Digital Repository Masters Projects Spring 2025 The Impact of a Standardized Education and Communication Process on Emergency Room Boarding Times Jillyn Graham Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Graham, J. 2025. The Impact of a Standardized Education and Communication Process on Emergency Room Boarding Times. Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP The Impact of a Standardized Education and Communication Process on Emergency Room Boarding Times Project Title by Jillyn Graham Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY April 26th, 2025 Ogden, UT Date Jillyn Graham, BSN, RN, MSN Student April 26th, 2025 Student Name, Credentials (electronic signature) Date Trish Gibbs, DNP, RN, CNE April 26th, 2025 MSN Project Faculty Date (electronic signature) Anne Kendrick, DNP, RN, CNE (electronic signature) DNP, N, CNE MSN Program Director Note: The program director must submit this form and paper. April 26th, 2025 Date 1 The Impact of a Standardized Education and Communication Process on Emergency Room Boarding Times Jillyn Graham, BSN, RN, MSN Student Annie Taylor Dee School of Nursing Weber State University MSN Project 2 Abstract Purposes/Aims: This project aims to evaluate the impact of a standardized education and communication process for charge nurses to decrease emergency room (ER) boarding times for critically ill patients. Rationale/Background: Emergency departments nationwide face severe overcrowding and prolonged boarding times, negatively impacting patient care and outcomes. Methods: The study implements a standardized education and communication process between the ER and inpatient units. Charge nurses will receive core competency training in patient flow management, communication, situational awareness, clinical decision-making, and nurse-patient assignments. To implement this project, a training proposal has been created to introduce effective communication education; pre- and post-tests will be used and taken into consideration with the training; posters will be put up with practical communication tools to be used. Results: Implementing the standardized process can significantly improve patient outcomes by reducing ER boarding times, mortality, length of hospital stay, and ventilator days. Enhanced communication between ER and inpatient charge nurses facilitated better patient flow and throughput. Conclusions: Implementing a standardized education and communication process for charge nurses in ERs can reduce boarding times and improve patient outcomes. Effective communication and training can expedite patient admissions, reducing complications related to prolonged ER boarding. Keywords: emergency room, emergency department, overcrowding, boarding times, standardized education, communication process, charge nurses, patient outcomes. 3 The Impact of a Standardized Education and Communication Process on Emergency Room Boarding Times Emergency rooms nationwide suffer overcrowding and prolonged boarding times for the critically ill (Rocha, 2021). Overcrowding is defined as a situation that occurs when the identified need for emergency services exceeds the available resources in the emergency room (Savioli, 2022). Since 1980, overcrowding has been the main factor limiting correct, timely, and efficient hospital care (Savioli, 2022). This phenomenon is especially problematic in the emergency department, where there is a pre-existing lack of capacity, and intake volumes have increased by 30% in the last decade (Mohr, 2020). Emergency room overcrowding threatens healthcare quality and equity worldwide (Benjamin, 2024). In 2022, the International Federation of Emergency Medicine reported that overcrowding is worse than ever (Benjamin, 2024). Additionally, emergency room nurses and physicians specialize in stabilizing the critically ill. These clinicians are not equipped to care for these patients long-term. When the process for admitting the critically ill patient is absent, and the patient remains in the emergency room for more than six hours, mortality, length of stay, and morbidities increase (Shaw, 2023). Furthermore, overcrowding has a ripple effect, creating increased wait times in the ER, which delays patient care, negatively impacts patient satisfaction, and increases the burden on nursing staff (Mohr, 2020). Overcrowded ERs lack adequate space, equipment, and staff to meet patient demands, decreasing patient safety, satisfaction, and overall care quality (Benjamin, 2024). By implementing a standardized education and communication process with the inpatient units, we can mobilize and move critically ill patients out of the emergency room in less than six hours from when the admit order is input, thereby significantly improving patient outcomes and decreasing mortality and length of hospitalization (Probus, 2020). Leadership and 4 management need to support a standardized education for charge nurses. The charge nurse’s role includes managing nursing resources and facilitating patient care (Wolf, 2024). Wolf emphasizes the top five competencies of a charge nurse as patient flow management, communication, situational awareness, clinical decision-making, and nurse-patient assignments. A core competency training to identify evaluation and implement strategies to improve charge nurse performance must be implemented at an organizational level (Wolf, 2024). Statement of the Problem Patients admitted as inpatients are boarded in the ER until the floor can assume care. Boarding critically ill patients in the ER negatively impacts their care and the organization. The first hours of resuscitation are crucial to the outcomes of the critically ill (Nesbitt,2020). When the patient has been stabilized, the ongoing critical care in the intensive care unit is now crucial to the patient’s mortality. When patients board in the emergency room, their hospital length of stay, ventilator days, and morbidity increase (Nesbitt, 2020). ER boarding has also been associated with poor clinical outcomes and worsening organ dysfunction (Mohr, 2020). The paradigm of inpatient care in the ED needs to be developed to address the quality of care and patient safety (Probus, 2020). Facilities and organizations pay little attention to training nurses who assume the charge nurse role (Wolf, 2024). Charge nurses receive little to no training, which leads to significant negative consequences for both the nurse who assumes the charge nurse role and the staff and patients. This can be identified as a gap in the training of charge nurses. There is very little literature on best practices for charge nurse training and evaluation or recommendations on operationalizing that process (Wolf, 2024). Charge nurses facilitate patient flow, and this leads to improved patient throughput. ER charge nurses must communicate and coordinate with the floor 5 as a vertical aspect of communication with the inpatient charge nurses (Wolf, 2024). Charge nurses identify and deal with throughput issues that inhibit emergency room patient flow; they must be trained to promote patient flow (Wolf, 2024). Significance of the Project One of the ways to decrease the critical care time in the emergency room is to implement a process to assist the charge nurses in the emergency room to communicate with the inpatient charge nurses and follow a standardized method to move patients more efficiently out of the emergency room (Wolf, 2024). This is a collaborative effort, and the role of charge nurses is pivotal in this process. This project will improve throughput and move patients through a hospital or healthcare facility from admission to discharge. The admission process can be simplified if the communication between the charge nurses starts at the time of the patient's arrival at the ER (Wolak, 2020). By implementing a standardized communication and education process for admitting patients, we can improve flow and reduce the challenges faced in emergency rooms while improving patient outcomes. This includes enhancing care by using the proper care, the right place, and the right time (Mohr, 2023). Empowering nurses with a standardized communication process when admitting patients from the ED to the floor can expedite the admission process, reducing the amount of time patients are boarded in the ED while also mitigating complications related to patient boarding such as poor patient satisfaction, increased length of hospital stay and an amplified risk of mortality and morbidity (Mohr, 2020; Wolak, 2020; Probus, 2020). In the ER, charge nurses are responsible for the frontline management of patient flow, determining how patients are prioritized and resources allocated (Benjamin, 2024). Patient flow 6 management decisions are especially consequential in overcrowded departments, which impact patient flow management (Benjamin, 2024). Charge nurses must have a global knowledge of the department’s abilities and see what is happening with the team. Charge nurse competency is a development process that requires more than a single training program or educational event alone (Wolf, 2024). The charge nurse must focus on communication skills, clinical decision-making, and situational awareness to facilitate safe, effective ED throughput (Wolf, 2024). The charge nurse role education requires clinical and leadership skills to facilitate patient flow while ensuring patient and staff safety (Wolf, 2024). If patient flow is not facilitated correctly, this can lead to overcrowding. Overcrowding leads to poor quality care and decreases patient and nurse satisfaction (Probus, 2020). The cycle of boarding patients in the ER causes delays in diagnostic processes and at the start of treatment (Savioli, 2022). This project is significant because it will streamline the process and reduce the variability by improving communication (Wolak, 2020). The communication process can enhance the quality of care and safety, resource use, costeffectiveness, and patient and staff satisfaction (Wolak, 2020). Providing a standardized communication process between the emergency department, inpatient nurses, and the house supervisor can improve handoffs so that pertinent patient information is preserved in the transfer of patient care (Wolak, 2020). Additionally, the project benefits the patients by improving their quality of care, decreasing their mortality, and improving their outcomes (Shaw, 2023). When the critically ill are boarded in the ER, this causes a vicious cycle that delays their home medication regimen, delays diagnostic treatments, fluid, and antibiotic therapy, delays disease-specific care, and results in more medication-related adverse events than the patients who do not board in the ER (Mohr, 2020). 7 Review of the Literature This literature review explores the current literature regarding emergency room boarding, overcrowding, and how communication regarding the admission process affects patient outcomes. The PICOT question used as a guide for this literature review was: In the emergency department, how does the implementation of a standardized education and communication process impact boarding times? Sackett’s framework was chosen for implementing this MSN project (Dustin, 2023). Framework This MSN project is using Sackett's framework model for evidence-based practice. This framework has a five-step approach. First, asking the question, (2) acquiring the best evidence, (3) appraising the evidence, (4) applying the findings to clinical practice, and (5) evaluating the outcomes of change, along with patient values and preferences and clinical skills (Dustin, 2023). Sackett’s framework is appropriate for this project because it provides an evidence-based process for reviewing, translating, and implementing research into practice to improve patient care, treatment, and outcomes (Dustin, 2023). Evidence-based practice should be the core competency of all healthcare professionals and apply to all clinicians. Sackett’s five-step model approach offers a more comprehensive breakdown of the process and closes the loop on the question, research, application, and evaluation of the process change. Within this project, the Sackett model was used, the PICOT question was asked, the best evidence was acquired, the evidence was appraised and reviewed, the evidence found will be applied to clinical practice, and then the evaluation and outcomes will be addressed after the evidence is introduced and utilized in practice. Evidence-based practice can improve patient care, treatment, and outcomes, and it 8 has been used in this MSN project (Dustin, 2023). Sackett’s framework allows for a more comprehensive breakdown of the research and evidence. Strengths and Limitations The Sackett model's strengths are that it utilizes the evidence-based practice five-step model as a point of alignment and allows for a more comprehensive breakdown (Dustin, 2023). Additionally, Sackett's five-step model considers patient values and preferences (Dustin, 2023). Few models and frameworks incorporate patient preferences and values, a key element of Sackett's five-step model. Limitations include the potential for patient and family values and preferences to be misunderstood, insincere, and even tokenistic (Dustin, 2023). Additional limitations to the Sackett model include greater clarification on patient and family values and preferences, and how they are integrated into the model. However, despite these limitations, this model can provide a process for transforming evidence into clinical practice and allow organizations to determine the readiness and willingness for change (Dustin, 2023). Analysis of the Literature This literature review will explore the different interventions used to help reduce ER overcrowding and boarding by standardizing education among charge nurses. It will examine various evidence-based practice solutions that aim to get boarded patients admitted to the floor sooner, reduce the patient's length of stay in the hospital, improve the patient’s outcomes, and decrease the mortality of patients who are boarded in the ER. The review will also examine the competencies of charge nurses and ways to enhance their training. 9 Search strategies A literature search was conducted to identify current evidence, using Google Scholar, Weber State University's Stewart Library's OneSearch and Advanced Search (which span multiple databases), and CINAHL to direct the initial exploration. Only articles from 2019 to 2024 were included in this literature review to keep information current. The search included keywords such as emergency department, overcrowding, boarding, critically ill, standardizing education for charge nurses, throughput, patient flow assessments, triage, length of stay, adverse events, and quality improvement. Various Boolean combinations were used to create a broad search. Synthesis of the Literature The themes identified in the literature are 1) Adverse patient outcomes, 2) reduced quality of care, 3) patient flow issues, and 4) decreased clinician job satisfaction (Owyang, 2019; Mohr, 2020; Rocha, 2021; Savioli, 2022). The education of charge nurses in managing nursing resources and facilitating patient care is essential to patient flow and clinician satisfaction (Wolf, 2024). Having core competencies training to identify, evaluate, and implement strategies will improve the performance of the admission process (Wolf, 2024). The charge nurse must focus on communication skills, clinical decision-making, and situational awareness to facilitate safe, effective emergency department throughput (Wolf, 2024). Adverse Patient Outcomes Overcrowding is one of the main factors limiting correct, timely, and efficient hospital care (Savioli, 2022). Hospitals are struggling to provide timely care in the ED due to length of stays and overcrowding; these are inconsistent with best practices to increase patient satisfaction (Probus, 2020). ED overcrowding is one of the most significant challenges for public health. It 10 is associated with increased hospital length of stay and hospital mortality, and ED boarding is the primary reason for ED overcrowding (Tuttle, 2022). ED crowding has been associated with delays in triage, diagnosis, and treatment, as well as increased morbidity and mortality for critically ill patients (Owyang, 2019). These issues negatively impact the emergency room by failing to deliver timely, effective care (Shaw, 2023). These patients who are boarded in the ER awaiting transfer to the ICU have a longer duration of mechanical ventilation, longer hospital length of stays, worsening organ dysfunction, and a fourfold increase in poor neurological recovery when their diagnosis is a stroke (Mohr, 2020). When a critically ill patient is mechanically ventilated in the ER, the ventilation practices in the ER are not sufficient and lead to an increased risk of acute respiratory distress syndrome (ARDS) (Owyang, 2019). Reduction in Quality of Care Lengthy emergency room visits lead to overcrowding and compromise the quality of care provided (Probus, 2020). Emergency rooms have increasingly become the choice for acute unscheduled care and the main entry for patients into the hospital (Rocha, 2021). The volumes in the ED have increased by over 30% in the last decade (Mohr, 2020). Patients being seen in the ER have multifactorial reasons for being seen and seeking care; this has an adverse effect on patients’ healthcare, the nurses, and the organization (Shaw, 2023). With this, there is what is referred to in the literature as an “exit block,” meaning patients are not being admitted or discharged promptly. Nurses spend 40% or more of their staff time caring for patients boarding in the ER instead of the new acute patients waiting for treatment (Savioli, 2022). Emergency room overcrowding and “exit blocks” are directly related to high inpatient occupancy (Shaw, 2023). Substandard inpatient processes can be a culprit of poor patient flow, and the lack of bed 11 capacity is the leading cause of longer boarding hours (JEN, 2022). When delays are present, the patients are at greater risk of experiencing poorer health outcomes (Muir, 2024). Patient Flow Issues Boarding the critically ill stresses an already-burdened emergency room (Mohr, 2020). The ER is not designed or trained to provide ongoing longitudinal care for the critically ill (Nesbitt, 2021). Nurses in the ER must continuously assess and care for the inpatient boarding in the ER while still providing life-saving measures for incoming ED patients (JEN, 2022). Even after disposition to the ICU is established, the patient’s prolonged experience in the ER, typically defined as the period after admission to physical transfer to the ICU, has been associated with worse outcomes for the critically ill (Owyang, 2019) The results or impact on patient care from boarding in the ER are unfavorable. Patients boarded in the ER are at a greater risk of deteriorating. They have an increased mortality rate, delayed drug administration, and lower patient satisfaction (Rocha, 2021). For example, the ED can miss treatments, home medications, and critical lab checks. There is also a delay in the administration of antibiotics (Rocha, 2021). ER nurses adapt to their resource use, staffing roles, and patient care processes to expand patient care capacity and throughput (Benjamin, 2024). As crowding increases, nurses become more engaged in the work of patient flow. One important strategy to combat overcrowding is improving the throughput or patient flow through healthcare institutions (Benjamin, 2024). Poor Staff Satisfaction Hospitals are struggling to provide timely care in the emergency department due to excessive length of stay in the emergency department and overcrowding; this is inconsistent with best practices and reduces patient and staff satisfaction (Mohr, 2021; Probus, 2020handoff a 12 standard handoff between the emergency room nurse and the inpatient nurse is lacking, it leads to longer wait times to be admitted, poor nurse communication, and dissatisfaction with reports (Wolak, 2020). Patient handoffs create an opportunity for inaccurate information to be transferred, a misunderstanding of information transferred, and insufficient information to be shared (Wolak, 2020). Inefficient ER handoff-to-inpatient handoff processes contribute to delayed patient care (Wolak, 2020). Nurse environments affect patient care and outcomes (Muir, 2024). The nurse's work environment is an essential indicator of nurses' reports on their well-being and the quality of patient care delivered in fast-paced, high-acuity care settings (Muir, 2024). Healthcare organizations must invest in better work environments with adequate nurse staffing, supportive nurse leadership, nurses' involvement in unit affairs, and strong interpersonal relations. These should all be considered when improving patient throughput in overcrowding (Muir, 2024). Summary of Literature Review Findings and Application to the Project The literature review identified several factors contributing to overcrowding and its impact on patients and staff. It highlighted the need for timely, clear communication utilizing a standardized tool to decrease boarding, prevent overcrowding, and improve patient outcomes. Decreased communication between the ER and inpatient nurses causes patient care delays (Wolak, 2024). Three themes emerged that decreased communication among ER nurses and inpatient nurses. Communication during transfers is essential and complex; there is a lack of tools to improve communication, handoffs, and quality improvement methods to facilitate communication (Savioli, 2022; Rocha, 2021; Muir, 2024; Bennage, 2024). Literature suggests that improving communication can enhance the quality of care, safety, resource use, cost efficiencies, patient experience, and staff satisfaction (Wolf, 2024). This MSN project aims to 13 standardize verbal reports to reduce variability and have a more efficient handoff. The ER and inpatient nurses must have consistent expectations regarding hand-off reports and education. The goal is to improve the patient flow process and decrease the length of stay in the emergency department and the wait time from ER to bed admission (Wolak, 2020). Project Plan and Implementation To understand the needs of my facility regarding improving education and communication among charge nurses, a needs assessment and surveys will be completed. The surveys will gather information from the nurses about current communication practices and challenges. We will identify key issues and determine common barriers to effective communication, such as time constraints, lack of standardized protocols, and misunderstandings (Lo, 2021). Once the data is collected and reviewed, we can put communication tools into practice. Implementing an SBAR (situation, background, assessment, and recommendations) is a precise tool that can be printed from the charting system (Lo, 2021). The SBAR will facilitate clear and concise handoffs between nurses (Abbazade, 2021). Within the SBAR, a handoff checklist will be implemented to ensure that all critical information is communicated (Abbazade, 2021). Charge nurse checkoff is from the start of the admission process to the throughput of the patient to the inpatient (Lo, 2021). Plan and Implementation Process The Plan, Do, Study, Act model will be used to implement the change (ihi.org). This model helps to develop a plan to test change (Kay, 2023). The change will be completed by developing evidence-based training sessions to improve communication and decrease boarding times. The training sessions will include effective communication techniques and the importance of accurate information. The training will also include in-person simulation training for nurses. 14 Role scenarios will be conducted to practice handoff processes and address potential challenges in a controlled environment. Before implementation, nurse leaders will be provided with education on utilizing and updating the electronic health record so that the inpatient nurse can follow the ongoing care in the ER (Benjamin, 2024). This ensures that floor nurses get real-time updates about the patient. The ER charge nurses, and inpatient charge nurses will also receive education on effectively communicating through the chat box in the electronic health record. Utilizing the chat box will provide quick and efficient communication between the nurses. Finally, daily huddles among all charge nurses within the hospital will be held and scheduled to augment communication among all charge nurses and improve throughput. During week one, nurse leaders would introduce a pilot program. This would include a needs assessment to evaluate current practices, outcomes, and barriers (ihi.org, 2024). Key stakeholders, including healthcare providers, patients, and administrative staff, are included in the planning process during week one. These clinicians will test the new communication tools and provide feedback. The program will be expanded to other units, a week at a time (ihi.org, 2024). Progress will be monitored, evaluated for effectiveness, and adjusted as needed. Regular audits will be performed to identify possible areas of improvement (Probus, 2020). A process will be developed for nurses to provide feedback on the communication process and suggest improvements. A post-survey will provide feedback on the changes and their impact on the care and communication. The focus is on team collaboration to ensure that the new communication processes are integrated into the standard of practice (Probus, 2020). Additionally, leadership support and champions in communication tools will promote the importance of effective communication. 15 Interdisciplinary Team Many healthcare professionals will contribute to this process. It is an interdisciplinary team of nurses, management, leadership, ambulatory staff, and providers. The ER physicians and ER nurses will be the starting point for the team. These frontline clinicians have the most significant impact on the patients in the ER and the initial contact with them (Hammer, 2022). The charge nurses for both the ER and the inpatient side are the communicators of bed availability. The house supervisor tracks the hospital’s availability, what they can intake, and what needs to be transferred to another facility (Hammer, 2022). Hospitalists and inpatient physicians are vital in inputting their admit orders to expedite the admission process. Teamwork is a critical part of creating a successful interdisciplinary team. There must be buy-in and support from the ER manager, inpatient managers, and directors to encourage staff to accommodate the needs of the patient and the hospital. Teamwork among all these individuals will impact patient care and outcomes (Probus, 2020). This type of teamwork includes working with all staff to share expertise, knowledge, and skills to impact patient care and outcomes. Leadership and their presence in the process will encourage staff to support the change (Savioli, 2022). Leadership must be involved with the change and help implement it throughout the hospital. Description and Development of Project Deliverables A PowerPoint proposal outline (see Appendix A) was created to present this project to stakeholders. A proposal outline provides a structured plan for the project, detailing objectives, timelines, and resources needed (Kay, 2023). This tool serves as a roadmap for project implementation. A well-defined proposal outline helps communicate the project’s goals, scope, and benefits to stakeholders, including funders, leadership, and team members (Kay, 2023). The 16 outline is crucial for obtaining approval from relevant team members and stakeholders. The proposal demonstrates the project’s feasibility, potential impact, and alignment to improve communication among the healthcare team and optimize patient outcomes (Kay, 2023). To inform the healthcare team of the upcoming SBAR training, a flyer was created for SBAR (situation, background, assessment, recommendations) (see Appendix C). The flyer effectively catches the target audience's attention, creates buy-in, and informs them about the project and education. It serves as a visual and concise tool to communicate the key points of the project. Flyers are distributed widely to ensure that all relevant clinicians are informed about the project. This helps spread the message quickly and efficiently. The flyer can be used electronically or physically to advertise upcoming projects, education, and training. SurveyMonkey will be used for evaluation purposes to create pre/post surveys (See Appendix D) for the healthcare team. The survey consists of a pre-assessment study to better understand the current experiences and needs regarding nurse communication and charge nurse education. The pre-survey provides baseline data that will be used to measure the effectiveness of the project over time (Abbaszade, 2021). The post-assessment survey will help evaluate the effectiveness of the communication survey and improve communication and education among charge nurses. The pre- and post-surveys should only take ten minutes to complete. These surveys are essential for collecting data from the target audience and can promote a sense of project ownership. The data helps understand clinician needs, preferences, and challenges, which can inform project development and decision-making (Abbaszade, 2021). Timeline Phase One. This phase includes planning and preparation, beginning during week one of implementation and lasting for one to two months. During this time, an introductory meeting will 17 identify key stakeholders, form a project team, define the project objectives and scope, and develop a project timeline and milestones. A needs assessment will be completed in weeks two through three. Pre-surveys will be conducted to assess current communication practices and identify gaps. Nurses, doctors, and other healthcare providers will provide input. Week four consists of developing training materials. The training materials are SBAR to fit the hospital's specific needs and ensure all information is accessible to all staff members. Weeks seven through eight are communication and promotion weeks. All staff members will be informed about upcoming training, and training sessions will be scheduled and promoted through internal communication channels. Phase Two. Phase two consists of months three to four, the training implementation phase. The stakeholders will be nurses, doctors, support staff, the IT team, and leadership. Pilot training sessions are conducted with a small group of healthcare providers. Afterward, feedback is gathered, and the necessary adjustments will be made to the training materials. During weeks eleven through fourteen, SBAR training will be rolled out to all staff members to ensure everyone receives it. The rollout will be in phases. Both in-person and online training are options. During weeks fifteen and sixteen, a support system will be established for staff members to ask questions and seek guidance. Additional resources, such as SBAR pocket cards and posters, will be provided in common areas. Phase Three. Phase three consists of months five through six. In this phase, continuous improvements are evaluated. Weeks seventeen through eighteen, post-training surveys will be conducted to evaluate the effectiveness of the training program. Feedback is gathered from the staff members on their experiences and challenges. During weeks nineteen through twenty, the survey results will be analyzed, and areas for improvement will be identified. The findings will 18 be communicated to the stakeholders and staff members. Weeks twenty-one through twentyfour are for continuous improvement. Changes are implemented based on feedback and survey results. Scheduled periodic refresher training sessions will be done to reinforce SBAR communication practices. After the implementation, continuous monitoring and assessment of ongoing communication practices will be needed to ensure constant improvement. This timeline gives a structured and practical approach to implementing SBAR training and enhancing communication among healthcare providers. Project Evaluation Formative methods can be used to evaluate the project. Formative methods that will be used are regular progress reports, frequent check-ins scheduled, and progress reports to monitor the project's status; this will help identify any deviations from the plan and allow for timely adjustments (Teachers Institute, 2023). Feedback will be gathered from stakeholders through surveys, interviews, and focus groups. The stakeholders can provide insights into the project’s effectiveness and areas needing improvement. Pilot testing will be done, and a small-scale version of the project will be implemented before full implementation; this will help identify potential issues and gather preliminary data on the effectiveness of the project (Teachers Institute, 2023). Summative methods evaluate the project once completed and assess its overall success (Teachers Institute, 2023). An outcome analysis will compare the project’s outcomes against its initial objectives and goals, determining if the project achieved its intended results and to what extent (Teachers Institute, 2023). An impact assessment will be done to evaluate the broader effects of the project on its target audience; this measures the long-term impact and sustainability of the project outcomes. A final stakeholder review will be conducted to discuss the success of 19 the project and areas for improvement. Diverse perspectives will be gathered, and data will be utilized to guide future projects. Ethical Considerations To address ethical considerations, informed consent will be obtained to ensure that all participants are fully informed about the project's nature and purpose and the potential risks and benefits (Hunt, 2021). Written consent will be obtained from the participants, ensuring they understand their right to withdraw at any time during the project. The participants' privacy will be protected by keeping their information confidential and, where appropriate, anonymous. Secure methods will be used to store and handle any information collected during the project. Encryption to protect data ensures that it cannot be read without the decryption key, even if it is intercepted. Any potential risks will be assessed, and steps will be taken to minimize any possible risks or harm to participants; the project's benefits will outweigh the risks. Transparency and integrity will be used to ensure that the project’s goals, methods, and funding sources are identified, and any findings of dishonesty will be reported (Hunt, 2021). The project will be sensitive to cultural differences and the needs and values of different cultural groups and will be conducted in a culturally appropriate manner. Continuously monitoring the project will ensure that the project is conducted ethically and protects the rights and well-being of all the participants involved (Hahn, 2021). Discussion This section will include evidence-based solutions for dissemination, significance to advance nursing practice, implications, and project recommendations. This MSN project aims to improve nursing communications by implementing a standardized education to train charge nurses throughout the facility (Wolak, 2020). The project will implement standardized tools to 20 improve handoff communication so that patient care is transferred precisely and accurately, decreasing the amount of information lost in the handoff of patients (Wolak, 2020). Evidence-based Solutions for Dissemination To disseminate this project, a poster format is used and presented on the project results to peers and faculty at Weber State University. The Holy Cross Hospital Davis nursing board will also share this presentation. The poster will contain significant findings and evaluation data from the project. To further disseminate the information to a broader audience, presentations will be organized to share the project results with relevant stakeholders, colleagues, and community members (CDC, 2021). Additionally, project findings will be communicated through social media. Utilizing social media platforms like Twitter, Facebook, LinkedIn, and Instagram to share project updates, insights, and outcomes is a valuable tool to inform, engage, and increase visibility amongst a larger group who might otherwise not have access (CDC, 2021). This combination of methods will effectively disseminate the project ideas and ensure they reach a diverse and broad audience (CDC, 2021). Significance to Advanced Nursing Practice This project of increasing the education among charge nurses to enhance patient stay and decrease ER wait times and ER boarding will benefit the nursing profession greatly by improving patient safety and decreasing medical errors and sentinel events (AACN, 2024). Training charge nurses in communication skills can help reduce these errors while empowering them with the tools necessary to create transformational change, mitigate errors, and improve patient outcomes (Wolak, 2020). 21 According to AACN (2024), improved communication leads to more accurate and timely information exchange, which improves patient care and outcomes. Additionally, proficient clinician communication can reduce misunderstandings and conflicts among staff, leading to a more positive work environment (Wolak, 2020; Wolf, 2024; Mohr, 2020). Further, effective communication helps coordinate tasks and responsibilities, leading to a more efficient workflow and reduced wait times (AACN, 2024). Finally, research suggests that clear communication facilitates smooth patient transfers between inpatient and ER, reducing delays, helps accurately exchange patient information, which is crucial for providing continuous and consistent care, and fosters collaboration between different units within the facility, leading to better patient care and outcomes (Franklin, 2023). Implications Prospective strengths of this project include improved communication. Enhanced communication training can lead to better coordination among healthcare providers, reducing errors and improving patient outcomes (Wolf, 2024). Effective communication can streamline workflows, reducing wait times and boarding in the ER (Abilson, 2025). Clear communication can enhance patient satisfaction by ensuring they feel heard and understood. Improved communication can boost staff morale by reducing misunderstandings and conflicts (Abilson, 2025). Limitations to the project include implementing comprehensive communication training programs, which can be time-consuming and costly (Wolf, 2024). Some staff may resist adopting new communication practices, which can hinder implementation. Also, maintaining the improvements over time requires ongoing effort and commitment. Some ways to reduce these obstacles and limitations would be to engage staff early by involving staff in the planning and 22 implementation to gain buy-in and address concerns early on (Emerging Nurse Leader, 2025). To provide ongoing support, the program is designed to offer continuous training and support to ensure staff are comfortable with the new communication practices. Additionally, the program will evaluate the effectiveness of the communication training program biannually and adjust as needed (Emerging Nurse Leader, 2025). Recommendations This MSN project addresses the need for a standardized education and communication process and its impact on boarding times in the ER. The research indicates that the charge nurse must focus on communication skills, clinical decision-making, and situational awareness to facilitate safe, effective ED throughput (Wolf, 2024). The communication process can enhance the quality of care and safety, resource use, cost, patient experience, and staff satisfaction (Wolak, 2020). However, a more comprehensive and interactive training module for charge nurses incorporates simulation-based training, role-playing, and case studies to enhance communication skills (Emerging Nurse Leader, 2025). Developing a continuous feedback loop through advanced communication tools, such as secure messaging apps and electronic health records integration, may improve nurses’ ability to address issues promptly (Emerging Nurse Leader, 2025). Conclusions Communication is vital to a successful healthcare team (Bennage, 2024). However, continued research regarding the long-term impact of improved communication training on patient outcomes and healthcare efficiency to determine the project's sustainability is necessary. Gathering data on the patients' perspectives on communication practices and how they affect 23 their overall experience and satisfaction with care would also help identify gaps further, decrease boarding times, and improve patient outcomes (Bennage, 2024). The key to addressing ED overcrowding lies in our ability to enhance patient flow within and throughout the hospital (Bennage, 2024). The ED cannot overcome overcrowding, a hospital-wide issue that needs to be addressed with standardized communication (Mohr, 2022). The ultimate goal is to improve the patient flow process and decrease the length of stay in the ED and the wait time for admissions (Wolak, 2020). Improving handoff would reduce ED length of stay for admitted patients and admit wait time. Doing this would make it achievable and positively contribute to throughput and capacity (Wolak, 2020). The SBAR handoff tool creates consistent expectations and lean principles by providing a step-by-step process (Wolak, 2020). 24 References AACN Blog. (2024). Retrieved from https://www.aacn.org/blog Abbaszade, A., Assarroudi, A., Armat, M. R., Stewart, J. J., Rakhshani, M. Hdi, N., & Sahebkar, M. (2021). Evaluation of the impact of handoff based on the SBAR technique on quality of nursing care. Journal of Nursing Care Quality, (36)(3), E38–E43. https://doi.org/10.1097/NCQ.0000000000000498 Abilson, A. (2025). Pros and cons of quality improvements in healthcare. Abilson. Retrieved from https://www.abilson.com/pros-and-cons-of-quality-improvement-in-healthcare/ Benjamin, E. (2024). Innovations in emergency nursing: Adapting patient flow, management to emergency department overcrowding. Journal of Emergency Nursing. Volume 51(2), 261-268. http://doi.org/10.1016/j.jen.2024.10.002 Bennage, J., Ford, C., Ezemenaka, C., I & Persing, T. (2024). Emergency department length of stay: A community hospital initiative. Advanced Emergency Nursing Journal 46(3), 263272. http://doi.org/10.1097/TME.000000000000525 Centers for Disease Control and Prevention. (2021). Dissemination and implementation research: Part 2. Retrieved from http://www.cdc.gov/nccdphp/dnpao/state-localprograms/pdf/dissemination-and-implementation.pdf Dustin, J., Melanson, A., & Mische-Lawson, L. (2023). Evidence-Based practice models and frameworks in the healthcare setting: A scoping review. BMJ Open, 13(5), e071188. https://doi.org/10.1136/bmjopen-2022-071188 Emerging Nurse Leader (2025). Reduce friction in nursing in 2025. Retrieved from https://emergingrnleader.com 25 Franklin, B., Yenduri, R., Parekh, V., Fogerty, R. (2023). Hospital capacity command centers: A benchmarking survey on an emerging mechanism to manage patient flow. The Joint Commission Journal on Quality and Patient Safety. 49(4). https://doi.org/10.1016/j.jcjq.2023.01.007 Hahn, E. (2021). Ethics, equity, and evaluation: Reflections on ethical considerations in the practice of evaluation. Institute for Community Health. Retrieved from http://icommunityhealth.org/ethics-equity-and-evaluation-reflections-on-ethicalconsiderations-in-the-practice-of-evaluation/ Hammer, C., Deprez, B., White, J., Lewis, L., Straughn, S., & Buchheit, R. (2022). Enhancing hospital-wide patient flow to reduce emergency department crowding and boarding. Journal of Emergency Nursing, 48(5), 603-609. http://doi.org/10.1016/j.jen.2022.06.002 Hunt, D.F., Dunn, M., Harrison, G., & Bailey, J. (2021). Ethical considerations in quality improvement: Key questions and practical guide. BMJ Open Quality, 10(e001497). http://doi.org.10.1136/bmjopenquality-2021-001497 Kay, S., Unroe, K. T., Lieb, K. M., Kaehr, E. W., Blackburn, J., Stump, T. E., Evans, R., Klepfer, S., & Carnahan, J. L. (2023). Improving communication in nursing homes using plan-do-study-act cycles of an SBAR training program. Journal of Applied Gerontology: The Official Journal of the Southern Gerontological Society, 42(2), 194–204. Lo, L., Rotteau, L., & Shojania, K. (2021). Can SBAR be implemented with high fidelity, and does it improve communication between healthcare workers? A systematic review. BMJ Open, 11(12), (e055247). https://doi.org/10.1136/bmjopen-2021-055247 Mohr, N. M., Wessman, B. T., Bassin, B., Elie-Turenne, M. C., Ellender, T., Emlet, L. L., Ginsberg, Z., Gunnerson, K., Jones, K. M., Kram, B., Marcolini, E., & Rudy, S. (2020). 26 Boarding of critically ill patients in the emergency department. 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Improving quality with emergency department throughput in a critical access hospital. Journal of Nursing Administration, 50(6), 363–368. http://doi.org/10.1097/NNA.0000000000000898. Rocha, H., M. Sc, Farre, A., & Filho, V. (2021). Adverse events in emergency department boarding: A systematic review. Journal of Nursing Scholarship, 53(4), 458-467. http://doi.org/10.1111/jnu.12653 Savioli, G., Ceresa, I., Gri, N., Piccini, G., Longhitano, Y., Zanza, C., Piccioni, A., Esposito, C., Ricevuti, G., & Bressan, M. (2022). Emergency department overcrowding: 27 Understanding the factors to find corresponding solutions. Journal of Personalized Medicine, 12(279) http://doi.org/10.3390/jpm12020279 Shaw V, Yu A, Parsons M, Olsen T, & Walker C. (2023). Acute assessment services for patient flow assistance in hospital emergency departments. Cochrane Database of Systematic Reviews 2023, (7). http://doi.org/10.1002/14651858.CD014553.pub Teachers Institute (2023). Formative vs. summative evaluation in education: Key differences explained. Retrieved from http://teachers.institute/assessment-for-learning/formative-vssummative-evaluation-differences/ Tuttle, E., Wisescup, C., Lemieux, E., Wang, X., & Modrykamien, A. (2022). Critically ill patients boarding in the emergency department and the association with intensive care unit length of stay and hospital mortality during the COVID-19 pandemic. Taylor and Francis Group, Baylor University Medical Center 35(2), 145-148. http://doi.org/10.1080/08998280.2021.2014761 Wolak, E., Jones, C., Leeman, J., & Madigan, C. (2020). Improving throughput for patients admitted from the emergency department: Implementing a standardized report process. Journal of Nursing Care Quality 35(4), 380-385. http://doi.org/10.1097/NCQ.0000000000000462 Wolf, L., Delao, A., Simon, C., & Burchill, C. (2024). Ensuring throughput: development and validation of charge nurse competencies for United States emergency care settings. Journal of Emergency Nursing 50(4), 523–536. http://doi.org/10.1016/j.jen.2024.02.009 28 Appendix A Deliverables: PowerPoint Training Proposal 29 30 31 Appendix B: Deliverables Training Proposal 32 33 Appendix C: Flyer 34 35 Appendix D: Deliverables Survey (Built-in SurveyMonkey) Pre-Assessment Communication Survey Question Title 1. What is your age? Under 18 18-24 25-34 35-44 45-54 55-64 65+ Question Title 2. What is your gender? Female Male Other (specify) Question Title 3. What is the highest level of education you have completed? school grade grade grade grade grade grade grade grade grade grade grade school college Did not attend 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th Graduated from high 1 year of 2 years of 36 college college college school school 3 years of Graduated from Some graduate Completed graduate Question Title 4. How many years of nursing experience do you have? Less than 1 year 1-3 years 4-6 years 7-9 years >10 years >20 years Question Title 5. What type of healthcare setting do you work in? Hospital Long Term Living Clinic Other, please specify Question Title 6. On a scale of 1-5, how would you rate the effectiveness of communication among nurses at your current workspace? Question Title 7. How often do you experience misunderstandings in communication among charge nurses? Never Rarely Sometimes Often Always Question Title 8. Have you ever received formal training in communication skills during your nursing career? 37 No Yes Question Title 9. How confident do you feel in your communication skills with other nurses? (1-5, 1 = not confident, 5=very confident) Charge Nurses Communication and Education Needs Assessment Question Title 1. How would you rate the current communication practices among charge nurses in your facility? Very Effective Effective Neutral Ineffective Very Ineffective Question Title 2. What are the main challenges you face regarding communication among charge nurses? Select all that apply. Time constraints Lack of standardized protocols Misunderstandings Inadequate training Technological issues Other Question Title 3. Please describe any other communication challenges not listed above. Question Title 4. How often do you experience misunderstandings in communication among charge nurses? Never Rarely Sometimes Often Always 38 Question Title 5. Do you feel adequate standardized protocols are in place for effective communication? Yes No Not Sure Question Title 6. If you answered 'No' or 'Not Sure', please explain what improvements you think are needed. Question Title 7. How effective are the current training programs for improving communication skills among charge nurses? Very Effective Effective Neutral Ineffective Very Ineffective Question Title 8. What type of training or resources would help improve communication among charge nurses? Select all that apply. Workshops Online training modules Regular meetings Mentorship programs Communication tools (e.g., apps, software) Other Question Title 9. Please provide any additional suggestions or comments regarding improving communication and education among charge nurses. Question Title 10. Please provide your name. First name Last name 39 Question Title 11. Please provide your email address. Email address Post-Assessment Survey Question Title 1. How would you rate the overall clarity of the previous survey? Very Clear Clear Neutral Unclear Very Unclear Question Title 2. How engaging did you find the previous survey? Very Engaging Engaging Neutral Not Engaging Very Unengaging Question Title 3. What did you like most about the previous survey? Question Title 4. What did you like least about the previous survey? Question Title 5. How easy was it to understand the questions in the previous survey? Very Easy Easy Neutral Difficult Very Difficult Question Title 40 6. Which aspects of the previous survey could be improved? (Select all that apply) Question Clarity Question Relevance Survey Length Answer Choices Engagement Level Other Question Title 7. If you selected 'Other' in the previous question, please specify. Question Title 8. How likely are you to participate in future surveys? Very Likely Likely Neutral Unlikely Very Unlikely Question Title 9. Do you have additional comments or suggestions for improving our surveys? Question Title 10. Please provide your name (optional) First name Last name Question Title 11. Please provide your email (optional) Email address 41 Appendix E: Timeline 42 The Impact of a Standardized Education and Communication Process on Emergency Room Boarding Times BACKGROUND This project evaluates how standardized training for charge nurses will impact ER boarding times for critically ill patients. Nationwide overcrowding in emergency departments strains resources and compromises care 1. Training will focus on patient flow, communication, situational awareness, decisionmaking, and nurse-patient assignments, aiming to move critically ill patients out of the ER within six hours of admission 3. • • • • • ER boarding impacts outcomes 2 Training gap for charge nurses 2 Role of communication in patient flow 3 Significance of standardized processes 4 Empowering charge nurses Benefits of Standardized Communication Jillyn Graham, BSN, RN, MSN Student Tricia Gibbs, DNP, RN, CNE Mary Hellyar MSN CNS-BC, APRN INTERVENTIONS Structured breakdown of the project into actionable interventions: • Planning and Preparation (Weeks 1-8) • Step 1 Introductory Meeting; Step 2 Needs Assessment; Step 3 Develop Training Materials; Step 4 Communication and Promotion • Training Implementation (Weeks 9-16) • Step 1 Pilot Training; Step 2 Training Rollout; Step 3 Support System • Continuous Improvement and Monitoring (Weeks 17-24) • Step 1 Post Training Surveys; Step 2 Analysis and Communication; Step 3 Refresher Sessions IMPACTS Potential Impacts of the Project: Improved communication among charge nurses by decreasing boarding times in the ER and improving patient outcomes METHODS The framework used was the Sackett framework model for evidencebased practice 5. Steps for Implementation and Deliverables: • Step 1: PowerPoint training proposal to stakeholders (weeks 1-4) • Step 2: SBAR tool implementation and education with posters and training on SBAR • Step 3: Workshops and Webinars • Step 4: Pre-Post Surveys • Step 5: Statistical Analysis REFERENCES 1.Benjamin, E. (2024). Innovations in emergency nursing: Adapting patient flow, management to emergency department overcrowding. Journal of Emergency Nursing, (51)(2), 261268. http://doi.org/10.1016/j.jen.2024.10.002 2.Bennage, J., Ford, C., Ezemenaka, C. I., & Persing, T. (2024). Emergency department length of stay: A community hospital initiative. Advanced Emergency Nursing Journal, (46)(3), 263272. http://doi.org/10.1097/TME.000000000000525 3. Wolf, L., Delao, A., Simon, C., & Burchill, C. (2024). Ensuring throughput: Development and validation of charge nurse Competencies for United States Emergency Care Settings. Journal of Emergency Nursing (50)(4), 523–536. http://doi.org/10.1016/j.jen.2024.02.009 4. Muir, K. J., McHugh, M. D., Merchant, R. M., & Lasater, K. B. (2024). Left without being seen: Nurse work environment and timely outcomes in New York and Illinois emergency departments. Journal of Emergency Nursing, 50(5), 660–669. https://doi.org/10.1016/j.jen.2023.11.010 5. Dustin, J., Melanson, A., & Mische-Lawson, L. (2023). Evidence-Based practice models and frameworks in the healthcare setting: A scoping Review. BMJ Open, (13)(5), e071188. https://doi.org/10.1136/bmjopen-2022-071188 • • • • • Improved communication and coordination Streamlined workflows 2 Increased patient satisfaction 1 Enhanced staff morale 1 Reduced ER boarding time and complications 3. Long-Term Results and Future Prospects • Sustainability • Patient perspective data • Hospital-wide impact • Improved handoff processes • Dynamic feedback loops CONCLUSIONS Relevant picture, graph or data set goes here The project emphasizes implementing a standardized education and communication process for ER charge nurses to address hospital-wide challenges, including ED overcrowding and prolonged patient boarding. Charge nurses can facilitate more efficient patient flow and reduce boarding times by enhancing communication skills, clinical decision-making, and situational awareness through training programs.