Dixon, John F. MSN, RN, CNA, BC; Larison, Kristine RN, MBA-HCA; Zabari, Mara BSN, RN, MPA-HA
John F. Dixon, MSN, RN, CNA, BC, is Nurse Researcher and Nursing Management/Leadership Consultant, The Center for Nursing Education & Nursing Research, Baylor University Medical Center–Dallas, 3500 Gaston Ave, Dallas, TX 75246 (e-mail: johndi@BaylorHealth.edu).
Kristine Larison, RN, MBA-HCA, is with Providence St Vincent Medical Center, Portland, Ore.
Mara Zabari, BSN, RN, MPA-HA, is Manager of Obstetrical Services, Providence Everett Medical Center, Everett, Wash.
Editor's Note: The AACN Standards for Establishing and Sustaining Healthy Work Environments states that “nurses must be as proficient in communication skills as they are in clinical skills.”1 The standards document, outlined in the last issue of this column, goes on to describe how communication mishaps contribute to medical errors, decrease quality of care, diminish staff morale, and negatively impact retention of nurses. Communication is a challenge in all human endeavors. And poor communication occurs regularly in everyday interactions from personal relationships to business transactions. Rarely, however, does faulty communication risk such grave consequences as when it occurs in the healthcare setting—where the lives of vulnerable patients lie in the balance.
Frequently, nurses laud the timeliness of the Standards and hail their usefulness in theory, but feel overwhelmed or confused at where to begin with implementation. Certainly, nurses must be thoughtful in how they approach implementation, resisting the urge to tell colleagues to simply “try harder” or “communicate better.” Skilled communication requires a plan that includes education, teamwork, commitment, evaluation, and ongoing vigilance to make it a reality in any unit, department, or team. A part of such a plan includes tools that assist staff in producing the desired outcome. Such is the case in helping staff learn to communicate more skillfully. As a result, I decided to use this issue to provide 2 successful examples from actual practice that provide a glimpse of communication tools that work. The following examples will delineate how real nurses, with a commitment to tackling this challenging issue, have made major progress in improving communication among team members in general and between nurses and physicians in specific.
The SAFE Tool—Baylor University Medical Center, Dallas, Tex
Communication is a complex process that takes place in hospitals between the professional cultures of nursing and medicine. Separate professional education and socialization processes have created divergent and distinct communication methods that often result in barriers among professionals.2 The outcome of these differences is often an unshared basis for communication. At Baylor University Medical Center in Dallas, Tex, we began addressing this issue in 2003, stimulated by discussions in our patient safety committee. We acknowledged that a method or tool might be useful to facilitate more accurate communication. Literature searches of multiple databases and the Internet proved fruitless in our quest for established, evidence-based resources, leading us to further investigate a method that would best meet the needs of our own healthcare team.
To develop the communication tool, we began by assessing nurse-physician communication. Nurses and physicians were asked to evaluate telephone discussions related to changes in patients' conditions both by self-report and through informal discussion. Nurses' reports indicated that in about a third of the conversations, initial orders from physicians were changed when the nurse raised concerns with the original orders from the physician. Physician concerns of communication with nurses included disorganization of information, illogical flow of content, lack of preparation to answer questions, inclusion of extraneous or irrelevant information, and delay in getting to the point. Concerns of nurses regarding physician communications included perceived inattentiveness especially during night hours, unwillingness to discuss goals of care, and feeling that a list of signs and symptoms had to be provided instead of just stating what the nurse thought the clinical problem was. Some nurses explained that the rationale for this last item was prior experiences when they had been direct but the physician accused them of diagnosing and practicing medicine. Interestingly, several physicians commented that they wanted the nurse to directly state what he or she thought the patient's problem was and if additional background information was needed they would specifically ask the nurse.
The next step to developing improved communication was to discuss the topic of communication with experienced nurses, novice nurses, new graduates, nursing students, and nursing faculty. For the most part, experienced nurses felt that they had established collaborative relationships with physicians with whom they commonly worked. There was mutual trust and respect for each other's assessments and viewpoints, dialogue was open, and credibility was not in question. These experienced nurses felt that they had developed their own effective communication style across the maturation of their practice. Novice nurses and new graduates shared that one of their greatest anxieties in role transition was talking with physicians. We asked various nursing students whether during their clinical rotations they had discovered a set report outline for nurses communicating with physicians. They told us that individuality and variation were the norm. In discussing this issue with nursing faculty, they reported that they did not teach a particular method for communicating with physicians to students.
Given the development of experienced nurses, we decided to target our initial efforts at novice practitioners, providing them with a structured outline for physician reports. This outline was crafted to avoid the previously identified concerns while incorporating patient advocacy and patient safety. From this work we developed 2 tools—the SAFE Report (Figure 1) and the SAFE Brief Patient History (Figure 2).
The SAFE Report begins with preparation for the dialogue and includes information to be obtained and activities to be completed before calling the physician. The body of the report creates structure and flow, focusing on essential content. The report closes with advocacy, chain of command, and patient safety. S is the Situation, a very brief and focused description of what is happening now; what prompted the call. A is Assessment—the nurse's clinical impression of what the patient's specific problem is. F is Findings & Figures and focuses on explicit relevant data or evidence that supports or leads to the clinical impression (the A). E is Express & Expect and instructs the nurse to engage in dialogue about interventions to address the patient need, such as orders for tests, medications, and treatments, or asking the physician to come see the patient.
Together, the elements of the SAFE report provide a defined structure and flow for the physician report and focuses the content on essential relevant information. If the orders received are not clear or the nurses feel they do not address the patient's need, then the nurses are prompted to advocate for the patient by discussing and/or clarifying the physician's goals of care. Should the dialogue end without resolution, the SAFE Report lists the institutional chain of command as a resource for the nurse. The final item is a reminder to read back any orders received per JCAHO's National Patient Safety Goals for hospitals.3 To assist the novice in instances when the physician requests background information, we created the SAFE Brief Patient History printed on the back of the SAFE Report (Figure 2). This outline also has a logical sequence and flow, focusing on essential content that includes key patient demographics, significant history, hospital course, current medications, allergies, and resuscitation status.
The SAFE Report was introduced to a group of new graduates in the medical-surgical internship to solicit initial feedback. After presenting SAFE, and working through case studies, each attendee received a pad of blank SAFE Reports to be used as worksheets. The majority felt that SAFE was one of the most helpful parts of the course. Physicians who reviewed SAFE felt that it was a good tool and one suggested that the SAFE Brief Patient History become a standard transfer report between departments.
Our next steps are to collect data to evaluate the effectiveness of the SAFE tool itself. With the January 2006 new graduate hires, we will evaluate the impact of SAFE on new graduates as they transition into practice. We will collect baseline data, introduce SAFE, collect follow-up data, and compare to the previously hired new graduate group who did not receive SAFE. Supporting activities include instructing the preceptors in use of SAFE and making SAFE available to experienced nurses if they wish to use this communication method.
Our goal at Baylor University Medical Center in creating the SAFE communication method is to make available an effective tool that assists and supports transition to professional practice, enhances communication with physicians, and results in safe passage for patients. If successful, we will also work to introduce SAFE into the curricula of local nursing programs. We feel that we have created a relevant and contextually valid tool and are anxious to see what outcomes our study will reveal.
SBAR Communication: Providence St Vincent Medical Center, Portland, Ore
The nursing department at Providence St Vincent Medical Center led an initiative in which maternal child nurses and physicians, in participation with the Vermont Oxford Network NIC/Q 2005 Evidence-based Quality Improvement Collaborative for Neonatology, developed a training program to improve obstetric and neonatal interdisciplinary and interspecialty team communication and performance. A major part of the work has been the development of interventions that focus on key communication skills related to team performance in high-risk deliveries and the use of simulation as the methodology for the training.
Our journey toward improved interdisciplinary communication started in 2001 when an interdisciplinary team consisting of clinicians from the perinatal and neonatal intensive care (NICU) units was formed to regularly review cases where patient outcomes were less than optimal. After repeated case reviews it became obvious that our major challenge was related to teamwork and communication among the different disciplines and specialties. This was especially true in high-risk deliveries where the multidisciplinary team comes together for a short period of time, for a high-risk event that requires a high degree of team functioning.
We began by mapping out our current high-risk delivery notification process to get a better understanding of our usual practice. In reviewing the map, we found that there was tremendous variation in our processes and communication depending on the individuals involved. Responding to high-risk deliveries is a core competency that needed to be done well every time. Realizing that it would take more than a new protocol to address the complexities of this process, the team turned to the literature to find the answers.
The nursing and medical literature was not particularly helpful in finding solutions; however, we did find many studies that showed strong correlations between team performance and clinical outcomes and medical errors. The review repeatedly referenced the aviation industry as a recognized leader and innovator in team performance training and was also recommended by the Institute of Medicine as a model for team performance improvement in healthcare.4 One method of performance training widely used in aviation is Crew Resource Management, a method that focuses on group dynamics, leadership, interpersonal communication, and decision making rather than the more traditional training of technical skills.
We turned to aviation for our training and hired Corporate Aces, a group of ex-Air Force pilots, to teach our staff and physicians basic communication and crew resource management skills. One of the communication skills we saw as especially promising was the use of SBAR, developed by Michael Leonard, MD, Kaiser Permanente. SBAR is an easy-to-remember, structured communication tool useful in framing any conversation, especially critical ones, requiring immediate attention and action.
The acronym SBAR stands for S:Situation, B:Background, A:Assessment, R:Recommendation. When clinicians structure their information in this way, it allows for an easy and focused way to set expectations for what information and how information will be communicated between members of the team. Physicians, trained to diagnose and treat, want to know “what is the problem?” The S (Situation) in SBAR states the problem the team faces clearly and succinctly. Nurses, trained to assess holistically, are naturally more descriptive in their communications. Background and assessment information gives the team objective and historical data pertinent to the situation. Communicating in an SBAR format allows each discipline to give and receive vital information in a way that satisfies varying communication styles and needs.
Efforts aimed at integrating the SBAR communication method into both nonurgent and urgent communications occurring in the maternal/child division began after the initial Corporate Aces training and continues in earnest to this date. An introduction to SBAR didactic presentation was given at staff, department, specialty, and operations meetings within the division. Trigger tools such as note pads containing the acronym SBAR and its definitions were printed and placed at all of the nursing stations. Staff were encouraged to script their SBAR prior to calling a physician or giving the report. Fill-in-the-blank SBAR templates specifically related to newborn hypogylycemia, hyperbillirubinemia, and respiratory distress were created to script the SBAR, ensuring that critical data elements were contained in the communication (Figure 3). Institutional procedures, such as reporting of critical laboratory values, now contain a scripted SBAR example. Early in our efforts to use SBAR, we noted an opportunity to enhance SBAR with an additional R, which stands for repeat back. SBAR-R, as we now used it, forces truly closed loop communication by ensuring that any orders given are repeated back or the established plan of care is verified.
Figure 3: Example of...Image Tools
Our experience with implementing SBAR-R has shown that there are 3 key elements necessary to establishing SBAR-R as the standard communication tool within the division. First, staff must practice organizing and delivering information in a structured format. This can be achieved by using SBAR-R for nonurgent communications on a daily basis and by scripting communications with SBAR-R templates. Second, using simulation-based team training affords healthcare team members an opportunity to practice using SBAR-R in a crisis situation. Engaging the perinatal team in a simulated crisis allows them to see the impact of communication errors as well as reflect on and practice avoiding communication errors using SBAR-R. Using simulation-based training, we have taught teams to give an SBAR-R related to the simulated crisis, request an SBAR-R if you are entering the scene, and confirm the SBAR-R if you require confirmation of the unfolding situation. Finally, SBAR-R is now being embedded into the procedures, practice guidelines, and policies of our unit, serving as a constant reminder of our communication expectations.
Being able to provide the safest and the highest quality of care is an important component of nursing and physician satisfaction and retention. Following this training, we repeatedly hear the nurses and physicians tout the benefits of hearing the other discipline's perspectives and having the opportunity to discuss with them what it looks like to be a highly functioning team. Some of the objective results of this training are increased staff and physician competence with team communications and teamwork. Our simulation scoring tools reflect the increasing use of the SBAR-R technique. There are other, less objective, results as well. This training has resulted in an increased awareness among the multidisciplinary team of the importance of teamwork. By emphasizing and reinforcing cooperation in patient care rather than in professional prerogatives and roles, we are changing our culture to one where relationships among the team are highly valued and collaboration in patient care management is paramount.
One of the authors (JD) thanks Sonya Flanders, BSN, RN, CCRN, for her contribution to, and ongoing work on, the SAFE initiative and the manuscript review.