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Older care home residents’ and their relatives’ knowledge, understanding and views of shift handovers: an exploratory, focused-ethnographic qualitative study using interviews and observations

Objectives To investigate residents’ and relatives’ views and experiences of handovers in care homes. This paper reports residents’ and relatives’ awareness of handovers, knowledge of and views on handover practices and purpose, and views on handover effectiveness. Outcomes, safety and satisfaction in clinical settings are influenced by shift handovers. Despite this link with quality, residents’ increasing support needs and the provision of 24 hours care in care homes for older people, little is known about handovers in these settings from a resident and visiting relative perspective. Setting Five purposively sampled care homes for older people in South East England. Participants Home managers (n=5), residents (n=16) relatives of residents (n=10) were interviewed; residents (n=15) and their interactions with staff were observed during handover periods. Participation was voluntary and subject to consent. Residents were identified by managers as having mental capacity to take a decision about participation which was then assessed. An ethnographic approach to data collection was taken, preceded by an evidence review. Results Shift handovers were largely invisible processes to participating residents and relatives, many of whom had given little thought to handover practice, logistics or effectiveness prior to study participation. Their awareness and understanding of handovers, handover practices, and handover purpose and effectiveness varied. There appeared to be an underlying assumption that administrative procedures in care homes would operate without input from residents or relatives. A small number of residents, however, were highly aware of the routine of handovers and the implications of this for the timing of and response to their requests for care or support. Conclusions The care home setting and perspectives of the effectiveness of handovers may influence awareness of, knowledge of and levels of interest in involvement in handovers.

8 Several studies have identified handover of information between 'outgoing' and 'incoming' shifts as 9 a key element influencing outcomes, patient safety and satisfaction in clinical settings 5-7 . There is 10 considerable research on nurse handovers in hospital settings 8 and a small, but growing, body of 11 research about hospital patient perspectives of or involvement in handovers e.g. 7 9 10-13 . Little attention 12 has been paid, though, to handovers in residential care settings, which is surprising given older 13 residents' profile. As in 24-hour clinical settings, at least two changes of shift occur daily in every care 14 home. Handovers -which may be between nurses, between care workers, between nurses and care 15 workers, and can involve senior managers -may be an important element in ensuring good, 16 consistent quality of care for residents although the CQC does not specifically monitor their quality.

17
The growth of the person-centred approach to care and encouragement for user involvement to 18 improve service delivery make the resident perspective potentially important in handover practice. 19 We previously conducted a study of staff perspectives of the content, purpose and effectiveness of 20 handovers in care homes for older people 14 . We now report a subsequent complementary  As organisational cultures 15 influence handovers, we took an exploratory, focused-ethnographic 16 , 3 qualitative approach. Unlike traditional ethnographic approaches, researchers undertaking focused 4 ethnography 16 enter the field with specific research questions aimed at addressing specific problems.

5
Ethical approval was obtained from [ANONYMISED]. 6 Principles of maximum variation sampling 17 were applied in the recruitment of care homes as this is 7 a very varied sector. A purposive sample of five homes in the South East region of England with 8 different characteristics was recruited from a sample matrix of 16 potential care homes. This was 9 constructed after identifying homes through researcher contacts and internet searches.
10 Managers/owners of these homes were then invited to take part, consecutively, to achieve our 11 target of five care homes. Table 1 gives details of the participating homes and Table 2 summarises   12 timings, location and coverage of shift handovers, as reported by managers.
13 Most residents were in their rooms at the handover times which meant they did not see or hear 2 handovers that took place in offices or elsewhere. Even when handovers were room-by-room, 3 residents were not always awake, or did not necessarily associate being visited in their rooms by 4 staff with the shift handover process. Whereas all three residents of Clematis Grove were aware that 5 handovers happened at shift changeover, only one of the two Violet Manor residents was aware that 6 handover happened but described this as a meeting in the lounge which was actually the post-7 handover meeting of incoming staff. 8 As for the handover times themselves, a small number of residents were aware that handovers 9 happened at the times researchers told them, some were aware of some handovers but not others, 10 some not at all, and some said handovers happened 30 minutes later. Those few residents most 11 aware of handovers and their timings were those who were less content with what they were doing 12 at handover times or who reported having to wait, for toileting assistance for example, at handover 13 time.
14 The proportion of residents saying they did not know what happened when staff started and finished 15 work was the same as those who were aware that incoming and outgoing staff met to speak with 16 each other. A small number presumed care staff were preparing for their shift by taking their coats 17 off and having a cup of tea; one thought staff were busy helping people get up at the morning  Family members were aware of shift times and locations, but fewer than half were fully aware of the 12 handover times and locations. Relatives either did not visit at handover times or were in their 13 relative's room when they took place. Despite the length of time some had been visiting their family 14 member in the care home and the frequency with which some visited, only one relative reported 15 being present during a room-by-room handover. 16  Living in a home that operated room-by-room handovers did not guarantee an understanding of 5 handovers, their content and the processes they involved. Accounts differed between the three 6 residents of one the homes operating room-by-room handovers whose staff were observed to 7 actively involve residents during room-by-room handover discussions:  Nevertheless, there was much speculation among family members about the minutiae of handovers.

Knowledge of and views on handovers practices and purpose
2 While one relative who had worked in care homes had experience of handovers, others, of course, 3 did not, although many relatives speculated correctly that staff were briefed on residents' health 4 needs and what had happened during the previous shift (including problems), and that relevant 5 information or notes about these were being handed over. One thought this information was likely 6 to be passed from nurse to nurse without any care worker involvement; another thought it was likely 7 to be from nurse to nurse and care worker to care worker, depending on the subject. 8 Whereas most relatives knew their family member had a care plan, most did not know whether 9 handover notes were made or assumed they were. Most knew of the existence of a 'file' about the 10 resident, but they did not know whether these were linked with handovers. Only two were aware of 11 a handover file that staff wrote in, and two that electronic records were kept. Generally, they felt 12 their involvement in handovers was unnecessary and were, hypothetically, only likely to be 13 interested in seeing handover records should a problem arise.
14 As with the former care worker, a handful of family members and residents stated that their 15 awareness, knowledge and views of handovers had been influenced by their, or a family member's, 16 work in nursing or social care.

17
Residents' awareness of and views on the length of handovers were relatively evenly divided, 18 sometimes influenced by their own needs at these times. Some had no idea of how long handover 19 conversations lasted; others considered they lasted a reasonable amount of time.

20
A subset of participants indicated that administrative matters, such as handovers, were not within 21 their scope of interest and they, therefore, were unaware of handover length: Those least content with handover length were residents who were awake and needing or wanting 4 assistance. A small number of relatives were concerned that the lack of visibility of staff at handover 5 times meant that vulnerable residents were, potentially, not being attended to, but half had no 6 concerns about residents while staff were busy doing handovers, feeling that residents were either 7 sleeping or the period was covered by some other activity (e.g. tea rounds). Not all relatives voiced 8 views on this. 9 Three-quarters of participants felt they did not know enough about handovers to suggest potential 10 improvements or reported being happy with the status quo and did not feel that changes were 11 necessary. Only one participant (a relative) made a suggestion concerning the topic of this paper, 12 expressing a wish for information about handovers to be part of the introduction to the home's 13 routines, what relatives could expect and any related procedures.
14 Views on handover effectiveness 15 All relatives considered shift handovers to be beneficial for residents and/or themselves. Benefits for 16 relatives mainly related to continuity of care; they gained peace of mind from knowing that staff 17 were well-briefed on their family member's needs and health, awareness of potential medication 18 needs relating to distressed behaviour, from knowing they would be made aware of any new 19 problems, and benefited from staff informing them on arrival of their relative's health and wellbeing. In contrast, three residents described occasions when they felt information had not been passed well 7 between shifts or when they felt they had been given limited information.  2  the nine participants who said they preferred long shifts to minimise the number of handovers,   3  two-thirds were linked with the homes operating three or four handovers and only one-third   4 with homes operating only two handovers.

5
All family members thought that staff attending handovers should be paid for time spent in 6 handover (our previous study 14 found that they were not always paid) as handovers were important.

7
Most family members were unsurprised to hear that staff were not always paid for handovers and 8 disapproved of this to differing degrees.

Discussion
Integration with prior work, implications, transferability, and contribution(s) to the field -Short summary of main findings; explanation of how findings and conclusions connect to, support, elaborate on, or challenge conclusions of earlier scholarship; discussion of scope of application/generalizability; identification of unique contribution(s) to scholarship in a discipline or field 14 (10) -16 (2) 16 (23) -17 (7) Limitations -Trustworthiness and limitations of findings 15 (22) -16 (11)

Other
Conflicts of interest -Potential sources of influence or perceived influence on study conduct and conclusions; how these were managed 18 (3) Funding -Sources of funding and other support; role of funders in data collection, interpretation, and reporting 18 (5-10) *The authors created the SRQR by searching the literature to identify guidelines, reporting standards, and critical appraisal criteria for qualitative research; reviewing the reference lists of retrieved sources; and contacting experts to gain feedback. The SRQR aims to improve the transparency of all aspects of qualitative research by providing clear standards for reporting qualitative research.
**The rationale should briefly discuss the justification for choosing that theory, approach, method, or technique rather than other options available, the assumptions and limitations implicit in those choices, and how those choices influence study conclusions and transferability. As appropriate, the rationale for several items might be discussed together. Our studies aim to inform staff and regulator reflection on good practice 5 in handovers and we recognise that quality is a multi-faceted concept. This paper focuses on 6 awareness of the occurrence of handovers, knowledge of handover purpose and logistical practices, 7 and handover effectiveness from residents' and relatives' perspectives. Handovers' potential impact 8 on residents' wellbeing will be reported separately.

10
As our study aimed to focus on a specific set of views and experiences during a specific event that is 11 influenced by organisational cultures, namely handovers, we took an exploratory, focused-12 ethnographic 15 , qualitative approach.

13
According to Wall's 15 synopsis of the development of focused ethnography, traditional ethnography 14 aims to describe cultural behaviours, generally without addressing a formal research question, 15 involves long-term fieldwork and is usually undertaken by researchers outside, and without 16 experience of, the culture being studied. Focused ethnography is a type of micro-ethnography 17 especially useful in addressing specific problems in fragmented and specialised study areas.

18
Researchers with background knowledge of the study topic enter the field with specific research 19 questions and short-term visits are undertaken with a defined sub-cultural group of participants.

20
Handovers are influenced by organisational cultures 16 which may be described as the way in which 21 things are done, or ways of behaving in a given work setting, whether this is a particular location 22 (such as a hospital ward or care home) or a wider field (such as types of care homes). Adopting this 23 perspective means that handovers can be seen as rituals in organisational settings. we included only homes awarded a rating of Good or Outstanding. Managers/owners were then 10 invited to take part, consecutively, to achieve our target of five care homes. Two did not respond.

11
Three refused as they thought they would contribute little, either because they were small homes 12 with handovers that were said to last only a few minutes, or because of the small proportion of 13 residents with capacity to undertake an interview (although not registered for people with 14 dementia). One agreed to remain on the reserve list should another withdraw. Another initially 15 agreed to participate but was replaced when it became clear that residents did not meet inclusion 16 criteria and its owner-manager offered another home in its place. Five homes were not approached 17 as our sample target had been reached. One care home participated in both studies. Table 1 gives 18 details of the participating homes and Table 2  varied expertise and backgrounds. Residents' and relatives' data in three homes were gathered by a 6 single researcher and, in two sites, two researchers undertook data collection in each. The lead study 7 researcher visited all five care homes and interviewed three managers, jointly with another 8 researcher in one home; the researchers gathering resident and relative data in the other two homes 9 interviewed their managers. Table 3 provides a breakdown of resident and relative participants by 10 care home and researchers undertaking data collection. Table 4 summarises participants' 11 characteristics briefly to protect their anonymity.
12  at one resident interview and a resident was also present at two relative interviews. 16 Before each interview, participants gave their consent, which followed a discussion with the 17 researcher of the study's aims and methods. Interviews were digitally audio-recorded, except for 18 three in which notes were taken due to recording consent being refused, a noisy environment 19 making recording impractical, and recorder malfunction respectively.  8 The first author undertook coding and initial analysis. Team meetings, which included an additional 9 researcher not undertaking fieldwork, supported and further developed themes identified; data 10 saturation was discussed in these. Three overarching themes resulted, two of which were relevant to 11 this paper (see Table 5).
12 Awareness of the occurrence of handovers 16 As Table 2 shows, most handovers took place early in the morning or in the late evening. These were 17 times when most residents were in their rooms which meant they did not see or hear handovers that 18 took place in offices or elsewhere. Many residents were asleep during handovers; thus their 19 experiences were limited to pre-and post-handover encounters with care workers or nursing staff.

20
These included staff greeting residents and bidding them farewell, delivering hot drinks and/or doing 21 a round of the rooms 'checking up' on residents. Even when handovers were room-by-room, 22 residents were not always awake, or did not necessarily associate being visited in their rooms by 23 staff with the shift handover process. All three Clematis Grove residents were aware that handovers happened at shift changeover, but 2 only one of the two Violet Manor residents was aware that handovers happened. The meeting in the 3 lounge which she described as 'handover' was actually the post-handover meeting of incoming staff.

4
As for the handover times themselves, a small number of residents were aware that handovers 5 happened at the times researchers told them. Some residents were aware of some handovers but 6 not others. Some residents were not aware of any handovers. Some residents thought handovers 7 happened 30 minutes later than they did. The few residents most aware of handovers and their 8 timings were those who were less content with what they (residents) were doing at handover times 9 or who reported having to wait, for toileting assistance for example, at handover time. notes about these were being handed over. One thought this information was likely to be passed 6 from nurse to nurse without any care worker involvement; another thought it was likely to be from 7 nurse to nurse and care worker to care worker, depending on the subject. 8 Most relatives knew their family member had a care plan or 'file', but they did not know whether 9 these were linked with handovers. Only two were aware of a handover file that staff wrote in.

10
Another two knew that electronic records existed. Generally, relatives felt their involvement in 11 handovers was unnecessary and were, hypothetically, only likely to be interested in seeing handover 12 records should a problem arise.

13
As with the relative who was a former care worker, a handful of family members and residents 14 stated that their awareness, knowledge and views of handovers had been influenced by their, or a 15 family member's, work in nursing or social care. 16 Residents' awareness of and views on the length of handovers were relatively evenly divided, 17 sometimes influenced by their own needs at these times. Some had no idea of how long handover 18 conversations lasted; others considered they lasted a reasonable amount of time.

19
A subset of participants indicated that administrative matters, such as handovers, were not within 20 their scope of interest and they, therefore, were unaware of handover length: In contrast, three residents described occasions when they felt information had not been passed well 6 between shifts or when they felt they had been given limited information. 7 Two residents voiced particularly strong opinions about the lack of availability of staff during 8 handover periods which impacted negatively on their wellbeing and physical care as staff were not 9 available to assist with using the toilet, resulting in the residents needing to wear incontinence pads.
10 Family members were mainly confident that the necessary information was passed on between 11 shifts and that the care homes caring for their relatives were doing this well. There were a few 12 exceptions, some of which were more about care home policies and frontline worker decisions about 13 communication with residents or relatives, rather than ineffective information-sharing or lack of 14 availability at handover. One relative highlighted how certain information may be handed over once, 15 but not twice, or may be overlooked, which had happened in her experience during periods where 16 certain support needs (e.g. assistance with eating) fluctuated. Most relatives considered that current 17 communication from the homes met their informational needs or they spoke to staff directly about 18 their relative when visiting, either to gain or to give information.

19
Family members' and residents' views on the length of shifts worked by care staff suggested 20 high confidence in the effectiveness of handovers and the quality of care provided by staff.

21
Their view, generally, was that quality of care did not suffer because staff worked long shifts, 22 although two residents and one relative had noticed staff being less attentive towards the end 23 of their shifts. Nevertheless, there were also inferences of slightly lower confidence in the 24 effectiveness of handovers in homes operating more than two shifts than initially apparent. Of 8 Role of the funding source: The views expressed here are those of the authors and not the funder.

9
The funder was not involved in the execution, analysis and interpretation of data, or the writing of 10 this paper. All authors are independent of the funder and were involved in data analysis.

Topics covered in interviews with residents
Relationship to resident.

Length of time visiting and frequency of visits.
Residents' cognitive ability to discuss their care. Awareness of numbers of shifts operating in care home and when they take place. Which staff (day/night) relative usually has contact with. Awareness of what happens during shift changeover times: how shifts communicate with each other, whether staff greet/bid farewell to resident relative and their feelings about this. Whether or not relative has witnessed a handover.
If a handover has taken place in family member's presence: -Description of typical conversation between staff changing shifts -Which staff were present, how they were involved and whether notes were taken -What was discussed and whether content was understandable by relative -Views on length of conversations -Whether staff involved resident and/or relative in conversations and how -Action they may take if do not agree with what is being said about their relative -Whether relative liked what happened during handover(s) witnessed Views concerning whether handovers benefit relative or resident relative and how. Passing on of information about resident given by relative. Any examples of occasions when important information was/was not handed over to oncoming shift. Knowledge of recording of handovers. Views on payment of care staff to attend handovers. Are they aware of resident relative needing/wishing help that is not available due to staff being busy with handovers? Does this happen at other times? Feelings about this. View on shift lengths and any impact these may have on care homes.
Whether key working operates in the home. Ideas for improvement of handover conversations. Anything else about shift handovers.

COREQ (COnsolidated criteria for REporting Qualitative research) Checklist
A checklist of items that should be included in reports of qualitative research. You must report the page number in your manuscript where you consider each of the items listed in this checklist. If you have not included this information, either revise your manuscript accordingly before submitting or note N/A.

Discussion
Integration with prior work, implications, transferability, and contribution(s) to the field -Short summary of main findings; explanation of how findings and conclusions connect to, support, elaborate on, or challenge conclusions of earlier scholarship; discussion of scope of application/generalizability; identification of unique contribution(s) to scholarship in a discipline or field 14 (10) -16 (2) 16 (23) -17 (7) Limitations -Trustworthiness and limitations of findings 15 (22) -16 (11)

Other
Conflicts of interest -Potential sources of influence or perceived influence on study conduct and conclusions; how these were managed 18 (3) Funding -Sources of funding and other support; role of funders in data collection, interpretation, and reporting 18 (5-10) *The authors created the SRQR by searching the literature to identify guidelines, reporting standards, and critical appraisal criteria for qualitative research; reviewing the reference lists of retrieved sources; and contacting experts to gain feedback. The SRQR aims to improve the transparency of all aspects of qualitative research by providing clear standards for reporting qualitative research.
**The rationale should briefly discuss the justification for choosing that theory, approach, method, or technique rather than other options available, the assumptions and limitations implicit in those choices, and how those choices influence study conclusions and transferability. As appropriate, the rationale for several items might be discussed together. Our studies aim to inform staff and regulator reflection on good practice 5 in handovers and we recognise that quality is a multi-faceted concept. This paper focuses on 6 awareness of the occurrence of handovers, knowledge of handover purpose and logistical practices, 7 and handover effectiveness from residents' and relatives' perspectives. Handovers' potential impact 8 on residents' wellbeing will be reported separately.

10
As our study aimed to focus on a specific set of views and experiences during a specific event that is 11 influenced by organisational cultures, namely handovers, we took an exploratory, focused-12 ethnographic 15 , qualitative approach.

13
According to Wall's 15 synopsis of the development of focused ethnography, traditional ethnography 14 aims to describe cultural behaviours, generally without addressing a formal research question, 15 involves long-term fieldwork and is usually undertaken by researchers outside, and without 16 experience of, the culture being studied. Focused ethnography is a type of micro-ethnography 17 especially useful in addressing specific problems in fragmented and specialised study areas.

18
Researchers with background knowledge of the study topic enter the field with specific research 19 questions and short-term visits are undertaken with a defined sub-cultural group of participants.

20
Handovers are influenced by organisational cultures 16 which may be described as the way in which 21 things are done, or ways of behaving in a given work setting, whether this is a particular location 22 (such as a hospital ward or care home) or a wider field (such as types of care homes). Adopting this 23 perspective means that handovers can be seen as rituals in organisational settings.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  we included only homes awarded a rating of Good or Outstanding. Managers/owners were then 10 invited to take part, consecutively, to achieve our target of five care homes. Two did not respond.

11
Three refused as they thought they would contribute little, either because they were small homes 12 with handovers that were said to last only a few minutes, or because of the small proportion of 13 residents with capacity to undertake an interview (although not registered for people with 14 dementia). One agreed to remain on the reserve list should another withdraw. Another initially 15 agreed to participate but was replaced when it became clear that residents did not meet inclusion 16 criteria and its owner-manager offered another home in its place. Five homes were not approached 17 as our sample target had been reached. One care home participated in both studies. Table 1 gives   18  details of the participating homes and Table 2 summarises timings, location and coverage of shift   19 handovers, as reported by managers.
12   1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  Visiting patterns ranged from daily to every 7-10 days, but most visited more than 3 times a week. Six relatives reported their relatives' cognitive or communication impairments precluded discussion with them about their care. 1 2 Residents and relatives were given the opportunity to volunteer for interviews and/or observations 3 via posters displayed in the care homes and by direct approach from the care home managers, 4 whom they knew, who provided a study Information Sheet. Residents were identified by managers 5 as having mental capacity to take a decision about participation. Researchers then spoke with or 6 emailed potential participants. Since residents and relatives were approached by the care home 7 managers, we are unable to quantify the refusal or drop-out rate of potential participants.

8
Individual observations (n=47) were undertaken during 30 handover periods over 23 days at 9 different times of day (morning n=14, day time n=3, evening n=13) during the week (n=24) and at 10 weekends (n=6). We aimed to be as unobtrusive as possible to mitigate the risk that behaviour might 11 change as a result of being observed. In vivo observations were recorded on a template devised for 12 the study (see Supplementary File 1).

13
Interviews, which took place at the care homes, lasted 8-38 minutes with residents and 15-33 14 minutes with relatives (see Supplementary File 2 for topics covered). A family member was present 15 at one resident interview and a resident was also present at two relative interviews. 16 Before each interview, participants gave their consent, which followed a discussion with the 17 researcher of the study's aims and methods. Interviews were digitally audio-recorded, except for 18 three in which notes were taken due to recording consent being refused, a noisy environment 19 making recording impractical, and recorder malfunction respectively. 8 The first author undertook coding and initial analysis. Team meetings, which included an additional 9 researcher not undertaking fieldwork, supported and further developed themes identified; data 10 saturation was discussed in these. Three overarching themes resulted, two of which were relevant to 11 this paper (see Table 5).

20
These included staff greeting residents and bidding them farewell, delivering hot drinks and/or doing 21 a round of the rooms 'checking up' on residents. Even when handovers were room-by-room, 22 residents were not always awake, or did not necessarily associate being visited in their rooms by 23 staff with the shift handover process.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   11   1 All three Clematis Grove residents were aware that handovers happened at shift changeover, but 2 only one of the two Violet Manor residents was aware that handovers happened. The meeting in the 3 lounge which she described as 'handover' was actually the post-handover meeting of incoming staff.

4
As for the handover times themselves, a small number of residents were aware that handovers 5 happened at the times researchers told them. Some residents were aware of some handovers but 6 not others. Some residents were not aware of any handovers. Some residents thought handovers 7 happened 30 minutes later than they did. The few residents most aware of handovers and their 8 timings were those who were less content with what they (residents) were doing at handover times 9 or who reported having to wait, for toileting assistance for example, at handover time.

10
The proportion of residents saying they did not know what happened when staff started and finished 11 work was the same as those who were aware that incoming and outgoing staff met to speak with notes about these were being handed over. One thought this information was likely to be passed 6 from nurse to nurse without any care worker involvement; another thought it was likely to be from 7 nurse to nurse and care worker to care worker, depending on the subject. 8 Most relatives knew their family member had a care plan or 'file', but they did not know whether 9 these were linked with handovers. Only two were aware of a handover file that staff wrote in.

10
Another two knew that electronic records existed. Generally, relatives felt their involvement in 11 handovers was unnecessary and were, hypothetically, only likely to be interested in seeing handover 12 records should a problem arise.

13
As with the relative who was a former care worker, a handful of family members and residents 14 stated that their awareness, knowledge and views of handovers had been influenced by their, or a 15 family member's, work in nursing or social care. 16 Residents' awareness of and views on the length of handovers were relatively evenly divided, 17 sometimes influenced by their own needs at these times. Some had no idea of how long handover 18 conversations lasted; others considered they lasted a reasonable amount of time.

19
A subset of participants indicated that administrative matters, such as handovers, were not within 20 their scope of interest and they, therefore, were unaware of handover length: In contrast, three residents described occasions when they felt information had not been passed well 6 between shifts or when they felt they had been given limited information. 7 Two residents voiced particularly strong opinions about the lack of availability of staff during 8 handover periods which impacted negatively on their wellbeing and physical care as staff were not 9 available to assist with using the toilet, resulting in the residents needing to wear incontinence pads.

10
Family members were mainly confident that the necessary information was passed on between 11 shifts and that the care homes caring for their relatives were doing this well. There were a few 12 exceptions, some of which were more about care home policies and frontline worker decisions about 13 communication with residents or relatives, rather than ineffective information-sharing or lack of 14 availability at handover. One relative highlighted how certain information may be handed over once, 15 but not twice, or may be overlooked, which had happened in her experience during periods where 16 certain support needs (e.g. assistance with eating) fluctuated. Most relatives considered that current 17 communication from the homes met their informational needs or they spoke to staff directly about 18 their relative when visiting, either to gain or to give information.

19
Family members' and residents' views on the length of shifts worked by care staff suggested 20 high confidence in the effectiveness of handovers and the quality of care provided by staff.

Topics covered in interviews with residents
Relationship to resident. Length of time visiting and frequency of visits.
Residents' cognitive ability to discuss their care. Awareness of numbers of shifts operating in care home and when they take place. Which staff (day/night) relative usually has contact with. Awareness of what happens during shift changeover times: how shifts communicate with each other, whether staff greet/bid farewell to resident relative and their feelings about this. Whether or not relative has witnessed a handover.
If a handover has taken place in family member's presence: -Description of typical conversation between staff changing shifts -Which staff were present, how they were involved and whether notes were taken -What was discussed and whether content was understandable by relative -Views on length of conversations -Whether staff involved resident and/or relative in conversations and how -Action they may take if do not agree with what is being said about their relative -Whether relative liked what happened during handover(s) witnessed Views concerning whether handovers benefit relative or resident relative and how. Passing on of information about resident given by relative. Any examples of occasions when important information was/was not handed over to oncoming shift. Knowledge of recording of handovers. Views on payment of care staff to attend handovers. Are they aware of resident relative needing/wishing help that is not available due to staff being busy with handovers? Does this happen at other times? Feelings about this. View on shift lengths and any impact these may have on care homes.

COREQ (COnsolidated criteria for REporting Qualitative research) Checklist
A checklist of items that should be included in reports of qualitative research. You must report the page number in your manuscript where you consider each of the items listed in this checklist. If you have not included this information, either revise your manuscript accordingly before submitting or note N/A. Data collection instruments and technologies -Description of instruments (e.g., interview guides, questionnaires) and devices (e.g., audio recorders) used for data collection; if/how the instrument(s) changed over the course of the study 5 (4-10) -6 (13-17, 7 (1) Units of study -Number and relevant characteristics of participants, documents, or events included in the study; level of participation (could be reported in results) 4 (13), 5 (1-2), 6 (1-6) Data processing -Methods for processing data prior to and during analysis, including transcription, data entry, data management and security, verification of data integrity, data coding, and anonymization/de-identification of excerpts 6 (13-17), 7 (1-5), 7 (6-9)  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y 2 Data analysis -Process by which inferences, themes, etc., were identified and developed, including the researchers involved in data analysis; usually references a specific paradigm or approach; rationale** 7 (2-5) Techniques to enhance trustworthiness -Techniques to enhance trustworthiness and credibility of data analysis (e.g., member checking, audit trail, triangulation); rationale** 7 (11-17)

Discussion
Integration with prior work, implications, transferability, and contribution(s) to the field -Short summary of main findings; explanation of how findings and conclusions connect to, support, elaborate on, or challenge conclusions of earlier scholarship; discussion of scope of application/generalizability; identification of unique contribution(s) to scholarship in a discipline or field 14 (10) -16 (2) 16 (23) -17 (7) Limitations -Trustworthiness and limitations of findings 15 (22) -16 (11)

Other
Conflicts of interest -Potential sources of influence or perceived influence on study conduct and conclusions; how these were managed 18 (3) Funding -Sources of funding and other support; role of funders in data collection, interpretation, and reporting 18 (5-10) *The authors created the SRQR by searching the literature to identify guidelines, reporting standards, and critical appraisal criteria for qualitative research; reviewing the reference lists of retrieved sources; and contacting experts to gain feedback. The SRQR aims to improve the transparency of all aspects of qualitative research by providing clear standards for reporting qualitative research.