TO PROMOTE PATIENT SAFETY, nurses need to communicate pertinent information to the incoming nurse at the change of shift. This communication addresses the patient's current clinical state as well as his or her future needs and goals to be accomplished by the health care team.1,2 Seventy percent of errors or sentinel events occur because of miscommunication during handoffs.3-5 Medical errors alone have added $19.5 billion to the already burdensome costs of health care.6 Bedside reporting offers a patient-centered approach to a vital interaction between health care providers that may reduce errors in health care settings.5,7-12 In spite of the benefits of implementing nursing bedside handoff communication, adoption of this process has not been immediately embraced by all nurses in the health care setting. This article describes how a surgical orthopedic trauma unit ultimately adopted a change of shift reporting process after failed attempts by using the Kotter's change model.13

Early attempts to address a standardized bedside handoff approach were initially introduced with a nurse manager-initiated pilot study. The "4 D handoff pilot study" was a communication method that directed nurses to assess and report key elements of patient care including drugs, drips, drains, and deep vein thrombosis concerns. While this approach addressed key elements of care, it was found to be unsuccessful because it was not endorsed by the staff who failed to recognize its utility. This failed attempt encouraged the staff to find a new way to implement bedside handoffs.

The problem of implementing bedside handoffs was addressed by performing a literature review to identify a change model that would motivate nurses to perform bedside handoffs. Three change models were analyzed, and a decision was made to use Kotter's change model (commonly used in business) because of its adaptability to the organizational structure and ability to incorporate different staff responses to change.13-15 Although Kotter's change model is not commonly used in nursing, it was chosen because it was clear and easy to apply. Furthermore, it uses effective imagery that is easily understood by staff nurses. The conceptual framework provided an ideal structure in which to approach system changes that address patient safety during bedside handoffs.

An essential component of safety reform uses staff input to create system change.16 The Kotter model recognizes the need to incorporate opinions from staff and other stakeholders.17 The Daily Management System (DMS), a process improvement tool to address problems when implementing new interventions, was used to meet this requirement. The DMS is a method of continuous improvement that enables frontline staff to respond immediately and continuously to quality issues.18 The purposes of the article are to describe the implementation of a bedside handoff process using Kotter's change model and the DMS to report the implementation effects on nurse compliance, patient and nurse satisfaction, and their perceptions of the process.

IMPLEMENTATION OF KOTTER'S MODEL

Kotter's model incorporates 8 steps for implementing change.13 During the planning and implementation process, the model and the DMS were used to plan and implement handoffs.

Step 1: Create a sense of urgency

Urgency is the ability to recognize pressing problems as opportunities.13 Addressing the problem can provide an opportunity for positive change in the culture rather than reacting to a single event. This initial step motivates a group to embrace change by highlighting the need to correct a pressing problem.

Administration recognized the importance of communication at the bedside. A sense of urgency was implemented by showing the staff the potential for sentinel events leading to poor outcomes due to a poor handoff procedure. Consideration for this risk for harm created motivation for change on the unit. The nurses on the unit were supplied with articles that described how bedside handoffs enhance communication among nurses, patients, and families.4,19,20 By highlighting risk for harm to patients, nurses were more likely to foster bedside communication in order to promote a safer environment for the patient.21

Step 2: Form a guiding coalition

A guiding coalition includes leaders to persuade others to adopt a new practices.13 The guiding coalition group consisted of a nurse director (manager), a nurse educator, resource nurses, an administrative clinical supervisor, a unit clinical advisor, and senior bedside nurses who were committed to bedside handoffs to assist in guiding the process. These nurse leaders received education on Kotter's 8-step change model by the nurse director.13,22 Leaders also reviewed literature regarding safety initiatives from the Institute of Medicine,23 the Institute for Healthcare Improvement,24 and the Robert Wood Johnson Foundation.25 Collectively, leaders used an understanding of Kotter's change model and national safety initiatives to form a cohesive team charged with creating a vision.

Step 3: Create a vision

The third step is to shape a vision to steer the change and develop strategic initiatives to achieve that vision.13 The vision of this project was to improve patient safety and communication among nurses, patients, and families at the bedside. The ultimate outcomes include improved satisfaction in providing and receiving care and preventing adverse events.4 The guiding vision was drawn from recent literature that supports the potential value of bedside handoffs.1,19 A 3-step process that reflected the vision was developed that included defining the responsibilities of the incoming and outgoing nurse and establishing a formalized communication structure for the handoff at the bedside (see Supplemental Digital Content, Table, available at: http://links.lww.com/JNCQ/A281).

Step 4: Communicate the vision

Once the vision has been established, the message should be shared with individuals who execute the plan.13 Articles describing the benefits of bedside handoffs and implementation of change according to the Kotter's model were made available and disseminated among the staff.16,22 Weekly staff meetings and education sessions were used to communicate the vision of the 3-step process.

Step 5: Empower others to act on the vision

Although a vision may be effectively communicated, adoption of change requires buy-in from others. To accomplish this step, team members should understand the vision and be given autonomy to act.13 The staff were empowered to adapt the vision by developing tools that establish the foundation of a "homegrown system."

One example of these changes included standardizing communication through the nursing Kardex, which would be electronically updated after each shift. Although the staff initially was introduced to SBAR (Situation, Background, Assessment, and Recommendation), it did not address the needs for efficient communication within their unit.26-30 Accordingly, the staff developed a new system that outlined a description of the situation, intervention, and plan (SIP). Not only did this new system address the challenges of the local environment, it also created a sense of ownership by those who were responsible for using it. Documentation of the handoff process mediated by SIP communication is shown in Supplemental Digital Content, Table, available at: http://links.lww.com/JNCQ/A281.

The DMS was adapted to identify, develop countermeasures, and implement and evaluate the change.18,31 For example, during a predetermined time, a nursing huddle was convened. A problem was identified that patients were found sleeping when handoffs occurred. The countermeasure developed by the group was that it was safer to wake patients, implement the bedside handoff, and introduce the incoming nurse. The countermeasure was implemented for a week and then evaluated. Nursing huddles were convened on a daily basis to evaluate the effectiveness of the countermeasure until 100% compliance was achieved. Leadership provided support to staff who were uncomfortable with the change. This process continued until all barriers that impeded staff adoption of the countermeasures were resolved.

Step 6: Create quick wins

Changes are easy to envision and initiate but difficult to sustain. In this step, teams are challenged to create visible and clear wins.32 At the local level, 2 examples of quick wins were identified. Staff were able to recognize missed medications on the electronic medication administration record at the beginning of the shift. Another example of a quick win was the realization that staff were able to complete their shift more efficiently and leave on time. Highlighting these quick wins reinforced momentum for the project.

Step 7: Build on the change

Successful organizations that implement change are able to support changes and continue innovation while maintaining the vision. The guiding coalition coached and supported staff. Changes were maintained and reinforced, keeping the overall vision in focus. Reinforcing the practical steps of maintaining SIP, fostering reflection, and emphasizing the need to sustain critical thinking resulted in development of new procedures. By using this process in association with the DMS, the staff were able to better provide patient care. For Example, a revision of the staff assignments allowed patients to be organized according to bed location, resulting in less walking and keeping nurses closer to their patients.

Step 8: Institutionalize the change

Solidifying change requires a cultural movement such that the vision becomes the norm. The bedside handoff became the norm on the unit by integrating the vision in new nurse orientation and education of float nurses. In this way, the bedside handoff became foundational in unit identity such that it became part of the culture of the unit. Buy-in from the majority made it easier to sustain the change. While there were a few nurses who were resistant, the majority supported the process. Ultimately, the new culture improved communication and satisfaction, making the unit an easier place to work.

OUTCOMES

The perspectives of patients and nurses were evaluated using surveys. The surveys were developed by the authors and administered to the patients and staff 1 month after implementation of the handoff.

Thirty (88%) of the patients reported that a bedside communication occurred between 2 nurses at change of shift. Twenty-nine (96%) were satisfied or very satisfied that nurses performed this communication at the bedside. Furthermore, all of the patients expressed satisfaction in the manner the information was shared.

All nurses consistently performed some form of bedside handoff although some did not include all of the elements of the handoff. Only 22 (79%) nurses indicated that they used the SIP method. In addition, 23 (82%) checked intravenous fluids, 21 (75%) checked drains, and fewer checked electronic medication administration record (n = 18, 64%), the presence of deep vein thromboses (n = 17, 61%), and the Kardex (n = 17, 61%).

Nurses completed a survey on their satisfaction and perceptions of the handoff process. On a scale of 1 (very dissatisfied) to 5 (very satisfied), the mean rating was 2.93 (SD = 0.55). Eighty-six percent (n = 24) reported that meeting with their patient before they began routine care gave them a feeling of satisfaction. Furthermore, a majority of nurses perceived that the bedside handoff improved efficiency (n = 18, 69%) and reduced patient errors (n = 18, 67%).

RECOMMENDATIONS

The success of this project has theoretical, practice, and quality improvement implications. The use of Kotter's model was highly effective because it was easy to follow, was structured, and provided an effective framework to implement a practice change in a health care environment. It can be used to make change happen in practice by selecting the right group of people who will motivate others to change until the practice becomes the norm. Kotter's model is adaptable to any setting that needs to implement a practice change. The DMS strengthens the Kotter change process, allowing for real-time correction of small problems before they become more difficult to solve. In summary, Kotter's model provides a systematic plan for change whereas DMS identifies countermeasures to address daily challenges.

There are a number of implications for practice. A change model is critical when contemplating practice changes in the inpatient environment. Identifying a change model that is best suited for staff, administration, and patients is essential for sustainability. Previous efforts to implement handoffs were unsuccessful in our setting because not all stakeholders were taken into consideration and change was not sustainable. Institutions looking to change the way nurses conduct bedside handoffs should consider outlining a written bedside handoff process that includes instructions for the incoming and outgoing nurse and the process at the bedside.

There are several implications for future quality improvement projects. While this project was implemented on 1 unit, the goal is to use this system on other units and have nurse managers evaluate its effectiveness. Specific safety outcomes should be evaluated with respect to implementation of bedside handoffs. This includes consideration for falls, pain management, medication errors, and acute changes in patient status.

CONCLUSIONS

Through the use of Kotter's model and the DMS method, changes were made to the way nurses communicate information at the bedside at change of shift. Outcomes of the handoff process reflect a successful implementation of a practice change.

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