Cornell, Paul PhD; Gervis, Mary Townsend MSA, RN; Yates, Lauren RN; Vardaman, James M. PhD
Even with advances in technology providing greater access and analysis, it is human communication and interaction that determine the use and value of information. This is especially true of healthcare, when the effects of poor communication can be disastrous. The Joint Commission (TJC) estimated that 65% of sentinel events were the result of communication problems.1 Brought to the nation’s attention in 1999 by the Institute of Medicine,2 government and organizations have invested heavily in research and training to address the issue. The problem is not easily solved because communication behaviors are often complex, embedded in an organization’s culture and processes, and influenced by one’s training and background.3,4
One area of concern is hand-off communication. Many factors make hand-off processes a challenge: They occur frequently (up to 6 times a day); care is transferred from person to person; multiple disciplines are often involved; and a large quantity of information is shared.5 Schools of nursing do not effectively prepare graduates to perform hand-offs, and there is little evidence for a singular best practice.5-7 The impact on patient outcomes is so critical TJC requires hospitals develop a standardized approach to hand-offs.8
Shift report, the transfer of patient care from an off-going nurse to an on-coming nurse, is a unique aspect of hand‐-off. Report is performed at least twice a day, at a similar time and location, between 2 similarly trained nurses. Although this type of hand-off superficially appears easier to execute, research suggests otherwise. Shift reports are often unstructured, inconsistent, inaccurate, and frequently interrupted; omit key information; take too long; and convey out-of-date or unnecessary information.6,7,9-14 The Situation, Background, Assessment, Recommendation (SBAR) communication protocol has been advocated as a means to address many of these shortfalls.7,11,15-17 Originally intended to improve nurse-physician communication in urgent care situations,3 SBAR was designed to expedite cross‐-disciplinary communication by creating a common and consistent structure for information, thus a shared mental model. The SBAR protocol has additional reported benefits, including improving social capital, legitimacy, and the formation of schemas for rapid decision making.14,18,19
As a shift report tool, SBAR provides the structure and consistency often found lacking in current practice.11,12,15-17,20 In one sense, SBAR provides a checklist of information, which some contend improves shift report.12,13,15 However, its structure and process make it more than a task to process information,8 addressing social, organizational, and even educational functions.10 Studies indicate that SBAR reduces shift report time11,16 and is received favorably by staff.6,17,21
The purpose of this study was to assess the impact and value of SBAR in shift reports. Four medical-surgical units provided the setting. Nurses were observed before and after SBAR implementation. To support the protocol and reinforce the informational structure, a paper-based SBAR tool was developed as a script for nurses. Following use of the paper version, an electronic version of SBAR was developed and made available on fixed and mobile computers. Several hypotheses were proposed. First, it was predicted that SBAR shift reports would result in improved time on task. This would be indicated by a reduction in the overall time to complete the report. Second, it was hypothesized that reports would be more consistent, exhibiting more time on shift report tasks and less on superfluous tasks (ie, a greater emphasis on completing shift report). Third, it was anticipated there would be less transcribing of information, with nurses relying on the SBAR report to provide the record. Fourth, an increase in computer utilization was expected with the availability of the electronic SBAR. And finally, it was hypothesized there would be a decrease in dependence on personalized, handwritten worksheets, known by some as cheat sheets.
Data were collected on 4 medical-surgical units of a 339-bed, midsouth suburban hospital. Each unit had 48 beds and 8 to 9 nurses per shift, with an average nurse-to-patient ratio of 1:6. All nurses in the hospital received classroom training on the SBAR protocol, including simulated encounters. Nurses were instructed to use the protocol during shift reports and interdisciplinary rounds. They could use it elsewhere in the care process but were not required to do so. During training, nurses were also introduced to a paper-based report tool that included SBAR information on each patient. These reports were available during shift reports and rounds. Later, they received training on how to access an electronic version of the SBAR report (see Figure, Supplemental Digital Content 1, http://links.lww.com/JONA/A240). All nurses were assigned mobile computer carts that provided wireless access to medical records and facilitated ease of access to electronic tools.
A variety of methods have been used to measure nurse workflow.22 Direct observation was used in this study because it is more objective, quantitative, and unobtrusive compared with other work sampling methods.22-24 A comprehensive protocol was developed and included the recording of 4 variables: nurse tasks, tools, collaborators, and location of work. Drawing from previous studies of workflow,23,25 staff defined a list of tasks that were mutually exclusive and exhaustive. All tasks likely to occur during shift report were identified. The list, shown in Table 1, includes tasks other than shift report. These occur while an on-coming nurse waits or performs other duties during the shift report. Thus, even though a shift report is in progress, an observer could record non–shift report activities. Staff also defined the tools, collaborators, and location variables. Tools included computers, documents, mobile workstation carts, and devices. Collaborators included nurses, charge nurses, physicians, patients, family, and ancillary staff. Locations included patient rooms, nurse station, nurse cubby, hallway, and conference rooms. The list of items and the protocol were pilot tested to ensure full coverage of all shift report events and circumstances.25
Observational data were recorded using a small tablet computer. The computer displayed the items of each of the 4 variables in checklist format. The observer selected or deselected items using a stylus and the touch-sensitive display. The computer recorded the contents of the checklist at a rate of 20 times a minute, providing a near continuous recording of events and circumstances. Each record was time and date stamped. These data enabled the analysis of frequency and duration of tasks, tools, collaborators, and location. They also allowed analysis of the co-occurrence of variables. Changes in time allocation before and after SBAR could then be assessed statistically. Observers were 3 senior-level nursing students who were trained in the definition of variables, behavioral indicators of each variable, and use of the tool. Training included classroom instruction and practice shadowing nurses. All observers were institutional review board (IRB) trained and certified.
Hospital staff developed the SBAR protocol and report tool and pilot tested both on a medical-surgical unit. Multiple versions were tested before finalizing a 4-page form. A condensed paper version of the form was used during the 2nd observation, and an electronic SBAR (see Figure, Supplemental Digital Content 1, http://links.lww.com/JONA/A240) was developed for the 3rd. The labels and format are identical to the paper form. Nurses typically printed a report on each patient under their care and carried it with them during shift report. When the electronic version was available, they could use either form of the report.
Three shift report observations occurred over an 8-month period: baseline, paper SBAR report, and paper and electronic SBAR report. Observations occurred Monday through Friday and included morning and evening end-of-shift reports. Shift reports began at approximately 6:45 AM or PM, depending on when nurses were ready to begin.
Nurses were informed in staff meetings and through memos of the goals and methods of the study, but they did not know in advance when they were going to be observed. On observation day, charge nurses randomly selected the nurses to observe. The observer approached the on-coming nurse and asked for permission to shadow them during shift report. If nurses consented to the observation and participation in the study, they were shown the tablet computer and were reminded of what was recorded. Participation was at the nurse’s discretion, and they were reminded they could opt out or end the observation at any time. None did. The observer started recording when the nurse stipulated the start of shift report. Once started, the observer used the checklist of variables to record the nurse’s tasks, tools, collaborators, and location of work. The start and stop times of all checklist items were time stamped by the computer, and observers only had to select and deselect items. The observer followed the nurse at all times except in patient rooms. While there, nurses could be seen from the hallway, and observers continued to record behaviors and tool use. Patient and medical data were not recorded, only behaviors and artifacts. The observation continued until the nurse confirmed all patients had been reviewed.
The 1st observation provided a baseline condition. Subsequently, staff received SBAR training, which included use of the protocol as well as the paper report. A 2nd observation occurred 5 weeks later. Additional training occurred when the SBAR report became electronic. One month after this training, and 4 months after the 2nd observation, a 3rd observation was conducted. Training occurred in February and June, and observations occurred in January, March, and August. The experimental design was reviewed by the hospital IRB. The repeated quantitative observation of staff constitutes a level 3 on the evidence scale.26
Seventy-five nurses participated in the study. Their mean (SD) age was 34.1 (9.9) years. The minimum age was 21 years and the maximum was 62 years. Approximately 51% (n = 38) had associate degrees; 42% (n = 32), bachelor of science in nursing; 4% (n = 3), nursing diplomas; and 3% (n = 2), master’s and LPN. Mean (SD) experience was 6.9 (8.2) years. The minimum and maximum experience was 4 months and 38 years, respectively. Mean (SD) employment in the hospital was 4 (5.1) years. In the baseline, 46 different nurses were observed. In the SBAR observations, 32 and 39 nurses were observed. Because of the random selection process, 13 nurses were observed twice in the baseline, and 4 and 12 nurses were observed twice in the 2 SBAR conditions.
Fifty-nine shift reports were observed in the baseline observation, 36 in the 2nd observation (paper SBAR), and 51 in the 3rd observation (electronic SBAR). The mean time required to complete shift report was 28.0, 31.2, and 28.7 minutes, respectively (Table 2, part A). These differences were not significant in an analysis of variance (ANOVA) procedure (F = 1.08; P = .34). In the observations, we distinguished between total report duration and the time spent performing shift report tasks. The percentage of time spent on shift report tasks was 54.6% during baseline and 62.7% and 66.4% in the 2 SBAR conditions (Table 2, part B). These differences were significant (F = 3.67, P < .03), showing an increase in percentage of time spent on shift report tasks under the 2 SBAR conditions. Ninety-five percent of shift reports included at least some time on non–shift report tasks.
The time spent in verbal communication as a percentage of the total shift report was 29.5% during baseline and 49.3% and 42.1% in the 2 SBAR conditions (Table 2, part C). This difference was significant in the ANOVA (F = 11.48, P < .01), indicating the amount of verbal communication was higher with SBAR. Writing during the shift report decreased from 21.1% to 11.2% with the paper SBAR but increased to 22.9% with the electronic SBAR (Table 2, part D). This ANOVA was also significant (F = 5.54, P < .01).
There were 3 computer options available during the shift report: at the nurse cubby, at the nurse station, or on a mobile cart. Nonetheless, time on the computer was low in all 3 observations: 4.1% during baseline and 2.2% and 1.4% in the SBAR conditions. Computer use was lowest when SBAR was available as an electronic report. None of these differences were significant, however (Table 2, part E). Use of a personal sheet varied substantially across the 3 observations. It was highest during baseline, being used nearly 35% of the time during shift report. It dropped to 1.5% and 5.8% with SBAR (Table 2, part F). The ANOVA indicated these differences were significant (F = 42.16, P < .01).
As part of the transition to using SBAR, nurses were encouraged to conduct the shift report in patient rooms. Although not hypothesized, this resulted in changes where shift report tasks occurred. During baseline, 54% of reporting took place in the nurse cubby, with 20% occurring in the hallway during transit and only 17% in the patient room. This changed in the SBAR conditions. Report locations were 10% in the cubby, 45% in the patient room, and 30% and 33% in the hallway during transit (Figure 1).
Of the 5 hypotheses, 3 were supported. It was expected the SBAR report tool would keep nurses more focused and would lead to shorter reports. Whereas their time on task improved (54.6% to 66.4%), the overall duration was unchanged. Given the common complaint that shift reports are too long,11-13 it is actually encouraging SBAR did not increase report time, although it did not shorten it.
The hypothesis of increased time on shift report tasks was supported. Shift reports rarely proceeded from beginning to end without interruption, as there were often calls, interactions, and miscellaneous tasks which must be performed at the beginning of a shift. This is borne out by the fact that more than 95% of the 146 observations included non–shift report tasks. However, the introduction of SBAR resulted in significantly more time spent on shift report tasks, with nurses switching to other tasks less frequently. Any increase in focus and reduction in nonpertinent tasks are positive from a process and cognitive perspective.
The hypothesized switch from writing to talking was supported, but not in all cases. Nurses conversed more with SBAR, implying more information was exchanged. Because an off-going nurse knows more about a patient than the codified information in the medical record,8 increased conversation is positive, especially in light of the finding that a larger percentage of time was spent on shift report tasks. Obviously, transcribing data already contained in the medical record is wasteful. With the SBAR report, on-coming nurses knew what was in the record and did not need to re-record it. Nonetheless, the amount of writing did not decrease. Further exploration of what is written and why are warranted in future research.
The expected increase in computer use did not occur. There are several reasons for this. First, the electronic SBAR was a report, created at the request of the user. The information was only as current as the latest update. Thus, the electronic report did not offer any advantage over the paper report in terms of data currency or linking to other information. Second, the mobile computer cart housed medication and nurse supplies. Although mobile, it was heavy and bulky and was not conducive to a fast-paced, mobile shift report. And 3rd, the process involved reviewing data, not entering or analyzing them. Although note taking on patients was observed, there was no new information entered into the medical record, obviating the need for a computer. Computer use is likely to change with new software and hardware products. For example, use would increase with hyperlinked data and more portable devices such as media tablets.
It was anticipated the SBAR report—either paper or electronic—would curtail the use of personal sheets. All the pertinent and topical information was contained in the report and should have eliminated the need for supplemental documentation. This was indeed the case, as the use of these notes dropped significantly. There was note taking, however, and writing occurred in the 2 SBAR conditions. As stated, these notes were not medical information but appeared to be reminders and “to-do” items. An analysis of the content is needed to better understand the writing behavior observed here.
By design, the structure and content of SBAR lend itself to concise communication. As such, it also enables and supports mobile work. This promotes practices such as bedside report, which benefit greatly from ubiquitous information access. It is interesting to note the variance in task times is greatest in baseline. As shown in Table 2, this occurs in all but 1 case (writing). A less variable process is a more reliable process, and consistency facilitates collaboration and coordination. Process consistency and standardization are major tenets of TJC recommendations.
Process and behavioral outcomes are only 1 way to measure impact. Patient outcomes such as length of stay and patient satisfaction should be considered. Likewise, staff reaction and perceptions are similarly important. These should be the subject of future research. A limitation of the study is the absence of an analysis of the information nurses wrote down on various informal forms (cheat sheets). An analysis of what nurses write down during report on these and other forms of documents would identify the shortcomings of SBAR and provide insight on additional needs. A different technology solution, in either hardware, software, or user interface, would impact the results found here. For example, a hyperlinked app available on a tablet would have been quite popular and resulted in much higher computer use. This study is not generalizable to other practice settings outside medical-surgical nursing units in this facility and should be replicated in other areas and other organizations for validation of the findings.
Implications for Practice
Findings suggest SBAR addresses many of the problems cited with existing shift reports: It provides structure, consistency, prioritization, accuracy, and comprehensiveness. In addition, according to these data, it does so without increasing the length of the shift report, which is also a frequent complaint. By providing an SBAR tool to accompany the protocol, there was more conversation about the patient and less time on transcribing. This enabled nurses to share the tacit knowledge they had on patients, information that was not always documented. The tool provided a checklist of topics to discuss, which enabled all nurses to report equally well, regardless of experience. Nurse-to-nurse use of SBAR facilitates development of schemas for presenting patients during report. This will benefit nurse-to-physician communication as well. The summarized and prioritized nature of SBAR is portable and accessible, especially compared with charts and laboratory reports. While our media were paper and computers, smartphones and tablets could easily convey SBAR information, making the report even more accessible and mobile. These protocols, tools, and devices support and promote the existing workflow of nurses and will expedite adoption. The SBAR protocol and report help accomplish TJC communication goals and improve shift report and can set the stage for improved communication between nurses and staff.
1. The Joint Commission. Improving handoff communications. Joint Commission Perspectives on Patient Safety. 2006.
2. Institute of Medicine. To Err Is Human: Building a Safer Health System. New York, NY: National Academy Press; 2000.
3. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004; 13 (suppl): i85–i90.
4. Sutcliffe K, Lewton E, Rosenthal M. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004; 79 (2): 186–194.
5. Ong M, Coiera E. A systematic review of failures in handoff communication during intrahospital transfers. Jt Comm J Qual Patient Saf. 2011; 37 (6): 274–291.
6. Hill W, Nyce J. Human factors in clinical shift handover communication. Can J Resp Ther. 2010; 46 (1): 44–51.
7. Riesenberg L, Leitzsch J, Cunningham J. Nursing handoffs: a systematic review of the literature. Am J Nurs. 2010; 110 (4): 24–34.
8. Patterson E, Wears R. Patient handoffs: standardized and reliable measurement tools remain elusive. Jt Comm J Qual Patient Saf. 2010; 36 (2): 52–61.
9. Athwal P, Fields W, Wagnell E. Standardization of change-of-shift report. J Nurs Care Qual. 2009; 24 (2): 143–147.
10. Staggers N, Jennings B. The content and context of change of shift report on medical and surgical units. J Nurs Adm. 2009; 39 (9): 393–398.
11. Nelson B, Massey R. Implementing an electronic change-of-shift report using transforming care at the bedside processes and methods. J Nurs Adm. 2010; 40 (4): 162–168.
12. Kerr D, Lu S, McKinlay L, Fuller C. Examination of current handover practice: evidence to support changing the ritual. Int J Nurs Prac. 2011; 17: 342–350.
13. Welsh C, Flanagan M, Ebright P. Barriers and facilitators to nursing handoffs: recommendations for redesign. Nurs Outlook. 2010; 58: 148–154.
14. Gephard S. The art of effective handoffs: what is the evidence? Adv Neonatal Care. 2012; 12 (1); 37–39.
15. Dunsford J. Structured communication: improving patient safety with SBAR. Nurs Womens Health. 2009; 13 (5): 385–390.
16. Street M, Eustace P, Livingston P, Craike M, Kent B, Patterson D. Communication at the bedside to enhance patient care: a survey of nurses’ experience and perspective of handover. Int J Nurs Pract. 2011; 17: 133–140.
17. Wentworth L, Diggins J, Bartel D, Johnson M, Hale J, Gaines K. SBAR: electronic handoff tool for noncomplicated procedural patients. J Nurs Care Qual. 2012; 27 (2): 125–131.
18. Vardaman J, Cornell P, Gondo M, Amis J, Townsend-Gervis M, Thetford C. Beyond communication: the role of SBAR in a changing health care environment. Health Care Manage Rev. 2012; 37 (1): 88–97.
19. Arora V, Johnson J, Meltzer D, Humphrey H. A theoretical framework and competency-based approach to improving handoffs. Qual Saf Health Care. 2008; 17: 11–14.
20. Costello M. Changing handoffs: the shift is on. Nurs Manage. 2010; 41 (10): 39–42.
21. Olvera L, Bliss M. Perfecting the patient handoff: improving the process for patients and nurses. Nurs Womens Health. 2010; 14: 496–504.
22. Cornell P, Riordan M, Herrin-Griffith D. Transforming nursing workflow, part 2: the impact of technology on nurse activities. J Nurs Adm. 2010; 40 (10): 432–439.
23. Cornell P, Riordan M, Townsend-Gervis M, Mobley R. Barriers to critical thinking: workflow interruptions and task switching among nurses. J Nurs Adm. 2011; 41 (10): 407–414.
24. Hendrich A, Chow M, Skierczynski B, Lu Z. A 36-hospital time and motion study: how do medical-surgical nurses spend their time? Permanente J. 2008; 12 (3): 25–34.
25. Cornell P, Townsend-Gervis M, Yates L, Vardaman J. Impact of SBAR on nurse shift report and rounding. Medsurg Nurs. 2014. In press.
26. Oman K, Duran C, Fink R. Evidence-based policy and procedures: an algorithm for success. J Nurs Adm. 2008; 38 (1): 47–51.