Bedside shift report: Nurses opinions based on their experiences

Abstract Background Nurse bedside shift report (BSR) improves satisfaction, quality and safety. Yet, postimplementation adoption rates remain low in hospitals where BSR has been introduced. Further research is needed to understand what content is most appropriate to discuss during BSR and what facilitators are from the clinical nurses' perspective. Aims Identify and describe acute care clinical nurses' and nursing supervisors' experiences and opinions regarding: process of BSR, appropriate content for BSR and barriers and facilitators related to implementation of BSR. Design A phenomenological qualitative study was conducted at an acute care 500 bed, not‐for‐profit academic medical centre located in the southern United States. Methods Clinical nurses (N = 22) and nursing supervisors (N = 12) from every inpatient division were recruited and interviewed. The data were analysed for relationships, similarities and differences. Themes were then identified by two independent researchers. Results Five themes were identified: (a) time constraints and clinical nurse's workflow must be taken into consideration; (b) a modified approach is necessary; (c) process and specific critical content should be individualized so that it is meaningful for all parties involved; (d) specific critical content that should be discussed outside the patient's room; and (e) specific critical content that should be discussed inside the patient's room. Conclusions One way to minimize interruptions is to conduct BSR using a modified approach, where a portion of the hand‐off occurs inside and outside the patient's room. In addition, this study identified the nurses' preferred location where specific critical topics should be discussed. Relevance to clinical practice Results from this study should be used to inform the practice BSR so the desired outcomes of patient and family satisfaction, nursing quality and patient safety can be realized. This study should influence future research aimed at identifying strategies for successful implementation and sustained use of BSR. The COREQ checklist was used to write manuscript.


| INTRODUC TI ON
In 2016, it was estimated that there were 251,000 preventable deaths per year making medical errors the third leading cause of death in the United States (Makary & Daniel, 2016). The exact cost of these medical errors is unknown, but studies estimate they cost the United States economy up to $19.5 billion each year (Milliman, 2010).
Finding from a study conducted by the Joint Commission's Annual Report on Quality and Safety (2007) found that 70% of serious medical errors are a direct result of some type of breakdown in communication from one caregiver to another in what is known as the 'hand-off' process (Joint Commission's Annual Report on Quality & Safety, 2007). As a result, nurse bedside shift report (BSR) has been recommended by national patient organizations as the gold standard (AHRQ, 2013;Joint Commission, 2015).
Nurse bedside shift report (BSR) has been identified as the gold standard because outcomes reported in the literature indicate it improves patient and family satisfaction, nursing quality and patient safety better than the traditional hand-off outside the patient's room (Grimshaw et al., 2016). BSR occurs at the patient's bedside where patients and their families can participate in the hand-off of critical content. Unfortunately, BSR is occurring inconsistently and infrequently across many acute care hospitals that have attempted to implement the practice. Fifty-one per cent of 653 hospitals recently surveyed acknowledge that significant patient details are frequently not transferred between caregivers during the hand-off process (Agency for Healthcare Research and Quality (AHRQ), 2014).

| BACKG ROUND (LITER ATURE )
Nursing hand-off requires the transfer of critical information from the off-going nurse to the oncoming nurse. A successful transfer of this information is required to ensure the continuity of patient care and to prevent adverse events and medical errors (AHRQ, 2013).
In 2006, the Joint Commission published a national patient safety goal that required organizations to have standardized approaches to hand-off and encouraged the active participation of patients in the process (Joint Commission, 2015). Following suit, AHRQ published an implementation handbook for BSR which included a checklist of items that should be discussed during the BSR (AHRQ, 2013). Table 1 represents an abbreviated version of AHRQ's checklist.
In 2017, the Joint Commission issued a sentinel event alert related to inadequate hand-off communication (Joint Commission, 2017).
The alert recommended the critical content that should be communicated during every hand-off and that hand-off should occur in a location free from interruptions and include the patient and family as appropriate (Joint Commission, 2017). Table 2 lists the critical content recommended by the Joint Commission.
Although studies in the literature have begun to investigate nurses' experience and opinions regarding of BSR, the most feasible process to conduct BSR and the specific critical content that should be included in BSR has yet to be fully defined. This study is the first to define specific critical content as unambiguous items that should be discussed or performed during BSR (i.e. an assessment of the patient's intravenous catheter is performed, a decision is made that the patient needs pain medication and the patient-controlled analgesia settings are checked to ensure they match the physicians order). Staggers and Jennings (2009) observed hand-off in a variety of different formats, recorded audio tapes, face-to-face and BSR and did describe a broad overview of the content they observed. High level overview of content is defined as overall themes of information that are discussed or performed during BSR (i.e. an assessment is performed, decisions are made, information is clarified, errors are intercepted and care is prioritized). Staggers and Jennings (2009) reported the following (a) 33% was clarifying details (i.e. exchanging questions and answers between the oncoming and off-going nurse), (b) 30% was factual information (i.e. patient' name, bed number, age, weight, laboratory tests, physician orders, locations of intravenous lines, tubes and drain locations and times medications and treatments were completed and/or due.), (c) 25% was nursing actions, knowledge, judgments and instincts combined with decisions; and (d) 13% was teamwork, relationship building and smoothing the transition of care (i.e. humour and laughter).  Kitson and Harvey (2016), the iPARIHS framework was designed to explain and predict the success of implementation of evidence into practice. The core constructs of the iPARIHS framework are innovation, recipients, context and facilitation (Kitson & Harvey, 2016). The interpretation of the iPARIHS constructs as they relate to this study were the innovation was BSR, the recipients were nursing supervisors and clinical nurses, the outer context was hospital administration, the inner context was the nursing culture and facilitation was the strategies used to implement BSR at the study site. The iPARIHS framework was chosen as the sensitizing framework for this study because it accurately represents the complexities of implementing BSR, helped to explain why BSR has not been successfully implemented and was useful to determine the key elements necessary to implement BSR successfully in the future. An excerpt from the in-depth interview guide which includes only the main questions and which iPARIHS concept(s), was used to develop them can be found in Table 3.

| Research design
To fulfil the purpose and specific aims of this research study, the investigators needed to understand the intricacies of BSR from both the frontline nurses and their supervisors who have tried to implement it. Therefore, a qualitative methodology, phenomenology, was used to explore the essence of the phenomenon, BSR.
Although the anticipated minimum sample size was 8, recruitment and data collection continue until saturation was achieved at 12 participants. A minimum of one nursing supervisor from every inpatient division at the study site was recruited and interviewed.
Eligibility criteria for participation of the nursing supervisors in-

| Participant recruitment
The lead investigator was employed at the research site and had access to the study population. Prior to recruiting, permission was Nurses interested in participating were asked to contact the principal investigator via email. The investigators were not made aware of any potential participants via any other routes.

| Obtaining consent
Prior to the interview, a waiver of written consent was requested and obtained from the IRB. An information sheet was provided to the participant to ensure the participant understood the purpose of the study, what the findings were to be used for and that they had the right to withdraw from the study at any time without consequence. Consent was considered obtained when: the nurse had reviewed the information sheet and verbally agreed to participate.
The IRB did not require written consent because there was no more than minimal risk to participants.

| Data collection
Participants completed a demographic questionnaire prior to each interview. The questionnaire captured personal information, registered nurse experience, BSR experience, registered nurse education and work information. In-depth interviews were conducted using an interview guide. The interview guides include broad open-ended questions that are strategically ordered and connected to ensure that valuable information was obtained throughout the interviews (Rubin & Rubin, 2012). The selection of these questions was influenced by the findings of the prior qualitative studies already mentioned, two pilot studies conducted by this principal investigator (Jimmerson, 2017(Jimmerson, , 2018 and the concepts of the iPARIHS framework. The questions were also chosen based off their ability to fulfil the aims of the study. In addition to the main questions listed on the interview guides, additional probing, clarifying and redirecting questions were asked as necessary to ensure rich data information is obtained (Creswell & Poth, 2018).

| Conducting the interview
The principal investigator contacted the identified participants to determine a mutually agreed time and place to conduct an in-depth face-to-face interview. Interviews occurred on the hospital campus.
The interviews occurred in a quiet room that was located in a different building than the inpatient unit to protect the confidentiality of the participant. All interviews occurred at times that participants were not being paid by their employer (i.e. before or after scheduled shift). The length of the interviews lasted approximately 30-60 min and were audio recorded on a password encrypted device. Only the principal investigator and the participant where in the interview. In addition to the using the interview guide, the principal investigator also took field notes immediately after each interview. The field notes were used to capture participants' non-verbal ques not captured via audio recording. The field notes were used to assist the investigators with analysis and interpretation of data. Probing, clarifying and redirecting questions were asked during the interview to ensure rich data information was obtained (Creswell & Poth, 2018). At the close of each interview, the principal investigator asked for participant's permission to set up a secondary phone interview in the event that new themes emerge, or additional clarification was needed.

| Ensuring dependability, confirmability and credibility
This study was completed in the principal investigator's place of employment where he is in a leadership role. Conducting qualitative research in one's place of employment can produce instant rapport with participants, insights that only an insider may be privy to and better translation of research findings into practice (Josselson, 2007; McConnell there are strategies that these investigators leveraged to ensure these risks were mitigated.
The investigators used sampling approaches that mitigated possible coercion, practised reflexivity to ensure objectivity and built rapport with participants to garner truthful responses. Participation was completely voluntary and non-coercive. They understood their own philosophical beliefs, did not project them into the study and allowed themselves to be challenged by what participants said throughout the course of the research (Moore, 2012). They took a step back at various stages of the research and practiced reflexivity to ensure they was not projecting bias in the study (Moore, 2012 To further ensure dependability, confirmability and credibility, the recordings were transcribed verbatim. After the recordings were transcribed verbatim, the principal investigator read the interviews to gain familiarity and to check for accuracy. Once accuracy was verified, two independent investigators classified the data into codes and themes.
The codes were then used to determine the emerging themes.

| Trustworthiness/Validation
According to Creswell and Poth (2018), qualitative investigators should engage in at least two validation methods to ensure that their study generates accurate and valuable information. The following strategies were used to ensure this study produced valid results: (a) Prolonged engagement and persistent observation. (b) Member checking is the most critical method used to establish credibility (Creswell & Poth, 2018). Throughout the process and at the conclusion of each interview, the principal investigator summarized and used probing questions to clarify important issues to ensure accurate accounts were recorded. Transcripts were not returned to participants. Secondary phone interviews were deemed to be unnecessary. Rich descriptions-Specific quotations from interviewees were included in this article.
This allows the reader to make their own decisions regarding transferability and accuracy of the conclusions (Creswell & Poth, 2018). The consolidated criteria for reporting qualitative research (COREQ) was used to ensure accurate and complete reporting of this study occurred (Tong et al., 2007). Please see the completed checklist: 'Consolidated criteria for reporting qualitative research' (Appendix S1).

| Data analysis
The demographic questionnaires were analysed using descriptive Once all interviews had been coded, the investigators analysed the data for relationships, similarities and differences (Giorgi, 1985). The emerging themes were identified and those pertinent to the aims of this article were reported in the results section.

| RE SULTS
Clinical nurse recruitment stopped after saturation was achieved at

| Theme 2: A modified approach is necessary
All 34 participants, without being prompted, reported that a modified approach, where a portion of the hand-off occurs inside and outside the patient's room, was necessary to complete a successful transfer of critical information from one shift to the next. In addition, participants reported that a modified approach was better that a full hand-off at the bedside for a variety of reasons.

| Theme 4: Specific critical content that should be discussed inside the patient's room
Participants were asked the following question: 'What topics do you think should be discussed at the bedside?' The most common responses to this question from nursing supervisors, clinical nurses and the combined group are summarized in Table 6.

| Theme 5: Specific critical content that should be discussed outside the patient's room
Participants were asked the following question: 'What topics do you think should not be discussed at the bedside?' The most common responses to this question by nursing supervisors, clinical nurses and the combined group are summarized in Table 7.

| D ISCUSS I ON
The iPARIHS framework facilitated the identification and description of why organizations have struggled to implement BSR successfully.
Furthermore, it helped to describe acute care nurses' experience and opinions regarding the most feasible process to conduct BSR and the specific critical content that should be discussed during BSR.
Findings from this study are congruent with recommendations from the Joint Commission and AHRQ that a successful transfer of critical content from the off-going nurse to the oncoming nurse should occur in a timely fashion. In their BSR implementation handbook, AHRQ (2013) acknowledges that hand-off should not take longer than 5 min which was consistent with the amount of time provided to clinical nurses at this academic medical centre to conduct handoff. This is also consistent with the findings from an observational study that reported the average nursing hand-off took 4.4 min (Staggers & Jennings, 2009 (Grimshaw et al., 2016;Spooner et al., 2015;Staggers & Jennings, 2009;Tobiano et al., 2017). Participants of this study reported that one way to minimize interruptions is to conduct BSR using a modified approach, where a portion of hand-off TA B L E 6 Specific critical content that should be discussed inside the patient's room occurs inside and outside the patient's room. This finding is further validated by a study conducted by Grimshaw et al. (2016). Clinical nurses in their study reported that a modified approach should be used to decrease the time BSR takes and ensure all important, information, sometimes sensitive and difficult to discuss in front of the patient, is delivered. According to the iPARIHS framework, successful implementation is most likely to occur when recipients are allowed to blend practice-based knowledge with the innovation (Kitson & Harvey, 2016). Therefore, a modified approach to BSR should be considered.
This study supports the Joint Commission's and AHRQ's position that the patient and family needs be involved in hand-off communications. However, the extent of patient and family involvement is not well defined by either the Joint Commission or AHRQ. The Joint Commission stated that patients and families should be included in hand-off as appropriate (Joint Commission, 2017). AHRQ (2013) positions that the hand-off of critical content should occur at the patient's bedside but acknowledged that sometimes sensitive information, information not yet shared by the doctor or a sensitive diagnosis such as HIV, should be shared prior to entering the room.
The findings of this study support the recommendation from AHRQ that some topics are not appropriate to discuss in the patient's presence. This finding is further validated by a qualitative study that found nurses were not able to say everything they wanted to at the bedside for fear of saying something that may upset the patient (Grimshaw et al., 2016). However, this study differed from AHRQ because it found that a modified approach was better, more feasible and made for a better hand-off than a hand-off of all critical content at the patient's bedside. Another study similarly reported that participants in their study felt a modified approach was necessary to ensure that nurses could say everything they needed to say in a timely fashion (Grimshaw et al., 2016). An observational study found the average number of interruptions in the intensive care setting was two interruptions per hand-off with a range of 0-7 (Spooner et al., 2015). Another study did not quantify the interruptions they observed but stated that interruptions were common in face-to-face hand-off (Staggers & Jennings, 2009). In addition, other qualitative studies found that interruptions by patients and families disrupted the flow of information and was perceived as a barrier by participants (Johnson & Cowin, 2012;Tobiano et al., 2017). One study found that nurses can control hand-off better if done outside of the patient's room, thus leading to less interruptions (McMurray et al., 2010).
Other studies purport that nurses perceived they could not say all of the things they wanted to in hand-off and were forced to censor information in a way that sometimes led to miscommunication of important information ( TA B L E 7 Specific critical content that should be discussed outside the patient's room Johnson & Cowin, 2012;Kerr et al., 2014;Khuan & Juni, 2017;McMurray et al., 2010;Tobiano et al., 2017). As aforementioned, the iPARIHS framework purports that recipients should be allowed to blend practice-based knowledge with the innovation, to increase the odds of successful implementation (Kitson & Harvey, 2016).
Therefore, a modified approach to BSR should be considered to help minimize distractions and ensure communication of critical content in a timely manner.
Results support that critical content that should be communicated during the hand-off process should be standardized (AHRQ, 2013;Joint Commission, 2017 found that hand-off should be flexible to produce good communication and should be based on the complexity of the patient (Johnson & Cowin, 2012). Another study found that although everyone should understand their role in the process of hand-off, it does not need to be uniform in all clinical areas (Bruton et al., 2016). Another study purported that a consistent and tailored structure was needed for an effective hand-off process but that it should be unique to the unit (Staggers & Jennings, 2009  Results from this study have expanded the existing body of knowledge on BSR and should be used to inform its practice so the desired outcomes of patient and family satisfaction, nursing quality and patient safety, can be realized. This study should influence future research aimed at identifying strategies for successful implementation of BSR successfully. This study further validates the usefulness of the iPARIHS framework in exploring why innovations have not been implemented successfully.

CO N FLI C T O F I NTE R E S T
None.

AUTH O R CO NTR I B UTI O N S
Joseph Jimmerson was responsible for the execution, scientific integrity, and administration of the study. He was responsible for the all correspondence with the designated study site, IRB, participants, and transcription services. He recruited participants, obtained consents, interviewed participants, sent recorded interviews to transcription service, and coded and analysed the data.
He was ultimately responsible for monitoring the integrity of the data, study progress, and ensured the study protocol was followed.
He prepared the findings for publication and is to be listed as first author. Patricia Wright was responsible for coding the first three interviews from both participant groups; independent from the primary investigator. She met with the PI to check for agreement in coding and to establish a codebook. The PI took that codebook, coded all remaining interviews, and established a final codebook with themes. She ensured that the themes identified correlated with the exemplar quotes provided and her understanding of the handoff process at UAMS. All discrepancies identified were investigated and a consensus between all investigators were reached before submission for publication. She aided the PI in preparing the findings for publication and is to be listed as second author. Patricia A.
Cowan was responsible for reviewing and critiquing the codebook created by the Principle Investigator Joseph Jimmerson and Coinvestigator Patricia Wright. She ensured that the themes identified correlated with the exemplar quotes provided and her understanding of the hand-off process at UAMS. All discrepancies identified were investigated and a consensus between all investigators were reached before submission for publication. She aided the PI in preparing the findings for publication and will be listed as third author.
Tammy King-Jones was responsible for reviewing and critiquing the codebook created by the Principle Investigator Joseph Jimmerson and Co-investigator Patricia Wright. She ensured that the themes identified correlated with the exemplar quotes provided and her understanding of the hand-off process at UAMS. All discrepancies identified were investigated and a consensus between all investigators were reached before submission for publication. She aided the PI in preparing the findings for publication and will be listed as fourth author. Claudia J. Beverly was responsible for reviewing and critiquing the codebook created by the Principle Investigator Joseph Jimmerson and Co-investigator Patricia Wright. She ensured that the themes identified correlated with the exemplar quotes provided and her understanding of the hand-off process at UAMS. All discrepancies identified were investigated and a consensus between all investigators were reached before submission for publication.
She aided the PI in preparing the findings for publication and will be listed as fifth author. Geoffrey Curran was responsible for reviewing and critiquing the codebook created by the Principle Investigator Joseph Jimmerson and Co-investigator Patricia Wright. He ensured that the themes identified correlated with the exemplar quotes provided and his understanding of the hand-off process at UAMS.
All discrepancies identified were investigated and a consensus between all investigators were reached before submission for publication. He aided the PI in preparing the findings for publication and will be listed as the six author.

DATA AVA I L A B I L I T Y S TAT E M E N T
Additional information regarding this study, including transcribed interviews, are available and can be requested via the following email: jjimmerson@uams.edu.