The mechanism of the nursing report is a comparatively ancient one. Certainly it was routinely used in the pre-Nightingale era of nursing and there are reports of such formal handover mechanisms in Chaucer and other medieval writings (Carrick P 2000). As the nursing profession has evolved over time, the requirements, expectations, demands and indeed the procedures employed in the giving of the nursing report, have also evolved and become more formalised. (Mason T et al 2003). The giving of the report can be a very useful procedure on many different levels. Obviously there is the imparting of information between members of the nursing team, but the report also has the potential of serving more subtle purposes such as increasing team bonding, team motivation, engendering of good working practices and increasing patient empathy amongst the whole nursing team. It also can serve the purpose of a forum for the interchange of ideas between professional members of staff. (Yura H et al. 1998). Other sources suggest that the peer pressure experienced by the new or student nurse, can shape their own practice by observing the attention to detail (or otherwise) as the report is presented. (Fawcett J 2005)
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We note that the procedure has “the potential” for these purposes, as with all processes that involve human input, there is inevitably an inbuilt variability of process. It is seldom perfect and a number of studies have shown that its standard and content can vary across a spectrum from excellent to abysmal (RCN.2003)
If we consider the evidence base for this statement, we can find support in two landmark studies that have been completed. The two authors (both Danes) coincidentally produced studies which were published in 1992 (Ljukkonen A 1992) (Kihlgren et al 1992). The latter study was structured in a way that analysed the functional components of the nursing reports in several large hospitals over a three month period, it then offered a period of training on improving the content and delivery of the reports, and then remeasured the staff performance using the same set of measurement parameters.
The paper itself is both long and detailed as well as being particularly analytical. To condense (and paraphrase) the findings of the initial section of the paper we can cite the findings that the initial reports were found to be:
Highly task oriented and (it was noted that) the staff often discussed the patients’ reaction in vague and general terms without imparting any specific or useful information.
The authors went on to comment that structure was frequently absent or minimal and the nursing process was seldom in evidence.
After the professional feedback sessions, the second analysis period showed a marked change to the fundamental nature of the reports to the extent that they now included the observation that there were:
More messages per report after the intervention compared to the control ward and the messages with psychosocial content had doubled. This was reflected in a greater appreciation and satisfaction on the part of the receiving nurses and a demonstrable improvement in team empathy
We note that the authors stated that in organising the mid-section training sessions they utilised the research work of Orlando (et al. 1989), who crystallised the essential elements of the nursing report into the basic concepts of “prioritisation, communication and presentation skills, together with instruction of the important ingredients of the actual nursing report.”
The Ljukkonen (A 1992) paper has similar findings but was set in two nursing homes for the elderly where the authors found that the low turnover in patients was the prime reason for the decline in nursing report standards observed. The lack of trophic peer pressure was also considered to be a major relevant factor.
The comments cited by Yura (regarding team building) earlier in this essay have their origins in this paper. Charboyer (2001) expands them further with the suggestion that a “vital part of the nursing process” is the ability to interact with all of the other members of the nursing team, both in terms of hearing (learning) and expressing opinions.
These two papers effectively pose the unformulated question “just what elements are ideally required in the definitive nursing report?”. We can take the lead from the Kihlgren paper which considered the work of both Orlando and Dugan (1989) who analysed the essential elements of the nursing report and categorised them as:
- Prioritising care and patient needs.
- Communication Skills.
- Non-Judgemental Approach.
The precursors of these elements were initially formulated in a paper published by Orlando in 1987 (Orlando I. J. 1987) who suggested that it was a fundamental function of the nursing process to prioritise the patient’s needs after elucidating them and use these perceived needs to instigate and plan an appropriate course of action which could be presented at the formal nursing report. He conceded that such an analysis was a function of the individual and unique interaction between patient and healthcare professional (by implication, the nurse) and that the nurse should ideally use their communication and analytical skills to present their assessment to the professional colleagues.
These concepts eventually evolved into Orlando’s preposition that the “backbone of the nursing report” would be this analysis and prioritisation of the patient’s perceived needs and their presentation in a “logical sequence”. Orlando concludes his original paper with the comment that this plan should be enunciated and modified in accordance with the patient’s illness trajectory at each successive nursing report so that the stated goals can be achieved as expediently as possible.
We have made earlier reference to the importance of good communication skills in the nursing report. It follows from our previous discussions that the communications skills must also ideally be in evidence between the healthcare professional and the patient in order for the nursing report to have maximal relevance (Arnold et al 2004). The importance of this comment can be judged from the fact that interpersonal communication is considered to be one of the six core attributes in consideration of optimum personal effectiveness in the “modern nurse manager“ (ICN 1998).
The traits and deficiencies in the area of communication in general, identified by both Ljukkonen and Kihlgren, were studied in greater detail by Heinmann-Knoch (2005), who analysed the topic in direct relation to the nursing report in admirable detail and went on to suggest the mechanisms by which such deficiencies could be addressed. If we accept, as Davies (et al. 2002) enunciates, that communication is a skill that is seldom innate or totally intuitive “it has to be learned, acquired and actively practised.”
Other authors point to the fact that other common failings of the nursing report include elements such as stereotyping or judgementalism. (Brechin A et al. 2000). When such elements are found to be present they clearly cross not only professional boundaries but also moral and ethical boundaries as well. (Stowers K et al. 1999)
Eye contact is an often overlooked element of professional interaction either between nurses themselves or between nurses and their patients. Eye contact implies attention and respect and can signal perceived degrees of dominance and submission in the pecking order (Hurley R 2006). Similarly lack of eye contact can imply ignorance, confusion, indifference, and ineptitude (Fielder A 2000). As a communication tool it can be used to advantage by the skilled professional nurse both to elicit information from patients and also to ensure attentive listening in the nursing report situation. (Platt, F W et al. 1999)
Body language is another often overlooked element in the art of communication. It has not received a great deal of overt scrutiny in the peer reviewed medical press but the majority of experienced healthcare professionals would attest to its value in both eliciting and conveying information (Edmondstone W M 1995). There is a considerable body of evidence to suggest that body language and nonverbal communication has a greater ability to impart information relating to the sincerity of the speaker than the words they are using (Trimboil A et al. 1997), equally it can be used to advantage when trying either to elicit or to suppress a response from the recipient (Tomlinson J 1998).
Reflection is a vital part of the learning process. It has been described and modified by many authors. Taylor (2000) suggests that it should be an active process embarked on after the event so that memories and perceptions of a situation can be rationalised and appropriate strategies considered for more optimal outcomes. Palmer (2005) observes that reflection is both a professional requirement and also a dynamic process whereby the practitioner will be prepared for any similar occurrences and can build a knowledge base to enhance his or her practice, and therefore grow as a professional. On a personal note I find that the Gibbs reflective cycle (Gibbs, G 1988 ) is both convenient, practical and useful
It is beyond doubt that the nursing report, in its ideal form, should be carefully constructed, structured and prepared. It should address all of the needs of the patient – not only the medical and nursing ones, but as Hendrick, (J. 2000) points out – it should also address the more subtle needs of the patient such as their psychological, socio-economic or social needs as well, if they are appropriate. Its proper delivery is not just a matter of chance or the last item on the shift for the departing staff nurse, it is one of the fundamental tools of the nursing profession and needs to be prepared, considered and focussed before it is actually invoked. The messages that the nursing report conveys are not simply those messages that relate to the continued nursing care of the patients, but also those that speak to the professional expectations of the nurses. Those who listen to their peers delivering the nursing report in a professional and intelligent way are more likely to be indoctrinated with professional attitudes and ideals than those who view the report as little more than a nuisance at the beginning of their shift. (Clarke J E et al. 1997). The nurse who uses all of the tools of communication, including presentation, positive body language and meaningful eye contact together with clear unequivocal language is far more likely to make a positive and dynamic impression with her report than the nurse who simply puts together a few sentences relating to each patient. (Hewison, A. 2004)
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