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
Purpose
Improve change of shift nursing handoff and
report on a 35 bed general surgery unit to
promote patient safety and increase patient
satisfaction
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
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
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
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
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
Baseline Data: Nurse Survey
“Catch
errors!”
“Concerns
about
HIPPA”
Visualize
patient
“met RN
right
away.”
“some info not
appropriate…”
“go over
the pain
plan.”
Less
anxiety
Clear care
plan
“Uneven #
staff between
shifts”
“How much
info…What
info?”
Patient
has
input
“really
long story
from pt.”
Takes too
long
“Already know
him…don’t
need to see
him.”
“I’m not
waking him
up!”
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
Baird 6 Nursing Bedside Report
Work Flow Process
Incoming nurse arrives
March 14, 2011
Ready to begin work at
0700, 1500, 1900 or 2300
Prepare for assignment—
gather information needed
Out going nurse
completes patient
assignment
Be ready to give
report
Prism
Begin bedside report at ten
minutes after the hour
(0710, 1510, 1910 or 2310)
Consider:
1. What can wait?
2. What needs to be done?
3. What can be finished after
report?
Let out going nurse know
if cared for patient before
In coming/out going nurse
enter patient’s room
Guidelines for
Nursing Bedside
Report
Special Notes:
Complete in room report at
patient’s bedside
What Patient Can Expect:
1. Orient to unit process of shift to shift report
2. Reinforce nurses will be performing a safety
check during shift change by coming into room,
checking on patient & asking some questions
3. Nurses will not wake patient if asleep
Admission During Shift Change: Help settle the
patient
Patient Care Issues that Need to be Addressed:
1. Go in the room
2. Go to nurse who is free
Staff Meeting Days: Continue bedside report
procedure
Leave patient’s room
Complete out of room
report directly outside
patient’s room
Out going nurse validates
nothing further needed
Out going nurse leaves
James M. Jeffords Institute for Quality/Lag
Update white
board with name
of in coming
nurse
Guidelines for
Nursing Bedside
Report
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
Survey Tool:
Nurse Feedback
Nurse Observation Tool
Date:
In room report given?
If yes:
Bed Number:
Yes
 No
Yes
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
No
Comments
Patient Interview Survey
Tool
Did the new nurse
introduce
her/himself during
change of shift
report?
Date
Bed
Number
YES
NO
Where you asked if you
had any special needs,
concerns or questions
during change of shift
report?
YES
NO
Comments
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
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
Findings: PDSA Cycle 2
Patient Interview
Nursing Bedside Report: Baird 6
Patient Interview Questions
New nurse introduced self during change of shift report
Nurse asked patient if any special needs/questions during change of shift report
100%
100% 100%
100% 100%
100%
100%
91%
80%
% Compliance
80%
60%
40%
20%
0%
April 2011
(n=23/n=20)
June 2011 (n=13)
July 2011 (n=17)
Sept 2011
(n=11)
Findings: PDSA Cycle 2
Process Compliance
Nurse Observation:
% Compliance Guidelines Nursing Bedside Report
October 13 - November 4, 2011
100%
% Compliance
80%
70%
67%
61%
60%
49%
40%
20%
0%
In Room Report Given
Introduce Oncom ing
RN to Patient
Checked lines/drains/
pum ps
Invited Patient to
Contribute/Ask
Questions
Findings: PDSA Cycle 2
Nurse Survey Giving Report
Nurse Survey: Overall Experience
Apr-11
Oct-11
% Positive Resoponse
100%
90%
80%
80%
78%
70%
60%
50%
Giving Report
Findings: PDSA Cycle 2
Nurse Survey Taking Report
Nurse Survey: Overall Experience
Apr-11
Oct-11
% Positive Response
100%
90%
80%
70%
70%
67%
60%
50%
Taking Report
Findings: PDSA Cycle 2
Nurse Feedback
“I like doing bedside
report more than
traditional reportinvolves patient
more in their care
and addresses their
concerns, if they
have any.”
“NOC-DAY
works well!”
“Patient s are
awake and can
participate.”
“Meeting patient
with new nurse,
review plan.”
“Making sure the
patient doesn’t have
“RNs not
anything they want
ready!”
to discuss before I
leave.”
“making me feel
safer leaving
knowing my
replacement has
seen the group.”
“RNs in the
fishbowl”
“Need to start
sooner.”
Patient Satisfaction Data
Press-
Ganey
Nurses Kept You Informed
Patient Satisfaction Data
HCAHPS
communication
Overall
What’s Next: PDSA Cycle
3
Reinforce individual components of bedside report:
 Patient education
-Orientation upon admission
-Set the stage 30-60 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
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
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.
Summary
Implementation of bedside report promotes
patient centered care by focusing on patient
safety and satisfaction. Further, bedside report
encourages successful transitions between
nurses.
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), 112-122.
Laws, D., & Amato, S. (2010). Incorporating
Bedside Reporting into Change-of-Shift
Report. Rehabilitation Nursing, 35(2), 70-74.