Implementation of Situation, Background, Assessment, and Recommendation (SBAR) Format During Handover in the Udayana University Hospital

Effective communication within the hospital environment can significantly improve practice safety in health services, especially during the handover process. Handover is a transfer of information during the shift transition. Numerous studies have presented evidence of the Situation, Background, Assessment, and Recommendation (SBAR) format in enhancing effective communication during handovers. Here, we aimed to explore SBAR communication during handovers in a public hospital in Bali. This quantitative descriptive study applied a cross-sectional approach and employed 20 participants who were selected using a total sampling technique. A questionnaire was enrolled to collect participants’ demography characteristics and the handover process. The majority of participants were female (90%), with a mean age of 28 years, a working duration <3 years (55%), and registered nurses (45%). SBAR format was effectively delivered during the handovers (95%), especially among female participants (85%), aged 29 years old (20%), participants with less than <3 years of working experience (55%), and registered nurses (40%). SBAR format assists a clear, complete, well-directed, and concise organization of clinical information during the handover process. According to the model care, we only found one team member (5%) with ineffective SBAR communication. Ninety-five percent of the participants had performed proper SBAR handovers. We assumed that model of care may associate with SBAR handovers skill.


INTRODUCTION
Patient safety is a cornerstone of high-quality healthcare services.It is set as an indicator to protect patients from unnecessary adverse impacts while providing medical procedures.Effective communication in the hospital setting could profoundly improve safety practices in health care services, especially during the handover process.Handover is the transfer of information at the time of shift.Several studies have presented evidence in the Situation, Background, Assessment, and Recommendation (SBAR) format for enhancing effective communication during handovers (Suardana, 2018).
Ineffective handovers deliver adverse consequences on patient safety and outcomes.Communication breakdown has been identified at various levels of health providers as the major cause of misperception, longer length of stay, and out-of-focus information that may threaten patient safety.SBAR format has been widely demonstrated as an effective communication tool to facilitate efficient handovers.SBAR-based effective communication is a framework of communication techniques introduced to health professionals to elaborate patient information (Tutiany, Lindawati & Krisanti, 2017).The Situation, Background, Assessment, and Recommendation (SBAR) format is an easy-to-remember mechanism designed to frame clinical information that consists of 1) S (Situation): patient's identity, current clinical issue, and medical diagnosis, 2) B (Background); history of diseases or supporting evidence that may trigger current situation, 3) A (Assessment); data conclusion, and 4) R (Recommendations): nursing care or medical planning (Suardana, 2018).
The Joint Commission estimated that 80% of serious medical errors are rooted in misinformation among health professionals.Further, an annual patient-safety survey by the Board of Research and Health Care Quality Survey in 2011 on 1,032 hospitals and 470,000 health professionals revealed that 50% of health professionals stated missing information had originated from poor shift transition reports (Riesenberg, 2012).Ineffective handovers have been Poor handovers associate with the emergence of several serious issues.It led to unnecessary delayed medical diagnosis, medication-related incidents, longer care duration, higher costs, and complaints/dissatisfaction (Indonesia Minister of Health, 2011).SBAR format frames the information more effectively, structured, and predictably (Pujiyanti, Dwiantoro, & Ardani, 2019).Furthermore, SBAR format implementation could reduce interruption or distraction during handovers due to its structured and focused format.It designs as a concise information report for a detailed and complete direction of clinical/nursing care planning (Suardana, 2018).
We conducted an interview session with the head nurse in the Isolation Ward of EF Udayana University Hospital prior to the study.She declared that the SBAR format had been implemented during the handovers.However, due to the Covid-19 pandemic, the handovers were only conducted in the nurse station to prevent infection transmission and efficiently use personal protective equipment.This study aimed to explore the implementation of the SBAR format in the Isolation Ward of EF Udayana University Hospital.

METHOD
This was a quantitative study with a cross-sectional design conducted on August 2021 in the Isolation Ward of EF, Udayana University Hospital.Twenty nurses and midwives in the ward from the total sampling technique were included in the study.Researchers chose respondents with a saturated sampling technique based on the inclusion criteria and exclusion criteria that have been set.Data were collected using a google-form-based-questionnaire.This questionnaire consisted of three primary sections: (1) study description and informed consent, (2) demography data (gender, age, work duration, model of care, and educational/professional background), and (3) SBAR implementation during handovers.
The third section of the questionnaire was adopted from a previous study (Riskayana, 2020).Twenty-six questions in this section were delivered with Likert Scale answers: Always (4), Often (3), Sometimes (2), and Never (1).The median score was 65.The effective and ineffective SBAR handover was indicated by the total score of ≥65 and <65, respectively.Data were then analyzed by SPSS Statistic 26.Numeric data were presented using a central tendency and frequency distribution.Categorical data: gender, model of care, educational background, and SBAR implementation were also shown in a frequency distribution.Data on the use of SBAR communication, when considered received in the Isolation Room of EF UNUD Hospital, will be categorized into effective and ineffective use based on the total score.

Implementation of SBAR Format on Handovers
Findings discovered 95% effective SBAR implementation and 5% ineffective SBAR implementation during the handovers.Table 2 shows the SBAR implementation according to participant's characteristic.
Table 2. shows that two male participants had performed effective SBAR implementation.All female participants showed effective SBAR handovers, however, one female participant delivered ineffective SBAR communication.Further, according to the age characteristics, 95% of participants showed effective SBAR communication delivery during the handovers (95%).Eleven participants (55%) with <3 years working duration identified with effective SBAR implementation.One out of nine participants with ≥ 3 years of working duration performed poor SBAR communication during the handovers.Three nursing team leaders (15%) and 16 team members (80%) nailed effective SBAR communication.Only one team member showed ineffective SBAR handovers.According to the educational/professional backgrounds, only one participant with registered nurse status performed poor SBAR handovers.

DISCUSSION
Findings revealed that 95% SBAR format was implemented effectively in the Isolation Ward of EF Udayana University.Participants declared that the SBAR provided an effective and complete handover format.Additionally, (Hastuti, Faridah, & Afiyanti, 2021) also stated that SBAR helped nurses to elaborate the information on medical diagnosis (situation), brief current clinical condition, history of diseases, history of surgical procedures, IV-line accesses, history of pain, and medical procedure given (background), comprehensive clinical condition (assessment), and final clinical/nursing and planning (recommendation).Numerous health-related studies also widely reported adequate implementation of the SBAR format to improve patient safety in healthcare providers (Hardini & Wahyuni, 2019).
We observed a proper SBAR implementation during handovers in the Isolation Ward of EF Udayana University.They had clearly stated the patient's name, age, admission date, medical diagnosis, nursing diagnosis, responses, physician (situation), complaints, vital signs and history of allergies (background), current clinical condition, current pain scale assessment result, consciousness state, risk of fall, nutrition status, elimination status, and abnormal findings (assessment), and nursing intervention recommendation and recommended medical procedures, laboratories results, medical and nursing intervention recommended, information for the family members or significant others, and discharge planning (recommendation).
Nurses require to transfer patients' information adequately during the handover sessions.Handover is a key to the continuity of care and patient safety (Dewi, 2012).SBAR improves communication between nurses during shift transition.It also builds more focused discussion for patient care (Tatiwakeng, Mayulu, & Larira, 2021).(Wati, Astuti, & Ilmi, 2019), in their study, discovered the influence of SBAR format implementation on handover sessions in Banjarmasin Public General Hospitals.Seven nurses had confirmed that SBAR-based handover assisted nursing handovers and improved patient safety.
We found no significant difference in SBAR handovers between the male and female participants.The majority of participants had demonstrated effective SBAR handovers.This finding was parallel with a study conducted by (Dirgantara, Sekarwana, & Somantri, 2020).They discovered no significant difference of effective SBAR handovers implementation among the male and female nurses.
The majority of participants were 24-34 years old.We also found effective SBAR handovers in all age ranges.Hunt and Orborn ( 2006) stressed barriers during a communication process involve the role of several factors, such as knowledge, experience, perspective, culture, language, etc.Their findings signified that younger age may indicate less experience that finally would affect the communication skill.In line with this finding, (Dirgantara, Sekarwana, & Somantri, 2020) also mentioned age, culture, and age as factors that may affect the eloquence in the clinical communication.Communication skills could be improved through training or observation of effective communication.Adequate communication skills would construct effective handovers and teamwork (Watulangkow & Sigar, 2020).(Suardana, 2018) discovered that age affected the skill in implementing SBAR format during handovers.
Working duration correlated with the SBAR handovers skill.Findings revealed that 19 participants (95%) had shown proper SBAR handovers.Only one participant (5%) with more than three years of working experience was identified with poor SBAR communication skills.Contrary to this finding, (Aryanti 2019) found no significant correlation between working duration and SBAR format implementation during handovers.(Dirgantara, Sekarwana, & Somantri, 2020) declared that working experience is associated with work performance.They also stressed that longer working duration provided better working and learning experience to obtain better work performance.A longer work duration may link to adequate communication skills.Nurses with longer work duration tended to perform better, more flexible, friendly, clear, and open-minded communication skills (Handayani & Armina, 2017).But another study also highlighted the possibility of better communication skills among younger nurses with a shorter working duration (Dirgantara, Sekarwana, & Somantri, 2020).They may show more passions for completing tasks perfectly, including delivering comprehensive and proper SBAR handovers.
According to the model care, we only found one team member (5%) with ineffective SBAR communication.Ninety-five percent of the participants had performed proper SBAR handovers.We assumed that model of care may associate with SBAR handovers skill.However, a study from (Lobo, 2019) found no correlation of the model of care with effective SBAR handovers.They signified that motivation had provided a more significant influence on nurses' work performance.Further, they also discovered a positive correlation between motivation and effective SBAR handovers among the nurses.
The majority of participants showed effective SBAR handovers.Only one registered nurse performed ineffective SBAR communication skills.Therefore, we assumed that educational/professional background did not associate with communication skills.In contrast with this finding (Suardana, 2018) discovered that registered nurses with higher levels of education had performed better communication skills in comparison with vocational nurses with lower levels of education.Parallel with their finding, Jiang et al. ( 2020) and (Watulangkow & Sigar, 2020) also stated that knowledge level correlated with SBAR communication skills.A higher level of education produced better SBAR communication skills.However, (Dirgantara, Sekarwana, & Somantri, 2020) discovered no correlation between educational background with SBAR implementation.(Lasmiah, Azis, & Mira, 2020) also confirmed similar findings.The educational background could have been associated with better communication skills (Dirgantara, Sekarwana, & Somantri, 2020).More specialized education, such as training or roleplay, may significantly improve SBAR communication (Anggraini, Novieastari, & Nuraini, 2020).

CONCLUSION
The SBAR format was effectively delivered during the handovers at Udayana University Hospital.It assists in a clear, complete, well-directed, and concise organization of clinical information during the handover process.We suggest enrolling a larger sample size in future studies to produce estimates that better approximate the population parameter.For nurses in the EF Isolation Room of Udayana University Hospital to improve communication based on improving the quality of the process and improving the quality of health services to patients major cause of patient safety incidents.Nearly 66% of cases of sentinel events occurred due to poor communication during handovers(Pujiyanti, Dwiantoro, & Ardani, 2019).Further, communication failures have contributed to 100.000 patient deaths/year (Cobbs, 2017).

Table 2 .
SBAR Implementation According to Participant's Characteristics