Hospitals are focusing on transforming the clinical environment to ensure patient safety and quality care through improved shift handoffs. They implement evidence-based interventions at the point of care to minimize the risk of medical errors and incidents and for quality performance consistent with value-based purchasing. Effective nurse-to-nurse information transfer is one way of ensuring a smooth care transition between the outgoing and oncoming nurse. This method also supports patient/family-centered care through the involvement of the patient and family in care planning. In bedside reporting, end-of-shift handoffs occur in the wards, as opposed to the nursing stations. This project will focus on nursing communication process improvement in a facility for better patient outcomes.
Nursing Practice Description
A nursing practice addressed in this paper is effective shift-to-shift reporting to foster clinical communication, patient safety, and patient-centered care. End of shift handovers at my facility (an acute care hospital) require improvement to avoid medical errors and sentinel events. Moving handoff reporting from hallways and nursing stations to the bedside will ensure effective information transfer during transitions.
The current practice at my facility is that nurse practitioners (NPs) in most units routinely complete shift reports at the nursing station, not at the bedside. The NPs cite inadequate training and time limitations as the reasons for this handoff practice. The handover usually occurs away from the patient or in the ward but without the involvement or visualization of the patient. The problem with this inconsistent practice is that information transfer from the outgoing nurse to the incoming colleague is often not successful. Crucial data about the patient’s status or treatment plan may be omitted, increasing the risk of medical errors (Sand-Jecklin & Sherman, 2014). Therefore, an intervention to ensure that communication during handoffs is as detailed and complete as possible is required.
Communication during nursing handoffs is crucial for improving patient safety and quality. Therefore, the rationale for the practice change is that a bedside handoff between outgoing and incoming nurses ensures safe and effective transitional care. It guarantees that the data shared is detailed and complete to prevent medical errors and incidents (Bradley & Mott, 2014). End of shift reports at my facility is completed at the nursing stations, a practice that is prone to information gaps and disruptions and precludes the opportunity to visualize the patient and assess his/her status. I have also observed that patient/family engagement during handoffs is limited. Bedside reporting (BSR) is an ideal practice for promoting safety and teamwork, as it creates an atmosphere where patients, families, and nurses collaborate in care teams (Bradley & Mott, 2014). It allows them to share information and align care plans with patient/family goals. A practice change to bedside nursing handoffs will enhance HCAHPs scores, foster clinician-patient relationships, promote collaboration and communication, and increase nurse accountability (Gregory, Tan, Tilrico, Edwardson, & Gamm, 2014). Thus, implementing BSR is a quality improvement initiative for delivering safe care at my facility.
Key Stakeholders
Internal stakeholders in my facility directly involved in the current shift-to-shift handoff include nurse practitioners (Licensed Nurses and Certified Nursing Assistants), physicians, and the transitions coordinator at the hospital. Other individuals with an indirect role in this practice are the director of nursing (DON) and unit managers. At the macro-level, the hospital’s management has also influenced daily patient care processes through policy.
Care providers, including physicians and NPs, can help plan, implement, and evaluate the BSR initiative. On-duty NPs will do patient rounding and give verbalized handoff reports to the oncoming nurses at the bedside using a standardized tool for information transfer. They will monitor vital signs, lab results, and incidents and collaborate with the patient/family in cross-checking this information during handovers. The doctors will track medication changes and issue new orders by working with the NPs. The transitions coordinator’s role will orient or educate the patient on BSR, improve communication within the team, and plan discharges. The DON and unit managers will have oversight and administrative role of mobilizing resources for this communication improvement project. Buy-in and support from the hospital’s management will be required for the change to succeed.
Evidence Critique Table
Evidence Summary
The purpose of the article by Panesar, Albert, Messina, and Parker (2016) was to describe the effect of an electronic medical record (EMR) combined with a standardized SBAR tool on nursing communication and documentation completeness. The records of 542 patients admitted to a pediatric unit of a hospital were examined during three phases after implementing each modality: paper, EMR, and EMR-SBAR. From the results, mean documentation quality scores based on a 4-point scale and nurse/physician notification increased from the first stage to the third one. Thus, an electronic SBAR tool ensures data completeness during reporting and enhances communication among clinicians.
Eberhardt (2014) sought to create and pilot an evidence-based SBAR note for electronic documentation of nursing handoffs. Based on the IOWA model for EBP, baseline data were collected on patient transfers from OR or Med-Surg units with the previous four weeks. Nurses’ views on current practices were also obtained through a survey. An electronic SBAR was then adopted to capture the handover processes and signed by the NPs at every handoff. Post-implementation data were then collected after four months. The results indicated that 50% of patient transfers to the OR were captured through the SBAR tool four weeks after implementing it. A 100% handoff from the Med-Surg unit to the OR were recorded using this note after four months. Nursing perceptions of this tool were positive during this period.
McAllen, Stephens, Swanson-Biearman, Kerr, and Whiteman’s (2018) article aimed at evaluating a practice change to BSR implemented in three medical units after four months. A gap analysis was first performed to establish evidence for the project. Before implementing BSR, baseline shift reporting was conducted in hallways or nursing stations. A SWOT analysis indicated that a shift to BSR at the facility was feasible. The nursing staff (n=67) were educated on using the tool for handoffs and patient confidentiality measures. Audit results after four months indicated a 94% compliance rate and a 24% decline in post-implementation patient falls. Thus, using BSR can improve patient care quality and safety.
Dorvil (2018) sought to identify an evidence base for a successful nurse bedside reporting through an integrated review of relevant articles. The inclusion criteria included quantitative and qualitative studies published in English in the 2006-2016 period. Systematic reviews were also incorporated in this work. The publications were searched from PubMed, CINAHL, and Medline databases using “bedside nurse report, bedside handoff, and bedside handover” as the Mesh terms. In total, 25 articles were used in the integrative review. The results indicated that BSR is conducted face-to-face at the bedside, enhances patient experience and care, and nurse satisfaction as well as lower overtime costs. However, bedside reporting is also associated with longer handover time.
Shirm, Banz, Swatz, and Richmond (2018) aimed at investigating the clinical involvement of nurses in the scholarly interaction when using BSR at a medical center. The authors developed an evidence base for implementing BSR as a best practice. Nurse characteristics and perceptions of this tool were collected through surveys and content analysis was done to identify key themes. The results showed differences in the perceptions of NPs from different units relating to BSR’s effectiveness. Those from acute/critical care were more receptive to bedside shift reports. Among the BSR’s best attributes identified by the respondents are supporting therapeutic patient/family partnerships and advancing professionalism, accountability, communication, and safety (Shirm et al., 2018). Thus, the active participation of nurses is critical to the success of a quality improvement project to implement bedside reporting.
Evidence-Based Practice Recommendation
The evidence reviewed uncover three procedures crucial to optimal nurse-to-nurse communication during handoffs: employing the SBAR note, completing shift-to-shift handovers at the bedside, and involving the patient and family. Using the SBAR tool to capture electronic medical records increases the effectiveness of provider-to-provider information transfer, documentation quality, and data completeness (Panesar et al., 2016). The tool is well received and positively perceived by critical care nurses, as it enhances professionalism, accountability, communication, and safety (Eberhardt, 2014; Shirm et al., 2018). Exclusive use of the SBAR note is possible when the nursing staff is involved in the project. It has been demonstrated to enhance clinical efficiency (lower overtime costs) and reduce patient falls (McAllen et al., 2018). Conducting handoffs at the bedside (as opposed to hallways or nursing stations) is an evidence-based best practice for improving provider communication.
Additionally, results from BSR studies indicate that bedside reporting enhances patient safety and care quality due to the NP’s ability to visualize the patient during handovers, identify and address potential errors, and seek clarifications before taking over (Panesar et al., 2016). Better patient experience and care and increased nurse satisfaction are the other outcomes of using BSR (Dorvil, 2018). BSR has also been demonstrated to promote patient/family involvement in care. It supports learning about one’s illness, medications, and treatment plan and provides an avenue for obtaining useful information to advance patient-centeredness (Shirm et al., 2018). Therefore, a recommended best practice is using the SBAR tool to conduct handoffs at the bedside in the presence of the patient and family.
Practice Change Model
Lewin’s theory is appropriate for implementing BSR at the facility. This three-step model allows for improvement and adjustments to address potential barriers. It comprises three basic stages: unfreezing, moving, and refreezing. The first step entails tackling staff attitudes and beliefs by explaining the reasoning behind BSR and expected outcomes to staff (Vines, Dupler, Van Son, & Guido, 2014). The goal is to address initial resistance by inspiring NPs to adopt a new practice that would improve information transfer and patient safety. In the moving step, the desired change is implemented. It entails guiding key activities at the organization. Refreezing is achieved when BSR is exclusively used for all handoffs at the facility.
Lewin’s planned change model is an appropriate framework for guiding staff training and the adoption of BSR as a handoff practice. The theory fits well with the proposed initiative because moving staff from reporting at the nursing stations or hallways to the bedside should be gradual to address resistance and sustain the new practice. The model is relevant, as creating new norms in information transfer at the end of a shift requires a cultural change to discourage a reversion to the current practice.
The three steps of Lewin’s model will facilitate the implementation of the new practice (BSR) at the facility. In the unfreezing stage, motivating forces will be increased through presentations on the link between effective nurse-to-nurse communication and patient safety and quality (Wojciechowski, Murphy, Pearsall, & French, 2016). Additionally, addressing concerns and negative attitudes towards bedside reporting, including higher handover time and workloads, will reduce the initial resistance to change. Thus, a pro-change movement will be created to move the facility to the next step. In the moving phase, implementation of the BSR will be initiated and piloted. Education will be provided to nurses on how to complete BSR using a standardized SBAR tool. Lewin’s refreezing step will facilitate the incorporation of BSR into daily practice through nurse champions and new policies to enforce compliance with exclusive bedside reporting.
Potential Barriers
Any change initiative is bound to face challenges. The strategy is to monitor and address them to ensure a successful implementation of the project (Moran, Conrad, & Burson, 2016). Some potential barriers to the adoption of BSR in my facility include staff turnover, resistance, and management changes. NP staffing may not remain the same throughout the project life. Nurses implementing bedside reporting may leave the hospital or find new positions within the facility. Thus, the duration of NP shifts and timing of handoffs are unlikely to remain the same throughout the phases of the project. The staff may resist conducting handovers using the SBAR tool at the bedside at first. However, building capacity on the elements of this method will ensure adherence to the new practice. Changes in hospital leadership, including that of the DON and unit managers, will also impact project implementation, as new leaders may not be committed to moving the handoff reporting to the bedside. They will be required to organize pre-implementation staff meetings and training of nurses on BSR.
Ethical Considerations
In planning and implementing this project, some ethical issues will be considered. Since the change is a quality improvement initiative, no therapy or intervention will be provided or withheld from participants. However, consistent with the ANA Code of Ethics’ provisions, informed consent will be obtained from patients and NPs included in the project (American Nurses Association, 2015). No identifying information will be indicated in questionnaires (baseline and post-adoption) to uphold participant anonymity. Additionally, to adhere to the requirements of the Health Insurance Portability and Accountability Act, the SBAR handover forms will not contain protected health information and captured data will only be used for this project (Epstein & Turner, 2015). If a patient refuses to have family participate in handoffs, the process will be conducted at the nursing stations. Additionally, the nurse-to-nurse handover will be done in private at the bedside so that other people in the ward will not overhear the exercise (Whitehead, Herbertson, Hamric, Epstein, & Fisher, 2015). Thus, individual privacy and confidentiality will be maintained when implementing bedside reporting.
References
American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: American Nurses Association.
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Moran, K. J., Conrad, D., & Burson, R. (2016). The Doctor of Nursing Practice scholarly project: A framework for success (2nd ed.). Burlington, MA: Jones and Bartlett Learning.
Panesar, R. S., Albert, B., Messina, C., & Parker, M. (2016). The effect of an electronic SBAR communication tool on documentation of acute events in the pediatric intensive care unit. American Journal of Medical Quality, 31(1), 64-68. Web.
Sand-Jecklin, K., & Sherman, J. (2014). A quantitative assessment of patient and nurse outcomes of bedside nursing report implementation. Journal of Clinical Nursing, 23(19), 2854- 2863. Web.
Shirm, C., Banz, G., Swatz, C., & Richmond, M. (2018). Evaluation of bedside shift report: A research and evidence-based practice initiative. Applied Nursing Research, 40, 20-25. Web.
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Whitehead, P. B., Herbertson, R. K., Hamric, A. B., Epstein, E. G., & Fisher, J. M. (2015). Moral distress among healthcare professionals: Report of an institution-wide survey. Journal of Nursing Scholarship, 47(2), 117-125. Web.
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