An Instructional Strategy for SBAR

SBAR communication tools and techniques are introduced to students in nursing programs nationwide to guide them in best practices for conveying patient information between disciplines. However, a standardized method of instruction for SBAR communication with a valid evaluation tool in place to discern if the nurse is using the SBAR hand-off properly is absent.  The professional development nurse educator specialist designs instructional strategies to shape and influence clinical practice for safe, effective patient care delivery. Simulation education is the forerunner of blending nursing theory and nursing practice. The ability to reproduce clinical situations at a specific time for instruction is an integral part that reinforces safe patient care practices (Bae, Lee, Jang & Lee, 2019).  The International Association for Clinical Simulation and Learning (INACSL) is an organization dedicated to the advancement of learning and transformation healthcare development through simulation (www.inacsl.org). Smith and Roehrs (2009) indicate that an increase in learning retention of nursing students when new information is introduced is evident. Ten years after the research conducted by Smith and Roehrs, learners and educators continue to expand their knowledge with simulation-based education (SBE).

In research studies, statistics exhibit learner satisfaction while improving problem-solving skills and fostering confidence in clinical competence. Foronda, Swoboda, Hudson, Jones, Sullivan, Ockimey & Jefferies (2016) boast ninety-eight percent of nursing students in their study expressed satisfaction of virtual simulation modules. Simulation can be applied to critical thinking and problem solutions for patient care pathways.  For the new graduate nurse transitioning to practice, the propensity for clinical mistakes has been established.  However, with simulation-based education using high-fidelity scenarios during new graduate residency training, patient care and safety can prevail with minimal errors and optimal patient outcomes.  Communication between healthcare disciplines is a crucial focus in the clinical setting. Simulation education may prove to be beneficial if an appropriate evidenced-based module can be developed.  The PICOT question: For new graduate nurses, how effective is SBAR hand-off instruction with simulation versus no instruction in determining communication competence within a twelve-week orientation period?  Using the constructivist learning theory approach combined with simulation-based education, this capstone project will blend didactic instruction with the learner’s interpretation of their clinical setting.  Huggins, Mansel, Tait & Bradley-Adams (2019) used low-fidelity simulation with role-playing to allow mental health students the ability to construct and process patient assessment strategies for meaningful learning with retention. Incorporating a similar process as Huggins, Mansel, Tait & Bradley-Adams (2019) for the educational issue of SBAR handoff communication validation using SBE, new graduates transitioning to practice can retain their knowledge gain as well as offer suggestions for improvement in the future. In addition, this capstone project may also reveal new information which can be used for policy/practice change.

Synthesis of the Literature

The healthcare delivery system attempts to provide safe, effective care for its consumers. Clear, concise communication is a key factor in patient safety measures for the acute care setting. Innovative teaching strategies with various simulation-based educations modules can be a useful tool used to validate standardized communication skills of practicing nurses.

Improvement of teamwork and collaboration among the interdisciplinary

healthcare teams is the driving force in quality patient care (Diaz, Shelton, Anderson & Gilbert, 2019).

Validation and meaningful learning guided by debriefing after simulation education was identified in the literature (Jeffries, Dreifuerst, Kardong-Edgren & Hayden, 2015). Hence, to develop effective collaboration and communication skills for new graduates, there must be a comfortable environment in which the learner feels valued in their role (Oner, Fisher, Attallah, Son, Homel, Mykhalchenko & Minkoff, 2018). The literature review was conducted to identify how the use of simulation-based education aids in the validation process for standardized nursing communication skills as well as the use of an SBAR communication tool.

Chamberlain University electronic databases were used to locate literature selections included: CINAHL Complete, Access Medicine, ProQuest Nursing, PubMed and Cochrane Library.  The assignment instructions dictated to use ten peer-reviewed, research studies published within five years of the current date. A literature search was conducted using the phrases “simulation education” and “SBAR communication.” SBE has been identified as a leading instructional method in the future of nursing education.  The learning opportunities are bountiful and can be implemented across multiple healthcare disciplines at the same time (Nakamura, Fujita, Tsukimori, Kobayashi, Sato, Fukushima, et al., 2019). Simulation-based education with meaningful debriefing assists in the development and identification of communication strategies needed for collaboration and teamwork (Diaz, Shelton, Anderson & Gilbert, 2019).  Clinical reasoning skills are also noted to improve as simulation scenarios are reviewed and debriefed by instructors (Bae, Lee, Jang & Lee, 2019).  Simulation training modules and scenarios and be produced in a structured and safe environment conducive for the learner’s needs (Oner et al., 2018). Blended learning combining didactics with simulation provides high satisfaction rates during evaluations from learners (Foronda, Swoboda, Hudson, Jones, Sullivan, Ockimey & Jeffries, 2016).  There were three recurrent themes identified in the literature chosen to support SBE.  The first was clinical reasoning associated with problem-based learning. The second and third was an improvement for communication opportunities due to the TeamSTEPPS® and DML© elements of SBE.

Clinical Reasoning

Nursing competencies have extensive involvement with clinical reasoning and problem-solving.  In short, the practicing nurse must use direct thinking with self-reflection as it relates to learning and adapting to a dynamic health care delivery environment. Effective communication and problem-solving strategies allow novice nurses to overcome fear and anxiety relating to their new role.  SBE permits engaged learning in a non-threatening or intimidating milieu.

Improved Communication

A patient’s healthcare experience correlates to effective communication among the interdisciplinary care team.  The role of the nurse is vital as he/she will be amidst patient status changes or deterioration. In order to ensure information is disseminated accurately for the safety of patients, clear communication is a necessary nursing skill.

Debriefing

Debriefing for Meaningful Learning© (DML) is the gold standard for simulated instructional methods.  It facilitates the learner’s self-directed reflective thinking based on his/her experience.  This is one of the modalities of the constructivist learning theory.  In addition, DML© can be performed with interdisciplinary health care workers simultaneously to foster collaboration and teamwork for quality patient care.

Summary of the Literature

In summary, the use of SBE to validate safe, effective patient care delivery skills of health care professionals is becoming a preferred pedagogy.  The complexity of patient diagnosis, treatment plans, and health maintenance require astute clinical reasoning of the new graduate nurse transitioning to practice. The ability to convey vital information to professional cohorts is necessary to promote health and wellness within the health care delivery system. Debriefing of simulated experiences uses a clear, concise, systematic evaluation that learners appreciate.  Standardized communication is a critical component in the exchange between health care workers.  TeamSTEPPS ® is a useful component of simulation learning for knowledge and performance improvement. When creating scenarios for SBE, patient standardization is optimized for learners to understand and construct the information in a meaningful environment.  New graduates will need confidence in their approach to overcome barriers associated with practicing at a novice level.

Intervention and Evaluation Plan

The SBAR communication tool is introduced in prelicensure programs; however, there is no objective and measurable evaluation tool to determine if the student understands how to use and apply it in the clinical setting.  In a traditional clinical setting, the nursing student would not be responsible for hand-off reporting or conveying information to the physician in the event of a deterioration in patient status.  Unfortunately, giving report is left up to the nurse’s style based on the nursing unit and patient population.  Multiple variations of SBAR evolve from the practicing nurse’s habits.

Objectives

            One short term goal for this project is to identify the need for a systematic evaluation of SBAR knowledge and appropriate application for a practicing nurse. Since breakdowns in communication have been noted extensively in poor patient outcomes, a competency for standardized communication is warranted.  As a long-term goal, the creation and implementation of a grading rubric for an SBAR competency in prelicensure programs could prove to benefit hospitals nationwide as new graduates to transitioning to practice become in employed with effective communication skills.

Description of the Practicum Site and Stakeholders

The practicum site for this capstone project is Doctor’s Hospital of Augusta, a Health Corporations of America (HCA) owned facility.  HCA has developed and implemented a specialty training apprenticeship for registered nurses (StarRN).  This program is designed to immerse new graduate nurses transitioning to practice with various clinical and communication skills to deter common mistakes associated with operating at a novice level. Didactic training and simulations with a mixture of nurse professional development specialists and educators contracted with HCA. The program is approximately twelve to sixteen weeks depending on placement in a specialty unit such as the intensive care unit or emergency department. The apprenticeship is designed to build confidence with the application of standardized communication to become an integral part of the healthcare delivery team despite their beginner status.

Change Model and Intervention Plan for each Step

Kotter’s eight-step change model is new for the orchestration of changes in the nursing process.

Step 1: Creating a Sense of Urgency

The first step is to increase urgency. To impart this on the nurse residents, the use of case studies from previously admitted patients with sentinel events demonstrates the urgent nature of effective communication (Small et al., 2016). As part of the intervention plan, the step will involve recognition of important issues as opportunities for change. Before implementing the SBAR hand-off instruction with simulation, a nurse educator should establish whether the program will create change and address the current communication problems among the newly graduated nurses in the healthcare setting. The sense of urgency will be created by showing the nurses the importance of effective communication in improving patient and organizational outcomes.

Step 2: Forming a Guiding Coalition

The step involves recruiting team members to spread the need for change. The nurse professional development specialist assisted with analysis of feedback from previous nurse residents without SBAR training and evaluation. The guiding coalition will include nurse leaders to persuade the other nurses to accept and support the proposed change (Small et al., 2016). For the current intervention, the team will comprise of the nurse administrator, nurse educator, resource nurse, senior bedside nurse, and unit clinical advisor. The director will teach the leading team in the Kotter’s 8-step change model to implement it in practice. They will be responsible for creating and communicating the vision for change with other members of the team.

Step 3: Creating a Vision

The third step involves the delineation of a chief aim or objective.  Having the residents reflect during simulation revealed how important communication is when planning and executing patient care.  The team should have a guiding vision to drive the change and create the necessary strategic initiatives to meet the objectives. (Small et al., 2016). The concept for the current intervention is to improve SBAR knowledge and appropriate application for a practicing nurse to enhance communication and patient care outcomes. This intervention outcome includes improved communication, better staff and patient satisfaction, and enhanced safety and quality of care. The guiding vision will be generated from the available literature that supports the efficacy of the SBAR hand-off instruction with simulation.

Step 4: Communicating the Vision

Step four of the intervention plan is the pivotal moment when the nurse acts as a change agent.  Presentation of research and evidence-literature from trusted organizational sources demonstrates a commitment to the vision. The step involves sharing the knowledge and design of the plan with the rest of the team that will be included in its implementation (Small et al., 2016). This process involves sharing the information that describes the benefits of the proposed change with the implementers. For example, a hand-off grading rubric was located at the Quality and Safety Education for Nurses (QSEN) and disseminated among the nurses taking part in the change process. The intervention plan will include regular staff meetings and education sessions to internalize the vision.

Step 5: Empowering Members of the Team

At step five of the Kotter change model, empowering change is monumental. The vision may be communicated effectively, but adoption of the new process necessitates support from members of the team (Small et al., 2016). Therefore, during this stage of the interventional planning, members of the team should understand, internalize, and have an opportunity to act autonomously. Showing support for cohorts who listen and seek to understand available options to implement change creates a viable network.  Engagement constitutes the ability and willingness to change. Having nursing staff from various units will review and suggest alternatives for the SBAR grading rubric accomplished in step five. The nurses involved in the change are empowered to integrate the vision by creating the foundation to improve communication in their work. This change included the standardization of communication using the SBAR communication tool.

Step 6:  Creating Quick Wins

The sixth step suggests creating short-term wins.  As a practicum student, being allowed to participate in a learning module to introduce the proposed practice change exemplifies a short-term goal. While it is easy to create a vision, it might be challenging to sustain the ultimate change. Therefore, the change team should create clear and visible wins (Small et al., 2016). For example, the implementation team might identify effectiveness in completing and handing off as a result of the implemented communication plan. Highlighting the small wins enhances the momentum to complete and sustain change. This step should include some mechanisms to celebrate success, such as having a staff dinner, once a milestone is achieved.

Step 7: Building on the Change 

Steps seven and eight show the professional attribute of perseverance. The intervention plan will support the hospital to implement, support, and continue maintaining the change (Small et al., 2016). For example, while the intervention plan to improve communication targets the current newly graduated nurses, it should be sustained to include other nurses in training and future practice. The coalition team and implementers should maintain the vision and reinforce it in practice. For instance, nurses should continue using the newly learned communication approach to improve their caregiving skills.

Step 8: Institutionalizing the Change

The coalition team and implementers should solidify the change and make it part of the organizational culture. The intervention plan includes a cultural change to make the vision a norm in the hospital (Small et al., 2016). The SBAR communication tool should become part of the way nurses communicate within the organization to improve the safety and quality of care. The hand-off communication strategy becomes the foundation of care in each unit. Wearing a student badge at the hospital draws attention to the program of study and accomplishments.  To bring the vision to light, discussions are conveyed by patient safety suggestion blogs. Multiple avenues like social media assist in reaching multitudes of health care consumers.

Implementation Plan

To implement this proposal.  Fourteen of the twenty-eight nurse residents will attend a simulation session. They will read aloud five case scenarios of a patient’s hospital course, diagnosis, past medical history, medications, and allergies, among other aspects. After reading the case studies, the patient’s status will deteriorate or improve resulting in a transfer to another unit. The students will verbally report to another nurse and write it in an SBAR format to send with the patient upon transfer.

Evaluation

To evaluate the efficacy of SBE on standardized communication using the SBAR tool, a grading rubric retrieved from qsen.org will be used.  The fourteen students who do not complete the simulation will review the same case study scenarios individually and write a report in an SBAR format. This intervention should give insight to the original PICOT question: For new graduate nurses, how effective is SBAR hand-off instruction with simulation versus no guideline in determining communication competence within a twelve-week orientation period?  The group that did not initially attend the simulation will complete the simulation the following day with different scenarios.  Groups will alternate during their SBE week of the residency program.

Tools to Evaluate Learning

Besides the learning rubric, the evaluation will include a pre-post intervention questionnaire to assess the level of knowledge developed through the implemented intervention plan to improve communication among new graduates. The nurses involved in the simulation training program will complete the quantitative survey before implementation and another after successful completion of the training to establish potential improvement of their SBAR hand-off communication. The results of the study will be compared to similar responses from nurses who will not take part in the intervention.

For instructors, the most effective evaluation will encourage effective teaching practice. The success of their instruction will be revealed in the successful knowledge development among the learners. Therefore, the survey will provide critical insights into the effectiveness of the instructors in training students using SBAR hand-off instruction with simulation. The evaluation results will provide essential insights into the need for change in the intervention to improve communication skills among newly graduated nurses.