Tips for Preparing a Nursing Shift Change Report
Are you feeling nervous about giving report as a brand new nurse? Are you an experienced nurse who is looking for areas of improvement, including your communication skills? If so, these tips are for you.
We’ll explain what a nursing shift change report is, what it should include, and tips you can begin implementing to make your report as efficient and smooth as possible.
What Is a Nursing Shift Change Report?
A nursing report is an exchange of patient information, status, care, and orders between nurses. It occurs at the end of one nurse’s shift and the beginning of the other’s. Some facilities use a written report that is universally structured; others allow nurses to structure their report how they deem fit.
Generally, you have a 30-minute time window that overlaps between the incoming and outgoing nurse, which is the time allotted for giving and receiving report. For those working in critical care, this translates to about 15 minutes of report for each patient. For those working in medical surgical units, this allows about five minutes per patient.
What Is Included in a Change of Shift Report?
The report should cover a summary of pertinent patient information. These elements include:
- Patient name and age
- Code status
- Alerts such as allergies, fall risk, or isolation precautions
- Status such as diet, IVs, or drains
- Care received: diagnostic tests, labs drawn, or wound dressing changed
- Review orders
- Transfer or discharge plan
- Review of body systems
Do note that depending on your unit and nursing specialty, components of a report may vary. For example, a cardiovascular intensive care unit (ICU) report may include titration parameters for Propofol. Whereas in a rehabilitation hospital, report may include physical therapy recommendations for out-of-bed assistance needs.
What Are the Types of Report?
Each unit will have their own style for delivering their nursing shift change report. Some common examples include:
- Face-to-face bedside report
- Face-to-face verbal report at nurse’s station
- Written report
- Blended report: part done at nurse’s station and part done at bedside
Why Is Report Important?
Nursing is an around-the-clock job. Patients require care before, during, and after a change of shift report. This means that the nurse doesn’t always have downtime to become overly familiar with their patient, their needs, or scheduled procedures before providing care to them. Nurses hit the ground running.
Nursing shift change report given between nurses sets up the incoming nurse for success. It allows for a smooth transition between care, improving communication between all nursing care staff. Reports ensure a safe continuity of care as responsibility is transferred from one caregiver to the next in real time.
Nursing Report Tips
- Use SBAR
- Assess changes together
- Review orders
- Don’t get stuck on small details
- Allow time for questions
- Involve the patient
1. Use SBAR
The SBAR method is a popular form of communication in the nursing world. It is designed to assist the user in delivering concise, pertinent information to make prompt decisions. You can structure conversations this way to ensure crucial information is conveyed. It stands for:
2. Assess Changes Together
Communication is key when giving report — leave no room for assumptions. If you are describing a change in your patient’s status, go a step further and assess your patient with the incoming nurse.
For example, if you state that your patient was alert and oriented at the beginning of your shift but became confused to place at 1600, assess the patient’s level of consciousness (LOC) with the incoming nurse. It’s important for you and the next nurse to be on the same page about the patient’s condition. Be sure to also notify the physician if necessary.
3. Review Orders
Allow time to review orders during the nursing shift change report. It’s even better if you can both review the electronic medical record (EMR) together.
Perhaps you forgot to mention an important order, such as restraints, or your coworker has a question about diet orders. These types of questions can arise and be addressed when you review orders.
4. Don’t Get Stuck on Small Details
Take advantage of your time and focus on the important details, like patient status, orders, discharge planning.
Things that do not need attention during report include:
Every single lab value: The incoming nurse can review them in the record when necessary. Share critical values or others that are pertinent.
If your patient had a critical potassium level this morning and received two or three IV infusions of potassium — share this. This is important.
If your patient had a routine CBC and everything came back normal, you do not need to review every single value.
Every medication: Many patients are taking a laundry list of medications. Share only those that are applicable.
If your patient is in significant pain, has a pain medication ordered every four hours as needed, and is requesting it every four hours — share this.
If your patient has 30 different medications prescribed, you do not need to review every single one during report.
Every single comorbidity and diagnosis: Some patients will have over 25 different comorbidities. Report those that are relevant.
If your patient is admitted for a surgery and has a diagnosis of alcohol use disorder (AUD), share this so the nurse and other team members can be alert for signs of withdrawal.
If your patient is admitted for pneumonia, is stable, and will be discharged soon, their 20 comorbidities and prior diagnoses do not need to be reviewed and discussed during report.
5. Allow Time for Questions
Plan to have time for the incoming nurse to ask questions that clarify or add more detail. This prepares the incoming nurse for their shift and ensures they know the plan for the patients they are assuming care for. You may need to mentally allot one to two minutes for questions in addition to the time you are speaking to make sure this time is provided.
6. Involve the Patient
When possible, include the patient in the bedside report. This requires strong soft skills, such as respectful communication and time management, to ensure it’s done without taking up too much time from other patients.
Even if you are only introducing the nurse for the next shift, it can go a long way in building trust and reducing errors. It also gives the patient a chance to ask any questions or make a request they want addressed.
For example, the patient may say, “Did you tell nurse Samantha that my next pain medication is due at 2000? I don’t want to miss it.” By doing this, the patient’s needs are met and rapport is built between the nurse and the patient.
Make Yourself the Best Nurse You Can Be
Now that you’ve learned how to prepare an awesome nursing shift change report, you can take your nursing career to the next level. Ready to make some improvements? IntelyCare can help you find a job that fits your lifestyle, allowing you to work where you want, when you want.