Lessons Learned From the Implementation of a Bedside Handoff Model

JONAVolume 43, Number 6, pp 315-317Copyright B 2013 Wolters Kluwer Health |Lippincott Williams & Wilkins

Lessons Learned From theImplementation of a BedsideHandoff Model

Jan Hagman, MS, RNKathleen Oman, PhD, RN, FAEN, FAANCatherine Kleiner, PhD, RNElizabeth Johnson, BSN, RNJamie Nordhagen, BSN, RN, OCN

At the University of ColoradoHospital, nurse-to-nurse shift re-ports traditionally occurred in aconference room setting andconsisted of nurse-to-nurse verbalcommunication. Evidence sup-ports moving this information ex-change to the patient bedside. Thismodel of report improves clinicaleffectiveness, patient safety, nurseefficiency, and staff satisfaction.Bedside reporting empowers pa-tients and families to ask questionsand contribute to their plan of careand increases patient satisfaction.This article describes the processof implementing and evaluating amodel of nurse-to-nurse bedsidehandoff report.

The University of Colorado Hos-pital (UCH) is a 375-bed tertiarycare hospital located in Aurora,Colorado. It is a 3-time MagnetA-designated facility known forevidence-based nursing practiceand innovation. The UCH wasvoted # 1 in quality by the Uni-versity Hospital Consortium in2011 and again in 2012. The im-plementation of a bedside handoffmodel was a nurse-driven qualityimprovement project designed toincrease clinical effectiveness, pa-tient safety, and patient and nursesatisfaction and improve financialperformance. The 1st unit to tran-sition to a bedside handoff modelwas a 13-bed acute care of theelderly unit, followed by the unitcaring for solid organ transplantpatients and ultimately to all med-ical surgical units. The acronymfor the bedside handoff model atUCH is the LookB report. It standsfor locate to the bedside, obtaininformation, observe the patient,and keep it timely. The goals ofthis process improvement initia-tive were to increase communica-tion between caregivers, increaseaccountability, improve patient

safety with timely verification ofhigh-risk medications, assist thenurse in prioritizing care, improvepatient and nurse satisfaction, anddecrease inconsequential overtime.

ImplementationDescribed by Kritsonis, KurtLewins 3-stage model of thechange process in human systems,known as the unfreezing-change-refreeze model, was the theoreticalframework used to guide the changeinitiative.1 Bedside handoff cham-pions were identified on each unitas role models, trainers, and keychange agents during implementa-tion. The champions, along withunit managers and educators, wereprovided with a Look Report ToolKit (LRTK) to streamline and stan-dardize the implementation of bed-side handoff across multiple units.The LRTK contained journal clubarticles supporting bedside hand-off, a journal club study guide, andan advertising poster for journalclub. The LRTK defined the lookacronym, provided staff-specificguidelines, and included an im-plementation action plan. The

JONA Vol. 43, No. 6 June 2013 315

Spotlight on Leadership

Author Affiliation: Nurse Manager (MsHagman), University of Colorado Hospital,Aurora; Research Nurse Scientist and As-sociate Professor (Dr Oman), College ofNursing, University of Colorado Denver;Research Nurse Scientist (Dr Kleiner),Level II Charge Nurse (Ms Johnson), andLevel IV Charge Nurse (Ms Nordhagen),University of Colorado Hospital, Aurora.

The authors declare no conflicts of interest.Corresponding Author: Ms Hagman,

University Of Colorado Hospital, 12605E 16th Ave, Mail Stop F-765, Aurora, CO80045 ([email protected]).

DOI: 10.1097/NNA.0b013e3182942afb

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

champions were given a PowerPointpresentation to assist with introduc-ing the concept of bedside handoffduring staff meetings. Frequentchampion meetings were initiatedearly in the process to discuss thetoolkit, purpose, vision, unit-specific barriers, and the role ofchampions in the collection ofmetrics. Audit training was pro-vided to the champions at monthlymeetings as well as ongoing feed-back regarding accuracy and com-pleteness of data. One of the initialmeetings took the form of a jour-nal club, in which champions wererequired to read, Who says youcant talk in front of the patient,2

The champions were asked tocomplete a study guide. Thechampions were responsible forconducting 1 or more journal clubofferings for continuing educationcredit on each of their units utiliz-ing the same article and studyguide. Mandatory reading andcompletion of the study guide wasa requirement for all RN staffparticipating in the transition tobedside handoff. This was fol-lowed by training of staff on theLook report process in prepara-tion for kickoff day and includedreview of scripting, role playing ofperceived difficult scenarios, op-portunities to troubleshoot staffconcerns, and review of staff ex-pectations.

Champions planned and im-plemented a kickoff day celebra-tion,whichtookonformsasdiverseas a coffee bar and potluck pizzaparty. The champions modeledbedside handoff provided staffwith immediate feedback and en-couraged compliance with the newexpectations. The champions iden-tified barriers to the new change-of-shift (COS) handoff process anddiscussed and problem solved these

issues at the monthly championsmeeting. Robust discussion allowedthe committee members to collec-tively brainstorm potential solu-tions to perceived barriers.

Look report champion meet-ings continued monthly for ongo-ing support of our main changeagents. Unit leaders recognizedstaffs ability to follow Look re-port guidelines and counseled teammembers noncompliant with thechange. Look report guidelineswere incorporated into the annualperformance reviews.

To assess how well Look re-port was being implemented, ran-dom unannounced observationswere conducted by Look reportchampions using a standardized as-sessment tool. Verbal updates fromchampions regarding the level ofimplementation and unit compli-ance occurred at monthly cham-pion meetings.

Lessons LearnedIdentifying a specific change modelto utilize in achieving staff success,alongwithatimelineofeducationalactivities, was pivotal in transition-ing from traditional COS report tobedside handoff. Unit leadershipcommitment was a critical factorfor success. Units with nurse man-ager, charge nurse, and championsupport demonstrated increasedstaff accountability and greatercompliance with the change. Dis-playing unit outcomes (inconse-quential overtime and compliancewith high-risk medication double-checks) and recognizing staff utiliz-ing proper Look report techniquesat staff meetings further reinforcedthis change in practice. It wasnoted that new-graduate nurseswere more accepting and open tochange than seasoned nurses andproved to be an excellent avenue

to facilitate the change to bedsidehandoff. As a result of this observa-tion, all subsequent new-graduateclasses are presented with Lookreport expectations and outcomesduring the didactic component ofnew-graduate nurse orientation.

The sacred cow phenomenonposed the largest obstacle in the im-plementation of the Look report.

Nurses often share frustra-tions encountered over the courseof a shift and socialize with co-workers during shift handoff. TheCOS exchanges can afford nursesthe opportunity to emotionallysupport each other and build co-hesive relationships.3 Despite roleplaying for training activities,many nurses remain uncomfort-able talking in front of patients.Frequent patient requests, concernfor disturbing sleeping patients,patients in isolation, nonYEnglish-speaking patients, and lack of pri-vacy in semiprivate rooms wereperceived barriers to bedside hand-off. Strategies to overcome thesebarriers remain ongoing and in-clude developing a Look reporttraining video, including Look re-port into simulation training activ-ities as well as seeking permissionto add Look report education tothe hospital orientation. The ad-vanced technology of our newelectronic medical record is beingexplored as additional avenue tostrengthen bedside handoff com-munication. Nurse satisfactionwith bedside handoff overall hasbeen positive, especially its contri-bution to patient safety and patientsatisfaction. Our bedside handoffmodel demonstrated great poten-tial to impact patient satisfactionby including patients in care de-cisions and keeping them informed.The use of staff champions in ashared governance model remains

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crucial to continued success ofthis project.

Acknowledgments

The authors would like to recognizethe outstanding work and commit-ment of the Handoff Communica-

tions Champions Committee andPeggy Heilman, BSN, RN, CCTN.

REFERENCES

1. Kritsonis A. Comparison of change

theories. Int J Sch Acad Intell Divers.2004;8(1).

2. Anderson C, Mangino R. Nurse shiftreport; who says you cant talk in front

of the patient? Nurs Adm Q. 2006;30(2):112-122.

3. Nelson B, Massey R. Implementing anelectronic change-of-shift report using

transforming care at the bedside pro-

cesses and methods. J Nurs Adm. 2010;40(4):162-168.

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Lessons Learned From the Implementation of a Bedside Handoff Model