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Title: Bedside shift-to-shift nursing report: implementation and outcomes

Author(s): Deby Evans, Julie Grunawalt, Donna McClish, Winnie Wood and Christopher R. Friese
Source: MedSurg Nursing. 21.5 (September-October 2012): p281.
Document Type: Report
Copyright: COPYRIGHT 2012 Jannetti Publications, Inc.
http://www.ajj.com
Abstract:
One unit's staff developed and evaluated an intervention to relocate shift-to-shift nursing report to the patient's bedside. Despite challenges related
to privacy, distractions, and integration of nursing technicians to the change, bedside shift report reduced shift report times and improved nursing
satisfaction.
Full Text:
Patients in acute care hospitals face an increasingly complex environment for care delivery. Because of the need for 24-hour care that is often
provided by multiple disciplines and services, communication among health care personnel is an essential component of safe, effective care. The
most frequent period of professional communication in acute care hospitals is the shift-to-shift report by nurses (Friesen, White, & Byers, 2008).
Literature Review
In her ethnographic study, Wolf (1988) identified the shift-to-shift nursing report as an "occupational ritual" (p. 232) whereby exiting nurses
formally released and incoming nurses accepted responsibility for patient care. She also identified shift-to-shift nursing report as "suspended time"
(p. 231) that enabled on-duty and off-duty nurses to focus on the data surrounding their patients. This report period usually involves the exchange
of verbal and written information, though practices vary widely across nursing units and hospitals. While the goal of nursing shift-to-shift report is
dedicated uninterrupted time, the extensive clinical experience of the authors suggests this is rarely the case.
A recent review summarized the published literature about handoffs in hospitals published between 1968 and 2008 (Cohen & Hilligoss, 2010).
This extensive review suggested handoffs are defined poorly in health care settings. Authors also identified the importance of high-quality
handoffs to patient safety and other important outcomes, and noted weak evidence that a standardized handoff approach results in improved patient
outcomes.
Significant challenges exist in the delivery of a successful nurse-to-nurse report. Results of a qualitative study that included observation, recording,
and transcripts of 20 handoffs between nursing staff (Kerr, 2002) indicated great complexity in nurse shift-to-shift report, partly due to the multiple
functions served by shift report. In particular, nurses struggled to balance competing demands for their time, maintenance of confidentiality of
patient information, and delivery of patient- and family-centered care. This finding suggests the importance of ensuring nurse report provides for
continuity of patient care and positive patient outcomes.
Motivated by sentinel events that identified handoffs between personnel as a pervasive problem, the Joint Commission (2008) originally
established improved "effectiveness of communication among caregivers" (p. 11) as a National Patient Safety Goal in 2006. This goal "requires
institutions to develop a standardized approach to 'handoff' communication, including opportunity for staff to ask and respond to questions" (p. 12).
Additionally, National Patient Safety Goal 13.01.01 was added to "encourage patients to be actively involved in their own care as a patient safety
strategy" (Joint Commission, 2008, p. 17).
In contrast to conventional report methods that may take place in the nursing station, conference room, or by tape recorder, bedside shift report is
defined as communicating about the patient condition, nursing assessment, and required interventions at the point of patient care (Friesen et al.,
2008).
Nature of the Problem
The primary motivator for this study was staff dissatisfaction with nurse-to-nurse report and the inability to complete the shift at the scheduled end
time. Specific issues included report occurring in large, noisy conference rooms, making it difficult for staff to hear accurate details and
information; staff frequently leaving late as nurses waited to hand off to nurses who were receiving report from another shift member or
socializing; no patient-family involvement during report; and the movement of the institution to computerized charting.
When the National Patient Safety goals (Joint Commission, 2008) are applied to nursing shift-to-shift report, nurses need adequate time, space, and
resources to execute their reports. Barriers identified to effective nursing handoffs include interruptions, lack of standardized reporting processes,
and underdeveloped information and communication technology. In this article, one medical-surgical nursing unit's journey to improve the process
of nursing shift-to-shift report is examined. The intervention focused on changing the context and structure of report. Importantly, the team
evaluated the effectiveness of this practice change on nursing job satisfaction and time spent delivering report.
Process
As part of the University of Michigan Hospital and Health Centers (Ann Arbor, MI), 5B is a 32-bed medical-surgical unit with 42 full-time

equivalent registered nurses, 12 nursing aides, one nursing supervisor, one educational nurse coordinator, one clinical nurse specialist, and a nurse
manager. In 2009, 5B delivered 10,288 patient days of care. The author's review of internal utilization data identified the most frequent admitting
diagnoses for the unit as diabetes, pneumonia, renal failure, and cancer.
Motivated by the desire to strengthen patient-centered care, reduce the use of call lights, increase the hours of direct care provided, and promote
staff retention, a team of unit-based nurses was formed to review existing report procedures and propose changes. In conjunction with the unit's
nurse manager, clinical nurse specialist, nursing supervisor, and educational coordinator, this team convened an 8hour, non-clinical workday to
review available literature regarding best practices in shift reporting, and plan their change. They identified bedside shift report as one strategy to
improve desired outcomes. Desired outcomes included improved staff satisfaction as evidenced by the ability to leave the unit at the scheduled
time, coupled with the ability to receive an audible report from another nurse with ample time for questions. Secondary outcomes included
increased patient satisfaction related to increased patient-centered care, increased clarity from patients regarding their assigned care teams, and
reduced use of call lights for patient needs.
After the group identified bedside reporting as one aspect of the desired change, members performed a benchmarking analysis with peer units and
institutions to identify options for nurse-to-nurse report formats. A variety of processes was in place, including taped, written, and face-to-face
report. Some units had published guidelines for report content, while others had no organized report elements. Report activities took place in
conference space, at the nursing stations, and at the bedside.
In the design of the new nurse-to-nurse report process, the team set several criteria based on the literature. First, report should take no longer than
30 minutes. Communication between nurses should be verbal. Report should occur at the patient's bedside, with the electronic medical record and
24-hour nursing flow-sheet available for review. Arriving and departing nurses would conduct a joint environmental safety scan (e.g., bed in low
position with brake locked, infusion pumps programmed and infusing correctly).
In the redesign of nursing report, the team explored the related issue of patient assignments. The desired change would be easiest to implement if
report had to be provided to as few different nurses as possible. Literature review and benchmarking analysis led the team to consider two patient
assignment approaches:
1. Bundled assignments. Charge nurses would create assignments that were as equitable as possible based on patient acuity, infectious precautions,
expected admissions, discharges, and transfers. Nurses would select their own bundles. Geographical pod nursing was also part of the bundled
assignment model or care. RNs were assigned to work in an area where patient rooms are located contiguously.
2. Arbitrary assignment. Charge nurses assign patients without explicit operational criteria, and without input from staff nurses.
The unit nursing staff elected bundled and pod assignments. Pod assignments were considered feasible given the physical layout of the unit. Nurse
leaders met with charge nurses, the clinical practice committee, and the nursing workload committee to review and approve guidelines for
implementation. The approved guidelines then were included in the charge nurse resource book, as well as displayed on the white board in the
nursing conference room for easy reference.
With approved guidelines and staff input, a cluster of eight beds was selected for a pilot. For the day of the pilot, the nursing leaders assigned
nurses and nursing technicians of varying levels of experience. The nurse manager, clinical specialist, and a graduate student intern observed the
process and performed a debriefing with the staff following the pilot. Reduced incidental overtime during the affected shifts, positive verbal and
written feedback from the clinicians and patients, and the absence of adverse patient events on the day of the pilot led the nursing staff to diffuse
pod nursing throughout the unit immediately.
Following the pilot and review by nurse leaders, a standard operating procedure (SOP) was drafted and approved. This SOP outlined
responsibilities of nursing staff in facilitating and conducting nurse-to-nurse shift report at the patient bedside. Team members also generated a
script for nurses to use during report (see Figure 1) to allow standardization of content; it was especially helpful for nurses new to the unit.
Evaluation of Outcomes
To evaluate the intangible effects of the process change, nurse leaders maintained log books of observations during the change process. The
intervention was expected to reduce time spent in report, improve nursing satisfaction with the report process, and facilitate a clear transition of
patient care. To be able to evaluate the success of the change, team members collected baseline data prior to implementation of bedside shift
reporting. In 2007, over a period of 2 weeks, the graduate student directly observed six nurses during the last hour of their shift, and averaged the
time spent conducting shift-to-shift report. Nurses also were asked to complete a survey about their satisfaction with the nursing report process (see
Figure 2). Finally, team members audited adherence to the practice of posting date and assigned personnel on each patient's bedside white board.
These measures were assessed again in 2008, 6 months following implementation of bedside shift report.
Results
Observational Evaluation
Leader observations indicated nurses were slow to adopt the new process. As their comfort with the technique increased, however, and leaders
continued to reinforce potential benefits of the new process, staff more widely accepted the intervention. Anecdotally, this report technique may
have averted adverse patient events. In several instances, for example, rapid response team calls were initiated because patient condition had
changed from last visualization to the time of report. During implementation, three significant issues arose. First, patients sometimes would
monopolize the report conversation. The report script was revised (see Figure 1) to assure pertinent information was conveyed between nurses on
all patients. Staff were encouraged to inform patients that nurses first had to discuss a few points, then would address non-urgent topics raised by
patients.
FIGURE 1. Bedside Shift-to-Shift Nursing Report Script Patient Introduction * Preferred name, age, diagnosis, and code
status if known Pain Management/Vital Signs * Patient pain rating, pain management interventions, physiological effects
of interventions Fluid Intake/Output * Fluid restrictions, intravenous infusion solutions and rates, surgical drains Skin
and Wound Assessment and Care * Current status of patient skin, risk for acquisition of pressure ulcers, interventions to

prevent pressure ulcers, wound assessment and location, prescribed treatments and schedule Glucose Monitoring and
Management * Serum glucose values, frequency of monitoring, management and evaluation of interventions
Cognitive/Perceptual * Mental status, pain description, and therapies (if not mentioned previously) Activity/Exercise *
Assessment of circulation, muscle strength, tolerance of activities, staff assistance required to ambulate Elimination *
Bowel sounds, nausea/vomiting, stool color/consistency, urine color/consistency Nutrition * Diet status, plan for
advancing diets Fall Risk * Patient risk for falls, related interventions Other * Discharge plan, scheduled tests and
procedures, documentation needs, education needs, and equipment needs

Several staff members voiced a concern that conducting report in a semi-private room would violate the Protected Health Information tenets of the
Health Insurance Portability and Accountability Act (HIPAA). To address this concern, the institution's risk management staff members were
asked to review the process. This consultation led to a process revision so potentially sensitive or private information (e.g., infectious diagnosis,
psychosocial matters) would be discussed in private conference room space.
Finally, assignment realignment by pods worked well for nurses but created an unintended adverse effect for nursing technicians who usually were
assigned to more than four rooms. Technicians preferred geographic proximity, but this would reduce the cohesion of the caregiving team. The
unit's leaders continue to explore various models of nursing assignments to promote patient continuity and teamwork, and address acuity concerns.
These include nursing assistant-nurse partnerships, nursing assistant self-assignment, acuity system-based assignments, and explicit feedback from
nursing assistants to the charge nurse on patient assignments.

Outcome Evaluation
Table 1 shows the empirical results from the outcomes evaluation, which included documentation of average shift report length in minutes, pro
portion of responses to all five questions (see Figure 2) that scored in the satisfied/very satisfied range, and an audit on the completion of bedside
white boards with accurate nurse and nursing assistant assignments. All three outcomes were assessed before and after implementation. Results
suggest bedside report increased nursing satisfaction, helped nurses prioritize their workflow better, and decreased the amount of time for report.
Anecdotally, the process also appears to have decreased the use of subjective language during report, such as unclear acronyms and abbreviations
forbidden by hospital policy and procedures.
Discussion

Improved prioritization of the workflow means the most acute patients are seen first after report, patients in the assignment are seen within the first
half hour of the shift, and oncoming nurses are able to visualize the patient themselves rather than rely on comments from colleagues. Nurses are
able to visualize the environment; make checks of the IV line, site, and fluids; and ask questions of patients and their colleagues. With decreased
report times, nurses spend less time socializing among themselves, resulting in decreased times to obtain report from an off going nurse. This
results in exiting nurses ending their shift on time, reducing incidental overtime and allowing direct patient care to begin sooner for the oncoming
shift.
Despite the above evidence, concern exists regarding the sustainability of bedside report; many nurses believe the process violates patient
confidentiality and they are not comfortable talking in front of the patient. Nurses worry the patient may ask for something during report, thus
impeding the report process. While the script is helpful to some nurses, continued coaching and leader support are required to sustain the
intervention. Continuing challenges for the unit include integrating nursing technicians in the redesign, despite differing patient assignments from
nurses. Clinical patient outcomes affected by the change, as well as feedback obtained from physicians and other colleagues, continue to be
reviewed.

Nursing Implications
Relocation of report to the bedside resulted in greater nurse satisfaction because nurses could give and receive a much more accurate handoff
without distractions, assess the patient and the immediate area (IV fluids/IV site/ pump rates) in real time, and avoid delays in receiving report and
asking questions. Patients were more involved in their care and were able to identify their caregivers for the shift, which promoted patient
satisfaction. The unit's budget improved from reduced incidental overtime. These findings suggest nurses can work with their leaders to
reconfigure shift-to-shift report with steps similar to those reported here.
Conclusion
A team-developed intervention to relocate shift-to-shift nursing report to the patient bedside resulted in improved satisfaction for nurses and
increased direct care time to patients. This project reflects a growing body of evidence to suggest standardized shift report techniques can improve
outcomes (Caruso, 2007; Kelly, 2005; Laws & Amato, 2010).
Acknowledgments: Authors wish to acknowledge the 5B (staff) for their willingness to experiment and adopt bedside shift-to-shift report, as well
as 5B's Lean Coach Kate Bombach for her wisdom and enthusiasm during the implementation of this change. Dr. Friese was supported by a
Pathway to Independence Award (R00NR010750) from the National Institute of Nursing Research, National Institutes of Health.
REFERENCES
Caruso, E.M. (2007). The evolution of nurse-to-nurse bedside report on a medical-surgical cardiology unit. MEDSURG Nursing, 16(1), 17-22.
Cohen, M.D., & Hilligoss, P.B. (2010). The published literature on handoffs in hospitals: Deficiencies identified in an extensive review. Quality
and Safety in Health Care, 19(6), 493-497.
Friesen, M.A., White, S.V., & Byers, J.F. (2008). Handoffs: Implications for nurses. In. R.G. Hughes (Ed.), Patient safety and quality: An
evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://www.ncbi.nlm.nih.
gov/books/NBK2649/pdf/ch34.pdf
Joint Commission. (2008). FAQs for the 2008 National Patient Safety Goals. Retrieved from http://www.jointcommission.org/ standards
information/npsgs.aspx
Kelly, M. (2005). Change from an office-based to a walk-around handover system. Nurse Times, 101(10), 34-35.
Kerr, M.P. (2002). A qualitative study of shift handover practice and function from a socio-technical perspective. Journal of Advanced Nursing,
37(2), 125-134.
Laws, D., & Amato, S. (2010). Incorporating bedside shift reporting into change-of-shift report. Rehabilitation Nursing, 35(2), 70-74.
Wolf, Z.R. (1988). Nurses' work: The sacred and the profane. Philadelphia, PA: University of Pennsylvania Press.
Deby Evans, RN, CMSRN, is Clinical Nurse Supervisor, University of Michigan Health System, Ann Arbor, MI.
Julie Grunawalt, MS, RN, GCNS-BC, is Nurse Manager, University of Michigan Health System, Ann Arbor, MI.
Donna McClish, BSN, RN, is Nurse Manager, University of Michigan Health System, Ann Arbor, MI.
Winnie Wood, MSN, RN, is Clinical Nurse Specialist, University of Michigan Health System, Ann Arbor, MI.
Christopher R. Friese, PhD, RN, AOCN[R], is Assistant Professor of Nursing, University of Michigan, Ann Arbor, MI.
TABLE 1. Outcomes Observed Before and After Bedside Shift-to-Shift Nursing Report Implementation Year 2007 2008 Average
Report Time 45 minutes 29 minutes Nurse Satisfaction with Report Process 37% 78% White Board Adherence 25% 98% FIGURE 2.
Satisfaction with Shift-to-Shift Nursing Report In an effort to improve communication between staff on the unit, we would
like to get your input on how you feel about the way shift-to-shift report is currently being done. Please circle the
number that represents your answer. 1. I have enough time to receive/give report. Completely Slightly Slightly Completely
Satisfied Satisfied Neutral Satisfied Dissatisfied 1 2 3 4 5 2. The report I receive is sufficient care for thepatient.
Completely Slightly Slightly Completely Satisfied Satisfied Neutral Satisfied Dissatisfied 1 2 3 4 5 3. The report I
received matches the patient's condition. Completely Slightly Slightly Completely Satisfied Satisfied Neutral Satisfied
Dissatisfied 1 2 3 4 5 4. My questions about the patient are answered before I begin his/her care. Completely Slightly
Slightly Completely Satisfied Satisfied Neutral Satisfied Dissatisfied 1 2 3 4 5 5. To maintain a smooth changeover of
patient care, I feel comfortable approaching a busy co-worker to obtain report. Completely Slightly Slightly Completely
Satisfied Satisfied Neutral Satisfied Dissatisfied 1 2 3 4 5 Your job title: RN-- NA-- Thank you for your time and
information. If you have any comments or suggestions, please write them on the bottom of this survey.

Evans, Deby^Grunawalt, Julie^McClish, Donna^Wood, Winnie^Friese, Christopher R.

Source Citation (MLA 7th Edition)
Evans, Deby, et al. "Bedside shift-to-shift nursing report: implementation and outcomes." MedSurg Nursing Sept.-Oct. 2012: 281+. Health
Reference Center Academic. Web. 14 Apr. 2015.
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