Bedside Shift Reports: What Does the Evidence Say?

Abstract

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.

Full text

JONA
Volume 44, Number 10, pp 541-545
Copyright B2014 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 communica-
tion 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.
Two major foci of modern medical care are patient-
centered care and improved quality and safety in pa-
tient care. Central to both of concerns is improved
communication among care professionals and be-
tween 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 acrosscare 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 errors
3-12
and ensure improved communica-
tion between nurses.
9,12-14
BSR also has been reported
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 im-
proving 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 be-
tween incoming and off going nurses. Many models
include interaction with the patient and informal care-
giver as part of the process.
2
According to literature,
moving shift reportto the patient bedside can contrib-
ute to additional benefits including nurse empower-
ment,
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 commu-
nication.
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
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 computer-
assisted search. The computer-assisted search yielded
310 potentially relevant citations. After the initial
review, 100 titles were deemed potentially appropri-
ate, and these abstracts were reviewed by the team. A
total of 33 studies met all inclusion criteria including
JONA Vol. 44, No. 10 October 2014 541
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 Uni-
versity, College Station; Assistant Professor (Dr Edwardson), School
of Public Administration, University of New Mexico, Albuquerque;
and Assistant Professor (Dr Gregory), Department of Pediatrics, Col-
lege 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
(gregory@tamhsc.edu).
DOI: 10.1097/NNA.0000000000000115
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

(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) team-
based variables, (2) dyadic relationships, (3) individual
benefits, (4) confidentiality concerns, (5) accountabil-
ity, 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 dis-
cussed positive attitudes
1,5,13
and feedback such as
improved patient-centered care,
1-3,5-10,14,16,20-24
family-
centered care,
1,5,13
care coordination,
3,7,20-22
team col-
laboration,
1,4,8,13,18,21,22,28
and engagement
5,6,29,9,10
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 pa-
tient 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 vari-
ables.
1,5,13
Models of BSRs provided a sense of ease
because family members were able to listen to informa-
tion 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 thattheylikedworkingin
teams because it increased communication and brought
nursing teams together.
21,22
Not only did BSRs con-
tribute to increased teamwork, but also the process
Table 1. Studies Fitting Inclusion Criteria: Summary of Findings
Category Summary of Findings
Team-based variables &Positive attitudes
1,5,13
&Improved patient-centered care
1-3,5-10,14,16,20-24
&Improved family-centered care
1,5,13
&Care coordination
3,7,20-22
&Team collaboration
1,4,8,13,18,21,22,28
&Engagement after implementation of BSR
5,6,9,10,29
Dyadic relationships &Nurse-patient dyadic relationship
)Patients are able to ask questions
3,8,11,17,19,28,30
)Share information regarding medical history
3,16,28
)Participate in the decision-making process
3,6,8,10,17,28
&Nurse-nurse dyadic relationship
)Increased socialization by sharing stories and experiences
21,31
)Emotional support to one another
11,21,31
)Communication
9,12-14
)Mentoring and coaching
4,17,18,21
)Networking opportunities
18,23
Individual benefits &Patient individual benefits
)Patient empowerment by being able to ask questions about their care
2-4,6,14
)Increased patient satisfaction
1-3,5-7,9, 14,16-18,23, 24
)Patients feel safer being able to see two nurses at shift change
3,5,6,16
)Increased patient safety
3-12
)Increased communication with nurses
3,4,6,10,16,18,22,24-26
)Increased understanding of care
4,5,14,22,28
&Nurse individual benefits
)Increased communication skills and accurate information
1,3,11-14,16,26,27
)Nurses’ involvement with care
3-5,13,20,27
)Nurse empowerment
16-19
)Nurses being able to visualize the patient
1,4,6,9,14,18,22
)Nurses leaving shift on time
13,14,21
)Reduction in time spent writing shift reports
2,5,13,14,18,21,23,26,32
)Building rapport with patients
17,31
)Increased nurse satisfaction
1,2,5,9,13,14,16,24,25
Confidentiality concerns &Privacy issues while discussing patient medical history
1-5,7-9,14,16,17,19,21,22,31
&Having to ask visitors to leave the room during BSRs
8,17
Accountability &Lack of confidence on medical knowledge
4,5,16,33
&Burden of having to be in control
2,17
&Higher confidence in thorough, more accurate reporting
6,14
Cost containment &Reduction in overtime accumulated between shift changes
1,7,13,14,18,21,23,32
542 JONA Vol. 44, No. 10 October 2014
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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 es-
sential 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
Fur-
thermore, communication, mentoring, and network-
ing opportunities were discussed in the nurse-nurse
relationship dyad.
4,17,18,21
In the nurse-patient relation-
ship, patients are able to ask questions, share infor-
mation 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 ques-
tions,
3,8,11,17,19,28,30
share information regarding medi-
cal 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, pos-
itive aspects of nurse-nurse dyadic relationships were
identified, including (1) increased socialization by shar-
ing stories and experiences, (2) providing emotional
support to one another, (3) increased communication,
(4) mentoring and coaching, (5) and networking op-
portunities.
20
Nurses cited overcoming feelings of dis-
comfort 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 under-
stood the same frustrations.
21,31
BSRs presented oppor-
tunities 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 stu-
dents, clinicians, administrators, and scientists.
23
Individual Benefits
Twenty-nine articles highlighted individual bene-
fits of BSRs for the patient, nurse, and even
physician.
1-4,16-28,31,32
From the patient perspective,
many of these articles focus on the improvement of
care understanding
4,5,14,22,28
and patient empower-
ment
2,4,6,14
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 pa-
tient,
1,4,6,9,14,18,22
building rapport,
17,31
leaving shifts
on time,
13,14,21
reducing time spent writing a shift re-
port,
2,5,13,14,18,21,23,26,32
and improving communica-
tion 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 com-
munication with nurses,
3,4,6,10,16,18,22,24-26
and5(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, in-
dicating issues with BSR sustainability.
2
Wakefield
and colleagues
2
recommended that continued moni-
toring 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 in-
travenous 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 individ-
ual nurse benefits. Nine (31%) indicated increased com-
munication 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 rap-
port with the patient, and lastly
17,31
9 (31%) indicated
increased nurse satisfaction.
1,2,5,9,13,14,16,24,25
JONA Vol. 44, No. 10 October 2014 543
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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 pa-
tient 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 use-
fulness 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 in-
terpersonal relationships.
1
Anderson and Mangino
1
note that high staff satisfaction could lead to decreased
turnover costs, which could subsequently affect posi-
tive 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 re-
ported to worry about privacy issues while discussing
patient medical records in semiprivate rooms and hav-
ing 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 diag-
nosis, 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 In-
surance 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 simul-
taneously during the shift change.
2,4-6,14,16,17,33
Nurs-
ing staff voice many concerns regarding their ability
to give BSR.
4
One nurse noted she was worried pa-
tients 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 ev-
erything 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 col-
leagues
14
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 on-
coming nurse.
14
Decrease in more than 100 hours of
overtime in the 1st 2 pay periods after the implemen-
tation 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 lon-
gitudinal results of BSRs as inconsistent.
2,5
Researchers
note that after further analysis of postimplementa-
tion data on BSRs, fluctuations in experience ratings
such as ‘‘nurse’s friendliness and courtesy’’ varied month-
to-month.
2
To sustain this practice, many studies
recommend assessing staff attitudes before and after
implementation to identify whether periodic interven-
tions 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 confer-
ence room to the bedside is a complex process, involv-
ing 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 com-
pliance.
29
Based on this literature, we found little evi-
dence 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 orga-
nization and patient populations, ensure consistency
in practice and implementation, set measurable indi-
cators, 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.
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