Evidence based practice

The study was designed to evaluate if moving shift handover to the patient’s bedside could lead to more cost effective care and if by reducing the amount of time that nurse were away from the bedside during handover could result in improved patient safety. Review of Literature When reviewing the literature, the researchers found that while bedside Andover was credited to improve communication and patient and staff satisfaction that very little empirical data was available about the economic, cost effective benefits of the process.

They discussed the findings of 7 articles that were reviewed and they cited 17 sources that were dated from 1947 to 2009. The oldest citations were related to the change management process and not directly related to bedside handover. Literature review found that the delay in nurses connecting with patients during traditional handover could result in reduced patient safety and in increase in adverse events (Caruso, 2007). Transoms, in an article in The American Nurse in 2009, reported anecdotally that bedside handover was more economical than traditional process but data was not provided.

The author did not find empirical data that measured adverse safety events specifically during handover but retrospective case studies and anecdotal accounts had inferred that reduction in events was an outcome of moving away from traditional methods of shift handover. “Nursing Handover at the bedside allows the nurse to visualize the patients at the start of shift and perform safety checks. (Caruso, 2007) Discussion of Methodology This study seed a mixed-method, evaluative approach involving quantitative (quasi-experimental) and qualitative (ethnographic) designs.

Researchers The study was conducted in three small rural Australian hospitals, on acute care units. The three sites while similar in fundamentals had some variances in size, patient populations and types of staffing matrixes. The study sampling size was 48 nurses who agreed to transition to the new process. Implementation of the process was replicated in the three sites to more accurately assess and measure results. The only criterion for staff was that they had to be currently working in the unit in a patient are role.

Data was collected in 3 stages using quantitative and qualitative Evidence based practice, task 1 By snoozed duration or length of handover and collecting data related to adverse patient events during handover, pre and post the process change. Researchers also used the ethnographic approach by observing nurse handovers to note the types of information discussed and the terminology used. In addition, nurses were interviewed about their perceptions and satisfaction with handover and asked to estimate how long the process takes to complete.

This was also done before and after implementation of the change. Researchers used Linen’s model of change management to put the process change in place. Specific Data Analysis Researchers collected demographic data only related to the age and gender of the sample group. Years of nursing experience was not recorded. This information was organized by age groups and recorded in table form. Quantitative data was collected as handovers at three sites were timed pre and post the practice change and this information was analyzed and presented in graphs demonstrating the any differences.

Results were tabulated by numbers of patients and staff and average times computed by unit. The mean length of handover with traditional handover was 0. 44 hours which deceased to 0. 22 hours after the move to bedside handover. Data on the number of adverse patient safety outcomes during handover were gather pre and post implementation and tabulated. Qualitative data collected from nurse interviews, pre implementation of bedside handover indicted that they found the traditional handover to be “difficult and time consuming. This data was presented in graphs, demonstrating the any differences with in the three sites. Nurses were also asked to estimate the time taken to complete shift handover pre and post implementation. Researchers used a mixed model, descriptive statistics to correlate results and draw conclusions. Researcher’s Conclusion: The authors concluded that there was a clear trend that indicated that shift handover conducted at the patient’s bedside was considerably shorter in duration.

Exact fugues or estimates, on how this would translate into cost savings in economic terms were not addressed. Researcher’s data found that adverse patient events decreased, which would correlate to previous research that this form of handover leads to improved patient safety outcomes. Researchers were not invoiced that this study could adequately validate that the process leads to improved accuracy and better communication and that further research was needed to fully explore those areas of the process. AY.

Assessment of Evidence: In reviewing all the information related to this study in the five areas contained in the graphic, the study was designed to test the hypothesis that a process change from a traditional method of shift handover to nurse handover at bedside would shorten the duration of time it took to conduct the process, which it turn could lead to economic benefits to the organizations that adopted the process modification. The researchers also wished to gather data that would establish that the new process lead to improved patient safety which also while enhancing patient care can also led to cost savings for organizations.

In addition, they sought to examine the nurses’ perceptions of both types of handover and if the views changed with the new process introduction. Digital recordings of the times it took the nurses to conduct handover complete handover at the bedside against using the traditional method. Unfortunately the study did not directly equate the time savings to cost deduction benefit in real terms or figures. The numbers of adverse patient events deceased from 18 prior to implementation of bedside handover, which was reduced to 7 events after the new process was in place.

This would seem to indicate that patient safety was enhanced by the new process. Site 3 data revealed that post implementation that nurses interviewed registered a slight increase in dissatisfaction with the process. The other two sites showed an increase in the satisfaction and all three sites estimated the time they took to complete handover showed significant improvements in all three units. The study concluded that handover was shorter after the process hang and that the reduction in adverse incidents within the time frame indicated that bedside handover increased patient safety.

The authors did acknowledge that the study was limited by sample size and that using a mixed method approach, was time consuming when the time for the study was limited. It is difficult to see how gathering data on the nurses’ preferences and perceptions about handover contributed to the aim of the study, which was to see if altering the method of delivery would impact duration of report and improve safety. The literature review the authors listed, did not state how many articles that were sourced but cited 7 articles that they had reviewed which were relevant to validate the need to answer their specific questions.

They did not find any empirical research data that demonstrated the cost effectiveness of the process. They could have made a larger more significant review of literature prior to implementation or better record their literature search and review results. The study lists the authors as the researcher, a doctoral nurse and a statistician research partner to analyze the results. As this was conducted over three rural sites, the article makes no mention of who assisted with data gathering and interviews or how the change was effected. Multiple people doing ethological observations and interviews can affect results.

It also does not speak to the time frame in which the study was conducted. In discussing methodology, the study makes note that 14 sessions in the 3 sites, where morning to afternoon handovers were observed and so there appears to be no data collection related to night shift which makes up one third of nursing hours daily. Given some of the night shift challenges such as less staffing, fewer doctors’ in house and often higher volume of sedated or confused patients, collecting no data from this group may have substantially altered the data.

While the study makes reference to observing styles and terminology used as baseline data prior to the process change, it does not address if the nurses’ used a standardized format, process or tool to ensure uniformity of the information being passed to the next shift during handover. It does not address if there was conformity in the structure of the handover across the 3 units, which could skew results for both duration and accuracy and therefore impact safety results.

The reduction in adverse events like falls could be related to the fact that after the change in handover method that the nurses were out rounding on tenants with the off going shift rather than having reduced staffing levels on the floor while staff give lengthy handcuffs away from the patients behind closed doors. The study recommended that further research is needed to address some of these bedside handcuff impacts the length and the safety data collected. AY. Ethical Issues: During any research that involves humans, there are always ethical concerns that must be considered.

The Murderer Code and the Declaration of Helsinki laid out ethical guidelines and rules for researchers to follow after some of the atrocities inducted by Nazi researchers during the Second World War were revealed. (Houses, 2007) Protection of privacy and informed consent are always one of the first issues that must be addressed. The participants should be made aware of any risks or hazards that they have the right to withdraw at any time from the study should they so choose. Researcher must “do no harm’ and demonstrate that there is benefit to the knowledge obtained.

In the United States, access to patients’ health information is protected and illegal without clinical necessity or patients consent. As this study as conducted in Australia, there may be different laws about access to health records and patient’s privacy but researchers would still be required to get consent from any patients where the handover was being observed by the researchers at the patient’s bedside. In this study, the researchers make no reference to how or if consent was obtained. They identify the nurses “self-selected” to partake in the study (Bradley & Moot, 2010), which one presumes means that they volunteered.

The authors did make note that two of the nurses refused to give their age when asked or demographic data so they may have been aware of their rights. Privacy of the patients health information being discussed during handover and consent for the presence of observers at the patient’s bedside is also not discussed in this study so none of the ethical data is discussed or available. The study does not address in the methodology if the study was approved by an Institutional Review Board and if consent was obtained from participants.

AS. Type of Research: There are numerous methodologies for conducting research and often the choice is related the hypothesis that is to be examined. This study utilized a mixed method approach and gathered both quantitative and qualitative data. ” Quantitative research is used measurement to determine the effectiveness of interventions”. (Houses, 2007) This method utilizes designs where collected data and results can be statistically and mathematically computed compared and analyzed.

Variables are accounted for and numbers pre and post implementation or interventions are measured and conclusions are drawn dependent on the numbers. The quantitative data included collecting demographic data from the sample group participants, the miming and logging the duration or length of the handovers and collecting data on the number of adverse patient safety incidents during the study period. Qualitative research is more humanistic in approach rather than numerical. It is concerned with the perceptions and acceptability of a process to patients and staff rather than determining effectiveness.

It is harder to measure but equally important in nursing research as no matter how successful and efficient a new procedure or process is unless it is well received by the patients and staff and the benefits apparent, it is unlikely to be effective and sustained. In this study qualitative data was collected by interviewing the nurse participants’ pre and post hand over process change to assess their perception of the traditional handover style and asked them to estimate how long the process usual took to complete.

The interviews were then repeated after the found value in the new process. The article also noted that ethnography, a form of qualitative research was utilized. Ethnography is observation and study of the culture and interactions of a target population or group. In this case the researchers observed the nurse to nurse handover to observe habits and terminologies that were art of the unit culture and habits. AAA.

Other Types of Research: There are different kinds of research design and the method chosen is often dependent on the hypothesis to be tested or contingent on the question to be answered. Research methods fall in to two main groupings, quantitative and qualitative. This article used both methods in a mixed method approach. This article could have done a better systematic review search of current literature to summarize the findings of other studies on the desired topic and make recommendations for a practice change bases on the findings.

Other subtypes of qualitative research include Phenomenological, which seeks to gather insight into a human experience, in the case of nursing research this would be a health related experience for example an awareness of how a patient copes with a chronic ailment like diabetes. Ethnology used in this study seeks to examine the interactions, terminology and subculture with a group like a group of patients in a barbaric support group in the article the authors looked at how the group of nurse participants usually delivered handover.

A grounded theory method seeks to gain knowledge or understanding related to a social process connected to a health matter or decision like the choice to make advanced directives. (Brown, 2009) Quantitative subtypes include; experimental research which is difficult to do in a nursing context and would have difficult to do in this study. It is based on scientific protocols that require control groups and random assignment of participants to the study or the control. Variables and other influences need to be negated or controlled and interventions must be consistent in each instance.

Descriptive studies where individual variables like pain or anxiety, that may fifer from patient to patient, are quantified using scales to provide a more uniform measurement for result assembly and rationalization. Correlation studies seek to examine the relationship between variables like lack of exercise and poor diets association to heart disease. These subtypes may not have worked well within the researchers framework but the descriptive method could be used to rate patient satisfaction with the process.

Problem: Beside handover has been credited with many benefits over traditional approaches to shift report. Claims include improved nurse communication and accountability, increased staff and patient satisfaction, reduction of everything from falls and medication errors to a decrease in staff overtime and call bell usage. Recent research links bedside handover to improved patient safety outcomes. More comprehensive studies are needed to test the validates of these assertions and ascertain if bedside handover is a patient safety initiative.

There are numerous driving forces that are making this method of shift to shift communication an increasingly popular strategy. “One of The Joint Commissions on Accreditation of Healthcare Organizations CACAO) 010 National patient Safety Goals (NAPS) was to improve shift handover communication,” (Indiana, 2012) “including an opportunity to ask and respond to questions”. (Rosenberg, Ileitis’s, & Cunningham, 2010) In 2009, the NAPS was to Communication lapses and failure to relay relevant information have been correlated to of all sentinel events in hospitals. (Alveolar et al. 2006) Inadequate communication has been acknowledged as an element related to the current issues of medical malpractice claims and sentinel patient safety adverse incidents. “Errors in communication give rise to substantial clinical morbidity and mortality. (Rosenberg, 2010) The change of shift and nurse to nurse hand over has been marked as an especially vulnerable time for patients, with less staff on the floor and distracted giving handover to colleagues, the potential for missed information and a poor patient outcome is higher than at any other time during the shift. Shift change updates are widely believed to be a point of vulnerability in complex systems with high consequences for failure” (Patterson, 2008). It has become of increasing importance to healthcare organizations that patient satisfaction scores are consistently in the high percentiles nationally. With the introduction of the Affordable Care Act in 2009 reimbursement is tied to improved outcomes and increase patient satisfaction with entries and providers.

Hospital Consumer Assessment of Healthcare Providers and Systems (HASPS) are Centers for Medicare & Medicaid Services’ (SMS) (Indiana, 2012) collects patient satisfaction data and have cut increasingly higher percentages from organizations funding who post low scores. Bedside handover according to the literature can have a positive impact on patient satisfaction by improving nurse patient communication, allaying patient anxiety and assisting tenant to be more involved with their plan of care and better informed consumers.

Catholic Healthcare West recorded improvement in patient satisfaction scores after the implementation of the bedside handover model. (Rush, 2012) Most articles on the topic agree that additional effort should be expended to collect empirical evidence to support the largely anecdotal evidence and retrospective case studies that point to improvements in patient safety. While government and financial initiatives encourage intuitions to move to this method of handover in an effort to meet ever increasing quality and safety goals, the profession must ensure that the evidence supports the validity of the change as best practice. 2. See Attached Matrix Baa. Annotated Bibliography Bradley, S. , & Moot, S. (September 2012). Handover: Faster and safer? Australian Journal of Advanced Nursing, 30(1), 23-32. This study evaluated if changing the process of shift handover from traditional form conducted in an off stage area to handover at the bedside could lead to improved safety for patients and cost reductions by shortening the duration of handover. The researchers also examined staff perceptions and satisfaction with the traditional method of handover versus the bedside handover model.

It used a mixed-method, evaluative approach involving quantitative (quasi-experimental) and qualitative (ethnographic) tools and design. Dry. Sarah Moot holds a doctorate in Nursing and is Head of the Mount Gammier Regional Centre for the University of South Australia; Stacy Bradley has a Bachelor of Commerce Management, in Accounting and is a research assistant pursing a PhD at the same institution, their credentials lends credibility to the article, which was printed in a peer reviewed Journal. Cairns, L. L. , Dusk, L. A. , Hoffman, R. L. , & Lorenz, Handcuff. The Journal of Nursing Administration, 43(3), 160-165.

This article was a mixed method design, quality improvement project conducted over a 3 month period in the University of Pittsburgh Medical Center, on a 23 bed inpatient unit. The purpose of the project was to determine if implementing bedside handover could improve the effectiveness of the process. Methodology was quantitative measures of indicators such as reduction in nursing overtime, recording the volume of call light activations during handover and qualitative survey measurement of patient satisfaction over the course of the process change. Results revealed a 15% decrease n overtime hours, a 33% decrease in call light usage and 14. % increase in patient satisfaction. These results lead to the conclusion that bedside handover positively impacted the unit in the areas measured. The study was led by a Doctor of Nursing Practice (DON) who was the director of the study unit in the university affiliated medical center and an Associate professor from the School of Nursing, at the University of Pittsburgh. The academic allied setting and researchers credentials lend credibility to the study. The article was printed in a peer reviewed nursing Journal. Shabbier, W. , Muscular, A. , & Wallis, M. 2010). Bedside nursing handover: A case study.

International Journal of Nursing Practice, 160, 27-34. Http://DXL. DOI. Org/DOI: The aim of the study to examine the perceptions of the nursing staff post introduction of bedside handover. This was a qualitative study using a descriptive case study framework at two hospitals on 6 units. The researchers conducted 532 bedside handovers were observed and 34 interviews conducted with nurses. They wanted to investigate if nursing strategies like managing visiting times and sensitive information during handover had been impacted by the relocation of handover to the patients’ bedside.

The finding of the study found that approximately 50% of staff was using an SABA format to deliver handover which an average took Just over one minute. Only one third of the patients participated. Comments gathered from the participants were very favorable about the practice but no negative comments were included for balance that would reflect the percentages in the findings. The researchers did develop a 3 stage summary guideline for before, during and post bedside handover that could be developed as and education tool for future implementation in other facilities Wendy Shabbier, PhD; RAN; is the Director of the

Research Centre for Clinical and Community Practice Innovation at Griffith University in Queensland, Australia. Anne Muscular, PhD; RAN is a Fellow of Royal College of Nursing, Australia and is Professor of Community Practice Innovation at Griffith University in Queensland, Australia. Marianne Wallis PhD RAN is Professor of the in Queensland, Australia, This article was published in a peer reviewed nursing journal. Hagen, J. , Oman, K. , Klein, C. , Johnson, E. , & Enraged, J. (2013). Lessons Learned From the Implementation of a Bedside Handcuff Model. The Journal of Nursing Administration, 43(6), 315-317.

This article is a retrospective case study of a process improvement project aimed to improving clinical effectiveness in the Magnet designated University of Colorado Hospital (SUCH). The authors noted that research evidence supported a move from traditional to bedside handover as a strategy to turn could increase financial performance. The article details the tools and approaches including a Journal club, study guides and visual aids used to implement the change on one unit initially as a model and subsequently hospital wide. They utilized unit champions to train staff and then qualitatively monitor and observe regress.

In recounting lessons learned from the process, the authors identified that initiating a change management plan that included training in a standardizing the process as important to success. They also reflected that even post implementation that barriers to success are still problematic, such as nurse reluctance to speak about sensitive topics in front of the patient and that privacy was often an issue in semi- private rooms. They felt that additional staff training could overcome some of the challenges. They noted that gains had been made in staff and patient satisfaction cost the process change but did not quantify gains.

This article authors primarily consisted of the unit manager a MS, and a Research Nurse Scientist who is an associate professor at the University of Colorado and was published in a peer reviewed nursing Journal. Jeff, L. , Simpson, E. , Campbell, H. , Irwin, T. , Lo, J. , Beseech, S. , & Cards, R. January 2, 2013). The Value of Bedside Shift Reporting. Journal of Nursing care Quality, 28(3), 226=232. This is a qualitative study that aimed to investigate nurse perceptions of the implementation of bedside handover on 4 acute care inpatient units in a large inner itty hospital.

Pre implementation planning and training was extensive and organized. Research assistant conducted interviews with patients and nurses pre and implementation. In addition satisfaction surveys and other audits were completed post process completion. The study found that the majority of the nurses perceived that bedside handover enhanced patient safety by having the ability to round on patients with the off going nurse, lead to opportunities to clarify medications and patient status changes in a timely and more accurate manner. Nurses also noted that patients were more engaged in their care and asked questions.

The nurse responded that the bedside method of handover was more patient centered. This study was led by Doctorate Nurse (PhD), who is the director of Nursing Research at Saint Michaels Hospital in Toronto and is affiliated with the University of Toronto, Canada. The authors academic qualifications, background and affiliations lend credibility to this study which was published in a peer reviewed nursing Journal. Johnson, M. , Jiffies, D. , & Nicholls, D. (2012). Exploring the Structure and Organization of Information within Nursing Clinical Handovers. International Journal of Nursing Practice, 180,

This qualitative study was designed to look at the content and organization of nurse to nurse change of shift handover to see if organization and delivery of information led to miscommunication. The handovers were recorded with hand held devices and 81 handovers of 126 patients were taped and transcribed and analyzed. The researchers chose a number of hospitals and 7 clinical disciplines including med-surd and mental health. The mental health handovers were eventually excluded as the content of the information contained in their hand over was markedly different from the other units.

They found that while there was some commonality of the information being delivered that there was little standardization of patients were involved in handover. They examined tools like SABA, (Situation, Background, Assessment and Reedbuck), (Recommend, was not used in Australia as opposed to the United States. ) They found that this toll was more useful when communicating with physicians and certain clinical settings and sites like Labor and delivery, Rapid response and cardiac Arrest.

The Format that they determined has the best results was, identification of the patient, clinical risks, clinical history, clinical tutus, care plan and outcomes of care (CISCO) They concluded that CISCO which is more in tune with nursing terminology and ideology, can steer the handover process to ensure vital information is conveyed in a consistent, coherent manner and as a result improve patient safety by avoiding omissions in care. They agreed that further research was needed to explore the possible rates of error reduction with the use of the CISCO format.

Mare Johnson, PhD RAN is the Director of the Centre for Applied Nursing Research, a Joint facility of the South Western Sydney Local Health District & University of Western Sydney, Australia. Diana Jiffies, PhD RAN is a Lecturer at the School of Nursing & Midwifery, University of Western Sydney, New South Wales, Australia. Daniel Nicholls PhD RAN is an Associate Professor and Clinical Chair in Mental Health Nursing Disciplines of Nursing & Midwifery, at the University of Canberra, Australia. They have both clinical and academic experience and credentials which give credence to the article.

This article was published in an international peer reviewed nursing Journal. Kerr, D. , Lu, S. , McKinley, L. , & Fuller, C. (2011). Examination of current handover practice: Evidence to support changing the tall. International Journal of Nursing Practice, 170, 342-356. Http://DXL. DOI. Org/DOI: This qualitative study aimed to explore handover routines at one facility and investigate clinical nurses’ perceptions of the quality and efficacy of handover regarding the existent shift handover style. The study was conducted over 6 weeks on 23 acute in patient units.

Nurses completed a survey 4 hours after the start of their shift when they had completed the assessments of their assigned patients about the quality and accuracy of the handover they received. There was no uniform practice for handover among the 23 units. Each unit had a slightly different process; written verbal, taped, rounds with the charge nurse and combinations of them all. They found that 32. 0% of the participants were frustrated by frequent interruptions. 27. 5% expressed concerns that the information they received was irrelevant and 25. % stated that handover took too long. 18. 3% were concerned that important information had not been passed on but on a positive note 80% felt prepared to care for their patients and found that the information delivered was easy to understand. Of most concern was that 40% of the nurses found it necessary to contact the nurse from the revises shift to clarify clinical data. The researchers concluded that the existing format for handover needed to change and that the patient should be involved but that there was a high likelihood of resistance to change from staff.

This article was coauthored by Debra Kerr, who holds Bachelors in Nursing, (BIN) Master’s degree in Business leadership, (MBA) and a PhD; she is a senior lecturer, Honors Coordinator, Victoria University, SST Albany, Victoria, Australia. Dry. SAA Lu holds a medical degree, MOBS, PhD and is a lecturer at Victoria University, SST Albany, Victoria, Australia. Louise Christine Fuller, BIN, Director of Nursing, Western Hospital, Victoria, Australia. This article was published in a peer reviewed nursing Journal. Manson, P. M. , Derby, K. M. , Workbooks, D. M. , & Foss, D. M. May-June 2012). Bedside Nurse-to-Nurse Handcuff Promotes Patient Safety. Mediums Nursing, Volvo. 21 [No. 3, 140-145. This was a qualitative research study conducted on 11 bed surgical unit, in the Mayo Clinic, Rochester, Minnesota; to determine if bedside handover could impact safety and satisfaction by having the oncoming nurse to visualize the patient in a imply manner, clarify care issues with the off going nurse and involve the patient in their care by giving then to ask questions about their care plan. 60 patients and 15 staff were surveyed pre and post the process change.

The conclusion was that bedside report increased nurses’ awareness of the impact of communication on patient safety and their accountability to their colleagues. They also reported the perception that call light use was decreased during handover after the change was implemented. Patient satisfaction increase and patients stated that they felt a sense f involvement and confidence when handover was conducted in their room. Pamela Manson is a clinical nurse specialist for the surgical intensive care unit and has a doctorate degree. Kelly Derby is a clinical nurse specialist and had a master’s degree.

Diane Workbooks is a nursing education specialist and has a doctorate degree and Diane Foss is a nurse manager. This is a peer reviewed Journal. Rush, S. K. (2012, January). Bedside Reporting: Dynamic dialogue. Nursing Management, 43, 40-44. Http://DXL. Did. Org/10. 1097/01. ANNUM. 0000409923. 61966 This article details a retrospective case study of qualitative study related to the implementation of a bedside handover process the Catholic Healthcare West (CHEW) system of hospitals (changed to Dignity Health in 2012) as a strategy to improve patient satisfaction scores and to move to a patient centered care model.

Pre implementation, patients noted on surveys lack of satisfaction with the amount of interactions that they had with nursing staff and the lack of information that they received about their medical condition and plan of care. The new process planning included a plan for roll, training, guidelines and a communication tool for staff to utilize. Observation was used to ensure competency and validation of process.

Significant gains were noted in patient satisfaction scores and the author recounted anecdotal accounts of how bedside handover averted adverse patient events and so she argued that it improved safety outcomes for patients. The author Sandra Rush is a BBS with a master’s degree in administration and is the director for service excellence at CHEW. This article was published in a peer reviewed nursing Journal. Triplett, P. , & Chevaliers, C. (April 2011). Nurses’ End-of-shift Report Process and Implementation of a Standardized Report Format Tool and Bedside Handcuff.

Serviceableness, 31(2). Retrieved from www. Confined. Org This is qualitative study related to introduction of bedside handover using a standardized format with a check list, in two critical care units in SST Paul Minnesota. Audits of adverse incidents related to medication administration pre implementation had shown that 39% of medication errors were discovered after the end of shift handover. This abstract recites literature to support the process change and the tools and methods used to affect the change. Unit surveys of the nursing staff were

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