Date of Award

Summer 2022

Project Type


College or School




Program or Major

Direct Entery Masters in Nursing

Degree Name

Master of Science

First Advisor

Pamela Kallmerten

Second Advisor

Elizabeth Evans


Background: Deficient or ineffective communication in clinical hand-off has been established by prominent international health organizations as a significant cause of adverse clinical events, compromising clinical safety, an ongoing common problem for healthcare professionals and institutions. Existing literature unanimously called for improvement in hand-off communication to improve patient outcomes and recommended beginning such efforts by building various types of structure into hand-off (McCloughen et al., 2008).

Aim: The aim of this quality improvement project was to improve clinical communication among nurses transferring care of patients in acute psychiatric care.

Methods: Utilizing the Plan, Do, Study, Act framework over a total of eight weeks, nurses on an inpatient behavioral health unit were surveyed about the current state of shift hand-off communication and related errors, received education about the existing I-PASS reporting structure in use at the hospital, implemented I-PASS reporting structure for shift report hand-off for three weeks, and were surveyed three weeks later to assess impact on communication.

Results: The results of the project indicated a 56 percent decrease in errors transmitted in shift report hand-off, and an overall improvement perceived by nurses in shift hand-off given and received.

Conclusion: The customized I-PASS report template for nursing shift hand-off is an effective tool to reduce communication errors in the acute behavioral health setting. Further observations are recommended after this project to evaluate sustainability, impact on time consumption, patient perception of the improvement, and usability for interdisciplinary communication in the microsystem.

Keywords: Behavioral health, psychiatric nursing, shift report, clinical hand-off, clinical handover, standardized communication, I-PASS