1. Improving Nursing Handoff During Change of Shift
A Quality Improvement Project
Donna L. B. Zarro, RN
Arvis Connolly, RN, BSN
Melanie Cardinal, RN, BSN
Linda Gruppi, RN, MSN

2. Purpose
Improve change of shift nursing handoff and report on a 35 bed general surgery unit to promote patient safety and increase patient satisfaction

3. Background Review 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

4. Evidence Based Practice
According to Anderson and Mangino, patients desire
and seek more information regarding disease and
treatment
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

5. Project Aim Implement use of bedside reporting between
incoming nurse and outgoing nurse to 100% of
patient population on 35 bed general surgery
unit by April 2011.
Process begins with incoming nurse meeting outgoing nurse
Process ends with formal acceptance of patient by incoming nurse

6. 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

7. Methodology
Unit 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

8. Baseline Data: Nurse Survey
“Catch errors!”
Less anxiety
Clear care plan
Visualize patient
Takes too long
“Concerns about HIPPA”
“met RN right away.”
“Uneven # staff between shifts”
“Already know him…don’t need to see him.”
“some info not appropriate…”
“How much info…What info?”
“really long story from pt.”
“go over the pain plan.”
“I’m not waking him up!”
Patient has input

9. 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

11. 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 assessment
5. 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

12. Survey Tool:
Nurse Feedback

13. Nurse Observation Tool
Date: Bed Number:
In room report given? Yes  No
If 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

14. 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
Comments

15. 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

16. Improvement Strategies: PDSA Cycle 2
Unit 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

17. Findings: PDSA Cycle 2
Patient Interview

18. Findings: PDSA Cycle 2
Process Compliance

19. Findings: PDSA Cycle 2 Nurse Survey Giving Report

20. Findings: PDSA Cycle 2 Nurse Survey Taking Report

21. Findings: PDSA Cycle 2 Nurse Feedback
“making me feel safer leaving knowing my replacement has seen the group.”
“I like doing bedside report more than traditional report-involves patient more in their care and addresses their concerns, if they have any.”
“NOC-DAY works well!”
“Patient s are awake and can participate.”
“RNs in the fishbowl”
“Meeting patient with new nurse, review plan.”
“Need to start sooner.”
“Making sure the patient doesn’t have anything they want to discuss before I leave.”
“RNs not ready!”

22. Patient Satisfaction Data Press-Ganey Nurses Kept You Informed

23. Patient Satisfaction Data HCAHPS Overall communication

24. What’s Next: PDSA Cycle 3
Reinforce individual components of bedside report:
Patient education
-Orientation upon admission
-Set the stage 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

25. 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

26. 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.

27. Summary
Implementation of bedside report promotes patient centered care by focusing on patient safety and satisfaction. Further, bedside report encourages successful transitions between nurses.

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