1. Mason, Diana J. PhD, RN, FAAN, AJN Editor-in-Chief

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At my first full-time nursing job 34 years ago, in an Army hospital on a medical and coronary ICU, the eight-hour shifts began and ended with a report that included RNs, LPNs, and medics. We discussed patients' changes during the previous shift, what they would need during the coming shift, and our own team issues that affected patient care. New nurses learned a great deal from these reports, and we all learned more about providing better care as we discussed what worked or didn't and shared information gleaned from medical rounds that day. This twice-a-shift conversation was an essential component of our work.


When I discovered, five years later, that nurses were moving to audiotaped reports, I was baffled and disturbed. If I tape-record my report for the next shift, what happens when a colleague has questions I didn't address? ("Look it up in the patient's chart," said one nurse. That reply assumes the information was charted and diminishes the time savings taped reports purportedly provide.) How does collaborative problem solving of difficult patient issues happen? (No time for that.) And what happens to the team building that's so essential to excellent care? (No time for that either, despite the evidence linking communication among clinicians and patient outcomes.)


In the 1990s many institutions hired consultants to find ways to reduce expenses, and many recommended cutting the overlap in shifts. The work of nurses and physicians was reduced to a series of tasks without any thought given to how such changes might introduce error. While the best institutions continued to measure success in terms of both cost and quality (and involved nurses in those determinations), many did not.


Tape-recorded shift reports are an example of how nurses have adapted to these institutional shifts in focus and values. Many grew weary of fighting. How many times will you slam yourself into a closed door before you conclude it will not open? But the door may be opening. The Institute of Medicine reported in Crossing the Quality Chasm: A New Health System for the 21st Century that patient "hand-offs" -whether from the ED to the unit, unit to ICU, hospital to home, or shift to shift-provide opportunity for error: "in a safe system, information is not lost, inaccessible, or forgotten in transitions," the report says. And with public concern growing about unsafe, inhumane health care, nurses have an even greater obligation to reassert what we know to be essential for safe care.

FIGURE. Reports are ... - Click to enlarge in new windowFIGURE. Reports are really chapters in the story of each patient.

Nurses know that developing good communication with colleagues takes time, and time is sacrosanct. But reducing shift reports to 15-minute, taped monologues fails to acknowledge their importance. These reports are really chapters in the story of each patient, and each shift adds to that story in ways that achieve the goals of care. We are, after all, a part of the patient's story, and we shouldn't diminish our own role in it. Some nurses have told me that they are doing walking rounds as a way to replace traditional shift reports. There is very little research on shift reporting, and such innovative models should be studied.


The elusive electronic health record will some day materialize in all U.S. institutions and could facilitate hand-offs by providing consistent, accessible information about patients and their care-but only if nurses insist that they be involved in designing the electronic system. For example, we could insist upon having the ability to print out reports that include the essential components of care, such as whether a do-not-resuscitate order is in place, whether dressings were changed on the previous shift, or whether a newly ordered medication was administered. We must be wary, however, that a printed report such as this doesn't replace the shift-to-shift report.


Nurses, other providers, and administrators often underestimate the validity of nurses' ideas, even though nurses have long had some of the solutions for delivering safe care such as face-to-face shift reports. It's time to reassert our role as guardians of the patient.