The Use of Mirrors in Critical Care Nursing

Wyona M. Freysteinson MN

Critical Care Nursing Quarterly April/June 2009 Volume 32 Number 2 Pages 89 - 93

Abstract

There is no known literature to guide the critical care nurse in the use of mirrors in patient care. This article explores how the author came to believe that mirrors were essential to nursing practice. Misconceptions and assumptions concerning mirrors are explored. A framework that conceptually explores the experience of viewing self in the mirror from the perspective of a person is presented. Five situations in which the mirror may be used in critical care are discussed. This article does not present an authoritative view on mirrors in nursing; rather, it is an invitation to dialogue about a unique element in the environment that may be used to enhance nursing care.

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CRITICAL CARE NURSES are educated in working with fragile critically ill patients. Their education is extensive and covers physical, psychosocial, and spiritual aspects of care. They are not, however, taught about the use of mirrors in their schools of nursing.1 Nursing mirror practice is based on one's patterns of knowing, beliefs, and values because there are no known guidelines to guide nurses in the use of the mirror with patients. This article discusses the potential use of the mirror in the care of some (not all) critical care patients.

HOW ONE MIRROR PRACTICE BEGAN

In the 1960s, an elderly woman, aged 78, was in a hospital intensive care area. Her physician notified the family that there was little else that could be done for her worsening condition. The family gathered at her bedside. Knowing that her great grandmother loved to have her hair combed, her 9-year-old great granddaughter found a comb and a mirror. After her hair was combed, the elderly woman serenely gazed into the mirror for several minutes. Within hours, she lapsed into a final coma (W.M.F., unpublished master's thesis, University of Saskatchewan, Saskatoon, Saskatchewan, 1994).

In the 1970s, a woman in her late 90s was lying in bed. Her body and face were severely contorted from rheumatoid arthritis. At best, she weighed 75 pounds, and her pain level was off the scale. She asked the 16-year-old aide to get a wet washcloth and wet her lips. She then asked the aide to retrieve her hand mirror from the drawer. The aide was terrified to show the elderly woman her face in the mirror: she was afraid the woman would be frightened to death by her own image. The aide stared in fascination as the elderly woman viewed her own face and appeared to be, for a moment, almost at peace (W.M.F., unpublished master's thesis, University of Saskatchewan, Saskatoon, Saskatchewan, 1994).

The author of this article was the great granddaughter and the aide in these case studies. In her school of nursing, her nursing instructor pointed out the equipment at the bedside, including the mirror in the overbed table. On the basis of her intimate experience with mirrors, and the mirror in the overbed table, the author assumed that mirrors were essential to nursing practice. The mirror became a small, but important part of her practice in many areas of nursing including trauma, intensive care, and coronary care. For those times when the bathroom mirror and overbed table mirrors were inadequate, she carried a pocket mirror.

MIRRORS IN HOSPITALS: CURRENT STATE

In a survey of 46 hospital wards in 3 hospitals in England, there was 1 mirror recommendation: “Mirrors should be lowered or enlarged to make washing, shaving and grooming easier for those who need to sit for this activity.”2^(p237) Nurses from Africa, Egypt, Japan, the Netherlands, Panama, Russia, Singapore, and the United Kingdom indicated that there were few mirrors in their hospitals. They reported more mirrors in the lobby and elevators of hospitals than in patient rooms.1 Freysteinson and Cesario 3 found that mirrors for the bed bound were not available in 70% of the American hospital units they surveyed.

MIRROR ASSUMPTIONS

There are several assumptions concerning mirrors in healthcare. Each of these assumptions may be true for some patients some of the time. Literature suggests, however, that these assumptions are not true all of the time.

People who are sick or dying do not want to look in mirrors

In 1990, when Freysteinson suggested a study of mirrors, a nursing leader viewed the project as preposterous. She said, “People who are sick and dying do not want to look in mirrors.” A study of 7 terminally ill women's perceptions of viewing self in the mirror indicated that this statement may be a misconception (W.M.F., unpublished master's thesis, University of Saskatchewan, Saskatoon, Saskatchewan, 1994). Nurses from around the world 1 indicated that although there are few, if any, mirrors in patient rooms, many patients do view self in the mirror. This is not to suggest that all patients want to look in mirrors. It does suggest, out of dignity and respect for human beings, that nurses may consider offering patients a choice in whether or not they wish to view self in the mirror.

Patients who want to look in a mirror will ask for a mirror

In an intensive care burn unit, there was a young man in his early 20s, who had suffered severe burns. For 3 weeks, he viewed the charred remains of his fingers, chest, pubic area, feet, and toes. On a daily basis, one of the nurses shaved his face and combed his hair. When the author asked whether he had seen his face in a mirror, his nurse said, “Oh my, I have not even asked him if he wants to look in a mirror. His face was untouched by the fire.” The young man also did not ask for a mirror.

Freysteinson uncovered that asking to view self in a mirror in a hospital may be viewed as narcissistic: “Maybe some people would be suspicious if they saw you looking in the mirror all the time” (unpublished master's thesis, University of Saskatchewan, Saskatoon, Saskatchewan, 1994, p. 109). In the Greek myth of Narcissus, a handsome young man falls in love with his reflection, which he views in a quiet pool of water. This myth may have had influence on present-day beliefs about the association between vanity and viewing self in a mirror.

Individuals with severe head trauma cannot recognize themselves in the mirror

Researchers in Belgium conducted a study of several patients in postcomatose state. Their concern was accurate diagnosis of vegetative state. Three tracking mechanisms were used: a person, an object, and a mirror. Eleven patients did not track a person or an object. They did, however, successfully track their reflection in a mirror. The researchers indicate that these 11 subjects would have been misdiagnosed as being in vegetative state without the use of the mirror.4

The author observed that in neurotrauma, patients with severe brain injuries may begin to focus on their reflection in the mirror in the early stages of recovery. As patients became well enough to be taken to a sitting position in bed, the author would open the overbed table mirror up when providing everyday hygiene care (ie, shaving, combing hair). She found that patients would stare at their reflection. Some patients would begin to assist in their own care while viewing self in the mirror.

MIRROR CONCEPTUAL FRAMEWORK

A study of the experience of viewing self in the mirror may be approached from a phenomenological perspective. One description of the experience of mirroring or viewing self in the mirror consists of 4 meaning moments that may occur sequentially or simultaneously: decision, assessment, knowledge, and consent (W.M.F., unpublished master's thesis, University of Saskatchewan, Saskatoon, Saskatchewan, 1994).4 Before these moments may occur, a person must be physically able to view self in a mirror, and mirrors must be readily accessible.

Self-decision: I decide

Viewing self in the mirror begins with a decision. “It is almost as if one converses with self and declares, ‘I am or I am not going to look in the mirror’” (W.M.F., unpublished master's thesis, University of Saskatchewan, Saskatoon, Saskatchewan, 1994, p. 45). Viewing self in the mirror may be habitual (ie, the habit of checking one's image in the mirror when washing one's hands). A person's decision may be a strong desire, or it may be a paradoxical decision of wanting, not wanting to view self in the mirror. One may fear what the mirror will reflect (ie, recent facial or chest trauma), and at the same time one may want to really know how one looks. The decision to view self in a mirror is based on any number of reasons. One woman was hospitalized after an accident that left her face severely bruised:

The first time I saw my black face was in the emergency room. I knew I would look bad, but when the nurse showed me in the mirror I couldn't believe it. I didn't think it could be so swelled up and so black, so fast…. The nurse didn't give me enough time. She gave me a look and flashed me away again…. She (the nurse) looked so grim about it. When she would go, I'd take another look. You'd think, am I looking worse or am I so repulsive…. I looked in the mirror more after I had visitors, because everyone kind of had different expressions on their faces. (W.M.F., unpublished master's thesis, University of Saskatchewan, Saskatoon, Saskatchewan, 1994, p. 105)

Self-assessment: I see

Before looking in the mirror, there is an anticipated glimpse in the mind's eye of what one may look like. Typically, one anticipates that one will look the same as the last time one glanced in the mirror. If a patient has suffered a traumatic injury to the face or chest, there may be dread, as one imagines what the mirror may reveal. There may also be anxiety and fear when one feels something foreign on one's face (ie, endotracheal tube, nasal gastric tube). The nurse may help the patient anticipate a truer picture of self through describing what the patient may see (ie, there is a little clear colored tube in your right nostril) before positioning a mirror for the person to see self.

When a person does view self in the mirror, one sees and evaluates the image. The image is compared with one's anticipated image. For the patient who can speak, the nurse may hear the image referred to as it or that. This is an indication of distanciation of body from self. On the other hand, the nurse may hear the words I or me. These words indicate an appropriation of the self to the self.

Self-knowledge: I know

Assessing and evaluating self in the mirror brings one to a self-explanation: I look like this because of such and such (ie, the accident, the surgery, I deserved this, etc). In critical care, it is important when patients are able to comprehend that nurses explain in simple terms the reason for various tubing, facial injuries, etc. These explanations may help to ease anxiety and clarify the image the patient sees in the mirror.

Self-knowledge is also colored by an individual's way of being in the world. One may face the world, for example, through a way of being that may be broadly described as anxiously, graciously, angrily, humbly, etc. Discerning this overall way of being may help guide the nurses in mirror and other interventions.

Self-consent: I consent

One consents to the knowledge of one's self in the mirror. Critically ill patients who are unable to speak may simply nod in acknowledgment, avert their eyes, or gently close their eyes to indicate that they have consented to the image in the mirror. Consent is lived on a horizon of hope to despair. A patient may hope that the tubes will be removed and the incision will heal, or the patient may feel despair and hopelessness. The nurse may help to alleviate hopelessness by discussing, for example, the length of time a tube may be present (ie, awhile, a few days).

TYPES OF MIRRORS RECOMMENDED FOR CRITICAL CARE AREAS

In order that nurses may use mirrors in patient care, having adequate mirrors available is essential. Mirrors for bed-bound and chair-bound patients are appropriate for critical care. Overbed table mirrors need to be in working order. If overbed table mirrors are not available, portable small unbreakable mirrors that attach to a table with suction caps may be used. Hand mirrors that are large enough to view one's entire face are also appropriate. For the patient who is able to sit in a chair at the bedside, a portable full-length mirror may be suitable. Bathroom mirrors should be equipped with tilting mirrors or a full-length mirror for the patient who uses a wheelchair.

Unbreakable mirrors may be found using the following Internet search terms: acrylic, chrome-plated, pediatric, shatterproof, tilting, and unbreakable mirrors. Perhaps future hospital rooms may be equipped with mirrors on flexible arms, which are attached to the bed, headboard, or ceiling. A mirror of this type would allow the bed-bound patient lying or sitting at any angle to use a mirror to visualize self and/or the environment.

Viewing self in the mirror is frequently something one may do in private. If viewing self in public, one may simply glance or glimpse oneself in a mirror. When considering the use of mirrors, nurses may need to consider the degree of privacy a patient may want and the amount of privacy possible in a critical care unit.

SITUATIONS WHEN NURSES MAY USE MIRRORS

Orientation and assessment

Nurses may consider using mirrors as tracking devices to determine whether a patient is in a vegetative state, or to determine whether a patient may recognize self in the mirror (orientation to self). Mirrors may even be of benefit in helping a patient become orientated to self.

Patients may simply want to assess or inspect themselves in a mirror. Nurses may facilitate this decision by having mirrors readily accessible and/or by gently asking whether a patient may want to view self in the mirror (ie, after shaving, etc).

Mirrors may also be used to orient a patient to facial tubing. An explanation of the tubing, together with allowing the patient to assess and evaluate the tubing by using a mirror, may help decrease anxiety, and the tendency to want to touch and feel the tubing with one's hands.

Environment

Mirrors of various sizes may be appropriate for the patient who requires mirrors to visualize the environment (ie, Stryker frame, halo traction). Mirrors may also be useful for patients who have to lie flat after a procedure for several hours. With an appropriately placed mirror, a patient may observe the environment (ie, people coming and going) more readily that may help decrease apprehension, anxiety, and/or boredom.

Procedures

Nurses in the Netherlands use mirrors to allow a child look at his or her chest as a nurse punctures an implanted access device with an appropriate needle. Nurses suggest when children are older than 4 years, this helps calm the child. Mirrors are also used to help the patient see during echocardiographic procedures.1 Mirrors may be considered during facial and upper-body dressing changes. It may be relatively easy for a patient to glance down at the incision site of a recently amputated arm during a dressing change; it is impossible, however, to view the incision on one's face or chest without the use of a mirror.

Self-care

For many individuals, mirrors are a typical part of daily hygienic activities. Combing one's hair, washing one's face, or shaving is almost impossible without the use of a mirror. For the patient who has progressed to the point of being alert and/or active during a bed bath, using a mirror is yet another way to return to daily living. When setting up bed-bound patients for self-care (ie, shaving), the nurse will want to position the mirror so that the patient may adequately see self.

Transfer/discharge

In the case of severe facial trauma, surgery, or burns, it is difficult to ascertain when and whether there is a best time to offer a patient a mirror.1 A patient on a positive medical trajectory will inevitably view self in a mirror. The possibility of a patient viewing self for the first time in the mirrors in a public hallway or elevator during the transfer is of concern. The initial viewing ought to be in the critical care area where professional support is available prior to transfer to a step-down unit. For the patient who is capable of viewing self in the mirror, the nurse may ask whether the patient wants privacy, the nurse, or the loved one to be present when looking in a mirror the first time after trauma or surgery. Developing consistent unit processes for the routine use of mirrors is recommended.

CONCLUSION

The study of mirrors in nursing is in its infancy. Research is needed on essentially all aspects of the nursing practices suggested in this article. If, however, nursing is a practice with a concern for the perspective of patient, a concern for the perspective of patient viewing self in the mirror is inevitable. Let the mirror dialogue begin.

REFERENCES

1. Freysteinson WM. International reflections on knowledge and use of the mirror in nursing practice. Nursing Forum. In press. [Context Link]

2. Monro A, Mulley GP. Hospital bathrooms and showers: a continuing saga of inadequacy. J R Soc Med. 2004;97:235–237. [Context Link]

3. Freysteinson WM, Cesario SK. Have we lost sight of the mirrors?: the therapeutic utility of mirrors in patient rooms. Holist Nurs Pract. 2008:317–323. [Context Link]

4. Vanhaudenhuyse A, Schnakers C, Bredart S, Laureys S. Assessment of visual pursuit in post-comatose states: use a mirror. J Neurol Neurosurg Psychiatry. 2008;79:223. [Context Link]

Key words: critical care nursing; mirror; patient care

CHARTING CHECKUP: Documenting a patient's initial assessment

LPN2009
May/June 2009
Volume 5 Number 3
Pages 4 - 7

DEPENDING ON WHERE YOU WORK, you may hear initial assessment information referred to by different names, including “nursing admission assessment” and “nursing database.” Some facilities have adopted initial assessment forms that include information gathered from different members of the healthcare team, such as physicians, nurses, advanced practitioners, social workers, physical or occupational therapists, nutritionists, and pastoral care workers. These forms may be called “integrated,” “interdisciplinary,” or “multidisciplinary” care team assessment forms. (For an example of the first page of a typical integrated admission database form, see Integrated admission database form.)

Documentation styles and formats vary, depending on the facility's policy and the patient population. Furthermore, healthcare facilities have different policies for documenting learning needs, discharge planning, and incomplete initial assessment data. You must be familiar with your facility's standards to document your initial assessment findings appropriately.

Documentation styles

Initial assessment findings are documented in one of three basic styles: narrative notes, standardized open-ended style, and standardized closed-ended style. Many assessment forms use a combination of all three styles.

Narrative notes consist of handwritten accounts in paragraph form, summarizing information obtained by general observation, interview, and physical exam.

Although narrative notes allow you to list your findings in order of importance, they also pose problems. In many cases, the notes mimic the medical model by focusing on a review of body systems. They're also time-consuming—both to write and to read. In addition, narrative notes require you to remember and record all significant information in a detailed, logical sequence—often an unrealistic goal in today's hectic world of healthcare. Finally, difficulty in interpreting handwriting can easily lead to misinterpretation of findings.

Narrative notes are most practical for independent practitioners. Within healthcare institutions, however, exclusive use of narrative notes wastes time and may jeopardize quality monitoring.

The standardized open-ended assessment form is a typical “fill-in-the-blanks” form that comes with preprinted headings and questions. This form saves you time in a couple of ways. Information is categorized under specific headings, so you can easily record and retrieve it. And the form can be completed using partial phrases and approved abbreviations.

Unfortunately, however, open-ended forms don't always provide enough space or instructions to encourage thorough descriptions. Thus, under the heading type of dwelling, one nurse may write “apartment,” whereas another may write “apartment in four-flight walk-up, without heat or hot water.”

Nonspecific responses can lead to misinterpretation. For instance, a nurse may write that a patient performs a task “within normal limits.” But unless normal limits have been defined, this notation is neither clear nor legally sound.

The standardized closed-ended assessment form provides preprinted headings, checklists, and questions with specific responses. You simply check off the appropriate response.

In addition to saving time, the closed-ended form eliminates the problem of illegible handwriting and makes checking documented information easy. The form can also be easily incorporated into most computerized systems.

This kind of form also clearly establishes the type and amount of information required by the healthcare facility. And even though the closed-ended forms usually use nonspecific terminology, such as “within normal limits” or “no alteration,” guidelines clearly define these responses.

The closed-ended form also has some disadvantages. For instance, many of them don't provide a place to record relevant information that doesn't fit the preprinted choices. In addition, the form tends to be lengthy, especially when a facility's policy calls for recording in-depth physical assessment data.

Documentation formats

Historically, nursing assessment has followed a medical format, emphasizing the patient's initial symptoms and a comprehensive review of body systems. Although many healthcare facilities still use a medical format to organize their nursing assessment forms, some facilities have adopted formats that more readily reflect the nursing process.

Most facilities that use a nursing format for assessment base it on either human response patterns or functional healthcare patterns. Other documentation formats are modeled on specific conceptual frameworks based on published nursing theories.

Integrated admission database form

Most healthcare facilities use a multidisciplinary admission form. The sample form below has spaces that can be filled in by the nurse, physician, and other healthcare providers.

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The North American Nursing Diagnosis Association-International (NANDA-I) has developed a classification system for nursing diagnoses based on human response patterns. These patterns relate directly to actual or potential health problems, as indicated by assessment data.

Thus, when you use an assessment form organized by these patterns, you can easily establish appropriate diagnoses while you record assessment data—especially if a listing of diagnoses is included with the form. The main drawback is that these forms tend to be lengthy.

Some healthcare facilities organize their assessment data according to functional healthcare patterns. Developed by Marjory Gordon, this system classifies nursing data according to the patient's ability to function independently. Many nurses consider functional healthcare patterns easier to understand and remember than human response patterns.

Documenting learning needs

Most initial assessment forms have a separate section for documenting a patient's learning needs. When you reassess your patient's learning needs, you can document your findings in the progress notes, on an open-ended patient education flow sheet, or on a structured patient education flow sheet designed for a specific problem such as diabetes mellitus.

Documenting discharge planning needs

Effective discharge planning begins when you identify and document the patient's needs during the initial assessment. Depending on the policy at your healthcare facility, you'll record the patient's discharge needs on the initial assessment form (in a designated section), on a specially designed discharge planning form, in a separate section on the patient-care card file, in the progress notes, or on a discharge planning flow sheet.

Documenting incomplete initial data

No matter what assessment tool you use, you may not always be able to obtain a complete health history during the initial assessment (the patient may be too ill to participate, and secondary sources may be unavailable). When this occurs, base your initial assessment on your observations and physical exam of the patient. When documenting your findings, be sure to write a comment such as “Unable to obtain complete data at this time.” Otherwise, it might appear that you failed to perform a complete assessment.

Try to obtain missing information as soon as possible, either when the patient is able to provide the information or when family members or other secondary sources are available. Be sure to record how and when you obtained the missing data. Depending on your facility's policy, you may record the information on the progress notes, or you may return to the initial assessment form and add the new information along with the date and your signature. Both methods have advantages and disadvantages.

Adding to the initial assessment form makes it easy to retrieve the data when it's needed—either during the patient's hospitalization or after discharge for quality assurance. Putting the information into the nursing progress notes aids in the day-to-day communication with others who read the notes, but also makes it difficult to retrieve the data later.

When you add information to complete an initial assessment, be sure to revise your nursing-care plan accordingly.

Selected reference

Complete Guide to Documentation. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2008:103–111.

Standardization of Change-of-Shift Report

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.

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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.

BACKGROUND

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.

NEW SHIFT REPORT

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.

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Figure 1. Sample first page of written shift report. RBS indicates rapid blood sugar.

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IMPLEMENTATION

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.

RESULTS

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.

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Figure 2. Average time for shift report.

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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.

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Figure 3. Number of falls during shift report.

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CONCLUSION

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.

REFERENCES

1. Anderson C, Mangino R. Nurse shift report: who says you can't talk in front of the patient? Nurs Adm Q. 2006;30(2):112–122. [Context Link]

2. Benson E, Rippin-Sisler C, Jabusch K, Keast S. Improving nursing shift-to-shift report. J Nurs Care Qual. 2007;22(1):80–84. [Context Link]

3. Caruso E. The evolution of nurse-to-nurse bedside report on a medical-surgical cardiology unit. Medsurg Nurs. 2007;16(1):17–22. [Context Link]

4. Hays M, Weinert C. A dramaturgical analysis of shift report patterns with cost implications: a case study. Nurs Econ. 2006;24(5):253–262. [Context Link]

5. Kerr M. A qualitative study of shift handover practice and function from a socio-technical perspective. J Adv Nurs. 2002;37(2):125–134. [Context Link]

6. Sexton A, Chan C, Elliott M, Stuart J, Jayasuriya R, Crookes P. Nursing handovers: do we really need them? J Nurs Manag. 2004;12(1):37–42. [Context Link]

7. Raines M, Mull A. Give it to me: the development of a tool for shift change report in a level I trauma center. J Emerg Nurs. 2007;33(4):358–360. [Context Link]

8. McKenna M. Improving the nursing handover report. Prof Nurs. 1997;12(9):637–639. [Context Link]

Key words: communication; nurse shift report; process improvement