The use of SBAR as a structured communication tool in the pediatric non-acute care setting: bridge or barrier for interprofessional collaboration?

ABSTRACT

SBAR (Situation, Background, Assessment and Recommendation) is a structured method developed for communicating critical information that requires immediate action. In 2016 the SBAR tool was introduced at the Amalia Children’s Hospital in the Netherlands to improve communication between healthcare workers. Despite formal training and the introduction of aids to facilitate implementation, observed adherence to the tool was low. A qualitative study was undertaken to study the use of SBAR by pediatric residents and nurses in the non-acute clinical care setting of an academic children’s hospital. Semi-structured focus group sessions were conducted and qualitatively analyzed using a constructed coding template to search for facilitators and barriers in the use of SBAR by different professionals. We found professionals’ use of SBAR was influenced by departmental, cultural, and individual factors. Important themes for effective implementation and use of SBAR in an interprofessional setting, like situation dependency, learning climate and professional identity had not been addressed during the initial implementation. To facilitate SBAR’s use it is important to identify professionals’ needs to use the tool effectively, to take into account how tasks and responsibilities are perceived by different professions, and to stimulate interprofessional feedback and role modeling.

KEYWORDS:

• Interprofessional learning
• communication
• tool implementation

Introduction

Structured communication tools have been widely implemented in hospitals to streamline communication between healthcare workers. These tools have been shown to increase patient safety, reduce unexpected deaths and decrease incidents due to communication errors (De Meester et al., 2013; Müller et al., 2018; Randmaa et al., 2014). Moreover, these structured tools may improve the perceptions of communication and bridge the gap in communication styles between professions (Achrekar et al., 2016; Randmaa et al., 2014; Raymond & Harrison, 2014). If team members participate more fully in the decision-making process (e.g., through interaction or information sharing), they may invest more in the decisions taken, give their support for improvement in teamwork and feel able to suggest innovations (West et al., 1990). Therefore, interaction and effective communication between team members, are regarded as essentials to enhance shared accountability, team climate and quality of care (Agreli et al., 2017; Reeves et al., 2013). Despite the fact that effective communication is increasingly recognized as an important competency and professionals are subjected to a variety of professional development programs and aids to enhance communication skills, the appliance of these skills in clinical practice is still low (Curtis et al., 2013; Joffe et al., 2013).

The SBAR (Situation, Background, Assessment and Recommendation) tool is a communication tool that effectively structures the exchange of patient information between healthcare professionals. SBAR has been adapted from other disciplines, like aviation and the military, as a method for clear communication (Pope et al., 2008; Thomas et al., 2009). SBAR is based on a statement of the situation, background, assessment, and recommendations related to a critical issue. By following this script, the reason for contact, relevant medical history of the patient and the current situation, the vital parameters, and the callers plan of action are efficiently communicated. The structure of the tool ensures that the caller can pass on all information that the other person needs to know, to answer a question or devise a plan essential for patient care. The SBAR tool can be used in different settings to effectively communicate patient information, be it in person, per telephone, on paper or in the digital patient file. As a result, critical patient information can be communicated effectively.

Background

SBAR has been proven to be effective in improving patient safety in the acute care settings, like for example, emergency and intensive care departments (Marshall et al., 2019; De Meester et al., 2013; Randmaa et al., 2014; Raymond & Harrison, 2014). However, outside the acute care setting, most research and suggested recommendations on structured communication tools are based on expert opinions or users’ satisfaction with the tool, using pre,- and postquestionnaires and have not yet been shown to improve communication effectiveness or patient safety (Horwitz et al., 2008; Renz et al., 2013; Riesenberg et al., 2009). Furthermore, the available knowledge on the effective transfer of patient information between professionals is based predominantly on studies within the curriculum of medical- and nursing students (Guimond et al., 2019; Uhm et al., 2019) and cannot simply be translated to “the workplace,” where healthcare professionals have already formed their own routines in communicating with other team members.

In the Amalia Children’s Hospital, the use of structured communication by SBAR was transferred from the intensive care setting into the non-acute care setting of the pediatric wards in 2016. During the introduction period both physicians and nurses were made aware of SBAR and its use by posters and by handing out SBAR instruction cards. Also specific aids, such as ‘SBAR Smart Phrases’(Clements, 2018) for standardized documentation in the electronic patient file and note blocks, with a pre-structured SBAR template, were made available. Formal education took place by means of instruction, scenarios, and role play during interprofessional training during which medical and nursing staff practiced the use of SBAR in a simulated environment. Despite the availability of these aids and the use of SBAR in medical team simulation, adherence to the SBAR tool was poor according to observations done by the Joint Commission International (JCI; Mehta et al., 2017) during a patient safety audit in June 2017.

As a result, patient care management organized a theme week to increase awareness of the SBAR tool, and to educate nurses and physicians further in the use of SBAR in different settings (in person, by telephone or written in the patient file). In May 2018, we audited the use of SBAR by nurses and residents during shifts at the pediatric care wards and found that 66% of the telephone calls regarding patient information were done with the use of SBAR, with no significant differences between nurses and residents overall (data not shown). This is in line with the findings of Compton et al. (2012), who reported the use of SBAR by 58.3% off nurses for critical communication after finishing a similar educational program on SBAR.

Knowing that formal preparations, creating awareness and introducing prompting aids do not guarantee the use of SBAR in clinical practice, led to the research question: What factors should be addressed to implement SBAR effectively outside the intensive care setting? To answer this question, we used a qualitative approach to study what helps or hinders the use of SBAR in the pediatric non-acute care department, along with ensuring a better communication standard among healthcare professionals with different backgrounds.

Methods

Setting

The Amalia Children’s Hospital is a Dutch tertiary referral hospital with a pediatric intensive care department, an emergency care department, and three pediatric clinical care wards (72 beds) where patients can be hospitalized for both short and long-term stay, in which care is offered by a broad spectrum of pediatric physician specialists, residents, and nurses. In 2016, SBAR was introduced by the patient care management team to help ensure effective transfer of patient information between healthcare professionals at the pediatric non-acute care wards. Also, nurses were appointed to special areas of attention (e.g., communication) to function as ambassadors in the workplace. This study was focused on the use of SBAR for the communication of patient information by nurses and residents working in the pediatric non-acute care department. Given the setting of a teaching hospital, we included residents and nurses in the focus groups, because these professionals directly communicate patient information during routine care and shifts at the pediatric wards.

Data collection

Focus group meetings were held until saturation was achieved. Focus groups were conducted between September 2018 and May 2019. To reduce risk introduced by perceived or real hierarchy across professional disciplines, focus groups were divided by profession (nurses and pediatric residents). An independent interviewer (educationalist) with extensive interview skills and no professional relation to the participants, conducted all focus groups after signing a confidentiality agreement. Focus group questions were open-ended and designed to further explore influencing factors for the use of SBAR. The focus groups consisted of 5 to 12 participants per group and lasted between 55 and 65 minutes. The collection of data ended when saturation of themes was reached after five interviews.

Data analysis

Focus group sessions were audio recorded and transcribed verbatim. All transcripts were anonymized and read repeatedly by the first author to ensure accuracy and to develop familiarity. Qualitative Analysis Software Atlas.ti (GmbH, Berlin, Germany), was used to organize the data. Data collection and analysis proceeded simultaneously, in an iterative fashion. Transcripts of the focus groups were analyzed following the template analysis approach as developed by King et al. (2019), entailing a thematical analysis using a constructed coding template. The template was based on the research question and the theoretical concepts of organizational implementation management (Cosby, 2006; Eid & Quinn, 2017). Four broad code categories formed the code manual: knowledge, attitude, self-efficacy, and organizational infrastructure (see Appendix 1). Two researchers, one pediatrician (EC) and one nurse (MH), independently analyzed all transcripts and quotations were classified according to the corresponding themes within the four categories. Discrepancies between researchers in the outcome of this coding process were discussed and resolved within the research team, consisting of two pediatricians, one nurse and two educationalists (EC, RE, MH, CF, and JD). Secondly, summarizing conditions were sought to describe influencing factors in the use of SBAR. During our analysis new factors emerged. According to the AMEE Guide for focus groups in medical education research (Stalmeijer et al., 2014), the guide with probing questions was adapted for the following round of focus groups to deepen our understanding of these factors and gather further information not captured during the first focus groups (see Appendix 2). After completing the interviews and analyzing the data, two researches (EC and RE) facilitated the analytic process by constructing relationship diagrams and affinity maps. Critical and reflective feedback from the whole research team on the emerging model was used to improve the rigor of the data collection.

Ethical considerations

Individually informed consent was obtained from each participant prior to each focus group. Participants received an information sheet explaining the purpose of the focus group and stating that the information they shared would be treated confidentially. The Central Commission for Human Rights Research (CCMO) Region Arnhem-Nijmegen granted ethical approval (File number 5961).

Results

In total, five focus groups meetings were organized. The groups included either pediatric nurses or residents. The first round consisted of two group sessions with one group of 8 residents and one group of 8 nurses. The second round consisted of three group sessions: one group of 12 residents and two groups of 5 and 6 nurses. After two rounds of group meetings saturation of data was achieved. Analysis revealed that there were four themes that were perceived to influence the use of SBAR in the context of non-acute care: Strategic, Contextual, Cultural, and Individual Factors. Components included in these factors and illustrative quotations are presented in Table 1. A conceptual diagram representing a model for implementation issues of SBAR within the context of the non-acute care is presented in Figure 1. The themes that emerged from the focus group interviews and how they were perceived to affect the use of SBAR by nurses and residents are explained below.

Table 1. Themes perceived to affect the use of SBAR in pediatric non-acute care

Components	Example Quotations
Hospital board of directors Patient care management   Communication ambassadors   Formal educators	“Around the time of the JCI, everybody was talking about SBAR and how we should communicate. Now I do not hear so much about this. I’m not sure if we are still supposed to use it [SBAR] all the time, or only during acute events?“(resident) “Oh, we have to learn a new acronym almost every month. We have SBAR, ABC, PWES. I just can’t keep up to speed with it …, all these numbers and letters I have to put down in the patient file. They [patient care management] come up with something new constantly and we have to keep track of these changes every time.”(nurse) When asked about role models in communication: “I think that some of the nurses are appointed to topic of communication, as a special area of attention. I think they know all about the best way to communicate how it should work, but I’m actually not sure of who they are at this moment.”(nurse) “I learned all about the importance of structured communication at [nursing] school. Our group mentor was very good in convincing us to use SBAR and how it helps to communicate clearly. So, during this internship I want to use it regardless of what others say or do.”(nursing student) “During our morning handovers we’re supposed to use SBAR for structure and clarity […]. However, I don’t think supervisors use SBAR themselves when they transfer patient information to us.”(resident)
Tool traits           Situational traits       Supportive preconditions	“And then you should put down assessment of vitals, but where do you put the regular physical examination and your differential diagnosis. They [supervisors] need to hear my considerations to be able to come to a conclusion and agree with my plan.”(resident) When asked about the meaning of the S in SBAR: Nurse 1: “Yes, the difference is whether you are reporting: in that case I just write down the reason for admission, but when you really need someone, then it’s the current situation.” Nurse 2: “Yes, the reason for calling … But some people get confused about this.”(nurse) “And when it becomes chaotic and panicky [after an acute problem arise], that’s when you need SBAR to keep overview and stay calm, but when I’m just discussing a patient problem with the doctor it feels way too formal to go through each point individual.”(nurse) “If I’m forced to stick to SBAR in a non-acute setting, not telling them [supervisors] my full assessment [of the patient] or my thoughts on the matter. Then, how can I express my clinical reasoning. I really need more words to show them what I know and think about the patient’s problem.”(resident) “We do not have many practice opportunities in our daily routines … We did try to use SBAR in handovers between nurses and team meetings, but a lot of felt it [SBAR] was not suitable for communicating concerns or your gut feeling about the patient.”(nurse) “I started working here 5 months ago and I didn’t get any instructions or what so ever about SBAR, learned that I should have looked this up in our instruction manual, but no one explained to me in what kind of situations SBAR should or shouldn’t be applied.”(resident)
Interprofessional interaction       Climate for learning               Role expectations	“I think if you work here it feels like you have to be easy going and friendly all the time. That if you’re always serious and putting people in their place, you will pay the price …. Well you know what I mean; you should stop being so strict and serious, all the time.” (nurse) “We really feel part of the Children’s hospital you know, and I do feel that we’re used to communicate in a certain way. It’s different with professionals outside of child care. We are more holistic and socially engaged …, although we do need more words, I guess that’s not really what you’re supposed to do when using SBAR.”(resident) When asked if they have ever received positive feedback on the use of SBAR: “No, I haven’t, but we need to give each other more compliments. It helps to change our work environment.” (nurse) “Sometimes I will overhear a colleague speaking to an attending and I think, like really are you serious? I don’t even know what you are talking about ….They usually find out for themselves, because they’ll get like a hundred questions in return.” (nurse) “I mostly look at my fellow residents for role models in effective communication. Some of them are really good in structuring a patient handover.”(resident) “When I notice effective communication, that’s mostly when I watch residents in acute situations … How the communicate and streamline the team.”(nurse) “I remember calling about a very sick patient on the ward, telling the doctor that the patient is unstable and needs immediate attention, probably because of an anaphylactic reaction … Then I was told that I spoke out of turn and should have completed all measurement before calling a doctor.”(nurse) “During shifts I will get calls with only bits of information they [nurses] want to pass on to me at the end of their shift. No question, no plan of action. What am I supposed to do with that? Then, I just pause en keep silent, hoping they will rephrase their story and ask me what they actually want.” (resident)
Motivation to use     Feeling competent         Perceived professional identity	“The use of SBAR seems like it costs a lot of time […], but actually thirty seconds […] and the team is streamlined, going forward.” (nurse) “At the PICU [pediatric intensive care unit] every transfer is structured using SBAR, even the morning handovers and those are complex patients too. I do not see a reason not to use SBAR in every day care.”(resident) “It [the use of SBAR] is not yet very automatic. An acute situation doesn’t happen every shift. At least not with me […] and then I’m already bumbling again when I pick up the phone to call for help, just thinking out loud in random order. So, it’s not quite there yet.”(nurse) “I called [a supervisor] and said: “I would like to discuss a patient who is lying in the emergency room because I would like to send him home.” I couldn’t imagine a better R, and then the supervisor blamed me for being too cocky with the handover. So, then I’m not sure anymore, what do actually want from me?” (resident) “There’s a difference between doctors and nurses ….We’re trained to have opinions about everything and come up with a solution. If you ask a nurse: Do you think this child is really sick? They often don’t know how to respond.” (resident) “I do not think we should use SBAR between nurses, it’s just not how nurses are used to talk to each other. We like to be more easy going and elaborate, not talking as formal as doctors do.”(nurse)

Figure 1. Conceptual diagram representing the factors which influence the use of SBAR by health care professionals

Strategic factors

Participants believed that at the time of the introduction of SBAR there was much focus on effective communication, because both patient care management and educators emphasized the use of SBAR. Patient care management organized a theme week to create awareness for structured communication with SBAR, including oral instruction sessions, and the introduction of aids such as pre-structured note blocks, smart phrases and posters). Shortly after the implementation phase, attention on the use of SBAR decreased, and other topics appeared to be prioritized by the management team. When nurses were asked who they perceived to be role models on communication within their own profession, they stated that some colleagues in the department were appointed as nurse ambassadors. However, nurses were not able to identify or name them. It was furthermore noticed that, although SBAR and the importance of clear communication is being taught in education of physicians, educators and supervisors in the workplace were less consistent in advocating the use of SBAR. On the other hand, nurses indicated that the setting of a teaching hospital can also be viewed as a facilitator for the use of SBAR, because the use of SBAR helped them to set a good example as a communicator and interdisciplinary collaborator to nursing students. Both nurses and residents mentioned a lack of proper introduction of the SBAR tool to new coworkers, especially related to the different settings in which SBAR could be used to convey patient information (e.g., acute versus non-acute situations and orally versus written patient information).

Contextual factors

Took traits

The rigidity of the SBAR script and formal way of formulating the patient information made it less feasible for communication during daily routines. In addition, the elements of the acronym SBAR were used differently depending on the context. For example, nurses indicated that for the element Situation, they usually write down the reason for admittance in the electronic patient file, whereas they are expected to state the reason for calling when they contact a physician about a patient during a shift. This led to confusion about how to use SBAR correctly. Both nurses and residents stated that SBAR does not leave enough room for their own considerations. Residents, for instance, want to share their differential diagnoses and clinical reasoning thoughts with their supervisor, before coming up with their plan or recommendations. Both nurses and residents believed that SBAR is very useful to structure and prioritize information for the other professional, to be able to create an overview of the situation. However, whereas residents stated that SBAR was also useful to communicate effectively with other physicians to create a shared perception of the situation, nurses expressed their doubts on the applicability of the tool for nurse to nurse communication, because of its rigid and stand-offish characteristics.

Situational dependency

SBAR was perceived as useful and effective during acute events because it helps to structure essential patient information, creates an overview of the situation and helps to communicate a plan of action. However, participants stated that during routine clinical care, SBAR is less suitable because the rigid structure does not allow for elaborations for educational purposes or social interaction. Also, during day-time care, as opposed to during shifts, health care professionals are more familiarized with the situation and background information of the patients on the ward, making them feel as if they were repeating themselves by using SBAR. Furthermore, nurses replied, when asked about the use of SBAR with team members other than physicians, that they do not think the SBAR tool to be useful for the transfer of patient information to non-physician healthcare professionals, including their nursing colleagues, physiotherapists, and physician assistants, as they usually have read the patient file, before attending to the patient during routine care.

Supportive preconditions

For nurses, the SBAR script is integrated into the electronic patient file with SBAR Smart Phrases (Clements, 2018), therefore they use it daily. However, SBAR is used differently in the written context than verbally, and nurses perceive that physicians need other information from them in the acute (spoken) situation than what is written down in the patient file. Nurses stated that during a rare and unexpected acute event it can be very challenging to extract the information that is needed by the physician from the patient file and convey this in the correct order. Other than this, nurses have limited practice opportunities for SBAR, because of the low prevalence of acute situations. The frequency of interprofessional team simulation, approximately once a year, is low and it was also noted that SBAR is not used during team meetings or patient handovers on a structural basis. Aids to create awareness of SBAR, such as note blocks, posters and a SBAR theme week, were initially regarded upon as stimulating, but lost their effect after a while. Moreover, some nurses indicated that they observed that more experienced nurses did not to use these aids as they had already formed their own routines.

Cultural factors

Interprofessional interaction

Participants perceived the general communications style with respect to colleagues as friendly and cooperative. On the other hand, the overall friendly communication style inhibited nurses from speaking up when SBAR was not being used if needed, because they were afraid this feedback would not be appreciated by their colleagues and could negatively affect their collaboration and team climate.

Climate for workplace learning

Participants indicated the importance of feedback to learn and improve using SBAR, however, feedback is hardly ever given or received to and from colleagues from the same and different profession. Feedback is given indirectly, rather than actively speaking up when communication was flawed. The presence of learners like students or novice nurses had a positive impact on their role modeling and feedback behavior. Residents stated that if nurses were to give them feedback, this would increase their alertness on the correct use of the SBAR tool and possibly would stimulate them to give feedback to nurses. Residents received conflicting feedback from their supervisors, giving them different instructions on how to structure their information. When it came to learning in practice, residents emphasized the lack of consistency in the use of SBAR by their supervisors, which prevented them from being a positive role model to the residents. Besides that, they mentioned that SBAR is not used in every department of the hospital. This made it difficult for residents to be consistent with SBAR themselves. Nurses tended to see residents as role models for effective communication, rather than people from their own profession. Residents emphasized the lack of consistency in the use of SBAR by their supervisors, which prevented them from being a positive role model to the residents. They mentioned that SBAR is not used in every department of the hospital. This makes it difficult for residents to be consistent with SBAR themselves. Nurses tended to see residents as role models for effective communication, rather than people from their own profession.

Role expectations

Participants emphasized the importance of discussing and reflecting on role expectations and communication style, for instance, by regular team debriefings. A better understanding of each other’s needs and expectations would make it easier to understand the usefulness of the tool in different care settings. The nurses in this study believed that discussing the patient’s plan, in the ‘Recommendation’ section of SBAR, is not one of their tasks. They indicated that it is up to physicians to decide upon a plan of action after being provided with the necessary information. Furthermore, some nurses shared their experiences of being reprimanded by physicians after providing them with a diagnosis or plan of action, which prevented them from making recommendations in the future. On the other hand residents indicated that they expected nurses to structure their information and conclude their story with a clear lead on what they expect the physician to do.

Individual factors

Motivation to use

Both nurses and residents were motivated to use SBAR, because it was useful in creating an overview of the situation and helped them to structure the information, they wanted to transfer to a team member. Nurses mentioned several times that they automatically “go through this structuring process in their heads,” but that the SBAR tool helped them to reinforce data collection steps and reporting mechanisms. Residents described that positive experiences with the tool in other departments motivated them to use SBAR in the clinical care setting as well. A high workload together with constantly changing work routines made some of the participants weary of change. Also, the time investment of learning to incorporate a new tool, without the prior conviction that it will be of use to you or your patient could prevent using SBAR. Some residents were not sure SBAR had an additional value to them, because they already had their own way of structuring information.

Feeling competent

The main barriers that undermined nurses feeling competent when using SBAR, is the difficulty they experience when filtering relevant information to convey to the physician. Assessing what the physician needs to know about the Background item in particular, is challenging. Also, the lack of exercise with structured communication during routine practice makes it difficult to use SBAR in the case of a rare acute event in the clinical care setting. Residents mentioned a high degree of competence regarding structured communication. Despite their confidence in being an effective communicator, some residents mentioned that contradictory feedback from their supervisors made them uncertain of how to use SBAR in non-acute situations, like discussing patients with their supervisor after a patient examination at the clinical ward.

Perceived professional role

SBAR is not (yet) part of the roles and tasks in daily practice, especially for nurses. They indicated that following a script when transferring patient information, does not align with the communication style of their professional group, which is traditionally less structured and formal and allows for more social interaction. Furthermore, from the interviews it became clear that there is a shared perception of the traditional roles of physicians and nurses regarding patient management. Nurses did not identify themselves with the task of diagnosing the patient problem or making recommendations. Residents, in contrast, believed that effective communication is part of their role and a responsibility as a physician. On the other hand, they struggled with the rigid format of SBAR and their identity as a childcare professional, as they needed to elaborate and share social context of the patient with other professionals.

Discussion

This qualitative analysis provides insights on what factors should be addressed to implement the use SBAR by healthcare professionals within the interprofessional context of a pediatric non-acute care ward. Poor communication is found in many different healthcare settings and is especially prominent in-patient hand-offs and settings where fast and effective management is indispensable (Shahid & Thomas, 2018). However, the process of interprofessional communication is complex and prone to misunderstanding. To overcome this, desirable communication strategies take little time and effort to complete, deliver comprehensive information efficiently, encourage interprofessional collaboration, and limit the probability of error (Luettel et al., 2007). Planning for implementation of patient safety issues that interfere with work routines and team culture should recognize the interaction between the intervention, the complex setting in which it is used, and the professionals involved (Grol et al., 2007). Consequently, the unreflected adoption of a communication tool, without an investment by the team to come to an agreement on effective communication and a shared philosophy on teamwork, will lead to failure to improve interprofessional collaboration (Müller et al., 2018). The findings in this study are in line with models of innovative climates in the literature, in which a clearly defined vision (strategy), a safe environment for professional development (learning climate), a shared concern and understanding of quality of performance (interprofessional interaction and role expectation) and practical support and opportunity to introduce and practice new routines (preconditions and situational dependency) are defined as the most important factors for innovation (West, 1990). As the interaction of these factors at multiple levels may influence the success or failure of quality-improvement interventions a deeper understanding of these factors is crucial (Grol & Grimshaw, 2003).

Situational dependency

The SBAR tool is widely used in different healthcare facilities as a communication and hand-off tool both intra-professional and inter-professional (Achrekar et al., 2016; De Meester et al., 2013; Randmaa et al., 2014; Raymond & Harrison, 2014), and is regarded as current ‘best practice’ to deliver information in critical situations (Taylor, 2010). However, it is important to realize that one size does not fit all, when it comes to improving interprofessional communication strategies in healthcare. SBAR might be an adaptive tool that is suitable for many healthcare settings, in particular when clear and effective interpersonal communication is required. We found that SBAR, which has been proven to be successful within the acute care setting, cannot automatically be translated into other departments with different communication styles and culture. Depending on the context and urgency of the situation, professionals indicated to be more or less motivated to use the SBAR tool. Healthcare professionals associate the tool with acute care settings, and this explains why they perceive it to be more relevant and easier to apply in an acute care setting or in a patient that is acutely deteriorating. Although, the feasibility of SBAR has been proven in non-acute care facilities to the satisfaction of professionals (Renz et al., 2013), these reports do not measure actual use. Research has shown that motivation and satisfaction of the SBAR tool can be high among healthcare professionals, without actually increasing self-efficacy or the use of SBAR in the workplace (Uhm et al., 2019). This is in line with our findings. Nurses and physicians stated that they mainly use SBAR to deliver information in critical situations. It helps them to collaborate because sender and receiver share the same mental model, understanding of the situation. This might also be the case for less urgent patient situations, however nurses indicated that there was no shared vision on how to adapt the SBAR tool to their specific needs. The barrier of situational dependency could be addressed by an interprofessional agreement on the use of SBAR in different clinical care settings. To come to such an agreement, professionals should be given the opportunity to reflect and discuss within the team what information each healthcare professional needs for the communication tool to be effective in both urgent and non-urgent situations.

Climate for workplace learning

This study highlights the importance of a departmental culture that accommodates healthcare professionals to improve their quality of work and facilitates interprofessional collaboration. A positive team climate occurs when team members use reflective processes to appraise potential weaknesses, monitor colleagues work performance, and share a belief in interdependence as a way of developing an integrated approach to action based on cooperation (Agreli et al., 2017). Healthcare professionals are continuously exposed to changes in their working environment. In response to changes, there will be both similarities and differences in reaction; professionals will have to defend or reconfigure their professional identity (Gover & Duxbury, 2012). However, when a shared interprofessional learning climate is lacking, strong professional identities may perpetuate hierarchical disciplinary boundaries in the process of team collaboration (Hotho, 2008; Langendyk et al., 2015). Therefore, creating a safe atmosphere where team members feel safe to speak up and are able to learn from each other, is essential for teamwork. (Reader et al., 2007).

Furthermore, a lack of understanding of others’ professional roles and responsibilities are main barriers to team effort and the interprofessional collaborative practice (Hazen et al., 2018). The hierarchical structure of the healthcare system and the stereotypes of the physician who reasons, diagnoses, and leads and of the nurse who cares, nurtures, and functions as a cooperative team member persist. This preconception seems to prevent nurses from making recommendations when using SBAR. If nurses believe that their inputs are not heard by physicians, they will probably make fewer suggestions, while residents expect more participation. Thus, there is a risk to enter a vicious circle, in which expectations are less and less met, leading to poor teamwork. These findings are in line with previous research on interprofessional collaboration and role perception and underline the importance of a shared vision on professional roles and responsibilities (Hazen et al., 2018), characterized by team evaluations, interprofessional practice opportunities and critical appraisal of team values and goals (Agreli et al., 2017; Blondon et al., 2017; Kostoff et al., 2016). Communication tools, such as SBAR, are designed to support communication across hierarchical boundaries, reducing inhibitions in hierarchical context by encouraging the sender to provide a personal assessment and suggestion of the situation (Recommendation; Donahue et al., 2011). However, our findings illustrate that the implementation of a communication tool without a shared philosophy, does not automatically lead to team members’ assertiveness, better interdisciplinary communication, and a shared perception of teamwork.

Furthermore, these findings emphasize the importance of role models and feedback in order to fundamentally change the way of thinking and acting and develop new routines and practices. Within the skill domain of interprofessional communication, the ability to deliver feedback to and receive feedback from team members is considered an essential competency. There are numerous factors that influence acceptability of feedback (Eva et al., 2012; Hattie & Timperley, 2007). Some of these factors, for example, the credibility of the feedback source may be especially important in the interprofessional context, whereas feedback from persons with a different profession could be more easily disregarded (Van Schaik et al., 2016). Our data suggest that safety for the exchange of feedback is not only an issue between physicians and nurses, but also within the same profession. Nurses believed that spontaneous feedback given to team members, especially to their nursing colleagues, was not accepted within the group. The climate at the workplace can be a constraining factor when it is perceived as competitive or lacking in trust or when new roles or tools are not valued or accepted (Sachdeva, 1996; West et al., 2010). These issues must be addressed in order to develop and be effective as a team. Interprofessional training sessions or team debriefings with the possibility to reflect up on their collaboration and practice effective communication were mentioned by participants during group sessions as a way of improving their collaboration.

Motivation to use

The decision to use SBAR is ultimately made at the level of the individual. We found that the individual strategies in using SBAR were influenced by a sense of autonomy as a professional, feeling of competence and perceived professional identity to incorporate a new tool into their work routines. These findings are in line with the theoretical concept of self-determination (SDT). This theory conceptualizes that goal directed behaviors, like learning new routines in the workplace, are driven by three innate psychological needs: autonomy (the need to feel ownership of one’s behavior), competence (the need to produce desired outcomes and to experience mastery), and relatedness (the need to feel connected to others) (Ryan & Deci, 2000).

The nurses in this study indicated that although they had a positive attitude toward SBAR in acute situations and interaction with physicians, they did not believe that the tool met their requirements for communicating patient information toward each other during routine care. They were less motivated to use the tool in these circumstances, which in turn led to a lack of familiarizing with the tool and less confidence in using the tool in more complex or acute situations. Feeling competent to perform a certain task, also called self-efficacy, is an important predictor of transfer of learned practices into the workplace (Bandura, 2001). To improve the use of SBAR in the clinical practice, the issue of autonomy, competence and relatedness to promote intrinsic motivation, needs to be addressed by showing professionals how the tool can help achieving their communication goals, promote interprofessional feedback and remodel their work environment. These opportunities are best created by health professionals themselves; for example, by using SBAR during team debriefings, or shared reflection on effective communication during simulated team training scenarios, as was mentioned by the participants in this study. In this way healthcare professionals can become familiar with the tool in less stressful conditions and build self-efficacy with regard to effective communication styles. Subsequently, they may adapt the tool to their needs and feel ownership for the effective use of SBAR in different settings.

Limitations

A limitation of this study is that the data were gathered at the pediatric non-acute care department of a teaching hospital. This specific context may limit the generalizability of our findings. Furthermore, we decided to interview both professional groups separately. This leaves out the possibility of interaction between professions, which could also have provided us and participant with additional insights regarding the effect of their communication styles and the use of SBAR.

Recommendations for clinical practice

Multiple aspects of implementation theories on the individual, contextual, social and organizational level should be considered, when introducing SBAR into a new setting. To enhance the use of the SBAR tool into a new healthcare setting it is important to identify professionals’ needs to use the tool effectively and to consider how tasks and responsibilities are perceived by different team members. This can be accomplished by investing in a consultation process with representatives of all involved disciplines, prior to the implementation phase to confer a sense of ownership to team members which may be essential to the success of interventions that seek to change behavior. Furthermore, our findings suggest that for successful implementation of SBAR in an interprofessional setting one should recognize differences in education levels, professional status, as well as perception of roles and responsibilities of the various health professions, since long established routines and (wrongful) assumptions may hamper to process to change interprofessional communication. To overcome these differences health, professionals need to be given opportunities to create a shared perception of team goals and interprofessional collaboration by introducing team debriefings and interprofessional evaluations of work routines. This may also foster a positive learning climate within the workplace, in which team members feel safe to implement new work routines and stimulate inter/intra-professional feedback and role modeling.

Conclusions

The results of this research suggest that for successful implementation of SBAR a supportive departmental environment, structurally, strategically, and culturally is crucial for healthcare professionals to engage with the tool and incorporate it into their workplace routines. Future research should focus on how the organization can help professionals to cross professional boundaries and exchange their needs and expectations in improving interprofessional communication.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website.

Additional information

Notes on contributors

Ester Coolen

Ester Coolen is a M.D., and PhD-candidate on the topic of teamwork in acute pediatric care. She works as a general pediatrician, educator and vice-director of the pediatric residency program at the Amalia Children's Hospital of the Radboud University Medical Center, Nijmegen, the Netherlands.

Rik Engbers

Rik Engbers is a PhD, educationalist and post-doctoral educational researcher and medical teaching policy advisor at the Radboud Health Academy of the Radboud University Medical Center, Nijmegen, the Netherlands.

Jos Draaisma

Jos Draaisma is a M.D., PhD, and post-doctoral researcher. He works as a general pediatrician and has extensive experience in innovative medical education as a senior educator and former director of the pediatric residency program at the Amalia Children's Hospital of the Radboud University Medical Center, Nijmegen, The Netherlands.

Maud Heinen

Maud Heinen is a PhD, registered nurse and senior post-docteral researcher in nursing science with expertise in innovation and quality of care at the Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.

Cornelia Fluit

Cornelia Fluit is a M.D., educationalist and professor in Medical Education. She is a senior researcher with specific expertise on workplace learning, coaching and feedback in Healthcare at the Radboud Health Academy of the Radboud University Medical Center, Nijmegen, The Netherlands.