Critical Information About A Patient 's Plan Of Care

In every profession there are changes that propel how tasks are done; nursing is no stranger to this. One of the biggest changes that have come into nursing’s daily events is how report hand-offs are being done. Gone are the days of taped report that each off going nurse must tape about each patient and the oncoming nurse must listen to. Nurses are now being encouraged to move their report to the bedside, in front of the patient (Trossman, 2007). It is very important to know how this can affect the patient and even the nurse’s schedule. With every change, there are positives and negatives that can finalize the decision to keep or forego

Bedside reporting has the primary function of sharing patient information between nurses, as they change shifts. The nurse ending their shift would report all the changes that have occurred in the state of the patient and all measures which have been taken for the respective patient. This information would be transmitted to the nurse commencing her shift, who would then write and further transmit all patient information occurring during their shift, to the nurse coming to replace them.

The hand over process of communication between nurses to nurses is done with the intention of transferring essential information for safe, and patient centered care. Traditionally, this shift report has been done away from the patient’s bedside, at the nurse’s station, or other place like staff’s room. In addition, the shift report used to be delivered through audio recording of the patient’s information. These reporting mechanisms did not include face-to-face reporting of the patient information, nor involvement of patient. Therefore, information regarding the patient’s care was not shared with the patient, leaving them out of his/her own care plan. Recent studies and development of Patient Centered Care Philosophy have challenged this belief of giving a report away from the patient. Tan (2015) said, “Shift report must not only be restricted in nurse to nurse communication, but it must involve patients as the recipients of care” (p. 1). Incorporating the patient into the end of shift report is essential for providing patient centered care and patient satisfaction. Nurses at the St Jude Medical center in the acute in-patient rehabilitation unit are not exceptional. Most of the end of the shift report between nurses are still done away from the patient. Aim of this paper is to make a change in the work place, which is the process of giving end of shift report at the bedside incorporating patient and families in the acute in-patient rehabilitation unit at St Jude Medical

Effective communication is crucial aspect of nursing yet too often is placed low on the priority list, especially at shift change. Information related to the care of patients is frequently disseminated at a crowded, noisy nurse station with several nurses rushing to leave and others attempting to get the information necessary to plan care and limit the constant distractions. It is this interaction that allows for information vital patient safety information to be communicated including the acuity of patients.

Traditionally, nursing shift-to-shift reports were organized methods of communication between only the oncoming and leaving nurse, designated to a location such as the central nursing station or nook of a hallway. Shift reports can be considered the foundation of how the day is going to plan out because it introduces the patient, diagnoses, complications, medications, consults, upcoming test and the entire plan of care. These reports are full of complicated and vital information and while set in certain locations that are vulnerable to interruptions, such as the nursing station, medical errors and miscommunication are more likely to be made. The Joint Commission’s 2009 and 2010 National Patient Safety Goals (Joint Commission, 2015) included two patient safety standards, first to encourage patients to be involved in their health care plan and second, to implement a standardized communication process for handoff reports between providers. Soon after in 2013, The Agency for Healthcare Research and Quality under the United States Department of Health and Human Services introduced a set of strategies to improve patient engagement along with safety and quality in patient care. Within these strategies the new method of nurse bedside shift report was developed, which suggests nurses to conduct shift-to-shift reports at bedside in the room of each patient, rather than out of the room. The benefits of this new method were

Traditionally nurses delivered clinical information about the patient, the clinical events on their shift and the plan of care to the oncoming shift to ensure continuity of care and to make sure that their colleagues were informed about tasks or instructions that needed to be completed by the next shift. This process had a variety of names; report, handover or handoff. The format was often different from unit to unit. It usually took place in an off stage room or office or at a charting station from away from the

Bedside reporting involves giving information or a report to the oncoming nurse in the presence of a patient. This method gives the patient an opportunity to ask questions and get clarification regarding his or her care. Bedside reporting increases patient satisfaction, quality of healthcare and nurse-to-nurse responsibility. Hospitals need to design a better handoff process that can easily reduce patient risks and increase patients’ involvement in their care. Emergency rooms shift reports usually take place at the nursing station of every patient care area. The departing nurse gives information verbally to the oncoming shift. Therefore,

Bedside shift reporting, is it necessary? Baker (2010) states that is has its benefits, from patient safety, increased patient involvement and staff teamwork, ownership and accountability.” (Baker, 2010) To promote stronger engagement, Agency for Healthcare Research and Quality developed the Guide to Patient and Family Engagement in Hospital Quality and Safety for bedside reporting. (AHRQ, 2013)

The purpose of this BSR project is to assess the nurse’s performance during their handoff report and develop some strategically possible solutions that may improve a patient quality of care, safety, and satisfaction. Communication plays such an important role between nurses and patients to emphasize that an “Effective workforce planning and policymaking require better data collection and an improved

Bedside report has also become a critical component to maintain patient safety. In the past nurses would give hand off report at the nurse’s station, leaving their patients alone. This time frame has proven to be when the majority of sentinel events occurred, such as falls (Ofori-Atta, J., 2014). Bedside report keeps patients involved in their care and reduces the risk of errors in communication between nurses and maintains patient

Communication between nurses at report change is essential. The next nurse needs the most important information whether it is as Situation-Background-Assessment-Recommendation (SBAR) that the Institute for Healthcare Improvement (n.d.) outlines to use or in another form. The case of Rio Grande Regional Hospital Inc v. Villarreal discusses how one nurse breached the standard of care because the record reflects that from the time Hermes was given the double-edged razor until he died neither Nurse Bergado nor any other nurse checked to see how Hermes was doing in the bathroom” (Find Law for Legal Professionals, 2016). At Baylor Scott & White at All Saints, we have a policy that each patient is rounded on physically every hour.

Change of shift in the nursing profession is unique (Caruso, 2007). Information is transferred between nurses verbally and through written communication. In many facilities shift report from one shift to another involved sitting down and getting all your orders from a caredex and then talking with the previous nurse face to face going over pertinent information regarding their patients. This type of report usually happens in a report room or sometimes in the hallways or other common

First, baseline data were collected on nurse perceptions about the shift report process and patient perceptions about nursing care were. The authors adopted the ‘Patient Views on Nursing Care’ patient survey tool (Larrabee et al. 1995) to perform the survey. Then same data were collected and analyzed three months and 13 months after the new approach was implemented. The data analysis approach included analysis of variance(ANOVA) to compare data collected during the baseline survey and data collected after the new approach was implemented.

Scottsdale Healthcare is an organization of magnet status and is continuously striving to find ways in which to improve patient satisfaction and quality of care. As of October 2011, Scottsdale Healthcare implemented bedside report in order increase patient satisfaction providing the patient and family knowledge in regards to their condition and plan of care in order to set goals for the patients recovery and gives them the ability to ask questions. Prior to bedside report taking effect, management gathered all employees from the unit going over what is to be expected and how bedside report was not only taking effect on our unit alone, but hospital wide. Nursing leaders knew that they had a situation at hand due to the fact that nursing staff was so comfortable in giving report at the nurses station and did not want to wake the patient or deal with a family member, but they remained positive and encouraged staff that this would dramatically change our satisfaction scores. In maintaining patient satisfaction scores, the hospital would qualify for reimbursement from Medicare. The nurse

The adoption of clinical information systems is one way that healthcare organizations are making an effort to improve patient safety, provide a means to exemplify regulatory compliance, and facilitate exchange of patient information between care providers (Kirkley & Stein, 2004; Nadzam, 2009). To achieve this goal, Barnes-Jewish Hospital (BJH) recently implemented a new CPOE/clinical documentation system. One of the objectives of the new system was to give bedside clinicians a standardized electronic tool, known as the Clinical Summary, for bedside shift hand-off reporting. Soon after go-live, it was identified that the standard nursing Clinical Summary did not meet