The ISBAR tool leads to conscious,

structured communication by
healthcare personnel
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Summary
Background: ISBAR is a patient safety communication structure
that aids simplified, effective, structured and anticipated
communication between healthcare personnel. No research has
previously been conducted on master’s students’ experiences of using
ISBAR in Norway. In the past, there have been calls for education
strategies that ensure students receive training in patient safety
communication.

Objective: To elucidate specialist nursing students’ experiences of

using ISBAR as a communication structure in clinical practice on a
master’s degree programme in specialist nursing.

Method: The study has a qualitative descriptive design, and

comprises three focus group interviews. A qualitative content analysis
was carried out.

Results: Using the tool made the students’ communication more

conscious, structured, clear and predictable. They conveyed objective,
unambiguous and specific observations and changes instead of giving
unfounded opinions. The students more readily proposed solutions of
their own and clarified medical regulations. Using ISBAR made them
feel more confident about their own communication and expertise,
and improved their teamwork and patient safety. However, the ISBAR
tool presented some challenges for the students since the
communication structure had not been implemented at the hospital.
Conclusion: Using ISBAR increases the awareness of users’ own
structured communication and expertise and allows them to obtain a
quicker overview of patient situations. The findings highlight the
importance of systematic training and simulation with the ISBAR
structure in order to improve patient safety, both in the training of
specialist nurses and in the specialist health service.
 Expertise
 Qualitative method
 Patient safety
 Specialist nursing students
 Teamwork

Teamwork and communication between healthcare personnel

are vital to quality of care and patient safety (1, 2). Patient safety
is defined as protection against unnecessary harm resulting
from the health service’s efforts or lack of efforts (3).

Communication failures in treatment teams are one of the most

common causes of adverse events in the specialist health
service, and about 70 per cent are due to human errors in non-
technical skills such as communication, management and
decision-making (1, 4, 5). A lack of structure and
standardisation is sometimes to blame for communication
failures (6).

The communication structure Identify, Situation, Background,

Assessment and Recommendation (ISBAR) was created to
standardise the effective transfer of information in the US
armed forces. ISBAR was adopted by the public health service in
the 2000s (1, 7) (Table 1).
What is ISBAR?
ISBAR is one of several frameworks for communication between
healthcare personnel in relation to patient situations. Use of the
instrument is considered to improve patient safety through
more structured, focussed and concise communication among
healthcare personnel (1, 8, 9). The US healthcare system
implemented ISBAR around 2003, and its overarching goal in
patient safety work is to improve communication (1).

Norway introduced a national programme for patient safety in

2014 (10), but communication between healthcare personnel
was not a focus area until 2017 (11). The further education
programmes in paediatric and intensive care nursing
recommend giving more attention to teamwork and patient
safety, as well as communication and interaction with patients
and their families, but team communication is not covered (12,
13).

Earlier research and the objective of the study

International studies show a reduction in unexpected deaths
from 0.99 to 0.34 per thousand, as well as significant and
personally experienced improvements in communication,
teamwork and safety since the implementation of ISBAR (1, 14–
16). Nurses found that they were better able to prioritise tasks
appropriately, better prepared in general (16, 17) and better able
to convey patient issues. The communication flow improved, as
did the communication and interaction with the treatment
team, and they felt more confident in their role (9, 14–16).

International communication training programmes and ISBAR

show an improvement in observational and assessment abilities
(16–19). Studies that include training in teamwork and
communication using full-scale simulation show only small
significant improvements compared to other teaching methods.
Nevertheless, simulation is recommended for training in
communication and teamwork (16, 17, 20, 21).

There is little research to confirm that theoretical skills are

transferred to practice (9). Wang et al. (19) show that students
want to use ISBAR in clinical practice after training. Bowling
(20) calls for education strategies that ensure that students
exercise patient safety in their nursing care.

No research has been found on master’s students’ experiences

of using a communication structure in actual patient situations
in a Norwegian context. The objective of the study is therefore
to elucidate specialist nursing students’ experiences of using
ISBAR as a communication structure in clinical practice on a
master’s degree programme in specialist nursing.

Method

Design
The study has a qualitative descriptive design, and comprises
focus group interviews.

Sample
All master’s students (n = 18) in the fourth semester of the
further education programmes in paediatric and intensive care
nursing were invited to participate by the management at a
relevant educational institution in southern Norway. One
student declined, and another was off sick on the data collection
day. The total number of students who participated was
therefore 16. All were women aged 27–49 with nursing
experience of between 4 and 16 years.

Context
The master’s degree programme in specialist nursing included
both the teaching of theory and full-scale simulation of non-
technical skills (6). There was no separate training programme
for the ISBAR structure, but the teaching was inspired by a
training programme on communication and teamwork (22).

The first semester consisted of a two-hour resource lecture on

teamwork and communication in a patient safety perspective,
with ISBAR as the chosen communication structure. The
students performed role plays in ISBAR communication as part
of the lesson.

Between the 2nd and the 4th semester, the students completed
about twelve full-scale simulations over the course of five days.
ISBAR and teamwork were one of the learning outcomes. The
students were encouraged to use ISBAR in clinical practice at
the hospital.

Data collection
We conducted three focus group interviews in January 2016,
immediately after the last simulation in the fourth semester.
One focus group consisted of four paediatric nursing students,
and two focus groups consisted of five and seven intensive care
nursing students respectively. The first author conducted two
interviews, and the third author conducted one. The second
author observed the focus group interviews and acted as
secretary (23).

We used an interview guide with two open-ended questions

about positive experiences and challenges when using ISBAR in
clinical practice. Audio recordings were made of the interviews,
which were then transcribed verbatim by two of the authors.
The interviews lasted between 57 and 70 minutes and were held
in a meeting room at the educational institution.

Analysis
We undertook a qualitative content analysis with an inductive
approach to the dataset (24). Raw data (68 pages) was read in
its entirety and divided into meaning units using NVivo 11 Pro
(25). Statements were condensed and systematised by content,
then described and partly interpreted into subcategories and
further abstracted into three main categories (24) (Tables 2 and
3). Interpretation is influenced by the researchers’
preconceptions (24).

All the authors are teachers, and three are intensive care nurses
with experience from ISBAR and simulation. The results are
supported by quotes from all the focus group interviews, where
different voices are heard.
Ethical considerations
The study has been reported to the Norwegian Centre for
Research Data (NSD) (project number 45068) and carried out
in accordance with the Declaration of Helsinki’s ethical
guidelines (26) on voluntary participation and anonymisation.
Participants received oral and written information about the
study, and all provided written consent.

Results
More awareness and structure in own
communication
Many students had experienced that the nurse and doctor used
different terminology in communication. Using ISBAR made
the students more aware of the importance of uniform
communication in content and language.

The students found that the patient problem was communicated

more clearly and more specifically when they used ISBAR. The
communication with the doctor improved, and the students
found that their language had become more uniform. The
students therefore felt that the teamwork had improved, and
that this teamwork served as a quality assurance measure in
patient treatment: ‘If we don’t have a common language
between ourselves and the doctor, then the problem doesn’t get
communicated… We actually communicate at a completely
different level with quite a few doctors.’ (ID1-7)

Some students found the ISBAR structure to be useful, effective

and time-efficient, and felt that the patient problem was
communicated more swiftly: ‘Being structured certainly saves a
bit of time...’ (ID1-4)

The structure and systematics of ISBAR

made communication clearer and more
predictable.
After the ISBAR training and simulation, all students agreed
that structured communication was necessary. The structure
and systematics of ISBAR made communication clearer and
more predictable.
The students did not forget important information, and this
made them feel more secure. They also conveyed patient
problems in a more objective manner. When the students
provided information, they focused on specific observations and
changes instead of unfounded opinions: ‘ISBAR helped to make
things more concrete. You describe what the problems are as
opposed to what you yourself feel. The observations that emerge
are more objective.’ (ID1-1)

The students agreed that ISBAR had made it easier for them to
propose their own solutions for patient treatment. They all said
that ISBAR had also made them aware of how important it was
to ask for advice and clear feedback and to confirm agreements
and instructions that had been drawn up. ISBAR thus became a
tool that could be used to prevent misunderstandings and as a
way of quality assuring the necessary information about the
patients:

‘When I’m communicating with doctors, I try to confirm

messages. Just yesterday, I wanted to wait to give a patient a
tablet. ‘We’ll wait to give the patient the tablet,’ I suggested.
‘That’s right,’ said the doctor. I’ve never suggested interventions
very consciously [to the doctor] before.’ (ID2-3)

Increased awareness of own expertise

Most students agreed that ISBAR had made them more
confident in their own assessments in the communication with
the doctor. Having confidence in their own assessments made
them more aware of their own expertise: ‘Its structure shows
that you’ve understood and have a lot of expertise. It helps make
you more analytical.’ (ID1-7)
ISBAR was particularly useful for use in acute care situations
because the students quickly gained an overview of the patient
situation. This made them feel better prepared and able to be a
step ahead if complications arose: ‘I think ahead more, think
worst case scenario. ISBAR helps to develop that way of
thinking.’ (ID1-7)

Several students found that when they used ISBAR, they

received feedback from the doctor that their observations,
assessments and solution proposals were relevant. This gave
them a good sense of mastery, and made them feel that they had
gained the respect of the doctors. They discovered through this
that their own expertise was useful input to patient treatment.

Using ISBAR provided more scope for professional discussions,

which led to agreement on treatment and further plans for the
patient. The students found that using ISBAR resulted in good
teamwork and improved patient safety: ‘I think the doctor
appreciates recommendations. When we have an opinion and
have assessed the situation, it’s no longer a top-down approach.
We can discuss things.’ (ID3-2)

It was widely agreed that the ISBAR structure was important for
all nurses, but particularly for newly qualified nurses. Some
students believed that experienced nurses were able to convey
the necessary information without using a fixed communication
structure.

However, the students were uncertain whether it was ISBAR

that had made them feel more secure in their own assessments,
or if it was because their expertise had improved: ‘You learn
more if you study for two years, and that impacts on the content
of my assessments in ISBAR.’ (ID3-3)

Several students also had positive experiences with using ISBAR

in oral reporting and written documentation. This applied to
communication between nurses, during patient transfers and
doctor’s rounds, and in the communication with patients’
families: ‘I also use ISBAR when I report to other departments,
when we have a patient who is to be moved, or for reporting in
general.’ (ID3-1)

Challenges of using ISBAR in clinical practice

Although most students thought that the ISBAR structure was
useful in acute care situations, some found it difficult to follow
the structure ‘automatically’ because ‘it takes many years to
master it’ (ID3-2). Another challenge was that the students
focused more on the sequential order in ISBAR than on the
content to be conveyed, which slowed them down.

The students felt it was important to focus on ISBAR at an early

stage in health studies in order to receive enough training. The
importance of high-volume simulation training was
emphasised: ‘It’s great that we have ISBAR in every simulation.
I felt after perhaps the fourth or fifth time, yes, this is working.’
(ID2-4)

The students found that the doctors could be impatient and that
they interrupted them when the students were conveying
information about patient situations in accordance with the
ISBAR structure: ‘[It’s a] drawback if the doctor is not familiar
with ISBAR and is wondering if the nurse will get to the point
soon.’ (ID2-1)
Some students said that it was sometimes difficult to suggest
their own solutions and elicit a response to them, particularly
from new doctors: ‘This can be a problem with new doctors if
they feel undermined by the nurses’ assessments and
suggestions.’ (ID3-1)

The students found it a drawback that the

ISBAR structure had not been
implemented and was not known
throughout the hospital.
Most of the students found that they often used ISBAR during
the doctor’s rounds, during telephone contact with the doctor
and in nursing reports. Some students said that they used
ISBAR subconsciously, while others had hardly used ISBAR at
all, but wanted to do so. The students found it a drawback that
the ISBAR structure had not been implemented and was not
known throughout the hospital. Some students received
comments such as: ‘I’ve never heard of that before...’ (ID1-2).

They feared, however, that it would be difficult to implement a

fixed communication structure for experienced nurses who
believed that their communication was already structured and
protected patient safety: ‘Those who have been working for a
long time are a huge challenge. They want to do what they’ve
always done, it’s what they know.’ (ID1-7)

Since ISBAR was not implemented at the hospital in question,

the students talked about different ways of implementing
ISBAR. They all agreed that ‘ISBAR is here to stay’ (ID3-2).
Several suggested holding a workshop with a focus on ISBAR as
a communication structure. They all believed that simulation
was a suitable method for learning and using the ISBAR
structure. Simulation can provide training and direct feedback
on the language, content and structure of the communication:
‘Using ISBAR at a workshop. You practice [and can] use it in
simulation situations, so all colleagues take part in
communication training. I think that’s the way to learn it.’ (ID1-
7)

Discussion

More awareness and structure in own

communication
All the students found that the communication was better
structured and the content was more specific when they used
ISBAR. They were more conscious about conveying key,
objective information about patients, and there were no
linguistic misunderstandings. Uniform terminology can play a
role in preventing misunderstandings and communication
failures (1, 5).

The findings correspond to studies showing that the ISBAR

structure improves both content and clarity in communication –
it distinguishes between essential and insignificant information
(14, 16). Nurses are also better prepared and can prioritise more
easily (16, 17).

The students pointed out that the ISBAR structure was

predictable; they did not forget important information, thereby
saving time in acute care situations. This predictability is
confirmed in research on ISBAR, and predictability and
effectiveness are two of the objectives of implementing the
structure (1, 8).

The students believed that the effectiveness of the tool was

dependent on whether they had integrated ISBAR into their
own professional practice. We interpret this to mean that the
importance of repeated simulations is crucial to learning, a view
that is supported by Husebø and Rystedt (6).

The students emphasised that getting advice was one of the

most important elements of the ISBAR structure in terms of
preventing misunderstandings and ensuring patient safety.
Being more aware of the importance of asking for clear feedback
and confirming agreements meant that the necessary
information about the patient was quality assured. It is
interesting to note that earlier research does not pinpoint
receiving advice as one of the most important features of the
ISBAR structure, but discusses clarity in general terms in all the
factors of the structure (20).

Increased awareness of own expertise

Greater confidence in their own assessments and analyses, and
an increased sense of mastery were prominent findings. The
students found it easier to obtain an overview of the patient
situation and were ready to deal with potential problems. Other
studies confirm that using ISBAR improves observational and
assessment abilities and self-confidence, and facilitates
decision-making (9, 17).
Greater confidence in their own
assessments and analyses, and an
increased sense of mastery were
prominent findings.
The students felt that they received more respect from doctors
when they used ISBAR. This led to more professional
discussions, which resulted in agreement on treatment
strategies. Professional discussions and respect from doctors
supported and strengthened their expertise and sense of
security in their practices. The students also found that ISBAR
encouraged good teamwork and ensured patient safety in the
nursing. These findings are in keeping with other studies (18).

The students reported that the ISBAR structure, together with

increased expertise through the training, made them more
analytical and inspired them to voice their own suggestions and
reflections. The ISBAR structure also seems to represent a tool
for developing clinical assessment and reasoning.

The students further found that ISBAR was useful in various

reporting contexts and in communication with patients’
families. This may indicate that the students have
subconsciously integrated ISBAR into their professional
practice, and that they use ISBAR in various situations.
Research shows that ISBAR is also used in the context of
reporting and doctors’ rounds (14, 15), and supports the
students’ experiences of being able to use ISBAR in such
situations.

Challenges of using ISBAR in clinical practice

The students found that using ISBAR was time-consuming
because the communication structure was not integrated into
the work routine in the hospital. It also emerged that it was
difficult to follow the structure automatically, despite them
finding it easier after several ISBAR simulations. These findings
show that high-volume simulation training is necessary.

Various studies show that classroom teaching alone leads to

little change in communication, while a significant
improvement in the nursing students’ communication can be
seen through both the teaching of theory and simulation (21,
27). A meta-analysis showed that simulation had a significant
impact compared to other learning strategies (21).

These findings and other research support recommendations

for the closer integration of theoretical and clinical components
in nursing education programmes, and for a greater focus on
clinical reasoning than on critical thinking in the study
programme (17).

The students were often interrupted by doctors who were not

familiar with ISBAR. Some found that certain doctors did not
allow a dialogue in which the students could convey their own
assessments. A systematic literature review shows that different
modes of communication, offensive behaviour and culture are
barriers to effective nurse-doctor communication (28), and
confirms the experiences of the students.

The students were often interrupted by

doctors who were not familiar with ISBAR.
An important leadership skill in teamwork is listening to input,
and obtaining and disseminating information (2, 29). Using
ISBAR alone is not enough to foster good teamwork. Human
factors, management and a patient safety culture are important
prerequisites for teamwork and patient safety. Attention to
improving non-technical skills, interprofessional collaboration
and team performance where everyone can have their say are
also crucial factors (29).

The students found it difficult to apply the ISBAR structure in a

field of practice that had not implemented ISBAR. The
Norwegian Patient Safety Programme lacks a clear focus on safe
communication and has therefore not been prioritised at a
number of hospitals. It was not until 2017 that ISBAR was
mentioned in the care bundle for hospitals concerning early
detection of deterioration in a patient’s condition (11).

Whether it is appropriate for the students to apply ISBAR in

clinical practice when the field of practice has not implemented
the communication structure is debatable. However, one
positive aspect is that the students gain experience in
introducing new knowledge on patient safety to the field of
practice. It will raise students’ awareness and make them more
knowledgeable about relevant quality measures. Patient safety
will also improve through the use of knowledge-based practices
and students will represent a useful resource in future
implementation processes (12, 13, 30).

Students feared it might be a challenge to implement ISBAR

with experienced nurses who showed little interest or
willingness to change their own communication structure.
However, the students used ISBAR to varying degrees, and
some used the structure subconsciously. These findings seem to
have similarities with the challenges of implementing
knowledge-based practices (30) and support the fact that
theoretical skills are not always transferred to practice (9).

The students suggested workshops where doctors and nurses

were taught theory and carried out interdisciplinary
simulations. In simulations, healthcare personnel can receive
specific feedback on what they are actually saying, and not just
on what they think they are saying. Communication and team
training are key factors for creating and maintaining a safety
culture (22, 29).

Methodological considerations
The study is important as no corresponding studies have been
conducted in Norway. The authors expected the sample
population to be well-informed and to have a large potential to
shed light on the subject of the study (23). The study has
between four and seven female respondents in each focus
group, which is in line with recommendations (23, 24).

Homogeneity can strengthen the group dynamics through

recognition of associative effects and past common experiences.
The absence of male participants may be a weakness of the
study. There were numerous congruent findings in the data
collected, which may be an indication of saturation.

The first and third authors participated in all the simulations

and followed the students throughout the master’s degree
programme. The first author gave the ISBAR resource lecture.
The authors’ existing knowledge provided a good basis for
understanding how ISBAR is applied in a hospital context.
As the interviewer was also a teacher on the master’s
programme, the students may have refrained from relating their
negative experiences, and answered in a way that they thought
the interviewer wanted to hear. In order to reduce this risk, the
second author was present in all the focus group interviews. The
interviewers did not supervise the students in clinical practice,
and the students were informed about the authors’ dual role as
both researchers and teachers before the interviews.

Preconceptions can influence the questions and the analysis,

such that certain elements might be overlooked or
underestimated (24). We tried to identify the preconceptions
throughout the research process by involving three of the
authors in the analysis process. Others may, however, analyse
and interpret the findings differently.

Conclusion
The findings of the study showed that the students became
more aware of their own communication structure when using
ISBAR in clinical practice. They also felt more confident about
their own expertise and communication, and were able to
obtain a quicker overview of patient situations. These elements
led to improved patient safety.

However, the students found it a challenge to use the ISBAR

structure in practice as it had not been implemented in the
hospital. The findings throw light on the importance of
systematic training and simulations with the ISBAR structure in
order to improve patient safety, both in the training of specialist
nurses and in the specialist health service.
We have not investigated the long-term effects of using ISBAR
in the students’ training. It is therefore important to conduct a
follow-up study of students and other healthcare personnel who
have received training in ISBAR.

References
1. Stewart KR, Hand KA. SBAR, communication, and patient
safety: An integrated literature review. (CNE SERIES). Medsurg
Nurs. 2017;26(5):297.

2. Ballangrud R, Husebø SE. Strategier og verktøy for

teamtrening. In: Aase K, ed. Pasientsikkerhet: teori og praksis.
2. ed. Oslo: Universitetsforlaget; 2015. p. 248–62.

3. Saunes IS, Svendsby PO, Mølstad K, Thesen J. Kartlegging

av begrepet pasientsikkerhet. Oslo: Nasjonalt kunnskapssenter
for helsetjenesten; 2010. Available
at: https://www.fhi.no/globalassets/dokumenterfiler/notater/2
010/notat_2010_kartlegging-av-begrepet-
pasientsikkerhet_v2.pdf(downloaded 13.12.2018).

4. St.Pierre M, Hofinger G, Simon R, Buerschaper C,

SpringerLink. Crisis management in acute care settings: Human
factors, team psychology, and patient safety in a high stakes
environment. 2. ed. Berlin: Springer; 2011.

5. Helsedirektoratet. Årsrapport 2017: Meldeordningen for

uønskede hendelser i spesialisthelsetjenesten. Oslo:
Helsedirektoratet; 2018. Available
at: https://helsedirektoratet.no/Lists/Publikasjoner/Attachmen
ts/1446/Arsrapport2017_Meldeordningen.pdf(downloaded
14.06.2018).

6. Husebø SE, Rystedt H. Simulering innen helsefag. In:

Aase K, ed. Pasientsikkerhet: teori og praksis i helsevesenet.
Oslo: Universitetsforlaget; 2010.

7. Improvement I-IoH. SBAR technique for communication:

A situational briefing model, 2013. Available
at: http://www.ihi.org/resources/Pages/Tools/SBARTechnique
forCommunicationASituationalBriefingModel.aspx(downloaded
14.06.2018).

8. Sharp L. Effektiv kommunikation för säkrare vård. Lund:

Studentlitteratur; 2012.

9. Buckley S, Ambrose L, Anderson E, Coleman JJ,

Hensman M, Hirsch C, et al. Tools for structured team
communication in pre-registration health professions
education: a Best Evidence Medical Education (BEME) review:
BEME Guide No. 41. Med Teach. 2016;38(10):966–80.

10. Saunes IS, Ringard Å. Hva gjøres for å bedre

pasientsikkerheten? Satsinger i sju land. Oslo: Nasjonalt
kunnskapssenter for helsetjenesten; 2013. Rapport 17/2013.
Available
at: https://www.fhi.no/globalassets/dokumenterfiler/rapporter
/2013/rapport_2013_17_pasientsikkerhet_andre_land.pdf (do
wnloaded 14.12.2017).
11. Helsedirektoratet. Tiltakspakke for tidlig oppdagelse av
forverret tilstand (sykehus): Nasjonalt
pasientsikkerhetsprogram I trygge hender 24-7; 2017. IS-2583.
Available at: http://www.pasientsikkerhetsprogrammet.no/om-
oss/innsatsomr%C3%A5der/_attachment/4084?
_download=false&_ts=159f9ca912b(downloaded 14.12.2017).

12. Utdannings- og forskningsdepartementet. Rammeplan for

videreutdanning i barnesykepleie. Oslo: UFD; 2005. Available
at: http://www.regjeringen.no/upload/kilde/kd/pla/2006/000
2/ddd/pdfv/269384-
rammeplan_for_barnesykepleie_05.pdf(downloaded
14.12.2017).

13. Utdannings- og forskningsdepartementet. Rammeplan for

videreutdanning i intensivsykepleie. Oslo: UFD; 2005. Available
at: http://www.regjeringen.no/upload/kilde/kd/pla/2006/000
2/ddd/pdfv/269388-
rammeplan_for_intensivsykepleie_05.pdf(downloaded
14.12.2017).

14. De Meester K, Verspuy M, Monsieurs, KG, Van Bogaert, P.

SBAR improves nurse-physician communication and reduces
unexpected death: A pre and post intervention study.
Resuscitation. 2013;84(9):1192–6.

15. Gausvik C, Lautar A, Miller L, Pallerla H, Schlaudecker J.

Structured nursing communication on interdisciplinary acute
care teams improves perceptions of safety, efficiency,
understanding of care plan and teamwork as well as job
satisfaction. Journal of Multidisciplinary Healthcare.
2015;8:33–7.
16. Foronda C, Gattamorta K, Snowden K, Bauman EB. Use of
virtual clinical simulation to improve communication skills of
baccalaureate nursing students: a pilot study. Nurse Educ
Today. 2014;34(6):e53–7.

17. Darcy Mahoney AE, Hancock LE, Iorianni-Cimbak A,

Curley MA. Using high-fidelity simulation to bridge clinical and
classroom learning in undergraduate pediatric nursing. Nurse
Educ Today. 2013;33(6):648–54.

18. Shin H, Kim M. Evaluation of an integrated simulation

courseware in a pediatric nursing practicum. J Nurs Educ.
2014;53(10):589–94.

19. Wang W, Liang Z, Blazeck A, Greene B. Improving

Chinese nursing students’ communication skills by utilizing
video-stimulated recall and role-play case scenarios to
introduce them to the SBAR technique. Nurse Educ Today.
2015;35(7):881–7.

20. Bowling AM. The effect of simulation on skill

performance: a need for change in pediatric nursing education.
J Pediatr Nurs. 2015;30(3):439–46.

21. Hegland PA, Aarlie H, Strømme H, Jamtvedt G.

Simulation-based training for nurses: Systematic review and
meta-analysis. Nurse Educ Today. 2017;54:6–20.

22. Agency for Healthcare Research and Quality R, MD.

AboutTeam STEPPS® 2017. Available
at: https://www.ahrq.gov/teamstepps/about-teamstepps/index
.html(downloaded 30.10.2017).

23. Malterud K. Fokusgrupper som forskningsmetode for

medisin og helsefag. Oslo: Universitetsforlaget; 2012.

24. Kvale S, Brinkmann S, Anderssen TM, Rygge J. Det

kvalitative forskningsintervju. 2. ed. Oslo: Gyldendal
Akademisk; 2009.

25. QSR International. NVivo 11 pro for Windows. Available

at: http://www.qsrinternational.com/nvivo-product/nvivo11-
for-windows/pro(downloaded 27.06.2017).

26. World Medical Association. Helsinkideklarasjonen.

Declaration of Helsinki – Ethical principles for medical research
involving human subjects 2013. Available
at: https://www.wma.net/policies-post/wma-declaration-of-
helsinki-ethical-principles-for-medical-research-involving-
human-subjects/(downloaded 14.12.2018).

27. Kesten KS. Role-play using SBAR technique to improve

observed communication skills in senior nursing students. J
Nurs Educ. 2011;50(2):79–87.

28. Tan T-C, Zhou H, Kelly M. Nurse-physician

communication – NDASH – An integrative review. J Clin Nurs.
2017;26(23–24):3974–89.
 29. Haerkens M, Jenkins D, van der Hoeven J. Crew resource
management in the ICU: the need for culture change. Annals of
Intensive Care. 2012;2(1):1–5.

30. Sandvik GK, Stokke K, Nortvedt MW. Hvilke strategier er

effektive ved implementering av kunnskapsbasert praksis i
sykehus? Sykepleien Forskning. 2011;6(2):158–65.
DOI: 10.4220/sykepleienf.2011.0098.

Teaching clinical handover with ISBAR

 Annette Burgess,
 Christie van Diggele,
 Chris Roberts &
 Craig Mellis

BMC Medical Education volume 20, Article number: 459 (2020) Cite this article
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Abstract
Clinical handover is one of the most critical steps in a patient’s journey and is a core skill that
needs to be taught to health professional students and junior clinicians. Performed well, clinical
handover should ensure that lapses in continuity of patient care, errors and harm are reduced in
the hospital or community setting. Handover, however, is often poorly performed, with critical
detail being omitted and irrelevant detail included. Evidence suggests that the use of a structured,
standardised framework for handover, such as ISBAR, improves patient outcomes. The ISBAR
(Introduction, Situation, Background, Assessment, Recommendation) framework, endorsed by
the World Health Organisation, provides a standardised approach to communication which can
be used in any situation. In the complex clinical environment of healthcare today, ISBAR is
suited to a wide range of clinical contexts, and works best when all parties are trained in using
the same framework. It is essential that healthcare leaders and professionals from across the
health disciplines work together to ensure good clinical handover practices are developed and
maintained. Organisations, including universities and hospitals, need to invest in the education
and training of health professional students and health professionals to ensure good quality
handover practice. Using ISBAR as a framework, the purpose of this paper is to highlight key
elements of effective clinical handover, and to explore teaching techniques that aim to ensure the
framework is embedded in practice effectively.

Background
Clinical handover is defined as “The exchange between health professionals of information about
a patient accompanying either a transfer of control over, or of responsibility for, the
patient” [1]. It is one of the most critical steps in a patient’s journey [2] and is a core skill that
needs to be taught to health professional students and junior clinicians. Performed well, clinical
handover should ensure that lapses in continuity of patient care, errors and harm are reduced in
the hospital or community setting [2]. The key function of clinical handover is to improve the
effectiveness of the actions taken by the recipient/s [1]. Despite its importance, clinical handover
is often poorly performed – with potentially serious consequences for the patient [1]. Australian
research suggests that critical detail is often omitted during handover, and included information
is sometimes irrelevant [3, 4]. Although essential to safe medical practice and provision of
excellence in patient care [2, 5, 6], training in clinical handover is often inadequate and not
always included in university healthcare curricula [3]. Using ISBAR as a framework, the purpose
of this paper is to highlight key elements of effective clinical handover, and to explore teaching
techniques that aim to ensure the framework is embedded in practice effectively.

ISBAR
Evidence suggests the use of structured, standardised frameworks for handover improves
information transfer and patient outcomes [7]. In order to improve handover, a number of
structured formats have been developed. One example is the I-PASS handover system,
developed for use in paediatrics (Illness severity, Patient summary, Action list, Situation
awareness and contingency planning, Synthesis by the receiver) [8]. However, one of the most
widespread and well-studied frameworks is ‘ISBAR’ (Fig. 1) [9,10,11,12]. ISBAR is based on
‘SBAR’ – a system developed by the US Navy to ensure clear, precise communications between
nuclear submarines. The ISBAR framework, endorsed by the World Health Organisation
provides a standardised approach to communication which can be used in a wide range of
clinical contexts, such as shift changeover, patient transfer for a test or an appointment, inter-
hospital transfers and escalation of a deteriorating patient [9, 10]. In the hospital setting, ISBAR
has been shown to increase transparency and accuracy when practicing interprofessional
handovers [10, 12]. ISBAR has also proven to be a successful tool for handover in rural and
remote Australian settings [11].

Fig. 1
ISBAR framework [9,10,11,12]

Full size image

Clinical handover works best when all parties are using the same framework [13] and ISBAR
provides a shared model for the transfer of relevant, succinct information between clinicians
[13]. By providing a clear and standardised framework, it can assist in reducing the power
differences that may hinder the transfer of information [13]. Information transfer may include:
doctor to doctor; nurse to nurse; doctor to nurse; allied health to doctor; nurse to allied health.
ISBAR can be used in a number of interactions, such as shift change, inter-hospital transfers,
reports and briefings, medical emergencies, and patient discharge to community services. This
approach doesn’t only apply to verbal communication, but can also be used in written forms,
including reports, memos, radiology request forms, and referral documents. The structured
framework of ISBAR is used extensively within the Australian healthcare system [12,13,14].

Tips for preparing for ISBAR

There are important elements to consider in the clinical handover process. Handover must
include transfer of accountability for patient care, and the confidentiality of patient information
must be maintained. Key tips for preparing for ISBAR are listed in Fig. 2 [12, 13].
Fig. 2

Key tips for preparing for ISBAR [12, 13]

Full size image

The benefits and challenges of using ISBAR are listed in Fig. 3 [13]. Challenges can include the
complexity of patient cases, and ensuring the person receiving the handover has understood
correctly. To help overcome challenges, face to face handover is recommended wherever
possible, allowing for interaction and clarification of information [13].

Fig. 3
Benefits and challenges of using ISBAR

Full size image

Flow of patient information is vital to patient safety, and a balance between efficiency and
comprehensiveness is required [6]. In planning and organising clinical handovers, it is essential
to consider:

1. 1.

Who should be involved?

2. 2.

When should it take place?

3. 3.
 Where should it take place?

4. 4.

How should it occur?

5. 5.

What information should be handed over?

Staff rosters should ensure shifts cross over, with dedicated handover time, and clear leadership
practices. Sufficient and relevant patient information is required during handover. Junior
members of staff must be adequately briefed, and clinically unstable patients must be highlighted
to senior clinicians [6, 15]. Any incomplete tasks must be clearly understood by the incoming
healthcare team. Similarly, once handover is complete, information must be acted upon. Tasks
need to be prioritised; patient care plans need to be acted upon; and unstable patients need to be
monitored and reviewed in a timely manner [6]. Key elements in helping to ensure continuity of
patient information and care during and following clinical handover are summarised in Fig. 4.

Fig. 4

Key elements in helping to ensure continuity of patient information and care during and
following clinical handover [6]

Full size image

The use of electronic systems may assist with the efficiency of handover. Within the hospital
setting, some functions of the electronic handover tools include provision of the name and
contact details of covering doctors for each consultant; and identification of patients in need of
review, and outstanding tasks [6]. Benefits of using electronic systems include the ability to have
multiple users, linkage of information; immediate update of information; and assistance with
further planning and prioritisation.

Education, training and practice in clinical handover

Although ISBAR is proving to be a valuable handover tool, for it to be successful, it must be
effectively taught, and health professionals must be adequately trained in its use [10]. A recent
systematic review of education interventions [16] revealed that although many handover studies
mention interprofessional practice, educational interventions occur predominantly within the uni-
professional context. This systematic review also highlighted inadequate reporting of educational
interventions and outcomes, thus impeding replication studies [16]. Teaching approaches were
mostly based on simulation and role-play, often sequenced with didactic teaching, video
examples of handover, discussion and reflection. The systematic review concluded that a greater
emphasis on multidisciplinary training of handover would add value to educational interventions
[16].

Organisations, including universities and hospitals, need to invest in the education and training
of health professional students and health professionals to ensure good quality handover practice.
However, due to time constraints in university curricula, and in hospital training, teaching and
practice in clinical handover may not be prioritised. By embedding the teaching of handover
within the university healthcare curricula, students are able to develop and practice required
communication skills to better prepare for their future roles [17, 18]. Along with further training
in the workforce, with dedicated teaching time, a well-led handover session itself, provides a
useful setting for clinical education [6]. There are a number of online tools and videos available
to assist with the teaching of ISBAR. For example:

 The New South Wales Excellence Commission, Clinical Handover

[19] http://www.cec.health.nsw.gov.au/improve-quality/clinical-handover

 ISBAR patient safety [20]: https://www.youtube.com/watch?v=h0Ol6CiJAZw

 ISBAR: identifying and solving barriers to effective handover in inter-hospital transfer

[21] https://www.youtube.com/watch?v=1Wl9qogPw1E

Support in education, training, practice, assessment and feedback are essential. Based on our
own extensive experience of facilitating clinical handover tutorials, with large interprofessional
classes (allied health, nursing, medicine, pharmacy, dentistry), we recommend the following
teaching method, which combines large class and small group activities [17, 18]. Students watch
suitable ISBAR videos online prior to class, and then attend a face-to-face class, facilitated by a
clinical teacher, with interactive discussion. Then in small, interprofessional groups, students use
relevant scenarios to participate in simulation/roleplay activities (approximately four students per
group), providing an active method of practicing clinical handover. Two examples of scenarios
are provided in Fig. 5. Learners can work in pairs to practice giving and receiving a clinical
handover. Direct observation, assessment, and feedback, from both peers and an experienced
clinician assist in the development of skills [22, 23]. When ISBAR is practiced in larger groups,
it is possible for class participants to duplicate the handover, until it is eventually performed to
‘perfection’.

Fig. 5
Examples of ISBAR scenarios

Full size image

Feedback and assessment
Examples of using ISBAR in a roleplay situation are found in Fig. 6. It is important to remember
that direct observation of clinical practice, with feedback by an experienced clinician helps to
close the gap between current and desired performance by the learner [21, 22]. Additionally,
verbal qualitative feedback, with group participation, provides a useful method in teaching
clinical handover [17, 18]. For example; “You gave excess information”; “The information was
unfocussed”. It is important that the person giving the handover realises that the ‘receiver’ is
likely to ask questions, and it is essential to have all available information at hand during ISBAR.
Specific assessment tools can also be used. The “Clinical Handover Assessment Tool” (CHAT)
was developed by Moore et al. (2017), and is based on the ISBAR handover framework [11]. We
have used this model in the assessment of ISBAR performance during small group sessions. The
items in this assessment tool are aligned with ISBAR, including, “Identifies self and position”,
“Identifies main problem”, “Gives appropriate history”, “Give appropriate
examination/observation”, “Makes logical assessment”, “Makes a clear recommendation” [11].
A four point scale, ranging from “Not performed competently” to “Able to perform under
minimal direction” is used to rate the learners’ performance. A global rating is also
provided, “How confident am I that I received an accurate picture of the patient?”. Importantly,
written qualitative feedback is also provided to the learner [11].

Fig. 6
Examples of the use of ISBAR in a role play

Full size image

Interprofessional practice and feedback with handover

Peer feedback within the interprofessional context is particularly valuable during
interprofessional clinical handover practice activities [17, 18]. Interprofessional activities, within
small groups, where participants share experiences within their own field of healthcare offers
valuable learning and teaching opportunities, leading to knowledge and skills being socially
constructed [17, 18]. Feedback from outside of one’s own health profession can be even more
beneficial and meaningful than feedback from within the same discipline. Multidisciplinary
feedback on the handover can help to provide an increased understanding of the knowledge,
roles and skills of other health professionals; and provide an increased understanding of how this
relates to their own health discipline [17, 18]. It also helps participants to reflect on their own
technique, terminology and communication methods.

Importance of ongoing training in clinical handover

The healthcare workforce has seen many changes in recent years, including reduced working
hours, and increasing demands for flexibility [24,25,26]. This is a consequence of better
recognition of the impact of doctor fatigue on patient safety, the importance of work/life balance,
an ageing healthcare workforce, and the increasing complexity of patient care. In turn, this
increases the number of individuals involved in the care of each patient. Therefore the need for
concise, accurate clinical handover is imperative [6]. High quality transfer of patient information
from team to team is an essential component of good patient care, alongside the expertise of
clinicians, teamwork and effective management [27]. However, good practices in clinical
handover do not happen by chance. Institutions and organisations (for example, hospitals,
universities, training and accreditation bodies) and their leaders, have responsibilities to ensure
practice in good clinical handover is achievable [6, 27].

Conclusion
Effective clinical handover is an essential component of safe patient care to ensure reduction in
errors, patient harm, and improve continuity of care. With rapidly changing work patterns within
the healthcare workforce, excellence in clinical handover is increasingly important. It is essential
that healthcare leaders and professionals from across the health disciplines work together to
ensure good clinical handover practices are developed and maintained. Protected teaching time
and resources are essential to support staff and students in these endeavours. While a number of
tools have been developed to improve handover, we have found the well-researched ISBAR to
be an ideal tool to employ for effective clinical handover. However, effective training and
practice in the use of ISBAR is essential. Ideally, this training will commence within university
healthcare curricula.

Take-home message
• ISBAR provides a standardised approach to clinical handover, and can be used in most
situations.
• For effective handover, think/talk/write and be clear/focused/relevant.
• Support for clinical handover training during university and healthcare training is essential to
good practice.

Availability of data and materials

Not applicable.

Abbreviations
ISBAR:
Introduction, Situation, Background, Assessment, Recommendation
I-PASS:
Illness severity, Patient summary, Action list, Situation awareness and contingency
planning, Synthesis by the receiver
CHAT:
Clinical Handover Assessment Tool

References

1. 1.

Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: deficiencies
identified in an extensive review. Qual Saf Health Care. 2010;19(6):493–7.
Google Scholar

2. 2.

Jorm CM, White S, Kaneen T. Clinical handover: critical communications. Med J Aust.
2009;190(11):s108–9.
Google Scholar

3. 3.

Moore M, Roberts C. Handover training in the workplace: having a CHAT. Clin Teach.
2019;16:248–52.
Article Google Scholar
4. 4.

Hunt GE, Marsden R, O’Connor N. Clinical handover in acute psychiatric and

community mental health settings. J Psychiatr Ment Health Nurs. 2012;19:310–8.
Article Google Scholar

5. 5.

Jeffries D, Johnson M, Nicholls D. Comparing written and oral approaches to clinical

reporting in nursing. Contemp Nurse. 2012;42:129–38.
Article Google Scholar

6. 6.

Australian Medical Association. Safe handover: safe patients. Guidance on clinical

handover for clinicians and managers: A.M.A. 2006; Available
at: https://ama.com.au/sites/default/files/documents/Clinical_Handover_0.pdf. Accessed
10 June 2020.
Google Scholar

7. 7.

Foster S, Manser T. The effects of patient handoff characteristics on subsequent care: a

systematic review and areas for future research. Acad Med. 2012;87(8):1105–
24. https://doi.org/10.1097/ACM.0b013e31825cfa69.
Article Google Scholar

8. 8.

Starmer AJ, O’Toole JK, Rosenbluth G, et al. Development, implementation, and

dissemination of the I-PASS handoff curriculum: a multisite educational intervention to
improve patient handoffs. Acad Med. 2014;89:876–84.
Article Google Scholar
9. 9.

World Health Organisation (W.H.O.). Patient safety curriculum guide: multiprofessional

edition. 2011. Available
at: https://www.who.int/patientsafety/education/mp_curriculum_guide/en/. Accessed on
31 May 2020.
Google Scholar

10. 10.

Marshall S, Harrison J, Flanagan B. The teaching of a structured tool improves the clarity
and content of interprofessional clinical communication. Qual Saf Health Care.
2009;18(2):137–40. https://doi.org/10.1136/qshc.2007.025247.
Article Google Scholar

11. 11.

Moore M, Roberts C, Newbury J, Crossley J. Am I getting an accurate picture: a tool to

assess clinical handover in remote settings? BMC Med Educ. 2017;17:213.
Article Google Scholar

12. 12.

Finnigan MA, Marshall SD, Flanagan BT. ISBAR for clear communication: one
hospital’s experience spreading the message. Aust Health Rev. 2010;34:400–4.
Article Google Scholar

13. 13.

Australian Commission on Safety and Quality in Health Care. OSSIE guide to clinical
handover improvement, vol. 2010. Sydney: ACSQHC; 2010.
Google Scholar

14. 14.
 Thompson JE, Collett LW, Langbart MJ, Purcell NJ, Boyd SM, Yuminaga Y, Ossolinski
G, Susanto C, McCormack A. Using the ISBAR handover tool in junior medical officer
handover: a study in an Australian tertiary hospital. Postgrad Med J. 2011;87:340–4.
Article Google Scholar

15. 15.

Yee KC, Wong MC, Turner P. Hand me an ISOBAR: a pilot study of an evidence-based
approach to improving shift-to-shift clinical handover. MJA. 2009;190(11):S121–4.
Google Scholar

16. 16.

Gordon M, Hill E, Stojan JN, Daniel M. Education interventions to improve handover in

health care: an updated systematic review. Academic Medicine. Published Ahead of Print
April; 2018.
Google Scholar

17. 17.

Burgess A, Roberts C, van Diggele V, Mellis C. Peer teacher training program:

interprofessional and flipped learning. BMC Med Educ. 2017;17:239.
Article Google Scholar

18. 18.

Burgess A, van Diggele C, Mellis C. Faculty development for junior health professionals.
Clin Teach. 2018;15:1–8.
Article Google Scholar

19. 19.
 The New South Wales Excellence Commission, Clinical
Handover http://www.cec.health.nsw.gov.au/improve-quality/clinical-handover.
Accessed 20 July, 2020.

20. 20.

Western Health. Australian Government. 2015. ISBAR patient

safety: https://www.youtube.com/watch?v=h0Ol6CiJAZw. Accessed 31 May 2020.
Google Scholar

21. 21.

Australian Commission on Safety and Quality in Health Care. 2012. ISBAR: Identifying
and Solving Barriers to Effective Handover in Inter-Hospital Transfer - Case Study
1.: https://www.youtube.com/watch?v=1Wl9qogPw1E. Accessed 31 May 2020.
Google Scholar

22. 22.

Hattie J, Timperley H. The power of feedback. Rev Educ Res. 2007;77:81–112.

Article Google Scholar

23. 23.

Burgess A, Mellis C. Feedback and assessment during clinical placements: achieving the
right balance. Advances in Medical Education and Practice. 2015;6:373–81.
Article Google Scholar

24. 24.

Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, Fineberg H, Garcia P, Ke Y,

Kelley P, Kistnasamy B, Meleis A, Naylor D, Pablos-Mendez A, Reddy S, Scrimshaw S,
Sepulveda J, Serwadda D, Zurayk H. Health professional for a new century: transforming
education to strengthen health systems in an independent world. Lancet. 2010;376:1923–
58.
 Article Google Scholar

25. 25.

Hawthorne L. International medical migration: what is the future for Australia? MJA
Open. 2012;1(Suppl 3):18–21.
Google Scholar

26. 26.

Health Workforce Australia. Health Workforce 2025 – Doctors, Nurses and Midwives,
vol. 1. Adelaide: Health Workforce Australia; 2012.
Google Scholar

27. 27.

Cowan D, Brunero S, Luo X, Bilton D, Lamont S. Developing a guideline for structured

content and process in mental health nursing handover. Int J Ment Health Nurs.
2018;27:429–39.
Article Google Scholar

Download references

Acknowledgements
The authors have no acknowledgements to declare.

About this supplement

This article has been published as part of BMC Medical Education Volume 20 Supplement 2,
2020: Peer Teacher Training in health professional education. The full contents of the
supplement are available online at
URL. https://bmcmedicaleducation.biomedcentral.com/articles/supplements/volume-20-
supplement-2.