Date of Conferral
12-31-2025
Date of Award
December 2025
Degree
Doctor of Nursing Practice (DNP)
School
Nursing
Advisor
Dr. Caroline Combs
Abstract
Problem: Inconsistent shift handoff communication in skilled nursing facilities (SNFs) contributes to adverse patient outcomes, including medical errors, falls, and pressure ulcers. Bedside shift reports (BSRs) are an evidence-based, patient-centered strategy to mitigate these risks, yet implementation at the project site was inconsistent. Methods: This staff education project implemented a standardized BSR program in a 100-bed SNF over seven weeks. The intervention trained 18 nursing staff (RNs, LPNs, CNAs) on BSR using the Situation-Background-Assessment-Recommendation (SBAR) communication framework. A pre- and post-test design was used to evaluate the impact on staff knowledge, shift report duration, and patient safety outcomes, including medical errors, falls, and pressure ulcers. Quantitative data were analyzed using descriptive statistics and paired T-tests. Results: Post-implementation data revealed a statistically significant increase in staff knowledge scores from 67.8% to 97.3% (p = .001). The average shift report duration decreased significantly from 5.4 to 3.67 minutes (p = .047). Clinically, medical errors decreased from 1.3% to 0.4%, and patient falls reduced from 5 to 2 per 1,000 patient days. Pressure ulcer rates remained unchanged. Both nurse and patient satisfaction with the handoff process were high (93.7% and 95.4%, respectively). Conclusions: The implementation of a standardized BSR program significantly improved nursing handoff communication, enhanced efficiency, and strengthened patient safety by reducing medical errors and falls. This project demonstrates that BSR is an effective, patient-centered practice for improving care quality in a SNF setting. Future efforts should focus on long-term sustainability and integrating targeted interventions for outcomes not impacted by BSR alone, such as pressure ulcer prevention.
Recommended Citation
Avwontom, Ngum, "Second- Generation Korean American Adults’ Parenting Styles: The Role of Acculturation and Enculturation" (2025). Walden Dissertations and Doctoral Studies. 19224.
https://scholarworks.waldenu.edu/dissertations/19224
