ISBAR – a better way to communicate

Acknowledgement: Southern Health & VMIA

ISBAR helps clinical staff to:

• Further develop their communication skills• Utilise these skills when making a telephone ‘referral’• Utilise questioning / prompting skills when receiving a

telephone referral• Use a standardised or common approach to

communication• Adapted from SBAR, a tool developed by the US

Navy to improve communication

Why is improving our communication important?

• Patient care is dependant on effective communication

- including telephone communication between all staff

involved in the care of the patient

• Effective communication has become more important

as healthcare has become more complex, highly

specialised and team-based

Why do we need a standard approach to verbal and written communication?

• It is a daily task• It is rarely ‘explicitly’ taught• Telephone referrals can be a source of frustration

for both the ‘giver’ and the ‘receiver’• Ineffective telephone communication can

compromise patient care

Some questions for you to think about…..

• How often do you make or receive a telephone

referral?• Generally, is making a telephone referral easy or

difficult?• Do you get frustrated when receiving information about

your patients/clients from other staff?• What have you experienced?• If sometimes difficult, why?• What information would you like when receiving a

referral or at handover?

Some of the challenges in good communication

• People are busy and don’t want more work! It takes time and practice to plan a good handover of patient/client information

• It can be difficult to summarise a complex case succinctly• The person making the referral:– is often asked about things they have already said– may not get the help they were expecting

• The person receiving the referral may– interrupt mid-sentence– make assumptions about the capability of caller

Video 1

Click on the black box and watch the video

• What are your thoughts on this doctor’s attempt at making

a referral?• What suggestions for

improvement would you give him?

He was focused, but not well prepared….

1. The doctor clearly states what he wants:

– he wants the other doctor to come and see the

patient

2. He checks he is talking to the right person

but …

- He doesn’t have important information at hand

3. The main problem is lack of preparation

- how long does it take to prepare?

- what things should be prepared before picking up the

telephone?

Video 2

Click on the black box again and watch a second video

• What are your thoughts on this doctor’s attempt at making

a referral?• What suggestions for

improvement would you give him?

Once again, prepared, but not focused

• This was obviously very exaggerated, however…

• The person on the other end of the phone gave up

because the information was neither concise nor

organised• All the relevant information was included, but the

message was not clear

• Note: the relevant information needs to be delivered

slowly and simply with appropriate emphasis and

repetition

ISBAR – what does it stand for?

I - Identify

S - Situation

B - Background

A - Assessment

R - Request

I = Identify

• Identify yourself - name, position, location

Identify the person you are talking to if not already

done• Identify the patient and unique ID number

“Hello. My name is Jasmine Sass, I’m a Division 1 RN

working in Acute at UMHCS. Are you the Doctor on call

today? … I’m calling about a patient - Terry Jones –

a 56 year old man in our Acute ward at present”

I = Identify

• Why give your name?– it is polite and professional to do so

• Why give your position?– helps the information receiver to know at what level to pitch their response/advice

• Why state where you are calling from?– the information receiver may work at multiple sites

• Why identify the person you are speaking to?– to make sure it is the appropriate person

I = Identify

• Why do you need their name?

– to document in the notes for future reference

• Why identify the patient - name, age, sex, location?

– helps identify the patient and helps the receiver to develop a mental picture of the patient

S= Situation

• Explanation of WHY you are calling

“I am calling you about a patient, Mr Jones. He is a 56

year old man, 3 days post total knee replacement who has

developed new atrial fibrillation with a blood pressure

of 105/66. He looks pale and feels unwell. I would like

you to come and assess this patient please”

S = Situation

• If urgent, make this clear at the start

“Mr Jones is a 56 year old man who is 3 days post total knee replacement and is here for rehabilitation. He has gone into atrial fibrillation. He is stable at present with a blood pressure of 105/66 but he is normally hypertensive. He looks pale and feels unwell. I am concerned about him and would appreciate it if you could come and help us stabilise him”

• Stating the purpose of the call at the start of the

conversation helps the receiver focus their attention

appropriately when listening to the story

B = Background

• Tell the story“I’ll tell you the story…”“I’ll give you the background information…”

• Provide RELEVANT information only. Deciding what is relevant is a skill that comes with experience

• Don’t forget ‘less is often more’– you may get the message across better with lessInformation

• Include aspects of history, examination, investigations and management where relevant

B = Background

• The volume of information will depend on the situation

– Less• if the receiver will see the patient themselves shortly. No

background may be quite appropriate in this situation.• if the receiver already knows the patient

– More• if you are wanting management advice over the phone

without the receiver seeing the patient• The receiver can always fill any important

gaps in your story by asking questions

A = Assessment

• State what you think is going on. Give your

interpretation of the situation• This is NOT about providing your diagnosis of the patient –

only a qualified medical practitioner can do this

• Don’t leave the receiver to guess what you are thinking

- Stating the obvious is helpful here- Include your degree of certainty- Be objective

A = Assessment

• “… the patient is febrile with a temperature of 39 deg”

• “The patient has improved but I am concerned they are still short of breath”

• “The patient has rated their pain at 8/10 despite 2.5 mg Morphine IV one hour ago”

R = Request

State what you want from the receiver• “We would be grateful for your opinion regarding the

need for surgery”• “I need help urgently, are you able to come now? …if not,

who should I call?”

Ask questions• “What would be the most appropriate pain relief we can

administer until you are able to come and assess the patient?

• “What would you like me to do for the patient whilst waiting for you to come in?”

Additional points …..

• What you say for Situation may be a concise summary of what you say for Assessment and Request. This repetition is helpful, as it emphasises the key purpose of the referral, as well as why it is important they come NOW!

• Sometimes the receiver will lead the conversation – you

can still use ISBAR as a guide

– Don’t forget, the receiver may not be familiar with ISBAR

• Practice makes perfect – use the ISBAR documentation form to help you organise the information you are going to convey

Preparing for the call

• Preparation is vital - use ISBAR to prepare• Make sure YOU are clear on the reason for referral before calling• Write down your questions• Document a written referral in the notes as per the practice for formal referrals in your hospital or include in nursing notes• Gather relevant patient details, notes, charts, ECGs, observations etc before making the call• Have pen and paper on hand to write down names, numbers and instructions, or use the ISBAR

documentation form

ISBAR template form

Use this form

to prepare before

presenting your client

Video 3 – how to do it properly

• Click on the black box to watch the last clip

• What are your thoughts on this attempt at making a

referral?• This is an example of ISBAR in

action!

Remember, ISBAR can be brief

• I - “Hi, I’m Carol, an ANUM in Acute today”

• S - “I would like you to come and see a 21 year old man who has had a significant skin reaction to an IV antibiotic”

• B - “He was admitted this morning for treatment of an

appendicectomy wound infection. He is a type 1 diabetic.

He has just had his first dose of Gentamicin,Metronidazole and Ampicillin”

• A – “He is anxious and appears flushed with an erythemous rash on his chest and arms. His blood pressure is normal”

• R - “Are you able to see him urgently?”

“What would you like me to do in the meantime?”

Receiving a referral or handover

Don’t forget you can help – you may need to help people stay on track – consider asking the following questions

– Are we using the ISBAR format?

– Can you give this to me in ISBAR format?

– Can you please identify …. patient’s name, location?

– What is the Situation?

– What is the Background?

– What is your Assessment?

– What do you think needs to happen?

Other applications of ISBAR

• Making a written referral• Presenting a case on a ‘ward round’• Handing over a complicated patient to covering staff• When transferring or receiving a patient from ED• ‘Standardised Forms’ development

How are we going to use ISBAR at UMHCS?

• At nursing handover• Making calls to our GP’s, or other allied health professional referrals• To present patients at the Continuum of Care meeting or brief• In our written documentation• As part of the review process of a number of our forms we use

including the Multidisciplinary Assessment Tool, Referral forms etc – this is part of the PDSA project

• To improve the quality of the information we share among one another about our clients and patients

• To improve our efficiency and time during handover and meetings

What next?

• Print out your certificate of completion

• Start practicing using ISBAR in your daily work

• Be ready to start the trial of using ISBAR in nursing handover on May 30

• Feel free to see Sharon Ed, Krystal Sheehan, Liz Wallace Joy Gadd or Fiona O’Toole if you have any further questions or need clarification, they’re the group working on SBAR and the whiteboard for the TeamSTEPPS project