Bedside shift report aids in the development of employee teamwork, ownership, and accountability, and has been shown to increase nurse satisfaction.1 It allows for the rapid determination of a patient's condition, surroundings, and treatment, which facilitates identification of medication errors, prevents patient falls, and provides the opportunity for nurses to recognize a change in a patient's clinical status.2 Moving shift report to the bedside promotes effective communication between patients and caregivers through transparency and open dialogue. Promotion of patient involvement in their own care plan enforces self-efficacy and adherence to treatment.
The goal of bedside shift report is to help improve the patient experience and ensure safe handoff of care between nurses by involving the patient and family.3 To improve the patient experience, we must change the way nurses practice and communicate with each other and their patients.4 One of the ways to change nursing culture is to introduce different techniques to communicate patient-specific care at shift change. By reporting at the bedside in the presence of the patient, a culture shift can occur.
The purpose of this project was to use a quality improvement process to reintroduce bedside shift reporting at a 294-bed community hospital in eastern North Carolina. The hospital consists of two medical-surgical units, a telemetry unit, an ICU, an ED, women and children's services, and a labor and delivery suite. It employs 1,100 staff members, 250 of who are RNs. Standard practice at this facility included nurse-to-nurse shift report at the nurses' station or in a conference room away from the bedside. Although bedside shift report had been introduced 2 years prior, the implementation failed. To better understand the reasons for the failure, clinical nurses and staff development specialists involved with the initial implementation were informally interviewed. It became apparent that the cause of the failure was multifaceted: inadequate staff education, lack of buy-in by nursing staff and leadership, and lack of accountability and supervision from nursing leadership.
Education about bedside shift reporting provided to clinical nurses was substandard; nurses reported a lack of understanding of the benefits and rationale. Because clinical nurses didn't understand the reason for the change, there was resistance to adopt the new method of patient handoff. Follow-up hadn't been carried out effectively and there was a lack of buy-in by not only clinical nurses, but also directors, unit managers, and supervisors who were responsible for ensuring the nurses' participation. Without leadership holding clinical nurses accountable for implementation of bedside shift report, they slowly reverted to the previous behavior of giving report at the nurses' station.
The strategy for the bedside reporting reimplementation project was based on the identified reasons that the first attempt failed: education, buy-in, and supervision. The following plan was devised in collaboration with hospital nursing leadership consisting of division directors, assistant directors, managers, supervisors, and the CNO. The initiative would begin with an education session at each department's staff meeting to reintroduce bedside shift report through a formal presentation and discussion. During the implementation process, nursing leadership would round twice daily at shift change to lend support and encouragement to staff members as they adapted to the new process. After 60 days, staff members would be accompanied by a member of the leadership team to validate competency in bedside shift report. Monitoring would then continue in the form of periodic rounding by the same nursing leadership to ensure that the process was being consistently utilized in daily practice.
Three months after the reimplementation of bedside reporting, unit nurse managers reported 100% nursing staff adherence during random spot checks. Although the project was eventually successful, the original plan required modification. The Plan, Do, Check, and Act (PDCA) method was used throughout the planning and initial implementation stages.5 However, there were challenges with the “check” step during implementation. The implementation plan was modified when the “check” step revealed the possibility of project failure as a consequence of rounding inconsistency.
Education sessions at the monthly unit meetings had three objectives: reintroduce the concept of bedside shift report, hear and resolve staff members' concerns related to the process, and recruit champions to help with the implementation of bedside shift reporting on each unit. The CNO was present at the meetings to support the initiative, answer questions, and speak to staff concerns. Additional time was allocated between the education session and the implementation start date to allow for all questions and concerns to be addressed.
The initial presentation delivered at staff meetings was well attended and proved to be an effective education method. The idea of bedside shift report was well received by most clinical nurses. The most common concern raised by the nurses was that giving report at the bedside would take longer than the current time frame allotted for report. Presented literature showed that bedside shift report is actually shorter in duration than report given elsewhere due to the inability to socialize and the report becoming more objective, concise, and relevant to the patient's care.6 Another concern was the issue of patient confidentiality. Because all of the patient rooms are private, nurses were instructed to close the door before starting report and allow the patient to choose whether any visitors were present. As a result of the education sessions, staff members understood the rationale for implementation of bedside shift reporting and its importance to patient safety and satisfaction.
Educational sessions delivered useful information that answered the clinical nurses' question and quelled their concerns about bedside shift report. To better understand and anticipate their behavior, Roger's Diffusion of Innovation Theory was used, which classifies individuals by their willingness to adopt new ideas: innovators, early adopters, early majority, late majority, and laggards.7 Innovators who were eager to be the first to adopt bedside shift report served as champions for the project. Early adopters readily chose to participate in the initiative. These innovators and early adopters acted as change agents during the implementation process.
According to the Diffusion of Innovation Theory, the rate of adoption increases as the tipping point is reached until fewer individuals remain who haven't adopted the innovation.7 The tipping point was apparent as an increasing number of clinical nurses, consisting of the early and late majority, embraced bedside shift report until there was only a small percentage who refused. The laggards struggled with the implementation process, not able or willing to adopt bedside shift report until it became the social norm.
The quality improvement project reaped positive outcomes for clinical nurses, including the sharing of knowledge between healthcare providers. Nurses are often floated between units and express anxiety when receiving a new assignment on an unfamiliar unit. Giving report at the bedside offered the opportunity for the offgoing shift to show the oncoming shift how to operate special equipment or devices specific to individual patients or units. Nurses expressed appreciation for the opportunity to visualize their patients in the presence of another nurse and gain insight into the operation of devices that they may not see as frequently. For example, patient-controlled analgesia pumps were a cause of angst for nurses floating from the telemetry unit to the medical-surgical unit. The opportunity to review the unfamiliar equipment with the offgoing nurse decreased stress for these nurses.
Clinical nurses frequently socialized when giving report at the nurses' station, which was a major source of frustration among coworkers. When delivering report at the patient's bedside, socialization was minimized, report was delivered swiftly and efficiently, and the nurses indicated satisfaction with the overall process. Shift report was limited to pertinent information, decreasing the length of time for overall report and increasing accountability because each nurse knew the patient's condition at the beginning and end of the shift.
The initial plan included department managers, nursing supervisors, and the CNO to round during the first 60-day implementation phase to show support and provide guidance to clinical nurses. Nursing leadership rounds didn't occur as planned and the project leader was the only person consistently rounding. The sheer magnitude of the undertaking was too much for one individual; using the check process of the PDCA method, it was determined that the implementation was in danger of failing for a second time.
Another project was underway related to maintaining current information on the patient's bedside whiteboard, which included rounding by nursing leadership. An appeal to the CNO resulted in nursing leadership making rounds for both projects at the same time. Although this was a deviation from the original plan, it enhanced staff acceptance of bedside shift report as active monitoring by nursing leadership continued. Although sound in theory, the competency validations that were planned as the “check” step in the PDCA method never materialized. As with the first implementation of bedside shift report, accountability validation through nursing leadership monitoring continued to be a challenge.
Some outcomes of this quality improvement project were expected and others weren't. Expected patient outcomes included the realization that the patient perspective was important to those providing care. Patients were also reassured by knowing who their nurse was on every shift and saw a significant reduction in the amount of time they spent alone during shift change. One patient, when questioned about the effectiveness of bedside shift report, praised the process for allowing her to encounter her nurse at the change of shift rather than waiting what seemed like “a couple of hours” to meet the nurse in charge of her care on the night shift. Family members related appreciation for clarification of their loved one's care plan without having to wait for a physician to round on a daily basis.
An unexpected outcome of the reimplementation project was the positive outcome among unlicensed assistive personnel (UAP). Although UAP weren't responsible for bedside reporting, they were expected to round on their patients together at shift change to introduce the oncoming shift and provide care continuity. Previously, UAP became upset after shift change if they felt they had been left with a wet or soiled patient, or a messy room. This led to job dissatisfaction and grumbling that had a detrimental effect on workflow. By rounding together, they solved this problem as they checked for patients' cleanliness and toileting needs.
Suggested modifications for future attempts at quality improvement projects include staggering implementation dates for each department and piloting the initiative in one or two departments before initiating it housewide. Staggering implementation start dates allows time to refine changes to the process so that lessons learned on one unit can be put to use in other departments as the implementation spreads. By piloting a quality improvement project, one can identify whether the improvement will be beneficial to the institution as a whole or if process changes are needed. A pilot program tests the overall usefulness of the improvement before time is spent initiating it throughout the facility.
The best-laid plans don't always come to fruition. Although attempts were made to include nursing leadership in the planning and implementation of this project, their participation in supervising and supporting the implementation didn't continue for the entirety of the project. Full exploration of strategies to maximize nursing leadership support is essential.
Quality improvement success
Utilizing a quality improvement approach was helpful in providing structure for this endeavor. Reimplementation of a project is challenging and must start with determining the reasons that the first attempt failed and then redesigning based on lessons learned. Key to the reimplementation of bedside shift report was appropriate staff education and support from nursing leadership during the implementation phases. Using the PDCA method and the Diffusion of Innovation Theory as guides proved useful in undertaking a daunting task and resulted in the successful implementation of bedside reporting.