The Institute of Medicine's 1999 report, To Err Is Human: Building a Safer Health System, revealed that medical errors cause at least 98,000 unexpected deaths in U.S. hospitals each year, highlighting the need to dramatically change the way health care is delivered in this country.1 A follow-up report in 2001, Crossing the Quality Chasm: A New Health System for the 21st Century, further underscored the need for a transformation in care delivery.2
Figure. Jane Hardima...Image Tools
To address the safety issues and suggestions for improvement highlighted in these reports, the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement launched a joint project in 2003 called Transforming Care at the Bedside (TCAB) to empower the staff on medical–surgical units to initiate and institute changes designed to improve inpatient care.3, 4 Initially pilot tested in just a handful of hospitals, the principles of TCAB have been adopted by many facilities nationwide since 2008.
TCAB values the central role nurses play in keeping patients safe and recognizes that they can't do this unless some of the burdens of their job—nonclinical duties, system inefficiencies, changes in work flow—are addressed. Perhaps most importantly, the unit must be structured in such a way that nurses at the bedside are able and encouraged to identify opportunities to improve the quality of care on the unit and to design and lead other nurses through the process of implementing new systems of care.3, 4
The American Organization of Nurse Executives (AONE) had already been helping to implement TCAB on units across the country when it developed the Care Innovation and Transformation (CIT) initiative in 2010. This program builds on the principles and success of TCAB, recognizing the important role of the nurse manager in ensuring that changes are successfully made to a unit's culture.5 It provides educational support to nurse leaders in the form of training and in the provision of tools designed to improve quality of care. To date, the AONE has helped to facilitate the adoption of TCAB and CIT in more than 150 U.S. hospitals.5
Units that embrace the principles of CIT create a culture of shared responsibility and accountability—one that supports a joint effort by the unit's nurse leaders and staff to continuously improve care processes. The CIT initiative is built on the assumption that to successfully effect change, the ideas and solutions for achieving a shared vision of excellent patient care must come from those working at the bedside. In providing a framework for nurse managers and directors to develop their ability to assist the staff in this regard, the CIT initiative is helping them become “transformational leaders.”
The concept of “transforming leadership” was first introduced in the late 1970s by James MacGregor Burns in the context of political leaders and their ability to motivate others to make significant changes and to develop their own leadership abilities. According to Burns, transformational leaders are both participatory and democratic; they empower and champion others to succeed.6 His work was expanded upon and applied to organizational psychology by Bernard M. Bass, who referred to “transformational leadership.”7 Curtis and O'Connell describe a transformational leader as one who shares responsibility, expects higher levels of accountability, and gives employees the power to achieve goals.8 Most employees understand their jobs well, the authors argue, and therefore are ideally positioned to help make decisions and solve problems on the unit.
Transformational leaders create a system in which staff members are encouraged and in fact obligated to advance their knowledge and practice and to participate fully in changes made to the unit, from conception through implementation.9 The nurse leader assists staff RNs in gaining the necessary skills and confidence to do this by acting as a coach and guide. This allows the staff to “own” their work as it progresses and leads to documented change on the unit, thus creating a culture of shared responsibility in meeting the goals of the organization.8
PARTICIPATION IN CIT
A few years ago, our facility's chief nursing officer (CNO) and the leadership of our 26-bed telemetry unit—the nursing director (one of us, DMcL), nurse manager (one of us, WB), and nurse educator, Emily Blanchette, BSN, RN—determined that the principles of TCAB were a good fit for our unit, which includes a staff of 31 RNs, 16 licensed nursing assistants (LNAs), and five health unit coordinators. We decided to participate in the AONE's program, which was then referred to as a TCAB initiative but later renamed CIT. This two-year, collaborative program enabled us to work with the staff of 30 hospitals across the nation, meeting face to face four times and communicating regularly via conference calls and a listserv, as we helped each other gain the skills and knowledge needed to improve care and employee satisfaction on our units.
The nurse leaders of our unit spent two months talking with the staff about the principles of TCAB and the types of changes we hoped to make under this initiative. These informal discussions also allowed us to determine which staff members would be interested in joining our CIT workgroup and which would lead the staff in implementing these changes. The AONE recommends that each participating facility create such a group—or core team—to work consistently throughout the two-year program. Our initial workgroup included the CNO, the unit's leadership, five staff RNs, and one LNA.
The first CIT collaborative meeting was held in Chicago, and the CNO, nurse manager, nursing director, and three RNs from the workgroup attended. There we learned more about how to use the CIT process to have a positive impact on patient care and the environment in which nurses practice. We were also taught how to use Plan-Do-Study-Act methodology; brainstorm to produce usable ideas; organize our efforts to make improvements; and collect meaningful data to validate the impact of any changes we would make on the unit.
At the meeting, we attended presentations by the representatives of other hospitals who detailed their success with TCAB. Over and over we heard how staffled innovation resulted in dramatic improvements. The staff on one unit described how they had significantly reduced the incidence of hospital-acquired pressure ulcers, while another discussed its success with instituting a “live” nursing report at the bedside. This was our first exposure to the concept of bedside nursing report; at the time, our method of giving report to the incoming shift was to tape it. Our colleagues at the meeting explained how conducting report in this manner had improved safety and patient satisfaction on their unit and increased RN time at the bedside.
Within six weeks of returning from the Chicago meeting, our CIT workgroup had scheduled mandatory meetings with the entire staff, in which we explained what we had learned about TCAB, conducted brainstorming sessions, and voted on and prioritized the ideas for change we'd produced at these sessions. As the nurse manager and nursing director, we facilitated, supported, and sometimes helped lead the workgroup, but the goal was to allow the other members of the group to guide these meetings.
It was suggested to us through the collaborative that we should initially focus on shorter-term, “easy wins.” These were ideas for change that received the highest number of votes from the staff and were quick to complete. We wanted to show them that TCAB would work—that an idea could start with the staff, move quickly through a trial, and be implemented on our unit.
REPORT AT THE BEDSIDE
Several months into our work with CIT, we decided it was time to tackle a change that didn't earn as many votes from the staff but could have a significant effect on job satisfaction and the care provided on our unit. Based on research10-13 and the successes described by the staff of other hospitals on the CIT conference calls, our workgroup decided that switching to bedside report would help us provide the patient-centered care we strived for.
Shift reports convey essential information about the patient's plan of care and must be communicated in a way that is easily understood by the incoming nurse. On our unit, nurses had been taping report for the next shift, a time-consuming and less interactive way of communicating compared with bedside report. Also, taped report doesn't include the patient in the process.
The literature supports the use of bedside report, with researchers noting greater satisfaction among nurses who have the chance to meet and briefly assess patients at the beginning of their shifts,10 as well as improvements in safety, efficiency and teamwork.11
Challenges. Giving a live report would be a significant challenge for some staff members, who had voiced their skepticism about the need for this change and discomfort with its execution. The entire staff would need to develop new communication skills and learn to be at ease when talking about patients in their presence to other nurses.
As Janet Harmon, RN, a staff nurse and member of the CIT workgroup, noted: “Coming out of the conference, we were excited and idealistic. We thought bedside report was the greatest thing, and everyone would love it. But when we returned to the unit and started talking about it, the rest of the staff wasn't as enthusiastic. They hadn't heard firsthand about the advantages of this practice, and trying to convey that was a challenge.”
We talked about bedside report with the staff during RN meetings and at our CIT workgroup meetings. The former occur six times a year, and we began to provide open forums at these meetings, so that we could collectively discuss bedside report. The CIT workgroup meetings were held biweekly, and participants focused on how best to attempt a trial of bedside report on our unit. Based on informal discussions and more formally at the RN meetings, it became increasingly clear to us that we were asking the staff to dramatically change a work-flow process that had been in place for many years—a ritual that was built into the start and end of every shift.
The nursing staff voiced many concerns. They were unsure of their desire and ability to give bedside report and were particularly concerned that
* it would take too much time.
* it would be too difficult to coordinate with incoming and off-going staff.
* patients would delay the report with requests for assistance.
* it would be hard to talk about sensitive topics (drug abuse and psychosocial issues, for example) in front of and with the patient.
* it would violate the Health Insurance Portability and Accountability Act of 1996 (HIPAA), because patients on our unit have semiprivate rooms.
Opinion leaders. How could we validate the concerns of our staff while ensuring that bedside report was instituted? The answer was to engage the opinion leaders on the unit. Opinion leaders are the informal leaders of the staff, those to whom others look for cues on behavior. They help to dictate the culture of the unit.
We identified nurses we believed were opinion leaders and then deliberately included in the workgroup some who had verbalized their reservations about bedside report. For instance, Betty Nichols, BSN, RN, “had mixed feelings about it. I had done it in the past and felt it wasn't efficient. I wasn't pleased we were going to trial this.” Similarly, Jane Hardiman, BSN, RN, said, “I didn't think there was a reason to change our process and didn't want to give it a try.” Alma Idrizovic, BSN, RN, expressed interest in the potential of bedside report but “was hesitant and afraid patients would ask questions I couldn't answer.”
We asked these staff members if they'd help to design the process by which we would implement bedside report. Laurie Epright, BSN, RN, told us she appreciated the opportunity to contribute to this effort. “I wanted to be a part of the process, to ensure it would be set up correctly.”
Despite some nurses’ remaining reservations, our unit's staff had a shared goal of providing safe, reliable, patient-centered care, and we all ultimately agreed to be responsible for creating a new process that would help us achieve this objective.
A standardized process. We started by observing the current practice of taped report. Members of the workgroup completed five observations each. We then made a list of potential barriers to implementing bedside report and detailed which procedures we thought could mitigate these. Regarding the fear that we would violate HIPAA privacy rules by having conversations in semiprivate rooms, we talked to the staff about how bedside report discussions are no different from other conversations nurses have with patients throughout a hospital stay. There are many overheard conversations in semiprivate rooms, and the information in the bedside report would be no different from information typically shared throughout a shift. We also decided that our process for report at the bedside should include an explanation to patients of what this practice would entail. We would then ask patients for their verbal consent and request that family members leave the room during report, unless the patient requested that they stay.
In order to evaluate how successfully these solutions would address the staff's concerns, members of the CIT workgroup conducted small, rapid-cycle tests (involving one nurse and one patient during one shift). Feedback from patients and the RN staff who work nights, for example, showed it would be helpful to ask patients whether they wanted to be awakened during a change of shift to be included in bedside report. Based on feedback such as this, the workgroup members established a standardized process for report at the bedside.
Education and training. The workgroup members were responsible for educating their peers on the new standard of care. We devoted an entire RN meeting to bedside report, in which the workgroup demonstrated how exactly this should be done. The rest of the staff was then encouraged to practice giving bedside report in different patient scenarios.
“Role-playing helps ease staff anxiety and fear about a new process,” explained Ms. Blanchette, the unit's nurse educator.
We took turns enacting these scenarios, particularly those in which we knew we would face challenges. One such situation involved a patient who was experiencing alcohol withdrawal. Some RNs, we believed, would feel awkward discussing this diagnosis with another nurse in front of the patient; however, when we used role-playing to explore this scenario, it made sense to include the patient in the discussion. In fact, it became apparent that the discomfort several nurses had cited as the reason for not wanting to conduct report at the bedside was their own—their discomfort with the manner or nature of the communication—not the patient's. We were then able to focus on what would be best for patients, such as the ability to hear during bedside report that both the incoming and off-going nurses understood the care plan.
Implementation. After the training was completed, we told the rest of the staff that our goal was to fully implement bedside report in two months, allowing for ongoing practice in the meantime. The workgroup members began giving bedside report to incoming nurses, and soon after we asked the other nurses on our unit to try the new process with just one patient. We asked all the RNs on the unit to identify previously unrecognized barriers to giving bedside report that occurred during this testing. The workgroup members were very vocal and engaged with their peers during these two months, reinforcing the rationale for this change, explaining how they'd developed the process, and providing coaching for those who were less comfortable with bedside report.
With each bedside report interaction, the nurses reported feeling increased comfort. Within a couple of weeks, almost the entire staff told us they'd discovered some of the benefits of this practice. One of these, noted Beverly Kennett, RN, was that the “nurses caught some things that might have gone unnoticed until much later.” One patient was found to be in respiratory distress, for instance, when the RNs entered the room to do bedside report. With taped report, the incoming RN would not have seen and assessed the patient so quickly.
By removing the need to listen to a taped report, which took up the first 30 minutes of a shift, the new practice of bedside report has helped to ensure that the nurses see all assigned patients within that first half hour. This is a significant benefit—it's a source of satisfaction and comfort to the nurses that they're familiar with each of their patients so soon after they've begun work.
Lessons for leaders. As the nurse leaders on the unit, we could have put together our best bedside report proposal and plan, educated the staff, and then implemented this new practice. However, that more traditional form of leadership fails to acknowledge that those who do the work must participate in any efforts to improve it. Since we as nurse leaders aren't giving shift report, we couldn't fully appreciate the barriers and complexities that might arise when trying to implement this practice at the bedside.
The staff, for instance, was aware of the interruptions that occurred when trying to do bedside report and told us they were concerned about patients asking for a glass of water or to use the bathroom during report. The workgroup decided the best way to avoid this was to ask the LNAs to make rounds prior to shift change. Without this insight from the staff nurses, we might have missed this potential barrier.
“We are at the bedside doing the work,” said Ms. Idrizovic, “and we were empowered to help change the process. Giving power to the staff nurses was helpful.”
As nurse leaders, we were particularly struck by the need to engage staff opinion leaders and maintain a continual presence during this process, while encouraging the autonomy of the staff in developing and implementing this change on our unit. We also had to learn to accept that, while this process can take some time, it is well worth the wait to achieve the desired results.
We fully implemented the practice of bedside report by October 2011, and patient satisfaction survey results showed significant gains the following quarter. Patients reported seeing improvements in
* communication with nurses.
* nurses’ involvement in their care.
* the explanations they were given regarding their daily routine.
* the staff working together on their care.
More recent results indicate, however, that we still have work to do, with scores in certain areas above baseline but falling below initial gains.
We are not alone in this challenge. Wakefield and colleagues found that the initial, substantial improvements in patient satisfaction scores after initiating bedside report on their unit trended downward over time and then varied by month.13 Systemic changes—including changes to the way their facility implemented electronic medical records—were found to disrupt the nursing staff's work flow and thus their interactions with patients; ultimately, this led to lower patient satisfaction scores. The authors concluded that continued monitoring of bedside report, communication with patients, and accommodations when work flow is disrupted are essential to maintaining the gains initially realized by the adoption of this practice.13
The improvement process needs to include a systematic approach to measuring results and providing ongoing feedback.14 This may be one reason why our scores have decreased: we did not design a robust process of ongoing monitoring and feedback. In order to address this, we are now in the process of bringing together the members of our original workgroup to make observations about the current state of our improvement process and to identify opportunities to better this. We know that bedside report is happening consistently on our unit; we just don't know whether the quality of that interaction is consistent with our original intention.
In the meantime, we're grateful that staff resistance to this change has not been an issue since it was first implemented. The unit's staff nurses have embraced bedside report, which occurs only on our unit in our facility (although it's currently being tested on another unit). When our staff members float to other units and thus don't conduct bedside report, they often return saying they don't want to go back to taped report. They tell us it takes too long, contains information that's not valuable, and, most importantly, delays them from seeing patients at the beginning of their shift.
Their comments echo the reasons why the staff and leadership on our unit first decided to work collaboratively to initiate the practice of bedside report: it's safer, it's more patient centered, and it brings greater satisfaction to our staff.
© 2013 Lippincott Williams & Wilkins, Inc.