Nurse-to-nurse report (change of shift or transfer of care) is an age-old skill that no one teaches you. It’s the source of concern for many in healthcare these days, but no one seems to take the time to spell out what makes a good report.
I remember reading that one of our certifying organizations is pushing for bedside hand-off reports–a study found that the hand-off report was the source of sentinel events, or at the very least the place where healthcare professionals are missing important care delivery information.
Still, I do not remember anyone cultivating this skill with me. I remember as a new graduate someone telling me to give report the way I assess the patient, but they never gave me specifics on the what, when, why and why not (not to mention the pertinent and less useful information to include in your report). Let’s be honest here, some nurses’ reports can be extremely lacking in information, while others are reading you the script from their next movie! Once again, there is no consistency.
I thought I’d give you some tips to make up a good hand-off report:
1. Always be prepared
- Be the Boy Scout (sorry, ladies). I approach giving report the same way I approach calling a physician. Have your ducks in a row, have all your information gathered and know what you want to say before you start saying it.
2. Anticipate
- Always anticipate the questions. What would you want to know about this patient if you were the one receiving the report and not giving it?
3. Nursing is a 24-hour job
- This is a strong and valid statement, yet none of us actually follow the advice. What happened during your shift that rolled over from the prior shift? What will roll over from your shift onto the oncoming shift? You need to be prepared and mindful of all the tasks and events taking place for your patient and turn them into actionable results, even if that means it was something that happened before you got there, or will happen after you leave.
4. Be organized
- Not only in your thought process, but in the delivery of your report. It’s a common practice to give your assessment findings in the same order as you perform the assessment (head-to-toe), but there is no right or wrong here, just be organized! Do not jump all over the place with no rhyme or reason. That’s how things get missed and mistakes are made.
5. Team effort
- Be sure to include the oncoming shift when making any change of shift decisions. Get their input. I don’t think I need to remind you how much more effective and safe patient care is when it’s a team effort.
I kept this list simple, because quite honestly there is more than one way to effectively deliver a good hand-off report. There are a ton of cheat sheets and tools you can use to help you. In the end, it’s your responsibility to be an effective and efficient communicator, so you will get out of it what you put into it.
