Nurses play a vital role in determining the clinical outcomes of their patients, particularly in relation to ensuring patient safety and continuity of care [1]. Extensive research demonstrates that deficiencies in clinical communication processes represent a significant risk to patient safety [2] and are a common source of sentinel events [3]. When communication is incomplete, unclear, or inaccurate, patient safety may be compromised [1].

Clinical handover is a critical and complex health care communication process, serving as the primary mechanism for transferring responsibility and accountability between shifts [4]. Effective and high-quality nursing handover is a core patient safety mechanism, facilitating the timely, accurate, and efficient exchange of clinical information [5]. Consistent with the National Safety and Quality Health Service (NSQHS) Standards, effective handover requires information to be clear, comprehensive, and precise to support safe, appropriate, and continuous care [6].

Conversely, inadequate or poorly executed clinical handovers can adversely affect patient outcomes [5]. Ineffective communication during handover has been associated with inaccurate clinical assessments [7], delayed diagnoses [6], inappropriate treatments, and medication errors [5]. The impacts of these failures range from minor disruptions to care to severe and potentially catastrophic outcomes. As health care systems increasingly adopt electronic medical records (EMRs) to support clinical communication, understanding how these systems influence the quality and safety of nursing handover is essential.

Efforts to structure and standardize nursing handover processes are often recognized as key improvement strategies for improving the quality and safety of clinical communication [8]. Standardized communication protocols and structured handover tools such as ISOBAR (Identification Situation Observations Background Assessment/Action Recommendation) [9] are “intended to prevent failures of information transfer” [10] by ensuring that information shared is relevant, concise, and focused [5]. Handover mnemonics like ISOBAR reduce the cognitive workload associated with performing handover [11,12] and were designed to overcome differences in communication styles, a factor contributing to communication errors [13]. By streamlining the handover process, these tools also enhance situational awareness within team-based environments, supporting the development of a shared mental model of a patient’s clinical status [13,14]. Standardizing handover processes is therefore a frequent recommendation aimed at improving handover quality and patient outcomes.

In Australia, NSQHS Standards provide a quality assurance mechanism and “a nationally consistent statement about the standard of care consumers can expect from their health service organizations” [15]. NSQHS Standard 6, “Communicating for Safety includes the criterion for communication at clinical handover,” encompassing structured clinical handover, defining minimum information content of handover, key principles of clinical handover, and engaging patients and caregivers in clinical handover processes [15].

Increasingly, bedside handover has been adopted as standard practice in Australian hospitals [1] and is promoted as a strategy to enhance patient engagement, transparency, and patient-centered care [16]. Best practice bedside handover requires nurses to communicate accurate, comprehensive, and contemporaneous clinical information in real time [5], often in the presence of the patient, their families, and caregivers. While this model of handover offers important benefits [1,16], it also increases the complexity of information exchange [17], requiring nurses to synthesize and communicate large volumes of clinical data efficiently [18] while maintaining patient engagement [16] and situational awareness [11,13]. These demands place heightened emphasis on the availability, accuracy, and usability of clinical information at the point of care, and on the systems through which that information is accessed and communicated during handover.

In this context, EMRs have been introduced internationally as a means of supporting complex clinical communication processes, including nursing handover. EMRs are clinical information systems that facilitate real-time access to patient data and provide structured system-level processes intended to support patient safety, quality improvement, and compliance with expected standards of practice [19,20]. Key patient safety mechanisms include electronic prescribing and medication administration, the use of alerts, checklists, and predictive tools and embedded evidence-based practices, supporting decision making at the point of care [19,21]. Beyond strengthening compliance, EMRs also enable continuous quality improvement by generating routinely collected data that can be used to monitor performance, identify variations in practice, and inform iterative improvement cycles [19].

With real-time access to up-to-date patient information, EMRs have been proposed as a means to address the communication challenges inherent to clinical nursing handover [9]. EMRs have the potential to support nursing handover through the use of structured EMR-based handover tools, thus aligning with the intent of NSQHS Standard 6, by supporting timely, accurate, and standardized communication of critical patient information [5].

The introduction of an EMR in itself does not guarantee improvements in clinical communication or patient safety. The literature remains equivocal regarding the extent to which EMRs improve efficiencies in health care, with some studies noting potential adverse effects on nursing handover, including increased work and decreased efficiencies [22,23]. Poorly planned or ineffective implementations of an EMR may disrupt established nursing workflows and may fail to provide the required cognitive support nurses require during handover [22,24]. Information fragmentation within EMRs and the need to navigate multiple screens or data sources may further increase nurses’ cognitive workload during handover, introducing new risks for both patients and clinicians [25,26]. Understanding both the intended benefits and unintended consequences of EMR adoption is essential to assessing their value in practice [27,28].

While EMRs provide the technological infrastructure to support structured and standardized handover, the effective translation of EMR functionality into safe and high-quality nursing practice is underpinned by nursing informatics capability. Nursing informatics describes the knowledge and skills required by registered nurses to integrate nursing science with information and computer sciences to manage, communicate, and apply clinical data, information, and knowledge in practice [29].

The presence of digital technology alone is insufficient to improve clinical outcomes. Contemporary nursing practice requires nurses to navigate an increasingly complex digital environment, meaningfully engage with digital systems, adapt workflows, and effectively use information within the realities of clinical practice [30,31], including during time-critical activities such as nursing handover. Nursing Informatics, therefore, provides an interpretive and operational lens through which the impact of EMR-facilitated handover can be understood. Within this context, nurses play a critical role in shaping documentation practices, information use, and workflow integration [32,33] in ways that either support or undermine the safety and quality objectives of a structured, best-practice nursing handover, occurring at the patient’s bedside.

While handover standardization alone has the potential to improve the effectiveness and efficiency of nursing handover and contribute to safer patient care [15], high-quality research linking the implementation of EMR-facilitated structured nursing handover to impacts on patient-related outcomes is still lacking. A knowledge gap therefore exists, as does an opportunity for further exploration of EMR-mediated solutions that may serve to support, standardize, and therefore enhance nursing handover.

Despite the widespread implementation of EMRs and increasing adoption of bedside handover, there remains limited empirical evidence examining how EMR-facilitated structured nursing handover translates into practice, particularly when compared with handover occurring in non-EMR environments within the same health service. Understanding how differences in information systems, workflow integration, and nursing informatics capability influence the quality of handover is essential to determining whether EMRs achieve their intended safety and quality objectives.

This gap is particularly salient for health services implementing EMRs in a staged or hybrid manner, where variations in digital maturity create a natural opportunity to examine the impact of EMR-enabled handover in context. It is within this organizational and digital landscape that the present case study was situated.

Eastern Health is a large public health service situated in Victoria, Australia, serving a wide catchment across Melbourne’s east. The organization spans 6 local government areas, covering 2816 square kilometers and comprising 21 health service locations. Eastern Health’s 3 largest acute hospital sites are Box Hill Hospital, Maroondah Hospital, and Angliss Hospital.

A full EMR was implemented at Box Hill Hospital in October 2017. At Angliss Hospital, Electronic Medication Prescribing and Administration was implemented in November 2016; however, inpatient clinical documentation has remained predominantly paper-based. At the time of the study (conducted March to May 2023), implementation of the full EMR across inpatient wards at Maroondah Hospital (including Electronic Medication Prescribing and Administration) and completion of the full EMR deployment at Angliss were planned for late 2025 and early 2026, respectively. As a result, Eastern Health operated within a hybrid digital environment with varying levels of maturity across sites.

The introduction of full EMR at Box Hill Hospital fundamentally altered the interface through which nurses accessed, synthesized, and communicated clinical information during handover. In contrast, nurses at Maroondah and Angliss continued to rely primarily on paper-based documentation supported by other limited digital systems. These contrasting documentation environments, operating within the same organization, provided a structured basis for systematic comparison of EMR-enabled and predominantly paper-based nursing handover within a shared organizational context.

The sampling frame comprised nursing handovers conducted on all acute general medical and acute general surgical wards across Box Hill, Maroondah, and Angliss Hospitals. Each site has a 24-hour emergency department and intensive care unit, providing comparable patient cohorts within their respective acute medical and acute surgical wards. The selection of these was intended to promote homogeneity between the EMR-enabled and non-EMR sites, thereby minimizing the impact of variability in patient acuity on nursing expertise and handover practices. A total of 12 wards were identified as suitable for inclusion in the study. The target population comprised clinical nursing staff responsible for conducting routine shift-to-shift handovers.

The purpose of this case study was to examine and compare the quality of nursing handover conducted in fully EMR-enabled wards at Box Hill Hospital with handover occurring in predominantly paper-based documentation environments at Maroondah and Angliss Hospitals. Handover quality was examined within routine clinical practice and assessed using two complementary measures: (1) the degree of compliance with the organization’s Clinical Handover Standard, and (2) clinical nursing staff’s self-reported perceptions of handover quality.

This purpose aligns with the study’s focus on understanding how differences in documentation environments and information access may shape the conduct and perceived quality of bedside nursing handover within a shared organizational context.

The primary aim of this study was to compare the quality of nursing handover in fully EMR-enabled wards and predominantly paper-based wards within acute inpatient settings.

Specifically, the study sought to compare nursing handover practices in fully EMR-enabled wards with those occurring in predominantly paper-based environments, by examining whether EMR presence was associated with:

To address the study purpose and aims, nursing handover practices were examined across EMR-enabled and predominantly paper-based wards within the same health service. This study used a comparative quantitative case-study design using 2 complementary quantitative data sources.

Case study research is “a distinctive form of empirical enquiry” [34] that investigates a contemporary phenomenon within its real-life context [35]. This approach is well-suited to health care settings, where complex clinical processes can be examined using observational methods alongside other data sources, allowing meaningful characteristics of real-world practice to be retained [34], while generating opportunities for more comprehensive explanations [36].

As described within the context section of this case study, the staged implementation of the EMR across Eastern Health provided a naturalistic opportunity to apply a comparative case study design, enabling examination of nursing handover practices in wards supported by a fully implemented EMR alongside those operating in predominantly paper-based environments. Comparative evaluations of health information systems remain relatively uncommon, with much of the existing literature relying on descriptive or correlational approaches [27]. As such, this design offered the potential to generate contextually grounded insights relevant to both local system optimization and the broader evidence base on formative evaluations of digital health systems.

This case study used 2 quantitative data collection instruments. First, structured observational audits of routine shift-to-shift nursing handover were conducted to assess handover quality based on observed compliance with key principles of Eastern Health’s Clinical Handover Standard. Second, posthandover surveys were administered to capture clinical nursing staff’s perceptions of the quality of handover received, with responses quantified using Likert-scales, responses to closed yes/no questions, and counts of affirmative responses. For both data sources, comparisons were undertaken between handover occurring in the EMR-enabled wards and those in predominantly paper-based wards. This multi-source quantitative approach enabled direct observation of the phenomenon being studied alongside quantified staff perceptions of handover quality [34].

Consistent with guidance on health information system evaluation, the use of multiple data sources allowed complementary insights to be integrated, supporting a more comprehensive understanding of nursing handover within differing documentation environments [27]. EMR-supported handover was examined from a nursing informatics perspective, focusing on nurses’ use of available documentation systems and the clinical information exchanged during routine handover practice.

The data collected and analyzed in this case study form part of a broader program of research examining nursing handover processes within EMR-enabled clinical environments. Subsequent analyses will explore nurses’ interaction with, and use of, EMR functionality during handover in greater depth.

The study was conducted across acute general medical and acute general surgical inpatient wards within 3 hospital sites of a single public health service in Victoria, Australia. Participants in the observational audits and posthandover surveys were nurses conducting routine shift-to-shift nursing handovers on the 12 selected wards during the data collection period. The distribution of wards by site, documentation environment, and the number of handovers audited is presented in Table 1.

For this comparative case study, the case was defined as the selected wards within the 3 hospitals of a single public health service. The unit of analysis was the individual shift-to-shift nursing handover. Data were collected between March and May 2023, across morning and afternoon shifts, encompassing both paper-based and EMR-enabled documentation environments.

A convenience sampling approach was used, whereby nurses giving handover on the selected wards during scheduled data collection periods were invited to participate. To promote variation in observed practice, handovers were sampled sequentially across different days, shifts, and times within each ward to capture variation in routine practice. Five handovers per ward were targeted to ensure adequate representation of routine handover practices within each clinical context, while remaining feasible given the resource-intensive nature of direct observational auditing across multiple sites. Five nursing handovers were sampled per ward, resulting in a total of 60 observed handovers across the 12 wards.

Eligibility for participation was defined to ensure consistency across wards and sites.

Ethics approval was obtained from Eastern Health’s Human Research Ethics Committee, HREC number LR22-042-84698. Reciprocal ethics approval was obtained from La Trobe University. Written informed consent was obtained from all nurse participants involved in the observational audits and posthandover surveys, including nurses giving and receiving handovers. Patients whose handovers were observed were provided with written information about the observational audit in advance. Patients were informed that no personal identifiers or health information would be collected or recorded as part of the audit. Verbal consent to proceed with handover observation was obtained from patients immediately prior to handover commencement. Participants received no financial or other compensation for their participation.

Observational audit findings were compared with results from Eastern Health’s Clinical Handover Nursing and Midwifery Audits conducted in 2022‐2023. Areas identified for improvement in the organization-wide audits aligned closely with findings in this case study, particularly in relation to bedside handover and patient and caregiver involvement.

Notably, overall performance relating to patient and caregiver inclusion was lower in this case study than in the organization-wide audits, suggesting potential variability in practice interpretation and reinforcing the need for further exploration of what constitutes effective patient inclusion and engagement in handover. Overall, these observational findings suggest that EMR availability was associated with variation in how handover was enacted across specific domains, rather than a uniform improvement or decline in overall handover quality.

This case study examined the impact of EMR implementation on both the process and perceived quality of nursing handover. Particular attention was given to how digital information systems shape nurses’ access to, synthesis of, and communication about patient information. In this study, handover quality was operationalized using 2 complementary process-level measures: observed compliance with the organization’s Clinical Handover Standard, and nurses’ self-reported perceptions of handover quality following shift-to-shift handover exchange. Together, these measures provide insight into how EMR-mediated workflows influence handover behaviors, rather than downstream patient outcomes. Overall, EMR implementation did not uniformly improve handover quality; rather, its effects were heterogeneous across process domains, partially supporting the study objectives.

Quantitatively, overall compliance with the Clinical Handover Standard did not differ meaningfully between EMR-enabled and paper-based wards, nor did overall staff perceptions of handover quality. However, analysis of individual observational indicators revealed variation across specific domains. These included bedside location of handover, promotion of patient engagement, communication of clinical risks and alerts, handover duration, and frequency of interruptions. These findings suggest that while aggregate measures of handover quality appeared comparable, EMR implementation influenced how handover was enacted across specific components of the process.

Observational audit findings relating to patient engagement during nursing handover did not correlate with staff’s self-reported perceptions of their own efforts to promote patient participation.

While bedside handover alone is insufficient to ensure meaningful patient engagement in the process [45], it remains a fundamental prerequisite in order for patient participation to occur. In this study, observational audits identified a compliance gap with bedside handover across both cohorts, with this gap more significant in the EMR-enabled wards. On this basis, lower observed rates of bedside handover in the EMR-enabled cohort would be expected to correspond with similarly reduced rates of self-reported promotion of patient engagement during handover. And yet the staff survey found that this was occurring in equal proportions across both cohorts, around 70% of the time.

The large mixed methodology study of Street et al [45] examining patient participation in handover may assist in explaining this, observing that whilst nurses do perceive the value in patient participation, ‘the best way to effectively help patients be more involved in bedside nursing handover is poorly understood’ [45]. The findings of this case study support this notion, suggesting that nurses, who may not understand how to effectively engage patients, may have limited insight into whether their handover practices genuinely facilitate patient engagement and participation.

This discrepancy may reflect an overestimation of patient engagement in staff self-reported data, potentially influenced by social desirability bias, whereby participants provide responses and report practices that are perceived as more acceptable [67]. In this instance, the self-reported practice aligned better with organizational expectations and the requirements of the Clinical Handover Standard, despite the decreased incidence of bedside handover necessary to facilitate the desired engagement.

Collectively, these findings highlight the value of using multiple measurement approaches when evaluating handover quality, as reliance on self-report alone may overestimate adherence to patient engagement principles.

Despite the reduced occurrence of bedside handover, potential data fragmentation, workflow changes, and reliance on workarounds (including paper-based and nonintegrated artifacts) in EMR-enabled wards, staff satisfaction with overall handover quality remained high across both cohorts. Clinicians may report satisfaction with systems they have learned to cope with, even when those systems impose additional cognitive or workflow burdens [56]. These findings likely reflect nurses’ ability to adapt to existing system constraints rather than optimal alignment between EMR design and nursing handover workflows.

Taken together, these findings suggest that staff satisfaction alone is an insufficient indicator of EMR effectiveness, reinforcing the need to examine how digital systems shape cognitive workload, workflow integration, and communication practices during nursing handover.

The contrast between consistently high staff satisfaction and observed variability in handover behaviors suggests adaptation and normalization of system constraints, reinforcing the importance of examining both objective and perceptual measures when evaluating digital clinical systems. Integrating observational and perceptual data strengthened interpretive validity and enabled identification of important differences between enacted and perceived practice that would not have been apparent using a single measurement approach.

Several limitations should be considered when interpreting the findings of this study.

First, the relatively small sample size of 60 handovers limited the ability to detect statistically significant differences across all measures, particularly given the complexity and variability inherent in clinical handover practices. While sampling 5 handovers per ward enabled exposure to routine practice within each setting, the number of observations per cohort was insufficient to support more granular analyses or make more robust comparisons. As a result, findings should be interpreted as indicative of patterns of use and areas of variation rather than definitive estimates of practice prevalence. In addition, this study focused on process-level indicators of nursing handover quality, including observed compliance with the organization’s Clinical Handover Standard and nurses’ self-reported perceptions of handover quality. These measures provide important insights into how handover is conducted in different environments but do not directly assess patient outcomes or safety events. As such, findings should be interpreted as reflecting differences in handover processes only. Furthermore, as an exploratory case study conducted within a single health service, the findings have limited generalizability beyond similar organizational and hybrid EMR contexts. However, the design provides rich, practice-based insight into how nursing handover is shaped within real-world digital environments.

Second, the use of a single auditor introduces the potential for investigator bias. To mitigate this risk, the observational audit tool was designed to minimize subjectivity, with items structured wherever possible to limit reliance on auditor interpretation. Consistent use of a single trained auditor also supported standardization of data collection across sites.

Third, a degree of Hawthorne effect may have occurred, as participants were aware that they were being observed. This is particularly relevant for highly visible elements of the Clinical Handover Standard, such as conducting handover at the bedside and performing patient identification checks. While this may have influenced overall adherence to the Clinical Handover Standard, it is unlikely to have affected the comparative analysis between the 2 cohorts, as any observation effect would have been equally probable in both groups.

Finally, the study focused exclusively on shift-to-shift nursing handover within inpatient wards and did not include handovers occurring in other settings such as interdepartmental transfers and other transitions of care. Future research should consider observing and evaluating handovers across a broader range of clinical contexts, with particular attention to how EMRs are configured and used to facilitate and support nursing handover under varying workflow, environmental, and cognitive demands.

This case study demonstrates that EMR implementation has the potential to produce both beneficial and unintended effects on the quality of shift-to-shift nursing handovers. While EMR-enabled wards showed positive impacts in accessing and communicating up-to-date clinical information, particularly in relation to clinical alerts and risks, these benefits did not translate uniformly across all dimensions of handover quality.

Findings indicate that a pre-existing reluctance to perform bedside handover may be exacerbated in EMR-enabled environments, with negative implications for patient inclusion and engagement. Limitations related to the physical environment, EMR interface and design, social factors, and cognitive factors appear to impede nurses’ ability to consistently promote patient participation during handover. These findings suggest that nurses may not have a clear or comprehensive understanding of the actions necessary to actively promote patient engagement, nor how to effectively assess these efforts, a challenge that appears more pronounced in digitally mediated handover contexts. This suggests a gap in informatics-enabled support for nursing practice, particularly in translating digital handover processes into patient-centered behaviors.

Positive impacts of EMR implementation included improved efficiency and reduced interruptions during handover, indicating a degree of user acceptance and adaptation. However, continued reliance on paper-based PFM-generated handover forms highlights persistent gaps in EMR functionality or design, and the need for workarounds to support cognitive and workflow demands during handover. While this study did not examine patient or safety outcomes directly, it provides important process-level evidence to inform the optimization of nursing handover within digitally enabled environments.

Collectively, these findings indicate that the presence of an EMR alone is insufficient to ensure high-quality nursing handover. Rather, the impact of EMR implementation on handover quality is mediated by nursing informatics capability and the degree to which digital systems are designed and aligned with nurses’ cognitive processes and clinical workflows. Where EMR interfaces fragment information or fail to provide integrated, task-specific handover views, nurses compensate through workarounds that may limit the potential benefits of digital systems. Optimizing nursing handover in digitally enabled environments requires EMR designs that explicitly support handover as a complex, cognitively demanding, and safety-critical nursing activity, rather than assuming that quality improvements will occur through digitization alone.

Future research should examine in greater depth how nurses interact with EMR systems during handover, including patterns of use, information navigation, and reliance on workarounds. Detailed analysis of user interaction with the EMR would assist in determining the degree to which the current technology suits the task being undertaken and which current digital tools are suited to the cognitive and workflow demands of nursing handover.

Qualitative exploration of nurses’ perceived barriers and facilitators to EMR use during handover would further inform understanding of how EMR interface design, functionality, workflow integration, and device availability may influence handover practices. Such insights could support the identification of design flaws that contribute to the ongoing reliance on paper-based handover forms and other nonintegrated artifacts in EMR-enabled environments.

Future studies may benefit from the evaluation of discrete components of EMR implementation, including device footprint, software interface design, workflow integration, and overall user experience, to better understand each element’s relative impact on the quality and effectiveness of nursing handover.

Comparative analyses across wards or sites with differing levels of digital maturity, including electronic prescribing and medication administration, may offer further clarification as to how specific EMR functionalities influence nursing handover processes and outcomes.