Date of Graduation

Summer 8-31-2020

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Cathy Coleman

Second Advisor

Margaret Levine


PROBLEM: Nursing shift reports are integral to nursing as they allow for the transfer of critical information and responsibility of patient care from one nurse to another. Ineffective communication during shift-to-shift reports can contribute to gaps in patient care and breaches in patient safety, including medication errors, falls, and sentinel events. The greatest risk of communication breakdown is during transitions in care.

CONTEXT: St. Louise Regional Hospital, a small community hospital, consisting of an eight-bed medical-surgical intensive care unit lacked structure in how handoff should occur and had variances in shift handoffs. Observation of the shift handoff at the nurses’ station revealed many communication gaps that have shown negative impacts on patient safety and outcomes. The improvement project described in this paper focused on evidence-based practices that support the benefits of bedside shift and implementations of standardized handoff tools.

INTERVENTION: Intervention included an education in-service for unit managers, educational coordinators, and staff nurses to emphasize the important benefits of bedside shift report.

MEASURES: The three components for evaluating improvement include outcome, process, and balancing measures to determine whether the improvement project has had the desired impact. The outcome measure expected to yield the following: direct observation of nurses during bedside report to calculate how often is being done, monitor for decrease in overtime due to more efficient shift-to-shift bedside reports, and a review of risk management reports observing for effect on the number and severity of medication errors.

RESULTS: The outcome measure is to increase the nurses’ compliance with bedside shift report in the intensive care unit to at least 80% within six months of implementation.

CONCLUSION: With the proposed change, bedside shift report will addresses all the safety hazards by reducing adverse events, such as medical errors, patient falls at shift change, and sentinel events. Bedside shift report improves patient safety, enhances the quality of care, improves patient and nurse satisfaction, decrease unnecessary healthcare expenditure, and saves time.