SBAR Summary

Implementation of a standardized reporting tool to be utilized during a patient triage visit required the masters prepared nurse to develop and design the communication tool. After obtaining approval from the Clinical Nurse Supervisor, a collaborative literature review was conducted on the most recent research on nurse to provider SBAR documentation. The masters prepared nurse determined SBAR documentation would improve communication between nurse and provider during a patient triage visit.
Engaging with staff registered nurses and providers proved to be of great value in determining what their ideal reporting tool would include. In addition to the SBAR format, staff expressed the need to identify the patient’s primary provider in the documentation.
This would allow the triage provider and the nurse to notify the appropriate team of the patient complaints, treatment plan, and need for follow up.
After meeting with staff, the next step in the process was to create the SBAR tool. The tool was divided into four categories, which included situation, background, assessment, and recommendation. The masters prepared nurse met with the Information Management Specialist to develop the template and insert it into the electronic health record system. This allowed for pertinent information to automatically populate the appropriate area within the SBAR template, eliminating the need to search through the electronic health record and manually enter the information. This included name, age, sex, vital signs, pain assessment tool, current medication list, and allergy assessment. Additionally, an area to document education provided with patient level of understanding were added to the template due to a facility requirement of documenting this process at each patient visit. An open field was added to the template to allow the nurses to enter additional information pertinent to the patient visit which are not addressed within the SBAR template.
The proposed SBAR reporting tool was then presented to the Clinical Nurse Supervisor and Director of Out-Patient Services for review and approval. The feedback received indicated that the tool was appropriate and therefore the trial SBAR template was ready to be presented to the team.
When implementing a change, it is important to teach the staff about the new concept and provide supporting evidence.
The team was presented with the tool and education regarding the SBAR template one week prior to the proposed start of the pilot. This allowed for feedback and identification of any barrier amongst the staff members.
The SBAR tool was utilized by the staff for a predetermined one-week period. The researcher was available to answer questions and provide support during the one-week period. After the initial pilot period, feedback from the nurses and provider were obtained, and minor changes were made to the template. The duration of the second trial was one week, and additional feedback was obtained. No changes to the template were identified after the second trial. The team feedback was shared with the Director of Out-Patient Services and Clinical Nurse supervisor. It was decided that the SBAR tool was appropriate for incorporation into the reporting process for a triage nursing, and would continue to be used by the team.
Monitoring of the teams use of the SBAR template during a nursing triage visit is ongoing. Although the SBAR template has not been approved for use facility wide, the initial feedback from the team indicated the communication has improved between the nurse and provider and they have integrated the process into daily
practice.