Date of Graduation

Summer 8-7-2021

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Sara Horton-Deutsch

Second Advisor

Tara O'Connor

Third Advisor

Liezel Buchner


Problem: Incremental overtime was found to majorly impact the financial well-being of a stroke unit. From an allocated budget of 22 hours per pay period, the unit’s incremental overtime averaged 40 hours. The stroke unit had skilled-mix competencies, further complicating handoffs. The absence of a standard reporting method means that reviewing patients’ charts takes approximately 10 to 15 minutes, extending what should be a quick, but thorough nurse knowledge exchange.

Context: The body of evidence reviewed indicated that pertinent information to patient care is not left out or missed when a standardized tool is used during handoff. Based on Lean methodology principles, focus was given to wasteful processes and the use of the evidence-based handoff tool ISBARED/ISHAPED, an SBAR derivative. The unit budget contributes to the overall healthcare spending of an organization. This is where services are rendered and metrics that matter are focused on the patients. It is also where finances matter in terms of waste and savings. As such, processes that are wasteful or redundant need to be reviewed and eliminated so that flow is smooth and care costs are minimized at all times. IOT takes a large bite from the unit budget due to suboptimal management of resources (time, money, or processes).

Intervention: This project did small tests of change indicating how this evidence-based tool could facilitate better flow at shift change and eliminate the 5-minute review of patients’ charts. ISBARED/ISHAPED has the potential to facilitate better flow at shift change; however, work ethics was acknowledged in this process. Small modifications exposed the intricacies of working in a unionized skilled-mix unit, the work culture, and the readiness for change. This project also intensified the Gemba walk of nurse leaders allowing nurses to concentrate on performance expectations, roles, and accountability in financial stewardship.

Measures: As an outcome measure, IOT per PP was monitored and represented as a graph. The process measures of IOT and NKE were the drivers for the project and were reviewed based on the number of nurses complying with the mandate through nurse leaders Gemba Walk. Chart reviews before handoff, NKE and IOT processes became an integral part of it. Huddle time between two shifts was also monitored to see how it affects IOT. The balancing measure is aimed at evaluating nurses’ engagement, participation, and readiness for the change.

Results: Generally, there was a decrease in IOT. The ISBARED/ISHAPED tool did not significantly make an impact to decrease IOT because only a few nurses were chosen to use it. However, based on their comments a greater impact would have been felt if all used it and prepared one for incoming shifts. This process would have eliminated the 5-minute review of patients’ charts and easily facilitate handoff, but the 5-minute review of charts was kept due to union agreements. The tool, however, demonstrated how this evidence-based tool can improve flow at the change of shift and provide a comprehensive communication tool for the NKE. On the other hand, the Gemba walk that tackled huddle time, coaching and supporting individual nurses, NKE and IOT processes made a great impact on processes, awareness, roles, accountability and collaboration to decrease IOT.

Conclusion: The ISBARED/ISHAPED handoff tool is an effective means to address the flow of information during nurse knowledge exchanges at the bedside, as it is an evidence-based, standardized form. However, its success requires purposeful use that can prove difficult when doing so challenges existing work processes and/or work culture.