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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 35 years. It has been an interesting journey in the best and worst practices of communication. The best practices shared in this article are aimed at improving communication and teamwork between shifts.

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 CNA’s. CNA’s may or may not communicate with each other directly as the staff transitions from one shift to the next. Usually, there is not a well-organized method of getting information to team members in other departments.

The Charge Nurses as leaders need to remember they set the tone for the entire shift. Charge Nurses need to “see through the shift” to get the desired results for the residents and staff.

Here then are “Seven Strategies for Successful Shift Interchange.”

Strategy #1

“In person” communication is the most efficient and effective, while “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 offgoing Charge Nurse or Nurses, the oncoming Charge Nurse or Nurses and oncoming CNA’s.

CNA’s 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 recently – “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 HIPPA Rules limit what a CNA needs to know about a resident.

Strategy #2

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. Charge Nurses must know which staff is assigned for the shift.

Strategy #3

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. Don’t 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 ones 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

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 Charge 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!

The 2B and 3B teams at St. John’s Specialty Care in Mars, PA continue to master effective time management at shift exchange. These units have higher numbers of staff because of very high resident acuity and high volume admission/discharge activity. Each unit potential is 60 residents, and the units typically have customers with high volume Therapy Utilization, Tracheotomy, Ventilator, IV, and G-tube clinical needs. On any given day, up to three Night Licensed Nurse Care Team members can be found giving report to an oncoming Day Shift team of nine or more staff. All required team members are in the same room at the same time promptly at 7am. The team records any absences or tardiness as a part of a team-based effort to maintain good attendance and prevent tardiness. The verbal report takes 10 minutes. The “Care Teams” are each acutely aware of the challenges facing each team, and the Team Report improves the Teamwork between them.

A Shift Interchange Meeting Agenda may look something like this:
7AM Start and Attendance Taken
7:00-7:10AM In-person Shift Report from Off Going Charge Nurse(s) to Oncoming Team
7:10-7:15 AM Charge Nurse Team “Huddle” with CNA’s and other front line staff
7:15-7:30 AM Oncoming and Offgoing Charge Nurses do Narc Count and MAR/TAR Check

Oncoming and Offgoing CNA’s do “Rounds” as outlined

Strategy #5

One key to keeping verbal 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 10a slept, Gloria in 101b slept, oh, and did you know her daughter-in-law went to school with my cousin Delores?” …the report can drone on and on and on…

We should talk only about the 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 24 Hour Report Format or 72 Hour Rolling Log. Let these forms drive shift report and keep teams on task with priority communication.

The goal is to pass the information to other shifts and to people who have not been present on the unit over the last day or two. 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 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 a format called the “72 Hour Rolling Log,” which easily keeps priority issues on the radar screen for 72 hours or longer if needed.

Strategy #6

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. Offgoing CNA’s are customarily assigned the responsibility of covering the unit, for example, during the 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 is 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

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 “Ya’ll 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 depressed or dissatisfied with their roommate. They can help identify sings of pain and depression and tell you all about a resident’s adjustment to facility life, as well as satisfaction with care and services. We fail to invite these front line staffs who are a great resource into our “inner circle” of communication. Many of them are also excluded from participation because of our own organizational HIPPA 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 everyday 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.

CONCLUSION 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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