Nursing Leadership and Management Field Experience
Patient safety is the top priority during healthcare delivery, and communication errors are observed to be the most common causes of adverse events during patient care. Today, healthcare organizations are striving to improve quality care while meeting the regulatory standards, and improving communication can be a great deal towards achieving those goals. Research indicates that effective communication requires situational awareness and the SBAR (Situation, Background, Assessment, Recommendation) technique is recognized as an effective communication tool for the patient’s handoff (Beigmoradi et al., 2019). This technique has shown improved quality care in hospitals through improved communication, reduced medical errors, improved relationships between providers, and promotion of patient safety. While the use of the SBAR technique can be effective in improving healthcare delivery, there is a need for the creation of an SBAR report checklist to monitor the practice and give feedback to colleagues.
Nurses form the largest team of healthcare providers in many healthcare organizations and they are at the forefront of improving quality care. Quality care delivery involves interaction between the nursing team, other healthcare providers, patients, and their families through proper communication. Well-established communication channels translate to improved patient satisfaction because care coordination and delivery of timely services are achieved (Spiridonov, 2017). My healthcare organization seems to have communication problems between nursing teams and physicians especially in the emergency department and the admitting unit. The SBAR communication strategy has been in place for the past five years to enable care transition and reporting of patients between healthcare teams but there seems to be ineffective communication using the strategy.
The communication problem in the organization has contributed to poor coordination of care, increased medical errors, and poor satisfaction of patients. Within the nursing team, shift change handoffs are poorly communicated with critical details about the patients being missed. Although the emergency department is the busiest in the facility, effective use of the SBAR technique can help in improving care transition and saving time. Secondly, nurses seem to have communication problems with the physician team when reporting cases or when seeking clarification. The result is increased medication errors, delayed procedures in the ED, and incomplete patient assessment leading to admission problems and patient dissatisfaction. The physicians claim appropriate inquiries are not made during phone calls while the nurses claim physicians do not respond promptly upon request. To solve the communication problem in the unit, there is a need to use an SBAR communication checklist to ascertain all elements are addressed when nurses communicate between themselves and with the physician team.
Description of the Problem
Sharing patient-specific health information during nursing shift change and normal multidisciplinary care require situational awareness. Situational awareness involves understanding the patient’s medical condition, current management, and clinical trajectory. Loss of situational awareness is a big blow to healthcare delivery because it hinders quality service delivery and leads to errors in medical care (Shahid & Thomas, 2018). The sharing of information between healthcare providers is key to solving the problem because it ensures a common understanding of the patient including the plan of care and expected outcomes. Communication failure and risk to patient safety is always a discussion topic for administrators, managers, researchers, and regulatory agencies. The main problem in my organization is that the SBAR technique has little room for improvement of communication when it should be the tool for improving communication. Despite the efforts to improve situational awareness, there is an increase in medical errors and the patient satisfaction scores from the department are poor.
The emergency department offers surveys to patients to assess the quality of services provided and the level of satisfaction. Previously, the department has recorded good scores attributed to good coordination of care and implementation of quality improvement processes like SBAR communication. However, patient satisfaction scores in the facility continue to decline due to poor communication. Numerous complaints of delayed admission, increased waiting times and increased adverse events are observed in the unit. When comparing the scores on nurses’ and doctors’ communication to patients with other departments, the ED has poor scores. This problem has also led to the decline of the overall hospital HCAHPS scores and without prompt intervention, it can affect hospital reimbursements from Medicare and Medicaid Services.
Effective communication is central to safe and effective patient care. Delivering care to patients requires clinical accuracy including proper diagnosis, performing procedures, and transferring care to colleagues. Research establishes that organizations with good communication channels enrich their patient’s health while those with poor communication impact the patient’s well-being (Shahid & Thomas, 2018). Better communication is a strategy that helps institutions to save costs, increase operating efficiency, and protect their patients. When considering the importance of improved communication, patient safety is one of the top reasons to create good communication channels in hospital departments. Additionally, good communication improves relationships between healthcare providers and fosters multidisciplinary approaches to patient care. Effective communication creates a platform for collaboration with colleagues which forms a strategy for problem-solving while improving quality care. The Joint Commission through the introduction of the National Patient Safety Goal to improve communication aims at providing safe, timely, effective, patient-centered, and equitable healthcare.
Communication in healthcare is a factor that is directly related to patient satisfaction. Concerning patient system interactions, patients need to convey information about their health to healthcare workers. Likewise, healthcare providers must communicate adequately and interpret the patient’s information to effectively address their concerns. Additionally, healthcare workers must convey adequate information to patients and colleagues to enable the making of healthy choices that meet the expected outcomes. Poor communication hinders patient satisfaction because of delayed procedures, increased errors, and failure to deliver quality services. To improve patient satisfaction, healthcare organizations must establish clear communication channels across all departments. Improved patient satisfaction has positive influences on reimbursements that can strengthen the financial status of the institution.
Explanation of Causes
Ineffective communication nullifies any attempt at delivering quality care because it leads to negative outcomes including a greater cost burden to organizations. Communication problems are multidimensional and can be influenced by organizational patient flow, information design, cultural backgrounds, education level, and hierarchical structure. Poor communication is likely to be observed in healthcare if the top management is not vigilant in fostering communication and implementing tools to improve the practice. For instance, institutions that use SBAR communication strategy are likely to perform better because of good care coordination than their counterparts (Shahid & Thomas, 2018). The second reason for poor communication is collaboration failure between healthcare teams. Failure for collaborative practice can result from a superiority complex, especially between physicians and nurses. Sometimes the physician team might fail to adhere to the calls by nurses because they have the upper hand in making decisions regarding the treatment of patients. The result is poor communication which affects the quality of services delivered.
Equality between healthcare teams can have a huge impact on communication in organizations. There is no special category of healthcare providers that should think safe and quality services are dependent on their input. A study conducted by Spiridonov (2017) found out that the main cause of poor communication is inequality between the characters of colleagues and individual healthcare teams. When one healthcare team is treated specially, communication fails to thrive (Spiridonov, 2017). Apart from differences in professionalism, poor communication can result from the education level between healthcare teams. Some individuals might find it difficult to report patient data and elaborate on some aspects because of their education level. When some information is missed, patients are greatly affected because the errors and adverse events observed can lead to death or increased cost of healthcare delivery.
Poor communication in healthcare is dependent on other factors such as the staffing ratios and the number of patients seeking healthcare delivery (Spiridonov, 2017). In busy healthcare departments such as the ED, effective communication can be hindered by the number of patients at a particular time ad the workload available. Consequently, low staffing ratios mean nurses and physicians will be overwhelmed with work leading to a breakdown in communication. Even with well-established communication tools in the department, providers might lack time to implement the practice leading to communication errors. Another common cause of poor communication is the failure to adhere to the set guidelines due to ignorance and personal factors. There is a need for every healthcare practitioner to monitor their colleagues for communication and report any barriers that might arise.
Identification of Stakeholders
Improving communication in healthcare is not an individual effort, but rather a collaborative practice between internal and external stakeholders. Internally, communication can be improved by involving the healthcare administration, the physicians, the nurses, and patients. These stakeholders are directly involved in implementing tools and monitoring processes to ensure good communication is established. Externally, payers and regulatory bodies can have an interest in ensuring good communication is established to meet the set standards and achieve quality.
The hospital administration functions to monitor processes and implement quality improvement projects in healthcare organizations. Good communication is part of the strategies used to achieve the set goals while ensuring every member of the healthcare team is informed about the QI projects. The primary function of the administration will be to ensure a quality improvement project is established to improve communication between nurses, physicians, and patients in the emergency department. The team will also ensure that the project is fully implemented, policies regarding the change are set and each member of the healthcare team follows the new guidelines.
Nurses spend most of the time with patients and other providers and improving communication can be a great deal to foster relationships at work. The role of nurses is to communicate to patients about their care and collaborate with the physicians to ensure quality care delivery to patients. Additionally, communication for nurses involves documentation of findings to enable continuity of care. The proposed change will involve the nurses and they will be responsible for communicating care to patients, fellow nurses during shift handoffs, and physicians. The physician team works together with the nurses to deliver quality services to patients and this involves good communication. The nurses and other healthcare members often consult with the physicians during admission and routine patient care. The role of the physicians will be to effectively handle information and make appropriate decisions regarding patient care. The team will also communicate directly with the patients and nurses during the process of quality improvement.
Patients and families are important members during quality improvement because they are direct recipients of care. These members will be part of the team to ensure the success of the proposed change by providing feedback on the process. Additionally, the patients will report their satisfaction with care which will form a basis to evaluate the success of the project. External stakeholders like the payers and regulatory bodies will evaluate the quality improvement process by analyzing patient satisfaction scores. Communication is an aspect that is highly emphasized in the HCAHPS scores whereby nurses and doctors are supposed to communicate care and attend to patients promptly.
Discussion of Stakeholders
In many healthcare systems, strategies are deployed to engage different stakeholders in decisions affecting hospital services. The hospital administrators are always at the forefront to make decisions regarding policy change and process improvement. These members have the power to accept project proposals and design ways to implement new strategies to improve quality. Secondly, the administrators have the power to make policies regarding the new change and take disciplinary action against those who do not follow the hospital policies. Apart from the power to make policies, the administrators are interested in improving quality care in the facility and engaging employees in making choices that can benefit the patients. The administration can influence the proposed project by demonstrating support to the improvement of communication which can change the way employees respond to quality improvement projects. Lack of support for the project will definitely hinder how nurses and physicians will respond to the new change.
The nursing team together with the nurse leaders are crucial team players when it comes to policies and process improvement in healthcare. They act as advocates for the patients and work to ensure that implemented projects are at the benefit of the patients (Malfait et al., 2017). The proposed project will be implemented by the emergency department nursing team who have the power to accept or deny the change with substantial evidence. Being the largest member of the healthcare team, the nurses have the power to change how communication is channeled in the unit to promote patient safety. The interest of the nurses can be described from the front of the nurse leaders and the regular nursing staff. Nursing leaders are interested in making decisions that can impact the quality of nursing care while saving costs for the patient. On the other hand, registered nurses are interested in implementing processes that can improve the patient experience while minimizing harm. Support of the proposal by the nursing team will definitely influence the other healthcare team members like the physicians into accepting the new change. Additionally, the nursing team can influence how the administration deals with process improvement including policy changes in the institution.
Process improvement in healthcare involves multidisciplinary approaches and physicians are part of the team that influences policy. The new project proposal will directly involve the physicians who will communicate care with the nurses and patients. This team has the power to accept the new proposal or make changes that can help in improving communication. Just like the nursing team, the physicians are interested in improving quality service delivery to patients through the implementation of projects. Additionally, the physicians are part of the team interested in improving patient experiences to achieve patient satisfaction. Through their involvement, the physicians can influence how other healthcare team members perceive the new change including the active involvement of the administration in support of the project.
Patient satisfaction corresponds with how well healthcare services align with the patient’s expectation of care. Today, patient satisfaction is the force behind the recognition of healthcare institutions and reimbursement by Medicare and Medicaid Services (Malfait et al., 2017). This means process improvement should aim at involving patients in their care while focusing on the individual needs of the clients. While patients might have little power in this project proposal, their perception of communication strategies can determine the change of methods. The patients/families have an interest in the project because the new change will affect how services are provided and how information is communicated in the unit. If the new project does not benefit the patients, they can influence policies regarding communication in the facility.
Explanation of Project
In recent years, the healthcare system has moved into interprofessional collaboration where communication is very important to ensure patient safety. While every organization strives to improve communication, there is a need to use evidence-based strategies and best practices to guide process improvement in the facilities. Additionally, every member of the healthcare team must be involved in communication improvement because the future of any organization depends on effective communication. The problem in my organization is poor communication between nurses and other healthcare teams which hinders patient safety and patient satisfaction. The primary purpose of this project is to implement a quality improvement program that can improve communication between nurses and physicians. Upon improvement of communication, the project aims at involving different members of the healthcare team to improve patient satisfaction through the use of implemented programs.
Evidence-based practice (EBP) is the conscientious use of current best evidence in making decisions about patient care. This strategy is supported by researchers and professional bodies to improve processes in healthcare because it uses approved methods for achieving quality care. In this project, evidence-based practice will be used to improve compliance with the already established SBAR communication strategy in the emergency department to improve upon the practice. Apart from benefiting the organization and the patient, this project will help me grow as a nurse by utilizing nursing research to achieve key competencies of my nursing profession. Therefore, this project aims at demonstrating the synthesis of key professional competencies in areas of communication and building relationships, knowledge of healthcare environment, leadership, collaboration, and organizational business administration. The project will demonstrate collaborative practice between nurses, physicians, patients/families, and the administration in improving communication in the identified unit.
The handoff from one healthcare provider to another is recognized to be vulnerable to communication failures. Due to this, effective communication is required to improve the quality of services and prevent errors that can result in inaccurate patient plans, delayed admissions, duplicate tests, and delayed discharge of the patient. The SBAR communication strategy is recognized as the most effective tool to improve communication between nurses and other healthcare teams. Despite the use of SBAR in many institutions, communication is still a problem because providers do not include all the necessary information while reporting care. The proposed solution in this project will involve the implementation of an SBAR handover checklist to serve as a tool to monitor the effective use of SBAR technique in communication for nurses and the physician team in the emergency department.
Improving communication in healthcare is a multidisciplinary approach that requires input from every staff member in the respective units. The proposed method of implementing the SBAR handover checklist will primarily involve the nursing team and the physicians in the emergency department into the admitting unit. The purpose of the tool is to allow observers to give feedback to their colleagues on their use of the SBAR communication technique in patient handover. The checklist which will contain structured questions regarding each part of the situation, assessment, background, and recommendation will be filled each time shift handoffs are given and when the nurses or physicians make calls to inform on patient care. At the end of the checklist, the individual will give an overall rating of the handover which will be either very effective, effective, fair, ineffective, or very ineffective. Because of the increased workload in the department, the charge nurse will be responsible for documenting the tool including calls made to or by the physicians.
Effective information transfer in the health care system is a vital component of safe patient care and one of the top priorities for improvements in patient safety worldwide. Among the areas that are challenging in nursing is the effective exchange of patient information during shift handoff. A research was conducted to assess the nursing handoff skill using the SBAR technique and its effectiveness assessed using a handoff questionnaire. The observational study involved 64 nurses in internal and surgical wards where handoffs were given using the SBAR technique while an observer assessed the performance of nurses and recorded the results. Upon analysis of the findings, it was observed that nurses paid more attention to routine aspects of patient care and overlooked aspects of reporting clinical background and assessment of systems (Beigmoradi et al., 2019). The conclusion from the study indicates SBAR checklists can help identify areas that are poorly addressed during communication giving room for improvement.
Improving quality and safety in healthcare has become a priority for hospitals worldwide. While addressing the issue of quality, improving communication is observed to be the hallmark of providing safe and reliable care (wang et al., 2017). An integrative literature review was conducted to determine strategies that are used to improve communication between nurses and physicians in intensive care units. Both qualitative and quantitative research articles were included in the integrative review done using the Medline, CINAHL, and Science Direct databases. The results from the integrative review identified the use of an electronic SBAR documentation template alongside other checklist tools as effective measures to improve communication. It was observed that the tool increased the frequency of using SBAR communication and it boosted proper reporting of cases in the intensive care units (Wang et al., 2017). Additionally, electronic recording SBAR tools served as reminders to the nurses to provide detailed and complete records of the changes in the patient’s conditions.
Communication in healthcare is important especially during critical events because an action is required immediately. Studies have focused on ways to improve communication during these times and the use of SBAR alongside read-back strategies top the charts. Lee and Kim (2020) conducted a study to determine whether SBAR communication and Read Back (SBAR-R) strategies are related to team task performance in a simulated emergency. The study used 49 teams and trained observers who recorded communication using an established checklist. Analysis of results indicated that SBAR communication was effective in improving communication during emergencies. However, the checklist determined that the information provided was mainly consistent with the assessment aspect of the SBAR technique (Lee & Kim, 2020). By using the observer method, healthcare organizations can help identify areas for improvement while using SBAR to communicate.
Patients admitted to healthcare settings are treated by interdisciplinary teams and effective communication is required to reduce adverse events. A prospective study was conducted to introduce and evaluate compliance with the documentation of the SBAR technique for improving communication. An SBAR form or checklist was disseminated during shift handover where the team leader recorded aspects that were addressed as per the standard guidelines. Upon analysis of results, it was observed that communication aspects such as allergies, relevant history, and identification of comorbidities were frequently skipped (Achrekar et al., 2016). It was also observed that the use of the checklist only served to be important for later debriefing rather than helping the situation at hand. The results are consistent with findings from Shahid and Thomas (2018) who established that SBAR provides a structured format of communication but becomes difficult to implement especially in a critical care setting where patients have complex medical histories.
Plan of Action
The initial steps for the project implementation will involve seeking approval from the hospital administration for the conduction of the study. Upon approval, the second step will involve involving the members of the healthcare team including nurses, physicians, and patients/families in the new change process. Communication of the project will be done through the emergency department unit in-charge. While communication is underlying, I will work together with the hospital research unit to identify evidence supporting the new practice. The gathered evidence will be used during the initial stakeholder meeting to describe the need for change and the relevance of the proposal to patients and the organization.
The second phase of implementation will involve the allocation of resources, identification of team leaders, and education of the nurses and physicians on the use of the SBAR checklist. The hospital administration will be contacted to provide resources such as meeting rooms and monitors for educational practices. The clinical nurse educator will help to mobilize the ED nurses and physicians for education about the SBAR technique and the relevance of the new proposal. Identification of the team leaders during the implementation phase will be done during the meeting. The last step will involve the actual implementation of the SBAR checklist use in improving communication. Weekly discussions will be held between the team leaders to discuss findings and solve any problems. Intermittent evaluations will be done at the end of each week to ascertain improvement and make minor changes.
A four weeks timeline will be enough to fully implement the proposed change in the hospital emergency department. Week 1 of the project will include seeking approval from the administration, collection of data regarding the new change, and communication of the project to the healthcare workers. Week 2 will involve allocation and mobilization of required resources, identification of training rooms, and scheduling training sessions for nurses and physicians. Week 3 will involve the selection of project team leaders depending on predetermined staff shifts, training of staff on the use of checklists, and communication of expected outcomes. Week 4 will involve the actual implementation of strategy and reporting of the findings at the end of the week during meetings.
Required resources and Personnel
To effectively implement the project, the hospital will provide ground for education and training of healthcare personnel. Additionally, writing materials and printing papers for the SBAR checklist will be required. To assist with the project, the nurse educator and the emergency department charge nurse will be involved. The nurse educator will organize the education programs regarding SBAR communication and the use of the SBAR checklist for providers. The ED charge nurse will ensure coordination of care within the department including communication between project leaders and staff.
Proposed Change Theory
Kurt Lewin described three stages of change management including unfreezing, changing, and refreezing. The unfreezing stage involves the creation of awareness for change through the presentation of facts. Lewin expressed the need to use effective communication and seeking support from leaders to ensure acceptance of the change. Upon establishing the need for change, the second stage involves the implementation of change which is made effective through education, communication, and provision of support. The last step involves refreezing to establish the act of reinforcing, solidifying, and stabilizing the new change. Efforts to prevent loss of the change include using rewards and making policies.
The unfreezing stage will be utilized by educating staff on the need for the new change by providing evidence of poor patient satisfaction scores. The administration department will be asked to support the new change to help employees accept the practice change. During the implementation phase, weekly meetings will serve to analyze results that will be communicated to the healthcare team during shifts. The team leaders will remind the nurses of the reason for the project to improve compliance with the SBAR communication strategy. The refreezing stage will be utilized through making policies regarding the use of checklists in improving communication. Continuous monitoring of the strategy by nurse leaders will also serve to reinforce the practice.
Barriers to Implementation
During the implementation of the project, time will be the most scarce resource because of the busy nature of the emergency department. It will be challenging for the team leaders to keep an eye on SBAR reporting during calls and shift handoffs including documentation. Additionally, the employees might find it difficult to address all aspects required depending on the urgency of the patient’s condition and available workload. The second anticipated barrier is the rejection of the practice by healthcare providers who might present a lack of time and limited staffing as hindrances to the new change practice.
Achrekar, M. S., Murthy, V., Kanan, S., Shetty, R., Nair, M., & Khattry, N. (2016). Introduction of situation, background, assessment, recommendation into nursing practice: A prospective study. Asia-Pacific Journal of Oncology Nursing, 3(1), 45. doi: 10.4103/2347-5625.178171
Beigmoradi, S., Pourshirvani, A., Pazokian, M., & Nasiri, M. (2019). Evaluation of nursing handoff skill among nurses using situation-background-assessment-recommendation checklist in general wards. Evidence Based Care, 9(3), 63-68.
Lee, K. R., & Kim, E. J. (2020). Relationship between interprofessional communication and team task performance. Clinical Simulation In Nursing, 43, 44-50. https://doi.org/10.1016/j.ecns.2020.02.002
Malfait, S., Van Hecke, A., Hellings, J., De Bodt, G., & Eeckloo, K. (2017). The impact of stakeholder involvement in hospital policy decision-making: A study of the hospital’s business processes. Acta Clinica Belgica, 72(1), 63–71. https://doi.org/10.1080/17843286.2016.1246681
Shahid, S., & Thomas, S. (2018). Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care–a narrative review. Safety in Health, 4(1), 7. https://doi.org/10.1186/s40886-018-0073-1
Spiridonov, S. I. (2017). Causes for ineffective communication between medical specialists. Journal of IMAB–Annual Proceeding Scientific Papers, 23(3), 1623-1626. DOI: 10.5272/jimab.2017233.1623
Wang, Y. Y., Wan, Q. Q., Lin, F., Zhou, W. J., & Shang, S. M. (2018). Interventions to improve communication between nurses and physicians in the intensive care unit: An integrative literature review. International Journal of Nursing Sciences, 5(1), 81-88. https://doi.org/10.1016/j.ijnss.2017.09.007
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