SampleBCapstoneFinalreport.pdf

A Case Study

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A case study of the implementation of bedside reporting

A Capstone Project Presented to

the Faculty of the School of Nursing

UMDNJ

In Partial fulfillment of the requirements

for the degree of Doctor of Nursing Practice

by

Joan Harvey MSN RN CCRN

Cheryl Holly EdD. RN

Approved: _________________________________________________, Chairperson

Approved: ___________________________________________, Committee Member

Approved: ___________________________________________, Committee Member

Approval acknowledged: __________________________________________________,

DNP Program Coordinator

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Abstract

The purpose of bedside nursing report is to communicate critical information pertinent to patient

care. This transfer of information occurs when a new shift begins. Studies regarding nursing

reports indicate that information is inconsistent among nurses. Despite attempts at creating

standardized reporting sheets and implementing reporting methods to guide nurses, a lack of

consistency remains, which can be a detriment to patient safety. Using Rogers Diffusion of

Innovation theoretical framework, the intention of this study was to construct a case study to

examine nurses’ perceptions of bedside report (the innovation) by comparing two nursing units

who have had different rates of innovation adoption. The results of this study provide insight as

to why these inconsistencies exist, what they encompass, and what information nurses consider

most important to transfer at the time of bedside report. Nursing leaders will benefit from first

hand information from bedside nurses reported perceptions. This information provides a guide to

improve the process of bedside reporting adoption. A case study approach allowed for

investigation of the impact of diffusion of bedside reporting as an innovation to nursing care and

communication between nurses and patients. For this case study, focus groups and observation of

participants was used to collect data on the innovation, its effect and adoption. Results from

focus groups provided greater understanding of the diffusion of bedside reporting, its impact on

nursing practice and patient care from the viewpoint of working nurses. Findings indicate strong

managerial expectations and visible nursing management present during shift report aids in the

adoption process. Despite comparable competency in nursing care, nurses who are actively

involved in shared governance roles and continuing education are more willing to adopt an

innovation. This was evident in self-reported information from the nurses during focus group

interviews.

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In conclusion, the results of this study can be used to assist nursing leaders in developing

a design for the implementation of bedside report. Implementation may however, require various

design strategies for different nursing units in order to accomplish the same outcome.

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A case study of the implementation of bedside report

Background

Communication of information in healthcare is a vital component to providing safe

patient care. Effective communication is necessary to report critical patient changes in a timely

fashion in a clear succinct manner. Such communication may be nurse-to-physician, nurse to

family, nurse-to-patient or nurse-to-nurse, as well as nurses to other members of the healthcare

team. The development of a strategy for effective communication amongst these practitioners is

the key to both successfully managing the patient’s healthcare experience as well as providing

for the provision of safe patient care.

Maintaining a safe patient care environment and the delivery of safe patient care has been

highlighted in medical reports and has been the focus of numerous federal reports. In 1999, The

Institute of Medicine (IOM) published a landmark report “To Err is Human”. It was reported,

“44,000 to 98,000 people die each year as a result of medical errors. More people die in a given

year as a result of medical errors than from motor vehicle accidents (43,458), Breast Cancer

(42,297) or AIDS (16,516).” (Institute of Medicine, 2001 p. 1) This landmark report received

enormous press and catapulted the issue of patient safety to the forefront of both consumer and

regulatory groups. The financial impact of preventable errors is overwhelmingly expensive.

Billions of dollars are spent as a result of preventable medical errors. The Institute of Medicine

led the way in promoting patient safety in hospital facilities and making recommendations on

what safety measures should be implemented. With the subsequent publication of Crossing the

Quality Chasm,(2001) not only were safety concerns identified but sizeable gaps in healthcare

quality were revealed. Recommendations from this second report called for another commission

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to identify priority areas for national action focusing on safety and quality. The results of this

follow-up commission, published in Priority Areas for National Action: Transforming Health

Care Quality (2003) called for groups at different levels to focus on improving care in a limited

set of priority areas thereby obtaining a deep, sustainable improvement in quality. One of the two

cross-cutting priorities identified was care coordination. Critical to the coordination of care in the

acute care setting are strategies to promote effective communication in reporting on patient’s

conditions.

Congruent with the recommendations from the IOM commission, The Joint Commission

assumed a leadership role in assuring that healthcare organizations addressed these key safety

concerns. Communication regarding patient care is at the forefront of the development of a

culture of safety, which is a mandate by The Joint Commission (TJC) through its national safety

agenda. In 2002, The Joint Commission established the National Patient Safety Goals. An early

goal was to “improve the effectiveness of communication among caregivers”. (“National Patient

Safety” 2009, p. 1) Initially in 2004, this focused on telephone orders and abbreviations and

subsequently broadened to address the timeliness and accuracy of reporting between healthcare

professionals. In 2006, TJC implemented a standardized approach to “hand off”

communications including an opportunity to ask and respond to questions. (“National Patient

Safety”, 2009) Despite the slight change in focus, the emphasis of the safety goal is to provide

up-to-date information, which is verifiable, and which limits interruptions during the hand off

process. Even though these regulations are in place, there remain concerns as to the consistency

of communication methods. This lack of consistency in nursing report can lead to gaps in

communication. Communication gaps can lead to catastrophic events. Poor communication,

misunderstanding information and failing to hand off critical information can leave the oncoming

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nurse caring for a patient at a disadvantage by not having information that may be necessary to

make critical decisions for safe patient care.

Patterson et al (2004) examined hand off in settings with high consequences for failure,

such as, NASA, the Johnson Space Center in Texas, Nuclear Power generation plants in Canada,

a railroad dispatch center in the United States and an ambulance dispatch center in Toronto.

Patterson found that hand offs in these settings were interactive, verbal, face-to-face interactions

between incoming and outgoing personnel. This allowed for questioning and checking for

accuracy of information. Validation of information was found to be an important factor in

maintaining the plan for care or daily operation. Incoming personnel did not initiate work tasks

until the hand off was complete. Likewise in healthcare, oncoming staff generally does not

initiate patient care delivery until a hand off process occurs. “Communication failures are

increasingly being implicated as important latent factors influencing patient safety in hospitals.”

(Sutcliffe, 2004, p. 187) Parker (1996) reports, “the nurses handing over had direct knowledge of

the patient and were able to convey idiosyncratic and personal knowledge of the patient. This is a

crucial element in professional nursing practice. The nurse can report on clinical judgments and

can be held accountable for the judgments made” (Parker, 1996, p. 25) Critical evaluation of

nursing actions can be evaluated and considered to be either continued or discontinued based on

the rationales for the action and the patient outcome.

In 2005, the Australian Council for Safety and Quality in Healthcare published a

literature review of clinical handover and patient safety. This report was compiled in an effort to

appraise the evidence available and the research completed regarding nursing handover.

Healthcare hand off processes, tools and guidelines for hand off were examined (Safety Council,

2005) The council identified three major domain areas related to handover variables which

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included systems design factors, organizational cultural factors and individual factors. While,

many of these variables were interrelated and the studies provided a description of the handover

strategies without adequate evaluation, findings indicated that system factors such as policies,

procedures, computers and information tools were variables that affected reporting. Additionally

cultural factors such as communication between professionals impact patient care along with

individual factors that relate to the knowledge and skill base of the nursing staff that are

transferring the patient information. After these finding were published the Australian

Commission on Quality and Safety for Healthcare contracted the e-Health Services group to

conduct additional literature reviews to provide resources for those who are working to improve

clinical handover. The findings of this literature review indicate that there remain areas of high

risk in the clinical handover setting. Risks were identified at several different points within the

handover process not only in the hospital setting but also amongst health care professionals

outside of acute care facilities. Additionally the review included areas of success such as

changing in reporting processes, use of electronic tools and reporting sheets to enhance the

communication. Lastly the group identified that there remains a gap in the literature on the study

of clinical handover. While studies have been completed, there are few and they are limited

studies.

Ethnographic studies on nursing handover (Kerr, 2002; Lally, 1999; Lamond, 2000;

Manias & Street, 2000; Parker, 1996) similarly report inconsistent information is being

transferred during the reporting process. The lack of consistency in the information being

transferred is an issue that has been examined with no particular one finding being an absolute

solution.

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Nursing shift report is anchored in ritual and transfer of power. Power can be

conceptualized as being in charge of care as well as holding power over others based on the

degree of information shared. A systematic review by Holly and Poletick (2010) examined

nurses’ intershift handover practices in acute care hospitals. Their metasynthesis reported that an

embedded hierarchy exists during the handoff between nurses. Within this hierarchy there is a

potential power differential, which influences the manner in which report is delivered and

received. Additionally they found that unit norms impact the content and style of report.

Clearly, communication is an issue during nurse transitions at the time of handover. One

method to decrease the gap in communication is to complete the hand off process at the bedside

–“bedside report”. Bedside report is a strategy that meets the criteria identified by Patterson

(2004) for safe reporting. It is a means to effectively meet the needs of patient by facilitating

active involvement in care. Patients become involved in the reporting process by asking

questions and validating information such as medical history, course of treatment and testing.

Bedside report is an interactive approach that provides opportunity for nursing to have the face-

to-face interaction with a nursing colleague and the patient. Nurses also have the ability during

bedside report, to ask questions, to validate findings, and complete succinct assessments to

corroborate information given.

Bedside report is a crucial exchange of information between the nursing staff and the

patient. The information discussed in nursing may vary from nurse to nurse, “some nurses

presented only the information in the medical record others presented information they had

gained over the course of the shift through interaction with the patient.” (Parker, 1996 p. 24) This

can lead to a gap in communication of critical results that may lead to a poor patient outcome.

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Instances where an incorrect limb has been removed such as in the Willie King case or incorrect

procedures being completed have been linked to miscommunication. (Charatan, 2009)

Nurses are the gatekeepers of patient care and information despite technological

advances. Nursing report is a transfer of power deeply rooted in rituals (Kerr, 2002; Lally, 1999;

Manias & Street, 2000) Obtaining the views and perceptions of nurses about bedside report will

assist in understanding the information transfer and perhaps why some information is included

and excluded in report. (Hays, 2003; Kerr, 2002; Lamond, 2000)

Challenges and barriers exist to the implementation of bedside report. Barriers such as

nurses’ perceptions that report is more time consuming and there is a lack of privacy for the

patient (Pepper, 1978) cause implementation to be halted. In 2005, Kassean and Jagoo identified

the following restraining forces to bedside reporting: “fear that this may lead to more work, lack

of confidence on the part of some nurses, fear of increased accountability, problems associated

with arriving late to work, and problems associated with disclosure of confidential information.”

(Kassean & Jagoo, 2005 p. 4)

It is important to examine behaviors during bedside report and nurse’s perceptions and

implementation of bedside report so that organizations can improve the safety mechanisms that

are in place and provide an environment conducive for nurses to conduct such a report. As the

main gatekeepers of information it is important to study what nurse’s view as important in hand

off, how they approach the hand off and what they feel about hand off at the bedside. Utilizing a

case study approach will assist in the identification of nurses who perceived this innovation as an

important change to the culture of safety and those who adopted this change at a faster rate than

others. Studying the two side-by-side and comparing will assist in identifying the important

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elements that led to the faster rate of adoption. This is important to identify for future

implementation.

This study reports the implementation of bedside report and examines the perceptions of

nurses in an acute care institution that has established beside report as the mode of patient hand

off. The purpose was to explore the nurse’s perceptions about bedside report and how nurses

have implemented the requirement for bedside reporting. Nurses’ experiences with reporting at

the bedside have had little exploration. Information obtained from this study, enables other

organizations who wish to implement bedside reporting, a framework to model for successful

implementation. The findings from this study reveal why inconsistencies are present in the

bedside reporting process, what nurses like and dislike about the process and what they feel is

important information to transfer during the hand off process.

Significance

Patient and Family Centered Care is a model of patient care delivery in the organization

that will be used as the study site for this project. This model was adopted in an effort to improve

care and communication to patients and families. There are various aspects of Patient and Family

Centered Care. One aspect to the implementation of a Patient and Family Centered Care Model

was the initiation of bedside nursing report. Bedside report is defined as nurses giving and

receiving the entire report at the bedside. Report is inclusive of patient history, reasons for

admission, testing and plan of care. Patient and family participation is encouraged. Education

for bedside nurses included reasons for implementation and the expectation for the transaction of

report at the bedside. The expectation of nursing leaders throughout the organization is that

nursing hand off will take place at the patient’s bedside. The results of this study provide

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information on what nurse’s perceptions are regarding bedside report, what they feel is important

and why inconsistencies occur. There is a dearth of information from the perspective of nurses.

The literature available examines the phenomenon of communication. Available literature on

bedside reporting is primarily from the perspective of the patient and or physicians; the voice of

the nurse, who is responsible for bedside reporting, is missing. This study attempts to close that

gap.

Review of the literature

Communication in nurse patient relationships is essential to good nursing care and clearly

a matter of satisfaction for both patients and nurses. Sheldon, et al., 2006; reported that nurses

did not feel prepared educationally to communicate in the manner in which they were expected

to do so. Conversations with patients and families and the difficulties and emotions that are

brought to the surface were themes discussed by Sheldon, et al. (2006) and Davis et al. (2003).

Wellard et al. (2003). (Wellard, et al., 2003) and O’Connell, MacDonald & Kelly (2008)

discussed barriers to effective communication in nursing and management of patient care at great

length, which included: issues of confidentiality, patients requesting immediate care, therefore

interrupting reporting process, perception that bedside reporting takes more time and

environmental issues of space and nothing to lean on to comfortably write during the bedside

reporting process.

Nurses are acutely aware of the need for communication and the importance of good

communication and they are able to articulate this though discussion. Wellard, and colleagues

(2003) reported through observation that the nurses did not practice what they verbalized and

tried to maintain a sense of control over the patient including the conversation, reporting and

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interactions. In addition, there was variation in the methods and comfort levels of nurses with the

years of experience they have in the field of nursing. (Davis, et al., 2003). Despite this the nurses

were able to articulate the importance of bedside report and spoke of the positive patient

responses. This study clearly demonstrates that nurses are aware of what they should be doing

but do not implement those practices at the bedside. When asked, they can clearly discuss the

importance and relevance of bedside report but simply do not conduct report at the bedside.

Nursing report fulfills an important role in communication of patient care needs. Nursing

report is conducted daily at a minimum of once per shift and more often in acute care facilities.

Examining the nurse’s perceptions of report is important for an organization to study. This is

significant knowledge to obtain to effectively implement a Patient and Family Centered Care

Model, which may include nursing bedside report. Having this knowledge will enable planners

to provide the appropriate tools for nursing to allow for bedside reporting to be successfully

implemented and adopted by nursing. Obtaining nursing perceptions and thoughts regarding this

process, feedback can be provided to the organizations where bedside report is currently not is

use. Having the nurse’s views will enable organizations to plan and educate according to the

needs of nursing not only the consumer. Bedside nursing report, which includes communication

with patients, is crucial to facilitating smooth patient care delivery throughout the hospital stay.

“The performance and function of shift handovers in health care is a widely neglected topic in

practice and research.” (Meiner, Hasselhorn, Nezet, Pokorski, & Gould, 2007 p. 535 ).

Studies and previous examinations of nursing report indicate that report is ritualistic in

nature and takes on a variety of formats such as verbal, taped and written. Additionally, report is

almost always outside the patient room in an area that is away from the patients and families.

“The nursing ritual of inter-shift handover serves the purpose of enhancing a shared value

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systems amongst nurses.” (Lally, 1999 p. 29) Report serves as a social function as well as an

educational forum for nurses to enhance ideas and knowledge as it related to the care of patients.

An issue related to confidentiality during information transfer has been identified in the literature

as an area of concern. There is a transition of power between the two shifts of nurses during

transfer of information. However it has been identified that there is inconsistency in what

constitutes nursing report and it often follows a medical model. (Davis, et al., 2003; Dodek &

Raboud, 2003; Evans, Pereira, & Parker, 2008; Hays, 2003).

Attempts have been made to standardize report and develop a tool to assist the nurse in

identifying the key points necessary to communicate information during the handover. (Bourne,

2000; Caruso, 2007; McCloughen, O”Brien, Gillies, & Mc Sherry, 2008; Miller, 1998). Little

has been studied regarding the nurse’s view of report. The literature is replete with evidence on

the patient’s views and families’ views regarding bedside report and rounding however little has

been explored regarding the viewpoint of the bedside nurse. Much of what has been studied has

been via a quantitative method with surveys.

Despite an organization’s desire to improve and have the best of the best whether it is in

technology or patient care delivery models the “key to success or failure of the project is related

to getting buy in from the clinicians who will be using it.” (Geibert, 2006, p. 207) Geibert (2006)

suggests that nurses need to know “what is it in for me?” Obtaining successful results rests on

the practitioners who will use the innovation. Referring to the implementation of an electronic

heath record, “no matter how good a system is, unless the staff supports its use, it will not deliver

results.” (Geibert, 2006, p. 208.) Hospitals are faced with the daunting task of improving

processes in a competitive market while maintaining operating budgetary margins. Leaders and

administrators have visions for improvement. However, despite innovations, nurses will

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ultimately learn to work around systems or processes that they do not like or do not understand

the reasons why implementation has occurred or that they do not value. (Geibert, 2006)

As reported by Hilz in 2000, there are multiple variables that influence nurses rate of

adoption of innovations. Individual factors, perception of technology and organizational

variables all play an important role in the adoption of an innovation by nursing staff. Individual

factors that increase a nurse’s tendency to resist change do not solely cause rejection. Combined

factors such as peer values, perceived advantage or disadvantage affect the rate of adoption and

successful implementation of innovation. This reinforces the need to examine nurses’

perceptions of bedside report in a case study approach.

In summary, the review of the literature demonstrates that bedside nursing report is a

highly complex process of information transfer, which is an integral component of nursing.

Having the correct essential information is critical to providing care. It has been demonstrated a

loss of information occurs in the reporting process therefore efforts have been made to

standardize the reporting process without success.

Theoretical Framework

The theoretical model that will guide this study is Roger’s Diffusion of

Innovations Theory (Rogers, 2003). This theory presents the process in which an innovation is

communicated through certain channels over time among the members of a social system

(Rogers, 1995). For the purpose of this project, the innovation is bedside report and the members

of the social system are the nurses, patients, family members and physicians. Rogers’ theory

provided the framework for diffusion of a pain management program in the City of Hope

National Medical Center located in Duarte California. (Dooks, 2001) Recognizing that pain

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management needed improvement, nurses with the qualities of early adaptors were purposively

selected to attend didactic training and clinical education by the pain experts. Organizational

support along with continued education and reinforcement to staff was provided. A three-month

post implementation evaluation was completed and although some barriers were encountered the

innovation (a pain resource nurse model) was maintained. “Targeting early adopters on each

unit, introducing them to the innovation of improved pain management and providing ongoing

support were the keys to maintaining a positive outcome.” (Dooks, 2001, p. 102)

Diffusion of Innovation consists of four main elements: Innovation, communication

channels, time and social systems. Innovation is a new practice idea or product that may be

perceived as new to the individual or the unit of adoption, which in this case is the nursing unit.

A communication channel is the process whereby the innovation (bedside report) is

communicated to the members of the social system (the nursing unit). The way in which the

innovation was communicated to the staff, Time, as one of the elements of the diffusion, process

is strength. Time is a process that allows the individual to make decisions once knowledge is

acquired. Time is not measured necessarily in days or months but rather in the number of system

members that adopt the innovation. (Rogers, 2003) Time measured in this study is the rate of

adoption. One nursing unit adopted the innovation more readily and another has not fully

adopted the innovation.

Characteristics of an innovation According to Geilbert (2006), the five characteristics of

innovations are: relative advantage, compatibility, complexity, trialability and observability.

According to the literature, relative advantage is when an innovation is perceived as better than

the idea it replaces. A greater perceived relative advantage of an innovation will result in a more

rapid rate of adoption. Compatibility is the degree to which an innovation is perceived as

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congruent with the values, experiences, and needs of potential adopters. Complexity is whether

an innovation is perceived as difficult to understand and use. Innovations that require the

development of new skills and understandings will be adopted more slowly. Trialability is the

degree to which an innovation may be experimentally tested (Beilenson, 2005) Observability is

whether the results of an innovation are visible to others. When individuals can see the results

and/ or benefits of an innovation, they will be more likely to adopt the innovation

Individuals can be classified into five adopter categories based on their characteristics

and responses to innovations. These groups are the innovators, early adopters, early majority,

late majority and the laggards (Figure 1). The system members are divided into categories

essentially based on the time of adoption and the attitude toward adoption. Innovators are those

who are cutting edge and risk takers. Early adopters are well integrated in the social system and

use innovations well. Early majority are those who adopt at a reasonable pace and are very

connected with the internal social system. The late majority are those who respond only when

necessary. Lastly laggards are those individuals who will resist innovation to the bitter end and

are suspicious of change.

Although Rogers initially proposed the Diffusion of Innovations Theory from a

sociological perspective, the use of Diffusion of Innovation Theory in healthcare has increased

over the past two decades. Advancement of technology and use of computerization are difficult

processes and present major challenges within the context of a healthcare setting. In the pre-

implementation phases, experienced staff does not often see technological advances as a positive

experience. It is overwhelming to some adult learners to change their practice habits, and to

adopt new methods of reporting important patient care information. As Rogers (2003) explains,

getting a new idea adopted is a very difficult task, even if it has obvious advantages. It is often a

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lengthy amount of time from when the new idea is ready for implementation to when it is widely

adopted. Therefore, the challenge for individuals or organizations is to develop a strategy or

framework on how to speed up the rate of diffusion of an innovation. The Diffusion of

Innovations Theory is advantageous in this aspect, as it creates a model that can be used from the

inception of the idea to post- implementation. It can be used by both individuals and

organizations to plan the adoption and implementation, inclusive of how to introduce it to the

users, plan the monitoring of the progress, and plan for evaluation and spread of the innovation.

The adoption of a new skill or concept in a hospital setting is often plagued with

challenges. Utilizing such a theoretical framework will guide the innovation (change) to bedside

reporting. “Diffusion is the process by which an innovation is communicated through certain

channels over time within a social system.” (Rogers, 2003, p.3) This theory supports the process

of transitioning to a bedside reporting format rather than a more traditional approach such as the

nurses sitting at a desk outside the room discussing the patient. Diffusion of innovation is simply

the spread of an idea or concept over time among members of a social system. Diffusion of

innovation takes a different approach than other theories of change. Instead of focusing on

persuading individuals to change, it sees the change primarily about the evolution or reinvention

of products or behaviors so they become a better fit for the needs of the individuals in the groups.

Diffusion of innovation offers valuable insights to the process of social change by investigating

what qualities make innovations spread successfully. This is key to this project. Illuminating the

perceptions of nurses about beside report will reveal what was successful and what was not

regarding the implementation of this process one year ago. With the information acquired from

the focus groups the researcher had identified barriers that inhibit the staff from conducting

bedside shift report and what enables those who do conduct report at the bedside. From an

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educational standpoint this is critical to implementing a new process. The importance of peer-

peer conversations, peer networks and understanding the needs of different user segments is an

important feature within the theory. (Robinson, 2009) In diffusion of change it is not the people

that change, but the innovation itself. To correlate this with this project the innovation is the

bedside report. Bedside report has been a part of nursing for many years. Nursing report is not a

new process, but conducting report at the bedside is a new practice in the hospital system. The

organization chosen for the site of the study has implemented bedside report within the past year.

It is known that some nursing units adopted this process more readily than others. Therefore this

study has examined one unit who has adopted this process more readily than another. The focus

group questions guided the group to discuss adoption rate and what has made the bedside

reporting process successful or unsuccessful.

The communication channel can be defined as the method where the innovation is spread.

The innovation (or idea) begins with the person who has knowledge about the innovation and

shares it with someone who does not have knowledge about the innovation. The innovation is

than moved via a system of channels for communication that become more complex as the

process evolves through the social system. In this study, the communication channels start with

leadership who required the change in the nursing report method from outside the patient’s room

to a bedside nursing report. This information was communicated to the nurse managers and

educators and than on to the bedside nurses. It is at this level where additional communication of

the process moves forward between the nurses—the end user of the innovation. The cycle is not

linear during this phase; feedback comes from the staff regarding additional questions and

clarification. This is the most crucial part for if clarifications are not given the outcome has the

potential to be poor. There are characteristics of the innovation that are considered prior to

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moving forward such as trialability, advantage, compatibility, observability and simplicity.

(Sanson-Fisher, 2004). Trialability refers to ability to try the innovation on a small scale prior to

actual implementation. An example would be to start the bedside reporting process on a small

unit to see what feedback is obtained. Measure the success on a small level and than move

forward after reviewing feedback and adjusting process as necessary. Reviewing goals of the

nursing unit (such as increasing nurse and patient satisfaction) and critically reviewing the

innovation to examine if this practice will makes things substantially better is considered

advantage. Compatibility is the consideration as to whether or not the innovation will work in the

current work environment and unit culture. Simplicity refers to how big of a change is this

overall; will this be practical and easy? (Rogers, 2003)

According to Rogers (2003) a social system is a set of units that are interrelated. Each

social system is related and operates as a team to solve problems as needed to accomplish a

common goal. Social systems and their methods of communication can actively facilitate or

inhibit diffusion of innovation. The social system in this project is each individual nursing unit.

As communication through channels is done within a facility or unit each member of the social

system need to go through an internal process for innovation decision-making. There are five

steps to this process that individuals use in order to decide to adopt or reject the innovation.

Knowledge is the first step and it is here the person becomes aware of the innovation and has

some idea of how it will function. Persuasion, the second step is defined as the individual

forming a favorable attitude toward the innovation, as if the individual reviewed the pros and

cons and convinced ones self that this innovation is worthwhile. Decision is the third step and it

is at this point where the individual engages in activities that lead to a choice to adopt or reject

the innovation. The fourth step is implementation and the innovation is put to use. Confirmation

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is the final step and this is a process where the person evaluates the results of an innovation-

decision that has been already made.

Theory of Diffusion of Innovation is not a new theory and has been tested repeatedly.

The theory has been used in sociology and social science as well as in healthcare. It has been

widely used in the area of information technology specifically the implementation of clinical

decision support systems in healthcare. Some of the clinical studies this theory has been applied

to but not limited to were the establishment of wound care protocols in Brazil, identification of

practice gaps in counseling, pain management research, and supporting cardiac recovery though

eHealth programs.

Theory of Diffusion of Innovation is applicable for this study as it is an easy format to

follow and guides the process from beginning to end. It is well suited as per the examination of

the literature thus far on the topic of nursing report and implementing a bedside reporting

method. However, despite the implementation, some nursing units have adopted this process

more readily than others and therefore theory of innovation is the preferable theory to utilize as a

guide to examine nurse’s perceptions and the adoption of the innovation.

Method

Stage 1.Comprehensive Literature Search

Prior to beginning the project, a comprehensive search was completed to identify all

articles related to nursing shift report. Key words for searching the literature included, nursing

perceptions of report, nursing report, shift report, nursing handover, intershift report, intershift

handover, nursing communication, healthcare communication, sign off, information transfer,

qualitative research, handover, hand off communication and diffusion of innovation. Inclusions

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were full text in the English language; no exclusion or inclusion dates were utilized. An initial

search was conducted used MEDLINE and CINHAL using the above keywords. Additional

databases searched were: PubMed, PsycINFO, Science Direct, Joanna Briggs Institute,

Scirus.com, Science.gov. Additional sites included: Agency for Healthcare Research and

Quality, National Library of Medicine, Institute for Health and Social care Research, Virginia

Henderson Library of Sigma Theta Tau International. Footnote chasing was completed for

articles of relevance to the topic under study and a question was posted on an advanced practice

nurse forum in addition to a list-serv for Magnet facilities in the United States. The table of

evidence provides a listing of the articles reviewed for this study and considered for background

and literature review.

Findings from this search indicated that:

1. Little has been studied regarding nurses’ perceptions of bedside report (Meibner,

Hasselhorn, Estryn-Behar, Nezet, Pokorski and Gould, 2007)

2. The nurse is the gatekeeper of patient information. (Howell, 1994, Poletick and Holly,

2010)

3. Patients and families prefer bedside report; their perception is that they are better

informed of condition and plan of care. (Anderson and Mangino, 2006, Bramwell,

Sheldon, 2006, Wellard, 2003 and Davis, 2003, Pothier, Monteiro, Mooktlar, &

Shaw, 2005)

4. There are many different forms of nursing report (verbal, taped, face to face, bedside,

charge nurses receiving information and than passing information on to staff).

(Bourne, 2000, Pothier, Monteiro, Mooktlar, & Shaw, 2005)

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5. Attempts to standardize report have not been successful globally. Creating change of

shift reporting documents as a guide to standardize report has also not been successful

globally. (Bourne, 2000, Caruso, 2007, McCloughen, O’Brien, Gilles, &McSherry,

2008, Miller, 1998, Holly and Poletick, 2010, Sexton, 2004)

6. Nursing report is a social event for nurses; it is not only a means of communication

amongst caregivers. It is also a way that new team members learn the ropes and

become acclimated to the nuisances of the nursing unit. (Bourne, 2000, Kerr 2002,

Hays, 2003)

7. There is a great sense of control for nurses during shift handover. (Lally, 1999,

Ekman and Segesten, 1995, Keatinge, Bellchambers, Bujack, Cholowski, Conway

and Neal 2002)

8. Nursing report is ritualistic. (Ekman, 1995, Evans, Pereira and Parker 2008, Lally,

1999)

9. Nurses perceive that there are many challenges to the delivery of report. (Watkins,

1997, Daiski, 2004, Caruso, 2007)

10. Due to the various forms of report, and lack of standardization, crucial information is

often missed during the exchange between nurses during shift report. (Hays, 2003,

Kerr, 200, Lamond, 2000, Patterson, 2004, Patterson, 2007, Pothier, 2005)

11. There is a noted hierarchy in nursing report. More seasoned and experienced nurses

prefer different information then less experienced nurses. (Wellard et al., 2003,

Poletick and Holly, 2010, Daiski, 2004, Hays, 2003, Lally, 1999, Parker, 1992)

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12. Managerial presence for constant oversight and reinforcement assisted decreasing the

rate of non-compliance. (Anderson and Mangino, 2006, Caruso, 2007, Kassean and

Jagoo, 2005, Magnet List serv)

13. Managers and educators collaborate to develop scripting to assist the staff and

practice reporting prior to implementation. (Magnet list serv, Caruso, 2007, Milner,

2005, Manojlovich, DeCicco, 2007, Pothier, Monterio, Mooktlar and Shaw, 2005)

14. Education and constant reinforcement crucial to maintain compliance with bedside

report. (Grey literature, Magnet list serv, Caruso, 2007, Royak-Schaler, Gadalla,

Lemkau, Ross, Alexander, Scott, 2006)

15. There is inconsistency in what constitutes nursing report and it often follows a

medical model. (Davis, et al., 2003; Dodek & Raboud, 2003; Evans, Pereira &Parker,

2008; Hays, 2003)

Stage 2.Study Design

This study was conceptualized as a case study of implementation of bedside reporting in

one community hospital involving interviews and observation. As the phenomenon of interest for

this project, i.e, the bedside report is a complex and highly contextualized process, with multiple

variables unsuitable for control, a case study method was chosen. (Yin, 2003). Case study

research permits the extensive study of a particular contextual phenomenon that occurs in real

life situations. Stake (1995) has proposed that case study research can take one of three forms: 1)

Intrinsic: where the case is studied for its own sake; 2) Instrumental: where the case is studied to

understand related issues or phenomena of interest; or 3) Collective: where the single case is

extended to include many cases. The case study proposed here was instrumental in nature, as the

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case (i.e. the nursing units) was studied to understand the phenomena (i.e. the implementation of

bedside reporting). Identification of the phenomenon of interest was the starting point of this

case study research. Procedural steps consist of the following: First step was to formulate the

research questions - What are the patterns of diffusion in bedside reporting on the two nursing

units selected?; What influences do the staff have on the success of the diffusion? Second,

Roger’s Diffusion of Innovation framework was identified as the underpinning theory to guide

the process and understand the integral rigor of the case study. Third, was to determine the case,

its context and phenomenon of interest. This was an important aspect of the case study because it

defined clear boundaries of the case and made the case study manageable. The context was the

two nursing units: telemetry and medical surgical/geriatric. The phenomenon of interest was the

diffusion of the bedside reporting process, its impact on the organizational structures, processes,

outcome and nursing practices. Fourth, the instrument case study design was used as the specific

case study approach. Fifth, was to identify the data collection methods most suitable to answer

the research questions. For this case these include brief questionnaires, focus groups and

observation. Sixth, analysis strategies appropriate to each data collection were selected: content

analysis, thematic analysis and statistical analysis. Seventh, analysis data will be refined;. Eight,

matrices will be used to reduce data into manageable chunks and conceptual groupings. Ninth,

conclusions will be determined and case description was developed.

Setting.

Ocean Medical Center (OMC) a 281-bed community hospital located in Brick, New

Jersey was selected as the site for this study. OMC is accredited by The Joint Commission and

has received the prestigious Magnet Award from the American Nurses Credentialing Center

three times. The units that were identified to participate in this study included a 40 bed geriatric

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nursing unit and a 40-bed telemetry unit. The geriatric unit is a brand new unit that has spacious

rooms and modernized equipment and storage space. The telemetry unit is a fast paced unit with

multiple layers of patient care equipment in the hallways and patient care areas. The geriatric

unit adopted the bedside reporting technique at a faster rate than the telemetry unit. There is

concern with the telemetry unit lagging behind in implementation. Introduction of bedside report

to OMC occurred in 2008. Nursing leaders reviewed the literature to reveal best practice for

meeting patient care needs and regulatory standards. Using a patient centered model for care

delivery with the patient actively participating in care and information exchange, bedside

reporting was implemented. The leadership of the organization led the education of the nurse

managers who than educated the nursing staff on the process. Education included power point

presentations, handouts and one to one discussion by the nurse manager to the staff nurses.

Content covered in the educational sessions were:

Reasons for implementation such as Hospital Consumer Assessment of Providers and

Systems Reporting,

Nothing without me (a book written about medical errors and the process of patients

taking charge of their care)

Improvement of nurse satisfaction along with sentinel event reporting.

The process of bedside reporting was then piloted on several nursing units. Education for

the management staff was completed May 5, 2008, the management team educated the staff

nurses the week of June 2nd and implementation began during the week of June 9th 2009. The

process has been adopted with mixed results throughout the organization as reported by

management staff, educators and direct observation of staff performing nursing report.

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Sample

The informants for this study were composed from a purposeful sample of nurses on one

of two nursing units within the setting. One nursing unit currently performs bedside reporting at

the bedside (geriatrics) and a second unit is inconsistent in its approach to bedside nursing report

(telemetry). These units were purposively selected in an effort to study the nurse’s perceptions of

bedside reporting and how it is implemented in these two units with differing acceptance of the

innovation. Questions to consider include: Why does staff on one unit go into the room to

perform bedside reporting and staff on the other nursing unit stay outside the room? What are the

differences in information transferred at the bedside or outside of the room? What are nurses

thoughts as to the location of ‘bedside reporting”? Each nursing unit has thirty nurses and a

sample of 6-8 nurses from each unit will be sought.

Nurses in these units are 24 to 60 years of age and have, on the average 10 years of

experience. The most common nursing degree held by these nurses is the associate degree; 99

percent are female.

Subject recruitment

Utilizing Roger’s Theory of Diffusion as a guide, the nursing units have been

purposively chosen based on the rate of adoption of bedside nursing report. Two methods

were used for subject recruitment: advertising, and discussion of the study during staff

meetings on the selected hospital units.

First method: Posters describing the proposed study were placed on the nursing

units in plain site. Potential participants were invited to either attend a staff meeting or

contact the PI for additional information.

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Second method. Following University of Medicine and Dentistry Institutional Review

Board (IRB) approval and Meridian Health IRB approval, the PI participated in unit-based staff

meetings where discussion regarding this study took place. The PI presented the eligibility

criteria and exclusion criteria. A letter of invitation (Appendix I) that contained information

about the project and its purpose was distributed. Information was distributed to detail that

participation was voluntary and the informants could with withdraw at any time. The participants

were asked to directly contact the researcher if they wished to participate.

Criteria for inclusion in the sample:

Registered professional nurse licensed in the state of New Jersey

Employment in a nursing role at the facility on one of the two selected units

Volunteer to participate

Criteria for exclusion in the sample were:

Limited proficiency in speaking or understanding English

Data Collection

Focus groups and brief demographic survey. A short survey was used to obtain self‐

reported information as it related to the nurses perception of their adoption to the

innovation (See Appendix III).

The focus group sessions lasted approximately ninety minutes and were conducted

away from the nursing units in a comfortable setting with chairs and tables. All interviews

were voice recorded. Light refreshments were available for all participants. An interview

guide was used to collect data (see Appendix IV). Two groups consisting of 6‐8 volunteer

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nurse informants were interviewed. There was only one group from each nursing unit. This

small number was chosen so that all participants would have the opportunity to participate

in the discussion. PI observations and field notes were taken both during and after each

focus group session to augment analysis of digitally voice recorded data. All digital voice

recordings were placed on a password‐protected USB drive and it, along with all

transcripts, was stored in a locked fire safe in the PI’s home office for data protection.

When data transcription from the Digital Voice Record was complete, its hard drive was

erased. All de‐identified transcripts will be maintained for as per UMDNJ IRB protocol.

Pseudonyms were assigned to all participants. Participants were given a nametag with

their pseudonym. These were prominently displayed and used to address each other during the

interview in an effort to maintain human subject protection. Participants at times used the

individual’s actual name, which was removed from the transcript.

The first thirty minutes of the sessions was a casual conversation regarding purpose and

introductions. The goal of this preliminary period was to develop a rapport among members of

the group and the researcher. Informants were reminded that there was no right or wrong answer

but that the investigator was interested in their own experiences and beliefs. Participants were

asked to complete a brief demographic questionnaire with five survey questions. (See Appendix

III) After initial review of the purpose of the focus group and completion of the survey, the tape

recorder and the reason for tape recoding was re-explained and subsequently the recorder was

turned on. By continuing casual conversation once the tape recorder was on, it was expected that

participants would be comfortable with the tape recorder and this would allow the group to

continue with informal dialog while becoming used to a tape recorder being on. This reduced the

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focus on taping and facilitated more spontaneous responses. Subjects were aware if they refused

to be taped or who were uncomfortable could withdraw at any time.

The topics for discussion were predetermined and sequenced. This assured similar

discussion within each group. There were two focus group sessions held. One group was the

telemetry nurses and the other was the nurses from the geriatric unit. A series of open-ended

questions addressing methods of reporting, style of reporting, affective domains of nurses as well

as the educational preparation for reporting were asked. Open-ended questions were used to

facilitate an informant-centered direction of responses. Following completion of the focus group,

the PI transcribed the tapes verbatim for subsequent data analysis.

Observation.

An attempt was made to observe each nurse who participated in the focus group to

validate and compare what was discussed in the focus group session and to observe the behaviors

and interactions between the staff and patients. An observation guide was used to provide

consistent items that were to be observed from each nurse. Only nurses who participated in the

focus groups were observed. The researcher recorded events and behaviors of nurses and

patients. The nurse researcher was familiar with the unit however is not one of the unit’s staff.

The primary researcher was the only person observing and did not participate in the reporting

process at any time nor did she participate in patient care. The primary researcher stood at a

distance but within sight and ability to listen and observe the shift-to-shift reporting process. The

overall aim of direct observation was to observe the interactions and behaviors during the

reporting process to see how well they have adapted to the innovation. Important items to note

included: 1. Did the nurses actually enter the room to give report? 2. Did the nurses speak to the

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patient/family and involve the patient/family in the reporting process? 3. Did the nurses review

assessment findings at the bedside and did they validate those findings? 4. What types of

information were handed over and in what format, i.e. verbal, hand written notes, scraps of

paper, computer reports?

Data Analysis

Survey. The survey questions and responses were entered into an excel spread sheet and

analyzed via descriptive statistics to obtain frequency of responses. This information provided

was to yield a greater understanding of the nurse’s perceptions of their rate of adoption. This

information also added to the data collected to identify self-reported information and compare to

what was revealed during focus group sessions and what was actually observed during the

bedside report.

Focus group interviews. A qualitative descriptive (QD) method was used to provide a

comprehensive summary of the questions under investigation. Sandelowski (2000) writes

that a qualitative descriptive study tends to be “low inference” (p. 335). Use of this

methodology required that there was less researcher deduction and a greater emphasis on

staying close to the surface of the subjects’ meaning. As the primary aim of this study was

to understand what nurses think about bedside reporting, it was felt that less

interpretation was desirable and thus QD was the most appropriate methodology.

All interviews were transcribed verbatim. All interviews were read and re-read by the

primary researcher. All personal identifiers were removed and pseudonyms identified

participants in the transcript record. The names of the participants were kept confidential and not

revealed to the organization management. Thereafter common themes were identified via line-

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by-line, word-by-word review of the transcripts conducted by the researcher. The transcripts

were read repeatedly, and initial metaphors or themes were identified within each. Initial analysis

strategies included note taking, constructing grids and making lists to monitor beginning

impressions. Listing assisted in monitoring of beginning impressions and creating a list of key

phrases, themes, concepts or metaphors from the transcripts. These were coded and labeled and

subsequently searched for thematic trends.

Member checking with participants of the focus groups was conducted to validate PI

perceptions. Field notations recording summarization of information gleaned during group

sessions and documentation of developing concepts performed after each focus group and during

content analysis was completed along with fact checking with group members following review

of field notes. Credibility was established by focusing on the elements of transferability,

dependability, and confirmability.

Human Subject Protection

The primary researcher, a nurse educator at OMC collected, maintained and analyzed all

data. She has no formal line power within the organization. The names of the participants are

kept confidential and not revealed to the organization. All informants are identified in transcripts

by pseudonyms only. Approval from the IRB from University of Medicine and Dentistry of New

Jersey and Meridian Health- Ocean Medical Center was obtained prior to the implementation of

the study. The study was explained and consent was obtained from all participants by reading a

written consent form for both the discussion group’s participation and observation. Informants

were asked to provide written consent to participate. The PI outlined protection of human

subjects, assurance of anonymity, all anticipated risks and benefits of participation, data

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collection and storage procedures, voluntary nature of participation, and projected use of the data

before each session.

The primary investigator completed the necessary educational components regarding

research and the protection of human rights as they relate to the research process. (CITI)

Risks and Benefits

The risks to the study included participants being identified as participating in this study.

This may have been perceived as threatening especially to those that may not have a favorable

view of bedside reporting. However, the researcher has no authority or power over any of the

potential participants so this risk is seen as minimal. Other potential risks included findings that

indicated nurses do not like bedside reporting and the organization being at risk for identification

when the study findings are disseminated. As a Magnet facility and leader in healthcare within

the state of New Jersey this may pose a potential threat to the organization and it’s leaders who

have promoted these changes. However, as it is a Magnet attribute to seek the best practice,

recommendations made by staff regarding the implementation of bedside reporting as a result of

this study can only serve to enhance OMC’s reputation in implementing evidence base best

practice and for fostering shared governance. This risk, then, is also seen as minimal.

Results

Research questions posed for this study included: Why inconsistencies are present in bedside

report? What nurses like and dislike about bedside report and what nurse’s feel is important

information to transfer during the handoff process. A case study approach was utilized. Two

different nursing units were examined; one in which the diffusion was readily adopted and

another where the adoption rate was much lower. The study revealed differences yet common

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concerns regarding bedside reporting. The main difference was the rate of adoption of the

innovation –bedside reporting. The geriatric unit performed this task more readily and discussed

including the family in report more often than the telemetry unit. However, the most common

concern about bedside reporting was the lack and inconsistency of information reported from one

shift to the oncoming shift. Concerns of not having the appropriate information to care for the

patient were paramount. Discussions ensued on how this left the nurse unprepared to deliver care

and have meaningful discussions with physicians and family members. Additionally there was

no increase seen in the observations or discussed in the focus groups regarding an increase in

patient and family participation in care as it related to bedside shift reporting. It was interesting

that the nurses did openly discuss that families will obtain the necessary needed information

whether or not they are present at the bedside during report.

Participant Description

There were a total of 11 nurses who completed the demographic survey, which was a

100% response rate (see Table 1). Of these, 74 % had with 0-5 years of nursing experience;

9.09% had 6-10 years of nursing experience and 18.81% had 16-20 years of nursing experience.

The majority of the nurses were prepared educationally through associate degree programs

(63.64%) and the remainder of the nurses had bachelor’s degrees (36.36%). One nurse was

currently in school in a bachelor of nursing program admitted that her thought processes and

decision-making have changed as a result of her course work. All participants were employed on

the day shift. On average, these nurses were 39.9 years of age, with 5.7 years of experience, and

5.9 years length of service in the facility.

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Fifteen nurses volunteered to participate in the study. Only eleven actually participated in

the interviews and observation. The majority of participants were educated at the associate

degree level. A total number of four volunteers did not participate.

Subject attrition was due to unavoidable circumstances for several of the participants.

One participant had a sick child, another had car trouble, and another completely forgot and

called the principal investigator to apologize. The fourth and final volunteer had been called in to

work the night before and was physically unable to participate due to the need for sleep.

Only nurses who participated in the interview were observed no other nursing staff

members were observed giving bedside report.

Participants responded to questions in the short survey regarding their own perception of

the rate of adoption to the innovation of bedside report. Out of eleven participants only two

(18%) felt they along with their nursing unit adopted very well to the innovation. Three nurses

(27%) felt they and the nursing unit adapted well to the innovation, three nurses (27%) were

neutral and the remaining four nurses (36%) responded that they and their nursing unit did not

adapt well to the innovation. Regarding the practice of bedside report 63.64% of the nurses

responded that bedside report was done all the time and that it was beneficial and 36.36% of the

nurses responded that bedside report is sometimes completed and felt it was rarely beneficial.

However, when asked to compare bedside report to sitting at a desk and receiving verbal report

63.64% of the nurses felt that bedside report is more comprehensive and 36.36 felt that it was

less comprehensive. Despite the higher percentage of bedside report being more comprehensive

than a traditional verbal report nurses still voiced concern in the focus groups over not having the

appropriate information given during reporting.

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Table 1

Sample Demographics for Survey (N = 11)

Age

Educational Level Years of Experience Length of Service at OMC

Nurse 1 */ 24 BSN 1.5 years 1.5years

Nurse 2 * 52 AAS 9 years 9 years

Nurse 3 */** 45 AAS 3 years 5 years



Nurse 6 */ 43 AAS 5 years 5 years

Nurse 7 */** 30 BS 2 years 4.5 years




Nurse 11 */** 35 BSN 11 years 12 years

*Participated in focus groups

**Participated in observation

Focus Groups

The primary researcher transcribed data obtained from focus groups verbatim. No

alterations were made to the transcribed data such as editing to complete sentences or insertion

of words. Transcribing the sessions assisted the PI to gain further insight to the nurse’s views

about bedside reporting. The PI was able to again listen to the emphasis on certain items that the

nurses wanted to emphasize. The transcripts were read and re-read several times. They were

transcribed and read three times without any markings. During the fourth review the PI started to

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mark the transcripts highlighting areas that were significant and words that were repeated. In the

margin on the fifth read the PI started to create categories. As these categories grew the

researcher developed additional categories to synthesize and streamline information into a few

categories of information. Ultimately the data was synthesized into one main category.

Interview

Line by line analysis of transcripts was completed. Table 2 is a list noteworthy

comments from the informant’s with notations of subcategories (10) and categories (3).

Nursing Barrier was listed as a subcategory whereby nurses felt bedside shift report was

unable to be completed based on the individual nurses’ own feelings and beliefs of the process.

Those items categorized as nursing barriers led the nurses to the decision not to report to the

oncoming shift at the patient’s bedside.

Nurse comfort zone another category, identifies statements made by the informants that

are associated with the nurse’s own physical and emotional well being as they relate to bedside

reporting. Nurses reported that they feel awkward or uncomfortable when giving report at the

bedside with some patients.

Patient barriers are identified as specific reasons related to the patient for not conducting

bedside report. These include patients who are confused, asleep, who they themselves do not

wish to participate in report because the content is repetitive, currently in isolation or become

“annoyed” with the reporting process. Interestingly enough this also includes patients who do not

understand what the nurses are discussing. One of the main purposes of bedside reporting is to

increase the patient participation in care and understanding the plan of care. It is noteworthy that

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the nurses decided not to include these patients in the reporting process, as this is an opportunity

to educate and clarify the patient’s plan of care.

Insignificant information is information transferred during the reporting process that is

not related to the patient or patient care. This information could be a casual conversation between

the nurses and patient, information that is common knowledge or information simply considered

irrelevant and not necessary to include in the time allotted for reporting. This information is

mainly social in nature and perceived as unnecessary.

Insufficient information is a category that is rather significant because this is what nurses

emphasized as problematic. This category is not having the necessary information transferred

during the reporting process, which leads the oncoming nurse to have to search for the needed

information in order to be adequately prepared to care for the patient.

Confidentiality of patient information is an issue that the nurses expressed during the

focus groups as a barrier to effective communication at the bedside. The nursing staff that

participated in the focus groups identified specific examples of breaches in confidentiality. The

examples were provided during the focus group interview as to why the nurses would not

conduct bedside reporting. The nurses felt it was not appropriate to discuss a patient diagnosis,

response to treatment or treatment plan while there may be visitors for another patient present.

This frequently occurred in semiprivate rooms. Additionally when visitors were not close family

members but rather friends it was felt that confidentially was not maintained.

Nurse Selection is a category that exposes conscious choices made by nurses as to

whether bedside reporting would be conducted. The nurses select patients to participate in

bedside report based on the perceived nursing and patient barriers.

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Managerial Expectation is a category whereby the nurses feel they do not have a choice.

The demeanor of the nurses changed during the focus group session when discussing the

mandates. While the nursing units differed in this area all of the nurses were not initially

comfortable with the items that are categorized as mandated. However with constant

reinforcement and support, the nurses on the geriatric unit became engaged and adopted the

innovation of bedside reporting. The nurses verbalized during the focus group sessions that

bedside report was expected of the manager and enforced by the management team. Bedside

report is now a daily routine that is readily performed by all staff. Despite bedside reporting

being a mandatory component of the geriatric unit managerial support plays and enormous factor

in engaging the nurses as a team to facilitate patient care and patient satisfaction with the

reporting process.

Information sharing is a category, which describes information that is transferred during

the reporting process. Within this category nurses share information related to patient care with

each other. The information shared is not always done at the bedside but rather maybe presented

in the “side bar” outside the patient’s room.

Lastly learning the ropes is a category that is defined as nurses learning the unit norms,

the expectations of the reporting process being a new employee or a new nurse.

After initial categorization all categories were than further divided into three main

areas: Nurse decision, Nurse Hierarchy and Mandated nursing actions.

Nurse Decision is a category that encompasses the subcategories whereby the nurse

makes a conscious choice not to conduct report at the bedside. These subcategories have

previously been defined but upon further review can be combined into the category of

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nurse decision because the nurses actually must decide on an action. Nurse Decision

category has the following subcategories:

◦Patient Barriers

◦Nurse Comfort Zone

◦Insignificant Information

◦Confidentiality

◦Nursing Barriers

◦Insufficient Information

◦Nurse Selection

◦Managerial Expectation

Nurse Hierarchy a category developed as a result of nursing actions that involve

nurses of varying levels of competency knowledge and tenure within a facility. Nurse

hierarchy includes the act of educating and yet being openly hostile to one another due to

lack of nursing knowledge. Hostile behavior is overt and often directed at nurses with

lesser experience of knowledge. Nurse Hierarchy incorporates the following categories:

◦Information Sharing

◦Learning the ropes

Mandated Nursing Actions a category by itself include items that are mandated by

nursing administration or regulatory agencies. Mandates are executed from nursing

leadership and when not adhered to nurses are subject to disciplinary action.

Ultimately a final synthesis of categories was made. Nurses are the gatekeepers of

all patient information. It is the nurse who ultimately decides what information will be

transferred during the reporting process; when, by whom and where the transfer of

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information will occur. Despite beside report being a mandated nursing action; nurses still

decide whether or not to perform this task.

Table 2 Selected Findings and Categorization

Finding Unit Sub Category Category Synthesis

“forced into it” Telemetry Nursing Barrier Mandated Nursing Action

“No choice” Telemetry Nursing Barrier Mandated Nursing Action

“Retaliation, threats of level one”

Telemetry Nursing Barrier Mandated Nursing Action

“Being written up” Telemetry Nursing Barrier Mandated Nursing Action

“Awkward” Telemetry Nurse Comfort zone

Nurse Decision Gatekeepers

“Uncomfortable” Telemetry Nurse Comfort Zone


“Patient hears information over and over”

Telemetry Patient Barrier Nurse Decision Gatekeepers

“patient’s are annoyed” Telemetry Patient Barrier Nurse Decision Gatekeepers

Patient is not interested anymore”


“you know the nurses that like to talk”

Telemetry Insignificant Information


“Retell story over and over again”



“You just want a quick report”

Telemetry Nurse Comfort

Nurse Decision

“Test results you don’t want to share”

Telemetry Nurse Comfort Zone


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“Person in the next bed listens”

Telemetry Confidentiality Nurse Decision Gatekeepers

“I have no problem with walking rounds”

Telemetry Nurse Comfort Nurse Decision Gatekeepers

“Seeing your patient knowing what’s going on”

Telemetry Nurse Comfort Zone


“Let me fix” Telemetry Nurse Comfort Zone


“get it over with” Telemetry Nursing Barrier Mandated Nursing Action

Gatekeepers

“Didn’t save anytime” Telemetry Nursing Barrier Nurse Decision Gatekeepers

Patients don’t know what you are talking about”


“Not your place to give information”

Telemetry Nursing Barrier Nurse Decision Gatekeepers

“You have certain nurses that tell you every time they took a breath”



“Long report” Telemetry Insignificant Information


“Get people that don’t give you any information in report”

Telemetry Insufficient Information

Information gathering

Gatekeepers

“wrong information in report”

Telemetry Insufficient Information


Gatekeepers

“You look up labs” Telemetry Insufficient Information


Gatekeepers

“Need something to write on”

Telemetry Nurse Comfort Nursing Barrier Gatekeepers

“Patient is sleeping” Telemetry Patient Barrier Nurse Decision Gatekeepers

“Patient is confused” Telemetry Patient Barrier Nurse Decision Gatekeepers

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“Not involved in the process”


“If the patient is not going to be part of report, just some information that doesn’t need to be shared with everybody”


“Worst thing –reporting is the lack of privacy, patient in the next bed has family and they all get quiet”


“I would take the person in the room and say I want you to see this”

Telemetry Nurse Comfort Nursing Decision Gatekeepers

“I have to show you step by step how to do everything? For each pt yeah so that’s another frustrating piece”

Telemetry Nursing Barrier Nursing Hierarchy

Gatekeepers

“teaching them how to do and assessment for each patient at the bedside”

Telemetry Nursing Barrier Nursing Hierarchy

Gatekeepers

I feel sorry that I have to wake the people up


“It depends on the group of people, sometimes I have a good group and I like them and ya know it does benefit certain patients”

Telemetry Nurse Selection Nurse Decision Gatekeepers

“if I know this pts confused were not going in “


“If they are awake you go in and give bedside


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report.”

I think its going as best as it can I think everyone is doing some form

Telemetry Managerial Expectation


“I think we go thru the motions because we have to”



“I just try to do it most of the time because I am the kind of thinker that the one time I don’t do it I’m going to get caught so that’s basically it’s the wrong reason”



“it’s selective its not for the right reason”



“It should be just a reporting off of the information you were given in regular shift to shift report”



“it’s selective I think we should be able to, it should be our judgment”



“we should be able to say alright lets give report at this bedside because they have something to say”


It’s nice to be able to share what we know about bedside report

Geriatric unit

Nurse Comfort Nurse Decision Gatekeepers

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with other people

I feel kind of short-changed when we don’t do it

Geriatric Unit


like when we don’t go in a room for whatever reason

Geriatric Unit

Nurse Selection Nurse Decision Gatekeepers

it could be a little like ahh ya know (shrugging shoulders) gut retching I don’t know how much they know yet,

Geriatric Unit


Not sure what to say or share

Geriatric Unit


sometimes we get mis-information that they correct us especially about what really brought them to the hospital

Geriatric Unit

Insufficient Information

Nurse Hierarchy Gatekeepers

at the desk and we were able to say really anything

Geriatric Unit

Information Sharing


so all of the nonsense gets left out

Geriatric Unit


or it is a side bar Geriatric Unit


nurses are still hesitant to go into the room because there might be some family members still there they don’t really want to interact with them

Geriatric Unit


now you have a different view and you can put the pieces together now differently

Geriatric Unit

Information Sharing


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and you can go

benefit of bedside report it permits more patient and family education

Geriatric Unit

Information Sharing


not writing it not writing down a thing and in my head I’m going write this down write this down its important but I think

Geriatric Unit

Information Sharing


that happens because of the different shifts

Geriatric Unit

Information Sharing


this is the trick to put it this way ..so I think it is important to take the time for the care of the patient

Geriatric Unit

Information Sharing


because our mother XXXXX expects that of us. And we ….we just do it,

Geriatric Unit

Managerial Expectation

Mandated Nursing Action

Perhaps its not enforced as much or there’s not somebody looking down and saying ya know this is mandatory and this is what we’re gonna do now and this is how we’re gonna do it. And if you don’t do it find somewhere else to go

Geriatric Unit


Mandated Nursing Action

and she supports everything we do so why wouldn’t we do what she wants done

Geriatric Unit



plus its concrete there’s no question you’re not

Geriatric Managerial Mandated

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in limbo about what your responsibilities are

Unit Expectation Nursing Action

The test results that are not told

Geriatric Unit

Information Sharing


We have that pre conversation about Lung CA and when you go in you say it different so that you know what I am talking about that what I count on from the side bar

Geriatric Unit

Information Sharing


If they don’t know the answer you go look it up in the computer or you go find out you can use the computer look up the H&P the consults radiology the labs and read somebody else’s notes from the day before or ten days before> but it that takes a lot of time

Geriatric unit

Insufficient Information


I think it has to starts from day one when you are hired and it starts with your preceptor

Geriatric Unit

Learning the ropes


Its also who is teaching you too right

Geriatric Unit

Learning the ropes


from the beginning sit down and tell that person what’s important to… I don’t know right from the start

Geriatric Unit

Learning the ropes


I have one of those too it is a list of what’s important to give in report I give it to people when I precept

Geriatric Unit

Learning the ropes


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Observation

Direct observation of focus group participants was completed within two weeks of focus

group sessions. This was done to validate what the participant stated they did as compared to

actual nursing practice. A total of 13 direct observations were completed. Efforts were made to

see all participants complete a full report in both oncoming and reporting off to another shift. All

participants were professional and greeted each other kindly. The main difference between the

two units when observed was the location of the bedside report. On the geriatric unit report was

at the bedside for every patient every time the Principal Investigator (PI) was present. The PI did

not come before the shift and announce her presence. Random times were selected so that the

reporting process was almost complete or already started. The PI did not participate in any way

in the report, but rather stood to the back of the group. However, once the participants were

aware of the PI’s presence they smiled and carried on without any further interruptions. The

geriatric unit reported more on the mental status of the patient and comfort levels; whereas the

telemetry unit was regimented in cardiac information and reasons for telemetry use. It is

important to note the atmosphere on the nursing units is totally different. The geriatric unit is a

brand new 40-bed unit built specifically for the acute care of the elderly patient. The unit is

modernized with large desks with long hallways and patient care rooms that are large and

spacious. Inside the room there is an area where the nurses can discuss patient care with one

another and have the ability to write and review information. The nursing unit is significantly

less noisy and lighting is dimmer during the reporting time. The rate of activity of patients

moving off the unit to testing and or walking in the hallways is at a significantly lower level than

that of the telemetry unit. There are a few physicians seen reviewing charts and going into

patient rooms.

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Alternately the telemetry unit is a fast paced 40- bed unit with bright lighting, constant

beeping noises bursting with activity at both change of shifts. At any given point there are

several patients being transferred off the nursing unit to testing, stretchers and transporters are in

the hallways moving equipment to pass through with patients. Transporters are asking nursing

questions if a patient can be transported at this time and if the patient will need the

accompaniment of a nurse. These are typical interruptions during report. There are several

physicians at the nurse’s station, additional physicians are making rounds visiting patients prior

to procedures and asking questions of the nurses, patients and monitor technicians.

Notably, members of the management team of the geriatric unit are on the unit before

7:00 am. The assistant nurse manager is present creating assignments and speaking to the night

shift about the events of the past twelve hours. The management team is walking in and out of

the rooms visible during the reporting process. He nurses in the focus group discussed the

benefits of having the managers present to filed questions and aid in the process of compliance.

The management team on the telemetry unit arrives between 8:30 and 9:00 am and immediately

discusses length of stay and potential patients for triage. The nurses are questioned as to who is

on telemetry, how long the patient has been on telemetry and if they meet the criteria to stay on

the telemetry unit.

During direct observation of bedside reporting on the geriatric unit it is interesting to note

that I watched the nurses who were about to receive report sit at the desk and highlight papers

along with retrieving information from the computer. This lasted for fifteen minutes. Afterwards

the nurses got up from the desk to look for the night shift nurse. One night shift nurse was found

reporting off to another nurse sitting at the main desk. They continued report at the desk;

however, the nurse patiently waited for them to finish and said, “I am ready.” The nurse who was

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about to receive report expected the report to be at the bedside not at the desk and she made

certain that this process was completed. Clearly the nurse reporting off knew that the expectation

of this nurse was bedside report and she would not be able to continue to give report at the desk.

The other nurse started with walking in and out of each patient room. She introduced herself by

name told the patient’s she was the next nurse coming on shift. She started cleaning and

removing unneeded items out of the rooms. She continued this process in and out of all of her

rooms until she reached the end of the hallway and met the nurse who was reporting off duty.

Having nurses who are early adopters of the innovation and act as informal leaders as such on

the nursing unit enhance the rate of adoption.

On the geriatric unit the reporting process included a head to toe assessment with a

history of the patient. There was a great emphasis on the emotional status and comfort level. The

nurses included the patient in the reporting process as it related to pain medication and

effectiveness. Also included were other measures of comfort that alleviated the patients pain and

projected plans for discharge.

Nurses on the telemetry unit were observed to be primarily interested in medical

diagnosis and medical interventions during the bedside reporting process. All of the nurses

began report by performing “walking rounds”. They went into each room to briefly observe on

the patient. All of the nurses greeted the patients and small conversation regarding their comfort

level ensued. Little interaction with the patients was noted. When family members were present,

they were acknowledged but not specifically included in the conversation. Family members were

not asked if they had any questions or if they understood the transaction during report. However

if the family member did have a question, the question was answered in a polite professional

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manner. The average bedside shift report lasted 12.5 minutes per patient on the telemetry unit

and 6.2 minutes on the geriatric unit.

On the telemetry unit the questioning often began with “are you back tomorrow?” This

determination filtered the amount of information that the oncoming nurse would write down or

the amount of history information that was handed off. If the nurse was coming back the next

morning or evening information was not as lengthy and detailed. If the nurse was not coming

back a more detailed report was given and the recipient would write down more information

because he/she knew they would be required to have this information for the next person. The

next piece of information that was routinely asked was “why is the patient on tele?” This is a

standard expectation that all nurses are aware of why the patient is present on the telemetry unit

and what rhythms and treatments they are receiving. This information is crucial for monitoring

length of stay and bed management. This is done twice daily and therefore an expectation of the

nurses. The detailed information that is asked of the nurses both giving and receiving report on

this unit are related to cardiac diagnoses, treatment and management of patient care. The nurses

clarify when they are to draw the next laboratory tests; they clarify the cardiac rhythms by

questioning and actually looking at the rhythm strips. Chart retrieval to review physician’s

progress notes was an additional method the nurses used to clarify reported findings on cardiac

rhythms.

Chest pain was an area of concern, which prompted additional questioning of each other

during the reporting process on the telemetry unit. Clarification of characteristics and methods of

pain relief were always asked. Additionally if a patient had experienced any pain through any

shift, during walking rounds the nurses specifically told the patient to report any return of pain

immediately and the nurses always asked if the patient had any pain at the present time.

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The telemetry unit focused on a medical model whereas the geriatric unit based report

more in a holistic manner regarding patient care that included medical diagnoses but focused on

treatments and interventions along a greater emphasis on the emotional status and comfort level

of the patient.

Table 3 Observations

Observation Number

Number of Participants

Length of time Number of interruptions

Pt/Family Participating

1 2 20 minutes 6 Call placed to a family member for consent

2 2 10 minutes 3 Discussion on cath and consent needed

3 2 20 minutes 0 none

4 2 15 minutes 2 Patient and family did participate in report and thanked nurses for care received today and for information

5 2 5 minutes 0 0

6 2 10 minutes 0 0

7 2 10 minutes 0 0

8 2 10 minutes 2 Patient and family participation regarding explanation of wound care

9 2 5 minutes 0 Explanation of mental status and methods to calm patient

10 2 7 minutes 0 Patient participated discussed pain relief status along with medications and other measures that relived her pain

11 2 4 minutes 1 Patient was included in the reporting process to discuss the effectiveness of

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medications and relief of symptoms

12 2 7 minutes 2 Patient was not able to participate in a meaningful manner however nurses introduced selves and told the patient who would be staying for the day and who would be leaving.

13 2 9 minutes 1 Mental status and treatment plan regarding discharge disposition discussed Physician rounded and discharge planning reviewed with nurse.

Table 4 Interruptions to Nursing Report

Observation Number Number of Interruption Content of Interruption

1 6 1-Asked secretary to place call to family

2- Call placed to pharmacy re: pre procedure medication

3- Transport interrupted reporting process for transport question regarding another patient.

4-MD asked questions of the nurses

5- MD returned requesting information that the nurses did not know and MD was unable to retrieve information. The nurse stopped report retrieved the chart and obtained the information to convey to the MD.

6- Cardiac Catheterization lab called the nurse regarding the patient status.

2 3 1-Transport spoke to the nurse to see if

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another patient could be taken for testing.

2- Patient care technician came to nurse to alert of her of another patient’s elevated blood sugar.

3-Lab called with a critical result.

4 2 1-Transport ambulance service called nurse to discuss status of patient and stability for travel.

2-Lab called with a critical result

8 2 1-X-ray called for a mode of transport for the patient

2- Call placed to family for consent

11 1 1-Another nurse requested to use the portable phone

12 2 1-Patient care technician came in to discuss mental status of another patient.

2- Family phone call to check on another patient.

13 1 1-Physician rounds and discussed plan with nurse.

Table 5 Information Transferred During Report

Observation Number

Information Transferred

1 Concentration on chest pain and cardiac rhythm. Vital signs, lab reports, procedures done throughout the day and what needs to be completed for the oncoming shift. Medications administered and on call for cardiac catheterization lab procedure. Assessment findings –head to toe method used

Vital to the start of the day was the fact that the patient was going for a cardiac catheterization and there was not a consent on the chart and the patient was scheduled within the next ½ hour and had already received pre-procedure medication.

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2 Head to toe assessment, clear concise reporting of labs, vital signs, general condition, emotional status of impending catheterization, procedures done and medications to be administered and need for consent for cardiac cath.

3 Great detail discussed on why the patient was transferred to the telemetry unit, what the cardiac rhythm was and the current plan of care. Probing for additional reasons of admission and medical history, discussion regarding appropriateness of patient transfer and concern over possibility that the patient will soon be triaged off the unit.

Nurse to nurse “negative assessment”

4 Clarification of telemetry rhythm included background history and why the patient was on the telemetry unit. Head to toe assessment reported inclusive of lab values and vital signs Discussion regarding getting a bed at another facility for additional procedures.

5 Clarification of cardiac rhythm, head to toe assessment, lab values, vital signs, general condition, procedures necessary for next shift, medications administered and general assessment findings.

6 Minimal questioning, regimented head to toe assessment findings reported along with vital signs, lab results, procedures completed throughout stay medications administered and necessary items to complete during the next shift.

7 Clarification of treatments and testing performed, vital signs, lab results, procedures completed, general condition, procedures necessary during the next shift.

8 Specifics on wound care regimen, emotional status and pain status. Medications and treatments that were used to alleviate the pain, vital signs, lab results, procedures completed and necessary care for the next shift.

9 Specifics on methods to calm patient were discussed. A geriatric chair that provided comfort and safety for the patient was moved into the room. Nurses discussed activities that held patient’s interest and assisted in calming patient were key components

10 Inquires and discussion surrounding wound care, dressings for the care and radiology reports. Plan for discharge and needs for discharge was discussed. The comfort level of the patient was a primary concern and methods for relieving discomfort other than pain medication were reviewed such as positioning, activity and distraction.

11 Specific inquires were made to the patient’s level of comfort and rest. Interesting to note, this patient was on isolation and the nurses did go in and report off to one another with interactions and participation from the patient. Nurses discussed at great length the patients blood pressure and current treatment

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regimen.

12 Considerable discussion on plan of care and discharge. This was a Monday morning report and “nothing was done with the patient over the weekend” and the nurses were worried about the length of stay and why the patient was not moved over the weekend. It was noted that a note was left in the chart for the case manager to contact the day shift nurse as soon as she arrived.

13 Plan for care after discharge and planning for the actual discharge discussed with reporting nurses and physician.

Inconsistencies were found in report because different aspects of patient information

were prioritized differently among nurses. Nurses base the questions they ask of one another on

the questions asked of them throughout their shift. Nurses become accustomed to the routine

questions asked by specific physicians and will seek out the information so that they are prepared

when the physician rounds. Likewise events such as special procedures and a patient discharge, a

specific line of questioning may be prompted. The patient diagnosis and specialty of the nursing

unit is a major factor in the information that is transferred during report. Nurses who are newer to

the role, the nursing unit or who are temporary staff may provide the oncoming nurse a different

report than they are accustomed.

Inconsistencies are present as nurses learn reporting from one another. There is not a

standard method of reporting that is currently utilized nor is reporting officially taught in nursing

education programs. Despite recommendations from JCAHO on reporting nurses continue to

decide on what is necessary to include and exclude in report. When nurses enter into the work

force they learn through a preceptor. Nurses adopt what the preceptor feels is important to

include in report. As they advance through a career, a nurse develops his or her own reporting

style and inclusions of patient information based on experiences.

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During the observation phase of this project, it was noted different nursing specialties

require different information to be passed on from shift to shift. For example, the telemetry unit

is very focused on vital signs, laboratory results and continuous electrocardiogram monitoring.

Due to the high demand for beds, the nurses must be intimately aware of why the patient requires

telemetry monitoring; this is something that is reported to each other during nursing report.

When the nurse manager rounds this is one of the first questions asked of the nursing staff.

Whereby on the geriatric unit, patient behavior and response to others is paramount to report to

the oncoming shift. Due to the nature of the patient mental status and response to others, the

nurse’s bedside report consists of what interventions work to calm patients and maintain

orientation during the hospital stay. Additionally for this population, change is so disruptive;

the plan of care for discharge is discussed in every report. It is a priority to return the patient to a

familiar environment.

Nurses felt the reporting process took much longer than necessary because they were

stopped by interruptions to deliver patient care during report. Noted in Table 3 are a list of the

interruptions that occurred during the observation phase of the study. Nurses are repeatedly

interrupted often regarding patients other than the one they are receiving report on. Interruptions

lead to the need to change focus, work flow and are often frustrating to the nurse as reports may

become lengthy or shortened due to needs that must be addressed promptly.

Specific examples of confidentiality concerns and inappropriate comments made by

roommates were revealed within the focus group sessions. This was disturbing to the nurses, they

felt the patient’s privacy was being violated and they were unable to control the behavior of the

roommate. Furthermore nurses disliked the fact they were unable to probe the nurse who was

giving report for additional information. Clearly there is a disparity among reporting techniques

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of nurses and often nursing report will lack critical information. Nurses do not want to point out

the shortcomings of other nurses and therefore will seek out additional information after the shift

report. This causes great anxiety and places the nurse in a position where he/she is not prepared

with adequate information to care for the patient. Subsequently the nurse will need to retrieve the

data needed. This process is time consuming and will place the nurse at a disadvantage as it

relates to time management. Nursing care is delayed as a result of searching for information.

Nurses feel awkward and uncomfortable giving report at the bedside. This was

validated during the observation portion of study; nurses appeared nervous and rushed

while inside the patient’s room. The nurses appeared less nervous and were much more

relaxed and confident while giving face to face report outside of the patient room. Nurses

are afraid they are going to verbalize information that may be inappropriate or discuss a

finding that the patient is not aware.

“I know we just have our papers and say it…. just say …a CAT SCAN shows mets CA I just circle it (the words ) and nod to the other person and go, so ya know…. and say well ya know she’s open for this….. just so that the patient doesn’t know what going on but than you continue to talk to the nurses”

This uncomfortable feeling lead the nurses to utilize their own nursing judgment as

to what to include and not include at the bedside. Significant information will continue to

be handed off to one another but this will be done in a “sidebar” outside the patient’s view.

On the geriatric unit the nurses enjoyed having the families present. These nurses

are able to validate the care provided and give the family reassurance about the patient

response to treatment and discuss the plan of care. Even though the telemetry unit nurses

did not overly express as much pleasure with family members presence during report, they

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felt it unnecessary and “rude” to ask family members to leave during report. This surfaced

when the focus group was discussing confidentiality and the interviewer asked if the

nurses asked the family members of the patient in the next bed to leave during report. The

nurses clearly felt that it was rude and they did not want to impede on the visiting session.

“but they do kick them out at 8 o’clock at night, we’re coming in at 7‐ 730 to give report and your telling the family member they have to leave and then they have to leave in 30 minutes anyway and you are taking another 10 minutes out of the visit and they just drove an hour……. that’s rude.”

Discussion

The findings of this study are similar to those found in other studies completed on

bedside report. (Meibner, Hasselhorn,Estryn-Behar,Nezet,Pokorski,Gould, 2007, Miller, 1998,

McCloughen, O’Brien, Gillies, McSherry, 2008, O’Connell, MacDonald, Kelly, 2008.) Nurses

are uncomfortable with discussing patient care status in front of others. Expressions of concern

related to violations of confidentiality and federal regulations regarding privacy laws were

repeatedly discussed in one of the focus groups.

Nurses control the information passed on from shift to shift based on the patient’s

condition, the unit norms and whether or not the nurse as an individual feels it necessary.

Variations exist among nurses from different units as to what is important or necessary to include

in the bedside report. Despite having a preprinted guide with pre-populated information, nurses

continue to use their own personal methods to determine what questions to ask and what is

necessary to include or exclude. A participant in the focus group refers to her own list of

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necessary items to include in the reporting process. As she educates fellow nurses, she shares this

with the new nurse to use as a guide.

“I have one of those too it is a list of what’s important to give in report I give it to people when I precept and if we are in report like I have somebody I am precepting now when she’s giving report if she’s forgetting something like the person I am precepting now I have to say she may start at the radiology reports and I have to say to her you have to start from here (pointing to her head) and shell back up and go all the way down and than will tell why they’re here uhmmm but I do have a list…a piece of paper”

The geriatric unit approaches the lack of information in report in a

different manner. This unit is engaged and empowered to promote education and

staff development.

I think one of the pitfalls in report is like you might start off with a patient who came in nausea and vomiting and abdominal pain than they skip to had a hip and spine x-ray…well ok what happened to the nausea and vomiting and abdominal pain.? Has it resolved? Laughter you have to also know how to re orient the person giving you report just as an orientee like just go back and say wait wait and back up? And where are they from? So I think a lot of times were are continuing educating each other the same way.

Additionally they are engaged and empowered with advancing their

education. They compare themselves to those that are not.

“I think another aspect that is interesting is that the majority of nurses on this unit are in school or going back to school and we believe in nursing as a profession and continuing education where as maybe other units that have a more difficult time with this maybe they might not all be interested in going back to school and enhancing their careers”

Contrary to the nurses on the geriatric unit, the nurses on the telemetry

unit find it disrupting to educate and validate findings to other nurses during the

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reporting process. Below is an excerpt from the focus group with the nurses

discussing amongst each other frustrating points they find as a result of bedside

reporting.

“I don’t have 20 min for you to listen to their lungs and I want to get on with report, you can’t give the responsibility to the next shift cause ’re constantly like oh well …..what? and than this …..and I’m like do I have to show you step by step how to do everything? For each pt? yeah so that’s another frustrating piece”

“yes but there’s a few people who are just not willing to take on so you just basically”

“doing their assessment for them”

“teaching them how to do and assessment for each pt at the bedside”

“it’s true!!!”

Nurses who did not readily adopt bedside report did find it necessary to complete walking

rounds to validate the verbal information.

Waking rounds was perfect’ that was a good way to see things from the start…. Before we did…they are good because before we did walking rounds you went in and you found IV’s that were empty things weren’t done patients are a mess…… like really when was the last time you looked at this person?

Yes you saw your patient , your patient saw you

Know you know what is going on and when you do walking rounds and you see a patient like that your like oh let me fix this for you ….before you leave….. like I m not going to leave them like a train wreck when they pulled out an IV… like they are like ok I will take care of it or you are not walking into something or leaving somebody with something there is no big surprise. I like doing walking rounds when I am coming and going

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Memorable moments for both groups included finding a patient in distress and being

able to act and intervene with success in a timely manner. Both groups reported finding patient’s

in distress and having both shifts present to assess the situation and report findings as beneficial

to patient care and nursing process.

“I mean there’ times like…remember that time you walked in with that one nurse into 46 and the patient was like half dead in the bed? Do you remember that?”

Laughter from the group

“Do you remember that? Do you remember that? and you were like what’s up with this and they are like oh yeah they have been like that all night and than we called a rapid response?”

Another participant expressed similar findings during bedside report:

“There is something but I think it is the times that it just occurred we were starting to go into bedside report and ok so it is a few minutes after 7 pm at night I walk into the room and the nurse but A bed is not looking good and she starts to seize if we hadn’t walked in at that time we would not have been in there for 20-30 min we would have been at the desk giving report the patient would have been seizing a long time we called a Rapid Response and in a minute or so….. and of course I think it is just timing but we were all there and got the appropriate care right away . Maybe just a timing thing.”

Both focus groups had similar concerns of the disparity between the information

conveyed between the night shift and the day shift. The oncoming day shift often asked more

questions of the night shift nurses reporting off due to learned experiences. The experiences of

being questioned by family members, physicians and other members of the healthcare team

molded their questioning technique as to what is important to include during the reporting

process:

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“Like you see they got extra potassium yesterday and you ask why and they are like I don’t know, so you ask what it was at and they …. I don’t know it’s things like that ya know.”

“Yea and like they don’t know where anything is and what the labs are and they have no idea how busy it can be for us who have to investigate and get the information for the doctor and he’s like what was it last night, where is it and your like give me a minute I have to find that information”

“they don’t have to know the big picture, they don’t have the doctors on the floor they don’t have family asking questions they have nobody asking them those million questions they don’t have to know they should know it of course but”

Similarly the staff from the geriatric unit expressed concerns with the lack

of information received to perform adequately during the next shift.

They don’t have anyone asking them questions and they can get away with it

But than the next shift …how are they gonna know the whole picture

we have to look it up

go fish

Yeah go fish

Not having the necessary information needed causes delays for the oncoming shift.

Nurses will gather additional information from several difference sources whether it is a

computerized source or a hard copy of the medical record. Nurses find themselves asking the

questions and not receiving the information. Nurses fail to continue to probe because they do not

want to cause worry and fear in the patients nor do they want to make the nurses appear

incompetent.

You can’t stop and question somebody to the point you want to about it …without making the patient afraid now or ya know… or like making the nurse look stupid like my CBI …at one point when

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they didn’t know how to calculate the true urine and I’m trying to ask that simple question at the bedside and they

Didn’t have any idea what you are talking about

So I mean and that’s you make them look stupid when you are asking over and over again but again

Yea but it so…

Yeah but if you don’t know what a true urine is and you’ve been a nurse for a while…

But you want your patients to not to be afraid

All talking at the same time…no no you don’t want them…to be afraid

You don’t want them afraid

Yeah and the patients think this one took care of me all night long and you she’s got not clue what she’s doing

And she doesn’t know what that means?

I think that kinda have a clue at that point from certain people…they know they don’t have a clue

Conclusion

This case study was conducted to gather information why one nursing unit would adopt a

bedside reporting technique better than another. Nursing unit culture and leadership expectations

play an enormous role in the adoption of bedside reporting. Even when unit managers are

supportive of the process if they are not present to monitor and enforce the practice of bedside

reporting, workarounds will occur. As the unit management team actively supports the process,

nurses gradually become accustomed to the practice and actually feel “short changed” when

report is not at the bedside.

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Findings reveal that missing pieces of information remain during bedside report. A

significant finding is that nurses are the gatekeepers of information and decide what to include in

report based on personal experience and the type of patient they are rendering care to. Not only

do the nurses decide what to include in report they decide what patients they include in the

reporting process when giving bedside report. Bedside nursing report is selective based on the

nurse’s perceived benefit for the patient and if the patient will actually participate in the

reporting process. This occurs despite the mandate for bedside report.

Comparing the units examined, the rate of adoption was directly related to the manager

input, feedback and presence. Additionally the nurses on the unit whose rate of adoption was

superior had greater involvement in shared governance roles within the unit, were actively

involved in research, performance improvement projects and were currently pursuing bachelors

degrees in nursing. Although only one nurse in the focus group on the geriatric unit was

currently in school for a BSN; the group discussed that many of the nurses on the unit were back

in school and involved on unit level projects. The nurses on both units had similar years of

experience and basic nursing competency however one group (the geriatric group) were simply

more involved in unit level activities compared to the telemetry group.

The inconsistencies noted in the reporting process were similar on both units. Both units

had areas of missing information, and intentionally selected the information passed on in the

reporting process. Both nursing units chose the information that would be passed on in front of

the patient had a discussion in a side bar outside of the patient’s room. Inconsistencies were

present due to comfort levels of nurses, varying degrees of nursing knowledge, positive and

negative experiences in the nursing profession and the type of nursing care provided. The level

of patient acuity and type of nursing care provided led the nurses to decide what information they

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felt was important to transfer during report. The geriatric unit nurses did not prioritize lab data

(i.e. the potassium level) as high as the telemetry unit nurse. Nor did the telemetry nurse unit

highly prioritize the activities that kept demented patients calm and less anxious. Whereas the

geriatric nurses saw value in playing cards with the patients to decrease anxiety, telemetry nurses

did not view this as a nursing intervention. Their focus of care and nursing interventions were

closely linked to that of a medical model of care regarding preserving cardiac function and

optimizing cardiac output.

The nurses of both groups liked being able to see the patients early in the shift rather than

forty-five minutes to an hour into the shift. Also both groups liked being able to validate reported

findings with visual observation of items such as wounds, dressings and surgically placed drains.

However the telemetry unit pointed out that the same could be accomplished with walking

rounds. The nurses from the telemetry group verbalized more dislikes as it related to the actual

process of being at the bedside. The nurses expressed concerns of physical discomfort in not

having a comfortable writing surface and having to stand for the entire report. Although three of

the geriatric nurses also discussed feeling awkward during bedside report, the majority of the

geriatric nurses felt comfortable. The telemetry nurses did not like reporting at the bedside at all;

they felt it violated patient privacy and they needed to be more selective with reporting findings

to one another.

Implications for Practice

A consistent guideline is necessary in order to facilitate a transition of care between shifts

so that information is not lost. However a guideline needs to be developed that will take into

consideration the nurses personal needs as well as those of the patient. Additionally guidelines

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specific to the specialized unit of nursing care needs to be explored and developed. It was clear

during this case study that the information transferred between shifts is different based on the

shift worked and the specialty of the nursing unit. Clearly the nurses have different priorities and

perceived knowledge needs that are used individually as a guide to the reporting process.

Nursing leadership presence on the nursing unit during shift reporting positively impacts

the adoption rate. Leadership presence reinforces the innovation and hastens the adoption

process. The staff is aware of the expectation and is held to the standard. During initial

implementation it may be beneficial for nurse managers to be present during the report to assist

and guide the bedside nurse. Having leaders available adds a dimension of comfort to the nurse if

a dilemma arises during the reporting process.

A nursing unit schedule that provides overlapping coverage of ancillary personnel to

answer phone calls and assist with call lights during walking rounds will minimize interruptions

during the reporting process. Additionally nurse leaders such as assistant nurse managers can

provide coverage to aid physicians and receive calls from the laboratory regarding critical values

during the time of report, which will in turn lessen interruptions.

The addition of an educational component about nursing report to nursing schools and in

hospital nursing orientation would be beneficial. Such a component would assist the new nurse

in the identification of important features that are necessary to include in report. Curriculums

within nursing schools do not offer formalized education on the reporting process and this is

often a technique of learned behavior.

To enhance rates of adoption through an organization it is imperative to identify the

informal leaders on the nursing unit when implementing a large change in nursing practice.

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Targeting these individuals and providing them with the necessary education regarding the

innovation will assist in the rate of adoption. Educational sessions for the staff champions should

be off campus. Highlighting these early adopters and making them feel valued will greatly assist

in the rate of adoption. Staff nurses respond well to other staff nurses and having those

individuals lead the implementation of an innovation such as bedside report will have a greater

impact than having the administration “tell the nurses” a change in practice is necessary.

The final implication of this study is for leaders to reconsider the method of giving

bedside report. Leaders in health care organization need to listen to the voice of the bedside

nurse. Both nursing units explored in the study discussed the redundancy of information and the

need to select the information passed on in front of the patent. While the intentions of bedside

report are meant to satisfy various needs of patients, families, nurses and the organization itself,

similar benefits can be achieved from a modified bedside reporting technique seen in walking

rounds which include the introduction of the oncoming care giver, a brief synopsis of the patient

status and a review of the current plan of care.

Implications for Research

Additional focus group study as well as large scale questionnaires regarding the use of

bedside reporting may be helpful in identifying methods to improve nurses’ comfort level with

such reporting techniques.

Additional research is indicated to explore the how nurses determine what is important to

include and withhold in the reporting process. Nurses are the true gatekeepers of patient care and

patient information. Nurses decide on what information they act upon and what information they

report to one another. Nursing report remains a very complex process that serves multiple

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functions. Further exploration on how nurses process information is needed. Examining how

nurse decision-making is influenced by the nursing unit and level of nursing experience could

provide insight as to how nurses become the gatekeepers of information and why they choose to

share certain aspects of information the way they do.

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Author(s) (year)

Title

Journal Country of

Origin

Study Design Data Collection

Method

Description of

Subjects

Salient Findings

Anderson, C.D. and Mangino, R.R. (2006)

Nurse Shift Report Who says you can’t talk in front of the patient?

Nursing Administration Quarterly

30(2) 112-222.

USA General Article Case study on one nursing unit that implemented bedside shift reporting at a 600 bed urban medical center

Focus was on patients requesting more information, patient centered care and frequent updates on health status of the patient.

Staff nurses sought control by developing routines and transition.

A well defined methodical process was utilized to implement report and staff was educated regarding this process.

Resources were provided to the staff to promote success-handouts, laminated pocket guides and a unit manual with detailed content for nursing reference and a detailed letter to patients and families about the process.

Athwal, P. Fields, W., Wagnell, E.

Journal Nursing Care

USA General Article The article describe as clinical nurse led initiative that changed

Challenges were met to implementation due to changing of long term

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(2008)

Standardization of Change of shift report

Quality 24(2) the traditional reporting from a conference room to a combination of written report and verbal report at the patients bedside.

nursing practice.

Bedside staff support was integral to implementation.

Process was initially a trial to compare best practice with current literature and redesign reporting according to need.

Time spent on report was considerably decreased.

Fall rates decreased because nurses rounded earlier and were able to meet immediate needs of the patient.

Standardization of reporting information.

Australian Council for Safety and Quality in Health Care March 2005

Clinical Handover and Patient Safety Literature review Report

Australia Literature Review Report

Three major domains relating to handover variables were identified:

System design factors-policies procedures work systems and routines, supervision, information tools and systems, and differences in computer based reports and written reports as well as checklists, tape recording devices are used as methods of

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communication.

Organizational cultural factors communication between providers impacts patient care and interpersonal relationships influence communication ability and willingness to share information.

Individual factors-variables related to knowledge, skills and attitudes.

Bourne, C. (2000)

Intershift report a standard for handover

Nursing Times Research

UK General Article Various types of handovers (bedside, written, verbal and non verbal)

Purpose of handover was identified (managerial, psychosocial-ritualistic and passing on responsibility)

Need to standardize reporting-tools have been developed to use as a guide

Intershift reports most important mechanism to convey important information to others

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Bramwell, R., and Weindling, M. (2005)

Families views on ward rounds in Neonatal Units

Archives of Disease in Childhood

UK Short structured interview

34 tertiary prenatal centers

Information is acquired

Could over hear what is happening with others

Families felt included and actively participated in care

Despite information being obtained there were too many people rounding and this is intimidating.

Budz, B. McConechy, M.C. (2007)

Quality Improvement Initiative: Clinical Bedside Rounds

Canadian Association of Critical Care nursing Journal

British Columbia

QI Project Utilization of a tool made a significant difference in improving communication and keeping the family informed.

Cahill, J (1998)

Patient’s perceptions of bedside handovers

Journal of Clinical Nursing

UK Qualitative research design utilized in grounded theory

Unstructured tape recorded interviews

10 Informants recruited one day before discharge

Maintaining professional distance

Patients identified a clear divide between themselves and nursing staff

Patients did not like professional jargon

Patients did not feel they had full understanding of their illness to enable them to initiate dialogue.

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Caruso, E. M. (2007)

The evolution of Nurses to nurses bedside report on a Med Surg Cardiac Unit

MedSurg Nursing 16(1)

USA General Article Nurses view report as the “sacred cow”. Despite education and knowledge consistent reminders and support with the bedside report process was needed.

Nurses did not want to interrupt patient to move report along.

Some nurses were more comfortable with communication than others

Nurses were educated on process prior to implementation

Inconsistencies with compliance –frustration with redundancy of having the patient listen with every shift change

Charlton, C.R., Dearing, K.S., Berry, J.A., and Johnson, M.J. (2008)

Nurse practitioners’ communication styles and their impact on patient outcomes: An integrated

Journal of the American Academy of Nurse Practitioners

USA General Article

Literature review

Communication styles were described in the literature: Biomedical and biophysical.

The biophysical communication style which includes patient centered communication positively influenced patient outcomes by improving patient satisfaction, increasing compliance with

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literature review treatment plans and improved patient health.

Currie, J. (2000)

Audit of nursing handover

Nursing Times UK General article discussing an audit process to gather information on nursing handover.

Results of the audit highlighted the need for patient involvement.

Handover should be done utilizing relevant information from current care plans and pathways to ensure accuracy of information.

Only 20% of handovers took place in the patient’s room.

Only 60% of the group observed used nursing documentation as part of the handover process.

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Daiski, I. (2004)

Changing nurses’ dis-empowering relationship patterns

Journal of Advanced Nursing 48(1)

Canada Descriptive and Exploratory

Interviews with nurses that were audio-taped, transcribed and analyzed for themes.

Twenty staff nurses from a large Canadian city. Participants were deliberately chosen so as to obtain views from nurses of various age groups, diverse educational preparation and practice experience.

Themes identified:

Nurses look up to other professionals; nurses eat their young, role of women and societal expectations of women and nursing.

Nurses largely remain an oppressed group dominated by those considered to be more powerful such as physicians.

Nurses feel they are not considered in the decision-making process and they do not feel respected by physicians.

Davis, S., Kristjanson, L.J., and Blight, J. (2003)

Communicating with families of patients in an acute hospital with advanced cancer.

Cancer Nursing 26(5)

Australia Exploratory qualitative Focus group interviews Sixty nurses from a major metropolitan teaching hospital from Oncology/cancer surgery/radiotherapy wards

Most significant finding was that of team communication. This has been found to be central to the quality of nurse-family communication.

Clear role definition for the nurse needs to be identified to decrease barriers related to communicating bad news to patients and families.

Dodek, P.M. and Raboud, J. (2003)

Explicit approach to rounds in an ICU improves communication

British Columbia

Quantitative Utilization of survey Assistant head nurses, Pharmacists, medical students, respiratory therapists, fellows and

Improved communication and satisfaction of health care providers is achieved when a clear explicit approach to clinical and

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and satisfaction

attending physicians. educational responsibilities along with reporting assessments and plans for patient care are implemented.

Donaldson, N., Rutledge, D.N., Ashley, J. Lt Col. (2004)

Outcomes of Adoption: Measuring Evidence uptake by individuals and organizations

Worldviews on Evidenced Based Nursing Third Quarter Supplement

USA General article When changing nursing practice to enhance evidence based patient care, managers must integrate monitoring and evaluation, which are specific targets and outcomes.

Case example presented on decreasing falls.

Roger’s Diffusion Theory is used as a guide.

Dooks, P. (2001)

Diffusion of Pain Management research into nursing practice

Cancer Nursing 24(2)

Canada General Article Using a Roger’s theory as a guide using evidence based practice as a guide to the development of pain management strategies that were evidenced based.

Barriers to implementation remain.

Practice was not sustainable.

Dowding, D. (2001)

Examining the effects of

Journal of advanced Nursing

Scotland Experimental methodology-factorial design with two independent variables

Nurses were randomly placed in experimental conditions (4 groups) and were played an audiotape of shift

Convenience sample of 48 nurses working in general medical and surgical wards

First question-altering the structure of shift report would affect the nurses’ ability to access appropriate knowledge

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manipulating information given in the change of shift report has on nurses’ care planning ability

report. During the report they were encouraged to take notes as they normally dp. Afterward report they were asked to count backwards from 100 to 1 and than they were asked to write down as much information as possible that they could recall from report.

and plan patient care- the results indicated that shift reports were retrospective in nature

Overall ability of nurses studied to accurately recall information heard during report is limited.

Second question of altering the information content of shift report would affect the nurses ability to access appropriate knowledge and plan of care.-indicated the recall would be higher of content was manipulated.

Ekman I., Segesten, K. (1995)

Deputed power of medical control: the hidden message in the ritual of oral shift reports

Journal of Advanced Nursing 22

Sweden Ethnography/Qualitative 10 oral shift reports were observed and tape-recorded and subsequently transcribed verbatim.

RN’s and LPN’s Report is ritualistic in nature.

There is a clear pattern of handing over power and control of patient care.

Reports were not used as a means of communicating nursing activities but rather they were retrospective in nature and discussed medical issues.

Evans, A.M., Pereira, D.A., Parker, J.M. (2008)

Nursing Inquiry 15(1)

Australia General article reporting on the findings of a study that considered how anxiety functions to organize nursing

Nursing report is ritualistic and keeps nursing anxiety under control thereby enabling the nurse to practice.

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Discourses of anxiety in nursing practice: a psychoanalytic case study of the change of shift handover ritual

practice. Handover allows the anxiety to be displaced onto the next nurse who will care for the patient.

Fink, R., Thompson,C.J., Bonnes, D. (2005)

Overcoming barriers and promoting the use of research in practice

Journal of Nursing Administration 35(3)

USA Descriptive cross sectional pre survey and post survey design

Barriers to research utilization scale and the Research factor Questionnaire

A convenience sample of RN’s employed at a large university affiliated Magnet Hospital215 responses with pre implementation and 239 responses post implementation

After baseline data were collected the Professional Resources Practice outcomes research manual was distributed to all nursing units in addition to multiple organizational strategies such as addition of evidenced based nursing philosophy, research competencies journal clubs, grand rounds.

Journal clubs was a key strategy to facilitate the use of research by the nurses.

Geibert, R.V. (2006)

Using Diffusion of Innovation concepts to enhance implementation of an electronic health record to support evidence-based practice

Nursing Administration Quarterly 30(3) 203-210.

USA Utilization of an electronic health record assists the clinician in finding answers to clinical questions.

Resistance to the implementation of technology is common.

Utilization of Rogers Diffusion of Innovations theory as a guide assists

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in the process

Greaves, C. (1999)

Patients perceptions of bedside handover

Nursing Standard

UK Qualitative method using semi structured interviews

Semi structured interviews

Four patients were interviewed

Patients want to be involved in the handover because they need want the access to information. The patients do not express concern over possible breaches of confidentiality and prefer being passive during the handover process.

Hardey, M., Payne, S., Coleman, P. (2000)

‘Scraps’ : Hidden nursing information and its influence on the delivery of care

Journal of Advanced Nursing 32(1)

UK Ethnography Data collection included non participant observation, tape recording of handovers, semi structured interviews and review of informal and formal documents

23 handovers were tape recorded

34 nurses (which included students, auxiliaries, staff and senior nurses) participated in semi structured interviews

The rationale for scraps was born out of perceived inadequacies of documentation.

Three main themes were derived: construction and content of scraps, the role and the use of scraps and confidentiality and disposal.

Scraps represent a way to organize nursing knowledge a “to do list”.

Scraps may serve as a way to socialize into the unit culture and processes.

Scraps are minimally discussed in the literature but very common in practice.

Hays, M.M. Journal for nurses in staff

USA General article Literature review exploring implications

Self esteem of bedside nurses needs to be

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(2003)

The Phenomenal shift report

development for staff development and management regarding shift report

enhanced along with the need for collegial support.

Shift report is more than communication of patient information; it is social where nurses can express both humor and concern.

Nurse’s level of experience is often reflected in communication patterns during report.

Educational interventions should be developed to combine the intended and non-intended consequences of reporting.

Hilz, L.M. (2000)

The Informatics nurse specialist as change agent: Application of Innovation-Diffusion theory

Computers in Nursing

USA General Article Innovation diffusion theory may be used as a guide to implement technology into practice.

Howell, M. (1994)

Confidentiality during staff reports at the bedside

Nursing Times UK Qualitative study examining the attitudes of staff and patients regarding bedside reporting with the focus on confidentiality.

Two questionnaires were developed one for staff and one for patients; however interviews of both groups were also conducted

Twenty staff members nurses and twenty patients

It is the perception of the patients that confidentiality is maintained.

Staff members do not discuss distressing information at the bedside but rather away from the

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bedside with careful consideration to the content of report.

Some patients did not even realize staff were giving report-as patients were older they were more interested in participating in the reporting

James, K., Biley, F. (1989)

Change from an office based to a walk around handover system

Nursing Times 101(10)

Ireland Quantitative Questionnaire 15 Nurses and 10 patients

Change is difficult. Trust acceptance and involvement are critical to success.

Having staff involvement allowed for change to move forward.

Jarvis D., Woo M., Moynihan A., Levin D. (2006)

Parental Satisfaction Increases with involvement in bedside rounds

Critical Care Nurse April 98

USA Prospective descriptive study without the use of a control group

Survey of 16 questions 41 families Parents were mostly supportive of involvement in decision making for their children

Supportive of rounds and participation in questioning.

Kassean, H.K., Jagoo, Z.B.

BMC Nursing Mauritius General paper Paper addressed shortcomings of traditional report and

Resistance to change in practice was overcome by maintaining open

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(2005)

Managing change in the nursing handover from traditional to bedside handover-a case study from Mauritius.

focused on patients being central to the process of managing care

communication.

Support of the management team and key personnel was paramount to success.

Change has generated enthusiasm of staff to question other facets of practice.

Keatinge, D., Bellchambers, H., Bujack, E., Cholowski, K., Conway, J. Neal, P. (2002)

Communication: principal barrier to nurse-consumer partnerships

International Journal of Nursing Practice 8

Australia 8 month Pilot project

14 workshops were conducted obtaining information from nurses

Audio-taped discussions and written documentation of nurse perceptions on specific topics.

199 nurses represented a range of acute care clinical settings such as hospitals and hospitals in the home

Barriers to communication included:

Power/control, education, system resources, staffing resources, nurse practice.

The majority of communication related strategies developed were those that occur during information transfer.

Poor communication leads to repetitive reports to health care professionals.

Kerr, M.P. (2002)

Journal of Advanced

UK Qualitative study 20 handovers were observed and audio-

Nurses were interviewed and

Handover is highly complex and has many

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A qualitative study of shift handover practice and function from a socio-technical perspective.

Nursing 37(2) taped

12 individual and two group interviews with nursing staff about handovers was conducted

observed functions.

Handover is a system with inherent tensions such as formal and informal practices, comprehensiveness verses overload, and confidentiality verses family centered care.

Kleiber, C., Davenport, T., Freyenberger, B. (2006)

Open bedside rounds for families with children

American Journal of Critical Care 13(5)

USA General article about a quality improvement initiative

Nurses feel caught in the middle between family and physician for communicating information.

Including parents in rounds did not increase the length of rounds.

A simple intervention such as opening rounds to parents of children in the PICU was positively perceived by physicians, nurses and parents.

Parents were able to see the heath care team planning care and for discharge.

Parents were able to understand the child’s needs and learn how to care for the child upon discharge.

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Kowalski, W.J., Lawson, L. and Oelberg, D.G. (2003)

Parent and nurse perceptions of confidentiality, rounding and visitation policy in a neonatal intensive care unit

Neonatal Intensive Care 16(3)

USA Qualitative Free form interviews 18 NICU Nurses and 16 parents of NICU patients

1 NICU receptionist was interviewed

Nurses believed that parents listened to confidential information on patients other than their own children.

Parents are actually unable to hear the transfer of information between caregivers.

Lally, S. (1999)

An investigation into the functions of nurses’ communication at the inter shift handover.

Journal of Nursing Management

UK Qualitative- Observational study Six intershift handovers were observed, data was transcribed and themes analyzed

Components of the nursing process emerged as themes from the data.

Insight to the culture of the unit revealed through one another nurses learn the ropes and the group becomes more cohesive.

Nurses perceive doctors as superior and look to one another for support and encouragement.

Nursing rituals are meaningful and assist the nurses in identifying goals and values of the group.

Latta, L.C., Dick, R., Parry, C., and

Academic USA Qualitative Semi-structured 18 parents were interviewed after their

Parents viewed being present on the unit during

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Tamura, G.S. (2008)

Parental responses to involvement in rounds on a pediatric inpatient unit at a teaching hospital: a qualitative study

Medicine 83(3) interviews participation in rounds

rounds as positive.

Three main themes emerged: communication, participation and teamwork.

Lamond, D. (2000)

The information content of nurse change of shift report: a comparative study

Journal of Advanced Nursing 31 (4)

England Quantitative 2X2 design comparing twp hospitals and the type of ward.

5 consecutive reports were audio taped and the medical notes and nursing documentation were examined

Total of 60 patients records reviewed for content analysis

More information was recorded in the notes rather than the medical record.

Specific types of information were not recorded in the notes but discussed in report.

Differences in functional status were reported differently among surgical patients verses medical patients.

Lamont, L., Levenson, R. (2001)

Patients, careers and staff: talking to each other to improve health care service delivery

Health Expectation 4

UK General Article Describes how one local healthcare organization to address issues to involve patients and those who care for them in service development.

Key messages from the workshop: improving communication, improving access to services; developing partnerships with professionals and developing positive attitudes.

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Manias, E., Street, A. (2000)

The handover: uncovering the hidden practices of nurses

Intensive and critical care nursing 16

Australia Ethnography Professional journaling, Participant observation, individual and focus group interviews

6 registered nurses in a 16 bed critical care unit of a public teaching hospital in Australia

Nursing handover has many forms and serves different purposes.

Handover process involves a complex network of communication.

Five practices for consideration identified: the global handover serving the needs of the nurse coordinators, the examination, the tyranny of tidiness, the tyranny of busyness and the need to create a sense of finality.

Martin, D.R., and Tipton, B.,K. (2007)

Patient advocacy in the USA: Key communication role functions

Nursing and Heath Science 9

USA Qualitative 12 semi structured interviews

Purposive sample of 12 patient advocates from an 8 hospital network in a western urban area of the US

Seven communication role categories were identified: liaison, feed-back remediation provider, counseling and support provider, system monitor, troubleshooter, investigator and group facilitator.

Manojlovich, M. and DeCicco, B. (2007)

Healthy work environments, Nurse Physician Communication and Patients’ Outcomes

American Journal of Critical Care

USA Non experimental descriptive design

Nurses were surveyed utilizing the Conditions for work Effectiveness Questionnaire II and the Practice Environment Scale of the nursing Work Index were used to measure characteristics of the work environment

866 nurses working in 25 intensive care units

Healthy work environments are important for nurse-physician communication

As communication between nurses and physicians increased medication errors decreased.

The more experienced

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The ICU Nurse-Physician Questionnaire was used to measure the Nurse-physician communication

nurses had reported medication errors more readily.

Suggested the use of a professional model to deliver patient care and adequate staffing may improve nurse physician communication.

Meibner, A., Hasselhorn, H.M., Estryn-Behar, M., Nezet, O., Pokorski, J., Gould, D. (2007)

Nurses’ perception of shift handovers in Europe-results from the European Nurses’ early exit study.

Journal of Advanced Nursing

Europe Quantitative Questionnaire 10 European Countries participated

39,898 surveys completed from over 600 hospitals

Nurses have dissatisfaction with shift handovers.

Reasons included were: too many distractions, insufficient information exchange poor atmosphere and poor management.

McCabe, C. (2004)

Nurse-patient communication: an exploration of patient’s experiences

Issues in Clinical Nursing

Ireland Qualitative Un structured Interviews

Purposive sampling of 8 patients

In contrast to the literature, the findings of this study indicate that nurses are not good at communicating with patients because they do not provide enough information.

It is thought that the nurses were too busy to

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communicate well.

However nurses communicate better with patients if they use a patient centered approach.

McCloughen, A., O’Brien,L., Gillies, D., McSherry, C. (2008)

Nursing Handover within mental health rehabilitation: An exploratory stuffy of practice and perception

International Journal of Mental Health Nursing 17

Australia Qualitative Interviews

Audio taping content of verbal handover

Audio taping face to face interviews with nursing staff

38 Nurses-

2 handover times were audio taped-via random selection over a 7 -day period for a total of 10. Three volunteer nurses were interviewed.

The findings of this study reveal the need for nursing handovers to have a strong professional foundation and be developed by the uniqueness and specialized contexts of the nursing unit.

McKenna, L.G. (1997)

Improving the nursing handover report

Professional Nurse 12 (9)

Australia General Article Methods discussed to revise nursing report so that there is efficient use of time.

Discussion on different methods of reporting, verbal, taped written.

Nursing report maybe comprised of nurses reporting on their social activities rather than the patient’s condition

Milner, F.M., Estabrooks, C.A., Humphrey, C. (2005)

Clinical Nurse educators as agents for change:

International Journal of Nursing Studies 42

Canada Quantitative Survey

Alberta Nurse Survey

389 nurses Clinical nurse educators are underutilized. The use of research to promote evidenced based nursing practice should be implemented with the support of clinical nurse educators

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increasing research utilization

Reconfiguring the clinical nurse educator role and providing additional education regarding research may be important strategies for improving evidenced based nursing practice.

Miller, C. (1998)

Ensuring continuing care: styles and efficiency of the handover process

Australian Journal of Advanced Nursing

Australia General article Discussions on the four main styles of handover

Types of handover: recorded, bedside, verbal and written.

Nursing report is a ritualistic practice, obsessive, repetitive task.

Minishi-Majanja, M.K. (2005)

The diffusion of innovations theory as a theoretical framework.

South African Journal of Library and Information Science

South Africa General article Describes how Diffusion of Innovation theory can be utilized in library science

Theory used to explain the adoption process in the field of library science.

Theory components identified and explained in detail with specific examples relating to two different research projects in library science.

Muething, S.E., Kotgal, U.R., Schoettker, P.J., Gonzalez Del Ray, J., DeWitt, T.G. (2009)

Family centered beds

Pediatrics 119(4)

USA General Article Family involvement improves communication, shares decision making.

Concerns that arose: teaching residents in front of the families may be hampered, time of rounding may be increased and lastly

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confidentiality.

Murrary C.E. (2009)

Diffusion of innovation theory: A bridge for the research-practice gap in counseling

Journal of Counseling and development 87

USA General article Description of the practice research gap and an overview of diffusion of innovation theory.

An overview of the theory components is outlined within the article.

Applications of Diffusion of Innovation theory to counseling research are reviewed.

O”Connell, B., Macdonald, K., Kelly, C. (2008)

Nursing Handover: It’s time for a change

Contemporary Nurse 30

Australia Quantitative Survey 176 nurses responded to the survey

In general nurses were satisfied with report however areas for improvement were recognized. Theey are: subjectivity of handover information, the time taken to conduct handover, repetitive nature of information, handover from a nurse who has not cared for the patient.

Patterson, E. S. (2007)

Communication Strategies from High reliability organizations

Annals of Surgery 245(2)

USA Editorial Article Reduce complexity

Reveal hidden events and activities

Focus attention

Employing strategies attempts to systematically

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decrease the human factors involved in communication so that crucial pieces are not missed

Patterson, E.S., Roth, E.M., Woods, D.D., Chow, R., Gomes, J. (2004)

Handoff strategies in settings with consequences for failure: lessons for healthcare operations

International Journal for Quality in Health Care 16(3)

USA An analysis of observational data for evidence of use of 21 handoff strategies

Observation and interviews

Subjects in each of the following settings space shuttle mission control, nuclear power, railroad dispatching and ambulance dispatching

Understanding how handoffs are conducted in settings with high consequences for failure can jumpstart endeavors to modify handoffs to improve patient safety.

The settings investigated have similar characteristics of the health acre industry: they are composed of highly complex interconnected systems that are driven by events under high pressure with constraints on resources.

Healthcare does not have information “at a glance”.

In healthcare handoffs varying according the coverage and responsibility.

Recommendations: face to face reporting, include others in handoff so one person does not have all the information; flagging items in the chart of great importance, reduce

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interruptions.

Pearcy, P.A., and Elliot, B.A. (2004)

Students impressions of clinical nursing

Nurse education today 24

UK Exploratory design using a qualitative approach

Focus groups 14 undergraduate nurses

The culture of the nursing unit influences nursing student learning experiences, students learn form the negative aspects of nursing as a job, nurses on the job and remember the negative experiences the most. The student mentors were influential members of the staff.

Pepper, G. A.

Bedside report would it work for you?

Nursing 78 USA General Article Technical advantages for ensuring better continuity of patient care by improving accuracy of information.

Professional advantage by involving patient and family in care.

Staff resistance, initial outlays of time in reporting, confidentiality are all barriers that need to be overcome for successful implementation.

Phipps, LM., Bartke, C.N., Spear, D.A., Jones, L.F., Foerster, C.P., Killian, M.E.,

Pediatric Critical Care Medicine 8(3)

USA Prospective, blinded, observational study

Observational and survey

Admissions, family members and staff surveys

No significant amount of difference between the time spent on rounds in the presence or absence of family members.

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Hughes, J.R., Hess, J.C., Johnson, D.R., and N.J., Thomas (2007)

Assessment of parental presence during bedside pediatric intensive care unit rounds: Effect on duration, teaching and privacy.

There was no significance in the time spent on teaching in the presence or absence of family members.

Parents did not perceive that their own or the child’s privacy was being violated.

Pieper, B., Caliri, M.H.L. (2002)

An international partnership: Impacting wound care in Brazil

Journal WOCN

USA/Brazil General Article Discussion on nursing literature regarding international partnerships.

Utilizing Rodgers Theory of Diffusion a successful wound care educational program was launched with positive outcomes for patients.

Poletick, E.B. and Holly, H. (2010)

A systematic review of nurses’ inter-shift handoff reports in acute care hospitals

JBI Library of Systematic Reviews 8(4)

USA Systematic Review Evidence suggests reporting serves several purposes along with the transfer of information.

The nurse is the gatekeeper of information and chooses what to include in report, to act on and maintains the flow of information.

There are multiple methods to transfer information, which are recommended to decrease

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the information decay and gaps in communication.

Pothier, D., Monterio, P., Mooktlar,M., Shaw,A. (2005)

Pilot study to show the loss of important data in nursing handover

British Journal of Nursing 14(20)

UK Quasi experimental

Simulation: of nursing handover

Direct observation of handover in a simulated setting 12 fictional patients were used for the study, nurses received a verbal report and waited 60 minutes before reporting off to the next participant

Three different groups were studied, verbal only group- no note taking allowed, verbal group with allowed note taking and a third group that were given a type written sheet of information and verbally handed over information

5 volunteer nurses were solicited from advertisements on wards with one hospital.

Data was lost in all groups during handover.

The group that retained more data was the group with the type written sheet.

Roberts D. (2007)

Clear Communication Accept nothing less

MEDSURG Nursing 16(3)

USA Editorial Article Nurses need to develop a worldview and accept changes in reporting process not because the change os required by a regulatory agency.

Nurses need to continue to be advocates for the patients and assist in the development of clear concise communication among caregivers for the sake of patient safety.

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Royak-schaler, R., Gadalla, S., Lemkau, J.P., Ross, D., Alexander, C., and Scott, D. (2006)

Family perspectives on Communication with healthcare providers during end of life cancer care

Oncology Nursing Forum 33(4)

USA Exploratory qualitative design

Focus groups/questionnaire

24 spouses and relatives of deceased patients with cancer who were treated at a specific cancer center

Highlights the importance of training staff on content, timing and potential biases as it relates to information delivery on end of life care

Sanson-Fisher, R.W. (2004)

Adopting best evidence in practice Diffusion of Innovation theory for clinical change

The Medical Journal of Australia 180(6Suppl): S55-S56.

Australia General Article Utilizing the diffusion model can provide insight as to why some practices of change are fully implemented and others are not despite the evidence in the literature.

Sheldon, K.K., Barrett, R. and Ellington, L. (2006)

Difficult communication in nursing

Journal of Nursing Scholarship 38(2)

USA Grounded theory methodology and follow up questionnaire

Focus groups Thirty nurses Five major themes in difficult communication were identified specific diagnosis and clinical situations, patient and family emotions, nurses emotions, triangle of nurse physician patient communication and nurse coping behaviors with difficult communication.

Shirey, M.R. Nursing Administration

USA General article The nurse leader’s role for facilitating EBP in a

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(2006)

Evidenced based practice how nurse leaders can facilitate innovation

Quarterly (2006)

nursing facility utilizing the theoretical framework of diffusion of innovation is reviewed.

Slauenwhite C.A., Simpson, P. (1998)

Patient and family perspectives on early discharge and care of the older adult undergoing fractured hip rehabilitation

Orthopaedic nursing

Jan/Feb17(1)

Canada Qualitative Interview/questionnaire 23 patients who had experienced hip fracture

A high number of families and patients had mismatched care by nurses and this was heightened in periods of transition.

Stefancyk, A.L. (2008)

American Journal of Nursing108 (11)

USA General Article Rounds responsibility became the nurses instead of the interns and allowed for more contribution by nursing and the patients.

Sutcliffe, K.M., Lewton, E., and Rosenthal, M.M. (2004)

Communication Failures: An Insidious Contributor to Medical Mishaps

Academic Medicine 79(2)

USA Qualitative Semi structured interview random selection of participants at a predetermined location (600 bed teaching hospital)

26 medical residents Communication failures are complex and are not only related to information transfer.

Communication failures are related to lack of knowledge, hierarchy (resident vs. attending), role conflict and ambiguity.

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Timonen, L., Sihvonen, M. (2000)

Patient participation in bedside reporting on surgical wards

Journal of Clinical Nursing 9(4)

Finland Quantitative –comparison of patients and nurses opinions of the purpose of report, patient participation and factors that promote or prevent participation

Survey 118 nurses responded to questionnaire

Patients did not participate during conversation in reporting sessions as much as nurses thought they did. Patients assume a very passive role in the hospital.

Patient’s believed information in report was only for the nurses so they did not feel it necessary to participate.

Nurses thought that patients refrained from participation because they had difficulty formulating questions.

Patients did not understand the medical jargon used by the nurses in the reporting process.

Towle, A. (2006)

Where’s the patient’s voice in health professional education

Nurse education in practice (6)

Canada General article International conference addressing the question where is the patients voice.

Discussion from students of all healthcare fields on methods to include patient in care.

Watkins,S. (1997)

Professional Nurse 12(4)

UK General Article Changing of office handover reporting to reporting conducted at the

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Introducing bedside handover reports

patient’s bedside required knowledge of the change theory.

Most patients welcomed bedside report and there was increased job satisfaction among the nursing staff.

Confidential concerns were raised.

Continued use of private conversations to discuss confidential matters away from the patient such as possible medical diagnosis of carcinoma.

Implemented use of nursing diagnosis rather than medical diagnosis for reporting.

Wellard, S. Lillibridge, J., Beanland, C., Lewis, M. (2003)

Consumer participation in acute care settings: An Australian experience

International Journal of Nursing Practice 9

Australia Qualitative interpretative design to develop an understanding of how nurses in acute care environments interact with patients to support their participation in health care planning and delivery.

Focus groups and observation

Sample size 20 nurses a total of three focus groups. Six nurses in their first year of practice, eight nurses who had more than one year of practice –with no management or leadership knowledge and six nurses who had roles as team leaders and or managers. All the nurses in the focus groups were kept in a category according to

Consumer participation is an important component of high quality health care services.

Nurses can articulate the value of having patients participate in care however there are varying rates of participation noted in actual practice.

Nurses who were more senior understand the value and input of

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work classification. patients in care.

Issues of control remain among nurses.

Decision-making was completed away from the bedside and different levels of staff had varying amounts of patient interaction.

Communication with patient sis limited to time spent during specific tasks.

Findings in direct observation directly contrast the findings in the focus groups.

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Figure 1

Five Categories of Adopters

Innovators Early Adopters Early Majority Late Majority Laggards

Individuals who prefer to be on the cutting edge and are risk takers. Innovators are active in seeking new information and ideas.

These individuals have opinions that are well respected by leadership. They use innovations well and are very successful.

Very connected within the peer system and will lead the innovation once on board.

Skeptical of change however responsive to the pressures of economic need for changes. Suspicious of change.

Very traditional individuals who do not like change and are often highly suspicious of change and change agents.

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Appendix 1

INVITATION LETTER

Dear Nursing Colleague,

My name is Joan Harvey. I am a student at UMDNJ in the Doctor of Nursing Practice Program. I am completing my doctoral studies and finishing with a capstone project under the supervision of my advisor, Dr. Cheryl Holly. My area of inquiry is Nurses’ perceptions regarding bedside report and how it is implemented. There has been much published about the patients and families perceptions of bedside report and very little published on what the bedside nurses think about such reporting techniques. Nurses at Meridian Health have been performing bedside report for approximately fifteen months and I am interested in your thoughts and perceptions about this innovation.

You are invited to participate in a focus group discussion and observation regarding bedside reporting. Participation is strictly voluntary. There will be a total of three sessions you will only be asked to sit in on only one of these sessions. The sessions will last approximately 90 minutes. The first 30 minutes is dedicated to getting to know one another as participants and having a light snack. All sessions will be audio taped and transcripts will be typed verbatim. Your names will not be used in the transcripts nor your units identified. You will remain anonymous and only a predetermined pseudonym will be used in the transcripts. Additionally, the researcher will be observing bedside report and will observe your giving and receiving bedside report. The researcher will not be participating in report in any manner nor participating in patient care during this time. Notes will be taken during this observation.

You are eligible to participate if you volunteer and are:

Registered professional nurse licensed in the state of New Jersey Employed in a nursing role at the facility on one of the two selected units Volunteer to participate Proficient in English

Your consideration to participate in this study is greatly appreciated. If you wish to participate or have any questions regarding participation please contact Joan Harvey (primary investigator) at 732-859-6396. If you have any questions that you do not wish to address to me, please feel free to contact my doctoral capstone advisor, Dr. Cheryl Holly, at 973-972-9055 or [email protected] Additionally you may contact UMDNJ-Newark IRB Stanley S. Bergen Building 65 Bergen Street Suite 511 Newark, N.J. 07101

Sincerely,

Joan Harvey

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Appendix II

CONSENT TO TAKE PART IN A RESEARCH STUDY

TITLE OF STUDY: A study of nurses’ perceptions regarding bedside report

This consent form is part of an informed consent process for a research study and it will give information that will help you to decide whether you wish to volunteer for this research study. It will help you to understand what the study is about and what will happen in the course of the study.

If you have questions at any time during the research study, you should feel free to ask them and should expect to be given answers that you completely understand.

After all of your questions have been answered, if you still wish to take part in the study, you will be asked to sign this informed consent form.

The study doctor (the principal investigator) or another member of the study team (an investigator) will also be asked to sign this informed consent. You will be given a copy of the signed consent form to keep.

You are not giving up any of your legal rights by volunteering for this research study or by signing this consent form.

Why is this study being done?

The intention of this study is to examine nurses’ perceptions of bedside report. The results of this study will provide insight as to why these inconsistencies exist, what they encompass, and what information nurses consider most important to transfer at the time of bedside report

Why have you been asked to take part in this study?

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You have been asked to participate in this research study because you are a registered nurse who is employed at Ocean Medical Center and you and your fellow nurses on your nursing unit participate in bedside shift report.

Who may take part in this study? And who may not?

Nurses who are employed by Ocean Medical Center working on 4 north and 5 west who conduct bedside shift report will be invited to participate in this study, and who volunteer and are registered professional nurses licensed in the state of NJ.

How long will the study take and how many subjects will participate?

The study will last six months. A maximum number of 20 nurses will participate in the study all at the same study site (Ocean Medical Center). The nurses will be participating a total of 4 hours. (1.5 hours in a focus group session and 2.5 hours observational study while nursing report is being conducted).

What will you be asked to do if you take part in this research study?

Each participant will be asked to attend a focus group session that will be audio‐taped which will last approximately 1.5 hours. During which a round table discussion with a series of predetermined questions will be conducted. Each participant will allow themselves to be observed during the conduct of bedside report which will last up to 2.5 hours

Are there any benefits for you if you choose to take part in this research study?

Benefits from this study include the refinement of the bedside reporting process, which may be part of a publication that will add to the nursing literature on the topic of nurses’ perceptions of bedside reporting. However, you will receive no direct benefit or financial remuneration from taking part in this study.

What are your alternatives if you don’t want to take part in this study?

If you do not wish to partake in the study you may refuse to do so. Additionally you may withdraw from the study at any time.

Will there be any cost to you to take part in this study?

There are no costs to the participant to take part in this study.

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Will you be paid to take part in this study?

There will be no monetary reimbursement to participate in this study.

How will information about you be kept private or confidential?

All efforts will be made to keep your personal information in your research record confidential, but total confidentiality cannot be guaranteed.

Pseudonyms will be assigned to all participants. Each participant will be given a name tag with their pseudonym. These will be prominently displayed and used to address each other during the interview in an effort to maintain human subject protection. All digital voice recordings will be on a locked password protected computer and it along with all transcripts will be stored in a locked fire proof safe in the PI’s home office for data protection. When data transcription from the Digital Voice Record is complete its hard drive will be erased. All de‐identified transcripts will be destroyed upon completion and submission of capstone project.

What will happen if you are injured during this study?

There are no risks of physical injury as a result of participating in this study.

Who can you call if you have any questions?

If you have any questions about taking part in this study

Joan Harvey

9 Forester Drive

Barnegat New Jersey 08005

7328596396

If you have any questions about your rights as a research subject, you can call:

EXAMPLE: IRB Director

(973)9723608 Newark

(732)2359806 New Brunswick/Piscataway

(856)5662712 Stratford/Camden

What are your rights if you decide to take part in this research study?

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You have the right to ask questions about any part of the study at any time. You should not sign this form unless you have had a chance to ask questions and have been given answers to all of your questions.

Do I have to sign this authorization form?

You do not have to sign this authorization form. But if you do not, you will not be able to participate in this research study

If I sign, can I revoke my authorization or withdraw my information later?

If you decide to participate, you are free to withdraw your authorization regarding the use and disclosure of your responses (and to discontinue any other participation in the study) at any time. After any revocation, your responses will no longer be used or disclosed in the study, except to the extent that the law allows the researchers to continue using and disclosing your information Therefore, you should be aware that the researchers may continue to use and disclose the information that was provided before you withdrew your authorization if necessary to maintain integrity of the research or if the data had already been stripped of all identifiers.

If you wish to revoke your authorization for the research use or disclosure of your responses as information in this study, you may do so in writing by contacting

Joan Harvey

9 Forester Drive

Barnegat New Jersey 08005

7328596396

What personal information will be used or disclosed?

No personal information will be disclosed. Data extracted from the demographic form and survey sheet will be collected and grouped. No specific identifiers will be published.

Who may use or disclose the information?

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The following parties are authorized to use and/or disclose your information in connection with this research study:

The UMDNJ‐Institutional Review Board

Joan Harvey‐Primary researcher

Who may receive/use the information?

The parties listed in the preceding paragraph may disclose your information to the following persons and organizations for their use in connection with this research study:

The Office for Human Research Protections in the U.S. Department of Health and Human Services.

When will my authorization expire?

Your authorization for the use and /or disclosure of your health information will expire in one year from approval.

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AGREEMENT TO PARTICIPATE

I have read this entire form, or it has been read to me, and I believe that I understand what has been discussed. All of my questions about this form or this study have been answered.

Subject Name:

Subject Signature: Date:

(If Required By The IRB)

Witness Name:

Witness Signature: Date:

Signature of Investigator/Individual Obtaining Consent:

To the best of my ability, I have explained and discussed the full contents of the study including all of the information contained in this consent form. All questions of the research subject and those of his/her parent or legal guardian have been accurately answered.

Investigator/Person Obtaining Consent:

Signature: Date:

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I understand that I have the right to ask questions about any part of the future study at any time. I understand that I should not sign this form unless I have had a chance to ask questions and have been given answers to all of my questions.

I have read this entire form, or it has been read to me, and I believe that I understand what has been discussed.

All of my questions about this form or this study have been answered.

Subject Name:

Subject Signature: Date:

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Appendix III

Participant Survey

Staff Demographics

1. How long have you been a nurse?

0-5y 6-10 y 11-15y 16-20 y 21-25y 26plus n/a

2. What is your highest level of education?

Diploma AAS BSN MSN Doctorate

3. How long have you worked in your current position?

0-5y 6-10 y 11-15y 16-20 21-25y 26 plus

4. What shift do you work?

Days Nights Varies

Please rate the following questions based on the below scale:

1. How well did you see the nursing unit adapting to bedside report?

Very well Well Neutral Not well No adaption

2. How well did you adapt to bedside report?

Very well Well Neutral Not well No adaption

3. What is your degree of satisfaction to bedside nursing report?

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Very satisfied Satisfied Somewhat satisfied Unsatisfied

4. Please rate yourself regarding your practice of bedside report (defined as: inside the patients rooms with the oncoming nurse and patient/family).

Done all the time Sometimes done Rarely done Never done

5. How beneficial to you view bedside report?

Very beneficial Somewhat beneficial Rarely beneficial Never beneficial

6. Compared to sitting at a desk and receiving verbal report verses receiving report at the bedside do you believe bedside report is

More comprehensive Somewhat comprehensive Less comprehensive

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Appendix IV

Focus Group Guide to Questioning

Your participation is strictly voluntary. If at any time you wish to discontinue your participation,

you can do so at any time. As employees of the facility, please know that there are no

consequences for your participation. In addition, your comments and information will be treated

as confidential. No names will be used when reporting findings. Nor will individual nursing units

or campuses’ be identified. I ask that you speak clearly and loud enough as the session will be

audiotaped. I do not want to miss any of your important comments; I ask that one person speak at

one time because your thoughts and input are very important. Please know that this is an

informal discussion and we can refer to one another on a first name basis. As a reminder the

purpose of this study is to explore nurses perceptions of bedside report. Once the transcripts are

complete and common themes identified I will ask one participant in the group to review the

themes for accuracy.

Distribute name tags with pseudonym.

Read Consent for Focus Group and Observation here and obtain verbal consent from

each participant.

1. You were all notified by letter inviting you to participate in this study. Can you tell me

your initial reactions upon receiving such an invitation to participate?

2. Tell me how you feel when you give report to one another at the bedside? What does the

word ‘bedside’ mean to you in terms of where the report can be given?

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3. Is bedside reporting new to you? If so, how well do you feel you have adopted this

technique? How about your peers? If bedside reporting is not new to you, do you think it

is going well on your unit?

4. Describe to me what occurs during bedside nursing report.

5. Can you elaborate on the interactions between patients, families and the nurses during

bedside report? What are your feelings regarding this?

6. How did you learn how to give the bedside report?

7. Do you have suggestions for others in how to give bedside report?

8. What information do you believe is important to provide during bedside report?

9. What is the most memorable experience you have had giving bedside report?

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Appendix V

Observation Guide:

1. Shift:_______

2. Location: Unit:____________; In or outside of patient room;__________

3. Time started:________________; Time ended:_________________

4. Were any questions asked:________________________________

If yes, category of question:

i. Clarification__________________

ii. Asked for more detail ______________________

iii. Other:_________________________

5. Were any prompts used: (e.g., scraps of paper, computer reports, patient chart).

Specify_____________

6. Who was involved in the report: ______nurse; _____physician; ________patient;

______family; ___________other. Specify:____________

7. What information was handed over: (circle any)

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Vital signs, lab results, procedures done, general condition, emotional status,

procedures necessary during the next shift, medications administered, assessment

findings. Other: Specify:_____________________________________________

8. Comments:

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