The quality of communication interactions between nurses and patients has a huge
impact on patient outcomes.

As the largest members of the healthcare team, nurses are routinely involved in
communication to patients, providers, and families.

The problem discussed in the project was poor communication among nurses.

The challenge of communication especially during shift handoffs was observed to
affect the quality of care and patient safety.

A quality improvement program was required to address the increasing rate of
medication errors, low patient satisfaction scores, and other safety events.

Through the use of evidence-based practices, the use of SBAR communication
technique was proposed to solve the problem.

Explanation of How Gap was Bridged

Poor communication between nurses and
other health care providers can have a
significant negative effect on patient safety,
quality of care, and patient outcomes
(Muller et al., 2018).

The problem identified in the facility was
poor communication that resulted in poor
patient satisfaction and medication errors.

There was a lack of a communication
protocol that could ensure a clear passage of
patient information during shift handoffs.

Presentation of shift handoffs at the nursing
station instead of the patient’s bedside was
also a challenge.

Explanation of How Gap was Bridged

The review of the literature indicated that the use of communication tools could help
in addressing the healthcare issue.

The Institute for Healthcare Improvement (IHI) SBAR communication tool was
identified to address the communication problem.

The reason for selecting this tool was because it offered a practical strategy to assist
nurses to implement a non-hierarchical communication model for improving clinical
care outcomes (Bonds, 2018).

Upon full implementation of the new change, shift handoffs were done at the
patient’s bedside using the SBAR communication technique.

Today, a standardized communication strategy for nurses exists in the organization.

Developing and Launching the Project

Step 1 involved seeking approval from the hospital administration to implement the

To gain the support of the administration, the clinical nurse educator was used to
influence the administrators towards accepting the project.

Step 2 involved a review of literature and communication of the new project to the
nursing team and other stakeholders.

The literature review identified areas of consensus among researchers that supported
the implementation of the project.

Communication of the project to the employees was made through the
administration, internal memos, and the use of noticeboards.

Developing and Launching the Project

Step 3 involved the identification of key stakeholders and the definition of their

Key stakeholders for the project included the project manager (me), hospital
administration, nursing team, clinical nurse educator, and the information technology

Step 4 involved education and training for the nurses and other healthcare providers
on SBAR communication.

Step 5 involved the identification of the implementation team and monitoring of the
new change.

Developing and Launching the Project

Discussion of Successes

The first aspect of success for the project was the ability to convince the
organization to support the project.

The second aspect of success was the improvement in the awareness of staff about
the importance of communication in healthcare.

The project was successful in demonstrating the use of evidence-based practices to
improve quality and patient safety

Supported by the IHI and other professional organizations, SBAR communication
worked perfectly to improve communication among nurses.

The implementation of the project managed to inculcate the spirit of teamwork and
interprofessional collaboration in nurses.

How Successes Will Inform Future Projects

The first aspect that can be emphasized in future projects is the implementation of
change using strategies that are well-supported by evidence.

It was easier to implement SBAR communication in the unit because clear
guidelines on the use of the technique were available.

The second aspect that can be emphasized in future research is the importance of
education and training of employees during change management.

Another aspect that can be copied in future projects is the multidisciplinary approach
to change management.

The involvement of several healthcare teams and the formation of a
multidisciplinary committee greatly helped realize better outcomes.

Aspects that Did Not Go Well

Projects can fail to go well due to barriers such as inadequate leadership support,
financial constraints, time, and lack of employee involvement.

The first obstacle observed was a lack of organizational readiness for the new
change process.

The second aspect was the lack of enough time to coordinate events during the
process implementation phase.

Nurses especially those in the night duty found it difficult to attend the training
sessions due to lack of time.

An extra week was required to fully implement the new change.

Understanding What Did Not Go well

In future projects, the project manager should assess the position of the organization
in accepting new change proposals.

Future projects should involve employees from the start including the collection of
views and addressing issues of concern before implementation.

Proper timing of projects through the creation of a project schedule in the future will
help solve the issue of organizational readiness.

Future projects should begin with consultation from the administrators to promote
acceptance and support of change initiatives.

Supporting the Plan

The short-term plan to support the
project will involve the use of the BSR
checklist by the charge nurses. The
composition of the checklist is
provided in the next table.

The second strategy will involve
routine audits to ascertain the
improvement of communication.

Long-term maintenance will involve
the use of education and training.

The use of policies will ensure the
practice is sustained in the institution.

Resources for Post-Implementation

BSR checklists will be required during the short-term sustainability of the project.

The checklists will be used by the charge nurses to monitor SBAR communication
in every handoff shift

Conference room for education and training programs.

Hospital whiteboards for communication of strategies to patients.

Computers and screens for demonstration of communication during training.

Clinical nurse educator to facilitate education sessions.

Information technology team to assist during education, training, and
communication of information in the facility.

Integration of MSN Program Outcomes

Assemble Scientific Findings

The fourth MSN program outcome requires nurses to assemble scientific findings
from nursing, biopsychosocial fields, genetics, public health, and organizational
sciences for the continual improvement of nursing care across diverse settings.

The project involved a literature search of 30 credible sources that formed the
foundation of the intervention used.

The project used evidence-based practice from the literature to implement SBAR
communication. strategy in the institution.

The communication strategy used was supported by professional organizations like
the IHI, the Joint Commission, and the WHO.

Integration of MSN Program Outcomes

Interprofessional Collaboration

The seventh MSN program outcome requires the nurse to construct interprofessional
teams to communicate, coordinate, collaborate, and consult with other health
professionals to advance a culture of excellence.

Interprofessional teams during project implementation included the nurses,
physicians, IT team, research department, and administrators.

During the education of nurses, the clinical nurse educator collaborated with the
CMS representatives.

The IT team worked collaboratively with the nurses and the nurse educator to ensure
the success of the project.


Bonds, R. L. (2018). SBAR tool implementation to advance communication, teamwork, and the
perception of patient safety culture. Creative Nursing, 24(2), 116–123.

Institute for Healthcare Improvement. (n.d.). SBAR tool:

Moss, E., Seifert, P. C., & O’Sullivan, A. (2016). Registered nurses as interprofessional collaborative
partners: Creating value-based outcomes. Online Journal of Issues in Nursing, 21(3), 4.

Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W. E., & Stock, S. (2018). Impact of the
communication and patient hand-off tool SBAR on patient safety: A systematic review. BMJ
Open, 8(8), e022202. https://doi.org/10.1136/bmjopen-2018-022202