Cornell, Paul PhD; Townsend-Gervis, Mary MSA, RN; Vardaman, James M. PhD; Yates, Lauren MSN, RN
It has long been recognized by The Joint Commission (TJC), Institute of Medicine, and others that communication among hospital staff is problematic.1‐4 These problems may at times be miscues, but may also pose a significant risk to patient safety. For example, TJC estimates 65% of sentinel events are the result of communication breakdowns.5 Problems can also result from organizational hierarchy, power, training, and status.6 This is especially the case in communication between nurses and physicians,2,7 but occurs elsewhere as well.1,8
Hospital communication is further complicated by the work setting, where conditions change quickly, and staff is dispersed. Information is contextual, and the surrounding circumstances influence subsequent action. Staff needs to see “the whole” in order to interpret meaning and decide next steps.9 Ascribing meaning does not come solely from access to information; it requires time and concentration. In the case of nursing, the work is dynamic and influenced by temporal and spatial factors, hardly affording ample time to reflect.10 Nurse work is often interrupted, with considerable task switching and multitasking.11 This leads to a novel use of verbal and recorded information.12 Nurses consult both sources continuously and dynamically, but prefer verbal communication, despite its highly interruptive nature.9,13,14
Researchers at Kaiser Permanente examined a perennial source of communication problems: that between nurse and physician, especially during urgent and time-sensitive situations.15 They found differences in training, hierarchy, gender and style were often at the root of miscommunication.16 Drawing from the military, aviation, and nuclear energy industries, they developed a 4-part, scripted protocol for communicating about patients called SBAR—situation, background, assessment, and recommendation.1,17 Research suggests SBAR helps establish a common language and expectation, which reduces the effects of differences in training, experience, or hierarchy.16,18 This helps users form schemas and contributes to social capital.19 The evidence-based adoption of SBAR has led to recommended use in hand-offs, medication reviews, rounds, and postsurgery meetings.3,6,20
Communication across disciplines is even more challenging, as each has its own language, paradigms, and methods.5 This is further complicated by the fact that disciplines are typically not collocated, making verbal exchanges serendipitous and unplanned.13,21 When the exchange between disciplines is collaborative, requiring negotiation and achievement of joint goals, it is considered interdisciplinary.5,22 Despite the benefits of information sharing, teams can have problems with role ambiguity and purpose,23 transient team processes,13 and interruptions.24 Standardization has been found to facilitate interdisciplinary efforts14 but may impede the sharing of tacit knowledge.25
Beyond information access, an important goal of communication is achieving situation awareness26 about the patient and their circumstances. Situation awareness is defined as a level of understanding that enables the individual to make a decision or formulate a plan. Situation awareness is highly contextual and involves the individual’s perception, comprehension, and projection of the current situation.14,27 It is also transitory and easily degraded with changes in circumstances, lack of feedback, or the passage of time.28 In teamwork, there is collective situation awareness when each member becomes sufficiently informed to effectively collaborate and comes about through shared mental models.29,30 Development of team-situation awareness is aided by physical artifacts—such as checklists and information displays—and formal processes such as interdisciplinary rounds (IDRs), safety huddles, and briefings.27
In the current study, we explore the impact of 2 interventions on staff communication in medical-surgical (M/S) units. One is the use of daily IDR to review patient status and care plans. These rounds are attended by a staff nurse, charge nurse, pharmacist, dietitian, case manager, and others when appropriate. The 2nd intervention is SBAR, which is introduced to facilitate the presentation of patient data. Four rounding conditions are observed, and impact is assessed in a multivariate manner, including staff situation awareness, patient satisfaction, and length of stay (LOS).
In a work setting, assessing situation awareness is difficult—we cannot stop the proceedings and test staff on their knowledge of the patient. Here we measure situation awareness indirectly using patient review time. Nurses perform a patient review, and when all staff are sufficiently informed, they decide as a group to move on to the next patient. When they agree to move on, the staff acknowledge they know what they need to know about a patient. This is our surrogate measure for achieving situation awareness. Our 1st hypothesis is that IDR and SBAR help achieve situation awareness, which will be reflected in decreased patient review times.
Nurses often communicate in narrative style6,31 and learn on the job. Presentation skill varies with experience, which can be counterproductive in an interdisciplinary setting. Hypothesis 2 asserts the script provided by SBAR will serve as an equalizer, raising the consistency of all nurses.
The effects of multidisciplinary teams on patient satisfaction have been examined, but the results are mixed.32 With IDR and SBAR, nurses should be better informed about a patient’s status and plan. This should lead to increases in patient satisfaction with nurse knowledge and communication. Nationally validated patient experience surveys (Press-Ganey33 and the Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS]34) are used to measure satisfaction with nurse communication and knowledge. Our 3rd hypothesis is these indices will be positively influenced by IDR and SBAR.
Interdisciplinary rounds have a strong focus on discharge planning and continuity of care. Improved situation awareness between staff should lead to better plans, which in turn should result in shorter LOS. One study found a significant decline in LOS from 6.5 to 5.3 days,32 and another observed a 15% decrease with IDR.35 Our last hypothesis is that SBAR and IDR will impact LOS in a positive manner.
Observations took place on the 3 M/S units of a 339-bed, suburban, acute care hospital. Each M/S unit contained 48 beds with 8 to 9 nurses per shift, with an average nurse-patient ratio of 1:6. Interdisciplinary rounds were typically organized by a charge nurse, with each staff nurse taking the lead in presenting patients. Attending staff included dietitians, pharmacists, and case managers.
Patient review times were measured by the observer with a stopwatch. There was a clear beginning and end, verbally and behaviorally, to each review, enabling the observer to consistently record duration. (One observer was used throughout.) Length of stay, Press-Ganey, and HCAHPS data from the 3 units were accessed from hospital records.
The form of IDR was a case conference, involving a review of each patient’s status and care plan. Case conferences were convened every Monday through Friday morning.
Four conditions were observed. In the baseline condition, meetings were held in unit conference rooms. Staff nurses arrived singly to present their patients, reciting from memory, using personal notes, and occasionally referencing patient charts. Case conferences were conducted in this manner for 3 years before the study.
To reduce time lost to nurses queuing up and waiting, a mobile conference was developed whereby staff traveled to the “cubbies” of nurses (cubbies were located in patient care areas assigned to the nurse). Charge nurses managed the meeting, and staff nurses presented patients as before. All staff remained standing during the conference. These observations comprised the Mobile condition.
Following the baseline and mobile observations, all nurses received classroom and simulation training on the SBAR protocol. Nurses were also introduced to a paper-based SBAR report tool, which was printed at the beginning of shifts. The 3rd observation, the paper-SBAR condition, was conducted approximately 6 weeks after SBAR training.
Three months following the 3rd observation, nurses received training on an electronic-SBAR tool. The report was identical to the paper version and was available on desktop and laptop computers. It did not have hyperlinked data or animation and was as current as the last update. The case conference was again mobile, and nurses used a mobile computer cart or the desktop computer at their cubbies. This 4th observation comprised the electronic-SBAR condition. All 4 conditions occurred between January and September.
Each of the 4 observational conditions consisted of a number of case conference sessions conducted on each of the 3 M/S units. During each session, the observer recorded the duration of patient reviews and the tools and documents used and took field notes on behaviors of interest. All staff were informed in advance of the observations, and the observer’s presence was obvious to all. The observer was institutional review board (IRB) trained and certified, and all procedures were reviewed and approved by the organization’s IRB.
The age of nurses in the 3 M/S units ranged from 21 to 62, with an average and SD of 34 and 9.7 years. Their employment at the hospital ranged from 3 months to 32 years, with an average of 4.5 years. Their nursing experience ranged from 3 months to 38 years, with an average of 6.3 years.
Across the 4 conditions—baseline, mobile, paper-SBAR, and electronic-SBAR—28 sessions were observed. Sessions included 25 to 41 patient reviews and lasted 48 to 75 minutes. A total of 960 patient reviews were recorded. Results from the 4 conditions are shown in the Table 1. Included is the number of patients reviewed, the mean and SD of review times, and tool use by the nurses. An analysis of variance on patient review times was significant (F = 17.25, P < .001). Between the baseline and mobile conditions, a t test was significant (t = 5.49, P < .001), suggesting IDR reduces review times. While the 2 SBAR conditions also had significantly lower review times than the baseline condition, they were not an improvement over the IDR-only mobile condition. A t test comparing the paper-SBAR condition to the electronic-SBAR was significant (t = 1.97, P < .005), indicating the electronic-SBAR resulted in longer reviews. These results support our 1st hypothesis.
All nurses were observed to present in a similar manner with the introduction of SBAR. Regardless of age, experience, or tenure, all used a consistent structured format. There was little consistency in patient presentation during baseline, with some nurses launching into long narratives and others waiting to be asked questions. The increased consistency supported hypothesis 2.
The HCAHPS question on satisfaction with nurse communication is shown in Figure 1. The figure shows the percentage of patients responding “always” to questions regarding nurse listening, treatment, and explanations. The trend line is positive—although not significant—showing improved communication over time. Press-Ganey results on 3 indices of nurse communication are shown in Figure 2. These percentages reflect the frequency of patients responding “good” or “very good” regarding their satisfaction with nurse behavior. These results are flat over time, showing no change in satisfaction. These provide partial support for our 3rd hypothesis. Length of stay fluctuated across the 3 units, but did not improve over the time period, showing lack of support for hypothesis 4.
Two of the 4 hypotheses were supported, with partial support for another. Patient review times in the baseline condition were significantly longer, patient presentations varied considerably from nurse to nurse, and younger nurses were less comfortable and confident in their presentation. Instituting IDR resulted in a sizable drop in average review time, from 102 to 69 seconds. The paper-SBAR also yielded shorter reviews than baseline. The electronic-SBAR reviews were shorter than baseline, but significantly longer than mobile and paper-SBAR. This is possibly a technology limitation as the computers froze on occasion, and the SBAR report could not be seen in its entirety on the screen without navigation.
Regarding situation awareness, we cannot say unequivocally that IDR alone sped up acquisition. The results were in line with our hypothesis, however. Situation-background-assessment-recommendation led to more consistent and structured patient reviews, which is valuable to interdisciplinary teams. In addition, less experienced nurses presented patients as well as experienced ones when using SBAR. Presentation consistency is valuable from a process perspective—it is a TJC recommendation and a staple of quality programs and lean design.4
Prior to the introduction of the paper-SBAR report, nurses wrote notes and reminders in a variety of ways. Each nurse had his/her own style, which was problematic when information had to be shared. With the paper-SBAR, they had a place to write transitory information and a structure for recording it. The electronic version did not allow note writing and was not as portable and accessible as paper. Even with a 15-inch computer monitor, the entire SBAR form could not be viewed at once. Different technology, such as media tablets, touch screens, and larger monitors for group display, would impact these results.
Patient satisfaction, as reflected in the HCAHPS results, improved over the course of the study whereas the Press-Ganey indices remained unchanged. Satisfaction is influenced by a variety of factors and, in the case of HCAHPS, fluctuated by more than 15% during the span of the study. Even if nurses and staff were better informed, this may not be visible to the patient. At best, the surveys were an indirect measure—neither specifically addressed satisfaction with SBAR or IDR.
Like satisfaction, LOS is influenced by a number of factors. Our expectation here was that the improved communication afforded by IDR would result in better discharge planning and continuity of care. Length of stay showed no change, however. One possible explanation is that, even if the hospital improved its ability to discharge patients, other aspects of care provision did not. A second issue was the role of the case manager. In many care models, case managers play a strong role in ensuring continuity of care and reducing LOS. In our study, their influence was not as strong as it might have been.
Limitations and Future Research
Measuring situation awareness in a finite way is a challenge, especially in real time and in applied settings. Existing methods of measurement include after-action reports, critical incident, and user testing.26 None of these are applicable in a setting where up to 41 patients are reviewed in an hour’s time. Consensus to end a review indicates staff acquired what they needed to know about a patient. This is a reasonable surrogate for situation awareness, but not a precise measure.
Only nurses received SBAR training, and the tools were designed for their use. In future efforts, staff training in SBAR and discipline-specific tools will be developed. Technology will be a game changer with IDR, requiring a rethinking of the results found here. Mobile, hyperlinked, touch-sensitive media tablets will alter how information is accessed and how staff engages one another verbally.
Situation-background-assessment-recommendation is straightforward to learn, but requires diligence in implementation. It is easy to revert to old habits and workarounds when pressed for time. Our results suggest SBAR provides a shortcut for communication while maintaining comprehensiveness and clarity, especially in an interdisciplinary setting. Interdisciplinary rounding, when performed regularly, not only provides the multiple perspectives desired, but it also reduces communication barriers between disciplines.
The consistency and structure of what and how information is communicated and the repeatability of daily IDR achieve TJC recommendations. These data support the notion that it also accelerates situation awareness among staff. This frees up time for dialog and the exchange of tacit knowledge, one of the benefits of face-to-face communication.14
Consistency and repeatability also benefit staff development. The effect on inexperienced nurses by enabling them to present as well as veteran nurses is beneficial to the team as well as the nurse. This im proves social capital and feelings of legitimacy.19 This is likely to have a similar impact on the non-nursing staff as well. Those less familiar with other disciplines will acclimate quicker under these circumstances.
There are challenges. A mobile group meeting moving through an M/S hallway can be easily distracted by calls, patients, family, other staff, and even the cleaning crew. Staff must be vigilant to keep these distractions from slowing the team. Care must be taken to protect patient privacy and confidentiality. A mobile team meeting is also difficult to support technologically, at least in terms of information displays. Nonetheless, the overall benefits of SBAR and IDR outweigh the challenges, and healthcare organizations should invest in their use.
Given the Centers for Medicare & Medicaid Services’ increased scrutiny of LOS, patient satisfaction, and patient safety, IDR and SBAR are not only good practice improvements, their implementation will have an impact on the bottom line.
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