Think of any interaction with another member of the health care team as akin to a baton handoff in a track and field race. Each runner in the relay is part of the team. In order to successfully complete the race, there must be a smooth and seamless handoff of the baton from one runner to another.
Though the SBAR format (situation/background/assessment/recommendation) is taught as a template to communicate a clinical concern, there is much more to effective communication with primary care providers (PCP) than simply running through this template in its sequential order.
In one survey of nurses who had recently graduated, one of the themes was that they were not well prepared to communicate with physicians and were uncomfortable doing so when they needed to communicate a concern (Neal-Boylan, 2013).
Clinical Reasoning > SBAR
Clinical reasoning is greater or more important than the SBAR! This is my equation for practice that emphasizes how clinical reasoning must come FIRST in order to recognize the need to call a PCP and communicate an SBAR.
The student or new nurse must FIRST be able to clinically reason by recognizing EARLY signs of a patient problem and the significance or relevance of clinical data collected or the problem that is present will go unrecognized until it has progressed and becomes life threatening. (see my recent blog on clinical reasoning)
Sepsis is an excellent example of this when tachycardia and elevation of temperature go unrecognized until the BP slides and septic shock is present.
Be sure that clinical reasoning as well as the SBAR are emphasized and practiced together! Case studies that contextualize this content to practice are an effective tool to accomplish this needed objective.
PCP’s In Their Own Words
As a nurse educator who remains current in clinical practice in the critical care float pool of a large metro hospital, I had the opportunity to pick the brains of several physicians as well as nurse practitioners.
Their insights will help build on how the SBAR format is taught and will help contextualize effective communication with PCP’s to the clinical setting.
Four Principles to Prepare the Way
In order to communicate effectively with physicians, there must be an understanding of the lived reality of the one you are communicating with.
The following insightful points were from a highly respected physician who stated what nurses need to keep in mind and remember the following when communicating with physicians:
- Most physicians are by nature very competitive. Do not challenge this competitive spirit by provoking them with a hint of/or obvious challenge. If this is sensed, the nurse will quickly lose.
- Keep all communication simple and on point.
- Communicate a spirit of collaboration if a physician is being difficult. State your concern, but preface it with, “I need your help.”
- Do not DEMAND your recommendation-COLLABORATE. For example, communicate your concern for additional pain meds, recommend a higher dose, but then state, “What do you think?” This approach promotes collaboration and a team approach to meeting the needs of the patient.
Five Specific Points
- Dialogue and have a voice in any interaction. When requesting a pain medication and you suggest morphine and the physician agrees or suggests Dilaudid, but states a dose that is likely too low, don’t be afraid to have a little give and take. Suggest a slightly higher dose range or more frequent prn schedule and you will likely get what your patient needs.
- If you do not understand the rationale for an order or medication the doctor wants to order, be humble and do not hesitate to ask for clarification. Don’t fake it! Remember that this is also a patient safety issue.
- When calling because of a patient concern, make it a priority to give just enough information to allow the provider to visualize what is going on. Don’t give too little information and don’t give too much that is not directly relevant to the primary concern. Make it “just right”!
- If you have a serious concern, be specific with clinical data that supports your concern and if possible be clear on what you want.
- Know the patient’s story well enough so that you are able to answer basic questions related to your clinical concern.
Communication Must Be Practiced
Though effective communication with physicians and other primary care providers (PCP) is essential to safe patient care, most students do not get this needed practice in the actual clinical setting because they are students.
It is only after they graduate that they will communicate directly with a primary care provider, and for many it will be in the middle of the night!
But like any clinical skill, communication with the PCP must be practiced. How does your program practice this essential skill in the context of directly relating a concern to a PCP?
Simulation lab with a patient that develops a clinical concern is a natural way to contextualize communication with a PCP is a great place to start.
What about clinical post-conference? Do you develop scenarios that reflect common patient change of status and then have students practice this together with needed critique from the group and faculty?
In Closing
As a nurse educator, preparing students to pass the NCLEX® is important, but your ultimate objective is to prepare your students for real-world clinical practice.
Both clinical reasoning and the SBAR are essential nurse thinking skills that need to be practiced to accomplish this essential objective of nursing education.
Now that the semester is coming to a close, reflect and see how you are currently integrating clinical reasoning as well as principles of effective communication with a PCP in your content.
If there is room for improvement, make it a priority to get this on your radar and integrate both clinical reasoning and practicing the SBAR into your content and curriculum.
What do you think?
What have you found effective to integrate PCP communication in your content?
Comment below and let the conversation begin!
References
Neal-Boylan, L. (2013). The nurse’s reality gap. Indianapolis, IN: Sigma Theta Tau International.
Keith Rischer – Ph.D., RN, CCRN, CEN
As a nurse with over 35 years of experience who remained in practice as an educator, I’ve witnessed the gap between how nursing is taught and how it is practiced, and I decided to do something about it! Read more…
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