Poor communication is a leading cause of sentinel events in health care (The Joint Commission, 2015). In Crossing the Quality Chasm, the Institute of Medicine (2001) recommended redesigning health care processes, emphasizing cooperation among clinicians “to ensure an appropriate exchange of information and coordination of care” (p. 9). This document brought to light the challenges inherent in the health care delivery system and endorsed efforts to improve interprofessional communication.
Communication breakdowns between clinicians arise when messages are not clearly conveyed by the sender or are misinterpreted by the recipient (Woodhall, Vertacnik, & McLaughlin, 2008). Differences in the ways nurses and physicians communicate can lead to communication failures. Nurses learn to report information in a narrative format with many details, whereas physicians may be trained to focus on key elements and report succinctly (Foronda, MacWilliams, & McArthur, 2016; Woodhall et al., 2008). Because of these differing communication styles, important details may be missed, overlooked, or misunderstood. To address the complexity involved in communication, including diversity of disciplines as well as individual characteristics, one approach is to standardize communication.
SBAR (Situation, Background, Assessment, and Recommendation) is a standardized format for communication that originated in the United States military. For example, it was used when a naval submarine officer needed to relate a potentially dangerous situation in briefing the ship's captain (Heinrichs, Bauman, & Dev, 2012). This framework has been adapted to the international health care environment for reporting patient concerns to other disciplines, including nurses' communication with physicians. The acronym has gained wide acceptance as it is easy to remember and cues the individual to remember key elements in a communication to assist in patient safety (Institute for Healthcare Improvement, 2015).
SBAR has helped to flatten the hierarchy between nurses and physicians (Heinrichs et al., 2012) by creating a collaborative effort to improve communication, leading to improved job satisfaction for both clinician groups (Haig, Sutton, & Whittington, 2006). SBAR encourages open communication among providers, allowing them to share information, ask questions, and suggest interventions to promote patient care (Haig et al., 2006) by leveraging a standard communication process that attends to pertinent clinical variables rather than perceived clinical rank or status. By following the SBAR format, nurses are empowered to express recommendations (De Meester, Verspuy, Monsieurs, & Van Bogaert, 2013) and suggest interventions that can help the patient. The implementation of SBAR into clinical environments has been affiliated with improved admission and discharge medication reconciliation and decreased adverse events (Haig et al., 2006). Further, SBAR has increased nurses' perceptions of effective communication and collaboration (De Meester et al., 2013). When used in both oral and written forms of communication, SBAR has enhanced patient safety through improved handoff of patient information among caregivers.
Simulation is an educational strategy that has been linked to improving interprofessional communication skills (Foronda, Gattamorta, Snowden, & Bauman, 2014). Nursing students who used virtual clinical simulation to practice interprofessional communication using ISBAR (Identification, Situation, Background, Assessment, and Recommendation) verbalized increased comfort using the format (Foronda et al., 2014). According to Kesten (2011), nursing students who received role-play focusing on communication skills in addition to didactic instruction performed significantly better on the skilled communication than those who had didactic teaching only. It should be noted that the addition of “I” for identification further clarifies the communication process by succinctly adding role clarity to the communication process. Role clarity is an important facet during crisis communication processes.
Foronda et al. (2015) developed a rubric to measure nurse–physician communication called the ISBAR Interprofessional Communication Rubric (IICR) (Table 1). The tool was found to be valid and reliable when tested in a multisite, international simulation study. However, this study was only performed in academic settings and the participants were nursing students. The rubric had not been tested with clinical nurses; thus, it was unknown whether the rubric was appropriate for nurse education in hospital-based simulation settings. The primary aim of this study was to determine whether the IICR was a reliable tool among hospital-based nurses. The secondary aim was to examine the RNs' communication performance scores.
ISBAR Interprofessional Communication Rubric
Design and Sample
This study used a prospective design involving RNs in a pediatric nurse residency (PNR) at an urban children's hospital. The institutional review board affiliated with the hospital provided approval for this study. Using a convenience sampling approach, new graduate nurses (defined as graduating within the past year) were asked to participate in a simulation that was similar to others they had already completed during one of their residency classes. Because a signed consent form could link participants to this study, we used a waiver of documentation of informed consent to minimize a potential breach of confidentiality. No demographic data were collected from the nurses. Their performance in the simulation was not shared with their nurse manager or director to avoid any negative impact on their employment.
The IICR was used to measure nurse–physician communication (Table 1). This is a tool that has been validated previously and demonstrated a reliability of 0.79 with nursing students (Foronda et al., 2015). The tool ranged from 0 to 15 points, with 15 points being the highest score achievable. A score of 10 would indicate a passing communication performance. A score of less than 10 would indicate a need for remediation. The tool had not been used with nurses until this study.
The staff development specialists at the facility reviewed the ISBAR rubric and completed interrater reliability testing prior to implementation of this study. The raters viewed two videos of simulated communication performances and independently evaluated the performances using the rubric. A score with 85% accuracy or higher was required to pass the training. All raters completed the training without remediation.
An online educational module on ISBAR was created by two academic nurse educators with the assistance of an instructional designer. This 15-minute, free module was shown to the new graduate nurses in their residency class immediately prior to the simulation. The module explained the history of ISBAR, differences between communication patterns of nurses and physicians, and frustrations reported by nurses and physicians when ineffective communication occurs. Additionally, the module included two demonstrations—one excellent and one poor—of nurses using ISBAR to communicate patient concerns to a physician during a telephone call. The new graduate nurses watched the module as a cohort and completed an ungraded 10-question assessment upon completing the module.
Nurse residents (N = 8) performed in a high-fidelity simulation developed by the National League for Nursing titled “Vernon Watkins” that was adapted to require two communications from the bedside nurse to a physician. To meet the requirements for a children's hospital, the 68-year-old Vernon was adapted to an 18-year-old. One of the new graduate nurses played the role of Vernon's sister in keeping with the institution's patient- and family-centered care delivery model. This two-part simulation required the primary nurse to perform an ISBAR telephone call to a physician in response to a patient event. Vernon was 5 days postoperative following a hemicolectomy and experienced new onset shortness of breath and calf pain on the day of discharge. Nurses were expected to assess his anxiety, respiratory distress, leg pain, and abnormal vital signs and anticipate a deep vein thrombosis and potential pulmonary embolism. The participants were asked to “think out loud,” a technique that is frequently used in simulation. The nurse serving as the bedside nurse in each of the ISBAR simulations correctly verbalized assessment findings and shared what they believed to be happening (i.e., a deep vein thrombosis), as well as possible interventions.
In the simulation, two opportunities existed to demonstrate ISBAR in communicating patient concerns. The first was after responding to a call from Vernon with complaints of leg pain and shortness of breath. After performing a physical assessment, the nurse called the physician with concerns. The second opportunity to present information using ISBAR occurred after change of shift and nursing handoff but before the oncoming nurse had entered Vernon's room and completed the assessment. This time, the nurse received a call from the physician who was instructed to follow up on Vernon's status. In this call, certain elements of ISBAR were missing. However, many of the nurses updated the physician from the report they had received from the off-going nurse and stated that they had not yet assessed Vernon. They offered to call the physician back after assessing him. This presented a realistic scenario that was discussed further in the debriefing.
This simulation was held during one of the PNR classes with both the acute and critical care groups. The PNR groups had nine to 11 members, but each group was split into two for this simulation to allow more nurses to make the ISBAR call and receive feedback on their performance. All simulation performances were observed, as is standard protocol for simulation. One to two staff development specialists facilitated the simulation session, with one playing the role of the physician receiving the ISBAR telephone call without prompting the nurse for information. Meanwhile, two staff development specialist raters observed from the simulation center control room and scored the nurses' communication performance independently using the IICR. The nurses were not identified on the rubric; rather, nurses were labeled as Nurse A, Nurse B, and so on.
A structured debriefing model centered in experiential learning was used to ensure all debriefings concentrated on the learning objectives. The debriefing focused on typical postoperative assessments, differentiating between normal and concerning findings, and when to notify a physician. These were important initial teaching points, since unrecognized abnormal findings would have been worrisome. As the inpatient units tend to have highly specialized patient populations, we also focused on adolescent-specific concerns, such as including the patient in decision making and patient education. Debriefing further explored nurses' previous experiences communicating concerns to physicians and how these concerns were shared with their physician colleagues (in person, telephone, or text message).
Participants also shared the types of responses they received from physicians and whether their suggested interventions or recommendations were communicated and received such that they facilitated optimal patient care for their patient. If they had not previously made recommendations, the nurses reflected on what they would need to do to be prepared and able to make a recommendation to a physician using the ISBAR technique. Strategies included obtaining an opinion from a more experienced nurse prior to making the ISBAR call to validate assessment findings and practicing the ISBAR call with another nurse before calling the physician to ensure that all pertinent information was communicated. If nurses were unsure of which potential interventions to suggest, their recommendation to the physician was that they come assess the patient at bedside immediately.
To obtain interrater reliability of the ISBAR tool, the nonparametric correlation Spearman's rho was calculated using rating data of eight nurses. All statistical analyses were performed using SPSS®, version 22 software.
Eight new graduate nurses agreed to participate in the simulations. Using Spearman's rho, the reliability coefficient between rater 1 and rater 2 was rs = .91, demonstrating high reliability. The median communication performance score of the nurses participating in the current investigation was 7.3 (interquartile range = 5.3) of a possible 15 points. This indicates that the average performance score was less than a passing score, indicating a need for remediation.
This study demonstrated that the IICR was a reliable tool in the context of staff development specialists evaluating new graduate RNs in a hospital-based setting, increasing applicability for the rubric beyond the academic setting. The nurses demonstrated a median communication performance score of 7.3, indicating a need for remediation in this area. In a similar study undertaken with evaluation of communication performance using the IICR with nursing students as opposed to nurses, the students demonstrated a median communication score of 11.0 (interquartile range = 3.0) (Foronda et al., 2015). Of note, the nurses in this study demonstrated a much lower score than the students. This difference warrants further inquiry.
Graduate nurses are negotiating the transition from student to professional. They may struggle to apply their academically acquired knowledge to new clinical practice environments. These clinical environments will likely differ from the controlled learning environments found in classrooms, simulation laboratories, and supervised clinical environments. Perhaps the difference in scores between the subjects in the two studies could be attributed in part to the difference of the ideal conditions of the simulated environment from the actual clinical environment in terms of application of best practices. In the controlled academic environment, teaching faculty are careful to model and reinforce best practices. In the actual interprofessional clinical practice environment, graduate nurses may encounter powerful contradictions to previously learned communication practices. Although this hypothesis is purely speculative, it warrants further investigation.
The live scoring component may have caused raters to miss items. Although live scoring may provide less time for deliberation and second-guessing of scoring, it may not allow for the same level of thoroughness that video capture and replay affords. Perhaps the nurses rating subjects decidedly chose to report only the most relevant items on the rubric to be succinct or save time. This provides direction as well on the rubric as it may be desirable to decrease the number of items.
In each of the simulations in the study, the nurse assigned to make the ISBAR call verbalized her/his concern for a potential clot based on Vernon's difficulty breathing and sudden, sharp calf pain. However, when calling the physician, the nurses provided the situation, background, and assessment, but several times the recommendation was a general request to come assess the patient. Nurses suggested interventions including radiographs, doppler ultrasound, and laboratory tests, as well as the need for the physician to come to bedside immediately during the simulation. Despite this recognition, the nurses did not consistently inform the physician of the suspected post-operative complication or possible interventions to help the patient.
When asked about this in debriefing, nurses discussed several factors that may account for their performance using ISBAR to share patient concerns. Although all the RNs had learned about SBAR in school, most of them had never spoken to a physician during their clinical experiences. Rather, they had communicated patient concerns to either their clinical instructor or staff nurse at their clinical site. This caused them to feel less confident when speaking with physicians. Another reason shared by one new graduate nurse was that she hesitated to make recommendations for fear she was wrong and that a rotating resident may agree with her suggestions. Her concern was that her recommendation could unintentionally harm a patient in this teaching environment.
This narrative seems rooted in experience or lack thereof and is not unexpected. Benner (1984) argued that experience afforded experts to think in action and in ways not yet available to novices. In other words, experience influences the quality of clinical decision making. Gee (2003) argued that complex learning and the ability to function in complex situations is in part a function of pattern recognition. Although the graduate nurses were able to correctly identify potential signs and symptoms of thrombosis (a pattern), they may have lacked the global understanding of the consequences of the underlying diagnosis. This in part may have been because the simulation experience as experienced by the graduate nurses was detached from current perceptions of clinical practice. In short, the risk of not calling the physician to the bedside was not recognized as the more serious of errors.
Another factor affecting nurse recommendations was hesitance to diagnose, which is considered to be within the physician's scope. New graduate nurses were encouraged to consider their recommendations as possible health conditions and interventions that may have helped other patients with those conditions instead of making a definitive diagnosis. The question arises whether making a recommendation is appropriate for new graduate nurses, who are not trained to diagnose or prescribe. Conversely, the ISBAR script may benefit from the verbiage “What are your recommendations?” in the event that the nurse is uncertain. Although resident physicians in the institution where this investigation took place have indicated that they appreciate when nurses make recommendations and suggest potential interventions, new nurses may lack the confidence in their assessment to make these recommendations. A comprehensive report from a nurse that includes recommendations may help junior physicians in academic settings, who may not be familiar with all the patients on the unit, to understand their concerns and make treatment decisions. New graduates, whether they are nurses or physicians, are novices and as such are learning their respective roles. Both are coming to terms with the expectations and limitations associated with their professional roles found within the complex health care delivery paradigm.
The assessment and recommendation components of the ISBAR communication tool are not specific to health care, yet it appears the sociocultural interpretation of the words assessment and recommendation may create unique challenges in the context of the interprofessional communication paradigm found in health care. Gee (2003) argued that practice professions necessarily occur within situated social constructs. Communities of practice often have and adhere to their unique cultural mores and expectations in terms of professional acculturation. Although ISBAR is clinically and culturally agnostic, when applied across disciplines ISBAR may be interpreted in such a way that it creates confounding variables.
For the second ISBAR interaction, the nurse received a call from a physician following up on Vernon's status. The nurse was asked if she/he was the nurse caring for Vernon, which may explain missing elements of the Introduction. The nurse had received handoff but had not yet met or assessed the patient, accounting for some missing elements of ISBAR in the call with the physician. During the conversation, the nurses explained that they had not yet assessed Vernon, shared their understanding of interventions that had been completed by the previous nurse, and offered to call the physician back after assessing Vernon. Practically speaking, nurses often receive calls from parents or other clinicians seeking updates during handoff and would need to share what they know and offer to call back with more information following their assessment.
All new employees at this hospital receive education about SBAR and other safety behaviors in a mandatory safety course attended within the first 3 months of hire. However, nurses and other clinicians are rarely given opportunities to practice using SBAR. The course does not focus on communication differences and the dissatisfaction that ensues when communication is unclear. The implementation of more technology (e.g., pagers, computerized physician order entry, and cellular telephones) in this institution has resulted in fewer face-to-face interactions between residents and nurses. Often, concerns are communicated electronically—for example, via text page, and as a result, closed loop communication does not occur. Thus, the need for succinct communication of patient concerns has never been greater.
One limitation of this study was that the simulations were not videotaped. This was purposeful to protect the confidentiality of the nurses participating in the study but allowed the raters to observe the call only once. Thus, they may have missed or underscored particular elements of ISBAR that were relayed to the physician. Another limitation was the small sample size of eight nurses. Further, this study only examined ISBAR communicated via telephone and nurse–physician communication. Due to technological advances, we acknowledge there are various additional forms of communication outside of verbal transactions that take place throughout the patient care paradigm but were not considered in this study.
The data regarding communication performance of the nurses support the need for continuing education on best practices of communication. As such, we recommend the use of simulation as an ideal pedagogy to teach this important skill and endorse the use of a validated tool to measure communication performance. Through improving evaluation practices in simulation, we are able to give more descriptive feedback to learners, as well as improve the science of simulation education.
On the basis of the simulation debriefing, we posit several additional considerations when teaching communication. Educators may suggest that new graduate nurses consider validating assessment findings with a more experienced nurse or charge nurse at the bedside prior to making a telephone call to a physician. Further, educators should offer interprofessional simulations for the health care team to practice communication among other skills. Education regarding deescalation and conflict resolution is recommended (Leape & Berwick, 2005; Leape et al., 2012).
The evidence suggests that communication continues to be an area of struggle for the health care team. Improving nurse–physician communication is a priority for patient safety. We are in the beginning stages of an educational revolution involving interprofessional education, and future study regarding best practices of communication is needed. Educators should strive to enforce standardized formats for communication and measure communication using valid and reliable evaluation instruments. The IICR is a tool that may be used to help train and evaluate the complex construct of communication. By assessing simulation performances with valid and reliable instruments, we will improve the science of simulation and further the opportunity for translation into practice.
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ISBAR Interprofessional Communication Rubric
|Quantitative Rating||No Credit (0)||Remediation (1)||Pass (2)||Exceeds Expectations (3)||Score|
|Identify||RN student fails to identify self||RN student concisely identifies one of the three criteria: name, position, where he/she is calling from||RN student concisely identifies two of the three criteria: name, position, where he/she is calling from||RN student concisely identifies all criteria: name, position, where he/she is calling from||Score|
|Situation||RN student fails to provide the situation||RN student concisely provides one of the three criteria: patient by name and age, diagnosis or chief complaint, reason for the call/problem||RN student concisely provides two of the three criteria: patient by name and age, diagnosis or chief complaint, reason for the call/problem||RN student concisely provides all criteria: patient by name and age, diagnosis or chief complaint, reason for the call/problem||Score|
|Background||RN student fails to provide background information on the patient||RN student concisely provides one of the three criteria: admission date, relevant past medical history, recent interventions for the patient||RN student concisely provides two of the three criteria: admission date, relevant past medical history, recent interventions for the patient||RN student concisely provides all criteria: admission date, relevant past medical history, recent interventions for the patient||Score|
|Assessment||RN student fails to provide assessment data||RN student concisely provides one of the three criteria: vital signs, LOC/behavior, relevant assessment data||RN student concisely provides two of the three criteria: vital signs, LOC/behavior, relevant assessment data||RN student concisely provides all criteria: vital signs, LOC/behavior, relevant assessment data||Score|
|Recommendation||RN student fails to provide a recommendation||RN student concisely provides one of the three criteria: suggests potential reason for condition or suggests interventions, explains urgency of actions, repeats back all orders, clarifying if needed||RN student concisely provides two of the three criteria: suggests potential reason for condition or suggests interventions, explains urgency of actions, repeats back all orders, clarifying if needed||RN student concisely provides all criteria: suggests potential reason for condition or suggests interventions, explains urgency of actions, repeats back all orders, clarifying if needed||Total score|