Why shift change?

Several of the L&D blogs I’ve read recently have talked about all hell breaking loose about the time the nurses change shift — typically, several pregnant women show up at the same time, just an hour or two before shift change, which wreaks havoc with assignments, etc. Occasionally, some of these women need lots of care, and the general craziness that is going on by having so many patients being admitted to the hospital within a short space of time, means that somebody is going to get the short end of the stick. Then there is the load of paperwork that the outgoing group of nurses have to complete so that the incoming nurses understand what is going on.

This post is more based on this thing I read about communication lapses that harm patients, one of which being “change of shift.” Now, I understand that a single nurse cannot stay at the hospital 24/7, so there will have to be some sort of shift change from one nurse to another at any particular time, but I wonder if there can be a better way to handle “shift change.” Not being a nurse nor working in a hospital, I may be completely off the wall, but I think there might be a better way to make things happen than for all the night nurses to stop and all the day nurses to start all at the same time. It seems like a recipe for confusion and disaster.

What if, instead of there being “day shift” and “night shift,” each nurse came in at a different time? For example, instead of six nurses all coming on at 7 a.m., maybe one could come in at 5, another at 6, another at 7, etc. Is there some sort of magic for all nurses to begin the work-day at 7 or 8? If the shifts were staggered, it seems like there could be greater continuity of care for the patients. If all night nurses stop working at the same time and all day nurses start working at the same time, it would be easy for one of them to “drop the ball” and forget to include some important detail that happened during the shift. But if the on/off times were staggered, then the first day nurse could be part of the night team for an hour or two and could get in on all the patients’ problems and concerns that happened overnight. Then as other day nurses come on as night nurses go off, they can gradually be acclimated to what went on when they weren’t on shift.

When I worked at the pharmacy, I usually worked the whole time it was open, whenever I worked that day. Sometimes I’d only work half a day, or might be gone running errands for a few hours, but these times were fairly rare. Of course, I wouldn’t work on my day off, and sometimes some pretty important things happened on my day off. Usually, it would be no problem, because my coworkers would fill me in on all the important stuff that I missed, or if something came up (typically, a customer wondering if some special order was ready, or if the doctor had called in a prescription or something), I could easily say, “Let me check,” and within a few seconds ask somebody who was there and be able to give the customer an answer. But I didn’t like coming in to work in the middle of the day, because I just felt completely out of the loop — I didn’t know who had ordered what medicine, or anything else that was going on. We were a small pharmacy with just a few regular staff, so it was almost guaranteed that somebody was always at the pharmacy who knew something about everything that had gone on. Sometimes, though, that wasn’t the case, and I always hated those times. For example, somebody would come by to pick up medicine, and the order hadn’t been filled, and we couldn’t figure out why not. Where was the medicine? Where was the prescription? Who had answered the phone and forgotten to fill the order? Were they even at the right pharmacy? Usually, the person picking up the medicine was just a “go-fer” for our customer, and he didn’t know what it was he was supposed to be picking up — he just knew he had to get medicine for Mr. or Mrs. So-and-so. There were a lot of times when we had to call somebody who had worked in the past few days to figure out what Mr. or Mrs. So-and-so were supposed to have gotten.

Just in typing this, I am feeling tense and frustrated, because I’m remembering what it felt like when these things happened — when I didn’t have the answer, and sometimes wasn’t even really sure of the question, but I was supposed to answer it anyway — when I was missing some vital information that affected my ability to easily take care of our customers — when I just didn’t know.

Perhaps this doesn’t happen at shift change in hospitals. Maybe they can more easily transmit all the useful information from one nurse to another. At a pharmacy, we usually filled 300-400 prescriptions a day and easily had over 100 different customers within the space of 10 hours (most in and out within 5-10 minutes), so there were more possibilities for a lapse of communication to occur; whereas most L&D units will deal with just a few women for a lengthy period of time. But while medical information can be easily charted, sometimes there is that personal factor that cannot quite be reduced to short-hand and charts. What if the laboring woman had a friend who just had a baby who was stillborn, and told her first nurse about her fears of stillbirth, and the nurse wrote down the clinical information but did not communicate the non-clinical information, i.e. the fears, to her successor. Or perhaps her mother or grandfather is dying of cancer, and she is grieving while laboring. Or perhaps the baby’s father is a jerk and stormed out of the hospital room mid-shift. There can be some very valuable personal information that can be lost in the flurry of one group of nurses leaving and another group coming on.

But I rather suspect that in most hospitals, all the nurses that are on shift at the time this important personal information is given will know about it by shift’s end, so it seems that even if one nurse forgets to tell her replacement something important, one of the other night-shift nurses can fill in the blanks for the new nurse about not only her own patients but also all of the other patients that are there, and there can be greater continuity of care for all patients that way.

So, what do you think? Am I wrong? Particularly you current and past L&D nurses — is what I have suggested even workable? What have I left out?


2 Responses

  1. law enforcement does this in our area… usually by rank… with the higher ranking members (charge nurses for you maybe?) coming in an hour earlier than the bulk .. followed by the extra staffing members an hour after those. sometimes the late members it seemed to annoy them more feeling like they play catch up all shift though.

    i know some floors at my moms hospital split their people working 12s in half… some 7 to 7, some 3 to 3. so then it has about half who are in the middle when half are new.. and easier to get someone to pick up 4 or 8 here and there when there is already a transition time there.

  2. As someone who works L&D and NICU and who makes the schedule for the nurses, I have a few things to add. It may seem anecdotal that there is mass craziness at change of shift, but it is just that, anecdotal. Change of shift for me is actual the safest time to be admitted, you have double the hands to help in an emergency. As we all well know, babies have their own agendas as to when to come into the world. I can not schedule for it. We do up staff for “scheduled” procedures such as inductions and planned C/S’s. I am all for flexible scheduling, but we just can not predict the mysteries of labor and delivery.

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