Communicating is a key part of our everyday practice. We communicate with patients, the practice team and external colleagues. We communicate face to face, over the phone and in writing. Therefore, it is not surprising that communication problems are common in healthcare settings.
Consider how often communication is an issue in your practice: how often do errors occur and how often does a communication error result in a significant event? How have these errors been addressed in the past and was a solution found?
A common problem
Research shows that communication and interpersonal issues are a common root cause of patient safety incidents.
The frequency with which this occurs varies but it is cited as high as 80 per cent in some settings1 and a root cause in as many as 66 per cent of sentinel safety events.2 Our own anecdotal experiences as GPs and intuition confirm it is indeed a common problem.
For such a common problem in general practice, we have not identified or implemented a solution. When communication problems arise, we may provide feedback to the individuals involved, we may ask colleagues to be more careful in future communications or we may simply accept communication breakdown is inevitable.
The acronym SBAR (situation, background, assessment and recommendation) is a structured communication tool that originated in large-scale organisations, such as the nuclear industry and the military. It provides a shared mental model for communication across a range of scenarios. It is increasingly being used in healthcare, particularly during handovers between staff or where a patient's care needs escalating.
In general practice SBAR can be used in a number of ways, such as asking a colleague for advice or referring a patient to secondary care.
The following example demonstrates how SBAR can be used:
Situation is the opening statement. This should be one or two short sentences and only a few seconds long. It may include identifying the patient, what they are presenting about and the context.
For example, a practice nurse comes to your consultation room and says: 'I have just seen a Mr John Smith, a 28-year-old man in my diabetes clinic.'
Background gives further details about the patient, including history, examination, key findings and relevant investigations. This may include details of medication and any allergies the patient may have.
For example: 'John was recently diagnosed with diabetes mellitus. He is a lorry driver and is otherwise fit and well.
He is currently on metformin, although his BMI is only slightly raised.
'His mother and his younger sister both have diabetes, and the sister is on insulin. I have addressed lifestyle factors, and he is compliant with diet. However, his fasting home glucose measurements remain raised at 8-12mmol per litre.'
Assessment is your personal assessment of the situation, including differential diagnosis and any concerns.For example: 'I am concerned he may have type-1 diabetes rather than type-2, which, given his occupation, is really important for him.'
Recommendation is what you feel needs to be done next. It is an explicit statement and, where appropriate, includes a timeline.
For example: 'I think he needs referral to an endocrinologist. Would you be able to do that please?'
You may feel that SBAR is similar to how you have already been taught to communicate in your medical training.
However, its strength lies in providing a simple structured tool, which can be used across disciplines and has been shown to improve and reduce communication-related safety incidents.
It removes the uncertainty from communications by preventing the use of assumptions and reticence.
It has also been shown to be more time efficient because it forces the communicator to collate relevant information and prepare the communication beforehand.
Consider how often a practice nurse, receptionist, secretary or secondary care doctor asks you for advice or an opinion.
How varied is the communication you receive and what is the potential for misunderstandings?
SBAR provides an opportunity to standardise the way information is communicated in your practice. Not only can it be used in face-to-face communication but it is also helpful in written communication.
There are modifications of the SBAR tool. For example, sometimes SBARR is used. The second 'R' stands for readback, where the receiver of the information repeats what is said to confirm their understanding. Other organisations have used SBARD, where 'D' stands for decision.
While SBAR seems simple and straightforward, training may be required to ensure effective use. The NHS Institute for Innovation and Improvement has a wide range of resources that practices can use.
These include videos of SBAR being used in a range of scenarios, a presentation that can be used for training, an e-learning module, prompt cards and a guide to implementing SBAR in your practice.
Further information is available at www.institute.nhs.uk/SBAR. These resources are free to NHS workers in England.
- Dr Dawda is a GP in Hertfordshire, Dr Jenkins is a GP in Staffordshire and Dr Varnam is a GP in Manchester. They are all associates in safer care at the NHS Institute for Innovation and Improvement
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1. Agency for Healthcare Research and Quality, January 2004. www.ahrq.gov/RESEARCH/jan04/0104RA25.htm
2. Root causes: a failure to communicate: identifying and overcoming communication barriers. Joint Commission Perspectives on Patient Safety, 2002; 2(9): 4-5.