As health care providers try to accomplish more in less time, the relationships between patients and providers and among providers naturally suffer. Mis-communication, flawed assumptions, decreased staff and patient satisfaction, and poor or nonexistent care coordination result.
To Err Is Human and Crossing the Quality Chasm, reports from the Institute of Medicine, stress that good communication is critical to ensuring safe and reliable care.1,2 The current challenge in health care is to create an environment in which open and transparent communication is the norm rather than the exception. One way to do this is by adopting strategies that have been successful in other industries. For example, crew resource management, a training program developed by the aviation industry and adapted to other workplaces, contributes to a team-centered approach by emphasizing shared decision making and interpersonal communication.3 Using communication tools such as situation–background–assessment–recommendation (SBAR) communication ensures that messages are clear and unambiguous even in stressful situations.3
Another challenge facing health care organizations is attracting and retaining nursing professionals in an environment beset by rapid change and constrained resources.4 At Wentworth-Douglass Hospital, a community, nonprofit acute care hospital in Dover, New Hampshire, our leadership grew concerned that new nurses were losing sight of their reasons for pursuing the profession and that experienced staff were disillusioned by processes outside their control, ranging from a fluctuating census and increased patient acuity to unreliable equipment and having to hunt for and gather supplies. As Donna Diers wrote, "Nursing is two things; the care of the sick (or the potentially sick) and the tending to the environment within which care happens."5
We recognized the importance of these challenges and felt that participating in the Transforming Care at the Bedside (TCAB) initiative could help us address them.
We formed a TCAB team of approximately 20 staff nurses, pharmacists, case managers, physicians, clinical coordinators, educators, and supervisors. The mission statement we developed was to establish a patient-centered healing environment with mutually beneficial partnerships among patients, families, and health care providers in a physically comforting area. Improving communication was critical to achieving this aim. Since becoming involved in TCAB in May 2005, we have implemented three major initiatives: moving the location of the change of shift report to the bedside, implementing the safety huddle, and establishing nurse–physician "intentional" rounds at the bedside.
A 28-bed medical–surgical telemetry unit, 3 North, piloted our tests of change. Staff members were task oriented rather than patient centered, there were communication problems, handoffs were time-consuming, and many staff members reported feeling uninvolved and unappreciated. Therefore, the staff and leadership were open to participating in an innovative project that would help them transform the way they worked. We ended up not only improving communication, but also creating a new unit that is centered on the TCAB philosophy.
CHANGE OF SHIFT REPORT
The standard practice for giving change of shift reports was for the off-going nurses to audiotape reports about every patient on the unit, which all on-coming patient-care personnel listened to together in a conference room. The report generally took between 30 and 40 minutes. Staff members proposed moving the shift report to the bedside to save time, increase accountability, and involve the patients in this important exchange of information. This was our first major test of change using the TCAB approach.
Trials and adaptations. On the first day of our trial, which involved both shifts, we put the tape recorder in the closet. The unit-based educator and clinical coordinator were present during the change from night shift to day shift to provide support and to help the off-going nurses adapt to the new way of updating the staff coming on duty. When the day-shift nurses arrived, they found the night-shift nurses who were caring for their patients and they went to the bedside together. The nurses later commented that patients liked having the off-going nurse introduce the on-coming nurse.
But some staff complained that the new process didn't allow the entire staff to hear the conditions of all patients. They also said they missed being able to gather as a team in the morning and evening and felt they were losing a means of socializing that is important for group processes. As a result, we adapted and instead began the shift report in the conference room with a 30-second taped review of each patient, after which the off-going and on-coming nurses linked up at the bedsides for detailed reports.
Despite written guidelines and one-on-one feedback, the 30-second taped reports gradually turned into the detailed reports of the old days. The bedside portion of the new process also needed refining. Nurses continued to use medical terminology, which caused many patients to feel confused or left out. Some nurses exhibited what we call stage fright—an uncomfortable feeling when talking about a patient in her or his presence.
After about two months, the TCAB team went back to the drawing board to refine our approaches in these problem areas and reinforce our successes. To standardize the information presented in reports, we developed guidelines that stressed using the SBAR format. We did role playing to increase nurses' comfort levels with using patient-centered language. We reinforced the importance of one of the TCAB philosophies, "Nothing about me without me," which promotes patient-centered care and transparency by involving the patient in all aspects of care.6 We addressed concerns about privacy and confidentiality in semiprivate rooms by having nurses always ask patients for their permission to round at the bedside. Patients who are uncomfortable with having their care discussed are free to decline, though this is rarely the case. We also educated staff on the importance of involving patients in hand-off communications as both a safety measure and a way to improve patient satisfaction.
Outcomes. Before implementing this test of change, the staff often didn't talk much with patients or each other. A quick "Any questions?" or a cursory overview of an issue was the norm. Today, nurses engage in meaningful exchanges with the patient and with each other as they discuss the patient's condition, interventions, and care plan. The monologue of data and tasks has been replaced with a thoughtful, informed analysis of the patient's status and plan. Patients are involved and aware that a cohesive, knowledgeable team is managing their care. The relationships among the caregivers have developed as well, eliminating the social separation between the shifts.
We evaluated the change of shift report using both qualitative and quantitative data. We found that the average length of time it took to complete rounds was less with the bedside report than with the taped report, which often included extraneous information and took 40 minutes or longer. In contrast, after a few months the bedside reports began to average 25 to 30 minutes when reporting guidelines were followed. Also, the off-going nurses consistently reported being able to leave work on time, which hadn't been the case with the taped report.
The quality of patient information being exchanged also improved, with staff members indicating that bedside reporting enhanced the continuity of care. As Nita K. Love, RN, said, "With a taped report you only get the data that the previous caregiver deemed relevant, and you are unable to ask questions and get clarification. With a bedside report you see firsthand what the patient does and does not understand, and you also gain the patient's insight and input." Kara Bliven, RN, said "The body of information is always contained within the patient. Bedside rounds assist with putting the puzzle together."
We gathered patient feedback from our existing patient satisfaction survey. One patient and his wife wrote, "We were very impressed with the nurses' report at rounds. We could comment and ask questions, and we felt we were participants in my care." Another patient said, "I liked the staff coming into the room together at change of shift, even the licensed nursing assistants. They didn't talk over me, but made me a part of it."
Analysis. Changing the shift report was difficult because it involved changing the way we delivered information. It made public a process that used to take place behind closed doors. This change required patience and flexibility from all involved. A major benefit was that it allowed patients to participate in their own care.
Shift report was our first test of change, and in retrospect we felt that we may have approached it without adequate preparation and education. For example, rather than using the TCAB "one nurse, one patient, one day" approach, we implemented this change across both shifts at the same time. Starting small and going slowly would have allowed us to first identify areas for improvement. Still, making this change in the way we communicated started a cultural transformation at our hospital.
In our brainstorming about how to improve the shift report, we came up with the idea of having a team huddle, which we dubbed a safety huddle. This five- to 10-minute gathering at the beginning of shift change replaced the brief taped report delivered behind the closed doors of the conference room and gives us the information we need to work as a team. Both shifts assemble at the central nurses' station and the off-going staff succinctly report the critical information on each patient that everyone needs to know, including code status, diagnosis, tests scheduled for the day, fall risk, safety issues, and plan for the day (see Figure 1). We also review educational opportunities, such as in-services, that are offered that day. The on-coming and off-going nurses then head to the bedsides for the detailed reports.
When asked about the value of the safety huddle, Jana Otis, BSN, RN, PCCN, said, "On a busy, high-acuity unit, you never know whose room you will find yourself running into. So it is critical to have some idea of the condition of all patients on the unit and what their treatment plans include." Staff RN Love said, "Safety huddle allows for better transfer of care when covering breaks. Staff are more likely to have time to take breaks and feel confident in doing so, knowing that the other staff are well equipped to care for their patients." By giving everyone an overview of the unit's patients, the safety huddle also facilitates collaboration among nurses of varying levels of experience.
NURSE–PHYSICIAN INTENTIONAL ROUNDING
The new change of shift report and safety huddles improved communication among nurses and with patients. Our next task was to improve communication with physicians. We wanted to try rounding with the nurse and the physician at the bedside, including the patient as an active participant. We called this "intentional rounding."
We introduced intentional rounding in November 2007 with two physicians and gradually added physicians by informally explaining the process to them and asking them to include the nurses in rounding. The nurses covered for each other when a physician was ready to round and the patient's nurse was unavailable.
When a physician arrives on the unit, she or he checks the board to see which nurse is caring for the patient. The physician reviews the patient's chart and then uses the computerized Hill-Rom nurse locator system to pinpoint the nurse's location on the unit. Together the nurse and physician enter the patient's room, assess the patient, and review any test results. The nurse, physician, and patient review the care plan, upcoming tests, and the potential discharge date. The providers discuss the goals for the day and answer the questions of the patient and family.
Evolution of the process. Observation has revealed that intentional rounding has improved the exchange of critical information among the patient, nurse, and physician. The process is always evolving. We continue to encounter challenges and come up with new ideas to make the process work better for everyone. For example, we recently started wheeling a computer into the room during rounds to ensure that the patient information we need is at our fingertips.
One challenge is teaching new providers, especially physicians, about our rounding process. We are now planning training sessions that will introduce new staff to our various patient-centered care initiatives. We also need to work out the logistics of rounding with multiple providers at all times of the day. When asked about problems with intentional rounding, Lorraine Mancuso, MSN, RN, said, "Sometimes rounding at the bedside isn't possible, such as when you are caring for a critically ill patient and a physician comes to see another patient. Sometimes several doctors round at the same time, and you just need to prioritize, or catch the end of rounds for one patient."
Outcomes. Within three months of beginning this test of change, physicians were regularly seeking out nurses for intentional rounding at the bedsides of their patients on the unit. Our aim was for intentional rounding to occur with 50% of the patients, a figure that could vary based on how many patients each physician had on 3 West. The data on how many patients have intentional rounding are collated and reported to staff monthly as well as at our monthly TCAB meetings. After more than a year of intentional rounding we have surpassed our goal, with an average of 67% of patients now getting this service. Nurses from units that do not practice nurse–physician rounding at the bedside report that physicians nonetheless seek them out for rounding, so it appears that there has been a change in the culture and an improvement in our standard of care.
The director of our hospitalist program, Cathleen Ammann, MD, stated, "[Intentional rounding] has improved the way we practice medicine in so many ways. We are able to share information, test results, and goals of care with the patient and family in a way that gets everyone on the same page, cuts down on interruptions and calls to the physician, and leads to better patient satisfaction. Logistically, it turned out to be much less of a challenge than I had thought it would be and has been well worth it."
Anecdotally, nurses have reported an increased feeling of collaboration with physicians and a sense that their input is valued. Annual surveys of the nursing staff show increased satisfaction with their working relationship with physicians, from 78% reporting satisfaction in 2006 (before intentional rounding) to 91% in 2008 (see Figure 2).
SPREADING THE CHANGES
Many changes have occurred at Wentworth-Douglass Hospital as a result of our TCAB work. On the floor where our original TCAB unit is located, we renovated a nonpatient area to create a 14-bed, private-room unit. This new unit, 3 West, opened with the understanding that it would incorporate the TCAB philosophy into all of its practices. The capacity of our TCAB pilot unit, 3 North, subsequently decreased from 28 beds to 18 and it now has more private rooms.
The bedside change of shift report and the safety huddle have spread to all inpatient medical–surgical units in the hospital. At staff request, a small test of the bedside change of shift report also began on the maternal–child unit, and another recently began on the critical care unit. Nurse–physician intentional rounding has spread to three units, and plans are in place to spread it to a fourth. Positive feedback from nurses, physicians, and patients has encouraged us to speed up the spread of this initiative to other units.
With patience, education, and teamwork, we created a system that empowers nurses, engages physicians, and enables patients to take part in discussions that revolve around them. One of the most important lessons we learned in our effort to improve communication is that change takes time. It has been more than two years since we embarked on our journey to transform the care we deliver at the bedside. Multiple tests of change have produced a sustained culture of reliable, patient-centered care in which all caregivers continually strive for optimal communication.
The most compelling outcome of our TCAB journey is the change we have seen in our patients. They now ask questions and have come to expect bedside exchanges of information from both nurses and physicians. They like the reports being given at the bedside and enjoy having their nurses and physicians come into the room together to talk to them. Patients have written to tell us that hospitalization after our new communication tools were put in place was a different and better experience than any previous hospitalization had been.
Another major outcome is high staff satisfaction. Voluntary turnover among nurses on our two TCAB units is less than 5%. On a recent staff satisfaction survey, 100% of responders from 3 West agreed with the statement "I am part of an effective work team that continuously strives for excellence even when conditions are less than optimal."
We learned the value of having a day-to-day leader on the unit to provide guidance and support and to emphasize to staff the unit's commitment to this initiative. Because change takes time, it is important to have several TCAB champions to maintain enthusiasm, offer support, and help new staff integrate TCAB into their practices.
We found that posting information and updates on results on a monthly basis helps keep the staff informed and excited about progressing toward our goals. We celebrate successes, no matter how small, with unit gatherings, food, and "star cards," our organization's employee recognition program. We educate staff with one-on-one feedback, nursing grand rounds presentations, poster presentations, and more, and we encourage each other to always remember why we do what we do: for the sake of the patients! We have learned that when you approach change with a patient-centered philosophy, the best decisions are clear.