The facility is currently using recorded shift reports for nursing shift handoffs. Effective shift-to-shift communication must convey critical patient information to facilitate continuity. I observed that recorded shift reports were completed in nurse stations, not at the bedside, which gives room for communication lapses. Critical information may be lost when transcribing recorded/audio-taped reports. Furthermore, the practice limits patient/family involvement in their care. As a result, patient satisfaction decreases medical error risk increases, and nursing collaboration and accountability declines.
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The Rationale for Change, Quality Improvement, or Innovation
A practice change from recorded shift reports to bedside shift reports is required to improve the quality of patient care. Adopting bedside shift-to-shift reports at the facility will enhance inter-professional communication regarding the patient’s status and treatment plan. Bedside shift reports will also give patients/families an opportunity to be involved in their care. As a result, the inpatient experience will improve, leading to higher patient satisfaction. Further, the improved exchange of critical information between the outgoing nurse and incoming nurse is likely to occur when shift change occurs at the bedside. Moreover, the incoming nurse can observe the patient, room conditions, wounds, and IV site/drips and receive critical patient information before the handover (Melnyk & Fineout-Overholt, 2015). This will improve the continuum of care, minimize the potential for sentinel events, and enhance patient safety.
Causes of the Problem
From my observation, bedside reports are not conducted at the facility because there is no impetus for a practice change. The busy environment and the possibility of completing more than two shift reports create a feeling that bedside reporting is time-consuming. The nurses opt to complete the shift reports at their nurse stations after the shift. Disruptions at the nurse stations could affect the quality of the shift reports.
It was also observed that the nurses were unclear on what to put in the shift reports, which results in incomplete or unnecessary transition information. Unclear or inconsistent information in the shift-to-shift reports increases the risk of medical errors. Therefore, staff training is required to educate the nurses on the important components of the shift reports. The transition to bedside reporting will enhance the accuracy and integrity of the information.
Nurse communication at the facility was observed to below. This scenario favors recorded shift reporting at the nursing station at the expense of face-to-face contact or patient visualization. The staff needs to keep the patient informed about his/her health status and respond to patient concerns to improve the inpatient experience. Bedside reporting keeps the patient engaged, which translates into higher patient-satisfaction levels.
Identification of Stakeholders
Stakeholders comprise of people with a stake in an intervention or a practice decision. The key stakeholders of the bedside shift reports project include:
- Chief nursing officer (CNO)
- Unit manager
- Staff nurse
- Quality improvement staff
Stakeholders’ interest, power, and influence
- Chief nursing officer – The CNO, as the coordinator of the nursing department, has power and influence over the nursing staff (Marquis & Huston, 2015). He/she will mobilize support and buy-in at the administrative level for a successful practice change. The CNO has high levels of interest in a project that improves patient safety and satisfaction, nursing outcomes, and overall hospital rating.
- Unit manager – Has high formal power to mobilize resources for the practice change in the Unit. He/she also has a high influence on Unit nurses as a nurse champion. His/her interest in the project relates to his/her clinical and administrative roles.
- Staff nurse – Has high levels of interest, as bedside reports contain complete information and are fast to complete. He/she has high levels of informal power as a change agent. He/she also has a high influence related to the implementer role, clinical accountability, and direct patient contact.
- Physicians – A physician champion has significant levels of power and influence to promote physician buy-in and support for the project. His/her interest in the project is also high due to its implications for quality and clinical outcomes.
- Educator – Has high levels of interest related to knowledge/evidence utilization and links with the hospital. However, the educator has low power/influence as an external stakeholder in this project.
- Quality improvement staff – Has a high interest in a quality improvement project. Bedside reports will promote safe/quality care, nurse communication, and patient satisfaction. The team’s significant power and influence over the project are tied to its quality improvement mandate.
- Patient – Has high levels of interest in the project, as bedside reports will make him/her more engaged, informed, and less anxious. He/she has low power and influence related to the lack of awareness and limited capacity to mobilize strategic resources.
- Spouse/family – He/she would want to be involved in care planning. Therefore, family interest in bedside reporting is high. However, family/spousal power or influence in this project is low because they do not control strategic resources.
Purpose of Project
Incomplete or inconsistent information in recorded reports can disrupt the continuum of care and compromise patient safety. The purpose of this project is to improve the shift-to-shift reporting process at the facility through bedside reports. Specifically, the change project aims to establish a standardized approach to shift-to-shift information exchange, enhance patient involvement in care planning/decisions, and support the continuum of care. The expected outcomes of the project include better nurse communication, strengthened inter-professional communication, higher patient safety, and improved patient and nurse satisfaction outcomes.
The proposed solution will involve an evidence-based practice change from recorded shift reports to bedside reporting within a three-month period. The goal is to replace the current recorded/audio shift reports with bedside shift reports. For the change to be successful, the involvement of the nursing leadership is required. I will persuade the CNO to institute a bedside shift-to-shift reporting policy in the facility to enforce compliance. Furthermore, the CNO will train champions drawn from the RNs to spearhead the change process. The nurse champions will educate the nursing staff on the components of the bedside reporting process.
Besides, an electronic SBAR tool will be made available for use in bedside handoffs. The nurses will also undergo mandatory training that will involve handover role-plays and case studies. A post-implementation assessment will be done to evaluate their understanding of the process. To prevent disruptions, nurse aides will communicate the bedside reporting time to the patients. Newly admitted patients will receive brochures informing them of the reporting process at the facility and their role in it. The project will be implemented in all units, including MED-Surg and Orthopedic.
Moving to bedside shift reporting has been shown to improve multiple quality nursing indicators. An effective shift handover ensures that the incoming nurse receives complete information for safe and appropriate patient care (Jeffs et al., 2013). Most costly sentinel events are attributed to miscommunication during shift handover. Critical components of the report may be omitted during the transcription of audiotapes or recorded reports (Bradley & Mott, 2014). This has implications for patient safety outcomes. Bedside handover creates a culture of safety, which reduces the potential for errors and promotes the quality of care delivered (Bradley & Mott, 2014). It also removes communication barriers, lapses, and omissions that increase the risk of adverse events.
Another positive outcome of bedside reports is improved nurse communication and collaboration. Gregory, Tan, Tilrico, Edwardson, and Gamm (2014) found that bedside shift reports create an atmosphere of open communication between the nurse and the patient/family. Nurse communication is a crucial indicator of patient satisfaction in the HCAHPS survey. Evidence shows that a shift handover conducted at the bedside engages and enlightens the patient, which reassures the patient, reduces anxiety, and increases satisfaction (Jeffs et al., 2013; Gregory et al., 2014). It also gives patients an opportunity to participate in their own care.
Standardization of bedside reports has been suggested as a means of achieving positive results. Wakefield, Ragan, Brandt, and Tregnago (2012) found a connection between non-standard bedside reports and low patient and nursing satisfaction. Therefore, standardized bedside reports create a positive work environment that enhances job satisfaction. Evans, Grunawait, McClish, Wood, and Friese (2012) identify nurse-patient/family collaboration as an outcome of bedside handover. Further, collaborative care planning ensures patient-centered care, a key indicator of quality care. The evidence reviewed indicates that implementing a change project (a standardized bedside reporting) will enhance patient safety outcomes and improve the inpatient experience and nursing outcomes at the facility.
Plan of Action
The project will be implemented in the orthopedic and MED-Surg units of the facility. At any given shift, the units have a combined nursing staff of 12 RNs and 10 CNAs. The proposed nursing practice change in this hospital will follow Lewin’s change framework. My initial action involved advocating for a bedside reporting policy through meetings with the leadership. The specifics of policy were discussed in a series of meetings with the CNO and the Unit Managers, which also helped gain leadership buy-in and approval. I also conducted a pre-implementation survey, which showed that nurses perceive bedside reports as time-consuming and demanding. This marked the unfreeze stage of the framework.
Going forward, my next step (moving stage) will involve training nurse champions (RNs) to lead deliberations with the nurses on the benefits of bedside shift reports with respect to patient safety outcomes and satisfaction. Subsequently, a patient survey will be held two months after adopting the bedside reports to reveal patient/family views about their involvement in care and nurse communication. The nursing staff will undertake a three-week training to equip them with relevant skills on bedside shift reporting process and use of an electronic SBAR tool. The implementation surveys based on stakeholder feedback will precede the refreeze stage where the nurse champions will lead the transition at the unit level.
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The change project will be implemented from January through March 2017 (12 weeks). Week 1-2 of the project will involve establishing unit-level bedside reporting committees led by the nurse champions (RNs). Week 3-4 will involve collecting baseline data, developing the SBAR tool, and conducting the initial nursing survey. Week 5-7 will involve initial patient/family survey and development of bedside reporting training programs, brochures, and posters for nurses and admitted patients. Week 8-11 will involve conducting nursing staff training on bedside reporting workflow and holding discussion forums. Week 12 will involve post-implementation surveys to evaluate the project’s success. The timeline is summarized in the Gantt chart below.
|Time||Week 1-2||Week 3-4||Week 5-7||Week 8-11||Week 12|
|Establishing unit-level bedside reporting committees||X|
|Baseline data collection, SBAR tool development, and initial nursing survey||X|
|Patient/family survey, training program, and educational brochures/posters||X|
|Nurse training sessions and discussion forums||X|
|Post-implementation surveys and project evaluation (HCAHPS scores and compliance rate)||X|
Required Resources and Personnel
The implementation of the project will require financial support, time, equipment, human resources, and other resources. The printing of materials for nursing staff and patients is estimated to cost $200. Additional financial support ($1500) will be required to cater for nurse training costs, i.e., payment of the RNs training the nurses ($40/hr). The three-week training will be held in four one-hour sessions weekly. The equipment required includes chairs, whiteboards, and projectors for the training. A classroom will also be required for the training. Further, the unit managers will do some personnel adjustments and reallocation of staffing to allow nurses to attend the training at the bedside without causing disruptions.
Proposed Change Theory
A successful practice change requires a change management strategy to manage attitudes and perceptions that would cause resistance (Sullivan, 2013). Lewin’s change model is relevant to the proposed practice change project. The model comprises three stages of change management, namely, “unfreeze, moving, and refreeze” (Sullivan, 2013, p. 45). The initial phase (unfreeze) involves creating stakeholder recognition for the need for change through awareness activities. My first action in this step will include holding discussions with the stakeholder groups to draw comparisons between recorded shift reports versus bedside shift reporting to create an impetus for change. I will use case studies to illustrate the downsides of the current practice and vouch for bedside reporting. I will also involve nurses as change agents in developing a standardized bedside reporting protocol.
The second phase, i.e., the moving phase, will involve nurse champions (RNs) providing technical support to nurses at the unit level. Nurses unclear on bedside reporting workflows will receive assistance from the champions. The unit champions will also evaluate the progress and communicate the implementation challenges faced. In the third phase, i.e., refreeze, the unit managers and the CNO will lead the transition to bedside shift reports. They will also address the challenges and provide leadership support to achieve cultural change and full compliance (Sullivan, 2013).
Barriers to Implementation
One of the anticipated barriers to successful implementation is low compliance by nurses. Within the first few months, nurses may find bedside shift reports time consuming and tedious. I will involve the unit managers and the nurse champions to monitor the process and enforce compliance. Another potential barrier relates to staff skills/capacity to use bedside shift reports. Staff training sessions will be conducted to equip nurses with the expertise to use the SBAR tool in bedside shift reporting. The dilemma related to handling patient confidentiality in the presence of the family may also hamper the use of bedside reports. Nurse training through case studies and scenarios will help nurses deal with such dilemmas. Financial and organizational constraints may also affect the implementation process.
Learning Objectives and Outcomes
The bedside shift reports project achieves the communications and building relations objective of the course. Its ultimate aim is to strengthen inter-professional and nurse-patient communication and teamwork at the facility. The Clinical Nurse Leader roles in implementing evidence-based patient safety and CQI initiatives relate to the curriculum’s objectives of leadership and collaboration. The anticipated project outcomes include improved teamwork, collaboration, communication, and patient safety.
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