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P Patient assessment. Nurses must be able who need to contact VMOs to report deteri- C Conscious state
to carry out a comprehensive patient oration in a patient’s condition. It uses a hybrid A Airway
assessment, particularly for patients whose of the bullet-point preferred communication B Breathing (rate, depth and ease of respira-
condition is deteriorating. style of doctors and the descriptive narrative tion)
A Assertive communication. Nurses must style of nurses.2 The format helps nurses to S Sphygmo! Systolic! (pulse, blood pres-
know how to communicate assessment structure their communication in a logical sure, fluid balance, etc)
outcomes in a clear, concise manner and sequence, facilitating rapid comprehension by A All round (sum up the patient and the
gain an appropriate response. VMOs. Prompts on the form ensure that a environment to get the full picture)
C Continuum of care. This ensures that comprehensive assessment has been done and V Vital signs (do the data confirm what you
patient safety is maintained from carer to that all pertinent details are at hand before see?)
carer and from shift to shift by the timely, calling the VMO. There is space on the form to I Intuition and insistence (get help if
accurate and complete transfer of responsi- record the doctor’s orders and directions for required).
bility for patient care. follow-up. Once used, the form is filed in the
T Teamwork with trust. All health care pro- This final step reinforced the need for asser-
patient’s medical record. The forms are pro-
viders, regardless of their position and tive communication and use of the SBAR
vided in pads kept at nurses’ stations, and
experience, have the right to express their reporting tool.
there is a flowchart on the cover to remind
concerns or opinions about a patient in a nurses of the key points in the sequence of
trusting and respectful team environment. assessment and reporting. Evaluation
Both the handover prompt card and the In April 2008, baseline data were collected from
Implementation reporting template use the SBAR system (see nurses and VMOs to investigate their opinions
An action research process was used to imple- below), a communication format originally of handover methods and to identify problems
ment and monitor the PACT Project. Action devised for military use and subsequently with current procedures. The nurses’ question-
research is a form of research that empowers shown to be effective in a range of health care naire comprised 38 Likert-scale statements,
participants to change their practice and gives settings.2,5-7 The SBAR acronym provides an three open-ended questions and three demo-
ownership of this change to participants. It is easy-to-remember structure for giving graphic questions. The VMOs’ survey was
designed to create change in practice through required information in a logical sequence: much shorter, with two closed-response and
a series of iterative cycles of problem identifica- three open-ended questions. Nurses’ question-
S Situation. What is the patient’s diagnosis naires were distributed with payslips and
tion, change implementation, reflection and
or reason for admission? VMOs received their questionnaires at the
evaluation.4 Expressions of interest were
sought from nursing staff to form a critical B Background. What is the clinical back- monthly Medical Advisory Committee meeting.
group for the action research. Seven nurses ground or context? Post-implementation data were collected from
from medical and surgical wards responded A Assessment. What is the current situation nurses in December 2008. Questionnaires with
and were identified as “PACT Champions”. and what do I think is the problem? seven Likert-scale statements and space for
They led the development, implementation R Recommendation. What action do I rec- additional comments were placed at nurses’
and evaluation of the project, met monthly ommend or what do I want you to do? stations. The PACT Champions also took part
with the project team and acted as conduits in a discussion moderated by the external
These tools were refined using action project team members (E C and EP). The dis-
between the project team and ward staff. Staff
research with input from the PACT Champi- cussion was recorded digitally and transcribed,
were kept informed throughout the project by
ons and incorporating changes through a and key themes were identified. All evaluation
monthly PACT newsletters, posters and PACT
number of drafts. data were anonymous and confidential.
noticeboards in wards and in the staff dining
room.
Project workshops Ethics approval
Project tools Two workshops were developed by the project Ethics approval was given by the region’s Joint
Two communication tools were developed, team and PACT Champions to ensure that staff Hospitals’ Ethics Committee and La Trobe Uni-
refined and implemented as part of the PACT had the skills needed to use the communica- versity’s Human Research Ethics Committee.
Project: tion tools effectively. Each mandatory work-
(i) Handover prompt card. This provides a shop lasted 1 hour and staff were paid to RESULTS
template for standardising shift-to-shift and attend.
person-to-person handover. It guides the (i) Assertive communication workshop. This Baseline data
speaker to give information in a standardised interactive workshop drew on theory and Responses were received from 49 nurses
sequence, thereby establishing a routine that experiences of staff. Examples of good and (response rate, 54%) and 16 VMOs (response
also enables receivers to note whether any poor communication techniques were shown, rate, 73%). The responses from both groups
information is omitted. Measuring 6 9 cm, and staff used role-plays to learn assertiveness confirmed the key assumption underpinning
coloured hot pink and laminated, the prompt principles to ensure that their message was the project, namely that there was scope for
card is designed to clip onto each nurse’s heard and acted upon. improvement in the way clinical handovers
identity badge. A similar card, of A4 size, has (ii) Patient assessment workshop. This work- occurred.
been attached to the handover desk at the shop outlined a focused assessment method Key results from the nurses’ survey included
nurses’ station on all wards. for examining deteriorating patients. The acro- the following:
(ii) Reporting template. This is a standard nym CAB SAVI was used to highlight key • 32% stated that they always get the infor-
script or template to be followed by nurses assessment criteria: mation they need at handover;
• 94% identified that different nurses give Another theme was that the assessment PACT Project at the time. There is no way of
handover in different ways; workshops and SBAR tool led to earlier inter- knowing whether the non-responders had sim-
• 82% agreed that we needed a standardised vention and clear documentation of contact ilar views to those who did reply. The response
way of giving handover; with VMOs and their responses. Champions rate to the post-implementation questionnaire
• 85% felt that there was room for improve- also noted that a similar tool would be valu- was even lower and this was mainly due to two
ment in the way nurses communicate; able for preoperative admissions and interhos- external events. Firstly, the hospital was
• 86% felt that there was room for improve- pital transfers, as it would help ensure that all redeveloping the operating suite, resulting in
ment in the way that nurses and VMOs com- relevant information was given. minimal elective surgery, with many nurses on
municate; and The main problem identified by the Cham- leave. Secondly, clerical changes meant it was
• 60% said they would like to deliver hand- pions was the difficulty of ensuring that all staff no longer possible to attach questionnaires to
over more effectively. attended the workshops and continued to use payslips, so they were left at nurses’ stations —
An additional two nurses’ questionnaires the tools, especially given the large proportion a less reliable means of distribution.
were returned blank except for comments of part-time and casual staff. A longer period of evaluation is needed,
about the project being a waste of money. including consideration of patient outcomes.
Key issues identified by VMOs included the DISCUSSION We are undertaking an audit of completed SBAR
following: forms and a sentinel events audit of risk-man-
Our baseline findings confirmed that staff were agement reports before and after the implemen-
• Their need for detailed and specific clinical
information; dissatisfied with the communication of clinical tation of the program to look for evidence of a
information and that this led to stress and reduced number of incidents related to commu-
• The need for nurses to specifically identify
frustration when the required information was nication failures, comparing year-to-year data.
the issue/problem;
not available, or when it was communicated Until these are complete, the final outcomes of
• The importance of nurses having all
inappropriately or at the wrong time. The the PACT Project will not be known.
information at hand before contacting the doctor;
PACT Project has shown that the use of simple
• Their need to know whether all protocols
structured tools can improve communication.
and standing orders had been carried out. COMPETING INTERESTS
This, in turn, should reduce the risk of adverse
patient outcomes. The workshops on assess- None identified.
Post-implementation data ment and assertive communication were an
Completed questionnaires were received from essential component of the project in building AUTHOR DETAILS
25 nurses (an estimated response rate of 28%). nurses’ confidence and reinforcing the need Eileen Clark, BA, MLitt, MSocSc, Senior Lecturer1
Overall, the results suggested that the PACT for a standardised approach. Sally Squire, RN, BEd, GradDipMgt, Staff
Project was initially successful at improving Initial resistance to the project on the part of Development and Education Manager2
handover: Anne Heyme, RN, GradCertOrthoNurs, Nursing
some nurses was not surprising. Nursing
• 68% of nurses stated that they always get Unit Manager2
workloads and staff turnover remain high, and Mary-Ellen Mickle, RN, RM, BHS(Nurs), Quality
the information they need at handover; in these circumstances new projects are often and Risk Manager2
• 68% of nurses believed shift-to-shift not greeted with enthusiasm. The Champions Eileen Petrie, RN, PGDipCPN, PhD, Senior
handover had improved; and were integral to the success of the project, as Lecturer1
• 72% agreed that handover was more struc- they maintained their passion for it through- 1 Division of Nursing and Midwifery, La Trobe
tured now than at the start of the project. out the year and worked hard to ensure that all University, Wodonga, VIC.
Nurses also believed that their own staff knew about, participated in and benefited 2 Albury Wodonga Private Hospitals, Albury, NSW.
communication skills had improved: from the project. Correspondence: elclark@westnet.com.au
• 80% felt more confident when commun- Sustainability is a key challenge for any
icating with doctors; innovation. Steps taken to maintain the project REFERENCES
• 72% agreed that they now communicate include the use of eye-catching hot pink on all 1 Joint Commission on Accreditation of Healthcare
more effectively; and PACT materials as a visual reminder to staff, Organizations. Sentinel event statistics. http://
• 62% agreed that the SBAR tool helped www.jointcommission.org/SentinelEvents/Statis-
incorporating the program into orientation for tics (accessed Sep 2008).
them to know what they should say when new staff, and requiring staff to attend an 2 Leonard M, Graham S, Bonacum D. The human
communicating with doctors. annual refresher in-service session. In the factor: the critical importance of effective team-
The PACT Champions identified that there longer term, benchmarking adverse patient work and communication in providing safe care.
Qual Saf Health Care 2004; 13 Suppl 1: i85-i90.
had been initial resistance to the project outcomes and staff satisfaction surveys against 3 Wong MC, Yee KC, Turner P. Clinical handover
among some experienced nurses, but this had other hospitals may show the ongoing success literature review. Hobart: eHealth Services
dissipated as the benefits of the project became of the program and act as reinforcement for it. Research Group, University of Tasmania, 2008.
4 Kemmis S, McTaggart R, editors. The action
apparent, especially for junior staff. The fol- This project has been developed and tested research planner. 3rd ed. Geelong: Deakin Univer-
lowing quotes are a sample of their comments: in one regional, for-profit hospital and the sity, 1988.
It was “What a load of crap!” at first, then 2 outcomes cannot be generalised beyond this 5 The SBAR technique: improves communication,
enhances patient safety. Jt Comm Perspect Patient
weeks later, “Gee, we get good handover site. The positive responses to the project sug- Saf 2005; 5 (2): 1-8.
now”. gest that it has the potential for successful 6 SBAR initiative to improve staff communication.
Really good for grads and students. implementation elsewhere, but further evalu- Healthcare Benchmarks Qual Improv 2005; 12 (4):
40-41.
Good idea, good reminder of important ation is needed. The relatively low response 7 Markley J, Winbery S. Communicating with physi-
issues to hand over. rate to the nurses’ baseline questionnaire sug- cians: how agencies can be heard. Home Health
Helps me do a good handover when I’m gests that staff had not been motivated suffi- Care Manage Pract 2008; 20: 161-168.
tired at the end of the shift. ciently to participate and did not value the (Received 13 Oct 2008, accepted 27 Jan 2009) ❏