Name
Capella University
NURS-FPX4005 Nursing Leadership: Focusing on People, Processes, and Organizations
Prof. Name
Date
Ineffective communication during shift-to-shift patient handoffs in the Emergency Department (ED) at Jones Memorial Hospital (JMH) has emerged as a substantial barrier. Inconsistent use of systematized handoff tools, such as SBAR (Situation, Background, Assessment, Recommendation), has led to gaps in transferring patient data, delayed care, and increased safety risks (Bindra et al., 2021). This plan supports an interdisciplinary approach to enhance communication and foster a culture of accountability during shift transitions.
This plan proposes a strategy to address communication gaps during patient handoffs in the ED at JMH. It aims to ensure the accurate exchange of patient data through the use of standardized protocols, such as SBAR and I-PASS, as well as staff training. By achieving these goals, the plan will decrease the chance of mistakes and improve care during shift transitions.
Initially, forming an interdisciplinary team to improve patient handoffs may require extra coordination. However, by reinforcing standardized communication practices, this approach will streamline shift changes and support better patient outcomes.
Enhancing communication during patient handoffs at JMH will require resources such as I-PASS protocols, training, the integration of I-PASS checklists into the electronic health record system, and collaboration between clinical and IT teams to ensure accurate data transfer.
Implementing standardized handoff protocols fosters interdisciplinary communication, facilitates accurate data exchange, reduces the risk of miscommunication, and enhances patient safety.
Success will be evaluated through regular audits, staff feedback, and key performance indicators focused on handoff communication, care coordination, and patient safety outcomes. Compliance with the SBAR protocol will be tracked, along with incident reports, to measure improvements in communication accuracy and error reduction (Kazemi et al., 2024). The efficiency of collaboration will be evaluated using principles from Crew Resource Management (CRM), with monthly evaluations supporting improvement and staff development.
Kotter’s 8-step change management model provides a roadmap for improving patient handoff communication in the ED at JMH. The process begins by creating a sense of urgency, where leadership presents real examples of delayed care and safety risks caused by poor handoffs (Harrison et al., 2021). Building a guiding coalition of nurses, physicians, and administrators ensures interdisciplinary ownership. The next steps involve developing and communicating a clear vision centered around the consistent use of I-PASS and SBAR during shift changes. Training sessions, standardized checklists, and real-time simulations help empower staff and remove barriers to execution. Short-term wins are achieved through pilot programs that demonstrate improvements in communication.
The change is combined by integrating I-PASS and SBAR into electronic workflows. Finally, the new communication practices are secured in JMH’s culture through education and leadership support. For instance, a real-world example occurred at Johns Hopkins Hospital, where the execution of Kotter’s model facilitated the successful integration of the I-PASS protocol. This initiative enhanced the quality of patient handovers by standardizing communication and improving patient safety (Rehm et al., 2021). To create buy-in, TL at JMH are introducing interdisciplinary simulation workshops to standardize handoff tools, such as I-PASS and SBAR. JMH uses TL and CRM principles to reduce fatigue and boost staff engagement during patient transitions.
Transformational Leadership (TL), when combined with the principles of CRM, offers a strategic approach to enhancing collaboration during patient handoffs in the JMH. Through inspirational leadership, teams are guided toward shared goals that prioritize effective communication (Samardžić et al., 2021). Nurse TLs are crucial in establishing clear handoff protocols, encouraging interdisciplinary engagement. TL supports this transformation by initiating training workshops that involve nurses, physicians, and care coordinators participating in simulations and practicing the handoff devices, such as I-PASS and SBAR (Alanazi et al., 2022). CRM complements this by promoting key teamwork behaviors, such as briefings, assertive communication, and situational awareness that close communication gaps. JMH leadership fosters a culture of psychological safety, empowering staff to speak up and improve care.
At JMH, the ED team is dedicated to improving the quality and consistency of patient handoffs. The interdisciplinary team includes charge nurses, bedside clinicians, communication leads, and executive leadership. Charge nurses will supervise the execution of standardized handoff tools like SBAR and I-PASS, monitor adherence, and organize regular training sessions (Nasiri et al., 2021). Bedside clinicians will contribute frontline perceptions on the practicality of handoff protocols and engage in simulation-based CRM training to strengthen communication. Communication leads will refine message delivery processes and facilitate workshops to ensure clarity and reliability in patient updates.
Executive leaders will evaluate the efficiency of these initiatives by reviewing handoff-related safety incidents, patient outcomes, and staff feedback. The integration of SBAR will promote structured communication. CRM principles will reinforce teamwork, role clarity, and raise the standard of patient care in the ED. For instance, At JMH, charge nurses and bedside clinicians co-lead CRM-based simulations to enhance handoff consistency through the use of SBAR, fostering staff buy-in. Executive leaders track safety metrics and staff feedback to evaluate and refine interdisciplinary training outcomes.
The initiative to improve handoff communication at JMH will require dedicated resources to confirm efficient execution. Staff will be responsible for overseeing the rollout of consistent handoff protocols, such as SBAR and I-PASS, and evaluating program outcomes. Existing resources, including meeting rooms, digital communication tools, and electronic health record systems, will be utilized to support data sharing without incurring additional costs.
Anticipated expenditures include hiring external communication and CRM specialists for simulation-based training ($180–$220 per session) and organizing annual staff growth workshops focused on handoff best practices ($500–$ 1,500 per year). Leveraging current access to patient records, staff schedules, and incident reporting tools will be crucial for monitoring adherence to protocols and outcomes. The estimated annual investment for training time, coordination meetings, and performance audits is projected between $20,000 and $25,000. This financial commitment will support sustainable improvements in patient safety within the ED.
If targeted efforts to improve handoff communication at JMH are not implemented, ongoing communication gaps continue to jeopardize patient safety and increase clinical errors. Ineffective shift changes can lead to delayed care and heightened risks of regulatory noncompliance and legal consequences (Chien et al., 2022). Miscommunication during handoffs burdens frontline staff and decreases job satisfaction. This contributes to higher staff turnover and increased costs related to recruitment and training. The lack of reliable discussion methods such as SBAR and I-PASS could result in inconsistent patient care experiences and damage the JMH’s public status. For example, at the Mayo Clinic, TL helped implement standardized communication tools, reducing handoff errors. A rise of one point in management scores was linked with a 3.4% reduction in fatigue and a 9% rise in job gratification (Hu et al., 2022).
The initiative to strengthen handoff communication at JMH presents a strategic opportunity to enhance security and care coordination. The integration of standardized protocols like SBAR and I-PASS, supported by Kotter’s change management model and guided through TL and CRM, ensures a structured and sustainable approach to communication improvement. Ongoing training and leadership engagement reduce errors, enhance team liability, and foster a culture of quality care across all shift transitions.
Alanazi, N. H., Alshamlani, Y., & Baker, O. G. (2022). The association between nurse managers’ transformational leadership and quality of patient care: A systematic review. International Nursing Review, 70(2), 175–184. https://doi.org/10.1111/inr.12819
Bindra, A., Sameera, V., & Rath, G. P. (2021). Human errors and their prevention in healthcare. Journal of Anaesthesiology Clinical Pharmacology, 37(3), 328–335. https://doi.org/10.4103/joacp.joacp_364_19
Chien, L. J., Slade, D., Dahm, M. R., Brady, B., Roberts, E., Goncharov, L., Taylor, J., Eggins, S., & Thornton, A. (2022). Improving patient‐centred care through a tailored intervention addressing nursing clinical handover communication in its organizational and cultural context. Journal of Advanced Nursing, 78(5), 1413–1430. https://doi.org/10.1111/jan.15110
Harrison, R., Fischer, S., Walpola, R. L., Chauhan, A., Babalola, T., Mears, S., & Le-Dao, H. (2021). Where do models for change management, improvement, and implementation meet? A systematic review of the applications of change management models in healthcare. Journal of Healthcare Leadership, 13(2), 85–108. https://doi.org/10.2147/JHL.S289176
Hu, J. S., Phillips, J., Wee, C. P., & Pangaro, L. N. (2022). Physician burnout—evidence that leadership behaviors make a difference: A cross-sectional survey of an academic medical center. Military Medicine, 188(7), e1580. https://doi.org/10.1093/milmed/usac312
Kazemi, S., Hashemi, S., Rahmani, A., & Mahmoudi, H. (2024). Investigating the impact of nursing shift change audit on the safety of emergency department patients. International Emergency Nursing, 78, 101551. https://doi.org/10.1016/j.ienj.2024.101551
Nasiri, E., Lotfi, M., Mahdavinoor, S. M. M., & Rafiei, M. H. (2021). The impact of a structured handover checklist for intraoperative staff shift changes on effective communication, OR team satisfaction, and patient safety: A pilot study. Patient Safety in Surgery, 15(1). https://doi.org/10.1186/s13037-021-00299-1
Rehm, C., Zoller, R., Schenk, A., Müller, N., Nerschbach, N., Zenker, S., & Schindler, E. (2021). Evaluation of a paper-based checklist versus an electronic handover tool based on the Situation Background Assessment Recommendation (SBAR) concept in patients after surgery for congenital heart disease. Journal of Clinical Medicine, 10(24), 5724. https://doi.org/10.3390/jcm10245724
Samardžić, M., Doorn, C. M., & Maynard, M. T. (2021). What do we really know about crew resource management in healthcare? Journal of Patient Safety, 17(8), e929–e958. https://doi.org/10.1097/pts.0000000000000816
t initiative. Pediatric Quality & Safety, 9(3), e726. https://doi.org/10.1097/pq9.0000000000000726
Olatoye, F. O., Elufioye, O. A., Okoye, C., Nwankwo, E., & Olakunle, J. (2024). Leadership styles and their impact on healthcare management effectiveness: A review. International Journal of Science and Research Archive, 11(1), 2022–2032. https://doi.org/10.30574/ijsra.2024.11.1.0271
Omonaiye, O., Stockham, K., Darzins, P., Kitt, C., Newnham, E., Taylor, N. F., & Considine, J. (2024). Hospital discharge processes: Insights from patients, caregivers, and staff in an Australian healthcare setting. Public Library of Science ONE, 19(9), e0308042. https://doi.org/10.1371/journal.pone.0308042
Rahpeima, E., Bijani, M., Karimi, S., Alkame, A., & Dehghan, A. (2022). Effect of the Implementation of interdisciplinary discharge planning on treatment adherence and readmission in patients undergoing coronary artery angioplasty. Investigación Y Educación En Enfermería, 40(2). https://doi.org/10.17533/udea.iee.v40n2e08
