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SBAR in Vietnamese private hospital
The SBAR is a powerful tool that is used to improve the effectiveness of communication between individuals. It is easy to use and can help medical staff learn the key components needed to send a complete message

A Vietnamese private hospital desired to achieve Joint commission International (JCI )certification to designed the forms, the tools and methods to communication by SBAR tools in hospital to improve the medical team to communicate, handover and hand off process. Besides a research and analysis offshoot of the company that insures Harvard-affiliated hospitals. The cases — including 1,744 deaths and $1.7 billion in malpractice costs — involve communication.

SBAR is a short alphabet of:

Situation: Clearly and briefly define the situation. For example, ‘Mr. Jones has multiple prescriptions of Coumadin in his home and he is unclear as to which ones he is supposed to take.’

Background: Provide clear, relevant background information that relates to the situation. In the example above, you should consider including the patient’s diagnosis, the prescribing physicians, and the dates and dosages of the medications.

Assessment: A statement of your professional conclusion.

Recommendation: What do you need from this individual? For example, ‘Please clarify which is the correct dose of Coumadin for Mr. Jones to take and which physician will be responsible for managing his anticoagulant therapy?

Describe the initiative and the reason/purpose for the initiative
An effective communication helps patients stay comfortable, safety, support care and prevent complications. The medical committee has issued Circular 07/2014/TT-BYT Promulgating the code of conduct for officials, civil servants and employees working at healthcare establishments. Pursuant to the Law on Cadres and Officials No. 22/2008/QH12 dated November 13, 2008; Pursuant to the Law on Civil Servants No. 58/2010/QH12 dated November 15, 2010; Pursuant to the Law on Anti-corruption Law No. 55/2005/QH11 dated December 09, 2005; Pursuant to the Law on Medical Examination and Treatment No. 40/2009/QH12 dated November 23, 2009; Pursuant to the Government's Decree No. 63/2012/ND-CP dated August 31, 2012 on defining the functions, tasks, powers and organizational structure of the Ministry of Health; The Minister of Health hereby promulgates the Circular on the code of conduct for officials, civil servants and employees working at healthcare establishments.

Joint commission International (JCI) requested:(1) IPSG.2.2 Improve effective communication  in ME2 clarifies the forms, tools or methods are used to support the process handover (2) COP.2.2 Care of patient in ME6 requiring the hospital allow texting of orders to collect data and monitor communication. (3) GLD.1.2 Outcome of communication.(4)ACC: Access to care and continuity of care to ensure update the latest information.

The nursing department researched the nursing report about the missing information, frequency, reasons on nursing file for assessing the nursing competence in 2018. We found the most of issues was communication, 10 nursing randomized discharge files and had faults from filling the blanches to the nursing care plan, many confused on the checkbox forms ,we found the tools which is compatible SBAR in nursing care. Director of nursing built the training program for nurse and update the new SBAR form ( For procedure and for hand-off). She raised an action plan for 2018 in the monthly meeting. The nursing department reported update the issues on nursing file, who was in charge, which department with the evident pictures. The report were effective to the excellent nursing pride.

How were the outcomes measured?
Nursing department made a plan to improve the communication in hospital. A observation team was called one deputy of director of nursing, 3 nurse managers and one secretary and monthly record keeping from a cross-sectional 10 discharge files studied to count the number of errors or wrote did not means special areas of nursing not recorded to hand over the in-patient care. The data included the missing information, frequency, reasons on nursing file. This Root Cause Analysis (RCA) data raised to nurse manager monthly meeting, nurse managers reported to the department and staff involved. Nursing department informed all staffs after 6 months records and gave them the detail the department, the staff changed and the targets of nursing file in 2018, guided the new version of SBAR form and choose A&E department for pilot. The general report were done with the board of directors.

Describe the outcomes that occurred?
After 3 months the status of missed information of the nursing file had started to change. The number of faults went down from 56 faults on one discharge file after 9 months we had 3 faults. Some nurses did not pass the training how to write the nursing forms, some nurses always at top of the nursing missed. Director of nursing wrote the warning letter to him. We update the new SBAR form and required putting patient file. The nursing Kardex form support the nurse to hand off caring inpatient did not working well, some department kept another did not keep. With new support information tool, staffs nurse have improved the nursing file.

Ethical aspects of the initiative---how were ethical principles upheld?
Ethical nursing code or ethics give the guideline for nurse practice. The ethical standard of Vietnamese nurse asked the safe communication by:


 * Article 4. Respect patients and their family’s members 4. Provide adequate information about their treatments 5. Safeguard patients’ secrets related to their diseases and personal lives. 6. Treat all patients fairly and equally.
 * Article 5 . Be friendly with patients and their family’s members 1. Provide self-introduction and greetings to patients and their family’s members in a friendly way. 2. Listen to patients and their family’s members and reply in a caring and polite way. 3. Take care of patients with a friendly smile. 4. Help patients relieve their pains caused by their diseases and surgeries.
 * Article 7. Maintain and enhance professional capacity 1. Fully perform responsibilities of a nurse. 2. Follow technical processes, clinical instructions when taking care of patients. 3. Study on a continuous basis to update knowledge and professional skills. 4. Participate in research and evidence-based practice

The medical committee has issued Circular 07/2014/TT-BYT Promulgating the code of conduct for officials, civil servants and employees working at healthcare establishments.

Vietnam Nursing Competency Standard, standard 8: ensuring continues care (1) Criteria 1: Handover the status of the patient to the next care team specifically, exactly. (2) Criteria 2: Coordinate effectively with patients, families and colleagues to ensure care continuous care for patients. (3) Criteria 3: Establish measures to perform continuous care for patients.

=== Were the rights of patients protected as new practice was incorporated? === "Putting patient first" is a Logan of the hospital. We were worry the staffs fill the form and delayed treatment or lost the gold hour. We will fill paper work for critical emergency case. The medical team should finish paper work as soon as possible. However, the emergency department have never missed the SBAR form.

Who is accountable for bringing about changes in practice?
Director of nurse of hospital: Good plan, power decision, closed observe and fluency actions, gave the guideline for special case or unintended outcomes.

Nurse managers: Feedback, reported exactly every month, collect good evident, communicate, training, update the report.

Nurse staffs: Practice to the standard of performances, guidelines,

What were the unintended consequences or outcomes?
First the nurse complaint about the increased the nursing paper. We designed the form follow checkbox style and

Continue caring patient, increase satisfaction, friendly environment.

Decrease the medical errors and increase patient safety goals.

Improve the medical communication, team-work.

Standardizes information to be given and lessons on communication variability, making report concise, objectives and relevant.

Did practice change occur as a result of the initiative?
First of all, we just focused improving nursing record for lack the information from ex-shift, nursing department created a hand off form. We found many issues at the lunch time and handed over when transferred patient to do Para-clinical procedures. We made one more procedure SBAR form.

What were the barriers to practice change?
This was new tool and we need time to adapt, the staff handover by talking and without writing down and the next shift. SBAR model have some limited:

The concept of SBAR was unfamiliar difficult to learn and practice so it necessary follow-up. A supportive environment, role-playing, and a skills assessment may help with the process. SBAR has been the weak point of nurses who is intimidating for some nurses. Having to wake up patients and families when the practice of bedside charting occurs. disclosing sensitive topics or new information that has not been shared with the patient and/or family before or after the bedside charting takes place. An alternative to this can be for nurses to makes plans to share new or sensitive information before or after bedside report. Sharing of confidential information with the patient where it could be over heard by other patients.

What are the ethical aspects of any practice change?
The safe culture was speared in staffs, effective communication between doctor and nurse, team work and happy to report, to write medical file which it is evident base to protect nurse practice. We considerate nursing writing when industry 4.0 are going quickly. The skill of nurse could develop by basic nursing skills. Nursing role is responsible by patient's delegated caring, report, and communicate.

Did it benefit patient care, did it result in more equitable care for those who need it? What are the effects on trust from patients/staff, accountability?
The review of studies significant showed communication errors nursing handover, the discharged file problem reported was the omission of detailed patient information. SBAR communication model provides for more effective and enhanced family and patient outcomes on CIH. Using SBAR when producing bedside reports increases patient and family satisfaction and also increases their level of comfort when dealing with outlying situations. SBAR also allows nurses to be more effective when giving reports outside of the patients room. SBAR is a model used in communication that standardizes information to be given and lessons on communication variability, making report concise, objective and relevant.

SBAR allows patients and medical team have the time to discuss any questions to gain exact information related to their plan of care. SBAR allows patients to be fully aware of whom their nurse is on every shift and the patients felt of safety and comfort nurse always had full information around looking after them during shift change.

SBAR use has not only improved the relationship between the doctors and the nurses. The problem between the communication between nurses and doctors is that the levels of teamwork and interaction are different therefore causing ineffective communication.

SBAR has been used in quality improvement projects that have looked at ways of avoiding hospitalizations.

JCI guideline using SBAR for improve the medical communication. It suits to Vietnamese culture and social. This is simple tool and big benefit to patient. SBAR can use to guide medical report, handover by daily communication or official file by writing down.