Recently I had the privilege of presenting at the New York State Partnership for Patients (NYSPFP) Patient and Family Engagement Forum, a series of events designed to increase hospitals’ learning and capacity around the critical issue of engagement. The topic of this particular forum was “supporting the safe handoff of care,” and I presented on AHRQ’s Guide to Patient and Family Engagement in Hospital Safety and Quality, focusing on the Guide resources to help hospitals implement nurse bedside shift report.
Knowing that the forum would include a question and answer session, I had come prepared to address the concerns we have heard repeatedly about implementing bedside shift report:
- Privacy and HIPAA: What if we have semi-private rooms? What if family members are present and the patient doesn’t want them there?
- Efficiency: What if we go into patients’ rooms and we get ambushed with questions – isn’t this process going to take forever?
- Sensitive situations: What if a patient has a diagnosis about which they are unaware? What if there are situations we need to discuss without the patient present (for example, a difficult family situation)?
I had ready answers to all these questions (which are all addressed in the Guide), and sure enough, all of them came up. But these hospitals, who clearly had gone beyond the contemplation stage to thinking how this could be operationalized in their institution, had additional questions that illustrated how challenging implementation can be in the “real world.”
One nurse manager noted that the majority of her staff are currently out on leave. On any given shift, she only has two “permanent” nurses – the rest are temporary staff or floaters. How do they establish new procedures with such a large number of temporary staff?
Another nurse manager of a labor and delivery unit noted that their unit currently does block shift reporting, where all nurses receive report on all patients. This allows for flexibility, since patients require different levels of care based on how they progress through labor – i.e., if a nurse has two patients who both dilate to 9 cm at the same time, another nurse will need to step in. How would they make sure all nurses were informed if they moved to a one-to-one transfer of information at the bedside?
A third hospital noted that their rooms were so small that it was difficult to roll the mobile computer workstation into the patient’s room to conduct shift report at the bedside.
There are ways to work around each of these situations, but as much as I wanted to, I couldn’t give each of these hospitals a step-by-step approach to addressing the problem. What I could tell them was the following:
- Step back and address underlying problems. Planning for the implementation of bedside shift report might surface larger issues that need to be addressed. For example, one hospital tried to implement bedside shift report and found that nurses were being interrupted with large numbers of patient calls. Stepping back, they realized that the underlying problem was inadequate touch points with patients. So, they implemented hourly rounding. Once this was in place, patients knew that nurses would be in to see them regularly and that their needs would be met. Nurses were then able to successfully implement bedside shift report with fewer interruptions.
- Work with staff to surface problems and brainstorm solutions. Staff can be great at highlighting problems and reasons why something won’t work. With this in mind, put them to work surfacing problems and then generating solutions. Explain to them that the desired end goal is bedside shift report – given the roadblocks facing implementation, what are creative ways to get to that end goal?
- Don’t forget the patients and families in the process. Just as staff can help you think outside the box, so can patients and families. They can look at the issue with fresh eyes and an outside perspective, helping generate solutions that you might not have considered.
Given the challenges facing the hospitals who attended the forum, it’s highly likely they won’t hit on the perfect answer the first time out. They will need to implement, assess what’s working, build on successes, and revamp the process to address what’s not working. This is the familiar Plan-Do-Study-Act (PDSA) improvement cycle, but one thing that’s always bothered me about the visual depiction of this cycle is that it shows constant movement around the same circle. Instead, I like to think about the PDSA cycle as a wheel on a car, propelling you forward. I also like to think about words of wisdom that my cousin once provided to explain his navigation philosophy: “All roads get to where you’re going. Some just take a little longer.” Implementing engagement strategies in the real world is like that – as long as you’re on a path, you will get to where you want to go. Some paths might just take a little longer.