Role-Play Using SBAR Technique

to Improve Observed Communication Skills in

Senior Nursing Students
Karen S. Kesten, DNP, APRN, CCNS

ABSTRACT
Patients in the care of clinically expert professionals suffer medical errors with alarming frequency. The Joint Commissions National Patient Safety Goals strives to improve
the effectiveness of communication among caregivers by
recommending the implementation of a standardized tool
known as SBAR (Situation, Background, Assessment, and
Recommendation). This experimental study evaluated data
from undergraduate nursing students (N = 115) on their
performance using a standardized communication tool
SBAR. The mean performance scores of the didactic plus
role-play students were significantly higher than those who
had didactic instruction alone (t = 2.6, p = 0.005). Findings suggest role-play may have a place in teaching communication skills in nursing schools as well as continuing
education and training in hospitals and other health care
settings. Interdisciplinary communication training may
provide even more effective learning. The link between effective communication and improved patient outcomes
also should be studied.

Received: January 18, 2010

Accepted: May 19, 2010
Posted: December 30, 2010
Dr. Kesten is Assistant Professor and Program Director, Acute Care
Nurse Practitioner and Acute and Critical Care Clinical Nurse Specialist
Programs, Georgetown University School of Nursing and Health Studies,
Washington, DC.
The author thanks Mary E. Johantgen, PhD, RN, for her guidance and
mentorship.
The author has no financial or proprietary interest in the materials
presented herein.
Address correspondence to Karen S. Kesten, DNP, APRN, CCNS, Assistant Professor and Program Director, Acute Care Nurse Practitioner and
Acute and Critical Care Clinical Nurse Specialist Programs, Georgetown
University School of Nursing and Health Studies, St. Marys Hall 266, 3700
Reservoir Road, Washington, DC 20057; e-mail: ksk@georgetown.edu.
doi:10.3928/01484834-20101230-02

Journal of Nursing Education Vol. 50, No. 2, 2011

killed communication and respectful interaction among

the health care team members are critical to achieve optimization of quality patient care outcomes. Accurate communication, particularly during clinical handoffs, is the focus of
international, national, and local initiatives. Organizations such
as the World Health Organization, World Alliance for Patient
Safety, Institute for Healthcare Improvement, National Patient
Safety Agency, Agency for Healthcare Research and Quality,
and Australian Commission for Safety and Quality in Health
Care have identified skilled communication during clinical
handoffs as a priority.
In more than 2,900 sentinel events occurring in the United
States, reported between 1995 and 2005, more than two thirds
reported miscommunication as the root cause in their occurrence (Joint Commission on Accreditation of Healthcare Organizations, 2006b). Sentinel events are defined as unexpected
occurrences involving death or serious physical or psychological injury (Joint Commission on Accreditation of Healthcare
Organizations, 2006b). Such events are called sentinel because
they signal the need for immediate investigation and response.
Ineffective communication between nurses and physicians has
been linked to medication errors, patient injuries, and patient
deaths (Gurses & Carayon, 2007; Knaus, Wagner, Zimmerman,
& Draper, 1993; Manojlovich & DeCicco, 2007). From 2004
to 2005, communication failures were a contributing factor in
25% to 41% of sentinel events in Australia (Australian Institute
of Health and Welfare & the Australian Commission on Safety
and Quality in Health Care, 2007; Wakefield, 2007).
In 2001, the Institute of Medicine (IOM) called for reform in
communication norms, team performance, and risk assessment
processes (IOM, 2001). Health care organizations worldwide
must now implement a standardized approach to handoff communications (Joint Commission on Accreditation of Healthcare
Organizations, 2006a). Both the IOM and the Joint Commission endorse the application of a teamwork model developed
by the U.S. military and the Federal Aviation Administration to
provide clear, direct, unequivocal team communication (Mahlmeister, 2005). This teamwork model uses a structured communication tool called SBAR (Situation, Background, Assessment,
and Recommendation) defined in Table 1. The SBAR technique
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ROLE-PLAY USING SBAR TECHNIQUE

TABLE 1
Components of SBAR Communication
Component

Question

Situation

What is going on with the patient?

Background

What are the clinical facts

surrounding the problem?

Assessment

What do I think the problem is?

Recommendation

What should be done to correct the

problem?

Note. SBAR = Situation, Background, Assessment, and Recommendation.

Source. Mahlmeister (2005).

provides a framework for communication among members of

the health care team about a patients condition during an urgent
situation when information must be transmitted rapidly and
concisely. The Joint Commission further recommends education and training, communication tools, discussion forums, and
interventional strategies to improve interdisciplinary communication (Rosenstein & ODaniel, 2008).
Recently, the Agency for Healthcare Research and Quality
(n.d.) has recommended a Team Strategies and Tools to Enhance
Performance and Patient Safety (TeamSTEPPS) approach to
improving patient safety in organizations. This teamwork system is designed to improve communication and teamwork skills
among health care professionals. TeamSTEPPS is an evidencebased training curriculum used to integrate teamwork principles into health care systems. Similar to the U.S. Department
of Defenses Patient Safety program, TeamSTEPPS uses SBAR
as a communication tool as one component of the training curriculum.
To comply with the mandate issued by the IOM (2001), facilities were rapidly attempting to disseminate the use of SBAR,
without adequate evidence of best practice for teaching strategies using the skilled communication technique. Until recently,
health care facilities worldwide have been promoting tools such
as SBAR to be widely used to increase effectiveness of communication with no evidence-based method of teaching skilled
communication in health care documented (McCauley & Irwin,
2006). Effective strategies for teaching interprofessional communication need to be systematically evaluated and are urgently
needed to advance the current patient safety and quality care
agenda. This study was designed to address this gap in the literature regarding specific teaching strategies for skilled communication.
The purposes of this research were:
l To determine whether the type of skilled communication
instruction (didactic versus didactic plus role-play) influences
nursing students knowledge of skilled communication.
l To determine whether the type of skilled communication
instruction influences nursing students skilled communication
performance in simulated experiences.
The study was conducted at a private university-based school
of nursing that provides undergraduate and graduate nursing
80

education in a major metropolitan city in the United States. The

target population was senior nursing students in traditional and
second-degree nursing programs.
LITERATURE REVIEW

A literature review was conducted to evaluate interprofessional communication training, use of the SBAR tool, and the
educational strategies used to offer communication training for
nurses. The literature was supportive of the need for interprofessional communication training to improve patient safety.
Background exploration on the need for interprofessional
team communication revealed teamwork that reduces error and
improves patient safety is grounded in communication that is
timely, accurate, complete, and unambiguous (Dixon, Larison,
& Zabari, 2006; Guise & Lowe, 2006). Effective team communication is open, continuous, multidirectional, nonhierarchical,
collegial, respectful, and direct (IOM, 2001). All members of
the team have an obligation to speak up as well as an obligation
to listen (Mahlmeister, 2005). This obligation is especially true
in acute or critical situations requiring an urgent or emergent
response to a patient need.
The literature reveals that the SBAR tool was developed in an
attempt to standardize communication between individuals and
has been adopted by health care providers (Schneider, 2005).
Effective team communication methods and tools from high reliability industries are potential sources of innovation for health
care (Helmreich, 2000; Leonard, Graham, & Bonacum, 2004;
Markley & Winbery, 2008). Standardized communication tools
from the aviation industry such as SBAR use assertive communication, critical language, and situational awareness that can
greatly enhance safety by setting expectations for what is communicated and how team communication is effective (Harris,
Treanor, & Salisbury, 2006; Leonard et al., 2004). The SBAR
communication technique provides a standardized framework
representing a hybrid of medical and nursing communication
styles intended to enhance nurse-physician communication.
In the health care arena, Kaiser Permanente of Colorado was
one of the first to formally adopt SBAR and to develop a worksheet that outlines SBAR format and guidelines (Institute for
Healthcare Improvement, n.d.). SBAR allows for an easy and
focused way to set expectations for what will be communicated
and how among members of the team, which is essential for
developing teamwork and fostering a culture of patient safety
(Kaiser Permanente, n.d.). The SBAR tool can be used as a
situational briefing during pre-procedures, during handoffs, or
at any time there is an unexpected change in the patients care
(Haig, Sutton, & Whittington, 2006). Since 2004, successful
implementation of the SBAR technique has been demonstrated
in high-risk settings such as intensive care, emergency departments, and operating rooms, with improvement in patient and
staff satisfaction, clinical outcomes, team communication, and
patient safety (Leonard et al., 2004; McFerran, Nunes, Pucci, &
Zuniga, 2005).
Findings from a study conducted in Canada suggest that staff
found the use of the adapted SBAR tool in the outpatient setting
helpful in both individual and team communications, which
ultimately affected perceived changes in the safety culture of
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the study team (Velji et al., 2008). In another study, the use of
SBAR technique to ensure effective communication among
health care workers reduced the number of sentinel events from
89.9 per 1,000 patient days to 39.96 per 1,000 patient days per
year (Haig et al., 2006). Haig et al. (2006) also found improved
medication reconciliation at patient admission from 72% to 88%
and at discharge from 53% to 89% after implementing effective
communication among health care professionals using SBAR.
In addition, Haig et al. (2006) found SBAR is an effective technique that has been shown to improve interdisciplinary satisfaction in communication. Limitations of the SBAR tool involve
the need for education and training for a multidisciplinary staff
and the difficulty some health care professionals may have with
assertive communication, for fear of being wrong (Leonard et
al., 2004).
The application of SBAR communication to the health care
environment is a promising concept, but the evidence required
for development of effective team training interventions is currently being established (Thomas & Helmreich, 2002). Until the
advent of SBAR and TeamSTEPPS for application in health care,
rarely had a standardized communication tool been used when
teaching interprofessional communication. One pilot study on
SBAR and nurse-physician communication tested an education
intervention and recommended simulations of critical situations
with emphasis on effective communication and conflict resolution training (Hamilton, Gemeinhardt, Mancuso, Sahlin, & Ivy,
2006; Woodhall, Vertacnik, & McLaughlin, 2008).
In the emergency department, Morey et al. (2002) found
that after implementation of multiple medical team training
sessions, improved team behaviors were noted, staff attitudes
toward teamwork improved, and clinical errors were reduced.
Labor and delivery units found that after implementation of
multiple teamwork strategies and tools, a 50% reduction in the
Weighted Adverse Outcome Score was observed (Mann, Marcus, & Sachs, 2006). In addition, a 50% decrease in the Severity Index, which measures the average severity of each delivery
with an adverse event, was reported after team training (Mann
et al., 2006). Intensive care units implemented a patient daily
goals form to facilitate staff communication and found a 50%
decrease in mean length of stay in the intensive care unit from
2.2 to 1.1 days (Pronovost et al., 2003).
After implementation of a preoperative briefing, operating
rooms reported increased communication, increased administration of properly timed prophylactic antibiotics prior to incision from 84% to 95%, and increased preoperative deep vein
thrombosis prophylaxis prior to induction from 92% to 100%
(Awad et al., 2005). Interdisciplinary team training involving communication techniques resulted in a 16% reduction in
nursing turnover rate and a 19% increase in operating room
employee satisfaction (Leonard et al., 2004). The evidence
is mounting to support adopting teamwork strategies for significant improvement in patient outcomes and improvement in
work satisfaction.
Further evidence exists in case study and anecdotal accounts
in the literature. Ascano-Martin (2008) implemented role-play
of shift report using a standardized SBAR communication technique with senior nursing students in postclinical conference
and reported an increase in self-confidence in giving report. In
Journal of Nursing Education Vol. 50, No. 2, 2011

addition, the students active participation during the role-play

sessions stimulated higher level learning and critical thinking
ability (Ascano-Martin, 2008).
Communication among health care professionals has not
been effectively taught in the past, and if it was taught, a consistent approach likely was not used. The literature on teaching
nurses skilled communication revealed a variety of instructional
methods, variable methods for observation of communication
behavior, diverse evaluation tools, and few studies that specifically examined nurse communication skills. Of the few research studies available, several showed a positive relationship
between communication training and effective communication
skills acquired by nurses. Several studies used a combination of
didactic and interactive instructional methods, especially roleplay and skill practice to teach the content. Positive effects on
nurses communication knowledge and attitudes were shown in
studies using a combination of didactic and interactive strategies (Boyle & Kochinda, 2004; Velji et al., 2008). Interactive
strategies such as role-play exercises appear to be an effective
teaching method to improve communication skills for nurses.
Because there is little evidence to support a particular teaching strategy to teach SBAR, further studies are warranted using
a randomized, controlled, experimental design. Studies that examine educational best practices in skill training to optimize the
nurse-provider communication by using a standardized communication technique are needed.
METHOD
Sample

This study was approved by the universitys institutional ethics review board. This experimental study was conducted using
a convenience sample and a randomly assigned experimental
group (didactic plus role-play) and a control group (didactic
only) via the use of a table of random numbers. The first research question examined changes in knowledge and used a
pretest-posttest design. The second research question examined
differences in performance between the experimental and the
control groups, and used a posttest only control group design.
A convenience sample of traditional and second-degree senior
nursing students receiving the same curriculum was drawn. A
total of 156 students were invited to participate in this study.
Of these, 115 students voluntarily agreed to participate. One
hundred four students participated in the Communication
Knowledge Pretest-Posttest, and 109 students participated in
the SBAR Observation. The attrition rate was 0.9%. Reasons
for the attrition included illness, death in the family, and failure
to appear for the appointed data collection time.
Procedures

Two research assistants who were trained for this study

obtained informed and voluntary consent from the study participants outside of class time. Senior nursing students were
recruited for the study by the research assistants, who had no
teaching relationship to the students. All appropriate steps were
taken to ensure that there was no coercion to participate in the
study. The entire convenience sample received didactic instruction mid-semester with the knowledge pretest administered
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ROLE-PLAY USING SBAR TECHNIQUE

TABLE 2
Objectives and Content Outline for Didactic Content on
Skilled Communication
Objectives
Following the instructional module on skilled communication,
participants will be able to:
Identify three benefits of using a structured communication
technique with a provider
List five steps the nurse should complete before notifying
the provider
Define the four components of SBAR communication
Delineate five pieces of information that could be used to
describe the situation
Describe appropriate information to include related to the
background of the patient
Describe an appropriate assessment statement and
recommendation statement
Demonstrate effective use of the SBAR tool when
communicating a concern about a patient to a provider in
the simulation laboratory
Content Outline
I. Need for skilled communication in health care
A. Institute of Medicine report
B. Joint Commission recommendations
II. History of SBAR
A. Military
B. Aviation
III. Urgent situations
IV. Steps prior to contacting a provider
V. Definition of SBAR
A. Situation
B. Background
C. Assessment
D. Recommendation
VI. Documentation
VII. Examples
VIII. Questions
Note. SBAR = Situation, Background, Assessment, and Recommendation.

prior to instruction and the knowledge posttest administered to

the entire group at the completion of the semester.
The skilled communication education module was developed
to be presented to nursing students in one group for the didactic
portion. Content validity was established by consultation with
four expert faculty members who teach communication skills
to nursing students. A 1-hour presentation on the theory and
science known to improve communication to prevent errors in
health care and an introduction to the SBAR method of commu82

nication took place in the classroom. Instruction was delivered

to the students via lecture with PowerPoint slides and included
didactic content on the SBAR steps for the skilled communication dialogue between the nurse and the health care provider.
An SBAR Skilled Communication handout was provided to the
nursing students to organize this activity. This handout labeled
the four SBAR steps of Situation, Background, Assessment,
and Recommendation, and provided a fill-in blank next to each
subtopic. Table 2 describes the content outline of the communication instruction.
The intervention group received role-play instruction in addition to the didactic instruction on skilled communication. The
role-play instruction consisted of a 40-minute role-play exercise
conducted by the communication expert faculty. The objective
for the role-play exercise using SBAR was for students to demonstrate appropriate use of the SBAR tool when given a case
scenario. The case scenario consisted of a brief one paragraph
description of the clinical patient situation. Students needed to
organize the content into an SBAR format. Following demonstration by faculty of the role-play exercise, the intervention
group, divided into pairs, received four case scenario role-play
exercises with instructions to communicate using SBAR. Each
student participated in four role-play scenarios. Time was devoted to role-play practice, allowing 20 minutes per student pair.
Students were observed by faculty members during the roleplay exercise. An additional 20 minutes were devoted to student
demonstration of role-play and debriefing of role-play interactions and behaviors with faculty. Table 3 provides an example
of a scenario script for the ideal role-play demonstration.
All of the students participated in the simulation exercise
at the completion of the semester, and the research assistants
observed the students communication performance. All of the
students had two previous simulation experiences in their sophomore and junior years with nonurgent case simulations. The
research team developed two clinical simulations, each involving a patient with a complex diagnosis who developed a medical emergency. The simulations were developed to incorporate
theory content and clinical content from the students practicum
in emergency and critical care units. Each participant was given
a report on the patient and instructed to assess the patient and to
prioritize care as if in an actual emergency department. Students
were instructed on how to reach a provider should they have an
urgent question or request. A faculty member played the role
of the care provider receiving the SBAR report and provided
orders based on the information communicated. Every simulation exercise was videotaped for review on DVD by the research
assistants. After each simulation exercise, students participated
in routine debriefing during which faculty guided a reflective
discussion on the student performance.
Instruments

Demographic data including gender, age, English as a second language, program of study, and cohort were collected from
participants at the time of pretesting. There were no instruments
in the literature to measure skilled communication knowledge
of SBAR. Therefore, communication knowledge of SBAR was
assessed by the SBAR Knowledge Pretest-Posttest instrument,
which was developed and piloted by the author. Content validity
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KESTEN

was established, and faculty

TABLE 3
experts reviewed the testing
SBAR Role-Play Script
instrument and made recommendations for revision. ReSBAR Component
Script
view of the objectives and
Situation
Mrs. J is a 65-year-old woman with end-stage renal disease and a critical
content outline took place by
potassium level of 6.9 mEq/L.
the expert reviewers.
Background
Mrs. J has a medical history of hypertension and was admitted yesterday for
Communication perforabdominal aortic aneurysm repair. She missed dialysis 2 days ago. She has no
mance was measured by obknown allergies and is a full code status.
serving the behavior of the
Assessment
The patient currently has no apparent distress, and her vital signs are stable.
nursing students for compliThe ECG shows tall tent-like T waves.
ance with the SBAR method
Recommendation
I recommend that we start stat dialysis because the ECG shows signs of
of communication when conhyperkalemia. What medications would you like me to give to treat her
tacting a provider with a pahyperkalemia? The patient needs emergent dialysis.
tient concern. Students were
given a scenario in the simulation laboratory that required
Note. ECG = electrocardiogram; SBAR = Situation, Background, Assessment, and Recommendation.
an urgent response and contact of a provider. Because
there were no instruments in
the literature to measure the observed behavior using SBAR,
RESULTS
the SBAR Observed Behavior Checklist Tool was created by
the author and was pilot-tested to inform the current study. ReThe sample of 115 senior nursing students consisted of
visions of the SBAR Observed Behavior Checklist Tool were
49.6% second-degree students (n = 57) and 50.4% traditional
made based on the results of the pilot and the expert reviewbaccalaureate nursing students (n = 58). Participants ranged in
ers recommendations. Interrater reliability on the observation
age from 20 to 48, with an average age of 24. The majority of
tool was established through the use of two independent raters.
the participants were women (91.3%), with 13% using English
Forty students were observed by both reviewers. Interrater relias a second language. The intervention and control groups were
ability was established using Cohens Kappa (Kappa = 0.857,
not significantly different in age, gender, English as a second
p < 0.001) to measure the agreement between the evaluations of
language, type of program (traditional or second-degree), or cothe two reviewers when both were rating the same event. The
hort (April versus December 2008).
researcher trained the reviewers in the use of the SBAR Observed Behavior Checklist Tool through demonstration in the
Comparison of Knowledge by Type of Instruction
simulation laboratory and review of the videotaped DVD reThe knowledge means and change in knowledge scores for
cordings.
all of the students and by treatment group, age, gender, English as a second language, program of study, and cohort in time
Data Analysis
(April versus December 2008) are compared in Table 4. For all
The intervention and control groups were compared based
of the students, the mean score on the Skilled Communication
on the demographic data: gender, age, English as a second
Knowledge increased from 62.1 (SD = 14.5) to 85.2 (SD = 10.5).
language, program of study, and cohort. The purpose of this
The mean change in knowledge (M = 23.1, SD = 16.1) reflects a
comparison was to establish like groups. A t test of the means
statistically significant difference as measured by paired sample
was used. To answer the first research question, Does type
t test analysis (t = 14.5, p < 0.001). This finding reflects a large
of instruction influence communication knowledge?, scores
effect size of 1.59, as was anticipated with the communication
were calculated for each participant on the knowledge preknowledge research aim. This finding confirms that all of the
test and posttest. Differences were tested using a dependent
students demonstrated a significant change in knowledge after
t test to determine whether there was a significant differreceiving instruction on the SBAR communication. To deterence. To answer the second research question, Does type of
mine which instructional method of didactic instruction alone
instruction improve performance?, differences in observed
or didactic instruction plus role-play demonstrated a greater
use of SBAR components were examined by type of instrucchange in knowledge, an independent t test found no statistition. A sequence of chi-square analyses was completed based
cally significant difference between the groups. Both groups
on responses to the five yes/no items on the nonparametric
demonstrated a significant gain in communication knowledge
SBAR Observed Behavior Checklist. Chi square was used to
from the instruction they received.
evaluate proportion differences between the control (didactic
only) group and intervention (didactic plus role-play) group
Comparison of Total SBAR Communication
total scores on first observation data. Chi-square analysis
Performance Score: First Observation
was used to test for differences in the individual items (N =
The primary focus of this study was on observable behavior5) that comprise the SBAR Observed Behavior Checklist
al performance of skilled communication using the SBAR tool.
Tool as well as the total scores.
Students were given two opportunities to demonstrate SBAR in
Journal of Nursing Education Vol. 50, No. 2, 2011

83

ROLE-PLAY USING SBAR TECHNIQUE

TABLE 4
Comparison of Communication Knowledge by Treatment Group and Demographic Data

All students (n = 104)

Pretest (N = 104)

Posttest (N = 104)

Change in Knowledge
(N = 104)

Mean (SD)

Mean (SD)

Mean (SD)

Paired t (p Value)

62.1 (14.5)

85.2 (10.5)

23.1 (16.1)

t = 14.5 (p < 0.001)

Statistical Significance

Group
Controla (n = 53)

60.4 (15.9)

84.7 (11.5)

24.3 (17.2)

t b = 0.8

63.9 (12.8)

85.7 (9.4)

21.8 (15.1)

(p = 0.42)

< 25 (n = 80)

65.8 (12.3)

86.5 (9.8)

20.8 (14.5)

t = 2.8

> 26 (n = 24)

50 (15)

80.8 (11.8)

30.8 (19.1)

(p = 0.007)

Female (n = 95)

63.5 (14.2)

85.8 (10.5)

22.3 (16.2)

t = 14

Male (n = 9)

47.8 (9.7)

78.9 (9.3)

31.1 (13.6)

(p < 0.001)

Yes (n = 12)

51.3 (9.4)

83.3 (10.7)

32 (16.1)

t = 14.6

No (n = 92)

63.5 (14.6)

85.4 (10.5)

21.9 (18)

(p < 0.001)

66.9 (13.5)

87.5 (10.3)

20.6 (15.9)

t = 14.3

57.3 (14)

82.9 (10.4)

25.6 (16.1)

(p < 0.001)

April 2008 (n = 49)

61.6 (16.1)

86.9 (10.7)

25.3 (18)

t = 14.2

December 2008 (n = 55)

62.6 (13.1)

83.6 (10.3)

21.1 (14.1)

(p < 0.001)

Intervention (n = 51)
Age

Gender

English as second language

Program
Traditional (n = 52)
Second degree (n = 52)
Cohort

Didactic instruction only.

Independent t test.
c
Didactic instruction + role-play.
b

the simulated experience. To this end, the first observation data

only were used to assess communication performance. First
observation data were deemed untainted by previous exposure
during the simulation or by previous attempts. The observation
components are included and labeled in Table 5. The summed
total on the five components of performance resulted in scores
ranging from 0 to 5. The control group (n = 55) demonstrated
a mean first observation score of 3.6 (SD = 1.1), whereas the
intervention group (n = 54) demonstrated a mean first observation score of 4.1 (SD = 0.9). A one-tailed t test for unequal
variances was used to address the second research question and
found this to be a statistically highly significant difference (t =
2.6, p = 0.005). This finding represented a moderate effect size
of 0.56. In support of the research hypothesis, students who received role-play instruction in addition to didactic instruction
performed significantly better on the skilled communication
first observed behavior than those students who received didactic instruction alone.
Overall, compliance with SBAR was defined as a total score
>4 on first observation. In the control group (didactic alone),
23 of 55 participants (42%) scored >4 on first observation. In
84

the intervention group (role-play plus didactic), 39 of 54 participants (72%) scored >4 on first observation. These results demonstrate a statistically significant difference between the groups
(x2 = 12.8, p = 0.01). As summarized in Table 5, chi-square
analysis demonstrated no statistically significant difference in
compliance with items 1, 2, 4, and 5 between the control and
intervention groups. Observed behavior 3 demonstrated that the
intervention group (n = 35, 64.8%) performed significantly better (x2 = 5.79, p = 0.02) than the control group (n = 23, 41.8%).
This behavior necessitated that students identify the treatment
to date regarding the patient they were calling about. It is interesting to note that this treatment information was not stressed
in the didactic portion of the training for either group but that
the role-play group performed better on demonstration of this
component of skilled communication.
DISCUSSION

The results of this study demonstrate that nursing students

knowledge of skilled communication increases as a result
of didactic instruction with use of a standardized commuCopyright SLACK Incorporated

KESTEN

nication technique. Several

table 5
studies reported improved
Comparison of Components of SBAR Communication Performance in
communication after skilled
First Observations by Type of Instruction
communication training using didactic instruction, but
Controla
Interventionb
none of the studies used
Group
Group
SBAR (Berkenstadt et al.,
(N = 55)
(N = 54)
2008; Boone, King, GreshObserved Behavior Checklist Item
n (%)
n (%)
Chi Square
p Value
am, Wahl, & Suh, 2008;
23 (42)
39 (72)
12.8
0.01
Total score >4
Boyle & Kochinada, 2004;
Observation 1, component 1: Before
53 (96.4)
54 (100)
2.00
0.16
Brown, Boles, Mullooly,
calling the provider, the student
& Levinson, 1999; Fallowassessed the patient, reviewed
field, Saul, & Gilligan, et
the most recent progress note or
al., 2001; Faulkner, 1992;
received report on the patient
Heaven & Maguire, 1996;
Observation 1, component 2: While
42 (76.4)
47 (78)
2.07
0.15
Krautscheid, 2008; Messspeaking
with
the
provider,
the
mer, 2008; Paxton, Rhodes,
student identified himself/herself,
& Crooks, 1988; Razavi
the patient, and the problem
et al., 1993, 2000, 2002;
Observation 1, component 3: While
23 (41.8)
35 (64.8)
5.79
0.02
Schlundt, Quesenberry, Pispeaking
with
the
provider,
the
chert, Loren, & Boswell,
student identified the treatment to
1994; Whitson et al., 2008).
date regarding the patient he or she
This study demonstrates a
was calling about
change in knowledge that
Observation 1, component 4: While
37 (67.3)
42 (77.8)
1.51
0.22
was significant in all of the
speaking with the provider, the
students regardless of age,
student related the most recent vital
gender, program of study,
signs and any changes from prior
English as second language,
assessments
or cohort. However, older
Observation 1, component 5: While
39 (70.9)
42 (77.8)
0.67
0.41
students, defined as those
speaking with the provider, the
older than age 25, demonstudent made a recommendation or
strated significantly greater
a request
change in knowledge than
younger students, with
Note. SBAR = Situation, Background, Assessment, and Recommendation.
younger students having
a
Didactic instruction only.
higher pretest scores. Oldb
Didactic instruction + role-play.
er students demonstrated
greater gain in knowledge
of the skilled communication technique; this may be explained by the adult learning
nicate regarding an urgent patient concern to a provider must
theory that adult learners retain knowledge that they can use
not be arbitrary.
and apply immediately (Knowles, 1984). Gender differences
This study supports evidence that exists in case study and
at baseline also were observed. Although pretest scores in
anecdotal accounts in the literature. Ascano-Martin (2008) immen were lower than in women, men showed significantly
plemented role-play of shift report using a standardized SBAR
greater change in knowledge than women. Due to the small
communication technique with senior nursing students in postsample of male students, this finding may be attributed to
clinical conference and found an increase in self-confidence
artifact of group size.
in giving report. In addition, the students active participation
Although students reported previous knowledge of SBAR
during the role-play sessions stimulated higher level learning
technique, few had actually ever practiced using it. Communiand critical thinking ability (Ascano-Martin, 2008). Case study
cating succinctly with pertinent information in an acute situreports in perioperative settings demonstrate how the use of
ation requires forethought and practice using a tool such as
SBAR as a standardized approach to handoff communication
SBAR. Students who received role-play instruction in addihelps minimize risks to patient safety (Amato-Vealy, Barba, &
tion to didactic instruction performed significantly better on
Vealy, 2008).
the skilled communication first observation than students who
The nursing department at Providence St. Vincent Medical
received didactic instruction alone. This finding is the most
Center in Portland, Oregon, realized increased staff and phyinteresting aspect of the study as it confirms the relationship
sician competence with team communications after initiating
between role-play instruction and performance. The critical
didactic presentations and trigger tools to reinforce the use of
nursing action of knowing when, what, and how to commuSBAR communication (Dixon et al., 2006). The use of roleJournal of Nursing Education Vol. 50, No. 2, 2011

85

ROLE-PLAY USING SBAR TECHNIQUE

play was recommended as an instructional method. In addition,

Dixon et al. (2006) recommended that staff practice organizing
and delivering information in a structured format, that simulation-based team training be offered to afford practice, and that
SBAR be embedded in practice guidelines, policies, and procedures. Application of role-play instruction of SBAR in home
health settings was demonstrated at Aria Home Health in Dallas, Texas, where the SBAR tool was implemented to formalize nurse-physician communication processes by educating the
staff regularly, providing role-play opportunities, and allowing
the staff to practice (Markley & Winbery, 2008). This research
study demonstrates the effect of role-play instructional methodology to teach nurses skilled communication using SBAR.
Anecdotal reports of successful use of SBAR as a standardized communication technique for nurses and providers are
emerging throughout the literature. These include editorials in
case management journals; information links in skin and wound
care journals; and reports in emergency, perioperative, home
health nursing, and pediatric journals (Pope, Rodzen, & Spross,
2008; Powell, 2007; Sibbald & Ayello, 2007; Streitenberger,
Breen-Reid, & Harris, 2006). This research study provides
nursing faculty with information regarding the importance of
teaching skilled communication using a standardized communication tool to nursing students as well as identifying effective instructional methods to improve outcomes. This research
study addresses the gap that exists in the literature regarding the
best method to teach skilled communication to nurses and the
best method to produce observable change in communication
behavior. This study demonstrates that in addition to didactic
instruction, participating in a role-play exercise using a standardized communication technique such as SBAR may improve
communication performance.
LIMITATIONS AND RECOMMENDATIONS

Limitations of the study relate to the setting, sample, and

design. Possible prior exposure of students to SBAR in the
clinical arena may have influenced performance, irrespective
of the teaching approach. Although there was representation
of baccalaureate students and second-degree nursing students,
generalizing to other student populations or nurses working in
organizations may not be possible. Further limitations relate to
the scenarios that were developed for this study as there were
no existing tools. Administering the posttest to students once
at the end of the semester a few weeks after instruction rather
than testing at several subsequent intervals is another limitation
of the study. Future studies should use a broader student and
licensed population, multiple reviewers, and multiple scenarios.
Interdisciplinary training would be a good approach.
Health care facilities across the nation are attempting to implement SBAR as a skilled communication tool. Knowledge of
an effective instructional method to teach skilled communication will assist educators in implementing SBAR education in
health care facilities and schools of nursing. The evidence that
didactic and role-play instruction of the skilled communication
tool SBAR improves the observed use of SBAR by nursing students will encourage disciplines within and outside of nursing
to implement the teaching method.
86

CONCLUSION

Results from this project provide evidence-based outcomes

that may influence practice for in-service education, continuing education, facility orientation, interdisciplinary education,
and nursing curriculum. This project builds the evidence toward improving communication training of nurses and providers, which may ultimately improve patient outcomes. Future research conducted in an interdisciplinary setting using
role-play to teach skilled communication is recommended.
Instructing all health care team members as well as the provider, as the receiver of this communication, on what to expect when nurses and team members use the SBAR technique
can only enhance communication. If communication between
nurses and health care providers is improved, the implications
for improving patient outcomes and patient safety have great
potential. Next steps include using this instructional method
to teach international nurses skilled communication. Future
research investigating the specific impact of SBAR communication on patient outcomes, medication errors, and sentinel
events is recommended.
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