Current Nursing Practice Healthcare Setting Requiring Change

Translational Research

Current Nursing Practice in the Healthcare Setting Requiring Change

There are numerous areas within nursing that demand change in everyday healthcare practice. More often than not, irrespective of the healthcare setting, an inventive group is required to conduct research and facilitate change. I presently work as a clinical educator in my hospital. There are numerous practices that require change or upgrading. Subsequent to conducting a review and research analysis, my decision is to include bedside reporting, which is lacking within the hospital. Bedside report occurs between the outward-bound and inward-bound nurse alongside a patient’s bedside while conducting a shift change. The meeting is purposed to facilitate patient engagement in trade of real-time information during shift change. This provides both the inward-bound nurse and the patient the prospect to ask questions and authenticate significant information regarding the history of the patient and care plan prior to the outgoing nurse leaving (Rush, 2012). Most importantly, bedside reporting is in alignment with patient-centered procedures in contrast to provider centered-care medical system and is anticipated to have a positive impact on the organizational nursing output together with patient satisfaction.

Justification for Bedside Reporting as a Proposed Practice Change

At the present moment, the hospital provides in-patient nursing services to several patients. Nurses are expected to change shifts at least two to three times every single day. The problem being faced at the moment is that plenty of time is wasted in recording information of the patient medical history, diagnosis and medical status. In addition, the prevailing system of recorded hand-off results in several medical errors and mistakes within the organization. Some of the medical mistakes that are presently being experienced in the hospital include patient blood incompatibility, air embolism together with catheter-associated urinary tract infections. In addition, there is the major problem of collapses in communication amidst nurses and between nurses and patients. There is a significant need to introduce bedside reporting within the hospital as it will generate significant benefits (World Health Organization, 2013).

The proposed practice change will enhance patient safety and quality. In particular, bedside reporting is a prospect to make certain there is efficacious communication between the nursing personnel, patients and their immediate families. This new practice change within the hospital will augment patient safety together with service delivery. In addition, the enhanced level of communication in the course of the shift report can aid in pinpointing and dealing with medical errors. Secondly, bedside shift reports will aid the hospital in having better patient experience of care. In accordance to a report by the World Health Organization (2013), subsequent to carrying out bedside reporting, hospitals demonstrated a rise in patient satisfaction scores and enhancements in the relationship between the nurses and patients. In addition, it is expected that the proposed practice change will give rise to a significant decrease in the average number of call lights that are turned on by patients at the change of the nurses’ shifts.

The proposed practice change will also have a constructive impact on the hospital at large owing to increased nursing staff satisfaction. This is for the reason that nurses are able to visualize their patients in a faster manner, improved practical learning between the older and newer nurses together with an increase in accountability. In addition, nurses are able to communicate more often and in a faster manner thereby resulting in lesser medical blunders. For instance, in accordance to research conducted by Anderson and Mangino (2006), bedside shift report had numerous positive results for the healthcare facility including the recovery of numerous hours of incidental time in the initial two-pay periods of the study, increased personnel satisfaction from the visualization pf patients within the 20 to 30 minutes of the beginning of the nursing shift, increase in physician satisfaction owing to the feeling of having more informed and conversant patients, increased patient satisfaction and medical diagnosis and status insight and a general sense of patient safety.

Another justification of the proposed practice change in the hospital encompasses time management as well as accountability between nurses. In accordance to a report by the World Health Organization (2013), subsequent to executing bedside report, hospital nursing staff have relayed a better capability to place priorities on their cases or responsibilities in the course of their shift and a general decline in staff time. For instance, one research study demonstrated a decline in over-shift time by 100 hours within the beginning 2-pay periods on a general surgical unit comprising of 32 beds. Another research study demonstrated a decline of $8,000 that is directly linked with a decline in time for reporting in shifts. This indicates the major need for instituting bedside report within the hospital to not only increase the accountability of nurses and the time spent during shifts but also generate cost savings across different medical departments.

Key Stakeholders who are Part of Current Nursing Practice

Determining the key stakeholders involved in the nursing practice can be simple and also challenging. The aspect taken into consideration in pinpointing the stakeholders include the parties directly influenced by the change and the parties with the authority to carry out and implement such change within the healthcare setting. In that regard, the following persons within the hospital have been determined as being the key stakeholders in the proposed practice change of bedside reporting: clinical operators, clinical educators, nurses directly dealing with patient care, facilities rendering treatment to the patients and the organization as a whole.

To begin with, clinical operators will be impacted by the proposed change for the reason that they are the supervisors and managers responsible for oversight of the clinical personnel. In this regard, the clinical operators are liable for embracing such change and thereafter carrying out such change within the entity.

Secondly, clinical educators within the healthcare setting are liable for teaching new and prevailing personnel to the newly proposed change practice and also offering guiding principles to facilitates its effectiveness. In essence, the clinical educators will give instructions regarding the tools ascertained by the research study. Clinical teaching and education deals with the attainment of the several skills and capabilities to facilitate efficacious practice in healthcare professions. Changes in curricula or practice for healthcare professionals institutes a progressively more significance of methodical learning of key skills and demonstration of how to acquire such skills and become fully competent. Being a new practice introduced into the hospital setting, clinical educators will be liable for such patient-based and patient-centered teaching and learning, which necessitate being cognizant of not only the nurses learning but also the welfare of the patient (Eta et al., 2011).

Third, the nurses are the stakeholders that will be significantly impacted by the proposed change practice. This is for the reason that they will be tasked with the main duties of espousing and practicing the beside report change on an everyday basis. Nurses are responsible for the safe hand-off of the patient between each other and also including the patient and family. Essentially, nurses are the party responsible for explaining the process, appealing the patient and family to be part of the bedside shift report, and handing the form of the bedside report to the patient. It is imperative to note that devoid the nurses, it will be problematic to assess the efficacy of the change.

Other key stakeholders within the healthcare setting who will be influenced by the practice change are patients. Bedside reporting places patients at the core of care providing them with a more active role within the care being rendered to them. Thereby, the patients will largely profit from the proposed change by experiencing increased patient safety and also being included in their plan of care. With regard to bedside reporting, patients are positioned at the center of care. By carrying out bedside reporting during the change in nursing shifts, both the patient will have the chance to ask questions, demonstrate their apprehensions and worries, and to communicate objectives of the care, all which are phases that increase patient safety.

Evidence Critique Table

Full APA Citation

Evidence Strength

Hierarchy

Types of Studies

Ofori-Atta, J., Binienda, M., & Chalupka, S. (2015). Bedside shift report: Implications for patient safety and quality of care. Nursing2017, 45(8), 1-4.

IV

Non-Experimental

Descriptive

Spinks, J., Chaboyer, W., Bucknall, T., Tobiano, G., & Whitty, J. A. (2015). Patient and nurse preferences for nurse handover—using preferences to inform policy: a discrete choice experiment protocol. BMJ open, 5(11), e008941.

IV

Non-Experimental

Descriptive

Bradley, S., & Mott, S. (2014). Adopting a patient?centred approach: an investigation into the introduction of bedside handover to three rural hospitals. Journal of clinical nursing, 23(13-14), 1927-1936.

III

Quasi Experimental

Case Controlled

Achrekar, M. S., Murthy, V., Kanan, S., Shetty, R., Nair, M., & Khattry, N. (2016). Introduction of situation, background, assessment, recommendation into nursing practice: A prospective study. Asia-Pacific journal of oncology nursing, 3(1), 45.

III

Quasi Experimental

Prospective

Salani, D. (2015). Implementation of shift report at the bedside to promote patient-and family-centered care in a pediatric critical care unit. Journal for nurses in professional development, 31(2), 81-86.

VI

Qualitative Study

Qualitative Studies

The first study discussed the need for carrying out bedside reporting in an effective and evidence-based practice manner. The key is that numerous patients are provided with medical care in hospitals in an everyday basis, which includes several shift changes. Therefore, through bedside reporting, medical errors are prevented and in overall the quality and safety of care is improved. This study indicates the implementation of the situation, background, assessment, and recommendation (SBAR) communication tool that facilitates the restructuring of reports in a significant manner. However, the study presents the SBART tool, which includes thanking the patient at the culmination of the process. The tool is delineated as follows:

1. Situation

The outgoing nurse makes an introduction of the oncoming nurse. Subsequently, the oncoming nurse conducts a greeting of the patient whilst checking the wristband for verification of both the name and the date of birth. This also includes the provision of diagnoses and the nurse makes sure the patient information board in the room is up to date.

2. Background

This segment encompasses involvement of the patient in the report for changing the shift. The patient is requested to listen and subsequently ask questions or provide additional information. A succinct but pertinent information on the health history of the patient is given, circumstances that resulted in hospitalization and the anticipated length-stay in the hospital.

3. Assessment

This section includes momentarily conducting an assessment of systems comprising of vital signs, all tubes and invasive lines. Pain assessment is also conducted together with substantiation of the accuracy of medication pumps especially with regard to the rate of infusion.

4. Recommendation

This takes into account social and communication needs, objectives for the patient, any incomplete orders, and the plan for providing patient care. The patient and the oncoming nurse are given the opportunity for questions.

5. Thank

The final phase is giving thanks. The nurse should thank the patient at all times.

The SBART tool is a material and simple context for communication that is employed for setting any conversations, instituting prospects and communicating any imperative information to patients (Ofori-Atta, Binienda, & Chalupka, 2015).

Bedside reporting enhanced the teamwork of the staff by providing nurses the chance to work in tandem at the bedside, guaranteeing responsibility. Through the use of a standardized format such as the SBART tool diminishes the risk of miscommunication for the reason that it successfully deals with dissimilar styles of communication. In addition, improved communication aids the oncoming nurse to rank assignments based on need and makes certain that the nurses are in sync and informed. The adoption of bedside reporting guarantees patient satisfaction scores mirroring the increased positive experiences of the nurses. The study indicates that through the assimilation of the SBAR tool, there was a decline in overtime by a period of 100 hours in the initial period owing to the succinct reporting.

In this study, the researchers sought to espouse the SBART tool to facilitate concise reporting and substantiate that the information is understood by both the patient and oncoming nurse and patient information is up-to-date (Ofori-Atta, Binienda, & Chalupka, 2015).

The second article delineates bedside report as a chance to attain patient engagement and promotion of patient-centered care. Moreover, it lays emphasis on the need to take into consideration the inclinations of both nurses and patients when carrying out bedside shift report to capitalize on the efficacious uptake of this practice. Spinks et al. (2015) make use of a distinctive discrete choice experiment design to prompt the likings and inclinations of both patients and nurses for the most significant aspects of bedside report common to both parties. Through this approach, the study shows that it is conceivable to ascertain any dissimilar perspectives between nurses and patients in order to pinpoint any form of disconnection. It is important to ensure that both of these parties are in tandem with the implementation of bedside report. In addition, the article delineates obstacles to bedside shift report and the different approaches to overcome them and increase the probability of espousal (Spinks et al., 2015).

In the third article, the authors lay emphasis on the advantage of the bedside report handover model over the customary closed-door handover method done at the office. The article accentuates that different from other available approaches, bedside shift report is more patient-centered. The authors, Bradley and Mott (2014) made use of Lewin’s 3-stage model of change which includes the phases of unfreezing, changing, and refreezing, and employed it for a theoretical foundation and structure for the research study. In the unfreezing stage, activities carried out were purposed to gain an understanding on the perspective of nursing on the prevailing and proposed hand-off practice. The changing phase encompassed staff being given guiding principles through a collaborative process in which the new change is carried out and monitored. It also includes a change in the organization’s policies, norms, and policies. The final phase of refreezing was aimed to stabilize the new change to safeguard it from regressing. The activities included normalizing the conducts of staff members, gaining the perspectives of patients and computing the time incurred in bedside shift report.

Akin to other studies, the results from this article demonstrate that patients are more inclined to bedside report approach over the traditional closed-door office report and hand-off method. The fundamental differences pointed out by patients are that bedside reports assimilate social elements for the patient, patients have the chance to become acquainted with the individual providing nursing and medical care to them, and that patients are incorporated in the discussion associated to their care. Moreover, the article indicated that nursing staff believed that there was in increase in the level of patient engagement in their care through bedside report.

In the fourth study, Achekar et al. (2016) assess the introduction and implementation of bedside reporting using the situation, background, assessment, recommendation (SBAR) form. Imperatively, the tool’s format permits short, systematized and foreseeable information flow amid professionals. The key objective of SBAR method is to enhance the efficacy of communication through communication procedure standardization. The tool was introduced in a hospital setting using a self-instructional approach.

The fifth article encompasses an analysis by Salani (2015) on the implementation of bedside shift report within a pediatric critical care unit to facilitate both patient and family-oriented care. The author delineates the development of a quality improvement intervention that comprises of pre-planning, execution and the evaluation or assessment process. Notably, Lewin’s force field model of change was utilized as the theoretical framework. In the first phase, the staff becomes cognizant of and acknowledges the need for a change. The second phase of the theory is movement which encompasses the involvement of staff in the planning and execution of the change. Implementation necessitated the promotion of a distinctive alliance between the healthcare professionals and the patients together with their families. The final phase encompassed evaluation. According to Salani (2015), it is imperative to note that change is not easy and ought not to be overlooked. In addition, so as to maintain the new proposed practice change, everyday monitoring of compliance is pivotal. Most of all, bedside report implementation encourages better communication, a more wide-ranging patient handoff, heightened patient safety, involvement of the patient and family, and augmented satisfaction of the staff, patient, and family.

The outcomes of the study demonstrated that the use of the SBAR tool in bedside reporting has aided nurses in having an intensive and easy communication in the course of transition of care while handing off the patient. The study indicated that the utilization of standardized SBAR in nursing practice for bedside shift assignment will enhance communication between nurses and therefore guarantee patient safety. SBAR communication technique is an evidence-based strategy for enlightening not just communication between professionals, but all sorts of communication particularly when united with proper evaluation skills, clinical decision making along with critical-thinking skills. Documentation in nursing ought to delineate patient\'s ongoing standing from one shift to another with entry of each and every nursing interventions (Achekar et al., 2016).

Recommended Best Practice

The best practice recommended for implementation in the hospital setting based on the evidence summary is the SBART tool. The key advantage of this practice is that will offer an organized tool not just from nurse to nurse but also from nurse to patient. Owing to its outline and context, it is anticipated that the SBART tool will provide accurate and succinct patient and healthcare information devoid of overlooking imperative facts while providing the oncoming nurse a fitting depiction of the patient and his or her healthcare needs. Moreover, this tool will place the patients at the center of care enabling not just the oncoming nurse but also the patient to ask questions. Therefore, any information that might have been disregarded or lost in the course of the traditional shift change within the hospital is retained. According to Blom et al. (2015), SBAR provides a context for communication between members of the healthcare team regarding the status and medical condition of the patient and enables the gathering, organization, and interchange of data and information together with an efficacious strategy to cultivate and augment teamwork. It offers a chance to sustain concentration and emphasis in the transference of information and ensure that the information is succinct, precise and simple to comprehend. Moreover, this practice will make it possible to have better patient safety by having a framework for the information content when conducting communication concerning patients.

Practice Change Model

The practice change model that is suitable to apply to the proposed bedside reporting practice change in the hospital is the Stetler’s Model. One of the key advantages of this model is that it does not completely lay emphasis on official changed steered by nurses in organizational setting and therefore permits the use by individual nurses also. In addition, this model encourages the utilization of internal as well as external evidence. The Stetler’s Model comprises of five phases, varying from looking for evidence regarding a clinical problem to formal and informal assessments. Decision making concerning whether a certain change in practice ought to be made encompasses the deliberation of substantiating evidence, placing fit, feasibility, and prevailing practice (Gawlinksi and Rutledge, 2008).

Application of the Identified Model to Guide the Implementation of the Proposed Practice Change

The first phase of the model has already been finished by pinpointing the aim and sources, problems and the different stakeholders. The outcome has also been delineated longstanding as increasing patient safety by augmenting the efficiency of communication between nurses and patients during a change in shifts. This is period when the nurse is able to make verifications of the health history of the patient, discoveries on physical assessment, together with plan of care encompassing prescribed medications. In the same manner, the patients will be able to ask questions, come up with objectives with the nurse for the short-term period and the long-term period. Therefore, communication amongst personal is augmented while guaranteeing nurse accountability. Short-term outcomes would consist of increased satisfaction of the staff in terms of reliability and through bedside reporting.

Based on the research studies conducted, there is adequate and reliable evidence supporting and promoting SBART as an efficacious tool for bedside reporting and any healthcare organization seeking to espouse it might be required to transform it to suit its distinctive setting. However, with regard to the hospital that I work in, it would not be necessary to make an adaptation of the tool in order to fit its setting. This is for the reason that the model in itself is fitting to the objectives of bedside reporting in the hospital. Despite the fact that there is considerable information on its benefits, the hospital will have to come up with key metrics for the long-term period to determine the impact of SBART on patient safety. Nonetheless, several research studies have shown that SBART is an efficacious and proper tool that increases patient safety, enhances teamwork between healthcare providers and also increases the level of transparency and shared accountability for patient care.

The implementation would also necessitate engaging hospital personnel. Imperatively, it will be pivotal to present evidence of the importance of bedside reporting using the SBART tool in a manner that brings about their approval and espousal. The most efficacious way of accomplishing this is through a comprehensive dialogue. Basically, by allowing the staff to pinpoint any shortcomings or red flags regarding the current practice will facilitate in providing them with insight as to why the hospital is in need of the practice change. As a result, when demonstrating the evidence as to why the practice change ought to be implemented, for instance, medical blunders and increased time consumption in communication during patient hand-off, this could give rise to staff perceiving its significance. Subsequent to appraisal and review of the evidence by the hospital staff together with candid dialogue, then the practice change implementation can go ahead. The tool can be shown to be not only advantageous but also efficacious and therefore is appropriate for the hospital.

The hospital will also be required to attain pilot metrics on where the healthcare organization stands at the present moment. This takes into account looking at Press Ganey survey questions and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey questions. On one hand, Press Ganey questions can include how effective the nurses kept the patient informed, how effective they worked in tandem to provide patient care and staff endeavor to include the patient in decisions regarding their treatment and plan of care. On the other hand, HCAHPS questions can encompass the frequency of nurses explaining medical and nursing aspects in a manner that the patient can comprehend during their hospital stay. Another aspect includes the general ratings of the hospital and the likelihood of recommendation for the hospital. Aside from the patients, the hospital staff will also be engaged. The hospital will allot out a hospital staff survey to ascertain their feelings and outlooks towards bedside reporting as a new medical practice. Nonetheless, it will be imperative to make certain that fundamental questions are closed ended to ascertain that the data is basically inferred. Regardless, the staff will be granted a section at the culmination of the survey for recommendations and suggestions on the introduction and implementation of bedside report in the hospital.

Subsequent to all these steps, the hospital will thereby be able to carry out the proposed practice change. Owing to the fact that the hospital does not presently undertake bedside report at all, this proposal recommends the execution of bedside reports using the SBART format. This is a standardized format that would be employed at any given point when an ongoing nurse’s shift ends and is handing off care of the patient to the oncoming nurse. Being an entirely new practice within the hospital setting, there will be need for comprehensive education to the clinicians. This will be necessary so to make sure that the form is utilized as purposed. The training will take into account the education of clinicians in small groups of less than 20 nurses being taken through a session of approximately 40 to 60 minutes. In particular, the training session will comprise of guiding principles and instructions on the format of the SBART tool and practical scenarios including role plays on how to conduct bedside shift reports. Staff engagement will be imperative during the education in order to generate a consistent and unified learning prospect. Lack of effective staff participation during the education will most likely result in insufficient learning and therefore lead to poor implementation of the bedside report practice.

Once the pertinent hospital staff members have been educated, the practice change will be ready for execution. Taking into consideration that the hospital makes use of electronic health records (EHR), the information technology department of the entity will have to upload the form for use amongst clinicians. Hospital staff will require ample time to become acquainted and skilled with utilizing the tool and also considerable time will be necessitated in order to obtain relevant and reliable metrics. The execution phase for the proposed practice change will be approximately 4 to 5 months. At the culmination of this period, a survey will be handed out to hospital staff to make a determination as to whether they consider the tool to be beneficial in relaying patient data and information, whether bedside report was more effective in terms of communication, patient satisfaction and reduced time spent, and whether the practice should be embraced. Majority of these questions will be closed ended and include a Likert Scale to determine the magnitude of perspectives. In addition, the survey will provide a section that will allow staff to write down any other information they deem to be necessary.

Finally, in the longstanding period, the hospital will have to conduct an assessment of the Press Ganey survey questions and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey questions. The responses and the metrics will pinpoint whether the proposed practice change is beneficial to the staff, patients, and organizational as a whole with regard to healthcare provision. Aspects such as patient safety, patient satisfaction, clinical satisfaction, patient hand-off periods, and cost savings will be analyzed to determine if there have been any improvements. The assessment of hospital staff attitudes and opinions both prior and subsequent to the implementation is important in pinpointing when succeeding implementation instigators might be necessitated. In addition, in the event that any new nurses or clinicians become part of the hospital staff, they will have to be completely assimilated into the expected approaches of undertaking work.

Barriers to Successful Implementation of Practice Change

Carrying out practice change within the hospital is expected to face barriers and obstacles. According to Tacia et al. (2015), barriers to efficacious implementation emanate from several factors comprising of different levels of education and clinical experiences of nursing personnel, and the lack of comprehension regarding its significance to ideal high-quality patient care. In particular, nurses in advanced roles are acknowledged as pivotal to fostering and steering a cultural change that encourages evidence-based practice in the hospital setting and all through the scope of health care. One of the anticipated changes in carrying out bedside report in the hospital is resistance from the nurses. Organizational change is expected to face some magnitude of resistance owing to the perspective of having practices undertaken in the usual way. Bearing this in mind, it is all the more imperative to gain the nurses’ backing and support at the initial phases of the project. At any point when a new practice is introduced within the organizational setting, it is expected that there will be one segment that will embrace the conceptions and carry along with the proposition. However, there is another segment that will be hesitant to accept the change and therefore it is necessary to formulate a thorough demonstration and dialogue of the facts linked with the issue pinpointed (Wallis, 2012). In addition, in the traditional approach of patient handoff, the nurses had become accustomed to socializing with each other in the course of the shift report. As a result, it is expected that there will be considerable resistance to largely decreasing the time for socialization. The nurses might also be against bedside reporting because of the apprehension of not knowing what to say and how to conduct oneself during the bedside shift report, especially in front of both the patient and the family.

Another barrier to the implementation of the proposed practice change is education, which is a key aspect. Notably, individuals educated approximately two decades ago did not obtain learning or training on evidence-based practice approaches to care. The inference of this is that nurse educators will be forced to spend additional time to teach nurses the manner in which they can effectively carry out bedside reporting, which is will be a new practice. Another barrier is that despite the fact that patients will be involved and engaged in the bedside shift report, this can result in increased time wasting. This is linked to the apprehension that the oncoming nurse would be considerably held up by the several wishes and questions posed by the patient. Moreover, there is also the challenge that change in behavior is not simple. This is for the reason that nursing workshops undertaken in a day or two are not likely to bring about sustainable change. It is necessitated for nursing leaders to position sufficient EBP mentors that can work in tandem with clinicians to assist them in learning the newly required skills and practices and how to execute them incessantly. The key lies in generating a framework together with a support system where new evidence-based practice can be maintained (Wallis, 2012).