Abstract:

Communication is a very important aspect of medical training. Poor communication is the root cause for the majority of complaints against the National Health Service (NHS) (Pincock S. , 2004). Communication is especially important at handover to ensure continuity of appropriate medical care and to ensure safety of patients. The added constraint in medical handovers is that the process is limited by time. The SBAR (Situation, Background, Assessment and Recommendation) tool is intended for effective transfer of information between health professionals in a concise, factual and standardised structure. This article assesses the importance of teaching communication in medical education with particular emphasis on handover, the available literature on SBAR and the author’s view on SBAR as a communication tool for medical students and trainee doctors.

Introduction

Communication lies at the heart of good medical practice. The General Medical Council has mandated the need for good communication skills to ensure that patients are kept informed of their condition, progress, investigations, treatment and progress. Good communication skills are also necessary to ensure continuity of patient care and to ensure patient safety. The introduction of the shift system has made effective communication more important (General Medical Council).

Poor communication is the root cause for the majority of complaints in the National Health Service. Poor communication between health professionals, failure to take informed consent and improper handling of complaints are the major reasons and effective communication could have reduced the disputes and complaints (Pincock S. , 2004).

Teaching communication to medical students in UK medical schools

The UK council of communication skills in undergraduate medical education was established in 2005 with the aim of raising awareness, to improve current teaching, to improve and to develop consensus on the communication training provided to medical students (The UK council of communication skills in undergraduate medical education). This in the author’s opinion represents a major step towards recognition of the need for training medical students in communication skills training. In addition to the benefits which better communication has in relation to patient safety and reducing complaints, research has indicated that teaching communication skills to medical students improved their overall performance (Smith, Hanson, & Tewskbury, 2007).

The medical handover: communication is vital

The National patient safety agency (NPSA), London has defined handover as “The transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis” (National Patient Safety agency, 2007).

Medical handover is one of the most important procedures and has the potential for causing errors and harm if done improperly. It is also a very frequent occurrence with the advent of the shift system of working. The General Medical Council has also recognised the importance of a good handover and explained that “‘keep colleagues well informed when sharing the care of patients” (General Medical Council).

Benefits of a good handover

Good handover has several benefits both for the doctor and the patient. For the doctor the handover session can be used to improve communication skills and can also be used to teach clinical medicine. A good handover also makes working less stressful as the doctors on the shift have will have good knowledge about the patients and their management plans. The British Medical Association has also opined that clear communication at handover will protect the doctor against blame for errors (British Medical Association, 2004).

Good handover also benefits the patient by providing continuity of care, providing safety, decreasing repetition and in providing better service satisfaction. There are several critical incidents of patient safety being compromised because of the lack of clear handover between teams (British Medical Association, 2004).

Constraints to good handover

There are several constraints to a detailed handover. In the author’s own experience of handover in an intensive care area, the time allocated for handover is often insufficient to handover all details of patient care. Although the morning handover is led by the consultant on call and attended by a multidisciplinary team involving the physiotherapist and the in charge nurse, evening handover often involves only the junior doctors on call. Because of the complex problems which most patients on intensive care have, the handover often extends beyond the allocated time of 30 minutes. This means that the doctors who are leaving are unable to do so on time and those who are starting are not able to get on with their duties on time; both these situations lead to a sense of dissatisfaction with the job. The handover venue varies from the patients’ bedside to the doctors’ office and therefore lacks uniformity and continuity. Further the handover can be interrupted by non-emergency calls from different parts of the hospital. On some occasions handover is taken by one team while the other team is setting up the ventilator and this results in an unsatisfactory handover.

Because of the presence of personnel from paediatric, intensive care, anaesthetic, nursing and other allied health back grounds at the morning handover, there are significant differences in the style, length and the importance which different people place on different aspects of the handover. Also the experience levels of the different trainees are variable and they vary in the ability to highlight important aspects of patient care and in their ability to summarise the progress of a patient in a concise way.

Need for a structure to handover

One of the criticisms of handover among healthcare professionals is the “hint and hope” approach where one person hints at what might be going on without giving any specific details and hopes to get a specific response or action (Featherston, 2005).

The handover process needs to be streamlined to allow transfer of a large amount of information regarding very sick patients with complex needs in a time limited manner. This means that there is a need for a system of handover which is structured, complete, relevant and concise to ensure uniformity of the process and to ensure continuity of patient care.

Literature of handover in other hospital settings

A study of handover of clinical care from ambulance crew to the emergency department personnel showed that there were concerns regarding the quality and quantity of handover, the staff perception of handover and staff education. This study also identified the need for a standardised handover process which would enable smooth transfer of patient care and also provide opportunity for the receiving team to assess and prioritise their work (Bost, Crilly, & Wallis, 2010). The British Medical Association (British Medical Association, 2004), The General Medical (General Medical Council) and the National patient safety agency (National Patient Safety agency, 2007) have all emphasised the need to develop a system of effective handover.

SBAR

SBAR (Situation, background, assessment, recommendation) is a communication technique that provides a structure for communication between healthcare professionals. SBAR was developed by Dr. Leonard and colleagues in 2006. It is useful for handover from nurse to nurse, doctor to doctor and doctor to nurse. SBAR enables healthcare professionals to communicate in a specific framework.

When applied to handover communication, S stands for situation which is a short description of the problem, its severity and when it started. B stands for pertinent background describing the admission diagnosis, results of investigations and other clinical information. Details of current resuscitation status could also be included in this. A stands for the handing over team’ assessment of the patient status and R stands for recommendation on how the patient should be managed. Recommendation can also be used to update the team receiving the handover on how quickly a patient needs to be seen and this can help them prioritise their tasks.

Literature on use of SBAR

SBAR is relatively new and there have only been a few studies looking into its impact on communication and patient safety. One study demonstrated that staff found SBAR tool helpful in team and individual communication. As a result of this the study team using SBAR perceived an improvement in patient safety culture. The study group also showed an improvement in reporting of incidents and near misses in the team and in the institution where study was done (Velji, Baker, & Fancott, 2008).

Another study found fewer missed information at handover and suggested that this improved patient safety. The authors of this study opined that this was the result of information transfer in a concise and organised format (Haig & Sutton, 2006).

Other studies have reported mixed results. A study from Texas found no or slightly negative impact on the nurse confidence while talking to physicians, safety on the unit and satisfaction with working on the unit. However there was some benefit on communication openness and in feedback about errors. It must be noted that this study was based on a comparison of key outcome measures following a four hour classroom training on SBAR which the authors themselves describe as inadequate. The authors have advised caution regarding the widespread use of SBAR despite the lack of evidence of its effectiveness (Carroll, 2006).

The SBAR collaborative communication evidence based practice study (SBAR EBP) showed that use of SBAR resulted in transfer of evidence, knowledge and clinical skills. The second outcome from this study was the benefits noted in communication, teamwork and safety environment. However as the authors of this study note, there are no studies so far which demonstrate benefits in patient outcomes or patient collaboration. This study also noted that no physicians participated in the SBAR collaborative-communication education. The authors also noted that physicians felt that SBAR teaching was meant for nurses and that doctors do not need to attend nursing classes (Beckett & Kipnis, 2009).

Summary of the evidence and opinion

It is the author’s view that SBAR as a tool for handover will act as a uniform model around which staff can communicate at handover. It also encourages critical thinking around the time of handover. It allows precise, complete and concise transfer of information at handover. This is likely to improve better team working and ultimately improve patient safety. However there are likely to be impediments to the implementation of SBAR for handover. Doctors especially at more senior levels are likely to ask for evidence regarding the positive effects of SBAR on patient safety before they support its implementation on a wider basis. Therefore there is a need for large well designed studies to demonstrate a significant benefit from use of SBAR not only on the staff perceptions and communication skills but also on patient safety.

Teaching SBAR to medical students and trainee doctors

It is author’s opinion that communication models on medical handover should be taught from medical school days. The transition from student to doctor is huge and medical students should be trained to have the skills to make this transition as smooth as possible. There is limited literature available on teaching SBAR to medical students. One study using a simulated clinical setting found that medical students who went through 40 minute training on a modified SBAR model (ISBAR), performed significantly better than controls on a content and clarity global rating score (Marshall, Harrison, & Flanagan, 2009). There is literature available on teaching SBAR to nursing students and the benefits it has had (Thomas, E, & Johnson, 2009), (Wood, 2008) (Kesten & Karen, 2011). The uptake of SBAR seems to be more robust amongst the nursing professionals than the medical professionals. As the uptake of SBAR increases it would become more important that medical professionals also become proficient in the use of SBAR as a model of communication. Therefore there is a need for both doctors in training and medical students to be trained in the use of SBAR.

Recommendations on training in SBAR for use in medical handover

Based on the experience of handover in an intensive care setting and after review of the above literature, it is the author’s opinion that systems for handover need a radical overhaul to ensure patient safety and to improve communication within teams. One of the steps is a structure to the handover progress in the form of the SBAR. As a first step junior doctors need training in the use of SBAR for handover. Prior to the intervention, a baseline assessment of communication skills using an appropriate tool would help monitor progress. This can be in the form of an interactive small group discussion where the process of SBAR is fully explored. It is also important to present the available evidence on SBAR and how it can improve communication outcomes and potentially patient outcomes. A simulation exercise at the end of the discussion will also help doctors understand the skills needed. This teaching session needs to be done on several days and at times and location which facilitate and encourage junior doctor participation. The aim is to ensure that all the junior doctors in the particular unit or institution have the opportunity to attend this session.

A separate session needs to be organised for the consultants who will be supervising the junior doctors as they implement SBAR. Consultants will need to play a major role in enforcing the use of this tool and also to monitor the effectiveness of this tool. Consultant supervision is essential to support the handover process using SBAR and also to facilitate the involvement of multidisciplinary teams at the handover.

Handover based on SBAR should also be accompanied by robust changes like having a dedicated time and place for the morning and night handovers, making sure that the handover is not interrupted for non-emergency reasons and to ensure the availability of electronic resources which can facilitate handover.

After a pre-defined period where SBAR process is implemented, there needs to be an evaluation of the effect SBAR has had on the handover process in particular and communication in general. Evidence of improvement in the handover process will encourage staff to improve further on their skills. The process of implementation should be dynamic and continuous until the process becomes a part of the working culture.

Summary and conclusions

Inadequate handover poses significant risks to the personnel involved, their organization and their patients. Handover therefore needs to be complete, specific, concise and structured to allow effective transfer of information. Use of SBAR will provide a structure to the handover progress. There is evidence that use of SBAR has positive benefits on team working and communication and it is likely that this has a positive effect on patient safety. The process of implementation of SBAR will involve training of staff with supervision and mentoring from senior members of the team. There is also a need to conduct well designed studies to assess the impact of SBAR on medical handover and to determine potential benefits to patient safety.

=Do nurses need theory? A question that can be considered on many different levels. If one considers the evolution of nursing over time, one can observe that the nurse of antiquity was arguably as dependent on the prevalent theories of the day as the current nurse. Theory determines practice and theory justifies practice (Einstein paraphrased in Kuhse & Singer 2001). The nurse who changed the blood letting bowls of antiquity was as dependent upon the theories of imbalances in the humors for her practice as were the nurses in the wards of Ignaz Semmelweis (Semmelweis IP. 1861) who may well have found the idiosyncratic insistence on hand washing to remove the presence of the unseen agents of infection completely bizarre until the evidence base of reduction in puerperal infection could be clearly established.

In this latter comment we can find one of the major dilemmas facing the nursing theorists of today. The plethora of nursing theories have been subsumed into a goal (albeit defined by the theorists themselves) of finding a unified nursing theory. One that will define the human condition and also medical science’s response to the management of the various conditions of pathophysiology that can befall it. The stumbling block of many theories is the difficulty in establishing a credible evidence base to support it. (Brechin A et al. 2000). To revisit the Einstein quotation cited earlier, one can have a theory that may determine practice, but it is only with the demonstration of an evidence base that the theory can actually be used to justify practice.

One of the luminaries of nursing theory and practice was Martha Rogers, the late Dean of Nursing at New York University. To illustrate the point, Rogers published many nursing theories in her working life. Some (the Unitary theory) have gained a degree of general acceptance others have faded in the mists of time. It was her stated goal to define a unified theory of nursing. (Meleis, A 1997). The Rogerian approach appeared to have little room for establishment of evidence bases and we would suggest that this approach is essentially flawed. (Halpern S D 2005).

To consider an extrapolation into other scientific disciplines by way of analogy, we note that it has not been possible to define a unified theory of biological science. Biology is essentially a study of life in general. It does not seek to be a theory of life. Although theories may be postulated in the explanations of the various phenomenon encountered in the field, such as natural selection or the function of the genome, these are used to test the various hypotheses underpinning practical observations, laboratory work and in some cases, mathematical models. There is no all-encompassing biological theory. At a more fundamental level we can observe that biology is based on chemistry which, in turn, is ultimately based on principles of physics. Again we can observe that there is no unified theory encompassing the entire field. (after Green J et al. 1998). This analogy is applicable to nursing theory if one considers the huge range of skills and requirements needed by the modern professional nurse. The spectrum of tasks required and expected of the nurse in a variety of situations is legion. To be effective the nurse must understand the human condition from the viewpoint of the pathophysiology, the psychology, the human dynamic and socio-economic elements of the patient’s presentation and disease trajectory. (Yura H et al. 1998). Much of our understanding of these elements is encapsulated into various concepts or theories which are perhaps best regarded as dynamic and fluid or in a process of evolution. (Wadensten et al. 2003).

A practical consideration would suggest that the nurse is responsible for giving medication, undertaking procedures of medical intervention as well as caring for the general physical well-being of the patient, they record various parameters of their patient’s progress. They can be the patient’s advocate in terms of their dealings with other healthcare professionals, organisations or even commercial concerns. (Hogston, R et al. 2002). In order to carry out these ( and many other) functions efficiently. The nurse needs to be competent in a huge number of areas with skills in interpersonal relationships, organisational, technical and clerical areas. It follows that these skills are derived from a large number of disparate areas such as anatomy, physiology, therapeutics, psychology, management theory, bookkeeping and tabulation. (Mason T et al. 2003)

The point being made here is that, in the light of these comments, it seems inappropriate to consider that there should be, in Rogerian terms, a unified theory of nursing (Rogers, M E 1970). The overall goal would undoubtedly be that the professional nurse should seek to improve the overall well-being of their patients. This target is the accumulative result of any number of different and disparate processes and skills form many differing academic and human disciplines. We would suggest that it is not amenable to the reductionist philosophy of Rogers.

Despite the notable article by Christensen (P et al. 1994) which criticises authors who have applied such strategies to both extrapolate from and to expand implications of Rogerian theory, reductionist strategies are not totally inappropriate. In a further scientific analogy, we can point to a classic case of reductionism which contributed greatly to our understanding of the natural world. When Newton made his mathematical models linking orbiting planets, projectiles and falling apples, he produced one of the most dramatically valid reductions in scientific literature. Reductionism per se. is not an inappropriate process.

Herein lies a frequently perpetuated fallacy that permeates the field of literature on nursing theory. The term “Reduction“, in a nursing context, can have two distinct connotations. It can be observed that some nursing theorists apply the term to the tendency of some healthcare professionals to visualise and regard the patient as a number, a set of symptoms or a demonstration of a particular element of pathophysiology rather than as an individual in their own specific socio-economic, cultural and psychological setting. (Alcock P, 2003). Although this is a completely appropriate and specific use of the term, it is distinctly different from the implications of “Reductionism” in the scientific and analytical sense. Some nursing theorists (viz. Christensen) use the term in a derogatory or disparaging form that does not appreciate or even acknowledge the positive aspects of the technique. (Hott, J R et al. 1999).

We would suggest that such confusion in the terminology has led to some nursing theory being discredited. If we expand this theme by staying with Rogerian theory as an illustration of the point, we can suggest that in the broader context of medicine generally, scientific reduction has enabled progress in medical science by allowing the accurate identification of causal agents of disease and thereby allowing the development of appropriate strategies to combat and eliminate them. Nursing theorists should embrace this aspect of the concept of reductionism while combating any suggestion of a reduction of the status of the patient from that of an autonomous human being (Mill JS 1982).

To consider the situation as Christensen does and to decry the use of reductionism and to treat events as essentially causal, does no favours for the analytical process that is central to any theoretical process. It effectively takes nursing theory out of the realms of science which, almost by definition, considers processes as cause and effect. (Polit, D F et al. 1997). Even if we consider processes that are essentially acausal such as the spontaneous degradation of atomic nuclei, one can point to the fact that these processes are still quite capable of being considered reliable processes because they can be detected, demonstrated, quantifiable, repeatable and amenable to statistical analysis. If we contrast this to the nursing theorists in general, and perhaps Rogers in particular, we can show that their writing and reasoning is largely devoid of causal argument and subsequent reasoning. (Barnum, B J. S. 1998).

The reasons for this are clearly a matter of speculation. The less charitable analyst might be tempted to conclude that some of the theories propounded do not meet common sense standards. Few of the theories meet the criteria that would satisfy a reputable evidence base as they appear to avoid rigorous testing. To take a specific example, the theory of therapeutic touch is certainly complete enough to permit a degree of submission to testing. Much of the literature cited by Rogers is however, very subjective, done by unblinded clinicians and very speculative. Some is purely in the form of no more than reported anecdotes (Rosa, L et al. 1998).

This trend has done little to increase the confidence of the analytically minded investigator in the usefulness and relevance of nursing theory. To a casual observer, who considered only these elements of nursing theory, it might appear that the theorists had allowed themselves to become detached from the scientific rigour of logical deduction or experimental validation and thereby effectively deprived the field of any degree of precision of predictive possibility (which any useful theory should have). To support this view, one can cite Rogers herself (cited in Meleis 1997). “Reality does not exist but appears to exist as expressed by human beings”.

In this respect, we can put forward a coherent argument that nursing does not need theory.

Having presented this argument, we can also examine the opposing view put forward by Prof Margaret Rosenthal (Rosenthal 2000) in her thought provoking book “Changing Practice in Health and Social Care“. The book itself is primarily about accountability in healthcare, but in its discussion it considers the relevance of the nursing theorists in general. The author puts forward the view that the public have experienced a decline in the trust and standards of the healthcare professionals. She cites the media as being one of the major contributors to this erosion, rather than the actual reality of the situation and suggests that the way forward is to submit all types of clinical practice to the scrutiny of its evidence base. She suggests rejecting practices that do not have a secure evidence base in favour of those that do so that “at every level so that the public in general and the patients in particular, are able to feel confident in every therapeutic manoeuvre that they are offered“. (quote from McNicol M et al 1993 Pg 219). As an overview the author suggests that all dealings, whether they are practical or theoretical, should have “accountability as their watchword”.

In some respects, this is a simple conceptual extension of the comments advanced by Florence Nightingale a century and a half earlier, that the ultimate objective of working in a healthcare environment as a healthcare professional is to provide the best form of support, treatment and care for the patient. (Nightingale F 1859). We would both concur and expand the sentiments expressed by adding that this may be best achieved by considering that the best form of treatment is the one that has the strongest evidence base for its use.

Having made these comments, it is appropriate to consider the more positive aspects of nursing theory. If we accept Wadenstein’s view (Wadenstein B et al. 2003) that it is an important purpose of theories to challenge practice, create new approaches to practice and remodel the structures of rules and principles, then we could usefully progress this argument by considering some of those theories which help to explain patient behaviour and thereby modify the nursing approach.

The basic nursing process is traditionally based on assessment, planning, implementation and evaluation. The particular theories that we shall consider here, together with the models that they support, all basically follow the same pattern, but each analyses the patient situation from a different aspect or in different terms. (Fawcett J 2005)

The Roper Logan Tierney model (Roper, Logan and Tierney 2000) is primarily concerned with the activities of daily living. It requires identification of the problems and then dealing with them on a problem solving basis. This type of model has been extensively reported, evaluated and is one of the most generally accepted models of the nursing process. (Holland K et al. 2003). This type of approach is very useful for problems which are mainly or primarily based on a physical or disability orientated disease process. Its major shortcomings revolve around the fact that it is not very useful in describing strategies that cope with patient responses that are overtly manipulative or psychological in nature. The theories that underpin this model have largely withstood the test of time and clinical practice and have accumulated a large evidence base in the literature. (Holland K et al. 2003).

For patients who fall into the category of manipulation or functional symptomatology as a result of an adaptation process for coping with their illness the Roy adaptation model (Roy 1991) is useful in describing the abilities of a patient to adapt (or maladapt) to the evolving pattern of their illness. This model allows for changing perceptions and adaptation mechanisms on the part of the patient and can be used to explain the various behaviour patterns exhibited by various patients as their disease trajectory unfolds. It allows for the major patterns of illness adaptation but has the major shortcoming that it does not allow for the behaviour patterns that are consistent with denial of the underlying diagnosis. The patient who has a diagnosis of terminal cancer but copes with a total refusal to accept it and continues as if all is well, is not described in this particular approach. The model dismisses this as a degree of cognitive distortion rather than a coping mechanism. It can be seen as possibly choosing to ignore the reality of the situation and changing the theory to make it more coherent. It would categorise the patient as not adapting to the situation by choosing to ignore it. (Steiger, N. J. et al. 1995)

This particular situation is better dealt with by the application of the theories associated with the Johnson Behavioural System ( in Wilkerson et al 1996). This model can be considered useful in describing the situation of denial considered above but it too has shortcomings insofar as most experienced clinicians would note that a patient in denial of a terminal illness almost always is forced into acceptance by the progressive nature of the illness itself. (Johnson, D. E. 1990) The majority therefore have to accept their terminal status as they are overtaken by progressive physical manifestations of the disease process and other symptoms.

This element of the argument is presented as showing that the basis of some nursing theories is valid and useful but also even the most accepted theories have their shortcomings and limitations. (Tomey A M, Alligood M R 2005). To paraphrase the comment of Wadensten (et al 2003), one can observe that the nursing models and theories all have their place, but one has to add the caveat that there is not one satisfactory theory or model which can account for all aspects of care and all eventualities.

The thrust of this essay is directed at the preposition that some nursing theories are indeed useful and some are not. Even a brief consideration of the literature on the subject will reveal a plethora of opinions. (Powers, B. A 1995). It is vital to consider each theory or model in isolation and make a critical judgement relating to its ability to inform the nurse and to predict practice for the overall benefit of the patient. Those, such as the ones discussed in the early part of this essay, which rely heavily on intuition and anecdote and also have a marked lack of independent validation, are clearly less likely to be of value to the practical nurse and, in the worst analysis, in the opinion of Prof. Rosenthal, may contribute to the reduction of public confidence in the healthcare professions in general terms. By contrast, the more accepted, reproducible and statistically valid theories which have predictive value and are amenable to independent validation are much more likely to be considered of value to the profession in general terms.

In direct consideration of the title of this essay “Does nursing need theory?” the considered answer must be a qualified “Yes” but within the limitations that we have outlined here.

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