A Practical Guide to the Implementation of Bedside Report in a ...

Crit Care Nurs QVol. 44, No. 3, pp. 324–333Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

A Practical Guide to theImplementation of BedsideReport in a Critical Care Setting

Alaina Martini, BSN, RN, CCRN, PHRN;Johnna Resek, BSN, RN, CNRN

Blended bedside report increases peer-to-peer accountability among nurses, improves communi-cation between nurses as well as patients, and promotes patient safety. Despite the literature thatdocuments bedside report is best, a practical guide to initiating this process in a hospital settingis lacking. A unit-based council composed of staff nurses and 1 member of nursing managementon a neurosurgical intensive care unit designed a unit-wide education initiative involving multiplemodalities and peer-to-peer training. This combination led to a successful culture change fromtraditional report to blended bedside reporting process. Key words: bedside report, blendedbedside report, handoff, implementation of bedside report, peer-to-peer training

I N a complex health care setting suchas a critical care unit, the communica-

tion of pertinent patient information and thetransfer of nursing responsibilities betweencaregivers is an essential component of pa-tient safety. With medical errors reportedas the third leading cause of death, andmiscommunication identified as a contribu-tor to harm in 80% of medical malpractice

Author Affiliations: Neurosurgical ICU, AlleghenyGeneral Hospital, Pittsburgh, Pennsylvania.

The authors thank the Neurosurgical Intensive CareUnit Based Council members Gloria Beltz; TheresaChiaramonte, BSN, RN, CNRN; Vicki Cohen, MSN, RN;Elysha Decola, RN; Michelle Grenesko, BSN, RN; Bran-don Hartnett, BSN, RN; Guy Hughes, RRT; DebbieMelone, MSN, RN, CNRN; and Jake Yaglowski, BSN, RN.We would also like to extend our appreciation to Ju-dith Depalma, PhD, RN, and Marge DiCuccio, PhD, RN,NEA-BC, for their guidance and mentorship.

The authors have disclosed that they have no signif-icant relationships with, or financial interest in, anycommercial companies pertaining to this article.

Correspondence: Alaina Martini, BSN, RN, CCRN,PHRN, Neurosurgical ICU, Allegheny General Hos-pital, 320 E. North Ave, Pittsburgh, PA 15212([email protected]).

DOI: 10.1097/CNQ.0000000000000368

lawsuits,1 a standardized form of report is inthe best interest of both the nurse and thepatient. Since 2005, The Joint Commissionhas addressed the failure in communicationbetween health care providers by making im-plementation of a standardized approach tohand off communication a National SafetyGoal. This institutional approach should al-low staff the opportunity to ask questionsand respond to them.1 This communicationhas been identified by many names: bedsidereport, handoff, sign-out, and shift report.

It is proven that “bedside report increasesclient safety and satisfaction; creates trust be-tween the nurse and client; reduces commu-nication errors; and promotes accountability,teamwork, and respect among staff.”1 De-spite its importance to patient safety, nurseshave been resistant to participating in bedsidereport, citing patient confidentiality, increasein report time,1 and frequent interruptionsby patients.2 It is challenging for institu-tions to have the nurse endorse bedsidereporting. Faced with patient safety goals andoverwhelming evidence that bedside reportis beneficial to patient safety,3 institutionshave implemented policies and proceduresfor care transitions, but little research has

Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

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Implementation of Bedside Report in a Critical Care Setting 325

been done on the best practice for utiliza-tion of this process. This article details theimplementation of a standardized bedside re-porting process in a large teaching hospitalin a 22-bed neurosurgical intensive care unit(ICU) by a unit-based council consisting ofbedside nurses and a member of nursingmanagement.

WHY BEDSIDE REPORT?

Bedside handoff, bedside report, and shift-to-shift report can all be defined as a criticaltransition of care. This is a time whenessential information about the patient isexchanged between nurses as well as the re-sponsibility of caring for the patient. Thisinteraction between nurses must include theopportunity for questioning between thegiver and receiver of information.4 There areseveral different types of report, includingtraditional, bedside, and blended. The tradi-tional report consists of a face-to-face handoffthat takes place in a private setting away fromthe patient’s bedside. Bedside report is essen-tially a shift report that is solely conductedat the patient’s bedside. Blended report oc-curs when half of the report is conductedface-to-face in a private setting and the otherhalf is conducted face-to-face at the patient’sbedside.4

Advantages to blended report includeincreased nursing accountability, team-work, report accuracy, enhanced patientcare/transition of care, and increased patientas well as nurse satisfaction. The blendedreport approach also alleviates nursing fearsof exchanging sensitive information at thebedside and frequent patient interruptionsduring critical information exchange.5

CURRENT CONDITION

During a period of turnover with a large in-flux of new nurses joining the neurosurgicalICU, staff began to become dissatisfied withinconsistencies in the amount of informationexchanged in report, nonstandardized organi-zation of information, and lack of cleanliness

of patient’s rooms. While speaking with staff,the unit-based council realized that therewas no standard for shift report or hand-off. Staff reported an education/knowledgedeficit on bedside reporting and the absenceof concrete expectations for report. Theunit-based council believed that nursing sat-isfaction, communication between staff andpatients, and patient safety could all be im-proved by researching and implementing anevidence-based practice shift report.

Taking on a project of this size can be over-whelming, so devising an organized approachwas a key to success. First, the team con-ducted a thorough literature review to ensurethat the new standards developed would bebased upon best practice. The literature notonly informed on evidence-based practice butalso allowed the unit-based council to see thatresearch on implementing bedside report waslacking. After an evaluation of all 3 distinct re-port types, blended report was chosen as themodel to structure the new bedside reportprocess.

Blind observations, a presurvey and casualconversation with staff members confirmedthat while bedside reporting was regarded asvaluable to nurses, there was a need for a stan-dardized process of giving bedside report.The unit-based council created several formsto outline what information was expected tobe communicated during bedside report, andthe order in which that information was tobe relayed. A 3-pronged unit education wasthen developed to engage all types of learn-ers (visual, auditory, and kinetic). During uniteducation, the importance of bedside reportwas reviewed and the new standardized bed-side report process was introduced to staffmembers. Thirty and ninety days followingimplementation, an evaluation of staff partic-ipation and attitudes of staff members wereconducted to determine the success of theproject.

THE PRESURVEY

Before devising a unit-wide standard forbedside report, an anonymous presurvey was


326 CRITICAL CARE NURSING QUARTERLY/JULY–SEPTEMBER 2021

distributed to gauge nurses’ perceptions ofbedside report. Six questions were asked us-ing a 5-point Likert scale, simultaneously 2third-party observers (a unit secretary andrespiratory therapist) conducted blind obser-vations of RN shift handoff and recorded thenumber of RNs who went into the patient’sroom and completed bedside report. Ninety-five percent of nurses believed that bedsidereport promoted patient safety and 73% ofthe nurses stated that they always or usuallycomplete bedside report. While in reality, ourobservers recorded that the nurses were onlyexecuting bedside report 34% of the time.The other 66% of the time, nurses were usinga traditional report model and only exchang-ing information outside the patient’s room.See Table 1.

STANDARDIZATION OF FORMS

The next critical step in defining theblended bedside report process was to de-sign a set of standardized forms that detailed

what information was to be exchanged dur-ing report and where this exchange was totake place. The first form created was the bed-side report checklist; it was a guide to followeach time report was given. The checklist en-tailed an outline that separated the blendedreport into 3 specific areas: a handoff outsidethe patient’s room, a patient safety check, anda room/environment assessment. The bed-side checklist was posted outside of eachreport station so that it could be easily refer-enced during report. The staff was educatedon the checklist contents during peer-to-peereducation.

The outside handoff was composed ofitems that should be discussed away fromthe patient such as code status, history,summary of present admission, plan of care,physical assessment, and family issues. Theexpectation outside of the patient’s room alsoincluded accessing the patient’s electronicchart to quickly review active orders, elec-tronic medication record, laboratory results,and work list.

Table 1. Presurvey Resultsa

Presurvey Results by Percentage

Question Always Usually Sometimes Rarely Never

How often do you completebedside report?

26% 47% 24% 3% 0%

StronglyAgree Agree Neutral Disagree

StronglyDisagree

Does bedside report promoteaccountability and sense ofownership in your practice?

50% 42% 8% 0% 0%

Does bedside report providepeer-to-peer learningopportunities?

45% 45% 5% 5% 0%

Do you think standardizedbedside report tools increaselength of report time?

13% 29% 47% 8% 3%

Do you believe bedside reportpromotes patient safety?

50% 45% 5% 0% 0%

Does standardized reportincrease efficiency andcommunication betweennurses?

45% 24% 21% 10% 0%

aSource: Neurosurgical ICU Unit Based Council.



The patient safety check outlined what ac-tions/assessments would be completed at thepatient’s physical bedside. Starting with anintroduction of the new caregiver, this checkwould then progress to a brief neurologicalassessment and the review of tubes, drains,drips, and other devices. It was expected thatthe placement of all tubes and drains be ver-ified by both RNs, for example, endotracheal(ET) tube, orogastric or nasogastric tube,external ventricular devices (EVDs), Jackson-Pratt and lumbar drains, chest tubes, vascularaccess, and urinary catheters. All continuousmedication drips were to be checked toensure that the correct concentration, rate,and weight were programmed accurately intothe pump. At this time any abnormal findingssuch as skin issues, incisions, or negative pres-sure wound therapy pump were also to beverified.

One of the most common issues RNs re-ported was that patients’ rooms were leftwith unused supplies scattered around andtrash was left on RN workspaces. Adding aroom environment section to the checklistgave RNs an opportunity to address this issueconstructively. During this portion, white-boards were to be updated, fall precautions

such as bed alarms, side rails, fall band, andcall light were to be double checked as wellas verifying the presence of adequate suppliessuch as pads, linen, mouth care kits, and tubefeeds. See Form 1.

The second document developed was astandardized report sheet. This defined the in-formation to be conveyed during the physicalassessment, creating a higher level of effi-ciency and consistency in the information ex-change. Structured from a collection of hand-written report sheets on the nursing unit,this sheet was available on the unit but notrequired for use by all nurses. The physicalassessment began with the neuroassessment,and then progressed to respiratory, cardiovas-cular, gastrointestinal, genitourinary, and skinassessments. As this was created for a neuro-surgical ICU, much of the report sheet wasdevoted to the neuroassessment. Emphasiswas placed on the content of the neuroassess-ment as well as the order of this information.The unit’s expectation was that the neu-roassessment would begin with level of con-sciousness, and then move to eyes, speech,protectives, extremities, sensation, drains,and National Institutes of Health StrokeScale/Score.

Form 1. Bedside report checklist. Source: Neurosurgical ICU Unit Based Council.



The standardized report sheet was mainlyutilized by newer nurses or nurses still onorientation but was introduced to all nursesduring the peer-to-peer education. The ex-pectation was that all information would bepresented in the order outlined on the stan-dardized report sheet. It was not mandatedthat all nurses use the sheet, as long as thosewho did not use it were able to give report inthe correct order. See Form 2.

Finally, an existing hospital-wide patientclinical summary sheet, already familiar to thestaff, was utilized that detailed basic patientinformation such as physician service, codestatus, chief complaint, allergies, and patientstay synopsis. This sheet was initiated at thepatient’s admission to the hospital and waspassed between RNs at every shift changeand even followed the patient to other unitsthroughout their treatment course. It offeredthe nurse the ability to have a brief record ofimportant clinical events and to update theplan of care after each shift. The patient sum-mary sheet allowed RNs to get an idea of the

details of the entire patient’s stay in a shortamount of time. During bedside report educa-tion it was reinforced that daily entries shouldbe concise and limited to pertinent informa-tion only, thus increasing efficiency of reporttime. See Form 3.

INITIAL EDUCATION

Change of shift huddle (a brief meet-ing conducted with both shifts to exchangeimportant unit information) created an ex-cellent platform to introduce backgroundeducation and important safety statistics rel-evant to bedside report. Appealing to bothauditory and visual learners, 2 sunflower-shaped structures were created with eachpetal highlighting a bedside report pearl. Staffwas asked to read 1 petal at each morninghuddle over a 2-week period and received asmall reward was promised to encourage en-gagement. After each petal was read, it wasthen placed on a centralized display boardfor all staff, patients, and family members to

Form 2. Standardized report sheet. Source: Neurosurgical ICU Unit Based Council.



Form 3. Nursing hand-off report sheet patient summary. Source: Neurosurgical ICU Unit Based Council.

view. This allowed 14 members of the staff tobecome fully engaged in the initial process.

In addition to the huddle blasts, copies ofan article relevant to bedside report wereposted on the display board for staff to readand complete a short quiz. This form of ed-ucation was chosen to draw in a more visualbut introverted learner who may not have hadthe courage to participate in the more publichuddle blasts. The article chosen, “Off to aGood Start: Bedside Report,”6 was brief andcontained a relevant case study about an in-tensive care nurse’s experience with bedsidereport saving a patient’s life. Staff complet-ing the article quiz were entered in a nominalgift card drawing. This form of education wasvoluntary and engaged another 8 membersof the staff prior to the mandatory hands-ontraining.

DEVELOPMENT OF A PEER-TO-PEERHANDS-ON TRAINING

Six staff nurses were chosen by the unit-based council as bedside report champions

to further engage the unit staff in bedsidereport education. These 6 nurses were strate-gically selected to encompass all levels of thenovice to expert paradigm; 2 expert nurses(greater than 10 years in the ICU), 2 mid-dle nurses (4-5 years in the ICU), and 2 newnurses (1 year or less experience in the ICU)comprised this group. In addition to theirexperience levels, these nurses were identi-fied as social group leaders on the unit andthus could influence large portions of the staffby their involvement in the project. Each ofthe 6 champions received a letter detailingtheir role and responsibilities documentingtheir participation in the project for theirprofessional portfolios.

The bedside report champions attendeda 4-hour class in which they were taughtthe new blended bedside report processand the concept of a hands-on peer-to-peertraining. By choosing champions from thestaff, the bedside report process evolvedfrom a management-centered mandate to anurse-driven initiative. The nurse championsthen partnered with the unit-based council



team members to train the rest of thestaff.

Inspired by the case study selected for theinitial education training, the hands-on or ki-netic learning experience needed to appearrealistic and applicable to bedside nursingpractice. Mock scenarios were constructedbased on previous patients admitted to theunit and were composed of a patient sum-mary sheet, a bedside report sheet utilizingthe standardized report form, and a bedsidechecklist. The checklist was constructed forthe use of the champions with discrepan-cies highlighted in red that differed from theverbal report given. Therefore, the impor-tance of a bedside check was highlighted toincrease patient safety and decrease humanerror.

Each training scenario was composed of anuntrained staff member (receiver of report),a champion (giver of report), and a mockpatient staged in an empty bedside, playedby another champion or unit-based councilmember. The expectation of the hands-on

training was that every staff member re-ceived a bedside report from a championincluding the introduction/education of thestandardized report sheet, patient summary,and bedside checklist forms. The pair pro-ceeded into the room to complete a bedsidesafety check and discover the discrepanciesfrom the verbal report. Afterward a debriefingoccurred of the experience and discussion ofthe impact of a bedside report.

To aid in the mock patient setup, a toolkit was constructed containing lines, drains,intravenous (IV) tubing and solutions, and apair of IV pumps that could be programmedwith drip rates. An example of 1 item usedwas an ET tube cut and placed in a holderat an inaccurate measurement that could beplaced on the mock patient. Another wasa medication drip infusing into a test tubetaped to the mock patient’s wrist; this dripwould be programmed to infuse at the wrongrate and patient weight. A complete list ofthe toolbox items and their utilization in themock scenario can be found in Table 2.

Table 2. Mock Scenario Toolboxa

Heparin, nicardipine, propofol, hypertonic saline, norepinephrine drips• Drip running at incorrect rate• Wrong weight entered into IV pump• Drip running that was supposed to be on hold• Incorrect concentration of drip (eg, norepinephrine 16 mg in 250 mL instead of 4 mg in 250 mL)• IV tubing expiredSubclavian central line, PICC line, arterial line, peripheral IVs• Line was at incorrect measurement length• Line on right side instead of left (or vice versa)• Dressing out of dateEndotracheal tube, OG/NG tube• Tube length was a different number• Tube size was incorrectEVD drain• EVD was at incorrect level• EVD was clamped instead of openedSoft restraints, mitts• Restraints applied to incorrect limb• Restraint order expiredID band, allergy band, fall risk band• Band was not present when supposed to be

Abbreviations: EVD, external ventricular device; ID, identification; IV, intravenous; OG/NG, orogastric/nasogastric;PICC, peripherally inserted central catheter.aSource: Neurosurgical ICU Unit Based Council.



Scenario Example

Full report was given by the RN cham-pion or unit-based council member fromstart to finish outside the room and accom-panied by a bedside assessment. This wasdesigned to take approximately 15 minutes,corresponding to half of a standard 2-patientICU assignment. During traditional (verbal)report outside the room, it was communi-cated to the receiver of report that the patientwas localizing with the right upper extrem-ity (RUE), ET tube was at 24 cm, the EVDwas open at 5 mm Hg, the peripherally in-serted central catheter (PICC) was at 0 cm atthe skin, the hypertonic saline drip was onhold, and the patient was wearing a fall band.Upon entering the mock patient’s room forbedside assessment, the goal was for the re-ceiver of report to notice that the patient waswithdrawing with the RUE, the ET tube wasactually at 22 cm, the EVD was open at 0 mmHg, the PICC was at 5 cm at the skin, thehypertonic saline drop was running, and thepatient was missing a fall band.

If the receiver of report did not note allchanges, it was remediated in the short de-briefing session after the training scenarioended. This provided yet another demonstra-tion of how blended bedside report couldreduce medical errors. Four different scenar-ios were constructed based on actual patientsituations where important aspects of carewere overlooked. One scenario was randomlyselected for use by the RN champion/unit-based council member to prevent staff fromsharing scenario answers. Scenarios could beadapted and customized for individual unit’sspecialty assessments and considerations.

Unit-wide education began with 2 weeksof daily huddle blast facts and the optionalcase study article and then progressed to3 weeks of hands-on mock scenarios with amock patient and RN champion. After over90% of staff had completed the hands-ontraining of blended bedside report, the unit-based council considered bedside report fullyimplemented in the neuro-ICU. The expec-tation for the RNs was that they wouldcomplete a blended bedside report 100% of

the time. It took approximately 5 to 6 weeksto complete the entire training process.

EVALUATION

Staff resistance to change and length oftime required to train all staff RNs were the 2biggest barriers faced by the unit-based coun-cil. The presurvey indicated that almost allRNs believed blended bedside report was bet-ter for patient safety, but only one-third ofthese RNs were actually practicing blendedreport. The goal during the process changewas not just to tell the RNs about the new pro-cess, but rather demonstrate with researchand concrete evidence why blended besidereport was the best possible modality. Sincethe team was able to demonstrate that the lit-erature proved blended bedside report wassuperior before implementation, staff resis-tance was not as great a barrier as initiallypresumed to be.

Very few nurses expressed issues withthe new process, and the ones who didwere mainly concerned with the amountof time that blended report would add toshift change. Immediately after implementa-tion some staff reported an increase in reporttime, but after staff became more familiarwith the blended process, report times de-creased. By the 19th-day postimplementationmark, report times had returned to 25 to 30minutes, approximately the same amount oftime it took to give report before the blendedprocess was introduced.

Another barrier to blended bedside reportimplementation was the time that it took forall staff RNs to be trained and signed off onthe hands-on portion of the unit-wide educa-tion. Staff RNs all had to be trained duringtheir scheduled shifts; this proved difficultwhen staff RNs were busy with their assignedpatients and unable to step away for bed-side report training. The unit-based councilattempted to combat this barrier by designat-ing a time for each staff RN to be trainedand by asking the charge nurse to cover thestaff RN’s patients during this time. While intheory this was an adequate solution, charge



nurses often had an assignment of their ownand were unable to cover a second assign-ment at the same time. In an ideal world, allRNs would be able to attend the blended bed-side report training before being assigned topatients.

Thirty days after the blended bedside re-port project was implemented, third-partyobservers (the same unit secretary and res-piratory therapist) again audited shift changereport and RN compliance with blendedbedside report had increased to 80% from34%. At the same time, the team also con-ducted a 1-month postsurvey to reassess theRN’s attitudes toward bedside report. Thesurvey again was anonymous and consistedof 7 questions with a Likert scale and 1open-ended question. When asked whetheradequate education was provided to facilitatebedside report, 93% of nurses chose eitherstrongly agreed (53%) or agreed (40%). One

hundred percent of nurses surveyed statedthat they strongly agreed (80%) or agreed(20%) that blended bedside report promotespatient safety. One year after implementation,a final audit of compliance was conductedby the same third-party observers and 94% ofnurses were performing bedside report. SeeTable 3.

Although all parts of this improvementprocess were valuable in changing and influ-encing the performance of bedside report, itwas the belief of the implementation teamthat the entirety of the process was what ledto a successful cultural change. Other units inthe same hospital adopted some portions butnot the entire process and did not reach thesame desired results.

The culture change extended beyondthe borders of the neurosurgical ICU. Theblended bedside reporting process was rec-ognized by both float pool nurses and nurses

Table 3. Postsurvey Resultsa

Postsurvey Results by Percentage

Question Always Usually Sometimes Rarely Never

How often do you completebedside report?

53% 47% 0% 0% 0%

StronglyAgree Agree Neutral Disagree

StronglyDisagree

Does bedside report promoteaccountability and sense ofownership in your practice?

67% 33% 0% 0% 0%

Does bedside report providepeer-to-peer learningopportunities?

67% 33% 0% 0% 0%

Do you think standardizedbedside report tools increaselength of report time?

13% 40% 27% 20% 0%

Do you believe bedside reportpromotes patient safety?

80% 20% 0% 0% 0%

Does standardized reportincrease efficiency andcommunication betweennurses?

60% 34% 6% 0% 0%

Do you feel adequateeducation was provided tofacilitate bedside report?

53% 40% 7% 0% 0%

aSource: Neurosurgical ICU Unit Based Council.



from other ICUs who were pulled to work ashift in the neurosurgical ICU. Often whenneurosurgical ICU nurses were pulled toother units, they returned the courtesy ofgiving a blended bedside report. MultipleICU nurses remarked that they wished thisprocess was a part of their unit’s culture.

FUTURE CONSIDERATIONS

Upon implementation, a standard was cre-ated for both the verbal and bedside reportcomponents of the blended report. However,the content or adherence to the new stan-dards was not audited, only the completionof both verbal and bedside portions wasaudited. This would be an interesting area for

future study. To further investigate whethera true unit culture change occurred, it wouldbe valuable to study if new nurses who werenot present for the initial blended reporteducation comply with both participationand content of report.

Time efficiency was a concern for nurses,as previously stated it was the number 1barrier to blended bedside report implemen-tation. The time it took for nurses to givetraditional report then at the 3-month markwas measured, but this time was not mea-sured 1 year after the implementation ofblended bedside report. This measurementwould have been a valuable factor to deter-mine the maintenance of this practice. Anyevidence gained would be useful in poten-tially revisiting the process to streamline itsefficiency.

REFERENCES

1. Vines MM, Dupler AE, Van Son CR, Guido GW. Improv-ing client and nurse satisfaction through the utilizationof bedside report. J Nurses Prof Dev. 2014;30(4):166-173; quiz E1-E2.

2. Ofori-Atta J, Binienda M, Chalupka S. Bedside shiftreport: implications for patient safety and quality ofcare. Nursing. 2015;45(8):1-4. doi:10.1097/01.nurse.0000469252.96846.1a.

3. Patterson ES, Wears RL. Patient handoffs: standard-ized and reliable measurement tools remain elusive.Jt Comm J Qual Patient Saf. 2010;36(2):52-61.doi:10.1016/s1553-7250(10)36011-9.

4. Dorvil B. The secrets to successful nurse bedsideshift report implementation and sustainability. NursManage. 2018;49(6):20-25. doi:10.1097/01.numa.0000533770.12758.44.

5. Sand-Jecklin K, Sherman J. A quantitative assessmentof patient and nurse outcomes of bedside nursing re-port implementation. J Clin Nurs. 2014;23(19/20):2854-2863.

6. Sadule-Rios N, Lakey K, Serrano M, et al. Off to a goodstart: bedside report. Med Surg Nurs. 2017;26(5):343-345.


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