Have you ever finished a change-of-shift report and still only knew the patient's name? Entered a room to find the I.V. bag empty and the indwelling urinary catheter drainage bag full? Started your day with trips to the radiology department that you didn't know were scheduled, or why? Let's face it: we've all received or given a less than ideal change of shift report at some point in our nursing careers. Common reasons for ineffective handoff communication include length of report (too long or short), lack of policy and direction in reporting, little to no nurse education in regards to effective handoff (both in school and nurse orientation), variability in individual nurse's abilities to accurately give handoff, and most importantly, lack of a standardized format (or tool) in place that would promote consistency throughout the unit.1 Change-of-shift reporting and patient information handoff is a vital part of patient care, particularly in CCUs where nurses are frequently responsible for one to two critically ill patients at any given time. And depending on the patient's clinical status, the nurse's knowledge of these patients must be detailed. Postreport, nurses must immediately begin assessing and using their critical thinking skills to care for their patients. Being well prepared at providing effective communication handoff at change of shift is critical.
Joint Commission and change of shift
In 2006, The Joint Commission required that all information handoffs at change of shift be part of a standardized process across the healthcare community.2 Seven years later, this mandate doesn't appear to be fully implemented nationwide. Although relatively little research has been conducted on change-of-shift reporting, the one recommended protocol seen throughout this research is implementation of a standardized, change-of-shift reporting process.
The importance of a change-of-shift report can't be underestimated. Not only does the report provide nurses with an effective and meaningful way to transfer responsibility and accountability of patient care, it helps build team cohesion, enhances shared values, and supports ritualistic functions.3 A change-of-shift report is an integral part of every nurse's daily routine. To provide proper transfer of responsibility and meaningful patient care, the report must be accurate, clear, concise, complete, and timely and cost-effective for both offgoing and oncoming nurses.
Despite its importance, the change-of-shift report is often an overlooked piece of the healthcare administration puzzle. The use of a change-of-shift report isn't specifically taught in nursing schools, isn't part of nursing orientation at many institutions, and is rarely part of nursing policy. Moreover, The Joint Commission notes that 65% of all sentinel events and 90% of root cause analyses include ineffective or insufficient communication as a contributing factor.2
How one facility made it work
Keeping the SBAR (situation, background, assessment, recommendations) reporting model in mind, the med/surg ICU nurses at Forbes Regional Hospital in Monroeville, Pa., a 350-bed facility providing tertiary care in a community setting, set out to develop an ICU-specific, standardized, change-of-shift tool that would be beneficial to the nursing staff and ultimately their patients. The goal of this program was to not only regulate the report process but also develop a standardized change-of-shift reporting tool that would help build on all six of the Quality and Safety Education for Nurses (QSEN) competencies identified by the Institute of Medicine. (See About QSEN.) Funded by the Robert Wood Johnson Foundation, QSEN helps future nurses attain the knowledge, skills, and attitudes necessary to continuously improve the quality and safety of the healthcare systems in which they work.4
Other attempts were made in the past to incorporate an SBAR handoff sheet at each change of shift, but were rejected by the nursing staff at Forbes. In our high-acuity and constantly changing ICU, filling out a new report sheet at each shift was too cumbersome for the nursing staff. Even as the nursing staff required a higher level of consistency and routine to work more efficiently, they simply didn't have the time to trial a new protocol. With these challenges in mind, the nurses at Forbes developed a change-of-shift reporting tool that begins at admission. If the foundation of information is complete and thorough at the time of admission, then shift updates are just that, shift updates.
As a result, clinical nursing staff at our facility developed a hybrid, double-sided, 8.5 in x 11-in (21.6 cm x 27.9 cm), index card for all vital information on patients admitted into the ICU. Information gathered upon admission is noted on the front of the card, with shift updates noted on the back. The card is durable, tangible, colored (bright green), and contains a brief synopsis of the patient's clinical status and medical history, admission status, initial assessments, and emergency contact information. In addition, the card provides space on the back for multiple shift updates including test results, changes in pain intensity ratings, and SBAR reporting. The only information the offgoing nurse is responsible for remembering is what happened in the previous 12-hour shift. This card is used solely as a nursing communication tool, therefore it doesn't need to be part of the patient's medical record. However, the cards are filed on the unit so that in the event of a readmission, the nursing staff has all prior information readily available. Upon long-term implementation of this standardized tool, in addition to making it a priority to teach and practice consistency in communication handoffs, we hope to reduce gaps in change-of-shift reporting and increase quality of patient care. We also hope to reduce overtime expenses by shortening the report window and increasing clarity of information collected and communicated.
Breaking down barriers
One obstacle to successful implementation of a new reporting protocol is anxiety, which can lead to errors. Lack of education, preparation, and confidence can all play a role in the anxiety a nurse can experience over implementation of a new change-of-shift reporting process. As a result, we decided to conduct an initial 14-day implementation trial to assess confidence, preparedness, value of current tool, anxiety levels, and ease of medical record searching. All categories were quantified via a tabulated 200-point scale (assuming all 20 nurses surveyed were to give a 10 for each question). Staff nurses were given a 5-question, preimplementation questionnaire in which they were asked to rate their attitudes on the categories listed above on a Likert scale of 0-10. Some questions included how confident nurses felt when giving a change-of-shift report to an oncoming nurse, level of anxiety before reporting, and how useful nurses thought the current patient information tool was for change-of-shift reporting. Education on change-of-shift reports was provided to all nursing staff via a 15-minute presentation that explained the current evidence-based practices in use on change-of-shift report and the rationale associated with their use. The tool was then implemented for the 14-day trial period. Posttrial, the staff was given the same questionnaire in order to determine attitude changes.
The results of the trial were positive overall for the ICU nurses at our facility. The change-of-shift report tool comparison study concluded that confidence in giving report and preparedness postreport increased, while nurse anxiety level and medical record searching decreased. Further studies will allow us to determine if this tool and education on change-of-shift reports will increase patient safety. This particular report tool continues to be part of the standard patient admission packet in the ICU at our facility. Although this tool was specifically designed for the high-acuity patient, modifications can be made to implement this tool in other nursing units.
The Forbes Regional Hospital, like many other facilities in the United States, relies heavily on paper documentation; however, when electronic medical records become the standard, we will make every effort to fully integrate this change-of-shift report format into electronic form. In addition, Forbes Regional Hospital intends to make this change-of-shift report tool a larger part of nursing orientation with the hope that over time, it will further promote and facilitate patient safety.
Give change a chance
Change-of-shift report tools continue to be an integral yet understudied aspect of direct patient care. Through the research and tool development conducted at our facility, nurses have successfully begun to move forward in an effort to educate staff and standardize the handoff process. In our constantly changing nursing profession, improvements in handoff communications can only help to decrease communication barriers, increase report efficiency, and ultimately increase patient safety.
About QSEN
QSEN, funded by the Robert Wood Johnson Foundation, aims to prepare future nurses with the knowledge, skills, and attitudes needed to continuously improve healthcare system quality and safety.
The first phase of the project identified six competencies: patient-centered care, evidence-based practice, quality improvement, teamwork, safety, and informatics. In the second phase, pilot schools integrated these competencies in their nursing programs and shared their teaching strategies and resources on the QSEN website (http://www.qsen.org).
The third phase, which started in November 2008, aims to continue promoting innovation in teaching the six competencies, developing faculty expertise, and creating ways to improve all nursing programs through the content in textbooks, accreditation and certification standards, licensure exams, and continued competence requirements.
Source: Quality and Safety Education for Nurses, http://www.qsen.org/overview.php.
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