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JONA
Volume 43, Number 7/8, pp 422-428
Copyright B2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
Improving Shift Report Focus and
Consistency With the Situation,
Background, Assessment,
Recommendation Protocol
Paul Cornell, PhD
Mary Townsend Gervis, MSA, RN
Lauren Yates, RN
James M. Vardaman, PhD
OBJECTIVE: The Situation, Background, Assess-
ment, Recommendation (SBAR) protocol was used
to improve shift reports in 4 medical-surgical units.
BACKGROUND: The SBAR protocol is increasingly
advocated for use during shift reports, but data on
the efficacy are limited.
METHODS: Nurses were trained on SBAR in 4
medical-surgical units in a tertiary care hospital. Nurse
tasks, tools, and locations were recorded during ob-
servation audits.
RESULTS: The average time for shift reports did not
decrease using SBAR. Nurses spent significantly more
time on tasks specific to report. There was signifi-
cantly more dialogue and less writing with SBAR.
CONCLUSION: The introduction of SBAR made
reports more focused, with more time spent discuss-
ing the patient and less on transcribing information.
The SBAR protocol provides a concise and priori-
tized structure that enables consistent, comprehen-
sive, and patient-centric reports.
Even with advances in technology providing greater
access and analysis, it is human communication and
interaction that determine the use and value of in-
formation. This is especially true of healthcare, when
the effects of poor communication can be disastrous.
The Joint Commission (TJC) estimated that 65%
of sentinel events were the result of communication
problems.
1
Brought to the nation_sattentionin1999
by the Institute of Medicine,
2
government and or-
ganizations have invested heavily in research and
training to address the issue. The problem is not eas-
ily solved because communication behaviors are of-
ten complex, embedded in an organization_sculture
and processes, and influenced by one_strainingand
background.
3,4
One area of concern is hand-off communication.
Many factors make hand-off processes a challenge:
They occur frequently (up to 6 times a day); care is
transferred from person to person; multiple disciplines
are often involved; and a large quantity of informa-
tion is shared.
5
Schools of nursing do not effectively
prepare graduates to perform hand-offs, and there
is little evidence for a singular best practice.
5-7
The
impact on patient outcomes is so critical TJC re-
quires hospitals develop a standardized approach to
hand-offs.
8
Shift report, the transfer of patient care from an
off-going nurse to an on-coming nurse, is a unique
aspect of hand-off. Report is performed at least twice
a day, at a similar time and location, between 2 sim-
ilarly trained nurses. Although this type of hand-off
superficially appears easier to execute, research sug-
gests otherwise. Shift reports are often unstructured,
422 JONA Vol. 43, No. 7/8 July/August 2013
Author Affiliations: President (Dr Cornell), Healthcare
Practice Transformation, Dallas, Texas; Chief Nursing Officer
(Ms Townsend-Gervis); Advanced Nurse Clinician (Ms Yates),
Baptist Memorial Healthcare, DeSoto, Mississippi; Assistant Pro-
fessor (Dr Vardaman), Department of Management, Mississippi
State University, Mississippi State.
The authors declare no conflicts of interest.
Correspondence: Dr Cornell, HPX LLC, 3412 Parr Road,
Grapevine, TX 76051 (ptcornell@gmail.com).
Supplemental digital content is available for this article.
Direct URL citations appear in the printed text and are provided
in the HTML and PDF versions of this article on the journal_s
Web site (www.jonajournal.com).
DOI: 10.1097/NNA.0b013e31829d6303
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
inconsistent, inaccurate, and frequently interrupted;
omit key information; take too long; and convey
out-of-date or unnecessary information.
6,7,9-14
The
Situation, Background, Assessment, Recommendation
(SBAR) communication protocol has been advocated
as a means to address many of these shortfalls.
7,11,15-17
Originally intended to improve nurse-physician com-
munication in urgent care situations,
3
SBAR was
designed to expedite cross-disciplinary communica-
tion by creating a common and consistent structure
for information, thus a shared mental model. The
SBAR protocol has additional reported benefits, in-
cluding improving social capital, legitimacy, and the
formation of schemas for rapid decision making.
14,18,19
As a shift report tool, SBAR provides the struc-
ture and consistency often found lacking in current
practice.
11,12,15-17,20
In one sense, SBAR provides a
checklist of information, which some contend im-
proves shift report.
12,13,15
However, its structure and
process make it more than a task to process infor-
mation,
8
addressing social, organizational, and even
educational functions.
10
Studies indicate that SBAR
reduces shift report time
11,16
and is received favor-
ably by staff.
6,17,21
The purpose of this study was to assess the im-
pact and value of SBAR in shift reports. Four medical-
surgical units provided the setting. Nurses were
observed before and after SBAR implementation.
To support the protocol and reinforce the informa-
tional structure, a paper-based SBAR tool was devel-
oped as a script for nurses. Following use of the paper
version, an electronic version of SBAR was developed
and made available on fixed and mobile computers.
Several hypotheses were proposed. First, it was pre-
dicted that SBAR shift reports would result in im-
proved time on task. This would be indicated by a
reduction in the overall time to complete the report.
Second, it was hypothesized that reports would be more
consistent, exhibiting more time on shift report tasks
and less on superfluous tasks (ie, a greater emphasis on
completing shift report). Third, it was anticipated
there would be less transcribing of information, with
nurses relying on the SBAR report to provide the re-
cord. Fourth, an increase in computer utilization was
expected with the availability of the electronic SBAR.
And finally, it was hypothesized there would be a de-
crease in dependence on personalized, handwritten
worksheets, known by some as cheat sheets.
Methods
Participants
Data were collected on 4 medical-surgical units of a
339-bed, midsouth suburban hospital. Each unit had
48 beds and 8 to 9 nurses per shift, with an average
nurse-to-patient ratio of 1:6. All nurses in the hos-
pital received classroom training on the SBAR pro-
tocol, including simulated encounters. Nurses were
instructed to use the protocol during shift reports and
interdisciplinary rounds. They could use it elsewhere
in the care process but were not required to do so.
During training, nurses were also introduced to a
paper-based report tool that included SBAR infor-
mation on each patient. These reports were available
during shift reports and rounds. Later, they received
training on how to access an electronic version of the
SBAR report (see Figure, Supplemental Digital Con-
tent 1, http://links.lww.com/JONA/A240). All nurses
were assigned mobile computer carts that provided
wireless access to medical records and facilitated ease
of access to electronic tools.
Observational Instrument
A variety of methods have been used to measure nurse
workflow.
22
Direct observation was used in this study
because it is more objective, quantitative, and unobtru-
sive compared with other work sampling methods.
22-24
A comprehensive protocol was developed and included
the recording of 4 variables: nurse tasks, tools, col-
laborators, and location of work. Drawing from pre-
vious studies of workflow,
23,25
staff defined a list of
tasks that were mutually exclusive and exhaustive. All
tasks likely to occur during shift report were identi-
fied. The list, shown in Table 1, includes tasks other
than shift report. These occur while an on-coming
nurse waits or performs other duties during the shift
report. Thus, even though a shift report is in progress,
an observer could record nonYshift report activities.
Staff also defined the tools, collaborators, and loca-
tion variables. Tools included computers, documents,
mobile workstation carts, and devices. Collaborators
Table 1. Tasks Recorded During Observation
Observers select the 1, most dominant task:
Safety huddle: preshift meeting to review patient
safety issues
Shift report (SR) writing: the on-coming nurse
handwriting information relating to SR
SR verbal: conversation related to SR
SR computer: on-coming nurse using the computer
during SR
Reviewing: non-SR review of written or electronic
information
Writing: writing and transcribing information not
related to SR
Computer use: general use of the computer
Verbal communication: general conversation with
staff, patients, or family
Gathering: collecting supplies and materials
Walking: walking while visibly doing no other task
Waiting: waiting while visibly doing no other task
Other: any activity not listed above
JONA Vol. 43, No. 7/8 July/August 2013 423
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
included nurses, charge nurses, physicians, patients,
family, and ancillary staff. Locations included patient
rooms, nurse station, nurse cubby, hallway, and con-
ference rooms. The list of items and the protocol were
pilot tested to ensure full coverage of all shift report
events and circumstances.
25
Observational data were recorded using a small
tablet computer. The computer displayed the items of
each of the 4 variables in checklist format. The ob-
server selected or deselected items using a stylus and
the touch-sensitive display. The computer recorded
the contents of the checklist at a rate of 20 times a
minute, providing a near continuous recording of
events and circumstances. Each record was time and
date stamped. These data enabled the analysis of
frequency and duration of tasks, tools, collaborators,
and location. They also allowed analysis of the co-
occurrence of variables. Changes in time allocation
before and after SBAR could then be assessed sta-
tistically. Observers were 3 senior-level nursing stu-
dents who were trained in the definition of variables,
behavioral indicators of each variable, and use of the
tool. Training included classroom instruction and
practice shadowing nurses. All observers were insti-
tutional review board (IRB) trained and certified.
SBAR Tool
Hospital staff developed the SBAR protocol and re-
port tool and pilot tested both on a medical-surgical
unit. Multiple versions were tested before finalizing a
4-page form. A condensed paper version of the form
was used during the 2nd observation, and an electronic
SBAR (see Figure, Supplemental Digital Content 1,
http://links.lww.com/JONA/A240) was developed for
the 3rd. The labels and format are identical to the paper
form. Nurses typically printedareportoneachpatient
under their care and carried it with them during shift
report. When the electronic version was available, they
could use either form of the report.
Procedure
Three shift report observations occurred over an
8-month period: baseline, paper SBAR report, and
paper and electronic SBAR report. Observations oc-
curred Monday through Friday and included morn-
ing and evening end-of-shift reports. Shift reports
began at approximately 6:45 AM or PM, depending on
when nurses were ready to begin.
Nurses were informed in staff meetings and
through memos of the goals and methods of the
study, but they did not know in advance when they
were going to be observed. On observation day,
charge nurses randomly selected the nurses to observe.
The observer approached the on-coming nurse and
asked for permission to shadow them during shift
report. If nurses consented to the observation and
participation in the study, they were shown the tablet
computer and were reminded of what was recorded.
Participation was at the nurse_s discretion, and they
were reminded they could opt out or end the ob-
servation at any time. None did. The observer started
recording when the nurse stipulated the start of shift
report. Once started, the observer used the checklist
of variables to record the nurse_s tasks, tools, col-
laborators, and location of work. The start and stop
times of all checklist items were time stamped by the
computer, and observers only had to select and de-
select items. The observer followed the nurse at all
times except in patient rooms. While there, nurses
could be seen from the hallway, and observers con-
tinued to record behaviors and tool use. Patient and
medical data were not recorded, only behaviors and
artifacts. The observation continued until the nurse
confirmed all patients had been reviewed.
The 1st observation provided a baseline condition.
Subsequently, staff received SBAR training, which in-
cluded use of the protocol as well as the paper report.
A 2nd observation occurred 5 weeks later. Additional
training occurred when the SBAR report became elec-
tronic. One month after this training, and 4 months
after the 2nd observation, a 3rd observation was con-
ducted. Training occurred in February and June, and
observations occurred in January, March, and August.
The experimental design was reviewed by the hospital
IRB. The repeated quantitative observation of staff con-
stitutes a level 3 on the evidence scale.
26
Results
Seventy-five nurses participated in the study. Their
mean (SD) age was 34.1 (9.9) years. The minimum
age was 21 years and the maximum was 62 years.
Approximately 51% (n = 38) had associate degrees;
42% (n = 32), bachelor of science in nursing; 4% (n =
3), nursing diplomas; and 3% (n = 2), master_sand
LPN. Mean (SD) experience was 6.9 (8.2) years. The
minimum and maximum experience was 4 months
and 38 years, respectively. Mean (SD) employment in
the hospital was 4 (5.1) years. In the baseline, 46
different nurses were observed. In the SBAR obser-
vations, 32 and 39 nurses were observed. Because of
the random selection process, 13 nurses were ob-
served twice in the baseline, and 4 and 12 nurses were
observed twice in the 2 SBAR conditions.
Fifty-nine shift reports were observed in the base-
line observation, 36 in the 2nd observation (paper
SBAR), and 51 in the 3rd observation (electronic SBAR).
The mean time required to complete shift report was
28.0, 31.2, and 28.7 minutes, respectively (Table 2,
part A). These differences were not significant in an
424 JONA Vol. 43, No. 7/8 July/August 2013
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
analysis of variance (ANOVA) procedure (F=1.08;P=
.34). In the observations, we distinguished between
total report duration and the time spent performing
shift report tasks. The percentage of time spent on
shift report tasks was 54.6% during baseline and
62.7% and 66.4% in the 2 SBAR conditions (Table 2,
part B). These differences were significant (F= 3.67,
PG.03), showing an increaseinpercentageoftime
spent on shift report tasks under the 2 SBAR con-
ditions. Ninety-five percent of shift reports included
at least some time on nonYshift report tasks.
The time spent in verbal communication as a
percentage of the total shift report was 29.5% during
baseline and 49.3% and 42.1% in the 2 SBAR con-
ditions (Table 2, part C). This difference was signif-
icant in the ANOVA (F=11.48,PG.01), indicating
the amount of verbal communication was higher
with SBAR. Writing during the shift report decreased
from 21.1% to 11.2% with the paper SBAR but in-
creased to 22.9% with the electronic SBAR (Table 2,
part D). This ANOVA was also significant (F=5.54,
PG.01).
There were 3 computer options available during
the shift report: at the nurse cubby, at the nurse sta-
tion, or on a mobile cart. Nonetheless, time on the
computer was low in all 3 observations: 4.1% during
baseline and 2.2% and 1.4% in the SBAR conditions.
Computer use was lowest when SBAR was available
as an electronic report. None of these differences were
significant, however (Table 2, part E). Use of a per-
sonal sheet varied substantially across the 3 observa-
tions. It was highest during baseline, being used nearly
35% of the time during shift report. It dropped to
1.5% and 5.8% with SBAR (Table 2, part F). The
ANOVA indicated these differences were significant
(F=42.16,PG.01).
As part of the transition to using SBAR, nurses
were encouraged to conduct the shift report in patient
Table 2. Means and Variances of Key Variables
A. Shift Report Duration
Observation n Minutes SD Min Max
Baseline 59 28.0 11.7 8.1 52.5
Paper SBAR 36 31.2 10.7 9.4 52.6
Elect SBAR 51 28.7 8.8 17.4 64.0
B. Shift Report Tasks
Observation n Time Spent on Shift Report Tasks SD Min Max
Baseline 59 54.6% 25% 7% 100%
Paper SBAR 36 62.7% 20% 23% 100%
Elect SBAR 51 66.4% 18% 29% 97%
C. Verbal Communication
Observation n Time Spent on Verbal Communication SD Min Max
Baseline 59 29.5% 25% 0% 92%
Paper SBAR 36 49.3% 20% 9% 53%
Elect SBAR 51 42.1% 15% 17% 64%
D. Writing
Observation n Time Spent Writing SD Min Max
Baseline 59 21.1% 21% 0% 77%
Paper SBAR 36 11.2% 11% 0% 40%
Elect SBAR 51 22.9% 14% 0% 62%
E. Computer
Observation n Time Spent on Computer SD Min Max
Baseline 59 4.1% 13% 0% 82%
Paper SBAR 36 2.2% 4% 0% 16%
Elect SBAR 51 1.4% 4% 0% 21%
F. Personal Sheet
Observation n Time Spent on Personal Sheet SD Min Max
Baseline 59 34.9% 30% 0% 87%
Paper SBAR 36 1.5% 4% 0% 18%
Elect SBAR 51 5.8% 9% 0% 36%
JONA Vol. 43, No. 7/8 July/August 2013 425
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
rooms. Although not hypothesized, this resulted in
changes where shift report tasks occurred. During
baseline, 54% of reporting took place in the nurse
cubby, with 20% occurring in the hallway during
transit and only 17% in the patient room. This changed
in the SBAR conditions. Report locations were 10%
in the cubby, 45% in the patient room, and 30% and
33% in the hallway during transit (Figure 1).
Discussion
Of the 5 hypotheses, 3 were supported. It was ex-
pected the SBAR report tool would keep nurses more
focused and would lead to shorter reports. Whereas
their time on task improved (54.6% to 66.4%), the
overall duration was unchanged. Given the common
complaint that shift reports are too long,
11-13
it is
actually encouraging SBAR did not increase report
time, although it did not shorten it.
The hypothesis of increased time on shift report
tasks was supported. Shift reports rarely proceeded
from beginning to end without interruption, as there
were often calls, interactions, and miscellaneous tasks
which must be performed at the beginning of a shift.
This is borne out by the fact that more than 95% of
the 146 observations included nonYshift report tasks.
However, the introduction of SBAR resulted in sig-
nificantly more time spent on shift report tasks, with
nurses switching to other tasks less frequently. Any
increase in focus and reduction in nonpertinent tasks
are positive from a process and cognitive perspective.
The hypothesized switch from writing to talking
was supported, but not in all cases. Nurses conversed
more with SBAR, implying more information was
exchanged. Because an off-going nurse knows more
about a patient than the codified information in the
medical record,
8
increased conversation is positive,
especially in light of the finding that a larger percent-
age of time was spent on shift report tasks. Obviously,
transcribing data already contained in the medical
record is wasteful. With the SBAR report, on-coming
nurses knew what was in the record and did not need to
re-record it. Nonetheless, the amount of writing did
not decrease. Further exploration of what is written
and why are warranted in future research.
The expected increase in computer use did not
occur. There are several reasons for this. First, the
electronic SBAR was a report, created at the request
of the user. The information was only as current as
the latest update. Thus, the electronic report did not
offer any advantage over the paper report in terms
of data currency or linking to other information. Se-
cond, the mobile computer cart housed medication
and nurse supplies. Although mobile, it was heavy and
bulky and was not conducive to a fast-paced, mobile
shift report. And 3rd, the process involved reviewing
data, not entering or analyzing them. Although note
taking on patients was observed, there was no new
information entered into the medical record, obviat-
ing the need for a computer. Computer use is likely to
change with new software and hardware products.
For example, use would increase with hyperlinked data
and more portable devices such as media tablets.
It was anticipated the SBAR reportVeither paper
or electronicVwould curtail the use of personal sheets.
All the pertinent and topical information was contained
Figure 1. Locations of shift report.
426 JONA Vol. 43, No. 7/8 July/August 2013
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
in the report and should have eliminated the need for
supplemental documentation. This was indeed the
case, as the use of these notes dropped significantly.
There was note taking, however, and writing occurred
in the 2 SBAR conditions. As stated, these notes were
not medical information but appeared to be remind-
ers and ‘‘to-do’’ items. An analysis of the content is
needed to better understand the writing behavior ob-
served here.
By design, the structure and content of SBAR
lend itself to concise communication. As such, it also
enables and supports mobile work. This promotes
practices such as bedside report, which benefit greatly
from ubiquitous information access. It is interest-
ing to note the variance in task times is greatest in
baseline.As shownin Table 2, this occurs in all but 1
case (writing). A less variable process is a more re-
liable process, and consistency facilitates collaboration
and coordination. Process consistency and standard-
ization are major tenets of TJC recommendations.
Limitations
Process and behavioral outcomes are only 1 way to
measure impact. Patient outcomes such as length of
stay and patient satisfaction should be considered.
Likewise, staff reaction and perceptions are similarly
important. These should be the subject of future
research. A limitation of the study is the absence of
an analysis of the information nurses wrote down on
various informal forms (cheat sheets). An analysis of
what nurses write down during report on these and
other forms of documents would identify the short-
comings of SBAR and provide insight on additional
needs. A different technology solution, in either hard-
ware, software, or user interface, would impact the
results found here. For example, a hyperlinked app
available on a tablet would have been quite popular
and resulted in much higher computer use. This study
is not generalizable to other practice settings outside
medical-surgical nursing units in this facility and should
be replicated in other areas and other organizations
for validation of the findings.
Implications for Practice
Findings suggest SBAR addresses many of the prob-
lems cited with existing shift reports: It provides
structure, consistency, prioritization, accuracy, and
comprehensiveness. In addition, according to these
data, it does so without increasing the length of the
shift report, which is also a frequent complaint. By
providing an SBAR tool to accompany the protocol,
there was more conversation about the patient and
less time on transcribing. Thisenabled nurses to share
the tacit knowledge they had on patients, informa-
tion that was not always documented. The tool pro-
vided a checklist of topics to discuss, which enabled
all nurses to report equally well, regardless of expe-
rience. Nurse-to-nurse use of SBAR facilitates devel-
opment of schemas for presenting patients during
report. This will benefit nurse-to-physician commu-
nication as well. The summarized and prioritized na-
ture of SBAR is portable and accessible, especially
compared with charts and laboratory reports. While
our media were paper and computers, smartphones
and tablets could easily convey SBAR information,
making the report even more accessible and mobile.
These protocols, tools, and devices support and pro-
mote the existing workflow of nurses and will ex-
pedite adoption. The SBAR protocol and report help
accomplish TJC communication goals and improve
shift report and can set the stage for improved com-
munication between nurses and staff.
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