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STRUCTURED
Communication
IMPROVING PATIENT SAFETY WITH SBAR

The Institute of Medicine (1999) has estimated that as many as 98,000

people die in US hospitals each year due to preventable medical er-
rors. The Joint Commission (2004) reports that 72 percent of root
causes identified during the reviews of sentinel events related to in-
fant death and injury during delivery are attributable to communica-
tion failures. As a result, the Joint Commission (2008) has identified
effective communication as one of its National Patient Safety Goals.

Jennifer Dunsford, RN, BN

The Institute of Medicine (1999) has estimated that as many as
98,000 people die in U.S. hospitals each year due to preventable
medical errors. The Joint Commission (2004) reports that 72
percent of root causes identified during the reviews of sentinel
events related to infant death and injury during delivery are
attributable to communication failures. As a result, the Joint
Commission (2008) has identified effective communication as
one of its National Patient Safety Goals.
Communication tools like SBAR (Situation, Background,
Assessment and Recommendation) can help nurses focus
communication to improve the effectiveness of information
transfer. SBAR is especially important in urgent or high-acuity
situations where clear and effective interpersonal communica-
tion is critical to patient outcomes.
Communication
The implications of missed or ineffective communication can be
severe. A patient’s clinical condition can deteriorate very quickly,
and the ability to impart nursing assessment data rapidly and in a
way that will be received as intended can literally mean the differ-
ence between life and death. In 2004, the Joint Commission issued
a sentinel event alert (Joint Commission, 2004) on preventing in-
fant death and injury during delivery. This alert identified com-
munication as a root cause in 72 percent of the cases of perinatal
death or permanent disability reported to the Joint Commission
between 1996 and 2004 under the sentinel event policy.
Bottom Line
• Communication failures
can lead to medical errors that may compromise
patient safety.
• Tools such as SBAR can help nurses and other
health care providers improve the effectiveness of
information transfer.
• Clear communication is especially important in
urgent or high-acuity situations.
The complex nature of the work done in health care settings
today sets the stage for potential failures of communication.
Higher nurse-patient ratios can result in heavy workloads and
fatigue. Increased acuity, staff shortages and factors such as the
level of staff experience can add undue stress to the work envi-
ronment, all of which increase the risk of error.
Communication can be a factor in any error, and can be
affected by hierarchies, power gradients, culture, climate or re-
Jennifer Dunsford, RN, BN, is the quality coordinator at Grace Hospital
in Winnipeg, Manitoba, Canada. Address correspondence to: jduns-
ford@gmail.com.
DOI: 10.1111/j.1751-486X.2009.01456.x
386 © 2009, AWHONN
lationships with the rest of the health care team. Problems with
the sending or receiving of verbal and nonverbal messages can
occur as a result of fatigue or lapses in attention and memory.
Improving communication through the use of tools such as
SBAR can help to minimize the risk of any of these failures.
What is SBAR?
The Institute for Healthcare Improvement and the Joint Com-
mission both support the use of SBAR as a form of structured
communication. It can be used for any patient-related com-
munication between practitioners, including nurse-to-nurse at
handoffs, nurse-to-physician at rounds, when there is a change
in a patient’s health status or for team briefings before surgery
or other high-risk procedures.
First, the speaker presents the situation, by identifying
herself, stating the patient’s name and briefly describing the
problem. The speaker then provides the background, provid-
ing the patient’s diagnosis or reason for admission, medical
status and relevant history. The next section is the assessment,
wherein specific information on vital signs, recent labs and
other quantitative or qualitative data are provided. This sec-
tion can include a provisional diagnosis or clinical impression.
The recommendation is the action item. The immediate need is
explained clearly and specifically, including what is necessary
to address the problem. The whole process is short and concise,
lasting a minute or two at most.
SBAR can serve as a template or checklist for nursing commu-
nication. In recent years, health care has borrowed the practice of
using checklists from the aviation industry, where they have long-
standing history of ensuring that nothing is missed in a high-risk
situation. Pronovost et al. (2006) have shown that the checklist
can reduce central line infections dramatically in the intensive care
unit (ICU) setting. Some standardized communication models
http://nwh.awhonn.org
 BOX 1
SBAR COMMUNICATION
Step Components
Situation • Identify yourself, your unit
and the patient.
• Briefly describe the problem
and your concern.
• What is going on with the
patient?
• Give the headline—one to
two sentences describing the
reason for the communication.
Background • Provide the patient’s diagnosis
or reason for admission, medical
status, relevant history.
• Have the chart available.
• Give the clinical context—as
much information as required to
clearly and quickly set up for the
assessment data.
Assessment • Provide specific information
on vital signs, recent labs, other
quantitative or qualitative data.
• Offer a provisional diagnosis
or clinical impression.
• If offering a diagnosis is inap-
propriate, express your concern.
• Give the problem as you see it,
again using a headline describ-
ing the problem.
Recommendation • Explain what you need.
• Be clear and specific regarding
your expectations and time
frame.
• Read back orders.
• Figure out what is needed
immediately to correct the
problem.
October November 2009
Sample of routine
Sample of urgent or non-urgent
communication communication
• “I’m calling about Mrs. • “I am calling about
Jones, who has fetal Mrs. Jones who has
heart rate pattern a fever of 101.5.”
of minimal variabil-
ity and repetitive late
decelerations for ___
(time), and she has not
progressed since _____
(time).”
• “She is a 24-year-old • “She is a 24-year-old
G2P1 whose water G2P2 who delivered
broke at 6 a.m., and was by cesarean section for
induced with Cytotec fetal distress yesterday
beginning at 8 p.m. All at 2300.”
other parameters are
normal.”
• “Normal interventions • “Her other vital signs
are not changing the are normal. Her wound
pattern. Baby is not is clean, lochia normal,
tolerating labor.” lung sounds normal.
Patient has no com-
plaints.”
• “I need you to come • “Would you like me
now and I will prepare to get a urinalysis,
to move her to the OR.” blood cultures and/or
chest X-ray?”
Nursing for Women’s Health 387
act as guidelines or checklists for practitioners who are consider-
ing the information that needs to be received by another party in
any high-risk situation. A number of such communication check-
lists have been developed and are in use at health care facilities in
the United States and elsewhere (see Box 2).
Why SBAR Works
Dayton and Henriksen (2007) identify individual, group and
organizational factors related to communication failures, and
recommend structured and explicitly designed forms of com-
munication for health care providers. Structure allows practi-
tioners with different communication styles to communicate
more efficiently by improving the ability to encode and decode
verbal messages effectively. This reduces the risk of errors or
misinterpretation and improves patient safety.
Verbal and nonverbal communication are an integral part
of all nursing care; thus, it’s critical for the individual nurse to
ensure communication is as clear as possible. Nurses collect
and impart assessment information to physician and nursing
colleagues, and must do so in a way that will get the best results
for the patient in the most efficient manner possible. Stand-
ardizing the structure of critical communications by using a
tool such as SBAR helps the speaker organize thoughts and be
prepared with critical information, and allows more receiver
attention to be focused on the important points of the mes-
sage by eliminating the less important aspects (see Box 1). It
means that the receiver does not have to filter through noncriti-
cal information, such as small talk or indirect “hint-and-hope”
statements, to get to that which requires a response (a data-
supported imperative such as, “I need you to come and assess
the patient. When can you be here?”). With a checklist, it is also
less likely that the speaker will forget to mention something,
resulting in the provision of more complete information.
SBAR is not a panacea for solving communication prob-
lems. Depending on the organization, it can require a funda-
mental culture change to gain a critical mass of support. One of
the concerns around the adoption of SBAR is the hierarchical
nature of health care organizations, and the potential for “turf
wars.” Nurses are trained to communicate in broad, narrative
ways. Physicians tend to speak in “headlines” and need concise
information in order to make a timely clinical judgment or
diagnosis (Groff & Augello, 2003). These two communication
styles can be almost mutually exclusive, and can cause tension.
Nurses must become comfortable with issuing what is essen-
tially a directive to a physician (“I need you to come and assess
the patient now”). This can be especially challenging for newer
or junior nurses who may still be developing skills and confi-
dence in their training and knowledge.
How to Implement SBAR
If SBAR is to be implemented throughout an organization,
senior leadership support is required (Leonard, Graham, &
388 Nursing for Women’s Health
Bonacum, 2004; Ottewill, Urben, & Elson, 2007). It’s critical to
engage all parties in the design of the program, including physi-
cians and nurses, to foster ownership of and commitment to
the process (Manning, 2006). When Kaiser Permanente imple-
mented its Perinatal Patient Safety Project, of which SBAR was a
component, it was recognized that a multidisciplinary team ap-
proach was required. The team at each of the four pilot sites con-
sisted of representation from all relevant disciplines (including
nurses, midwives, neonatologists, pediatricians, unit assistants,
etc.) and was co-chaired by a nurse manager and an obstetrician
(McFerran, Nunes, Pucci, & Zuniga, 2005). Comprehensive ap-
proaches to teamwork such as this have been credited with im-
proving the perception of safety climate and reducing nursing
turnover in other organizations (Groff & Augello, 2003).
Once institutionalized, the use of an accepted convention
provides a shared mental model, improving communication
and, by extension, safety. Training and education are necessary
to ensure a common understanding of the technique and pur-
pose for all staff. In St. Paul, Minnesota, HealthPartners Regions
Hospital implemented SBAR in its Birth Center by identifying
and prioritizing the need to train staff in common language and
SBAR around fetal heart rate monitoring. HealthPartners also
identified the need for reinforcement and undertook train-the-
trainer workshops to ensure new staff is educated in SBAR. The
technique is also reinforced regularly with all staff. In addition,
clinical leaders provide and request communication in SBAR
format to act as role-models. This implementation was part of
a larger improvement effort at HealthPartners. A number of
important patient safety goals were met as a result, including
FIGURE 1
Plan-Do-Study-Act (PDSA) Cycle
PLAN DO
Needs assessed Change
Problem studied implemented on
Change mapped a small scale
ACT STUDY
Adjustments Results analyzed
implemented Feedback sought
Adjustments made
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 Understanding the differences in communication styles
among practitioners, disciplines, genders and
cultures is the basis for effective communication
increased safety climate survey results, indicating an improved
staff perception of safety on the unit (Institute for Healthcare
Improvement, n.d.-a).
It’s also important that the program be embedded in prac-
tice in a way that makes work simpler and safer (Leonard et al.,
2004). Rapid cycle change techniques such as the Model for Im-
provement, as adapted by the Institute for Healthcare Improve-
ment (n.d.-b) can be used to test improvement initiatives such
as the implementation of a structured communication model.
This technique can be used on a very small scale (individual)
or a larger scale (unit, program or an entire organization). It’s
composed of a series of test cycles consisting of planning, im-
plementing, analyzing and revising a change, also known as
Plan-Do-Study-Act or PDSA (see Figure 1).
PDSA has been shown to help organizations implement qual-
ity improvement projects like SBAR (Institute for Healthcare
Improvement, 2003). A working group composed of interested
staff and project champions should start by identifying a pilot
area. In the plan phase, the working group becomes familiar with
SBAR technique and the components of each section. Tools such
as reminder cards and informational posters can be evaluated
and selected. Once background has been gathered and the con-
cepts understood, the team plans the actual implementation.
In the do phase, the group trials the change in the pilot area.
The first test can be attempted on as small a scale as a single
phone call to a physician, or as broadly as all calls on a par-
ticular unit or shift. It’s important to keep this phase confined
to a fairly small scope so that any issues can be resolved before
spreading the change more widely.
Once trialed, the next step is to critically study the effec-
tiveness of the communication. It may help to collect preim-
plementation data, such as time from phone call to physician’s
arrival on the unit. This can then be compared with time-to-ar-
October November 2009
rival after the change. Other questions, developed on the basis
of complaints or issues identified by the staff, such as whether
the nurse received the required order, can also help to evaluate
the technique. The working group, in collaboration with the pi-
lot testers, should ask evaluative questions. Did this work? Do I
feel understood? What differences to the technique would have
improved the outcome?
The act phase is the final step in the PDSA process. Here, the
learning gained from the study phase is incorporated into the
process. Adjustments and adaptations facilitate the adoption
of the change by strengthening the evidence supporting it. For
example, a unit implementing SBAR may identify the need for
tools like SBAR reminder cards at each telephone. When feed-
back is considered and quickly adopted, it reinforces the collabo-
rative efforts of the pilot group, and ensures that the process that
is ultimately adopted is one that works for everyone who uses it.
Once the process is refined, the cycle continues, by expanding
the practice to other areas, and incorporating the lessons learned
with each iteration. The result is that the organization’s SBAR
process is customized for its unique needs, and therefore more
likely to be used consistently. The standardization maintains
structure in communication and all the associated benefits.
An implementation plan involving the PDSA cycle can be
quite effective in larger-scale projects. It’s important to spread
the learning quickly as practitioners adapt their communica-
tion style to the technique. It’s critically important to engage
in the “study” part of the PDSA cycle quite openly and in an
ongoing manner, to maintain the momentum of the change.
Celebrating success and transparently and quickly addressing
challenges or problems will demonstrate responsiveness to in-
put, and result in a more robust process (see Box 2 for SBAR
resources developed by organizations who have managed suc-
cessful implementations).
Nursing for Women’s Health 389
SBAR in Individual Practice
Although an organization-wide implementation of SBAR
communication is optimal, individual practitioners can still
structure their own communication in ways that are efficient
and effective. Understanding the differences in communication
styles among practitioners, disciplines, genders and cultures is
the basis for effective communication.
When an individual nurse is considering engaging in a prac-
tice change, it may be appropriate to consider doing a mini-
PDSA cycle first with a nursing colleague, perhaps at a handoff
before a break, or with an interested colleague. This can help
alleviate anxieties while the technique is being practiced and
fine-tuned. It also provides some experience with adjusting to
different styles and situational contexts. It may be beneficial to
carry an SBAR guide or reminder to help facilitate the process
in urgent or stressful situations.
Conclusion
Preventable medical errors continue to occur at alarming rates,
and communication failures are at the root of many of these
incidents. Adopting a structured communication tool such as
SBAR can help nurses focus communication to improve the ef-
fectiveness of information transfer. The technique can be im-
plemented on any scale, from individual to institutional, and
facilitates the interpretation of interdisciplinary dialects, born
from differing educational systems, hierarchies, power gradi-
ents, culture, climate and relationships among members of the
health care team, ultimately improving patient safety. NWH
http://nwhTalk.awhonn.org
References
Dayton, E., & Henriksen, K. (2007). Communication failure: Basic
components, contributing factors and the call for structure. Joint
Commission Journal on Quality and Patient Safety, 33(1), 34–47.
Groff, H., & Augello, T. (2003). From theory to practice: An interview
with Dr. Michael Leonard. Retrieved July 25, 2009, from http://
www.rmf.harvard.edu/files/documents/Forum_V23N3_a5.pdf
Institute for Healthcare Improvement. (n.d.-a). Improvement sto-
ries. Perinatal care: General. Retrieved July 25, 2009, from http://
www.ihi.org/IHI/Topics/PerinatalCare/PerinatalCareGeneral/
ImprovementStories/
Institute for Healthcare Improvement. (n.d.-b). How to improve:
Improvement methods. Retrieved July 25, 2009, from http://www.
ihi.org/IHI/Topics/Improvement/ImprovementMethods/How-
ToImprove/
Institute for Healthcare Improvement. (2003). The breakthrough
series: IHI’s collaborative model for achieving breakthrough im-
provement. Retrieved July 25, 2009, from http://www.ihi.org/NR/
rdonlyres/3F1925B7-6C47-48ED-AA83-C85DBABB664D/0/
TheBreakthroughSeriespaper.pdf
390 Nursing for Women’s Health
BOX 2
SBAR RESOURCES
The National Health Service in the United King-
dom suggests SBAR as one of its successful Service
Improvement Tools
See: http://www.nodelaysachiever.nhs.uk/Service
Improvement/Tools/IT138_SBAR+-+Situation
BackgroundAssessmentRecommendation.htm
Ascension Health in the United States has made
remarkable strides in reducing elective inductions,
operative vaginal delivery rates and birth trauma
rates since implementing a strategic plan, including
SBAR communication, in 2004.
See: http://www.ihi.org/NR/rdonlyres/E8DE1B16-
7F12-4C80-ABFC-EFAC4EA97063/3237/Seton
PerinatalSBARReportTooltophysicianaboutacriti.pdf
The Institute for Healthcare Improvement lists a
number of perinatal SBAR tools that can help indi-
viduals and organizations get started on improving
communication techniques.
See: http://www.ihi.org/IHI/Topics/PerinatalCare/
PerinatalCareGeneral/EmergingContent/Perinatal-
SBARTools.htm
Institute of Medicine. (1999). L. T. Kohn, J. M. Corrigan, & M. S.
Donaldson (Eds.). To err is human: Building a better health care
system. Washington, DC: National Academy Press.
Joint Commission. (2004). Sentinel event alert: Preventing infant
death and injury during delivery. Issue 30. Retrieved July 25, 2009,
from http://www.jointcommission.org/SentinelEvents/Sentinel
EventAlert/sea_30.htm
Joint Commission. (2008). 2008 National patient safety goals:
Hospital program. Retrieved July 25, 2009, from http://www.
jointcommission.org/PatientSafety/NationalPatientSafety-
Goals/08_hap_npsgs.htm.
Leonard, M., Graham, S., & Bonacum, D. (2004). The human fac-
tor: The critical importance of teamwork and communication in
providing safe care. Quality and Safety in Health Care, 13(Suppl
1), i85–i90.
McFerran, S., Nunes, J., Pucci, D., & Zuniga, A. (2005). Perinatal
patient safety project: A multicenter approach to improving pa-
tient safety. Journal of Perinatal Neonatal Nursing (19)1, 37–45.
Ottewill, M., Urben, J., & Elson, D. (2007). Safe hand-over: Safe
care. Midwives, 10(11), 507–509.
Pronovost, P., Needham, D., Berenholz, S., Sinopoli, D., Chu, H., &
Cosgrove, S., et al. (2006). An intervention to decrease catheter-
related blood stream infections in the ICU. New England Journal
of Medicine, 355(26), 2725–2732.
Volume 13 Issue 5