SBAR Implementation Change Plan for Labor & Delivery Units

Introduction and Change Issue

The benefits of SBAR are apparent to the nursing staff in the Labor, Delivery, Recovery, and Postpartum Unit of a university birth center. All nursing staff receives training in SBAR, and it has been implemented successfully for a few months at a time. However, nursing staff soon revert to historical ways of communicating about patient care, which have predominantly consisted of giving a verbal report. This change proposal addresses how to move toward sustained, consistent implementation of SBAR as standard operating procedure in the unit.

SBAR stands for Situation-Background-Assessment-Recommendation and is a framework for communication about patients' conditions used by members of a healthcare team. The following discussion draws from the Institute for Healthcare Improvement (2011). The benefits of using SBAR by hospital staff include:

Benefits of SBAR Communication

(a) It is an easy-to-use, easy-to-remember mechanism; (b) it is a concrete way to frame conversations that fosters effective and timely communication; (c) it permits information to be easily accessed and recorded with fidelity, which is particularly important for communicating about patients with critical care issues or those requiring immediate attention and action by members of the healthcare team; (d) it helps healthcare team members stay focused on the standards and expectations for patient communication; and (e) it fosters a "culture of patient safety" and supports the development of effective teamwork (Institute for Healthcare Improvement, 2011).

A number of discrete variables have been found to be related to the implementation of SBAR. Some of these variables have emerged as hearsay and observation by supervising staff. To gain a firm picture of the key drivers of failed implementation, a survey will be administered to a stratified, randomly selected sample of hospital staff. Anecdotal information about failed implementation will be used as an aid in constructing the survey. The following variables, for example, have been noted to be related to failed SBAR implementation:

Implementation Variables and Barriers

(a) Details about patient care, patient histories, and treatments are being missed; (b) shift reports tend to be too long and convoluted to serve as effective communication tools; and (c) socializing is intermixed with verbal reports about patients, resulting in important patient information being missed or miscommunicated during the handoff conversation.

Peter Drucker (1993) argued that the organizational form assumed by healthcare agencies is the most complex of all human organizational structures. The confluence of different professional roles and stakeholders with conflicting time horizons, motivations, goals, and perspectives contributes to this intractable complexity (Golden, 2006). A four-stage change model (Golden, 2006) is proposed as a way of bringing SBAR implementation to acceptable levels within the target hospital unit. Golden's (2006) four stages are briefly described below.

Golden's Four-Stage Change Model

Stage One: Determine the desired end state. During this stage, needs assessments and environmental scans are used to identify a performance gap between the current status in the organization and the level to which the organization aspires.

Stage Two: Assess readiness for change. Once objectives have been clarified, a situational analysis will be carried out to identify whether stakeholders recognize the need for change; the degree of competition for resources and the attention of leaders and management; whether new capabilities to close the performance gap have been identified; and whether the organizational history biases stakeholders against the change process — a situation that is an opportunity for leaders to learn how to ameliorate that influence and to prevent the same sort of outcome.

Stage Three: Broaden support and organizational redesign. The change effort needs to move from behind the scenes to center stage and, in doing so, must enlist the support of champions through active advocacy and must work on the indicated redesign of the organization.

Stage Four: Reinforce and sustain change. The effort in this stage is designed to maintain progress made in the three previous stages. Tasks include performance monitoring, showcasing success, rewarding implementers and supporters, recognizing and analyzing losses or failures, reconsidering objectives in light of new information and opportunities, and fine-tuning any realigned systems.

Conclusion

Ambrose (1987) emphasizes action planning in his framework for managing complex change, providing formats that help make sense of the clutter inherent in complex organizational change. Other elements in Ambrose's framework include vision, skills, incentives, and resources. A key benefit of Ambrose's framework is that clear and predictable outcomes characterize each stage, which enables diagnosis of the process if the change does not appear to be succeeding and requires retooling. Change agents must do the best that they can, while recognizing that adhering to a preset change timeline may be far less important than following the designated sequence of tasks and completing all stages of the change process (Kotter, 1996).