Handoff of patient information during shift report between nurses is a time of risk and liability. A quality improvement project was conducted on a 23-bed inpatient unit to measure the value of a bedside change-of-shift report in improving the effectiveness of shift report. Indicators including end-of-shift overtime, call light usage, nurse perceptions, and patient satisfaction were impacted by the change in process.
A core component of nursing practice is to ensure the communication of information facilitating the transition of care from one provider to another. The complexity of today's healthcare environment challenges nurses to communicate in ways that consistently achieve positive outcomes related to quality and safety. In today's complex healthcare system, patients are likely to encounter greater numbers of providers, resulting in greater number of handoffs. Handoffs are defined as "the transfer of information as well as responsibility and authority during exchanges in care across the continuum; to include opportunities to ask questions, seek clarity, and confirm."
1. With each handoff, the probability of experiencing lost or missing information increases. In a study focusing on newer nurses and near misses or adverse events, incomplete or missing information was frequently implicated as the cause of those events.
2. In addition, the most frequently cited root cause of sentinel events evaluated by the Joint Commission (TJC) is communication failure during handoffs.
3. Handoffs are dependent on the communication style and skill of healthcare providers in addition to the experience and knowledge of both individuals and often result in process inconsistencies.
4. An experienced provider may provide more in-depth information or may conversely assume a baseline of knowledge among peers that may not be present. A frequently occurring opportunity for patient handoff is end-of-shift report. In many settings, end-of-shift report occurs in a less than consistent manner based on preference or patterns of the individual providers.
5. Most frequently, end-of-shift report occurs away from the patient's bedside, either taped or face-to-face. Content often lacks structure and consistency and tends to be lengthy.
6. Distractions and interruptions frequently occur while nurses are engaging in shift report, resulting in potential failures in communication. Questions from oncoming nurses may be left unanswered and are challenging to be addressed once the nurse leaves his/her shift. Report occurring away from the bedside does not provide an opportunity for the patient to be included in developing or revising the plan of care and goals, a practice that has been shown to promote better patient outcomes. Previous research has focused on shift handoff by measuring indicators such as overtime, call light usage, and staff perceptions of teamwork, but few have coupled this with patient and nurse satisfaction.
Since the Institute of Medicine issued its hallmark report To Err Is Human: Building a Safer Health System in 1999, nursing leaders have been looking for more efficient innovative ways to improve patient safety, including developing strategies that would make processes more clear and standardized, and thus decrease the chance of errors by healthcare workers. As early as January 2006, TJC formally acknowledged that handoff communication from one nurse to another during shift report represents a vulnerable step in the provision of safe patient care and introduced a national patient safety goal requiring health care organizations to implement a standardized approach to handoff communication. Research conducted by McMurray et al revealed that active participation from patients during handoff reduces communication errors and duplication of services or treatments. Furthermore, patients have better outcomes and less fragmented care when they are involved in the handoff.
Despite the demonstrated relationship between communication and patient safety, research suggests that communication handoffs among nurses are still a challenge today. As healthcare has evolved and becomes more specialized, the number of clinicians involved in patient care has increased, thus creating more opportunities for ineffective handoffs. The use of standardized tools has been recommended as a means of decreasing adverse events involving handoffs. Alvarado et al reported that a standardized patient safety checklist and face-to-face report at the bedside improved the effectiveness of communication of nurses at change of shift.
Another approach to standardized handoff communication is known as ISBAR (introduction, situation, background, assessment, and recommendation). This tool was developed by the military and then adopted by the airline industry to alleviate communication barriers when relaying critical information. Pesanka et al evaluated a tool focusing on a standardized handoff using SBAR during hospital transport. This initiative, known as "ticket to ride," resulted in improvements in patient satisfaction with transport staff and decreased adverse events.
Research identifies numerous benefits to both nurses and organizations related to bedside shift report, including financial savings, increased accountability, mentoring opportunities, and patient satisfaction. The study of Anderson and Mangino6 of bedside shift report revealed positive outcomes, including a financial savings of more than 100 hours of incidental overtime after initial implementation. Staff satisfaction increased as measured by a staff survey before and after implementation. Results obtained from the patient satisfaction survey revealed an increase in patients' perceptions of staff keeping them informed and in how well the staff worked together. Kassean and Jagoo18 used bedside handoff as a quality improvement opportunity and found that patients reported satisfaction with their inclusion in the plan of care and with the methods in which information about their care was shared. Nurses practicing on a stroke rehabilitation unit in a large metropolitan hospital found that bedside shift report promoted staff accountability and teamwork as well as increased patient collaboration in care planning. A recent study conducted on a 34-bed progressive care unit in a west coast community hospital found that bedside shift reporting resulted in less overtime and less call light usage during change of shift.
While numerous benefits to bedside shift report have been documented, changes in daily routine and practices can be a difficult transition for nurses. Recent studies identifying hurdles to the implementation and adoption of bedside shift report cite nurses' concerns about compromises in patient confidentiality, length of time required to complete report, and discussion of sensitive items such as test results, complex family dynamics, or patient adherence to treatment as barriers.
Share this news with friends!!!