. All the participants agreed to do the tape-recorded interview; also all of them met the inclusion criteria of the study except one of the participants who had less than three years experience. Even though one of the participants had less than three years experience all the information collected from this participant was very useful and it answered the interview questions.

The author transcribed the data every day after the interview because that helped to remember all the interview discussion and details. After all the data was transcribed the recorded interview was reviewed many times for the accuracy of the information that was taken from the participants. All the data was transcribed and the data was analyzed by using Graneheim & Lundman, 2004 step of qualitative content analysis in nursing research. This method of qualitative content analysis was used in this study because it is a method used for interpretation of the text data through the systematic classification process of coding and identifying themes or patterns from the narrative data which explained the experiences. Graneheim & Lundman, 2004, content analysis is based on Krippendorff, (1980) which is regarded as important literature concerned with the content analysis method and its use in viewing the data as texts, images, and expressions, which can be created to be seen, read interpreted and acted on, to have meaning. Moreover the term of content analysis is about 60 years old and is used in the English language (Krippendorff,2013). The author has referred to a new book which is used in the content analysis method written by Krippendorff, 2013, which discusses an updated explanation of the content analysis method. Granheim & Lundman, (2004) in their method of content analysis had summarized one way of using the content analysis method. The author contacted one of the authors of the article; Granheim & Lundman, (2004), Granheim in Umeå University, regarding their experiences of using content analysis and the reply was that they had used this method in 1300 studies and had good experiences of using it. No shortcomings of the method were mentioned!

The author has previous experiences of working as a nurse in Saudi Arabia that may affect the understanding of the narrative data which can be seen in trustworthiness and the credibility of the result (Hsieh & Shannon, 2005). In the qualitative content analyses the analysis focused on latent content, which dealt with the relation aspect in the data with the author's interpretation as to the meaning of the content (Graneheim & Lundman, 2004). The result was concluded after reading the data several times and making meaning units for all the highlighted sentences, and from that meaning unit the condensed meaning units were used as sub-themes and categorizing the sub themes to have end themes which can be shown as a result for this study. The study highlights themes which are considered as important aspects of the communication between nurses during the verbal hand-over report e.g. the advantages of the hand-over report communication, the challenges of verbal hand-over report. This important aspect in the result agreed with different literature which had studied the same areas of the hand-over communication between nurses.

The author is speaking English as a second language and all of the participants also speak English as a second or third language, which makes the data analysis challenging. The author listened to the recorded data many times for the accuracy of the data transcription, which is required for rational responsibility (Munhall, 2007). The content analysis method was used to analyze the data in this study. Because this study is looking for the nurses experiences, the method used needed to have their opinions and explanation of their experiences. The content analysis is a good method that can be used to study the personal experiences (Elo & Kyngas, 2007). The method was used in this study for the identification of the themes which required analyzing the narrative sentences to meaning units then to condensed meaning units that have the main sub themes and themes (Graneheim and Lundman, 2004).

Participants
The author did not include the gender and the age of the participants to keep all the participants' information confidential. The inclusion criteria of this study was with nurses who have experience in hospitals in Saudi Arabia more than three years, because the aim of the study is looking for the nurses experiences of communicating during verbal hand over in multi-cultural settings. The participants of this study were selected by their head nurse unit which may affect the answers of the participants, in some way. Accidentally there was one participant included who did not have three years experience; they had less than one year´s experience. The inclusion of this participant was very positive for the study result as this participant was facing for the first time, the issue of communicating in multi-nationalities in the work place. The data which was collected from this participant gave new thought and they discussed issues that experienced nurses had become used to and that were no longer an issue for them. It is an important issue which can awake many suggestions and solutions for the challenges which can face the newly assigned nurses. As a nursing researcher looking for the improvement of the nursing research areas recommended that in the communication area in nursing, it is important to study the experiences of the newly assigned nurses. This focus can help to improve communication issues which can affect patient's safety or the quality of care.

Result
Three themes were discovered regarding the nurses' experiences during verbal hand-over report in the in-patient unit. The themes explained the nurses' experiences during communicating in the hand-over report which show the advantage for the nurses when they are communicating and the challenges which can face them during their communication in verbal hand-over reports. Moreover it shows the impact of hand-over communication has on the nursing care.

The participants in this study worked in multi-cultural workplaces and they are also from different nationalities and backgrounds, and speaking English as a second or third language, which increases their experiences of communicating with each other, according to one of these participants:

"During the hand-over the first time I receive from another shift, I have a difficulty with the diction of different; we are working in multi nationality settings, multi cultural settings"

The result of this study includes different aspects of the nurses experiences of exchanges with the patients which can be related to the nurse's situation as working in a multi-nationalities work place and not speaking their mother language, some of these aspects are considered as general aspects in the communication between the nurses during the verbal hand-over report. All these nurse's experiences in this study can add to the quality of care and can enhance the patient's safety. Some aspects such as nurses needs to speak Arabic, which is the patients' language there, are arising from the results which can be considered by the hospital in Saudi Arabia for the improvement of patient care (Mebrouk, 2008).

The advantages of the nursing hand-over verbal communication
The verbal hand-over communication between nurses is considered an important aspect to provide the care which can help the nurses to start their care, having a full picture about their patients. Nurses are exchanging the patients' information and responsibilities during the hand-over report to be able to cover all the patients' needs. According to Randell, Wilson & Woodward, (2011), the verbal hand-over communication is the way of insuring the transmutation of the necessary information including handling the responsibility from outgoing nurses to the incoming nurses between the shifts. That makes the nurses aware of what was done or given to the patients in the last twelve hours. Being aware of the patients situations helps the nurses to provide the care smoothly and achieve the patients' satisfaction with high quality of care. According to Hoban, 2003, all the information which had been transferred to the incoming shift has to be helpful for the nurses in order to be able to provide continuous patient care.

The nurses mentioned that there is documented information about all patients. Even though the patient's data is documented the nurses need to exchange the patient's information verbally because there is important information about the patients which cannot be written in the patient's files, such as special patients' needs. Therefore nurses had mentioned that the verbal hand-over report is giving the complete picture about the patient. The verbal communication and discussion about the patient's condition helps the nurses in assessing their patients and being able to connect between what was written in the file and what they receive from the verbal hand-over reporting (Strople & Ottani, 2006).

Even though the incoming nurses usually know most of the patients that they are receiving from the outgoing shift, because most of the patients in in-patient units are staying sometimes for one week or more which allowsthe nurses in the unit to become familiar with their conditions and history. The verbal hand-over communication updates the nurses' knowledge about the patients and the entire environment around the patients, which is covering what the nurses need to know about updated information (McCloughen, O'Brien, Gillies & McSherry, 2008). After the verbal hand-over the nurses have the current information about the patients that allows them to provide good care for their patients.

The nurses when they are communicating during the verbal hand-over are taking the information which can help them know about their patient's condition. Therefore the nurses need to be clear in communicating the patient data to give the exact patient situation and condition to the other shift. During the verbal hand-over report nurses are discussing the patients' conditions, updated medications and the prognosis of the disease and it also includes things to be observed during the coming hours, such as fluid intake and output. Moreover nurses are giving their suggestions and recommendations about the care that needs to be provide to the patients or special patients' needs which cannot be documented in the patients files.(Randell, Wilson, Woodward, 2011). Those suggestions and recommendations enhance the aspect of having clear information during the verbal hand-over communication which was mentioned by the participants in this study during the verbal hand-over communication. They are getting clear information about their patients, because they can ask about and discuss the patients' conditions and prognosis and if there are any important things to be done for the patients during the next coming hours of the shift. In addition the nurses in this study mentioned that the verbal hand-over report can help them in clarifying any doubt about their patients. Hand-over communication between the nurses provides clear practice about the patients and can be used as guidelines for the incoming shift (Edozien, 2011).

Hand-over communication according to the participants is providing a holistic view about the patients and the environment around the patients. Edozien, 2011, mentioned that the hand-over makes the nurse more aware of what happens to the patients and to the environment around the patients. Therefore the hand-over is enhancing the understanding of the nurses about the patients needs which helps them in maintaining care for their patients, because the hand-over shows the whole picture about the patient.

In the result the nurses mentioned that the hand-over report is a way of helping nurses manage the care, because during exchange of the patients' information nurses came to know which the critical condition patients are and which patients need to be observed or the patients who have improved and have stable conditions. Therefore some nurses were taking notes on paper during the verbal hand-over report to help them remember everything about the patients and prioritize their work.

Nurses were aware of the tool or method that they were using during their verbal hand-over communication report, which helps them to transfer all the important information of the patients one by one, and becoming ready for handling the patients' responsibilities. The method used in that hospital is called SBAR and they are covering all the patients' aspects by using this method during the handing over the patients during shift exchange. Moreover having the standardized way of exchanging the patients data will enhance the patients' safety and decrease the possibility of errors. The standardized way of transferring the patient responsibility and information between nurses can help nurses to have effective communication, which helps the nurses to ask and replay any information during the hand-over about any unclear patient data (Haig et al., 2006; Hohenhaus, Powell, & Hohenhaus, 2006). Additional to that, when the nurses are following the right tools or methods during handling the patients responsibilities during exchanging the patients' data may reduce medical errors. The verbal hand-over communication report covers all that the nurses' need to know about the patient's information, situations and the environment around the patients. Therefore nurses after the hand-over report feel confident to start their work, because they know already from where they can start to apply the care. Moreover they know most of the patients' conditions and needs. Nursing satisfaction can reflect the patient's satisfaction which increases the quality of care and can cover all the patient's needs and wishes (Lo, 2011).

The participants in that hospital started to use the SBAR method six months back when it became a standardized method of reporting. The SBAR is an American method style of reporting used in American hospitals. Questions arise as to is this method useful to apply in a work place which is quite different from America especially when it comes to the language. Most of the nurses who are working in hospitals in Saudi Arabia are speaking English as a second or third language which can create issues in communicating between the nurses who have a different nationality and diction in their spoken English. Even though it is a new method, most of the nurses have become familiar with SBAR as a method used during the hand-over communication. Moreover nurses mentioned that SBAR is used in communication with other health workers to exchange important information about the patients. To prove if this method is a suitable method to use in hospitals in Saudi Arabia further study and research needs to be done. Furthermore, it is important to evaluate (with an evaluation tool) the use of SBAR and measure the impact it has on health care outcomes.

Challenges of hand-over verbal communication
Patient's condition or the number of the patients can affect the time of the hand-over report which can reflect on nurses starting their care for the patients (O'Connell & Penney, 2001; Hohenhaus et al, 2006). Most of the nurses had mentioned that having critical patients in the in-patient units makes the hand-over reporting longer than usual. However, the time of handing over the patients' information is time consuming but on the other hand nurses are assumed to have a clear and complete picture about their patients, especially in the critical condition patient. The awareness of the time of the hand-over can help the nurses in managing their work hour's duty. Even though the verbal hand-over report is considered as time consuming when there are critical patients, the verbal hand-over can also save time for the nurses because they are able to memorize most of the patients' information and are not looking to the patient's files every now and then.

Nurses working in a multi-cultural place of work can create challenges for the nurses during communication in the verbal hand-over report. The nurses are speaking the English language as their second or third language and difficulties may arise such as understanding different dialects and pronunciations. Moreover these differences in the diction of their English can causemisunderstanding between the nurses when they are exchanging the patient's information, however sometimes the misunderstanding can accrue with people having the same mother tongue language people. In addition to that misunderstandings can be due to miscommunication during the verbal hand-over, sometimes the communication between the nurses depends on the nurse's way of communication (Woodhall et al., 2008).
The nurses need to have communication skills to be able to transfer clear ideas to the other staff. Nurses mentioned that some nurses easily forget things and that can cause miscommunication, which affects the hand-over quality and can miss important information or things that relate to the patient's care and wishes. The most important aspect which can affect exchanging the patients' information during the verbal hand-over report is that some nurses are forgetting things (Nagpal, et al 2012). Therefore miscommunication can affect the patients' care and the nursing satisfaction of the work. According to Cypress, 2011, poor communication between the nurses when they are exchanging the patient's information can be shown as a negative health care outcome and it will affect the patients care. These challenges are connected to each other if one accrues the other things will happen and if the verbal hand-over communication causesmisunderstanding and miscommunication that can lead to uncompleted patients' data especially verbalized information which can miss important information about the patients.

The impact of verbal hand-over report for nursing care
Verbal hand-over communication can help the nurse to achieve patient satisfaction especially for those nurses who can speak the Arabic language. One participant had mentioned that their ability to speak Arabic with her patients helps them understand the patients more and helps them to provide the right care for the patients, which canincrease patient satisfaction. Verbal communication, involving the patients, can lead to a good outcome. The patient is central of the care and by knowing the patient's wishes about the care and treatments can help in satisfying the patients while enhancing the patient's health improvement. Therefore it is important that the nurse knows the patient's needs and wishes which helps the nurses to also be satisfied with the care they provided= to the patients and their families. Involving the patients during the hand-over report gives the nurses better understanding about their patients. Patients also are able to express their feelings including the social needs when they are involved in hand-over reporting to the next shift (Llan, et al. 2012; Lyhne, Georgiou, Marks, Tariq, & Westbrook, 2012). Therefore in the hospital in Saudi Arabia they need to include a program which can help the nurses to learn Arabic to allow them to be involved with the patients and be able to understand the patient's feeling about the care that they are provided with. The meaning of providing complete nursing care includes good communication between the patients and the nurse who provides the care, because the nurses have to give good support to their patients (Llan, et al. 2012).

The nurses are working to gather data to protect and promote the health and wellbeing of the patients. One of the important roles in their care is communicating with each other regarding the patients' data which includes all the patients' details and information and most of this information is related to the patients' life (Nursing and Midwifery Council,2008). Therefore the nurses are aware about the need to practice daily verbal hand-over communication report to be sure with the care that they are going to provide including the documented patients' data. The hand-over report helps the nurses to create their care plans after receiving the verbal hand-over report from the outgoing shift. In in-patients units with a lot of patients and different procedures the verbal hand-over report helps nurses to cover all the important information and knowledge about the procedures that need to be done to the patients and what preparation the patient requires before that procedure.

Nurses also mentioned that they are receiving recommendations between them during the verbal hand-over report and that can help them in the care. Since the nurses in this study are using SBAR as a method of communication regarding the patients` conditions the nurses are encouraged to provide recommendations about the patient's care or about patient's wishes (Woodhall et al., 2008). However some patients feel comfortable with talking with one or two nurses in the unit, so this nurse can hand over the recommendation to the other nurses during the hand-over report and can exchange the recommendations to cover the patient's needs.

When the patients are admitted to the hospital they hope to get high quality care and to have treatment for their illness, or cure from their disease. Nurses are aware about the importance of patients' safety and if the patients are satisfied with the care that helps their improvement (Leape, Berwick, 2005). Patient safety is connected to quality of care provided by nurses. Therefore nurses are aware of the interests of providing clear communication and patients' data to each other between the shift exchange and knowing everything about the patients' care and their care needs. Moreover nurses are cooperating with each other to provide high quality of care. The question arises when talking about the quality of care the nurses are communicating during verbal hand-over, is it the way of the handover between the nurses helping the nurses in providing the quality of care or the content of this verbal hand-over whatever the form of communication is (Kerr, 2002). Most of the nurses mentioned that both of these aspects are affecting the hand-over communication and can affect the care and patients' safety.

When the nurses are aware of the method of hand-over communication and have standardized methods to exchange the patient information and responsibilities they feel more confident in their provision of care for the patients whatever the patients' condition. Moreover the clear method used during the hand-over helps the nurses in memorize all the patients' data and that can reflect on the care because the nurses are able to prioritize their work, by knowing which patient is critical and which patient is stable. Moreover the nurses considered the verbal hand-over report as a complement of the documented report and both of them cover the patient's data and help the nurses in exchanging information between each other and receiving the patient's responsibilities. Nurses mentioned also that a hand-over report ensures them that all information which needs to be handed over to the other shift is covered which makes them satisfied with the knowledge they give or that they received.

Even though some nurses in the study mentioned that they are not receiving complete information about their patients and they are recognizing that after reading some information in the patient's file, that may be related to the nurses not handing over complete data or due to their way of communicating, it does not relate to the hand-over report as a means of sending clear and good pictures between the nurses.
Conclusion

In this study the result shows the nurse's experiences during the verbal hand-over report in Hospital in Saudi Arabia. The study figured out the advantages and challenges when nurses are working in multi-cultural work places and having English as a second or third language. The hand-over verbal communication experienced between the nurses had many advantages which can be connected with nurses´ satisfaction in providing high quality care and that this reflects positively in patient's satisfaction and safety. The points considered as challenges are related and connected to; miscommunication, misunderstanding, incomplete patient data and language issues. The advantages and challenges shown in the result section of this study are important factors to be taken into consideration, for further research in the area of communication in hand-over reporting.

Recommendation

Further study
Family plays a large part in the Saudi Arabian culture and this does not end when a person is admitted to hospital. Most of the patients have their family in attendance with them in the hospital. The nurses in this study did not mention the patient's social aspects when they were talking about their experiences of the verbal hand-over communication. As a cultural country social life is considered as an important issue when discussing the patient's health information. Nurses who are working in Saudi hospitals have different backgrounds of cultural and hospital roles. Therefore as a recommendation for the hospitals in Saudi Arabia that they have training and education programmes for new nurses and provide basic courses in the Arabic languages and Saudi Arabian culture. These courses will help the nurses gain a deeper understanding of the patients' and their families' wishes about the care and treatment and it help the nurses to provide high quality care with confidence to achieve the patient's satisfaction.

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Appendix I

INSTRUMENT
Interview guide
In this study the interview was guided according to Kvale & Brinkmann, (2009); the structures of the interview questions were built to be conversational, , but in a professional way, such as an interview. The questions include a specific approach and style of questioning.

1- Describe the type of shift handover reporting used on your unit.
2- How much of your working time per shift, would you estimate, goes to handover reporting on your unit?
3- What are your experiences of communication during verbal handover reporting?
4- How does the verbal handover report prepare you to provide good nursing care during your shift?

Appendix II

PARTICIPANTS' INFORMATION

Research title

Communication in verbal handover report: Nurses´ experiences from in-patient hospital units in Saudi Arabia. (Qualitative Study)
In this study the ethical issue which is related to professional nursing practice will be considered during the research to the good for the patients and nurses with avoiding harm.
All nurses who will participate in this study will be unnamed and all the information regarding them or patients' will be handle with respecting their privacy and autonomy.
Codes will be used to name the participants during the analysis so that the researcher can get the benefit from the participants' experiences.
All the participants will be inform before the interview regarding the study and the consent for their participation will be taken before starting the interviews.
The participants are able to leave the interview in any time if they don't want to complete in participating the study.
All the patients' and nurses information will be handled as privacy information any question that not clear can be explain to the nurses in interview, for nurses who speak Arabic language if they need to explain the unclear part of the question in Arabic that will be explain to them
The researcher of this study is looking for nurses who are having experiences three or more than in hospital in Saudi Arabia.
Any unclear parts can be answer by the researcher of this study and nurses who participate in the study they have the right to ask.
Interview guide
In this study the interview guided according to Kvale & Brinkmann, (2009) the structures of the interview questions is build near conversation, but in a professional way as interview. The questions include a specific approach and style of questioning.

1- Describe the type of shift handover reporting used on your unit?
2- How much of your working time per shift, would you estimate, goes to handover reporting on your unit?
3- What are your experiences of communication during verbal handover reporting?
4- How does the verbal handover report prepare you to provide good nursing care during your shift?

This paper approve that you agree to participate in the study of communication in verbal handover report nurses´ experiences from in-patient hospital units in Saudi Arabia an interview study.
I read the study proposal and I read the interview questions. Also I agree that they will use tape-recorded during the interview. After I had read all the qualifications of participation in the research, I have no objection to participate.

Name

Department

Signature

Researchers' information
Haniha Alyamany (nursing master student)
+46739366028
Haniha-alyamany@student.shh.se
Research supervisor
Marie Tyrrell (International Bachelor of Science in Nursing Programmer)
+46(0)8-4062878
marie.tyrrell@sophiahemmethogskola.se