The Most Crucial Half Hour At A Hospital: The Shift Change


By Laura Landro

Hospitals are transforming the traditional way nurses change shifts to reduce the chance of errors and oversights in the transfer of information. A critical side effect: patients feel safe, included and satisfied.

Studies show that so-called bedside shift reports, with both nurses meeting in the presence of the patient during the handover, help nurses communicate better, not only with each other but with patients and their families. Studies show the approach helps reduce the number of patient falls and catch safety issues such as an incompatible blood transfusion and dangerous air bubbles that form in arteries.

“Conducting nurse change-of-shift report at the bedside with the patient and family should be viewed as a core safety strategy in hospitals today,” says Beverley Johnson, chief executive officer of the Institute for Patient-and-Family-Centered Care, a nonprofit group based in Bethesda, Md., which offers webinars for hospitals on adopting bedside shift reporting. “It is a very tangible way to ensure that complete and accurate information is shared and there is mutual understanding of the care plan and other priorities.”

It is a big change from the traditional shift change in many hospital units, where nurses going off duty typically confer in a hallway or at the nursing station with the nurse coming on for the next shift, giving a rundown of their patients’ status and needs. In some cases nurses may simply write up a report in the medical record for the next shift to read.

But that critical information may be missed during shift changes. When nurses aren’t in the room for the handover, patients not only fall more often but also may have problems with intravenous lines or urinary catheters. And there is no opportunity for patients and family members to ask questions, state concerns or convey their own goals.

In contrast bedside reporting helps improve patients’ ratings of their hospital experience at a time when Medicare is linking some payments to quality measures including how well hospitals score on patient satisfaction surveys.

Bedside reporting has met with some resistance on nursing units because of concerns that it would take up too much time and put nurses in danger of violating patient confidentiality. But patient advocacy groups say privacy rules should not be a barrier, as long as patients are told conversations may be overheard and asked about issues they would prefer to remain private. The groups say patients should have the option to designate which family members can be present.

The University of Washington Medical Center in Seattle convened a patient and family advisory council for help in developing more inclusive policies including bedside nursing shift reports, and staffers say they were strongly influenced by the experience of one participant, Christine Hernandez. Ms. Hernandez says she wasn't allowed to be present during shift change reports and found it nearly impossible to get updated information when her husband, Gustavo, was in intensive care for six weeks in 2007 for a series of heart surgeries, suffering multiple complications.

“I was so hungry for information that I was desperate, but I didn’t want to make anyone angry or be the meddlesome wife,” Ms. Hernandez says. “Shift change would have been a perfect opportunity for a family member to be present for a little rundown on his current status and expectations for the next shift,” she says. “It would definitely help alleviate stress and make them feel more empowered in a seemingly helpless situation.”

Nurses went through training sessions last spring, on how to efficiently perform a bedside report, overcome concerns about what to say in front of patients, and engage patients in the process. They began bedside shift reporting in July. Depending on the hospital unit, nurses may have to hand off three to six patients per shift within a half-hour, spending 3 to 7 minutes with each. Keri Nasenbeny, assistant administrator of patient care services, says some reports are relatively quick, which leaves time for more complicated cases. If they become more involved, nurses can suggest continuing the conversation with patients and families after the report.

Patricia Kritek, a physician and associate medical director of the University of Washington Medical Center, says sometimes patients just want to be left to sleep and don’t want to be on the shift reports or doctor rounds. “If someone doesn’t want us in there, that’s totally fine too,” she says.

Joyce Casey, 49, a school nurse and heart patient hospitalized at the University of Washington last week, says in past experiences, she felt uncomfortable when she could hear hospital staff just outside of her room, “talking about you as if you were not there.” The bedside reports make her feel comfortable speaking up about her concerns and issues.

The University of Vermont Medical Center in Burlington started training nurses in bedside shift reporting in the fall of 2013, and has been rolling out the practice in different units since last year. Nurses use a six-step format to go over basic issues, perform safety checks, discuss any tests and then ask patients if there is anything they want them to know. “If a patient or family had a different perception or is worried about something they have the opportunity to say it while both nurses are there,” says Sue Murdock, director of nursing research and education at the hospital.

Kate Miller, a nurse in the general surgery unit, says being at the bedside with another nurse who has taken care of the patient for an entire shift forges a more personal connection, “so you see the person and not just a piece of paper.”

Nurses were also persuaded when they saw the improvement in patient satisfaction surveys when bedside reports were used, says Karen McKnight, a quality improvement consultant at the hospital. Patients gave much higher scores for their hospital experience overall and on communication with nurses than when there was no bedside report.

Thomas DeVarney, who was hospitalized at University of Vermont Medical Center last week for an abdominal obstruction, says he felt comforted when the nurse going off duty mentioned a change in his medications to the oncoming nurse. “It left me with a secure feeling that the new nurse wasn't showing up without important information about me,” Mr. DeVarney says.


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