Wolf (1939} relates that change of shift report is one of the "most powerful arenas of professional socialization and communication" (p. 78). Additionally, shift report offers the most concentrated period of time in which nurses communicate. The nursing literature reflects the notion of change of shift report as a socializing process (Howell, 1994; Walsh & Ford, 1992; Wolf, 1989). Wolf (1989) relates the language or jargon of nursing as being essential to this change of shift socialization and communication. He reports that explicitly "professional nursing language serves to express comptes meanings without lengthy discussion" and implicitly allows group cohesiveness through use of "in-group language" (p. 79). Wolf (1989) further comments, "When information ia exchanged about the status of patients during shift report, the distinctive language of the working nurse is used as seasoned nurses teach novice nurses what it means to be a nurse" (p. 78).
How do instructors and students confront a clinical "hand over" or a shift report which does not support professional socialization and the movement from novice to beginning practitioner? This article outlines a learning project that successfully turned a negative clinical learning experience into a positive learning process allowing nursing students to practice professional behaviors.
A review of the literature reflecta limited research and articles addressing change of shift report. However, the current literature reflects three specific modes in the process of intershift communications:
* Oral report ito include bedside reports).
* Audiotaped report.
* Written (or silent) report.
An innovative method involves automated voice-based systems that allow up to 12 nurses to produce their shift reports conveniently through a touch-tone telephone (McGiIl, 1994). None of the literature addressed generation of voice-activated change of shift reports. However, with voice-recognition technology in use for nursing documentation (Trofino, 1993), it may be on the horizon.
Smith (1986) describes the need to assess where reports should take place, the "right place" environmentally Client confidentiality and privacy are especially important on a busy unit. Locating an area which can be assured of privacy and ia free from interruptions is essential to maximize the exchange of information.
The structure or formatting of end of shift report allows meaningful organization of large amounts of data (Kilpack & Dobson-Brassard, 1987). The structure of the shift report varies substantially baaed on variables particular to the specific nursing unit. Riegel (1985) suggested use of the Roy Adaptation Model as an organizer for shift reporting. Kilpack and Dobson-Braseard (1987) recommend the clients' problem lists and the subjective/objective assessment plan (SOAP) format be used for change of shift report. Kiely (1984) recommended a systems approach in the intensive care unit, while Böiger and Asghari (1987) report successful use of the nursing diagnosis as a framework for report. Reiley and Stengrevics (1989) found using a problemoriented form, with a demographic information form attached, facilitated written change of shift report.
The content of the shift report contains information which may be unique to the unit; however, it also contains information which does not (or should not) vary from established nursing practice. According to Smith (1986), specific components of shift report should include:
* Identification of clients,
* Reason for admission.
* Nursing diagnoses.
* Change in clients' conditions or protocols.
* Clients' emotional statue.
* Additional information (e.g., blood gas levels, electrocardiogram patterns, treatments, medications).
The learning project described in this article evolved from the clinical situation the instructors and students experienced. There were two clinical instructors and four different groups of senior-level nursing students (Groups A, B, C, and D) who participated in this learning experience. Each student group was on the psychiatric unit for 2 days for 3 consecutive weeks before beginning a 7-week rotation in a community agency. This particular learning project began with student groups A (Tuesday and Wednesday rotation) and B (Thursday and Friday rotation) listening to the staffs audiotaped shift report on the psychiatric nursing unit during the first week of the clinical experience. On completion of the report, students began to spontaneously critique it. Students were asked to share how they would improve the audiotaped reporta. They identified the following areas that needed improvement:
* Client identification information.
* More indepth description of the clients' current status.
* Statement of nursing diagnoses.
* Information students needed for provision of client care that day.
The students also recognized the staff's personal responses to client behaviors without a discussion of their self-analysis and no recommended therapeutic nursing interventions.
The instructors discussed how this experience could be developed into a positive learning activity. The outcome was a recommendation to the students that Group A audiotape their shift reports on their clients for Group B. Therefore, students on the unit Tuesday and Wednesday would audiotape reports for students on the unit Thursday and Friday; that group then would audiotape for students returning to the unit the following Tuesday and Wednesday. To enhance the learning process, the instructors usually assigned the same cheats to the student groups. After the students affirmed their desire to be involved in this activity, they were given the freedom to determine the structure for these shift reports. The faculty provided the audiotape and tape recorder for students' use.
The students were consistent in their choice of framework - the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-/V) (American Psychiatric Association, 1994). The DSMIV contains standard nomenclature of emotional illnesses used by health care practitioners. The DSM-IV identifies Axes which function to provide a biopsychosocial approach to psychiatric assessment. Axis I reflecta the clinical syndrome of clients (e.g., schizophrenia, major depression). Axis II represents identified personality disorders or mental retardation. Axis HI represents the general medical condition or physical disorders of clients. These first three Axes comprise the official diagnostic assessment. Axis IV, originally a rating scale of severity of psychosocial stress, has been changed in DSM-IV to a checklist reflecting a nine-category list of psychosocial and environmental problems. Axis V is the Global Assessment of Functioning (GAF) Scale and may represent clients' highest functioning within the past year, current functional status, or functional status at discharge. The students were familiar with this structure because of its inclusion in classroom content and their textbook.
Each thent had this data present in the chart. Using this information in the audiotaped reports reinforced students' ability to communicate in the proper psychiatric terminology and feel a part of an interdisciplinary team. The DSM-IV Axes also provided a concrete organizational structure to communicate information from multiple data sources (e.g., activity therapy, occupational therapy, group therapy) and abstract concepts. However, there was variation from one student group to another on how the Axes were used. Group A used Axes I, II and ??. Group B used all five Axes. Groups A and B had their clinical experience during the first 3 weeks, while groups C and D had their clinical experience the second 3 weeks. Groups C and D will be discussed separately.
Ail students began their reports with identification information on the clients and then proceeded to the information related to the DSM-IV Axes. The students (Group A) who chose not to use Axes IV and V did so because they felt this information was not current. Instead, Group A stated the nursing diagnosis that was the function of their 2 days of work and shared the interventions that worked. If some interventions did not work, they also shared these, with recommendations of different approaches. Group B presented all five Axes and then added the same information as Group A. The students were encouraged to critique the reports of their fellow classmates as well as compare them to their reports. Students were able to recognize the professionalism of their peers; the need to prioritize the content of their focused communication; the need for concise reports in the "real" work setting; the need for practical, usable information; and the need for current holistic assessments of the clients. In response to this meta-analysis, both groups A and B modified their report processes and in the end used only the first three Axes with the extra identified content of Group A. As the clinical experience moved toward completion, students appeared confident in their ability to assume the professional role behaviors of presenting a shift report to their colleagues.
When Groups C and D began their clinical experience, they had been present in the classroom during discussions and application of nursing diagnoses to clinical situations for 4 more weeks than groups A and B. These students also were given the same opportunity to audiotape their shift reports for the next student group. Both groups chose all five Axes of the DSM-TV. They critiqued their peers' reports and modified their processes as did the first two groups. Groups C and D differed from the first two groups hi how they modified their reports. Instead of eliminating Axes IV and V, these students continually updated this information.
They reported the clients' current status with respect to the identified psychosocial and environmental problem categories - Axis IV. They completed Axis V by completing a GAF and requesting validation of this perception from the physicians or the nursing staff This data was highly significant for the group of thente being cared for on the unit. These clients presented high levels of anxiety and were vulnerable to fluctuation in responses from the external environment. Suicidal activity, eelf-mutilation, and anxiety attacks were behaviors demonstrated by several of the individuals on the unit. In a counterresponse, students maintained a current assessment of Axes IV and V. This provided students with a feeling of predictability of the clients' behaviors through their current knowledge base.
Groups C and D showed growth by making the need for significant current client data a priority. Also, because of thenextended classroom exposure to clinical situations, these two groups were able to integrate more of their theory base into their planned client care.
All studente were given timely feedback from the instructors. The instructors met on a weekly basis to review the client assignments and discuss the reporte given by the student groups. Because the report evaluation was completed by an instructor who was not in the clinical setting with those students, evaluation data aud insights were enriched by the second data source.
The student groups also varied in their choice of place in which to do their recording. All groups preferred to record their reports without the instructor present, which demonstrated a high level of selfdirected learning. Some students chose private places where their peers could not interrupt them. Others chose to tape in a room with peers present. This latter group often had a member who would tell the clinical instructor what a good report one of their peers had just taped. This group of students tended to work in teams on the unit and assist each other in tasks which benefited from team effort. It was apparent in all groupe that the studente had the ability to determine the approaches that supported their learning processes and were comfortable initiating that process. Their group members were supportive of the individual's preference, which is part of the norms established through their collaborative group work in the classroom setting.
This learning project turned a potentially negative learning environment into an educational experience which allowed students to grow on several levels. This project supported the interactive process of learning through the ongoing dialogue between students and faculty and among student groups. Students were permitted to structure this experience in a meaningful manner. Their skills in thinking critically were enhanced by critiquing and comparing their peers' reports to their own perceptions and by modifying their process accordingly. Through discovery processes, students altered their attitudes, cognition, and behavior. An attitude of simplicity toward creating a shift report was altered to one of "this takes thought" on the part of the reporter. Previous perceptions, on what constituted significant and relevant information, were cogniti vely modified to include prioritization and time constraints of the work environment. Behavioral changes were present in the refinement of the audiotaped reports. The studente practiced taking the role of their professional nursing practice and behavior.
This learning project effectively created a positive and open educational environment. The activity was problem oriented, with ready application to the students' practice setting. It aleo supported the development of behaviors which assist in role transition. The instructors facilitated an analysis of the students' discovery, helped them determine a desired outcome, recommended a technique, and provided reeeurcea. Throughout the procese, the instructors encouraged critical evaluation of the activity using their past exposure to shift reports and their perceptions of an ideal report. The outcome was an enthusiastic response to the clinical activity and growth for the students and faculty.
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