Improving Clinical Communication Through Structured Conversation

Mary Lou Manning

Disclosures

Nurs Econ. 2006;24(5):268-271. 

In This Article

Communication Tools

How would you address the following statements?

  • The care team works together and is well coordinated for every patient, every day.

  • The care team actively involves the patient in setting daily goals.

  • During nursing change of shift report I always give (or receive) relevant, patient-centered information.

  • I always speak up if I perceive a problem in caring for patients.

  • I am always confident and comfortable approaching all members of the health care team.

If you did not answer "always" or "absolutely" to each question, consider implementing the following approaches and tools.

Patient safety briefings are an easy, efficient tool to share information. The purposes of these briefings are to keep members of the clinical unit informed, anticipate needs, and make appropriate plans. Any member of the team can institute unit-based patient safety briefings, but often the charge nurse orchestrates them. Briefings are conducted at a designated place at predetermined times and should last no more than 5 minutes. A list of three to five questions can be developed by the staff to act as prompts. Questions should be relevant to the unit and the patient population.

Some examples of prompt questions are:

  • What are the patient safety risks on the unit today?

  • Is anyone worried or concerned about any particular patients?

  • Do any patients need close observation that we all need to know about?

  • Are there any new medications or equipment that might cause a safety risk?

  • Identify and introduce new or re-assigned staff.

The daily patient goal sheet is a simple, multidisciplinary, patient-centered communication tool designed to facilitate communication by requiring the care team to define (with the patient) explicit goals for the day (Pronovost et al., 2003). The goal sheet prompts the care team to identify and clarify daily goals and specific activities and work to achieve the goals. It also provides an easy mechanism for communicating goals with family members.

Ideally, the goal sheet is completed during daily multidisciplinary bedside rounds. The nurse or physician extracts the pertinent details, completes the sheet, and displays it at the patient's bedside. Some units use colored paper and display the goal sheet on the patient's clipboard, others may write the goals on mounted white boards.

The goal sheet should be tailored to the patient population of any given patient care unit, the patients, and the moment. For example, one team decided to create a goal sheet with four quadrants (daily goals, discharge criteria, team members, and questions). Another team created a systems list with a few questions. Initially, the team should use the goal sheet on one or two patients to determine if the identified information is helpful. The goal sheets will go through many iterations and modifications and should continue to evolve. The goal sheet should be updated throughout the day. The inevitable daily changes in the course of a patient's hospitalization make it imperative to keep information up to date.

Pronovost and colleagues (2003) found that use of the daily goal sheet helped decrease the average length of stay in a critical care unit. The goal sheet is a tool that supplements rather than supplants existing communication practices within each discipline.

Effective communication is particularly important in the transfer of patient care from one nurse to another during shift change. Such transitions are often highly variable and vulnerable to error. One practice is for the outgoing nurse to summarize information about each patient onto audiotape. The incoming nurse listens to the taped report and has no opportunity to clarify information or ask questions. The outgoing nurse may fail to report critical information such as a medication change or pending diagnostic study. Information may also be distorted or misinterpreted by the incoming nurse, increasing the risk for patient harm.

Conducting nurse-to-nurse shift report at the bedside, in the presence of the patient puts the patient central to all care activity information (Anderson & Mangino, 2006). It allows the outgoing nurse to introduce the incoming nurse to the patient, thus creating an explicit transfer of responsibility. It provides the incoming nurse the opportunity to actively ask questions and visually inspect the patient, while checking identification bands and treatment modalities (for example, intravenous fluids) with the outgoing nurse. If in use, daily patient goal sheets can provide the focal point for bedside report. Bedside reports also provide the opportunity to reassess the patient's goals from the prior period and update the goals as needed. Anderson and Mangino (2006) observed increased patient, staff, and physician satisfaction as well as financial savings after implementing bedside shift report.

Traditionally, nurse shift report is learned "on the job." Such an activity that can jeopardize patient safety requires the process be formalized and structured. A formal process of instruction, supervision, and feedback is warranted.

There is a delicate balance between delivering too much and too little information. SBAR is an easy-to-remember tool that provides a structured, orderly approach to improve effective communication of accurate, relevant information, especially in emergent patient situations. SBAR helps limit the jargon, keeps the message clear and crisp, and removes the influence of hierarchy and personality (see Table 1 ).

For example, Jeffrey Clarke, 3 months old, was admitted 2 days ago for fever, diarrhea, and dehydration. He was on intravenous therapy for 24 hours and started bottle feeding yesterday.

S: Hi, this is Mary Lou, the nurse caring for Jeffrey Clarke, a patient on 6 South. Are you familiar with this patient?

MD: Yes, I admitted him.

S/B: He has been afebrile throughout the day. His temperature is now 39.5 rectal. During the past 4 hours he had five loose watery stools and he is refusing bottle feeding.

A: I am worried that he is becoming more dehydrated.

R: I think he may need his IV restarted.

If a change in treatment is ordered then ask specifically: When would you like an update? How long do you expect until we see improvement? If the patient does not improve, when would you like me to call again?

SBAR is a helpful tool to structure and organize clinical information so it can be delivered in a clear, concise manner. It is not a prescription and should be modified to meet the needs of the intended use. Haig, Sutton, and Whittington (2006) reported a decreased rate of adverse events after implementing the tool.

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