Research: Improving Quality in Nurse Communication in Care Homes: Introduction of SBAR (Situation Background Assessment Recommendation) – a tool to catalyze change
2016/38 - Jyoti Tiwari
As part of the dissertation module for the BSc in Nursing, kindly sponsored by the Florence Nightingale Foundation and BUPA, a service improvement project was carried out in the work place. The report aims to analyse and critique the agreed service improvement project as well as describe the challenged faced personally and professionally. A range of options and potential solutions were explored and the most appropriate approach was selected to achieve successful improvements in the project. Evidence to underpin the project was gathered from a variety of sources and critically analysed. Effective change management was explored from identifying the problem to sustaining the change.
Improving the work processes by creating and designing systems while keeping clients at the centre of everything is a pressing need in the NHS currently. The National Leadership Framework (NLC 2011) emphasizes that frontline staff are key to these service improvements and it could be any staff irrespective of their job title. Being a Registered Nurse and bound by The Code (NMC 2015), it is imperative for improving the services in a constant basis. The importance of carrying out service improvement is also discussed by the Health and Social Care Act (2012) by exploring that there is a need for change in the NHS, including quality of services in long term care. In addition to that, the needs for improvement in services has also been influenced by the policies produced by the government in response to the Mid- Staff enquiry (Department of Health 2014a; 2014b). It is crucial for any improvement action to be prepared in a systematic way.
Recognition of problem
The first step to effectively managing the change is the Recognition of the problem. This took place in the current work setting by analysing the fax forms that were used by the nurses to send fax to GP’s. The pre- project data identified that out of the 100 fax forms that were being used, 50 came back from surgery requesting for more information prior to GP making any decision about the treatment. This is an example of the ineffective communication that occurs in the health care. It is obvious that this has delayed the process of effective medical management and affects the patients safety. Out of the 5 domains from the NHS outcomes framework 2015/16 (Department of Health 2014), ineffective communication affects domain 3 and 5. It is therefore, crucial for any service improvement to work towards fulfilling the domains. In this situation, it was important to improve the way nurses wrote information to GP. Effective Communication and its importance has also been mentioned in The Code (NMC 2015). This document emphasizes on nurses communicating clearly and accurately to prevent any possible delay in treatment.
It has been explained by the NHS Institute for Innovation and Improvement (2008) that a Route - Cause Analysis is a suitable approach to identify the cause of a problem. So, this was carried out in a fish bone diagram to identify the causes behind the problem. The fish bone identified three aspects of key causes for the faxes being returned from GP. One of the important ones was that the nurses did not always know what information to write on the fax form and had to hint and guess. This was supported by the GP who explained that she could not make decision on the basis of one fax which was inadequately completed and had to send fax back for more information. Another key aspect was the method used which identified that the FAX form that was being used did not actually state what information was needed. One of the barriers that nurses experienced was that forms were not always available when they needed it and the high turnover of agency staff made the condition worse as they did not know residents and the processes to escalate issues.
First of all, the options for solving the problem was identified using the current evidence based literature. There were two tools identified for improving the approach of communication in health care industry. The first one was the RSVP (Reason Story Vital Signs Plan) approach which had very little amount of research available. Featherstone et al (2008) recommended its usage over the use of SBAR (Situation Background Assessment Recommendation) criticizing that SBAR was more difficult to remember compared to RSVP. However, there were no researches found comparing SBAR’s importance over RSVP. On the other hand, SBAR tool was recommended by the NHS England, Royal College of Nursing and the Royal College of Physicians. It was supported with loads of evidences. It was therefore obvious to choose SBAR as the service improvement option.
Once the option for change was carried out the second step was to explore the users of change. Early adopters were identified as these are the key people for the improvement as suggested by Moore (2007).
Finally, barriers for the project were analysed. One of the barrier that was identified was to change the culture. It was quite difficult to change the way the qualified and experienced nurses communicated with the team. This was solved with the trainings videos showing the use of SBAR.
This project has proved to be an invaluable source in my personal and professional development. The total journey of the project has been excellent. Exploring each step of the change management model into the proposed plan into details has increased my level of knowledge and understanding of not only the topic but also each steps. Also choosing the topic, designing the survey forms, creating a poster and the little tasks that were involved into the work has been a huge learning step. As it was my first project, I was nervous and did not know where to start, however, I now feel that I would be able to start another project with lots of confidence and knowledge. I also learnt that the project lead ought to be around throughout the project, especially in the early implementing stages. This is to enable clarification on any misunderstandings of the project.
Having realised the importance of structured communication produced by SBAR, after disseminating the project into the British Journal of Nursing, I would be looking to examine if SBAR would not only be used in health care but in the other sectors too like raising concerns with accountancy, housekeeping and maintenance departments.
The evaluation concluded the improvement to be a success with rooms for improvement as it was not a 100 percent achievement. Therefore, it would be continuously monitored and team would be supported to sustain the change until a better idea comes when today’s change would be resistance for tomorrow. The wealth of knowledge and experience that the project has provided has been invaluable.