NURSE-PATIENT COMMUNICATION, INTERDISCIPLINARY COMMUNICATION, AND PATIENT SAFETY

Clinical Simulation in Nursing (2020) 43, 44-50

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Featured Article

Relationship between Interprofessional Communication and Team Task Performance

Kyeong Ryong Lee, PhD, MDa, Eun Jung Kim, PhD, RN, ACNP-BCb,* aDepartment of Emergency Medicine, School of Medicine, Konkuk University, Konkuk University Medical Center, Seoul 05029, Republic of Korea bSchool of Nursing, Research Institute of Nursing Science, Hallym University, Chuncheon, Gangwon-do 24252, Republic of Korea

KEYWORDS simulation training; nursing education; communication; performance; healthcare; crew resource management;

team communication; interprofessional communication

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Abstract Background: Communication among health care professionals is essential for ensuring quality patient care and safety. Although communication appears to be crucial during critical events, this assumption has not been widely evaluated. This study aimed to determine whether Situation, Background, Assess- ment, Recommendation, and Read-Back (SBAR-R) communications are related to team task perfor- mance in a simulated emergency. Methods: A convenience sample of 49 teams with 194 nursing students participated. Trained ob- servers rated team task performance and SBAR-R communication with a mock doctor in a team- based simulated emergency. Results: SBAR-R communication scores differed significantly according to overall team task perfor- mance. The initial team performance, including patient assessment, correlated positively with SBAR with the physician. The team task performance without error correlated positively with read-back communication. Conclusions: These findings suggested that the SBAR-R communications are important to consistent team performance in an emergency.

Cite this article: Lee, K. R., & Kim, E. J. (2020, June). Relationship between interprofessional communication and team task performance. Clinical Simulation in Nursing, 43(C), 44-50. https://doi.org/10.1016/ j.ecns.2020.02.002.

� 2020 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

Poor teamwork and communication among health care staff correlates with patient safety incidents and worse outcomes for patients (De Meester, Verspuy, Monsieurs, &

research did not receive any spe-

e public, commercial, or not-for-

ym.ac.kr (E. J. Kim).

ernational Nursing Association for Clinic

2

Van Bogaert, 2013). The Joint Commission identified failure in communication as one of the root causes for over 60% of reported sentinel events in 2013 (The Joint Commission, 2014). Common barriers to effective communication include inconsistency in team membership, varying communication styles, distractions, fatigue, lack of confidence, and misinter- pretation of cues (Foronda, MacWilliams, & McArthur, 2016). Team training and standardization of verbal

al Simulation and Learning. Published by Elsevier Inc. All rights reserved.

Communication and Team Task Performance 45

communication have been suggested as methods for improving communication among health caregivers and, thereby, patient safety (Rabøl et al., 2011).

Situation, Background, Assessment, Recommendation and Read-back (SBAR-R) communication form the most

Key Points � Team performance correlated with SBAR and read-back commu- nication in a simulated emergency.

� Initial team taskperfor- mance was positively associated with SBAR communication.

� Team task performance using verbal instruction correlated with read- back communication.

frequently implemented framework in the health care setting (Kostiuk, 2015). This framework is one standardized method of communication that is sim- ple, concise, and fully rele- vant to the information medical teams need. By us- ing SBAR, the person starts to communicate by noting what is currently happening and then moves on to the context, provides a problem assessment, and suggests a solution (Rodgers, 2007). The SBAR technique helps staff members anticipate the

information needed by colleagues and encourages assess- ment skills. It allows one to promptly formulate the informa- tion with the right level of detail. The technique of read-back, the fundamental mechanism of closed-loop communication, involves a person receiving information and then repeating it back verbally to the sender (Boyd et al., 2014). Grbach, Vincent, and Struth (2008) adapted SBAR to I-SBAR-R format, adding an identification of the person calling and read back the orders to promote safe practice. Especially dur- ing a critical event, nurses and physicians often communicate over the telephone, which makes these communications error prone (Rabøl et al., 2011). Read-back lets the sender know the message has been received and provides an opportunity to correct any mistakes (Boyd et al., 2014). In health care, the potential risks of not using closed-loop communication are increasingly acknowledged, and read-back is considered to be an essential feature for error prevention and quality of care. The Joint Commission’s National Patient Safety Goal that addresses communication requires write-down and read-back of the critical value information on a timely basis (Singh & Vij, 2010).

Communication among health care professionals is known to be particularly crucial in the context of critical events, but this assumption has not yet been widely evaluated and there is a lack of clear relationship between team performance and communication. Previous studies of health care professionals or students mainly have focused on improvement in commu- nication skills, perceived interprofessional competence, and critical thinking skills as a result of SBAR training (Foronda et al., 2016; Kesten, 2011; Kostoff, Burkhardt, Winter, & Shrader, 2016), and few studies have investigated how SBAR-R communication contributes to patient-important outcomes (Shahid & Thomas, 2018).

Nurses are at the forefront of ensuring patient safety, but there is little reliable evidence on nurses’ performance in interprofessional teams (IOM, 2003). This study attempted to identify whether verbal critical incident report focused on SBAR-R communication tool is related to team task per- formance and can affect patient outcomes in a simulated emergency. We hypothesized that the association between team task performance and interprofessional communication would be more apparent in nursing students who lack clinical experience than in those already familiar with clinical practice. Similarly, we hypothesized that read- back communication would be important for students unfa- miliar with the situation and environment when acting on verbal instructions without introducing errors or missing important aspects. The results of this study may help iden- tify specific nursing behaviors that are essential to ensuring patient safety. We conducted this study in nursing students.

Methods

Study Design

This study used a prospective observational study design to examine the relationships between nursing students’ team task performance and SBAR-R communication.

Setting and Participants

This study was approved by the university’s institutional review board. The study was conducted at a university. From 2015 to 2016, senior-level nursing students enrolled in the integrated nursing practicum, a required nursing laboratory course before graduation, were eligible for inclusion, and all students agreed to participate (N ¼ 194). All of the students had no previous simulation experience and had the same experience completing all the clinical exercises required for graduation. The students were grouped into 49 teams by name in an alphabetical order for convenience to partici- pate in the simulation training; 47 teams included four mem- bers with the other two teams having three members. The analysis unit was the observed behavior of the team.

Measures

The fundamental measures of this study were team task performance and SBAR-R communication using checklists developed by researchers.

Team task performance was categorized into two phases: the initial team performance before a call to a mock doctor and the team task performance after receiving verbal instructions from a doctor via phone. These were measured using a checklist of observable key actions based on practice guidelines derived from the literature.

The initial team performance phase refers to the stage in which team members work together at the beginning of an

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Communication and Team Task Performance 46

encountered emergency. The expected behaviors by the team were as follows: obtaining a brief, targeted history; checking vital signs; performing a targeted physical exam- ination; cardiac monitoring; checking oxygen saturation and administering oxygen, if needed; and elevating the head of the bed. The phase related to the team task performance after the call to doctor assessed the key clinical actions in response to the mock doctor’s verbal order and was as follows: administering and maintaining oxygen through a nasal prong; establishing an intravenous line; administering aspirin, nitroglycerin, morphine, and heparin; obtaining venous blood for laboratory tests; and arranging 12-lead electrocardiography (ECG). A dichoto- mous scoring scale of 0 ¼ not done and 1 ¼ done was used to assess each item. The possible scores for this checklist ranged from 0 to 12 for the initial team performance and 0 to 8 for the actions after the call to the mock doctor.

SBAR-R communication behaviors were assessed using a checklist. We assessed the participants’ ability to apply the SBAR-R technique when reporting to the mock doctor and receiving telephone instructions in the simulated emergency scenario. These communication behaviors were categorized into two phases: SBAR reporting to a mock doctor after the initial assessment and read-back after receiving the order from the mock doctor. The checklist included 29 key communication behaviors. The scenario included four items: patient’s name, sex, age, and reason for the phone call (major problem). The background included three items to obtain a previous diagnosis or past history of the patient. The assessment used nine items to be reported, including vital signs. The recommendation comprised two items including one general suggestion about problem solving and one concrete suggestion. The verbal read-back comprised 11 items to be evaluated as closed communication while clearly the identifying the doctor’s instructions. A dichotomous scoring scale of 0 ¼ not done and 1 ¼ done was used. The possible scores ranged from 0 to 18 points for SBAR and 0 to 11 points for read-back communication.

We also recorded the time of the first call and the number of calls to the physician. The contents of the tools had been validated bythree expertswithsimulationtrainingexperience.

Procedures

Medical emergencies can have devastating consequences. Chest pain can be a sign of an impending catastrophic medical condition if a patient collapses, and its effective management requires the medical team to perform several tasks simultaneously. These tasks include information gathering and immediate life support including administra- tion of oxygen, morphine, aspirin, and nitroglycerin, applying 12-lead ECG, establishing an intravenous line, and sampling of venous blood.

Before the simulated emergency scenario, students received a mini-lecture about SBAR-R communication and

determined the team leader. Each of the 49 teams was presented with a scenario involving an acute myocardial infarction using a high-fidelity patient stimulator. According to the expected sequence of clinical actions, the team should take a series of four phase actions. In the scenario, the patient presented to the emergency department because of chest pain. The expectation for the first phase was immediate assessment and initial management of the patient by the team. Each team’s initial task performance before the call to the mock doctor was assessed. In the second phase, the team leader then reported the patient’s condition to the mock doctor over the telephone, and communication behaviors were assessed using the SBAR checklist. In the third phase, the team leader received a verbal order about the key actions from the doctor over the telephone. The read-back checklist was used to evaluate the leader’s closed-loop communication behaviors. A doctor was immediately available by telephone, if requested. A faculty member played the role of the doctor receiving the SBAR report and provided orders based on a premade order set. In the fourth phase, the team’s perfor- mance of the expected actions in accordance with the physician’s order was assessed using the checklist.

All simulation exercises were videotaped for assessment. Two trained assessors independently reviewed five of 49 videotaped simulation scenarios. Cohen’s kappa, a measure of interrater reliability, ranged from 0.78 to 0.87 for team task performance and from 0.67 to 0.91 for SBAR-R communi- cation, and these values were judged to be acceptable. The remaining cases were measured by one assessor.

Data Analysis

We used descriptive statistics to assess team task perfor- mance and SBAR-R communication. The mean team task performance score was 13.80 (SD 2.59) and the median was 14. We categorized the individual teams into better or worse teams with respect to their team task performance. Scores �14 of 19 were categorized as better (n ¼ 26) and those <14 were categorized as worse (n ¼ 23). The Mann-Whitney nonparametric U test was used to compare the SBAR-R communication between the better and worse teams. Because of the ordinal nature of the scores, the nonparametric Kendall rank correlation was used to examine the correlations between team task performance and SBAR-R communication. The data were analyzed us- ing IBM SPSS Statistics (IBM Corp., Armonk, NY, USA).

Results

Team Task Performance

Eleven key actions were assessed to examine the initial team performance. Most teams performed brief and targeted history taking (94%), and about half of the teams

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Table 1 Descriptive Measures of Team Task Performance and SBAR-R Communication (n ¼ 49) Category Behavior Markers % of Frequency

Initial performance Obtaining present history 94 Obtaining past history or family history 55 Checking vital signs: blood pressure 100 Checking vital signs: pulse 47 Checking vital signs: respiration 37 Checking vital signs: body temperature 78 Performing targeted physical examination 41 Applying the cardiac monitor 88 Checking oxygen saturation 90 Administering oxygen 18 Elevating head of bed 57

Key action after call to a physician Administering and maintaining oxygen 92 Establishing the intravenous line 78 Administering aspirin by chewing 88 Administering NTG by sublingual 92 Administering morphine by IV 90 Administering heparin by IV 29 Obtaining venous blood for laboratory test 49 Arranging (requesting) the 12-lead ECG 47

SBAR-R communication (% of scores) SBAR-R communication 62 Situation 72 Background 56 Assessment 63 Recommendation 30 Read-back 66

Note. SBAR-R ¼ situation, background, assessment, recommendation and read-back; NTG ¼ nitroglycerin; IV ¼ intravenous; ECG ¼ electrocardiogram.

Communication and Team Task Performance 47

performed past or family history taking (55%). For vital signs, the teams checked the patient’s blood pressure (100%), pulse (47%), respiratory rate (37%), body tem- perature (78%), and oxygen saturation (90%). Most teams applied the cardiac monitor (88%) and half elevated the head of the bed (57%). However, only 18% of the teams initially administered oxygen to the patients.

Eight key actions were assessed to examine team performance after receiving verbal instruction from the mock doctor. Most teams administered oxygen (92%), aspirin (88%), sublingual nitroglycerin (92%), and morphine (90%), and established an intravenous line (78%). Less than one-third (29%) of the teams administered

Table 2 Comparison of SBAR-R Communication Between Better (�14 (n ¼ 49)

Variables Better Teams Median (IQR) (n ¼ 26)

W (

SBAR-R 20 (16-22) Elapsed time to first call in seconds 179 (156.5-179) 1 Frequency of call 2 (2-3)

Note. SBAR-R ¼ situation, background, assessment, recommendation and read

heparin to the patient. About half of the teams obtained a blood sample for laboratory tests (49%) and arranged for the use of a 12-lead ECG (47%). Table 1 shows the relative distribution of scores.

SBAR-R Communication Behaviors

The communication behaviors when reporting to and receiving instructions from the physician are shown in Table 1. SBAR-R communication behaviors were on average 62% of possible frequencies. The SBAR-R were 72%, 56%, 62%, 30%, 66% of possible frequencies, respectively.

of 19) and Worse (<14 of 19) Teams in Team Task Performance

orse Teams Median IQR) (n ¼ 23)

Mann-Whitney U test Z p

17 (14-19) 167.50 -2.645 .008 25 (103-174) 133.00 -3.327 .001 2 (2-3) 240.50 -1.277 .202

-back.

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Table 3 Correlation Coefficients Among Team Task Performance and SBAR-R Communication (n ¼ 49)

Variables

Initial Performance SBAR Read-Back

taub (p) taub (p) taub (p)

SBAR 0.313 (0.004) d Read-back 0.153 (0.164) 0.076 (0.486) d Performance after receiving verbal instruction 0.175 (0.129) 0.072 (0.529) 0.285 (0.014)

Note. SBAR-R ¼ situation, background, assessment, recommendation and read-back.

Communication and Team Task Performance 48

Comparison of SBAR-R Communication Between Better and Worse Teams According to the Task Performance Scores

Table 2 shows the difference in SBAR-R communication between better and worse teams according to the task per- formance scores. The SBAR-R scores differed significantly between better and worse teams (U ¼ 167.5, p ¼ .008). There was a significant difference in elapsed time to first call (U ¼ 133.0, p ¼ .001), but no difference in the numbers of calls (U ¼ 240.5, p ¼ .202) between better and worse teams.

Correlations Between Team Task Performance and SBAR-R Communication

Table 3 shows the correlations between team task perfor- mance and SBAR-R communication. The initial team perfor- mance score correlated positively with SBAR scores (taub ¼ 0.313, p ¼ .004). The score for team performance af- ter the call to the physician was correlated positively with the read-back score (taub ¼ 0.285, p ¼ .014). No significant cor- relations were observed between the initial and postcall team performances (taub ¼ 0.175, p ¼ .129) or between the SBAR and read-back communication (taub ¼ 0.076, p ¼ .486).

Discussion

The strength of our study is the use of observable assessment tools, which contributed to the reliability of the results. Observation of behaviors or events is considered to be more accurate and reliable than self-assessment, particularly for human factor skills and behaviors (Siassakos et al., 2011).

The main finding of our study was that SBAR-R communication was associated with the overall team task performance of nursing students with limited clinical experience. SBAR-R is an important technique for infor- mation delivery (Chapelain, Morineau, & Gautier, 2015) and preventing or reducing the risk of errors (Andreoli et al., 2010; De Meester et al., 2013; Randmaa, M�artensson, Swenne, & Engstr€om, 2014). In addition to the aforementioned findings, this study showed that the

better teams had a higher interprofessional communication score than the worse team, which suggests that successful team performance is related to interprofessional communi- cation during a critical event. This result is consistent with a study by Reising et al. (2017) who reported a positive cor- relation between interprofessional team communication and procedure accuracy in the simulation. Also, Chapelain et al. (2015) showed that the number of sponta- neous information exchanges between pairs of participants correlated positively with overall performance and with ac- tions performed at the right moment.

Before the call to the mock doctor, SBAR communica- tion correlated significantly with initial team task perfor- mance. This finding suggests that the teams that were successful in the first phase of recognizing the situation and gathering pertinent information performed the SBAR report better than teams that did not. We also assessed the elapsed time to the first call to the doctor as an indicator of rapid situational awareness and astute decision making. The teams that performed well had a shorter time to the first call to the doctor than the teams that did not. This is consistent with the study of De Meester et al. (2013), where SBAR communication was related to the ability to recog- nize the situation and collect information about the patient.

The SBAR technique is a simple technique, but it requires clinical reasoning beyond communication. To formulate information at an appropriate level, situation awareness, ability to make decisions, and assessment skills are required. Conversely, the SBAR technique helps health care personnel to anticipate the information that their colleagues need and to gather and formulate appropriate levels of information.

The second phase of team task performance, successful performance after verbal instruction, was related more to verbal read-back than to the initial team task performance. This result suggests that, particularly for novices with little clinical experience, the ability to complete crucial clinical actions in a timely way without missing information or making a mistake is strongly linked to the read-back for clarifying verbal orders. This is in accordance with Boyd et al. (2014), who noted that knowledge of transferred in- formation during a simulated crisis was significantly improved if the receiver repeated back the information. Us- ing the read-back technique may increase the information transfer between team members, which increases the

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Communication and Team Task Performance 49

chances of successful team performance without mistakes and should therefore improve patient safety. The use of read-back to ensure that communications are both sent and received is an important factor in reducing or prevent- ing medical errors (National Coordinating Council for Medication Error Reporting and Prevention, 2001), but it is not being implemented continuously in health care set- tings (Miller, Riley, & Davis, 2009). The skill and timing of using read-back should be part of training and should be encouraged as part of critical team behaviors.

In our study, the SBAR-R performance rate was 62%, which is higher than that reported by other studies. Chapelain et al. (2015) observed that the performance score of SBAR communication by nursing students was 35.4% in a simulated emergency. Miller et al. (2009) found that SBAR and read-back skills of nurses were not consistently observed during critical events, in which key behavioral markers of closed-loop communication occurred <15% of the time. The reason for the relatively high performance rate of SBAR-R in our study is pre- sumed to be that students received SBAR-R training before participating in the scenario. In particular, because read-back is the ability to read information again for veri- fication but not to require the synthesis of knowledge (Perry, Wears, & Patterson, 2008), read-back skill may be easily improved by training.

The recommendation performance rate was 30%, which was the lowest of SBAR-R elements in our study. Nurses must be able to use the ‘‘recommendation’’ to communicate exactly what they need from the physician (Woodhall et al., 2008). However, even if they did not know how to resolve the situation, the technique of recommendation may help empower training nurses to formulate a recommendation given to the doctor (Woodhall et al., 2008).

Based on the results of this study, further research is proposed. First, empirical studies are needed to verify the effectiveness of SBAR-R training on performance level or error in various clinical conditions. Second, because SBAR- R communication may help health care staff learn how to judge situations and collect critical information, we suggest that empirical studies are needed to determine whether SBAR-R training can improve reasoning skills.

Limitations

First, this study was conducted in a university, so the results cannot be generalized to the wider health care setting. Second, we measured only those SBAR-R communication behaviors required in the scenario, and our findings are limited by not being able to measure the quality of SBAR- R, such as the systematic nature of the delivered informa- tion or occurrences of misreported information. Similarly, we observed only the expected task performance of each team in the scenario and did not directly assess any errors. Third, although the data were collected for 2 years, the

number of teams was small for detailed analysis. Neverthe- less, our results demonstrated clear relationship between SBAR-R communication and team task performance.

Conclusions

Our study provides evidence supporting the use of SBAR-R communication by health care professionals during a clinical crisis. The result of our study showed that communication among nursing students was directly related to successful team performance. Although SBAR communication correlated with initial team task perfor- mance, verbal read-back was crucial for successful team task performance without missing information or making mistakes. These findings suggest that the SBAR-R commu- nication is an important factor for ensuring consistent team performance. This is a crucial skill for nursing students to learn to ensure effective communication and patient safety during a clinical crisis.

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