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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.