ACCORDING TO THE Joint Commission’s (TJC’s) Sentinel Event Database, communication was identified as a leading root cause of sentinel events in the United States.1 It is progressively recognized that poor communication is a major factor in health care errors and remains a serious challenge to overcome in health care. With the lack of interprofessional communication between physicians and nurses, shortage of patient-staff interaction, and deficiency of effective nurse handovers, it is a major risk point leading to poor patient experience and having an effect on both patient safety and clinical outcomes.2 According to TJC, 12 122 sentinel events were reported in the United States between 1995 and 2015.1 Research conducted during the 10-year period of 1995 to 2005 has revealed that ineffective team communication is the root cause for approximately 66% of all medical errors during that period.1,3 Studies conducted during the past 3 decades confirm that the clinician’s ability to explain, listen, and empathize can have an overpowering effect on patient satisfaction and experience of care.3 As many hospitals may report, the rising importance of patient satisfaction and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores required by the Centers for Medicare and Medicaid Services are causing a shift in how hospitals evaluate and manage their health care organization. It is time for hospitals to focus on employee engagement to enhance communication in which will, in turn, improve patient safety and experience, boosting the bottom line. With the amount of patient and clinician dissatisfaction and poor patient outcomes, addressing the issue of how to improve communication is of the utmost importance.3 A 2016 goal of TJC for the US National Patient Safety is to “improve the effectiveness of communication among caregivers.”4 (p8) Because patient care often suffers when health care providers do not communicate efficiently and effectively, health care leaders need to discover ways to enhance communication to decrease the risk of sentinel events and to improve the overall patient experience. This article will identify and discuss different communication protocols that can be used to enhance the consistency of more efficient and effective communication within a health care organization to overall improve patient care and patient satisfaction.
In a study by Cornell et al,5 the effect and effectiveness of a paper-based situation-background-assessment-recommendation (SBAR) protocol and electronic-based SBAR protocol were measured from shift reports and interdisciplinary rounds. The information collected and observed consisted of report times, report consistency, quality of information, the use of paper handling, transcription times, and patient review times. The authors stated that the amount of time to complete shift reports before using the SBAR framework was approximately 53 minutes. After a total of 51 shift reports were recorded using the protocol, the authors noted that SBAR decreased the amount of time to complete shift reports down to 41 minutes using paper SBAR and approximately 38 minutes when using electronic SBAR. When applying the SBAR technique to interdisciplinary rounds, the authors observed that of the 269 patient reviews recorded it decreased patient review times from 119 seconds to 58 seconds. Because of this study, the authors noted that when the SBAR protocol is used it enables a focused way to set expectations for nurses and physicians to communicate the condition of a patient’s health and have more consistent shift reports across the board. The SBAR protocol has shown to also decrease patient review times and allow for new nurses to perform more proficiently like well-experienced nurses. The SBAR technique overall has shown to provide a successful framework for communication and has enhanced nurse-nurse communication and reduced the time spent on nurse shift reports and staff rounds.5
ONLINE VIRTUAL CLINICAL SIMULATION
In a pilot study by Foronda et al,6 the use of an online virtual clinical simulation, CliniSpace, was evaluated for the effectiveness of enhancing communication skills of baccalaureate nursing students. Because medication errors and sentinel events have been connected to miscommunication, it was decided to conduct this study to reveal whether the online virtual clinical simulation is an effective way to improve communication. The simulation identified substantial patient data and used the implementation of the identify, situation, background, assessment, and recommendation communication tool.
Students performed in two simulations that were scored by the CliniSpace identify, situation, background, assessment, and recommendation rating sheet. The authors stated that “student performance scores more than doubled from performance one to performance two.”6 The results of this study showed that the students felt less anxiety and had a better understanding of how to assess a patient and how to communicate more effectively.6
As Bates and Gawande7 noted, “failure of communication, particularly those that result from inadequate handoffs between clinicians has been shown to be a common factor underlying adverse events”.7 (p2527) A study by Bruton et al2 was conducted to understand the essential purpose, effect, and overall experience of nurse handover from both patient and staff perspectives. Researchers conducted interviews with the patients and staff in medical and surgical units of a hospital as well as observed nurse handover between these two departments. The researchers noted that different forms of nurse handover were demonstrated among the whole nursing team (office based), nurse in charge to nurse in charge, and bedside handover for the two units. There were various views on benefits of each type of handover, and communication problems were identified by the staff and patients. From the observations, the authors came to the conclusion that although it is important for medical teams to develop adequately structured content and style for nurse handover not all clinical areas will perform the exact same way because different units have different needs. The authors suggest that nurses be trained to deliver effective bedside handover specified to the particular unit because this will help develop consistency and confidence. It is also important for nurses to inform patients of the purpose of handover, so that patients understand what is happening and why. This will increase patient safety and enhance their overall patient experience because the patients will feel more informed and trust will be built.2 According to the Agency for Healthcare Research and Quality’s 2011 Hospital Survey on Patient Safety Culture, “50% of the half a million respondents from over 1000 hospitals believed important patient care information is often lost during nurse handover.”8 This reassures the importance of training nurses their role to communicate efficiently and effectively in nurse handovers, to decrease the risk of these errors.2
INTERPROFESSIONAL COMMUNICATION TRAINING SIMULATION
In an interprofessional communication training simulation study by Liaw et al,9 the authors conducted a program, using a presage-process-product model also known as the 3P, for enhancing medical and nursing students’ communication skills when caring for a patient with physiological deterioration. This program was composed using communication strategies adapted from Team Strategies and Tools to Enhance Performance and Patient Safety. In total, there were 127 medical and nursing students who partook in the simulation. Self-confidence in interprofessional communication and awareness in interprofessional learning was tested before and after the simulation. The authors noted that both medicine and nursing groups showed signs of improvement in self-confidence in their posttest scores when compared with their pretest scores. The simulation-based interprofessional communication program demonstrated improved perception toward interprofessional learning and an increase in effective communication among medical and nursing students in providing safe care.9
As previously discussed, patient satisfaction is becoming a huge factor for how health care leaders manage and run their health care organizations, because it affects the patient experience and may have an effect on reimbursement rates. Research has suggested the implementation of the acknowledge-introduce-duration-explain-thank (AIDET) protocol. The AIDET is a framework tool to enhance communication among patients, families, and medical staff. Sandlin et al10 observed the effectiveness of integrating the 5-step communication tool into perioperative areas of a health care organization through a program called “Partner in Care.”10 The results of this program revealed that by applying AIDET as a framework to enhance communication “promotes safety, quality outcomes, reduces patient and family anxiety, and increases patient satisfaction.”10 These findings from Sandlin et al10 support the idea that implementing AIDET in a health care organization can vastly improve a client’s overall patient experience and satisfaction from the services that they received.
BARRIERS TO EFFECTIVE COMMUNICATION
Mira et al11 discussed the idea that patients may not feel as though they are given enough information to appropriately make clinical decisions about their health. These authors identified barriers such as a lack of consultation time with the physician, as well as a lack of sources being used by patients, that contributed to the clinical decision-making process. The authors conducted a cross-sectional study and used questionnaires that aimed to detect significant aspects of communication among patients and their physicians. Among the 764 patients and 327 physicians, “35.1% of patients preferred to have the last word in clinical decisions”11 instead of allowing the physician to give their final decision. Certain factors, such as patient age and severity of the diagnosis, increased the likelihood of the patient taking a less active role in the decision-making process. Approximately 85% of patients stated that the amount of information that they received during the decision-making process was appropriate to make their own decisions in terms of their health. Among the physicians, approximately 20% reported that they felt the need to interfere when allowing the patient to make their own clinical choices. Patients who are older or have more severe ailments typically chose to allow the physicians to make the final clinical decision. Physicians tend to refrain from reporting all possible complications from a medicine or an interaction between medicines to the patient. Because of this, the authors noted that the patients do not always feel adequately informed or involved in terms of their own clinical safety.11
IMPROVING COMMUNICATION THROUGH SBAR AND AIDET
Communication is pivotal to health care outcomes, which includes patient safety and patient satisfaction. According to Hegan,12 “Communication reduces the chances of a breakdown in continuity of care, builds relationships and understanding. The majority of negligence cases are not related to the clinical quality of care but are triggered by an inadequate communication.”12 The SBAR and AIDET are two effective techniques used to facilitate and enhance productive communication skills to increase the likelihood of a positive and lasting effect on patients. These techniques can also reduce the risk of patients and their families taking legal action against a health care organization. When using SBAR as a tool for health care professionals to communicate effectively with one another, the medical staff first introduces themselves and their role in assessing the patient in their care, provides the patients name, and states the main problem or most important aspect to grab the other colleague’s attention immediately (situation). They then briefly explain the patient’s date of admission, diagnosis, and medical history and treatment to date (background). Next, the medical staff member then states the assessment of the patient that may include vital signs, level of consciousness, acute confusion, or any quantitative or qualitative data that is available (assessment). Finally, the health care professional precisely requests what they need during a set time frame and any solutions or recommendations for the next step of action (recommendation). Very similar to SBAR, AIDET is also a communication technique that can be used in the health care setting, however, is a more commonly used directly with patients. Health care professionals first acknowledge the patient by full name as well as any family members or visitors in the room and greets them with a friendly smile (acknowledge). The health care professional then introduces themselves by name and their role in the patient’s care (introduce) and always explains how long each step of the visit or procedure will be (duration). The next step in the AIDET protocol is for the medical staff member to clearly explain what they are going to do, how they are going to do it, and why they are doing it as well as answer any questions the patient may have (explain). The final step is to thank the patient for choosing their health care facility as their health care provider and summarize the patient’s visit (thank). After patients are discharged from a hospital, they may be asked to complete an HCAHPS survey. This is an important factor when measuring the performance of the health care organization. The HCAHPS survey is “a survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience.”13 This survey asks patients questions on topics regarding communication with their doctors, communication with their nurses, and medication communication. The results of this survey can affect a health care organization’s reputation and can determine government reimbursements, which can affect the hospital financially. This is why it is important for doctors and nurses to use communication protocols such as SBAR and AIDET to enhance their communication abilities. The research and studies of SBAR and AIDET have proven to increase the consistency of communication among the medical staff as well as enhance communication and listening skills between health care professionals and their patients. It is crucial for health care professionals to be able to communicate efficiently and effectively among one another because this affects patient safety and patient outcomes. The AIDET has been shown to decrease patient anxiety and creates the foundation for a mutual trusting relationship that will enhance the perception of the quality of care the patient receives, which increases patient satisfaction.
FUTURE OPPORTUNITIES FOR SBAR
In another article, Jenerette and Mayer14 present other positive factors of using the SBAR communication strategy to allow patients to feel more empowered to communicate during their health care experience.15 The authors discussed future opportunities to optimize the patient-provider relationship. Because SBAR has been “shown to improve patient safety in health care environments,”16 the authors suggested teaching patients how to also communicate using the SBAR protocol. This could then “lead to positive interactions while setting the tone for the remainder of the visit by enhancing credibility, trust, and positive self-presentation.”15,17 This proposes that patient’s satisfaction will increase, and the patients overall will have better health outcomes.14
Patient care often suffers when health care providers poorly communicate between each other and their patients. Addressing the concern for how health care leaders can enhance communication in a health care organization can be solved by implementing two important techniques such as SBAR and AIDET as well as additional staff training and educational programs. It is crucial for health care professionals to be able to communicate efficiently and effectively among one another because this affects patient safety and patient outcomes. By using the SBAR and AIDET communication framework, it will improve the consistency of communication among the medical staff as well as enhance communication and listening skills between health care providers and their patients. By striving to provide more effective communication in a health care organization, it will strengthen and improve patient safety and maximize patient satisfaction.
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