Tidwell, Tracy; Edwards, Jessica; Snider, Emily; Lindsey, Connie; Reed, Ann; Scroggins, Iva; Zarski, Christy; Brigance, Joe
Questions or comments about this article may be directed to Tracy Tidwell, MSN, at firstname.lastname@example.org. She is the director of the Pediatric Brain Tumor Program, Le Bonheur Children's Hospital, Memphis, TN.
Jessica Edwards, BSN RN-BC CNML, is patient care coordinator at the Le Bonheur Children's Hospital, Memphis, TN.
Emily Snider, MSN, is a neurosurgery nurse practitioner at the Le Bonheur Children's Hospital, Memphis, TN.
Connie Lindsey, RN MSN CNE BC, is a quality improvement specialist in physician quality, at the Le Bonheur Children's Hospital, Memphis, TN.
Ann Reed, MSN CNML, is the clinical director of neuroscience at the Le Bonheur Children's Hospital, Memphis, TN.
Iva Scroggins, MSN RN-BC, is a clinical educator at the Le Bonheur Children's Hospital, Memphis, TN.
Christy Zarski, RN, is a neuroscience staff nurse at the Le Bonheur Children's Hospital, Memphis, TN.
Joe Brigance, RN, is a neurosurgical nurse coordinator at the Le Bonheur Children's Hospital, Memphis, TN.
Change-of-shift reporting is essential and unique to the nursing profession. Shift change not only represents a switching of nursing personnel but also signifies a time when careful communication between healthcare providers occurs. The purpose of this handoff is to promote continuity of care, enhance patient safety, and deliver best practices. The method for delivery of shift report varies among hospitals and even from unit to unit within any given institution (Kerr, 2002). Too often, this communication can be hindered by irrelevant information that fails to address the needs of the patient. Most handoffs involve nurse-to-nurse communication exclusively, and the patient and his or her family/caregivers are seldom involved in the process (Caruso, 2007).
There is considerable focus in the literature on family-centered care. This approach to healthcare is based on collaboration and partnerships between families, patients, and healthcare providers. The purpose is to enhance quality of care and patient safety (Institute for Family-Centered Care, 2010). Patients who are very young or very old or who have chronic conditions are most dependent upon hospital care. They may feel isolated and are often dependent upon their families and social networks to assist with care and decision making (Kleiber, Davenport, & Freyenberger, 2006). It is important for nurses to consider how patients and families perceive this type of isolation and explore new ways of engaging them in their care.
One way nurses can promote a more collaborative, family-centered approach is to allow families and patients to participate in change-of-shift reporting through bedside reporting. This method of shift report puts patients and families at the center of care-related discussions and provides a forum for their questions, requests, or concerns to be addressed (Anderson & Mangino, 2006). The 2008 National Patient Safety Goals of The Joint Commission on Accreditation of Healthcare Organizations (2007) recommends that healthcare providers "encourage patients' active involvement in their own care as a patient safety strategy" (goal 13). Research indicates that by allowing this type of active participation, patients will be more compliant with suggested treatments and have better health outcomes (Kravitz & Melnikow, 2001).
The Neuroscience Unit at Le Bonheur Children's Medical Center is composed of 20 beds, with 6 of these designed to accommodate patients with more acute conditions. Patients admitted to the Neuroscience Unit have conditions ranging from acute to chronic, and they are generally admitted from either the Emergency Department or an intensive care unit. Families and patients are often thrown into a chaotic cycle of medical procedures, tests, and overwhelmingly complex and emotional decisions. Diagnoses range from seizure disorders and shunt revisions to catastrophic brain trauma and malignant tumors.
Nurses were typically assigned three to four patients each shift. Change-of-shift report has traditionally been held in the unit's conference room, with all nurses coming on shift listening to reports on every patient in the unit. Patients and caregivers were not involved in the process. The entire report generally lasted 35-40 minutes because of numerous interruptions from various sources. This often resulted in fragmented, lengthy, and disorganized reporting. Pertinent and/or safe information was sometimes forgotten or neglected because of disruptions. The environment was often tense and not conducive to questions, which, in turn, left room for error.
The Neuroscience Unit's nursing staff became increasingly frustrated with the process for change-of-shift reporting. They recognized that patient satisfaction scores were declining and families often expressed feelings of loss of control and high stress. Nurses complained about being late clocking out at shift change. Payroll reports showed a significant amount of nursing overtime hours. To address these concerns, the staff formed a team to define the issues and develop interventions. The team discussed the practice of bedside reporting used in the past and questioned whether it would have an impact on the currently identified issues. We believed that bedside reporting was a more family-centered approach that would enhance patient safety. A review of the literature was conducted and revealed several studies published on bedside reporting (Caruso, 2007). The majority of studies were conducted on adult medical-surgical units. The only pediatric studies were performed in pediatric neonatal intensive care units. The purpose of this pilot study was to determine if implementation of bedside reporting had an effect on patient/family satisfaction, nursing satisfaction, and hours of nursing overtime.
The sample consisted of all patients and their families admitted to the Neuroscience Unit from April 2007 through September 2007. Non-English-speaking patients and caregivers were excluded due to the unavailability of an interpreter at each shift change. Patient and caregiver participation was voluntary. All registered nurses on the Neuroscience Unit participated.
Nurses coming on shift would first check for patient assignments and then locate and meet with the nurse assigned to each patient. As often as possible, the same group, or block, of patients would be assigned to the nurse on the opposite shift. Exchange of information took place at bedside between nurses. Parents were encouraged to participate and were given the opportunity to ask questions, review the patient/parent assessment form with the nurses, and share concerns. Data were collected using both retrospective and prospective survey designs approved by the institutional review board. Informed consent was not required; however, family members and patients were asked if they wanted to be included during bedside report, when appropriate. Data were analyzed by a statistician in the Quality Management Department using SAS version 9.13 software.
We identified five questions aimed at assessing patient/family satisfaction with nursing care and communication from a vendor-developed patient satisfaction survey currently utilized by the hospital. Families and patients responded to the questions using a 5-point Likert scale (Likert, 1932). Data from these questions were collected retrospectively for a 6-month period prior to the implementation of bedside reporting and prospectively for the 6-month period immediately after implementation. Surveys were distributed to all patients being discharged, who returned them anonymously, and then we submitted them to an outside vendor who compiled the information.
To gauge nursing satisfaction, we developed a survey to measure the effectiveness and efficiency of the reporting system before the implementation of bedside reporting. The survey consisted of 11 questions. Ten questions used a 4-point Likert scale, with 4 = strongly agree, 3 = agree, 2 = disagree, and 1 = strongly disagree. Question 11 was open ended, and respondents were asked to describe, in three words or less, the current reporting system. There was an additional section of the survey that included demographic data, such as years of experience, number of years worked on the Neuroscience Unit, and shift worked. We distributed the survey via nurses' mailboxes, and they returned the completed survey anonymously to a locked collection box. The survey was readministered 6 months after the implementation of bedside reporting.
Overtime information for nurses, both before and immediately after the study, was collected from time clock reports. Clock-out times were reviewed between the months of October 2006 and April 2007 and between December 2007 and May 2008.
The average patient/family response rate, calculated from the number of surveys returned divided by the total number of patient discharges at the preimplementation of bedside reporting, was 35%. Data were analyzed over the 5-month period between June 2007 and October 2007. The average response rate after the implementation of bedside reporting for the period of December 2007 to April 2008 was 24%.
Of the five questions mentioned previously, two showed statistically significant differences between preimplementation and postimplementation responses. The frequency of "excellent" responses to the question "How well did nurses keep you informed about your child's treatment and condition?" was significantly higher after the implementation than before the implementation of bedside reporting (p = .0034). The frequency of "excellent" responses to the question "Did the staff on your nursing unit show respect for you and your child's needs?" was also significantly higher after the implementation than before the implementation of bedside reporting (p = .0074, Table 1).
A total of 31 surveys were distributed before the implementation of bedside reporting. Twenty-three surveys were returned, resulting in a 74% response rate. Participants (n = 23) included nurses with 1 month to 27 years of experience on the unit. Of the 23 respondents, 48% worked the day shift (n = 11) and 44% worked the night shift (n = 10). Four percent (n = 1) worked day shifts during weekends and 4% (n = 1) worked night shifts during weekends.
A total of 29 surveys were distributed via the nurses' mailboxes after the implementation of bedside reporting. Seventeen surveys were returned, yielding a 59% response rate. Participants included nurses with 6 months to 27 years of experience on the unit. Of the 17 respondents, 59% (n = 10) worked the day shift and 41% (n = 7) worked the night shift.
Table 2 displays the results of the nurses' satisfaction survey. Of the 10 questions asked on the postimplementation nursing survey, 7 were found to have significantly higher scores than in the preimplementation survey. The following 3 questions showed no significant differences between the preimplementation and postimplementation survey scores (Table 2): (1) "I actively listen to report on patients that are not assigned to me," (2) "The nurses I follow from the previous shift complete their job responsibilities," and (3) "The patient's condition matches what I get in report."
Overtime: Hours Spent Over Shift
A retrospective analysis before the implementation of bedside reporting showed that nurses stayed a total of 1,421 hours, or 100 hours per month (range = 67-137 hours), past their clock-out times between the months of October 2006 and April 2007. Analysis after the implementation of bedside reporting showed that nurses stayed a total of 923.5 hours, or 66 hours per month (range = 40-109.5), past their clock-out times between the months of December 2007 and May 2008. Using a two-tailed Student's t test, the number of hours over shift per nurse per month was significantly higher (p < .0001) for the period before the implementation than for the period after the implementation of bedside reporting. A paired t test was also performed to look at the average number of hours over shift per month for a given nurse before the implementation versus after the implementation of bedside report. Again, this difference was highly significant (p < .0001). At an average nurse's straight pay rate of $26.03 an hour, approximately $6,475 could be saved within a span of 6 or 7 months-a potential savings of more than $12,000 a year. Savings would likely be even greater because no overtime rates or other variables were considered when averaging the nurses' hourly pay rate.
Several outcomes, including increased patient/family and staff satisfaction and financial savings, were observed on the Neuroscience Unit after the implementation of bedside reporting. As seen in Table 1, the five key areas of patient satisfaction regarding the nursing staff were (a) level of concern for patient and family, (b) availability, (c) overall teamwork, (d) how well the nurses kept the patient and family informed, and (e) the respect with which patients and families were treated by the staff. Whereas each question showed an increase in satisfaction after the implementation of bedside reporting, the latter two were statistically significantly improved. The latter two questions align with the core concepts of patient/family-centered care, which are dignity/respect, information sharing, participation, and collaboration.
Another outcome included increased staff satisfaction. Before the implementation of bedside reporting, staff nurses commented that the change-of-shift report was "time-consuming, tense, unorganized, and tedious." Postimplementation comments included "efficient, quick, connecting, helpful, individualized, personal, safe, timely, collaborative, and informative." Table 2 shows that scores on 7 of the 10 questions on the nursing survey were significantly higher after the implementation of bedside reporting. The statement "I actively listen to reports on patients that are not assigned to me" was used primarily before the implementation of bedside report to find out if the nurses were actually listening to the whole report. This question was not applicable after the implementation. The items "The nurses I follow from the previous shift complete their job responsibilities" and "The patient's condition matches what I get in report" showed virtually no difference in scores before versus after the implementation of bedside report. This may be due to the fact that nurses did not identify these areas as being problematic prior to the study. For the most part, nurses have generally never verbalized that the patient's condition was different from that given in the report or that nurses on the previous shift did not complete their work.
Our financial outcome was the result of a decrease in the amount of time that nurses spent beyond the end of their shift. The time spent over shift decreased by 50% in the first 2 weeks after the implementation of bedside report. A decrease of almost 250 hours over a 7-month time frame was achieved. According to this study, bedside reporting takes less time, which translates into financial savings.
During this study, we observed changes that were neither measured nor anticipated. When discussions with the staff regarding implementation of bedside reporting began, many senior nurses voiced doubt about its feasibility. They verbalized to the manager that every nurse needed to hear report on every patient, that it was logistically impossible, and that it would be more time-consuming. They said things such as "Do this while I'm on vacation," "If you implement this, you'll see nurses resign," and "It will never work." After implementation, these same nurses became the biggest champions for the change. They stated that they would never go back to the old way of reporting and that when they stay over their departure time, it is rarely due to report.
Survey return rates for patient satisfaction were somewhat low. Historically, this rate has been low for the institution as a whole, with a mean return rate of 35% over the last 2 years. For studies where satisfaction is a key indicator, a higher completion rate is desired. Efforts to improve return rates for future studies may include offering nominal incentives, such as meal vouchers, stuffed animals, and others.
Return rates for nursing satisfaction were high both before and after implementation. However, postimplementation return rates were significantly lower. This may be due to the nurses' beliefs that they did not need to complete a satisfaction survey because they had voiced their opinions to the manager during the implementation period. Also, there was a 6-month lag time between implementation and administration of the survey. If the survey was available closer to the implementation time, the nurses may have been more inclined to participate.
Implications for Practice
Bedside shift reporting promotes family-centered care. As a result, patient and parent/caregiver satisfaction increases. Bedside shift reporting can also be utilized as a recruiting and retention factor, as seen by the higher scores in the nurses' satisfaction survey. Bedside shift reporting is a fiscally responsible outcome of this study. The yearly budget savings is clearly a significant factor in implementing this new shift reporting process.