JONA Volume 47, Number 3, pp 147-153 Copyright B 2017 Wolters Kluwer Health, Inc. All rights reserved. THE JOURNAL OF NURSING ADMINISTRATION Hardwiring Bedside Shift Report Sandra Scheidenhelm, DNP, RN, NEA-BC O. Ed Reitz, PhD, MBA, RN, NEA-BC OBJECTIVE: The purpose of this project was to increase nurse compliance with bedside report and increase patient satisfaction scores. BACKGROUND: Bedside report is an evidencebased practice used to increase patient involvement in their care and improve patient satisfaction. A change management strategy and standardized approach to bedside report can help increase nurse compliance with the process. METHODS: This study used a quasi-experimental, between-group, preimplementation and postimplementation comparison of patient satisfaction scores from returned surveys on 2 units in a 149-bed community hospital. We also compared nurse compliance with bedside report preimplementation and postimplementation. RESULTS: Five months after using a change management strategy to Bhardwire[ (ingrain systems and tools) bedside report, nurse compliance with bedside report and patient satisfaction scores improved in both intervention units. CONCLUSIONS: Discussion: Patient Satisfaction Improvement Articles Worksheet. A change management strategy and standardized approach to bedside report helped increase nurse compliance with the process, leading to improved patient satisfaction. The Joint Commission1 recommends patients to be actively involved in their care and the use of a stanAuthor Affiliations: Director of Professional Practice/Magnet Program Director (Dr Scheidenhelm), OSF St Joseph Medical Center, Bloomington, Illinois; and Assistant Professor (Dr Reitz), Mennonite College of Nursing at Illinois State University, Normal. Drs Scheidenhelm and Reitz are employees of OSF St Joseph Medical Center where this study was conducted. The facility has contractual relationships with Studer Group and Press Ganey. There are no other disclosures. Correspondence: Dr Scheidenhelm, DNP, RN, NEA-BC, OSF St Joseph Medical Center, 2200 E Washington St, Bloomington, IL 61701 (Sandra.L.Scheidenhelm@osfhealthcare.org). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal_s Web site (www.jonajournal.com).NURS 4400 Purdue University Patient Satisfaction Improvement Articles Worksheet

DOI: 10.1097/NNA.0000000000000457 dardized handoff communication process during change of care providers. Bedside report addresses both of these requirements. The primary function of bedside report is communication of patients_ clinical information and their plan of care from nurse-to-nurse at the change of shift.2 Failure to communicate pertinent clinical information adequately and consistently during shift report puts patients at risk of harm.3,4 Patient involvement at the bedside is crucial. Without their involvement, patients have lack of information about their care. Shift report away from the bedside does not allow patient involvement or active participation.Discussion: Patient Satisfaction Improvement Articles Worksheet. 5 A standardized approach to bedside report and manager support of nurses can enhance shift handoff and improve patient safety, outcomes, patient and nurse satisfaction, time management, and accountability.6,7 The facility in this project implemented bedside report in 2009 using video education for the implementation strategy. Subsequently, issues of inconsistency in both frequency and quality of bedside report seemed to be related to a lack of nursing leadership support, not holding staff accountable, and failing to address staff barriers, as well as a less than effective implementation plan. The purpose of this project was to increase nurse compliance with bedside report on inpatient units and patient satisfaction. It was surmised patient satisfaction would improve because nurses consistently performed shift report at the bedside. The objectives were to improve compliance with bedside report (process) and ultimately improve patient experience, resulting in improved patient satisfaction scores (outcome). Hardwiring Bedside Report Studer8(p2) defines hardwiring as a process to Bingrain systems and tools.[ Management reinforcement with staff regarding the benefits of bedside report has been reported to help gain nurse buy-in with the process.7,9-12 Addressing staff perceived barriers such as receiving JONA Vol. 47, No. 3 March 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. 147 report from too many nurses, interruptions to meet patient needs, confidentiality, and waking patients are issues to address before the implementation of bedside report.7,10,11,13 Using a standardized tool for bedside report is helpful. NURS 4400 Purdue University Patient Satisfaction Improvement Articles Worksheet

Researchers report the use of situation, background, assessment, and recommendation (SBAR) as helpful to guide nurses during bedside report.10,11,14-17 Monitoring compliance with bedside report and mentoring staff for at least 2 weeks have been reported as effective practices in supporting successful hardwiring of the process of bedside report.6,9-11,17 Patient Safety and Satisfaction Patients who experienced bedside report stated feeling safer.5 Safety scans are opportunities to review the environment for safety concerns or prevention measures and are performed by the care provider. Safety scans during bedside report in the literature include medication review, call light in reach, and reviewing suction, oxygen, and other equipment regarding proper settings and performance. Researchers have reported incidents such as medication errors, falls, and skin tears, decreased after bedside report implementation.18,19 Patients report better understanding of their care plans and discharge planning with bedside report, thus improving safety. Wilson2 found patients who experienced bedside report felt more involved in their care, leading to decreased complaints. Patients reported staff focused on them and their needs, worked as a team, and involved them in decisions. Patients felt viewed as partners and active participants with the healthcare team.20 Families also report feeling bedside report is an essential aspect of care.2,12 Patients and families have an opportunity to clarify and correct inaccuracies during bedside report. Bedside report encourages and supports patients and families to participate in their desired level of care decision making.4,7,20,21 Communication with nurses has been reported to improve with bedside report.9-11,21,22 Overall, patients felt more informed about their care and who was caring for them.5,14 After participating in bedside report, patients felt nurses listened, explained things in an understandable way, and treated them with courtesy.Discussion: Patient Satisfaction Improvement Articles Worksheet. 11,14 Opposition to Bedside Report Several researchers noted concerns with the implementation of bedside report.2,7,12,18,20 The main concern identified is a breach of patient privacy and the violation of the Health Insurance Portability and Accountability Act.7,18 Other concerns include the belief that the process will increase shift report time, medical jargon could confuse patients or increase their anxiety, and the patient or family will monopolize the 148 conversation during report.18,22 Providing educational materials for patients and using a script to inform patients of the process, what to expect, and how they will be involved, including Health Insurance Portability and Accountability Act issues, have been suggested to address these concerns.7 Organizational Assessment We conducted a strengths, weaknesses, opportunities, and threats analysis to assess the organization_s current state with bedside report. Strengths include congruence of the model with the mission of the hospital Bto serve persons with the greatest care and love.[23 The facility supports a culture of transparency, a nonpunitive approach to errors, and reporting of all safety concerns to a safety hotline. The hospital promotes teamwork through an interprofessional shared governance structure and works collaboratively to enhance patient satisfaction. One organizational weakness was the failure to use a change management strategy during the initial implementation of bedside report; therefore, using Lewin_s change theory15 was identified as an opportunity to hardwire the bedside report process. Another opportunity with bedside report is the hospital_s goals to achieve the upper quartile in patient satisfaction as measured by Press Ganey (PG). NURS 4400 Purdue University Patient Satisfaction Improvement Articles Worksheet

A threat to the organization is external pressure from the government and payers. Patient satisfaction, as measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), is part of Centers for Medicare and Medicaid Services_ reimbursement determination.24 Framework Peplau_s theory of interpersonal relations10 and Lewin_s theory of planned change15 provide the framework to reintroduce bedside shift report for this study. In Peplau_s theory, nurses aim to establish a therapeutic and trusting relationship during interactions with patients.10 During bedside report, nurses introduce the oncoming shift nurse, identify patient needs, review progress, and collaborate on the plan of care with the patient. This collaboration leads to an improved trusting relationship. Lewin_s framework has 3 phases: unfreezing, moving, and refreezing.15 Several researchers found the theory useful in hardwiring the bedside report process.15,17,25 During the unfreezing phase, the investigators presented the evidence behind bedside report, addressed staff barriers, and educated nurses on the impact of bedside report on patient satisfaction and financial reimbursement to the hospital. We worked with a team to conduct nurse simulations of the process and sought staff feedback in the unfreezing phase. In the moving phase, bedside JONA Vol. 47, No. 3 March 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. report began with assistance from the implementation team. They monitored nurses conducting bedside report and then mentored and supported nurses during implementation. In the final refreezing phase, bedside report is hardwired every shift, although not 100%. Studor reports, BOnce systems and processes are in place (hardwired) to sustain service and operational excellence, an organization is no longer dependent on a particular leader to ensure continued success.[8(p18) Methods Design, Sample, and Setting We conducted a quasi-experimental, between-group, preimplementation and postimplementation comparison of patient satisfaction scores from returned surveys on 2 units in a 149-bed community hospital. The units included a 46-bed medical/surgical (M/S) unit and a 12-bed obstetrics (OB) unit. We chose these units because the M/S unit is representative of the larger population in relation to sex and age. For comparison, we selected the OB unit because it has high patient satisfaction scores and a higher current nurse compliance with the bedside report process. We also compared nurse compliance with bedside report from random observation preimplementation and postimplementation. Procedure We trained a team to conduct simulations of bedside report and assigned an electronic learning module on the facility_s educational system to nurses on both units. The module included evidence supporting bedside report, addressed staff barriers to bedside report, and described the standardized approach to the process. With permission, we included tools from the Studer Group ToolkitTM26 in a packet given to each nurse. The toolkit included a detailed process on how to conduct bedside report, the SBAR format for the report, a patient letter describing the process for them, and a bedside handoff competency checklist. Next, the team used simulation of bedside report and a competency tool (see Document, Supplemental Digital Content 1, http://links.lww.com/JONA/A517) to check nurses_ adherence to the standardized process. The team monitored bedside report using the competency checklist for 2 weeks and then at 1 and 3 months postimplementation.NURS 4400 Purdue University Patient Satisfaction Improvement Articles Worksheet

We will monitor again at 6 months. We obtained patient satisfaction scores and patient demographics from the password-protected PG Web site for patients who returned surveys for the 4 months preimplementation and postimplementation. Instruments Press Ganey measures patient satisfaction through a survey integrating HCAHPS statements with satis- faction questions.27 The tools are used by many organizations (n = 935 PG, n = 1066 HCAHPS) to measure patient satisfaction and are supported as being valid and reliable.27 To determine bedside report compliance, the denominator was the number of nurses observed, and the numerator was the number of nurses who completed bedside report during random observations. Trained observers on each unit conducted observations during shift change on their scheduled shifts. If a nurse conducted bedside report, the observers documented Byes[ on the log, and they documented Bno[ if the nurse did not conduct bedside report (see Document, Supplemental Digital Content 2, http://links.lww.com/JONA/A518). Human Subjects_ Protection Before the study, we obtained institutional review board approval through the University of Illinois College of Medicine at Peoria and Illinois State University. We sent a consent cover letter explaining the purpose, procedure, risks, benefits, and alternatives to all nurses on the intervention units. We informed nurses that their participation in the random observations was voluntary and provided them with opt-out instructions. All data from PG were de-identified before obtaining them. For the preintervention and postintervention time frames, we obtained mean scores or percent Balways[ responses for each survey statement and the number of survey respondents with their sex and age. Data from the random observations included numerator (nurses completing bedside report), denominator (nurses observed), and date. Trained observers conducted all observations for 4 weeks before implementation and at 1 month postimplementation. We secured data on a passwordprotected program on a password-protected computer in a locked office. Data Management and Analysis We compared each intervention unit_s preimplementation and postimplementation mean score for the 3 statements Bnurses kept you informed,[ Bstaff included you in decisions regarding treatment,[ and Bnurses explained in a way you understand.[ We also compared the preimplementation and postimplementation percentile rank in the Blarge PG database[ (n = 723 hospitals) from facility reports. On the HCAHPS survey, we compared the total percentage of Balways[ responses and percentile rank in the LPG database (n = 1090 hospitals) before and after bedside report implementation for the Bcommunication with nurses[ domain and for the statement Bnurses explained in a way you understand[ from facility reports. For descriptive data analysis of the sample of patients who returned surveys, we used Statistical JONA Vol. 47, No. 3 March 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. 149 Package for the Social Sciences version 22 (Armonk, New York). Patient demographics included sex and age, including means, standard deviations, and range.

We conducted a statistical analysis separately or each unit_s (M/S and OB) individual patient satisfaction questions and nurse observations of the bedside report process. Statistical analysis included independent-samples t tests to compare preimplementation and postimplementation samples and mean scores for each unit_s patient satisfaction survey questions (P 9 .05). We compared the percent compliance with bedside report for each unit (number of Byes[ completed report/number of nurses observed) preimplementation to 1 and 3 months postimplementation. Results Participants For the 4 months before implementation, 197 patients returned surveys for the M/S unit, and 93 were returned for the OB unit. For the 4 months postimplementation, 190 patients returned surveys for M/S, and 99 patients returned surveys for OB. There were no significant differences in the 2 samples for either unit (Table 1). Random observations (Table 2) included 132 nurses preimplementation (n = 73 M/S, n = 59 OB), 202 nurses postimplementation at 1 month (n = 147 M/S, n = 55 OB), and 147 nurses at 3 months (n = 94 M/S, n = 53 OB). Discussion: Patient Satisfaction Improvement Articles Worksheet. Bedside Report Compliance Results Comparison of nurse compliance with bedside report, as observed through random observations, improved at 1 month on both units (Table 2). Preimplementation observations indicated the nurses complied with bedside report, 12% (M/S) and 55% (OB). Post- implementation, nurses complied with the process for 85% (M/S) and 84% (OB) at 1 month and 84% (M/S) and 90.6% (OB). These results confirm our hypothesis: the intervention increases nurse compliance with bedside report. Patient Satisfaction Survey Results We used independent-samples t tests to compare the mean scores separately for both units for the statements Bnurses kept you informed,[ Bstaff included you in decisions regarding treatment,[ and Bnurses explained in a way you understand.[ From facility PG reports, we compared preimplementation and postimplementation percentile ranks for these statements, for the Bcommunication with nurses[ domain, and for the statement Bnurses explained in a way you understand.[ We compared the percentage of Balways[ responses on PG and HCAHPS survey domain Bcommunication with nurses[ and the statement Bnurses explained in a way you understand[ for both intervention units based on facility reports. M/S Unit For the statement Bnurses kept you informed,[ the mean score of the preimplementation respondents was lower (mean [SD], 89.95 [15.99]) than the mean (SD) of the postimplementation (92.74 [12.84]) but was not statistically significant (t = j1.89, P = .059). The percentile rank greatly improved from 22 to 86. Although the mean (SD) improved from the preimplementation group (89.11 [16.12]) to the postimplementation group (91.16 [12.88]), the 2nd statement, Bstaff included you in decisions regarding treatment,[ also had no significant differences between the means (t = j1.359, P = .175) of the 2 groups. The percentile rank improved significantly from 33 to 96. For the Bcommunication with nurses[ domain, Table 1. Demographic Characteristics of Patient Satisfaction Survey Respondents to Preimplementation and Postimplementation of Bedside Report Survey Respondents OB sex Women OB age, y Range Mean (SD) M/S sex Women Men M/S age, y Range Mean (SD) Preimplementation, n (%) Postimplementation, n (%) 93 (100) 99 (100) 21-50 30.19 (4.56) 197 100 (51) 97 (49) 20-41 29.56 (3.83) 190 94 (49) 96 (51) 20-95 68.57 (15.67) 24-97 67.61 (16.36) Preimplementation, 4 months before October 1, 2015 to January 31, 2016; postimplementation, 4 months after March 15 to July 13, 2016. Abbreviations: OB, 12-bed obstetrics unit; M/S, 46-bed medical/surgical unit. 150 JONA Vol. 47, No. 3 March 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Table 2. Nurse Compliance With Bedside Report Preimplementation OB M/S 1-mo Postimplementation 3-mo Postimplementation n % n % n % 33/59 9/73 55.9 12.3 46/55 125/147 83.6 85.0 48/53 79/94 90.6 84.0 Preimplementation, January 6 to February 12, 2016; postimplementation, March 15 to April 19, 2016 (1 month), and May 15 to June 11, 2016 (3 months). Abbreviations: OB, 12-bed obstetrics unit; M/S, 46-bed medical/surgical unit. the percentage of Balways[ responses increased from 79.6 to 86.8, and percentile rank increased from 52 to 99. For the statement Bnurses explained in a way you understand,[ the mean (SD) score improved from 92.22 (14.79) to 94.3 (11.54) but was not significant (t = j1.158, P = .248). The percentage of Balways[ responses increased from 75.2 to 81.0, and percentile rank increased from 43 to 94 from preimplementation to postimplementation (Table 3). Obstetrics For the statement Bnurses kept you informed,[ the mean (SD) scor …