When nurses have a question about a clinical practice issue that they can turn to the literature to see what scientific evidence is available that addresses their question. However, as discussed in Week 2, not all evidence is created equal. When looking at the literature, it is important to evaluate each research study. Before assumptions can be made about the applicability of a study’s results, specific elements of a research design must be evaluated.
This week, you will examine elements of the strength of a quantitative research study’s design, including sample size, generalizability, statistical analysis and conclusions. Keep in mind all studies have flaws or are not valid for your population. Consequently, one study by itself will not warrant a change in practice. It is important to find a number of studies to support your change in practice.
Post the following:
ORIGINAL ARTICLE
A quantitative assessment of patient and nurse outcomes of bedside
nursing report implementation
Kari Sand-Jecklin and Jay Sherman
Aims and objectives. To quantify quantitative outcomes of a practice change to a
blended form of bedside nursing report.
Background. The literature identifies several benefits of bedside nursing shift
report. However, published studies have not adequately quantified outcomes
related to this process change, having either small or unreported sample sizes or
not testing for statistical significance.
Design. Quasi-experimental pre- and postimplementation design.
Methods. Seven medical-surgical units in a large university hospital implemented a
blend of recorded and bedside nursing report. Outcomes monitored included patient
and nursing satisfaction, patient falls, nursing overtime and medication errors.
Results. We found statistically significant improvements postimplementation in
four patient survey items specifically impacted by the change to bedside report.
Nursing perceptions of report were significantly improved in the areas of patient
safety and involvement in care and nurse accountability postimplementation.
However, there was a decline in nurse perception that report took a reasonable
amount of time after bedside report implementation; contrary to these perceptions, there was no significant increase in nurse overtime. Patient falls at shift
change decreased substantially after the implementation of bedside report. An
intervening variable during the study period invalidated the comparison of medication errors pre- and postintervention. There was some indication from both
patients and nurses that bedside report was not always consistently implemented.
Conclusions. Several positive outcomes were documented in relation to the implementation of a blended bedside shift report, with few drawbacks. Nurse attitudes
about report at the final data collection were more positive than at the initial postimplementation data collection.
Relevance to clinical practice. If properly implemented, nursing bedside report can
result in improved patient and nursing satisfaction and patient safety outcomes. However, managers should involve staff nurses in the implementation process and continue to monitor consistency in report format as well as satisfaction with the process.
What does this paper contribute
to the wider global clinical
community?
• Previous nursing bedside report
•
•
manuscripts have had very small
or unreported sample sizes for
patient and nursing bedside
report surveys and have rarely
attempted to calculate the statistical significance of their results.
Our patient and nurse survey
instruments examined a far
greater number of factors/issues
that are considered relevant to
bedside nursing report than any
other study of which we are currently aware.
We are also only the second published study to track changes in
patient falls during the handover
hour before and after implementing bedside report.
Key words: bedside shift report, nursing handover, nursing shift report, patientcentred care, patient satisfaction
Accepted for publication: 25 January 2014
Authors: Kari Sand-Jecklin, EdD, MSN, RN, AHN-BC, Associate
Professor of Nursing, West Virginia University, Morgantown; WV,
Jay Sherman, CNRN, ME, Clinical Research Nurse, West Virginia
University Healthcare, Morgantown, WV, USA
2854
Correspondence: Jay Sherman, Clinical Research Nurse, WVU Eye
Institute, 3rd Floor, P.O. Box 782, Morgantown, WV 26506, USA.
Telephone: +1 304 598 6128.
E-mail: shermanj@wvuhealthcare.com
© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 2854–2863, doi: 10.1111/jocn.12575
Original article
Introduction
Improving upon the effectiveness of communication is a
Joint Commission National Patient Safety Goal (JCAHO
2013). According to the Joint Commission (2011), one of
the factors leading to sentinel patient events is miscommunication. A significant percentage of a nurse’s communications
each day occurs during patient handoffs, and the safety of
the patient can be compromised at this time (Friesen et al.
2008). A survey of over half a million hospital staff found
that respondents rated the safety of patient handoffs second
lowest among 12 areas of patient safety (Sorra et al. 2012).
In a study concerning near miss incidents, nurses again identified patient handoffs as a factor (Ebright et al. 2004). In
recent years, bedside nursing handoffs have been presented
positively in the literature, with benefits such as improved
patient satisfaction, improved nurse communication and
shorter shift reports being identified. It was the goal of the
Medical Surgical Research Utilization Team at West Virginia
University to implement a change in practice to a blended
form of bedside nurse shift handoff, and to evaluate this new
format in terms of patient and nurse satisfaction as well as
impact on patient safety.
Background
The literature on nursing bedside report is focused in two
general areas. The first focus area is the process of implementing bedside report, either describing the experiences
related to implementation or explaining how other organisations could implement this change. The second area of
focus is improving the process of bedside report, often
through observation and identifying common themes, or by
describing how others may improve their own reporting
process. Unfortunately, although there is strong consistency
in the suggested strategies for the implementation of bedside report, there is a gap in the literature in terms of documenting quantitative patient and nurse outcomes
(Riesenberg et al. 2010, Novak & Fairchild 2012, Staggers
& Blaz 2012, Sherman et al. 2013). However, in the last
two years, several manuscripts have been published that in
some way quantified the potential outcomes of bedside
nursing report.
Identified benefits of bedside report
Numerous benefits of bedside nursing report have been
reported, with remarkably few drawbacks identified. The
most often reported benefit (identified by nine individual
manuscripts) is that patients are better informed (Searson
© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 2854–2863
Quantitative assessment of bedside nursing report
2000, Anderson & Mangino 2006, Laws & Amato 2010,
Tidwell et al. 2011, Maxson et al. 2012, Rush 2012, Thomas & Donohue-Porter 2012, Wakefield et al. 2012, SandJecklin & Sherman 2013). However, several of these manuscripts did not report sample size or statistical significance
(Anderson & Mangino 2006, Laws & Amato 2010, Thomas & Donohue-Porter 2012, Rush 2012, Wakefield et al.
2012), and others (Searson 2000, Maxson et al. 2012) were
based on small sample sizes. The study reported by SandJecklin and Sherman (2013) did find significant improvements in patient information as a result of bedside report
using a large sample size of 302 patients/families preimplementation and 250 postimplementation.
The second most often reported benefit of moving nursing report to the bedside is related to general improvements
in patient satisfaction. Improvements in patient satisfaction
are a primary goal of nursing practice changes. Radtke
(2013) and Reinbeck and Fitzsimons (2013) reported
improvements in patient responses to the Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS). However, such general changes in patient
satisfaction could be affected by many uncontrolled variables in addition to the implementation of bedside report.
Additional studies have found improvements in general
patient satisfaction with the practice change, but did not
report sample sizes (Willis 2010, Thomas & Donohue-Porter 2012, Cairns & Dudjak 2013), or presented only qualitative impressions (Trossman 2009).
Increased patient involvement in their care is another
reported benefit of bedside shift report. Sand-Jecklin and
Sherman (2013) found a significant improvement in nurse
perceptions of patient involvement in care based on comparisons of 148 nurses at baseline and 98 nurses after the
implementation of bedside nursing shift report. Other studies reporting this outcome either did not report sample size
or had very small sample sizes or data that did not lend
itself to quantitative analysis (Searson 2000, Kelly 2005,
Anderson & Mangino 2006, Cairns & Dudjak’s 2013).
Several positive nurse-related outcomes have also been
associated with bedside shift report. Improved nurse teamwork is one of these reported outcomes. Unfortunately, the
studies reporting this did not report sample size or significance (Anderson & Mangino 2006, Laws & Amato 2010,
Thomas & Donohue-Porter 2012), had a small sample size
(Tidwell et al. 2011) or were based on qualitative impressions (Trossman 2009). An increase in nursing accountability as a result of bedside shift report was noted by
a number of researchers (Anderson & Mangino 2006,
Laws & Amato 2010, Maxson et al. 2012, Thomas &
Donohue-Porter 2012, Sand-Jecklin & Sherman 2013),
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K Sand-Jecklin and J Sherman
with Sand-Jecklin and Sherman reporting statistically significant increase in nurse perception of report-promoting
accountability. Increased report accuracy was also identified
as an outcome (Kelly 2005, Anderson & Mangino 2006,
Thomas & Donohue-Porter 2012, Cairns & Dudjak 2013),
as was an improvement in patient safety (Cahill 1998,
Chaboyer et al. 2009, Trossman 2009, Laws & Amato
2010), although studies reporting these results were based
on unreported or very small sample sizes. Additionally, the
safety improvements were based on the perceptions of nursing staff, rather than direct patient safety data. However, in
a South Australian study on bedside handover outcomes,
Bradley and Mott (2012) reported a reduction in patient
safety incidents (burns, medication errors, skin tears and
falls) after implementing a bedside nursing report.
Additional benefits of bedside nurse report that have been
mentioned in the literature include improved nurse–patient
relationship (Searson 2000, Anderson & Mangino 2006,
Thomas & Donohue-Porter 2012), increased mentoring
opportunities (Trossman 2009), increased nurse ability to
answer physicians’ questions at the beginning of the shift
(Anderson & Mangino 2006, Maxson et al. 2012), general
improvement in nurse satisfaction with report (Tidwell et al.
2011, Evans et al. 2012), reduction in patient discharge
times due to improvement in patient education (Chaboyer
et al. 2009), better task prioritising at the beginning of shift
(Federwisch 2007), a decrease in falls (Athwal et al. 2009),
improvements in nurse friendliness and attitude and more
prompt response to patient calls (Wakefield et al. 2012), and
a decrease in patient call light use (Cairns & Dudjak 2013).
It should be noted again that of the above-mentioned manuscripts, only Tidwell et al. (2011) and Maxson et al. (2012)
reported statistically significant results, albeit both with
small sample sizes and with Tidwell’s study being performed
on a paediatric unit and therefore not as generalisable. Additionally, the Athwal et al. study (2009) contained a very
small sample size, Evans et al. (2012) did not report the
study sample size and Federwisch (2007) had a qualitative
study design.
Drawbacks of bedside report
Few negative outcomes have been reported related to the
implementation of bedside nurse report. Most studies
reporting negative outcomes are either qualitative in nature
or are based on unreported or small sample sizes. Privacy
has been voiced as a concern by nurses (Anderson & Mangino 2006, Caruso 2007, Laws & Amato 2010) and a very
small number of patients (Timonen & Sihvonen 2000).
Some patients have found report redundancy tiring (Cahill
2856
1998, Caruso 2007), have disliked the use of medical jargon
(Cahill 1998, Searson 2000) or have felt anxious from
repeatedly hearing about their condition (Timonen & Sihvonen 2000). Sand-Jecklin and Sherman (2013) reported
nurses’ perceptions of reduced report efficiency and effectiveness, and increased stress associated with report after the
implementation of a blended format of nursing shift report.
Finally, there is the question of report length. Of the nine
manuscripts reporting on this, seven found that bedside
report took less time (Anderson & Mangino 2006, Caruso
2007, Athwal et al. 2009, Tidwell et al. 2011, Bradley &
Mott 2012, Evans et al. 2012, Cairns & Dudjak 2013).
Howell (1994) reported that half of surveyed nurses
thought it took longer and half did not. Sand-Jecklin and
Sherman reported that although a significant number of
nurses perceived that bedside report took more time, actual
overtime data indicated there was no significant difference
between baseline and postimplementation overtime.
Of the 13 papers that give specifics about the bedside
reporting process implemented, nine used some type of
‘blended’ reporting process. Anderson and Mangino (2006),
Athwal et al. (2009) and Laws and Amato (2010) combined a written report with the bedside report. Howell
(1994), Caruso (2007), Chaboyer et al. (2009) and Reinbeck and Fitzsimons (2013) reported that nurses discussed
information they deemed to be sensitive privately, away
from the patient bedside. Federwisch (2007) and Trossman
(2009) described a group meeting with all of the nurses
before the off-going nurse would meet with the oncoming
nurse at the bedside. Only, Tidwell et al. (2011), Bradley
and Mott (2012), Thomas and Donohue-Porter (2012) and
Wakefield et al. (2012) reported that the entire report took
place at the bedside.
Bedside nursing report has increased greatly in popularity
recently. In fact, in just the last two years, the literature has
approximately doubled in size. These studies have been
almost universally positive, but unfortunately have suffered
from small or even unreported sample sizes. Additionally,
only in the last two years have studies begun to calculate
the significance of their results. What evidence there is does
suggest that a blended report (with part at the bedside)
may lead to beneficial results for both patients and nurses,
but more evidence is needed.
Methods
Baseline data and instrumentation
After internal review board approval for the study was
obtained, we collected baseline data related to nurse percep© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 2854–2863
Original article
tions about the shift report process and patient perceptions
about nursing care. The ‘Patient Views on Nursing Care’
patient survey tool was adapted from the Larrabee ‘Patient
Judgments of Nursing Care’ instrument with permission
from the author (Larrabee et al. 1995). Instrument revisions
were based on the literature that indicated potential
changes in patient perceptions with the implementation of
bedside report. The patient survey had 17 items dealing
with the following nurse behaviours: treating the patient
kindly and with respect, listening to the patient, informing
the patient about their care, teaching so that the patient
could understand, working with other nurses, passing along
information from shift to shift, including the patient in
report discussions and keeping the patient’s health information private (Sand-Jecklin & Sherman 2013). All items had
a five-point Likert-type response option, with five indicating
excellent care and one indicating poor care. Overall instrument reliability according to Cronbach’s a was 096, and
interitem correlations ranged from 049–080. We distributed anonymous patient surveys, along with a cover letter
to a convenience sample of patients who had been hospitalised for at least 48 hours and were scheduled for discharge
from the medical surgical units on multiple days during the
month of baseline data collection. Family members were
encouraged to complete the survey if patients were unable
to complete it themselves, but only one survey was provided to each patient or family member. Patients were given
an envelope in which to seal their completed or blank survey forms prior to returning them to the researcher. Surveys
were returned to the researcher in a sealed envelope to protect confidentiality.
Nurse perceptions of shift report were collected via an
online survey. The ‘Nursing Assessment of Shift Report’
survey was based on a review of the literature, focusing on
nurse-identified benefits and pitfalls of bedside report. The
instrument was reviewed by an instrument develop expert
as well as nurse managers, staff nurses from the medicalsurgical units being studied and revised based on feedback.
The 17-item nursing survey contained items such as perceived efficiency and effectiveness of report; perceptions of
report helping to identify recent changes in patient status
and promote patient safety; whether they felt that report
promoted patient involvement in care; the influence of
report on nurse mentoring, teamwork and accountability;
and perceptions of whether report provided all information
needed for patient care (Sand-Jecklin & Sherman 2013).
Item response items were in Likert-type format with five
agreement options (strongly agree to strongly disagree).
Demographic items asking about nurse age, number of
years in nursing, education and typical shift worked were
© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 2854–2863
Quantitative assessment of bedside nursing report
also included in the instrument. Instrument reliability
(Cronbach’s a) was 090, with interitem correlations ranging from 020–071.
Fliers announcing the survey were posted on the medicalsurgical units of the university hospital, and all nurses
working on the units received an email that asked them to
complete the survey, by clicking on the included web link.
Baseline data for both patients and nurses were collected
during the same month.
We also collected baseline data on patient falls during
shift change, medication errors and nurse overtime during
the same month-long period. Only patient falls occurring
during the hours of shift change (7–8 am, 2–3 pm, 7–8 pm,
11 pm–12 midnight) were included in data collection, as
falls occurring at other times during the day would not be
directly related to the shift report process. Nursing overtime
was measured via employee time records. Nine staff nurses
per unit were selected for monitoring of work-time records,
ensuring a balance of nurses based on nursing experience.
Overtime minutes for 10 shifts in the month were calculated.
Implementation of the practice change
Prior to the practice change, nurses at this large mid-Atlantic university hospital listened to a recorded patient report
prior to shift change. As discussed in the background section of this paper, the majority of published papers implemented a ‘blended’ recorded and bedside shift report. As
this seems to be the format that is the least redundant for
the patients and also that allows for private discussion of
any issues that may not be appropriate for the patient to
hear at that time, we decided to do likewise. In making this
move, the focus of the recorded portion of report (using the
Situation, Background, Assessment, Recommendation format) was to be on new issues and abnormal patient assessment findings. The bedside component of report was to
include request for permission to conduct report at the bedside; introductions; discussion of the plan of care; visualisation of patient incisions, drains and lines; pain assessment;
and review of any potential safety issues. We developed an
educational video for nurses, including guidelines and
examples of bedside shift report, and also distributed
printed guidelines for both bedside and recorded report
(Sand-Jecklin & Sherman 2013).
After nurse education, bedside nursing report was implemented across the seven medical-surgical units at the facility.
During the first days of implementation, clinical preceptors
and nurse managers were present to facilitate the change
and guide staff nurses in the report process. We distributed
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K Sand-Jecklin and J Sherman
a brief evaluation survey to nurses’ unit mailboxes one
month after the practice change occurred, to learn about
nurse perceptions of the new blended report format and to
identify the need for practice change reinforcement. The
survey asked what was going well with the new report process, what was not going well and what suggestions the
nurse had for improving the report process.
At three months postpractice change, we obtained
patients and nurse satisfaction data following the same process that was used at baseline data collection. One narrative
question was added to the Patient Views on Nursing Care
survey for postimplementation data collection: ‘Please tell
us how you felt about the nurse-to-nurse shift report at
your bedside’. Patient fall, medication error and nurse overtime data were also collected.
Based on the initial postimplementation data, several
actions were taken to improve the consistency of use of the
blended shift report format. An ‘Improving Bedside Report’
tip sheet was distributed by the research team to all medicalsurgical nurses, and posters related to making bedside shift
report successful were placed on the study units. In addition,
managers and clinical preceptors periodically observed nursing staff during both recorded and bedside report, providing
immediate one-on-one feedback related to the process. New
medical record updates (including a summary screen
designed for use in bedside report) and documentation
guidelines were introduced relating to patient plan of care,
and guidelines for incorporating patient plan of care into
bedside report were also distributed. We hoped that these
additional interventions would address some of the identified
issues with report efficiency and inconsistency.
Final postimplementation data were collected 13 months
after the implementation of bedside shift report. The data
collection process was identical to that used at baseline and
three-month postimplementation data collection periods.
Data analysis included ANOVA comparisons of pre- and postimplementation patient and nurse survey responses, with
descriptive analysis of medication errors and patient falls.
Repeated measure comparisons were made between baseline and the two postimplementation data points for nurse
overtime, and descriptive analysis with thematic coding was
completed for the patient narrative comments and the narrative nurse survey.
Results
Patient survey data
The Patient Views on Nursing Care survey was completed
by 233 patients at baseline data collection, 157 patients at
2858
three-month postimplementation data gathering, and 154
patients at 13-month postimplementation data gathering.
Family members completed 70 baseline surveys, 72 (three)month postimplementation surveys, and 53 (13)-month postimplementation surveys. Satisfaction with nursing care
was high both at baseline and before and after the implementation of bedside report, with all item means being at
least 42 of five points on all three surveys.
Prior to completing ANOVA comparisons between all preand postimplementation responses, we filtered out the family survey responses, and family members may not have
been present with the patient at the time of nursing shift
reports; thus, their responses may not reflect the impact of
the change to bedside nursing report. ANOVA revealed significant differences for the items ‘made sure I knew who my
nurse was’ and ‘encourage to be involved in care’, with
responses at the 13-month postimplementation data collection being significantly more positive than at baseline for
both items, using Dunnett T-3 post hoc comparisons. Additionally, we found significant differences in patient
responses to the items ‘include in shift report discussion’
and ‘pass along important information from shift to shift’.
Post hoc testing did not demonstrate specific differences
between the data collection points; however, both postimplementation means were higher than baseline (see Table 1
for analysis results).
Analysis of patient narrative comments on the postimplementation surveys indicated that most comments were globally positive (good care, caring nurses, professional, etc).
However, the next most common response on both surveys
(representing 10 and 18% of total responses) was that bedside report was not used, was used inconsistently or consisted of only an introduction of the oncoming nurse. The
third most common response was that the patient felt
informed and had good explanations as a result of bedside
report (8% of responses to the three-month postimplementation survey and 10% of responses at 13 months postimplementation). Other patient responses related to bedside
report were positive, with only one patient in each survey
indicating concerns about privacy during bedside report.
See Table 2 for a summary of patient comments.
Nurse survey data
The baseline nurse perception survey was completed by 148
nurses, 98 completed the three-month postimplementation
survey, and 54 completed the 13-month postimplementation
survey. There was nurse representation from each of the
seven targeted units, and all work shifts among the survey
respondents. The most common age range of respondents
© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 2854–2863
Original article
Quantitative assessment of bedside nursing report
Table 1 Patient Views on Nursing Care survey
Baseline
3 Months
postimplementation
13 Months
postimplementation
Survey item
M (SD)
M (SD)
M (SD)
F (df)
P
Made sure I knew who my nurse was
Treat me with respect
Help me feel comfortable
Treat in a polite and friendly way
Listen carefully without interrupting
Tell me what I need to know about tests/procedures
Tell about plans for discharge
Ask if I have questions or concerns
Answer questions and concerns
Encourage me to be involved in care
Work with me to meet my needs
Teach in a way I could understand
Make sure I understand what I need to do about health
Nurses work well together
Communicated important information shift to shift
Included in shift report discussion
Keep health information private
456
464
460
469
457
439
419
449
455
436
446
446
443
459
440
400
462
471
476
467
476
466
447
435
459
457
447
458
454
450
465
461
431
470
476
476
465
473
468
455
441
461
462
459
461
462
462
471
460
429
474
448 (2, 537)
226
055
068
133
156
199
136
038
290
189
176
255
135
362 (2, 515)
318 (2, 448)
120
0012
011
058
051
027
021
014
026
069
0056
015
017
008
026
0027
0042
030
(074)
(069)
(075)
(068)
(079)
(096)
(110)
(086)
(083)
(093)
(087)
(088)
(084)
(072)
(092)
(124)
(075)
Table 2 Patient narrative responses related to bedside report
Globally positive
comments
(nurses nice, caring,
professional)
Bedside report
not used, used
inconsistently or
only for introductions
Felt informed, good
explanations
Comments about
specific nurses, not
related to bedside
report
Good or improved
communication
Introduced next shift
Report works well
3 Months
postimplementation
(%)
13 Months
postimplementation
(%)
106 (42)
93 (48)
24 (10)
34 (18)
20 (8)
19 (10)
9 (4)
15 (8)
9 (4)
6 (3)
7 (3)
6 (2)
10 (5)
8 (4)
was 22–34 years old, while mean years in nursing ranged
from 102–105. The most commonly held current degree
was the BSN for all surveys. There were no significant differences in respondent demographics between the baseline
and the two postimplementation surveys.
ANOVA indicated a significant difference in nurse responses
to several survey questions. For items ‘the current system is
an effective means of communication’, ‘the current system
© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 2854–2863
(064)
(061)
(071)
(062)
(068)
(085)
(100)
(079)
(076)
(092)
(076)
(084)
(086)
(074)
(073)
(110)
(065)
(054)
(057)
(067)
(057)
(062)
(074)
(090)
(070)
(073)
(074)
(073)
(071)
(071)
(064)
(073)
(109)
(059)
is an efficient means of communication’ and ‘report is relatively stress-free’, baseline responses were significantly more
positive than the three-month postimplementation
responses, but not the 13-month postimplementation
responses, indicating that nurses’ responses rebounded to
baseline data at the last data collection point. Nurse
responses to the items ‘the current system helps assure
accountability’ and ‘the current system promotes patient
involvement in care’ were significantly more positive in
both postimplementation surveys in comparison with baseline. Responses to ‘report helps prevent patient safety problems’ were significantly more positive at 13 months
postimplementation than both baseline and three months
postimplementation. Finally, nurse perceptions that ‘report
is done in a reasonable amount of time’ were significantly
more positive at baseline than at both postimplementation
surveys (see Table 3).
Patient and nurse outcome measures
The number of patient falls during shift change for all units
decreased from 20 preimplementation to 13 at three
months postimplementation and 4 at 13 months postimplementation. Documented medication errors decreased from
20 preimplementation to 10 at three months postimplementation. However, between the 3- and 13-month postimplementation data collection periods, the hospital implemented
a new patient incident reporting system, which required
documentation of ‘near-miss’ medication errors, errors in
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K Sand-Jecklin and J Sherman
Table 3 Nurse perceptions of report format
Preimplementation
3 Months
postimplementation
13 Months
postimplementation
Survey item
M (SD)
M (SD)
M (SD)
F (df)
P
Report is effective means
of communication
Report is efficient means of
communication
Report helps identify changes
in patient condition
Report helps assure accountability
System ensures professional report
Report is relatively stress-free
Report gives opportunities
for mentoring
Report promotes patient involvement
in care
Report prevents delays in patient care
and discharge
Report helps prevent patient safety
problems
I feel adequately informed after report
I feel informed about patient plan of
care after report
I feel informed about patient discharge
plan after report
I feel informed about patient teaching
needs after report
Report is completed in a reasonable time
Nurses on the unit keep patients
informed about care
There is good teamwork between
shifts on the unit
404 (056)
361 (099)
398 (071)
1004 (2, 297)
0000
389 (076)
332 (113)
378 (083)
1178 (2, 294)
0000
364 (087)
378 (088)
391 (065)
343
380
363
355
381
362
302
364
385
387
348
380
(098)
(077)
(085)
(088)
010
(079)
(058)
(084)
(081)
646 (2, 296)
227
1318 (2, 297)
156
0002
011
0000
021
5074 (2, 297)
0000
264 (096)
366 (092)
381 (085)
340 (096)
310 (109)
324 (080)
275
007
341 (091)
360 (087)
393 (061)
749 (2, 297)
0001
359 (081)
354 (083)
346 (095)
347 (086)
378 (069)
369 (075)
251
119
008
031
315 (096)
312 (100)
322 (092)
019
083
311 (099)
317 (093)
333 (091)
103
036
369 (086)
380 (073)
308 (116)
376 (066)
324 (116)
390 (059)
392 (081)
379 (071)
383 (095)
drawing medication peak/trough levels, medications missing
from patient drawers and other medication events. Thus,
no valid comparison could be made between the three data
collection points after the final 13-month postimplementation data collection. Nurse overtime data comparisons indicated no significant change in overtime between baseline
and either of the postimplementation data collection periods, either for overtime as a whole or for overtime on individual nursing units. Thus, overtime data do not parallel
nurse perceptions that bedside report is more time consuming than the previous recorded report format.
Discussion
Several positive outcomes have been documented as a result
of implementation of a blended form of recorded and bedside report at this large university hospital. Patients perceived better nurse-to-nurse communication, more patient
involvement in care, more involvement in shift report and
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(094)
(086)
(105)
(089)
231
1122 (2, 297)
086
084
0000
043
043
staff making sure the patient knew who his/her nurse was.
The changes in patient perceptions on the items reflecting
these issues together with the lack of change of response to
the more broad or general survey items would seem to indicate the direct influence of bedside report on patient perceptions. These findings reflect the reports of the previous
studies (Searson 2000, Kelly 2005, Anderson & Mangino
2006, Cairns & Dudjak 2013). In addition, patient falls at
shift change were reduced after the implementation of bedside report, and medication errors were found to be
decreased at three months postimplementation of the new
reporting system. These findings are important, as patient
safety is a critical aspect of quality patient care.
Nurses perceived increased nurse accountability,
increased patient involvement in care and increased prevention of patient safety problems as a result of implementation of bedside nursing report. These perceptions are also
reflected in other publications (Cahill 1998, Anderson &
Mangino 2006, Chaboyer et al. 2009, Trossman 2009,
© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 2854–2863
Original article
Laws & Amato 2010, Maxson et al. 2012, Thomas &
Donohue-Porter 2012). The rebounding of nurses’ perceptions about the effectiveness, efficiency and stressfulness of
report to approximately baseline levels at the 13-month postimplementation data collection point would seem to indicate that it may take longer than three months for nurses
to become comfortable with the practice of bedside report.
To our knowledge, no other studies have monitored outcomes from a change to bedside nurse report for an
extended period of time. Thus, these findings are significant
in terms of providing quantitative support for continued
monitoring of the implementation and outcomes of bedside
report for at least a year postimplementation.
On the less positive side, nurses had a lower level of
agreement with the statement that shift report was completed in a reasonable amount of time at both postimplementation data collection points. In contrast to this
perception, data on nurse overtime demonstrated no significant difference between baseline and either of the postimplementation data collection points. Potential explanations for
these conflicting findings may be that nurses developed efficiencies in areas other than bedside report, in order to be
able to leave work on time, or that the inconsistencies in
implementation of bedside report contributed to the perception that it took longer than a reasonable amount of time.
The majority of other studies monitoring report time indicated that bedside report took a shorter amount of time than
prior forms of report, (Howell 1994, Anderson & Mangino
2006, Caruso 2007, Athwal et al. 2009, Tidwell et al. 2011,
Bradley & Mott 2012, Evans et al. 2012, Cairns & Dudjak
2013, Sand-Jecklin & Sherman 2013). This continues to be
an area in which more monitoring is needed.
An area of concern in the study findings is that both
patients and nurses reported some inconsistencies in bedside
reporting after the practice change was implemented,
despite additional interventions between the 3- and 13month data collection periods focused on standardising the
reporting process and supporting staff in implementation of
bedside report. In review of the implementation process,
the research team realised that it might have been more
helpful to gather a larger group of change champions from
all units and shifts to create a ‘critical mass’ of nursing staff
that were in support of bedside report and demonstrated
effective reporting processes.
Conclusions
Our patient survey and nursing instruments found several
positive outcomes in relation to the implementation of a
blended bedside shift report. Almost all of the 34 survey
© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 2854–2863
Quantitative assessment of bedside nursing report
items indicated some improvement from baseline to
13 months postimplementation; however, the change was
not significant for the majority of items. Nurse attitudes significantly rebounded on many issues from the three months
postsurvey to the 13 months postsurvey. There was a
decrease in falls at shift change. The only significantly negative outcome was nursing perception of the length of
report, but this was not supported by overtime data. Over
time, there may have been an increasing inconsistency in
the performance of the blended bedside shift report.
Limitations
One of the identified study limitations was related to participant sampling; we used a convenience sample of medicalsurgical patients scheduled for discharge and all nurses
whose home unit was a medical-surgical unit. The patient
and nurse respondents may not have fully represented the
total population of patients and nurses on the study units.
Additionally, as the nurse survey did not collect identifiers
and no limitations were imposed on the number of surveys
submitted from any one computer ISP address, it is possible
that nurses may have completed more than one survey either
during the baseline or the two postimplementation data collection times. Both patients and nurses reported some inconsistencies in the use of the blended bedside reporting
process, but we did not measure the degree or frequency of
these inconsistencies. Our recommendation to others measuring the outcomes related to the implementation of bedside report would be to include one or more items in both
the patient and nurse surveys that would be able to quantify
any inconsistencies in implementation. Finally, a practice
change unrelated to bedside report (implementation of a
new medication error reporting system), impacted the data
collected for this study, making full comparison of medication error data impossible. This did not affect the collection
of our patient falls data in any way though.
Relevance to clinical practice
Based on the findings of this practice change evaluation
study, we suggest that a blended form of recorded and bedside shift report may improve patient perceptions of communication among nurses, patient involvement in care and
patient safety, as well as nurse perceptions of accountability
and promotion of patient safety, without significantly
impacting nurse overtime. A blended report mechanism may
also impact the frequency of medication errors and patient
falls at shift change. However, this blended report format
may be perceived by nursing staff as less efficient than a
2861
K Sand-Jecklin and J Sherman
totally recorded report format, particularly within the first
few months after implementation. As with all practice
changes, it is important to address perceived barriers to the
new practice behaviour, to continue to reinforce appropriate
behaviour and to periodically monitor process and outcome
variables. Monitoring should continue for at least a year postimplementation of the practice change. It may also be helpful to have several change champions on each shift to
promote and support the move to bedside report, in order to
quickly attain a critical mass of nurses who are implementing the process as it was envisioned. Additional studies on
quantifiable outcomes of a blended recorded and bedside
shift report process are warranted in all areas/specialties of
acute care facilities, in order to provide additional documentation of ‘best practices’ in terms of nursing shift report.
Acknowledgements
The authors wish to express their appreciation to the following Medical Surgical Research Team Members for
their participation in the literature review process: Christine Daniels, MSN, MBA, RN, NE-BC; Samantha Richards, MSN, MBA, RN; Holly Mattingly, BSN, MBA,
RN; Sharon Tylka, BSN, RN; Ella Grimm, BSN, RN,
NE-BC; Nancy Stelzer, MSN, RN, NE-BC; Rhonda Hamilton, BSN, RN, ONC; Katy Hall, BSN, RN, ONC; Jennifer Johnson, BSN, RN, CNRN; Traci Ashcraft, BSN,
RN, BC; Susan Heiskell, MSN, RN, BC and Dr. Stacey
Culp.
Disclosure
The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions
to conception and design of, or acquisition of data or
analysis and interpretation of data, (2) drafting the article
or revising it critically for important intellectual content,
and (3) final approval of the version to be published.
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1
APPENDIX E
Appraisal Guide:
Findings of a Qualitative Study
APA Formatted Citation: (4 pts.)
Answer Here:
Synopsis (12 pts.)
1. What experience, situation, or subculture does the researcher want to understand?
Answer Here:
2. Does the researcher want to produce a description of an experience, or a social process,
or an event, or is the goal to generate a theory?
Answer Here:
3. How was data collected?
Answer Here:
4. How did the researcher control his or her biases and preconceptions?
Answer Here:
5. Are specific pieces of data (e.g., direct quotes) and more generalized statements (themes,
theories) included in the report?
Answer Here:
6. What are the main findings of the study? (10 Pts.)
Answer Here:
Credibility (18 pts.)
Yes
No
Not
Clear
Is the study published in a source that required peer review?
Were the methods used appropriate to the study purpose?
Was the sampling of observations or interviews appropriate and
varied enough to serve the purpose of the study?
*Were data collection methods effective in obtaining in-depth data?
Did the data collection methods avoid the possibility of oversight,
underrepresentation, or overrepresentation from certain types of
sources?
Reproduced with permission from: Brown, S. J. (2018). Evidence-based nursing: The research-practice connection
(4th ed.). Burlington, MA: Jones & Bartlett Learning.
2
Were data collection and analysis intermingled in dynamic way?
*Is the data presented in ways that provide a vivid portrayal of what
was experience or happened and its context?
*Does the data provided justify generalized statements, themes, or
theory?
ARE THE FINDGINGS CREDIBLE?
Clinical Significance (6 pts.)
All
Some
No
Yes
No
Not
Clear
*Are the findings rich and informative?
*Is the perspective provided potentially useful in providing insight,
support, or guidance for assessing patient status or progress?
* = Important criteria
Comments
Answer Here:
Reproduced with permission from: Brown, S. J. (2018). Evidence-based nursing: The research-practice connection
(4th ed.). Burlington, MA: Jones & Bartlett Learning.
1
APPENDIX F
Appraisal Guide:
Findings of a Quantitative Study
APA Formatted Citation: (4 pts.)
Answer Here:
Synopsis (16 pts.)
1. What was the purpose of the study (research questions, purposes, and hypotheses)?
Answer Here:
2. How was the sample obtained?
Answer Here:
3. What inclusion or exclusion criteria were used?
Answer Here:
4. Who from the sample actually participated or contributed data (demographic or clinical
profile and dropout rate)?
Answer Here:
5. What methods were used to collect data (e.g., sequence, timing, types of data, and
measures)?
Answer Here:
6. Was an intervention tested? Answer Yes or No
A. How was the sample size determined?
Answer Here:
B. Were patients randomly assigned to treatment groups?
Answer Here:
7. What are the main findings of the study? (10 pts.)
Answer Here:
Credibility (14 pts.)
Yes
No
Not
Clear
Is the study published in a source that required peer review?
*Did the data obtained and the analysis conducted answer the
research question?
Were the measuring instruments reliable and valid?
Reproduced with permission from: Brown, S. J. (2018). Evidence-based nursing: The research-practice connection
(4th ed.). Burlington, MA: Jones & Bartlett Learning.
2
*Were important extraneous variables and bias controlled?
*If an intervention was tested, answer the following five
questions:
Were participants randomly assigned to groups and were
the two groups similar at the start (before the
intervention)?
Were the interventions well defined and consistently
delivered?
Were the groups treated equally other than the difference
in interventions?
If no difference was found, was the sample size large
enough to detect a difference if one existed?
If a difference was found, are you confident it was due to
the intervention?
Are the findings consistent with findings from other studies?
All
Some
No
ARE THE FINDINGS CREDIBLE?
Clinical Significance (6 pts.)
1. Note any difference in means, r2s, or measures of clinical effects (ABI, NNT, RR, OR)
Answer Here:
Yes
No
Not
Clear
All
Some
No
*Is the target population clearly described?
*Is the frequency, association, or treatment effect impressive
enough for you to be confident that the finding would make a
clinical difference if used as the basis for care?
ARE THE FINDINGS CLINICALLY
SIGNIFICANT?
* = Important criteria
Comments
Answer Here:
Reproduced with permission from: Brown, S. J. (2018). Evidence-based nursing: The research-practice connection
(4th ed.). Burlington, MA: Jones & Bartlett Learning.
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