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Bedside shift report: Implications for patient safety and quality of care

Ofori-Atta, Judymae MSN, BSN, RN

doi: 10.1097/01.NURSE.0000469252.96846.1a
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Judymae Ofori-Atta is a staff nurse at the UMass Memorial Medical Center in Worcester, Mass.

The author has disclosed that she has no financial relationships related to this article.

BEDSIDE SHIFT REPORT (BSR) can save lives. According to the Inspector General Office, Health and Human Services Department, less-than-competent hospital care contributed to the deaths of 180,000 Medicare patients in 2010. However, the real number may be higher: According to one estimate, between 210,000 and 440,000 patients who go to the hospital each year for care suffer some kind of preventable harm that contributes to their death. This would make medical errors the third leading cause of death behind heart disease and cancer.1

BSR is a fairly new concept for many nurses today, although as far back as 1978 it was implemented by Memorial Sloan-Kettering Cancer Center in New York.2 Recently, other institutions have been putting their own unique stamp on BSR in compliance with Joint Commission standards. This article will show how shift report has gone through a metamorphosis, moving from the nurse's station to the patient's bedside. The goals are to improve safety and to give patients a better understanding of their condition and treatment plan.

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A change in focus

Traditionally, change-of-shift report has been done at the nurses' station, away from patients. Patients are aware of the change-of-shift report time; they know their nurses are at the nurse's station, and for an hour or more they're basically “alone.” Research has shown that sentinel events are more likely to occur during this “alone” time.3 BSR eliminates that alone time and gives the patient a feeling of inclusion with the nurses as part of the healthcare team.

With increasing scrutiny of patient safety and quality-of-care issues in healthcare delivery, hospitals have begun making changes in this traditional model to create a patient-centered system based on current standards and best practices. The Joint Commission has put forth a set of patient safety goals to improve quality of care. The 2015 Hospital National Patient Safety Goal (NPSG) 2 is to “improve the effectiveness of communication among caregivers.” NPSG 13 is intended to “encourage patients' active involvement in their own care as a patient safety strategy.” The rationale states that “communication with the patient and family about all aspects of care, treatment, and services is an important characteristic of a culture of safety.”4,5 BSR complies with these standards.

Besides increasing patient satisfaction, compliance with these standards has also been shown to reduce costs to healthcare facilities. Among the benefits: less paid overtime, decreased legal costs related to falls and medication errors, and the overall bonus of improved patient experience surveys scores from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).6

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How (and why) BSR works

By definition, BSR is the change-of-shift report between the offgoing nurse and the oncoming nurse that takes place at the bedside. This makes patients a part of the process in the delivery of their care.

The Agency for Healthcare Research and Quality (AHRQ) defines BSR as “an opportunity to make sure there is effective communication between patients and families and nursing staff.” It also states that one of the rationales for BSR is the creation of an environment where patients, families, clinicians, and hospital staff work together to improve the quality and safety of care.7 Research has shown that when patients are that third voice engaging in decisions that impact their health, measurable improvement in safety and quality result.8

Thousands of patients are cared for every day in hospitals across the nation. Just imagine how many shift changes are occurring. A preventable error that doesn't necessarily lead to death, but one that causes an injury or disability is devastating to the patient and costly to the institution.

Patients shouldn't have to worry about safety when making a decision regarding hospitalization, but the truth is that even with improvement in many aspects of healthcare, organizational process flaws and the human element create the potential for error. Patients watch the news and are on the Internet every day; they may see the statistics on preventable errors and mistakes that can cost patients their life during hospitalization. The sad fact is that errors do occur, and stopgaps have to be put in place to ensure patient safety.

Because nurses are the first line of defense when it comes to patient safety, BSR is an integral part of the care plan. The nurse is accountable for the communication that occurs during the change-of-shift report. This is the time that the nurse can verify the patient's health history, physical assessment findings, and plan of care, including prescribed medications.

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Evidence-based practices

The AHRQ has an evidence-based guide to help hospitals work with patients and families to improve quality and safety. This guide has four strategies that help hospitals partner with patients. Strategy 3 states: “The goal of the Nurse Bedside Shift Report strategy is to help ensure the safe handoff of care between nurses by involving the patient and family. The patient defines who their family is and who can take part in bedside shift report.”7

Federwisch gives an example of how BSR saved a patient's life at one facility.9 A postoperative patient prescribed patient-controlled analgesia was given an antiemetic at 1910 just before change of shift. When two nurses entered her room at 1920 for the BSR, her respiratory rate had dropped to 6 breaths/minute. One nurse stayed in the room while the other obtained and administered naloxone as per protocol. The patient quickly recovered without complications. Had the nurses been engaged in traditional shift report away from the patient, the result could have been tragic.

Transitions in care create the potential for medication errors. BSR can reduce the risk, in part because a two-verifier system lets the oncoming nurse verify with the offgoing nurse I.V. medications, pump settings, blood product compatibility, and possible drug adverse reactions. The nurse can also assess surgical wounds, check for pressure ulcers, and observe the patient's general appearance. During this time, the patient can ask questions and set short- and long-term goals with the nurse. This form of shift report improves staff communication while ensuring nurse accountability.3

In its guide to patient safety, the AHRQ cites institutions that noticed improvements in their HCAHPS scores after implementing BSR. For example, Emory Healthcare System, which includes three hospitals, received 98% on patient satisfaction. Patients reported “feeling more knowledgeable about their care.”7

MetroHealth Medical Center in Ohio implemented BSR with the goal of building partnerships with patients and families. After the education and implementation process, nurses stated they were more aware of patient care issues, enabling them to plan and prioritize their work.10

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Implementing BSR

Each institution using BSR establishes specific protocols in keeping with The Joint Commission's NPSG 13. Standardizing change-of-shift report requires teamwork, planning, and education in order to encourage nurses to accept the new concept. Nurses need to understand that this change improves quality of care, increases patient safety, and increases accountability.11

Several steps are involved in introducing and implementing BSR. The AHRQ recommends that the process be implemented on a small scale by using a small unit as a pilot. This helps clinicians learn what works and what doesn't.

Once a hospital has identified target areas of improvement, the next step is to get the staff's buy-in, which is crucial to the success of BSR. A slide presentation can show how BSR is conducted and familiarize the staff with tools that will assure a uniform process. The most important of these is the situation, background, assessment, and recommendation (SBAR) communication tool, which streamlines report significantly. On one 34-bed progressive care unit employing 55 nurses, use of SBAR decreased report time from approximately 40 minutes to 10 minutes. The institution saved $8,000 in 2 months due to reduction in overtime.6

Patients and family are informed about BSR during the previous shift and when their nurse is rounding. Nurses have to be trained in the critical elements of BSR using the same language with introductions, continuing the process using SBAR, and thanking the patient at the end.11 (See Using SBAR plus T for BSR.) Presenting a consistent message builds trust with the patient and family.

According to AHRQ, the critical elements of BSR are as follows:

* Introduce the nursing staff, patient, and family to one another.

* Invite the patient and (with the patient's permission) family to participate. The patient determines who is family and who can participate in BSR.

* Open the electronic health record at the bedside.

* Conduct a verbal report using the SBAR format in words the patient and family can understand.

* Conduct a focused assessment of the patient and a room safety assessment.

* Review tasks to be done.

* Identify patient's and family's needs and concerns.7

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Nurses and patients reap the rewards

The advantages for the nurse begin with the efficiency of report, which streamlines all pertinent information and saves nursing time. BSR improves staff's teamwork by giving nurses the opportunity to work together at the bedside, ensuring accountability. Using a standardized format reduces the risk of miscommunication because it overcomes different communication styles. Better communication also helps the oncoming nurse prioritize assignments according to need. The nurse is informed about the patient earlier in the shift because report time is shortened. Nurses are always on the same page during the report because they're both looking at the same information at the same time.12

The patient benefits from BSR too. Listening to report, the patient learns about the plan of care and the goal for the day. The BSR process acknowledges the patient as a partner and reassures the patient that the nurses work as a team. Knowing that nursing staff is getting the information needed to facilitate care decreases patient and family anxiety and improves patient satisfaction.12,13

Institutions adopting BSR will see patient satisfaction scores reflecting the patients' more positive experiences. They'll also notice a decrease in medication errors, a decrease in sentinel events, and less nurse overtime. One study noted a decrease in overtime by 100 hours in the first two pay periods4 due to the fact that the structured SBAR makes report more concise. Another study showed a “decrease in patient falls during change of shift, dropping from one to two patient falls per month, to one patient fall in six months.”13

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Challenges and concerns

Nurses have raised some concerns when it comes to BSR, namely:

* unknown visitors or family in the room

* disclosure of new diagnoses or lab information that a healthcare provider hasn't yet discussed with patient

* patient sleeping

* patient unable to participate due to cognitive or sensory limitations

* questions from patient that need lengthy clarification, increasing report time

* lack of privacy in semiprivate rooms, leading to potential violations of the Health Insurance Portability and Accountability Act (HIPAA).

Because patients are made aware of the BSR during the admission process, they can be asked at this time about sharing information when friends and family are visiting. The patient has the final word on whether the family stays or leaves during the report time. If the patient wants complete privacy during this time, the nurse can courteously ask family and friends to leave to allow interaction between nurse and patient. In addition, time should be set aside before or after BSR for the sharing of sensitive information that hasn't been told to the patient with the oncoming nurse.

Patients should also make the decision whether they would like to be awoken for the BSR. Restful sleep is an important step in the healing process. Nurses need to obtain consent from patients if they'd like to be awakened for the report.

If a patient has a question requiring a lengthy answer, the nurse can delay the response until later; for example, by saying, “Mrs. Smith I'd like to talk to you more about that. Can I come back after I complete report on our other patients?”14

Under HIPAA, can nurses engage in confidential conversations with patients even if their conversations might be overheard? According to HIPAA guidelines, the answer is yes, provided that providers have made every reasonable effort to protect patient privacy. HIPAA acknowledges the reality that incidental disclosures may occur. The law isn't violated if reasonable safeguards have been put in place to protect patient's privacy.7

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Embrace the change

As institutions implement BSR, they need to take into account that the change process is not without barriers and challenges. However, as healthcare continues to evolve into a patient-oriented domain, transparency is expected when it comes to patient safety. Initial efforts to replace an outdated reporting system may meet with cynicism about yet another new strategy, but attitudes will change as patients begin to voice the positives and nurses and institutions see the rewards in measurable outcomes that benefit the patient, family, and healthcare team.

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Using SBAR plus T for BSR11

The SBAR communication tool can be adapted for BSR as follows. A dry erase board placed in the patient's line of vision can be used to convey information such as the names of nurses and healthcare providers and to highlight the patient's goal for the day.

* Situation: The offgoing nurse introduces oncoming nurse. The oncoming nurse greets the patient, always calling the patient by name while checking patient's wristband to verify name and date of birth. The diagnoses are also given in this section and the nurse takes this time to update the in-room patient information board.

* Background: This section involves the patient in the change-of-shift report. Ask the patient to listen first, then ask questions or add more information at the end. Give brief but pertinent information on the patient's health history, including comorbidities and events that led up to the hospitalization, and the expected length of stay.

* Assessment: Briefly conduct a review of systems, including vital signs. Include all tubes and invasive lines, such as chest tubes, surgical drainage tubes, urinary drainage catheters, and venous access devices, associated with each body system assessed. Also assess for pain and assess all I.V. sites and medication pumps, especially the medication infusion rate, verifying for accuracy.

* Recommendation: This covers cultural and communication needs, all pending orders, goals for the patient, and plan of care. Allow time for questions from oncoming nurse and patient.

* Thank: Always thank the patient.

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REFERENCES

1. Allen M ProPublica. How many die from medical mistakes in U.S. hospitals. Scientific American. September 20, 2013. http://www.scientificamerican.com/article/how-many-die-from-medical-mistakes-in-us-hospitals.
2. Brooks B. Bedside shift report works for patients, staff. Medscape. 2013. http://www.medscape.com/viewarticle/803958.
3. Baker SJ. Bedside shift report improves patient safety and nurse accountability. J Emerg Nurs. 2010;36(4):355–358.
4. The Joint Commission. National Patient Safety Goals Effective January 1, 2015. http://www.jointcommission.org/assets/1/6/2015_NPSG_HAP.pdf.
5. The Joint Commission. National Patient Safety Goals. 2015 National Patient Safety Goals. http://www.jointcommission.org/standards_information/npsgs.aspx.
6. Sherman J, Sand-Jecklin K, Johnson J. Investigating bedside nursing report: a synthesis of the literature. Medsurg Nurs. 2013;22(5):308–312, 318.
7. Agency for Healthcare Research and Quality. Nurse Bedside Shift Report Implementation Handbook. http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.pdf.
8. Sherman R, Hilton N. The patient engagement imperative. Am Nurse Today. 2014;9(2):1–4.
9. Federwisch A. Bedside shift report ensures quality handoff. Nurse.com. 2007. http://news.nurse.com/apps/pbcs.dll/article?AID=/20071008/SW01/710080354#.VYluFflViko.
10. Laws D, Amato S. Incorporating bedside reporting into change-of-shift report. Rehabil Nurs. 2010;35(2):70–74.
11. The Studer Group. How-to of bedside shift report. http://www.studergroup.com.
12. National Patient Safety Foundation. Bedside change-of-shift reporting: a strategy to increase patient safety. 2011.
13. Agency for Healthcare Research and Quality. Guide to Patient and Family Engagement in Hospital Quality and Safety. 2013. http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/guide.html.
14. Griffin T. Bringing change-of-shift report to the bedside: a patient- and family-centered approach. J Perinat Neonatal Nurs. 2010;24(4):348–353.
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