- Email: [email protected]
Relationship between Interprofessional Communication and Team Task Performance
Clinical Simulation in Nursing (2020)
-,
1-7
www.elsevier.com/locate/ecsn
Featured Article
Relationship between Interprofessional Communication and Team Task Performance Kyeong Ryong Lee, PhD, MDa, Eun Jung Kim, PhD, RN, ACNP-BCb,* a
Department of Emergency Medicine, School of Medicine, Konkuk University, Konkuk University Medical Center, Seoul 05029, Republic of Korea b School of Nursing, Research Institute of Nursing Science, Hallym University, Chuncheon, Gangwon-do 24252, Republic of Korea KEYWORDS simulation training; nursing education; communication; performance; healthcare; crew resource management; team communication; interprofessional communication
Abstract Background: Communication among health care professionals is essential for ensuring quality patient care and safety. Although communication appears to be crucial during critical events, this assumption has not been widely evaluated. This study aimed to determine whether Situation, Background, Assessment, Recommendation, and Read-Back (SBAR-R) communications are related to team task performance in a simulated emergency. Methods: A convenience sample of 49 teams with 194 nursing students participated. Trained observers rated team task performance and SBAR-R communication with a mock doctor in a teambased simulated emergency. Results: SBAR-R communication scores differed significantly according to overall team task performance. The initial team performance, including patient assessment, correlated positively with SBAR with the physician. The team task performance without error correlated positively with read-back communication. Conclusions: These findings suggested that the SBAR-R communications are important to consistent team performance in an emergency. Cite this article: Lee, K. R., & Kim, E. J. (2020, -). Relationship between interprofessional communication and team task performance. Clinical Simulation in Nursing, Vol(X), 1-7. https://doi.org/10.1016/ j.ecns.2020.02.002. Ó 2020 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Poor teamwork and communication among health care staff correlates with patient safety incidents and worse outcomes for patients (De Meester, Verspuy, Monsieurs, & Financial Disclosure Statement: This research did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors. * Corresponding author: [email protected] (E. J. Kim).
Van Bogaert, 2013). The Joint Commission identified failure in communication as one of the root causes for over 60% of reported sentinel events in 2013 (The Joint Commission, 2014). Common barriers to effective communication include inconsistency in team membership, varying communication styles, distractions, fatigue, lack of confidence, and misinterpretation of cues (Foronda, MacWilliams, & McArthur, 2016). Team training and standardization of verbal
1876-1399/$ - see front matter Ó 2020 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ecns.2020.02.002
Communication and Team Task Performance communication have been suggested as methods for improving communication among health caregivers and, thereby, patient safety (Rabøl et al., 2011). Situation, Background, Assessment, Recommendation and Read-back (SBAR-R) communication form the most frequently implemented framework in the health Key Points care setting (Kostiuk, Team performance 2015). This framework is correlated with SBAR one standardized method of and read-back commucommunication that is simnication in a simulated ple, concise, and fully releemergency. vant to the information Initial team task performedical teams need. By usmance was positively ing SBAR, the person starts associated with SBAR to communicate by noting communication. what is currently happening Team task performance and then moves on to the using verbal instruction context, provides a problem correlated with readassessment, and suggests a back communication. solution (Rodgers, 2007). The SBAR technique helps staff members anticipate the information needed by colleagues and encourages assessment skills. It allows one to promptly formulate the information with the right level of detail. The technique of read-back, the fundamental mechanism of closed-loop communication, involves a person receiving information and then repeating it back verbally to the sender (Boyd et al., 2014). Grbach, Vincent, and Struth (2008) adapted SBAR to I-SBAR-R format, adding an identification of the person calling and read back the orders to promote safe practice. Especially during a critical event, nurses and physicians often communicate over the telephone, which makes these communications error prone (Rabøl et al., 2011). Read-back lets the sender know the message has been received and provides an opportunity to correct any mistakes (Boyd et al., 2014). In health care, the potential risks of not using closed-loop communication are increasingly acknowledged, and read-back is considered to be an essential feature for error prevention and quality of care. The Joint Commission’s National Patient Safety Goal that addresses communication requires write-down and read-back of the critical value information on a timely basis (Singh & Vij, 2010). Communication among health care professionals is known to be particularly crucial in the context of critical events, but this assumption has not yet been widely evaluated and there is a lack of clear relationship between team performance and communication. Previous studies of health care professionals or students mainly have focused on improvement in communication skills, perceived interprofessional competence, and critical thinking skills as a result of SBAR training (Foronda et al., 2016; Kesten, 2011; Kostoff, Burkhardt, Winter, & Shrader, 2016), and few studies have investigated how SBAR-R communication contributes to patient-important outcomes (Shahid & Thomas, 2018).
2 Nurses are at the forefront of ensuring patient safety, but there is little reliable evidence on nurses’ performance in interprofessional teams (IOM, 2003). This study attempted to identify whether verbal critical incident report focused on SBAR-R communication tool is related to team task performance and can affect patient outcomes in a simulated emergency. We hypothesized that the association between team task performance and interprofessional communication would be more apparent in nursing students who lack clinical experience than in those already familiar with clinical practice. Similarly, we hypothesized that readback communication would be important for students unfamiliar with the situation and environment when acting on verbal instructions without introducing errors or missing important aspects. The results of this study may help identify specific nursing behaviors that are essential to ensuring patient safety. We conducted this study in nursing students.
Methods Study Design This study used a prospective observational study design to examine the relationships between nursing students’ team task performance and SBAR-R communication.
Setting and Participants This study was approved by the university’s institutional review board. The study was conducted at a university. From 2015 to 2016, senior-level nursing students enrolled in the integrated nursing practicum, a required nursing laboratory course before graduation, were eligible for inclusion, and all students agreed to participate (N ¼ 194). All of the students had no previous simulation experience and had the same experience completing all the clinical exercises required for graduation. The students were grouped into 49 teams by name in an alphabetical order for convenience to participate in the simulation training; 47 teams included four members with the other two teams having three members. The analysis unit was the observed behavior of the team.
Measures The fundamental measures of this study were team task performance and SBAR-R communication using checklists developed by researchers. Team task performance was categorized into two phases: the initial team performance before a call to a mock doctor and the team task performance after receiving verbal instructions from a doctor via phone. These were measured using a checklist of observable key actions based on practice guidelines derived from the literature. The initial team performance phase refers to the stage in which team members work together at the beginning of an pp 1-7 Clinical Simulation in Nursing Volume Vol
Communication and Team Task Performance encountered emergency. The expected behaviors by the team were as follows: obtaining a brief, targeted history; checking vital signs; performing a targeted physical examination; cardiac monitoring; checking oxygen saturation and administering oxygen, if needed; and elevating the head of the bed. The phase related to the team task performance after the call to doctor assessed the key clinical actions in response to the mock doctor’s verbal order and was as follows: administering and maintaining oxygen through a nasal prong; establishing an intravenous line; administering aspirin, nitroglycerin, morphine, and heparin; obtaining venous blood for laboratory tests; and arranging 12-lead electrocardiography (ECG). A dichotomous scoring scale of 0 ¼ not done and 1 ¼ done was used to assess each item. The possible scores for this checklist ranged from 0 to 12 for the initial team performance and 0 to 8 for the actions after the call to the mock doctor. SBAR-R communication behaviors were assessed using a checklist. We assessed the participants’ ability to apply the SBAR-R technique when reporting to the mock doctor and receiving telephone instructions in the simulated emergency scenario. These communication behaviors were categorized into two phases: SBAR reporting to a mock doctor after the initial assessment and read-back after receiving the order from the mock doctor. The checklist included 29 key communication behaviors. The scenario included four items: patient’s name, sex, age, and reason for the phone call (major problem). The background included three items to obtain a previous diagnosis or past history of the patient. The assessment used nine items to be reported, including vital signs. The recommendation comprised two items including one general suggestion about problem solving and one concrete suggestion. The verbal read-back comprised 11 items to be evaluated as closed communication while clearly the identifying the doctor’s instructions. A dichotomous scoring scale of 0 ¼ not done and 1 ¼ done was used. The possible scores ranged from 0 to 18 points for SBAR and 0 to 11 points for read-back communication. We also recorded the time of the first call and the number of calls to the physician. The contents of the tools had been validated by three experts with simulation training experience.
Procedures Medical emergencies can have devastating consequences. Chest pain can be a sign of an impending catastrophic medical condition if a patient collapses, and its effective management requires the medical team to perform several tasks simultaneously. These tasks include information gathering and immediate life support including administration of oxygen, morphine, aspirin, and nitroglycerin, applying 12-lead ECG, establishing an intravenous line, and sampling of venous blood. Before the simulated emergency scenario, students received a mini-lecture about SBAR-R communication and
3 determined the team leader. Each of the 49 teams was presented with a scenario involving an acute myocardial infarction using a high-fidelity patient stimulator. According to the expected sequence of clinical actions, the team should take a series of four phase actions. In the scenario, the patient presented to the emergency department because of chest pain. The expectation for the first phase was immediate assessment and initial management of the patient by the team. Each team’s initial task performance before the call to the mock doctor was assessed. In the second phase, the team leader then reported the patient’s condition to the mock doctor over the telephone, and communication behaviors were assessed using the SBAR checklist. In the third phase, the team leader received a verbal order about the key actions from the doctor over the telephone. The read-back checklist was used to evaluate the leader’s closed-loop communication behaviors. A doctor was immediately available by telephone, if requested. A faculty member played the role of the doctor receiving the SBAR report and provided orders based on a premade order set. In the fourth phase, the team’s performance of the expected actions in accordance with the physician’s order was assessed using the checklist. All simulation exercises were videotaped for assessment. Two trained assessors independently reviewed five of 49 videotaped simulation scenarios. Cohen’s kappa, a measure of interrater reliability, ranged from 0.78 to 0.87 for team task performance and from 0.67 to 0.91 for SBAR-R communication, and these values were judged to be acceptable. The remaining cases were measured by one assessor.
Data Analysis We used descriptive statistics to assess team task performance and SBAR-R communication. The mean team task performance score was 13.80 (SD 2.59) and the median was 14. We categorized the individual teams into better or worse teams with respect to their team task performance. Scores 14 of 19 were categorized as better (n ¼ 26) and those <14 were categorized as worse (n ¼ 23). The Mann-Whitney nonparametric U test was used to compare the SBAR-R communication between the better and worse teams. Because of the ordinal nature of the scores, the nonparametric Kendall rank correlation was used to examine the correlations between team task performance and SBAR-R communication. The data were analyzed using IBM SPSS Statistics (IBM Corp., Armonk, NY, USA).
Results Team Task Performance Eleven key actions were assessed to examine the initial team performance. Most teams performed brief and targeted history taking (94%), and about half of the teams pp 1-7 Clinical Simulation in Nursing Volume Vol
Communication and Team Task Performance Table 1
4
Descriptive Measures of Team Task Performance and SBAR-R Communication (n ¼ 49)
Category
Behavior Markers
% of Frequency
Obtaining present history Obtaining past history or family history Checking vital signs: blood pressure Checking vital signs: pulse Checking vital signs: respiration Checking vital signs: body temperature Performing targeted physical examination Applying the cardiac monitor Checking oxygen saturation Administering oxygen Elevating head of bed
94 55 100 47 37 78 41 88 90 18 57
Administering and maintaining oxygen Establishing the intravenous line Administering aspirin by chewing Administering NTG by sublingual Administering morphine by IV Administering heparin by IV Obtaining venous blood for laboratory test Arranging (requesting) the 12-lead ECG
92 78 88 92 90 29 49 47 (% of scores) 62 72 56 63 30 66
Initial performance
Key action after call to a physician
SBAR-R communication SBAR-R communication Situation Background Assessment Recommendation Read-back
Note. SBAR-R ¼ situation, background, assessment, recommendation and read-back; NTG ¼ nitroglycerin; IV ¼ intravenous; ECG ¼ electrocardiogram.
performed past or family history taking (55%). For vital signs, the teams checked the patient’s blood pressure (100%), pulse (47%), respiratory rate (37%), body temperature (78%), and oxygen saturation (90%). Most teams applied the cardiac monitor (88%) and half elevated the head of the bed (57%). However, only 18% of the teams initially administered oxygen to the patients. Eight key actions were assessed to examine team performance after receiving verbal instruction from the mock doctor. Most teams administered oxygen (92%), aspirin (88%), sublingual nitroglycerin (92%), and morphine (90%), and established an intravenous line (78%). Less than one-third (29%) of the teams administered
heparin to the patient. About half of the teams obtained a blood sample for laboratory tests (49%) and arranged for the use of a 12-lead ECG (47%). Table 1 shows the relative distribution of scores.
SBAR-R Communication Behaviors The communication behaviors when reporting to and receiving instructions from the physician are shown in Table 1. SBAR-R communication behaviors were on average 62% of possible frequencies. The SBAR-R were 72%, 56%, 62%, 30%, 66% of possible frequencies, respectively.
Table 2 Comparison of SBAR-R Communication Between Better (14 of 19) and Worse (<14 of 19) Teams in Team Task Performance (n ¼ 49) Variables
Better Teams Median (IQR) (n ¼ 26)
Worse Teams Median (IQR) (n ¼ 23)
Mann-Whitney U test
Z
p
SBAR-R Elapsed time to first call in seconds Frequency of call
20 (16-22) 179 (156.5-179) 2 (2-3)
17 (14-19) 125 (103-174) 2 (2-3)
167.50 133.00 240.50
-2.645 -3.327 -1.277
.008 .001 .202
Note. SBAR-R ¼ situation, background, assessment, recommendation and read-back.
pp 1-7 Clinical Simulation in Nursing Volume Vol
Communication and Team Task Performance Table 3
5
Correlation Coefficients Among Team Task Performance and SBAR-R Communication (n ¼ 49) Initial Performance
SBAR
Read-Back
Variables
taub (p)
taub (p)
taub (p)
SBAR Read-back Performance after receiving verbal instruction
0.313 (0.004) 0.153 (0.164) 0.175 (0.129)
d 0.076 (0.486) 0.072 (0.529)
d 0.285 (0.014)
Note. SBAR-R ¼ situation, background, assessment, recommendation and read-back.
Comparison of SBAR-R Communication Between Better and Worse Teams According to the Task Performance Scores Table 2 shows the difference in SBAR-R communication between better and worse teams according to the task performance scores. The SBAR-R scores differed significantly between better and worse teams (U ¼ 167.5, p ¼ .008). There was a significant difference in elapsed time to first call (U ¼ 133.0, p ¼ .001), but no difference in the numbers of calls (U ¼ 240.5, p ¼ .202) between better and worse teams.
Correlations Between Team Task Performance and SBAR-R Communication Table 3 shows the correlations between team task performance and SBAR-R communication. The initial team performance score correlated positively with SBAR scores (taub ¼ 0.313, p ¼ .004). The score for team performance after the call to the physician was correlated positively with the read-back score (taub ¼ 0.285, p ¼ .014). No significant correlations were observed between the initial and postcall team performances (taub ¼ 0.175, p ¼ .129) or between the SBAR and read-back communication (taub ¼ 0.076, p ¼ .486).
Discussion The strength of our study is the use of observable assessment tools, which contributed to the reliability of the results. Observation of behaviors or events is considered to be more accurate and reliable than self-assessment, particularly for human factor skills and behaviors (Siassakos et al., 2011). The main finding of our study was that SBAR-R communication was associated with the overall team task performance of nursing students with limited clinical experience. SBAR-R is an important technique for information delivery (Chapelain, Morineau, & Gautier, 2015) and preventing or reducing the risk of errors (Andreoli et al., 2010; De Meester et al., 2013; Randmaa, M artensson, Swenne, & Engstr€ om, 2014). In addition to the aforementioned findings, this study showed that the
better teams had a higher interprofessional communication score than the worse team, which suggests that successful team performance is related to interprofessional communication during a critical event. This result is consistent with a study by Reising et al. (2017) who reported a positive correlation between interprofessional team communication and procedure accuracy in the simulation. Also, Chapelain et al. (2015) showed that the number of spontaneous information exchanges between pairs of participants correlated positively with overall performance and with actions performed at the right moment. Before the call to the mock doctor, SBAR communication correlated significantly with initial team task performance. This finding suggests that the teams that were successful in the first phase of recognizing the situation and gathering pertinent information performed the SBAR report better than teams that did not. We also assessed the elapsed time to the first call to the doctor as an indicator of rapid situational awareness and astute decision making. The teams that performed well had a shorter time to the first call to the doctor than the teams that did not. This is consistent with the study of De Meester et al. (2013), where SBAR communication was related to the ability to recognize the situation and collect information about the patient. The SBAR technique is a simple technique, but it requires clinical reasoning beyond communication. To formulate information at an appropriate level, situation awareness, ability to make decisions, and assessment skills are required. Conversely, the SBAR technique helps health care personnel to anticipate the information that their colleagues need and to gather and formulate appropriate levels of information. The second phase of team task performance, successful performance after verbal instruction, was related more to verbal read-back than to the initial team task performance. This result suggests that, particularly for novices with little clinical experience, the ability to complete crucial clinical actions in a timely way without missing information or making a mistake is strongly linked to the read-back for clarifying verbal orders. This is in accordance with Boyd et al. (2014), who noted that knowledge of transferred information during a simulated crisis was significantly improved if the receiver repeated back the information. Using the read-back technique may increase the information transfer between team members, which increases the pp 1-7 Clinical Simulation in Nursing Volume Vol
Communication and Team Task Performance chances of successful team performance without mistakes and should therefore improve patient safety. The use of read-back to ensure that communications are both sent and received is an important factor in reducing or preventing medical errors (National Coordinating Council for Medication Error Reporting and Prevention, 2001), but it is not being implemented continuously in health care settings (Miller, Riley, & Davis, 2009). The skill and timing of using read-back should be part of training and should be encouraged as part of critical team behaviors. In our study, the SBAR-R performance rate was 62%, which is higher than that reported by other studies. Chapelain et al. (2015) observed that the performance score of SBAR communication by nursing students was 35.4% in a simulated emergency. Miller et al. (2009) found that SBAR and read-back skills of nurses were not consistently observed during critical events, in which key behavioral markers of closed-loop communication occurred <15% of the time. The reason for the relatively high performance rate of SBAR-R in our study is presumed to be that students received SBAR-R training before participating in the scenario. In particular, because read-back is the ability to read information again for verification but not to require the synthesis of knowledge (Perry, Wears, & Patterson, 2008), read-back skill may be easily improved by training. The recommendation performance rate was 30%, which was the lowest of SBAR-R elements in our study. Nurses must be able to use the ‘‘recommendation’’ to communicate exactly what they need from the physician (Woodhall et al., 2008). However, even if they did not know how to resolve the situation, the technique of recommendation may help empower training nurses to formulate a recommendation given to the doctor (Woodhall et al., 2008). Based on the results of this study, further research is proposed. First, empirical studies are needed to verify the effectiveness of SBAR-R training on performance level or error in various clinical conditions. Second, because SBARR communication may help health care staff learn how to judge situations and collect critical information, we suggest that empirical studies are needed to determine whether SBAR-R training can improve reasoning skills.
Limitations First, this study was conducted in a university, so the results cannot be generalized to the wider health care setting. Second, we measured only those SBAR-R communication behaviors required in the scenario, and our findings are limited by not being able to measure the quality of SBARR, such as the systematic nature of the delivered information or occurrences of misreported information. Similarly, we observed only the expected task performance of each team in the scenario and did not directly assess any errors. Third, although the data were collected for 2 years, the
6 number of teams was small for detailed analysis. Nevertheless, our results demonstrated clear relationship between SBAR-R communication and team task performance.
Conclusions Our study provides evidence supporting the use of SBAR-R communication by health care professionals during a clinical crisis. The result of our study showed that communication among nursing students was directly related to successful team performance. Although SBAR communication correlated with initial team task performance, verbal read-back was crucial for successful team task performance without missing information or making mistakes. These findings suggest that the SBAR-R communication is an important factor for ensuring consistent team performance. This is a crucial skill for nursing students to learn to ensure effective communication and patient safety during a clinical crisis.
References Andreoli, A., Fancott, C., Velji, K., Baker, G. R., Solway, S., Aimone, E., & Tardif, G. (2010). Using SBAR to communicate falls risk and management in inter-professional rehabilitation teams. Healthcare Quarterly, 13(13), 94-101. Boyd, M., Cumin, D., Lombard, B., Torrie, J., Civil, N., & Weller, J. (2014). Read-back improves information transfer in simulated clinical crises. BMJ Quality & Safety, 23(12), 989-993. https://doi.org/10. 1136/bmjqs-2014-003096. Chapelain, P., Morineau, T., & Gautier, C. (2015). Effects of communication on the performance of nursing students during the simulation of an emergency situation. Journal of Advanced Nursing, 71(11), 2650-2660. https://doi.org/10.1111/jan.12733. De Meester, K., Verspuy, M., Monsieurs, K. G., & Van Bogaert, P. (2013). SBAR improves nurseephysician communication and reduces unexpected death: a pre and post intervention study. Resuscitation, 84(9), 1192-1196. https://doi.org/10.1016/j.resuscitation.2013.03.016. Foronda, C., MacWilliams, B., & McArthur, E. (2016). Interprofessional communication in healthcare: an integrative review. Nurse Education in Practice, 19, 36-40. https://doi.org/10.1016/j.nepr.2016.04.005. Grbach, W., Vincent, L., & Struth, D. (2008). Reformulating SBAR to ‘‘ISBAR-R. Retrieved from https://qsen.org/reformulating-sbar-to-i-sbar-r/. Institute of Medicine. (2003). The Future of the Public Health in the 21st Century. Washington, DC: National Academies Press. Kesten, K. S. (2011). Role-play using SBAR technique to improve observed communication skills in senior nursing students. Journal of Nursing Education, 50(2), 79-87. Kostiuk, S. (2015). Can learning the ISBARR framework help to address nursing students’ perceived anxiety and confidence levels associated with handover reports? Journal of Nursing Education, 54(10), 583-587. Kostoff, M., Burkhardt, C., Winter, A., & Shrader, S. (2016). An interprofessional simulation using the SBAR communication tool. American Journal of Pharmaceutical Education, 80(9), 157. Miller, K., Riley, W., & Davis, S. (2009). Identifying key nursing and team behaviours to achieve high reliability. Journal of Nursing Management, 17(2), 247-255. https://doi.org/10.1111/j.1365-2834.2009.00978.x. National Coordinating Council for Medication Error Reporting and Prevention. (2001). Recommendations to reduce medication errors associated
pp 1-7 Clinical Simulation in Nursing Volume Vol
Communication and Team Task Performance with verbal medication orders and prescriptions. The National Coordinating Council for Medication Error Reporting and Prevention.Retrieved from http://www.nccmerp.org/recommendations-reduce-medication-errors-associated-verbal-medication-orders-and-prescriptions. Perry, S. J., Wears, R. L., & Patterson, E. S. (2008). High-hanging fruit: improving transitions in health care. Performance and Tools. In Henriksen, K., Battles, J. B., Keyes, M. A., & Grady, M. L. (Eds.), Advances in Patient Safety: New Directions and Alternative Approaches (3. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK43656/. Rabøl, L. I., Andersen, M. L., Østergaard, D., Bjørn, B., Lilja, B., & Mogensen, T. (2011). Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. BMJ Quality & Safety, 20(3), 268-274. Randmaa, M., M artensson, G., Swenne, C. L., & Engstr€om, M. (2014). SBAR improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: a prospective intervention study. BMJ Open, 4(1), 1-8. https://doi.org/10. 1136/bmjopen-2013-004268. Reising, D. L., Carr, D. E., Gindling, S., Barnes, R., Garletts, D., & Ozdogan, Z. (2017). Team communication influence on procedure
7 performance: findings from interprofessional simulations with nursing and medical students. Nursing Education Perspectives, 38(5), 275276. https://doi.org/10.1097/01.NEP.0000000000000168. Rodgers, K. L. (2007). Using the SBAR communication technique to improve nurse-physician phone communication: a pilot study. AAACN Viewpoint, 29(2), 7-9. Shahid, S., & Thomas, S. (2018). Situation, Background, Assessment, Recommendation (SBAR) communication tool for handoff in health careea narrative review. Safety in Health, 4(1), 7. https://doi.org/10. 1186/s40886-018-0073-1. Siassakos, D., Fox, R., Crofts, J. F., Hunt, L. P., Winter, C., & Draycott, T. J. (2011). The management of a simulated emergency: better teamwork, better performance. Resuscitation, 82(2), 203-206. Singh, H., & Vij, M. S. (2010). Eight recommendations for policies for communicating abnormal test results. The Joint Commission Journal on Quality and Patient Safety, 36(5), 226. The Joint Commission. (2014). Sentinel Event Data e Root Causes by Event Type. Oakbrook Terrace. IL: The Joint Commission. Woodhall, L. J., Vertacnik, L., & McLaughlin, M. (2008). Implementation of the SBAR communication technique in a tertiary center. Journal of Emergency Nursing, 34(4), 314-317.
pp 1-7 Clinical Simulation in Nursing Volume Vol
-,
1-7
www.elsevier.com/locate/ecsn
Featured Article
Relationship between Interprofessional Communication and Team Task Performance Kyeong Ryong Lee, PhD, MDa, Eun Jung Kim, PhD, RN, ACNP-BCb,* a
Department of Emergency Medicine, School of Medicine, Konkuk University, Konkuk University Medical Center, Seoul 05029, Republic of Korea b School of Nursing, Research Institute of Nursing Science, Hallym University, Chuncheon, Gangwon-do 24252, Republic of Korea KEYWORDS simulation training; nursing education; communication; performance; healthcare; crew resource management; team communication; interprofessional communication
Abstract Background: Communication among health care professionals is essential for ensuring quality patient care and safety. Although communication appears to be crucial during critical events, this assumption has not been widely evaluated. This study aimed to determine whether Situation, Background, Assessment, Recommendation, and Read-Back (SBAR-R) communications are related to team task performance in a simulated emergency. Methods: A convenience sample of 49 teams with 194 nursing students participated. Trained observers rated team task performance and SBAR-R communication with a mock doctor in a teambased simulated emergency. Results: SBAR-R communication scores differed significantly according to overall team task performance. The initial team performance, including patient assessment, correlated positively with SBAR with the physician. The team task performance without error correlated positively with read-back communication. Conclusions: These findings suggested that the SBAR-R communications are important to consistent team performance in an emergency. Cite this article: Lee, K. R., & Kim, E. J. (2020, -). Relationship between interprofessional communication and team task performance. Clinical Simulation in Nursing, Vol(X), 1-7. https://doi.org/10.1016/ j.ecns.2020.02.002. Ó 2020 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Poor teamwork and communication among health care staff correlates with patient safety incidents and worse outcomes for patients (De Meester, Verspuy, Monsieurs, & Financial Disclosure Statement: This research did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors. * Corresponding author: [email protected] (E. J. Kim).
Van Bogaert, 2013). The Joint Commission identified failure in communication as one of the root causes for over 60% of reported sentinel events in 2013 (The Joint Commission, 2014). Common barriers to effective communication include inconsistency in team membership, varying communication styles, distractions, fatigue, lack of confidence, and misinterpretation of cues (Foronda, MacWilliams, & McArthur, 2016). Team training and standardization of verbal
1876-1399/$ - see front matter Ó 2020 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ecns.2020.02.002
Communication and Team Task Performance communication have been suggested as methods for improving communication among health caregivers and, thereby, patient safety (Rabøl et al., 2011). Situation, Background, Assessment, Recommendation and Read-back (SBAR-R) communication form the most frequently implemented framework in the health Key Points care setting (Kostiuk, Team performance 2015). This framework is correlated with SBAR one standardized method of and read-back commucommunication that is simnication in a simulated ple, concise, and fully releemergency. vant to the information Initial team task performedical teams need. By usmance was positively ing SBAR, the person starts associated with SBAR to communicate by noting communication. what is currently happening Team task performance and then moves on to the using verbal instruction context, provides a problem correlated with readassessment, and suggests a back communication. solution (Rodgers, 2007). The SBAR technique helps staff members anticipate the information needed by colleagues and encourages assessment skills. It allows one to promptly formulate the information with the right level of detail. The technique of read-back, the fundamental mechanism of closed-loop communication, involves a person receiving information and then repeating it back verbally to the sender (Boyd et al., 2014). Grbach, Vincent, and Struth (2008) adapted SBAR to I-SBAR-R format, adding an identification of the person calling and read back the orders to promote safe practice. Especially during a critical event, nurses and physicians often communicate over the telephone, which makes these communications error prone (Rabøl et al., 2011). Read-back lets the sender know the message has been received and provides an opportunity to correct any mistakes (Boyd et al., 2014). In health care, the potential risks of not using closed-loop communication are increasingly acknowledged, and read-back is considered to be an essential feature for error prevention and quality of care. The Joint Commission’s National Patient Safety Goal that addresses communication requires write-down and read-back of the critical value information on a timely basis (Singh & Vij, 2010). Communication among health care professionals is known to be particularly crucial in the context of critical events, but this assumption has not yet been widely evaluated and there is a lack of clear relationship between team performance and communication. Previous studies of health care professionals or students mainly have focused on improvement in communication skills, perceived interprofessional competence, and critical thinking skills as a result of SBAR training (Foronda et al., 2016; Kesten, 2011; Kostoff, Burkhardt, Winter, & Shrader, 2016), and few studies have investigated how SBAR-R communication contributes to patient-important outcomes (Shahid & Thomas, 2018).
2 Nurses are at the forefront of ensuring patient safety, but there is little reliable evidence on nurses’ performance in interprofessional teams (IOM, 2003). This study attempted to identify whether verbal critical incident report focused on SBAR-R communication tool is related to team task performance and can affect patient outcomes in a simulated emergency. We hypothesized that the association between team task performance and interprofessional communication would be more apparent in nursing students who lack clinical experience than in those already familiar with clinical practice. Similarly, we hypothesized that readback communication would be important for students unfamiliar with the situation and environment when acting on verbal instructions without introducing errors or missing important aspects. The results of this study may help identify specific nursing behaviors that are essential to ensuring patient safety. We conducted this study in nursing students.
Methods Study Design This study used a prospective observational study design to examine the relationships between nursing students’ team task performance and SBAR-R communication.
Setting and Participants This study was approved by the university’s institutional review board. The study was conducted at a university. From 2015 to 2016, senior-level nursing students enrolled in the integrated nursing practicum, a required nursing laboratory course before graduation, were eligible for inclusion, and all students agreed to participate (N ¼ 194). All of the students had no previous simulation experience and had the same experience completing all the clinical exercises required for graduation. The students were grouped into 49 teams by name in an alphabetical order for convenience to participate in the simulation training; 47 teams included four members with the other two teams having three members. The analysis unit was the observed behavior of the team.
Measures The fundamental measures of this study were team task performance and SBAR-R communication using checklists developed by researchers. Team task performance was categorized into two phases: the initial team performance before a call to a mock doctor and the team task performance after receiving verbal instructions from a doctor via phone. These were measured using a checklist of observable key actions based on practice guidelines derived from the literature. The initial team performance phase refers to the stage in which team members work together at the beginning of an pp 1-7 Clinical Simulation in Nursing Volume Vol
Communication and Team Task Performance encountered emergency. The expected behaviors by the team were as follows: obtaining a brief, targeted history; checking vital signs; performing a targeted physical examination; cardiac monitoring; checking oxygen saturation and administering oxygen, if needed; and elevating the head of the bed. The phase related to the team task performance after the call to doctor assessed the key clinical actions in response to the mock doctor’s verbal order and was as follows: administering and maintaining oxygen through a nasal prong; establishing an intravenous line; administering aspirin, nitroglycerin, morphine, and heparin; obtaining venous blood for laboratory tests; and arranging 12-lead electrocardiography (ECG). A dichotomous scoring scale of 0 ¼ not done and 1 ¼ done was used to assess each item. The possible scores for this checklist ranged from 0 to 12 for the initial team performance and 0 to 8 for the actions after the call to the mock doctor. SBAR-R communication behaviors were assessed using a checklist. We assessed the participants’ ability to apply the SBAR-R technique when reporting to the mock doctor and receiving telephone instructions in the simulated emergency scenario. These communication behaviors were categorized into two phases: SBAR reporting to a mock doctor after the initial assessment and read-back after receiving the order from the mock doctor. The checklist included 29 key communication behaviors. The scenario included four items: patient’s name, sex, age, and reason for the phone call (major problem). The background included three items to obtain a previous diagnosis or past history of the patient. The assessment used nine items to be reported, including vital signs. The recommendation comprised two items including one general suggestion about problem solving and one concrete suggestion. The verbal read-back comprised 11 items to be evaluated as closed communication while clearly the identifying the doctor’s instructions. A dichotomous scoring scale of 0 ¼ not done and 1 ¼ done was used. The possible scores ranged from 0 to 18 points for SBAR and 0 to 11 points for read-back communication. We also recorded the time of the first call and the number of calls to the physician. The contents of the tools had been validated by three experts with simulation training experience.
Procedures Medical emergencies can have devastating consequences. Chest pain can be a sign of an impending catastrophic medical condition if a patient collapses, and its effective management requires the medical team to perform several tasks simultaneously. These tasks include information gathering and immediate life support including administration of oxygen, morphine, aspirin, and nitroglycerin, applying 12-lead ECG, establishing an intravenous line, and sampling of venous blood. Before the simulated emergency scenario, students received a mini-lecture about SBAR-R communication and
3 determined the team leader. Each of the 49 teams was presented with a scenario involving an acute myocardial infarction using a high-fidelity patient stimulator. According to the expected sequence of clinical actions, the team should take a series of four phase actions. In the scenario, the patient presented to the emergency department because of chest pain. The expectation for the first phase was immediate assessment and initial management of the patient by the team. Each team’s initial task performance before the call to the mock doctor was assessed. In the second phase, the team leader then reported the patient’s condition to the mock doctor over the telephone, and communication behaviors were assessed using the SBAR checklist. In the third phase, the team leader received a verbal order about the key actions from the doctor over the telephone. The read-back checklist was used to evaluate the leader’s closed-loop communication behaviors. A doctor was immediately available by telephone, if requested. A faculty member played the role of the doctor receiving the SBAR report and provided orders based on a premade order set. In the fourth phase, the team’s performance of the expected actions in accordance with the physician’s order was assessed using the checklist. All simulation exercises were videotaped for assessment. Two trained assessors independently reviewed five of 49 videotaped simulation scenarios. Cohen’s kappa, a measure of interrater reliability, ranged from 0.78 to 0.87 for team task performance and from 0.67 to 0.91 for SBAR-R communication, and these values were judged to be acceptable. The remaining cases were measured by one assessor.
Data Analysis We used descriptive statistics to assess team task performance and SBAR-R communication. The mean team task performance score was 13.80 (SD 2.59) and the median was 14. We categorized the individual teams into better or worse teams with respect to their team task performance. Scores 14 of 19 were categorized as better (n ¼ 26) and those <14 were categorized as worse (n ¼ 23). The Mann-Whitney nonparametric U test was used to compare the SBAR-R communication between the better and worse teams. Because of the ordinal nature of the scores, the nonparametric Kendall rank correlation was used to examine the correlations between team task performance and SBAR-R communication. The data were analyzed using IBM SPSS Statistics (IBM Corp., Armonk, NY, USA).
Results Team Task Performance Eleven key actions were assessed to examine the initial team performance. Most teams performed brief and targeted history taking (94%), and about half of the teams pp 1-7 Clinical Simulation in Nursing Volume Vol
Communication and Team Task Performance Table 1
4
Descriptive Measures of Team Task Performance and SBAR-R Communication (n ¼ 49)
Category
Behavior Markers
% of Frequency
Obtaining present history Obtaining past history or family history Checking vital signs: blood pressure Checking vital signs: pulse Checking vital signs: respiration Checking vital signs: body temperature Performing targeted physical examination Applying the cardiac monitor Checking oxygen saturation Administering oxygen Elevating head of bed
94 55 100 47 37 78 41 88 90 18 57
Administering and maintaining oxygen Establishing the intravenous line Administering aspirin by chewing Administering NTG by sublingual Administering morphine by IV Administering heparin by IV Obtaining venous blood for laboratory test Arranging (requesting) the 12-lead ECG
92 78 88 92 90 29 49 47 (% of scores) 62 72 56 63 30 66
Initial performance
Key action after call to a physician
SBAR-R communication SBAR-R communication Situation Background Assessment Recommendation Read-back
Note. SBAR-R ¼ situation, background, assessment, recommendation and read-back; NTG ¼ nitroglycerin; IV ¼ intravenous; ECG ¼ electrocardiogram.
performed past or family history taking (55%). For vital signs, the teams checked the patient’s blood pressure (100%), pulse (47%), respiratory rate (37%), body temperature (78%), and oxygen saturation (90%). Most teams applied the cardiac monitor (88%) and half elevated the head of the bed (57%). However, only 18% of the teams initially administered oxygen to the patients. Eight key actions were assessed to examine team performance after receiving verbal instruction from the mock doctor. Most teams administered oxygen (92%), aspirin (88%), sublingual nitroglycerin (92%), and morphine (90%), and established an intravenous line (78%). Less than one-third (29%) of the teams administered
heparin to the patient. About half of the teams obtained a blood sample for laboratory tests (49%) and arranged for the use of a 12-lead ECG (47%). Table 1 shows the relative distribution of scores.
SBAR-R Communication Behaviors The communication behaviors when reporting to and receiving instructions from the physician are shown in Table 1. SBAR-R communication behaviors were on average 62% of possible frequencies. The SBAR-R were 72%, 56%, 62%, 30%, 66% of possible frequencies, respectively.
Table 2 Comparison of SBAR-R Communication Between Better (14 of 19) and Worse (<14 of 19) Teams in Team Task Performance (n ¼ 49) Variables
Better Teams Median (IQR) (n ¼ 26)
Worse Teams Median (IQR) (n ¼ 23)
Mann-Whitney U test
Z
p
SBAR-R Elapsed time to first call in seconds Frequency of call
20 (16-22) 179 (156.5-179) 2 (2-3)
17 (14-19) 125 (103-174) 2 (2-3)
167.50 133.00 240.50
-2.645 -3.327 -1.277
.008 .001 .202
Note. SBAR-R ¼ situation, background, assessment, recommendation and read-back.
pp 1-7 Clinical Simulation in Nursing Volume Vol
Communication and Team Task Performance Table 3
5
Correlation Coefficients Among Team Task Performance and SBAR-R Communication (n ¼ 49) Initial Performance
SBAR
Read-Back
Variables
taub (p)
taub (p)
taub (p)
SBAR Read-back Performance after receiving verbal instruction
0.313 (0.004) 0.153 (0.164) 0.175 (0.129)
d 0.076 (0.486) 0.072 (0.529)
d 0.285 (0.014)
Note. SBAR-R ¼ situation, background, assessment, recommendation and read-back.
Comparison of SBAR-R Communication Between Better and Worse Teams According to the Task Performance Scores Table 2 shows the difference in SBAR-R communication between better and worse teams according to the task performance scores. The SBAR-R scores differed significantly between better and worse teams (U ¼ 167.5, p ¼ .008). There was a significant difference in elapsed time to first call (U ¼ 133.0, p ¼ .001), but no difference in the numbers of calls (U ¼ 240.5, p ¼ .202) between better and worse teams.
Correlations Between Team Task Performance and SBAR-R Communication Table 3 shows the correlations between team task performance and SBAR-R communication. The initial team performance score correlated positively with SBAR scores (taub ¼ 0.313, p ¼ .004). The score for team performance after the call to the physician was correlated positively with the read-back score (taub ¼ 0.285, p ¼ .014). No significant correlations were observed between the initial and postcall team performances (taub ¼ 0.175, p ¼ .129) or between the SBAR and read-back communication (taub ¼ 0.076, p ¼ .486).
Discussion The strength of our study is the use of observable assessment tools, which contributed to the reliability of the results. Observation of behaviors or events is considered to be more accurate and reliable than self-assessment, particularly for human factor skills and behaviors (Siassakos et al., 2011). The main finding of our study was that SBAR-R communication was associated with the overall team task performance of nursing students with limited clinical experience. SBAR-R is an important technique for information delivery (Chapelain, Morineau, & Gautier, 2015) and preventing or reducing the risk of errors (Andreoli et al., 2010; De Meester et al., 2013; Randmaa, M artensson, Swenne, & Engstr€ om, 2014). In addition to the aforementioned findings, this study showed that the
better teams had a higher interprofessional communication score than the worse team, which suggests that successful team performance is related to interprofessional communication during a critical event. This result is consistent with a study by Reising et al. (2017) who reported a positive correlation between interprofessional team communication and procedure accuracy in the simulation. Also, Chapelain et al. (2015) showed that the number of spontaneous information exchanges between pairs of participants correlated positively with overall performance and with actions performed at the right moment. Before the call to the mock doctor, SBAR communication correlated significantly with initial team task performance. This finding suggests that the teams that were successful in the first phase of recognizing the situation and gathering pertinent information performed the SBAR report better than teams that did not. We also assessed the elapsed time to the first call to the doctor as an indicator of rapid situational awareness and astute decision making. The teams that performed well had a shorter time to the first call to the doctor than the teams that did not. This is consistent with the study of De Meester et al. (2013), where SBAR communication was related to the ability to recognize the situation and collect information about the patient. The SBAR technique is a simple technique, but it requires clinical reasoning beyond communication. To formulate information at an appropriate level, situation awareness, ability to make decisions, and assessment skills are required. Conversely, the SBAR technique helps health care personnel to anticipate the information that their colleagues need and to gather and formulate appropriate levels of information. The second phase of team task performance, successful performance after verbal instruction, was related more to verbal read-back than to the initial team task performance. This result suggests that, particularly for novices with little clinical experience, the ability to complete crucial clinical actions in a timely way without missing information or making a mistake is strongly linked to the read-back for clarifying verbal orders. This is in accordance with Boyd et al. (2014), who noted that knowledge of transferred information during a simulated crisis was significantly improved if the receiver repeated back the information. Using the read-back technique may increase the information transfer between team members, which increases the pp 1-7 Clinical Simulation in Nursing Volume Vol
Communication and Team Task Performance chances of successful team performance without mistakes and should therefore improve patient safety. The use of read-back to ensure that communications are both sent and received is an important factor in reducing or preventing medical errors (National Coordinating Council for Medication Error Reporting and Prevention, 2001), but it is not being implemented continuously in health care settings (Miller, Riley, & Davis, 2009). The skill and timing of using read-back should be part of training and should be encouraged as part of critical team behaviors. In our study, the SBAR-R performance rate was 62%, which is higher than that reported by other studies. Chapelain et al. (2015) observed that the performance score of SBAR communication by nursing students was 35.4% in a simulated emergency. Miller et al. (2009) found that SBAR and read-back skills of nurses were not consistently observed during critical events, in which key behavioral markers of closed-loop communication occurred <15% of the time. The reason for the relatively high performance rate of SBAR-R in our study is presumed to be that students received SBAR-R training before participating in the scenario. In particular, because read-back is the ability to read information again for verification but not to require the synthesis of knowledge (Perry, Wears, & Patterson, 2008), read-back skill may be easily improved by training. The recommendation performance rate was 30%, which was the lowest of SBAR-R elements in our study. Nurses must be able to use the ‘‘recommendation’’ to communicate exactly what they need from the physician (Woodhall et al., 2008). However, even if they did not know how to resolve the situation, the technique of recommendation may help empower training nurses to formulate a recommendation given to the doctor (Woodhall et al., 2008). Based on the results of this study, further research is proposed. First, empirical studies are needed to verify the effectiveness of SBAR-R training on performance level or error in various clinical conditions. Second, because SBARR communication may help health care staff learn how to judge situations and collect critical information, we suggest that empirical studies are needed to determine whether SBAR-R training can improve reasoning skills.
Limitations First, this study was conducted in a university, so the results cannot be generalized to the wider health care setting. Second, we measured only those SBAR-R communication behaviors required in the scenario, and our findings are limited by not being able to measure the quality of SBARR, such as the systematic nature of the delivered information or occurrences of misreported information. Similarly, we observed only the expected task performance of each team in the scenario and did not directly assess any errors. Third, although the data were collected for 2 years, the
6 number of teams was small for detailed analysis. Nevertheless, our results demonstrated clear relationship between SBAR-R communication and team task performance.
Conclusions Our study provides evidence supporting the use of SBAR-R communication by health care professionals during a clinical crisis. The result of our study showed that communication among nursing students was directly related to successful team performance. Although SBAR communication correlated with initial team task performance, verbal read-back was crucial for successful team task performance without missing information or making mistakes. These findings suggest that the SBAR-R communication is an important factor for ensuring consistent team performance. This is a crucial skill for nursing students to learn to ensure effective communication and patient safety during a clinical crisis.
References Andreoli, A., Fancott, C., Velji, K., Baker, G. R., Solway, S., Aimone, E., & Tardif, G. (2010). Using SBAR to communicate falls risk and management in inter-professional rehabilitation teams. Healthcare Quarterly, 13(13), 94-101. Boyd, M., Cumin, D., Lombard, B., Torrie, J., Civil, N., & Weller, J. (2014). Read-back improves information transfer in simulated clinical crises. BMJ Quality & Safety, 23(12), 989-993. https://doi.org/10. 1136/bmjqs-2014-003096. Chapelain, P., Morineau, T., & Gautier, C. (2015). Effects of communication on the performance of nursing students during the simulation of an emergency situation. Journal of Advanced Nursing, 71(11), 2650-2660. https://doi.org/10.1111/jan.12733. De Meester, K., Verspuy, M., Monsieurs, K. G., & Van Bogaert, P. (2013). SBAR improves nurseephysician communication and reduces unexpected death: a pre and post intervention study. Resuscitation, 84(9), 1192-1196. https://doi.org/10.1016/j.resuscitation.2013.03.016. Foronda, C., MacWilliams, B., & McArthur, E. (2016). Interprofessional communication in healthcare: an integrative review. Nurse Education in Practice, 19, 36-40. https://doi.org/10.1016/j.nepr.2016.04.005. Grbach, W., Vincent, L., & Struth, D. (2008). Reformulating SBAR to ‘‘ISBAR-R. Retrieved from https://qsen.org/reformulating-sbar-to-i-sbar-r/. Institute of Medicine. (2003). The Future of the Public Health in the 21st Century. Washington, DC: National Academies Press. Kesten, K. S. (2011). Role-play using SBAR technique to improve observed communication skills in senior nursing students. Journal of Nursing Education, 50(2), 79-87. Kostiuk, S. (2015). Can learning the ISBARR framework help to address nursing students’ perceived anxiety and confidence levels associated with handover reports? Journal of Nursing Education, 54(10), 583-587. Kostoff, M., Burkhardt, C., Winter, A., & Shrader, S. (2016). An interprofessional simulation using the SBAR communication tool. American Journal of Pharmaceutical Education, 80(9), 157. Miller, K., Riley, W., & Davis, S. (2009). Identifying key nursing and team behaviours to achieve high reliability. Journal of Nursing Management, 17(2), 247-255. https://doi.org/10.1111/j.1365-2834.2009.00978.x. National Coordinating Council for Medication Error Reporting and Prevention. (2001). Recommendations to reduce medication errors associated
pp 1-7 Clinical Simulation in Nursing Volume Vol
Communication and Team Task Performance with verbal medication orders and prescriptions. The National Coordinating Council for Medication Error Reporting and Prevention.Retrieved from http://www.nccmerp.org/recommendations-reduce-medication-errors-associated-verbal-medication-orders-and-prescriptions. Perry, S. J., Wears, R. L., & Patterson, E. S. (2008). High-hanging fruit: improving transitions in health care. Performance and Tools. In Henriksen, K., Battles, J. B., Keyes, M. A., & Grady, M. L. (Eds.), Advances in Patient Safety: New Directions and Alternative Approaches (3. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK43656/. Rabøl, L. I., Andersen, M. L., Østergaard, D., Bjørn, B., Lilja, B., & Mogensen, T. (2011). Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. BMJ Quality & Safety, 20(3), 268-274. Randmaa, M., M artensson, G., Swenne, C. L., & Engstr€om, M. (2014). SBAR improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: a prospective intervention study. BMJ Open, 4(1), 1-8. https://doi.org/10. 1136/bmjopen-2013-004268. Reising, D. L., Carr, D. E., Gindling, S., Barnes, R., Garletts, D., & Ozdogan, Z. (2017). Team communication influence on procedure
7 performance: findings from interprofessional simulations with nursing and medical students. Nursing Education Perspectives, 38(5), 275276. https://doi.org/10.1097/01.NEP.0000000000000168. Rodgers, K. L. (2007). Using the SBAR communication technique to improve nurse-physician phone communication: a pilot study. AAACN Viewpoint, 29(2), 7-9. Shahid, S., & Thomas, S. (2018). Situation, Background, Assessment, Recommendation (SBAR) communication tool for handoff in health careea narrative review. Safety in Health, 4(1), 7. https://doi.org/10. 1186/s40886-018-0073-1. Siassakos, D., Fox, R., Crofts, J. F., Hunt, L. P., Winter, C., & Draycott, T. J. (2011). The management of a simulated emergency: better teamwork, better performance. Resuscitation, 82(2), 203-206. Singh, H., & Vij, M. S. (2010). Eight recommendations for policies for communicating abnormal test results. The Joint Commission Journal on Quality and Patient Safety, 36(5), 226. The Joint Commission. (2014). Sentinel Event Data e Root Causes by Event Type. Oakbrook Terrace. IL: The Joint Commission. Woodhall, L. J., Vertacnik, L., & McLaughlin, M. (2008). Implementation of the SBAR communication technique in a tertiary center. Journal of Emergency Nursing, 34(4), 314-317.
pp 1-7 Clinical Simulation in Nursing Volume Vol