“SAMANTHA” is an RN who works the day shift on a 10-bed specialty unit. Every day she comes into work hoping to receive a quick report so she can go about caring for her patients. Unfortunately, report is never quick. Instead, it's filled with the distractions of other nurses giving report, constant interruptions, and the exchange of unnecessary information. On some days, Samantha doesn't start patient care until 45 minutes into her shift. She longs for a better, more efficient way to handle shift-to-shift report.
A crucial part of a nurse's daily routine revolves around providing and receiving important patient information during shift-to-shift report. An accurate exchange of essential information is needed to provide quality care in a safe patient environment. Not only does shift report promote patient safety, but it also promotes accurate information and continuity of care.1 Improving shift-to-shift handoff by using a standardized bedside format is key to enhancing communication and promoting teamwork among nurses.2
This article describes an evidence-based project to move change-of-shift report to the bedside, including how the change was implemented and what nurses had to say about the new system postimplementation.
Setting the scene
Traditionally, shift-to-shift report takes place at the nurses' station, with multiple distractions, or in a conference room that takes nurses away from patients. This unstructured form of report often wastes time with extraneous conversation and inconsistent, disorganized patient information.3
Nurses don't always proficiently formulate information that needs to be exchanged and struggle with what can be left out. This prolongs the handoff process, forcing nurses to stay late, and lengthens the time when patients are left unseen. Research has shown that sentinel events, call bell usage, and patient falls are all more frequent during this period of patient “alone” time.4,5
After a prolonged handoff time, some nurses have difficulty getting organized, prioritizing their workflow, and starting their nursing care.6 Both the National Academy of Medicine and The Joint Commission agree on the seriousness of inadequate and inaccurate patient handovers and have addressed the need for a standardized handoff process.7
Both organizations also say that nurses should encourage patients to be actively involved in their own care to increase patient safety. This inclusion of the patient and family, if appropriate, during bedside report (BSR) enhances communication between the patient and nurses as part of patient- and family-centered care. By having a real-time conversation with the patient and family, the nurses can establish a trusting relationship that encourages the patient and family to feel more comfortable voicing their questions and concerns. This promotes a sense of security and empowerment among patients when they feel that they play an active role in maintaining the accuracy of the patient handoff.8
For these reasons, a proposed evidence-based intervention (EBI) was introduced to answer the following question: In an acute care setting, would a structured BSR improve nursing satisfaction and patient safety? The EBI defined BSR as “the change-of-shift report between the off-going nurse and the oncoming nurse that takes place at the patient's bedside. This makes patients a part of the process in the delivery of care.”5 With the use of a standardized tool of ISBAR—introduction, situation, background, assessment, and recommendations—open communication should be maintained, which would increase nursing satisfaction (once nurses became comfortable with the process) due to improved communication and increased efficiency. As communication and accountability improve, patient safety would also improve.
A 10-bed rehabilitation unit was chosen to implement this EBI due to unit leadership's interest in and support for this project. The unit has a clinical manager, a care manager, and 10 regularly scheduled RNs. Even in this smaller unit, challenges to the change were anticipated. Lewin's change theory was selected to guide the process of moving nursing report away from the nursing station and to the bedside.
The initial stage, named the unfreezing stage by Lewin, involved preparing the nursing staff for the EBI with an announcement in the hospital nursing publications as well as unit-based educational offerings.9 This time was used to focus on recruiting the nursing staff's energy and support by emphasizing the benefits of BSR, such as improved accuracy of information and increased communication with the patient and family. Nurses who voiced an increased interest in this intervention were recruited to champion this procedure on the unit and serve as resources to the other clinical nurses during the implementation. This change in practice could enhance the patient- and family-centered care that the institution and its nursing staff strive to provide.
The moving stage of the process involved having a champion or unit leadership present during shift changes to encourage and support nursing staff during the new process.9 It was recognized that changing the established pattern for patient handoff would require great support from unit leadership and clinical champions on a shift-to-shift basis.
The final stage, the refreezing stage, included the unit incorporating the new BSR process into its daily routine.9 This would involve continued support from unit leadership and validation of the benefits of this new process to the nursing staff as well as the patients.
Although the implementation of BSR has many benefits for the patient and family, the focus was on the BSR's effect on overall nursing satisfaction. A preimplementation survey was distributed to all nurses on the unit before the start of education to identify potential obstacles and current concerns with BSR. This survey indicated nurse dissatisfaction with the current process of shift report due to the time before and during report that wasn't related to patient information and the lack of accountability.
Announcements were provided for 2 weeks to present the concept of BSR to nursing staff members and gain their buy-in before the start of education and initiation of the practice change. The practice change was promoted in the hospital's monthly newsletter and a poster was displayed on the unit to reinforce education and useful tools to facilitate communication.
One-on-one education was provided to all nurses to explain the benefits of BSR. They were given handouts, which included guidelines for BSR, communication examples using AIDET (acknowledge, introduce, duration, explanation, and thank you) and ISBAR, and a template for BSR.10 (See What's AIDET?) The education was well received and the nurses were excited to participate in BSR, an EBI.
During the implementation of BSR, nurses were instructed to obtain their assignment at the beginning of their shift and proceed to the bedside with the offgoing nurse to receive patient handoff. When entering the patient's room, the oncoming nurse would be introduced to the patient. I.V. fluids and medications were assessed for accuracy, and any catheters, tubes, or drains were assessed for proper placement and patency. Safety equipment, such as call bells or safety alarms, were also checked at this time. Patients who could participate were involved in the process. Any additional information that raised concerns for the patient's privacy or emotional distress was communicated at the nurses' station.
Throughout this process, nurses were supported by leadership. Manager presence during shift changes served to encourage the staff to continue the new process of nursing report at the patient's bedside. Nursing concerns could be addressed in real time with the presence of leadership throughout this implementation.
After 60 days, a postimplementation survey was distributed to all nurses on the unit to reevaluate their satisfaction with nursing report. This survey showed an improvement in overall nurse satisfaction with shift report. The nurses also identified an improvement in nurse accountability and a slight improvement in the time required to give report. (See Survey result averages.)
Moving report away from the nurses' station led to less socializing and fewer distractions, shortening the report process. The survey also indicated that nurses perceived an improvement in the quality of nurse–patient and family communication. The graph above shows a slight decline in nursing communication; the authors believe that one neutral response skewed the results due to the small sample size (N = 10).
Patients play an important role in the BSR process. The goals of BSR were to improve patient safety by bringing the nurses to the patients during shift change and increasing patient involvement in report. Safety data were reviewed for 2 months before the implementation of BSR to identify any patient falls during shift report and any medication or treatment errors. Safety data records were reviewed again after 60 days of implementation. Due to the baseline low volume of medication errors and falls on the unit and the short duration of this implementation, no significant change in safety data was seen following implementation.
Timekeeping records were reviewed for incidental nursing overtime accrued on each shift. Timekeeping data showed an increase in incidental overtime during the 60-day implementation period. Although the new process may be associated with a learning curve, further evaluation revealed an increase in acuity and census during the implementation period. For these reasons, not all of the additional overtime can be attributed to the change in report format. Continuing this implementation for another 60 days and then reviewing nursing survey results, timekeeping, and patient safety data again could shed more light on this.
Where the walk goes from here
Implementing a change in nursing practice is challenging. Sustaining that change can be even more challenging. Although the initial 60-day implementation period has ended, it's important that this new process continue in the nurses' daily routines.
Unit leadership, both formal and informal, is crucial in maintaining the nurses' energy and enthusiasm for BSR. Leadership involvement is believed to be one of the top five factors in sustaining a change in healthcare processes.11 Continued leadership presence during shift change will serve to support and remind nurses to continue to take their report to the bedside. Having a clinical nurse champion for the process is also beneficial because the clinical nurses value their peers. Benefits of BSR can be discussed and nursing concerns about the process can be addressed.
Clinical nurses need to be encouraged to share ideas for improving the process.12 Effective unit leaders can facilitate this process by engaging all the team members in BSR. Through this engagement of staff, successes can be celebrated and challenges can be explored for possible solutions.
AIDET is an acronym for a consistent, systematic approach to communication among healthcare professionals that can be used to provide a structured BSR between nurses at shift change, as well as when other forms of clear communication are needed throughout a shift. AIDET represents the following five communication behaviors; each is presented with an example of how it's used for a patient handoff at the bedside:
- Acknowledge: Greet the patient and any other family or healthcare team members who are participating in your patient handoff at the bedside.
- Introduce: Introduce yourself and the oncoming nurse to the patient. Allow the patient and/or designee an opportunity to introduce themselves as well.
- Duration: Provide an accurate estimate for the time your handoff report will take, and let the patient and/or designee know how long you'll be caring for the patient that day. If any visitors at the bedside need to step away during report, give them an estimated time they'll need to wait before returning to the bedside.
- Explanation: Explain to the patient and/or designee what you'll be doing in the immediate future or over the course of your shift in a clear, step-by-step fashion. Answer their questions and make sure they know how to contact you when needed before you leave the patient's room.
- Thank you: Thank the patient and/or designee for their time and participation in your bedside report and validate any information or concerns that they've disclosed. When visitors return to the bedside, also thank them for their cooperation with this important process in the patient's care.
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