Improving Nursing Handoff During Change of Shift

1. 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

2. Purpose Improve change of shift nursing handoff and report on a 35 bed general surgery unit to promote patient safety and increase patient satisfaction

3. 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

4. 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

5. 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

6. 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

7. 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

8. Baseline Data: Nurse Survey “Catch errors!” Less anxiety Clear care plan Visualize patient Takes too long “Concerns about HIPPA” “met RN right away.” “Uneven # staff between shifts” “Already know him…don’t need to see him.” “some info not appropriate…” “How much info…What info?” “really long story from pt.” “go over the pain plan.” “I’m not waking him up!” Patient has input

9. 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

11. 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

12. Survey Tool: Nurse Feedback

13. Nurse Observation Tool Date: Bed Number: In room report given? Yes  No If yes:

14. Patient Interview Survey Tool

15. Findings: PDSA Cycle 1Two 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

16. 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

17. Findings:PDSA Cycle 2 Patient Interview

18. Findings:PDSA Cycle 2 Process Compliance

19. Findings:PDSA Cycle 2Nurse Survey Giving Report

20. Findings:PDSA Cycle 2Nurse Survey Taking Report

21. Findings:PDSA Cycle 2Nurse Feedback “making me feel safer leaving knowing my replacement has seen the group.” “I like doing bedside report more than traditional report-involves patient more in their care and addresses their concerns, if they have any.” “NOC-DAY works well!” “Patient s are awake and can participate.” “RNs in the fishbowl” “Meeting patient with new nurse, review plan.” “Need to start sooner.” “Making sure the patient doesn’t have anything they want to discuss before I leave.” “RNs not ready!”

22. Patient Satisfaction Data Press-GaneyNurses Kept You Informed

23. Patient Satisfaction Data HCAHPS Overall communication

24. 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

25. 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

26. 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.

27. Summary Implementation of bedside report promotes patient centered care by focusing on patient safety and satisfaction. Further, bedside report encourages successful transitions between nurses.

28. 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.