Checklists come to nursing
Program bumps teach lessons going forward
Sometimes the best lessons come when things do not work out as planned. Nathan Rozeboom, RN, MPH, CCRN, a nurse manager at Harborview Medical Center in Seattle, learned that in the aftermath of a project for his master’s degree three years ago. At the time, he was assistant manager in a neuro intensive care unit.
"I felt like we nurses needed to standardize how we approached report," he says. "Every nurse was doing something just a little differently. And as a unit, we weren’t doing very well at checking patient ID bands, nor were we regularly checking patient IV drips or alarms together at the change of every shift."
There had been a few instances where a patient’s intracranial pressure (ICP) was vastly different for the incoming nurse than what the outgoing nurse reported. Rozeboom explains that this potentially could lead to a patient decompensating if the readings were wrong and potential problems were missed: "The patient’s brain could swell dangerously if you miss early signs like increasing pressure."
Importantly, this kind of error is something that can be addressed quickly and simply if the nurses just checked the readings together. "It would also be a good opportunity for education if one nurse was not following proper procedure," he adds, "or if one of them was reading the pressure incorrectly."
There were cases where patients could have been potentially harmed, and Rozeboom says he tried to publicize those near-misses so that the nursing staff would understand the need for change.
Another problem was the very place where nurses were doing handoff: not at the bedside, but gathered by the desk on the unit. That often led to digressions away from the subject at hand — the patient — to issues like an upcoming Joint Commission survey or someone’s upcoming wedding or vacation.
Rozeboom brought up the idea of creating safer handoffs to his unit best practice committee and mooted the idea of a checklist — he is a fan of Atul Gawande’s book, The Checklist Manifesto — as well as starting bedside shift-change reporting. His literature searches showed that there hadn’t been anything like it done in a nursing situation before, but his sense was that it would positively impact both staff and patients.
After approval, he sent out a short survey to nursing staff to gauge their interest and solicit ideas about what items should be on a checklist, how safe they thought shift change reports were currently, the points they thought could be made better, and the issues they thought were potential barriers to change. About half the staff responded to his survey.
Educational rounds
Rozeboom created posters to put around the unit for the two weeks prior to implementation as a way to educate staff on the new program, and the checklist was laminated and attached to every bedside computer in the unit as a reminder. "We thought about making a paper checklist but did not want to kill a million trees," Rozeboom says. It was not then an option to put it into the EHRs.
The entire staff were involved in educational rounds on the new process. And because Rozeboom says "nurses love free things," he had pens made to give out to the staff that said "Patient Safety First." He composed a letter for patients and their families explaining the new handoff process and the rationale behind it.
A post-implementation survey was planned for two months after the project started. Once given, the response rate for that was 60%. Everything was set for success. Except it did not turn out as well as Rozeboom hoped.
There were certainly champions among the nurses and positive outcomes from the changes. Among them:
• While the pre-survey showed only 13% of staff thought that handoffs were safe all the time, after the project, that number rose to 64%.
• Checking the patient ID wristband improved from 29% "All the time" before the new process started, to 50% "All the time" in the post-implementation survey.
• Family satisfaction hit 100% during the implementation month and for three months after.
• While errors did not decline significantly, there were stories about near-misses caught because of the checklist.
Despite those successes, there were also nurses who seemed adept at finding reasons why they couldn’t do a bedside report.
About three years after Rozeboom’s project was implemented in the neuro ICU, about half the nurses are still using the bedside report practice and checklist process, he says. Because he was not the manager on the unit, Rozeboom says he couldn’t mandate that all nurses use the new protocol at the time. He kept at the staff, jollying them along and trying to troubleshoot the barriers or find out why specific nurses or managers did not like using the process.
Sometimes, a good catch of a near-miss would result in a convert to the process, Rozeboom says. But for many nurses, it was a non-starter. "I think a lot of nurses are scared of two things — first of talking about scary things in front of patients and families. But they want to know." Increasingly, national regulatory and professional bodies are recognizing the importance of patient involvement and understanding, he adds, and being present for the shift report is one more way of increasing that.
Secondly, they are afraid of being caught out in a mistake, or being shown not knowing something. "But sometimes you can turn to the family member and ask them a question when you forget what a situation was, or when something last happened, or when the doctor was last in, and they like that involvement," he says.
After the neuro ICU tried the new process, another intensive care unit also attempted bedside reporting and faced the same issue. But there is increasing support at Harborview for it, and Rozeboom believes that it will likely be implemented by mandate across the entire hospital in the near term. Committees and managers are already talking about it.
"I had hoped for grassroots buy-in," he says. "I had never done anything on this scale before. Maybe if I had come out with a training video to educate staff or something." Having role-play training before going live might also have made nurses more comfortable with the idea when they finally started bedside reporting in the patient rooms.
Rozeboom thinks often about what went wrong and how to improve on the implementation, and he talks about it with the managers who will likely spearhead implementation of bedside report on two acute care floors in Harborview. A consulting firm working with the hospital to improve patient satisfaction wants them to solidify hourly rounding implementation first, but is keen to start on a project based on Rozeboom’s experience after that.
"I learned a lot from this, and I think it could work. You need more than one champion across shifts. You need to mandate it. And I think you have to make a change all on one day, rather than having it creep slowly through the organization," he says.
Preparing the ground
For organizations thinking about this, he thinks a way to get greater buy-in from the start might be to prepare the ground with a smaller initial project. Get the nurses used to the idea of being in the patient room together at shift change in a more informal way, he suggests. "Have a program where the nurse leaving brings in the next nurse to introduce to the patient," he says. "As a nurse, you do not want the person coming after you to see that the room is a mess, that the fluids are about to run out or that the patient board is not complete. It is powerful, and gets the thought of sharing in their minds."
If you decide to go the whole hog, have a gung-ho champion do the reports with the nurses to validate what they are doing, answer questions as they arise, and gently guide them in the right direction if they drift, he says.
"Culture change is not easy," Rozeboom says. "Although everyone agreed that this was a good project and important, there were many strong-willed nurses who liked giving report at the desk and could find a million reasons why they couldn’t give report in the room."
