Improving Nursing Handoff During Change of Shift

A Quality Improvement Project

Donna L. B. Zarro, RN Arvis Connolly, RN, BSN

Melanie Cardinal, RN, BSNLinda Gruppi, RN, MSN

PurposeImprove change of shift nursing handoff

andreport on a 35 bed general surgery unit to promote patient safety and increase

patient satisfaction

BackgroundReview of literature indicated: Increase in patient anxiety during shift change Safe handoff will promote patient safety and satisfaction Standardized shift report will insure continuity of care, less loss of significant data and teaching opportunities for all nurses

Evidence Based PracticeAccording to Anderson and Mangino, patients

desireand seek more information regarding disease andtreatment

An informed patient is a happy participant in care

Less stress=faster recovery Participation in care creates better outcomes Bedside report puts patients in the center of

the information Oncoming nurse obtains significant data to

prioritize care, manage patient loads effectively, and collaborate with outgoing nurse and patient

Project AimImplement use of bedside reporting betweenincoming nurse and outgoing nurse to 100%

ofpatient population on 35 bed general surgeryunit by April 2011.

Process begins with incoming nurse meeting outgoing nurse

Process ends with formal acceptance of patient by incoming nurse

Measures Patient Satisfaction Data -Press Ganey: Nurses kept you informed to increase to 89.2% - HCAHPS: Overall communication to increase to 80% Patient interview: 100% compliance with staff introduction and concerns/needs Nurse observation: 100% compliance with

bedside report process

MethodologyUnit based Practice Council, comprised of staff

nurses, a licensed nursing assistant and management, initiated a quality improvement project focusing on safe handoff, a Joint Commission patient safety goal.

Asked Quality Consultant to assist in developing performance improvement education and strategy

Educated council members Used Plan, Do, Study, Act (PDSA) and rapid

cycle performance improvement methodology

Baseline Data: Nurse Survey

Visualize patient

“I’m not waking him

up!”

Takes too long

Less anxiety

“How much

info…What info?”

“Catch errors!” Clear care

plan

“some info not appropriate…”

“Concerns about HIPPA”

“Uneven # staff

between shifts”

“really long story

from pt.”

“go over the pain

plan.”Patient

has input

“met RN

right away.”

“Already know him…don’t need to see

him.”

Improvement Strategies: PDSA Cycle 1

Developed standardized bedside report workflow process

Defined what patient could expect Addressed special situations: -sleeping patient -admissions at change of shift -confidentiality/behavior Created guideline tool for nurses Educated staff via patient scenarios Created survey tools: patient interview, staff

satisfaction, and observation Rolled out bedside reporting March 29, 2011

Incoming nurse arrives

Ready to begin work at 0700, 1500, 1900 or 2300

Begin bedside report at ten minutes after the hour

(0710, 1510, 1910 or 2310)

Let out going nurse know if cared for patient before

In coming/out going nurse enter patient’s room

Complete in room report at patient’s bedside

Leave patient’s room

Complete out of room report directly outside

patient’s room

Out going nurse validates nothing further needed

Out going nurse leaves

Prepare for assignment—gather information needed Prism

Out going nurse completes patient

assignment

Be ready to give report

Guidelines for Nursing Bedside

Report

Guidelines for Nursing Bedside

Report

Consider: 1. What can wait? 2. What needs to be done? 3. What can be finished after report?

Baird 6 Nursing Bedside Report Work Flow Process

March 14, 2011

James M. Jeffords Institute for Quality/Lag

Update white board with name

of in coming nurse

Special Notes:

What Patient Can Expect: 1. Orient to unit process of shift to shift report2. Reinforce nurses will be performing a safety check during shift change by coming into room, checking on patient & asking some questions3. Nurses will not wake patient if asleep

Admission During Shift Change: Help settle the patient

Patient Care Issues that Need to be Addressed: 1. Go in the room 2. Go to nurse who is free

Staff Meeting Days: Continue bedside report procedure

Baird 6 Guidelines for Nursing Bedside Report

In Room Report 1. Position self at head of bed as near patient as possible, speak clearly. 2. Introduction of oncoming nurse to patient 3. State reason for admission/surgery 4. Perform pain assessment5. Discuss significant events for shift (nausea, vomiting, ambulation issues) 6. Review/assess all lines, drains, pumps, IV fluids and urinary catheter 7. Involve patient and ask: - Is there anything else you would like to say? - Do you have any questions? - Do you need anything now? 8. Let patient know you will be back in to see them

Out of Room Report: As needed, based on complexity 1. Negotiate undone tasks 2. Discuss any psychosocial issues 3. Identify any care/consults needed to address continuum of care

Survey Tool: Nurse Feedback

Date: Bed Number: In room report given? Yes NoIf yes:

Yes No Comments

Introduced in coming nurse to patient

Checked lines/drains/pumps/ IV fluids/ urinary catheters for correct solution, setting, entry port

Invited patient to contribute/ask questions

Nurse Observation Tool

Patient Interview Survey Tool

Did the new nurse introduce

her/himself during change of shift

report?

Where you asked if you had any special needs, concerns or questions during change of shift

report?

Date Bed Number

YES NO YES NO Comments

Findings: PDSA Cycle 1 Two Week Post Implementation Patient Interview - Introduction of on coming nurse: 100% compliance - Asking if pt. had questions/needs: 80% compliance Nurse Survey - Giving Report: Overall Experience Positive 78% - Taking Report: Overall Experience Positive 70% - Liked: standardization, meeting/visually seeing pt. , pt. involvement, care planning - Did Not Like: waking sleeping pt. time consuming getting report multiple people/receiving report for large pt. assignment

Improvement Strategies: PDSA Cycle 2Unit Based Practice Council reviewed findings: Addressed reluctance to wake patient for

report Educated patient about importance of bedside report and when report will take place Asked LNA to remind patient about bedside

report

Nursing Bedside Report: Baird 6 Patient Interview Questions

100% 100% 100% 100%

80%

100% 100%91%

0%

20%

40%

60%

80%

100%

April 2011 (n=23/n=20)

June 2011 (n=13) July 2011 (n=17) Sept 2011(n=11)

% C

ompl

ianc

e

New nurse introduced self during change of shift report Nurse asked patient if any special needs/questions during change of shift report

Findings: PDSA Cycle 2Patient Interview

Nurse Observation: % Compliance Guidelines Nursing Bedside Report

October 13 - November 4, 2011

70% 67%

49%

61%

0%

20%

40%

60%

80%

100%

In Room Report Given Introduce OncomingRN to Patient

Checked lines/drains/pumps

Invited Patient toContribute/Ask

Questions

% C

ompl

ianc

e

Findings: PDSA Cycle 2Process Compliance

Findings: PDSA Cycle 2Nurse Survey Giving Report

Nurse Survey: Overall Experience

78% 80%

50%

60%

70%

80%

90%

100%

Giving Report

% P

ositi

ve R

esop

onse

Apr-11 Oct-11

Findings: PDSA Cycle 2Nurse Survey Taking Report

Nurse Survey: Overall Experience

70%67%

50%

60%

70%

80%

90%

100%

Taking Report

% P

ositi

ve R

espo

nse

Apr-11 Oct-11

Findings: PDSA Cycle 2Nurse Feedback

“Meeting patient with new nurse,

review plan.”

“NOC-DAY works well!”

“I like doing bedside report

more than traditional report-involves patient

more in their care and addresses

their concerns, if they have any.”

“Making sure the patient doesn’t have anything they want to

discuss before I leave.”

“Patient s are awake and can

participate.”

“making me feel safer leaving knowing my

replacement has seen the group.”

“RNs in the fishbowl”

“RNs not ready!”

“Need to start sooner.”

Patient Satisfaction Data Press-GaneyNurses Kept You Informed

Patient Satisfaction Data HCAHPS Overall communication

What’s Next: PDSA Cycle 3Reinforce individual components of bedside report:

Patient education -Orientation upon admission -Set the stage 30-60 minutes prior to report Checking lines/drains/tubes for correct

solution/setting/entry points Communication to enhance patient experience -AIDET communication framework -Language of Caring Revise tools to capture data from each shift

Challenges with Implementation

Nurses unwillingness to change habits Nurses punching in at the last minute and

starting report late Uncomfortable waking patients Semi-private room does not provide enough

privacy and confidentiality Streamlining of significant data while

maintaining key pieces Takes too much time. Hard to only spend

2-3 minutes per patient

Lessons Learned Can’t just “throw it out there.” Success due to using quality

improvement process -tests of change -rapid cycles -addressed barriers quickly Culture change takes time: requires

education, vigilance, and encouragement.

SummaryImplementation of bedside report promotespatient centered care by focusing on

patientsafety and satisfaction. Further, bedside

reportencourages successful transitions betweennurses.

ReferencesAnderson, C. D., & Mangino, R. R. (2006).

Nurse shift report: Who says you can’t talk in front of the patient? Nursing Administration Quarterly, 30(2), 112-122.

Laws, D., & Amato, S. (2010). Incorporating Bedside Reporting into Change-of-Shift Report. Rehabilitation Nursing, 35(2), 70-74.