Module 3 – Discussion. SBAR stands for Situation, Background, Assessment, and Recommendation. SBAR was originally designed as a communication tool for nurses. They soon added the idea that it could also be utilized for reports. The following link gives an example of how to use the SBAR tool as a reporting device.
Instructions:
Read the How to Give a Nursing Handoff Report Using SBARLinks to an external site. https://nursebrain.com/2021/05/how-to-give-a-nursi… article.
Based on the example given, develop a report sheet that contains the categories that are important when giving a report.
Save the report sheet, and share it with your colleagues. ATTACH THE REPORT
Please respond to at least one (1) of your classmate’s postings and critique their report sheet as to the utility, usefulness, and orderliness of the sheet.
To see the grading rubric, click on the 3-dot menu 3-dot menu on the top-right side of screen.
Giving an Effective Nursing Handoff Report using SBAR
Effective communication during nursing shift changes, also known as nursing handoff reports, is crucial for maintaining patient safety and continuity of care. One systematic method for structuring nursing handoff reports is the SBAR (Situation, Background, Assessment, Recommendation) technique. This article will explain how to give a nursing handoff report using the SBAR method along with a sample nursing report sheet that utilizes the SBAR format.
The SBAR Method
SBAR is an acronym that represents the four components of a structured communication technique: Situation, Background, Assessment, and Recommendation.[1] Each component serves a specific purpose in concisely yet comprehensively conveying important patient information.
Situation
The situation component provides a brief summary of the patient’s current status, including their name, location, age, and chief complaint or reason for admission. This gives the oncoming nurse an overview of who the patient is and why they are in the hospital.
Background
The background provides relevant historical information about the patient to give context to their current situation. This may include past medical history, surgeries, diagnostic testing results, current medications, and any other factors important for understanding the patient’s case. Only information directly relevant to the patient’s current care needs to be included.
Assessment
The assessment component involves a head-to-toe Assessment of the patient’s current condition. It summarizes the patient’s vital signs, physical assessment findings, lab results, diagnostic tests, and any other pertinent details. Any abnormal assessment findings or changes since the last report should be highlighted.
Recommendation
The recommendation states the plan of care, anticipated treatment and orders, upcoming tests or procedures, and any specific instructions or guidelines for the oncoming nurse. It allows the offgoing nurse to recommend the priorities and next steps in the patient’s care to facilitate a smooth transition.
Using a structured communication method like SBAR helps ensure that handoff reports are consistent, comprehensive yet concise. It promotes the transmission of key information in a clear, organized format to enhance patient safety and quality of care.[2]
Sample Nursing Report Sheet
The following is a sample nursing report sheet formatted using the SBAR method:
Situation
Background
Mrs. Smith is a 65-year-old female admitted 2 days ago with pneumonia. She has a history of COPD, hypertension, and diabetes. Her chest x-ray on admission showed bilateral infiltrates. She is currently on supplemental oxygen and a course of antibiotics.
Assessment
Vital signs have been stable. Oxygen saturation is 95% on 2L nasal cannula. Lung sounds remain coarse bilaterally but slightly improved. No fever or increased work of breathing. Blood sugars have been well-controlled on her home medications. She is ambulating with a walker and diet has advanced to regular.
Recommendation
Mrs. Smith will complete her antibiotic course today. Repeat chest x-ray scheduled for tomorrow morning to assess treatment response. Discharge planning to begin if significant improvement seen on imaging. Continue current care plan and monitor for any changes in condition. Call physician if oxygen needs increase or respiratory status deteriorates.
Critique of Sample Nursing Report Sheet
The sample nursing report sheet provided is a useful tool for systematically documenting a patient handoff report using SBAR. The sheet is neatly organized with clear section labels to guide the user. Relevant categories are included in each section to prompt inclusion of key information elements.
Use of this structured report sheet would help ensure consistency in communication of important patient details between nurses. It promotes organization of the report in a logical sequence following the SBAR framework. Inclusion of both assessment findings and recommendations/next steps provides a comprehensive yet concise overview.
A potential improvement could be adding space for additional notes or comments. This would allow documentation of any unique care considerations or non-medical information pertinent to the patient. Overall, this sample report sheet demonstrates an effective format for handoff communication using SBAR that could be easily implemented in clinical practice.
Conclusion
The SBAR technique is a useful standardized method for structuring nursing handoff reports. Use of a structured reporting format like the sample nursing report sheet presented helps ensure consistent, comprehensive yet concise communication of key patient information between nurses. This promotes continuity of care and patient safety during shift changes. Implementing SBAR for nursing handoffs is recommended as an evidence-based best practice.
References:
Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. Journal on Quality and Patient Safety, 32(3), 167–175.
Manser, T. (2009). Teamwork and patient safety in dynamic domains of healthcare: A review of the literature. Acta Anaesthesiologica Scandinavica, 53(2), 143–151.
Patterson, E. S., & Wears, R. L. (2010). Patient handoffs: Standardized and reliable measurement tools remain elusive. Joint Commission journal on quality and patient safety, 36(2), 52–61.
Radtke, K. (2013). Improving patient satisfaction with nursing communication using bedside shift report. Clinical Nurse Specialist, 27(1), 19-25.
Thomas, L., & Donohue-Porter, P. (2012). Blending evidence and innovation: Improving intershift handoffs in a multihospital setting. Journal of Nursing Care Quality, 27(2), 116–124.
