In November's installment of Transforming Care at the Bedside, I described the steps leading to our first test of change, which involved nurses presenting patients in morning rounds. I detailed the adjustments we made and the feedback we received.
The staff on White 10, a 20-bed general medical unit at Massachusetts General Hospital, had identified a problem with the accessibility of the three-ring binders kept at the bedside that hold the flow sheets and medication administration records for each patient. Each morning during the shift change, nurses, physicians, aides, and secretaries all competed for these "green books." Hoping to eliminate the physicians' need for the binders before rounds to make them more available to others, the nursing staff proposed having nurses use the green books to present a clinical snapshot of their patients' previous 24 hours, a function formerly performed by interns. Despite some preliminary awkwardness, the nurses and physicians adjusted quickly.
The change seemed simple at first, but soon it became clear that making the nurses' role more prominent would alter the culture of rounds on our unit, which historically had been centered around the physician. Traditionally nurses took turns attending rounds, held by a team of four to six physicians and medical students in a small conference area. Nurses had listened to the physicians' assessments and plans of care and played a supportive role, interjecting assessments and suggestions when a physician asked, "Is there anything from a nursing standpoint?"—typically as the team prepared to move on to the next patient. Being assertive under such circumstances was difficult even for experienced nurses, and on our unit many staff members are novices.
As is the case at most teaching institutions, physician teams at Mass General change monthly. One month after introducing our first test of change, a new team was assigned to White 10; on their first day, they questioned the way we conducted morning rounds. I was reluctant to have the nurses assume their prior role, so I held an impromptu meeting in my office with a few of the new physicians. Keeping an optimistic tone, I described the background of the Transforming Care at the Bedside (TCAB) initiative and our early successes. The physician leader was troubled that he hadn't been told about the change in procedure before his team rotated to White 10. I'd met with his peer the previous month, and I acknowledged that I should have communicated with him before their rotation onto the unit. I also tried to shift his focus to the benefits of the new procedure.
The physicians were also concerned that the new way of conducting rounds might be more time-consuming. I assured them that the nurses' increasing skill with their new role meant they wouldn't slow down the process—in fact, I'd observed that it actually saved time. One physician noted that, as a group, they tended to process information visually and, therefore, they needed to see the flow sheets to fully understand the patient's condition. I suggested that the nurse could pass the flow sheets to the physicians after presenting the summary.
Although the new physician team agreed to continue with the new format for rounds, I left that meeting somewhat deflated. The conversation had focused on the process's possible problems rather than on its potential benefits. The thought of having to tell the staff to go back to the old way of conducting rounds was very unsettling. I wanted the physicians to see what I'd been seeing: increased collaboration and better teamwork between physicians and nurses.
Our inability to negotiate a "win–win" with the new physician team early on led to additional meetings between the nursing and physician leadership. The first didn't take place for another month, and eventually we agreed to continue with the new procedure while we gathered data on the impact of the change; meanwhile, physician teams continued to change monthly. Four months into the new process, the leadership teams met again and discussed possible changes to how rounds were conducted throughout the Department of Medicine. But because these suggested changes were still being developed, our process remained in place and nurses continued to present their patients in our unit's rounds.
As the physician teams rotated through White 10, I often overheard physicians commenting on the positive impact of the nurses' new role in rounds. Colleagues on other units also told me that physicians had asked them—hopefully—if their unit conducted rounds the way nurses on White 10 did.
Before we knew it, the one-year mark was approaching. Before beginning this test of change, each nurse had completed an adaptation of the Collaboration and Satisfaction About Care Decisions tool—a questionnaire that measures collaboration between nurses and physicians—and we readministered it at the one-year point. Responses indicated that improvements had been made during the year, the greatest in response to the statement "Over the past month, decision-making responsibilities for patient care were shared between nurses and physicians."1
Today, a year after initiating our first test of change, nurses are still presenting patients in morning rounds. Nurses are taking an active, formal role and physicians are reflecting upon its positive impact. By making minor tweaks to the way nurses present the clinical snapshots, we've been able to sustain this change. Our work is having an effect hospital-wide, with nurses becoming more active and vocal in patient care rounds.
1. Baggs JG. Development of an instrument to measure collaboration and satisfaction about care decisions. J Adv Nurs
This is the fourth in a series of articles from Massachusetts General Hospital in Boston describing one general medical unit's experiences with Transforming Care at the Bedside (TCAB). An initiative begun by the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement, TCAB was developed as a way to improve care on medical–surgical units, patients' and family members' experience of care, and teamwork among care team members, and to increase the satisfaction and retention of nurses. The TCAB philosophy engages all care leaders but empowers bedside nurses to generate ideas and solutions for change. Mass General is one of 68 hospitals participating in a two-year TCAB initiative led by the American Organization of Nurse Executives and funded by a grant from the RWJF. For more information on TCAB, go to www.rwjf.org/pr/product.jsp?id=31512.