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  • Writer's pictureKelly Willis, MSN, MBA-HM

Using SBAR to Document Staff Opportunities

SBAR (Situation, Background, Assessment, and Recommendation) is a typical practice communication approach in healthcare. Initially developed by the military for nuclear submarine communication, it later became the standard in healthcare settings for communicating patient concerns to providers.

The Importance of Clear Communication In Nursing Units

In medical settings, even a simple miscommunication—or lack of same—could have potentially dire consequences.

When we’re talking about the health of an individual, accuracy is crucial, as the notes we share help to identify persisting patterns. Since all information is saved for later documentation, the more precise the notes are, the easier it is to form strategies for treatment.

Accurate documentation is also essential when it comes to dealing with staff issues and opportunities. SBAR is now the gold standard for nurse-to-nurse hand-off reports. We use it in emails and other forms of communication as a documentation tool.

What Does SBAR Mean?

Each letter of the acronym has an associated term that helps with the documentation process:

Situation: This is the subject line. This line should be concise, up to three words that communicate the issue or opportunity.

Background: This gives context to the issue/opportunity. What led to it? How did it come to land on your desk? Briefly describe the pattern.

Assessment: This part lists the information gathered from conversations. It will help to determine the appropriate action going forward. It starts with the leader addressing the issue/opportunity with a staff member, followed by the perceptions of the staff member and/or others involved in the discussions. Include anything the leader has personally witnessed.

Recommendation: What do you, as a leader, recommend to be done about this? Here, document actions you have taken or will take, what you recommend for HR or your supervisor to do, and any discussion about future progressive or disciplinary actions, if necessary.

An Example of SBAR

A staff member is consistently late to begin their shift, and it’s starting to affect unit morale.

We initiate the conversation and follow it up with documentation. The date of the discussion with the staff member is Monday, May 20th, 2019.

Situation: Jane Doe tardiness

Background: Jane has been reported late for her shift 15 times in the last three months. She received a verbal warning on 5/1/2019. The staff is complaining about her tardiness.

Assessment: I met with Jane in my office on Monday, 5/20/2019, @ 13:45. She was offered a union representative but verbally declined. Jane was notified that the topic of the meeting was her continued lateness, even after the verbal warning was issued.

Jane's Perception: Jane stated that her tardiness is due to difficulty getting her daughter ready to go to school in the morning. Because of her daughter’s diabetes, Jane must ensure that she has insulin and everything else she needs for school, which sometimes causes her to be late for her shift. She stated that she is trying to get to work on time but often finds it challenging.

Recommendations: I recommended to Jane that she begin this process at home earlier in the morning. This will give her more time to address these issues and arrive on time. Per policy, I have issued a written warning along with a Performance Improvement Plan outlining the problem, actions to improve this issue, and the expected outcomes. We will reconvene to discuss progress on Thursday, June 20th, 2019 @ 13:45.

SBAR documentation clearly outlines the issues, expectations, and outcomes. It is brief, complete, and to the point. If you want to become a more accurate and effective communicator in the workplace, the SBAR method is highly recommended.

SBAR Basics: A resource Guide for Healthcare Managers, is an awesome clear/concise communication guide to communicate your message as clearly and concisely as possible (I receive a small commission for a sale of this book or any other item on Amazon if you click on the link below).


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