"My day was really busy," I said to the seasoned nurse in front of me, digging into the pocket of my scrubs for the creased report sheet I had scribbled on throughout the day. "Neuro-wise, our patient was in and out of consciousness," I continued, "with an inconsistent GCS [Glasgow Coma Scale score]. But his daughter came later in the day, he ate some lunch, and then he had two bowel movements."
I knew what I was saying didn't make chronological sense or follow the shift report structure that was expected on my new unit. I was nervous. The seasoned nurse was known for her attention to every detail, and I couldn't even remember the systems I was supposed to use to guide me. Neuro, cardiac, respiratory, GI, GU, skin. Each one blurred into the other.
"Amanda, we've been over this," the nurse said. "The key to giving an organized handoff report is to stick to the structure of the systems. Never waver. The body tells its own story in its natural order." I nodded in response, promising to do better next time. On my way out that evening, I threw my crumpled report sheet on top of the growing pile on the floor of my locker, wondering when I'd ever get it right.
THE IMPORTANCE OF SHIFT REPORT
Whether you're a student or just starting your first job in a clinic, hospital, or home care setting, you won't spend a single day as a nurse without giving or receiving report. This important piece of communication, sometimes called handoff communication or handover or shift report, is not only a necessary part of nursing, it also falls under the scrutiny of major accrediting bodies such as the Joint Commission, making its way into the National Patient Safety Goals nearly every year.1 And rightly so: mistakes made during handoff can have serious consequences, directly affecting patient safety and quality of care. Among handoff-related errors noted in recent studies are dosage discrepancies, care orders delayed or not given at all, transfer of incorrect information, and drug charts not updated.2, 3 But when handoff communication between clinicians improves, so do patient outcomes-from decreases in unexpected patient deaths4 to reductions in rates of pressure ulcers and patient falls5 to enhanced patient safety.6
Report practices may vary within institutions, with ICUs following a more detailed handoff practice than medical units, for example. And nurses may be required to use tools to give and receive report, like the Situation, Background, Assessment, Recommendation form or the head-to-toe system (see examples of commonly used tools in Table 1.7-9). Regardless of your facility's standard for report, it is important to find your personal practice within it, and develop strategies to help you remember and communicate details about your patient. In her seminal work, From Novice to Expert: Excellence and Power in Clinical Nursing Practice, Patricia Benner writes about the skill of the expert offgoing nurse not only in communicating information about the prior shift, but also in steering the incoming nurse toward an awareness of what might lay ahead.10 Mastering these high-level skills will take novice nurses additional time and effort, but it can be done. Follow the specific steps discussed below and practice the suggested strategies, and they will help you master both the receipt and the delivery of report.
GETTING REPORT
Each shift begins with getting report, and when you start participating in report as a new nurse, you will hear abbreviations, terminology, and slang no nursing class could have prepared you for. Try to control your urge to ask questions or make assumptions as you listen. Instead, keep an open mind-absorb the details as they're given and make a note of those that should have been but weren't, minimizing interruptions and ignoring distractions as much as possible. Remember, if your mind is elsewhere when your patients' cases are presented, you'll be unprepared to tackle the challenges that will arise throughout the day.
Wait to ask for clarification until the end of report- this will encourage you to connect the dots to figure out what's being said. For example, if the nurse giving report says, "GCS is low" and you don't know what GCS stands for, if you wait, the nurse might go on to say, "The patient moves to deep stimuli but not purposefully, and his pupils are fixed," which suggests she's talking about neurologic status, and the specific abbreviation can be queried at the end of report.
Fashioning a report sheet. If your institution requires the use of a report tool-whether a worksheet or a portion of the electronic health record (EHR)-use it. While it may seem rote or even useless to fill in each blank, these tools were created by experts for a variety of nurses to use. Plus, studies have shown that the use of standardized tools in report increases handoff efficacy and decreases error rates.5, 11, 12 But no matter what tool is required, don't let it consume your attention while receiving report. It might make sense at first to take notes on a blank sheet of paper with a patient identification label for a header. Then, at the end of report, transfer your notes to your institution's worksheet or EHR. This will serve to both refine and clarify the information you heard, which will help to further solidify it for you.
Adding to your report sheet. As soon as you receive report, you become responsible for passing your patient's information along to the next shift. As such, your data collection begins the moment you return pen to pocket and start your first patient assessment. As you mature as a nurse, you won't need to write down your entire physical assessment before entering it into the EHR or chart. But for now, as you start your career, you might, and that's okay. As you do your assessment, think about giving report. Think ahead to what your incoming colleague might need to know about your patient, focusing on the exceptions to the norm you find. If your patient's lungs are clear to auscultation but she or he has a slight cough, write a note about the cough so you remember to remind the incoming nurse to see if it continues or worsens.
The worksheet or EHR is also the place to note anything you did for your patients throughout the day that was unusual. You wouldn't report to the incoming nurse that you gave your patients their scheduled medications, for example; this is expected of you as a nurse and is already in the medication administration record you might review together. But if your patient pulls out his urinary catheter and, to decrease his chances of developing a catheter-associated urinary tract infection, you advocate for a condom catheter to replace it, record when the catheter came out and when the patient is due to void. This will not only alert your colleague to a change in the patient's care, it will also set a deadline for an important assessment of his urinary status.
Focus on the important things. Many nurses like to add "anecdotals" to report: "He's so chatty," or "Watch out, this one has a history of iv drug abuse," or "Goodness, she rang her call light every second." This information should be critically assessed. A report that a patient is a frequent caller should tell you to spend much of your first hour building that patient's trust and trying to understand the root cause of her need for attention, not give you the opportunity to gossip about the patient. Likewise, the report of a history of iv drug abuse, though it may have been communicated with an eye roll, should tell you that your patient may have a higher tolerance to pain killers than someone without such a history, not give you permission to share your personal opinion of addiction. Unfortunately, many reports devolve into gossip and slander of patients, and so important details are either wasted or lost. Critically thinking about noxious behavior or reported annoyances will help you better understand what your patients require, and will help you provide personalized care.
Don't just gather facts, connect them. If you receive report that your patient has diarrhea or loose stool, for example, you should think to see if his diet, medication, or bowel regimen was altered to cause this change in his condition. Likewise, if you receive report that your patient prefers to take pills with applesauce, it should occur to you that she might need to be placed on aspiration precautions. Similarly, the report of a rising oxygen requirement and a mildly elevated temperature should not go uncorrelated in your mind; your first order of business after receiving report should be to assess your patient for progressing fever or changes in lung sounds indicative of developing pneumonia. When it comes to sick patients, all data should be viewed as parts of an overall clinical picture to be critically reviewed and discussed with the care team, never as lone occurrences.
GIVING REPORT
Giving report as a new nurse is nerve racking. First, you'll be handing off to a nurse from a different shift team, one you may not know well. Second, unless there is a class of new graduates starting at the same time on the same unit, you'll likely be giving report to a nurse with more seniority and experience than you. Because you will likely be very nervous, and because report is an exchange of important information-the care you provided, the orders you fulfilled, and any changes in your patient's condition-take time to prepare. Whether that means reviewing the data as you transfer them from your report sheet to the facility's worksheet, or studying your personal notes, use this time to think about your patient's body as comprising separate systems. As you move from the top of the head to the tiniest toe, ask yourself: What happened in each system? Did any organ fail or improve in its function? Did you insert any new devices anywhere? By the time you reach the toes, you will have composed the story of your patient's day. Be sure to make time to prepare report so you will be organized and calm when giving it. If necessary, ask your preceptor or charge nurse to cover your patients while you do it; it's that important.
Take your time. Regardless of the way in which you give report-at the bedside, face to face at the nurses' station, or in writing-take your time. The day that awaits the incoming nurse is sure to be busy and full. A high-quality, intentional, and well-thought-out report will prepare your colleague for her or his shift far better than any time saved in rushing.
Emphasize the key elements. This trick isn't easy for beginners, but give it a try starting on day 1. Simply say the following at the end of giving report: "So, in summary, with emphasis on the key factors[horizontal ellipsis]" and fill in the blank with your patient's status and outstanding items that require your colleague's attention. For example, "So, in summary, with emphasis on the key factors, Ms. Smith is being treated for an exacerbation of congestive heart failure, so keep a close eye on her breathing about 30 minutes before her Lasix is due and consider giving her a nebulizer with her dose." This allows you to share with the incoming nurse the information you think is important.
You can use this technique when getting report, too-although your effort to repeat back key elements may prompt a clarification from your more senior colleague: "Well, yes, look at her before you bring her the Lasix, but keep a close eye on her breathing whenever you're in the room; her heart failure is pretty progressed and she also sneaks orange soda when you're not looking, so she might need more Lasix altogether." While your attempt at summation will be appreciated, the offgoing nurse may use it to make sure her or his message (and assessment) is crystal clear.
Take it the extra step to the bedside. There's no better place to give report than at the patient's bedside. According to the Robert Wood Johnson Foundation's Transforming Care at the Bedside initiative, when nurses involve patients and families in bedside handoff report, communication about care plans and changes in patient care improves, which improves patient outcomes, as well as patients' and nurses' satisfaction.13 Although giving handoff report at the bedside is supported by research and generally accepted as best practice, it may not be the culture you walk into. In that case, set your standards early (say, "Could we go and see the patient together?"). Simply being near your patients makes report more of a conversation than a list of clinical details, which it can tend to feel like.
Let it go. One of the most important parts of giving report is doing exactly that-giving it. This means you let it go and let another nurse take it from you. The work of a nurse, especially a new nurse, is demanding and stressful. Work as hard as you can to finish on time. By working steadily and documenting throughout the day, you should be able to give a complete report and leave your unit at the time your schedule dictates. To do this consistently, it helps to create a routine to follow. And to enable you to leave your workday behind, it helps to create a ritual: throw your report sheet onto the floor of your locker, walk home with music blaring in your headphones, talk to a friend on the phone in your car. Whatever you do, you must learn that though nursing is a 24/7 profession, your work time is limited. No matter what happened on your shift, your colleague is the one responsible as soon as report is over.
CONCLUSION
Getting and giving handoff report are skills to refine and master early in your career. They will help you set the priorities of the day, learn to summarize your patients' plan of care, and guide communication across disciplines as your patients' care manager. Plus, the acts of giving data to the incoming nurse and repeating details from the offgoing nurse serve as double-checks that nothing in your report was given in error or missed in receipt. Canadian nurse researcher Rosea Beuthin says about the narrative practice of report, "Stories hold meaning, and when persons tell of their experiences[horizontal ellipsis] they are afforded an opportunity to make sense of all that is happening."14 Because EHR adaptations and innovations are currently in development, some experts hope handoff will soon be automated and error proof. At the end of the day, however, it is the sharing of our patients' stories with other nurses face-to-face that keeps patients safe, keeps us safe, and helps us to cultivate the soul of our nursing practice.
REFERENCES