SBAR has just come to my hospital and I am sure it will be helpful in the nurse’s dealings with the on-call residents. Most of the time they are first year residents and know absolutely nothing about giving orders, so they need the help of experienced nurses to help them make the transition to being the “doctor”. Working in a teaching facility has its drawbacks, communication between nurses and residents is usually at the top of the list.
I read this article and I fully enjoyed seeing the difference between the different approaches and I loved that there was even a bit of whimsy mixed in with the educational stew. It’s not only new graduates who sometimes need to have this information; experienced nurses who are stressed and worried about their patients can sometimes forget to get themselves organized and prepared before calling the doctor, so we all benefit from this improved way to communicate.
By Sandy Keefe, MSN, RN
|New staff nurses Amanda Alarcon, RN (standing), and Joanne Lukaszewicz, RN, present some patient data to endocrinologist Joseph Rosa, MD, in a chart room on the med/surg unit of St. Vincent’s Medical Center, Bridgeport, CT. Photo courtesy St. Vincent’s Medical Center|
When Sheryl Hollyday, MSN, RN, cardiovascular service line educator, and Diane Sheehan, BSN, RN, orientation coordinator, performed a tongue-in-cheek skit that highlighted what not to do when calling a physician, new graduate nurses at St. Vincent’s Medical Center, Bridgeport, CT, were intrigued and wanted to learn more.
“It served as an icebreaker that led to a productive discussion about communication,” Sheehan noted.
The exercise was part of a roundtable of volunteer physicians and newly graduated nurses. The physicians spoke without scripts, sharing examples and tips about how to deal with challenging behavior from doctors.
The physicians “emphasized that if the nurse believes there is an area of concern and communicates that clearly, most physicians will welcome the call and appreciate what’s being done for their patients,” Hollyday said.
The idea for the roundtable came from past new graduates.
“Every year we have a staff education retreat, and we invite several new nurses,” said Nina Fausty, MSN, APRN, assistant vice president of patient care services. “We solicit their feedback and ask for recommendations about how we can better meet their needs. Anxiety about physician communications was one of their greatest concerns.”
New grads emphasized their preference for experiential learning over didactic classroom sessions during the roundtable. “As a result, we have made many changes, such as role playing, shadowing experiences in relevant departments and fostering communication, critical thinking and clinical skills through the use of simulation,” Sheehan said.
The roundtable has been a resounding success, she added. “Many [new grads] were apprehensive about asking questions like when to call, what’s important to convey and how to prepare themselves for those phone calls,” Sheehan said. “After we had the open forum meeting with the attending physicians, they were more comfortable and confident on this topic.”
Communication Becomes Curriculum
Marion Smith, MA, RN, AOCN, BC, nurse educator and coordinator of the Nurse Residency Program at NYU Langone Medical Center, New York, NY, believes today’s new grads are more comfortable with communication than their predecessors. “They are coming out of school with more of a sense of their identity, and that allows them to communicate more assertively,” she said. “They expect people to respect them as professionals.”
NYU’s new-grad program builds upon that foundation. “One of our first seminars is on communication in general,” Smith explained. “We talk about assertive communication and active listening. Our new grads write [and share] clinical narratives about communication issues as a way of looking at their practice, and if physician communications come up in one of those narratives we discuss the topic.”
Communication is a theme throughout the first year of the residency program at NYU. During the seminar about handling emergencies, the group discusses the nurse’s role in communicating about the patient’s status in an escalating situation, while an advanced pain management seminar includes advice from an advanced practice nurse.
“The nurse might say, ‘Mrs. Smith seems to be in a lot of pain and doesn’t want to get out of bed today. I’m concerned she won’t be able to go home tomorrow,'” Smith said. “That’s an assertive communication that highlights issues of concern to the physician.”
Facing the Challenge
Anne Walker, MEd, RN, shares a similar perspective in Facing the Challenge: Difficult Conversations, a seminar she teaches for the Vermont Nurses in Partnership.
“New grads face a shock coming into the workforce with an average of less than 450 hours of clinical time,” she explained. “They’re not well-prepared to interact with colleagues and physicians at the professional level. We teach them to voice their needs and to articulate them well.”
Walker recommends reflective practice, staying in the moment, having a common purpose and asking questions to understand the other’s point of view. She uses a process known as MRI (mental, rehearsal and intermission) that allows new grads to identify communication barriers, prepare for the conversation and be proactive rather than reactive.
“The rehearsal part of the process involves ‘what if’ scenarios,” she said. “Most of the time, the ‘what ifs’ don’t happen, but if they do, how will you handle it? What if the physician yells at you at 3 a.m.?”
Andi Churchill-Boutwell, RN-BC, ONC, clinical educator in the surgical care unit at Rutland Regional Medical Center, Rutland, VT, found Walker’s approach very helpful.
“As a result of the workshop, we will be better able to use the reflective-listening process to have effective conversations,” between nurses and physicians, she said. “As preceptors, we must be good role models for our new nurses. When we are in a difficult situation or conversation, we must treat the other person with respect and truly ‘hear’ the person.”
Donna Cill, DNP, FNP-BC, director of continuing education and clinical faculty for the nurse practitioner program at the University of Medicine & Dentistry of New Jersey (UMDNJ) -School of Nursing, Newark, teaches a communication module based on the SBAR (situation, background, assessment, and recommendations) model.
“The only way for a nurse to be confident in communications with a physician is to be competent,” she emphasized. “Are we organized enough? Do we know enough to give the physician the information needed for good decision-making? The SBAR model helps ensure the nurse can answer those questions appropriately.”
Cill emphasized that attitude matters. “Our nurse residency and nurse refresher programs consistently teach that nurses are the physicians’ colleagues,” she said. “They need us to be advocates for patients, to be insightful and competent clinicians, and to give them the information they need to provide excellent patient care.”
During the program, new grads complete a case study using the SBAR format. “We need to be direct and confident in the way we speak,” Cill emphasized. “The ‘R’ in SBAR refers to recommendation. As nurses, we are the experts on our patients, and we need to make those recommendations. Many times physicians, especially new residents, need those recommendations.”
While most SBAR communications do a great job of getting the point across, the nurse has a duty and responsibility to follow through. “If the physician doesn’t seem to take the nurse’s communication seriously, it’s important to think about the patient first,” Cill said. “What would happen if the nurse doesn’t communicate and advocate effectively on the patient’s behalf?”
New grads need guidance to go up the chain of command. “I encourage nurses to work with their preceptors to get used to calling physicians,” Sheehan said. “Instead of calling blindly, we help them prepare by doing a quick head-to-toe assessment that we’ve practiced in our simulation lab. If the physician’s answer sounds totally off the wall, we suggest the new grad say, ‘I’m new and I just want to learn, so could you explain why this is the plan of care?'”
Preparation is the key to successful communication, Hollyday concluded. “Yes, there will be physicians who are grouchy at 2 a.m.,” she said, “but we encourage the new grads to let the doctor know they’re new; hopefully that will cut them some slack.”
Sandy Keefe is a frequent contributor to ADVANCE.