JONA
Volume 43, Number 3, pp 160-165
Copyright B 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
Utilizing Bedside Shift Report to Improve
the Effectiveness of Shift Handoff
Leslie L. Cairns, DNP, RN
Linda A. Dudjak, PhD, RN
Handoff of patient information during shift report
between nurses is a time of risk and liability. A qual-
ity improvement project was conducted on a 23-bed
inpatient unit to measure the value of a bedside
change-of-shift report in improving the effectiveness
of shift report. Indicators including end-of-shift over-
time, call light usage, nurse perceptions, and patient
satisfaction were impacted by the change in process.
A core component of nursing practice is to ensure the
communication of information facilitating the tran-
sition of care from one provider to another. The com-
plexity of today’s healthcare environment challenges
nurses to communicate in ways that consistently achieve
positive outcomes related to quality and safety. In
today’s complex healthcare system, patients are likely
to encounter greater numbers of providers, resulting
in greater number of handoffs. Handoffs are defined
as ‘‘the transfer of information as well as responsibil-
ity and authority during exchanges in care across the
continuum; to include opportunities to ask questions,
seek clarity, and confirm.’’1(p266) With each handoff,
the probability of experiencing lost or missing in-
formation increases. In a study focusing on newer
nurses and near misses or adverse events, incomplete
or missing information was frequently implicated as
Author Affiliations: Unit Director (Dr Cairns); Chief Nursing
Officer (Ms Lorenz), University of Pittsburgh Medical Center; As-
sociate Professor (Dr Dudjak); Assistant Professor (Dr Hoffmann),
School of Nursing, University of Pittsburgh, Pennsylvania.
The authors declare no conflicts of interest.
Correspondence: Dr Cairns, University of Pittsburgh Medical
Center, 200 Lothrop Street, Pittsburgh, PA 15213 (cairnsll@upmc.edu).
Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are provided in the
HTML and PDF versions of this article on the journal’s Web site
(www.jonajournal.com).
DOI: 10.1097/NNA.0b013e318283dc02
160
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Rosemary L. Hoffmann, PhD, RN
Holly L. Lorenz, MSN, RN
the cause of those events.2 In addition, the most fre-
quently cited root cause of sentinel events evaluated
by the Joint Commission (TJC) is communication
failure during handoffs.3 Handoffs are dependent on
the communication style and skill of healthcare
providers in addition to the experience and knowl-
edge of both individuals and often result in process
inconsistencies.4 An experienced provider may pro-
vide more in-depth information or may conversely
assume a baseline of knowledge among peers that may
not be present. A frequently occurring opportunity for
patient handoff is end-of-shift report. In many
settings, end-of-shift report occurs in a less than con-
sistent manner based on preference or patterns of the
individual providers.5 Most frequently, end-of-shift
report occurs away from the patient’s bedside, either
taped or face-to-face. Content often lacks structure
and consistency and tends to be lengthy.5 Distractions
and interruptions frequently occur while nurses are
engaging in shift report, resulting in potential failures
in communication. Questions from oncoming nurses
may be left unanswered and are challenging to be
addressed once the nurse leaves his/her shift. Report
occurring away from the bedside does not provide
an opportunity for the patient to be included in de-
veloping or revising the plan of care and goals, a
practice that has been shown to promote better pa-
tient outcomes.5-7 Previous research has focused on
shift handoff by measuring indicators such as over-
time, call light usage, and staff perceptions of team-
work, but few have coupled this with patient and
nurse satisfaction.8,9
Background
Since the Institute of Medicine10 issued its hallmark
report To Err Is Human: Building a Safer Health
System in 1999, nursing leaders have been looking
JONA  Vol. 43, No. 3  March 2013
for more efficient innovative ways to improve patient
safety, including developing strategies that would
make processes more clear and standardized, and thus
decrease the chance of errors by healthcare workers.
As early as January 2006, TJC formally acknowl-
edged that handoff communication from one nurse
to another during shift report represents a vulnerable
step in the provision of safe patient care and intro-
duced a national patient safety goal requiring health
care organizations to implement a standardized approach
to handoff communication.3 Research conducted by
McMurray et al11 revealed that active participation
from patients during handoff reduces communica-
tion errors and duplication of services or treatments.
Furthermore, patients have better outcomes and less
fragmented care when they are involved in the handoff.
Despite the demonstrated relationship between
communication and patient safety, research suggests
that communication handoffs among nurses are still
a challenge today.12 As healthcare has evolved and
becomes more specialized, the number of clinicians
involved in patient care has increased, thus creating
more opportunities for ineffective handoffs.12 The
use of standardized tools has been recommended as a
means of decreasing adverse events involving hand-
offs.12 Alvarado et al13 reported that a standardized
patient safety checklist and face-to-face report at the
bedside improved the effectiveness of communica-
tion of nurses at change of shift. Another approach
to standardized handoff communication is known as
ISBAR (introduction, situation, background, assess-
ment, and recommendation).14 This tool was devel-
oped by the military and then adopted by the airline
industry to alleviate communication barriers when re-
laying critical information.12 Pesanka et al15 evaluated a
tool focusing on a standardized handoff using SBAR
during hospital transport. This initiative, known as
‘‘ticket to ride,’’ resulted in improvements in patient sat-
isfaction with transport staff and decreased adverse
events.15
Research identifies numerous benefits to both
nurses and organizations related to bedside shift
report, including financial savings, increased account-
ability, mentoring opportunities, and patient satisfac-
tion.4-7,9,16,17 The study of Anderson and Mangino6
of bedside shift report revealed positive outcomes, in-
cluding a financial savings of more than 100 hours of
incidental overtime after initial implementation. Staff
satisfaction increased as measured by a staff survey
before and after implementation.6 Results obtained
from the patient satisfaction survey revealed an in-
crease in patients’ perceptions of staff keeping them
informed and in how well the staff worked together.6
Kassean and Jagoo18 used bedside handoff as a qual-
ity improvement opportunity and found that patients
JONA  Vol. 43, No. 3  March 2013
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
reported satisfaction with their inclusion in the plan
of care and with the methods in which information
about their care was shared. Nurses practicing on a
stroke rehabilitation unit in a large metropolitan hos-
pital found that bedside shift report promoted staff
accountability and teamwork as well as increased pa-
tient collaboration in care planning. A recent study
conducted on a 34-bed progressive care unit in a west
coast community hospital found that bedside shift
reporting resulted in less overtime and less call light
usage during change of shift.13
While numerous benefits to bedside shift report
have been documented, changes in daily routine and
practices can be a difficult transition for nurses. Re-
cent studies identifying hurdles to the implementa-
tion and adoption of bedside shift report cite nurses’
concerns about compromises in patient confidential-
ity, length of time required to complete report, and
discussion of sensitive items such as test results, com-
plex family dynamics, or patient adherence to treat-
ment as barriers.6
About the Project
The purpose of this project was to evaluate the effects
of redesign of shift handoff report on effectiveness
and efficiency measured by the amount of end-of-
shift overtime, frequency of call light usage during
change-of-shift times, patients’ perceptions of being
involved in their care, and staff perceptions of its
effects on limitations identified in the existing method
of automated shift report. The project was conducted
on a 23-bed inpatient trauma unit in a large tertiary
academic hospital in southwestern Pennsylvania as
a result of this units’ staff nurse concerns about the
length, accuracy, and disorganization of the current
method of automated shift report. The framework
used for this project was the W. Edwards Deming’s
plan-do-study-act (PDSA) model. The PDSA model is
a recognized method of performance improvement
incorporating tracking, defining, and evaluating a
practice or process change. Deming’s model for im-
provement is based on doing the right thing for every
patient every time.19 An anonymous 7-question survey
was developed by the investigator to determine satis-
faction with current automated shift report practice
and to elicit specific concerns regarding the imple-
mentation of bedside shift report. The survey was ad-
ministered to the nurses on the unit 3 months before
and 3 months after bedside shift report implemen-
tation. The survey tool was tested on the 3 manage-
ment team members from the project unit for clarity
of content and then issued via SurveyMonkey to
nurses working on the unit. Respondents were asked to
use a 5-point Likert scale (1 = strongly agree to 5 =
strongly disagree) to indicate the degree to which
161

Table 1. End-of-Shift Overtime Results
Before After
Implementation Implementation % Change
End-of-shift 6,194 min 5,281 min 15%
overtime (103 h) (88 h) (10 min/d)
they agreed with statements related to bedside shift
report (See Document, Supplemental Digital Con-
tent 1, which illustrates the questions from the pre-
implementation and postimplementation surveys,
http://links.lww.com/JONA/A197).
After completion of the survey period and before
implementing bedside shift report, mandatory edu-
cation sessions were conducted on the nursing pilot
unit. The sessions were 1 hour in length and high-
lighted key points related to bedside shift report, such
as benefits, goals, report-process guidelines, and mea-
sures of success. Key points were presented using a
PowerPoint presentation, handouts, and role play to
demonstrate the process of bedside shift reporting.
Three case studies were formulated by the investiga-
tor based on the most common concerns identified in
the staff survey. These concerns were related to confi-
dentiality, interruptions, and pertinent information
to be shared. As part of their participation in the unit-
based education sessions, staff used case studies to
engage in role playing to brainstorm potential ap-
proaches to these scenarios. A visual assessment of the
physical, emotional, and psychological state of the pa-
tient’s body systems as well as the environmental and
social issues involved with the patient was the
method in which the nursing staff performed bedside
shift report; they felt that a standardized tool would
not be helpful. To introduce the new process to
patients during the implementation period, all newly
admitted patients received a letter upon admission
that was written by the nurse clinician on the unit,
explaining how the nurses would be conducting shift
report. During this same timeframe, staff gathered
informally each day for a ‘‘staff debriefing’’ to discuss
any additional concerns or situations that were en-
countered with the newly implemented method of
shift report.
One month after initiating bedside shift report,
unit nurses received a 2nd survey via SurveyMonkey
to evaluate their satisfaction with bedside shift re-
port. In addition to the original, preproject survey, 2
additional questions focused on the perception of the
new versus previous process. Before initiating bed-
side shift report on this unit, baseline data on 3 out-
come measures were collected over a 3-month period:
162
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(1) end-of-shift overtime, defined as the number of
minutes a nurse worked in excess of a regularly sched-
uled shift and extracted from the electronic payroll
system used in this hospital; (2) call light activations
during the time of shift report were obtained from
standard usage reports generated by the nurse call
system; and (3) patient responses to 2 questions on
the patient satisfaction survey used routinely through-
out the organization, with results obtained through
the Press Ganey patient satisfaction survey (www
.pressganey.com): ‘‘Nurses kept you informed’’ and
‘‘Staff included you in decisions related to treatment.’’
Three months after implementation of bedside shift
report, the data measuring the same indicators were
collected to determine the impact of the project. After
analysis of preimplementation and postimplementa-
tion results, the findings were shared with unit staff
nurses via staff meetings by the investigator and feed-
back was used to evaluate the need for changes to the
new process.
Results
Project outcomes confirmed positive relationships be-
tween bedside shift reporting and end-of-shift overtime,
call light usage, and patient and nurse satisfaction.
The total number of end-of-shift overtime minutes ex-
perienced in the 3-month time period before implemen-
tation was 6194 minutes compared with 5281 minutes
after implementation for the same period of time
(Table 1). Whereas the reduction in overtime between
the preimplementation and postimplementation phases
averaged a modest decrease of 10 minutes per day, on
an annual basis, this difference represented a decrease
of 61 hours per year. Depending on whether the over-
time was paid at a straight hourly rate or at time and
a half (which would vary depending on the individ-
ual nurse’s total worked hours during a pay period),
savings ranged from $23,920 to $35,880 per quarter.
Annually, this represents a reduction of $95,680 to
$143,520 in salary expense, or 23% of the salary bud-
get for the pilot unit.
Table 2. Call Light Activations Before
and After Implementation of Bedside
Shift Report
Before After %
Implementation Implementation Change
Call light usage 1,591 1,075 33%
7 AM-8 AM 809 501 38%
7 PM-8 PM 782 574 27%
JONA  Vol. 43, No. 3  March 2013
Figure 1. Mean patient satisfaction scores: nurses kept you informed.
Call light usage during change-of-shift times de-
creased by 33% in the 3-month period after imple-
mentation of bedside report (Table 2). Findings are
felt to be related to the locations distant from the pa-
tient’s bedside around the unit where report was ex-
changed, thus rendering the nurse inaccessible to the
patient. Patient satisfaction was positively impacted
by the implementation of bedside shift report. During
the postimplementation phase of this project, there
was an increase in the mean patient satisfaction scores
on both questions related to patients being informed
and included in their treatment plan (Figures 1 and 2).
The finding regarding improved patient satisfaction
validates the findings of a quality improvement study
conducted by Anderson and Mangino.6
Nursing response on the postimplementation sur-
vey revealed several interesting changes in their percep-
tions about shift report. Nurses who agreed or strongly
agreed that report was concise and contained infor-
mation pertinent to the patient’s condition increased
from 38% (n = 11) to 77.8% (n = 14) after imple-
mentation of bedside report. After implementation,
less than half of the nurses agreed or strongly agreed
report that time was excessive after implementation
of bedside shift report (38.9%, n = 7). An increased
percentage of nurses also reported that information
Figure 2. Mean patient satisfaction scores: staff included you in decisions related to treatment.
JONA  Vol. 43, No. 3  March 2013
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
received in the report was more consistent with the
actual patient condition (72.4% [n = 21] before
implementation vs 83.4% [n = 15] after implemen-
tation). In anecdotal comments noted at the end of
the postimplementation survey, nurses described an
increased sense of confidence when assuming care of
the patient and the opportunity to visualize the pa-
tient opposed to relying on information received in
taped or written report. After implementation of bed-
side shift report, a higher percentage of nurses agreed
or strongly agreed that coworkers were available for
questions after receiving report. In addition, nurses
also indicated that bedside shift report took less time
than the automated method of shift report and it did
not interfere with the ability to complete their tasks
during their shift. Finally, 50% of the nursing staff
reported that teamwork and accountability im-
proved on the unit after implementation of bedside
shift report (Table 3).
Sustaining bedside shift report has not been with-
out challenges and requires ongoing monitoring and
encouragement. Occasionally, individual nurses would
revert to the variations of the process of report, includ-
ing holding report at the nurse’s station or outside
the patient room. Routine observation and individ-
ual feedback by the unit director have been useful in
163
 Table 3. Nurse Response of Agreed or Strongly Agreed to the Nurse Survey
Report is concise; contained only pertinent information
Information contained in report consistent with initial assessment
Nurses available after report for questions
Time required for report is excessive
Time required for report interfered with ability to complete work within shift
correcting this behavior. Because of the outcomes re-
sulting from this project, bedside shift report is now
being expanded to other units in the hospital.
Limitations
Several limitations were identified in this project. Be-
cause the duration of the project was 3 months, the
ability to identify actual trends in patient satisfaction
scores and to obtain responses from a larger sample
of patients was limited. It could not be confirmed
whether the reduction in end-of-shift overtime was
the result of bedside shift report or of other factors
such as individual nursing practice or staff aware-
ness. This project was conducted on 1 unit in a single
facility, and thus, the outcomes are not generalizable
to others without further study. When employees
provide feedback as part of a change in work process,
there is a concern about the validity of responses
based on concerns of confidentiality.
Implications and Recommendations
for Practice
Although performed on a daily basis, shift report is
an inconsistent element of nursing practice. The goal
of this project was to redesign the delivery of shift
report to improve the effectiveness and consistency
of shift handoff. Positive outcomes of the new pro-
cess were reductions in shift overtime and call light
usage and an increase in patient satisfaction. The
10 minute per day decrease in overtime, at an average
hourly rate of $26 to $39, resulted in a reduction in
salary expense ranging between $24,000 and $36,000
for a single quarter during the project. Annually, this
practice change would represent a savings of $96,000
to $144,000.
The reduction in call light usage during change
of shift not only has the potential to contribute to
patients’ positive perceptions of timeliness in nurses’
response time but also has significant safety implica-
tions for the patient who is at risk for falls or whose
condition is unstable or deteriorating. Engaging staff
in the development of standard handoff reporting
164
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Before Implementation After Implementation
(n = 29) (n = 18)
38.0% 77.8%
72.4% 83.4%
75.9% 88.9%
48.2% 38.9%
41.4% 27.8%
process, tailored to their patient population, served
to increase adoption of the process change. Extend-
ing the data collection phase to include a larger vol-
ume of patient responses over a longer period of time
is recommended to demonstrate sustained impact on
the identified indicators.
The need for consistent reinforcement, commu-
nication, and education was identified as essential to
effectively integrating this change in process across
time. The active interaction of the unit director was
essential in calling out deviations from the new prac-
tice and reaffirming the goals and benefits. Timely
dissemination of preliminary progress was effective in
conveying an ongoing commitment from unit leader-
ship as well as encouraging their efforts, particularly
for staff that were skeptical or resistant. Acknowl-
edging staff feedback throughout the process was
instrumental in achieving a sense of ownership and
fostering the accountability and teamwork. It is also
important to provide education in advance of imple-
mentation, especially to identify goals and benefits
and to elicit perceived barriers and concerns. Using
this feedback as a basis for case studies used in the
education sessions added an element of reality and
relevance to the experience for staff. The role playing
that occurred around the case studies was valuable in
offering credible scripting options in response to
patient or family questions and also validated actual
behaviors that could be used to address concerns such
as confidentiality. With breakdowns in shift handoff
cited as one of the most common causes of adverse
events in hospitals, it is critical that nurses at the bed-
side understand the positive impact and potential out-
comes of new practices such as bedside shift report.
Nursing leader and bedside care providers should be
challenged to implement cost effective, evidence-based
strategies such as bedside shift report to do our part to
improve patient safety and satisfaction.
Acknowledgments
The authors acknowledge the nursing staff of 12D
who participated in the process improvement project.
JONA  Vol. 43, No. 3  March 2013
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