Until 2007, nurses at Riley Hospital for Children in Indianapolis relied on traditional shift change reporting methods to communicate patient care information from caregiver to caregiver. But when challenged by Riley’s leadership team to find ways to improve hospital documentation, the Clinical Practice Council began looking at a standardized approach to hospitalwide shift change reporting.
After a six-month pilot program, an educational video and PowerPoint® presentation, and another six-month training process, Riley implemented its hospitalwide nurse-to-nurse shift change report at the bedside with families.
Not only did leadership, the nursing staff, and physicians accept the process, but patients and families also became more involved and felt safer as a result.
Riley was recently recognized for its efforts by the National Patient Safety Foundation with the 2010 Socius Award, which symbolizes the relationship between healthcare providers and the patients and families they serve.
Developing a hospitalwide process
Melanie Cline, RN, MSN, clinical director at Riley, teamed up with a 30-person group of staff nurses, educators, the clinical nurse specialist, clinical managers, and the family-centered care coordinator to review current literature and best practices for shift report processes.
“Our highest priority was to include parents in the process as their involvement and input is critical to achieving the best outcomes for each child,” says Cline.
The old process consisted of the charge nurse gathering information from the nurses going off shift about 30 minutes before the change of shift. Another 30 minutes would pass while the charge nurse documented the information.
In addition to making sure the parents were included in the shift report, Cline also had to keep the staff’s best interests in mind. Nurses commonly complained that the handoff information they received could be 60?90 minutes old with the previous process. The staff nurses coming on shift would often find that their patient’s condition had changed by the time they got to the patient.
“When dealing with pediatrics, a child’s condition can change within a matter of minutes,” says Cline. “Getting to the patient sooner is better so potentially avoidable problems are picked up right away.”
Another factor that was vital to determining the components of the shift report was making sure the nurse going off shift and the nurse coming on shift could visualize the patient together, says Cline. This helped develop an understanding of how the patient was assessed on the previous shift.
Finally, Cline and her team developed five standards that are always included in the shift change report:
- Head-to-toe assessment
- Nurse-to-nurse involvement in viewing
- Medication check
- Orders verification
- Care plan
The five standards of a shift report
The head-to-toe assessment, the first of the five standards, involves the nurses coming on and off shift as well as the patient’s parents. This assessment enhances patient safety—in fact, it has helped identify a few near misses.
“In one case, nurses were discussing pain in a 3-year-old’s left knee, and the mother spoke up and corrected their information, saying it was actually the right knee that was bothering the patient,” says Cline.
The second shift report standard ensures that nurses examine their patient together and discuss how each patient was assessed and monitored. Cline offers the example of a patient’s breathing: Nurses can establish how the patient is breathing and how each patient’s “normal” breathing looks.
The third standard, medication check, is a safety measure that also saves time. During the old process, nurses coming on shift would often have to call the previous nurse at home to double-check medication information.
“By conducting the medication check in real time, it helps save time and eliminates oversights or omissions on the chart,” says Cline.
The orders verification, the fourth standard, involves reviewing all current physician orders and communicating the implementation status of all new orders.
Finally, nurses discuss the care plan with the patient and the family at the patient’s bedside. This is where the next 12 hours of care are planned.
Cline says the entire process takes 30 minutes to complete, and even though the new process takes the same amount of time as the old one, in the grand scheme of things, it saves the staff time.
For instance, nurses no longer need to call nurses off shift to clarify a medication question because the two nurses review this information together during the shift report. Also, with parents now involved in the process, nurses can get questions answered up front as opposed to trying to find the parents later on during the shift.
Education and training
Before these standards and the bedside shift report could be implemented hospitalwide, Cline and her team developed a PowerPoint presentation and video to help educate staff members on the new process. The video reviewed the process step by step—using staff nurses as actors—and reminded staff of the importance of consistency.
Patients and their families also were involved in making the video. At the end of the video, parents described in their own words how the old process was sometimes scary but the new one helped them feel safer.
“It was very powerful for the staff to hear a parent’s testimony about how the old shift report left them out of the process, which can be frightening,” says Cline.
After viewing the video and PowerPoint presentation, those team members responsible for developing the new process coached and observed nursing staff on three occasions prior to rolling out the new bedside shift reporting.
“The 30 staff members who were part of the developmental process came in days, nights, and weekends to coach and mentor their colleagues,” says Cline.
The process took another six months for all units at Riley to successfully implement, making the total time for implementation one year, Cline says.
Finally, in January 2008, all nurses at Riley were involved in the nurse-to-nurse shift change bedside reporting involving parents.
Buy-in from all levels
Some nurses were skeptical of the new process, thinking it would take more time than before because the addition of family involvement would slow them down, says Cline.
As time passed, however, the skeptics began to appreciate the new bedside reporting for the communication it improves and the questions it eliminates—both of which save time in the end.
“The process kind of sold itself to a lot of the staff because of the situations they avoided, like the near misses,” says Cline. The new process ensures that nurses coming on shift visualize patients before the nurse going off shift leaves the unit.
Words of advice
As family-centered care is the focus at Riley, Cline suggests getting the parents or family members involved early on and keeping them engaged throughout the process.
“Having the patient and their family involved is critical,” says Cline. “It helps with any clarification or mix-up in communication that might occur during handoffs and offers comfort to the patient and family during this critical time.”
This article was adapted from one that originally appeared in the August 2010 issue of Patient Safety Monitor (Briefings on Patient Safety), an HCPro publication.
Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.
