Miscommunication among health care providers, when patients are transferred or during bedside shift report, accounts for 80% of serious medical errors (American Nurses Association, 2012; Reinbeck & Fitzsimons, 2013). Health care organizations have an increased awareness and urgency to respond to issues regarding patient safety and miscommunication (Griffin, 2010; Institute of Medicine, 2001; The Joint Commission, 2009; The Joint Commission International Center for Patient Safety, 2005). Bedside shift reporting was included as a Joint Commission patient safety goal requiring up-to-date information about the care, treatment, current condition, and recent or anticipated changes in the patient (Rush, 2012). Bedside shift reporting is defined as “the transfer of information as well as responsibility and authority during exchanges in care across the continuum; to include opportunities to ask questions, seek clarity, and confirm” (Cairns, Dudjak, Hoffman, & Lorenz, 2013, p. 160). Bedside shift reporting focuses on the RN-to-RN handoff communication with the added benefits of increased accountability, mentoring opportunities, and patient and staff satisfaction (Cairns et al., 2013).
Bedside shift reporting, an essential part of clinical practice and a method of communication among health care providers, can occur at different locations and in a variety of diverse approaches (Sherman, Sand-Jecklin, & Johnson, 2013). Past approaches included breakrooms, nursing stations, hallways, face to face, audio recording, or print-out patient information without patient or family involvement. These outdated practices tended to be long lasting and disruptive and lacked consistency (Reinbeck & Fitzsimons, 2013). By incorporating a standardized and consistent bedside shift reporting format, the needs of nursing staff were addressed for best practices through fostering open communication between nurses, patients, and families.
Including the patient in the bedside shift report enhanced accountability and communication among the health care team and care delivery showing improved outcomes and satisfaction. Ferguson and Howell (2015) found that documenting best practices in the delivery of care regarding bedside shift reporting remains a challenge. Negative outcomes from ineffective bedside shift reporting and communication between caregivers includes patient harm, delays, avoidable treatment, and prolonged length of stay (Reinbeck & Fitzsimons, 2013).
The literature review included the nurses and patients' perspective on the importance of incorporating bedside shift reporting on a structured standardized routine basis. Other common themes included collaboration, empowerment, work effectiveness, and accountability. The Robert Wood Johnson Foundation and the Institute for Healthcare Improvement collaborated with frontline staff nurses on the Transforming Care at the Bedside (TCAB) to address point of care, engagement of bedside staff, quality of care, and staff satisfaction (Dearmon et al., 2012; Robert Wood Johnson Foundation, 2011). Essential features of TCAB strengthened the link between patient outcomes, while improving the work environment for frontline staff (Roussel et al., 2012). The core principle of TCAB was the facilitation of quality improvement within the hospital by relying on nurse and frontline staffed teams providing the most direct care to patients (Roussel et al., 2012).
Numerous studies have explored bedside shift reporting from the nurse's and patient's perspective (Cairns et al., 2013; Ferguson & Howell, 2015; Gregory, Tan, Tilico, Edwardson, & Gamm, 2014). The study by Cairns et al. (2013) found that nurses practicing in a stroke rehabilitation unit in a large metropolitan hospital stated that bedside shift report promoted staff accountability and teamwork, as well as increased patient collaboration, in care planning. Ferguson and Howell (2015) reported that communication at the bedside enhanced efficacy in delivery of patient care, good patient outcomes, increased satisfaction with care delivery, enhanced accountability for nursing professionals, and improved communications between patients and their direct care providers. The study by Gregory et al. (2014) found that bedside shift reports were viewed as an opportunity to reduce errors and important to ensure communication between nurses. Studies by Sand-Jecklin and Sherman (2013, 2014) found that nurses perceived bedside shift reporting increased accountability and participation. They also found that nurses felt that safety checks were being implemented well and that falls and medication errors were decreased.
Bedside shift reporting motivated employee ownership, teamwork, and accountability, allowing patients to recognize that participation improves safety, increased rapport between nurse and patients, and reassured patients that the nurses work as a team with everyone thinking in a similar way (Baker, 2010; Laws & Amato, 2010; Manion, 2012; Roussel et al., 2012; Salani 2015).
Tobiano, Bucknall, Sladdin, Whitty, and Chaboyer (2018) found that patients can contribute information about their care and improvement, which could help make a smooth transition of care, improve quality and safety, thus refining the nurse–patient relationship.
Recent studies recognizing obstacles to the application and acceptance of bedside shift reporting cite nurses' concerns about compromising patient privacy, length of time to complete report, and conversations of confidential or private items, complicated relationships, or patient compliance as negative outcomes (Cairns et al., 2013). Battié and Steelman (2014) reported that clarity of patient information, continuity of care, and the ability to ask questions are just a few key elements of effective bedside shift reporting for all involved participants. Communication tools must address the ever-changing health care arena and the complexity of patients and their needs. Griffin (2012) found the issue of bringing report to the bedside and the discussion of sensitive topics or new information not yet shared with the patient or family was a concern for many nurses. However, the nursing staff should plan ahead so that sensitive or new information is shared before or after the bedside report with the goal of modifying staff behavior so the patients and families can be included in the report process (Griffin, 2010).
Continuing education intervention must explore viability, suitability, relevance, and effectiveness as strategies to improve communication and patient participation through bedside shift reporting (Malfait, Eeckloo, Lust, Van Biesen, & Van Hecke, 2017). Ferguson and Howell (2015) investigated how bedside reporting supports nursing research studies. The need to evaluate bedside shift reporting from the nurse's perspective in regard to accountability, empowerment, work effectiveness (opportunity, information, support, and resources), job activities and satisfaction, and organizational relationships and communication is critical. The purpose of the current study was to provide an intervention of educational learning activities on bedside shift reporting to enhance accountability and empowerment among frontline nurses. These interventions also emphasized the importance to include pertinent patient information and safe transitional care with standardized implementation by all members of the health care team.
Collaborative Care Model
The Collaborative Deliberation Model for patient care (Elwyn et al., 2014) served as the framework, with concepts addressing the need to work collaboratively while communicating difficult decisions, considering new alternatives, or changing behaviors. This innovative and flexible model promotes independence and accountability in nursing practice, reduces duplication in the performance of nursing tasks, enhances effective communication, and outlines tools for collaboration among members of the nursing and interprofessional teams (LeClerc, Doyon, Gravelle, Hall, & Roussel, 2008). Collaborative relationships with the health care team and patients are central to this model (Laws & Amato, 2010). The goal was to build a partnership between the nursing staff incorporating patient and family involvement, thus promoting interactions through open communication and mutual relations (Laws & Amato, 2010). Implementing bedside shift reporting was congruent, supporting a collaborative approach to how nursing care should be provided (Laws & Amato, 2010).
Bedside shift reporting reflects partnerships of patients and families with health care providers having the ability to collaborate among teams. Collaboration can be evidenced through bedside shift reporting. Working together to benefit all involved and having the ability to see collaboration at its true existence through this new innovative way of reporting is paramount to patient and staff outcomes. Through bedside shift reporting, collaboration can be measured and validated as an innovative evidence-based practice exemplar. Several issues can be measured, including accountability and ownership, work effectiveness, improvement, and satisfaction. Collaboration is a shared commitment, where all partners have a right and an obligation to participate. This can be affected equally by the benefits and risks arising from the organization.
This was a single group pretest–posttest design that examined the effect of a bedside shift educational program on accountability and structural empowerment. A convenience sample of nurses who worked at a 250-bed South Florida Hospital on two medical–surgical units participated. Eligible RNs were full or part time, regardless of job title, spending all of their time in direct patient care. Non-direct care nurses were excluded from this intervention.
A 45-minute learning module presentation on “Bedside Shift Reporting” was created by one of the investigators (J.W.), with handouts provided. The module consisted of a PowerPoint® presentation on recent best practices for bedside shift reporting focusing on patient safety, communication (organizational relationships), patient and family involvement while addressing accountability, work effectiveness (opportunity, information, support, and resources), and job activities and satisfaction. A new bedside reporting tool was presented as developed in conjunction with highly regarded nurse managers consisting of physical assessment, critical laboratories, core measures, diet, code status, and expected date of and barriers to discharge. Following completion of the educational intervention, learners (a) improve accountability in practice, (b) increase effectiveness in practice, (c) increase job activities and satisfaction, and (d) improve communication and organizational relationships.
Demographics. Demographic data were gathered through an eight-item questionnaire. Demographic data included gender, age group, ethnicity, nursing education level, number of years of experience, primary shift work, full- or part-time status, and average number of hours worked per day.
Specht and Ramler Accountability Index (SRAI). The SRAI measures individual nurse accountability and provides a tool for measurement of a concept recognized as an important facet of professional nursing practice (Specht, 1996; Specht & Ramler, 1991). The instrument provides a mechanism to evaluate the impact of organizational changes designed to enhance the practice of professional nursing (Specht, 1996). The index has the advantages of being relatively short and easy to administer and score, with initial reliability estimates that indicate good internal consistency (Specht & Ramler, 1991).
The SRAI tool consists of 11 items on which respondents indicate the extent to which they agree with each statement on a scale from 1 to 4, ranging from 4 = definitely true to 1 = definitely false. Two example questions on this instrument measure how nurses hold one accountable for the care each nurse delivers and how nurses monitor quality of nursing care received by patients on their unit.
Sorensen, Seebeck, Scherb, Specht, and Loes (2009) administered the SRAI, with high scores indicating high levels of perceived accountability and low scores indicating low levels of perceived accountability. The Cronbach's alpha values ranged from .40 to .74, with only two correlations less than .50 (Sorensen et al., 2009). There was evidence of construct validity with Specht's (1996) initial 5-item scale; the Cronbach's alpha for Sorensen et al. (2009) was .82, demonstrating strong internal reliability with that of .94 (n = 167) in the study by Specht and Ramler (1991).
Conditions for Workplace Effectiveness Questionnaire-I and -II. The Conditions for Workplace Effectiveness Questionnaires (CWEQ) consists of CWEQ-I and CWEQ- II, which measure the concept of structural empowerment, seen as a measurement of workplace culture. The 31-item CWEQ-I questionnaire consists of four subscales plus two global items, a nine-item Job Intervention Scale, and an 18-item Organizational Structural Empowerment (OSE) scale (Laschinger & Shamian, 1994). The CWEQ-II was implemented for data gathering for this intervention (Laschinger, Finegan, Shamian, & Wilk, 2001), and is a modification of the original CWEQ-I that consists of 19 items on a Likert scale ranging from 1 = none or strongly disagree to 5 = a lot or strongly agree. These items measure six components of structural empowerment described by Kanter (1977, 1993) (opportunity, information, support, resources, formal power, and informal power), and a two-item global empowerment scale that is used for construct validation purposes. Items on each of the six subscales are summed and averaged to provide a score for each subscale ranging from 1 to 5. The CWEQ-II demonstrated strong internal reliability with work effectiveness (12 items) with a Cronbach's alpha of .92, n = 166; nursing job activities (satisfaction) (three items: formal power) with a Cronbach's alpha of .91, n = 170; organizational relationships (communication) (four items: informal power) with a Cronbach's alpha of .86, n = 168; and empowerment (nine items) with Cronbach's alpha of .94, n = 168. Construct validity for the CWEQ-II (Laschinger et al., 2001) was established.
A flyer invitation regarding the upcoming education–learning intervention was provided 2 weeks prior to all nurses. A poster was placed in two nursing staff lounges to encourage nurses to participate in this study. All nurses who wanted to participate contacted the researchers. The nurses were encouraged to attend one of the 45-minute educational learning intervention sessions. These sessions were offered 20 times throughout the day and night to accommodate all shifts. Pretest data were collected on site immediately prior to the education–learning intervention.
The researchers met with the nurses, administered the three questionnaires including demographics, SRAI, and CWEQ-II, and completed the educational program. A question-and-answer session followed with reinforcement of information. The posttest data, including the demographic survey, SRAI, and CWEQ-II, were collected after 1 month at their annual skills competency day. This allowed time for the participants to use the information that was provided in the educational learning intervention session. The nursing leadership in the two units monitored the participants' use of bedside shift reporting while encouraging them to apply this new change into practice to ensure sustainability. Suggestions and changes to bedside shift reporting were also gathered verbally between the nursing staff and leadership during this 1-month time frame, to ensure buy-in from the nurses.
Human Subjects Protection
After obtaining institutional review board approval from the academic institution and the South Florida hospital, the recruiting strategies began. Confidentiality of all information related to the participants, including demographic data, questionnaire scores, and quantitative data, was maintained at all times. No identifiable information was collected, with only aggregate data reported. Individual participant questionnaire scores were not shared with nurse managers or administrators. Consent was implied with the completion of the questionnaires.
Of a convenience sample of 184 RNs working in this South Florida hospital, 104 nurses (representing the majority of the nurses working in the two units) completed the pretest, with only 73 of those completing the post-test. The participants consisted of 75% women and 25% men both pretest and posttest. The sample was ethnically diverse with the majority being Latino (pretest, 55.8%; posttest, 60.3%), yielding similar results.
Of the 104 participants, 104 answered the questions on work effectiveness (opportunity, information, support, and resources), organizational relationships and communication, and job activities and satisfaction, with only 95 (91%) addressing empowerment and 90 (87%) addressing accountability for the pretest. Of the 104 who participated in the pretest, only 73 (70%) completed the SRAI and CWEQ- II posttest data for work effectiveness (opportunity, information, support, and resources), organizational relationships and communication, and job activities and satisfaction, with 71 (68%) for accountability and only 63 (61%) completing global empowerment (Table).
Participants' Scores of Specht and Ramler Accountability Index-Individual Referent (SRAI) and the Conditions for Workplace Effectiveness Questionnaire-II (CWEQ-II)
All data gathered were not matched given that the pretest was independent of the posttest sample. Therefore, there are no identifiers to match the responses in each sample group. The statistical data analyses were performed using SPSS® version 23. The scores were not normally distributed, thus utilizing the nonparametric Mann-Whitney U test to analyze the group differences. There were statistically significant differences in all subscale mean ranks: global empowerment, with the pretest lower than the posttest (pretest M = 23.00, n = 95; posttest M = 24.98, n = 63, z = −3.32, p = .00); work effectiveness (opportunity, information, support, and resources), with pretest significantly lower than the posttest (pretest M = 46.30, n = 104; posttest M = 52.00, n = 73, z = −4.75, p = .00); organizational relationships and communication, with pretest significantly lower than the posttest (pretest M = 16.00, n = 104; posttest M = 18.00, n = 73, z = −5.14, p = .00); nurse job activities and satisfaction with pretest significantly lower than the posttest (pretest M = 12.00, n = 104; posttest M = 13.00, n = 73, z = −4.51, p = .00). The study results indicated no statistical that difference between the pretest and the posttest of accountability (pretest M = 3.17, n = 90; posttest M = 3.17, n = 71, z = −.44, p = .65).
The results in Table demonstrated that global empowerment was related to improved collaborative partnerships. The results indicated that in global empowerment the pretest was significantly lower than the posttest. Work effectiveness (opportunity, information, support, and resources) was improved following the delivery of the bedside shift report interventions. The results found in organizational relationships and communication, the pretest rank was significantly lower than the posttest rank. The results in nurse job activities and satisfaction indicated that the pretest was significantly lower than the posttest. The fact that accountability did not show any significance may be due to the nurses' feeling that they were already accountable prior to the intervention.
These results indicated the importance of building healthy positive work environments that offer opportunities to empower nurses for achieving their work and accept accountability of outcomes, thus contributing to their institutions' organizational goals. Global empowerment, work effectiveness (opportunity, information, support, and resources) and nurse job activities and satisfaction highlight the importance of nursing staff collaborating with their patients. This collaboration fosters a sense of collective accountability for practice, resulting in improved outcomes.
The participants voiced their concerns during the intervention to include time constraints, fear of the unknown, and lack of confidentiality due to the semi-private rooms. Documented broad range barriers to implementation of the intervention included the nurses' inadequate knowledge and understanding of bedside shift reporting, resistance to change, scant buy-in, shortage of employee empowerment, diverse organizational culture, nurses' time off, staff turnover, and vacancies. Other known barriers included minimal support and guidance from nurse mangers and leaders following the intervention, decreased self-confidence and trust, poor communication skills, fear of breaching confidentiality, and unsatisfactory teamwork. Proper implementation included overall satisfaction in the improved bedside shift reporting, accountability, and empowerment of the nurses, thus improving the quality of patient care with positive outcomes.
The generalizability of the findings is limited by use of a convenience sample with data collection from one hospital. Having only a short time span from pre- to postdata gathering could have had an effect on data results. Time constraints were a factor given that the nurses had to get back to their units for patient care. Because several of the nurses did not listen carefully to the instructions, they did not complete the entire survey. Self-selection bias, fear about retaliation and job security, and limited postdata collection occurring during their annual skills competency day may have influenced individual scores. The participants were not matched from pretest to posttest.
As with any new educational intervention effort, planning and identifying areas of improvement and ways to sustain this improvement are important parts of the process. Establishing a multidisciplinary team to include hospital leaders, frontline nurses, key clinical and management staff were imperative to the success and sustainability of this new program. Having this leadership and team support provided the necessary buy-in needed for sustainability. From the inception of the idea to change practice, unit managers and leaders made a clear case for the need for change and the expectations for the outcomes.
Future research is needed to establish empirical links between accountability, organizational relationships and communication, global empowerment, work effectiveness (opportunity, information, support, and resources), and nurse job activities and satisfaction. In retrospect, gathering identifiable demographic information could have produced numerous other findings, revealing more interesting discoveries. Comparison analysis could have been performed if participants were matched with valuable information by incorporating demographic data into the analysis. For example, comparing gender with accountability and work effectiveness (opportunity, information, support, and resources) or ethnicity with accountability and work effectiveness (opportunity, information, support, and resources) scores could have affected scores.
The participants identified that they experienced improved bedside shift–reporting capabilities, with positive staff and patient outcomes within the health care system. With the incorporation of a new standardized bedside shift–reporting tool, more collaborative and quality care should be established. Enhanced safe, quality care along with increased patient and staff satisfaction may improve the Hospital Consumer Assessment of Healthcare Providers and Systems scores for the hospital. Organization relationships and communication among health care providers and patients and their families becoming more and more involved in health care is another huge benefit that influences the importance of bedside handoff communication.
Change is upon the health care industry, and health care providers must embrace the opportunity to improve quality and improve communication among providers and patients and thus increased safety and continued continuity of care. This study presented valuable results to affect the future of nursing care.
The long-term goal of this project was to spread the standardized bedside shift–reporting format tool house wide so all nursing areas could reap the benefits of improved accountability, empowerment, work effectiveness, communication, and nurse job satisfaction. Exploring a longitudinal approach to identify the relationship between demographics and structural empowerment, length of stay, and discharge planning with the improved bedside reporting is warranted.
Another recommendation includes exploring longitudinal effects of bedside handoff communication to include patient satisfaction, length of stay, shift overtime, Hospital Consumer Assessment of Healthcare Providers and Systems scores, and nurse satisfaction. There is a need for consistent reinforcement, communication, and education of nurses during orientation. In addition, bedside handoff communication must be included in annual competences so it is effectively integrated as an essential change over time.
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Participants' Scores of Specht and Ramler Accountability Index-Individual Referent (SRAI) and the Conditions for Workplace Effectiveness Questionnaire-II (CWEQ-II)
|n||Mean Rank||Sum of Ranks||n||Mean Rank||Sum of Ranks|
| Global empowerment||95||69.65||6616.5||63||94.36||4944.5|
| Work effectiveness (opportunity, information, support, resources)||104||73.69||7663.5||73||110.82||8089.0|
| Organizational relationships and communication||104||72.63||7554.0||73||112.32||8199.0|
| Nursing job activities and satisfaction||104||74.72||7771.0||73||109.34||7982.0|