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Cheryl Boldt RN, LNHA

Shift Report is the most important meeting of the day in a Long Term Care Organization. We have participated in and witnessed shift interchanges in a variety of long term care and hospital settings over the past 40 years. It has been an interesting journey in best and worst practices of communication. The best practices shared in this article are aimed at improving communication and teamwork between shifts and even departments.

The method of communication and what information is shared at shift exchange can vary extensively even within the same facility. Nurses share with nurses who may or may not share with CNAs. CNAs may or may not communicate with each other directly as the staff transitions from one shift to the next. There is usually not a well organized method of getting information to team members in other departments. The Nurses as leaders need to remember they set the tone for the entire shift. Nurses need to see through the shift to get the desired results for the residents and staff. Here then, are 7 Strategies for Successful Shift Interchange.

Strategy #1. Shift Report is given in-person and includes Front Line Staff
In-person communication is the most effective and efficient and taped shift report usually meets with strong opposition from excellent communicators. Not having to face the oncoming shift in-person does have the advantage of minimizing the chances of having to deal with potential conflict or questions from oncoming staff. In-person shift report minimizes misinterpretation, allows opportunity for clarification, and promotes teamwork. Minimum required attendance at shift report is the off-going Charge Nurse or Nurses and the oncoming Charge Nurse or Nurses and oncoming CNAs.

CNAs need to know everything about the residents they care for and the dynamics of relationships with the residents and  families. As Dee, a CNA with Altercare of Mentor in Mentor, Ohio so passionately stated during a shift report improvement initiative, We are closer to the resident than anybody else. We need to know everything about a resident. It is surprising the number of nurses who still feel there are many things a CNA does not have to be told. In fact, there is a false belief that HIPAA Rules limit what a CNA needs to know about a resident.

Strategy #2. Start on time with all required attendees present
Staff members the organization has identified as critical participants at shift report must be present and ready to go at the start of the shift in the designated meeting place. This would mean they are not punching the time clock at the shift start time or walking down the hall on the way to the shift report location. Meeting location should allow timely access to the licensed staff if there is an emergency. Nurses must know which staff is assigned for the shift.

Strategy #3.The team records attendance and tardiness daily at start time
The practice of Team Members taking attendance and even writing names on the board of who is absent and tardy has proven to be a very effective team approach to preventing absenteeism and tardiness. Dont forget the ever-important element of celebrating success when targeted team goals for attendance and tardiness are set and hit. We want our teams present and accounted for so the shift can get off to a great start! Peer pressure and being accountable to our team members is more effective than using only a central office monitoring process that is frequently delayed in rewarding or disciplining for attendance habits.

Strategy #4. Set an agenda and put a time limit on each agenda item
Clearly establish the expectations for the content and time limit for shift report and shift interchange tasks. If we do not do this, the process can end up as varied as the preferences and communication styles of each Nurse. Taped shift report started because of our inability to stay on task when in the presence of other human beings. Just think of your team as a sports team who has a limited amount of time for a game starting huddle. The clock is ticking down, the buzzer sounds, and it is time to Play Ball! Here is a sample shift report agenda:

7AM Start and Attendance Taken
7:00-7:10AM In-person Shift Report from Off-going Nurse(s) to Oncoming Team
7:10-7:15 AM Nurse Team Huddle with CNAs and other front line staff
7:15-7:30 AM Oncoming and Off-going Nurses do Narcotic Count and MAR/TAR Check

Oncoming and Off-going CNAs do Rounds as outlined

Strategy #5. Use 7-Day Rolling Logs to drive report
The key to keeping in person team shift report to 10 minutes or less is to assure we do not run down the entire roster. The habit of going down the roster and mentioning every resident by name and room number and then feeling the need to say just a little something about them has to go away. You know what happens Mabel in 101a slept, Gloria in 101b slept, Oh, and did you know her daughter-in-law went to school with my cousin Delores? and the report can drone on and on and on.

Shift report should cover stuff that counts. You know, the priorities that really need to be communicated. This includes the status of medical changes in resident condition as well as customer concerns or requests. The status of these issues should all be documented on your 7-Day Rolling Log. These logs can drive shift reports and keep teams on task with priority communication. This tool also helps trigger/remind the staff to document the status of each of these issues. This is also a great format to use for all team members in all departments so they can keep themselves informed throughout the day (and when they return to work after time off). It replaces the old 24-hour sheet process. Any team member can access the 7-Day Rolling Log or add an issue to it. The only rule is that the issue added must be reviewed with the Licensed Nurse so we assure a clear understanding of the issue can be communicated, followed up on, and the pocket care plan and Master Care Plan in the medical record updated by the nurse and team member if a care plan update is indicated.

The team needs to carry information forward for a period of time that is sufficient to alert all staff to the issue or problem. The standard of practice should be to follow up for 72 hours. This means communication for 72 hours is required. As you experiment with moving information forward for 72 hours on a 24-Hour Report form, you will likely have someone say There must be a better way because this gets very confusing. Thus, the evolution of the 7-Day Rolling Log easily keeps priority issues on the radar screen for 72 hours or longer if needed. There is also a format called a 72-hour rolling log you can use if you are not faced with multiple changes in condition daily.

Strategy #6. Plan for Shift Overlap
The organization determines who needs to overlap and how much time they need to overlap. It is fairly standard to have 30 minutes of shift overlap for licensed nurses to assure time for report as well as MAR/TAR checks and Narcotic Count. Off-going CNAs are customarily assigned the responsibility of covering the unit during the i.e. 10-minute verbal meeting portion of shift exchange. CNA Rounds improve quality of care and teamwork (no shift wars) if critical resident issues (fall prevention approaches) and other issues of mutual concern (things people complain about) are rounded on together and resolved together. Again, the organization determines the amount of time and how the time should be used. Shift overlap was eliminated in many facilities because the time was used poorly. Waiting at the time clock to punch out and standing at the desk complaining about the other shift was not considered a good use of this time. Organizational leaders have been very open to incurring the costs of a shift overlap again if the outcome of improved communication between shifts and departments is achieved on employee and customer surveys.

Strategy #7. Yall Come!
In many facilities, you will find Housekeepers, Laundry Staff, Dietary Staff, Restorative, Administrators, Social Workers, Activity Staff, and Directors of Nursing at various shift reports. This is a Yall Come! philosophy! Why involve some of these other front line team members? Front line staff from other disciplines are valuable members of our teams. Housekeepers, for instance, know a lot of stuff! If you want to know almost anything about a resident, just ask a housekeeper! Savvy Social Workers are talking to housekeepers every day. They can tell you all about who is dissatisfied with the organization or dissatisfied with their roommate. They can help identify sings of pain and depression and tell you all about a residents adjustment to facility life, as well as feelings about care and services. We often fail to invite these front line staff who are a great resource into our inner circle of communication. Many of them are also excluded from participation because of our own organizational HIPAA policy. The best practice for front line staff from other departments or Department Managers is to develop a habit of routine attendance. Housekeepers on day shift may come to the early morning report and afternoon housekeepers would come to the afternoon report. Social Workers may find the afternoon report every day to work better with their schedules. The Administrator and DNS should have routine attendance worked into their schedules on all shifts over the course of the month.

Shift Interchange requires prejudicial directives, support, and monitoring. If you would like to improve Teamwork and Communication in your organization, take a look at this critical aspect of your operation.

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