Project: SBAR Training for Undergraduate Nursing Students
Communication in Healthcare: SBAR
Teaching undergraduate nursing students how to effectively use SBAR communication strategy to articulate pertinent patient information to primary care providers.
Challenge and Opportunity
Project
Design an in-person training that teaches undergraduate nursing students how to effectively identify and communicate pertinent patient information to the patient’s attending provider (physician, nurse practitioner, or physician assistant).
Project Background
Why SBAR Communication Training Was Important
Communication is a critical component for nearly every human interaction. However, in the medical profession, communication is the basis for how critical information is transmitted from one professional to another. Because of the complexity of patients and the amount of information collected from patients, it becomes an important skill for nurses to be able to focus on and communicate specific problems or needs to a patient’s primary care provider (PCP).
SBAR is an effective tool for helping discern which information will be included in communications between healthcare providers.
SBAR stands for situation, background, assessment, and recommendation.
The goal of SBAR is to ensure that only the data that is pertinent to a patient’s current clinical problem or need is organized and communicated to the other party.
This cuts down on the sharing of irrelevant pieces of information that distract from current issues that need to be dealt with urgently.
SBAR requires the nurse to critically think through their problem prior to calling. It requires that the nurse pull together pertinent data and propose recommendations/solutions for the problem they are trying to solve.
Most medical providers (physicians, etc) are very busy. When they need to be contacted about a patient, a well-structured story with only pertinent data helps them to quickly be able to make decisions based on that information. The SBAR format provides this structure.
In addition, the SBAR communication strategy can be used in a variety of settings outside of medicine, where clear communication of problems and needs is warranted. This makes learning the SBAR format an exceptionally useful skill to master - even outside of the immediate healthcare context.
Analysis
Performance (gap) Analysis
In the simulation department, healthcare students participate in a variety of hands-on training events. One of those types of students is nursing students.
Upon observing many of these nursing students during simulated medical scenarios, it was noted that they often struggled with using proper communication techniques when calling their patient’s PCP. More often than not, students would call before having a clear idea of what it was that they needed from the provider. It was also noted that students were unclear on what information to include in their communication.
Therefore, it was determined that the SBAR communication strategy could provide an easy-to-use, structured format for presenting pertinent patient data in an organized, informative way.
Desired Performance
Students will use the SBAR format each time they contact the patient’s patient’s primary care provider (in simulation and in the real-world setting).
Actual Performance
During simulated scenarios, students do not use any form of structured communication when calling their patient’s PCP. Common patterns of mistakes include: presenting information randomly, lack of clarity around why they are calling, forgetting to identify themselves or their patient, being unsure of what information to include in the call, and being unprepared when asked specific questions about their patient’s current physical status (vital signs, etc).
Gap
Upon discussion with the primary instructor, it was discovered that the students are not provided with in-depth instruction or practice using any communication technique. The students are assigned to read a chapter on communication, which lists SBAR, but it is not identified as a focused topic of their instruction. Therefore, the gap was a lack of knowledge and skill in effective communication techniques for communicating pertinent patient information to primary care providers.
Root Cause For Gap
Students had not been trained on how to use a structured communication technique (like SBAR) for obtaining and communicating pertinent patient information.
Instructional Goal
The first semester nursing student will correctly and consistently use the SBAR format to communicate a patient problem or need to a patient’s primary care provider (PCP).
Students will be encouraged to use the SBAR template when communicating patients’ needs in the healthcare setting and/or in simulated healthcare settings while practicing.
Domains (levels) Of Learning
The instructional goal will deal primarily with intellectual skills. To perform this goal, students will use a combination of discrimination, concrete concepts, rule using, and problem solving. There will also be certain skills that will require recall of verbal information and use motor skills and cognitive strategies.
Task Analysis
Main steps for achieving the goal:
State the situation
State the pertinent background Information
State your assessment of the problem
State your recommendation
Substeps (skills) & learning domains:
State the situation
Identify self (verbal information)
Identify patient name
Ask patient name; verify through patient armband (verbal information)
State quick recap of patient’s reason for initial stay/encounter
Review patient chart and history to view patient’s reason for being admitted or presenting to facility (verbal information)
Clearly identify the current problem or need
Recognize abnormal history (intellectual skills)
Recognize abnormal physical exam findings (intellectual skills)
State the pertinent background information
Provide clear, relevant information that relates to the situation (intellectual skills)
State current vital signs & any changes from previous set
Obtain current set of vital signs (verbal information)
State pertinent physical exam findings
Perform pertinent physical exam (intellectual skills, motor skills)
State medical history pertinent to problem
Review medical history (verbal information, intellectual skills)
State your assessment of the problem
State your opinion of what could be causing the patient’s current problem
Perform physical exam (intellectual skills, motor skills)
Take a complete history of the current problem or need (intellectual skills, cognitive strategy, and verbal information)
Recall history-taking techniques previously learned (verbal information, cognitive strategy)
Review patient medical history
Obtain chart for viewing (motor skills)
State your recommendation
Clearly state what you think you need to solve this problem (intellectual skills)
Understand medication and non-related medications for various medical problems (verbal information, intellectual skills, cognitive strategy)
Ask for recommendations of how to solve this problem (verbal information, cognitive strategy)
Entry Behaviors/Skills:
Below are the entry level behaviors and skills that must be achieved prior to this instruction.
Completed or currently taking a physical exam course
Recognizes normal and abnormal findings
Completed or currently taking instruction on how to take a patient history
Recognizes symptoms in a history that point to disease processes
Completed anatomy and physiology
Uses correct terminology when referring to physical problems
Completed coursework over various disease processes and symptoms of diseases
Identifies vital signs and knows the normal ranges
Verbalizes specific characteristics of various disease processes
Reads a patient chart
Learners and Contexts Analysis
Learners
The learners are nursing students in their first semester of nursing school. The students are in the Bachelor of Science in Nursing program. The learners do not start clinical rotations in the hospital setting until their second semester; however, they do attend simulated scenarios in the simulation department. It is there that they will practice the patient care and communication skills they are learning in their initial coursework.
The students are provided with various patient problems and then tasked with trying to solve that problem while communicating with their peers, as well as the simulation staff who serve as simulated primary care providers. Information was obtained from the primary course instructor/coordinator.
Contexts
The first-semester nursing students practice their patient care and communication techniques in simulated patient scenarios. They will enter the hospital setting the following semester, where they will further their training while taking care of actual patients.
The simulation experience is meant to create an authentic learning experience for students, in an effort to prepare them for caring for patients in similar settings. During simulation, the students are required to use their newly learned skills in order to take care of their patient. This includes physically calling a simulation staff member who plays the role of the patient’s primary care provider. Students will need to use appropriate communication techniques, even during simulated training since these are the exact skills that will be used in the actual healthcare setting.
Unique (Custom) Solution
Design & Development, & Implementation (approach)
A custom, hybrid training was designed and implemented. A custom webpage was created to host learning content and practice activities.
Because the students were going to start attending patient simulations where SBAR could be practiced, it was suggested that the students would benefit from instructional materials that could be presented to them just prior to their scheduled simulation experience. Therefore, it was decided that the training would consist of two parts:
pre-training materials that would be presented to them online one day prior to their simulation experience
followed by an in-person pre-training experience just prior to their simulated experience
The training would include relevant content, practice activities, and an SBAR template that could be used during practice and simulated scenarios.
Course Structure (framework), Activities, and Assessments
➤ The course was structured around the four main steps of the SBAR communication technique:
Situation
Background
Assessment
Recommendation
Learning activities included online and in-person learning and practice activities. The learning activities included learning content, case studies with built-in feedback, and incorporation of a downloadable SBAR template.
Assessments included independent, online practice activities (with feedback), in-person practice with feedback, and demonstration through hands-on simulated clinical scenarios (with SBAR templates available).
A Task-Objective-Assessment Table was created to demonstrate the link between learning tasks, objectives, learning levels, and assessments.*
*The Task-Objective-Assessment Table can be seen via email request..
➤ Entry level knowledge:
Below are entry level knowledge and behaviors that were required prior to participating in the training.
Successful completion of or current participation in a physical exam course (implies the ability to recognize normal and abnormal clinical findings)
Successful completion of history-taking coursework (implies the ability to recognize symptoms in a history that point to disease processes)
Completion required courses in anatomy and physiology (implies the understanding and uses of correct terminology when referring to physical problems)
Completion of coursework over various disease processes and symptoms of diseases
Training in and competence in vital signs and normal ranges
Ability to read a patient chart
Course Strategies
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The lesson included verbal information to be learned and intellectual skills that would build on that verbal information.
In order to introduce the verbal information in this lesson, a written explanation was developed for each of the major steps in the instructional goal.
Each step represented one information cluster and were sequenced to present each cluster in order.
A web page article was selected as an appropriate medium to present this information.
This medium was felt to be appropriate because it could easily be accessed by this group of learners, could easily incorporate relevant information, and would provide written case scenarios that would closely resemble the real-world context for nurses (where they must read patient charts and discriminate information).
In addition, a web post article would require no additional instructions or barriers to use since these students were already proficient in using web site links for class. Therefore, an article could easily be distributed and students will be able to easily access the link to the article from home or on their mobile device.
Further, the webpage could include worked examples of cases, providing students with the ability to practice the skills they were learning in the lesson, while also being able to quickly obtain the feedback and rationale for correct answers.
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The course included the following learning materials:
Online SBAR lesson (content)
Three case scenarios with completed examples embedded within the lesson
SBAR template
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Gagne’s 9 events of instruction were used to facilitate the learning process during the training experiences.
The following is a breakdown of how the nine events were used:
Gain attention
To gain attention, aspects of motivational theory were utilized.
To gain attention, the discussion began with highlighting the importance of communication in healthcare. To address relevance, it was explained that proper communication is a skill that spans the entire career of nursing and beyond. To address relevance and satisfaction, it was pointed out that a nurse’s ability to communicate well has an impact on their relationships with other professionals, their credibility, their efficiency, and their patient’s outcomes. To increase feelings of confidence, it was explained that the SBAR tool is a simple, but very effective, tool for helping them learn how to properly organize and construct their communication to other professionals and to become better problem-solvers.
By explaining the relevance of this topic, providing them with a simple tool that will help them achieve their goals, and encouraging them to practice right away - the goal was for students to feel both excited to learn and confident that they will be able to use the new information right away.
Inform learners of objectives
The objectives for the lesson were clearly stated, indicating that the goal of the training was for them to learn how to use the SBAR format to properly communicate a patient problem or need. They were also provided with a printable SBAR template.
Stimulate recall
To stimulate recall for this particular group of students, they were reminded of general communication standards - such as reminders to always introduce themselves first when communicating with anyone. They were also reminded of good problem solving techniques, such as to clearly identify problems before trying to solve them. Because they were first semester nursing students and because they were learning a new, unfamiliar format, there was not any specific prior knowledge that was felt to need to be addressed first. Because of the nature of SBAR, each problem or need will vary depending on circumstances. So, there was no specific prior knowledge, other than basics of communications that needed to be included.
Present the content
Sequence, clusters, and strategies
The sequence for this instruction was based on the sequence of the superordinate skills. Because they have a natural sequence in which they are presented, each skill builds from the previous. Each superordinate skill is considered its own cluster and would be taught as such, followed by the next superordinate skill cluster. At the end, all clusters would be brought together for a summary. Students were instructed on the steps of SBAR. They are taught to identify themselves, identify the patient, state the situation, provide relevant background, state their opinion or concern, and then either ask for or make a recommendation.
Provide learning guidance
Each step of SBAR was presented one at a time, with an example of each step below. At the end of the presentation of each step, the whole SBAR format of communication was put together for the learner to view.
Elicit performance
The learners were given three case scenarios to read. They are also provided an SBAR template and asked to try and construct a properly formatted call to the patient’s physician, using the case details.
Provide feedback
Each case scenario had a link embedded which took them to the completed example of the case scenario, properly formatted in SBAR.
Assess performance
Students were able to compare their attempts at using SBAR for the case scenarios with completed examples provided in the lesson. The completed examples also provided additional rationale for why the call was constructed in that way.
Enhance retention and transfer to the job
For this lesson, the learning context is very closely related to the eventual performance contexts because nursing will encounter very similar problems in the actual work environment. However, the performance context will become increasingly more complex and require varying levels of experience.
Enhanced retention and transfer could be increased by having students consistently use the SBAR templates to structure their communication throughout their training and during their clinical rotations.
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Assessments
The assessment plan for this lesson includes three case scenarios presented within the lesson. Each case scenario was presented, with a link that takes the learner to the completed/worked example of the case. Each completed scenario highlighted relevant information, marked out irrelevant information, showed the case presented in appropriate SBAR format, and then provided a detailed rationale for additional understanding. The students were encouraged to use the provided SBAR template or a piece of paper to practice constructing each case into SBAR format before they view the completed examples.
The students then participated in an SBAR pre-training experience and a simulated learning experience (where they were encouraged to use SBAR for communication during the simulated case experience).
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One-on-one evaluations
One-to-one evaluations are considered the first phase of formative evaluation. This phase helps to gain insight by seeing a learner’s initial reaction to our instruction. By having a learner review materials together with us, one-on-one, it allows them to help us identify obvious errors and correct them as necessary. By selecting a few people who represent the characteristics of that audience, we get to ensure that we correctly identified the characteristics that represent the learner and that we created instruction appropriate for those characteristics. Ultimately, the learners during the one-on-one evaluations judge the materials for clarity, relevance of content, and ability to work through the materials in an expected time with assumed skills. And, the goal after one-on-one evaluations is instruction that has been initially refined and ready to be tested on larger audiences.
The target learner for the one-on-one evaluation was a first semester nursing student. A phone interview/review was completed. The criteria for the evaluation was based on appropriateness for target learners (based on their current knowledge and skill level), relevance for nursing students, structure (logical flow) of content, competence obtained from the lesson, and judgment on practice exercises provided in the training.
Below are the specific criteria/questions used for the one-on-one evaluation:
Was the instruction interesting/relevant to you as a nursing student?
Did you understand what you were supposed to learn? In other words, was the objective of this lesson clear to you?
Was the content presented in a clear, understandable way?
Were the practice exercises relevant?
Did the practice exercises help you practice the skills you learned in the lesson?
Did you receive sufficient feedback on the practice exercises?
Do you believe that you will be able to use this training in your career as a nurse?
Do you have any suggestions for improving the lesson? (easier language, better sequence, changes to practice exercises, etc?) Any feedback is appreciated.
What did you like about this lesson? (practice exercises, content, relevance, etc?)
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The evaluation resulted in positive feedback. The student did not have any critiques or recommended revisions for the training.
Below were her responses to the questions asked:
Q: Was the instruction interesting/relevant to you as a nursing student?
A: “I felt like it was simple and straightforward. It was easy to grasp and I felt like I was learning a real life skill. I felt less bombarded than with my other courses. I felt like this skill was great for my first semester. It helped build my confidence because I could grasp it. It helped me feel encouraged that I could continue learning about medical things.”
Q: Did you understand what you were supposed to learn? Was the objective clear?
A: “Yes, for sure. It was easy to understand. The introduction made it clear. It was extremely organized.”
Q: Was the content presented in a clear, understandable way?
A: “It was definitely something I could do on my own. I could do it easily at home. I didn’t need any extra reiteration.”
Q: Were the practice exercises relevant? Did the practice exercises help you practice the skills you learned in the lesson?
A: “Yes. I loved the Trevor Clever one. It helped me learn how to deal with a difficult situation. It helped me learn how to present information in an ethical, professional way.
The exercises and having to take out a piece of paper helped solidify the information by having to practice.”
Q: Did you receive sufficient feedback on the practice exercises?
A: “Yes”
Q: Do you believe that you will be able to use this training in your career as a nurse?
A: “Absolutely. As a new nurse and in the clinical setting, you are nervous. I would probably have read the whole chart, been chaotic, and added too much detail. This honestly helps me feel like I can communicate with other healthcare providers.”
Q: Do you have any suggestions for improving the lesson? (easier language, better sequence, changes to practice exercises, etc?) Any feedback is appreciated.
A: “You could always add more practice examples - maybe even more challenging ones for extra practice. It might be nice to have more with how to deal with family situations.”
Q: What did you like about this lesson? (practice exercises, content, relevance, etc?)
A: “It was set up well. It helped going over it the night before simulation. I felt well-prepared. I also liked that it was on a separate website. I liked the change from Sakai (our learning portal from school). I liked that it was different. It was refreshing.”
Face-To-Face Evaluation Results
For those students who were willing to comment face-to-face, there were a couple of helpful comments. First, one student suggested a change in the look of the feedback on their practice exercises. Specifically, on the feedback for their exercises, the student shared that the use of bolded text and marked out text was a little hard to read. She suggested that relevant areas instead be highlighted in order to help them stand out. This change was made and made a great improvement to the readability of the case feedback. Another student commented that they liked the practice exercises because they were at a level that first semester nursing students could understand.
Online Survey Evaluation Results
An online survey was distributed with 30 responses received back. However, while reviewing comments from the students, it became apparent that students were not evaluating my SBAR lesson specifically, they were reviewing their first simulation experience that occurred just after my review with them.
The comments received on the lesson were mostly comments about what types of patients they had encountered during simulation, comments about the instruction they received or didn’t receive inside simulation rooms, and comments about their nursing courses.
Therefore, because my lesson was reviewed just prior to their simulation experience, students misunderstood the survey. Therefore, the survey findings were not valid for the SBAR lesson.
Course Deliverables (course materials)*
SBAR course
Practice exercises (3)
Completed examples of practice exercises with rationale
Downloadable SBAR template (PDF)
Video links for examples of ways to use SBAR (2)
*Course learning materials can be requested in their entirety via email request.
