Nationwide, undergraduate prelicensure nursing instructors are faced with the challenges of preparing graduates who must be well equipped to enter a dynamic workforce. In addition, the demand for graduate nurses who are skilled in the application and use of interprofessional communication techniques has increased. Hence, it is becoming increasingly imperative that effective communication methods are integrated into nursing curricula to ensure students are confident with multiple ways of interdisciplinary communication to improve patient outcomes in progressively complex health care environments (American Association of Colleges of Nursing [AACN], 2008; Institute of Medicine, 2010). In addition, accrediting and regulatory bodies, including the AACN, Institute for Healthcare Improvement (IHI), National League for Nursing, and Quality and Safety Education for Nurses, recognize the need for integrating current practice trends into clinical and classroom settings as a matter of patient safety, specifically, use of standardized methods of interdisciplinary communication such as SBAR (Situation, Background, Assessment, and Recommendation). In this article, SBAR is used interchangeably to denote either a technique, framework, tool, or form, all of which imply a method of communication.
Nurses and physicians have very different communication patterns, and evidence indicates that the use of SBAR bridges this communication gap (Compton et al., 2012; Narayan, 2013; Woodhall, Vertacnik, & McLaughlin, 2008). The IHI (2014) recognizes SBAR as a framework for communication between members of the health care team and a key resource for developing a culture of safety in organizations. Researchers have examined the use of SBAR by nurses in acute care facilities (Compton et al., 2012; Haig, Sutton, & Whittington, 2006; Joffe et al., 2013; Vardaman et al., 2012; Wentworth et al., 2012; Woodhall et al., 2008), long-term care (Field et al., 2011), and home health care (Narayan, 2013). Despite reports of numerous advantages to using SBAR (Novak & Fairchild, 2012; Woodhall et al., 2008), researchers have found the “R” (recommendation) component of the SBAR presents a challenge. Although SBAR may be linear in nature, early patterns of recognition and clinical judgment must be present for students to engage in any form of clinical decision making or recommendation (Tanner, 2006). Deciding on an appropriate course of action is often difficult for students and novice nurses who may not be able to fully recognize patterns of clinical decline.
Despite the widespread use of SBAR for communication in health care settings, little is known about how undergraduate nursing students interpret clinical cues and changes in patient condition and identify these using SBAR. The purpose of this study was to identify how second-semester junior nursing students in a pharmacology course, based on a case study embedded with cues such as signs and symptoms of opioid analgesics and reversal agents, use SBAR as a communication tool. The research question was: How do students notice and interpret multiple embedded clinical cues and reflect these using SBAR when exposed to a case study and clinical data in preparation for an in-class simulation? Tanner’s (2006) clinical judgment framework phases (noticing, interpreting, responding, and reflecting) were used to provide structure and context to each component of the clinical scenario for the entire simulation. University institutional review board approval was obtained prior to data collection.
A descriptive design was used for this study. Participants comprised a convenience sample of 80 second-semester nursing students enrolled in a pharmacology theory course. The focus of the in-class simulation was recognizing multiple embedded clinical cues of an actual impending overdose in a postoperative patient receiving morphine via a patient-controlled analgesic pump (PCA) (Lancaster, 2014). A total of 13 cues (seven verbal [audio] and six written) of impending clinical crisis were embedded into the presimulation data. The first embedded cues were presented verbally during an audiotaped change of shift nursing report and included the following:
- The patient was given “a bunch” of morphine and Ativan (lorazepam) in the postanesthesia care unit.
- PCA was initiated on the floor when the patient complained of pain.
- The dose of morphine was at the extreme upper limit for an opioid naive patient.
- At the time of the shift report, the patient and PCA pump had not been assessed per protocol, making the patient 90 minutes overdue for an assessment.
- The patient was lethargic but could be aroused.
- The outgoing nurse suggested that the oncoming nurse check the PCA right away as she was “running behind.”
- The patient’s daughter was hovering and overly concerned.
Students also were presented with other written clinical cues of impending crisis, which included the written PCA assessment flowchart. Finally, students were provided the written policy and procedures for PCA use and overdose management. This included protocols for monitoring vital signs, consciousness, and carbon dioxide levels, as well as an order for the opioid reversal agent Narcan (naloxone).
In preparation for the in-class simulation activity, students were required to complete the following:
- Assigned reading from the pharmacology and medical–surgical text about care of a patient receiving morphine, reversal agents, and appropriate and inappropriate PCA use.
- Listen to the patient’s change of shift audiotaped nursing report.
- Review the patient’s PCA assessment flowchart.
- Review the patient’s written clinical update.
- Review the written policy and procedure for care of a patient using a PCA and overdose management.
- Complete the change of shift SBAR form and submit to the instructor at the beginning of the activity.
The SBAR shift report (handoff) form included the following major elements: Situation (diagnosis or complaint, allergies, and code status), Background (relevant history, issues, and problems), Assessment (activity level, physical assessment, oxygenation issues, PCA orders and use, pain, and diet), and Recommendation (laboratory results, tests, discharge needs, and other findings). The SBAR assignment was graded as either complete or incomplete. Prior to this course and in-class activity, students had been exposed to the SBAR technique as part of a health assessment theory course, during simulations in the simulation center, and also at various times in clinical settings. Students were aware of the history, clinical background, and current surgical trajectory as they were exposed to the same patient multiple times via an unfolding case study in the associated medical–surgical theory course.
The SBAR forms were collected at the beginning of the in-class simulation and consisted of responses by students on the SBAR forms to the case study and clinical data. The completed SBAR forms initially were read by researchers to grasp which embedded clinical cues were transferred onto the SBAR by students. Single words and phrases (noted in the findings) that indicated students were able to recognize embedded cues or have an initial grasp of the clinical situation and take action based on assessment data were grouped. Frequency data for these phrases were completed. All statistics were calculated using SPSS® version 21.0.
A convenience sample of 80 assignments was used for the SBAR analysis. Although 69 students completed a voluntary demographic questionnaire, all 80 completed the SBAR assignment. Of the 69 students who completed the demographic questionnaire, 84% (n = 58) were women, 55% (n = 38) were ages 21 to 23, and 61% (n = 42) were in their third year in college.
For the SBAR analysis (80 assignments), three phrases emerged: go check, need to, and missed. The majority of students noticed that the PCA pump was ordered (n = 76, 95%), and transcribed the ordered dose correctly onto the SBAR (n = 74, 92.5%). Twenty-seven percent (n = 22) of the students correctly documented the last dose of PCA pain medication, and 47.5% (n = 38) documented the presence of the PCA policy and protocol with subsequent naloxone availability. All of the students noticed the patient’s decreased level of consciousness (n = 80, 100%); however, only 28.8% (n = 23) documented the last set of vital signs correctly. One student (1.3%) noted that the daughter was attentive.
Twenty-two percent of students (n = 18) both noticed and indicated a response to embedded clinical cues. Sixteen students (20%) indicated that they would “go check” the patient. One student (1.3%) indicated the “need to get current vital signs now,” and one student (1.3%) wrote “missed last check.” Finally, despite this being a descriptive study, an assessment was conducted to explore what factors might influence the likelihood that some clinical cues were more likely to predict a response by students. A post-hoc simple binary logistical regression with all predictors revealed no statistical significance (χ2 [7, N = 80] = 10.67, p = 0.221).
Bridging the gap between noticing clinical cues and forming an appropriate course of action with subsequent reflection using SBAR remains paramount, as interdisciplinary communication and decision making are necessary for safe patient care. Results of this study indicated that the majority of students were unable to successfully follow all of Tanner’s (2006) clinical judgment framework phases. This is consistent with Lasater’s (2007) study in which effective noticing, interpreting, responding, and reflecting followed a process of beginning, developing, accomplishing, and exemplary dimensions. The majority of students exhibited an initial perceptual grasp of the clinical situation by readily noticing that the PCA pump was ordered (95%), correctly transcribing the ordered dose of narcotic (92.5%), and noting the patient’s decreased level of consciousness (100%). Students may have been successful in the first phase of noticing as the information was provided in both audio and written format, and students also were asked to complete an SBAR form.
The second and third phases of Tanner’s (2006) framework involve skill to bring meaning and understanding to a situation, as well as action or response to the situation. The ability to interpret data and respond was expressed by students’ documenting any of three phrases: go check, need to, and missed. These action words indicated an understanding of the situation, interpretation of information, and a subsequent response. However, the majority of students did not reach these phases. Only 22% (n = 18) noticed and indicated any response to embedded clinical cues. Tanner’s interpreting and responding phases require use of analytical, intuitive, and narrative skills. These second-semester nursing students were still developing the analytical skills needed to breakdown a clinical situation and determine essential components that influence response. This was confirmed by students’ inability to reason through the scenario and recommend a course of action on the SBAR, despite ample clinical cues and sufficient clinical data.
Implications for Nursing Education and Practice
Academicians and hospital-based educators should examine curricula to increase opportunities for students and novice nurses to practice uncovering clinical signs of patient deterioration and communicate these along with potential clinical recommendations in a standardized fashion. Standardizing communication techniques is beneficial to students and improves competency in communication (Kesten, 2011; Krautscheid, 2008). Useful strategies for developing clinical judgment for patient safety can include embedding cues into scenarios and expecting students to reflect these on the SBAR, which simultaneously exposes them to the most current interdisciplinary communication technique. Specifically, in academic settings, there may be opportunities to introduce SBAR as a competency check-off routinely incorporated into classroom activities, prior to entering or leaving simulations (handoff), or in the learning laboratory. In clinical settings, SBAR can be used when students routinely update nursing staff. In addition, it is suggested that faculty:
- Expose students to multiple types of SBAR forms and have students choose the form most appropriate to the clinical scenario.
- Consider SBAR as the framework for all student and instructor e-mail communication as a means to promote familiarity, consistency, and increased communication productivity.
- Consider having students review patient SBAR forms in the clinical setting, as a way to promote real-time use.
- Introduce ambiguity in theory classes when presenting patient scenarios to increase students’ opportunities to reflect, prioritize, and transfer information onto the SBAR form.
- Consider the SBAR as a possible format for summative and evaluative assessment of a simulation or case study.
Nursing instructors and hospital educators should adapt SBAR forms to meet the needs of new practitioners or more clearly define the appropriate use of different types of SBAR forms. Nurse educators, along with their agency counterparts, can systematically examine easy to learn tools, such as the SBAR, as a way to assist student and novice nurses in prioritizing and disseminating the most important information to providers.
Future research should include predictive studies specifically examining which aspects of a clinical situation, whether in the classroom, clinical, or simulation arena, are most important in assisting nursing students and novice nurses in reaching a judgment about a situation and communicating the appropriate “R” to providers. Studies exploring factors predicting student response in case study simulation activities also can be conducted. Some evidence indicates debriefing, reflection, and faculty guidance rank as more important than case notes to students when examining factors that contribute to clinical judgment (Kelly, Hager, & Gallagher, 2014). Additional studies exploring students’ and novice nurses’ grasp of Tanner’s (2006) model including reflection in-action and reflection on-action, critical to evaluating one’s practice, are needed. In addition, studies exploring the comfort level of faculty with the SBAR technique, best pedagogies for teaching SBAR use, and the effect of SBAR use on student mistakes in practice, incident reports, and other never-events are warranted.
The structure of the form may have limited what students believed should have been reported on the form. Nursing students also are very rule based, and it may have been too difficult to translate cues onto the open narrative portion of the form; it is possible that the cues were lost in the data itself. Finally, this was a paper exercise, and students may have had a lower level of engagement, assuming that if they noticed something, they would write this on the SBAR.
Exposing students to multiple ways of gathering information, evaluating clinical cues, determining appropriate action, and communicating changes to the health care team will prepare them for complex clinical practice situations. Educators are encouraged to evaluate courses and develop innovative ways of incorporating SBAR into classroom, clinical, and simulation settings.
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