| Pam Athwal MSN, RN Willa Fields DNSc, RN, FHIMSS Esther Wagnell BSN, RN | Journal of Nursing Care Quality April/June 2009 Volume 24 Number 2 Pages 143 - 147 |
Abstract
This article describes a clinical nurse–led initiative that changed the traditional group shift report in the conference room to a combination of a written report with a nurse-to-nurse verbal exchange at the patient's bedside. The new process resulted in less time spent in shift report, financial savings from reduced overtime, and a decrease in the number of patient falls and call lights during change of shift.
CHANGE-OF-SHIFT REPORT is an integral part of a nurse's daily routine, and it provides essential patient information to oncoming nurses. Hospitals vary in their method of communicating information to the oncoming shift of nurses, ranging from face-to-face verbal reports in the conference room or at the patient's bedside to taped and written reports. Shift report promotes patient safety, best practices, and continuity of care through communication among nursing staff.1–6 Shift reports that lack a formal structure and guidelines can lead to inefficiencies and the sharing of irrelevant and inadequate information.6 The purpose of this article is to describe a bedside clinical nurse–led initiative to design a standardized shift report that created a more time-efficient process while improving the quality of information reported.
Sharp Grossmont Hospital, located in the east inland region of San Diego County, is a 481-bed, tertiary care, not-for-profit, Magnet-designated community hospital. The hospital serves a semirural, suburban community covering approximately 750 square miles of area and half a million residents. The shift report performance improvement (PI) project began in the 34-bed Progressive Care Unit (PCU), which has an average daily census of 28, an average length of stay of 2.5 days, and approximately 8 to 10 discharges and admissions per day. The patient population is primarily cardiac medical patients. There are 55 registered nurses, 1 educator, 15 nursing assistants, 8 monitor technicians, and 1 equipment technician. The monitor technicians also function as unit secretaries. The PCU has a unit practice council that meets monthly and is led by bedside clinical nurses. A responsibility of the council is to discuss, prioritize, and sanction unit-based PI projects.
During a monthly PCU staff meeting, the bedside clinical nurses voiced dissatisfaction with the shift reports discussed in the conference room. They stated that there were inconsistencies in the information shared, and some nurses were unclear of what to include or not to include in shift reports. In addition, many times shift report lasted longer than the allotted 30 minutes, which resulted in staff overtime. A formal structure and guidelines for shift report did not exist. The nurses were directed to present these concerns to the unit practice council, and a task force was sanctioned to design an improved shift report process and format.
The existing shift report was studied for 2 months to identify the length of time spent in shift report, staff opinions of the current process, and ideas for improvement. Observations were conducted during both the 7:00 AM and 7:00 PM shift reports, without the knowledge of the staff. All off-going and oncoming nurses attended the 30- to 60-minute shift report in the conference room. The oncoming nurse would write down pertinent information while following along with the Kardex. Shift report was problematic because the lack of structure lent itself to story telling about the events of the shift. To compound the situation, each oncoming nurse had a different way and speed of writing down the information. Experienced nurses also verbalized frustration with the new nurses because they did not know what was important to present in report or what was important to write down when receiving report. Furthermore, when information was missing, nurses were sometimes called at home. Physicians were frustrated because the oncoming nurses often did not have vital information available when asked for it. Comments to the physicians such as “I don't know; I did not get that in report” were common.
Some nurses struggled with organization and prioritization of their workday and had difficulty capturing important patient information on paper. Shift report became a source of contention between the 2 shifts because not only was report taking too long but nurses also complained that they did not receive adequate information to provide patient care effectively. Nurses complained about being behind at the beginning of the shift due to shift report and that it took an entire shift to get caught up.
The shift report also affected patient satisfaction. Twice a day, all nurses were in the conference room for up to an hour. Patients complained that it took too long to see a nurse during that time, and this was reflected in patient satisfaction comments. Because of the time it took for shift report, off-going nurses were not introducing patients to the oncoming nurses. Therefore, patients often did not learn who their nurse was until later in the shift when direct care was provided.
A review of the literature was conducted to determine what evidence existed on alternatives to shift reports. The literature was replete with examples of face-to-face, taped, and written shift reports. Anderson and Mangino 1 and Caruso 3 recommended involving the patient in the shift report by having a verbal report at the patient's bedside. Others have described a preprinted tool for facilitating shift reports.2,7 McKenna 8 suggested a combination of bedside, written, or tape-recorded approaches, depending on the needs and culture of the individual unit.
The new shift report incorporated best practices from the literature, results from staff comments, and the physical layout of the unit. The result was a combination of a written update followed by a private shift report conducted at the patient's bedside. With this new process, the oncoming nurse reviews the written update and then meets with the off-going nurse to answer any questions and clarify the information. The 2 nurses then conclude the report at the patient's bedside, with an introduction of the oncoming nurse to the patient.
The written update is a concise report sheet (Fig 1). The top portion of the report sheet includes patient information, and below this section are 2 identical boxes for Shift Update. If the patient is hospitalized for more than 2 shifts, then additional pages are stapled to the report sheet with an area for the addressograph and Shift Update sections. Each Shift Update section contains information specific to that shift such as vital signs, cardiac rhythm, blood glucose results, assessments, abnormal laboratory results, plan of care, and “med clock,” which identifies times the patient is to receive medications. It was anticipated that the report sheet would decrease the amount of time needed for a shift report and include necessary information to ensure continuity of care.
| | Figure 1. Sample first page of written shift report. RBS indicates rapid blood sugar. |
Implementation of the new shift report process with the redesigned written update, verbal report, and nurse introduction at the patient's bedside was challenging because it involved changing a long-held practice of shift reports in the conference room. Fortunately, staff-level support existed because the bedside clinical nurses developed the new process, and it was approved by the unit practice council. Initially, the new process and written guidelines were introduced at staff meetings and reinforced with educational in-services. The redesigned shift report process was trialed by all nurses for 1 month. After the trial period ended, minor modifications were made and the council voted to implement the new process because of overall staff satisfaction and reduction in the length of time for report. A poster was created detailing the benefits and evidence gathered in support of the new system.
Nurses update the report sheets throughout the shift and place the completed forms in a file holder in the staff conference room. Oncoming nurses review the report sheet and then receive a verbal update and introduction to the patient at the patient's bedside. The report sheets are discarded when the patient is discharged or transferred from the unit.
The new shift report was evaluated on the amount of time spent for shift report, overtime expenses related to shift report, call lights, staff satisfaction, and patient falls. Valid patient satisfaction data related to shift report were unavailable postimplementation, although patients have made comments about the new shift report. The results were overwhelmingly in favor of the new system. The amount of time expended for shift report decreased from 30 to 60 minutes in the conference room to no time in the conference room and 10 to 15 minutes at patients' bedside (Fig 2). Shift report is completed for all patients within 15 minutes, and nurses rarely need to work overtime to complete shift report. A 2-month review of overtime data demonstrated that there was an $8000 reduction directly associated with the decrease in time for shift report. Prior to the new shift report, there was an average of 6 call lights on by the end of report. Because part of the report now takes place at the patient's bedside, it is rare for a call light to go unanswered during the change of shifts.
| | Figure 2. Average time for shift report. |
During daily manager rounds and staff meetings, bedside clinical nurses positively responded to queries about the new shift report. They reported that with less time spent in shift report, they could provide patient care sooner and the off-going nurses could leave work on time. Oncoming nurses also commented about their satisfaction with the written report that contained pertinent patient information.
A review of incident reports indicated that prior to the new shift report, there were 1 to 2 patient falls each month at change of shift. Once the new shift report was implemented, there was only 1 patient fall in 6 months between 7:00 AM and 7:30 PM (Fig 3). With the new shift report, nurses could see patients earlier in the shift, and patients have reported that they “like having the nurses come to the bedside and introduce each other” rather than waiting until the end of report.
| | Figure 3. Number of falls during shift report. |
The new shift report has met the original objective of creating a more standardized and time-efficient process. Nurses are clear about what information to provide the oncoming nurses, patients meet their nurse sooner, nurses can leave work on time, and there has been a financial savings from a reduction in overtime usage. Since the advent of conducting part of the shift report at the patient's bedside, there has also been a decrease in the number of patient falls and call lights. These results suggest that by standardizing shift report and changing the process, we attained our goal of creating a more time-efficient process while improving the quality of information provided.
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Key words: communication; nurse shift report; process improvement
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