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Nurse Educator
Vol. 34, No. 4, pp. 176-180
Copyright ! 2009 Wolters Kluwer Health |
Lippincott Williams & Wilkins
Nurse Educator
Nurse Educator
The SBAR Communication Technique
Teaching Nursing Students Professional Communication Skills
Cynthia M. Thomas, EdD, RNC, CDONA
Evelyn Bertram, MS, RN
Doreen Johnson, MA, RN
The Joint Commission and Institute for Healthcare Improvement have mandated healthcare organizations to improve
professional communication. Nursing students lack experience in communicating with physicians. As a result, recent
graduates may not be prepared to meet the demands of professional communication to ensure patient safety. The authors
discuss the SBAR (situation, background, assessment, recommendations) communication technique implemented during a
2-day simulation exercise that provided an organized logical sequence and improved communication and prepared graduates
for transition to clinical practice.
E
ffective communication between nurses and physi
cians is extremely important to patient safety.
Nurses are often overwhelmed by the complexity
of patient care, increasing technology, emerging standards
of care, and enforcement from regulatory agencies. Over-
stimulation may result in poor communication between
healthcare team members. The Joint Commission reports
that communication errors contribute to the majority of
sentinel events reported.1 Another report indicates medical
errors to be the eighth leading cause of death in America.2
The Joint Commission and the Institute for Healthcare Im
provement recommend the SBAR (situation, background,
assessment, recommendations) communication technique
to improve communication and reduce medical errors. 3
Nursing Students and Recent
Graduate Nurses
Nursing students are traditionally prevented from receiving
physician orders. As a result, recent graduates lack ex
perience with interprofessional communication skills and
are fearful of making mistakes. Omission of vital patient
information including the patient's age, sex, race, and
medical history is common when transferring information
from one professional to another.4 Students and recent
graduates are still developing vital communication skills,
such as listening, assimilating, interpreting, gathering, and
sharing information.5 However, healthcare organizational
staff have an expectation that new graduates perform these
communication skills safely and effectively, at the same time
recognizing that these skills are most often learned ''on the
job.''5 In addition, Anderson6 reported that nurses and
Authors' Affiliations:  (Dr Thomas), School of
Nursing, Ball State University, Muncie, Indiana; Clinical Director of ICU
(Ms Bertram), Community Hospital, Anderson, Indiana; Chief Nursing
Officer (Mrs Johnson), Ball Memorial Hospital, Muncie, Indiana.
Corresponding Author: Dr Thomas, Ball State University, School of
Nursing, 2000 University Ave, Muncie IN 47306 (cmthomas@bsu.edu).
physicians experienced increased frustration with poor
professional communication.
Faculty are challenged to find innovative strategies to
improve communication skills among nursing students
preparing them for safe practice as graduate nurses. The
SBAR communication technique is a simple, brief, yet
effective structured approach to transfer critical information.7
As management/leadership faculty, we successfully imple
mented the SBAR approach with a variety of strategies,
improving both clinical practice preparation and communi
cation competency of our senior nursing students.
SBAR-defined
The Joint Commission (1) describes the SBAR communi
cation technique as the:
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?
SBAR was developed by the military, adapted by
the aviation industry, and adopted for use at Kaiser
Permanente of Colorado.8 SBAR can be applied to almost all
forms of communication between healthcare professionals
and thus provides a standard framework to transfer important
information. SBAR helps nursing students and recent graduate
nurses organize their thoughts prior to calling physicians,
during handoff to another nurse, and when transferring
patients to other organizations or levels of care. 9 Experienced
nurses can also benefit from the SBAR technique to save time,
reduce frustration, and improve overall communication.
How Does SBAR Work?
SBAR works by communicating what is happening at the
present time (S = situation), providing a structure for
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background information (B = background), formulating
the completed health assessment (A = assessment), and
offering possible solutions (R = recommendations).10 The
SBAR format provides a brief, organized, predictable flow
for information improving critical thinking and communi
cation skills.7
Barriers to Effective Communication
Multiple factors translate to poor, ineffective communication.
Healthcare organizations are complex and have high noise
levels due to the multitude of equipment and the continual
hum of people. Researchers at The John Hopkins University
found that high noise levels in hospitals increased the stress
level for the employees and increased the risk for errors
because information was not heard correctly.11 Vijay12 discov
ered that elevated noise levels contribute to employees' stress
levels or may lead to depression and irritability in addition to
increased medical errors related to the inability to concentrate.
Noise was also found to interrupt a patients' healing process
while negatively impacting the patient's hospital experience.13
Nurses and physicians are educated differently and
communicate differently. In general, nurses are taught to be
descriptive in their thought and spoken language. Physi
cians, on the other hand, are concise in thought and speak
in shorter sentences and become impatient waiting for the
point of the nurse's call.8,14 Not surprising, cultural differ
ences, a diverse workforce, educational levels, stress, fear,
and fatigue all contribute to communication failure and dif
ferences.5 Rosenstein and O' Daniel15 reported that nurses
often expressed fear when calling physicians and frequently
postponed calls, resulting in delayed patient care. Experi
enced nurses can recall feelings of fear and intimidation
calling a physician for the first time. Inexperienced nurses
may suffer from brain fog, forget to bring their notes, and
respond inconsistently to physician questions.
Evaluation of Skills Prior to SBAR
Implementation
Faculty developed a 2-day simulation role-play experience
and evaluated the communication, decision making, prob
lem solving, organizing, time managing, and critical-thinking
skills of senior nursing students to assess students' communi
cation skills prior to their first management/leadership clinical
experience. The first day consisted of reading and transcribing
physician orders, reviewing incident reports, and evaluating
actual narrative nursing notes. Students also participated in
crisis management role-play and a group-scheduling exercise.
Particular attention was given to physician orders and
communication skills. Students were given the opportunity
to interpret actual physician orders written specifically for the
simulation exercise. The orders were obtained from volunteer
physicians, physician assistants, and nurse practitioners. Many
orders had errors either in dosing or improper abbreviation
use and were difficult to read. Faculty evaluated the students'
ability to find and report the errors. Students' communication
skills were evaluated for clarity, scope or depth, organization
of thoughts, and the ability to be concise and accurate when
providing information to others during role-play.
On the second day, students assumed the charge nurse
role. Emphasis was placed on effective communication
Nurse Educator
between faculty/physicians and other healthcare team mem
bers during the simulation role-play. Students were given
specific practice scenarios, which required critical thinking,
problem solving, decision making, and communication skills.
Faculty assumed different roles, such as physicians, case
managers, family members, and other nurses. Faculty also
controlled the time and direction of the role-play. Students
were required to call faculty/physicians to receive orders or
to give a patient status report. This was accomplished by
placing the students in mild to moderate stressful situations
requiring multitasking, decision making, and problem solv
ing to replicate a realistic hospital environment.
Faculty discovered students lacked appropriate knowl
edge of a logical, sequential communication process. We saw
their fear through their facial expressions, delayed speech,
and sweating when calls were placed to the physician. These
same behaviors increased during the actual faculty/physician
conversations. Students had difficulty organizing their
thoughts, forgetting to state their identity, and forgetting to
identify the patient  or  from  where they were calling.  Almost
all students forgot to bring the patient's medical record with
them to the telephone. They lacked appropriate knowledge
of the patient's present condition and history and never
offered recommendations to support the reason for their call.
When the faculty/physician asked questions regarding
the patient's present condition or previous laboratory values,
most students were unable to answer the questions effec
tively. Students' responses included, ''I don't know, or I'll
have to ask another nurse.'' The most common statement
made by students to the faculty/physician was ''I'll have to
call you back.'' Many students demonstrated a flight of ideas
and lacked an organized structure to their communication.
Students were given immediate constructive feedback from
faculty regarding their performance.
Once students began their hospital clinical experience,
clinical faculty noticed that the experienced nurse paired with
the student would automatically telephone the physician with
the report or for a new order, then relayed the information to
the student. This behavior did not change when physicians
were physically present on the unit. Faculty then noted the
student stood silent while the experienced nurse gave the
physician report. Faculty realized students were being denied
this important piece of the communication process. The lack
of participation in the communication process decreased the
opportunity for the student to improve the necessary skill.
Clinical managers serving as student preceptors during
the management/leadership clinical rotations also expressed
to clinical faculty the inability of students and recent
graduates to effectively and safely communicate. Managers
believed that poor communication led to increased medical
errors and decreased quality of patient care. Because nursing
students traditionally are not allowed to accept physician
orders, it was apparent that we had to develop innovative
teaching strategies to improve effective communication skills
prior to graduation.
SBAR Application
Based on our observations of student performance during
the previous semester's 2-day simulation role-play exercise
without the SBAR communication technique being used and
manager/preceptor feedback from the student's hospital
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clinical rotation, it was apparent that we needed to address
the student's lack of professional communication skills. The
following semester we implemented, at the school's practice
laboratory, the SBAR communication technique as part of the
course lecture and simulation exercises to prepare students
for use in the clinical area. A half-hour lecture was given on
the use of the SBAR communication technique at the
beginning of the first simulation day. Each student was given
an SBAR reference guide to use during the remainder of the
simulation exercises and for use during the clinical experi
ence. The SBAR format was to be used for all communication
between student/nurse and faculty/physician role-play.
Faculty initially prompted students if they struggled during
the simulation role-play exercise. As the students worked
through various simulation exercises using SBAR, faculty
noted increased confidence, decreased fear, and improved
thought organization. As the day progressed, students
learned from each other's mistakes and successes.
Faculty then reinforced the SBAR technique in the
classroom through case study role-play and during hospital
clinical experience. To implement the SBAR technique in the
classroom, students were given a case study and paired to
role-play physicians and nurses. SBAR was also threaded
throughout specific management/leadership topics such as
safety, quality management, time management, and critical
thought, which demonstrated how a failure to communica
tion had an impact on quality of care. The clinical faculty
reinforced the use of SBAR while making clinical rounds with
students and preceptors. Preceptors were encouraged to
allow students to give the handoff report and discuss patient's
plan of care with physicians using the SBAR technique.
Role-Play Application Case Study
Figure 1 illustrates the case study used by the students to
apply the SBAR communication principles in the class
room. Students read the case study, and pairs of student
groups role-played the nurse and physician. Faculty
moved around the classroom, listened to student's inter
actions, and provided feedback.
Students were instructed to answer the following
questions using the SBAR communication technique: what
information does the physician need regarding the cur
rent situation (S = situation)? What was Mrs Burton's back
ground or medical history (B = background)? What
information will the physician need from the health assess
ment (A = assessment)? And what are the appropriate
recommendations (R = recommendation)?
Review of Appropriate Case
Study Response
While the students were engaged in the classroom role-play,
we listened to the responses students gave to each other to
ensure they included the appropriate SBAR response criteria.
Following the role-play exercise, the students received an
appropriate SBAR response guide document to serve as a
reference.
Figure 1. Role-play scenario.
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Page 4
Appropriate SBAR Response Guide
S = Situation:
Dr Hall, this is Jim Jones, RN, calling from the 4 west
medical floor at Mountain View Hospital. I am calling
about Mrs Burton in room 403. Her condition has
changed, and I wanted to update you with her current
medical status. I just assessed her personally; she is
complaining of a headache, experiencing photosensi
tivity, and dizziness. The most recent blood pressure is
220/120, pulse 120, and her respiratory rate is 24. There
has been a steady increase in her vital signs since her
admission. The vital signs were BP160/90, P 98, and
R16 on admission to the floor; BP 180/100, P 102, and
R 18 at 10:15 last night around 10 PM, and at 7:30 this
AM they were 186/110, P 100, and R 22. She is also
diaphoretic and holding her head between her hands.
She is also complaining of being dizzy.
B = background:
Apparently, last month, she had an episode of hyper
tension noted at a health fair. She was unable to tell me
what her blood pressure was at the time, but the nurse
who took it told her it was quite elevated. She had been
instructed to notify her physician, but she failed
to follow through. She was admitted last night around
10 PM through the ED for an unexplained fall at home
the day before. She does not take any medication.
A = assessment:
I am concerned about the combination of the blood
pressure episode last month at the health fair; the steady
increase in her vital signs since admission, the current
headache, complainant of being dizzy, and now being
diaphoretic along with the photosensitivity may all in
dicate hypertension with the potential for a future CVA.
R = recommendation:
Would you consider ordering an antihypertensive medi
cation at this time and establishing a target blood pressure
as future call orders? As a standard nursing measure, I will
be checking Mrs Burton's vital signs every 2 hours for the
next 24 hours. Based on her future medical state, we can
determine how closely to monitor her after the next 24-hour
period. Would you like for me to call you with an update on
her progress after the next assessment in 2 hours?
Conclusion. As the semester progressed, we witnessed
improved communication, increased confidence, and orga
nized information as students became more familiar with
using the SBAR communication technique. We recognize that
when students graduate, they may become overwhelmed
with their new role responsibilities and may forget important
steps in the professional communication process. Figure 2
illustrates important considerations prior to making calls to
physicians and was given as an additional reference docu
ment to help students with professional communication after
graduation. We did not formally evaluate the communica
tion skills of this group of students prior to or after the SBAR
technique was implemented; however, a formal evaluation
will be conducted for future students.
The implementation of the SBAR communication tech
nique during the 2-day simulation exercise, reinforced in the
classroom with a case study role-play and during the
students' hospital clinical experience, provided an organized
logical sequence to improve the communication skills of
Figure 2. Important considerations before calling physicians.
Nurse Educator
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Page 5
senior nursing students. The SBAR technique encourages
students to organize information quickly and concisely,
which then allows physicians to make clinical judgments
based on the  concrete  information that  the  nurses  provide.
The SBAR technique assisted students to better organize
critical information. Both faculty and clinical staff saw that
students had improved confidence and critical thoughts and
made better decisions. In addition, the students' ability to
identify and solve problems continued to improve over time
as they used the SBAR communication technique. Based on
our experience, the SBAR communication technique gives
students a tool with the potential to improve their transition
from academia to clinical practice.
Reference
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http://www.jointcomission.org/AccreditationAmbulatoryCare/
Standards/09_FAQs/NPSG/Communication/NPSG.02.05.01/.
Accessed December 28, 2008.
2. Goeckner B, Gladu M, Bradley J, Bibb SC, Hicks RW. Differ
ences in perioperative medication errors with regard to orga
nization characteristics. AORN J. 2006;83(2):351-368.
3. Institute for Healthcare Improvement. Web and action: using SBAR to
improve communication. 2006. Available at http://www.ihi.org/ihi/
fbmms/Sh()wForum^spx?ForumID:97. Accessed November 11, 2008.
4. Ascano-Martin F. Shift report and SBAR: strategies for clinical
post conference. Nurse Educ. 2008;33(5):190.
5. Manning ML. Improving clinical communication through
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6. Anderson DE. Bridging the professional chasm: tools for col
laborative communication. Med Surg Matters. 2008;17(1):8-9.
7. Powell SK. Editorial: SBAR-it's not just another communica
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8. Pope BB, Rodzen L, Spross G. Raising the SBAR: how better
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10. Rodgers KL. Using the SBAR communication technique to
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AAACN Viewpoint. 2007;29(2):7-10.
11. Hospital noise stresses patients and staff. ASHA Leader. 2006;11(3):5.
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New Guidelines for Management of ST-Elevation Myocardial Infarction (STEMI)
The American Heart Association (AHA) and the American College of Cardiology (ACC) have recently
released updated recommendations for patients presenting with ST-elevation myocardial Infarction. The need
for fast action is the primary message of these revised recommendations since permanent heart damage is
known to occur if blood flow is not restored within twenty minutes of the onset of symptoms.
The new guidelines provide four specific decision making criteria to determine if thrombolytics or stents
should be used with patients presenting with STEMI: 1) the time that has passed since the onset of symptoms;
2) the risk of death; 3) the risk of intracranial hemorrhage with thrombolytic use and; 3) how much time
is needed to get the patient to a cardiac catheterization lab for stent insertion.
The guidelines also recommend the daily use of aspirin and beta blockers. ACE inhibitors are strongly
recommended. If intolerance to ACE inhibitors is a concern, angiotensin receptor blockers are recommended.
Statin drugs are advised on discharge for those with low-density lipoprotein levels (LDL) greater than or equal to
100 mg/dl. Sidney Smith, Co-Chair of the Task Force noted that this guideline is more aggressive than the original
''Adult treatment III goal recommended by the National Cholesterol Education Panel''. Smith continues to note
that aggressively lowering the LDL improves the patient outcomes in large clinical trials of statin drugs.
Nurses in emergency rooms or in other immediate care facilities need to be aware of these guidelines. Providing the
correct assessment data can make a critical difference in time of treatment, appropriateness of treatment, the
extent of myocardial damage, and even survival. Full guidelines are available at http://circ.ahajournals.org/cgi/
content/full/112/12/e154.
Source: American Heart Association. March 26, 2009. Emergency Medicine Cardiac Research and Education
Group (EMCERG). Available at http://www.emcreg.org/news_events/news/articledetails.html?RecID=89.
Accessed March 26, 2009.
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