TCAB in Action

Improving Communication Among

Nurses, Patients, and Physicians
A series of changes leads to cultural transformation at a TCAB hospital.
By Kimberly B. Chapman, MS, RN, CNL

s health care providers try to accom- We formed a TCAB team of approximately 20

A plish more in less time, the relationships

between patients and providers and
among providers naturally suffer. Mis-
communication, flawed assumptions,
decreased staff and patient satisfaction, and poor or
nonexistent care coordination result.
To Err Is Human and Crossing the Quality Chasm,
staff nurses, pharmacists, case managers, physicians,
clinical coordinators, educators, and supervisors.
The mission statement we developed was to estab-
lish a patient-centered healing environment with
mutually beneficial partnerships among patients,
families, and health care providers in a physically
comforting area. Improving communication was
reports from the Institute of Medicine, stress that critical to achieving this aim. Since becoming
good communication is critical to ensuring safe and involved in TCAB in May 2005, we have imple-
reliable care.1, 2 The current challenge in health care mented three major initiatives: moving the loca-
is to create an environment in which open and tion of the change of shift report to the bedside,
transparent communication is the norm rather than implementing the safety huddle, and establishing
the exception. One way to do this is by adopting nurse–physician “intentional” rounds at the bedside.
strategies that have been successful in other indus- A 28-bed medical–surgical telemetry unit, 3 North,
tries. For example, crew resource management, a piloted our tests of change. Staff members were
training program developed by the aviation indus- task oriented rather than patient centered, there
try and adapted to other workplaces, contributes to
a team-centered approach by emphasizing shared
decision making and interpersonal communica-
tion.3 Using communication tools such as situation–
background–assessment–recommendation (SBAR)
communication ensures that messages are clear and
unambiguous even in stressful situations.3
Another challenge facing health care organizations
is attracting and retaining nursing professionals in an
environment beset by rapid change and constrained
resources.4 At Wentworth-Douglass Hospital, a com-
munity, nonprofit acute care hospital in Dover, New
Hampshire, our leadership grew concerned that new
nurses were losing sight of their reasons for pursu-
ing the profession and that experienced staff were
disillusioned by processes outside their control,
ranging from a fluctuating census and increased patient
acuity to unreliable equipment and having to hunt
for and gather supplies. As Donna Diers wrote,
“Nursing is two things; the care of the sick (or the
potentially sick) and the tending to the environment
within which care happens.”5
We recognized the importance of these challenges Patient Jerry Howard (center) discusses her plan of care with William
and felt that participating in the Transforming Care Danford, MD, and author Kimberly B. Chapman during nurse–physician
at the Bedside (TCAB) initiative could help us ad- intentional rounding at Wentworth–Douglass Hospital in Dover, New
dress them. Hampshire. Photo courtesy of Rachel Bragg.

ajn@wolterskluwer.com AJN ▼ November 2009 ▼ Vol. 109, No. 11 Supplement 21

Transforming Care
were communication problems, handoffs were time-
consuming, and many staff members reported feel-
ing uninvolved and unappreciated. Therefore, the
staff and leadership were open to participating in an
innovative project that would help them transform the
way they worked. We ended up not only improving
communication, but also creating a new unit that is
centered on the TCAB philosophy.
CHANGE OF SHIFT REPORT
The standard practice for giving change of shift
reports was for the off-going nurses to audiotape
reports about every patient on the unit, which all
on-coming patient-care personnel listened to together
in a conference room. The report generally took
between 30 and 40 minutes. Staff members proposed
moving the shift report to the bedside to save time,
The current challenge in health care is to
create an environment in which open and
transparent communication is the norm
rather than the exception.
increase accountability, and involve the patients in
this important exchange of information. This was
our first major test of change using the TCAB ap-
proach.
Trials and adaptations. On the first day of our
trial, which involved both shifts, we put the tape
recorder in the closet. The unit-based educator and
clinical coordinator were present during the change
from night shift to day shift to provide support and
to help the off-going nurses adapt to the new way of
updating the staff coming on duty. When the day-
shift nurses arrived, they found the night-shift nurses
who were caring for their patients and they went to
the bedside together. The nurses later commented that
patients liked having the off-going nurse introduce
the on-coming nurse.
But some staff complained that the new process
didn’t allow the entire staff to hear the conditions of
all patients. They also said they missed being able to
gather as a team in the morning and evening and
felt they were losing a means of socializing that is im-
portant for group processes. As a result, we adapted
and instead began the shift report in the conference
22 AJN ▼ November 2009 ▼ Vol. 109, No. 11 Supplement
room with a 30-second taped review of each patient,
after which the off-going and on-coming nurses
linked up at the bedsides for detailed reports.
Despite written guidelines and one-on-one feed-
back, the 30-second taped reports gradually turned
into the detailed reports of the old days. The bedside
portion of the new process also needed refining.
Nurses continued to use medical terminology, which
caused many patients to feel confused or left out.
Some nurses exhibited what we call stage fright—
an uncomfortable feeling when talking about a
patient in her or his presence.
After about two months, the TCAB team went
back to the drawing board to refine our approaches
in these problem areas and reinforce our successes.
To standardize the information presented in reports,
we developed guidelines that stressed using the SBAR
format. We did role playing to increase nurses’ com-
fort levels with using patient-centered language. We
reinforced the importance of one of the TCAB philoso-
phies, “Nothing about me without me,” which pro-
motes patient-centered care and transparency by
involving the patient in all aspects of care.6 We ad-
dressed concerns about privacy and confidentiality
in semiprivate rooms by having nurses always ask pa-
tients for their permission to round at the bedside.
Patients who are uncomfortable with having their
care discussed are free to decline, though this is rarely
the case. We also educated staff on the importance
of involving patients in hand-off communications as
both a safety measure and a way to improve patient
satisfaction.
Outcomes. Before implementing this test of change,
the staff often didn’t talk much with patients or each
other. A quick “Any questions?” or a cursory overview
of an issue was the norm. Today, nurses engage in
meaningful exchanges with the patient and with
each other as they discuss the patient’s condition,
interventions, and care plan. The monologue of
data and tasks has been replaced with a thoughtful,
informed analysis of the patient’s status and plan.
Patients are involved and aware that a cohesive, knowl-
edgeable team is managing their care. The relation-
ships among the caregivers have developed as well,
eliminating the social separation between the shifts.
We evaluated the change of shift report using both
qualitative and quantitative data. We found that the
average length of time it took to complete rounds
was less with the bedside report than with the taped
report, which often included extraneous information
and took 40 minutes or longer. In contrast, after a few
months the bedside reports began to average 25 to
30 minutes when reporting guidelines were followed.
Also, the off-going nurses consistently reported being
www.tinyurl.com/TCABajn
TCAB in Action

able to leave work on time, which hadn’t been the idea of having a team huddle, which we dubbed a
case with the taped report. safety huddle. This five- to 10-minute gathering at the
The quality of patient information being exchanged beginning of shift change replaced the brief taped
also improved, with staff members indicating that report delivered behind the closed doors of the con-
bedside reporting enhanced the continuity of care. ference room and gives us the information we need to
As Nita K. Love, RN, said, “With a taped report work as a team. Both shifts assemble at the central
you only get the data that the previous caregiver nurses’ station and the off-going staff succinctly
deemed relevant, and you are unable to ask questions report the critical information on each patient that
and get clarification. With a bedside report you see everyone needs to know, including code status, diagno-
firsthand what the patient does and does not un- sis, tests scheduled for the day, fall risk, safety issues,
derstand, and you also gain the patient’s insight and and plan for the day (see Figure 1). We also review
input.” Kara Bliven, RN, said “The body of informa- educational opportunities, such as in-services, that
tion is always contained within the patient. Bedside are offered that day. The on-coming and off-going
rounds assist with putting the puzzle together.” nurses then head to the bedsides for the detailed
We gathered patient feedback from our existing reports.
patient satisfaction survey. One patient and his wife When asked about the value of the safety hud-
wrote, “We were very impressed with the nurses’ report dle, Jana Otis, BSN, RN, PCCN, said, “On a busy,
at rounds. We could comment and ask questions, and high-acuity unit, you never know whose room you
we felt we were participants in my care.” Another will find yourself running into. So it is critical to
patient said, “I liked the staff coming into the room have some idea of the condition of all patients on
together at change of shift, even the licensed nursing the unit and what their treatment plans include.”
assistants. They didn’t talk over me, but made me Staff RN Love said, “Safety huddle allows for bet-
a part of it.” ter transfer of care when covering breaks. Staff are
Analysis. Changing the shift report was difficult more likely to have time to take breaks and feel con-
because it involved changing the way we delivered fident in doing so, knowing that the other staff are
information. It made public a process that used to well equipped to care for their patients.” By giving
take place behind closed doors. This change required everyone an overview of the unit’s patients, the safety
patience and flexibility from
all involved. A major benefit
was that it allowed patients to
participate in their own care.
Shift report was our first
test of change, and in retro-
spect we felt that we may have
approached it without ade-
quate preparation and educa-
tion. For example, rather than
using the TCAB “one nurse,
one patient, one day” ap-
proach, we implemented this
change across both shifts at
the same time. Starting small
and going slowly would have
allowed us to first identify
areas for improvement. Still,
making this change in the way
we communicated started a
cultural transformation at
our hospital.

SAFETY HUDDLE
In our brainstorming about
how to improve the shift
report, we came up with the Figure 1. Safety Huddle Guidelines

ajn@wolterskluwer.com AJN ▼ November 2009 ▼ Vol. 109, No. 11 Supplement 23

Transforming Care
huddle also facilitates collaboration among nurses
of varying levels of experience.
NURSE–PHYSICIAN INTENTIONAL ROUNDING
The new change of shift report and safety huddles
improved communication among nurses and with
patients. Our next task was to improve commu-
nication with physicians. We wanted to try round-
ing with the nurse and the physician at the bedside,
including the patient as an active participant. We called
this “intentional rounding.”
We introduced intentional rounding in November
2007 with two physicians and gradually added physi-
cians by informally explaining the process to them
and asking them to include the nurses in rounding.
The nurses covered for each other when a physician
was ready to round and the patient’s nurse was
unavailable.
When a physician arrives on the unit, she or he
checks the board to see which nurse is caring for the
patient. The physician reviews the patient’s chart and
then uses the computerized Hill-Rom nurse locator
system to pinpoint the nurse’s location on the unit.
Together the nurse and physician enter the patient’s
room, assess the patient, and review any test results.
The nurse, physician, and patient review the care
plan, upcoming tests, and the potential discharge
date. The providers discuss the goals for the day and
answer the questions of the patient and family.
Evolution of the process. Observation has revealed
that intentional rounding has improved the exchange
of critical information among the patient, nurse, and
95
90.6
90
Percentage of nurses reporting satisfaction
In November 2007 we
began our Physician-
Nurse Intentional
85 Rounding Initiative
80.4
80
77.8
75
70
0
2006 2007 2008
Figure 2. Staff satisfaction on 3 North. Nurses’ overall level of satisfaction
with their working relationships with physicians has increased.
24 AJN ▼ November 2009 ▼ Vol. 109, No. 11 Supplement
physician. The process is always evolving. We con-
tinue to encounter challenges and come up with new
ideas to make the process work better for everyone.
For example, we recently started wheeling a com-
puter into the room during rounds to ensure that the
patient information we need is at our fingertips.
One challenge is teaching new providers, especially
physicians, about our rounding process. We are now
planning training sessions that will introduce new
staff to our various patient-centered care initiatives.
We also need to work out the logistics of rounding
with multiple providers at all times of the day. When
asked about problems with intentional rounding,
Lorraine Mancuso, MSN, RN, said, “Sometimes
rounding at the bedside isn’t possible, such as when
you are caring for a critically ill patient and a physi-
cian comes to see another patient. Sometimes sev-
eral doctors round at the same time, and you just
need to prioritize, or catch the end of rounds for one
patient.”
Outcomes. Within three months of beginning this
test of change, physicians were regularly seeking out
nurses for intentional rounding at the bedsides of their
patients on the unit. Our aim was for intentional
rounding to occur with 50% of the patients, a figure
that could vary based on how many patients each
physician had on 3 West. The data on how many
patients have intentional rounding are collated and
reported to staff monthly as well as at our monthly
TCAB meetings. After more than a year of intentional
rounding we have surpassed our goal, with an average
of 67% of patients now getting this service. Nurses
from units that do not practice nurse–physician round-
ing at the bedside report that physicians nonetheless
seek them out for rounding, so it appears that there
has been a change in the culture and an improvement
in our standard of care.
The director of our hospitalist program, Cathleen
Ammann, MD, stated, “[Intentional rounding] has
improved the way we practice medicine in so many
ways. We are able to share information, test results,
and goals of care with the patient and family in a
way that gets everyone on the same page, cuts down
on interruptions and calls to the physician, and leads
to better patient satisfaction. Logistically, it turned
out to be much less of a challenge than I had thought
it would be and has been well worth it.”
Anecdotally, nurses have reported an increased
feeling of collaboration with physicians and a sense
that their input is valued. Annual surveys of the
nursing staff show increased satisfaction with their
working relationship with physicians, from 78%
reporting satisfaction in 2006 (before intentional
rounding) to 91% in 2008 (see Figure 2).
www.tinyurl.com/TCABajn
TCAB in Action
SPREADING THE CHANGES
Many changes have occurred at Wentworth-Douglass
Hospital as a result of our TCAB work. On the floor
where our original TCAB unit is located, we reno-
vated a nonpatient area to create a 14-bed, private-
room unit. This new unit, 3 West, opened with the
understanding that it would incorporate the TCAB
philosophy into all of its practices. The capacity of our
TCAB pilot unit, 3 North, subsequently decreased
from 28 beds to 18 and it now has more private rooms.
The bedside change of shift report and the safety
huddle have spread to all inpatient medical–surgical
units in the hospital. At staff request, a small test of
the bedside change of shift report also began on the
maternal–child unit, and another recently began on
the critical care unit. Nurse–physician intentional
rounding has spread to three units, and plans are in
place to spread it to a fourth. Positive feedback from
nurses, physicians, and patients has encouraged us
to speed up the spread of this initiative to other units.
LESSONS LEARNED
With patience, education, and teamwork, we created
a system that empowers nurses, engages physicians,
and enables patients to take part in discussions that
revolve around them. One of the most important
lessons we learned in our effort to improve com-
munication is that change takes time. It has been
more than two years since we embarked on our jour-
ney to transform the care we deliver at the bedside.
Multiple tests of change have produced a sustained
culture of reliable, patient-centered care in which
all caregivers continually strive for optimal commu-
nication.
The most compelling outcome of our TCAB
journey is the change we have seen in our patients.
They now ask questions and have come to expect bed-
side exchanges of information from both nurses and
physicians. They like the reports being given at the bed-
side and enjoy having their nurses and physicians
come into the room together to talk to them. Pa-
tients have written to tell us that hospitalization
after our new communication tools were put in place
was a different and better experience than any pre-
vious hospitalization had been.
Another major outcome is high staff satisfaction.
Voluntary turnover among nurses on our two TCAB
units is less than 5%. On a recent staff satisfaction
survey, 100% of responders from 3 West agreed with
the statement “I am part of an effective work team
that continuously strives for excellence even when
conditions are less than optimal.”
We learned the value of having a day-to-day leader
on the unit to provide guidance and support and to
ajn@wolterskluwer.com
emphasize to staff the unit’s commitment to this ini-
tiative. Because change takes time, it is important
to have several TCAB champions to maintain enthu-
siasm, offer support, and help new staff integrate
TCAB into their practices.
Multiple tests of change have produced a
sustained culture of reliable, patient-centered
care in which all caregivers continually strive
for optimal communication.
We found that posting information and updates
on results on a monthly basis helps keep the staff
informed and excited about progressing toward our
goals. We celebrate successes, no matter how small,
with unit gatherings, food, and “star cards,” our orga-
nization’s employee recognition program. We educate
staff with one-on-one feedback, nursing grand rounds
presentations, poster presentations, and more, and
we encourage each other to always remember why we
do what we do: for the sake of the patients! We have
learned that when you approach change with a patient-
centered philosophy, the best decisions are clear. ▼
Kimberly B. Chapman is a staff nurse at Wentworth-Douglass
Hospital in Dover, NH. Contact author: kimberly.chapman@
wdhospital.com.
REFERENCES
1. Institute of Medicine (U.S.). Committee on Quality of Health
Care in America. Crossing the quality chasm: a new health
system for the 21st century. Washington, D.C.: National
Academies Press; 2001. http://www.nap.edu/books/
0309072808/html.
2. Kohn LT, et al., editors. To err is human: building a safer
health system. Washington, D.C.: National Academies Press;
2000. http://www.nap.edu/books/0309068371/html.
3. Leonard M, et al. The human factor: the critical importance
of effective teamwork and communication in providing safe
care. Qual Saf Health Care 2004;13 Suppl 1:i85-i90.
4. Viney M, et al. Transforming Care at the Bedside:
designing new care systems in an age of complexity. J Nurs
Care Qual 2006;21(2):143-50.
5. Diers D. Speaking of nursing: narratives of practice, research,
policy, and the profession. Sudbury, MA: Jones and Bartlett
Publishers; 2004.
6. Berwick DM. Escape fire: lessons for the future of health
care. New York: Commonwealth Fund; 2002.
AJN ▼ November 2009 ▼ Vol. 109, No. 11 Supplement 25