Date of Award


Degree Name

Nursing (D.N.P.)


College of Nursing

First Advisor

Cynthia McCurren

Second Advisor

Cynthia Beel-Bates

Third Advisor

Tim Hock


Communication in healthcare is pivotal for transferring patient clinical information. Communication is important between and within disciplines and throughout the continuum of care. Poor communication has been found to be the third leading root cause of sentinel events (event which may cause death, permanent harm, or severe temporary harm) within hospitals behind human factors and leadership. Standardization of nursing handoffs using the Situation Background Assessment Recommendation (SBAR) model and conducting the handoff at the patient’s bedside have produced positive outcomes including improving patient safety, improving nursing and patient satisfaction, and increasing time efficiency for nurses. The PICO question for this DNP Project (DNPP) was “Will the implementation of an evidence-based communication process improvement project (at shift change using SBAR during bedside handoffs) decrease fall incidence; improve safety vigilance, patient satisfaction with nurse communication, and nurse satisfaction with handoffs; and promote time efficiency of nursing handoffs on a rehabilitative skilled nursing unit in the long-term care setting?” Project outcomes were: (a) fall incidence, (b) time efficiency of handoffs, (c) nurse satisfaction with handoffs, (d) patient satisfaction with nurse communication, and (e) safety double checks. An evidence-based communication process using SBAR during a bedside handoff had a positive impact on reduction in fall rates and prevention of adverse safety events in the long term care (LTC) setting. Fall rates at shift change were reduced by 87.5% and 14 patient safety events averted throughout the DNPPP. Interventions resulting in fall prevention in the long term care setting are key to cost savings and patient safety promotion.

Included in

Nursing Commons