JONA Volume 44, Number 10, pp 541-545 Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

THE JOURNAL OF NURSING ADMINISTRATION

Bedside Shift Reports What Does the Evidence Say? Sean Gregory, PhD, MBA, MS Debra Tan, MPH Michael Tilrico, BS

Nicholas Edwardson, PhD, MS Larry Gamm, PhD

Bedside shift reports are viewed as an opportunity to reduce errors and important to ensure communication between nurses and communication. Models of bedside report incorporating the patient into the triad have been shown to increase patient engagement and enhance caregiver support and education. Nurse shift reports and nurse handovers are 2 of the most critical processes in patient care that can support patient safety and reduce medical errors in the United States. Nurses continue to not recognize the evidence supporting this practice and adopt bedside report into practice.

to support communication with and engagement of patients and their family caregivers.4-12 Nurse shift report and nurse handovers are 2 of the most critical processes in patient care that can improve patient safety and reduce medical errors in the United States. In response to the Joint Commission’s National Patient Safety Goals,15 BSR has been supported as improving patient safety, patient-centered care, and nurse communication as well as reduce medical errors.15 In most models,2 BSR occurs at the patient’s bedside between incoming and off going nurses. Many models include interaction with the patient and informal caregiver as part of the process.2 According to literature, moving shift report to the patient bedside can contribute to additional benefits including nurse empowerment,16-19 patient-centeredness,1-3,5-10,14,16,20-24 patient satisfaction,1,2,5-7,9,14,16-18,23,24 and increased communication.1,4,6,10-14,16,18,22,24-27 This article summarizes a systematic literature review of BSRs and serves as a mechanism to relate the support for improving quality of care,2 patient safety,15 and patient-centered care.2,3

Two major foci of modern medical care are patientcentered care and improved quality and safety in patient care. Central to both of concerns is improved communication among care professionals and between this team and the patient. Evidence supports that breakdowns in communication and occurrences of medical errors occur during patient handoffs.1,2 Handoffs of the patient across care settings during an episode of care are often of concern in this regard,1 but handoffs of patients from nurse-to-nurse during shift changes are receiving increased attention, as well.2 Bedside shift report (BSR) is viewed as an opportunity to reduce errors3-12 and ensure improved communication between nurses.9,12-14 BSR also has been reported Author Affiliations: Assistant Professor (Dr Gregory), Graduate Research Assistant (Ms Tan), Research Assistant (Mr Tilrico), and Professor (Dr Gamm), Department of Health Policy & Management, School of Public Health, Health Sciences Center, Texas A&M University, College Station; Assistant Professor (Dr Edwardson), School of Public Administration, University of New Mexico, Albuquerque; and Assistant Professor (Dr Gregory), Department of Pediatrics, College of Medicine, Health Sciences Center, Texas A&M University College Station. The authors declare no conflicts of interest. Correspondence: Dr Gregory, Health Sciences Center, Texas A&M University, TAMU 1266, College Station, TX 77843 ([email protected]). DOI: 10.1097/NNA.0000000000000115

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The Evidence About Bedside Report Methods A computer-assisted search was conducted in the MEDLINE, PubMed, and the Ovid interface to Medline databases to identify relevant published articles. An additional search was also conducted in Google Scholar to identify any missing literature. Manual searches of references from relevant articles were performed to identify studies that were missed by our computerassisted search. The computer-assisted search yielded 310 potentially relevant citations. After the initial review, 100 titles were deemed potentially appropriate, and these abstracts were reviewed by the team. A total of 33 studies met all inclusion criteria including

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(i) data specific to nurses and (ii) shift reports at the patient’s bedside. Studies with (i) nonempirical data, (ii) nonYpeer-reviewed articles, (iii) overlapping cohort studies, (iv) articles not in the English language, and (v) published abstracts were excluded. The review of the 33 articles produced 6 categories of work: (1) teambased variables, (2) dyadic relationships, (3) individual benefits, (4) confidentiality concerns, (5) accountability, and (6) cost containment. Results are summarized by category in the Table 1. A brief summary of each category of findings follows. Team-Based Variables Twenty-five studies reporting team-based variables discussed positive attitudes1,5,13 and feedback such as improved patient-centered care,1-3,5-10,14,16,20-24 familycentered care,1,5,13 care coordination,3,7,20-22 team collaboration,1,4,8,13,18,21,22,28 and engagement5,6,29,9,10

after implementation of BSR. In 64% of these studies (n = 16), increased patient care after implementation of BSRs was noted.1-3,5-10,14,16,20-24 By including the patient in the model of report, BSR was additionally shown to clarify and contribute further significant information to the care process.20 Few articles (12%; n = 3) cited increased family-centered care within team-based variables.1,5,13 Models of BSRs provided a sense of ease because family members were able to listen to information communicated between nurses during the process of transition.1,5,13 This prompted family members to participate and become aware of nursing treatments, interventions, and plans for care that were provided.28 Enhanced team collaboration was noted in 8 articles (32%). Nurses reported that they liked working in teams because it increased communication and brought nursing teams together.21,22 Not only did BSRs contribute to increased teamwork, but also the process

Table 1. Studies Fitting Inclusion Criteria: Summary of Findings Category

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Summary of Findings 1,5,13

Positive attitudes Improved patient-centered care1-3,5-10,14,16,20-24 Improved family-centered care1,5,13 Care coordination3,7,20-22 Team collaboration1,4,8,13,18,21,22,28 Engagement after implementation of BSR5,6,9,10,29

Team-based variables

& & & & & &

Dyadic relationships

& Nurse-patient dyadic relationship ) Patients are able to ask questions3,8,11,17,19,28,30 ) Share information regarding medical history3,16,28 ) Participate in the decision-making process3,6,8,10,17,28 & Nurse-nurse dyadic relationship ) Increased socialization by sharing stories and experiences21,31 ) Emotional support to one another11,21,31 ) Communication 9,12-14 ) Mentoring and coaching4,17,18,21 ) Networking opportunities18,23

Individual benefits

& Patient individual benefits ) Patient empowerment by being able to ask questions about their care2-4,6,14 ) Increased patient satisfaction1-3,5-7,9,14,16-18,23,24 ) Patients feel safer being able to see two nurses at shift change3,5,6,16 ) Increased patient safety3-12 ) Increased communication with nurses3,4,6,10,16,18,22,24-26 ) Increased understanding of care4,5,14,22,28 & Nurse individual benefits ) Increased communication skills and accurate information1,3,11-14,16,26,27 ) Nurses’ involvement with care3-5,13,20,27 ) Nurse empowerment16-19 ) Nurses being able to visualize the patient1,4,6,9,14,18,22 ) Nurses leaving shift on time13,14,21 ) Reduction in time spent writing shift reports2,5,13,14,18,21,23,26,32 ) Building rapport with patients17,31 ) Increased nurse satisfaction1,2,5,9,13,14,16,24,25

Confidentiality concerns

& Privacy issues while discussing patient medical history1-5,7-9,14,16,17,19,21,22,31 & Having to ask visitors to leave the room during BSRs8,17

Accountability

& Lack of confidence on medical knowledge4,5,16,33 & Burden of having to be in control2,17 & Higher confidence in thorough, more accurate reporting6,14

Cost containment

& Reduction in overtime accumulated between shift changes1,7,13,14,18,21,23,32

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subsequently improved timeliness and consistency of information.13 Five articles (20%) noted improved care coordination after implementation of BSRs.3,7,20-22 Because many healthcare provider teams function in multiplex, dynamic environments, coordination is essential in providing optimum patient care.20 By bringing nurses together at the bedside, BSR facilitates increased care coordination.20 Dyadic Relationships Seventeen articles referred to dyadic relationships in the effectiveness of BSRs, namely, the nature of nurse-nurse and nurse-patient relationship.3,4,6,8-14,16-18,21,23,28,31 In the nurse-nurse dyadic relationship, nurses receive either increased socialization by sharing stories and experiences and offer emotional support to one another.11,21,31 Furthermore, communication, mentoring, and networking opportunities were discussed in the nurse-nurse relationship dyad.4,17,18,21 In the nurse-patient relationship, patients are able to ask questions, share information regarding medical history, and participate in the decision-making process.3,6,8,10,11,16,17,19,28 BSR also improves aspects of nurse-patient dyadic relationships such as patients being able to ask questions,3,8,11,17,19,28,30 share information regarding medical history,3,16,28 and participate in the decision-making process.3,6,8,10,17,28 Patients reported being pleased when asked for their input, especially being invited and encouraged to ask questions.3,28 Patients stated that this helped clarify what they wanted to know, as well as their expectations or misunderstandings.3,28 Moreover, a model of BSRs encouraged patients to participate in the decision-making process.3,28 Of the 17 articles citing dyadic relationships, positive aspects of nurse-nurse dyadic relationships were identified, including (1) increased socialization by sharing stories and experiences, (2) providing emotional support to one another, (3) increased communication, (4) mentoring and coaching, (5) and networking opportunities.20 Nurses cited overcoming feelings of discomfort during BSRs, as well as the lack of opportunity to express feelings of stress and exchange thoughts on patient care.11,21,31 Moreover, BSRs provided a way to share stories and experiences to others who understood the same frustrations.21,31 BSRs presented opportunities for teaching, mentoring, and coaching.4,17,18,21 As mentioned earlier, nurses enjoyed working together in bedside report models because they encouraged and improved communication between nursing shifts.14,21,22 BSRs also provided networking opportunities for students, clinicians, administrators, and scientists.23 Individual Benefits Twenty-nine articles highlighted individual benefits of BSRs for the patient, nurse, and even

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physician.1-4,16-28,31,32 From the patient perspective, many of these articles focus on the improvement of care understanding4,5,14,22,28 and patient empowerment2,4,6,14 by being able to ask questions about their care. Still other articles report patient benefit from BSRs through more prompt delivery of care.3,13 From the nurse perspective, individual benefits included empowerment,16-19 being able to visualize the patient,1,4,6,9,14,18,22 building rapport,17,31 leaving shifts on time,13,14,21 reducing time spent writing a shift report,2,5,13,14,18,21,23,26,32 and improving communication skills.1,3,11-14,16,26,27 Of the 29 articles citing individual benefits for BSRs, there were various subthemes of individual patient benefits. Five (17.2%) noted patient empowerment by being able to ask questions,2-4,6,14 13 (44.8%) indicated increased patient satisfaction,1-3,5-7,9,14,16-18,23,24 4 (13.8%) reported the patient feeling safer after seeing 2 nurses change shift,3,5,6,16 10 (34.5%) noted increased patient safety,3-12 10 (34.5%) mentioned increased communication with nurses,3,4,6,10,16,18,22,24-26 and 5 (17.2%) noted an increased understanding of care.4,5,14,22,28 Patient satisfaction scores significantly improved after implementation of BSR.1,4 Longer-term results also showed significant month-to-month variation, indicating issues with BSR sustainability.2 Wakefield and colleagues2 recommended that continued monitoring and periodic reinforcements to support BSRs should be applied in order to be successful. BSR was reported as providing patients an opportunity to gain better understanding of their care plan.16 Patient safety was improved with regard to BSRs and led to avoidance of adverse patient events.14 Nurses were able to visualize the patient and noticed differences from the initial encounter with the patient to the time of bedside report.1,14 Nurses were also able to assess the environment, including checking the intravenous line, site, and chest tube drainage devices that needed attention.5,14 Patient falls at shift change and medication errors were reduced.6 Patients reported that they felt safe when experiencing shift reports at the bedside.5 Of the 29 articles citing individual benefits for BSRs, there were also numerous subthemes of individual nurse benefits. Nine (31%) indicated increased communication and accurate information,1,3,11-14,16,26,27 6 (20.7%) cited increased nurse involvement with care,3-5,13,20,27 4 (13.8%) noted nurse empowerment,16-19 7 (24.1%) alluded to nurses being able to visualize the patient,1,4,6,9,14,18,22 3 (10.3%) indicated that nurses were able to leave their shift on time,13,14,21 9 (31%) mentioned a reduction in time spent writing a shift report,2,5,13,14,18,21,23,26,32 2 (6.9%) cited building rapport with the patient, and lastly17,31 9 (31%) indicated increased nurse satisfaction.1,2,5,9,13,14,16,24,25

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After implementing BSRs, average report time decreased from 45 minutes to 29 minutes.14 Nurse satisfaction with the report process increased from 37% to 78%, and white board adherence significantly improved from 25% to 98%.14 Reasons for increased nurse satisfaction are attributed to receiving accurate handoff without distractions, assessment of the patient and environment in real time, and avoiding delays in receiving report and asking questions.14 BSR has been associated with staff leaving on time and increased usefulness and quality of information on the report.13 Physicians reported increased satisfaction because they felt they were ‘‘more informed.’’11(p117) Furthermore, BSR was reported to increase staff satisfaction and interpersonal relationships.1 Anderson and Mangino1 note that high staff satisfaction could lead to decreased turnover costs, which could subsequently affect positive financial outcomes.1 Confidentiality Concerns Fifteen articles expressed confidentiality concerns with reference to BSR.1-5,7-9,14,16,17,19,21,22,31 Nurses were reported to worry about privacy issues while discussing patient medical records in semiprivate rooms and having to ask visitors to leave the room during BSR.2,4,5,14 Some staff members had voiced skepticism in being able to discuss sensitive topics such as infectious diagnosis, drug abuse, and psychosocial issues, in front of and with the patient.2,4,5,14 Moreover, nurses were concerned such practices would violate the Health Insurance Portability and Accountability Act of 1996.4,14,17 Accountability Eight articles note pros and cons for accountability with regard to BSRs. Fear of being accountable for the patient, lack of confidence on medical knowledge, and the burden of having to be in control were countered with the advantages regarding the patient’s ability to interact with the incoming and outgoing nurses simultaneously during the shift change.2,4-6,14,16,17,33 Nursing staff voice many concerns regarding their ability to give BSR.4 One nurse noted she was worried patients would ask her questions she could not answer.4 Nurses were reported to frequently ‘‘apologize for not knowing enough about the patient or not getting everything done.’’18(p394) Nurses also voiced concern and anxiety regarding speaking in front of the patient.33

Cost Containment Eight articles cited that BSRs are a major contributor to reducing overtime accumulated between shift changes and financial savings.1,7,13,14,18,21,23,32 Evans and colleagues14 found decreased report times when utilizing BSRs. As a result, nurses spent less time socializing among themselves, which led to exiting nurses ending their shift on time, reducing incidental overtime, and allowing direct patient care to begin sooner for the oncoming nurse.14 Decrease in more than 100 hours of overtime in the 1st 2 pay periods after the implementation of BSRs was reported in 1 study.32

Conclusion Despite strong evidence demonstrating the benefits of BSRs, issues still remain regarding sustainability of BSRs after implementation. Few studies report the longitudinal results of BSRs as inconsistent.2,5 Researchers note that after further analysis of postimplementation data on BSRs, fluctuations in experience ratings such as ‘‘nurse’s friendliness and courtesy’’ varied monthto-month.2 To sustain this practice, many studies recommend assessing staff attitudes before and after implementation to identify whether periodic interventions such as ‘‘implementation boosters’’ may be needed to sustain desired change in practice.2 The transition from tape-recorded shift reports or shift reports done away from the patient in the nursing station or conference room to the bedside is a complex process, involving multiple interfaces and system changes. Evidence in literature suggests standardization of BSR models to yield greater accuracy, increase patients’ and nurses’ satisfaction, and save nurses time.29 These results seem to indicate that a standardized BSRs will increase compliance.29 Based on this literature, we found little evidence to support the use of specific structure, protocol, or method for BSR. The evidence is clear that there are multiple benefits to models of BSR. The challenge for nurse executives is to identify a model for their organization and patient populations, ensure consistency in practice and implementation, set measurable indicators, support the adoption by clinical nurses, and adjust models as appropriate to attain and sustain the outcomes. The multitude of evidence should be used as foundational in developing future studies.

References 1. Anderson CD, Mangino RR. Nurse shift report: who says you can’t talk in front of the patient? Nurs Adm Q. 2006;30(2): 112-122.

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2. Wakefield DS, Ragan R, Brandt J, Tregnago M. Making the transition to nursing bedside shift reports. Jt Comm J Qual Patient Saf. 2012;38(6):243-253.

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3. McMurray A, Chaboyer W, Wallis M, Johnson J, Gehrke T. Patients’ perspectives of bedside nursing handover. Collegian J R Coll Nurs Aust. 2011;18(1):19-26. 4. Burke W, McLaughlin D. Partnering for change. Am J Nurs. 2013;113(2):47-51. 5. Caruso EM. The evolution of nurse-to-nurse bedside report on a medical-surgical cardiology unit. Medsurg Nurs. 2007; 16(1):17. 6. Sand-Jecklin K, Sherman J. Incorporating bedside report into nursing handoff: evaluation of change in practice. J Nurs Care Qual. 2013;28(2):186-194. 7. McMurray A, Chaboyer W, Wallis M, Fetherston C. Implementing bedside handover: strategies for change management. J Clin Nurs. 2010;19(17-18):2580-2589. 8. Laws D, Amato S. Incorporating bedside reporting into changeof-shift report. Rehabil Nurs. 2010;35(2):70-74. 9. Maxson PM, Derby KM, Wrobleski DM, Foss DM. Bedside nurse-to-nurse handoff promotes patient safety. Medsurg Nurs. 2012;21(3):140-144; quiz 145. 10. Cahill J. Patient’s perceptions of bedside handovers. J Clin Nurs. 1998;7(4):351-359. 11. O’Connell B, Penney W. Challenging the handover ritual. Recommendations for research and practice. Collegian. 2001;8(3): 14-18. 12. Randell R, Wilson S, Woodward P. The importance of the verbal shift handover report: a multi-site case study. Int J Med Inform. 2011;80(11):803-812. 13. Nelson BA, Massey R. Implementing an electronic change-ofshift report using transforming care at the bedside processes and methods. J Nurs Adm. 2010;40(4):162-168. 14. Evans D, Grunawalt J, McClish D, Wood W, Friese CR. Bedside shift-to-shift nursing report: implementation and outcomes. Medsurg Nurs. 2011;21(5):281-284, 292. 15. Joint Commission. National Patient Safety Goals. Oakbrook Terrace, IL: Joint Commission; 2009. 16. Kerr D, McKay K, Klim S, Kelly AM, McCann T. Attitudes of emergency department patients about handover at the bedside. J Clin Nurs. 2014;23(11-12):1685-1693. 17. Radtke K. Improving patient satisfaction with nursing communication using bedside shift report. Clin Nurse Spec. 2013; 27(1):19-25. 18. Cairns LL, Dudjak LA, Hoffmann RL, Lorenz HL. Utilizing bedside shift report to improve the effectiveness of shift handoff. J Nurs Adm. 2013;43(3):160-165.

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