Date of Doctor of Nursing Practice Project Completion

2026

Abstract

Purpose

Improving handoff communication among unlicensed assistive personnel (UAPs) in a group home through Situation, Background, Assessment, Recommendation (SBAR) tool implementation.

Background

Communication failures during shift handoffs among unlicensed assistive personnel (UAPs) in a group home contributed to missed information, inconsistent care, and resident safety events. Baseline observations showed that only 37.5% of handoffs met criteria for high-quality communication, and approximately 75% of safety incidents were related to communication breakdowns.

Methodology

This project was conducted in a group home serving adults with intellectual and developmental disabilities and included 19 UAPs. The Plan-Do-Study-Act (PDSA) model and Adult Learning Theory guided implementation. Interventions included SBAR education sessions, role-playing activities, standardized handoff forms, peer champions, and weekly audits with feedback. Data were evaluated using an SBAR checklist, a Handoff Quality Rating Tool (HQRT), and incident reports.

Results

SBAR adherence improved from 56% to 92%, complete SBAR documentation increased from 60% to 91%, and high-quality handoffs improved from 37.5% to 76%. Total resident safety incidents decreased by 50%.

Implications

The findings showed that using SBAR improved handoff quality and consistency while reducing total residency safety incidents. Although the project was limited by a small sample size, a single setting, and a short implementation period, the improvements suggest that SBAR can be successfully used by UAPs.

Continued SBAR training during orientation, routine audits, staff feedback, and leadership support may help sustain these improvements. Future efforts should evaluate long-term outcomes and consider expanding SBAR to other group homes and similar care settings.

Keywords

SBAR, handoff communication, quality improvement, unlicensed assistive personnel, group home, patient safety

Included in

Other Nursing Commons

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