NUR 7020 Module 3 Handoff Communication Paper: SBAR, Mnemonic Evidence and a Bedside Report Redesign Example

What Was Not Said at 1900: Redesigning Shift Report on a Hoboken Telemetry Unit

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M.S. in Nursing, Nursing Administration, Thomas Edison State University

NUR-7020: Nursing Administration: Executive Managerial Process

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Month Day, Year

What Was Not Said at 1900: Redesigning Shift Report on a Hoboken Telemetry Unit

Two Missed Messages

The hospital, the unit and the patients in this paper are invented. The 28-bed telemetry unit at a hospital in Hoboken cares for patients with heart failure, arrhythmias and chest pain. Report has always been given at the nurses' station, nurse to nurse, from handwritten notes. In the spring, two events reached the unit's safety review. In the first, a patient's new order to hold an anticoagulant before a procedure was not passed on at 1900, and the night nurse gave the evening dose. The procedure was postponed a day. In the second, a day nurse mentioned that a patient seemed "a bit confused" but did not say that the confusion was new. The night nurse assumed it was the patient's baseline, and a urinary infection with early sepsis was recognized six hours later.

Nobody was careless. Report happened at a noisy station during the busiest half hour of the evening, each nurse used a personal style and nothing ensured that new orders, changes in condition or pending results were covered.

A Shared Mental Model

Haig et al. (2006) described how one health system adopted SBAR, a structure for communication with four parts: situation, background, assessment and recommendation. The format began in military and aviation settings, where people with different training must communicate quickly and accurately, and was adapted for health care to help nurses and physicians share critical information. The authors argued that SBAR's value lies less in the letters than in creating a shared mental model: when everyone expects information in the same order, the listener knows what is coming, notices what is missing and can ask about it. They described using SBAR across the organization, for calls to physicians, handoffs and even administrative reports, so that it became a common language.

What the Mnemonic Evidence Shows

Riesenberg et al. (2009) reviewed the published literature on handoff mnemonics and found two dozen different ones, with SBAR by far the most often cited. Few studies had tested whether any mnemonic improved patient outcomes, and many reports described a tool's adoption without measuring its effect. The authors concluded that structured handoffs were widely recommended but that evidence for any particular mnemonic was limited, and they called for studies measuring outcomes.

For the manager, the review suggests that choosing a mnemonic is less important than implementing one well: training, consistent use and checking that the structure is followed.

Communication as a Work Environment Standard

Six standards for a healthy work environment come from the critical care nursing association (American Association of Critical-Care Nurses, 2016). Its six standards begin with skilled communication and go on to true collaboration, sound decision making, adequate staffing, recognition that means something and authentic leadership. Skilled communication is listed first. The standard asks nurses to communicate as expertly as they perform clinical care and organizations to give them the structures, time and training to communicate well. The standards also hold that leaders must model and support these behaviors.

The Redesign

The unit council chose an SBAR-based report form adapted for nursing handoff, with fixed sections: situation, including code status and any new orders in the past twelve hours; background; assessment, including any change from the previous shift; recommendations and pending items; and a final question to the receiving nurse, "What else do you need?" The form lives in the electronic record and fills in vital signs and active orders automatically, leaving nurses to add judgment.

Report moves to the bedside, where it is possible. The off-going nurse introduces the oncoming nurse to the patient, the two look at the patient, lines and drips together and the patient is invited to correct or add anything. Sensitive information, such as a new diagnosis the patient has not yet heard, is shared away from the bedside first. Report times are protected: technicians answer call lights during the half hour of shift change, and the charge nurse holds non-urgent calls.

Every nurse completes a one-hour session with role play and a short video. The manager and charge nurses observe five handoffs a week for the first three months using a checklist, give feedback on the spot and share overall results at staff meetings.

Leading the Change

The manager expected resistance, and it came. Several experienced nurses said bedside report would take too long and that patients would ask questions nurses could not answer at shift change. Rather than overrule them, the manager invited the two loudest doubters to try the new process for two weeks on one hallway and to report back to the council. They timed each report, noted what went wrong and proposed two changes: a short script for introducing the oncoming nurse and a rule that detailed family questions are answered after report rather than during it. Their changes were adopted, and their account of the trial persuaded colleagues more than any memo from the manager would have. The manager also attended evening report herself twice a week for the first month, which signaled that the change mattered and let her fix problems on the spot.

Patient Involvement

Bedside report changes the patient's role. Patients hear their plan, meet their next nurse and can catch errors, such as an allergy omitted or a test that was supposed to be canceled. A few patients find it intrusive at night, so nurses ask whether the patient wants to take part when asleep.

Measures

The unit will track audit results for each section of the report, events in which information was not passed at handoff, patient experience questions about nurses explaining things and the time report takes. A staff survey on communication will be repeated at six months.

Limits

Evidence for specific handoff tools is limited, and the unit's results may reflect the attention that comes with any change. Bedside report takes longer at first and can be hard with confused or sleeping patients. Audits depend on observers who are busy themselves.

Conclusion

Two events showed that critical information depended on each nurse's personal style of report. SBAR offers a shared mental model, the mnemonic review shows that implementation matters more than the tool and the healthy work environment standards make skilled communication a leadership responsibility. A structured bedside report with protected time, training and audits gives the unit a common language for the half hour when details slip away most easily.

References

American Association of Critical-Care Nurses. (2016). AACN standards for establishing and sustaining healthy work environments: A journey to excellence (2nd ed.). American Association of Critical-Care Nurses.

Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. The Joint Commission Journal on Quality and Patient Safety, 32(3), 167-175. https://doi.org/10.1016/S1553-7250(06)32022-3

Riesenberg, L. A., Leitzsch, J., & Little, B. W. (2009). Systematic review of handoff mnemonics literature. American Journal of Medical Quality, 24(3), 196-204. https://doi.org/10.1177/1062860609332512