Journal of Interprofessional Care

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The use of SBAR as a structured communication

tool in the pediatric non-acute care setting: bridge
or barrier for interprofessional collaboration?

Ester Coolen, Rik Engbers, Jos Draaisma, Maud Heinen & Cornelia Fluit

To cite this article: Ester Coolen, Rik Engbers, Jos Draaisma, Maud Heinen & Cornelia Fluit
(2020): The use of SBAR as a structured communication tool in the pediatric non-acute care
setting: bridge or barrier for interprofessional collaboration?, Journal of Interprofessional Care, DOI:
10.1080/13561820.2020.1816936

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JOURNAL OF INTERPROFESSIONAL CARE
https://doi.org/10.1080/13561820.2020.1816936

ORIGINAL ARTICLE

The use of SBAR as a structured communication tool in the pediatric non-acute care
setting: bridge or barrier for interprofessional collaboration?
Ester Coolena, Rik Engbersb, Jos Draaismaa, Maud Heinenc, and Cornelia Fluitb
a
Department of Pediatrics, Radboud University Medical Center Amalia Children’s Hospital, Nijmegen, The Netherlands; bRadboud Health Academy,
Radboud University Medical Center, Nijmegen, The Netherlands; cIQ Health Care, Radboud Institute for Health Sciences, Radboud University Nijmegen
Medical Center, Nijmegen, The Netherlands

ABSTRACT ARTICLE HISTORY

SBAR (Situation, Background, Assessment and Recommendation) is a structured method developed for Received 16 March 2020
communicating critical information that requires immediate action. In 2016 the SBAR tool was introduced Revised 20 August 2020
at the Amalia Children’s Hospital in the Netherlands to improve communication between healthcare Accepted 26 August 2020
workers. Despite formal training and the introduction of aids to facilitate implementation, observed KEYWORDS
adherence to the tool was low. A qualitative study was undertaken to study the use of SBAR by pediatric Interprofessional learning;
residents and nurses in the non-acute clinical care setting of an academic children’s hospital. Semi- communication; tool
structured focus group sessions were conducted and qualitatively analyzed using a constructed coding implementation
template to search for facilitators and barriers in the use of SBAR by different professionals. We found
professionals’ use of SBAR was influenced by departmental, cultural, and individual factors. Important
themes for effective implementation and use of SBAR in an interprofessional setting, like situation
dependency, learning climate and professional identity had not been addressed during the initial
implementation. To facilitate SBAR’s use it is important to identify professionals’ needs to use the tool
effectively, to take into account how tasks and responsibilities are perceived by different professions, and
to stimulate interprofessional feedback and role modeling.

Introduction structures the exchange of patient information between healthcare

professionals. SBAR has been adapted from other disciplines, like
Structured communication tools have been widely implemen­
aviation and the military, as a method for clear communication
ted in hospitals to streamline communication between health­
(Pope et al., 2008; Thomas et al., 2009). SBAR is based on
care workers. These tools have been shown to increase patient
a statement of the situation, background, assessment, and recom­
safety, reduce unexpected deaths and decrease incidents due to
mendations related to a critical issue. By following this script, the
communication errors (De Meester et al., 2013; Müller et al.,
reason for contact, relevant medical history of the patient and the
2018; Randmaa et al., 2014). Moreover, these structured tools
current situation, the vital parameters, and the callers plan of
may improve the perceptions of communication and bridge
action are efficiently communicated. The structure of the tool
the gap in communication styles between professions
ensures that the caller can pass on all information that the other
(Achrekar et al., 2016; Randmaa et al., 2014; Raymond &
person needs to know, to answer a question or devise a plan
Harrison, 2014). If team members participate more fully in
essential for patient care. The SBAR tool can be used in different
the decision-making process (e.g., through interaction or infor­
settings to effectively communicate patient information, be it in
mation sharing), they may invest more in the decisions taken,
person, per telephone, on paper or in the digital patient file. As
give their support for improvement in teamwork and feel able
a result, critical patient information can be communicated
to suggest innovations (West et al., 1990). Therefore, interac­
effectively.
tion and effective communication between team members, are
regarded as essentials to enhance shared accountability, team
climate and quality of care (Agreli et al., 2017; Reeves et al., Background
2013). Despite the fact that effective communication is increas­
SBAR has been proven to be effective in improving patient
ingly recognized as an important competency and profes­
safety in the acute care settings, like for example, emergency
sionals are subjected to a variety of professional development
and intensive care departments (Marshall et al., 2019; De
programs and aids to enhance communication skills, the appli­
Meester et al., 2013; Randmaa et al., 2014; Raymond &
ance of these skills in clinical practice is still low (Curtis et al.,
Harrison, 2014). However, outside the acute care setting,
2013; Joffe et al., 2013).
most research and suggested recommendations on structured
The SBAR (Situation, Background, Assessment and
communication tools are based on expert opinions or users’
Recommendation) tool is a communication tool that effectively

CONTACT Ester Coolen Ester.coolen@radboudumc.nl Radboud Institute for Health Sciences, Department of Paediatrics (804), Amalia Children’s Hospital,
Radboud University Medical Centre, 6500 HB, Nijmegen, The Netherlands
Supplemental data for this article can be accessed on the publisher’s website.
© 2020 The Author(s). Published with license by Taylor & Francis Group, LLC.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
2 E. H. A. J. COOLEN ET AL.
satisfaction with the tool, using pre,- and postquestionnaires
and have not yet been shown to improve communication
effectiveness or patient safety (Horwitz et al., 2008; Renz
et al., 2013; Riesenberg et al., 2009). Furthermore, the available
knowledge on the effective transfer of patient information
between professionals is based predominantly on studies
within the curriculum of medical- and nursing students
(Guimond et al., 2019; Uhm et al., 2019) and cannot simply
be translated to “the workplace,” where healthcare profes­
sionals have already formed their own routines in communi­
cating with other team members.
In the Amalia Children’s Hospital, the use of structured
communication by SBAR was transferred from the intensive
care setting into the non-acute care setting of the pediatric
wards in 2016. During the introduction period both physicians
and nurses were made aware of SBAR and its use by posters
and by handing out SBAR instruction cards. Also specific aids,
such as ‘SBAR Smart Phrases’(Clements, 2018) for standar­
dized documentation in the electronic patient file and note
blocks, with a pre-structured SBAR template, were made avail­
able. Formal education took place by means of instruction,
scenarios, and role play during interprofessional training dur­
ing which medical and nursing staff practiced the use of SBAR
in a simulated environment. Despite the availability of these
aids and the use of SBAR in medical team simulation, adher­
ence to the SBAR tool was poor according to observations done
by the Joint Commission International (JCI; Mehta et al., 2017)
during a patient safety audit in June 2017.
As a result, patient care management organized a theme
week to increase awareness of the SBAR tool, and to educate
nurses and physicians further in the use of SBAR in different
settings (in person, by telephone or written in the patient file).
In May 2018, we audited the use of SBAR by nurses and
residents during shifts at the pediatric care wards and found
that 66% of the telephone calls regarding patient information
were done with the use of SBAR, with no significant differences
between nurses and residents overall (data not shown). This is
in line with the findings of Compton et al. (2012), who reported
the use of SBAR by 58.3% off nurses for critical communication
after finishing a similar educational program on SBAR.
Knowing that formal preparations, creating awareness and
introducing prompting aids do not guarantee the use of SBAR
in clinical practice, led to the research question: What factors
should be addressed to implement SBAR effectively outside the
intensive care setting? To answer this question, we used
a qualitative approach to study what helps or hinders the use
of SBAR in the pediatric non-acute care department, along
with ensuring a better communication standard among health­
care professionals with different backgrounds.
Methods
Setting
The Amalia Children’s Hospital is a Dutch tertiary referral
hospital with a pediatric intensive care department, an emer­
gency care department, and three pediatric clinical care wards
(72 beds) where patients can be hospitalized for both short and
long-term stay, in which care is offered by a broad spectrum of
pediatric physician specialists, residents, and nurses. In 2016,
SBAR was introduced by the patient care management team to
help ensure effective transfer of patient information between
healthcare professionals at the pediatric non-acute care wards.
Also, nurses were appointed to special areas of attention (e.g.,
communication) to function as ambassadors in the workplace.
This study was focused on the use of SBAR for the commu­
nication of patient information by nurses and residents work­
ing in the pediatric non-acute care department. Given the
setting of a teaching hospital, we included residents and nurses
in the focus groups, because these professionals directly com­
municate patient information during routine care and shifts at
the pediatric wards.
Data collection
Focus group meetings were held until saturation was achieved.
Focus groups were conducted between September 2018 and
May 2019. To reduce risk introduced by perceived or real
hierarchy across professional disciplines, focus groups were
divided by profession (nurses and pediatric residents). An
independent interviewer (educationalist) with extensive inter­
view skills and no professional relation to the participants,
conducted all focus groups after signing a confidentiality agree­
ment. Focus group questions were open-ended and designed to
further explore influencing factors for the use of SBAR. The
focus groups consisted of 5 to 12 participants per group and
lasted between 55 and 65 minutes. The collection of data ended
when saturation of themes was reached after five interviews.
Data analysis
Focus group sessions were audio recorded and transcribed
verbatim. All transcripts were anonymized and read repeatedly
by the first author to ensure accuracy and to develop familiar­
ity. Qualitative Analysis Software Atlas.ti (GmbH, Berlin,
Germany), was used to organize the data. Data collection and
analysis proceeded simultaneously, in an iterative fashion.
Transcripts of the focus groups were analyzed following the
template analysis approach as developed by King et al. (2019),
entailing a thematical analysis using a constructed coding
template. The template was based on the research question
and the theoretical concepts of organizational implementation
management (Cosby, 2006; Eid & Quinn, 2017). Four broad
code categories formed the code manual: knowledge, attitude,
self-efficacy, and organizational infrastructure (see
Appendix 1). Two researchers, one pediatrician (EC) and one
nurse (MH), independently analyzed all transcripts and quota­
tions were classified according to the corresponding themes
within the four categories. Discrepancies between researchers
in the outcome of this coding process were discussed and
resolved within the research team, consisting of two pediatri­
cians, one nurse and two educationalists (EC, RE, MH, CF, and
JD). Secondly, summarizing conditions were sought to
describe influencing factors in the use of SBAR. During our
analysis new factors emerged. According to the AMEE Guide
for focus groups in medical education research (Stalmeijer
et al., 2014), the guide with probing questions was adapted
for the following round of focus groups to deepen our

understanding of these factors and gather further information
not captured during the first focus groups (see Appendix 2).
After completing the interviews and analyzing the data, two
researches (EC and RE) facilitated the analytic process by
constructing relationship diagrams and affinity maps. Critical
and reflective feedback from the whole research team on the
emerging model was used to improve the rigor of the data
collection.
Ethical considerations
Individually informed consent was obtained from each parti­
cipant prior to each focus group. Participants received an
information sheet explaining the purpose of the focus group
and stating that the information they shared would be treated
confidentially. The Central Commission for Human Rights
Research (CCMO) Region Arnhem-Nijmegen granted ethical
approval (File number 5961).
Results
In total, five focus groups meetings were organized. The groups
included either pediatric nurses or residents. The first round
consisted of two group sessions with one group of 8 residents
and one group of 8 nurses. The second round consisted of three
group sessions: one group of 12 residents and two groups of 5
and 6 nurses. After two rounds of group meetings saturation of
data was achieved. Analysis revealed that there were four
themes that were perceived to influence the use of SBAR in
the context of non-acute care: Strategic, Contextual, Cultural,
and Individual Factors. Components included in these factors
and illustrative quotations are presented in Table 1.
A conceptual diagram representing a model for implementa­
tion issues of SBAR within the context of the non-acute care is
presented in Figure 1. The themes that emerged from the focus
group interviews and how they were perceived to affect the use
of SBAR by nurses and residents are explained below.
Strategic factors
Participants believed that at the time of the introduction of
SBAR there was much focus on effective communication,
because both patient care management and educators empha­
sized the use of SBAR. Patient care management organized
a theme week to create awareness for structured communica­
tion with SBAR, including oral instruction sessions, and the
introduction of aids such as pre-structured note blocks, smart
phrases and posters). Shortly after the implementation phase,
attention on the use of SBAR decreased, and other topics
appeared to be prioritized by the management team. When
nurses were asked who they perceived to be role models on
communication within their own profession, they stated that
some colleagues in the department were appointed as nurse
ambassadors. However, nurses were not able to identify or
name them. It was furthermore noticed that, although SBAR
and the importance of clear communication is being taught in
education of physicians, educators and supervisors in the
workplace were less consistent in advocating the use of
SBAR. On the other hand, nurses indicated that the setting of
JOURNAL OF INTERPROFESSIONAL CARE 3
a teaching hospital can also be viewed as a facilitator for the use
of SBAR, because the use of SBAR helped them to set a good
example as a communicator and interdisciplinary collaborator
to nursing students. Both nurses and residents mentioned
a lack of proper introduction of the SBAR tool to new cow­
orkers, especially related to the different settings in which
SBAR could be used to convey patient information (e.g.,
acute versus non-acute situations and orally versus written
patient information).
Contextual factors
Took traits
The rigidity of the SBAR script and formal way of formulating
the patient information made it less feasible for communica­
tion during daily routines. In addition, the elements of the
acronym SBAR were used differently depending on the con­
text. For example, nurses indicated that for the element
Situation, they usually write down the reason for admittance
in the electronic patient file, whereas they are expected to state
the reason for calling when they contact a physician about
a patient during a shift. This led to confusion about how to
use SBAR correctly. Both nurses and residents stated that
SBAR does not leave enough room for their own considera­
tions. Residents, for instance, want to share their differential
diagnoses and clinical reasoning thoughts with their super­
visor, before coming up with their plan or recommendations.
Both nurses and residents believed that SBAR is very useful to
structure and prioritize information for the other professional,
to be able to create an overview of the situation. However,
whereas residents stated that SBAR was also useful to commu­
nicate effectively with other physicians to create a shared per­
ception of the situation, nurses expressed their doubts on the
applicability of the tool for nurse to nurse communication,
because of its rigid and stand-offish characteristics.
Situational dependency
SBAR was perceived as useful and effective during acute events
because it helps to structure essential patient information, cre­
ates an overview of the situation and helps to communicate
a plan of action. However, participants stated that during routine
clinical care, SBAR is less suitable because the rigid structure
does not allow for elaborations for educational purposes or social
interaction. Also, during day-time care, as opposed to during
shifts, health care professionals are more familiarized with the
situation and background information of the patients on the
ward, making them feel as if they were repeating themselves by
using SBAR. Furthermore, nurses replied, when asked about the
use of SBAR with team members other than physicians, that they
do not think the SBAR tool to be useful for the transfer of patient
information to non-physician healthcare professionals, includ­
ing their nursing colleagues, physiotherapists, and physician
assistants, as they usually have read the patient file, before
attending to the patient during routine care.
Supportive preconditions
For nurses, the SBAR script is integrated into the electronic
patient file with SBAR Smart Phrases (Clements, 2018), there­
fore they use it daily. However, SBAR is used differently in the
4 E. H. A. J. COOLEN ET AL.

Table 1. Themes perceived to affect the use of SBAR in pediatric non-acute care.
Components Example Quotations
Hospital board of “Around the time of the JCI, everybody was talking about SBAR and how we should communicate. Now I do not hear so much about this. I’m
directors not sure if we are still supposed to use it [SBAR] all the time, or only during acute events?“(resident)
Patient care “Oh, we have to learn a new acronym almost every month. We have SBAR, ABC, PWES. I just can’t keep up to speed with it . . ., all these numbers
management and letters I have to put down in the patient file. They [patient care management] come up with something new constantly and we have to
keep track of these changes every time.”(nurse)
Communication When asked about role models in communication: “I think that some of the nurses are appointed to topic of communication, as a special
ambassadors area of attention. I think they know all about the best way to communicate how it should work, but I’m actually not sure of who they are at
this moment.”(nurse)
Formal educators “I learned all about the importance of structured communication at [nursing] school. Our group mentor was very good in convincing us to use
SBAR and how it helps to communicate clearly. So, during this internship I want to use it regardless of what others say or do.”(nursing student)
“During our morning handovers we’re supposed to use SBAR for structure and clarity [. . .]. However, I don’t think supervisors use SBAR themselves
when they transfer patient information to us.”(resident)
Tool traits “And then you should put down assessment of vitals, but where do you put the regular physical examination and your differential diagnosis.
They [supervisors] need to hear my considerations to be able to come to a conclusion and agree with my plan.”(resident)
When asked about the meaning of the S in SBAR: Nurse 1: “Yes, the difference is whether you are reporting: in that case I just write down the
reason for admission, but when you really need someone, then it’s the current situation.” Nurse 2: “Yes, the reason for calling . . . But some
people get confused about this.”(nurse)
“And when it becomes chaotic and panicky [after an acute problem arise], that’s when you need SBAR to keep overview and stay calm, but
Situational traits when I’m just discussing a patient problem with the doctor it feels way too formal to go through each point individual.”(nurse)
“If I’m forced to stick to SBAR in a non-acute setting, not telling them [supervisors] my full assessment [of the patient] or my thoughts on the
matter. Then, how can I express my clinical reasoning. I really need more words to show them what I know and think about the patient’s
problem.”(resident)
Supportive preconditions “We do not have many practice opportunities in our daily routines . . . We did try to use SBAR in handovers between nurses and team meetings,
but a lot of felt it [SBAR] was not suitable for communicating concerns or your gut feeling about the patient.”(nurse)
“I started working here 5 months ago and I didn’t get any instructions or what so ever about SBAR, learned that I should have looked this up in
our instruction manual, but no one explained to me in what kind of situations SBAR should or shouldn’t be applied.”(resident)
Interprofessional “I think if you work here it feels like you have to be easy going and friendly all the time. That if you’re always serious and putting people in their
interaction place, you will pay the price . . .. Well you know what I mean; you should stop being so strict and serious, all the time.” (nurse)
“We really feel part of the Children’s hospital you know, and I do feel that we’re used to communicate in a certain way. It’s different with
professionals outside of child care. We are more holistic and socially engaged . . ., although we do need more words, I guess that’s not really
what you’re supposed to do when using SBAR.”(resident)
Climate for learning When asked if they have ever received positive feedback on the use of SBAR: “No, I haven’t, but we need to give each other more compliments.
It helps to change our work environment.” (nurse)
“Sometimes I will overhear a colleague speaking to an attending and I think, like really are you serious? I don’t even know what you are talking
about . . ..They usually find out for themselves, because they’ll get like a hundred questions in return.” (nurse)
“I mostly look at my fellow residents for role models in effective communication. Some of them are really good in structuring a patient
handover.”(resident)
“When I notice effective communication, that’s mostly when I watch residents in acute situations . . . How the communicate and streamline the
team.”(nurse)
Role expectations “I remember calling about a very sick patient on the ward, telling the doctor that the patient is unstable and needs immediate attention,
probably because of an anaphylactic reaction . . . Then I was told that I spoke out of turn and should have completed all measurement
before calling a doctor.”(nurse)
“During shifts I will get calls with only bits of information they [nurses] want to pass on to me at the end of their shift. No question, no plan of
action. What am I supposed to do with that? Then, I just pause en keep silent, hoping they will rephrase their story and ask me what they
actually want.” (resident)
Motivation to use “The use of SBAR seems like it costs a lot of time [. . .], but actually thirty seconds [. . .] and the team is streamlined, going forward.” (nurse)
“At the PICU [pediatric intensive care unit] every transfer is structured using SBAR, even the morning handovers and those are complex patients
too. I do not see a reason not to use SBAR in every day care.”(resident)
Feeling competent “It [the use of SBAR] is not yet very automatic. An acute situation doesn’t happen every shift. At least not with me [. . .] and then I’m already
bumbling again when I pick up the phone to call for help, just thinking out loud in random order. So, it’s not quite there yet.”(nurse)
“I called [a supervisor] and said: “I would like to discuss a patient who is lying in the emergency room because I would like to send him home.”
I couldn’t imagine a better R, and then the supervisor blamed me for being too cocky with the handover. So, then I’m not sure anymore,
what do actually want from me?” (resident)
Perceived professional “There’s a difference between doctors and nurses . . ..We’re trained to have opinions about everything and come up with a solution. If you ask
identity a nurse: Do you think this child is really sick? They often don’t know how to respond.” (resident)
“I do not think we should use SBAR between nurses, it’s just not how nurses are used to talk to each other. We like to be more easy going and
elaborate, not talking as formal as doctors do.”(nurse)

written context than verbally, and nurses perceive that physi­
cians need other information from them in the acute (spoken)
situation than what is written down in the patient file. Nurses
stated that during a rare and unexpected acute event it can be
very challenging to extract the information that is needed by
the physician from the patient file and convey this in the
correct order. Other than this, nurses have limited practice
opportunities for SBAR, because of the low prevalence of
acute situations. The frequency of interprofessional team simu­
lation, approximately once a year, is low and it was also noted
that SBAR is not used during team meetings or patient hand­
overs on a structural basis. Aids to create awareness of SBAR,
such as note blocks, posters and a SBAR theme week, were
initially regarded upon as stimulating, but lost their effect after
a while. Moreover, some nurses indicated that they observed
that more experienced nurses did not to use these aids as they
had already formed their own routines.
Cultural factors
Interprofessional interaction
Participants perceived the general communications style with
respect to colleagues as friendly and cooperative. On the other
hand, the overall friendly communication style inhibited
 JOURNAL OF INTERPROFESSIONAL CARE 5

Board of Directors Strategy

Quality of care Formal educators

accreditation Strategy

Vision on quality of care

Departmental Strategy

Patient Care Communication

Management Ambassadors Team climate
Supportive preconditions
Teaching hospital Role expectations

Departmental Context Departmental Culture

Professional Feedback
Type of care Tool traits
identity Role
Introductional
model
program
Competing Feeling
demands Competent

Individual Strategy

Motivation Task
to use responsibility

Making use of SBAR in Pediatric Clinical Care

Figure 1. Conceptual diagram representing the factors which influence the use of SBAR by health care professionals.

nurses from speaking up when SBAR was not being used if
needed, because they were afraid this feedback would not be
appreciated by their colleagues and could negatively affect their
collaboration and team climate.
Climate for workplace learning
Participants indicated the importance of feedback to learn and
improve using SBAR, however, feedback is hardly ever given or
received to and from colleagues from the same and different
profession. Feedback is given indirectly, rather than actively
speaking up when communication was flawed. The presence of
learners like students or novice nurses had a positive impact on
their role modeling and feedback behavior. Residents stated
that if nurses were to give them feedback, this would increase
their alertness on the correct use of the SBAR tool and possibly
would stimulate them to give feedback to nurses. Residents
received conflicting feedback from their supervisors, giving
them different instructions on how to structure their informa­
tion. When it came to learning in practice, residents empha­
sized the lack of consistency in the use of SBAR by their
supervisors, which prevented them from being a positive role
model to the residents. Besides that, they mentioned that SBAR
is not used in every department of the hospital. This made it
difficult for residents to be consistent with SBAR themselves.
Nurses tended to see residents as role models for effective
communication, rather than people from their own profession.
Residents emphasized the lack of consistency in the use of
SBAR by their supervisors, which prevented them from being
a positive role model to the residents. They mentioned that
SBAR is not used in every department of the hospital. This
makes it difficult for residents to be consistent with SBAR
themselves. Nurses tended to see residents as role models for
effective communication, rather than people from their own
profession.
Role expectations
Participants emphasized the importance of discussing and
reflecting on role expectations and communication style, for
instance, by regular team debriefings. A better understanding
of each other’s needs and expectations would make it easier to
understand the usefulness of the tool in different care settings.
The nurses in this study believed that discussing the patient’s
plan, in the ‘Recommendation’ section of SBAR, is not one of
their tasks. They indicated that it is up to physicians to decide
upon a plan of action after being provided with the necessary
information. Furthermore, some nurses shared their experi­
ences of being reprimanded by physicians after providing them
with a diagnosis or plan of action, which prevented them from
making recommendations in the future. On the other hand
residents indicated that they expected nurses to structure their
information and conclude their story with a clear lead on what
they expect the physician to do.
Individual factors
Motivation to use
Both nurses and residents were motivated to use SBAR,
because it was useful in creating an overview of the situation
6 E. H. A. J. COOLEN ET AL.
and helped them to structure the information, they wanted to
transfer to a team member. Nurses mentioned several times
that they automatically “go through this structuring process in
their heads,” but that the SBAR tool helped them to reinforce
data collection steps and reporting mechanisms. Residents
described that positive experiences with the tool in other
departments motivated them to use SBAR in the clinical care
setting as well. A high workload together with constantly
changing work routines made some of the participants weary
of change. Also, the time investment of learning to incorporate
a new tool, without the prior conviction that it will be of use to
you or your patient could prevent using SBAR. Some residents
were not sure SBAR had an additional value to them, because
they already had their own way of structuring information.
Feeling competent
The main barriers that undermined nurses feeling competent
when using SBAR, is the difficulty they experience when filter­
ing relevant information to convey to the physician. Assessing
what the physician needs to know about the Background item
in particular, is challenging. Also, the lack of exercise with
structured communication during routine practice makes it
difficult to use SBAR in the case of a rare acute event in the
clinical care setting. Residents mentioned a high degree of
competence regarding structured communication. Despite
their confidence in being an effective communicator, some
residents mentioned that contradictory feedback from their
supervisors made them uncertain of how to use SBAR in non-
acute situations, like discussing patients with their supervisor
after a patient examination at the clinical ward.
Perceived professional role
SBAR is not (yet) part of the roles and tasks in daily practice,
especially for nurses. They indicated that following a script
when transferring patient information, does not align with
the communication style of their professional group, which is
traditionally less structured and formal and allows for more
social interaction. Furthermore, from the interviews it became
clear that there is a shared perception of the traditional roles of
physicians and nurses regarding patient management. Nurses
did not identify themselves with the task of diagnosing the
patient problem or making recommendations. Residents, in
contrast, believed that effective communication is part of
their role and a responsibility as a physician. On the other
hand, they struggled with the rigid format of SBAR and their
identity as a childcare professional, as they needed to elaborate
and share social context of the patient with other professionals.
Discussion
This qualitative analysis provides insights on what factors
should be addressed to implement the use SBAR by health­
care professionals within the interprofessional context of
a pediatric non-acute care ward. Poor communication is
found in many different healthcare settings and is especially
prominent in-patient hand-offs and settings where fast and
effective management is indispensable (Shahid & Thomas,
2018). However, the process of interprofessional communica­
tion is complex and prone to misunderstanding. To overcome
this, desirable communication strategies take little time and
effort to complete, deliver comprehensive information effi­
ciently, encourage interprofessional collaboration, and limit
the probability of error (Luettel et al., 2007). Planning for
implementation of patient safety issues that interfere with
work routines and team culture should recognize the interac­
tion between the intervention, the complex setting in which it
is used, and the professionals involved (Grol et al., 2007).
Consequently, the unreflected adoption of a communication
tool, without an investment by the team to come to an agree­
ment on effective communication and a shared philosophy on
teamwork, will lead to failure to improve interprofessional
collaboration (Müller et al., 2018). The findings in this study
are in line with models of innovative climates in the literature,
in which a clearly defined vision (strategy), a safe environ­
ment for professional development (learning climate),
a shared concern and understanding of quality of perfor­
mance (interprofessional interaction and role expectation)
and practical support and opportunity to introduce and prac­
tice new routines (preconditions and situational dependency)
are defined as the most important factors for innovation
(West, 1990). As the interaction of these factors at multiple
levels may influence the success or failure of quality-
improvement interventions a deeper understanding of these
factors is crucial (Grol & Grimshaw, 2003).
Situational dependency
The SBAR tool is widely used in different healthcare facilities as
a communication and hand-off tool both intra-professional
and inter-professional (Achrekar et al., 2016; De Meester
et al., 2013; Randmaa et al., 2014; Raymond & Harrison,
2014), and is regarded as current ‘best practice’ to deliver
information in critical situations (Taylor, 2010). However, it
is important to realize that one size does not fit all, when it
comes to improving interprofessional communication strate­
gies in healthcare. SBAR might be an adaptive tool that is
suitable for many healthcare settings, in particular when clear
and effective interpersonal communication is required. We
found that SBAR, which has been proven to be successful
within the acute care setting, cannot automatically be trans­
lated into other departments with different communication
styles and culture. Depending on the context and urgency of
the situation, professionals indicated to be more or less moti­
vated to use the SBAR tool. Healthcare professionals associate
the tool with acute care settings, and this explains why they
perceive it to be more relevant and easier to apply in an acute
care setting or in a patient that is acutely deteriorating.
Although, the feasibility of SBAR has been proven in non-
acute care facilities to the satisfaction of professionals (Renz
et al., 2013), these reports do not measure actual use. Research
has shown that motivation and satisfaction of the SBAR tool
can be high among healthcare professionals, without actually
increasing self-efficacy or the use of SBAR in the workplace
(Uhm et al., 2019). This is in line with our findings. Nurses and
physicians stated that they mainly use SBAR to deliver infor­
mation in critical situations. It helps them to collaborate
because sender and receiver share the same mental model,
understanding of the situation. This might also be the case

for less urgent patient situations, however nurses indicated that
there was no shared vision on how to adapt the SBAR tool to
their specific needs. The barrier of situational dependency
could be addressed by an interprofessional agreement on the
use of SBAR in different clinical care settings. To come to such
an agreement, professionals should be given the opportunity to
reflect and discuss within the team what information each
healthcare professional needs for the communication tool to
be effective in both urgent and non-urgent situations.
Climate for workplace learning
This study highlights the importance of a departmental culture
that accommodates healthcare professionals to improve their
quality of work and facilitates interprofessional collaboration.
A positive team climate occurs when team members use reflec­
tive processes to appraise potential weaknesses, monitor col­
leagues work performance, and share a belief in
interdependence as a way of developing an integrated approach
to action based on cooperation (Agreli et al., 2017). Healthcare
professionals are continuously exposed to changes in their
working environment. In response to changes, there will be
both similarities and differences in reaction; professionals will
have to defend or reconfigure their professional identity
(Gover & Duxbury, 2012). However, when a shared interpro­
fessional learning climate is lacking, strong professional iden­
tities may perpetuate hierarchical disciplinary boundaries in
the process of team collaboration (Hotho, 2008; Langendyk
et al., 2015). Therefore, creating a safe atmosphere where
team members feel safe to speak up and are able to learn
from each other, is essential for teamwork. (Reader et al., 2007).
Furthermore, a lack of understanding of others’ professional
roles and responsibilities are main barriers to team effort and
the interprofessional collaborative practice (Hazen et al., 2018).
The hierarchical structure of the healthcare system and the
stereotypes of the physician who reasons, diagnoses, and
leads and of the nurse who cares, nurtures, and functions as
a cooperative team member persist. This preconception seems
to prevent nurses from making recommendations when using
SBAR. If nurses believe that their inputs are not heard by
physicians, they will probably make fewer suggestions, while
residents expect more participation. Thus, there is a risk to
enter a vicious circle, in which expectations are less and less
met, leading to poor teamwork. These findings are in line with
previous research on interprofessional collaboration and role
perception and underline the importance of a shared vision on
professional roles and responsibilities (Hazen et al., 2018),
characterized by team evaluations, interprofessional practice
opportunities and critical appraisal of team values and goals
(Agreli et al., 2017; Blondon et al., 2017; Kostoff et al., 2016).
Communication tools, such as SBAR, are designed to support
communication across hierarchical boundaries, reducing inhi­
bitions in hierarchical context by encouraging the sender to
provide a personal assessment and suggestion of the situation
(Recommendation; Donahue et al., 2011). However, our find­
ings illustrate that the implementation of a communication
tool without a shared philosophy, does not automatically lead
to team members’ assertiveness, better interdisciplinary com­
munication, and a shared perception of teamwork.
JOURNAL OF INTERPROFESSIONAL CARE 7
Furthermore, these findings emphasize the importance of
role models and feedback in order to fundamentally change the
way of thinking and acting and develop new routines and
practices. Within the skill domain of interprofessional com­
munication, the ability to deliver feedback to and receive feed­
back from team members is considered an essential
competency. There are numerous factors that influence accept­
ability of feedback (Eva et al., 2012; Hattie & Timperley, 2007).
Some of these factors, for example, the credibility of the feed­
back source may be especially important in the interprofes­
sional context, whereas feedback from persons with a different
profession could be more easily disregarded (Van Schaik et al.,
2016). Our data suggest that safety for the exchange of feedback
is not only an issue between physicians and nurses, but also
within the same profession. Nurses believed that spontaneous
feedback given to team members, especially to their nursing
colleagues, was not accepted within the group. The climate at
the workplace can be a constraining factor when it is perceived
as competitive or lacking in trust or when new roles or tools are
not valued or accepted (Sachdeva, 1996; West et al., 2010).
These issues must be addressed in order to develop and be
effective as a team. Interprofessional training sessions or team
debriefings with the possibility to reflect up on their collabora­
tion and practice effective communication were mentioned by
participants during group sessions as a way of improving their
collaboration.
Motivation to use
The decision to use SBAR is ultimately made at the level of the
individual. We found that the individual strategies in using
SBAR were influenced by a sense of autonomy as
a professional, feeling of competence and perceived profes­
sional identity to incorporate a new tool into their work rou­
tines. These findings are in line with the theoretical concept of
self-determination (SDT). This theory conceptualizes that goal
directed behaviors, like learning new routines in the workplace,
are driven by three innate psychological needs: autonomy (the
need to feel ownership of one’s behavior), competence (the
need to produce desired outcomes and to experience mastery),
and relatedness (the need to feel connected to others) (Ryan &
Deci, 2000).
The nurses in this study indicated that although they had
a positive attitude toward SBAR in acute situations and inter­
action with physicians, they did not believe that the tool met
their requirements for communicating patient information
toward each other during routine care. They were less moti­
vated to use the tool in these circumstances, which in turn led
to a lack of familiarizing with the tool and less confidence in
using the tool in more complex or acute situations. Feeling
competent to perform a certain task, also called self-efficacy,
is an important predictor of transfer of learned practices into
the workplace (Bandura, 2001). To improve the use of SBAR
in the clinical practice, the issue of autonomy, competence
and relatedness to promote intrinsic motivation, needs to be
addressed by showing professionals how the tool can help
achieving their communication goals, promote interprofes­
sional feedback and remodel their work environment. These
opportunities are best created by health professionals
8 E. H. A. J. COOLEN ET AL.
themselves; for example, by using SBAR during team debrief­
ings, or shared reflection on effective communication during
simulated team training scenarios, as was mentioned by the
participants in this study. In this way healthcare professionals
can become familiar with the tool in less stressful conditions
and build self-efficacy with regard to effective communication
styles. Subsequently, they may adapt the tool to their needs
and feel ownership for the effective use of SBAR in different
settings.
Limitations
A limitation of this study is that the data were gathered at the
pediatric non-acute care department of a teaching hospital.
This specific context may limit the generalizability of our find­
ings. Furthermore, we decided to interview both professional
groups separately. This leaves out the possibility of interaction
between professions, which could also have provided us and
participant with additional insights regarding the effect of their
communication styles and the use of SBAR.
Recommendations for clinical practice
Multiple aspects of implementation theories on the individual,
contextual, social and organizational level should be consid­
ered, when introducing SBAR into a new setting. To enhance
the use of the SBAR tool into a new healthcare setting it is
important to identify professionals’ needs to use the tool effec­
tively and to consider how tasks and responsibilities are per­
ceived by different team members. This can be accomplished
by investing in a consultation process with representatives of
all involved disciplines, prior to the implementation phase to
confer a sense of ownership to team members which may be
essential to the success of interventions that seek to change
behavior. Furthermore, our findings suggest that for successful
implementation of SBAR in an interprofessional setting one
should recognize differences in education levels, professional
status, as well as perception of roles and responsibilities of the
various health professions, since long established routines and
(wrongful) assumptions may hamper to process to change
interprofessional communication. To overcome these differ­
ences health, professionals need to be given opportunities to
create a shared perception of team goals and interprofessional
collaboration by introducing team debriefings and interprofes­
sional evaluations of work routines. This may also foster
a positive learning climate within the workplace, in which
team members feel safe to implement new work routines and
stimulate inter/intra-professional feedback and role modeling.
Conclusions
The results of this research suggest that for successful imple­
mentation of SBAR a supportive departmental environment,
structurally, strategically, and culturally is crucial for health­
care professionals to engage with the tool and incorporate it
into their workplace routines. Future research should focus on
how the organization can help professionals to cross profes­
sional boundaries and exchange their needs and expectations
in improving interprofessional communication.
Declaration of interest
The authors report no conflicts of interest. The authors alone are respon­
sible for the content and writing of this article.
Notes on contributors
Ester Coolen is a M.D., and PhD-candidate on the topic of teamwork in
acute pediatric care. She works as a general pediatrician, educator and
vice-director of the pediatric residency program at the Amalia Children's
Hospital of the Radboud University Medical Center, Nijmegen, the
Netherlands.
Rik Engbers is a PhD, educationalist and post-doctoral educational
researcher and medical teaching policy advisor at the Radboud Health
Academy of the Radboud University Medical Center, Nijmegen, the
Netherlands.
Jos Draaisma is a M.D., PhD, and post-doctoral researcher. He works as a
general pediatrician and has extensive experience in innovative medical
education as a senior educator and former director of the pediatric
residency program at the Amalia Children's Hospital of the Radboud
University Medical Center, Nijmegen, The Netherlands.
Maud Heinen is a PhD, registered nurse and senior post-docteral
researcher in nursing science with expertise in innovation and quality of
care at the Radboud Institute for Health Sciences, Radboud University
Medical Center, Nijmegen, The Netherlands.
Cornelia Fluit is a M.D., educationalist and professor in Medical
Education. She is a senior researcher with specific expertise on workplace
learning, coaching and feedback in Healthcare at the Radboud Health
Academy of the Radboud University Medical Center, Nijmegen, The
Netherlands.
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