Table 2.

Standardized observation protocol forms used to guide collection of data

Form section	Content
Study equipment checklist	List of five items needed for data collection (eg, forms, stopwatch)
Unit information	Eight information items to be gathered to characterize unit (eg, number of beds, number of nurses employed)
Nurse manager description of baseline documentation and communication practices	Two open-ended questions for assessing the unit's baseline documentation and communication policies, processes, and forms
Nurse profile	Seven interview items to assess nurse characteristics (eg, sex, race, education)
Shift report	Seven items gathered to characterize the hand-offs observed at start and end of shift (eg, start and stop time, narrative, number of nurses present)
Shift observations	Sheet to record and organize six items about each documentation and communication encounter (eg, start and stop time, narrative, copy of actual written documentation)
Post-shift interview	Seven interview questions for clarifying observations
Health information portability and accountability act identifiers	Eighteen identifiers to be removed from all copies of documentation before leaving observation site