The U.S. Navy Submarine Service is attributed with the development of a communication technique for critical situations. The technique is to standardize a message from one person to another in the order of Situation, Background, Assessment and Recommendation. For example in a submarine:
- Situation: Captain this is #1, we are having difficulty maintaining our speed
- Background: We are near a fishing fleet
- Assessment: I think we may be entangled in a fishing net
- Recommendation: I recommend we surface and cut away the netting
The captain says “make it so” or perhaps he says “no, all stop, send out divers”
About 15 years ago the method came to the attention of patient safety experts. It had several great features: 1) The person on the front line (like an ER doctor or nurse) could make a report quickly 2) the method was easy to learn and was consistent even when emotions were running high 3) It leveled the hierarchy so the person on the front line made a recommendation with situational awareness that the person receiving the message might not have. In a medical situation SBAR might sound like:
- Situation: Doctor this is the ICU nurse, your patient John Doe has become comatose and is breathing very slowly.
- Background: He has lung disease and was just admitted 2 hours ago
- Assessment: I think he is in respiratory failure
- Recommendation: I recommend we intubate as soon as possible.
The critical care doctor says: “Get me a scope and a tube, I will be right there”
Those health care professionals who embraced the method found it very helpful and it is still being used at many institutions. But, the idea has not had universal success for reasons that were not clear at the outset:
- Fear. Recommendations might be rejected.
- License: Some felt their license did not allow an assessment which was the equivalent of a diagnosis.
- Semantics: The word assessment means physical exam to nurses but it means diagnosis to physicians.
- Litigation risk: Some felt if a recommendation was followed and later proved to be an error they would be blamed and possibly sued.
Improved communication in critical health care situations is very important to the patient in distress, in fact, poor communication is responsible for many in-hospital errors. The SBAR technique is more difficult than one might think. And, implementing it requires more than just saying “wow, this is great, do it”. Techniques for implementation include some of the following:
- Audio or video recordings of the technique in use
- Practice sessions including both doctors and nurses.
- Role playing — the doctor giving the nurse a report and visa versa.
- Explanation of why the technique works
- Examples of errors in communication and how patients might suffer
- Emphasis on teamwork and not blame. A single negative comment by a physician or supervisor can take a great deal of effort to correct.
- Understand a critical assessment is not a final diagnosis but just a step in the right direction. The assessment is made at the training level of the person stating it. Some might say “breathing difficulty” some might say “respiratory failure”.
- Continued education and reinforcement. All new members of a medical team need to be instructed. This is an ongoing process.
Good communication improves patient safety especially when quick action is needed. SBAR is a framework for communication. Other methods may do the same thing but the history and success so far suggest it has wide applicability. Users of the technique express satisfaction (1). Communication always involves two parties — both must be accepting and well trained to use the technique. The World Health Organization has included SBAR in some of its publications (2) so wider use of the technique is expected.
Personal experience with SBAR
(1) Beckett, C. D. and Kipnis, G. (2009), Collaborative Communication: Integrating SBAR to Improve Quality/Patient Safety Outcomes. Journal for Healthcare Quality, 31: 19–28. doi: 10.1111/j.1945-1474.2009.00043.x
(2) Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. Journal on Quality and Patient Safety, 32 (3), 167–175.
(3) Anonymous (2007) Communication During Patient Hand-Overs. WHO Collaborating Centre for Patient Safety Solutions,Patient Safety Solutions,volume 1, solution 3, May 2007