Morning all,

As a Critical Care Outreach nurse of many years, one of my greatest bugbears is SBAR handover, or there lack of!

Within my trust, there is an SBAR proforma attached to the NEWS2 chart, which appears to be fit for purpose currently. (We are still on paper obs charts, moving to e-obs by the end of the year)

SBAR is taught and embedding in all our teaching and training, the candidates at the time of the courses are all able to giver perfect SBAR handovers in simulation but as soon as they walk out the door all of that seems to disappear. 

It is all too often we receive poor handovers for referrals, the lack of information and clarity means that we cannot prioritise patients effectively.

I am currently looking at the nuts and bolts of why this is and what we need to do to address the issues. I have started by sending a survey out to all registered nursing staff so that we can get feedback from those who should be using it. Hopefully, from the responses this may mean we can formulate a plan to improve this.

Does anyone else have the same issues/ concerns in you line of work?

Has anyone got anything that they do in their trust that works?

Hey @Kirsty Wood

This sounds like a really interesting piece of work you are doing and I'd be very interested to hear what you find.  I too feel your frustration with SBAR handovers..... lack of decent information during a referral puts the patients and us at risk.  

We have tried using stickers in the notes for SBAR, teaching it, promoting it.....most of the time the only way we achieve anywhere near this is by probing for it.

We use electronic observations which I believe has made nurses more aware of the significance of NEWS scores....but more often than not, we now receive a referral "my patient is scoring a 7 so you need to review" and if we let it, that would be the end of the conversation (the nurse wouldn't even necessarily know what is causing the score of 7!).

Please keep us posted on the nuts and bolts that you find out. Really interested.

Hope we can all put our heads together and improve SBAR everywhere.

PS: how about making your survey electronic and sharing it on Twitter? Think it could open up a wider audience for you and therefore expose more nuts and bolts?

Thank you

?

Thanks for your response @Danielle Haupt

The survey, through surveymonkey, has gone out to staff members direct to their emails and on our shared facebook page for the trust. Fingers crossed I get a decent amount of responses.

It is an interesting though putting it on twitter and finding out what the wider audience think, at this point I would need to gather data from my trust in particular, but after that could be an interesting option.

I have recently completed an evidence based essay for my foundation degree course about the positive and negative of the use of SBAR tool. 

It was very interesting subject to research 

Sounds great @Alex Entwisle. Be great if you could share some of your findings with us. ??

Hi @Alex Entwisle  what about putting the essay up on here so we can see - or tell us a brief synopsis of it

@Alex Entwisle just wondering if you are ready to share your findings yet? We are all super interested ?

 

This is my essay I did for my last year of my foundation degree course (apologies for spelling and grammer mistakes) 

 

The positives and the negatives of using the SBAR tool

Introduction 

Within this essay I am going to look at how the positive and the negative of using the SBAR tool

within the Emergency Department . The findings from this essay which will all be evidenced based I

will be concluding my essay with how it can I can improve my communication skills within my work

place.

 

According to Martin and Ciuzynski (2015), a large number of patients die every year in hospital and

healthcare environments as a result of poor documentation and communication between different

medical specialists. Industry standards and systems, help such as SBAR tool to improve the

communication. SBAR definition is situation, background, assessment, and recommendation (SBAR)

communication tool. If this is done well then, all our patients will be safer and the medical doctors

and nursing safer will be happier.  

 

Sackett et al (1996) informs you that Evidenced based practice (EBP) is “the integration of clinical

expertise, patient values, and the best research evidence into the decision-making process for patient

care”. If you have these three then you can start to explore the evidenced based practice.

 

Williams (2017) WRITES that it is proof put together nursing practices with respect to basic

reasoning and demonstrated results. Likewise called EBP, it supplements what medically trained staff

realised in a learning environment and what they read in nursing journals. It additionally causes them

assess the most recent research and innovation and decide how to apply it in a genuine world, and

within the areas in which you work in.

 

To address the implied question in this essay I intend to use medical journals. By researching I intend

to find out what impact the SBAR tool has had on clinical communication. I intend to look at various

journals which I will find by using the specific medical search engines: CINAHL, MEDLINE,

PUBMED.  I will make sure that all the information that I will look at will be that most up to date and

relevant to my work with an Emergency Department and a medical unit

 

Within the Emergency Department staff  need make sure that all interactions and clinical decision

about our patients care  are fully recorded in writing and this is done by using the SBAR tool which

every member of staff, who is qualified to make and follow up clinical decision must update. Within

my role as Assistant Practitioner I am able to make full use of the SBAR tool when I hand over any of

my patients to another team.  

 

ACT Academy (2018) define that the SBAR is a communication tool and is a simple to use and ,

organise patients notes, that will enable better communication between clinical staff. O'Shaughnessy,

(2015) informs us that the SBAR was initially created by the United States Military for

correspondence on atomic submarines, however in 1990s it has been utilised in a wide range of

medical services settings, especially identifying with improving patient safety. 

 

Novak (2012) states that there are various advantages to executing bedside handovers utilising a clear

communication tool, such as the SBAR tool. Novak (2012) also states that there has been finical

saving which originate from serious incidents, for example, falls and prescription mistakes, which can

happened during ward moves and ward handover. During these various handovers, this can become

side tracked by staff “catching up” about other than clinical issues. The SBAR tool is structure so this

should not happen if the handover is conducted well.

 

Bickhoff (2015) argues that the essential disadvantage to bedside handovers is the issue of keeping up

data protection inside an open setting. while different investigations found that patients were stressed

over the sharing of personal  details, This was more pronounced in Emergency Departments, where

patients in the room had a higher percentage of hearing other patients personal . In my department we

have stopped bedside handover, because we had complaints from patients on exactly this matter. So as

a team we came up with a compromise, we have the first part in a private room where we discuss the

patient’s details, and then we would walk around only going through the drug charts and observation

sheets. As this new form of ward round takes place, the new nursing staff can introduce themselves to

the patients.

 

In an article by Eberhardt (2014) carried out study which looked into the benchmark information

included what number of handovers was archived what's more, what frames of mind the nursing staff

had about current handover methods. The group gathered standard information through looking at

audits and patient record when patients moved from one department to another like from an

emergency department to another ward during a 1-month time span. They found that the area,

substance, and event of the documentation were conflicting. A clinical note, about the patient was in

fluctuating styles, was composed archiving a patient handover 32% of the time. A comment of a

during the patient handover to the observational sheet (the NEWS chart within the NHS) within the

patient's medical record 42% of the time. SBAR arrangement was not utilised by any stretch of the

imagination, nor was there any sign of a nurse to nurse handover. They disseminated surveys with

respect to current practices and culture toward patient handovers to all medical-surgical or theatre

nursing staff and the reaction rate was 28% and 31%, separately. Whereas 81% of the medical-

surgical carefully  knew of trusts approach to give handover report in SBAR design, 93% demonstrate

that they offered report to an  nursing staff under 25% of the time, and 86% expressed that handover

was in SBAR design under 25% of the time. The results from the theatre nursing staff surveys

certified these discoveries. 

 

 Lee et al (2016) performed a qualitative study finding recognised four fundamental subjects that

explains the utility of SBAR as an interprofessional specialised instrument across over clinical and

non-clinical setting. Firstly, is the common language between staff and their departments, for example

different specialities have different shortened words they use, this should not be happening we should

all be talking the same language within health care. Secondly the effective association of information

to distinguish quick issues. Thirdly they found the help of collective group-based communication like

a handover should  including shared basic leadership and compromise. Then lastly was Flexibility,

allowing use in various configurations, for example, face to face handovers , group presentation,

email correspondence and attaching the relevant documents. The way the team learnt from this study

is by involving the multi-disciplinary in activities that looked at the highlighted problems which they

thought they could improve on from the study which they performed. The one thing they found out

that the SBAR tool helped the staff who were not clinically trained to improve on their

communication skills  as well and how this helped them improve in their roles.  Since the SBAR

specialised communication tool becoming  well known across the NHS, incorporating  it into Doctors

and Nurses training. In my Foundation Degree course, we have had the SBAR tool/framework taught

to us twice within a our first year. 

 

Martin, Ciuzynski (2015) performed a study within a Children's Emergency Department. The

information was gathered from 32 nurse and 2 nurse practitioners who used a structure

communication tool and pre questionnaires were taken  and one on the use of the SBAR tool. The

study results showed 83% of patient experiences incorporated a joint assessment. A group handover

using the SBAR was directed 86%of the time. All trained nursing staff that has deemed competent to

handover verbalised patient's treatment designs in 89%of cases and 97%of cases, respectively.

Improved collaboration, communication, and nursing fulfilment scores were shown by those staff who

used the SBAR. I feel this represents my experiences, as I am someone who hands over to other

teams/ colleagues from wards. When I have completed my handover, I document in the notes that the

patient handover was completed and ward staff happy with verbal handover. 

 

Kesten (2011) tells us that the undertaking assembles the proof toward improving communication

between medical staff which includes Nurses and doctors, which may eventually improve patient’s

results. Future research directed in an interdisciplinary setting utilising training for all clinical staff.

Teaching all staff within the hospital environment mainly clinical staff, as the uses of the SBAR tool,

this will help staff to improve their own communication at work and also at home.

 

Muller et al (2018) tells us that studies could be completed better. They end their article by outline,

numerous authors guarantee that SBAR improves patient’s outcomes. There is some proof of the

forcefulness of SBAR execution on patient result; however this proof is restricted to specific  

conditions, for example, communication via telephone. Particularly high calibre studies are not

focusing on the shortcomings of the SBAR tool. Future studies are expected to further show the

advantage of SBAR as far as patient wellbeing what's more, continues raising the familiarity with

communication mistakes. SBAR may be a versatile tool that is reasonable for some human services

settings, specifically when clear and concise communication is required.

 

Eberhardt (2014) lastly informs us  that patient’s handover stays one of the most significant parts of

patients care. Compelling and productive communication is intrinsic to any handover for ideal and

safe patient care. Utilising evidenced  based practice, our association distinguished an issue and

executed an answer that built up reliable and contemporary communication  methodology. The SBAR

as a transfer tool  institutionalised the patient handover technique and expanded nursing adherence

and fulfilment with the new practice/documentation. We trust that the SBAR tool as a transfer

documentation proceeds to advance and improve communication  throughout the hospital setting.

 

It has been difficult to find any negative of  the use of the SBAR  tool. I think this is because it does

benefit the patient and staff. Like Muller et al (2018)  inform us that , the real impact of SBAR on

patient result is unclear. The wide selection of SBAR (or some other communication procedure)

without demonstrating the advantage may incomprehensibly limit enhancements on the grounds that

an issue probably illuminated will be less tended to. In this manner, the motivation behind this

efficient survey is to abridge the accessible proof for and assess the effect of the usage of SBAR in

clinical settings on patient wellbeing as estimated by the frequency of unfriendly occasions. The lack

of negative data show us that on the whole the SBAR works well within a clinical setting.  I think this

is because it can be used in any setting within a hospital, but continued studies and training must be

used.

 

 

Conclusion  

Currently there is no mandatory study day within my trust which all staff should go on to enhance

their collective knowledge of the SBAR tool. If there were, staff would most likely be better at using

the SBAR tool. I intend to feedback to my practice educator ti find out if we could include this into

documentation for all new starters into the Department

 

My experience from bedside handover is that it can take longer as relatives can keep asking

questions which could be answered at the end of the handover. Another problem is that patients

can hear other patients details and this is difficult as sometimes we have patients with very

confidential problems. It was agreed that patients with sensitive problems would be discussed

in a private room and then bedside handover for introducing the new team to the patients and going

through the documentation.  This was a problem within two areas in the Emergency Department,

the clinical decision unit and the main emergency department. In the main Emergency Department

we have the main hand over in the Staff Room then go out to the main department to get handover

from the relevant nurses who full the SBAR tool with the way our documentation is laid out.

 

In my department we use many different handover for example over the phone, transfers to wards,

ambulance handovers, bedside handovers in our short stay ward and shift handover times. As a

department we knew that we had to improve after we had incidents regarding handovers. In 2017 we

introduced the SBAR tool into our safety booklet in the department and have reduced some

incidents as well. We even do this within our department when we take the patients to our Clinical

Decision Unit. Within my role as assistant practitioner, I am qualified to do all of these types of

handovers. 

 

We as a department although we used the SBAR tool when handing over we found out that if there

was incident then there was no proof on what was said during that handover. In our Emergency

Department within our nursing documentation there is a SBAR form we must fill out when going to

the ward. Our Matron said this will help him if he has to follow up because it is all will be on the

SBAR form.  

 

We also use a red SBAR form if we are communicating to other department over the phone when

we have a concern about a patient. This helps us as Nurses to make sure we have all the relevant

information to tell the other person at the end of the phone.  I like this from because it has any

recommendations or when the doctor might come and review the patient.

 

This form and any other SBAR forms should always be kept within the medical notes, this is if there

is a concerns we call look back at the information.  I would not say that we are the perfect with the

SBAR tool, over the last year I think in the Emergency Department have improved at using the SBAR

tool when we have to talk to doctors or other colleagues on the phone about patients. We could get

better when it comes to the writing of the SBAR forms. At the end of the day this is to ensure patient

safety

 

The last point is that Dunsford (2009) point’s out, that is  preventable medical mistakes keep on

happening at disturbing rates, and communication failure  are at the because of a significant number

of these episodes. Embracing an organized specialised framework, for example, SBAR can help

medical staff communicate in a clear and concise manner. The strategy can be actualised on any scale,

from individual to trust wide, and encourages the understanding of interdisciplinary language, that

will enable all staff across the trust to improve the understanding and communication, which will lead

to improving patient security and safety . This is why NHS England and staff must keep using the

SBAR tool as so far the evidence shows it does work.

 

 

 

Reference list 

ACT Academy (2018) SBAR communication tool – situation, background, assessment, recommendation https://improvement.nhs.uk/documents/2162/sbar-communication-tool.pdf. [online] accessed 20/06/19 

Bickhoff. L. (2015) Bedside handovers: All it’s cracked up to be?http://www.definingnursing.com/handover/. [online] accessed 20/06/19 

Dunsford. J. (2009) Structured Communication: Improving Patient Safety with SBAR. https://onlinelibrary-wiley-com.ezproxy.brighton.ac.uk/doi/10.1111/j.1751-486X.2009.01456.x. [online] accessed 09/07/2019 

 Eberhardt. S. Nursing (2014) Improve handoff communication with SBAR. https://www.nursingcenter.com/wkhlrp/Handlers/articleContent.pdf?key=pdf_00152193-201411000-00006. [Online] Accessed 09/07/19 

Lee, S.Y, Hao,Y. C,Lien. W,Shiong. (2016)SBAR: towards a common interprofessional team-based communication tool. https://onlinelibrary-wiley-com.ezproxy.brighton.ac.uk/doi/full/10.1111/medu.13171. [online] accessed 09/07/2019 

 Kesten, K. (2011). Role-play using the SBAR technique to improve observed communication skills in senior nursing staff. https://search-proquest-com.ezproxy.brighton.ac.uk/docview/846979798/fulltextPDF/955FBFC6F8664EF0PQ/1?accountid=9727. [online] accessed 16/07/19 

Martin, H. S Ciurzynski (2015) Situation, background, assessment and recommendation- Guided huddle improve communication and teamwork in the emergency department. https://www-sciencedirect-com.ezproxy.brighton.ac.uk/science/article/pii/S0099176715002287. [Online] Accessed 09/07/2019 

Muller,M. J, Jürgen. M, Redaell. K, Klingberg. W, Hautz. S, Stock. (2018)Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review.https://bmjopen.bmj.com/content/bmjopen/8/8/e022202.full.pdf. [Online] Accessed 18/07/19

Novak.k, R Fairchild. (2012)Bedside reporting and SBAR: Improving patient communication and satisfaction.https://www-sciencedirect com.ezproxy.brighton.ac.uk/science/article/pii/S0882596312002692#bb0025.[online] accessed 20/06/19.  

O'Shaughnessy, G (2015). SBAR (Situation-Background-Assessment-Recommendation) An effective and efficient way to communicate important information http://www.giftoflifeinstitute.org/sbar-situation-background-assessment-recommendation/. [Online] accessed 16/07/19 

Sackett, D.L., Rosenburg, W.M.C., Muir Gray, J.A., Haynes, R.B. and Richardson,W.S. (1996) Evidence-based Medicine, what it is and what it isn’t, British Medical Journal, 312: 71–2. Accessed 16/07/19 

Williams. E (2017). What is evidenced based practice in nursing. https://careertrend.com/about-6618780-evidence-based-practice-nursing-.html.[online] accessed 20/06/19  

 

Fascinating Alex, thanks for sharing. I'll leave it to more informed experts than me to reflect and comment!

@Claire Cox Can we incude within 'Learn' on the hub too so that anyone researching will access this directly?

 

Alex, I've a question about patients and families involvement in handovers and SBAR. Is this an area of research and is there clear policy on this? In th examples you give above, I infer (maybe wrongly!) that the patient and family members were asking questions as this was the only route for them to be communicated with? I've been in that situation myself where my only source of information and opportunity to ask questions was in interupting a 'handover.' I'd welcome your reflections and that of others. @Joanne Hughes Might you have some thoughts too?

When you have limited time to handover you need to share evenly between all your patients. 

I would always explain this to the relatives and if I can’t answer them during handover time, then I would go back to them after the main handover 

Hi Kirsty,

Same issues. What were your survey findings? Would you be happy to share your survey questions? 

Thanks ?.

 

 

@Alex Entwisle Thank you for sharing your essay and your experiences, I am glad that you have been able to implement this within your department. 

 

@Viranga I am more than happy to share the survey question and findings. I will be looking at collating the project into an article, i am currently in the stages of implementing SBAR stickers and am hoping to evaluate the effectiveness of them and whether the addition training and resources have made an impact. 

I will be measuring the outcomes through a repeat survey and through our critical care outreach database, looking at whether there has been a direct increase in the use of stickers and SBAR handovers received.  

I’m looking at SBAR currently and the expectations of the tool. It’s interesting that it’s application has been heavily linked to handover but this is not the original purpose.

Increasingly, the medical profession are seeing it as not fit for purpose but I suspect (and am looking at at the moment) the actual problem is using the wrong tool for the purpose. 

Hi, I am looking at how SBAR can enhance communication skills. Can anyone suggest any reflective models I can I look at to conduct this critical reflective research  

@Claire Cox @Kirsty Wood @Alex Entwisle @Phil Gurnett is anyone able to help Shabnum? 

Interesting,  I'm not sure I am the best person to ask......what about you @Mary Darking?  Mary is my hero when it comes to any thing research related.

On 07/11/2019 at 23:35, Viranga said:

Hi Kirsty,

Same issues. What were your survey findings? Would you be happy to share your survey questions? 

Thanks ?.

 

 

I have attached a copy of the collated results from the survey I conducted within my trust at the end of last year. The results were surprising to us, given our experience. The response was pretty unanimous that staff knew what SBAR was and why it would be used, they mostly all reported using the tool and stated that they would not change the tool. 

As a team, we could only put the lack of SBAR referrals down to staff education and encourage them to use it more. 

So I proceeded with the relaunch by revamping the old SBAR form into a pre-printed sticker that could be directly applied in the clinical notes. 

The relaunch was advertised on the lead up through various forms of social media and hospital communications. 

I held an SBAR education stand in a communal staff area, which allowed me to engage and inform staff about SBAR and the upcoming changes. Also providing cake, obtaining staff pledges and playing SBAR games with prizes! (have attached photos with consent from participants)

The next stage was the roll out of the SBAR sticker, which took form in personally visiting each ward area using tea trolley teaching for engagement and added bonus of staff well-being. We provided drinks and treats for all staff, which they gratefully received whilst I spoke to them about the new sticker. (again photo attached)

We initially saw an increase in use, as you normally do with any new change. And so, to ensure the level of engagement a few weeks later ran a SBAR easter prize competition.

We continued to include SBAR teaching in any of our resuscitation and deteriorating patient course. We were asked for specific SBAR teaching to targeted staff groups. 

We provide SBAR superstar certificates for any staff member that provides an SBAR referral with extra attention if they use an SBAR sticker in the notes. With permission, they have a photo and which gets put on the hospital staff social media. 

The plan was for me audit the use of the stickers, however due to COVID this has not been feasible. 

General verbal feedback from the wards has been very positive. 

The challenge now will be to ensure a good level of interest and engagement. 

 

SBAR survey results.pdf

On 29/06/2020 at 18:14, Shabnum bibi said:

Hi, I am looking at how SBAR can enhance communication skills. Can anyone suggest any reflective models I can I look at to conduct this critical reflective research  

Hi Shabnum, 

Common models used for critical reflection in healthcare are Driscoll's model (what, so what, now what) or STARS technique ( situation, task, action, result, self-reflection). 

Hope this is helpful ? 

 

Amazing thank you kirsty!

Cake is always a good way of getting staff engaged !   

Interesting you talk about a sticker you put in the notes?  Do you have an electronic observation system?  We have, this is about a year old for us.  We are considering doing all the escalation documentation on there now, that way we can audit more easily.

Great pictures too!!

 

Great work and pictures Kirsty! Thank you for sharing. We have been paperless for some time now and also considering a move towards recording escalations electronically.

On ‎11‎/‎07‎/‎2020 at 08:23, Claire Cox said:

Amazing thank you kirsty!

Cake is always a good way of getting staff engaged !   

Interesting you talk about a sticker you put in the notes?  Do you have an electronic observation system?  We have, this is about a year old for us.  We are considering doing all the escalation documentation on there now, that way we can audit more easily.

Great pictures too!!

 

 

8 minutes ago, Viranga said:

Great work and pictures Kirsty! Thank you for sharing. We have been paperless for some time now and also considering a move towards recording escalations electronically.

Thanks for your feedback, we have started to go paperless as a trust over the last year. We do have electronic observations and more recently careflow connect. It is currently being used for ward handovers and team referrals as the first stage. I am led to believe escalation referrals will be introduced at some point but not aware of our trusts timeline. The wards will need to complete the referral using SBAR format electronically. We will be able to edit what specific information we are looking for to reflect the current deteriorating patient SBAR tool.