Using SBAR Communications

in Efforts to Prevent Patient

Rehospitalizations
Situation–Background–Assessment– do home health clinicians use this
Recommendation (SBAR) communica- method of shared communications with
tion has become the standard for physicians? This article explores why
communicating across disciplines. It communication between physicians
has demonstrated its effectiveness at and home health clinicians can be so
improving patient outcomes, enhancing problematic. It introduces the SBAR
patient and clinician satisfaction, and communication method, its origins, its
helping to control healthcare costs. It features, and some of the published
can help home healthcare clinicians evidence that it provides effective and
with efforts to prevent avoidable hospi- efficient communication, thereby
talizations. But how often and how well promoting better patient outcomes.

Mary Curry Narayan, MSN, RN, HHCNS-BC, COS-C

504 Home Healthcare Nurse www.homehealthcarenurseonline.com

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
C
ommunication—effectively getting your reasons interprofessional communication can be
message across—is difficult. The higher the so problematic. Several reviews in the medical
stakes, the more important the message, the and nursing literature have explored these com-
more difficult efficient and effective good commu- munication barriers, especially between nurses
nication becomes. Consider Sentinel Event statis- and physicians. Because of historical and social
tics reported by The Joint Commission (2005, factors, nurses and physicians have internalized a
2013; Tjia et al., 2009). Over the past decade, The hierarchical structure for communication and de-
Joint Commission has reported the root causes of cision making in which the physician is “in charge”
these events, and approximately 60% to 70% of (Hall, 2005; Leonard, Graham, & Bonacum, 2004;
the sentinel events they examined were related to O’Daniel & Rosenstein, 2008; Shannon & Myer,
communication problems. Analysis of the events 2012). However, this hierarchical model is not
shows that communication between healthcare effective in the complex healthcare environment
team providers frequently was ineffective (did in which no one person can have all the knowl-
not get the attention deserved) or inadequate edge needed for choosing the best course of
(did not include crucial information) resulting in action (Leonard, Graham, & Bonacum, 2004;
patient deaths and injury (The Joint Commission, Shannon & Myer, 2012). Healthcare has become
2005). too complex, each discipline has its own scope of
Effective and appropriate communication is expertise, and suboptimal outcomes occur when
needed in the home healthcare setting as much important perspectives are not voiced and heard
as it is needed in acute care settings, not only to (Leonard, Graham, & Bonacum, 2004; O’Daniel &
prevent sentinel events, but also to prevent hos- Rosenstein, 2008).
pitalizations and improve patient outcomes In addition, nurse and physician professional
(Quality Insights of Pennsylvania, 2006 ). How- education and training have tended to teach two
ever, hospitalization rates remain too high and different ways of communicating about patient
patient outcomes remain lower than desired. At issues. Nurses tended to learn to communicate
least some, if not most of these undesirable using a timeline descriptive narrative communi-
outcomes, are related to the difficulties and cation method whereas physicians tended to
complexities of interdisciplinary team communi- learn to communicate via prioritized bullet points
cation, especially with physicians. What we have (Leonard, Graham, & Bonacum, 2004; Shannon &
here is a failure to communicate! Myer, 2012). Because of this, physicians may
This article explores why communication be- have had a tendency to become frustrated with
tween physicians and home health clinicians can nurses’ communication styles, subtly feeling the
be so problematic. It introduces the Situation– communication style is evidence of a lack of
Background–Assessment–Recommendation critical thinking. At the same time, many nurses
(SBAR) communication method, its origins, its report that they feel too many physicians are
features, and evidence that it provides effective inpatient and rude, not valuing their input and
efficient communication, which can promote bet- insight into patients’ problems (Leonard, Graham,
ter patient outcomes. It analyzes each of the & Bonacum, 2004).
SBAR components and provides concrete recom- Exploration of nurse decision making about
mendations that home healthcare clinicians can when to call a physician about a patient problem
use when preparing to speak with a physician reveals another barrier to nurse–physician com-
about a patient problem and how to approach it. munication. Nurses are less likely to call a physi-
Finally, it presents a SBAR template for address- cian if they fear it will result in a psychologically
ing a chronic obstructive pulmonary disease unsafe interaction (Leonard, Graham, & Bonacum,
(COPD) exacerbation, with the goal of preventing 2004; O’Daniel & Rosenstein, 2008). Psychologi-
an avoidable hospitalization (Figure 1). cally unsafe interactions include ones in which the
nurse fears anger, insult, or disapproval from the
Research in Interdisciplinary physician or feels that “the call won’t make a dif-
Communication ference because the doctor won’t listen to me.”
Researchers have realized that interprofessional For interdisciplinary communication to occur
communication—or the lack of it—has compro- effectively, disciplines need to have a shared way
mised patient safety and have investigated the to communicate that works for all the disciplines

vol. 31 • no. 9 • October 2013 Home Healthcare Nurse 505

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 SBAR Template Communication About Exacerbation of COPD Symptoms

Situation:
• Dr. (name), this is (your name, discipline) from (name of your home health agency or hospice).
• I am calling about (patient’s name), who is experiencing increased dyspnea.

Background:
• Patient’s age ________
• Primary diagnoses: COPD (GOLD stage, if known: A-Mild, B-Moderate, C-Severe, D-Very Severe);
other primary/pertinent diagnoses.
• Recent important events. Examples include:
o Admitted to home care on (date) for (reason for home care).
o Discharged from the hospital on (date) after being treated for ___________.
• Oxygen use: _________ liters/minute, intermittent or continuous.
• Current respiratory medications, and frequency of use; recent increased frequency.
• DNR status if applicable: ____________
• Have available: medication profile, allergies, and phone number of pharmacy.

Assessment: (Only report primary/abnormal/pertinent data)

• Patient’s current symptoms:
o Dyspnea: Severity on Berg Scale: 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 r Intermittent r Constant
o Cough: r Increased frequency r Increased sputum r Increased purulence description
o r Fatigue r Restlessness r Anorexia r Difficulty sleeping r Vomiting r Anxious
o When did symptoms develop? __________ How severe are symptoms? ______________

• Physical assessment:
• Vital signs: Temp ________ Pulse _________ RR ________ BP __________ SaO2 _________
• Mental status changes: LOC _________________ r Confusion r Anxiety
• Skin color: r Cyanosis Location: ______________________ Capillary refill _________________
• Breathing effort: r Tripod positioning r Pursed lip breathing r Retractions r Nasal flaring
• Sputum: Color: _______________ Consistency: ________________ Amount _______________
• Lung sounds: r Crackles r Wheeze r Diminished Location: ________________________
• Peripheral edema: 1+r 2+r 3+r 4+r

• Analysis Examples
o I believe the patient has developed a respiratory tract infection.
o The patient’s COPD symptoms may have exacerbated because of today’s air quality alert.
o The patient’s COPD seems to have exacerbated but there are no signs of respiratory infection.

Recommendation: “We may be able to avoid hospitalization …” “We may be able to catch this early …”
r Antibiotic: Indicated for increase in dyspnea/sputum volume/sputum purulence.
r Systemic corticosteroid: Prednisolone, oral, 30-40 mg, daily for 10-14 days.
r Short-acting bronchodilators: r Change route to via nebulizer. r Change frequency to every 4 hours.
r Change/add beta-agonist or anticholinergic to______________________________________________.
r Home oxygen therapy: Titrate to ______ liters/minute to reach oxygen saturation of _______ (88-92%).
r Increase visit frequency to ___________ (every day x 2-3 days) to monitor treatment plan effectiveness.

Additional Interventions:
r No exposure to smoke/air pollution r Institute coughing/deep breathing/postural drainage
r Force fluids to _____ (2 to 2 ½ quarts) r Teach relaxation and energy conservation techniques

Figure 1. Situation–Background–Assessment–Recommendation (SBAR) communication about exacerbation

of chronic obstructive pulmonary disease (COPD) symptoms.
Notes: BP = blood pressure; DNR = do not resuscitate; GOLD = Global Initiative for Obstructive Lung Disease; LOC = level of consciousness;
Temp = temperature; RR = respiratory rate; SaO2 = oxygen saturation.
Source: Author.

506 Home Healthcare Nurse www.homehealthcarenurseonline.com

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
(The Joint Commission Center for Transforming Imagine a copilot on a jet engine passenger
Healthcare, 2010). One very effective answer is plane who realizes that his plane is on a collision
SBAR communication. course with another plane. He uses SBAR com-
munication to alert the plane’s captain:
Evolution of SBAR Communication
In 2002, Kaiser Permanente Health employed Situation: We have an emergency!
David Bonacum (2008) to investigate patient Background: We are in the path of another
safety. Bonacum was not a physician, but a qual- plane!
ity expert who had worked in the nuclear subma- Assessment: Crash imminent!
rine and aeronautical industries. On reviewing Recommendation: Pull up; turn left!
incident data from surgical, obstetrical, and in-
tensive care units (ICUs), he discovered that Bonacum and his colleagues realized that this
many of the “events” seemed to be caused by kind of communication method may be able to
communication failures. These incidents seemed avert the kinds of sentinel events and incident
to have something in common with nuclear sub- reports that were coming across their desks from
marine incidents and airplane crashes: a lack of surgical, obstetric, and ICUs, and other acute
effective communication in complex situations. care setting areas. Along with several other com-
For instance, piloting a jet plane is always a munication techniques, the Kaiser quality team
complex endeavor, which becomes even more instituted SBAR communication across multiple
complex in unexpected or crisis situations. In Kaiser Permanente inpatient settings as a way to
reviewing data of air plane crashes, it was discov- convey important information effectively and ef-
ered that frequently copilots realized that a di- ficiently. They were able to document a dramatic
saster was about to occur, which might have drop in the number of incidents in each setting
been avoided, except that the copilot was unable (Leonard, Graham, & Bonacum, 2004; Leonard,
to convey the imminence of the disaster and the Graham, & Taggart, 2004).
way to avoid it to the captain of the plane (Bona- SBAR communication was adopted by many
cum, 2008). The root cause of these communica- healthcare organizations, and it continued to
tion failures was traced to erroneous assump- demonstrate that it provided a framework for
tions about organizational hierarchy (“the shared communication across disciplines, which
captain must know what he is doing”) and the decreased “incidents” and enhanced patient care
ability to convey an urgent message in a way that (Beckett & Kipnis, 2009; Haig et al., 2006; Velji et
captured the captain’s attention, provided essen- al., 2008). Quality organizations promoted SBAR
tial information quickly, and suggested the way communication (Agency for Healthcare Research
to resolve the situation when an apparent solu- and Quality, 2012; Institute for Healthcare Im-
tion was evident to the copilot. provement, 2011; The Joint Commission Center
To alleviate communication problems, the for Transforming Healthcare, 2010; O’Daniel &
high-risk aeronautic industry adopted the Situa- Rosenstein, 2008). Soon it spread from high-risk
tional Briefing Model communication method areas to a way for clinicians to communicate with
from the nuclear submarine industry. This com- one another in all situations (Beckett & Kipnis,
munication method is a practical structure for 2009; Riesenberg et al., 2010). SBAR communica-
communicating critical information concisely, in tion has demonstrated that it enhances efficient
which relevant, timely, crucial information is communication that promotes effective collabo-
communicated succinctly. This method, as Bona- ration, improves patient outcomes, and increases
cum and his Kaiser colleagues (Leonard, Graham, patient satisfaction with care. SBAR is an evi-
& Bonacum, 2004; Leonard, Graham, & Taggart, dence-based best practice communication tech-
2004) described it, consists of four steps: com- nique. If your organization is not already using
municate the situation (the problem), provide SBAR, this is the time to start (Table 1).
essential background information (adequate con-
text), state assessment of the situation (analysis), SBAR in Home Care
and provide a recommendation for resolving the Several quality improvement projects describe
situation (“the fix”). This communication frame- using SBAR communication in home healthcare.
work is known as SBAR communication. The Home Health Quality Initiative (Home Health

vol. 31 • no. 9 • October 2013 Home Healthcare Nurse 507

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Quality Initiative, 2010; Quality Insights of Penn- Table 1. SBAR About SBAR
sylvania, 2006) advocated its use for preventing
avoidable hospitalizations and developed tem- Situation: Ineffective and inadequate communication,
plates that clinicians could use when calling a especially between home healthcare clinicians and
physician about a patient exacerbation to avert their patients’ physicians, increases patient hospital-
izations, increases healthcare costs, and decreases
an avoidable hospitalization. Several articles in the quality of patient care.
Home Healthcare Nurse reported quality improve-
ment projects in which SBAR communication Background: Physicians and clinicians may have
helped to lower agency hospitalization rates (Ev- learned different ways to communicate about patient
dokimoff, 2011; Kogan et al., 2010; Withey & issues and problems. Home healthcare clinicians
identify signs and symptoms, which, if not addressed
Breault, 2013). early, can result in more costly care, including hospi-
The SBAR tool has proven effective for pre- talizations. Because patient care is so complex, every
venting rehospitalizations of patients with perspective needs to voiced and heard and clinicians
chronic illnesses who have developed an early must be able to speak with assertive confidence about
their observations and recommendations about a pa-
sign or symptom of exacerbation, or other acute tient’s situation.
problems. In other words, the patient has devel-
oped a “situation.” The patient may have reported Assessment: Home healthcare clinicians need one
a worrisome symptom. For instance, the patient effective shared communication method to assure
may have developed one of the “yellow zone” effective communications with physicians.
symptoms on one of the excellent zone tools
Recommendation: Home healthcare clinicians should
(also known as “stoplight” or “green–yellow–red” consider using SBAR communication when commu-
tools) for heart failure (HF), COPD, diabetes, and nicating with the patient’s team members, especially
other chronic health issues (Home Health Qual- physicians.
ity Initiative, 2010). Or the clinician may have
picked up an ominous sign when performing a
scheduled patient assessment. In any case, the refill, pulse oximetry reading, respiratory effort,
situation requires collaboration with, and proba- breath and adventitious lung sounds on auscul-
bly orders from, the physician to resolve the tation, and so on.
problem. If the patient reports a new or worsening symp-
tom, such as dyspnea, diarrhea, and so on, use
Before Making the Phone Call: your symptom analysis questions—well-known
Four Steps from assessing pain—to analyze the symptom:
Before calling the physician about a patient situ-
ation, it is important to engage in some in-depth • Location: Where is it the worst?
data-gathering, critical-thinking and problem • Quality: What is it like? What adjectives
solving. First, assess the patient, anticipating describe it?
what the physician will specifically want to • Quantity: How much of it is there? What
know about that patient’s status. Beyond ob- is its severity on a 0-to-10 scale?
taining the patient’s vital signs, you need to What is its severity now, at its
perform a basic physical assessment and a fo- best, worst, after medication?
cused system-specific assessment for the body • Timing:
system(s) (e.g., cardiopulmonary, neurologic, ¢ Frequency: When does it occur? How often?

gastrointestinal) related to the presenting sign ¢ Duration: How long does it last?

or symptom (Maison, 2006). Consider what mea- ¢ Onset: When did it start? What do you

surements (e.g., blood glucose, weight) and think caused it to start?

specific assessment techniques—inspection, • Ameliorating/Aggravating Factors: What
palpation, percussion, and auscultation—you makes it better? What makes it worse?
can use to further investigate the body system(s) • Other symptoms: Anything else bothering you?
that could give clues about the nature or sever-
ity of the problem. For instance, if the problem The second step before calling the physician
seems to be a respiratory problem, besides the is to determine the urgency of the situation.
vital signs, what is the patient’s color, capillary “Situations” can be emergent, urgent, or routine

508 Home Healthcare Nurse www.homehealthcarenurseonline.com

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
(Visiting Nurse Associations of America [VNAA], • allergies and current medications,
2012). In home care, an emergent situation re- • recent changes in the patient’s treatment plan,
quires collaboration with the physician within • recent laboratory test results,
1 to 2 hours. Some situations require an immedi- • advance directive status, and
ate 911 call and immediate transfer to an emer- • pharmacy telephone number.
gency department. An urgent situation requires
collaboration within 6 to 12 hours and a routine The final step is to organize the information
situation can wait until normal business hours into the SBAR format and into primary and sec-
(VNAA, 2012). (Your organization may have dif- ondary data (Arizona Hospital and Healthcare
ferent times defined for emergent, urgent, and Association, 2007). Primary data are information
routine collaboration calls.) Some of the ques- about the patient’s situation that you think is
tions that help the clinician determine the ur- crucial to the physician’s decision making. It is
gency of the situation include: directly relevant to the reason you are calling
the physician. It concentrates upon abnormal
• How does the patient’s current status com- assessment data. Secondary data are assess-
pare with the status on previous visits, as ment data that are normal and information not
documented on progress notes? needed to make a decision about the patient’s
• How severe is the sign/symptom? (Generally, current situation. Secondary data are just
the more severe the symptom the more urgent “noise” when trying to convey crucial informa-
the situation.) tion; they hinder—and do not enhance—
• How suddenly has the sign or symptom communication when trying to solve patient
occurred? (Generally the more sudden the problems efficiently and effectively. However,
onset, the more urgent the situation.) secondary data are important to know, when the
• Can something be done to resolve this situ- doctor has further questions. If the doctor asks
ation? How urgently does it need to be done about the patient’s blood pressure, you want to
to keep the patient safe? have the answer, even if they were secondary
• What is the patient’s risk of harm or hospital- data in your opinion.
ization if this situation is not resolved within Ideally, your SBAR report should be less than 1
1 to 2 hours? Within 6 to 12 hours? By the minute, if possible, so part of your organizational
time of the physician’s regular office hours? preparation for the report is to determine how you
• What is the best time/way to reach this will be as concise and as succinct as you can be,
physician? How much time is there before while conveying the critical information (Arizona
that time? Hospital and Healthcare Association, 2007). Con-
sider a report based on the following 60-second
The third step to take before calling the physi- timeline:
cian is to access and review the patient’s record.
Compare your assessment data against the data • Situation: 10 seconds
in previous notes, to determine the trends that • Background: 20 seconds
are occurring. Be sure to have at your fingertips • Assessment: 20 seconds
all the information the physician may need from • Recommendation: 10 seconds
the patient’s medical record. Think ahead: con-
sider what information the physician may need
or ask for from the client record. Unless the phy- Giving the SBAR Report
sician is familiar with this particular patient, your During the actual SBAR call, communicate infor-
report may need to include information about mation using each of SBAR’s four fundamental
the patient’s: components: situation, background, assessment,
and recommendation (Table 2).
• age and major diagnoses,
• why the patient is being seen by home Situation
healthcare, In the initial statement made to the physician,
• when and why the patient was last seen in convey who you are, the patient’s name, and a
the hospital or the emergency department, very concise statement of the patient’s problem.

vol. 31 • no. 9 • October 2013 Home Healthcare Nurse 509

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table 2. SBAR Communication: A Concise, Effective Communication
Technique Used to Communicate With Physicians and Reduce Unnecessary
Hospitalizations
Meaning of Letter Information Data to Include Example

S Situation What is going on? • Patient’s name Dr. Jones, I’m calling because Mrs.
Jones has developed increased SOB
• Current problem
over the past couple of days.

B Background What is the context and • Patient’s age, gender Mrs. Jones is 72 years old, with diagno-
background? ses of heart failure and diabetes.
• Diagnoses
• She was admitted to home care
• Other pertinent informa-
5 weeks ago after being hospitalized
tion, as appropriate to
for HF exacerbation.
problem
• She is supposed to be on Lasix 40 mg
o Recent history
daily, but admits to forgetting to take
o Medications, allergies it several times over the past couple
o Etc. of days.

A Assessment What physical assess- • Pertinent physical Physical assessment findings include:
ment data will the doc- assessment findings • Bilateral fine crackles at posterior
tor want to know? • Perform a complete bases.
assessment before • 3+ pitting edema at ankles.
calling MD.
• 7 pound weight gain since last week.
• Respirations 28 with minimal activity.
• P =104, BP =152/88, BG=normal.
• She reports she is more SOB, but not
severely SOB.
What do you think the • Name the problem Because she seems to be having an
problem is? exacerbation of her CHF …

R Recommendation What do you think will Suggestions to resolve the I think if we increase her Lasix for a cou-
correct the problem? problem without ER/hospital. ple of days, we can resolve this situation
without hospitalization—and I am work-
ing on a plan so that she remembers to
take her medications.
Notes: BG = blood glucose; BP = blood pressure; CHF = congestive heart faliure; ER = emergency room; HF = heart failure; MD = medical doctor;
SOB = shortness of breath.
Source: Copyright © 2008, Mary Curry Narayan. Adapted from “Guidelines for Communicating With Physicians Using the SBAR Process” (courtesy of Kaiser
Permanente) and from “SBAR: A Home Health Package” (Quality Insights of Pennsylvania, 2006).

The goal here is to capture the physician’s at- Background

tention in 10 seconds or less. Do not waste In giving the physician background information
those 10 seconds apologizing for the call. Get about the patient, use your critical thinking and
right to the point: “Hello Dr. Brown. This is Mary clinical reasoning and judgment skills to deter-
White. I am a nurse from Best Home Care mine how much context the physician needs
Agency. I am calling about Mrs. Green.” Then about the patient. If you and the physician dis-
capture the physician’s attention by stating the cussed this patient three times in the last week,
situation, such as: you may need to provide less background infor-
mation than if you have reached an on-call phy-
• Mrs. Green is having increased dyspnea. sician who has never met this patient. If the
• Mrs. Verde has developed a cough and fever. physician knows nothing about the patient, or if

510 Home Healthcare Nurse www.homehealthcarenurseonline.com

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
the physician is in the middle of a chaotic day,
more contextual information may be necessary To alleviate
to “orient” the physician. Background informa- communication
tion that may be needed for the patient report
problems,
includes:
the high-risk
• patient’s age and major diagnoses that aeronautic
could impact the situation and how it is
industry adopted
resolved;
• why the patient is being seen by home the Situational
healthcare; Briefing Model communication method
• when and why the patient was last in the
from the nuclear submarine industry.
hospital (or emergency department);
• current medications the patient takes This communication method is a
that are directly related to the patient’s practical structure for communicating
situation;
critical information concisely, in which
• allergies, especially if medication orders are
anticipated; relevant, timely, crucial information is
• recent laboratory test results related to the communicated succinctly.
situation; and
• advance directive status.
Pulse oximetry is 91%. On auscultation,
Examples of important background information breath sounds are diminished, and with
include: course crackles throughout her lung fields.
She has a productive cough with gray-green
• Mrs. Green is a 72-year-old woman with thick mucous, which she reported started
COPD and HF. She was admitted to home earlier today. I believe she is having a COPD
care 3 weeks ago after a 4-day hospitalization exacerbation related to a lower respiratory
for HF. infection.
• Mrs. Verde is an 88-year-old woman with Stage • On assessment Mrs. Verde’s pulse is 124, res-
IV COPD. She has an advanced directive, indi- pirations are 32, and pulse oximetry is 87%.
cating future care should be palliative and she She is unable to use her bronchodilator in-
does not want to go back to the hospital. haler due to her dyspnea and is very anxious.
I believe the biggest problem interfering with
Assessment the patient’s palliative goals is her anxiety.
Report current signs and symptoms, and physi-
cal assessment data that are pertinent to the Analysis
problem in concise, bullet-point statements (see
Box 1). Using clinical judgment and critical- After reporting assessment data of the patient’s
thinking skills, report only the “primary” data— status, include an analysis or summary state-
the abnormal and crucial patient assessment ment of what you think the problem is, as shown
findings. If all vital signs are normal except the in the two examples above. Some home health-
blood pressure, just report the blood pressure, care clinicians may find it hard to offer their
along with the other abnormal or significant data. opinions about what is wrong with the patient
A statement at the end of your assessment re- and what should be done about it to the physi-
port, such as, “All other assessment findings cian, despite having a good sense what is wrong
were normal,” may be appropriate, if indeed you and how it can best be resolved. Remember that
did a good problem-oriented assessment of the because the physician is totally dependent on
patient. Examples include: your eyes and ears to evaluate the patient, the
doctor’s analysis of the patient’s situation is
• Currently Mrs. Green’s pulse is 108, respira- only enhanced when you offer your insights.
tions are 28 and temperature is 100.1 orally. Part of professional practice is to determine

vol. 31 • no. 9 • October 2013 Home Healthcare Nurse 511

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
nursing diagnoses and identify problems after
collecting assessment data. Box 1. Clarifying Terms
For clinicians who have a difficult time provid- One small discrepancy in the healthcare litera-
ing an analysis statement or articulating an as- ture about Situation–Background–Assessment–
sessment of what the findings indicate, start by Recommendation (SBAR) communication is
saying: what to include in “B: Background” informa-
tion from what to include in “A: Assessment”
• I think the patient has developed a lower re- data (Arizona Hospital and Healthcare Associ-
spiratory infection. ation, 2007). This issue is related to two differ-
• Do you think the patient has developed a ent definitions of the word assessment. One
lower respiratory infection? definition of assessment is an appraisal or
• The patient seems to have developed a lower summary statement of a situation (e.g., “My
respiratory. assessment is that the situation is serious.”).
However, to most clinicians an assessment is
Sometimes clinicians may not be able to de- the steps the clinician performs—the targeted
termine a specific reason for the signs and interview questions and physical assessment
symptoms the patient is showing. This may techniques—to help identify the patient’s diag-
mean the patient needs medical evaluation. At noses or problems. Some SBAR authors in-
this point you need to determine the urgency clude the interview and physical assessment
of the situation: Must the patient be seen by a data in the “Background” section of the tem-
physician on an emergent, urgent, or routine plates they propose for using the SBAR
basis? When this happens it is appropriate to method. Others consider the “Background”
summarize the patient’s situation with a state- section to be only the contextual information
ment like: that is known from what has happened to the
patient in the past—age, diagnosis, advance
• The patient seems to be having some sort of directives, recent significant history, and so
acute respiratory event. on—saving symptom and physical assess-
• I am not sure what is going on, but I think ment data for the “Assessment” section.
the patient needs medical evaluation, in your From experience, I have found that most
office and, if possible, today. home healthcare clinicians more intuitively
grasp the later method as a way to categorize
Recommendations data, which helps them to first set the context
Some clinicians may feel as intimidated provid- in adequate detail—age, diagnosis, signifi-
ing the physician with recommendations as cant medical history, and so on as the “back-
they do about providing a “diagnosis” (analysis) ground,” and then the patient’s current status
about what is happening with the patient. Re- via assessment techniques in the “assess-
member that it is a “best practice” to provide ment” section. A brief analysis statement is
these recommendations when you have them included before addressing the “Recommen-
and that research shows that, in general, physi- dation” section of the SBAR communication
cians want to know what you think should be method. (I use this way of categorizing “B:
done. It is the physician’s responsibility to also Background” and “A: Assessment” findings
analyze the data reported, to ask additional in this article.)
questions if the physician has concerns about
your analysis or recommendations, and to de-
cide whether the course of action you have As you think about what recommendations
recommended seems appropriate. It is your re- you should suggest to the physician, ask yourself
sponsibility to state clearly what you think is the following questions:
best for the patient. Making recommendations
is part of the collaborative process that is the • What action do I think the physician should
standard of quality interdisciplinary discus- take?
sions (Arizona Hospital and Healthcare Associa- • What option(s) should the physician con-
tion, 2007). sider?

512 Home Healthcare Nurse www.homehealthcarenurseonline.com

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 • How quickly do I need the physician to act
to keep this patient safe?
One of home
When formulating your recommendations, healthcare’s most
keep in mind the goals of care and what is best important goals
for the patient. One of home healthcare’s most
important goals is to prevent unnecessary hospi- is to prevent
talizations and emergency department visits. unnecessary
Therefore, consider if there is an intervention
that may prevent the need for such expensive
hospitalizations
options. What medications or treatments could and emergency
be initiated in the home? department visits. Therefore, consider if
For instance, several options are available to
intervene in the early stages of a COPD exacerba- there is an intervention that may prevent
tion: the need for such expensive options.
• If the patient has signs/symptoms of respira- What medications or treatments could be
tory viral or bacterial infection—increased initiated in the home?
dyspnea and increased sputum volume
or purulence—an antibiotic is indicated
(Global Initiative for Chronic Obstructive
Lung Disease [GOLD], 2013).
• Short-acting bronchodilators—beta2 ago- • Increase fluid intake (if no fluid retention) to
nists and anticholinergics—can be added thin and help clear excessive sputum pro-
or combined or can be given on a regular, duction (RNAO 2005/2010).
instead of on an “as needed,” basis (GOLD, • Avoid sources of smoke and air pollution to
2013). lessen respiratory burden (GOLD, 2013).
• Home oxygen therapy can be titrated to • Increase home visit frequency to every day
reach a target saturation level of 88% to 92% for 2 to 3 days to monitor the effectiveness
(GOLD, 2013). of the treatment plan.
• Oral corticosteroids should be considered.
Recommendation: prednisolone, orally, 30 Some examples of recommendation state-
to 40 mg each day for 10 to 14 days (GOLD, ments to be made to the physician include:
2013).
• Patients relying on metered-dose inhalers • To try to avoid hospitalization, should we
may benefit from using a spacer or nebulizer initiate a course of antibiotic therapy? I
to increase medication delivery to distal have the pharmacy number, and the pa-
airways (Registered Nurses’ Association of tient’s son can pick up the prescription. I
Ontario [RNAO], 2005/2010). can monitor the patient’s response over the
• Breathing and coughing techniques (e.g., next 2 to 3 days.
pursed lip breathing, double coughing, and • Would you recommend starting the oral
huff coughing) promote better oxygenation prednisolone the patient has available for
and help to expel excessive mucous inter- COPD exacerbations?
fering with gas exchange. (Huff coughing is • I think we might be able to treat the patient
a technique that moves airway secretions at home with more aggressive therapy by
despite the inability to take the deep breaths delivering his inhaled drugs via nebulizer in-
needed for effective coughing. Instruct the stead of metered-dose inhalers.
patient to take a medium breath in, and then
to make a sound like “ha,” while pushing air Once the physician responds, giving orders,
out as fast as the patient can with mouth repeat the orders back to the physician, and ask
slightly open. The patient repeats this 3 or 4 when the physician would like you to call back to
times, and then coughs.) (RNAO 2005/2010). report the efficacy of the instituted interventions.

vol. 31 • no. 9 • October 2013 Home Healthcare Nurse 513

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
What to Do When SBAR patient’s case manager and team members
Communication Fails (VNAA, 2012). It can even be taught to patients
Have you been in a situation where a physician and their caregivers as an effective way to com-
did not respond appropriately to your report? municate with their physicians about “early
For instance, you felt that patient needed an warning signs” of exacerbation and to prevent
emergency medical evaluation and diagnostic emergency care and hospitalizations (VNAA,
testing, and the doctor said to have the patient 2012).
make a routine appointment during office hours?
Or, conversely, the physician said to send the Conclusion
patient to the emergency room when you felt The SBAR communication method is an
the patient could be appropriately treated at evidence-based strategy for improving not only
home with a change in medications? Situations interprofessional communication, but all com-
like these—where clinicians feel the patient munication. It is particularly effective when
would be better served by a different course of hierarchical positions or critical situations
action—require clinicians to speak up and (high-stake situations that require quick com-
express their concerns. munication and decision making) make effec-
To express these concerns in an effective way, tive communication difficult. SBAR is not a
advocating for the patient and the best care, re- stand-alone technique. It must be combined
member to CUS. CUS is an acronym that helps with excellent physical assessment skills and
you know what to say when you think that the good clinical judgment and critical-thinking
physician is not listening to you or is making a skills to effectively accomplish the goals we
bad decision (Leonard, Graham, & Bonacum, seek. However, SBAR communication is a
2004). CUS stands for: communication framework that can promote
patient safety and enhance outcomes while
• C: I am concerned because … helping to control healthcare costs and de-
• U: I am uncomfortable because … crease hospitalizations.
• S: The safety of the patient is at risk because
… (Leonard, Graham, & Bonacum, 2004) Mary Curry Narayan, MSN, RN, HHCNS-BC,
COS-C, is a Home Health Clinical Nurse Specialist
Although initially used in healthcare to pre- and leads Narayan Associates, Vienna, Virginia.
vent errors, such as wrong site surgery, or to Narayan Associates provides quality, education,
assure a timely medical evaluation, CUS can and consulting services and patient/clinician
also be used to prevent rehospitalizations. For resources and tools to home healthcare agencies.
instance, saying something like, “I am concerned The authors and planners have disclosed that
that this plan is not going to adequately meet they have no financial relationships related to
the patient’s needs, and that he will end up in this article.
the emergency department if we don’t have a Address for correspondence: Mary Curry
plan for a COPD exacerbation in place now” or Narayan, MSN, RN, HHCNS-BC, COS-C, Narayan
“I am uncomfortable with this plan, because un- Associates, 10340 Brittenford Dr., Vienna, VA
less we address the patient’s respiratory infec- 22182 ([email protected]).
tion this afternoon, I fear he may require rehos-
pitalization.” DOI:10.1097/NHH.0b013e3182a87711

Expanding SBAR Use REFERENCES

Although SBAR communication has proved
Agency for Healthcare Research and Quality. (2012).
highly effective in interdisciplinary communica-
TeamSTEPPS long term care version. Accessed on
tions, it has also proven effective during “tran- May 12, 2013 at http://www.ahrq.gov/professionals/
sitions” and “patient hand-offs,” when transfer- education/curriculum-tools/teamstepps/longterm
ring the patient from one clinician, level of care, care/index.html
or setting to another (Riesenberg et al., 2010). Arizona Hospital and Healthcare Association. (2007).
SBAR communication can also be used to orga- SBAR Communication Standardization Toolkit. Phoenix,
nize coordination of care reports, between a AZ: Author.

514 Home Healthcare Nurse www.homehealthcarenurseonline.com

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Beckett, C. D., & Kipnis, G. (2009). Collaborative commu- Leonard, M., Graham, S., & Bonacum, D. (2004). The
nication: Integrating SBAR to improve quality/patient human factor: The critical importance of effective
safety outcomes. Journal of Healthcare Quality, 31(5), teamwork and communication in providing safe
19-28. care. Quality and Safety in Healthcare, 13(Suppl. 1),
Bonacum, D. (2008). Profiles in improvement: Institute i85-i90.
for Healthcare Improvement. Accessed on May Leonard, M., Graham, S., & Taggart, B. (2004). Effective
12, 2013 at http://www.ihi.org/knowledge/Pages/ teamwork and communication in patient safety. In
AudioandVideo/ProfilesinImprovementDoug Leonard, Frankel, & Simmonds (Eds.), Achieving
BonacumofKaiserPermanente.aspx safe and reliable healthcare (pp. 37-64). Chicago, IL:
Evdokimoff, M. (2011). One home health agency’s qual- Health Administration Press.
ity improvement project to decrease rehospitaliza- Maison, D. (2006). Effective communications are more
tions: Utilizing a transitions model. Home Healthcare important than ever: A physician’s perspective.
Nurse, 29(3), 180-193. Home Healthcare Nurse, 24(3), 1178-1182.
Global Initiative for Chronic Obstructive Lung Disease. O’Daniel, M., & Rosenstein, A. H. (2008). Profes-
(2013). Global Initiative for Chronic Obstructive Lung sional communication and team collaboration. In
Disease: Global strategy for the diagnosis, manage- R. G. Hughes (Ed.), Patient safety and quality: An
ment, and prevention of chronic obstructive pulmo- evidence-based handbook for nurses (Chap. 33).
nary disease; updated 2013. Accessed on May 12, Rockville, MD: Agency for Healthcare Quality and
2013 at http://www.goldcopd.org/uploads/users/ Research. Retrieved from http://www.ncbi.nlm.
files/GOLD_Report_2013_Feb20.pdf nih.gov/books/NBK2637
Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A Quality Insights of Pennsylvania. (2006). SBAR: A home
shared mental model for improving communication health hackage. Home Health Quality Initiative. Pub-
between clinicians. Journal on Quality and Patient lication number 8SOW-PA-HHQ06.176.
Safety, 32(3), 167-175. Registered Nurses’ Association of Ontario. (2005,
Hall, P. (2005). Interprofessional teamwork: Profes- updated 2010). Nursing Care of Dyspnea: The 6th
sional cultures as barriers. Journal of Interprofes- Vital Sign in Individuals With Chronic Obstructive
sional Care, 19(Suppl. 1), 188-196. Pulmonary Disease. Toronto, Ontario, Canada:
Home Health Quality Initiative. (2010). Best practice RNAO.
intervention package: Cross settings 1. Retrieved on Riesenberg, L. A., Leitzsch, J., & Cunningham, J. M.
May 12, 2013 from http://www.homehealthquality. (2010). Nursing handoffs: A systematic review of the
org/Education/BPIPS/Cross-Settings-I-BPIP.aspx literature. American Journal of Nursing, 110(4), 24-34.
Institute for Healthcare Improvement. (2011). SBAR Shannon, D., & Myer, L. (2012). Nurse-to-physician
toolkit. Retrieved on May 12, 2013 from http://www. communications: Connecting for safety. Patient
ihi.org/knowledge/Pages/Tools/SBARToolkit.aspx Safety and Quality Healthcare, 9(5), 19-26. Re-
The Joint Commission. (2013). Sentinel event data: treived from http://psnet.ahrq.gov/resource.
Root causes by event type. Retrieved on May 12, aspx?resourceID=25156
2013 from http://www.jointcommission.org/Senti- Tjia, J., Mazor, K. M., Field, T., Meterko, V., Spenard, A.,
nel_Event_Statistics/ & Gurwitz, J. H. (2009). Nurse-physician communi-
The Joint Commission Center for Transforming Health- cation in the long-term care setting: Perceived bar-
care. (2010). Improving transitions of care: Hand-off riers and impact on patient safety. Journal of Patient
communication. Retrieved on May 12, 2013 from Safety, 5(3), 145-152.
http://www.centerfortransforminghealthcare.org/ Velji, K., Baker, G. R., Fancott, C., Andreoli, A., Boaro, N.,
assets/4/6/CTH_Hand-off_commun_set_final_2010. Tardif, G., ..., Sinclair, L. (2008). Effectiveness of an
pdf adapted SBAR communication tool for a rehabilita-
The Joint Commission on Accreditation of Healthcare tion setting. Healthcare Quarterly, 11(3 Spec No.),
Organizations. (2005). The Joint Commission guide to 72-79.
Improving Staff Communication. Oakbrook Terrace, Visiting Nurse Associations of America. (2012). Safety:
IL: Joint Commission Resources. Communication with Physicians: SBAR. Procedure:
Kogan, P., Underwood, S., Desmond, D., Hayes, J., & 23:03. VNAA Clinical Procedure Manual. Washington,
Lucien, G. (2010). Performance improvement in DC: Author.
managed long-term care: Physician communica- Withey, M. B., & Breault, A. (2013). A home healthcare
tion in managing community-dwelling older adults. and school of pharmacy partnership to reduce falls.
Home Healthcare Nurse, 28(2), 105-114. Home Healthcare Nurse, 31(6), 295-302.

For 15 additional continuing nursing education articles on

communication topics, go to nursingcenter.com/ce.

vol. 31 • no. 9 • October 2013 Home Healthcare Nurse 515

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.