Earlier this month (July 2013), the Agency for Healthcare Research and Quality (AHRQ) released their Guide to Patient and Family Engagement in Hospital Safety and Quality, a new resource designed to help hospitals engage patients and families not only in their direct care, but also in hospital policy and infrastructure decisionmaking. The Guide contains four specific strategies that reflect meaningful opportunities to engage patients and families and improve safety and quality: Working With Patients and Families as Advisors, Communicating to Improve Quality, Nurse Bedside Shift Report, and IDEAL Discharge. Each strategy contains implementation guidance, training, and tools for healthcare providers, and materials for patients and families. Since 2009, several of us at AIR have spent a significant chunk of our professional lives working on this project, assisted by a fantastic team of subcontractors, consultants, and some amazing patients, family members, and advocates.
We believe that the interventions outlined in the Guide have the potential to be real game-changers in promoting engagement. One example is bedside shift report.
In many hospitals, the change-of-shift report takes place at the nurses’ station or out in the hallway. Off-going and on-coming nurses hand off patients by reviewing information on a sheet of paper or a computer. The scene is often slightly chaotic – there is rarely a perfect one-to-one exchange of patients between nurses (i.e., an on-coming nurse may take patients from two or even three off-going nurses). As a result, nurses may have to wait around for each other, and the whole process can take 45 to 50 minutes.
Imagine you’re a patient during this time. Your nurse comes in at 6:30 am to tell you that she is leaving and your new nurse will be in “soon.” At 7:30 am, nurse shift change begins. At 8:15, your new nurse is finished with shift change report. Now he needs to begin checking on each of his five patients. During this time, he also gets called to help admit a new patient to the unit. At 9:30, he finally comes in to see you. It’s been three anxiety-filled hours since you saw a nurse. You’re not sure what this new nurse knows about you, what has happened during your hospital stay so far, or your concerns.
This is a typical scene in many hospitals – but does it need to be? Bedside shift change, one of the strategies outlined in the Guide, moves the shift report between off-going and on-coming nurses to patients’ bedsides. Families are encouraged to be present, and patients are encouraged to participate by asking questions and contributing information.
Imagine that you’re a patient under this scenario. When you are admitted to the hospital, you receive a brochure about bedside shift report, and the admitting nurse tells you that bedside shift report takes place at 7:30 am and 7:30 pm. You make plans for your family to be present. At 7:40 am, the nurses enter your room and greet you and your family. They stand at your bedside, and the off-going nurse opens your electronic medical record. She gives a verbal report to the on-coming nurse, outlining your vital signs, history, current condition, and outstanding orders. You notice that she forgets to mention that you are diabetic, and you speak up to offer this information. Your nurses visually inspect your IV site and ask if you have any questions about your care. Your sister mentions that the physician had ordered some lab work, but you had not heard about the results. Your oncoming nurse promises to check on this. Then she asks about your goals for the next 12 hours. You want to take a walk around the unit. The nurse writes your goal on the white board in your room, and says that she will send in an aide to help you. Your questions have been answered, you and your family have current information about your care, and the whole interaction took less than five minutes.
Sounds great—so why aren’t all hospitals doing bedside shift report?
Like so many other strategies to promote patient and family engagement, conducting bedside shift report requires a paradigm shift and concrete changes in hospital practices. This isn’t easy to do. Nurses may worry that bedside shift report will take longer, that there will be violations of HIPAA or patient privacy, or that they will have to negotiate difficult interactions. Hospitals may worry about the difficulty of rolling out a new intervention and the resources involved.
However, when hospitals are willing to do the hard work, the benefits can be tremendous. Previous research and our own experiences implementing the Guide have shown that bedside shift report provides meaningful opportunities for engagement, improves communication, increases patient and nursing staff satisfaction, and (despite fears to the contrary) improves time management and accountability between nurses.
At the core, bedside shift report isn’t just about changing where nurses conduct shift report—it’s about making changes in how a hospital views patients and recognizing that patients and families should be active partners in their care. When that happens, it’s good for everyone involved.