Introduction
Nursing handoffs facilitate safe and effective exchange of crucial patient information and clinical care handover at the end of a shift (Staggers & Blaz, 2012). Traditionally, shift-to-shift reporting was done through verbal or recorded/audio reports made at the nurse stations. However, recorded reports have been associated with problems of inconsistent reporting, communication lapses, limited patient/family involvement, and sentinel events (Poh, Parasuram, & Kannusamy, 2013). The safety issues have implications for patient satisfaction scores as measured through the HCAHPS surveys.
The proposed practice change aims to move the facility from bedside shift reports to recorded/audio reports currently in use in a local hospital. Evidence supports the use of bedside reporting as a tool for improving clinical communication, care continuity, and patient safety outcomes (McMurray, Chaboyer, Wallis, Johnson, & Gehrke, 2011). Therefore, an evidence-based bedside shift reporting protocol would improve the quality and safety of patient care at the facility.
Problem Statement
The staff in the facility’s units is not using evidence-based guidelines for shift handoffs. The nurses are currently using recorded shift reports to exchange patient information at the end of a shift. Effective shift-to-shift communication must convey critical patient information to facilitate continuity of care. From my observation, nurses complete recorded shift reports in the nursing station, not at the patient bedside, which raises the potential for communication lapses. The handoff process introduces gaps in care delivery associated with lapses in communication. Medical errors due to the change-of-shift miscommunication have been associated with an elevated risk of sentinel events (Cairns, Dudjak, Hoffman, & Lorenz, 2013). Often, critical information may become lost or omitted when transcribing audio reports or handing over written reports.
Furthermore, the practice limits patient/family involvement in their care. As a result, patient satisfaction decreases, medical error risk increases, and nursing collaboration and accountability declines. Moving to bedside reporting would improve nursing outcomes and accountability, ensure safe handoff and quality care, and enhance the inpatient experience to increase the HCAHPS scores.
Problem Background
Patient safety issues affect the quality of care and the overall clinical outcomes of a hospital. One study found that most preventable nosocomial infections are caused by clinical errors and the lack of unit-level safety measures (Maxson, Derby, Wrobleski, & Foss, 2012). Evaluating shift-to-shift reporting practices of the facility is an important starting point for addressing patient safety issues. Recorded reports are a common practice for shift handoffs at our facility.
From my observation, bedside reports are not conducted at the facility because there is no impetus for a practice change. The busy environment and the possibility of completing more than two shift reports simultaneously create a feeling that bedside reporting is more time consuming and tedious than recorded/audio reports. The nurses often opt to complete the shift reports at their nurse stations after the end of the shift. However, disruptions at the nurse stations could affect the quality and accuracy of the shift reports. Further, recorded reports do not give the oncoming nurse an opportunity to familiarize himself/herself with the components of the report and visualize the patient during the handoff.
Another key observation made was the lack of a shift report protocol. It was observed that the nurses were unclear on what to put in the shift reports, which results in incomplete or unnecessary transition information. Unclear or inconsistent information in the shift-to-shift reports increases the risk of medical errors. Therefore, staff training is required to educate the nurses on the important components of the shift reports. The transition to bedside reporting will enhance the accuracy and integrity of the information.
Nurse communication at the facility was observed to be low. Duty nurses rarely address patient/family concerns or issues, primarily because of the fear of compromising patient confidentiality. This scenario favors recorded shift reporting at the nursing station at the expense of face-to-face contact or patient visualization. The staff needs to keep the patient informed about his/her health status and respond to patient concerns to improve the inpatient experience. Bedside reporting keeps the patient engaged, which translates into higher patient-satisfaction scores.
Description of the Practice Change, Quality Improvement, or Innovation
One of the identified barriers to the practice change at the facility is the limited understanding of the bedside handoff process and its benefits. Therefore, a smooth transition to bedside reporting would include an educational component to foster a cultural change. Specifically, my 12-week project will involve providing an educational offering about the bedside reporting process and a presentation of the evidence supporting bedside reporting process to stakeholders that are in a position to effect the practice change.
Already, I have held discussions with the leadership over the need for a practice change to bedside reporting. The specifics of change process were discussed in a series of meetings with the DON and the Unit Managers, which also helped gain leadership buy-in and approval. Through these meetings, unit-level committees were also created to oversee the change process. Week 3-4 will involve developing an SBAR tool by working together with the education team. The aim is to develop a tool aligned with the patient needs and demographics at each unit. Additionally, brochures and posters will be disseminated to patients/families to build awareness on their role in bedside reporting.
The educational component will involve the training of nurse champions (week 5-7). Subsequently, the champions will train the nurses in four one-hour sessions weekly (week 8-11). This will require liaison with the Unit Managers to readjust the staffing to allow nurses to attend the training. The aim is to increase the nurses’ knowledge, build their confidence in the new practice, and demystify the perception that bedside reports are tedious and time consuming (Gregory, Tan, Tilrico, Edwardson, & Gamm, 2014). The training will focus on the core elements of the bedside report workflow process. Nurses will also be taught on how to handle patient confidentiality in the presence of family/relatives. Additionally, they will participate in role-playing and case studies to familiarize themselves with real-life bedside reporting.
Rationale for the Practice Change, Quality Improvement, or Innovation
A practice change from recorded shift reports to bedside shift reports is required to improve the quality of patient care. Adopting bedside shift-to-shift reports at the facility will enhance inter-professional communication regarding the patient’s status and treatment plan. Bedside shift reports will also give patients/families an opportunity to be involved in their care. As a result, the inpatient experience will improve, leading to higher patient satisfaction. Further, improved exchange of critical information between the outgoing nurse and incoming nurse is likely to occur when shift change occurs at the bedside.
Moreover, the incoming nurse can observe the patient, room conditions, wounds, and receive critical patient information before the handover (Holly & Poletick, 2014). This will improve the continuum of care, minimize the potential for sentinel events, and enhance patient safety. Specifically, providing staff training on the bedside reporting will equip the nurses with skills to be the agents of change. The training on the components and workflow of bedside reporting will build unit-level capacity for the new practice and reduce the resistance to change.
Credible Sources
In this section, 30 credible sources related to the bedside shift-reporting Capstone project and published within the last five years will be reviewed in CINAHL Plus, MEDLINE, Cochrane, and PsycINFO databases. The review of literature will include each article’s applicability, the evidence grade assigned, a general appraisal of the findings, and a determination of whether the source will be included or excluded from the final list of sources that will be used to inform the project. See Appendix A Credible Sources.
Best Practices Identification
The sources reviewed give evidence to support the utilization of bedside reporting as an effective nursing handoff model associated with high nurse and patient satisfaction scores. Therefore, the identified best practices are founded on the present evidence from the review.
Bedside shift handoff where the off-going nurse briefs the incoming nurse is an evidence-based practice for improving communication, safety of care, and inpatient experience (Evans, Grunawait, McClish, Wood, & Friese, 2012). From a nursing perspective, a precise and complete report is essential for improved clinical outcomes. Wakefield, Ragan, Brandt, and Tregnago (2012) attribute the medication error risk to communication lapses and the lack of patient involvement. Bedside shift handover has been shown to have multiple benefits for nurses, including improved patient visualization and prioritization (Petersen, Blackmer, McNeal, & Hill, 2013). It also takes less time to complete a bedside handover compared to recorded reports that are prone to distractions. Further, the two nurses can collaborate in positioning the patient and providing essential supplies (Friesen, Herbst, Turner, Speroni, & Robinson, 2013). Thus, bedside reporting enhances nursing accountability for patient safety.
Recorded reports normally occur at the nurses’ station away from the patient. The taped reports have some inherent weaknesses: the nurse does not visualize the patient, taped reports are overtaken by events, and the patient is not involved (Halm, 2013). Thus, the best practice for a shift change is bedside reporting. Enhanced nurse-patient communication through face-to-face contact builds trust and supports patient-centered care (Hagman, Oman, Kleiner, Johnson, & Nordhagen, 2013). In addition, informing patients about their treatment reduces anxiety related to prolonged hospitalization (Thomas & Donohue-Porter, 2012).).
Studies indicate that involving the patients in their own care improves their “outcomes and satisfaction levels” (Kerr, McKay, Klim, Kelly, & McCann, 2014, p. 1687). This engagement is only possible in bedside shift handover that gives the patient an opportunity to listen and contribute to the safety and efficiency of the nursing care (Kerr, Lu, McKinlay, & Fuller, 2011). For instance, if there is an error in the bedside report, the patient can point it out to prevent sentinel events. Standardized reporting implemented in the SBAR tool is easier to conduct at the bedside and ensures complete and accurate exchange of critical patient information to support care continuity (Tobiano, Chaboyer, & McMurray, 2013).
Evidence Summary
Moving to bedside shift reporting has been shown to improve multiple quality nursing indicators. An effective shift handover ensures that the incoming nurse receives complete information for safe and appropriate patient care (Jeffs et al., 2013). The main concepts that emerge from the evidence reviewed relate to nursing communication, patient/family-centered care, and patient and nurse satisfaction.
Nursing communication
Most costly sentinel events are attributed to miscommunication during shift handover. Critical components of the report may be omitted during the transcription of audiotapes or recorded reports (Bradley & Mott, 2014; Kerr et al., 2014). This has implications for patient safety outcomes and the quality of care. Bedside handover creates a culture of safety and accountability, which reduces the potential for errors and promotes the quality of care delivered (Cairns et al., 2013; Kerr, Lu, & McKinlay, 2014). It also removes communication barriers, lapses, and omissions that increase the risk of adverse events (Freitag & Carroll, 2011; Petersen et al., 2013). Gregory et al. (2014) found that bedside shift reports create an atmosphere of open communication between the nurse and the patient/family. Nurse communication is a crucial indicator of patient satisfaction in the HCAHPS surveys (Sherman, Sand-Jecklin, & Johnson, 2013; Radtke, 2013). Evidence shows that a shift handover conducted at the bedside engages and enlightens the patient, which reassures the patient, reduces anxiety, and increases satisfaction (Jeffs et al., 2013; Gregory et al., 2014). It also gives patients an opportunity to participate in their own care (Rush, 2012; Maxson et al., 2012).
Patient/family-centered care
Studies indicate patient- and family-centered care is an outcome of teamwork and nurse partnerships with the client, family, and doctors (Halm, 2013; Reinbeck & Fitzsimmons, 2013; Tidwell et al., 2011). Improved patient experience is associated with nurse-patient collaboration, which supports patient information exchange and participation in clinical decisions (Friesen et al., 2013; Tobiano et al., 2013). Further, bedside shift reporting reassures the patient, keeps them informed about the information being shared, and helps manage privacy (Friesen et al., 2013).
Patient and nurse satisfaction
Vines et al.’s (2014) meta-synthesis revealed that bedside reporting improved patient and nurse satisfaction scores. Standardization of bedside reports has been suggested as a means of achieving better patient satisfaction scores (McMurray et al., 2011; Petersen et al., 2013). On their part, Wakefield et al. (2012) found a connection between non-standard bedside reports and low patient and nursing satisfaction. Therefore, standardized bedside reports create a positive work environment that enhances job satisfaction (Holly & Poletick, 2014).
Further, Evans et al. (2012) identify nurse-patient/family collaboration as an indicator of patient satisfaction. The evidence reviewed indicates that implementing a standardized bedside reporting through the SBAR tool enhances patient safety outcomes and improves the inpatient experience and nursing outcomes at the facility (Sand-Jecklin & Sherman, 2014; Thompson et al., 2011). It also enhances clinical efficiency, healthcare safety, and patient empowerment (Hagman et al., 2013; Kerr et al., 2011; Sand-Jecklin & Sherman, 2014).
Recommended Practice Change, Quality Improvement, or Innovation
The facility’s recorded shift handoffs occur at the nurses’ station away from the patient. Therefore, the approach is prone to communication lapses and disruptions that affect the integrity of the handoff process. Gaps in the transfer of critical patient information and lack of patient/family involvement elevate the medical error risk that compromises patient safety and quality outcomes. An evidence-based practice change could improve nursing efficiency and clinical outcomes at the facility. The studies reviewed give evidence in support of bedside reporting as a model for improving patient safety, inpatient experience, and nursing outcomes of accountability and efficiency. Therefore, it is recommended that the facility moves from its current recorded/audio reports to bedside reporting to improve patient safety, clinical efficiency, and patient/nurse satisfaction.
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