Metrics details Abstract Continuity of patient care is achieved by the clear and concise transfer of patient clinical information from one health care provider to another during handoff. Effective communication is a vital factor in providing safe patient care. Communication failure in a health care setting could lead to serious medical errors. Sharing patient-specific health care information during handoff requires situational awareness. In the hospital setting, most of the communication related to patient care occurs between nurses and physicians. Challenges of communication among health care providers are not limited to differences in training and reporting expectations.
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Metrics details Abstract Continuity of patient care is achieved by the clear and concise transfer of patient clinical information from one health care provider to another during handoff. Effective communication is a vital factor in providing safe patient care. Communication failure in a health care setting could lead to serious medical errors. Sharing patient-specific health care information during handoff requires situational awareness.
In the hospital setting, most of the communication related to patient care occurs between nurses and physicians. Challenges of communication among health care providers are not limited to differences in training and reporting expectations. SBAR is a reliable and validated communication tool which has shown a reduction in adverse events in a hospital setting, improvement in communication among health care providers, and promotion of patient safety. This narrative review has highlighted the challenges of communication among health care providers, use of the SBAR tool for effective handoff and transfer of patient care in various health care settings, and comparison of SBAR tool with other communication tools to assess the effective communication and limitations of SBAR communication tool.
Background A handoff between health care providers is the key factor in fostering continuity of care and providing safe patient care [ 1 ].
The handoff from one health care provider to another is recognized to be vulnerable to communication failures [ 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 ]. Effective communication is therefore central to safe and effective patient care [ 10 ]. The consequences of failed communication during handoff are medication errors, inaccurate patient plans, delay in transfer of a patient to critical care, delay in hospital discharge, and repetitive tests among others [ 12 ].
The Joint Commission has introduced the National Patient Safety Goal to improve the communication among caregivers [ 13 ]. The aim identified by the Institute of Medicine IOM is to provide a safe, patient-centered, timely, effective, efficient, and equitable health care [ 14 ].
Communication errors among health care providers are complicated by a hierarchical reporting structure, gender, education, cultural background, stress, fatigue, ethnic differences, and social structure [ 2 , 15 , 16 , 17 , 18 ]. It is reported that differences in communication styles between nurses and physician are one of the contributing factors to the communication errors [ 19 ]. Nurse-physician communication is subject to the effects of differences in training and reporting expectations [ 20 ].
A structured communication tool would be beneficial to effectively communicate the patient information, reduce the adverse events, promote patient safety, improve the quality of care, and increase health care provider satisfaction.
The aim of this paper is to review the challenges of communication among health care providers in clinical setting, to review the use of the standardized Situation, Background, Assessment, Recommendation SBAR communication tool during handoff, and to compare the SBAR tool with other communication tools to assess the communication during patient handoff.
Loss of situational awareness could lead to adverse events and hence compromise the patient care [ 21 ]. Achievement of this objective through a consistent, structured, and reproducible means will likely lead to improved patient satisfaction and outcomes. Communication failure risk to patient safety is always a topic of discussion for researchers, health care providers, administrators, and regulatory agencies.
Communication problems are multidimensional, being influenced by technology, personnel, process, information design, and biology itself [ 22 ]. Despite huge investments in technology to record, store, disseminate, and access information, studies still find communication in health care continues to be problematic [ 23 ].
Health care providers need to be cognizant of the challenges facing handoffs, including physical setting, social setting, language barriers, and communication barriers [ 24 ]. Some of the most commonly reported environmental obstacles to effective communication are distractions, insufficient time, and interruptions [ 25 ].
To avoid these preventable distractions, it is recommended that nurses and other health care providers share patient information in designated areas away from distraction [ 28 , 29 ].
Moreover, it has been suggested that it is imperative that the handoff process be standardized and trainees must be taught the most effective, safe, satisfying, and efficient ways to perform handoffs [ 24 ]. The Joint Commission [ 30 ] describes the SBAR communication technique as, Situation: what is the situation; why are you calling the physician?
Background: what is the background information? Assessment: what is your assessment of the problem? Recommendation: how should the problem be corrected?
In a health care setting, the SBAR protocol was first introduced at Kaiser Permanente in as a framework for structuring conversations between doctors and nurses about situations requiring immediate attention [ 31 ]. SBAR was originally implemented in health care settings with the intent of improving nurse-physician communication in acute care situations; however, it has also been shown to increase communication satisfaction among health care providers as well as their perceptions that communication is more precise [ 31 , 32 ].
The role of the SBAR tool during handoff has been highlighted and supported by various specialties such as anesthesia [ 33 , 34 ], perioperative medicine [ 35 , 36 ], postoperative medicine [ 37 ], obstetrics [ 38 , 39 ], emergency medicine [ 40 ], acute care medicine [ 41 , 42 ], pediatrics [ 43 ], and neonatology [ 44 ].
Example of SBAR tool in clinical setting An RN on the pediatric floor has an order for a child to have fluids by mouth as he is admitted with vomiting and abdominal pain. Initially, the patient has pain in the periumbilical area and now it is radiating to the right lower quadrant. His abdominal pain has gotten worse and now radiating to right lower quadrant. Oral fluids were ordered for him. Do we need to arrange ultrasound to rule out appendicitis? During handoffs, mnemonics may increase the memory of important steps and provide a structured and standardized process to follow.
The SBAR format provides a structured format for presenting medical information in a logical and succinct sequence; moreover, it is concise and easy to use [ 49 , 50 ].
Riesenberg et al. The absence of a good shared model or a flaw in the shared mental model could lead to medical tragedies [ 21 ].
Our daily experience in a health care setting has taught us that there are many opportunities to improve the transfer of information during handoff. Haig and colleagues performed a quality improvement project with the aim of sharing a common mental model in communication among care providers. Hence, the SBAR tool was effective in bridging the communication styles [ 16 ].
Due to concerns related to the uptake of the SBAR tool after the initial SBAR education and its consistent use in a clinical setting, the authors have suggested refresher education for nurses after initial SBAR education and a policy of annual validation of the use of the SBAR tool [ 51 ].
Communication breakdown, collaboration failure, and inability to recognize the clinical deterioration of patients are the main reasons for the occurrence of serious events in the hospital setting [ 52 ].
De Meester et al. This represents a shift in direction toward earlier detection, trigger, and response through better communication, likely due to SBAR tool [ 53 ]. In the ICU setting and operative room, clear and precise communication among team members is essential. Wong et al. This study highlights the fact that communication failure can delay the activation of the rapid response team which is associated with an increase in in-hospital deaths.
Postoperative care of patients requires handoff between the outgoing anesthetic team and the incoming intensive care team. These patients have complex medical and surgical histories, and communicating information during handoff should include the perioperative anesthetic and surgical issues, as well as recommended postoperative management [ 55 ]. Fabila and colleagues conducted a study to evaluate the recipient perception, completeness, and comprehensiveness of verbal communication and usability of the SBAR document during handoff from anesthetists to pediatric ICU care providers.
This study was comprised of four phases from assessment of current practice of handoff to development of the handoff process to implementation of the tool and post-intervention assessment. Similarly, another study was performed by Funk et al. Over 50 handoff interactions were observed to assess the completeness and comprehensiveness of verbal communication and usability of the SBAR document ISBARQ introductions, situation, background, assessment, recommendation, and questions checklist.
Most of the health care facilities have electronic medical records EMR with the goal of improving patient care by accurate and transparent documentation. Several evaluation studies have reported that the electronic handoff tools which are integrated into the EMR systems are superior to paper-based approaches as the electronic handoff tool provides more and better information to the team members during hand over [ 12 ].
The role of EMR in communication among health care providers has been evolving. To evaluate the impact on clinicians of integrating an EMR with a structured SBAR note on communications related to an acute change in patient condition, Pancesar et al.
Like other areas of medicine, health care providers in obstetrics medicine have patient safety concerns related to communication errors during critical events. Ting and colleagues conducted a study to evaluate the impact of the SBAR technique on safety attitudes in the obstetrics department.
In this study, the SBAR collaborative communication education course, which included an educational session on fetal heart rate monitoring, was implemented. In emergency medicine, it has been emphasized to learners that clear and patient-focused handoff is important to make sure an accurate diagnosis is made and patients receive life-saving treatment in a timely manner. McCrory et al. In a hospital setting, patients with complex needs are managed by an interdisciplinary team.
The SBAR communication tool supports common language among team members. It promotes shared decision making and conflict resolution among team members [ 58 ] which will likely improve patient satisfaction and outcomes. Structured SBAR protocol for the presentation of patient cases by nurses during interdisciplinary rounds has resulted in shorter review time during interdisciplinary rounds [ 59 ]. Townsend-Gervis et al.
This study showed significant improvement in Foley catheter removal, reduction in re-admissions rate, and improvement in patient satisfaction. The SBAR tool has shown improvement in communication among health care providers in a clinical setting by creating a common language; however, SBAR communication tool has a broader application which was assessed by Vanderman and his colleagues [ 60 ].
A qualitative case study was conducted to explore the implementation of the SBAR protocol and to investigate the potential impact of SBAR on the day-to-day experiences of nurses.
Three unique and related concepts, schema development, social capital, and dominant logic, were assessed. The authors revealed that SBAR may help nurses in rapid decision making schema development , provide social capital and legitimacy for less-tenured nurses, and reinforce a move toward standardization in the nursing profession Table 1. There was an improvement in nurse—medical provider communication. Limitations reported by nurses include the time required to complete the tool and non-verbal communication barriers not addressed by the SBAR tool [ 61 ].
Comparison of SBAR with other communication tools There are few studies which have looked into the comparison of SBAR with other tools to assess communication during handoff in a health care setting. SIGN-OUT was ranked as important or very important to patient care by all participants and was rated as useful or very useful by all participants.
Ilan et al. Forty individual patient handoffs were randomly selected by attending physicians. Elements of all three standardized communication tools appeared repeatedly throughout the handoff without any consistent pattern. The author concluded that ICU physicians do not commonly recommend communication tools during handoff and likely these tools do not fit the clinical work of handoff within the ICU setting due to the complexity of the cases [ 63 ].
ISBAR - Identify, Situation, Background, Assessment and Recommendation
Questions five and six, which asked staff to indicate their confidence levels on requesting a patient review or intervention, show somewhat conflicting results. Questions three and ten looked at confidence levels in providing and documenting information in an organised, succinct manner. Overall, there was a slight increase in these areas in the post pilot questionnaire, although the number of fives scored in 10a fell from five to three post-pilot with a corresponding increase in fours scored. As the majority of the nursing staff on the unit had attended COMPASS training prior to the pilot, one has to consider the possibility that they were already using the ISBAR method of communication albeit in a less formal format. However, of note are the scores of one and two pre-pilot regarding documentation of this communication in the areas of: Giving clinical findings in an organised manner Requesting an intervention Communicating when faced with unhelpful behaviour and Providing information about a patient not known to the physician which were not reported in the post pilot questionnaire. As loss of information during handover and between staff groups has been reported as a frequent characteristic of reported incidents, the formal use of ISBAR in sticker format may improve communication between members of the multidisciplinary team as well as ensuring accurate handover of all information between shifts. Sentinel event statistics.