sbar nursing case studies

15 Excellent SBAR Nursing Examples + How to Effectively Use SBAR in Nursing

Of all the skills nurses develop, communication is the most essential. We use communication to find out what concerns a patient and to relay our thoughts, opinions, and observations to other nurses, peers, and doctors. Communication may be verbal or nonverbal. Nurses must learn communication techniques and use them effectively. A common communication technique used in nursing today is called SBAR. Perhaps you have heard of this type of communication. Maybe you have not and are asking yourself, "What is SBAR in nursing?” In this article, you will learn what SBAR communication is, why it is important, and find 15 excellent SBAR nursing examples + how to effectively use SBAR in nursing.

What Does SBAR Stand For?

What exactly is sbar in nursing, when was sbar communication first introduced in nursing, when do nurses use the sbar communication technique in nursing, 7 reasons why sbar communication is so important in nursing, what is the difference between sbar and other forms of communication techniques in nursing, • check-back, what are the 5 main skills nurses require to use sbar in nursing, 1. observation:, 2. critical thinking:, 3. decision-making:, 4. interpersonal skills:, 5. excellent communication:, what are the 4 steps involved in sbar nursing communication, 1. situation:, 2. background:, 3. assessment:, 4. recommendation:, 6 things every nurse must do before beginning an sbar conversation, 1. assess the patient:, 2. verify current orders for the patient’s care:, 3. verify important information:, 4. organize your thoughts:, 5. have ready access to the patient’s chart or electronic health record:, 6. think like a doctor (sort of):, what are some examples of nurse-to-physician sbar communication in nursing.

What are Some Examples of Nurse-to-Nurse SBAR Communication in Nursing?

What are Some Examples of Nurse-to-Healthcare Provider SBAR Communication in Nursing?

5 Most Common Challenges Nurses Face When Using SBAR in Nursing and How to Overcome Them

Challenge #1: sbar in nursing is sometimes a difficult concept to learn and apply, about the challenge:, how to overcome:, challenge #2: sometimes, the amount of information given seems lacking, challenge #3: some nurses are apprehensive about giving recommendations to doctors, challenge #4: the culture within the healthcare field sometimes resists change, challenge #5: sbar communication usually occurs absent the patient’s presence, bonus 5 expert tips to effectively use sbar in nursing, 1. follow each step of the sbar technique., 2. get organized., 3. relay relevant information., 4. give the other person time to ask follow-up questions., 5. work with the team member you are reporting to so you can develop a suitable plan of action., my final thoughts, frequently asked questions answered by our expert, 1. is sbar in nursing a verbal or written communication tool, 2. are all types of nurses required to use the sbar technique in nursing, 3. is sbar a standard format in nurse and physician communication, 4. what information should nurses include when using sbar, 5. is sbar evidence-based, 6. what is the difference between sbar and soap, 7. is sbar a progress note, 8. how do you write a good sbar nursing note, 9. do nurses have difficulty using sbar, 10. do nursing schools teach sbar, 11. does sbar assist nurses to think critically, 12. how does nursing sbar improve patient safety, 13. how do i differentiate between background and assessment in an sbar, 14. what if i don’t have a recommendation when using the sabr tool, 15. can my recommendation upset the physician, 16. how to use sbar in a nursing home, 17. how to track which nurse is using sbar in hand-off, 18. what is i-sbar-r and how is it different from sbar in nursing, 19. is it okay not to use sbar in nursing, 20. does nursing sbar really work, 21. how to use sbar in nursing non-clinically.

What is SBAR in Nursing?

• What Is SBAR Used For in Nursing?

What Does SBAR Stand For?

• How to Use SBAR for Communication
• SBAR Examples
• History of SBAR

SBAR is an easy-to-remember acronym that helps healthcare professionals communicate quickly, efficiently, and effectively. 

When nurses use SBAR, it leverages their experience, their skill, and their critical thinking ability to both assess and make recommendations. 

SBAR introduces structure and discipline to healthcare communications.

Quick, efficient, and clear communication from and between healthcare professionals is integral to treating and caring for patients. SBAR is an effective and easy-to-use communication tool that divides patient status points to be conveyed into categories.    The use of the standardized technique is particularly helpful for nurses, who can use it to organize their thoughts and break vital information into segments that describe the,

• S - Situation
• B - Background
• A - Assessment
• R - Recommendation

By incorporating the SBAR framework into your mindset and practice, you provide yourself and those with whom you are communicating a concise and easily accessible summary of:

• What is happening with a patient
• What led up to the current situation
• Your professional assessment of the patient’s condition
• What you think should happen next

SBAR focuses on what is most relevant, eliminating extraneous detail. It is always helpful, but particularly so in emergent and high-stress situations where minimizing frustration and maximizing clarity is essential. 

What Is SBAR Used For in Nursing?  

SBAR can be used to communicate information between healthcare professionals, i.e., from nurse to physician or allied healthcare professional, as well as when relaying information to a patient or their caregivers.    It is commonly used during shift change between nurses as well as when transferring a patient to other units. 

• For example, a nurse will use SBAR when a patient is being transferred to a higher (med-surg to ICU) or lower level of care (ICU to med-surg)  Additionally, during a code event, SBAR can be helpful in delivering concise and relevant information.    
• SBAR communication is broken down into defined categories that stress concise language.  Every important point is included in a simple and straightforward way that saves time, reduces the need for questions, and improves understanding.   

SBAR is particularly effective for emergent situations, but is also useful when:

• A patient is first being admitted
• When a patient is being transferred from one care unit or team to another
• When a new nursing shift arrives and needs to be apprised of a patient’s condition
• For updating the patient or their family members about their current status and care plan

  SBAR emphasizes observation, critical thinking, decision-making, and communication. The acronym stands for: 

• S = Situation    

A brief description and summary of who the patient is and what is happening with them. It may include the patient’s name, age, room number or care unit, as well as who you are and the role you play in the patient’s care. 

• B = Background     

Brief synopsis of the patient’s history. This may include date and time of admission, admitting diagnosis, lab and diagnostic test results, and changes in status. 

• A = Assessment     

Professional nursing opinion of what is happening. 

• R = Recommendation 

Professional nursing recommendations for the next steps are based on your knowledge of the patient, your assessment of their status, and relevant subjective and objective data .

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How to Use SBAR for Communication  

There are many templates available to guide you through the use of SBAR, but committing the easy-to-remember organizational framework to memory will help you standardize its use for communicating about your patients.    SBAR helps you prioritize and organize what is most critical about each individual patient’s situation, regardless of whether you are explaining it in person, on the phone, or in writing. Its use ensures that the most vital information is relayed quickly so that appropriate action can be taken.    The most important things for you to remember when using SBAR are:

• Keep all points relevant
• Keep all points concise
• Eliminate unnecessary information 

The information conveyed via SBAR is meant to be comprehensive, but not overly detailed. It may invite additional questions that you should be prepared to answer, but even without those questions being asked should serve to provide enough information for another healthcare professional to move forward.    It’s also important to note that the recommendations may include medical interventions (such as medication recommendations, radiology, or lab draws), but ultimately, it is up to the medical provider to place orders for the patient and determine the next steps.    Nurses are often asked for their professional recommendations because they spend the most time with the patient and might be picking up on subtle cues from the patient.

SBAR Examples 

Example #1:.

Emergency nurse using SBAR framework regarding a pediatric patient admitted with vomiting and abdominal pain 

Here is how the nurse would quickly provide information to the pediatrician:    S (Situation): Dr. Smith, this is Lynne in the Emergency Department Five-year-old Julia Baker was brought to the E.R. by her father two hours ago complaining of abdominal pain and experiencing nausea, vomiting, and diarrhea. I would like to update you on her condition and clarify orders.    B (Background): Julia’s father reports that complaints of abdominal pain started this morning and she refused food. Since being admitted her pain has gotten worse (now rated as an 8 out of 10)  and is now radiating to the right lower quadrant. Oral fluids were ordered and her fever is 103.2 F orally.   A (Assessment): Julia looks pale, is febrile, and is experiencing increased pain, vomiting, and diarrhea since her time of admission.    R (Recommendation): I believe that Julia should be given intravenous fluids and that an ultrasound should be considered in order to determine whether she has appendicitis.

Example #2:

Evening nurse using SBAR report to convey information to morning shift nurse regarding patient admitted from nursing home    S (Situation): Mr. Goldring is an 83-year-old male in room 212, admitted last night at 23:20. Arrived via ambulance from Woods Manor North Nursing Home where he reportedly fell out of bed.    B (Background): Mr. Goldring is diabetic and has mild dementia. All of his supporting documentation has been entered into his chart, including a DNR. Family was notified of the fall by the nursing home and I contacted his daughter with an update shortly after she was admitted. Expect family to arrive this morning to meet with physician.    A (Assessment): Diagnostic X-rays reveal hip fracture, physical examination shows bruising on thigh, skin intact. Patient reports mild pain, morphine administered at 01:00 by ER staff.     R (Recommendation): Physician consultation with surgeon scheduled for this morning. Continue monitoring for pain, follow-up with surgeon regarding next steps.

History of SBAR  

Though SBAR is a healthcare communication tool, its roots lie in the U.S. military. 

Before Doug Bonacum joined Kaiser Permanente ’s environmental health and safety department, he was a part of the U.S. Navy’s submarine force. While on active duty he used a communication technique he referred to as SBAR to succinctly describe and assess mission-critical information up and down throughout the hierarchy.  

Years later when he joined Kaiser, he encountered,

Physicians and nurses complaining about poor communications 

Physicians complaining about nurses rambling 

Nurses complaining that physicians were not following their recommendations

He recognized that the structured format that had proven successful for the military would also help both the receivers and transmitters of patient information, as well as the patient. 

Now Vice President of Safety Management at Kaiser Permanente, he points to the need for the healthcare hierarchy to be “flattened” in the interest of patient safety, and credits SBAR for accomplishing that goal. 

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• Open access
• Published: 28 July 2018

Situation, Background, Assessment, Recommendation (SBAR) Communication Tool for Handoff in Health Care – A Narrative Review

• Shaneela Shahid   ORCID: orcid.org/0000-0002-5708-7819 1 &
• Sumesh Thomas 2  

Safety in Health volume  4 , Article number:  7 ( 2018 ) Cite this article

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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. The Joint Commission, Agency for Healthcare Research and Quality (AHRQ), Institute for Health Care Improvement (IHI), and World Health Organization (WHO) recognize SBAR (Situation, Background, Assessment, Recommendation) as an effective communication tool for patients’ handoff. 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.

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 Joint Commission reviewed a total of 936 sentinel events during the year of 2015; communication was identified as the root cause in more than 70% of serious medical errors [ 11 ]. 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.

Challenges of communication in health care

Sharing patient-specific health care information during handoff requires situational awareness, which is an understanding of a patient’s current condition and clinical trajectory. Loss of situational awareness could lead to adverse events and hence compromise the patient care [ 21 ]. Within the context of contemporary interdisciplinary teams providing care for patients, sharing the patient information should be aimed at ensuring a common understanding of the individual patient’s care plans and expectations. 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 ].

Health care providers involved in transferring patient information may be distracted by easily overlooked factors such as lighting, background noise, television/computer screens, crowding, or busy nursing stations [ 26 , 27 , 28 ]. 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 ].

SBAR defined

The prevailing gold standard handoff structure, Situation, Background, Assessment, Recommendation (SBAR), was originally developed and effectively used during submarine duty handoff by the US Navy. 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 2003 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. The ordering physician needs to be called to review the patient’s condition and clarify the order regarding fluid intake.

Situation : “Dr. Smith, this is Nancy on Pediatric floor, I have an order for clear fluid intake for little Jonny who is in room 420 with abdominal pain, I would like to update you regarding Jonny’s condition and clarify orders with you.”

Background : “I see that Jonny was admitted through Emergency Department with abdominal pain and vomiting. His abdominal pain has gotten worse and now radiating to right lower quadrant. Oral fluids were ordered for him.”

Assessment : “Jonny looks unwell as his abdominal pain has increased and he has been throwing up more since he was admitted.”

Recommendation : “I think we should keep him nil per os (NPO) and give him intravenous fluids. Do we need to arrange ultrasound to rule out appendicitis?”

SBAR communication tool for handoff

Medical associations and leading health care organizations (German Association of Anesthesiology and Intensive Care Medicine—Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin (DGAI), the Australian Commission for Safety and Quality in Health Care (ACSQHC), AHRQ, IHI, and WHO) are endorsing the SBAR method as the standard communication tool for handoff among health care providers [ 36 , 45 , 46 , 47 , 48 ]. 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. included 46 articles in a systematic review focused on health care handoffs using mnemonics; the review yielded 24 handoff mnemonics, with SBAR (Situation, Background, Assessment, and Recommendation) cited most frequently, approximately 69.6% [ 10 ].

Communication handoffs are critically important in creating a shared mental model around the patient’s condition [ 16 ]. 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. There was an increase in use of the SBAR tool, improvement in the medication reconciliation, and reduction in the rate of adverse events (Table  1 ). Hence, the SBAR tool was effective in bridging the communication styles [ 16 ].

Physicians’ perception of the quality of communication and nurses’ use of the SBAR tool after SBAR communication tool implementation was assessed by Compton and his colleagues. The authors reported two third of these nurses had “good to high” proficiency with SBAR and two third of physicians perceived that the last report they received from nurses regarding patients was adequate to make clinical decisions (Table  1 ). 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. conducted a study to determine the effect of the SBAR tool on the incidence of serious adverse events (SAEs) in hospital wards. This study showed an increase in unplanned ICU admission and a significant reduction in unexpected patient deaths following the introduction of SBAR (Table  1 ). 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. performed chart review of all ICU transfers to evaluate the critical message (CM) quality, the rapid response team (RRT) calling criteria, time to RRT activation, the presence of vitals, and the quality and timeliness of physician response (Table  1 ). 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. (Table  1 ). Authors reported significant correlation with in-hospital survival and the number of SBAR components in the CM. The authors suggest that the nurses’ education on the use of the SBAR tool for communicating the critical information to clinicians would improve the situation awareness and likely improve patient outcomes [ 54 ].

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) recommend the use of SBAR structured format for patient handoff in a perioperative setting [ 36 ]. 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. The author reported that the SBAR tool was perceived as a useful tool in prioritizing the high-risk patient information and immediate patient management during handoff between anesthesia and pediatric ICU care providers (Table  1 ); moreover, there was reduction of omission errors and fewer inconsistencies in patient descriptions [ 37 ].

Similarly, another study was performed by Funk et al. to establish a structured handoff based on the SBAR framework in the pediatric post-anesthesia care unit (PACU). 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. The ISBARQ checklist was associated with improvement in content information of handover and increased the provider’s satisfaction; however, there was no significant change in duration of handover (Table  1 ) [ 56 ].

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. performed a study in a Pediatric ICU. The author reported that integrating SBAR with the electronic medical record was associated with a complete documentation of critical pediatric patient events and an increase in documentation of attending physician and nursing notification (Table  1 ) [ 42 ].

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. The Safety Attitudes Questionnaire (SAQ) was completed by the nurses before and after the SBAR course. Most of the value ratings for the teamwork climate, safety climate, job satisfaction, and working conditions significantly improved in a post-intervention survey (Table  1 ) [ 38 ].

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. published a study to assess whether a modified “ABCSBAR” mnemonic (Airway, Breathing, Circulation followed by Situation, Background, Assessment, and Recommendation) improves handoffs by pediatric interns in a simulated clinical emergency without delaying or omitting the information on Airway, Breathing, and Circulation (ABC). The author concluded that there was improvement in inclusion and timeliness of essential information such as ABC; however, handoff duration was increased (Table  1 ) [ 57 ].

In a hospital setting, patients with complex needs are managed by an interdisciplinary team. Communication among interdisciplinary team members should be consistent, clear, and concise to make sure that all of the team members have a good understanding of the patient’s clinical information. 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. tested the impact of using the SBAR tool in the context of daily interdisciplinary rounds (IDR) to improve patient outcomes such as patient satisfaction, Foley catheter removal, and patient re-admission rates in the medical/surgical units of a hospital. This study showed significant improvement in Foley catheter removal, reduction in re-admissions rate, and improvement in patient satisfaction. This study’s results support the value of using SBAR during IDR to improve situational awareness and to maintain focus on relevant clinical issues (Table  1 ) [ 23 ].

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 ).

Ineffective communication between nurses and physician in the nursing home setting could affect the nursing home residents’ care and the work conditions for nurses and physicians. To examine the feasibility and utility of SBAR protocol in long-term care, Renz et al. conducted a quality improvement project to evaluate the impact of the SBAR tool on nurse communication with medical providers. There was an improvement in nurse–medical provider communication. Over 80% of nurses found the tool useful, helping them to organize the resident’s clinical information and provide cues on what needs to be communicated to the care providers (Table  1 ). 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. Horwitz and colleagues developed an easy-to-remember mnemonic SIGN-OUT (Sick, Identifying Data, General Hospital Course, New Events of the Day, Overall Health Status, Upcoming Possibilities with Plan, Task to Complete Overnight with Plan) tool for medical house staff. SIGN-OUT was compared by in-house physicians to SBAR using pretest and posttest self-reported attitudes following an hour educational session. Perceived comfort with providing SIGN-OUT increased (mean score from 3.27 ± 1.0 to 3.94 ± 0.90; p  < .001). 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. SIGN-OUT received a slightly higher rating than SBAR [ 62 ].

Ilan et al. performed a study using the video recording of patient handoff in an academic ICU in Canada to describe handoff communication patterns used by physicians in the ICU setting and to compare this with currently popular, standardized schemes for handoff communication. Forty individual patient handoffs were randomly selected by attending physicians. Two independent coders reviewed handoff transcripts, documenting elements of three communication tools: SBAR, SOAP (Subjective, Objective, Assessment, Plan), and MAN (Medical Admission Note). This study shows that the majority of handoff content consisted of recent patient status and the recommendation component of the handoff was missing in 50% of the handoffs. 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 ].

Adams and colleagues conducted a study to compare the D-BANQ (Demographics and Stability, Before I Began to Provide Care, As I Provided Care, and Next Care Provider, Needs to Know, Question) communication tool with WHO-SBAR (SBAR tool recommended by WHO) and CDPH-TJC (Joint Commission Communication During Patient Handoff). This study resulted in an alternative structure for handoff, D-BANQ, which aligns with WHO-SBAR and TJC-CDPH handoff structures and provides an easy-to-follow chronological format for the content that nurses identified as necessary to communicate during nursing activity. This study is supportive of both the WHO-SBAR and the TJC-CDPH structures for nursing handoff, and D-BANQ format provides additional refinement and clarification in communication thereby preventing errors and maximizing patient safety during handoff [ 64 ].

Handoff protocol Flex 11 has been studied and compared with SBAR communication tool; overall, there was no difference in workload, the amount of information required for handoff, and duration of handoff except Flex 11 was rated high for “ease of use” and “being helpful” as compared to SBAR tool [ 65 ].

Limitations of SBAR tool

SBAR is a reliable and validated communication tool that can be easily implemented in hospital-based practice for sharing information among health care providers; however, there are limitations of use in patients with complex medical histories and care plans, especially in the critical care setting. The SBAR tool requires training of all clinical staff so that communication is well understood. It requires a culture change to adopt and sustain structured communication formats by all health care providers.

Strengths and limitations of review

This narrative review identifies the challenges faced by health care providers during daily transfer of patient care and provides broader use of the SBAR communication tool for patient handoff in various health care settings including acute care. Another strength of this review is to provide greater insight into the SBAR tool by identifying the studies which have compared the SBAR tool with other communication tools for patient handoff as such readers can have a better understanding of SBAR tool usage.

There are few potential limitations to describe. It is a narrative review as such it might not be comprehensive enough to synthesize all the evidence on use of the SBAR communication tool for handoff in health care setting. Moreover, this review mainly focuses on the use of SBAR communication tool for patient handoff between nurses and physicians, therefore, findings of this review are not necessarily applicable to other types of communications such as nurse to nurse or physician to physician handoffs.

Future directions

There is a need for future research to assess the impact of a structured SBAR tool on patient-important outcomes and cost-effectiveness of the SBAR tool implementation compared to adverse events related to communication errors. Future studies on validation of the SBAR tool in various medical subspecialties, strategies to reinforce the use of SBAR during all patient-related communication among health care providers, and comparison studies on SBAR communication tool with I-PASS (Illness severity, Patient summary, Action list, Situation Awareness/contingency plan and Synthesis by receiver) communication tool would be beneficial. Minimizing communication errors in all spheres of medical practice will substantially improve patient safety and outcomes, quality of care, and satisfaction among health care providers.

Conclusions

Patient safety is the priority in patient care, and communication errors are the most common cause of adverse events during patient care. Health care providers make every effort to avoid communication errors during patient handoff. SBAR communication tool is a structured communication tool which has shown a reduction in adverse events in a hospital setting. Various medical associations and leading health care organizations have been endorsing SBAR communication tool for handoff among health care providers. This communication tool creates a shared mental model around the patient’s condition and has been used for transfer of patient care in various clinical settings. SBAR communication tool is easy to use and can be modified based on most of the clinical settings; however, it can be challenging to use for complex clinical cases such as ICU patients. Moreover, the use of SBAR communication tool requires educational training and culture change to sustain its clinical use. Future research is needed to assess the impact of the SBAR communication tool on patient outcomes, validation of tool in other subspecialties, and its comparison with other communication tools such as I-PASS.

Abbreviations

Airway, Breathing, Circulation

Airway, Breathing, Circulation, Situation, Background, Assessment, Recommendation

Australian Commission for Safety and Quality in Health Care

Agency for Healthcare Research and Quality

Critical Message

Demographics and Stability, Before I Began to Provide Care, As I Provided Care, and Next Care Provider, Needs to Know, Question

Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin

Electronic Medical Records

Intensive Care Unit

Interdisciplinary Round

Institute for Health Care Improvement

Illness severity, Patient summary, Action list, Situation Awareness/contingency plan and Synthesis by receiver

Introduction, Situation, Background, Assessment, Recommendation and Question

Medical Admission Note

Post-Anesthesia Care Unit

Pre-handoff, Equipment Handoff, Timeout and Sign out

Rapid  Response Team

Serious Adverse Events

Safety Attitudes Questionnaire

Situation, Background, Assessment, Recommendation

Sick, Identifying Data, General Hospital Course, New Events of the Day, Overall health Status, Upcoming Possibilities with plan, Task to complete over night with plan

Subjective, Objective, Assessment, Plan

The Joint Commission Communication During Patient Handoff

World Health Organization

SBAR, the structure recommended by the World Health Organization

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Shahid, S., Thomas, S. Situation, Background, Assessment, Recommendation (SBAR) Communication Tool for Handoff in Health Care – A Narrative Review. Saf Health 4 , 7 (2018). https://doi.org/10.1186/s40886-018-0073-1

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SBAR Report with Example

Table of contents, what is an sbar report .

An SBAR report is a tool of communication between members of the healthcare team about a client’s condition that follows the SBAR communication technique.

SBAR stands for: 

• B ackground
• A ssessment
• R ecommendation

What is the purpose of the SBAR technique? 

Using the SBAR technique, a structured framework for communicating critical information about client conditions, helps ensure clear and concise exchange of this information between healthcare team members.

What are the components of an SBAR report?  

The components of an SBAR report are:

• Situation: the current situation and reason for the report
• Background: relevant background information about the client’s condition, including medical history and the reason for current admission
• Assessment: clinical assessment findings including vital signs, changes in condition, and response to treatment so far
• Recommendation: recommendations for changes to the plan of care, further testing, or consultation with other healthcare professionals

SBAR report template

Download the free PDF cheat sheet for the complete template with examples at a glance. 

Situation template

“This is ________, nurse on floor/unit. I am calling about (patient name and location). The problem I am calling about is ______. Most recent vital signs are: BP___ , HR___ , RR___ , Temp___ .”

Background template

Provide background information related to the situation (for example: diagnosis, medications, allergies, labs, code status, pain level, interventions, and any other pertinent clinical information).

Assessment template

“I think the problem is ___________.”

“I am not sure what the problem is, but the client is deteriorating.”

Recommendation template

• State your request, if you have one, AND ask what the provider wants you to do.
• Read back and verify all verbal or telephone orders.
• Request a read-back when reporting critical lab values.

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SBAR Nursing Guide with Templates and Examples

Effective communication is crucial in any business, particularly healthcare, where continuity of care is vital. As healthcare professionals strive to provide patient care, communication structure, consistency, and repeatability ensure a shared understanding of the patient and their condition. This then leads to increased patient satisfaction.

The effects of poor communication can have severe consequences. Research shows that errors in clinical communication give rise to substantial morbidity and mortality. Passing clear and concise information between healthcare professionals, particularly during handoff, will ensure continuity of care. SBAR is a communication tool that facilitates information during ward rounds, shift exchanges, and team meetings. If you want to improve your communication mechanism in nursing, you must use the SBAR technique.

In this guide, we will explain what SBAR is, how it is used, its importance, and examples in nursing.

What is SBAR?

SBAR is an acronym for Situation, Background, Assessment, and Recommendation. It is a technique developed for the US military for the sole purpose of nuclear submarine communication. The aviation industry adopted a similar model. However, later on, it was quickly absorbed by the healthcare system, and now it is used worldwide.

SBAR has become popular in the healthcare industry, especially among physicians and nurses. The model was introduced at Kaiser Permanente in Colorado in 2002 to the rapid response team to investigate the safety of the patients. Its primary purpose was to eliminate inconsistency and other communication problems among healthcare professionals due to different communication styles. Later, other healthcare professionals adopted the technique, becoming among the best handover systems. Healthcare professionals are advised to use them while at work. For instance, they should use them during the handover of care when treating critically ill patients.

The Purpose and Importance of SBAR in Nursing

Communication in the hospital is more than just having access to information. It is about achieving situation awareness, particularly by understanding a patient's present condition and trajectory.

Communication consists of two premises: the first is that it occurs between the sender and the receiver. The second is an interaction between the sender and the receiver to exchange information verbally and nonverbally. While this is simple in typical communication, particularly in other professionals, in nursing, it is different. There are potential barriers that can interfere with and disrupt communication. Such barriers include:

• Communication styles
• Distractions
• Medical language or jargon
• Background noises
• Poor telephone connection
• Lack of structured approach
• Lack of confidence

Consequently, a communication technique like SBAR can help avoid these barriers and ensure efficient nurse communication.

SBAR is a technique used for framing all critical conversations that require immediate attention and action from a healthcare provider. When it is incorporated into practice, there will be a concise and easily accessible summary of the following:

• What is going on with the patient?
• What resulted in their current situation?
• A professional assessment of the condition of the patient
• What is expected to happen next?

SBAR is ideal because it only focuses on important information, thus eliminating all the extraneous details. It is necessary, particularly in highly stressful situations.

Reasons why the SBAR Technique is Important

Even though nurses can use other communication techniques in their work, SBAR offers more advantages. Here is a list of the benefits provided by the technique.

• It provides a framework for nurses to quickly and efficiently communicate with other nurses, doctors, and patients, thus saving time.
• When used correctly, it enhances communication among healthcare professionals.
• It guarantees that each member of the clinical facility receives pertinent information clearly and concisely.
• When clear and concise information is passed to the nurses, and other healthcare workers, they can quickly act on it.
• It bridges the difference in the gap between nurses and doctors. Communication styles allow them to communicate better.
• It allows healthcare professionals to learn effective communication strategies.

SBAR is helpful in emergencies, but it also comes in handy when:

• A patient is being admitted to the hospital.
• When a patient is being transferred from one care unit to another.
• To update a patient or family member about their status and current treatment plan.
• During shift changes, when a new nurse comes in and needs to be informed of the patient's condition.

Differences Between SBAR and Other Communication Tools

Various communication tools are used in nursing to ensure the effective passage of information. The following reviews those tools and how they differ from SBAR.

Handoff- When one healthcare provider is temporarily or permanently relieved of duty, pertinent information about the patient may be miscommunicated. The Handoff tool ensures this doesn't happen. This is a type of communication tool used in the transfer of patient care from one clinician to the other. Its main objective is to ensure the accurate transfer of patients' information to meet the patient's safety.

A proper handoff communication technique consists of the following:

• The passing of responsibility and accountability
• Information clarity
• Acknowledgment of the information by the receiver
• A chance to go through the information
• Knowledge about issues like the degree of certainty of the patient', how the patient is responding to treatment, any changes in their condition, and plan of care.

Call-out : This communication technique involves passing critical information during emergencies. This information will help healthcare workers anticipate and prepare for the next steps in caring for the patient. The critical part of call-out communication is that it is passed to a specific person.

Call out ensures the following things happen:

• Critical patient information is passed simultaneously to all team members during emergencies.
• Helping all involved personnel anticipate any changes or the next steps to take.

Check back: This tool is important for all involved parties, including patients and their families. This tool validates the exchange of information between all the involved parties. For instance, a patient and their family members can use the tool to confirm that they understand their symptoms and how to monitor them.

In the checkback system, one person initiates a message confirmed and accepted by the receiver. The receiver repeats the message to the sender, who verifies that it was correctly received.

SOAP : This is an acronym that stands for:

• Subjective- this describes why the patient is visiting the hospital or clinic and what their complaint is. This section also includes the patient's present illness, symptoms, past medical history, allergies, and any medications they are taking. The patient is referred to as the chief complaint (cc)
• Objective- refers to anything the nurse or medical personnel can observe from the patient during the first encounter. The nurse will note the patient's vital signs and laboratory and imaging results.
• Assessment- this involves the diagnostic impression as a result of "S" and "O." “A” should always reflect changes in "S" and "O."
• Plan- this is the final step in SOAP, which involves addressing the patient's needs and the next steps. It also includes a doctor's recommendation about more tests or treatments.

Soap is a problem-oriented approach that involves writing out information in patient charts. Healthcare professionals use it to guide their means of communication.

Skills Nurses Need to Use SBAR Effectively

Nurses must possess the following essential skills to effectively apply the SBAR technique in their day-to-day work.

• Observation : Good observation is essential as it helps monitor any changes or the progression of the patient's condition. The critical step in SBAR is assessment. Nurses with keen observation skills can quickly gather the necessary information to make proper recommendations.
• Critical thinking: Nurses are often responsible for making life-changing decisions through challenging and stressful situations. In SBAR, communication thinking critically will help nurses consider the patient's situation, background, and assessment data to come to the correct conclusion about the medical problem.
• Good communication: Excellent communication skills are necessary regardless of the communication technique. They should know how to communicate effectively with their words and body language. Nurses can demonstrate good communication skills by collecting and sharing helpful information in patient care. Nurses work closely with doctors and technicians and must always share patients' concerns.
• Decision Making - how well the nurse makes decisions during patient care will influence their effectiveness in healthcare practice and impact the patients' lives. Once the nurse has reviewed all the important data from the background and assessment, they can decide whether it's necessary to call in the doctor or whether it's necessary to implement the available standing orders.
• Interpersonal skills - nurses who have built their interpersonal skills can establish trust in patients and peers. This trust can be helpful in ongoing patient care, thus positively influencing their outcome.
• Active listening- listening keenly to a patient's concerns can help nurses know which type of intervention is necessary for their ailments. Active listening will also build trust among patients and peers. This will ensure clinicians communicate well and share the knowledge necessary to create a viable care plan .
• Empathy- Nurses are the first point of contact with patients and families who are likely overcome by anxiety or grief. Therefore, they must be compassionate and patient during difficult moments, especially when delivering bad news. This means communicating graciously and ensuring the patients feel safe no matter their situation.
• Technology skills: technology is vital in healthcare. Communicating in hospitals is highly dependent on advanced software skills, particularly in the communication department. When nurses collect patients' data during the background, they should transfer or update it diligently according to the treatment, diagnosis, and outcomes. Technologies are changing rapidly, and medical devices such as health monitoring systems are constantly advancing. So a nurse needs to have good technical skills.

Steps Involved in the SBAR Nursing Communication

SBAR consists of four steps: situation, background, assessment, and recommendation. These are fundamental building blocks for communication between healthcare workers. It involves passing around critical information that requires immediate attention and action.

These steps are described as follows:

Situation - this is the first step of the SBAR, and it involves providing a brief, clear, and concise description of the problem at hand by identifying the following:

• The role in the care of the patient
• Name of the patient
• The unit and room number of the patient

Then explain the problem, how it occurred, and its severity.

Please note that the nurse must identify themselves and the site they are calling from before relaying the patient's information.

Background - background is simply the history of the patient’s health. Here, you provide all the vital information, like why the patient has been admitted. You also have to provide background information about the patient, including:

• Admission date and time,
• Vital information,
• Available lab results
• Code status

If multiple lab reports exist, provide the date and time of the previous results and test changes.

Assessment - state what you think are your professional thoughts (diagnosis) based on all the information you have acquired in the situation and background.

You must have strong critical thinking skills as you conduct the assessment. This way, you can provide the doctor with relevant information about the patient. Meaning you must have done a background check, including receiving lab reports and other tests to determine the underlying cause of the patient's condition.

Recommendation : tell the person with whom you are communicating what you think should be done next.

To understand more about this model, consider the following scenario:

A female patient in her mid-thirties walks into the ER complaining of a throbbing headache. She also has visibly swollen feet and fingers. She is also pregnant and in her third trimester. The attending nurse quickly realizes the dangers of the situation and pages the obstetrics nurse, who rushes into the ER. As the obstetrician leaves, the other nurse fills out an SBAR.

Exercise: Try to fill out an SBAR of your own.

Please take note that for SBAR to work effectively, it requires teamwork. If you find it hard to fill any of the sections, ask the person you are communicating with for relevant help.

SBAR Template

This is a predesigned document that makes it easy to fill SBAR notes. It contains SBAR individual sections where you fill in patient-specific information. Once you have filled it out, print the document and share it with the relevant healthcare personnel.

Please take note that some hospitals prefer using SBAR notes in soft copies. In this case, you should use a template compatible with the current software. Before using any template, consider the mode of SBAR sharing.

The following are the different types of SBAR templates.

Nurses typically use SBAR to communicate important information about the patient to ensure they are properly cared for. This type of information should be relayed in a proper structure to ensure no information is lost. Using either of the above templates will guarantee that you do so.

Examples of Experiences in Clinical Settings where SBAR Is Used

The following are examples of how SBAR applies in a hospital setting.

SBAR for Patients with Chest Pain and Dyspnea

Situation : Hello, Dr. Swanson. This is Heather Jones, a med/surg nurse from the ABC hospital. I'm calling to inform you that your patient, 50 years old Mr. Henry Simpson, from room 58A, is experiencing shortness of breath and complaining of chest pain.

Background : Two weeks ago, Mr. Simpson was rushed to the hospital because he had a heart attack and was admitted to the hospital immediately for further observation. He is now complaining of severe chest pain. I've tasted his pulse rate and blood pressure, which are 124 and 100/58, respectively. Currently, he feels restless and experiences shallow breathing.

Assessment : He could be experiencing another cardiac event because of his history.

Recommendation : As per the standing order, I have initiated O2 per NC and requested an order for an EKG. I would also like you to come and assess him immediately.

SBAR for Patients with Hyperglycemia

Situation : Mary Philips, a 58-year-old patient in room 103A, has full code with a primary diagnosis of diabetes. She came into the ER complaining of blurry visions and exhaustion. Dr. Samson, her physician, has no directives on her file. The patient has no known drug allergies, has a history of C-diff, and left mastectomy, so blood cannot be drawn from her or have blood pressure readings. She is also on fluid restrictions because of a history of congestive heart failure. She also wears a hearing aid in her left ear.

Background : Mary has a history of hyperlipidemia, hypertension, left breast cancer (in remission), and heart failure. She has been taking medication, for I ordered an x-ray and CT scan, which came back negative. Her blood levels are slightly elevated, and her vital signs are stable. She takes insulin before meals (AC) and bedtime (HS).

Note: Including the patient's past illnesses is highly relevant as they could be connected to the current illness.

Assessment: The patient is repeatable and forgetful. Her respiratory system is within the normal range. She has edema 2+ and is taking medication. Her pulse is weak and on telemonitoring with an atrial-paced rhythm. She has been experiencing constipation (currently under laxatives) and is on a low-sodium diet. She uses a bedside commode because of urine incontinence. She needs help with her activity of daily living (ADL). There is a right PIV on her arm and a port for lab draws on the right side of her chest.

Note: this part should be conducted by qualified personnel, for instance, an RN. However, if it is a diagnosis, a medical doctor should do it.

Recommendation: Tomorrow at 9 am, Mary will have a consultation with a cardiac and neurologist at 10 am. If they clear her, she will be discharged in the evening.

If she gets a spike in her blood sugar levels, notify the doctor and immediately begin the insulin protocol.

SBAR for Patients with Pulmonary Embolism

Situation: Hello, Dr. Mike. I'm RN Amanda calling from Chicago medical center, where a 40-year-old Mrs. Jenifer, your patient, was admitted last evening in room 2b.

Background: Mrs. Jenifer came to the hospital last evening with an abdominal hysterectomy and bilateral salpingo-oophorectomy. She slept well, and all her vital signs remained normal overnight.

Assessment : She is currently experiencing a sudden onset of dyspnea. She is also complaining of dizziness, lightheadedness, and severe anxiety. Ms. Jenifer is also experiencing pain while breathing. She is coughing but trying as much as possible to prevent it because of the pain. She has an irregular heart rate which is elevated at 120. Her blood pressure is 110/58, and there is no consistent pulse rate because the pulse ox cannot detect it.

Recommendation: Because of what she is experiencing, I think she has a pulmonary embolism. I have already initiated oxygen as per the standing orders. I'm also requesting that you come and assess her immediately.

SBAR for a Patient with Upper Respiratory Infection

Situation: Mrs. Elena, a 72-year-old woman, is rushed into the ER and is admitted into room 4C with a severe upper respiratory infection. She has labored breathing, increasing to 28 breaths per minute in the past half an hour. The usual interventions have proven ineffective.

Background : Mrs. Elena has a history of congestive heart failure and chronic obstructive pulmonary disease.

Assessment : In the past 30 minutes, the patient's breathing has become worse, and none of these interventions, inhalers, oxygen, or breathing treatments has helped her receive the symptoms.

Recommendation : I have ordered immediate intubation. I also initiated a Rapid Response Team.

And That’s it on SBAR in Nursing

SBAR is a technique for passing patient information among healthcare professionals. It is a straightforward tool used to frame any communication, especially critical communications requiring immediate attention and action from nurses, clinicians, and other healthcare workers. It allows for a focused and direct means of setting expectations for what will be communicated and how between or among members of a team, which facilitates collaboration and by extension improves patient safety and care quality.

Related Readings:

• Steps for creating a nursing abstract poster presentation
• How to write a comprehensive SOAP Note
• How to write a good nursing PICO question
• Nursing care plan template and guide
• How to write a great nursing diagnosis paper.

This easy-to-remember acronym helps nurses, doctors, and technicians quickly, efficiently, and effectively communicate amongst themselves. The tool can be applied in any medical setting; the goal is to help and guide someone to take proper action concerning the patient. If you are a nurse and need help remembering or using the tool, the above guide should help you.

Health systems such as Kaiser Permanente have integrated the SBAR technique. We have looked at SBAR nursing examples and templates. If you need SBAR assignment help, you can place your order and get it done by our professional nursing writers .

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• Open access
• Published: 14 July 2023

Effectiveness of SBAR-based simulation programs for nursing students: a systematic review

• Jungmi Yun 1 ,
• Yun Ji Lee 1 ,
• Kyoungrim Kang 1 &
• Jongmin Park 1  

BMC Medical Education volume  23 , Article number:  507 ( 2023 ) Cite this article

Situation, background, assessment, and recommendation (SBAR) has been extensively used in clinical and nursing education. A structured communication program increases effective communication, positivity, and education satisfaction during inter-professional collaboration among nursing students. This systematic review aimed to identify and synthesize evidence on the effectiveness of SBAR-based simulation training for nursing students.

A research protocol was developed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. The protocol for this study was registered in PROSPERO (CRD42021234068). Eight bibliographical databases were searched for studies published between 2001 and 2021, using relevant search terms. Searches were conducted in PubMed, Embase, Cumulative Index to Nursing and Allied Health, and Cochrane Central Register of Controlled Trials for literature in English, and DBpia, Research Information Sharing Service, Korean Studies Information Service System, and Korea Institute of Science and Technology Information for literature in Korean. After screening titles, abstracts, and full-text papers, pertinent data were extracted, and critical appraisals of the retrieved studies were performed. Data were analyzed using the framework approach, and the findings were presented in a narrative summary. The Effective Public Health Practice Project “Quality Assessment Tool for Quantitative Studies” was used to assess the quality of the included studies.

Twelve studies were included: 3 randomized controlled trials and 9 quasi-experimental studies. Two overarching themes were noted, namely communication clarity and critical thinking. The results of six out of 12 studies produced significant results in favor of SBAR-based simulation in terms of communication clarity. Divergent results were obtained regarding communication ability, critical thinking, confidence, learning self-efficacy, and attitude toward patient safety. The results of these studies highlight that communication clarity ultimately leads to positive results in terms of nursing students’ behaviors related to patient safety.

Conclusions

This review provides a comprehensive update of the literature on the effectiveness of SBAR-based nursing simulation programs for nursing students. These programs were found to have positive learning outcomes because of clear and concise communication. Further studies on the effectiveness of various learning outcomes derived from SBAR-based programs are required.

Peer Review reports

Accurate communication skills among healthcare professionals are very important in the current healthcare environment, where multidisciplinary care and collaborative practice are recommended. A nurse’s ability to communicate is one of the most important competencies for efficiently providing information necessary to report a patient’s condition. A nurse’s clear communication ability contributes to improving the quality of nursing and minimizing accidents that may occur in clinical settings [ 1 , 2 ].

Situation, background, assessment, and recommendation (SBAR) has been extensively used in clinical and healthcare educational settings [ 3 ]. The SBAR includes the communication of the patient’s current situation, the background and causes of the situation, the assessment of the current condition, and the reporter’s recommendations for further treatment [ 3 ]. SBAR is a reliable and validated communication tool that can be easily implemented in hospital-based practices for sharing information among healthcare providers [ 4 ] and is a structured communication tool that enables clear communication in a short time [ 5 ].

Nursing students are expected to develop practical nursing competencies and communication skills through theoretical learning and clinical practice [ 6 ]. Still, many nursing college students merely observe in their clinical training. That is, their attitudes are pretty passive, which makes it challenging to achieve these educational goals. Simulation-based education may be a helpful supplement in clinical practice for nursing students to address this issue. This can improve nursing competencies by enabling iterative and direct learning using virtual scenarios [ 7 ].

A structured communication program increases effective communication, positivity, and education satisfaction during inter-professional collaboration among nursing students [ 3 ]. In previous studies, incorporating SBAR techniques into simulation-based education positively affected communication skills, clarity, and confidence [ 8 , 9 , 10 ]. Using SBAR, nurses can more accurately recognize patient condition changes, enabling precise, effective, enhanced communication and cooperation among healthcare staff [ 11 , 12 ]. Research on the effectiveness of SBAR in nursing education is still ongoing, and it is necessary to promote its implementation in the curriculum sufficiently.

As a result of reviewing research on structured communication programs in Korea, studies such as the SBAR program have been conducted using a combination of theory lectures, role-play, discussion, debriefing, team activity, case-based, and simulation methods [ 1 , 13 ]. Many overseas studies have applied a communication promotion program to nursing education using theoretical lectures, role-play, theater therapy techniques, online media use, simulations, pamphlets, reflection, feedback and discussion, and DVD viewing [ 14 , 15 , 16 , 17 ].

Most communication programs implemented for nurses or nursing students had statistically significant effects. Still, the concept and evidence of the program were not uniform, and the tools used by each researcher, research participants, and measurement period varied. Although simulation education is becoming more important in clinical practice when a simulation program using SBAR is applied, contradictory results (effective/ineffective) have been reported as research results, and the lack of high-quality literature (low-modest) was confirmed. Each program has a different composition, contents, and results; therefore, it is necessary to systematically examine the contents and effects of various simulation programs using SBAR [ 18 ]. Accordingly, the contents, effects, and trends of the SBAR-based programs were comprehensively reviewed and integrated to provide the best basis for future communication program development for nursing students. This systematic review aimed to identify and synthesize evidence on the effectiveness of SBAR-based simulation programs for nursing students.

This systematic review aimed to integrate and analyze the effects of SBAR-based nursing simulation programs for nursing students. The primary research question guiding this systematic review is: What is the impact of the SBAR-based simulation program on nursing students? To address this question, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews and meta-analyses [ 19 ]. The study protocol was registered on the PROSPERO website (CRD42021234068; https://www.crd.york.ac.uk/PROSPERO/ ).

Eligibility criteria

This study applied the PICO-SD (participants, intervention, comparison, outcomes, study design) tool as follows: (1) participants (P): nursing students; (2) intervention (I): nursing simulation programs that utilized SBAR-centered scenarios or activities; (3) comparison (C): different simulation programs or other educational interventions; (4) outcome (O): significant effects of the intervention; and (5) study design (SD): randomized controlled trial (RCT), or quasi-experimental design. Studies with nursing students as participants, either exclusively or as part of a sample including other healthcare students/professionals, are eligible for inclusion. The following studies were excluded: (1) single-arm studies, (2) observational studies, qualitative studies, mixed method studies, review articles, editorials, case studies, and proceedings, and (3) pilot studies. The publication year of the articles was limited from January 1, 2001, to June 30, 2021.

Search strategies and study selection

A systematic literature review was conducted for articles published from January 1, 2001, to June 30, 2021. We searched international studies in the following databases: PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Cumulative Index to Nursing and Allied Health (CINAHL). Domestic studies were searched in DBpia, Research Information Sharing Service (RISS), Korean Studies Information Service System (KISS), and Korea Institute of Science and Technology Information (Kisti). The keyword selection and search included Medical Subject Headings (MeSH) and Emtree for thesaurus in biomedical and life sciences. The keywords included “nursing,” “SBAR,” “ISBAR,” “SBAR-R,” “simulation,” “program*,” and “intervention*.” The search was limited to articles written in Korean or English.

In title screening, two independent reviewers (J.Y. and J.P.) examined the identified records’ titles to exclude irrelevant studies. Any discrepancies were resolved through discussion or consultation with a third reviewer (K.K.), if necessary. Next, the two reviewers examined the abstracts and keywords of the remaining records to refine the list of potentially relevant studies further. Any disagreements at this stage were also addressed through discussion or consultation with the third reviewer. Finally, the two reviewers independently assessed the full-text articles of the remaining studies for eligibility according to the pre-specified inclusion and exclusion criteria. Disagreements at this stage were also resolved through discussion or consultation with a third reviewer. We also manually screened the reference lists of the included studies and relevant reviews to ensure that all pertinent studies were identified.

Data extraction

To ensure the objectivity of data extraction, two reviewers (K.K. and Y.L.) independently extracted data from the included studies. We collected data regarding the authors, year of publication, country, study design, subjects, sample size, intervention characteristics, control groups, and outcome measurements. In case of disagreement between researchers, a consensus was reached by discussion with a third reviewer (J.Y.).

Quality assessment

We used the Effective Public Health Practice Project (EPHPP) “Quality Assessment Tool for Quantitative Studies” [ 20 ] to assess the quality of the included studies. Reviewers provided strong, moderate, or weak ratings for the following domains: selection bias, design, confounders, blinding, data collection methods, and withdrawals and dropouts. Strong, moderate, and weak global ratings were determined according to the number of weak ratings received [ 20 ]. The EPHPP tool was used to assess the quality of both RCT and quasi-experimental studies included in our systematic review. While the tool is applicable to both study designs, slight modifications were made as needed to accommodate the differences between RCTs and quasi-experimental studies. Two independent authors (J.Y. and J.P.) assessed the quality of the included studies, and any disagreements were resolved through discussion or consultation with a third reviewer (K.K.), if necessary.

Search results

Figure  1 shows the flow of the study selection process for this review. After searching eight databases, 453 studies were found. A total of 170 studies were removed as duplicates and the titles and abstracts of 283 studies were screened. Due to irrelevancy, 257 studies were excluded, the full texts of 26 studies were reviewed, and two additional articles were searched and reviewed from other sources. Ultimately, 12 studies were included in the narrative analysis.

PRISMA flow diagram of the study selection process

Description of the included studies

Table  1 presents the characteristics of the studies included in the narrative analysis. Of the 12 included studies, most were conducted in Korea [ 3 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ] and one each in Ireland [ 29 ], Spain [ 30 ], and the USA [ 31 ]. A quasi-experimental design was used in nine studies [ 3 , 21 , 23 , 24 , 25 , 26 , 27 , 28 , 31 ] and a RCT was adopted in the remaining three studies [ 22 , 29 , 30 ]. In two studies [ 24 , 29 ], more than one experimental group was designated. The total sample size was 886 participants (503 in the intervention group and 383 in the control group). The individual sample size of each group— the experimental and control groups of the included studies—was mostly under 50, and the average of both experimental and control groups was approximately 34.7.

Interventions of the included studies

The interventions in the included studies varied in detail, including orientation, pre-briefing, and role-play. The duration of the programs also varied between one and six hours. Except for one study [ 3 ], that applied a four-phase clinical practicum (CP) with SBAR training, the other eight studies in Korea included orientation, lecture, or educational sessions for more than 60 min before the simulation scenario performance with role-play. A recent study [ 24 ] applied for a three-session program. Each session consisted of education with orientation for 20 min, assertiveness skills or role-play for 15–20 min, and group discussion for 10 min. Other studies mostly ran a program comprising education with 60–120 min of orientation, role-play for 60–120 min, and debriefing/discussion for about 30 min. One study [ 29 ] adopted e-learning with simulations for a two-session program. Compared to the experimental groups, programs applied to the control groups included a diverse range of program in nursing education studies. These included e-learning programs, self-learning, group discussions, simulation programs, regular clinical practice, pre-briefing and debriefing sessions, conventional learning methods, and a focus on nursing processes and therapeutic communication. The variety of programs provided a comprehensive understanding of different approaches in nursing education and allowed for thorough evaluation of the experimental group interventions.

Outcomes of the included studies

Six studies measured “communication clarity” using communication clarity scale (CCS) by Marshall et al. [ 32 ], and one study [ 22 ] used a structured communication tool [ 33 ]. The “communication ability” was evaluated using the 15-item general interpersonal communication competence scale (GICC) [ 34 ] in three studies [ 22 , 23 , 24 ]. Other communication-related variables were “report clarity”, measured by two items each for SBAR [ 25 ], “capacities to identify roles and to communicate”, measured by KidSIM team performance (KidSIM-TPS) [ 30 ], “SBAR communication accuracy”, using the tool developed by Yu & Kang [ 3 ], and “SBAR communication” itself by checklist [ 27 ]. The other outcomes for examining the effects of the interventions included “confidence”, scored on visual analogue scale (VAS) in four studies [ 3 , 25 , 27 , 31 ], “clinical competence”, scored by the clinical competence instrument by Lee in one study [ 24 ], “self-efficacy” by general self-efficacy scale [ 28 ] and learning self-efficacy scale [ 3 ], and “critical thinking”, rated with the critical thinking instrument by Yoon in three studies [ 23 , 26 , 28 ].

Quality of included studies

An overview of the quality of the included studies is shown in Table  2 and the global ratings are presented in Table  1 . Of the 12 studies included in the present systematic review, nine studies were classified as weak, three as moderate [ 22 , 24 , 30 ], and none were classified as strong. Most of the studies were appraised as weak at the “selection bias” (11 out of 12 studies) and “blinding” (nine studies), whereas 11 studies were rated as strong at “confounders” and “withdrawals and dropouts”. Eight studies were evaluated as strong in the “data collection method” category. In the “study design” section, 10 studies were classified as moderate in consideration of randomization.

Overview of findings

The objective of this systematic review is to examine and synthesize the available evidence regarding the effectiveness of SBAR-based simulation training for nursing students. In this discussion, we will address two main themes: communication clarity and beyond communication, which encompasses communication ability, critical thinking, self-leadership, patient safety, confidence, and self-efficacy. Our findings suggest that SBAR-based simulation programs have the potential to enhance nursing students’ communication clarity, thereby contributing to improved communication in clinical settings.

Impacts of interventions

Six of the included studies measured the clarity of communication. A previous study showed that teaching SBAR techniques to healthcare providers can improve communication clarity in both classroom and clinical settings [ 35 ]. Adaptation to clinical practice is significant for novice nurses entering the clinical environment after graduation [ 27 ]. As an approach to address the communication difficulties of new nurses in the early stages of adjustment, offering a program including SBAR before graduation improved communication and information organization skills and increased the reliability of information transmission [ 36 ]. Previous studies have measured fidelity to SBAR by determining the extent to which users perform SBAR as intended (e.g., measures of adherence to the mnemonic during communication). Classroom-based studies achieved levels of fidelity to SBAR ranging from 71–87% and reported moderate to considerable improvements in the clarity of communication [ 3 , 32 , 37 ].

On the other hand, studies conducted in clinical settings have shown no or only moderate improvements in clarity, with fidelity ranging from 53–83% [ 38 , 39 , 40 ]. The lesser improvements in communication clarity seen in studies from clinical settings suggest the need to establish higher fidelity to SBAR as intended [ 35 ]. In other words, implementing without confirming adherence or exposing nursing students to SBAR only in classroom settings does not lead to the planned improvement in communication. Therefore, preparing a method to check and monitor fidelity to SBAR in a simulation program that reproduces the clinical situation is necessary.

In addition to communication ability, critical thinking, self-leadership, patient safety, confidence, and self-efficacy were also reported to achieve effectiveness as a result of the SBAR-based simulation program. SBAR-based education can improve critical thinking in the process of presenting various clinical judgment grounds to students and finding the best decision and evidence to confirm the decision [ 41 ]. In addition, it can be expected to improve self-leadership by giving individuals the spontaneity and self-direction necessary to judge, act, and perform work in a desirable way [ 21 ]. Furthermore, positive self-leadership can lead to self-confidence and self-efficacy in clinical performance. In previous studies, SBAR education and implementation positively improved patient safety competencies [ 21 , 22 ]. Repeated use of SBAR helps to structure what to observe, what information to collect, and in what order to deliver content to alert the doctor; such structured information can enable nurses to make quick judgments and actions in urgent situations [ 22 ]. Therefore, the use of standardized communication tools facilitates proficient performance of nursing students and ultimately improves patient safety competency [ 22 ].

The interventions included in the analysis consisted of orientation, pre-briefing, role-play simulation, debriefing, or discussion. In 8 studies, pre-briefing was performed for more than 60 min. Pre-briefing may comprise several activities that include planning, using facilitation strategies, and transferring information. For novice nursing students who do not have experience or practice in thinking like a nurse or with the processes of reflection [ 42 ], a structured pre-briefing activity could support metacognition or critical thinking [ 43 ]. Indeed, theory-based, structured pre-briefing can impact nursing students’ clinical judgment, perceptions of pre-briefing, and competency performance and may enhance meaningful simulation learning [ 43 ]. Simulations consisted of role-playing or self-assertive training. Role performance simulation, including SBAR before graduation, helps new nurses improve their communication and information organization skills and the reliability of information delivery. In addition, assertive training has a positive effect on enhancing communication confidence and interpersonal relationships. When providing debriefing and discussion, it is adequate to avoid lecture-type methods and to receive feedback after directly observing one’s performance [ 44 ]. It is necessary to strengthen communication skills based on self-reflection and group reflection.

Limitations

The program implemented in the literature included in this study confirmed the effectiveness of simulation education using SBAR. However, because there were differences in the intervention period, measurement methods, and intervention components of the programs, it was difficult to compare and analyze the effects in an integrated manner. In addition, programs implemented in the literature do not incorporate surveillance or other monitoring of fidelity to SBAR. This could potentially limit the effectiveness of simulation training using SBAR. Another limitation is the presence of additional interventions alongside SBAR in some included studies, which may have influenced the observed outcomes and made it difficult to isolate the specific impact of SBAR-based simulation training. Finally, additional studies reporting low fidelity or no improvement in communication clarity may not have been published; therefore, there is also a limitation due to publication bias.

Implications for practice and future research

Simulation approaches in nursing education are now being proposed as a new pedagogical method to complement or replace clinical practice. The findings of the current study suggest that SBAR-based simulation programs have positive effects on nursing students’ capabilities for practice, with satisfaction and intense concentration in the provided situation. In future research, standardized and validated interventions for SBAR training should be researched for effectiveness during nursing education. Another potential research study would be to identify the effects of different simulation methodologies, such as web-based, high fidelity, and virtual simulations.

This review provides a comprehensive update of the literature on the effectiveness of SBAR-based nursing simulation programs for nursing students. Our findings indicate that such programs lead to enhanced communication clarity and other positive learning outcomes among nursing students. However, given the variability in program components and measurement methods, it is essential to continue exploring the specific effects of SBAR-based simulation programs on various learning outcomes. This will enable a deeper understanding of the most effective strategies for optimizing communication and other crucial skills in nursing education.

Data availability

All data generated during this study are included in this published article.

Abbreviations

situation, background, assessment, and recommendation

Effective Public Health Practice Project

participants, intervention, comparison, outcomes, study design

Cochrane Central Register of Controlled Trials

Cumulative Index to Nursing and Allied Health

Research Information Sharing Service

Korean Studies Information Service System

Korea Institute of Science and Technology Information

Medical Subject Headings

clinical practicum

communication clarity scale

communication competence scale

KidSIM team performance

visual analogue scale

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This research was supported by PNU-RENovation (2020–2022).

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SBAR Nursing

Last updated on May 17th, 2022 at 07:21 pm

SBAR Nursing Example

The U.S. Navy established SBAR originally to relay information about nuclear submarines, but it was adopted by the healthcare system in the 1990s, and later on, used globally. Since then, SBAR was found to be a valuable method for organizing and presenting patient information.

To reduce the risk of error and ensure that the patient is treated appropriately, patient information should be communicated precisely, fast, and effectively at all times.

Importance of SBAR in Nursing

The SBAR approach is valuable as it provides nurses with a framework for promptly and efficiently communicating essential factors of critical circumstances.

The SBAR approach can be used by members of the healthcare team in a variety of situations and places. It might start early treatment as a patient is admitted to a unit.

It can be a good strategy to use when presenting new shift report briefings over the phone, at the nurses’ station, and even in front of patients.

Components of SBAR Nursing

How to demonstrate sbar nursing, what to do before using sbar nursing.

It is essential to understand what members of the healthcare team must do before consulting with the doctor. The physician will ask appropriate questions, and it is preferable if they can predict what inquiries and information he or she would ask.

When to Use SBAR Nursing

Who should use sbar.

SBAR is recommended by the Agency for Healthcare Research and Quality (AHRQ) for the following:

SBAR Nursing Example 1

Raiya Kurstey, a 66-year-old female admitted to the Intensive Care Unit (ICU), is exhibiting signs of cardiac arrest . Her nurse must inform the on-call physician about the matter. In this case, they might employ the SBAR approach as described in the following:

SBAR Nursing Example 4

A patient was admitted due to chronic back pain and underwent a spinal infusion. The patient notices erratic vital signs measurements and needs to discuss the patient’s condition with his physician and make some recommendations.

Patient safety is the most important consideration in patient care, and ineffective communication are the most frequent cause of adverse outcomes. During patient shift handover, health care providers make every effort to avoid communication mishaps.

Furthermore, maintaining the therapeutic use of the SBAR communication tool necessitates educational training and a shift in culture.

More research is needed to determine the impact of the SBAR communication tool on patient outcomes and the instrument’s validation in additional subspecialties and comparisons to other communication tools.

Nursing References

Gulanick, M., & Myers, J. L. (2022).  Nursing care plans: Diagnoses, interventions, & outcomes . St. Louis, MO: Elsevier. Buy on Amazon

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How to Use SBAR to Develop Clinical Judgment

This article was written in collaboration with Christine T. and ChatGPT, our little helper developed by OpenAI.

SBAR is an acronym for Situation, Background, Assessment, and Recommendation. It is a standardized communication framework used in healthcare settings, particularly by nurses, to facilitate clear, concise, and accurate information exchange between team members. This structured method ensures that all relevant patient information is communicated in a consistent and organized manner, promoting patient safety and enhancing the overall quality of care.

Related Terms

• Handoff Communication: The process of transferring patient care and information from one healthcare provider to another during shift changes, patient transfers, or consultations.
• ISBAR: An extension of SBAR, which includes the additional step of identifying oneself and the patient.
• CUS: An acronym for Concerned, Uncomfortable, and Safety issue, used to assertively express concerns about patient safety during communication.

Synonyms, Definitions, and Examples

Assessment Techniques and Tools

The effectiveness of SBAR communication can be assessed using various techniques and tools, such as:

• Observation of real-time communication during clinical practice or simulation exercises.
• Audits of written or electronic communication, such as handoff reports, progress notes, or care plans.
• Feedback from team members, patients, and families regarding the clarity and accuracy of communication.
• Assessment of patient outcomes and safety incidents, which can be linked to the quality of communication.

Assessment Frameworks

Assessment frameworks, such as the Joint Commission’s National Patient Safety Goals or the Institute for Healthcare Improvement’s (IHI) Model for Improvement, can help guide the evaluation and improvement of SBAR communication in healthcare organizations. These frameworks emphasize the importance of effective communication for patient safety and provide recommendations for implementing and assessing communication strategies.

Assessment Documentation

Documenting the assessment of SBAR communication is essential for tracking progress and identifying areas for improvement. Documentation may include:

• Records of observed communication during clinical practice or simulation exercises, noting strengths and areas for improvement.
• Audit findings of written or electronic communication.
• Feedback from team members, patients, and families.
• Data on patient outcomes and safety incidents related to communication.
• Plans for ongoing monitoring, improvement, and reassessment of SBAR communication.

Legal and Ethical Considerations

Effective communication is a vital aspect of providing safe, high-quality healthcare. As such, healthcare professionals have an ethical responsibility to ensure that their communication is clear, accurate, and timely. The use of standardized communication frameworks like SBAR can help meet these obligations, reducing the risk of errors, misunderstandings, and potential legal consequences. Furthermore, organizations should ensure that they are compliant with relevant laws and regulations governing patient privacy and confidentiality when implementing and assessing SBAR communication.

Real-Life Examples or Case Studies

Many healthcare organizations have successfully implemented SBAR to improve communication, patient safety, and clinical outcomes. Examples include:

• A large hospital system that implemented SBAR communication, resulting in a 50% reduction in adverse events and a 30% decrease in sentinel events.
• A long-term care facility that used SBAR to improve communication between nurses and physicians, leading to a decrease in unnecessary hospital transfers.
• A home healthcare agency that introduced SBAR for interprofessional communication, resulting in more effective care coordination and improved patient satisfaction.

Resources and References

• Institute for Healthcare Improvement’s SBAR Toolkit
• SBAR (situation, background, assessment, recommendation)
• SBAR: A Shared Mental Model for Improving Communication Between Clinicians

SBAR is a widely recognized and effective communication framework used in healthcare settings to ensure clear, concise, and accurate information exchange between team members. By using SBAR, healthcare professionals can promote patient safety, enhance the quality of care, and fulfill their legal and ethical obligations. Implementing and assessing SBAR communication in your organization can lead to significant improvements in communication and overall patient outcomes.

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Abela-Dimech F, Vuksic O. Improving the practice of handover for psychiatric inpatient nursing staff. Arch Psychiatr Nurs. 2018; 32:(5)729-736 https://doi.org/10.1016/j.apnu.2018.04.004

Achrekar M, Murthy V, Kanan S, Shetty R, Nair M, Khattry N. Introduction of situation, background, assessment, recommendation into nursing practice: a prospective study. Asia Pac J Oncol Nurs. 2016; 3:(1)45-50 https://doi.org/10.4103/2347-5625.178171

Bach S, Grant A. Communication and interpersonal skills in nursing, 2nd edn. Exeter: Learning Matters; 2011

Ballantyne H. Undertaking effective handovers in the healthcare setting. Nurs Stand. 2017; 31:(45)53-62 https://doi.org/10.7748/ns.2017.e10598

Dougherty L, Lister S. The Royal Marsden manual of clinical nursing procedures, 9th edn. Chichester: John Wiley & Sons; 2015

Frain J. Why clinical communication matters. In: Cooper N, Frain J (eds). Chichester: John Wiley & Sons; 2018

Herawati VD, Nurmalia D, Hartiti T, Dwiantoro L. The effectiveness of coaching using SBAR (situation, background, assessment, recommendation) communication tool on nursing shift handovers. Belitung Nursing Journal. 2018; 4:(2)177-185 https://doi.org/10.33546/bnj.464

NHS England. Leading change, adding value: a framework for nursing, midwifery and care staff. 2016. https://tinyurl.com/h45wu74 (accessed 6 July 2020)

NHS Improvement. SBAR communication tool: situation, background, assessment, recommendation. 2018. https://tinyurl.com/y7j7cekh (accessed 6 July 2020)

NHS Institute for Innovation and Improvement. The handbook of quality and service improvement tools. 2010. https://tinyurl.com/ycz9mwgj (accessed 6 July 2020)

Nursing and Midwifery Council. The code. Professional standards of practice and behaviour for nurses, midwives and nursing associates. 2018. https://tinyurl.com/gozgmtm (accessed 6 July 2020)

Park L, Allan J, Hill B. Data gathering and patient monitoring. In: Peate I (ed). Edinburgh: Elsevier; 2019

Renz SM, Boltz MP, Wagner LM, Capezuti EA, Lawrence TE. Examining the feasibility and utility of an SBAR protocol in long-term care. Geriatr Nurs (Minneap). 2013; 34:(4)295-301 https://doi.org/10.1016/j.gerinurse.2013.04.010

Royal College of Nursing. Communication. 2019. https://tinyurl.com/y9ghdjb8 (accessed 6 July 2020)

Ting WH, Peng FS, Lin HH, Hsiao SM. The impact of situation-background-assessment-recommendation (SBAR) on safety attitudes in the obstetrics department. Taiwan J Obstet Gynecol. 2017; 56:(2)171-174 https://doi.org/10.1016/j.tjog.2016.06.021

van der Wulp I, Poot EP, Nanayakkara PWB, Loer SA, Wagner C. Handover structure and quality in the acute medical assessment unit. J Patient Saf. 2019; 15:(3)224-229 https://doi.org/10.1097/PTS.0000000000000221

World Health Organization. Communicating during patient hand-overs. 2007. https://tinyurl.com/yaklbldw (accessed 6 July 2020)

Yu M, Kang K. Effectiveness of a role-play simulation program involving the SBAR technique: A quasi-experimental study. Nurse Educ Today. 2017; 53:41-47 https://doi.org/10.1016/j.nedt.2017.04.002

Using the SBAR handover tool

Laura J Park

Graduate Tutor, Adult Nursing, Northumbria University, Newcastle upon Tyne, explain how to reduce the risk of contamination

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This article will focus on using the SBAR handover as an effective communication tool. The SBAR (Situation, Background, Assessment, Recommendation) tool is used by all nursing fields within primary and secondary healthcare environments to aid patient safety ( NHS Improvement, 2018 ).

Communication in nursing

Acts of communication through handovers, ward rounds, shift exchanges and team meetings are examples of when information is exchanged between nurses and between nurses and other health professionals. Communication is one of the 6Cs, and is recognised as a fundamental aspect of nursing practice and as an essential interprofessional skill that has the power to influence team interplay and patient safety ( NHS England, 2016 ; Nursing and Midwifery Council, 2018 ; Herawati et al, 2018 ; Park et al, 2019 ).

An episode of communication, specifically in a patient handover, is the point where critical clinical information is passed between health professionals ( Ballantyne, 2017 ; Park et al, 2019 ). Ineffective communication in nursing has been linked in research to clinical errors, delays in diagnosis and patient dissatisfaction ( Frain, 2018 ; Royal College of Nursing, 2019 ).

Communication as a social activity, regardless of its context—whether face to face, over the phone or in writing—has two premises ( Bach and Grant, 2011 ). The first premise is that communication involves a sender and a receiver, the second is that the sender and the receiver interact to exchange verbal and non-verbal information ( Bach and Grant, 2011 ; Park et al, 2019 ). Although it may seem simple, communication in nursing is not, with multiple potential barriers to disrupt and interfere with the sender and the receiver ( Box 1 ).

Box 1.Barriers to effective communication in nursing

• Accents/other languages
• Medical jargon/language
• Background noise
• Communication styles
• Distractions
• Poor telephone connection
• Not using a structured approach
• Lack of confidence

Source: Park et al, 2019

These communication barriers can be overcome and/or reduced by the use of a consistent structured communication tool ( Abela-Dimech and Vuksic, 2018 ). Tools such as the SBAR tool improve the quality of episodes of communication, including handovers, as the tool enables thoughts to be standardised through applying a structured approach to sharing information ( Renz et al, 2013 ; Dougherty and Lister, 2015 ). This process bridges the gap between different communication styles ( Achrekar et al, 2016 ), allowing patient information to be delivered and received successfully ( Ballantyne, 2017 ).

The SBAR handover

Using the SBAR communication tool is recommended practice in multiple professional contexts (including in healthcare, the military and aviation) ( World Health Organization, 2007 ; van der Wulp et al, 2019 ). The tool was developed by the US navy and adapted for health care by Kaiser Permanente, a rapid-response team in the, USA ( Achrekar et al, 2016 ; NHS Improvement, 2018 ). Evaluations have found it to be effective in reducing clinical errors ( Ting et al, 2017 ; Yu and Kang, 2017 ; Abela-Dimech and Vuksic, 2018 ).

The SBAR handover tool can be used over the phone, face to face and through documentation. The SBAR tool consists of four sections, with each section made up of a set of predetermined structured parts ( Park et al, 2019 ). This structured approach provides a process that is easy to follow and one that is designed to help nurses to prepare for episodes of communication. It acts as a checklist, reducing information overload and allowing the information shared to be focused, factual, clear and without repetition ( Yu and Kang, 2017 ; Park et al, 2019 ). In addition, standardising handover practices provides nurses and other health professionals with confidence ( van der Wulp et al, 2019 ) as it streamlines information exchange, and acts as a prompt for the patient information one should expect ( NHS Institute for Innovation and Improvement, 2010 ).

Tips for using the SBAR handover

Tips for each of the four sections within the SBAR handover are outlined below ( Park et al, 2019 ) and in Figure 1 and Box 2 .

Box 2.Preparing for an SBAR handover

• Practise your SBAR handover beforehand
• Use the tool in order. Do not jump between sections (do not give information on assessment before the background information has been given, for example)
• Give yourself enough time
• Write down the information you want to include
• Check your environment is appropriate (ie free from disruptive noise and distractions)
• Do not be frightened to ask for information to be repeated or clarified

Clearly state the following:

• Your full name and profession. Multiple individuals from the same professional group working in the same setting may have the same or similar first name (such as Laura, Lauren, Lara, Lorna). Therefore, to reduce any potential confusion, ensure your full name and designation is given, for example, Laura Park, staff nurse
• If you are handing over/transferring a patient to a different location do not forget to give your current location—ward number/name and or department name
• Provide the patient's details, ensuring the patient's full name and age is given. The rationale for handing over information also needs to be given, for example because you are transferring the patient to another location or you are concerned about the patient's condition. For example, ‘I'm Laura Park, a staff nurse from ward 1 and I'm handing over Jill Smith, a 76-year-old female. I am concerned about her as she has a National Early Warning Score of 9.’

You need to be clear and concise about the patient information that needs to be shared:

• Here you need to focus on what information is important and relevant for the current situation and thus requires sharing. Information overload can lead to fragmented handovers. Not all past medical history may be relevant. In the case of Mrs Smith, providing information on her broken arm when she was 60 may not be relevant to this admission. An example of information to provide for the background part would include ‘Mrs Smith was admitted today, she is normally fit and well. She saw her GP 2 weeks ago where she was diagnosed with a urinary tract infection and prescribed oral antibiotics.’

The following needs to be clearly stated:

• The patient's current condition as well as their normal health status. If this includes their vital observations, ensure you include a full set and that you include both the patient's latest set and the ones documented before a change in their condition occurred. For example, ‘Mrs Smith was alert on admission 1 hour ago with all observations in the normal range except temperature at 37.1. She is now confused. Her observations are: BP: 90/58, pulse: 117, Sp0 2 : 94%, temperature: 38.0, respirations: 22’
• Here you may also state what you think the problem is. However, do not feel pressured to provide this. If you do not know what is wrong with the patient, simply say that. For example, ‘Mrs Smith may be septic.’

Recommendation

For the final section, tips include:

• Be clear in what you want/need from the professional you are handing over to. For example ‘Mrs Smith needs to be reviewed in the next 15 minutes’
• If information or a request/recommendation is given to you, repeat the request back to the professional giving the recommendation. Ask them for their full name and professional designation
• Take notes if needed ( Park et al, 2019 ).

LEARNING OUTCOMES

• Understand that there is a strong link between communication and clinical outcomes—ineffective communication during handovers is one of the leading causes of patient harm
• Know how to use the SBAR handover tool to reduce these risks by adding structure and consistency to the content of clinical nursing handovers

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Using SBAR to promote clinical judgment in undergraduate nursing students

• PMID: 25692739
• DOI: 10.3928/01484834-20150218-08

The purpose of this study was to describe how students identify and interpret multiple embedded clinical cues in a case study, and then reflect these using SBAR (Situation, Background, Assessment, and Recommendation). Using Tanner's model of clinical judgment, a descriptive design was used to examine SBAR assignments completed by second-semester nursing students (n = 80). The majority of students (n = 62, 77.5%) in the study were unable to successfully follow all of the clinical judgment phases of the model: noticing, interpreting, responding, and reflecting. Although SBAR is an important tool for communicating clinical information, gaps exist between noticing and interpreting clinical cues, and forming an appropriate course of action.

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Introduction of Situation, Background, Assessment, Recommendation into Nursing Practice: A Prospective Study

Meera s. achrekar.

1 Department of Nursing, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Navi Mumbai, Maharashtra, India

Vedang Murthy

2 Department of Radiation Oncology, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Navi Mumbai, Maharashtra, India

Sadhana Kanan

3 Department of Biostatistics, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Navi Mumbai, Maharashtra, India

Rani Shetty

4 Leelabai Thackersey College of Nursing, Mumbai, Maharashtra, India

Navin Khattry

5 Department of Medical Oncology, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Navi Mumbai, Maharashtra, India

The aim of the study was to introduce and evaluate the compliance to documentation of situation, background, assessment, recommendation (SBAR) form.

Twenty nurses involved in active bedside care were selected by simple random sampling. Use of SBAR was illustrated thru self-instructional module (SIM). Content validity and reliability were established. The situation, background, assessment, recommendation (SBAR) form was disseminated for use in a clinical setting during shift handover. A retrospective audit was undertaken at 1 st week (A1) and 16 th week (A2), post introduction of SIM. Nurse's opinion about the SBAR form was also captured.

Majority of nurses were females (65%) in the age group 21-30 years (80%). There was a significant association ( P = 0.019) between overall audit scores and graduate nurses. Significant improvement ( P = 0.043) seen in overall scores between A1 (mean: 23.20) and A2 (mean: 24.26) and also in “Situation” domain ( P = 0.045) as compared to other domains. There was only a marginal improvement in documentation related to patient's allergies and relevant past history (7%) while identifying comorbidities decreased by 40%. Only 70% of nurses had documented plan of care. Most (76%) of nurses expressed that SBAR form was useful, but 24% nurses felt SBAR documentation was time-consuming. The assessment was easy (53%) to document while recommendation was the difficult (53%) part.

Conclusions:

SBAR technique has helped nurses to have a focused and easy communication during transition of care during handover. Importance and relevance of capturing information need to be reinforced. An audit to look for reduced number of incidents related to communication failures is essential for long-term evaluation of patient outcomes. Use of standardized SBAR in nursing practice for bedside shift handover will improve communication between nurses and thus ensure patient safety.

Introduction

All patients have a right to effective care at all times. Patients admitted to health care setting are treated by a number of health care personnels. Communication between health care personnel accounts for a major part of the information flow in health care, and growing evidence indicates that errors in communication give rise to substantial clinical morbidity and mortality.[ 1 ] One of the risk factors leading to communication breakdowns during transition of care is a lack of standardized procedures in conducting successful handoffs, for example, use of the situation, background, assessment, recommendation (SBAR).[ 2 ] Studies indicate that use of structured handoffs will improve the quality of patient handover.[ 3 , 4 , 5 ] Hands off is the transfer of responsibility and accountability of a patient, from one nurse to another[ 6 ] either during shift handover or transfers of the patient from one department to the other.

SBAR was introduced by rapid response teams at Kaiser Permanente in Colorado in 2002, to investigate patient safety. It is an acronym for SBAR; a technique that can be used to facilitate prompt and appropriate communication. This communication model has gained popularity in healthcare settings, especially among professionals such as nursing staff. It is a way for health care professionals to communicate effectively with one another, and also allows for important information to be transferred accurately. The format of SBAR allows for the short, organized and predictable flow of information between professionals.[ 7 ] The main purpose of SBAR technique is to improve the effectiveness of communication through standardization of communication process.

Nurses often take more of a narrative and descriptive approach to explain a situation, while physicians usually want to hear only main aspects of a situation. The SBAR technique closes the gap between these two approaches allowing communicators to understand each other better. It includes a summary of the patient's current medical status, recent changes in condition, potential changes to watch for, resuscitation status, recent laboratory values, allergies, problem list, and a to-do list for the incoming nurse. It is specially used for communication between a physician and a nurse when there is a change in patient condition or between a nurse and nurse during patients shift to a new department or during shift change. It is a technique used to deliver quality patient care. It is a skill that can be learned.[ 8 ]

Published evidence shows that SBAR provides effective and efficient communication, thereby promoting better patient outcomes.[ 9 ] SBAR communication method is an evidence-based strategy for improving not only interprofessional communication, but all communication[ 10 ] especially when combined with good assessment skills, clinical judgment, and critical-thinking skills. Nursing documentation must describe patient's ongoing status from shift to shift with records of all nursing interventions.[ 9 ] In India, no such data was available. Therefore, the aim of this study was to introduce and evaluate the compliance to effective use of SBAR form during nurses’ handover in a tertiary care cancer center.

Data for this study were drawn from a larger research study. Ethical approval for the study was granted by the institutional review board. Of the 113 nurses in the larger study, 20 nurses involved in active bedside care were selected by simple random sampling using research randomizer software. A self-instructional module (SIM) on clinical communication skill for nurses (used in the larger study) incorporated the SBAR format in which information and use of SBAR was illustrated. The content validity of the format was established by giving it to clinical and nursing experts. The SBAR form was disseminated for use in clinical setting for hands off during shift handover.

Inter-rater reliability of the audit checklist was established using the kappa statistic to determine consistency among raters (κ = 0.91, P < 0.001). A retrospective audit was undertaken at 1 st week (referred to as A1) and 16 th week (referred to as A2) respectively, post introduction of SIM. Items in the audit checklist were scored as “1” for yes and “0” for no and “9” if not applicable. Though 100% compliance would be considered as excellent, a benchmark of 80% and above was considered as acceptable. The audit checklist had 29 items in four areas. The number of items under each domain was a situation (10), background (7), assessment (7), and recommendation (5). The content of the SBAR format was verified with clinical record of the patient. Nurses opinion about the SBAR form was captured using a three point (i.e., not at all, somewhat and very much) Likert scale having seven items and three multiple choice questions. The data were analyzed using descriptive (frequency and percentage) and inferential statistics (nonparametric test: Wilcoxon signed rank test).

The study included 20 nurses in the first audit and 19 nurses in the second audit. The survey on nurse's opinion was completed by 17 nurses.

Demographic variables

There were 6 (30%) males and 14 (70%) female nurses. Majority (80%) of nurses were in age group 21-30 years. There was an equal representation of qualifications, i.e., nurses who had a diploma or a degree in nursing. Nearly, two-third (60%) of them had <5 years of experience. SBAR score was correlated with demographic variables. A statistically significant association ( P = 0.019) was seen between overall audit scores and education/qualification. Nurses who were certified with a graduate degree showed a better score as compared to nurses who held a diploma in nursing [ Table 1 ].

Demographic variables of nurses

Audit findings

Compliance to SBAR documentation was audited at 2 times points A1 (first audit in 1 st week) and A2 (second audit in 16 th week). There was an absolute difference of 4% between A1 and A2, valid percent score was A1 (mean: 82, range: 61-96) and A2 (mean: 86, range: 70-96). There was a significant improvement ( P = 0.043) in overall scores between A1 (mean: 23.20, standard deviation [SD]: 2.96) and A2 (mean: 24.26, SD: 2.20). This difference may be due to the routine use of the form. When analyzed further into different domains of SBAR, a significant improvement was seen in “Situation” domain ( P = 0.045) as compared to other domains. The difference can be attributed to simplicity and objectivity of the content in situation domain.

Analysis on compliance to the four domains of situation, background, assessment, recommendation

There was an overall improvement in all sections of SBAR [ Figure 1 ] from first observation to second observation.

Section wise distribution of observation scores-situation, background, assessment, recommendation

During A1, only 45% ( n = 20) of the nurses in the study group had documented the age of patient while it was 79% ( n = 19) in A2. Item, wise comparison of A1 and A2, was carried out using McNemar test. Out of seven items in this domain, there was a significant difference in one item only, i.e., documentation of age ( P = 0.039). There was only a marginal improvement (A1-40%, A2-47%) in documentation related to patient's allergies and relevant past history while identifying comorbidities decreased from 45% in A1 to 5% in A2 [ Table 2 ].

Distribution of nurses based on observation of situation component of situation, background, assessment, recommendation

*Valid percentage is calculated ( n = 11)

Though 95% compliance was seen in most of the items under “Situation” in both audits, important information like the current treatment of patient (e.g., antiepileptic, or withhold tablet amlodipine, injection 5 fluorouracil is on continuous infusion and patient is on injection clexane) was not documented. Injection clexane is a high alert drug and requires nursing assessment and observation for bleeding, petechiae, hematuria, and black tarry stools. Transmission of this information is essential for patient care and safety [ Table 3 ].

Distribution of nurses based on observation of background component of situation, background, assessment, recommendation

There was almost 100% compliance in most of the items under the “Assessment” category in both audits. An area that needed to be focused on in A1 was pain score, Glasgow coma scale (GCS) score and fall risk as the compliance was 85%. Pain is considered to be a fifth vital sign and as a routine 4 hourly assessments is carried out. The area where nurses do not pay much attention is on GCS and fall risk assessment. Both these areas are important especially in an oncology unit, where patients may have neurological problems, are in older age group and are on medications for comorbidities, and thereby prone to electrolyte imbalance or have gastrointestinal disturbances. In A2, the compliance was 100% [ Table 4 ].

Distribution of nurses based on observation of assessment component of situation, background, assessment, recommendation

Recommendation

Compliance was around 90% in most of the area of recommendation. Though there was around 85-95% compliance related to investigation and reports, in some of the patient files that were sampled, the information related to pending reports such as those pertaining to serum electrolytes, calcium, or urine was not documented. Referrals for physiotherapy, psychiatry, and dietician reference were also not captured in approximately 90% of forms. One area which needed improvement was in plan of care. Only about 70% of the nurses had documented the plan of care. Information related to 4 hourly mouth care, watch for the motor deficit, neurological monitoring, incentive spirometry, observation for bleeding, discharge plan, care of tracheostomy tube, pressure points, and use of thromboembolic deterrent stocking was not incorporated in plan of care. This may be due to lack of clarity about information to be documented [ Table 5 ].

Distribution of nurses based on observation of recommendation component of situation, background, assessment, recommendation

Nurses opinion about situation, background, assessment, recommendation

Most (79%) of the nurses expressed that they found the SBAR form for shift handover very useful. This was consistent with a study by Velji et al . nurses reported use of SBAR helped them to “organize their thinking” and streamline data.[ 4 ]

They also opined that all information relevant to patient care was only somewhat (68%) captured, and 63% of nurses felt that it will improve patient safety. The contents were not at all difficult for 74% of nurses. Only 53% of nurses felt that patient involvement in documenting information in SBAR was very much necessary [ Figure 2 ].

Item wise distribution of nurse's opinion about situation, background, assessment, recommendation

It was interesting to note that though majority (68%) of the nurses expressed that they completed the documentation in 5-10 min, 21% nurses felt filling SBAR form was very much time consuming, while 42-37% expressed somewhat and not at all, respectively. They also opined that Assessment was easy (47%) to document while recommendation was the difficult (47%) part [ Figure 3 ].

Situation, background, assessment, recommendation — Level of difficulty

This study aimed to examine the introduction of SBAR into nursing practice using a self-instructional method. Currently, use of SBAR is not prevalent in hospitals across India. With the advent to accreditation concept in India, where the focus is on patient safety, it has become essential for nurses to excel in the work they undertake. Handover of the patient being an important area where information of the patient is transferred from one shift to another. The SBAR has been tested in Western countries and have been a part of standard care. It was unclear whether or not the SBAR tool would be commensurate with the needs of Indian nurses.

The findings suggest that introduction of a standardized handover tool like SBAR helped nurses to capture all relevant information pertaining to the patient. It is noted that in many instances important clinical findings were not documented. Laws and Amato, in his review, found reports of inconsistency between information provided and the actual status of the patient.[ 11 ] Miller et al ., in his study also suggested that nurses need to recognize and identify important clinical cues and act promptly to ensure patient safety.[ 12 ] Around 21% nurses felt SBAR form documentation as time-consuming. This was also brought forth by Renz et al . where 28% of nurses responded that SBAR tool was time-consuming.[ 13 ] It can be seen that only 53% of nurses felt patient involvement in documenting information and plan of care was necessary.

Patient's involvement is crucial as it provides them with an opportunity to ask questions, clarify, and share information which makes them less anxious, more compliant with the plan of care and more satisfied because they know what things are being monitored throughout the shift.[ 11 ] One area which needs improvement is in the documenting plan of care.

Limitations

The SBAR format was a self-report tool and some nurses might have had difficulty in understanding the contents required for documentation, and therefore, the accuracy of entry of SBAR data were questionable:

• Content analysis of all the SBAR forms was not done.
• The sample size was small and hence cannot be generalized.
• Patient care outcomes in terms of average length of stay were not evaluated but are important considerations for future research.

Nurses have a vital role in ensuring successful team performance by transferring relevant and critical information. SBAR technique helps in focused and easy communication between nurses especially during transition of patient care from one nurse to another. SBAR communication has become a standard, across disciplines as a mode of hands off communication.[ 9 ] Use of standardized hands off communication during bedside shift handover is essential for patient safety, as the benefits for patients outweigh the risks and cost of implementation.[ 14 ] The patient, who is the focus of all interaction, should be involved in decision-making and updated with information relevant to them, which in turn will help in reducing errors and create a sense of well-being and satisfaction.

The results suggest that individual and team training in various aspects of SBAR need to be initiated to bring about an impact by use of SBAR form. Importance and relevance of capturing information related allergies, comorbidities, assessment of pain, neurological monitoring, and aspects to be documented under the plan of care need to be incorporated as a regular part of continuing education program. An audit to look for reduced number of incidents related to communication failures is essential for long-term evaluation of patient outcomes[ 3 ] and thus, provide safe and quality care to patients.

Implications

SBAR form modified to organizational requirement can play an important role in transferring of information from one nurse to next during bedside shift handoff. SBAR can play an important role in communication between nurse and physician, especially when the doctor is not available in the premises and vital information regarding patient status need to be communicated. Though SBAR is regularly used in Western world and has been found to be effective, it is time that Indian nurses understand the importance of a standardized approach to bedside shift handoff and implement in their clinical practice to bring about a positive outcome for patients and thus play an important role in ensuring patient safety.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Acknowledgments

This article was written on the basis of a presentation given at the AONS 2015 Conference held in Seoul Korea by the Asian Oncology Nursing Society.