OBJECTIVE: The purpose of this project was to increase nurse compliance with bedside report and increase patient satisfaction scores. BACKGROUND: Bedside report is an evidence- based practice used to increase patient involvement in their care and improve patient satisfaction. A change management strategy and standardized approach to bedside report can help increase nurse compliance with the process. METHODS: This study used a quasi-experimental, between-group, preimplementation and postimplemen- tation comparison of patient satisfaction scores from returned surveys on 2 units in a 149-bed community hospital. We also compared nurse compliance with bed- side report preimplementation and postimplementation. RESULTS: Five months after using a change man- agement strategy to Bhardwire[ (ingrain systems and tools) bedside report, nurse compliance with bedside report and patient satisfaction scores improved in both intervention units. CONCLUSIONS: A change management strategy and standardized approach to bedside report helped increase nurse compliance with the process, leading to improved patient satisfaction Hardwiring Bedside Shift Report.
The Joint Commission1 recommends patients to be actively involved in their care and the use of a stan-
dardized handoff communication process during change of care providers. Bedside report addresses both of these requirements. The primary function of bedside report is communication of patients_ clinical infor- mation and their plan of care from nurse-to-nurse at the change of shift.2 Failure to communicate perti- nent clinical information adequately and consistently during shift report puts patients at risk of harm.3,4
Patient involvement at the bedside is crucial. With- out their involvement, patients have lack of infor- mation about their care. Shift report away from the bedside does not allow patient involvement or active participation.5 A standardized approach to bedside report and manager support of nurses can enhance shift handoff and improve patient safety, outcomes, patient and nurse satisfaction, time management, and accountability.6,7Hardwiring Bedside Shift Report
The facility in this project implemented bedside report in 2009 using video education for the imple- mentation strategy. Subsequently, issues of inconsis- tency in both frequency and quality of bedside report seemed to be related to a lack of nursing leadership support, not holding staff accountable, and failing to address staff barriers, as well as a less than effective implementation plan. The purpose of this project was to increase nurse compliance with bedside report on inpatient units and patient satisfaction. It was surmised patient satisfaction would improve because nurses consistently performed shift report at the bed- side. The objectives were to improve compliance with bedside report (process) and ultimately improve patient experience, resulting in improved patient satisfaction scores (outcome).
Hardwiring Bedside Report
Studer8(p2) defines hardwiring as a process to Bingrain systems and tools.[ Management reinforcement with staff regarding the benefits of bedside report has been reported to help gain nurse buy-in with the process.7,9-12Hardwiring Bedside Shift Report
Addressing staff perceived barriers such as receiving
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Author Affiliations: Director of Professional Practice/Magnet Program Director (Dr Scheidenhelm), OSF St Joseph Medical Center, Bloomington, Illinois; and Assistant Professor (Dr Reitz), Mennonite College of Nursing at Illinois State University, Normal.
Drs Scheidenhelm and Reitz are employees of OSF St Joseph Medical Center where this study was conducted. The facility has contractual relationships with Studer Group and Press Ganey. There are no other disclosures.
Correspondence: Dr Scheidenhelm, DNP, RN, NEA-BC, OSF St Joseph Medical Center, 2200 E Washington St, Bloomington, IL 61701 (Sandra.L.Scheidenhelm@osfhealthcare.org).
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal_s Web site (www.jonajournal.com).Hardwiring Bedside Shift Report
DOI: 10.1097/NNA.0000000000000457
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
report from too many nurses, interruptions to meet patient needs, confidentiality, and waking patients are issues to address before the implementation of bedside report.7,10,11,13 Using a standardized tool for bedside report is helpful. Researchers report the use of situation, background, assessment, and recom- mendation (SBAR) as helpful to guide nurses during bedside report.10,11,14-17 Monitoring compliance with bedside report and mentoring staff for at least 2 weeks have been reported as effective practices in supporting successful hardwiring of the process of bedside report.6,9-11,17
Patient Safety and Satisfaction
Patients who experienced bedside report stated feeling safer.5 Safety scans are opportunities to review the environment for safety concerns or prevention mea- sures and are performed by the care provider. Safety scans during bedside report in the literature include medication review, call light in reach, and reviewing suction, oxygen, and other equipment regarding proper settings and performance. Researchers have reported incidents such as medication errors, falls, and skin tears, decreased after bedside report implementa- tion.18,19 Patients report better understanding of their care plans and discharge planning with bedside report, thus improving safety. Wilson2 found patients who experienced bedside report felt more involved in their care, leading to decreased complaints. Patients reported staff focused on them and their needs, worked as a team, and involved them in decisions. Patients felt viewed as partners and active participants with the healthcare team.20 Families also report feeling bed- side report is an essential aspect of care.2,12 Patients and families have an opportunity to clarify and cor- rect inaccuracies during bedside report. Bedside re- port encourages and supports patients and families to participate in their desired level of care decision making.4,7,20,21 Communication with nurses has been reported to improve with bedside report.9-11,21,22Hardwiring Bedside Shift Report
Overall, patients felt more informed about their care and who was caring for them.5,14 After participating in bedside report, patients felt nurses listened, explained things in an understandable way, and treated them with courtesy.11,14
Opposition to Bedside Report
Several researchers noted concerns with the imple- mentation of bedside report.2,7,12,18,20 The main concern identified is a breach of patient privacy and the violation of the Health Insurance Portability and Accountability Act.7,18 Other concerns include the belief that the process will increase shift report time, medical jargon could confuse patients or increase their anxiety, and the patient or family will monopolize the
conversation during report.18,22 Providing educational materials for patients and using a script to inform patients of the process, what to expect, and how they will be involved, including Health Insurance Porta- bility and Accountability Act issues, have been sug- gested to address these concerns.7
Organizational Assessment
We conducted a strengths, weaknesses, opportuni- ties, and threats analysis to assess the organization_s current state with bedside report. Strengths include congruence of the model with the mission of the hospital Bto serve persons with the greatest care and love.[23 The facility supports a culture of transpar- ency, a nonpunitive approach to errors, and reporting of all safety concerns to a safety hotline. The hospital promotes teamwork through an interprofessional shared governance structure and works collabora- tively to enhance patient satisfaction. One organizational weakness was the failure to use a change management strategy during the initial implementation of bedside report; therefore, using Lewin_s change theory15 was identified as an opportunity to hardwire the bedside report process. Another opportunity with bedside re- port is the hospital_s goals to achieve the upper quartile in patient satisfaction as measured by Press Ganey (PG). A threat to the organization is external pressure from the government and payers. Patient satisfac- tion, as measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), is part of Centers for Medicare and Medicaid Services_ reimbursement determination.24Hardwiring Bedside Shift Report
Framework
Peplau_s theory of interpersonal relations10 and Lewin_s theory of planned change15 provide the framework to reintroduce bedside shift report for this study. In Peplau_s theory, nurses aim to establish a therapeu- tic and trusting relationship during interactions with patients.10 During bedside report, nurses introduce the oncoming shift nurse, identify patient needs, re- view progress, and collaborate on the plan of care with the patient. This collaboration leads to an im- proved trusting relationship. Lewin_s framework has 3 phases: unfreezing, moving, and refreezing.15 Sev- eral researchers found the theory useful in hardwiring the bedside report process.15,17,25 During the unfreez- ing phase, the investigators presented the evidence behind bedside report, addressed staff barriers, and educated nurses on the impact of bedside report on patient satisfaction and financial reimbursement to the hospital. We worked with a team to conduct nurse simulations of the process and sought staff feedback in the unfreezing phase. In the moving phase, bedside
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report began with assistance from the implementation team. They monitored nurses conducting bedside report and then mentored and supported nurses dur- ing implementation. In the final refreezing phase, bed- side report is hardwired every shift, although not 100%. Studor reports, BOnce systems and processes are in place (hardwired) to sustain service and operational excel- lence, an organization is no longer dependent on a particular leader to ensure continued success.[8(p18)Hardwiring Bedside Shift Report
Methods
Design, Sample, and Setting
We conducted a quasi-experimental, between-group, preimplementation and postimplementation com- parison of patient satisfaction scores from returned surveys on 2 units in a 149-bed community hospital. The units included a 46-bed medical/surgical (M/S) unit and a 12-bed obstetrics (OB) unit. We chose these units because the M/S unit is representative of the larger population in relation to sex and age. For comparison, we selected the OB unit because it has high patient satisfaction scores and a higher current nurse compliance with the bedside report process. We also compared nurse compliance with bedside report from random observation preimplementation and postimplementation.
Procedure
We trained a team to conduct simulations of bedside report and assigned an electronic learning module on the facility_s educational system to nurses on both units. The module included evidence supporting bed- side report, addressed staff barriers to bedside report, and described the standardized approach to the process. With permission, we included tools from the Studer Group ToolkitTM26 in a packet given to each nurse. The toolkit included a detailed process on how to con- duct bedside report, the SBAR format for the report, a patient letter describing the process for them, and a bedside handoff competency checklist. Next, the team used simulation of bedside report and a com- petency tool (see Document, Supplemental Digital Content 1, http://links.lww.com/JONA/A517) to check nurses_ adherence to the standardized process. The team monitored bedside report using the competency checklist for 2 weeks and then at 1 and 3 months postimplementation. We will monitor again at 6 months. We obtained patient satisfaction scores and patient demographics from the password-protected PG Web site for patients who returned surveys for the 4 months pre- implementation and postimplementation.Hardwiring Bedside Shift Report
Instruments
Press Ganey measures patient satisfaction through a survey integrating HCAHPS statements with satis-
faction questions.27 The tools are used by many organizations (n = 935 PG, n = 1066 HCAHPS) to measure patient satisfaction and are supported as being valid and reliable.27 To determine bedside report compliance, the denominator was the number of nurses observed, and the numerator was the number of nurses who completed bedside report during ran- dom observations. Trained observers on each unit conducted observations during shift change on their scheduled shifts. If a nurse conducted bedside report, the observers documented Byes[ on the log, and they documented Bno[ if the nurse did not conduct bedside report (see Document, Supplemental Digital Content 2, http://links.lww.com/JONA/A518).Hardwiring Bedside Shift Report
Human Subjects_ Protection
Before the study, we obtained institutional review board approval through the University of Illinois College of Medicine at Peoria and Illinois State University. We sent a consent cover letter explaining the purpose, procedure, risks, benefits, and alterna- tives to all nurses on the intervention units. We in- formed nurses that their participation in the random observations was voluntary and provided them with opt-out instructions. All data from PG were de-identified before obtaining them. For the preintervention and postintervention time frames, we obtained mean scores or percent Balways[ responses for each survey state- ment and the number of survey respondents with their sex and age. Data from the random observations included numerator (nurses completing bedside re- port), denominator (nurses observed), and date. Trained observers conducted all observations for 4 weeks before implementation and at 1 month post- implementation. We secured data on a password- protected program on a password-protected computer in a locked office.
Data Management and Analysis
We compared each intervention unit_s preimplemen- tation and postimplementation mean score for the 3 statements Bnurses kept you informed,[ Bstaff in- cluded you in decisions regarding treatment,[ and Bnurses explained in a way you understand.[ We also compared the preimplementation and postimple- mentation percentile rank in the Blarge PG database[ (n = 723 hospitals) from facility reports. On the HCAHPS survey, we compared the total percentage of Balways[ responses and percentile rank in the LPG database (n = 1090 hospitals) before and after bed- side report implementation for the Bcommunication with nurses[ domain and for the statement Bnurses explained in a way you understand[ from facility reports. For descriptive data analysis of the sample of patients who returned surveys, we used Statistical Hardwiring Bedside Shift Report
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Package for the Social Sciences version 22 (Armonk, New York). Patient demographics included sex and age, including means, standard deviations, and range. We conducted a statistical analysis separately or each unit_s (M/S and OB) individual patient satis- faction questions and nurse observations of the bedside report process. Statistical analysis included independent-samples t tests to compare preimple- mentation and postimplementation samples and mean scores for each unit_s patient satisfaction survey ques- tions (P 9 .05). We compared the percent compliance with bedside report for each unit (number of Byes[ completed report/number of nurses observed) pre- implementation to 1 and 3 months postimplementation.
Results
Participants
For the 4 months before implementation, 197 pa- tients returned surveys for the M/S unit, and 93 were returned for the OB unit. For the 4 months post- implementation, 190 patients returned surveys for M/S, and 99 patients returned surveys for OB. There were no significant differences in the 2 samples for either unit (Table 1). Random observations (Table 2) included 132 nurses preimplementation (n = 73 M/S, n = 59 OB), 202 nurses postimplementation at 1 month (n = 147 M/S, n = 55 OB), and 147 nurses at 3 months (n = 94 M/S, n = 53 OB).
Bedside Report Compliance Results
Comparison of nurse compliance with bedside report, as observed through random observations, improved at 1 month on both units (Table 2). Preimplementa- tion observations indicated the nurses complied with bedside report, 12% (M/S) and 55% (OB). Post-
implementation, nurses complied with the process for 85% (M/S) and 84% (OB) at 1 month and 84% (M/S) and 90.6% (OB). These results confirm our hypothesis: the intervention increases nurse compli- ance with bedside report.Hardwiring Bedside Shift Report
Patient Satisfaction Survey Results
We used independent-samples t tests to compare the mean scores separately for both units for the state- ments Bnurses kept you informed,[ Bstaff included you in decisions regarding treatment,[ and Bnurses explained in a way you understand.[ From facility PG reports, we compared preimplementation and postimplementation percentile ranks for these state- ments, for the Bcommunication with nurses[ do- main, and for the statement Bnurses explained in a way you understand.[ We compared the percentage of Balways[ responses on PG and HCAHPS survey domain Bcommunication with nurses[ and the state- ment Bnurses explained in a way you understand[ for both intervention units based on facility reports.
M/S Unit For the statement Bnurses kept you informed,[ the mean score of the preimplementation respondents was lower (mean [SD], 89.95 [15.99]) than the mean (SD) of the postimplementation (92.74 [12.84]) but was not statistically significant (t = j1.89, P = .059). The percentile rank greatly improved from 22 to 86. Although the mean (SD) improved from the pre- implementation group (89.11 [16.12]) to the post- implementation group (91.16 [12.88]), the 2nd statement, Bstaff included you in decisions regarding treatment,[ also had no significant differences be- tween the means (t = j1.359, P = .175) of the 2 groups. The percentile rank improved significantly from 33 to 96. For the Bcommunication with nurses[ domain,
Table 1. Demographic Characteristics of Patient Satisfaction Survey Respondents to Preimplementation and Postimplementation of Bedside Report
Survey Respondents Preimplementation, n (%) Postimplementation, n (%)
OB sex Women 93 (100) 99 (100)
OB age, y Range 21-50 20-41 Mean (SD) 30.19 (4.56) 29.56 (3.83)
M/S sex 197 190 Women 100 (51) 94 (49) Men 97 (49) 96 (51)
M/S age, y Range 20-95 24-97 Mean (SD) 68.57 (15.67) 67.61 (16.36)
Preimplementation, 4 months before October 1, 2015 to January 31, 2016; postimplementation, 4 months after March 15 to July 13, 2016. Abbreviations: OB, 12-bed obstetrics unit; M/S, 46-bed medical/surgical unit.
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the percentage of Balways[ responses increased from 79.6 to 86.8, and percentile rank increased from 52 to 99. For the statement Bnurses explained in a way you understand,[ the mean (SD) score improved from 92.22 (14.79) to 94.3 (11.54) but was not sig- nificant (t = j1.158, P = .248). The percentage of Balways[ responses increased from 75.2 to 81.0, and percentile rank increased from 43 to 94 from preimplementation to postimplementation (Table 3).Hardwiring Bedside Shift Report
Obstetrics For the statement Bnurses kept you informed,[ the mean (SD) score of the preimplementation respon- dents was slightly higher (96.56 [10.48]) than the mean of the postimplementation respondents (96.36 [10.44]) but was not statistically significant (t = 0.129, P = .897). Although the mean (SD) improved from the preimplementation group (94.26 [13.95]) to the postimplementation group (95.51 [9.32]), the
Table 2. Nurse Compliance With Bedside Report
Preimplementation 1-mo Postimplementation 3-mo Postimplementation
n % n % n %
OB 33/59 55.9 46/55 83.6 48/53 90.6 M/S 9/73 12.3 125/147 85.0 79/94 84.0
Preimplementation, January 6 to February 12, 2016; postimplementation, March 15 to April 19, 2016 (1 month), and May 15 to June 11, 2016 (3 months). Abbreviations: OB, 12-bed obstetrics unit; M/S, 46-bed medical/surgical unit.
Table 3. Patient Satisfaction Survey Responses
Survey Respondents Preimplementation,
Score/Rank/% Postimplementation,
Score/Rank/% t Pa
Patient satisfaction statements OB BNurses kept you informed[
Mean (SD) score 96.56 (10.48) 96.36 (10.44) 0.129 .897 Percentile rankb 99 99
BStaff included you in decisions regarding treatment[ Mean (SD) score 94.26 (13.95) 95.51 (9.32) j0.736 .463 Percentile rankb 99 99
BCommunication with nurses[ Percentage of Balways[ responsesb 90.60 94.60 Percentile rankb 99 99
BNurses explained in a way you understand[ Mean (SD) score 97.80 (7.12) 97.55 (8.34) 0.216 .829 Percentage of Balways[ responsesb 92.10 91.90 Percentile rankb 99 99
M/S BNurses kept you informed[
Mean (SD) score 89.95 (15.99) 92.74 (12.84) j1.89 .059 Percentile rankb 22 86
BStaff included you in decisions regarding treatment[ Mean (SD) score 89.11 (16.12) 91.16 (12.88) j1.359 .175 Percentile rankb 33 96
BCommunication with nurses[ Percentage of Balways[ responsesb 79.60 86.80 Percentile rankb 52 99
BNurses explained in a way you understand[ Mean (SD) score 92.22 (14.79) 94.30 (11.54) j1.158 .248 Percentage of Balways[ responsesb 75.20 81.80 Percentile rankb 43 94
Preimplementation, 4 months before October 1, 2015 to January 31, 2016; postimplementation, 4 months after March 2015 to July 13, 2016. Abbreviations: OB, 12-bed obstetrics unit; M/S, 46-bed medical/surgical unit. aSignificance set at .05 level. bObtained from facility reports.
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2nd statement, Bstaff included you in decisions regarding treatment,[ also had no significant differ- ences between the means (t = j0.736, P = .463) of the 2 groups. For the Bcommunication with nurses[ domain, the percentage of Balways[ responses increased from 90.6 to 96. For the statement Bnurses explained in a way you understand,[ the mean (SD) score decreased slightly from 97.8 (7.12) to 97.55 (8.34) but was not significant (t = 0.216, P = .829). The percentage of Balways[ responses also decreased from 92.1 to 91.9. The percentile rank remained at the 99th from preimplementation to post- implementation for all statements (Table 3).Hardwiring Bedside Shift Report
Discussion
Nurse compliance with bedside report increased on both units. Patient satisfaction mean scores, percentile rank, and percentage of Balways[ responses improved on all 4 statements for M/S. For OB, the satisfaction mean score improved on 1 statement and decreased slightly on 2 statements. The percentage of Balways[ responses improved on the Bcommunication with nurses[ domain and decreased slightly on 1 statement. The percentile rank for OB remained high at 99. Whereas M/S demonstrated high improvement, the OB unit saw less improvement. The OB unit had higher percentage compliance (55.9%) with bedside report preimplementation than M/S (12.3%), which may account for the difference in degree of improve- ment. There are a number of factors affecting the results. First, presenting the evidence supporting bedside report, addressing staff barriers, and educat- ing nurses on the impact of bedside report on patient satisfaction were crucial to gain staff buy-in. Second, the use of a competency tool for the bedside report process helped to ensure standardization. Third, the support of organizational leadership set the expecta- tion and allowed resources to monitor the imple- mentation for the 1st 2 weeks. Unexpected findings included the length of time it took to hardwire nurse compliance. The implementation team monitoring of nurses conducting bedside report and providing im- mediate feedback to nurses assisted in gaining buy-in, but nurse compliance took longer than we expected. To sustain the change, trained observers conducted random observations of nurse compliance with bed- side report at 1 and 3 months after the postimple- mentation 2-week monitoring ended. The observers will repeat random observations at 6 months post- implementation. We presented the comparison results of the preimplementation and postimplementation bedside report compliance and patient satisfaction to staff, managers, and directors of the units. In charge nurse meetings, we explained expectations to continue Hardwiring Bedside Shift Report
monitoring compliance and addressing issues with nurses. Without continued monitoring vigilance, the compliance with the process could decrease. Three months was deemed too brief a time frame to ingrain a new process.
These results are consistent with the following literature. Addressing staff barriers to bedside report, using a standardized approach to the process, and using SBAR help gain nurse buy-in to the process.7,10,11
Monitoring nurses conducting bedside report for at least 2 weeks is effective in hardwiring com- pliance.6,9-11,17 Bedside report is effective in improv- ing patient satisfaction scores for communication with nurses,9-11,21,22 keeping patients informed,5,14
and explaining things in a way they understand.11
The purpose of this project was to increase nurse com- pliance with bedside report and patient satisfaction scores. A change management strategy and standard- ized approach to bedside report helped increase nurse compliance with the process on these 2 units.
Limitations We conducted this project at 1 community hospital on 1 OB unit and 1 MS unit. This limits generaliz- ability to other facilities and patient populations. We recommend repeating the study in other facilities, including other samples. We also only randomly ob- served nurse compliance with the bedside report process. The actual compliance with the process is difficult to measure due to the inability to monitor every nurse on every shift. Other factors may influence patient satisfaction so we cannot generalize increased compli- ance with bedside report is solely responsible for the significant improvement. Further research control- ling for other patient satisfaction factors may address this limitation Hardwiring Bedside Shift Report
Conclusions
As organizations continue to implement evidence- based practices in a rapidly changing environment, providing resources and support to manage the change is important. A change management strategy and standardized approach to bedside report helped in- crease nurse compliance with the process. The use of Lewin_s theory of planned change15 was effective in increasing nurse compliance with bedside report, leading to improvement in patient satisfaction. We achieved improved compliance with bedside report by educating nurses, addressing nurse barriers, stan- dardizing the process, monitoring, and providing leadership support.
Acknowledgments The authors thank Natasha Smith, MSN, RN, CNL, and Angela Stiner, MSN, RN.
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