JONA
Volume 39, Number 9, pp 393-398
Copyright B 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
The Content and Context of
Change of Shift Report on Medical
and Surgical Units
Nancy Staggers, PhD, RN, FAAN
Bonnie Mowinski Jennings, DNSc, RN, FAAN
Objective: This study was conducted to describe
the current content and context of change of shift
report (CoSR) on medical and surgical units and
explore whether nurses use computerized support
during the CoSR process.
Background: Change of shift report is a commonly
occurring handoff that could contribute to gaps
in care.
Methods: Bedside, face-to-face, and audiotaped
CoSRs were audiotaped and observed on 7 medical
and surgical units in 3 acute care facilities in the
Western United States.
Results: Conventional content analysis revealed 4
themes: the Dance of Report, Just the Facts, Professional Nursing Practice, and Lightening the Load.
Observations exposed the lack of content structure,
high noise levels, interruptions, and no use of electronic health records in these facilities as a part of
the report process.
Conclusion: Improvements to CoSR include determining a consistent and tailored structure for report,
evaluating types of report suitable for particular
units, reducing interruptions and noise, and determining content amenable to computerization.
Gaps or discontinuities in care often occur when
responsibility for a patient changes hands.1 Gaps in
Authors’ Affiliations: Professor, Informatics (Dr Staggers),
College of Nursing, University of Utah, Salt Lake City; Health
Care Consultant (Dr Jennings), Evans, Georgia.
Corresponding author: Dr Staggers, College of Nursing 10 S.
2000 E., University of Utah, Salt Lake City, UT 84108 (nancy.
staggers@hsc.utah.edu).
Funding: This work was funded by a seed grant from the
University of Utah.
care ‘‘can occur anywhere, even if a hospitalized
patient never leaves the bed.’’2(p163) Change of shift
report (CoSR) represents a commonly occurring
handoff that could contribute to gaps in care. It is a
crucial handoff because nurses who are going offduty synthesize and convey patient information that
is received and used by nurses coming on shift.
However, CoSR serves more purposes than mere
information exchange. These include social, organizational, educational, and emotional functions.3-5
Moreover, CoSR is a complex process because of
the knowledge and expertise that are hidden in
these exchanges.4
Despite its importance, CoSR is not a topic of
recent research, and we know surprisingly little about
the CoSR process.6 Authors recently addressed various features of CoSR7-11 including suggestions to
incorporate handoff methods used in high-risk industries outside healthcare.6,11 However, more than
a decade has passed since researchers evaluated
CoSR on medical and surgical units in the United
States.12-15 This is important for 2 reasons. First,
recent studies reveal that handoffs and work complexity on medical and surgical units can contribute
to issues with patient safety.16-19 Second, electronic
health record (EHR) implementations greatly expanded during this period, and technology in general permeates nursing settings. Strople and Ottani20
strongly advocated the use of technology during
CoSR; however, whether nurses use EHRs during
CoSR has not been investigated. Therefore, this qualitative study was conducted to describe the content and context of CoSR on medical and surgical
units and assess whether nurses use EHRs during
report.
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393
Methods
Sample and Setting
Data were collected from 7 medical and surgical
units in 3 acute care facilities in the Western United
States. These included a federal facility (121 beds;
1 medical, 1 surgical unit), an academic medical
center (425 beds; 1 medical, 1 surgical, 1 combined
medical-surgical unit), and an oncology specialty
hospital (50 beds; 1 medical, 1 surgical unit). Appropriate institutional review board approvals were
obtained. The investigators obtained informed consent from nurses and, as appropriate, patients and
family members.
Sampling was guided by purposefully collecting data related to how report was done (report
types) and different shifts. The units used 3 report
typesVaudiotaped, bedside, and face-to-face. The
shifts started at 7 AM and 3, 7, and 11 PM. Reports
typically involved only 2 nurses.
Data Collection and Analysis
Data were collected on 13 different occasions from
September to November 2006. A total of 53 patient
reports involving 38 nurses were audiotaped and
observed, with the investigators remaining as unobtrusive as possible. Each audiotape was transcribed
verbatim. Field notes were recorded to capture features about the context of report such as the setting,
nonverbal aspects of report, and other activities.
The audiotapes were analyzed using conventional qualitative content analysis21 with codes
derived from the data rather than using an a priori
framework. The analysis moved back and forth
between the investigators working separately and
jointly. The first level of coding was very granular,
ultimately moving to a thematic understanding of
CoSR. The field notes were placed into a table to
systematically analyze the context of report.
Results
Sample Characteristics
Most nurses who listed their age (n = 34) were in
their 20s or 30s (66%). The modal educational level
was BSN (n = 24), although 1 nurse giving report
was a licensed practical nurse. Most were women
(n = 30; 79%). Shifts were 3 different lengths: 4, 8,
and 12 hours. Family members were present for 3 of
the 4 patients involved in bedside reports.
The Content of Change of Shift Reports
The content from these reports clustered into 4
themes: (a) the Dance of Report, (b) Just the Facts,
394
(c) Professional Nursing Practice, and (d) Lightening
the Load. No discernable differences were apparent
in the content of report across the mixture of shifts
except for the 4-hour shifts. The nurses who worked
these were inclined to apologize for not knowing
enough about the patient or not getting everything
done.
Although there was evidence of each theme in
each report type, content differed slightly across
them. For example, information in taped reports
tended to have more content related to the Just the
Facts theme and less content related to the Dance
of Report theme. Information indicative of Professional Nursing Practice was more common in bedside reports than the other types. All report types
contained data related to Lightening the Load but
was present least often in bedside reports.
The Dance of Report
This theme reflected the choreography of report. The
Dance of Report involved the discernible ‘‘movements’’ between report partners that were essential
to the process of basic human communication.
Across all report types, content most frequently related to this theme (33%). ‘‘Speed bumps,’’ such as
full interruptions, distractions, and forgetting something or losing one’s train of thought, were a part of
this theme. Speed bumps occurred most often when
reports were given in conference rooms or open
nurses’ stations. Except for taped report, clarifying
details was a part of the report, often involving an
extensive exchange of questions and answers. Report partners synchronized using common communication techniques. The nurse giving report might
include a screening question to learn whether the
oncoming nurse previously took care of or ‘‘knew’’
the patient. This allowed nurses to tailor report,
addressing only what occurred since the last time
the nurse cared for the patient. Synchronization
was least evident in taped reports and most dominant in bedside reports.
Just the Facts
Exchanging noncontroversial, factual patient data
requiring virtually no interpretation by the receiver
comprised 30% of the content of the shift reports.
This included the patient’s name, bed number, and
age. Precise values for weights, laboratory tests,
physician orders, and locations of intravenous lines
as well as various tubes and drains were mainstays
in this theme. The times medications or treatments
were completed or due were also a part of this
theme, such as ‘‘last blood sugar was at 1800. Next
one is due for you at 2300.’’
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Professional Nursing Practice
Data in this theme, representing 25% of the CoSR
content, related to nursing actions, knowledge,
reasoned judgments, and instincts combined with
care decisions. Assessments, observations, and decisions often reflected a sophisticated integration of
complex elements. For instance, a patient who was
on NPO (nothing by mouth) had an order for fastacting insulin. The nurse consulted with the physician and pharmacist to reconcile these 2, possibly
precarious orders, using clinical knowledge to safeguard the patient. In the report, the off-going nurse
stated, ‘‘By the time we figured it out and came up
with a new plan using regular insulin, I rechecked
her blood sugar just for joy, and it was 109 so I
gave her nothing.’’
This theme included nursing language: ‘‘She
pees in a hat,’’ ‘‘She’s on clears with popsicles,’’ and
‘‘They gave him four K riders and a Mag rider.’’
Each of these statements required the recipient to be
in-the-know and reflected an economy of expression common to the unit and nursing culture.
Data in this theme illustrated how nurses
considered patient preferences and acknowledged
patients as human beings. One nurse, for instance,
provided exacting details about how a patient liked
a patch applied, ‘‘She likes it cut. A third of it cut
off, put on her back, and the other two-thirds put
on her thigh.’’
Lightening the Load
Content in this theme (13%) reflected thoughtfulness toward other staff, teamwork, bonds between
nurses, and smoothing the transition of care from
one shift to the next. It also included shared humor,
laughter, and appreciation for the next shift. Comments were often simple but important like ‘‘Keep
an eye on him.’’
The Context of Change of Shift Report
Getting the Big Picture
Although responsibility for each patient was
ensured from shift to shift, it was not clear who
on the unit had a sense of the big picture. When the
investigators inquired about this on 5 units, the response was ‘‘no one.’’ On 2 other units, the charge
nurses, who also cared for patients, gave each other
an overview of all the patients on the unit and
shared any critical issues. Safety briefings, lasting
only a few minutes, were done on 3 units. These
occurred at the start of the shift, involved all staff,
and focused only on patients with the same last
names, those at risk for falls, and those with donot-resuscitate orders.
Not the Sounds of Silence
Observations included the investigators’ perception
about noise on the units in general and during report.
On most units, the nurses’ stations were exceptionally noisy, especially at shift changeVtelephones and
call bells were ringing; large groups of people congregated, laughed, talked loudly, and called to each
other.
The sound levels varied by report location. For
the 3 units where report was conducted in a conference room, nurses gathered in dyads around 1
large conference table. Report was given with all the
dyads speaking simultaneously, creating immense
peaks in the sound volume in the room. At one
point, the sound level was so great that an investigator wrote, ‘‘I can hardly think.’’ For 2 units,
nurses gave report in the hallway at a chart shelf
mounted outside patients’ rooms. Nurses examined
the patient’s chart and moved from room to room
to complete verbal report. Sounds competing with
report included television programs, call bells,
equipment alarms, and conversations among staff
in the hallway. Bedside reports were similar except
that report involving the patient and/or family
occurred in the patient’s room without the patient’s
chart. For taped report, nurses listened in converted
patient rooms, eliminating competing noise.
Patient Assignments
Except for taped report, oncoming and off-going
nurses went through a process of ‘‘finding’’ each
other to get report for their patients. This process
was typically casual and often time-consuming.
Forty-five to 60 minutes could elapse before nurses
connected. Commonly, nurses received report from
2 to 3 other nurses for their usual assignments of 4
to 5 patients. Exceptions were evident such as a
nurse who received report from 4 different nurses
and another dyad with a perfect assignment match.
These nurses were amazed but pleased by this
stroke of luck.
Report consumed an average of 16 minutes of
actual speaking time with a range from just under
5 minutes for 5 patients to a high of 28 minutes for
4 patients. Overall, report lasted 4.4 minutes per
patient in this sample. This time is somewhat deceptive as it does not include preparing for report or
other activities that typically lengthened time during CoSR, such as waiting for report partners.
Tools for Receiving and Giving Report
There was no evident structure for conducting report
across nurses, units, shifts, or report types. Nurses
typically created a personalized tool for receiving
report information. Although blank sheets of paper
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395
or 3 5-in cards were most commonly used, 1
nurse designed a personal form using a spreadsheet
so that information was always in the same order
from patient to patient. Oncoming nurses might
review the Kardex or interdisciplinary care plan in
preparation for report; they commented that Kardexes were often not up-to-date.
Nurses giving report also used a variety of
tools. Sometimes, the nurses giving report relied
more on their memory than notes. Other times, they
used notes they had written while getting report,
which they updated during their shift. For the unit
giving bedside reports, suggestions for structuring
report were displayed on a bulletin board. Yet, there
was no evidence that nurses on this unit used these
suggestions. Nurses giving report in the hallways
flipped through paper documentation to retrieve
pertinent information as they spoke.
None of the reports incorporated the use of an
EHR. This held true even in the facility with a mature EHR, where the nurses commented, ‘‘Everything is on the computer.’’ The EHR included all
results, orders, clinical documentation, and decision
support. The other 2 facilities had a partial EHR
for all results and medications. The partial EHR
was unavailable 1 day from midnight to 6 AM, generating issues that persisted into the 7 AM report
including comments about the stress the downtime
created.
Report Styles
Across shifts and report types, nurses giving report
shifted rapidly from topic to topic, speaking in a
clipped manner, using abbreviations and acronyms.
Despite this commonality, nurses used their own
style to guide what they emphasized, the tone they
used, and the order for delivering information. During face-to-face reports, the dyads usually maintained intense eye contact and leaned into each
other to hear and focus. This was especially noticeable in the noisy environments. At the conclusion of
report, the nurses would lean back, breaking the
intensity of the exchange, bringing report on that
patient to an end. Gesturing was another aspect
frequently observed in face-to-face reports, with gestures serving a 2-fold purposeVone to point to the
location of tubes or wounds, the other as a cue to
help remember things.
Interruptions
Reports, especially face-to-face reports, were rarely
completed without interruptions. People, including
nurse’s aids, clerks, physicians, and other nurses,
freely entered conference rooms during report. During a report, a nurse manager interrupted a room
396
full of people to say good morning. At times, nurses
from one dyad might hear something from another
dyad, causing them to stop their report to interject
information into the other report. Although extreme, in 2 cases, nurses actually shouted information across the conference table. The off-going nurse
giving report outside a patient room on 1 unit
stepped away from report 5 times. More commonly,
these interruptions resulted from equipment alarms
and information requests.
Discussion
Given concerns about handoffs and possible discontinuities in care,1,2,6 the investigators did not expect
to find CoSR content to be so informal, unstructured, and heavily reliant upon nurses’ memories.
The context of report reflects that interruptions are
common, the big picture of care on the unit is
largely lacking, and noise levels are high. These
features have not been previously reported, so comparisons with the past are not possible. A surprising
finding was that EHRs were not an adjunct to report even in the facility with a mature EHR. Some
of the content of report, such as Just the Facts, has
the potential to be accessed from computerized systems. The other 3 themes contained report content
that could not as easily be computerized.
These findings provide opportunities for administrators to assess and improve this critical patient
handoff. Having a consistent structure for report
could improve information completeness and accuracy and serve as a cognitive framework for nurses
to organize disparate information. Designing report
tools tailored to specific units may assist with information synthesis during report. Consistent structure could improve report by allowing speakers and
listeners to anticipate content and streamline and
synchronize communication. Moreover, content from
3 themes indicates the need for a report structure
that also allows opportunities for face-to-face exchange of information.
Nurse administrators can initiate ways of using
EHRs to facilitate report. At a minimum, EHRs can
display current, accurate information in Just the
Facts or 30% of report content. Yet, the computerization of report for medical-surgical units is not as
straightforward as it might seem. A data-intense
display of orders, results, and patient parameters
would not facilitate the kind of synthesis nurses demonstrate in report. Instead, a succinct display with
pertinent information is optimal. The use of a generic, computerized shift report format across units,
typical of current systems vendors, is problematic
because a CoSR format tailored to each unit is
JONA Vol. 39, No. 9 September 2009
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needed to fit at least the unit’s patient population.
For instance, using a body systems format during
report will work well for critical care settings. This
format is not suitable to medical-surgical units
where nurses need to manage problems and create
priorities in 4 to 5 patients during report. Likewise,
having to page through various screens to find
salient data will not promote information synthesis.
An optimal design would outline pertinent information, preferably on 1 or 2 screens, that nurses
need for this patient on this shift for this unit. To
the authors’ knowledge, this kind of sophisticated
design is not yet available.
Technology may not be a panacea for CoSR as
suggested by previous authors.20 The themes Professional Nursing Practice and Lightening the Load
include important content less amenable to computerization. How to reflect professional decisions
with rationale and care tips may not be accomplished by relying solely on an EHR. Last, other
purposes for report exist, such as socialization,
coaching, and content clarification. Even a full,
computerized report may not substitute for these
purposes.
Administrators can make improvements that
will affect the context of report such as ensuring
that the ‘‘big picture’’ is being assessed and communicated throughout shifts. Second, CoSR needs to
be recognized as a critical handoff and respected for
its importance. A quiet place away from distractions and interruptions is an imperative to improve
nurses’ cognitive focus and concentration. Interruptions during report need to be limited to urgent
ones. These tactics, although not simple, should
improve CoSR efficiency and effectiveness.
Last, patient assignments could be more consistent between report partners. This would ameliorate nurses having to ‘‘find’’ each other and decrease
time consumed during report. Although most nurses
spend less than 30 minutes in verbally exchanging
patient information, additional time is consumed to
get organized for report and ‘‘find’’ their report
partner and pertinent tools, as well as complete
other CoSR-related activities. Also, the type of report needs to be carefully considered. One nurse
commented that taped report was ‘‘antiquated’’;
however, it was efficient in providing succinct, factual information. Taped report allows coverage during report, making this method attractive, especially
if an opportunity to ask questions afterward is an
expected part of report. Some units may find their
patient complexity and acuity require a face-to-face
report, but the tradeoffs need to be evaluated.
This study has limitations. Data for this study
were collected just as the Joint Commission released
report guidelines using the Situation, Background,
Assessment, Recommendation (SBAR) structure.22
Anecdotal descriptions indicate that some institutions are using the SBAR process during report,
whereas other facilities are using it as originally
intendedVfor physician-nurse communication. The
authors could not locate empirical evaluations of
SBAR. Finally, other geographic locations might
reflect different content and contexts for report.
Future CoSR research should evaluate noncomputerized methods to improve the effectiveness and
efficiency of report, ways to decrease interruptions,
and optimal EHR designs to support CoSR. Why
nurses at facilities with advanced EHR functions
did not incorporate these into their shift reports remains to be studied.
Conclusion
Although handoff methods from industries outside
health could be incorporated into shift report and
evaluated,23 the optimal information required to
safely transfer patient care from one shift to the
next needs to be determined. Efficiencies could be
gained if superfluous data could be defined and
eliminated or, at least, given a lower priority. More
structure in report may improve the efficiency and
effectiveness of CoSR. Yet, even this obvious
strategy needs to be evaluated, given the finding of
this study that a topical outline proposed by a nurse
manager was not adopted. Change of shift report is
a critical handoff occurring on every unit in every
acute care setting several times a day each day of
the year. This study provides a sense of the content
and the context of contemporary CoSR. In conjunction with a recent editorial calling for improvements in CoSR,6 this study can be an impetus for
nurse leaders to assess and enhance their facility’s
change of shift processes.
Acknowledgment
The authors thank Rick McAferee, MBA, JD, doctoral student, for his work as a research assistant
on this project.
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