Bedside Shift Report: A Way to Improve Patient and Family Satisfaction with Nursing Care

Poor communication during the handoff process contributes to approximately 30% of malpractice claims costing up to $1.3 billion annually (Fenner, 2017), which demonstrates the importance of evaluating the quality of information exchange between nurses, patients, and families when associating quality of care to patient satisfaction (Kullberg et al.,2017). The following question guided this Evidence-Based Project (EBP) project. In adult, progressive care unit patients (P), does the implementation of a nursing bedside handoff (I) compared to current handoff practices (C) improve patient/family satisfaction with nursing care (O) over eight weeks (T)? The literature revealed evidence from 10 studies answering the practice problem and supported implementing a Bedside Handoff (BSH) bundle. Themes from the evidence included patient and family participation in care, bedside handoff and impact on patient and family satisfaction, nursing perceptions associated with bedside handoff process, and measuring patient and family satisfaction with nursing care. The BSH bundle included staff education, utilization of a standardized handoff communication tool, safety checks, and use of patient whiteboards. Direct observation occurred to understand staff compliance using the Handoff Observation Feedback Audit Tool. The project demonstrated that bundling evidence-based practices improved specific nursing care aspects that influence the patient and staff experiences and satisfaction survey results. BEDSIDE SHIFT REPORT AND PATIENT SATISFACTION 1 Bedside Shift Report A Way to Improve Patient and Family Satisfaction with Nursing Care The bedside handoff (BSH) demonstrates one of many strategies hospitals throughout the United States employ to encourage patients and families to participate in care and improve the patient/family hospital experience. The BSH process enhances the culture of patient safety, the delivery of care, and minimizes flaws in communication that compromise care resulting in unintended healthcare costs (da Silva dos Santos et al., 2018). When evaluating nursing care delivery and communication, the evidence-based approach of the BSH process shows improvement in patient/family satisfaction survey scores. (Radtke, 2013). This evidence-based practice (EBP) change project endeavors to assess patient/family perceptions of nursing care preimplementation and post-implementation of a nursing BSH bundle. The project proposal evaluates the evidence of BSH and explains the methodology of the project intervention. It also discusses practice recommendations based on the evidence, measures and outcomes, results, impact, sustainability, and dissemination. Significance of the Practice Problem The Agency for Healthcare Research & Quality (AHRQ) (n.d.) identifies the handoff process as a significant cause and contributor of adverse events, especially in the acute care and critical care areas. Considered the leading cause of deaths due to preventable errors in the US, the impact of poor communication leads to approximately 1,000 deaths per day and results in $2.9 billion spent each year nationally (Institute of Medicine, 2010). Poor communication makes up 30% of all malpractice claims, with $1.7 billion spent annually on organizations' payouts across the nation (Fenner, 2017). The organizational cost associated with medication errors, adverse events, or deaths is $50,000 per/injury (P. Ciampa, personal communication, November

Patient satisfaction surveys distributed by organizations to measure multiple nursing care dimensions link information exchange to patient-family satisfaction (Kullberg et al.,2017).

Hospitals use the Consumer Assessment of Healthcare Providers and Systems (HCAPS) survey
to collect data to understand patient satisfaction with nursing care and communication. The HCAPS patient satisfaction survey reported the VA Medical Center of Tampa, Florida, received a patient satisfaction percentage of 77%. This percentage exceeds the state rate of 76% but registers lower than the national percentage of 81% for patients who report satisfaction with nursing care and communication (U.S. Centers Medicare & Medicaid Services, n.d.). The significance of the HCAPS survey data identifies the need for improvement of patient satisfaction within the organization. The HCAPS survey fails to recognize unit specific patient satisfaction. Generalized assumptions of the survey results make it difficult to understand patient and family-specific needs from different types of units of care. Due to the unique needs of complex patients, the Nursing Intensive Care Satisfaction Scale (NICSS) was used in this project to measure satisfaction with nursing care from the critical care patient's perspective.

PICOT Question
In adult progressive care unit patients (P), does the implementation of a nursing bedside handoff (I) compared to current handoff practices (C) improve patient/family satisfaction with nursing care (O) over eight weeks (T)?

Population
Registered nurses, patients, and families on PCU served as the targeted population for the intervention. Registered nurses were the primary individuals to facilitate the change intervention, and non-licensed nursing staff and nurses who floated to the unit were excluded. Patients and families participated voluntarily and were queried to determine they met the following inclusion criteria. Patient survey distribution occurred if the patient spent ≥ 24 hours in the PCU setting and participated in ≥1 BSH or spent ≤24 hours in the unit and participated in at least one BSH during their stay on the PCU unit. Patients unable to participate due to medical limitations spent ≤24 hours in the unit and did not participate in BSH were excluded from the project.

Intervention
The change intervention included implementing a BSH bundle that included staff education, and utilization of a standardized handoff communication tool, safety checks, and use of patient whiteboards. The implementation of a nursing BSH bundle provided a strategy that focused on reducing avoidable adverse patient outcomes associated with communication, supported the delivery of PFCC, improved patient/family satisfaction with nursing care, and improved nurse-to-nurse accountability (AHRQ, 2017;Goldfarb et al., 2017;Small & Fitzpatrick, 2017;Starmer et al., 2013;Tobiano et al., 2018 ).

Comparison
The bundled intervention was compared to current handoff practices, which involved inconsistent shift-to-shift handoff practices. Inconsistencies included handoff reports occurring at the bedside, outside of the patient's room, and at the nurses' station. Nurses were expected to deliver PFCC by modifying traditional shift-to-shift handoff/report and including and allowing patient and family input during the handoff process (Herbst et al., 2013).

Outcome
This project intended to improve patient and family satisfaction with nursing care and staff satisfaction with the handoff process in a specialized critical care area. The patient and family satisfaction level with nursing care was compared to baseline data, where nurses did not use the BSH bundle. collectively generated 1,413 articles written in English from peer-reviewed journals. After removing 50 duplicates, a total of 1,363 non-duplicate articles underwent further screening.
Additional screening practices excluded 1,225 articles after applying limiters. An abstract and title review eliminated 128 full-text articles. After all limiters were applied, and title and abstract reviewed, a total of 10 articles were included for analysis. Of the ten studies included, the designs varied and included mixed-method, qualitative, quantitative, systematic reviews, and systematic reviews with meta-analysis studies. A flow diagram illustrates the study selection process (see Figure 1).
The John Hopkins Nursing Evidence-Based Practice evidence level and quality guide was used to grade the level and quality of evidence for primary and systematic review literature (Dang & Dearholt, 2017). The primary research level of evidence varied from Level II, III & V, with the quality grade of literature ranging from A-B. The study graded as Level III was conducted on a single unit, and the Level V graded body of evidence was classified as such because it was based on a consensus panel using scientific evidence and clinical practice guidelines (see Appendix A). There were two systematic reviews and one systematic review with meta-analysis. All three were rated Level IA studies (see Appendix B). The identified evidence supported implementing the BSH bundle as an effective strategy to improve patient/family satisfaction with nursing care and answered the clinical question.

Themes from the Evidence
All studies selected contained supportive evidence answering the proposed clinical question. The literature sources were synthesized by conducting a rigorous analysis of the evidence to identify common themes, trends, and perspectives related to the nursing BSH process. The literature review findings were summarized and compared to understand the research results better, noting similarities and differences. The literature synthesis identified the following four themes: patient/family participation in care, bedside handoff and impact on patient/family satisfaction, nursing perceptions associated with bedside handoff process, and measuring patient and family satisfaction with nursing care (see Figure 2).

Patient and Family Participation in Bedside Handoff
Extensive documentation shows BSH, including the patient/family, increases and promotes timely and effective communication between nurses, patients, and families (Clark et al., 2016;Malfait et al., 2019). Two articles identified families as surrogates and recognized family as a vital component to the decision-making process and part of the experience when patients could not do so themselves (Clark et al., 2016;Goldfarb et al., 2017). In contrast, other evidence suggested patients held mixed views about family involvement. However, nurses identified the family as a valuable resource when the patient could not participate (Tobiano et al., 2018). Evidence suggests increased tension, dissatisfaction, and poor patient outcomes occur when healthcare providers cannot align with patient/family values and goals of care (Goldfarb et al. 2017). One study indicated the BSH process helped patients feel informed, giving them an increased sense of control/relief. These patients reported satisfaction with nurse responsiveness and identified confidentiality breaches were not a significant concern (Luperi et al., 2016). The evidence identified that the BSH keeps patients/families informed when they actively participate, improves health outcomes, increases patient and family satisfaction, and offers a validated method for delivering PFCC ( Bigani & Correia, 2018;Clark et al., 2016;Elue et al., 2017). Luperi et al. (2016) indicated the BSH process should include a framework that allows patients to progressively engage in the process at different stages ranging from informative to shared decision-making when their condition permits or patients express a willingness to participate (see Appendices A and B).

Bedside Handoff and Impact on Patient and Family Satisfaction
Several studies reported BSH positively impacted patient/family satisfaction and satisfaction heavily correlated with effective communication strategies (Bigani et al., 2018;Clark et al., 2016;Elue et al., 2019;Skaggs et al., 2018). The literature identified specific nursing care components that influence patient/family satisfaction with care and included: nurses explaining things well, professionalism, nurse attentiveness, timeliness, and technical skills increased patient/family satisfaction with nursing care. Characteristics such as lack of attention and poor/lacking communication reported a negative impact on patient/family satisfaction (Clark et al., 2016;Elu et al., 2019;Lupieri et al.,2015;Romero-Garcia et al., 2019). Only one study reported that nurse-led intensive communication strategies failed to demonstrate an improvement in patient satisfaction (Goldfarb et al., 2107). Two studies measured patient satisfaction using

Nursing Perceptions and Bedside Handoff
Nurse perceptions varied amongst multiple studies. The evidence suggests nurses lack training and understanding of the Health Insurance Portability and Accountability Act (HIPPA), causing discomfort, avoidance, and stress during the implementation of BSH (Small & Fitzpatrick, 2017). One study indicated that nurses primarily viewed BSH in the traditional sense as occurring outside of the room and lacked structure resulting in a weak exchange of information (Small & Fitzpatrick, 2017). Two articles indicated nurses identified BSH as timeconsuming and raised concern for breaches in patient confidentiality (Bigani & Correia, 2018;Small & Fitzpatrick, 2017). Three studies validated that nurses reported BSH as the preferred form of shift handoff, improving accountability, patient safety, and patient participation (Bigani & Correia, 2018;Lupieri et al., 2016;Small & Fitzpatrick, 2017). Staff education and simulation training was considered an effective strategy to overcome barriers and supported staff engagement. The utilization of safety checks and patient/family inclusion during BSH confirmed reduced risk and improved patient safety outcomes. Lastly, audit tools provided an effective strategy to monitor compliance with the BSH process (Bigani & Correia, 2018;Skaggs et al., 2018;Small & Fitzpatrick, 2017;Tobiano et al., 2018) (see Appendix A).

Measuring Patient and Family Satisfaction with Nursing Care
Measuring patient/family satisfaction with care using a valid and reliable tool is essential to understanding nursing care delivery and quality. The literature identified several different surveys that measured patient/family satisfaction. Two research studies used the HCAPS survey (Elu et al., 2019;Small & Fitzpatrick, 2017). Elu et al. (2019) identified delayed results with little movement in HCAP scores, while Small & Fitzpatrick (2017) reported improved patient satisfaction survey results after implementing BSH. Clark et al. (2016) identified that the HCAP survey failed to measure patient and family satisfaction in the ICU setting and instead utilized the Family-Satisfaction in the ICU-24 (FS-ICU-24). The FS-ICU-24 questionnaire was identified as a valid and reliable tool to measure family satisfaction with care and decision-making in the ICU (Clark et al., 2016). Romero-Garcia et al. (2019) identified the NICSS as the only valid and reliable questionnaire that evaluated satisfaction from the critically ill patient perspective (see Appendix A).
In Summary, patient/family and staff satisfaction increased with the implementation and utilization of the BSH process in most of the studies reviewed in this literature search (Bigani & Correia, 2018;Elu et al., 2017;Goldfarb et al., 2017;Lupieri et al., 2016). Multiple studies confirmed that the BSH should consist of a standardized process that integrates safety checks and include utilizing a scripted report involving the patient and family (Bigani & Correia, 2018;Skaggs et al., 2018Small & Fitzpatrick, 2017. The use of patient whiteboards offered a costeffective measure to include patients in developing the patient care plan (Tobiano et al., 2018).
The research supported using a valid and reliable tool to measure patient/family satisfaction to improve nursing care processes (Romero-Garcia et al., 2019) (see Appendix A&B). The evidence suggests the organization will benefit from utilizing a more formalized and structured nursing BSH process.

Practice Recommendations
The recommended change is implementing a nursing BSH bundle to increase patient/ family satisfaction with nursing care. The BSH bundle consists of multiple evidence-based strategies validated in the literature. The bundle contains the following elements: nurse and patient/family education, utilizing a universal report "ISHAPED" (I=Introduction, S=Story, H=History, A=Assessment, P=Plan, E=Error Prevention, D=Dialogue) handoff tool, safety checks, and use of communication whiteboards. The implementation of these interventions offers a strategy for the exchange of information during the handoff process and provides nurses a systematic approach to engage in timely, accurate, and effective communication with peers, patients, and families (Bigani & Correia, 2018;Clark et al., 2016;Elue et al., 2017). Also, a patient-centered and structured handoff tool provides an opportunity to increase patient and family participation in the delivery of care conversations, maintains patient safety, promotes teamwork and accountability, and helps nurses understand patient/family values and goals of care (Bigani & Correia, 2018;Clark et al., 2016;Elue et al., 2017;Lupieri et al., 2016;Skaggs et al., 2018;Small & Fitzpatrick, 2017;Tobiano et al., 2018). The BSH process was an effective method to improve nursing communication, accountability, coordination of care, and validated patient/family information. The conduction of safety checks positively impacted nurse-sensitive indicators (Bigani & Correia, 2018). Patient whiteboards offer a communication tool and visual aid to display the patient's plan of care goals, preferences, and other daily reminders (Tobiano et al., 2018). The use of valid and reliable tools supports the delivery of nursing care and patient and family satisfaction with nursing care and staff satisfaction with the handoff process.

Description
The project occurred at a large West Central quaternary academic medical center located in Florida (U.S. Department of Veterans Affairs, 2018). The project site is part of an extensive healthcare system servicing four counties in Central Florida. The organization is part of a large

Organizational Need
Using the Medicare Hospital Compare Data Results of Patient Experience, information obtained from the survey results indicated lower patient satisfaction scores than National averages for patients reporting satisfaction with nursing communication (Medicare, n.d.).
Furthermore, the Medicare Hospital Compare data provides organizational patient satisfaction scores but fails to identify unit-specific information, especially in the critical care section.
Considered part of the critical care section, the PCU was selected because most patients are physically/mentally able to communicate orally and participate in the handoff process.
Additional considerations include PCU's interest in supporting the organization's mission to improve patient and family satisfaction with care.

Stakeholders
Key stakeholders were identified by using the "Key Stakeholder D.A.N.C.E" tool. The stands for decision, authority, need, connections, and energy (Kogon et al., 2015). The following individuals were identified as key stakeholders to assist with the successful implementation and completion of the project. Key stakeholders included the Nurse Manager (NM) and Doctorate of Nursing Practice (DNP) student/ Project Manager (PM) to make decisions, the Chief Nurse of Acute Care for authority, nursing staff representatives for needs, Assistant Nurse Manager (ANM), project champions, and patient representative for connections, and patients/families and nurses represent the energy (Kogon et al., 2015).

Organizational Support
The Nurse Manager and the Chief Nurse of Acute Care provided organizational support.
The Director of Nursing Education also endorsed approval, and permission to complete the project was granted during initial meetings. Random queries with the PCU staff provided feedback and identified mixed interest in the proposed project. Understanding each key stakeholder's perspectives proved an essential step in achieving the desired results of the plan (Kogon et al.,2015). The organization maintains a high level of commitment to continuous quality improvement and actively trains and practices Lean Six Sigma principles. Staff is knowledgeable and familiar with the utilization of Lean practices in the PCU, and their baseline knowledge of EBP supported the project's success.

Interprofessional Collaboration.
The project focused on developing a common language for team communication during the BSH process. Presenting information to team members, patients, and families in an easy to understand manner contributes to safe and effective interprofessional care (Interprofessional Education Collaborative Expert Panel, 2016). The project focused on developing team-based competencies and patient and family education to increase the teams' understanding of why, when, and how to use the BSH process and associated bundle components (Bradley, 2003).

Sustainability
EBP improvement involves a change in the organizational culture and addresses the need for modified behavior changes to sustain EBP improvement outcomes. According to Hovlid et al. (2012), sustained improvements occurring after a systematic change represent organizational learning. The PM created a PowerPoint presentation and reviewed the reproducible educational training content and baseline data with NM and ANM to obtain feedback before dissemination.
Staff education included content on BSH practices and instructions on utilizing the BSH bundle to sustain project outcomes.

Strength, Weakness, Opportunity, and Threat Analysis
A Strengths, Weakness, Opportunity, and Threat (SWOT) analysis was completed to determine the PCU's readiness to implement change. The SWOT identified positive and negative factors providing an avenue for prioritizing project needs (see Appendix C). Opportunities for improvement include enhancing the delivery of PFCC by establishing a standardized process to improve communication, patient safety, and peer-to-peer accountability by creating a BSH bundle.

Project's Vision and Mission
The organizational mission is to serve and honor Veterans by delivering exceptional care (U.S. Department of Veterans Affairs, 2019b, para. 6). The project vision was to embrace the "delivery of 5-star care" by delivering patient-centered evidence-based care (U.S. Department of Veterans Affairs, 2019b, para. 7). The mission and vision of the project aligned with the organization through its patient-centered and evidence-based approach.

Objectives
The EBP change project aimed to understand if nurses' specific set of actions supported the reliable and accurate exchange of information and improved patient/family participation in the handoff process. The BSH bundle's premise was to improve patient satisfaction with nursing care and staff satisfaction with the handoff process. The main objective was to compare preimplementation and post-implementation data to identify the clinical and statistical impact of the BSH bundle. The long-term objective was to sustain project outcomes with a policy change to include using the BSH bundle as the standard for nurses when giving shift-to-shift handoff throughout the organization.

Unintended Consequences and Risks
The project's goal was to enhance the communication and delivery of PFCC to improve patient/family and staff satisfaction. Unintended consequences for this project include medication errors, patient falls during the change of shift, delivery of inaccurate/incomplete information, technical failures, no improvement or impact on patient/family satisfaction with nursing care or staff satisfaction with the handoff process, and lack of staff engagement with using the BSH bundle during the change of shift time period. The most significant and expected barrier was staff resistance to change. Consequently, the BSH bundle supported operational changes in the PCU setting as they adapted to changes associated with the global Coronavirus (COVID-19) pandemic. Risk avoidance led to no overtime cost or adverse outcomes caused by inadequate communication during the handoff process.

Project Plan (Method)
The goal was to develop and trial a new BSH bundle using Kotter's framework to implement the change project. The project directed nurses to report and discuss critical elements associated with patient care to minimize risk and support peer-to-peer accountability (Small et al., 2016).

Kotter's Framework Model
Kotter's eight-step framework guided the BSH change process since it was identified as a practical framework to institutionalize change. Kotter's eight-step model of change includes (1) Create a sense of urgency, (2) Form a guiding coalition, (3) Create a vision, (4) Communicate the vision, (5) Empower others to act on the vision, (6) Establish quick wins, (7) Build on change, and (8) Institutionalize the change .

Create A Sense of Urgency
A sense of urgency was created based on the evidence found in the literature associated with BSH practices. The management and Project Manager (PM) highlighted the potential risks and impact of inadequate handoff procedures and implications for poor patient outcomes resulting from poor handoff practices. By highlighting risks, staff understood the importance of maintaining patient safety, the need for using a standardized communication tool, and the benefit of a BSH bundle (Small et al., 2016). A review of current hospital policies and the unit needs assessment findings were also used to create a sense of urgency. Baseline unit data was collected to demonstrate the magnitude of the problem and the need for practice change. Manager rounding was encouraged as a strategy to communicate urgency and the importance of the practice change (Small et al., 2016).

Form A Coalition
Workgroup members selected to help drive the EBP change project included the PM, unit manager, chief nurse, one project champion from day shift and night shift, and a nurse educator.
These individuals learned how to utilize and apply Kotter's framework to help facilitate changes in the BSH process (Small et al., 2016).

Create A Vision
Group members created a vision and identified key priorities discussed in the literature.
The group established nursing expectations and formalized the communication plan to utilize during the handoff process (Small et al., 2016). The project manager and project champions communicated the project timeline, goals, and objectives. Efforts enhanced staff connections between understanding the importance of handoff and its impact on patient safety.

Communicate the Vision
The project plan and mission were shared with staff by hosting education sessions to disseminate information and allow time for questions and answering concerns (Small et al., 2016). The NM, ANM, and PM supported the driving force to move change in a forward direction. Project team members utilized multiple communication forums such as education sessions, one-on-one conversations, and small group discussions with staff to offer support and guidance (Joshi et al., 2014). Project team members facilitated momentum as change agents displaying excitement about the vision and use of the BSH bundle.

Empower Others
Improving the culture of quality cannot occur without the participation and insight from the staff. The BSH bundle's use encouraged staff to speak up about patient safety concerns and helped promote peer-to-peer accountability. Management provided ongoing support to ensure that staff were clear about their roles and expectations and offered staff an opportunity to have control over BSH practices. Staff utilized the current organizational standardized communication tool ISHAPED, developed safety checklist and patient whiteboards autonomously. Random process audits evaluated staff compliance with various components of the BSH bundle. Audit findings were shared and communicated to staff to identify process gaps, generate discussion to help overcome barriers, and develop action plans to meet project goals and objectives.

Establish Quick Wins
The project plan included breaking the intervention feedback plan down into smaller, more tangible steps. Providing feedback to staff about the various components of the BSH bundle prevented staff from feeling overwhelmed and encouraged staff participation and buy-in.
Staff needed to see that their efforts contributed to the change process and awarding them for their efforts supported the project change efforts (Joshi et al., 2014). Quick wins were identified, such as staff engagement, improved communications, and the use of whiteboards. Methods used to acknowledge quick wins included recognition "in the moment" or at the time of handoff, in group settings, and during staff in-services. Data metrics that moved in a positive direction provided a sounding board to celebrate achievements toward meeting established goals and benchmarks. At the close of the project, a celebration meeting was hosted to recognize key stakeholders and share team successes.

Build on Change
Ongoing monitoring, reflecting on work practices, and reviewing process outcome measures at frequent intervals facilitated change. The project goal included staff transition to the integration and sustainment of a new BSH workflow process. The BSH bundle represents the standard of care nurses facilitate and use during the end-of-shift handoff. Also, a yearly staff competency checklist and audit tool was developed (see Appendix G). Sustainability was maintained by identifying champions of change at various levels within the organization. The purpose of preserving project champions is to inspire, coach, and mentor staff and hold them accountable for sustaining project objectives, goals, and expectations.

Institutionalize the Change
Staff and leaders discussed project outcomes and the current state of the project at its conclusion. To further promote the EBP project's sustainability, unit managers and designated unit champions were provided recommendations. Recommendations included the BSH Observational Feedback Audit Tool's continued use to monitor staff compliance with BSH bundle components and incorporation of the BSH education plan in unit nursing orientation plan.
Additional recommendations included the need for ongoing training and modifications to the current hospital handoff policy to use the BSH bundle. Chaghari et al. (2017) noted that inservice training supports staff competencies and achievement of organization goals. Direct observations also furnish an effective method to evaluate staff education and contribute to developing education plans.

Barriers and Facilitators
Barriers were anticipated and mitigated as best as possible. Staff were included in workgroup discussions and assisted with decision-making processes when problem-solving to build trust and gain buy-in. Involving the NM and ANM to participate in group discussions clarified staff expectations. Management officials were also encouraged to conduct leadership rounding to support staff compliance with handoff practices and processes. Project champions moved the project forward and helped staff overcome barriers to achieve project, timeline, goals, and outcomes. Project facilitators helped with the successful adaptation, uptake, and sustainability of the project and included executive and mid-level leadership and project champions (Harris et al., 2018).

Project Schedule
The project planning began with developing the project proposal and submitting the plan to the University of Saint Augustine's Evidence-Based Practice Project Review Council (EPRC) and Institutional Research and Development (R&D) Department for required review and approval. The timeline for the project was eight-weeks. Following approval, the team was assembled and prepared for implementation. Baseline data were collected, and training provided to project champions during weeks two and three. Staff was educated about the BSH bundle and project goals during week three. Weekly audits were done through direct observation, and audit findings were reported. Data collection and analysis occurred in weeks seven and eight. After week eight, all project data and outcomes were evaluated and analyzed. The PM shared project results with staff, unit management, and hospital leadership. Upon completion, handoff occurred with the PCU management to support project sustainability. A detailed project timeline is provided (see Appendix D).

Project Resources and Budget
Project resources utilized for this project included two-unit champions. The NM and ANM provided project and staff support, secured training sessions and materials, and a secure location to store patient/staff survey responses. The budget request for this project was submitted to hospital leadership for approval. Associated project costs included one-hour staff training sessions for twenty-nine employees at an average hourly rate of $35.00 per/ hour or $1,015.00 plus an additional $200.00 for office supplies such as paper, printing services, and whiteboard supplies for a total project cost of $1,215.00. Existing items included patient whiteboards located in each patient's room and electronic unit handoff forms situated in the organization nursing shared drive folder. There were no additional costs for these items. Financial costs associated with this project are documented in a budget table (see Table 1).

Evaluation Plan
The project evaluation plan examined whether implementing a BSH bundle improved patient and family satisfaction with nursing care compared to usual handoff practices within 60 days of implementation in a PCU setting. Kotter's eight-step model provided the framework for addressing the practice problem in the clinical setting. The project evaluation design involved comparing baseline data to post-intervention data. The PM recruited project participants, provided patient education, and distributed patient and staff surveys. The patient's primary care nurse assisted the PM with survey collection and safe storage of survey responses.
The DNP student functioned as the PM. The PM's roles and responsibilities included data collection, organization, analysis, and evaluation of data results. The data collection process began after University EPRC and R&D facility approvals. Data and surveys responses collected for this project did not contain patient sensitive information and upheld the anonymity of project participants. Data and survey responses were organized by the PM and stored in an electronic folder on a secure computer requiring a Personal Identification Verification (PIV) for login access. Password protection added additional security.
Process measures data were collected by developing a direct observation feedback tool (see Appendix G). Baseline data and post-intervention staff observation data metrics were compared and reported staff compliance using the BSH bundle components. Routine evaluations were conducted and included staff and key stakeholders' advice and criticisms from formal and informal methods. Feedback was used to determine the need for project modifications to help meet project goals and objectives. Data from outcomes are reflective of the impact of the intervention. Patient and family dissatisfaction and staff training costs were used as balancing measures. The project's balancing efforts helped identify unintended consequences of the project, such as unplanned overtime costs or lack of patient/family satisfaction resulting from the practice change. Financial measures monitored project costs and were evaluated weekly to ensure budget adherence. Financial benchmarks were established to adhere to the education time frame. The project budget was successfully met.

Variables
The independent variable in this project was the implementation of a BSH bundle.
Dependent variables for the project include gender, degree, and years of nursing experience.
Other dependent variables included nurse utilization of the ISHAPED handoff tool, participation and completion of safety checks, and utilization of patient whiteboards. Dependent variables were analyzed to determine if the BSH bundle components effectively improved patient satisfaction with nursing care and nurse satisfaction with the handoff process.

Missing Data
Observation audit feedback tool forms and staff surveys were collected daily and reviewed for completion and missing data. Missing information on observation forms was clarified with the project champion to validate findings and ensure data collection accuracy amongst collectors. Survey questions not answered were omitted.

Participant Selection
This project's total population included nurses, patients, and families on a single critical care step-down unit. In response to COVID-19, changes in the visitation policy occurred, and families were no longer allowed in the facility and were excluded from the project. Staff was encouraged to support family participation during the BSH process by using Virtual Video Conferencing (VVC). Nurses floating to the unit participated in the handoff process but were not evaluated on the BSH bundle's use at the time of handoff.

Data Collection
The project team included a PM, NM, ANM, and project champions. The PM conducted the literature review, presented findings, and sought University and facility approvals. The PM led the project team, who coordinated staff training sessions and meetings, monitored progress, validated, and collected results. Additionally, the PM monitored project progress and adherence to the timeline. The PM made project modification based on stakeholder feedback and reported findings during and at the time of completion. Project champions were educated on the handoff observation feedback audit tool, and inter-rater reliability tested amongst users before the data collection process to ensure consistency of results (Sylvia & Terhaar, 2014, p.92).The patient's primary care nurse assisted the PM with survey collection and safekeeping of survey results. The NM, ANM, and project manager monitored staff compliance and project progress.

Data Measurement
Primary data collected during the project included pre-intervention and post-intervention data. Baseline data was collected over three weeks to compare pre-intervention handoff practices. Tools of measurement used during the project included the NICSS Questionnaire to measure patient satisfaction, The Nurse Feedback Questionnaire to measure staff satisfaction, and the Handoff Observation Feedback Audit tool to evaluate staff compliance. Descriptive statistics were used to provide a basic understanding of project data sets, variables, and relationships (Research Connections, 2019). An Excel database was used to collect and organize primary and secondary data. The Statistical Package for Social Sciences (SPSS) was used to analyze and compare baseline and intervention data. The data used to evaluate the intervention was collected over eight weeks.

Bedside Handoff Bundle Observational Feedback Audit Tool
The audit tool's purpose was to evaluate compliance with the use of the ISHAPED standardized handoff form, completion of safety checks, turning/repositioning, review of infusing medications, outstanding tasks/orders, and discussion of patient goals/plan of care.
Compliance was measured as the number of staff who updated or reviewed the specific bundle variable during observation and evaluated by the total number of staff observed at that same time. The project goal included ≥ 90% of staff compliance with BSH bundle components' utilization within 60 days. The observational feedback audit tool was developed and approved for use in the practice setting by the Chief of Education/DNP preceptor (see Appendix G).

Nursing Intensive Care Satisfaction Survey
The Families were excluded in response to COVID 19 pandemic.

Nurse Feedback Questionnaire
A nurse feedback tool was developed based on the evidence to understand nurse satisfaction with handoff practices (see Figure 3). The questions gathered descriptive statistics to understand participant demographics and measured changes in accountability, adequacy of communication at the change of shift, prioritization of workload, completion of medication reconciliation, and ability of the BSH to foster relationships. The tool was created electronically, consisted of five questions, and used a five-point Likert scale of strongly agree (1) to strongly disagree (5) to rate each item. A lower score reflects greater nursing satisfaction with the overall quality of the BSH process. All nurses were invited to participate. The survey was voluntary and anonymous.

Efforts to Minimize and Adjust for Limitations
This project's limitations included the staff's willingness to participate, decreased project timeline, and staff and patient experiences. Leadership rounding was encouraged, and project goals were reinforced with unit management and leadership to supports staff adherence and evaluate the patient experience. Other factors included conditions in response to the COVID-19 pandemic included: No family visitation and reduced staff contact and in-person meetings

Formative and Summative Evaluations
Aggregate data were collected weekly by observing the handoff process, and data reported bi-weekly to staff and unit management. Data findings were used to identify gaps, and data findings shared with stakeholders to overcome barriers. Project development and improvement were acknowledged based on formal and informal feedback, nursing huddles, brainstorming sessions, and audit tool reports. Monthly goal reporting was provided to leadership. Upon completing the EBP change project, the project manager analyzed project results and made practice recommendations based on baseline and post-intervention findings.
Suggestions to include the BSH bundle into unit orientation and modification to current handoff policy to include utilizing the bundle.

Measurements
The project interventions were measured using outcomes, process, balancing, and financial measures (see Table 2). The expected outcome was to improve patient satisfaction by 5% post-intervention. Data results were compared pre-intervention and post intervention. An unpaired t-test and Chi-Square test were used to analyze results; a p-value of ≤ .05 was considered statistically significant and contributed to improving outcomes post-intervention.
Simple percentages determined patient satisfaction for each element of nursing care. The goal was to achieve a patient satisfaction score of ≥70% for each category of the NICSS evaluating nursing care. Staff satisfaction questionnaire responses rated less than two indicated that the percent of staff agreement favored using a BSH bundle and indicated clinical significance.
Process measures evaluated staff education and staff compliance with using the BSH bundle. The anticipated goal for staff utilization of each BSH bundle variable and percent of staff educated before implementation was ≥ 90%. Balancing outcomes were used to identify if a new problem developed due to the intervention (Institute for Healthcare, 2020). The anticipated goal for balancing measure was to prevent unplanned overtime costs associated with the handoff process or patient and family dissatisfaction that resulted from the practice change. Financial measures monitored project costs and were evaluated weekly to ensure budget adherence. Financial benchmarks were established to adhere to education time frame allocations.

Results
Descriptive statistics were used to provide a basic understanding of project data sets,

variables, and relationships (Research Connections, 2019). The Handoff Observation Feedback
Audit Tool was used to collect pre-intervention and post-intervention data to compare and analyze results (see Appendix G). The method used to collect information occurred through direct observation. Post-intervention observation data indicated that staff compliance improved for all BSH bundle components.
A total of 13 out of 29 nurses (44% of staff) completed the pre-intervention and postintervention questionnaire. Six nurses completed the pre-intervention, and seven completed the post-intervention questionnaire. All 13 nurse survey responses were used in data analysis.
Twenty-three percent of participants identified as male, and 75% as female. Sixty-two percent of participants graduated with a Bachelor of Science Degree in Nursing (BSN) compared to 23% of participants with an Associate Degree in Nursing (ADN) and 15% of participants with a Master of Nursing Degree (MSN). Forty-six percent of participants had ≥20 years of nursing experience, followed by 31% percent with 16-20 years, 15% with 6-10 years, and 8% with 1-5 years.
A total of 24 out of 32 (93%) patients met inclusion criteria and participated in the project by completing the NICSS questionnaire. A total of eight patients completed the NICSS preintervention, and 16 patients completed the post-intervention questionnaire. Ninety-seven percent of patients identified as male, and three percent identified as female. This patient population reflects the general population and is expected since the male gender is the predominant population served (Bialik, 2017). Participants ranged in age from 41 to 93, with a mean age of 66.7. An unpaired-sample t-test assuming unequal variance test was used to calculate the differences between all NICSS categories to determine the intervention's effectiveness with improving patient satisfaction with nursing care.

Statistical and Clinical Significance
Observation data were graphed to visualize differences amongst bundle variables and note changes in staff compliance. Staff compliance regarding review of medications indicated no difference, and compliance remained 100% in the pre-observation and post-observation intervention period. Nurses' review of patient positioning had a higher rate of compliance in the post-observation data. Overall, staff compliance with using the BSH bundle increased for each variable and was clinically significant (See Table 3). A chi-square test was run to determine the statistical significance of BSH variables that most contributed to improving nursing care delivery. The variables determined to have statistical significance included using the ISHAPED standardized communication tool, visual review of IV access, and assessment of pending nursing tasks and orders (See Table 4). The complete Chi-square analysis is included and can be reviewed in greater detail (see Tables 5-15).The statistical significance of the individual bundle components fluctuated, indicating that some variables did not improve patient and staff outcomes and require further evaluation. Patient satisfaction with nursing care and staff satisfaction with the handoff process increased after implementing the BSH bundle. The project results validate the clinical significance of the intervention bundle.
The Nurse Handoff Questionnaire pre-mean scores ranged from 2.33 to 1.67 compared to post-mean scores ranging from 1.57 to 1.14 (see Figure 4) Table 5).
An unpaired-sample t-test assuming unequal variance test was used to calculate the differences between all NICSS categories. The unpaired t-test determined an increase in the total mean NICSS scores as 5.33 in the pre-NICSS and 5.46 in the post-NICSS questionnaire. The unpaired t-test reported (p = .008) for all NICSS categories (see Table 16). The results indicate a 2.4% increase in patient satisfaction post-intervention and suggest that patients were more satisfied with nursing care delivery when using the BSH bundle. The unpaired t-test determined that nursing communication, holistic care, and consequences had statistical significance (see Tables 17-20). Nursing professional behaviors reported (p = 1.782) (see Table 20). This finding was not statistically significant and was not shown to improve patient satisfaction; this finding is contrary to what was identified in the literature, which states professional behaviors influenced patient satisfaction (Romero-Garcia et al., 2019). Each of the NICSS categories had a patient satisfaction score of 100%, indicating no changes occurred in the pre-intervention and postintervention period. These results make it difficult to determine the specific nursing care aspects that influence patient satisfaction. Two participants reported not being satisfied with nursing care delivery and accounted for eight percent of the project population. Overall, patient satisfaction increased when considering all NICSS categories, confirming the BSH's clinical significance to improve patient satisfaction with nursing care.

Protection of Human Rights and Privacy
There was no implication of breaches in patient confidentiality. There were no reported incidences of HIPPA violations or violations of patient or staff confidentiality. The data and surveys did not contain patient sensitive information and maintained participant anonymity.
Paperwork collected for this project was scanned into an electronic drive/ folder located on a secure computer that was password protected and required PIV as a login requirement. Password protection was applied to the folder storing data to provide an extra layer of security. Paper documents were destroyed using facility procedures to dispose of any patient sensitive information in designated shredder bins to ensure proper destruction. A secure server-generated electronic surveys and responses of the end-user were kept safe. The project was submitted to university and organizational committees to evaluate any conflicts of interest and project approval.

Impact
During the EBP project, the data obtained supported the expected outcome to improve patient satisfaction with nursing care and staff satisfaction with the handoff process. The project results specific to patient satisfaction with nursing care is consistent with the literature findings, Limitations of the project included the increased concern of the coronavirus pandemic and surge of COVID-19 patient cases in the facility. As a result, the project timeline was decreased and not implemented as initially planned. Towards the end of the eight-weeks, the PCU began to transition into an ICU to accommodate more ICU bed needs. The pandemic led to increased responsibilities of the PCU nurses. The project should be reproduced and conducted over a more extended period and in the absence of a pandemic.

Recommendations
Additional considerations include following the same project outline with families to evaluate family satisfaction with nursing care and using the BSH bundle to assess patient outcomes, such as patient falls and medication errors. This project indicated a clinical benefit for patients and staff working in a PCU setting. Modifications to hospital policies and procedures are needed to support staff compliance and sustainability of project outcomes. This EBP project should be tested on other hospital units to validate project outcomes with different patient populations to refine EBP and determine project sustainability.

Plans for Dissemination
Upon completing the project, the PM initially shared results with the PCU staff, NM, and ANM. Staff was queried for feedback regarding project successes and failures to improve project sustainability. A visual report using Microsoft PowerPoint will be created and presented to the Intensive Care Unit (ICU) Committee in December; the visual report will highlight project outcomes, recommendations, and next steps. A summary report of the project and results will be presented to the Patient Care Executive Board (PCEB) after the semester's closing to discuss long-term goals, hospital-wide dissemination, and policy change to support project sustainability within the organization.
Additionally, the EBP project will be shared using the Veterans Integrated Service Network (VISN) using regional and national forums. These forums provide an electronic venue for e-poster presentations to share EBP to promote VISIN wide dissemination. Projects the costs were shared with leadership officials for budget planning. Conference attendance, registration fees, travel cost, poster development, and printed material will have an approximate cost/per episode of approximately $2,320 (see Table 1).
Long-term goals include submission to a peer-reviewed journal and presentation at local and national nursing conferences (see Appendix D). The following periodicals will be considered for publication: Hospital Topics, Nurse Leader, American Journal of Nursing, and American Association of Critical-Care Nurses. These nursing journals were selected because of their longstanding credibility and familiarity in nursing to publish evidence-based nursing practices.
Before publication, a manuscript will be created to suit the publication format. This EBP project's publication is considered a long-term goal, and the final version of the manuscript will be submitted for publication consideration. The EBP project was completed following DNP capstone requirements and archived in SOAR, the University of St. Augustine for Health Sciences institutional repository that showcases scholarly work.

Conclusion
This EBP project evaluated the BSH bundle's impact on improving patient satisfaction with nursing care and nurse satisfaction with the handoff process. Methods used to accomplish this included identifying the practice problem's significance, reviewing the literature, and addressing the proposed PICOT questions. Kotter's framework provided a systematic method to address the practice problem, and Peplau's theory was applied to promote change in the practice setting. An organizational assessment and the mission and vision statements were used to develop project goals and outcomes. A project timeline guided the project from beginning to end to complete the project in eight weeks successfully.
Staff education in-services, ongoing education, and a handoff observation audit tool supported the PM's ability to collect and analyze staff compliance with the BSH bundle. Preand post-intervention data was necessary to understand the intervention's effectiveness and its ability to improve patient satisfaction with nursing care and staff satisfaction with the handoff process.
Organizational support, budget planning, and data transparency contributed to the success of the project. Project dissemination is multidimensional and endorses the utilization of best-practices and life-long-learning in the healthcare profession. Implementing a nurse-driven BSH bundle was an effective evidence-based strategy that demonstrated clinical significance with its use over time and improved outcomes specific to patient satisfaction with nursing care and staff satisfaction with the handoff process. This project serves as a guide and reference for future projects looking to improve the handoff process, nursing care delivery, and patient and staff satisfaction.            Patient Preferences   Staff education is critical to staff buy-in and utilization of BSH.
Bedside report promoted patient safety and was the preferred form of change-of-shift handoff communication for nurses, patients, and families.
BSH increased accountability and transparency as everyone is involved at the bedside and assist in getting everyone on the same page.
Change of shift report is vital to nursing care and should be consistently coordinated to accomplish patient safety. BH was considered positive and useful, but patients reported wanting to be more involved during the process. The use of medical jargon excluded patients from conversations.
Patients wanted to assure that their privacy was maintained but listening to report more valuable to them than confidentiality.
Patients were satisfied with participating in BH excluded from the conversation.
Confidentiality is not an issue for patients, but nurses should use discretion when reporting patient sensitive information in others' presence.
BSH should be a process based on a framework that allows critically ill patients to be involved progressively at different stages from informative to shared decision making when their condition and willingness to participate in the BH process is expressed.