Recently our Nurse Manager informed the nursing staff that we were now to conduct our shift report using certain "scripted" parameters. Basically, we are to wake patients up, conduct shift report at the bedside, include he patient in the process by giving him/her the opportunity to ask questions and add to the information we pass on to the oncoming shift, check all patient orders on the computer and then conduct a brief"physical exam" of the patient with the oncoming nurse. There are certain scripted things we are to say as well. For example the nurse going off shift is supposed to say:
"Good morning, Mr. Jones. I will be leaving shortly to go home to my family. This is Sally and she will be your nurse for the next shift. I have known Sally for 4 years and she is a fabulous nurse with excellent clinical skills. I feel confident I will be leaving you in good hands wth Sally as your nurse!"
After this, we are to continue on with the above outlined report, conduct the mini physical exam, check the orders in the computer and give the patient the opportunity to give feedback during our report. Generally we each have 5-6 patients on our very busy cardiac monitoring unit and our shift report is 30 minutes long!! My colleagues and I are at a loss to figure out how we will accomplish all of this in 30 minutes! I am all for including the patient and allowing them to give feedback, but I fear shift report will now take so long we won't be able to get all our work done! And what about visiting hours? Shift report takes place right in the middle of them at 7pm. Now there will be visitors for both patients adding their comments as well.
In addition, I am uncomfortable giving my opinion about the skills and expertise of the oncoming nursing staff. We are expected to stick to the script and give positive reinforcement about the capabilities of the next nurse coming on shift. What if he/she isn't a very good nurse or has poor clinical skills? Am I supposed to lie to the patient? And if I do, won't I be undermining my own credibility? Does anyone else think this is a little over the top?
Let me guess - your facility just adopted a new workplace accountability and strategic culture change tool? Something related to workplace accountability, leadership, culture, strategic goals and organizational missions using the principles of positive accountability and cultural transformation?
That is an extremely unreasonable expectation of management to ask of the unit nurses. Things rarely ever go as planned in bedside nursing, and to think report will go smoothly and conform to a scripted format tells me how very far removed from patient care your nurse manager has drifted. This is report, not a high school play. What about privacy concerns? What if the patient is confused or combative - or sedated?
The good news is I believe this will soon prove to be impossible to do. Hopefully you are paid hourly and not salary - having to pay everyone over time everyday will likely change your nurse manager's mind about this fabo idea.
We do a bedside report, it's a new JCAHO standard so it's pretty much being phased into most hospitals. But thus far they haven't been so bold as to give us an actual script of what to say, only the highlights of what we're to go over and give the patient time to respond and ask questions.
And actually, no, the shift to improving satisfaction does not have direct link to improving outcome.
Majority of recent studies conducted are showing exactly the opposite. They're showing that the higher the patient satisfaction the higher the overall mortality rates. Why?
We're giving patients what they want, not necessarily, what they need.
We're letting that stroke patient have their turkey sandwich that they pitched a fit about not being allowed to have because they're not safe to swallow but because they refused to abide by our order sets and are demanding it and getting verbally abusive over it we're caving and giving it to them only for them to aspirate and choke.
True story, almost had to call security on a stroke patient once because he was threatening to kick my teeth in if I didn't let him eat, despite him being COMPLETELY unsafe. I call the doc, the doc tells me to feed him, despite him being COMPLETELY unsafe. I made a note about noncompliance and against medical advice, but that doesn't change the fact that a fresh stroke patient pitched such a fit over a sandwich, that he got what he wanted, not what he needed.
There's three articles right there that are showing that a higher patient satisfaction rate actually tends to lead to worse outcomes because we're treating patients like customers and giving them everything they want, but NOT what they actually need or is in their best interest.
That last study cracks me up. They had higher mortality but lower readmission rates. Maybe because DEAD people don't get readmitted to a hospital!
". Pridit scores showed the highest-level HCAHPS scores were negatively correlated with quality, while mid-level scores were positively associated with quality. Specifically, higher satisfaction was associated with higher mortality rates and lower volumes, but lower readmission"
That last study cracks me up. They had higher mortality but lower readmission rates. Maybe because DEAD people don't get readmitted to a hospital!
". Pridit scores showed the highest-level HCAHPS scores were negatively correlated with quality, while mid-level scores were positively associated with quality. Specifically, higher satisfaction was associated with higher mortality rates and lower volumes, but lower readmission"
Right?
I mean yes I guess in a way higher patient satisfaction is linked to lower readmissions because it's hard to come back in when, like what could have happened to the gentleman in my scenario, you choke on the turkey sandwich you were told you were unable to swallow.
The other caveat to that is that not only are we reimbursed by patient satisfaction, even in instances where patients are unreasonable, but we're reimbursed by certification programs as well. I work at a platinum level stroke center on the east coast, we maintain that certification by remaining completely diligent with how we screen patients and what our bylines are once they're admitted.
I had a grown man threaten to kick my teeth in over a sandwich, and somehow I was the bad guy, bringing down patient satisfaction, when our accredited hospital, could get points deducted from their score, because we allowed a patient to eat that was not verified as safe by speech pathology first.
You think it's stupid to wake them, if waking them is the only way to accurately assess them?
I took DeeAngel's "it's beyond stupid" comment to be sarcastic, bssed on the preceding sentences. Of course we have to wake pts to assess them, but are we doing full head-to-toes on every pt *during report?* That sounds very time prohibitive.
I mean I do like to do a neuro assessment together, because sometimes it's hard to know exactly what the prior RN saw based on documentation alone, and subtle changes can signal significant problems. But otherwise no, I won't listen to bowel sounds or turn the pt to look at his coccyx while the other RN is trying to go home.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
I am looking forward to bedside report on me, while I am in a semi-private room, with another patient in the next bed. I will be go after everyone in sight!. There is absolutely no reason to devulge anything in front of another patient. There is no such thing as "low, hushed voices" when there is someone in ear shot. Even the hard of hearing will perk up when private information is being discussed.
What an attitude -- you'll "go after everyone in sight"! This is why we ask family and friends to leave for bedside rounds. The patients may hear incidentals from bedside rounds on the other patient (that can't be helped), but there's no excuse for family and friends to hear it also.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
If you search CINAHL for bedside reporting, you'll see that it improves outcomes. It helps catch errors, educates the patient, and more.
But....
There is no evidence that scripting improves outcomes. So, I would just say drop the script. Scripting is implemented to help people get used to a new way of doing things. You don't need it for good care.
Speaking to the oncoming nurse's skills is good all around for relationships between nurse and patient and nurse to nurse. It will not harm your credibility to find something good to say about someone. But if you really can't do it honestly, skip it. I hope you aren't handing off your patient to someone without adequate skills. If that is happening, you have a different kind of problem.
This won't be popular, but the truth is that patient satisfaction is tied to outcomes. So there is a good reason why the govt reimburses based on patient satisfaction. I don't know why hospitals arent educating their nurses about this part of the equation, but I did learn it nursing school as I am a recent grad.
So the shift to improving satisfaction has a scientific basis for improving outcomes.
That's why I don't mind doing it. And it makes sense when you think about it. If a patient is poorly informed, excessively stressed out, lacking in sleep or social life, poorly nourished, etc, it's going to negatively impact their wellness and ability to heal.
It's annoying to have to change your habits and style, but if it's going to improve outcomes its worth it right? Its totally not worth it to me to just make more money for the hospital, but I think I'm like most nurses in that I would adapt to anything to improve my patients health.
Edit: I probably would not wake up a patient for bedside report. I think you need to use your judgment. Rarely would this be okay. Sometimes its not okay to talk about a patient in front of family either. Use your judgment. Nursing judgment should override policy when necessary. This is just a guideline for improvement.
Increased satisfaction has been linked to poorer outcomes. It makes sense when you think about it. The diabetic patient with a blood sugar in the 600s is going to be upset about not getting his fourth ice cream cup, even though ice cream is demonstrably bad for him. The NPO patient may be incensed about not getting his cheeseburger for lunch even though you, the charge nurse, the nurse manager, the medical resident, the surgical fellow and the anesthesiologist have all done the appropriate teaching about being NPO for the OR -- giving him a cheeseburger would result in a cancelled surgery or a bad outcome from complications during intubation. He may be satisfied about getting the ice cream or the cheeseburger, but the outcome may be poor. The patient who is awakened for vital signs, incentive spirometry and PT may not be satisfied, but the outcome is likely to be better.
I just love it when recent graduates tell all the experienced nurses what they're doing wrong.
Satisfaction is a function of expectations. To attempt to impact the satisfaction (survey results) without managing expectations is utterly baffling to me, as this is a no brainer....
Tell patients exactly what to expect (these aspects will be congruent with survey question verbiage).
I've had that exact thought, and in my mind used the same words to describe it: utterly baffling!
What's more, in the case of clinical issues, I can't understand why we wouldn't respect the patient by educating (which, in time, helps to set expectations and sure seems like it would help with satisfaction.
My example: Patients often expect to receive antibiotics for viral illnesses. They expect them for various reasons - "wives' tales", prior experiences where their viral illness ran it's course and improved while they were taking unnecessary antibiotics, etc. So in this 'requesting antibiotics' situation we have options:
- Provide substandard and essentially disrespectful care by giving what we know is inappropriate treatment in order to not have an obvious 'dissatisfaction' issue
- Just tell the patient no, without educating - probable dissatisfaction issue (no one looked, no one cared, the doctor didn't "do anything")
- OR...we could sit down and have a few minutes' worth of an honest conversation explaining the current situation with unnecessary antibiotics. Have a pamphlet, an article, a discussion...explain the types of conditions that very rarely ever require antibiotics...
In this way, we respect the idea that patients are smart enough to digest this information, that they DO want what is best for them. Tell them a few home measures to help get through the sore throat/ear ache/whatever... I really believe that there is a way all of this can be done that will leave the patient feeling like it was a positive experience.
I've actually experimented on my own with this a little bit with positive results; admittedly my 'n' is small at this point. But the results were as I expected.
Yes, indeed, it IS utterly baffling why we would rather throw our resources towards an illusion of high quality care, instead of putting every resource towards simply providing high quality care.
Both sides: We are currently required to do a shift to shift brief bedside report and not wake a patient if they are sleeping. The point is to double check things like IVs, patient condition etc. It is also to improve accountability for things not done like education etc. Really is helpful in some situations. On the other hand, I had an overnight stay for chest pain in my hospital. ER at about 2000. Admission at 2300. Vitals at 2400, 0400, 0800. Full assessment at 2300 and 0800. Cardiac enzyme draws at 0200 and 0600. HOUSEKEEPING! And garbage emptied at 0500. Shift to shift report at 0715. DC'd the next morning and went home to bed!
3ringnursing, BSN
543 Posts
Let me guess - your facility just adopted a new workplace accountability and strategic culture change tool? Something related to workplace accountability, leadership, culture, strategic goals and organizational missions using the principles of positive accountability and cultural transformation?
That is an extremely unreasonable expectation of management to ask of the unit nurses. Things rarely ever go as planned in bedside nursing, and to think report will go smoothly and conform to a scripted format tells me how very far removed from patient care your nurse manager has drifted. This is report, not a high school play. What about privacy concerns? What if the patient is confused or combative - or sedated?
The good news is I believe this will soon prove to be impossible to do. Hopefully you are paid hourly and not salary - having to pay everyone over time everyday will likely change your nurse manager's mind about this fabo idea.