Introduction
This paper describes an evidence-based project to move my facility from recorded reports to bedside handoffs. Currently, nurses routinely complete their shift-to-shift documentation outside the patient room, a practice that limits patient/family involvement and is prone to communication errors that raise the potential for sentinel events. The stakeholders and their roles in the project are described. Further, scholarly evidence is reviewed to provide a basis for recommending a new practice. An appropriate change framework, i.e., Kotter’s 8-step model, is selected to guide the adoption of bedside handoffs at the facility. Additionally, implementation barriers and ethical implications of the project are described.
Nursing Practice Identification
Patient safety is a fundamental quality competency in nursing. It entails the delivery of safe care devoid of medical errors that would affect clinical outcomes and hospital performance. Currently, non-verbal handover is a standard practice in most units at my facility. Nurses complete shift reports outside the patient room, usually at their station, not in wards. This approach creates a practice gap due to potential communication errors or inconsistent information because the outgoing team is often tired. A safer shift change would ensure accurate reports during handoffs.
Nursing Practice Description
The current practice involves completing shift reports outside patient rooms, usually in nursing stations. Errors related to incorrect abbreviations, incomplete data, and transcription mistakes have occurred in the past. From my observation, the busy hospital environment makes nurses defer completing reports until after the shift. Additionally, there is a general feeling that bedside reporting is tedious and time-consuming, and therefore, impractical, especially for clinicians who have to conduct more than two handovers.
As such, handoff reports are completed at the nursing stations after each shift. However, this environment is prone to disruptions and noise, which may affect the quality of the reporting. Furthermore, it prevents patients and their families from knowing the treatment plan, raising questions, or participating adequately in clinical decisions. Often, conversations occurring in nursing stations during handovers involve critical safety issues such that direct observation of the patient is required to avoid misunderstandings. Although bedside reporting has been implemented at my work unit, it is not being done as effectively as anticipated it should. Compliance is low as most nurses continue to handover at the nursing station.
I have also observed that nurses at the MED-Surg unit are often unclear on the content of bedside shift reports. This knowledge gap leads to redundant, inconsistent, or incomplete information, which elevates the medical error risk. Therefore, it is clear that staff training is required to enable nurses to implement the change. Communication between incoming and outgoing teams is also low. Nurses often hand over recorded reports at the end of a shift at the nursing station, sometimes without each other’s presence or actual patient visualization. Essential information may be lost during transcription of recorded documents or audiotapes. The practice also reduces patient/family involvement in care, which results in low satisfaction and reduces nursing accountability. In this unit, accurate shift-to-shift communication is required to ensure that critical and complete patient information is passed to the incoming clinician for effective care continuity.
Why Nursing Practice Needs to Change
A practice change from recorded shift reports to bedside reporting is needed at my facility to improve patient safety and prevent medical errors. Implementing this change will foster better communication between teams and enhance the accuracy of the information exchanged. It will allow nurses to raise issues related to patient safety before taking over. Unlike in recorded reports, in bedside handoffs, the incoming nursing team has the opportunity to visualize the patient and countercheck the information in the presence of the outgoing staff. As a result, the medical error risk is minimal.
Another important reason for the practice change is to ensure patient- and family-centered care. Recorded reports are handed over outside the patient room, which limits patient/family engagement in the plan of care. The communication occurring at shift changes usually revolves around patient safety. Issues touching on inpatient care at the unit are declared so that the nurses taking over are aware of them. However, since the shift change occurs away from the bedside, the information exchanged is not subject to interrogation by the patient or family.
A complete move to bedside reporting at the facility will not only foster effective communication between teams, but it will also support patient/family involvement in care. A key outcome of this practice change is better inpatient experience that will translate into higher patient satisfaction with nursing care. Additionally, bedside handoffs could improve the quality of the information exchanged. The incoming team will also have an opportunity to assess the patient, conditions of the room, and status of surgical-site sepsis, IV site, deep vein thrombosis, and drips (Melnyk & Fineout-Overholt, 2015). As a result, patient safety will improve, resulting in fewer medical errors at the unit.
Key Stakeholders
Stakeholders comprise of people or groups with an interest in a nursing practice. They are the individuals who will be affected either directly or indirectly by the planned change. For this project, the key stakeholders are the Chief Nursing Officer (CNO), surgical unit manager, staff nurses, quality improvement team, patients, families, and physicians.
Stakeholders’ Roles
Chief Nursing Officer
The CNO coordinates all activities in the facility’s nursing department. The position holder has considerable influence over staff nurses. For the proposed practice change, the CNO will help in mobilizing buy-in and support from hospital administrators. He/she will also formulate a bedside reporting policy that will be implemented in all units. The CNO has interest in a practice change that would reduce medical errors and improve patient outcomes and the facility’s quality ranking locally and nationally.
Unit Manager
He/she is the individual who oversees the day-to-day nursing operations of a unit. As such, he/she is quite influential at this level and can serve as a nurse champion for the project. The medical-surgical unit manager will serve clinical and administrative roles in the proposed change initiative. Specifically, he/she will ensure that the change is implemented at the unit according to the goals of the organizational leadership.
Staff Nurses
Registered nurses (RNs) at all units will play the role of an implementer or facilitator. They will help transition the facility to bedside reporting; however, adequate training and awareness creation on issues of confidentiality and patient involvement will be needed before rolling out the project. The RNs are the change agents that will lead the shift to bedside reporting.
Physicians
The change project will also affect physicians. Doctors must interpret test results or use abbreviations that facilitate bedside reporting. Their interest in this project is related to its potential impact on patient safety and quality. A physician champion will be required to push for acceptance of the project among medical practitioners, e.g., surgeons.
Quality Improvement Team
The facility’s quality assurance unit spearheads initiatives that improve clinical outcomes. Given this mandate, the team will provide guidance in this project. It will help mobilize resources and provide technical support for the change.
Patients
They have high interest in the change project since bedside reporting is consistent with the goals of patient-centered care. The current practice makes patients disengaged, less informed, and anxious about their plan of care or progress. In the proposed change, they will be required to be involved in care planning by talking and asking the nurse questions.
Family
Family members (spouse, siblings, etc.) have a role to play in developing the plan of care for the patient. Their interest in the project relates to the social and financial support for their sick relative. They will be involved in the change initiative as stakeholders to ensure safe care continuity between shifts.
Evidence Critique Table
Evidence Summary
A change project to implement bedside shift reporting is an evidence-based practice (EBP) that is associated with communication accuracy, improved care continuity, and higher safety outcomes. A study by Bradley and Mott (2014) sought to examine the outcomes of bedside nursing handover program adopted by three rural facilities. It employed a mixed-methods approach to compare pre- and post-intervention perception data collected from 9 inpatients and 48 RNs. The study found that patients favor bedside handoffs over closed-door shift changes occurring outside the patient room. They cited social aspects – conversation with nurses, awareness of care plans, and involvement in their care – as the primary reason for preferring this style of care to other approaches (Bradley & Mott, 2014). The study’s findings support the proposed practice change to bedside handoff to ensure patient-centered care and improve patient outcomes and satisfaction at the hospital.
Likewise, a quantitative study by Sand-Jecklin and Sherman (2014) found improvements in post-implementation outcomes of a blended bedside handoff method. The researchers used a quasi-experimental design to compare pretest and posttest results of a change project implemented in seven MED-Surg units of a hospital. Four outcomes were measured, namely, “patient and staff satisfaction, patient falls, nursing overtime, and medical errors” (Sand-Jecklin & Sherman, 2014, p. 2859). The results indicated significant post-implementation gains in these measures attributed to the bedside handoff method. Further, the nurse’s perceptions of this approach improved. Specific post-implementation improvements were reported in patient safety and engagement and nursing accountability, while declines were noted in overtime, medical errors, and patient falls (Sand-Jecklin & Sherman, 2014). These findings support a change to bedside reporting as a quality improvement project that would improve patient and nursing satisfaction and clinical outcomes at the facility.
A related study by Scheidenhelm and Reitz (2017) also affirm the significance of bedside shift changes. It used a quasi-experimental design to compare inpatient satisfaction and nurse compliance before and after implementation of this initiative. After a 5-month period of implementing a change management strategy to establish a change practice, nurse adherence to standardized bedside reporting improved as well as inpatient and nursing satisfaction levels (Scheidenhelm & Reitz, 2017). Therefore, addressing implementation barriers and ongoing monitoring will help ingrain the change in the psyche of the clinical team, resulting in better nursing compliance and patient experience. The proposed quality initiative will incorporate training and nurse involvement in the project to increase adherence and patient/nursing satisfaction.
Similarly, Kullberg, Sharp, Johansson, Brandberg, and Bergenmar (2017) found a significant improvement in patient satisfaction in the person-centered handover (PCH) group compared to the non-verbal handoff arm. The study used a cross-sectional design to compare baseline and intervention results between the two groups in an oncological environment. Patients from the PCH wards reported higher patient satisfaction than those from the control wards – handovers involved electronic health record (Kullberg et al., 2017). The PCH handoff intervention emphasized patient safety and involvement in plans of care. The study’s results suggest that person-centered handover increases patient satisfaction scores due to greater patient/family engagement and accurate information exchange. Its findings are consistent with the goal of the proposed practice change, which is to promote patient-centered care through bedside reporting.
Patient participation in handoffs has been explored in other studies. Tobiano, Bucknall, Sladdin, Whitty, and Chaboyer (2018) examined the modalities of patient involvement in bedside handovers in a systematic review of quality improvement (QI) projects. Using an evidence synthesis tables, the researchers identified two classifications of patient perceptions: “patient-centered handover and nurse-centered handover” (Tobiano et al., 2018, p. 245). On the other hand, the nurses’ views aggregated into three groups: patient confidentiality, facilitation of patient involvement, and obtaining information from the sick during handoffs. Implementation barriers linked to nurses’ uncertainty on how to involve patients or handle sensitive data were also identified in QI projects. The patient’s function in bedside reporting included sharing information about the treatments or progress (Tobiano et al., 2018). The authors identified nurse training and standardization of handoffs as possible ways implementation barriers could be removed. The findings support the proposed practice change to bedside handover, which is consistent with patient-centered care.
Recommend Best Practice
The recommended best practice in shift-to-shift change is bedside handover that involves verbal exchanges between nursing teams and the patient. Evidence from the studies reviewed associates this approach with a lower risk of adverse events, minimal patient falls, and nurse and staff satisfaction due to the improved accuracy of shift changes (Sand-Jecklin & Sherman, 2014; Scheidenhelm & Reitz, 2017). The transition to bedside reporting is also linked to patient-centered care, which translates into better inpatient experience (Kullberg et al., 2017). It enhances patient participation in individual care plans, which results in higher satisfaction scores. Patients are able to ask questions and share clinical information about their condition and progress during the handoff (Tobiano et al., 2018).
A fundamental dimension of the proposed practice change focuses is nursing communication, which is critical in effective shift-to-shift change. The shift change is a period that demands attention and accurate information exchange about the patient to guarantee the safety of care. However, in most cases, patients are not included. An accurate communication about the patient helps in safe patient care delivery across the healthcare continuum. The social components of bedside care, i.e., nurse-to-patient and nurse-to-nurse conversations and opportunities for patient/family participation in clinical decisions, make it the most preferred approach to handover among patients and nurses (Bradley & Mott, 2014). Factors such as fewer care omissions, greater involvement, shorter LOS, and reduced healthcare costs contribute to high patient satisfaction.
Success in adopting the planned bedside reporting at the facility will depend on how well implementation barriers are addressed. According to Tobiano et al. (2018), uncertainties on how to handle sensitive patient data, involve the patient or family, and solicit from patients are some of the challenges nurses face when conducting patient-centered handovers. Therefore, training of nursing staff will be required to reduce resistance to change and promote compliance. Additionally, standardization of the handover process and clarity on the modalities of patient involvement will help address implementation barriers.
Practice Change Model
The approach to the challenge of moving the facility to bedside handoffs involved identifying an appropriate evidence-based change model from literature. Schaffer, Sandau, and Diedrick (2013) describe multiple EBP frameworks, including The John Hopkins Model and the ACE Star Model, which fit clinical education or decision-making. They emphasize three considerations for selecting an appropriate change model: it must support the EBP project activities, include an educational aspect, and provide an implementation plan. Other frameworks that were considered in this analysis included change models by Kotter, Cohen, and Lewin. Based on Schaffer et al.’s (2013) criteria, Kotter’s 8-step change model was identified to be most relevant to the proposed project.
Model Justification
Kotter’s change model was chosen for four main reasons. First, it is adaptable to different practices and organizational contexts (Small et al., 2016). It stipulates the conditions necessary for a successful change in a series of context-specific stages. Second, unlike other frameworks, Kotter’s model is comprehensive; it includes eight action steps that facilitate a gradual transition to the planned quality or performance level. Thus, applying this framework in the bedside reporting project will help manage resistance and achieve success.
Third, the model is clear and simple to apply. Its concepts are straightforward, and thus, can be readily understood by the change agents (nurses). It gives an ideal conceptual structure for implementing process changes to ensure safe care transition during bedside handovers. Fourth, Kotter’s framework recognizes the importance of including the views of staff – nurses and doctors – in a quality improvement project (Sand-Jecklin & Sherman, 2013). Stakeholder involvement throughout the change process will be critical to the success of the transition.
Model to Guide Implementation
Kotter’s 8-step model will be used to implement the proposed change, i.e., a move from recorded shift reports to bedside handoffs. The aim is to reduce resistance and promote stakeholder ownership of the project. This process is described in the following sections.
Step 1: Create Urgency
This initial step entails eliciting a feeling of an insistent necessity in the psyche of the stakeholders. Creating a sense of urgency will enable them to recognize current challenges as opportunities that could be exploited (Kotter, 2012). Responding to the problems and initiating honest discussions about the problem will spark a positive cultural change and encourage the staff to be more receptive to the initiative.
In the proposed project, a sense of urgency will be elicited through honest discussions with staff about the likelihood of medical error risks related to a deficient handover process. The nurses at the MED-Surg unit will receive literature describing how bedside reporting improves communication accuracy and patient/family participation (Kerr, Lu, & McKinlay, 2013). By emphasizing the possibility of the current practice result in sentinel events, the nursing staff is likely to embrace the new practice to promote patient safety.
Step 2: Form a Powerful Coalition
An alliance of key people within the institution can help persuade others to embrace the change (Kotter, 2012). The team should include influential individuals with high levels of power – expertise or position – and interest in the project. In the proposed change, the coalition will comprise the director of nursing, unit manager, and nurse champion who will guide the transition to bedside reporting. The leaders will be trained on safety initiatives and elements of the model to spearhead the change at the facility (Kotter, 2012).
Step 3: Create a Vision
At the brainstorming stage, participants propose many ideas and solutions to the problem. These concepts need to be linked together to form a clear vision for the planned change and develop a strategy to execute it (Kotter, 2012). The proposed project aims to promote patient safety through accurate bedside communication between nurses during shift handovers. The outcomes related to this vision are better inpatient experience and lower medical errors. The strategic initiatives will include defining the roles of the departing and incoming teams during handoffs and creating a standardized bedside handover process.
Step 4: Communicate the Vision
The vision created must be shared with implementers to embed it in day-to-day operations of the organization (Kotter, 2012). Frequent communication of the vision will keep it fresh on the stakeholder’s minds. For this project, booklets and brochures outlining the advantages of bedside handovers and Kotter’s change framework will be circulated among nurses. Additionally, the vision will be shared with staff during weekly meetings at each unit.
Step 5: Remove Obstacles
Effective communication of the vision alone cannot lead to the adoption of the change. Efforts should be made to obtain buy-in from all stakeholders. This step entails empowering the project team to act (Kotter, 2012). Change leaders will be introduced to the change to help steer the organization towards bedside reporting. They will be empowered to align standardized tools to the communication needs of each unit. The ‘homegrown solution’ will create a sense of ownership among nurses and reduce resistance to change. It will also include countermeasures to address challenges unique to each unit during the bedside handoff process.
Step 6: Create Short-term Wins
Sustaining change is often a challenge in organizations. However, creating visible short-term wins could motivate staff and silence critics (Kotter, 2012). Teams should set achievable targets to justify the investment in the change. The proposed project will highlight short-term wins to motivate nurses to continue with bedside reporting. It will focus on staff recognition of omitted medications on electronic health record before taking over and the amount of time spent conducting bedside handoffs versus completing recorded reports.
Step 7: Build on the Change
It is important to continue focusing on improvements to realize real change. In this step, institutions keep on innovating without losing focus of the vision (Kotter, 2012). The powerful coalition created will train and support nurses throughout the change process. Further, the project will stress reflective practice and critical thinking to help develop improvements in the bedside reporting structure.
Step 8: Institutionalize the Change
Consolidating the gains made needs a cultural shift to normalize the change. The proposed project’s vision will be incorporated into orientation programs for new staff to make bedside reporting a part of the organization’s culture. Further, current nurses will receive training to equip them with skills to implement the change. Support from the staff and recognition of key team members will also help sustain the transition to bedside communication.
Barriers to Implementation
Anticipated barriers to the implementation of the EBP project relate to gaps in translating research into practice. Addressing these challenges will be crucial for a successful move to bedside reporting at the facility. Schmidt and Brown (2015) identify three categories of barriers to the adoption of EBP findings in nursing practice: institutional culture, RNs’ practice beliefs, and inadequate research support. One potential barrier to moving the facility to bedside handoffs is inadequate resources to support the change. The project will compete with other quality initiatives for funding. To justify the investment, the hospital’s quality rating and the potential to achieve better outcomes from bedside reporting will be highlighted during meetings with the nurse leaders.
Another potential barrier is nurse resistance to change, resulting in low compliance. As Schmidt and Brown (2015) indicate, the nursing staff may resist a project from the onset, pretend to favor it or embrace it wholly depending on collective attitudes towards change and perceived autonomy or authority. At first, most nurses may find bedside handoffs tedious and time-consuming compared to the recorded reports they are used to. Strategies to overcome this barrier include using nurse champions (unit managers) to monitor and enforce the transition to the new practice.
Research-related barriers may also affect the implementation of this project. In particular, inadequate staff skills or capacity to adopt bedside reporting or interpret and apply Kotter’s eight steps will constrain the change process. Creating formal training opportunities for nurses to gain knowledge on the new practice will help overcome this challenge (Schmidt & Brown, 2015). They will learn about how to address patient confidentiality issues in the patient room when family members are present. Case studies and scenario analysis will prepare them for such dilemmas. Nurse champions will deliver the educational component to staff to build the necessary support and capacity (communication skills) for the change.
Another barrier relates to the scheduling of bedside handovers. If the handoff occurs at the same time for all nurses, then there will be no one to respond to call lights. Staggering the times when the outgoing team hands over to the incoming team could help address this problem. Nurse aides could also respond to call lights during the handoffs to avoid interruptions.
Ethical Implications
Ethical considerations relevant to this project relate to the roles and responsibilities of the nursing staff. Provision three of the Code of Ethics specifies that nurses have an obligation to preserve patient health and safety when providing care (American Nursing Association [ANA], 2015). In the proposed change, staff nurses will have an ethical responsibility to prevent errors and, if they occur, report them to the incoming team before handing over. They will be responsible for documenting their mistakes or omissions and communicating them to others to guarantee patient safety across shifts. Bedside handoffs will ensure that accurate communication takes place between nurses.
The new practice has the potential to force nurses to violate safety procedures in a bid to meet bedside handoff requirements. Initially, they may find the change tedious. The requirement to communicate patient information at the bedside may also lead to moral distress. The outgoing nurse could omit errors he/she committed or sensitive data when conducting bedside handovers. Thus, it will be crucial for unit managers to create moral awareness on how to navigate through these dilemmas during handoffs.
Nurse leaders have a role in ensuring that the staff has the necessary competencies to provide quality care. Provision five of the Code stipulates that nurses have an ethical obligation to ensure the competence and professional development of themselves and others (ANA, 2015). In the proposed project, it will be unethical to have nurses who lack bedside reporting skills to implement the change without first training them. The unit managers will identify knowledge deficits and develop an educational intervention to remediate them.
Ethical decisions are at the heart of patient-centered care. The unit managers will need to emphasize patient safety as an outcome of bedside handoff to motivate staff nurses to embrace the practice. Additionally, they have a responsibility of ensuring that there is a greater awareness of ethical issues related to exchanging sensitive clinical information in the presence of other parties and involving the patient or family in care. The unit managers will be required to develop confidentiality guidelines for bedside handoffs. Standardizing the new practice, including establishing clear policies for shift-to-shift changes, will also be important to prevent moral distress among nurses.
References
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