SBAR Communication and Patient Safety

1.0 INTRODUCTION

It is the right of all patients at all times to receive the most effective health care. The introduction of SBAR enables effective investigation to patient safety. This study aims to establish how effective SBAR training programs are to student nurses. In doing so, it seeks to analyze the implementation of SBAR training programs and compare its impact to student nurses without such training. This study begins with a brief background of the problem related to communication tools and how the aspect of patient safety is ultimately affected as a problem. This helps in the analysis of the effectiveness of this SBAR structured communication training. In order to achieve its objective, the study adopts a systematic literature review method. The literature search and qualitative use of reliable literature has been presented in the course of the study. This method has enabled the critical comparison and analysis of the effectiveness of SBAR training programs in different circumstances. The reliability and validity of the nature of literature used is not a concern, as clearly shown in the study. The most appropriate criteria and critical appraisal tool have been used to determine the validity and the quality of literature used. The emergent themes across all main literature used have been clearly analyzed and concurrently discussed. Based on the evidence presented, the thematic concerns that arise from this topic have been evaluated and the implications for practice have been generated. The study further concludes and presents viable and practicable recommendations based on valid evidence.

1.1 Background

As foundationally highlighted by Achrekar et al (2016), at all times, all patients have the right to effective clinical care. A number of health care personnel are always involved in cases of patient admissions to health care settings. Information flow in these settings is therein majorly accounted for by communication between the health care personnel concerned. In instances of communication errors, there can be substantial clinical mortality and morbidity (Narayan, 2013). This problem mostly affects clinical handoff in nursing practice. The lack of standardized and structured practice procedures is one of the risk factors that lead to breakdown in communication during the transition of care. Patient hand off refers to the act of transferring accountability and responsibility of a patient from a nurse, to another. Most studies show that the presence and implementation of structured handoffs importantly improves the quality of patient hand off (Clark et al, 2009). Throughout most studies, handoffs from one health care provider to another are a recognizable vulnerability factor to communication failures (Cohen & Hilligoss, 2009). The root cause identified by the Joint commission for more than 70% of serious medical errors in 2015 was communication; onto which a total of 936 sentinel events were reviewed (Shahid & Thomas, 2018). There are various confirmed consequences of failed communication in handoffs; these include repetitive tests of the patients, discharge delay, delay in the transfer to critical care (cases where the patient requires critical care), ambiguous patient plans and medical errors. The aim of introducing structured communication tools such as SBAR is to provide equitable health care in a timely, efficient, effective, and safe and patient- centered manner (Riesenberg et al, 2009). Certain challenges are involved in communication; situational awareness is required in sharing specific health care information of patients among health care professionals. Situational awareness refers to the clear understanding of a patient’s specific current medical condition and the way forward or the trajectory of the patient’s status. Patient care can, therefore, be directly compromised in situations of adverse sentinel events arising from the loss of situational awareness (Machaczek et al, 2013). Patient safety risks to communication failure are always a matter of discussion for health care providers, administrators, regulatory agencies and researchers. Sharing of vital and specific patient information should aim to ensure a compromised understanding of the respective patient’s expectations and care plans. Patient outcome and satisfaction is likely to be improved only through structured, consistent and reproducible methods.

Problems in communication are also multidimensional; they are directly influenced by information design, biology, process, personnel and technology (Shahid & Thomas, 2018). In spite of the continuous developments in technology in terms of accessing, recording, storing and disseminating information, communication in health care is still troublesome. Health care personnel have to be extremely aware of the challenges that directly face handoffs, such as the language barriers, communication barriers, social settings and physical settings. Insufficient time, interruptions and distractions are some of the most commonly reported obstacles to efficient and effective communication within certain environments (Shahid & Thomas, 2018). Distraction may easily occur through certain overlooked and underrated factors such as noises in the background, busy nursing stations, computer or television screens, mobile phones, lighting and even crowding (Martin et al, 2013). It is therefore imperative to standardize and introduce training pragmas that would promote safe, satisfying, efficient and effective performance by student nurses. There are various factors that complicate communication errors. Some of these factors include gender, differences in ethnic and religious backgrounds, social structures, fatigue, stress, cultural and educational background, gender and the hierarchical reporting structure. Additionally, the differences in the style of communication between the physicians and student nurses are one of the main contributory factors to the errors in communication. This factor is manly influenced by the training that the student nurses undergo and their reporting expectations (Thomas et al, 2009). In order to investigate patient safety, rapid response teams first introduced SBAR in Colorado in 2002 (Achrekar et al, 2016). This technique can be promptly used to facilitate appropriate and effective communication. This technique ultimately allows for structured format presenting organized, short and predictable information flow among the health care professionals. The main purpose, as already predetermined, of this technique is to improve effective communication among health care personnel by standardizing the process of communication (Thomas et al, 2009). Ultimately, the reduction of adverse medical events, improvement of patient safety, increment of health care provider satisfaction and the improvement of the quality of health care depend the implementation of a structured communication tool.

2.0 METHODOLOGY

In order to analyze the effectiveness of SBAR training programs, a critical literature review had to be conducted. This content- based analysis compared and contrasted the effects and outcomes of nursing practice from different perspectives. The design of this study primarily adopted a systematic literature review where a number of articles were searched, retrieved and carefully selected for the dissemination of the most appropriate information in the study. This part of the study provides for the replication of the authors’ findings and the identification of any methodological issues that can arise. With all matters that may arise from methodology considered, this section looks at every bit of information on how the study came to be; how the topic was structured from the PICO framework, how the key words and sentences (if any) were generated, which databases were most appropriate, the literature search and selection, relevance of the materials selected, analysis of the literature, the inclusion and exclusion criterion, critical appraisal tools and a blatant summary of the articles selected.

2.1 Review question

The review question was:

How effective are Situation, Background, Assessment and Recommendations (SBAR) training programs for student nurses?

The generation of an appropriate review topic has very well been founded by Sackett et al (2000), where they stated that three foundational components exist in a well answerable and well-designed clinical question. As a result, they came up with the PICO framework; this is what was used as a basis for generation of the above key words and terms. PICO refers to Patient (P), intervention (I), Comparison intervention wherever applicable (C) and the Outcome (O). This framework has widely been interpreted and adopted in various other clinical researches. Its purpose has always been to increase search precision and to improve search strategies in a basic literature review (Schardt et al, 2007). The PICO framework, as was founded, has been shown below:

2.2 Key words

From the topic selected, certain key words are present. The generation of these key words enabled the fast and selective search of literature that has been used in the study. The generation of key terms is ultimately the first step in the literature search process. In order to conduct an effective and relevant search, generation of key terms must be done. The aim of the study is to analyze the impact of SBAR training programs to student nurses. From this objective, certain key words can be generated for an effective search. For instance: Situation, Background, Assessment, Recommendations, training, student nurses. For additional literature, the study also had to generate key terms that would be important in obtaining more literature on the topic selected. An example is: training of student nurses, nursing settings, and effectiveness of SBAR. In order to increase sensitivity, with the possibility of increasing the potential identification of more relevant articles for this review, the second step in regards to the search strategy and specifically the use of key words, was the identification of synonyms (Bettany- Saltikov, 2012).The Boolean operator ‘or’ was then used to connect the synonyms to the identified key words, thereafter enabling the identification of other articles with the use of any of those synonymic terms. It was also necessary to account for variations in the use of synonyms, which was possible; truncations were used as a result (Aveyard, 2010). Since the whole study is a critical literature review, only medical subject headings (MESH) were identified and used as search terms. The study, in its search strategy, also tried to find possibly used abbreviations and key words. The search ultimately had to be specific so that only the most relevant and most appropriate articles would be used in the review.

2.3 Database selection

Across all forms of research, there exist quite a number of electronic databases. The origin of the existence of a variety of electronic databases was made possible by the recent advances in technology. Using these electronic databases, however, is only possible if one has the necessary technology skills and sufficient information on how to use them through library tutorials. In order to increase the number of relevant articles and literature obtained, it is crucial to select the most appropriate databases to use in one’s literature search (Bettany- Sltikov, 2012). A preliminary search was first performed to obtain the specific outline of medical research being investigated. This review entails an exploration of various researches on the effectiveness of SBAR training programs to student nurses. The preliminary search conducted, therefore, was aimed at obtaining the specific purview of the research topic so the relevance basis could be established; the preliminary search was conducted via google scholar. In a bid to increase the efficiency of the literature search, it was necessary to try and concentrate on databases that would produce much more analytical and practical literature on the topic, instead of the general medical nature of the implementation and theories of practice associated with SBAR in both clinical and social settings. The databases selected included Medline, BMC, CINAHL, BNI, NCBI, PUBMED, PMC and BMJ. The choice of databases to be used was ultimately based on which database would result into much more detailed, valid and reliable literature; the selected databases enabled a more detailed and wider search, which undoubtedly helped in the answering of the review question.

2.4 Inclusion and exclusion criteria

The study focuses on the impact created by SBAR training programs to student nurses. Considering this foundation, focus was given to student nurses; who are nurses in training. Apart from that, the search conducted also ultimately includes only SBAR training programs. SBAR is a communication tool that involves the processes of Situations, Backgrounds, Assessments and Recommendations; no other type of communication tool or program was considered. In addition to these foundational requirements, literature search also considered the fact that focus should be placed on articles of primary research; specific focus was accorded. Specific and thorough focus was also accorded to only peer reviewed and published literature. The advantage of focusing on peer reviewed journals is that these kinds of journals are professionally scrutinized and criticized by respective field experts. This allows for the exclusion of pseudoscience journals, which may basically be unreliable and may also have errors (Ware, 2008). Another thing that was beyond the scope of this study was literature originally published in other languages. The research puts its focus on English- published research. Additionally, the study, in a bid to maintain the reliability and practicability of the literature used, focuses on research articles and journals published within the last 10 years. The summary of the inclusion and exclusion criteria is in the table below:

2.5 Critical appraisal tool

According to Aveyard (2010), a tool used for critical appraisal is meant to guide the evaluation of the research and to facilitate the critical appraisal process. In consideration of the research design, it is important to select the most appropriate tool for critical appraisal. This research, just like most clinical researches, has adopted the Critical Appraisal Skills Programme (CASP). The CASP tool has been chosen for its versatility and specificity. This tool enabled the evaluation and analysis of the articles selected.

2.6 Search outcomes

Across all databases used, an initial search returned over 200 articles (The PRISMA diagram below shows the search). Following basic refinement on the search strategy and key words used, as discussed earlier, the search conducted across all databases resulted in 30 full text articles for review. Further refinement was done (using the inclusion and exclusion criteria); this resulted in 18 full text articles available for review. The next step for selection involved the use of the CASP tool; used for critical appraisal. After critically appraising the 18 full text articles, only 7 articles were eventually selected, and this constituted the number of full text articles used in the research. The search results obtained have been presented in the PRISMA diagram. Further results on the search outcome can be seen in appendix 1

2.7 Literature selected

After various selection and appraisal methods, as explained in the foregoing parts, a total of 7 main articles were selected; all of which entailed primary research. Primary research refers to the research built from first hand collection and analysis of data. Such methods of first hand collection of data include interviews, surveys, ethnographic research, observations and experiments, as in clinical research. The conduction of primary research allows for the obtaining of original and validated data and the dissemination of valuable information. The literatures selected were:

Achrekar, M., Murthy, V., Kanan, S., Shetty, R., Nair, M., Khattry, N. (2016) ‘Introduction of Situation, Background, Assessment, Recommendation into Nursing Practice: A Prospective Study’, Asia Pac J Oncol Nurs

Chaharsoughi, N., Ahrari, S., Alikhah, S. (2014) ‘Comparison the Effect of Teaching of SBAR Technique with Role Play and Lecturing on Communication Skill of Nurses’, J Caring Sci

Herawati, V., Nurmalia, D., Hartiti, T., Dwiantoro, L. (2018) ‘The effectiveness of coaching using SBAR (Situation, Background, Assessment, Recommendation) communication tool on nursing shift handovers’, Belitung Nursing Journal

Kesten, K. (2011) ‘Role- play using SBAR technique to improve observed communication skills in senior nursing students’, The Journal of Nursing Education

Randmaa, M., Martensson, G., Swenne, C., Engstrom, 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

Uhm, J., Ko, Y., Kim, S. (2019) ‘Implementation of an SBAR communication program based on experiential learning theory in a pediatric nursing practicum: A quasi- experimental study’, Nurse Educ Today

Yu, M., Kang, K. (2017) ‘Effectiveness of a role- play simulation program involving the SBAR technique: A quasi- experimental study’, Nurse education today; 53, pp. 41-47

2.8 Hierarchy of evidence and Evidence based research

Best research evidence and clinical expertise is integrated with the patient values in evidence based practice (Sackett et al, 2000); this simply means that evidence based practice portrays effective relationships between professional practice and the values of the client (See figure).

An illustration of the hierarchy of evidence is important in order to understand the best form of evidence used in the research. According to Greenhalgh (2014), systematic reviews of randomized controlled trials can be found at the top of the list whereas opinions from experts can be found at the bottom (See figure). Methodological flaws form the basis upon which some research should not be used to inform an evidence based practice. Looking at various researches, it is necessary to scrutinize and evaluate research articles and published books based on methodologies, research designs and findings. To advance this notion, Loannidis (2005) further highlights that even the highest regarded researches may be falsified and flawed; an example can be seen in the work that caused the change of the Cardiology guidelines on perioperative beta blocker usage by Professor Polderman (Poldermans et al, 2009). The fabrication of this work may have resulted in a number of deaths (Cole, 2014). According to Moule and Goodman (2014), for nursing research, randomized controlled trials offer the ‘gold standards’ of evidence based research. The hierarchy of evidence simply means that studies are graded in accordance with the strength of evidence and the research designs (Polit & Beck, 2012). For this review, the studies included are composed of mixed research design methods, qualitative methods and quantitative methods.

2.9 Data extraction

Appendix II presents the data extraction table; containing the details on the author, article title, date, main objective, method/ research design, sample population and size, main findings, strengths and limitations of the literature used in this study. This has been guided by Timmins and McCabe (2005). In regards to data synthesis, a systematic and narrative approach has been adopted; specific focus has been accorded to the summarizing of evidence, interpretation of findings and comparisons of the indifferences and characteristics (Moule & Goodman, 2014).

3.0 FINDINGS

3.1 Data analysis and synthesis of findings

From the 7 selected papers, data was analyzed and themes thereafter generated. Due to relevance and clarity, some themes were only identified but not included within this section; this was also aimed at asserting relevance to the focus question. Further understanding on the studies included in this review showed that quantitative research has its foundation on post- positivist paradigm which seeks to explain the effect in relation to the cause, and also focuses on how relationships. Qualitative research, on the other hand, looks at the experiences of individuals so as to explore the understanding of certain phenomena (Parahoo, 2014). A critical appraisal of the papers was also done and the presentation of the findings is what has been discussed below. A discussion of the analysis of the findings has been done in the subsequent chapter. The results from the literature have been recorded in form of a table (as shown in the appendices); this was done in a bid to help identify recurring themes across all studies on the SBAR training program and its effect on student nurses. From the previous chapter, it can be clear that the patient values and beliefs are a very important element in evidence based practice; Sackett et al (2000), portraying effective relationships between professional practice and patient values constituted a significant foundation on determining the primary themes recurrent from the studies. From the studies analyzed, five primary themes relating to the effectiveness of SBAR training program emerged.

1. SBAR training programs increases speaker and receiver confidence in handoff reports

A simple framework for conducting handoff reports is given upon the introduction of SBAR communication tool for the standardization of communication. The question of how to conduct an effective handoff report is eliminated in such cases; the speaker of the report is provided for a set method of how to conduct an effective handoff. As a result, the speaker’s ability to give an effective report and his confidence is improved (Christie & Robinson, 2009). In their experimental study, Uhm et al (2019) assessed communication performance through the SBAR communication tool on a communication clarity scale. The handover confidence level was used to measure how communication was perceived. In the course of the study, the perceived physician- nurse collaboration, practicum satisfaction and clinical practice efficacy were evaluated. The results were that the participant group demonstrated significantly higher confidence in communication in handoffs, compared to the control group. The study, however, concentrates its findings on pediatric nursing practicum. Shahid & Thomas (2018) reiterate the fact that communication handoffs are foundationally important in the creation of a shared model of mentality around the condition of the patient. The study affirmed that SBAR technique brings about a more consistent standard of handoff reports when trained to the student nurses. Yu and Kang (2017) find that the SBAR training program could be used to cultivate competence in communication in the student nurses and improve their communication skills. Kesten’s study (2011) looked at the overall performance of student nurses in role play in the effect of SBAR communication tool. Data was evaluated from 115 nursing students and it was found that the mean performance score of didactic plus role play students was notably higher compared to those without instructions. Chaharsoughi et al (2014) conducted a quasi- experimental study involving 78 nurses who were randomly assigned to role play and divided into groups. Although this study particularly looks at role play as an important educational method of teaching SBAR to student nurses, what can be derived from the study is that this SBAR technique effectively improves confidence in communication, consequently improving communication between the parties in health care. Achrekar et al (2016) involved 20 nurses in their study; their results indicated that SBAR technique effectively helps nurses in the development of easy communication and focus during transition of care of the patient during handoff. Achrekar et al (2016), however, focused on nurse to nurse shift handover and not any other communication issues that may arise from other professional relationships. As a result of SBAR training, handoffs are much more standard regardless of the position of its users, the experience of the medical practitioners and the profession. This factor enables the effective utilization of the communication tool and the improvement in confidence of both the user and the receiver simply because there is more focus given to the information being exchanged rather than the individual exchanging the information. The concept of improvement of communication confidence in handoffs has been supported in a number of other reports. In reviewing the impact of this communication tool on handoff abilities in nursing students, simulated and experimented scenarios depict that the use of this tool enables a better organization of thoughts, therein improving the confidence of the student nurses in the conduction of an effective handoff report (Muller et al, 2018; Thomas et al, 2009; Wentworth et al, 2012).

2. SBAR training programs creating a common language for communication in professional practice in patient care

In regards to patient care, the SBAR technique establishes a common communication language among the professional practitioners. According to Chaharsoughi et al (2014), unwanted hospital errors and poor patient care is usually caused by one main factor; ineffective communication. There is normally a gap that exists in communication between two professions, especially in cases whereby there should be a guide in exchange of information between a physician and a nurse. This communication gap can only be bridged when there is a unification and harmonization of the styles of communication of the different parties in information exchange. Muller et al (2018) had their study set in a wide range of environments such as nursing homes, primary care settings and secondary care settings. In their study, they generally ascertained that breakdown in communication between nurses and physicians are the root problem in adverse clinical routine events, especially during handover. The findings of their study presented a total of 26 different patient outcomes and different significant improvements in communication in cases where SBAR technique was applied. The intervention group in Randmaa et al (2014) depicted significant improvements in the factors involved in communication accuracy (p=0.039) and the climate of safety (p=0.011) in SBAR technique. The SBAR technique ultimately improves patient care by the different parties in a professional setting. Additionally, the use of this tool temporarily flattens the perceived hierarchy in professional settings, therein causing much more effective communication channels between the providers of health care; this is ultimately the logic behind creation of a common language used in communication, especially in regards to patient care (De Meester et al, 2011). From a historic point of view, professional medical practitioners such as nurses and physicians are taught to maintain certain styles of communication that reflect the perceptions and need of their respective professions. Nurses usually directly perceive the small but significant changes in individual patient conditions; basically because they are literally the bed side caregivers involved in patient care. As a consequence, nurses tend to use a subjective communication style; narratively communicating in a way that reflects the constant caregiving that informs their nursing profession. On the other hand, physicians are used to using an objective style of communication; this style echoes an action- oriented traditional medical education which demands quick response given to expertise on the treatment and even diagnosis of the condition affecting the patient based on objectivity. The communication gap referred to in this context arises in the cases where there is a clash between these two traditionally and commonly perceived styles of communication. The clash usually jeopardizes the safety of the patient in question (Achrekar et al, 2016). In using the SBAR technique or communication tool, professional communication regarding patient safety is usually combined, thereby establishing a standard method that promotes effective information exchange between medical professionals.

3. The introduction of SBAR programs improves the accuracy, efficiency and efficacy in handover communication

Upon the introduction of SBAR, hand over reports adopt a standardized format which on continued use, becomes a habit to the users; which in turn increases hand over efficiency and accuracy (Christie & Robinson, 2009). According to the findings of Chaharsoughi et al (2014), through intervention, communication between healthcare professionals became more effective; SBAR training programs were rendered to be tools for building effective communication between professionals in clinical settings. Directly related to handover, Herawati et al (2018) conducted a quasi- experimental study involving 54 nurses, their aim was to analyze the impact of SBAR coaching on handovers conducted by nurses to physicians and vice versa. They recorded an increase and a significant improvement in nursing shift handovers in the intervention group in comparison with the control group. They concluded that SBAR communication tool was ultimately effective on handovers. Uhm et al (2019) support this theme in their study; as part of the concluded results, they stated that the SBAR program in pediatric nursing practicum improves the senior year students’ perceived handover confidence. They also concluded that this program significantly improves communication clarity. Effective learning is also promoted in cases of improvement in interdisciplinary communication; this was the finding in Kesten’s (2011) study. In the study conducted by Achrekar et al (2016), efficient and effective communication is improved upon the introduction of SBAR communication tool. Moreover, Yu and Kang (2017) support these findings in their study which aimed to develop a role- play program involving SBAR technique and analyze its effects on 62 senior nursing students. The findings of this study were that higher scores were displayed by the intervention group (t=-3.05, p=0.003); this was on communication clarity. This communication tool, in improving communication, not only improves person to person communication, but also improves all other forms of communication (Achrekar et al, 2016). This involves a combination of good critical- thinking skills, clinical judgment and clinical assessment skills. Evidently, performing a task in the same manner for a continuous period increases the proficiency in performance. For instance, in a certain study highlighted from the evidence reviewed, the introduction of the SBAR communication tool caused a significant decrease in nurse- nurse shift handoff times from around 45 minutes during the pre- SBAR to 7 minutes post- SBAR (Christie & Robinson, 2009). SBAR programs ultimately improves inter- disciplinary communication; increasing the volume and veracity of information shared and reducing the time spent while sharing this information (Cornell et al, 2014). Through this, more time is dedicated to activities that pertain to patient care primarily because there is an improved efficiency in handover and a reduction in the time spent on unnecessarily or extraneous patient information. Moreover, the use of a standardized method of communication consistently improves the efficacy and accuracy of exchange of information (Randmaa et al, 2014). The speaker is forced to purposefully and consciously have a more organized information report due to the requirement of consistently format the report. The SBAR technique therein results in a more accurate and meaningful report. The structure of the report is guided by a standardized expectation, thereby causing the speaker to give a relevant, focused and factually correct report. The use of the SBAR tool, altogether, brings about gains in efficacy, efficiency and accuracy in communication and information exchange (Yu & Kang, 2017).

4. SBAR training programs improve effective communication perceptions among healthcare practitioners

As already illustrated, the SBAR communication tool is considered to be an effective framework for organization of handoff reports. Across most of the reviewed studies, the SBAR tool has resulted into more functional handoff reports which in turn improve perceptions of effective communication in nurse-to-physician and nurse-to-nurse scenarios (Achrekar et al, 2016). Uhm et al (2019) conducted their quasi- experimental study with a specific objective of looking at the impact of SBAR on communication perception, among other things. The experimental group of the study recorded significantly higher SBAR communication (p<.001) compared to the control group; it was clearly demonstrated that SBAR tool improves communication perceptions among on the nursing students. Improved perceptions of communication basically refer to approvals or positive agreements on the impact of SBAR in communication. Yu and Kang (2017) convened a sample of 62 student nurses from two Korean universities. They illustrated that among healthcare providers, the use of SBAR can be linked with the increase in communication and relation levels among these professionals. Communication would be much more efficient, and therefore much more perceived. Randmaa et al (2014) further state that as a result of the statistically significant improvements in the factors of safety climate (p=0.011) and interpersonal communication (p=0.039), there was also a recorded improvement in members’ of staff perception of communication between professionals and their perceptions of the safety climate created. Improved perceptions on effective communication as a result of SBAR are actually not unexpected; this is simply because of the various results that can be witnessed upon introduction of the program.

5. Utilization of SBAR tool promotes patient safety practice in healthcare organizations

There are much more structured handoff reports resulting from the SBAR framework. Undoubtedly, Achrekar et al (2016) find that the use of SBAR increases and improves collaboration within the team directly responsible for patient care. The actual effects of the SBAR tool have been demonstrated to have quantifiable outcomes on patient safety such as on medication errors, restraint use and patient falls. Upon realization of the effectiveness of this tool, the healthcare provides become more willing to use the tool which produces a progressive cycle. This arises from the fact that the providers continually perceive the SBAR tool to be worthwhile and effective. According to Uhm et al (2019), the improvement in communication clarity, collaboration among the healthcare practitioners and practicum satisfaction generates a positive attitude towards clinical practice. Kesten (2011) looks at the impact of the SBAR tool on patient outcome. The study develops a link between improved patient outcomes and effective communication that arises as a result of the intervention. The author’s findings suggest that the continuous and progressive practice may be developed in nursing schools as well as medical education and training in hospitals and clinical care settings. Better results in the patient safety realm are achieved as a result of an increase in the number of providers using the tool. The progressive cycle generated by the providers furthers the positive effects of SBAR on patient safety and communication synergistically. Randmaa et al (2014) even state that implementation of this tool can be associated with an improved patient safety climate; which in turn, positively generates behavior in practice. The tool is more often used to contribute towards improved communication and patient safety with more widespread and consistent improved perceptions towards its effects. In the course of growth, the tool is engrained in the habits of its users, which leads to better expectations with reliability and dependability of handoff reports endowed (Cornell et al, 2014). The utilization of the SBAR tool develops patient safety culture of health care organizations (Randmaa et al, 2014). The competencies, behavior patterns, perceptions and attitudes that constitute the style, proficiency and commitment of an organization’s health and safety management is what is referred to as the safety culture. In addition, this patient safety practicum is comprised of an environment in which perceptions are shared; especially those regarding the significance of patient safety, mutual trust is present and confidence in the efficiency and efficacy of activities is present. Herawati et al (2018) affirm that this tool is effective on handovers and increases the capability of the head nurses and the effectiveness of nursing shift handovers. Through the SBAR training program, a higher patient safety culture is created. This can be seen through the creation of mutual trust and the efficacy of handoff reports and shift changes (Chaharsoughi et al, 2014). Regardless of the different views and perspectives of respective studies, the SBAR communication tool has been brought out to have an advantageous persistence across the reviewed studies. Even though Achrekar et al (2016) focus on nurse to nurse shift handovers, SBAR conclusively helps nurses develop easy communication during transition; these are the professionals directly in charge of bedside patient care. Uhm et al (2019) clearly conducted their experiment based on pediatric practicum outcome; however; this aspect does not hinder their findings in relation to the SBAR technique. The SBAR training program ultimately caused improved clarity in communication and the perceived handover confidence in the senior year nursing students. In other studies, such as Chaharsoughi et al (2014) and Kesten (2011), the authors foundationally based their studies on role play as a method of teaching SBAR programs to the intervention groups. Taking this angle, however, only increases specificity and relevance levels in regards to answering the review question. The findings of the effectiveness of SBAR program on student nurses have coherently been relayed. The next chapter provides a critical discussion on what has been relayed in this chapter.

4.0 DISCUSSION

4.1 Critical Analysis

This review aimed at looking at the effectiveness of the SBAR training programs on student nurses. Optimal patient outcomes can be achieved through collaborative practice in clinical settings (WHO, 2010). It is essentially through effective communication between the healthcare professions that comprehensive service to the patients can be provided (Lancaster et al, 2015). Uhm et al (2019) asserts that one of the crucial outcomes of nursing education is communication performance. Despite this being a crucial outcome, imprecise and unclear communication is a common phenomenon among the healthcare personnel (Tang et al, 2013). Medication errors often arise as a result of lack of professional collaboration and communication. Collaboration and interdisciplinary communication can be interfered with by tensions, conflicts and misunderstandings resulting from differences in interests and opinions (Lancaster et al, 2015). Communication and the consequences of its failure in clinical practices have formed one of the major foundations for discussions and researches in many forums. As a main factor in the engendering of unwanted hospital errors and impeding suitable patient care, ineffective communication calls for major reforms and recommendations in both clinical and other primary care settings (Chaharsoughi et al, 2014). SBAR presents one such structured solution. Among health care professionals, this tool can be used as a standard and systematic way of building and improving communication. As a result, this topic has been carefully selected; literally because it is important to analyze and evaluate one of the most advocated and implemented structured communication tool used in the modern society today. This is the reason why this review looks at the effectiveness of SBAR training programs for student nurses. Kesten (2011) also brings out the concept of recommendations; recommendations refer to the ability of person to provide advice in issues to do with solving the current problems of the patients appropriately. This also includes the ability to offer suggestions and opinions on the patient’s issues in a bid to improve nursing quality. Compton et al (2012) states that in most occasions, student nurses find difficult to offer recommendations to other medical practitioners, basically because of their limited clinical experience. It is, on the same note, necessary to provide the required definite treatment and also communicate the recommendations conclusively in clinical situations. Chaharsoughi et al (2014) found that student nurses depict very low levels of competence in this aspect. An increase in the student nurses’ critical and integrative abilities resulted from the implementation of the SBAR program. In support of the findings relayed in the previous chapter from the review, Blom et al (2015) conducted a quasi- experimental study and used SBAR questionnaires to evaluate the perceptions of utilizing SBAR in terms of functionality; they concluded that the perceptions of communication in nurse-to-nurse and nurse-to-physicians were ultimately improved. In this study, there was a linked increase in the proportion of participants in the survey who agreed that the structure used for handoffs was much more efficient. The study recorded an increase of 25% from pre- SBAR to post- SBAR. There was a common perception demonstrated by authors that the level of collaboration and communication within the patient care system is increased as a result of this training (De Meester et al, 2013; Beckett & Kipnis, 2009). It is clear that one of the major advantages of SBAR training programs is that it enables the dedication of more time to patient care, rather than exchange of information. In addition, the introduction of SBAR training programs while reducing the overall number of hours spent in lengthy and avoidable handoff reports, they help hospitals and other clinical settings save financially (Freitag & Carrol, 2011). The improvement in clarity of information being exchanged translates into a reduced number of incidences resulting from miscommunication. SBAR communication tool proves to improve clarity and in the same moment, also increase the volume of information being shared (Marshall et al, 2009). According to Thomas et al (2009), the provision or introduction of SBAR communication training to student nurses ultimately improved their information- organization skills, their communicative competence, familiarity with the tool’s communication and increased their reliability in the transmission of information. Additionally, according to Cho (2013), the SBAR technique for nurses in South Korea relieved some of the factors causing communication errors such as stress and conflict, improved their abilities to express themselves and increased their levels of competence in collaborations with a diverse range of other professionals.

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