Collaborative Communication: Integrating SBAR to Improve Quality/Patient Safety Outcomes
For more information on this article, contact Cynthia Beckett at firstname.lastname@example.org.
Abstract: Creating work environments that sustain open and supportive communication positively influence teamwork, staff satisfaction, and improved patient quality and safety. The Situation, Background, Assessment, and Recommendation (SBAR)-collaborative communication evidence-based practice (EBP) study described in this article introduced collaborative communication integrating SBAR communication process in a pediatrics/perinatal services department of a 271-bed community hospital in northern Arizona. EBP processes framed the study. Evaluation methods for intervention effectiveness and study outcomes integrated both quantitative and qualitative strategies. Staff transferred evidence, knowledge, and skills into practice to achieve enhanced communication, collaboration, satisfaction, and patient safety outcomes meeting the study goal.
Purpose/Evidence-Based Practice Question
Collaborative communication and teamwork are essential elements for quality care and patient safety. Adverse patient occurrences are an extremely common outcome of communication failures (Leonard, Graham, & Bonacum, 2004). In 2004, the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) analyzed 2,455 sentinel events from hospitals across the United States and reported through root cause analysis over 70% of the events were due to communication failures, and approximately 75% of the patients involved died (Leonard et al., 2004). Although improving communication has been included as a Joint Commission's National Patient Safety Goal for hospitals since 2003, in 2006, handoff communications were included as a specific communication subset. NPSG 02.05.01 states “The organization implements a standardized approach to handoff communications, including an opportunity to ask and respond to questions” (Joint Commission, 2006).
Michael Leonard, MD, from Kaiser Permanente-Denver introduced a collaborative communication tool to support patient safety and outcomes. The structured communication tool is Situation, Background, Assessment, and Recommendation (SBAR) (Haig, Sutton, & Whittington, 2006). The SBAR tool provides a framework for organizing information in a clear and concise format; it facilitates consistent collaborative communication between healthcare providers throughout the hospital setting (Carroll, 2006). Collaborative communication enhances nurse, physician, and patient satisfaction as well as improves patient safety and outcomes by building teamwork and positive work relationships (Boyle & Kochinda, 2004).
In evidence-based practice (EBP), the question is presented in a PICOT format: Population (P), Intervention (I), Comparison (C), Outcome (O), and Timeframe (T)—if applicable (Melnyk & Fineout-Overholt, 2005). The focused PICOT question is: “In pediatric/perinatal healthcare providers working in an acute care hospital (P), does SBAR collaborative communication for handoff reports (I) positively influence teamwork, communication, and patient safety outcomes (O) as compared with traditional communication for reporting (C)?” The timeframe (T) was 3 months from introduction of intervention to evaluation of outcomes.
This study aimed to evaluate the effectiveness of the SBAR collaborative communication intervention for best practice. EBP processes framed the study. Evaluation methods for intervention effectiveness and study outcomes integrated both quantitative and qualitative strategies.
Review of the Evidence
Electronic databases searched for evidence included Cochran, CINAHL, Health and Psychosocial Instruments, Medline, PubMed, PubMed Central, EBSCO, Joanna Briggs Institute, and Centre for Reviews and Dissemination. A gray literature search was conducted for unpublished studies and evidence. Keywords used in a detailed search strategy were SBAR, communication, teamwork, collaboration, safety, quality, and physician–nurse relations. Twenty articles found through the search process included two systematic reviews (level I), five research studies (one-level II; one-level V; and three-level VI), and 13 articles (level VII) that provided expert opinion and foundational knowledge. All of the searches included English language only and human studies. In-depth appraisals were completed for each of the articles to determine the strongest and most applicable evidence.
The literature shows that nurses and physicians are taught different communication styles in their educational programs. Nurses are taught to be very detailed and descriptive in their conversations, but not to “medically” diagnose the problem or situation. Physicians express themselves in brief statements, providing only the specific facts (Haig, Sutton, & Whittington, 2006). Disconnect in communication styles leads to dysfunctional physician–nurse communication and a significant increase in errors in patient care (inconsistency in the plan of care, medication errors, falls, increased hospital-acquired infections, failure to rescue/mortality, and increased lengths of stay; Arford, 2005; JCAHO-SBAR Technique, 2005; Leonard et al., 2004).
Common outcomes found across studies between 2000 and 2006 were improvements in communication, teamwork, patient safety/outcomes, and satisfaction (Boyle & Kochinda, 2004; Carroll, 2006; Coeling & Cukr, 2003; Haig, Sutton, & Whittington, 2006; Kaissi, Johnson & Kirshbaum, 2003; Leonard et al., 2004; Makary et al., 2006; Pearson et al., 2006; Simpson, James & Knox, 2006; Zwarenstein & Bryant, 2000). Studies reported that the SBAR communication tool alone will not significantly improve outcomes. An educational intervention that provides information on communication strategies and styles, and collaboration/teamwork strategies will have a positive effect on work environments, resulting in improved communication, teamwork, satisfaction, and patient safety outcomes. The studies identified the need for larger, multiple-site studies to evaluate the efficacy and long-term effects on such an intervention.
Design and Methods
This study used two frameworks: Advancing Research and Clinical Practice through Close Collaboration (ARCC) and Management Change Theory. The first framework, ARCC, provided project guidance for development of the PICOT question, search strategies to identify relevant evidence, critical appraisal of the evidence, integration of the evidence into the EBP project plan, and evaluation of the evidence for the decision to implement the intervention across the organization (Melnyk & Fineout-Overholt, 2005).
An educational intervention used best evidence from research, theories, experts, and opinion leaders. Study investigators reviewed organizational behaviors and history in the areas of communication, collaboration, and patient safety. Investigators also assessed a readiness for change, and staff was engaged to participate.
The second framework, Management Change Theory by John P. Kotter, includes eight steps for change: (1) establish a sense of urgency, (2) create a powerful guiding coalition, (3) develop a vision, (4) communicate the vision, (5) empower others to act on the vision, (6) plan for and create short-term wins, (7) consolidate improvements and produce more changes, and (8) institutionalize new approaches (Borkowski, 2005). Changing how nurses and physicians communicate and work together for improved patient safety outcomes is a re-learning process. As in the above steps, during our study focus was placed on identifying short and long-term goals for success, that is, using the intervention initially only in the pilot units, and improving communication and relationships that will in turn improve the work environment and overall satisfaction.
Institutional Review Board Approval
The Northern Arizona Healthcare Institutional Review Board approved this initial study in February 2007 (#NAH-020807). The study, conducted from April through July 2007, received continued approval for hospital-wide continuation in February 2008 and January 2009.
This study implemented the SBAR Collaborative Communication Education (SBAR-CCE) intervention. The EBP process identified and applied evidence to create an intervention that would implement sustainable change in practice. A convenience sample of 215 staff and 30 physicians working in a pediatric/perinatal services department in a 271-bed community hospital located in northern Arizona was asked to participate in a pre/postintervention survey to determine the effectiveness of the intervention. There were five units within the department: Obstetrics, Labor/Delivery, Special Care Nursery (Neonatal Intensive Care), Pediatrics, and Pediatric Intensive Care.
At the SBAR-CCE introduction, the primary investigator provided staff with information about the study, asked them to participate, and obtained informed consent before completing the pre/postintervention surveys. The SBAR-CCE intervention, based on the evidence for best practice, included teambuilding and collaboration strategies, positive communication techniques, communication styles, empathy, and problem-solving strategies. Intervention classes offered in 16 1-hr sessions at various times throughout a 2-week timeframe provided ample opportunities for day and night shift staff to participate. The intervention included didactic content, role-play, and an original DVD demonstrating traditional and SBAR communication. The leadership team served as role models/mentors for their staff after the educational trainings. Evaluations were completed for each of the educational sessions. The “Safety Attitudes Questionnaire: Teamwork and Safety Climate Survey” (Sexton et al., 2006; UTCEPSRP, 2001) was administered before, and 3 months after, the SBAR-CCE.
Physicians chose not to attend the SBAR-CCE. Education was presented during the physician department committee meetings through handouts and discussion. The content provided was identical to the SBAR-CCE; however, the timeframe was limited by the pediatrics/perinatal physician department committees to 20 min. The DVD was available on the units. Physicians were asked to participate in the pre/postintervention surveys after informed consent was provided.
The primary investigator provided all the SBAR-CCE intervention educational sessions to ensure consistency in content and presentation among groups. Classes were conducted in the same manner to ensure study fidelity. Evaluations and surveys were not reviewed until after the final class.
The Teamwork and Safety Climate Survey was evaluated for its psychometric properties, benchmarking data, and emerging research by Sexton et al. (2006). Scale reliability was 0.9, with factor intercorrelations of 0.72 for teamwork climate and 0.94 for safety climate. Through multilevel factor modeling, all item correlations were p<.05. This pre/postintervention survey tool was offered to all department staff and physicians that had been working in the pediatric/perinatal units a minimum of 1 month. Statistical analysis using SPSS version 14 determined the differences in the pre/postintervention survey groups. Analysis determined the effectiveness of the intervention to evaluate differences over time and between groups using independent samples t tests. The Mann–Whitney U test for nonparametric variables determined statistical significance of the group differences.
Corbin's grounded theory qualitative methods guided the analysis of interviews and observations to identify patterns and themes. Investigators recorded observations on each of the units and recorded comments, reflections, and activities throughout the study.
Study outcomes were patient safety, teamwork climate, safety climate, and communication physician-to-nurse and nurse-to-nurse. Outcome measures included the 27 items in the Teamwork and Safety Survey. Confounding variables that affected the study outcomes were current patterns of collaboration/teamwork, relationships, communication, and the work environment on the individual units. Baseline data were collected on all units before the intervention.
Pre/postintervention questionnaire data were evaluated for differences in outcomes over time. Descriptive, independent samples t tests and Mann–Whitney U nonparametric statistics were used for analysis to determine group differences and statistical significance. Out of a possible 215 staff, 212 staff participated in the SBAR-CCE intervention. Staff were provided informed consent before the completion of the pre/postintervention surveys. There were 141 completed preintervention surveys (group 1) and 71 completed postintervention surveys (group 2). A paired t test was excluded because of repeated measures and the inability to identify paired samples due to the lack of identifiers on many of the surveys in both groups.
Survey analysis is divided into three sections: demographics, teamwork climate, and safety climate. Demographic data included gender, position, ethnicity, unit, and years of experience for the preintervention and postintervention survey groups (Table 1). All participants were recruited from the pediatrics/perinatal department. The two groups were similar in the areas of gender, position, ethnicity, and years of experience. There were small differences in the distributions of the units between the two groups (Table 1).
Table 1. Demographics
|Years Experience||<6 months||7.9||4.4||6.8|
Pre/postintervention groups were analyzed for group differences in the Teamwork and Safety Climates items (Table 2). Significance levels were p<.05 for all items.
Table 2. Teamwork and Safety Climate Survey Pre/Postintervention Surveys
The Teamwork and Safety Climate survey is comprised of 27 items. The first 14 items are specific to teamwork climate, and the final 13 items are focused on safety climate. Differences were seen between the groups after the SBAR-CCE intervention. The Mann–Whitney U showed 18 of the 27 items to have statistically significant differences after the intervention. At the 95% confidence interval, 12 of the 27 items showed statistical significance. Effects sizes for the individual items ranged from small 0.1 to medium 0.5. There were 6 items with a small effect, 21 items with medium effect, and 0 items with large effect. Six of the 14 teamwork climate items (1, 2, 5, 9, 13, and 14) showed statistically significant differences between groups after the intervention. Three of the remaining items (3, 4, and 7) showed statistical significance only on the Mann–Whitney U, and five items (6, 8, 10, 11, and 12) showed no significant differences between the groups. Of the 13 safety climate items, six items (18, 20, 21, 22, 23, and 25) showed statistical significance between groups, three items (15, 16, and 17) statistical significance only on the Mann–Whitney U, and four items (19, 24, 26, and 27) showed no significant differences between groups postintervention (Table 2).
Qualitative data included recorded notes from staff observations and interviews. Grounded theory methods were used to analyze the findings. The overarching theme for SBAR-CCE effectiveness was “Positive Communication.” The following comments from participants provided support for the theme: “good framework,”“strong foundation for communication,” and “increases awareness.”
Increased, consistent use of the SBAR collaborative communication processes was observed. One staff shared her experience with SBAR (Table 3). Interviews of staff and physicians were conducted across the department. Staff and physicians stated that communication and collaboration had improved. Physicians remarked that they were being “SBARed” and “Phone and in-person reports had greatly improved” (Table 4).
Table 3. Living SBAR
|“I love my job—SBAR works”|
|“When people ask me where I work and I respond, ‘Labor and Delivery,’ they tell me, ‘How wonderful and beautiful to have a job like that.’ However, things may not always go as planned and communication is especially important when complications arise. Fortunately, FMC recently implemented a new communication tool—SBAR that really focuses on patient safety. SBAR is an acronym for: situation, background, assessment, and recommendation|
|SBAR promotes consistency in communication about the patient's background, current needs, and condition. When using SBAR, I describe the current situation, give the physician or other caregiver patient background and the most current assessment of the patient, and then my recommendation of what needs to be done. SBAR is a great tool because it saves you the embarrassment of giving a nurse or doctor, ‘hearsay information’ when you have not assessed the patient yourself|
|Just a few weeks after my SBAR training, a very critical patient came in to our department and I witnessed SBAR in action. That night, the patient needed many care providers from other departments, who were not familiar with the patient. SBAR made it possible to give a quick, concise, and complete report of the situation, so that they could understand the patient's background and with a current assessment of what they needed to do, along with the recommendations. We were able to stay organized throughout the process. Using SBAR allowed us to provide critical facts in order to give fast, life-saving care to the patient|
|It took 4 hr to stabilize our patient. Through the multidisciplinary actions of FMC's staff we calmly and harmoniously coordinated our efforts to generate a positive patient outcome. I am so proud to work with such a wonderful team of devoted professionals. FMC benefits from the use of SBAR because it truly creates a good communication system between staff and departments and ultimately gives better patient outcomes.”|
Table 4. Physician Response to SBAR
|“Did you just SBAR me?”|
|Labor and Delivery (L/D) nurse M.T. assessed a patient in the triage area of the unit. She discovered that the patient was in active labor—dilated to 7 cm, had an elevated blood pressure of 170/106, and the electronic fetal monitor showed that the fetus was having decelerations to 70 beats per minute with every contraction. She was contracting every 3–4 min.|
|Nurse M.T. looked up the physician on call, reviewed her assessment data, and prepared to call Dr. X. This physician was known for interrupting during phone reports and was often difficult to communicate with during nights. It was 2:30 a.m.|
|When Dr. X answered the phone, nurse M.T. took a deep breath and stated:|
(S) This is M, I am working on L/D tonight and I have your patient Mrs. K.
(B) Mrs. K is a gravida 1, para 0 with no history of complications or problems in her pregnancy as found in the prenatal record on file in the unit.
(A) She is in active labor, 7-cm dilated, contracting every 3–4 min; her vital signs are stable except for her blood pressure which is 170/106, and the fetal strip is showing decelerations to the 70s with every contraction.
(R) I need orders to admit this patient for labor, and I need you to come in to the unit now; I am concerned about her blood pressure and the fetal strip.
|She then took a breath … There was a brief moment of silence. Then Dr. X stated, “I will be right in.”|
|Approximately 20 min later, Dr. X walked into the L/D unit and walked directly up to nurse M.T. He looked at her and stated: “Did you SBAR me? That was the most complete and clear report that I have ever received.”|
|Nurse M.T. and Dr. X then proceeded to Mrs. K's room to collaborate on her plan of care.|
|This is an example of how SBAR has positively influenced the physicians and has increased their openness to the strategies of collaborative communication and SBAR.|
SBAR-CCE improved patient safety outcomes by enhancing physician–nurse communication and relations. The strong reliability of the survey tool, consistency in providing the SBAR communication process, and the delivery of the intervention increased fidelity and reliability of the data produced by the study. Providing role models/mentors encouraged staff at all levels to adopt changes in process and communication.
Because participants inconsistently provided identifiers for the pre/postintervention surveys, independent samples t tests were used. Out of 212 staff who participated in the education intervention, only 141 completed the pre-intervention survey and 71 completed the postintervention survey. The units were extremely busy during the time the postintervention survey was completed and collected. It was also during regular hours instead of during class time as in the preintervention survey. These barriers prevented staff participation. Increased numbers and paired samples would add to the strength of the study.
Also, no physicians participated in the formal SBAR-CCE or surveys. Physicians stated “This is something that nurses need to do”; “I don't need to go to a class to learn this”; “I know about SBAR”; and “Doctors shouldn't have to attend a nursing class.” While some physicians are adopting the strategies and embracing collaborative communication strategies, for full implementation of this EBP process, total physician adoption is integral for even greater collaboration and satisfaction scores.
Finally, the 3-month time frame was inadequate to truly measure sustainable change. Six to 12 months would allow for greater application of knowledge into practice and a true measure of permanent change.
Clinical Implications/Future Research
The SBAR-CCE intervention proved so successful that it is being disseminated across the entire healthcare organization to facilitate a sustainable improvement in communication, collaboration, and safety. Continued reinforcement and expansion of collaborative communication strategies integrating SBAR is ongoing in the pediatric/perinatal department.
The future of this study is bright with options for integration with other variables to determine depth of clinical effects in regards to quality indicators such as patient fall risk, medication errors, and other sentinel events. Involving physician champions and other healthcare disciplines in future research in the areas of collaborative communication and EBP will optimize overall satisfaction, resulting in an enhanced work environment with better patient outcomes.
There were two main outcome goals for the SBAR collaborative communication EBP study. The first was that participants would transfer evidence, knowledge, and skills to practice. This goal was accomplished as the staff began to utilize the collaborative communication strategies and SBAR tool during their communications. Coaching by mentors assisted them in the implementation of this change.
The second outcome goal was that communication changes would result in improved patient safety/outcomes; improved teamwork/collaboration; and overall satisfaction of nurses, physicians, staff, and patients. Evidence shows that when the SBAR tool is used in isolation, it will increase consistency of the handoff/shift report but there are no studies that demonstrate improvements in patient outcomes, collaboration, or teamwork. This study confirms that when the SBAR tool is used in conjunction with the collaborative communication model, statistically significant changes are noted in the communication, teamwork, and the safety climate.
Staff and physicians reported significant improvements in satisfaction and collaboration in their clinical areas. Patients stated they experienced an enhanced climate of patient safety as hospital in-patients.
Changing communication processes was a re-learning process. Empowering nurses, physicians, and staff to be proactive in communication and collaboration for best practice and improved patient safety provided positive teamwork. Establishing a team of mentors who provided support during the change was vital. This process takes time, but the long-term outcomes can be significant. Identifying goals for success proved critical to the EBP process, that is, improving communication and relationships that improved the work environment and overall satisfaction. Evaluating the success of the intervention and looking for new and different ways to fine tune or improve the process proved to be an important step in the change. Finally, incorporating evidence and changes in practice is difficult for some, but can be an exciting professional growth process and a strong staff satisfier if done with forethought and staff involvement.
Implications for Quality Management Practice
Quality management practice can be guided by studies that explore patient outcomes related to collaborative communication interventions such as SBAR-CCE. Outcomes could include fall risk, medication errors, and other patient safety issues. Assisting nurses and physicians to change their current practice of handoff communication can be difficult. Patterns and routines in communication processes are challenging to change. Providing the leadership teams with strong communication and collaboration strategies facilitates improvements in work environment, communication at the nurse-to-nurse and physician-to-nurse levels, teamwork/collaboration, satisfaction, and patient safety and outcomes.
Networking is ongoing to share the SBAR-CCE study protocol with other hospitals in Arizona, EBP meetings and symposia, and research conferences. Other opportunities for quality improvement include teaching SBAR strategies in the nursing curriculum at the local community colleges and universities to provide a firmer foundation for managing the quality and safety of hospital-based patient care.
Cynthia D. Beckett, PhD, RNC-OB, LCCE, is the director of Pediatrics/Perinatal Services and EBP at Northern Arizona Healthcare-Flagstaff Medical Center (Flagstaff, Arizona). She is responsible for integrating EBP into pediatrics/perinatal services, and across the entire healthcare organization to improve patient safety and outcomes.
Gayle J. Kipnis, MSN, RNC-OB, AHN-BC, is a doctoral student at School of Nursing, University of California at San Francisco, with a research focus on patient safety. She has participated in SBAR Collaborative Communication research at Northern Arizona Healthcare-Flagstaff Medical Center (Flagstaff, Arizona).