Journal of Interprofessional Care

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The use of SBAR as a structured communication

tool in the pediatric non-acute care setting: bridge
or barrier for interprofessional collaboration?

Ester Coolen, Rik Engbers, Jos Draaisma, Maud Heinen & Cornelia Fluit

To cite this article: Ester Coolen, Rik Engbers, Jos Draaisma, Maud Heinen & Cornelia Fluit
(2020): The use of SBAR as a structured communication tool in the pediatric non-acute care
setting: bridge or barrier for interprofessional collaboration?, Journal of Interprofessional Care, DOI:
10.1080/13561820.2020.1816936

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JOURNAL OF INTERPROFESSIONAL CARE
https://doi.org/10.1080/13561820.2020.1816936

ORIGINAL ARTICLE

The use of SBAR as a structured communication tool in the pediatric non-acute care
setting: bridge or barrier for interprofessional collaboration?
Ester Coolena, Rik Engbersb, Jos Draaismaa, Maud Heinenc, and Cornelia Fluitb
a
Department of Pediatrics, Radboud University Medical Center Amalia Children’s Hospital, Nijmegen, The Netherlands; bRadboud Health Academy,
Radboud University Medical Center, Nijmegen, The Netherlands; cIQ Health Care, Radboud Institute for Health Sciences, Radboud University Nijmegen
Medical Center, Nijmegen, The Netherlands

ABSTRACT ARTICLE HISTORY

SBAR (Situation, Background, Assessment and Recommendation) is a structured method developed for Received 16 March 2020
communicating critical information that requires immediate action. In 2016 the SBAR tool was introduced Revised 20 August 2020
at the Amalia Children’s Hospital in the Netherlands to improve communication between healthcare Accepted 26 August 2020
workers. Despite formal training and the introduction of aids to facilitate implementation, observed KEYWORDS
adherence to the tool was low. A qualitative study was undertaken to study the use of SBAR by pediatric Interprofessional learning;
residents and nurses in the non-acute clinical care setting of an academic children’s hospital. Semi- communication; tool
structured focus group sessions were conducted and qualitatively analyzed using a constructed coding implementation
template to search for facilitators and barriers in the use of SBAR by different professionals. We found
professionals’ use of SBAR was influenced by departmental, cultural, and individual factors. Important
themes for effective implementation and use of SBAR in an interprofessional setting, like situation
dependency, learning climate and professional identity had not been addressed during the initial
implementation. To facilitate SBAR’s use it is important to identify professionals’ needs to use the tool
effectively, to take into account how tasks and responsibilities are perceived by different professions, and
to stimulate interprofessional feedback and role modeling.

Introduction structures the exchange of patient information between healthcare

professionals. SBAR has been adapted from other disciplines, like
Structured communication tools have been widely implemen­
aviation and the military, as a method for clear communication
ted in hospitals to streamline communication between health­
(Pope et al., 2008; Thomas et al., 2009). SBAR is based on
care workers. These tools have been shown to increase patient
a statement of the situation, background, assessment, and recom­
safety, reduce unexpected deaths and decrease incidents due to
mendations related to a critical issue. By following this script, the
communication errors (De Meester et al., 2013; Müller et al.,
reason for contact, relevant medical history of the patient and the
2018; Randmaa et al., 2014). Moreover, these structured tools
current situation, the vital parameters, and the callers plan of
may improve the perceptions of communication and bridge
action are efficiently communicated. The structure of the tool
the gap in communication styles between professions
ensures that the caller can pass on all information that the other
(Achrekar et al., 2016; Randmaa et al., 2014; Raymond &
person needs to know, to answer a question or devise a plan
Harrison, 2014). If team members participate more fully in
essential for patient care. The SBAR tool can be used in different
the decision-making process (e.g., through interaction or infor­
settings to effectively communicate patient information, be it in
mation sharing), they may invest more in the decisions taken,
person, per telephone, on paper or in the digital patient file. As
give their support for improvement in teamwork and feel able
a result, critical patient information can be communicated
to suggest innovations (West et al., 1990). Therefore, interac­
effectively.
tion and effective communication between team members, are
regarded as essentials to enhance shared accountability, team
climate and quality of care (Agreli et al., 2017; Reeves et al., Background
2013). Despite the fact that effective communication is increas­
SBAR has been proven to be effective in improving patient
ingly recognized as an important competency and profes­
safety in the acute care settings, like for example, emergency
sionals are subjected to a variety of professional development
and intensive care departments (Marshall et al., 2019; De
programs and aids to enhance communication skills, the appli­
Meester et al., 2013; Randmaa et al., 2014; Raymond &
ance of these skills in clinical practice is still low (Curtis et al.,
Harrison, 2014). However, outside the acute care setting,
2013; Joffe et al., 2013).
most research and suggested recommendations on structured
The SBAR (Situation, Background, Assessment and
communication tools are based on expert opinions or users’
Recommendation) tool is a communication tool that effectively

CONTACT Ester Coolen [email protected] Radboud Institute for Health Sciences, Department of Paediatrics (804), Amalia Children’s Hospital,
Radboud University Medical Centre, 6500 HB, Nijmegen, The Netherlands
Supplemental data for this article can be accessed on the publisher’s website.
© 2020 The Author(s). Published with license by Taylor & Francis Group, LLC.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
2 E. H. A. J. COOLEN ET AL.

satisfaction with the tool, using pre,- and postquestionnaires pediatric physician specialists, residents, and nurses. In 2016,
and have not yet been shown to improve communication SBAR was introduced by the patient care management team to
effectiveness or patient safety (Horwitz et al., 2008; Renz help ensure effective transfer of patient information between
et al., 2013; Riesenberg et al., 2009). Furthermore, the available healthcare professionals at the pediatric non-acute care wards.
knowledge on the effective transfer of patient information Also, nurses were appointed to special areas of attention (e.g.,
between professionals is based predominantly on studies communication) to function as ambassadors in the workplace.
within the curriculum of medical- and nursing students This study was focused on the use of SBAR for the commu­
(Guimond et al., 2019; Uhm et al., 2019) and cannot simply nication of patient information by nurses and residents work­
be translated to “the workplace,” where healthcare profes­ ing in the pediatric non-acute care department. Given the
sionals have already formed their own routines in communi­ setting of a teaching hospital, we included residents and nurses
cating with other team members. in the focus groups, because these professionals directly com­
In the Amalia Children’s Hospital, the use of structured municate patient information during routine care and shifts at
communication by SBAR was transferred from the intensive the pediatric wards.
care setting into the non-acute care setting of the pediatric
wards in 2016. During the introduction period both physicians
Data collection
and nurses were made aware of SBAR and its use by posters
and by handing out SBAR instruction cards. Also specific aids, Focus group meetings were held until saturation was achieved.
such as ‘SBAR Smart Phrases’(Clements, 2018) for standar­ Focus groups were conducted between September 2018 and
dized documentation in the electronic patient file and note May 2019. To reduce risk introduced by perceived or real
blocks, with a pre-structured SBAR template, were made avail­ hierarchy across professional disciplines, focus groups were
able. Formal education took place by means of instruction, divided by profession (nurses and pediatric residents). An
scenarios, and role play during interprofessional training dur­ independent interviewer (educationalist) with extensive inter­
ing which medical and nursing staff practiced the use of SBAR view skills and no professional relation to the participants,
in a simulated environment. Despite the availability of these conducted all focus groups after signing a confidentiality agree­
aids and the use of SBAR in medical team simulation, adher­ ment. Focus group questions were open-ended and designed to
ence to the SBAR tool was poor according to observations done further explore influencing factors for the use of SBAR. The
by the Joint Commission International (JCI; Mehta et al., 2017) focus groups consisted of 5 to 12 participants per group and
during a patient safety audit in June 2017. lasted between 55 and 65 minutes. The collection of data ended
As a result, patient care management organized a theme when saturation of themes was reached after five interviews.
week to increase awareness of the SBAR tool, and to educate
nurses and physicians further in the use of SBAR in different
Data analysis
settings (in person, by telephone or written in the patient file).
In May 2018, we audited the use of SBAR by nurses and Focus group sessions were audio recorded and transcribed
residents during shifts at the pediatric care wards and found verbatim. All transcripts were anonymized and read repeatedly
that 66% of the telephone calls regarding patient information by the first author to ensure accuracy and to develop familiar­
were done with the use of SBAR, with no significant differences ity. Qualitative Analysis Software Atlas.ti (GmbH, Berlin,
between nurses and residents overall (data not shown). This is Germany), was used to organize the data. Data collection and
in line with the findings of Compton et al. (2012), who reported analysis proceeded simultaneously, in an iterative fashion.
the use of SBAR by 58.3% off nurses for critical communication Transcripts of the focus groups were analyzed following the
after finishing a similar educational program on SBAR. template analysis approach as developed by King et al. (2019),
Knowing that formal preparations, creating awareness and entailing a thematical analysis using a constructed coding
introducing prompting aids do not guarantee the use of SBAR template. The template was based on the research question
in clinical practice, led to the research question: What factors and the theoretical concepts of organizational implementation
should be addressed to implement SBAR effectively outside the management (Cosby, 2006; Eid & Quinn, 2017). Four broad
intensive care setting? To answer this question, we used code categories formed the code manual: knowledge, attitude,
a qualitative approach to study what helps or hinders the use self-efficacy, and organizational infrastructure (see
of SBAR in the pediatric non-acute care department, along Appendix 1). Two researchers, one pediatrician (EC) and one
with ensuring a better communication standard among health­ nurse (MH), independently analyzed all transcripts and quota­
care professionals with different backgrounds. tions were classified according to the corresponding themes
within the four categories. Discrepancies between researchers
in the outcome of this coding process were discussed and
Methods resolved within the research team, consisting of two pediatri­
cians, one nurse and two educationalists (EC, RE, MH, CF, and
Setting
JD). Secondly, summarizing conditions were sought to
The Amalia Children’s Hospital is a Dutch tertiary referral describe influencing factors in the use of SBAR. During our
hospital with a pediatric intensive care department, an emer­ analysis new factors emerged. According to the AMEE Guide
gency care department, and three pediatric clinical care wards for focus groups in medical education research (Stalmeijer
(72 beds) where patients can be hospitalized for both short and et al., 2014), the guide with probing questions was adapted
long-term stay, in which care is offered by a broad spectrum of for the following round of focus groups to deepen our
 JOURNAL OF INTERPROFESSIONAL CARE 3

understanding of these factors and gather further information a teaching hospital can also be viewed as a facilitator for the use
not captured during the first focus groups (see Appendix 2). of SBAR, because the use of SBAR helped them to set a good
After completing the interviews and analyzing the data, two example as a communicator and interdisciplinary collaborator
researches (EC and RE) facilitated the analytic process by to nursing students. Both nurses and residents mentioned
constructing relationship diagrams and affinity maps. Critical a lack of proper introduction of the SBAR tool to new cow­
and reflective feedback from the whole research team on the orkers, especially related to the different settings in which
emerging model was used to improve the rigor of the data SBAR could be used to convey patient information (e.g.,
collection. acute versus non-acute situations and orally versus written
patient information).
Ethical considerations
Contextual factors
Individually informed consent was obtained from each parti­
cipant prior to each focus group. Participants received an Took traits
information sheet explaining the purpose of the focus group The rigidity of the SBAR script and formal way of formulating
and stating that the information they shared would be treated the patient information made it less feasible for communica­
confidentially. The Central Commission for Human Rights tion during daily routines. In addition, the elements of the
Research (CCMO) Region Arnhem-Nijmegen granted ethical acronym SBAR were used differently depending on the con­
approval (File number 5961). text. For example, nurses indicated that for the element
Situation, they usually write down the reason for admittance
in the electronic patient file, whereas they are expected to state
Results
the reason for calling when they contact a physician about
In total, five focus groups meetings were organized. The groups a patient during a shift. This led to confusion about how to
included either pediatric nurses or residents. The first round use SBAR correctly. Both nurses and residents stated that
consisted of two group sessions with one group of 8 residents SBAR does not leave enough room for their own considera­
and one group of 8 nurses. The second round consisted of three tions. Residents, for instance, want to share their differential
group sessions: one group of 12 residents and two groups of 5 diagnoses and clinical reasoning thoughts with their super­
and 6 nurses. After two rounds of group meetings saturation of visor, before coming up with their plan or recommendations.
data was achieved. Analysis revealed that there were four Both nurses and residents believed that SBAR is very useful to
themes that were perceived to influence the use of SBAR in structure and prioritize information for the other professional,
the context of non-acute care: Strategic, Contextual, Cultural, to be able to create an overview of the situation. However,
and Individual Factors. Components included in these factors whereas residents stated that SBAR was also useful to commu­
and illustrative quotations are presented in Table 1. nicate effectively with other physicians to create a shared per­
A conceptual diagram representing a model for implementa­ ception of the situation, nurses expressed their doubts on the
tion issues of SBAR within the context of the non-acute care is applicability of the tool for nurse to nurse communication,
presented in Figure 1. The themes that emerged from the focus because of its rigid and stand-offish characteristics.
group interviews and how they were perceived to affect the use
of SBAR by nurses and residents are explained below. Situational dependency
SBAR was perceived as useful and effective during acute events
because it helps to structure essential patient information, cre­
Strategic factors
ates an overview of the situation and helps to communicate
Participants believed that at the time of the introduction of a plan of action. However, participants stated that during routine
SBAR there was much focus on effective communication, clinical care, SBAR is less suitable because the rigid structure
because both patient care management and educators empha­ does not allow for elaborations for educational purposes or social
sized the use of SBAR. Patient care management organized interaction. Also, during day-time care, as opposed to during
a theme week to create awareness for structured communica­ shifts, health care professionals are more familiarized with the
tion with SBAR, including oral instruction sessions, and the situation and background information of the patients on the
introduction of aids such as pre-structured note blocks, smart ward, making them feel as if they were repeating themselves by
phrases and posters). Shortly after the implementation phase, using SBAR. Furthermore, nurses replied, when asked about the
attention on the use of SBAR decreased, and other topics use of SBAR with team members other than physicians, that they
appeared to be prioritized by the management team. When do not think the SBAR tool to be useful for the transfer of patient
nurses were asked who they perceived to be role models on information to non-physician healthcare professionals, includ­
communication within their own profession, they stated that ing their nursing colleagues, physiotherapists, and physician
some colleagues in the department were appointed as nurse assistants, as they usually have read the patient file, before
ambassadors. However, nurses were not able to identify or attending to the patient during routine care.
name them. It was furthermore noticed that, although SBAR
and the importance of clear communication is being taught in Supportive preconditions
education of physicians, educators and supervisors in the For nurses, the SBAR script is integrated into the electronic
workplace were less consistent in advocating the use of patient file with SBAR Smart Phrases (Clements, 2018), there­
SBAR. On the other hand, nurses indicated that the setting of fore they use it daily. However, SBAR is used differently in the
4 E. H. A. J. COOLEN ET AL.

Table 1. Themes perceived to affect the use of SBAR in pediatric non-acute care.
Components Example Quotations
Hospital board of “Around the time of the JCI, everybody was talking about SBAR and how we should communicate. Now I do not hear so much about this. I’m
directors not sure if we are still supposed to use it [SBAR] all the time, or only during acute events?“(resident)
Patient care “Oh, we have to learn a new acronym almost every month. We have SBAR, ABC, PWES. I just can’t keep up to speed with it . . ., all these numbers
management and letters I have to put down in the patient file. They [patient care management] come up with something new constantly and we have to
keep track of these changes every time.”(nurse)
Communication When asked about role models in communication: “I think that some of the nurses are appointed to topic of communication, as a special
ambassadors area of attention. I think they know all about the best way to communicate how it should work, but I’m actually not sure of who they are at
this moment.”(nurse)
Formal educators “I learned all about the importance of structured communication at [nursing] school. Our group mentor was very good in convincing us to use
SBAR and how it helps to communicate clearly. So, during this internship I want to use it regardless of what others say or do.”(nursing student)
“During our morning handovers we’re supposed to use SBAR for structure and clarity [. . .]. However, I don’t think supervisors use SBAR themselves
when they transfer patient information to us.”(resident)
Tool traits “And then you should put down assessment of vitals, but where do you put the regular physical examination and your differential diagnosis.
They [supervisors] need to hear my considerations to be able to come to a conclusion and agree with my plan.”(resident)
When asked about the meaning of the S in SBAR: Nurse 1: “Yes, the difference is whether you are reporting: in that case I just write down the
reason for admission, but when you really need someone, then it’s the current situation.” Nurse 2: “Yes, the reason for calling . . . But some
people get confused about this.”(nurse)
“And when it becomes chaotic and panicky [after an acute problem arise], that’s when you need SBAR to keep overview and stay calm, but
Situational traits when I’m just discussing a patient problem with the doctor it feels way too formal to go through each point individual.”(nurse)
“If I’m forced to stick to SBAR in a non-acute setting, not telling them [supervisors] my full assessment [of the patient] or my thoughts on the
matter. Then, how can I express my clinical reasoning. I really need more words to show them what I know and think about the patient’s
problem.”(resident)
Supportive preconditions “We do not have many practice opportunities in our daily routines . . . We did try to use SBAR in handovers between nurses and team meetings,
but a lot of felt it [SBAR] was not suitable for communicating concerns or your gut feeling about the patient.”(nurse)
“I started working here 5 months ago and I didn’t get any instructions or what so ever about SBAR, learned that I should have looked this up in
our instruction manual, but no one explained to me in what kind of situations SBAR should or shouldn’t be applied.”(resident)
Interprofessional “I think if you work here it feels like you have to be easy going and friendly all the time. That if you’re always serious and putting people in their
interaction place, you will pay the price . . .. Well you know what I mean; you should stop being so strict and serious, all the time.” (nurse)
“We really feel part of the Children’s hospital you know, and I do feel that we’re used to communicate in a certain way. It’s different with
professionals outside of child care. We are more holistic and socially engaged . . ., although we do need more words, I guess that’s not really
what you’re supposed to do when using SBAR.”(resident)
Climate for learning When asked if they have ever received positive feedback on the use of SBAR: “No, I haven’t, but we need to give each other more compliments.
It helps to change our work environment.” (nurse)
“Sometimes I will overhear a colleague speaking to an attending and I think, like really are you serious? I don’t even know what you are talking
about . . ..They usually find out for themselves, because they’ll get like a hundred questions in return.” (nurse)
“I mostly look at my fellow residents for role models in effective communication. Some of them are really good in structuring a patient
handover.”(resident)
“When I notice effective communication, that’s mostly when I watch residents in acute situations . . . How the communicate and streamline the
team.”(nurse)
Role expectations “I remember calling about a very sick patient on the ward, telling the doctor that the patient is unstable and needs immediate attention,
probably because of an anaphylactic reaction . . . Then I was told that I spoke out of turn and should have completed all measurement
before calling a doctor.”(nurse)
“During shifts I will get calls with only bits of information they [nurses] want to pass on to me at the end of their shift. No question, no plan of
action. What am I supposed to do with that? Then, I just pause en keep silent, hoping they will rephrase their story and ask me what they
actually want.” (resident)
Motivation to use “The use of SBAR seems like it costs a lot of time [. . .], but actually thirty seconds [. . .] and the team is streamlined, going forward.” (nurse)
“At the PICU [pediatric intensive care unit] every transfer is structured using SBAR, even the morning handovers and those are complex patients
too. I do not see a reason not to use SBAR in every day care.”(resident)
Feeling competent “It [the use of SBAR] is not yet very automatic. An acute situation doesn’t happen every shift. At least not with me [. . .] and then I’m already
bumbling again when I pick up the phone to call for help, just thinking out loud in random order. So, it’s not quite there yet.”(nurse)
“I called [a supervisor] and said: “I would like to discuss a patient who is lying in the emergency room because I would like to send him home.”
I couldn’t imagine a better R, and then the supervisor blamed me for being too cocky with the handover. So, then I’m not sure anymore,
what do actually want from me?” (resident)
Perceived professional “There’s a difference between doctors and nurses . . ..We’re trained to have opinions about everything and come up with a solution. If you ask
identity a nurse: Do you think this child is really sick? They often don’t know how to respond.” (resident)
“I do not think we should use SBAR between nurses, it’s just not how nurses are used to talk to each other. We like to be more easy going and
elaborate, not talking as formal as doctors do.”(nurse)

written context than verbally, and nurses perceive that physi­ such as note blocks, posters and a SBAR theme week, were
cians need other information from them in the acute (spoken) initially regarded upon as stimulating, but lost their effect after
situation than what is written down in the patient file. Nurses a while. Moreover, some nurses indicated that they observed
stated that during a rare and unexpected acute event it can be that more experienced nurses did not to use these aids as they
very challenging to extract the information that is needed by had already formed their own routines.
the physician from the patient file and convey this in the
correct order. Other than this, nurses have limited practice
Cultural factors
opportunities for SBAR, because of the low prevalence of
acute situations. The frequency of interprofessional team simu­ Interprofessional interaction
lation, approximately once a year, is low and it was also noted Participants perceived the general communications style with
that SBAR is not used during team meetings or patient hand­ respect to colleagues as friendly and cooperative. On the other
overs on a structural basis. Aids to create awareness of SBAR, hand, the overall friendly communication style inhibited
 JOURNAL OF INTERPROFESSIONAL CARE 5

Board of Directors Strategy

Quality of care Formal educators

accreditation Strategy

Vision on quality of care

Departmental Strategy

Patient Care Communication

Management Ambassadors Team climate
Supportive preconditions
Teaching hospital Role expectations

Departmental Context Departmental Culture

Professional Feedback
Type of care Tool traits
identity Role
Introductional
model
program
Competing Feeling
demands Competent

Individual Strategy

Motivation Task
to use responsibility

Making use of SBAR in Pediatric Clinical Care

Figure 1. Conceptual diagram representing the factors which influence the use of SBAR by health care professionals.

nurses from speaking up when SBAR was not being used if SBAR is not used in every department of the hospital. This
needed, because they were afraid this feedback would not be makes it difficult for residents to be consistent with SBAR
appreciated by their colleagues and could negatively affect their themselves. Nurses tended to see residents as role models for
collaboration and team climate. effective communication, rather than people from their own
profession.
Climate for workplace learning
Participants indicated the importance of feedback to learn and Role expectations
improve using SBAR, however, feedback is hardly ever given or Participants emphasized the importance of discussing and
received to and from colleagues from the same and different reflecting on role expectations and communication style, for
profession. Feedback is given indirectly, rather than actively instance, by regular team debriefings. A better understanding
speaking up when communication was flawed. The presence of of each other’s needs and expectations would make it easier to
learners like students or novice nurses had a positive impact on understand the usefulness of the tool in different care settings.
their role modeling and feedback behavior. Residents stated The nurses in this study believed that discussing the patient’s
that if nurses were to give them feedback, this would increase plan, in the ‘Recommendation’ section of SBAR, is not one of
their alertness on the correct use of the SBAR tool and possibly their tasks. They indicated that it is up to physicians to decide
would stimulate them to give feedback to nurses. Residents upon a plan of action after being provided with the necessary
received conflicting feedback from their supervisors, giving information. Furthermore, some nurses shared their experi­
them different instructions on how to structure their informa­ ences of being reprimanded by physicians after providing them
tion. When it came to learning in practice, residents empha­ with a diagnosis or plan of action, which prevented them from
sized the lack of consistency in the use of SBAR by their making recommendations in the future. On the other hand
supervisors, which prevented them from being a positive role residents indicated that they expected nurses to structure their
model to the residents. Besides that, they mentioned that SBAR information and conclude their story with a clear lead on what
is not used in every department of the hospital. This made it they expect the physician to do.
difficult for residents to be consistent with SBAR themselves.
Nurses tended to see residents as role models for effective
Individual factors
communication, rather than people from their own profession.
Residents emphasized the lack of consistency in the use of Motivation to use
SBAR by their supervisors, which prevented them from being Both nurses and residents were motivated to use SBAR,
a positive role model to the residents. They mentioned that because it was useful in creating an overview of the situation
6 E. H. A. J. COOLEN ET AL.

and helped them to structure the information, they wanted to this, desirable communication strategies take little time and
transfer to a team member. Nurses mentioned several times effort to complete, deliver comprehensive information effi­
that they automatically “go through this structuring process in ciently, encourage interprofessional collaboration, and limit
their heads,” but that the SBAR tool helped them to reinforce the probability of error (Luettel et al., 2007). Planning for
data collection steps and reporting mechanisms. Residents implementation of patient safety issues that interfere with
described that positive experiences with the tool in other work routines and team culture should recognize the interac­
departments motivated them to use SBAR in the clinical care tion between the intervention, the complex setting in which it
setting as well. A high workload together with constantly is used, and the professionals involved (Grol et al., 2007).
changing work routines made some of the participants weary Consequently, the unreflected adoption of a communication
of change. Also, the time investment of learning to incorporate tool, without an investment by the team to come to an agree­
a new tool, without the prior conviction that it will be of use to ment on effective communication and a shared philosophy on
you or your patient could prevent using SBAR. Some residents teamwork, will lead to failure to improve interprofessional
were not sure SBAR had an additional value to them, because collaboration (Müller et al., 2018). The findings in this study
they already had their own way of structuring information. are in line with models of innovative climates in the literature,
in which a clearly defined vision (strategy), a safe environ­
Feeling competent ment for professional development (learning climate),
The main barriers that undermined nurses feeling competent a shared concern and understanding of quality of perfor­
when using SBAR, is the difficulty they experience when filter­ mance (interprofessional interaction and role expectation)
ing relevant information to convey to the physician. Assessing and practical support and opportunity to introduce and prac­
what the physician needs to know about the Background item tice new routines (preconditions and situational dependency)
in particular, is challenging. Also, the lack of exercise with are defined as the most important factors for innovation
structured communication during routine practice makes it (West, 1990). As the interaction of these factors at multiple
difficult to use SBAR in the case of a rare acute event in the levels may influence the success or failure of quality-
clinical care setting. Residents mentioned a high degree of improvement interventions a deeper understanding of these
competence regarding structured communication. Despite factors is crucial (Grol & Grimshaw, 2003).
their confidence in being an effective communicator, some
residents mentioned that contradictory feedback from their
Situational dependency
supervisors made them uncertain of how to use SBAR in non-
acute situations, like discussing patients with their supervisor The SBAR tool is widely used in different healthcare facilities as
after a patient examination at the clinical ward. a communication and hand-off tool both intra-professional
and inter-professional (Achrekar et al., 2016; De Meester
Perceived professional role et al., 2013; Randmaa et al., 2014; Raymond & Harrison,
SBAR is not (yet) part of the roles and tasks in daily practice, 2014), and is regarded as current ‘best practice’ to deliver
especially for nurses. They indicated that following a script information in critical situations (Taylor, 2010). However, it
when transferring patient information, does not align with is important to realize that one size does not fit all, when it
the communication style of their professional group, which is comes to improving interprofessional communication strate­
traditionally less structured and formal and allows for more gies in healthcare. SBAR might be an adaptive tool that is
social interaction. Furthermore, from the interviews it became suitable for many healthcare settings, in particular when clear
clear that there is a shared perception of the traditional roles of and effective interpersonal communication is required. We
physicians and nurses regarding patient management. Nurses found that SBAR, which has been proven to be successful
did not identify themselves with the task of diagnosing the within the acute care setting, cannot automatically be trans­
patient problem or making recommendations. Residents, in lated into other departments with different communication
contrast, believed that effective communication is part of styles and culture. Depending on the context and urgency of
their role and a responsibility as a physician. On the other the situation, professionals indicated to be more or less moti­
hand, they struggled with the rigid format of SBAR and their vated to use the SBAR tool. Healthcare professionals associate
identity as a childcare professional, as they needed to elaborate the tool with acute care settings, and this explains why they
and share social context of the patient with other professionals. perceive it to be more relevant and easier to apply in an acute
care setting or in a patient that is acutely deteriorating.
Although, the feasibility of SBAR has been proven in non-
Discussion
acute care facilities to the satisfaction of professionals (Renz
This qualitative analysis provides insights on what factors et al., 2013), these reports do not measure actual use. Research
should be addressed to implement the use SBAR by health­ has shown that motivation and satisfaction of the SBAR tool
care professionals within the interprofessional context of can be high among healthcare professionals, without actually
a pediatric non-acute care ward. Poor communication is increasing self-efficacy or the use of SBAR in the workplace
found in many different healthcare settings and is especially (Uhm et al., 2019). This is in line with our findings. Nurses and
prominent in-patient hand-offs and settings where fast and physicians stated that they mainly use SBAR to deliver infor­
effective management is indispensable (Shahid & Thomas, mation in critical situations. It helps them to collaborate
2018). However, the process of interprofessional communica­ because sender and receiver share the same mental model,
tion is complex and prone to misunderstanding. To overcome understanding of the situation. This might also be the case
 JOURNAL OF INTERPROFESSIONAL CARE 7

for less urgent patient situations, however nurses indicated that Furthermore, these findings emphasize the importance of
there was no shared vision on how to adapt the SBAR tool to role models and feedback in order to fundamentally change the
their specific needs. The barrier of situational dependency way of thinking and acting and develop new routines and
could be addressed by an interprofessional agreement on the practices. Within the skill domain of interprofessional com­
use of SBAR in different clinical care settings. To come to such munication, the ability to deliver feedback to and receive feed­
an agreement, professionals should be given the opportunity to back from team members is considered an essential
reflect and discuss within the team what information each competency. There are numerous factors that influence accept­
healthcare professional needs for the communication tool to ability of feedback (Eva et al., 2012; Hattie & Timperley, 2007).
be effective in both urgent and non-urgent situations. Some of these factors, for example, the credibility of the feed­
back source may be especially important in the interprofes­
sional context, whereas feedback from persons with a different
Climate for workplace learning
profession could be more easily disregarded (Van Schaik et al.,
This study highlights the importance of a departmental culture 2016). Our data suggest that safety for the exchange of feedback
that accommodates healthcare professionals to improve their is not only an issue between physicians and nurses, but also
quality of work and facilitates interprofessional collaboration. within the same profession. Nurses believed that spontaneous
A positive team climate occurs when team members use reflec­ feedback given to team members, especially to their nursing
tive processes to appraise potential weaknesses, monitor col­ colleagues, was not accepted within the group. The climate at
leagues work performance, and share a belief in the workplace can be a constraining factor when it is perceived
interdependence as a way of developing an integrated approach as competitive or lacking in trust or when new roles or tools are
to action based on cooperation (Agreli et al., 2017). Healthcare not valued or accepted (Sachdeva, 1996; West et al., 2010).
professionals are continuously exposed to changes in their These issues must be addressed in order to develop and be
working environment. In response to changes, there will be effective as a team. Interprofessional training sessions or team
both similarities and differences in reaction; professionals will debriefings with the possibility to reflect up on their collabora­
have to defend or reconfigure their professional identity tion and practice effective communication were mentioned by
(Gover & Duxbury, 2012). However, when a shared interpro­ participants during group sessions as a way of improving their
fessional learning climate is lacking, strong professional iden­ collaboration.
tities may perpetuate hierarchical disciplinary boundaries in
the process of team collaboration (Hotho, 2008; Langendyk
Motivation to use
et al., 2015). Therefore, creating a safe atmosphere where
team members feel safe to speak up and are able to learn The decision to use SBAR is ultimately made at the level of the
from each other, is essential for teamwork. (Reader et al., 2007). individual. We found that the individual strategies in using
Furthermore, a lack of understanding of others’ professional SBAR were influenced by a sense of autonomy as
roles and responsibilities are main barriers to team effort and a professional, feeling of competence and perceived profes­
the interprofessional collaborative practice (Hazen et al., 2018). sional identity to incorporate a new tool into their work rou­
The hierarchical structure of the healthcare system and the tines. These findings are in line with the theoretical concept of
stereotypes of the physician who reasons, diagnoses, and self-determination (SDT). This theory conceptualizes that goal
leads and of the nurse who cares, nurtures, and functions as directed behaviors, like learning new routines in the workplace,
a cooperative team member persist. This preconception seems are driven by three innate psychological needs: autonomy (the
to prevent nurses from making recommendations when using need to feel ownership of one’s behavior), competence (the
SBAR. If nurses believe that their inputs are not heard by need to produce desired outcomes and to experience mastery),
physicians, they will probably make fewer suggestions, while and relatedness (the need to feel connected to others) (Ryan &
residents expect more participation. Thus, there is a risk to Deci, 2000).
enter a vicious circle, in which expectations are less and less The nurses in this study indicated that although they had
met, leading to poor teamwork. These findings are in line with a positive attitude toward SBAR in acute situations and inter­
previous research on interprofessional collaboration and role action with physicians, they did not believe that the tool met
perception and underline the importance of a shared vision on their requirements for communicating patient information
professional roles and responsibilities (Hazen et al., 2018), toward each other during routine care. They were less moti­
characterized by team evaluations, interprofessional practice vated to use the tool in these circumstances, which in turn led
opportunities and critical appraisal of team values and goals to a lack of familiarizing with the tool and less confidence in
(Agreli et al., 2017; Blondon et al., 2017; Kostoff et al., 2016). using the tool in more complex or acute situations. Feeling
Communication tools, such as SBAR, are designed to support competent to perform a certain task, also called self-efficacy,
communication across hierarchical boundaries, reducing inhi­ is an important predictor of transfer of learned practices into
bitions in hierarchical context by encouraging the sender to the workplace (Bandura, 2001). To improve the use of SBAR
provide a personal assessment and suggestion of the situation in the clinical practice, the issue of autonomy, competence
(Recommendation; Donahue et al., 2011). However, our find­ and relatedness to promote intrinsic motivation, needs to be
ings illustrate that the implementation of a communication addressed by showing professionals how the tool can help
tool without a shared philosophy, does not automatically lead achieving their communication goals, promote interprofes­
to team members’ assertiveness, better interdisciplinary com­ sional feedback and remodel their work environment. These
munication, and a shared perception of teamwork. opportunities are best created by health professionals
8 E. H. A. J. COOLEN ET AL.

themselves; for example, by using SBAR during team debrief­ in improving interprofessional communication.
ings, or shared reflection on effective communication during
simulated team training scenarios, as was mentioned by the
participants in this study. In this way healthcare professionals Declaration of interest
can become familiar with the tool in less stressful conditions The authors report no conflicts of interest. The authors alone are respon­
and build self-efficacy with regard to effective communication sible for the content and writing of this article.
styles. Subsequently, they may adapt the tool to their needs
and feel ownership for the effective use of SBAR in different
settings. Notes on contributors
Ester Coolen is a M.D., and PhD-candidate on the topic of teamwork in
acute pediatric care. She works as a general pediatrician, educator and
Limitations vice-director of the pediatric residency program at the Amalia Children's
A limitation of this study is that the data were gathered at the Hospital of the Radboud University Medical Center, Nijmegen, the
Netherlands.
pediatric non-acute care department of a teaching hospital.
This specific context may limit the generalizability of our find­ Rik Engbers is a PhD, educationalist and post-doctoral educational
ings. Furthermore, we decided to interview both professional researcher and medical teaching policy advisor at the Radboud Health
Academy of the Radboud University Medical Center, Nijmegen, the
groups separately. This leaves out the possibility of interaction Netherlands.
between professions, which could also have provided us and
Jos Draaisma is a M.D., PhD, and post-doctoral researcher. He works as a
participant with additional insights regarding the effect of their general pediatrician and has extensive experience in innovative medical
communication styles and the use of SBAR. education as a senior educator and former director of the pediatric
residency program at the Amalia Children's Hospital of the Radboud
University Medical Center, Nijmegen, The Netherlands.
Recommendations for clinical practice
Maud Heinen is a PhD, registered nurse and senior post-docteral
Multiple aspects of implementation theories on the individual, researcher in nursing science with expertise in innovation and quality of
care at the Radboud Institute for Health Sciences, Radboud University
contextual, social and organizational level should be consid­
Medical Center, Nijmegen, The Netherlands.
ered, when introducing SBAR into a new setting. To enhance
the use of the SBAR tool into a new healthcare setting it is Cornelia Fluit is a M.D., educationalist and professor in Medical
Education. She is a senior researcher with specific expertise on workplace
important to identify professionals’ needs to use the tool effec­ learning, coaching and feedback in Healthcare at the Radboud Health
tively and to consider how tasks and responsibilities are per­ Academy of the Radboud University Medical Center, Nijmegen, The
ceived by different team members. This can be accomplished Netherlands.
by investing in a consultation process with representatives of
all involved disciplines, prior to the implementation phase to
References
confer a sense of ownership to team members which may be
essential to the success of interventions that seek to change Achrekar, M. S., Murthy, V., Kanan, S., Shetty, R., Nair, M., & Khattry, N.
behavior. Furthermore, our findings suggest that for successful (2016). Introduction of situation, background, assessment, recommen­
implementation of SBAR in an interprofessional setting one dation into nursing practice: A prospective study. Asian Pacific Journal
of Oncology Nursing, 3(1), 45–50. https://doi.org/10.4103/2347-5625.
should recognize differences in education levels, professional 178171
status, as well as perception of roles and responsibilities of the Agreli, H. F., Peduzzi, M., & Bailey, C. (2017). Contributions of team
various health professions, since long established routines and climate in the study of interprofessional collaboration: A conceptual
(wrongful) assumptions may hamper to process to change analysis. Journal of Interprofessional Care, 31(6), 679–684. https://doi.
interprofessional communication. To overcome these differ­ org/10.1080/13561820.2017.1351425
Bandura, A. (2001). Social cognitive theory: An agentic perspective.
ences health, professionals need to be given opportunities to Annual Review of Psychology, 52(1), 1–26. https://doi.org/10.1146/
create a shared perception of team goals and interprofessional annurev.psych.52.1.1
collaboration by introducing team debriefings and interprofes­ Blondon, K. S., Maitre, F., Muller-Juge, V., Bochatay, N., Cullati, S.,
sional evaluations of work routines. This may also foster Hudelson, P., Savoldelli, G. L., & Nendaz, M. R. (2017).
a positive learning climate within the workplace, in which Interprofessional collaborative reasoning by residents and nurses in
internal medicine: Evidence from a simulation study. Medical
team members feel safe to implement new work routines and Teaching, 39(4), 360–367. https://doi.org/10.1080/0142159x.2017.
stimulate inter/intra-professional feedback and role modeling. 1286309
Clements, B. (2018). Development and implementation of standardized
documentation tools;Smart phrases: Within the electronic medical
Conclusions record (EMR) of an outpatient transplant clinic. Biology of Blood and
Marrow Transplantation, 24(3), S455. https://doi.org/10.1016/j.bbmt.
The results of this research suggest that for successful imple­ 2017.12.739
mentation of SBAR a supportive departmental environment, Cosby, J. L. (2006). Improving patient care: The implementation of change
structurally, strategically, and culturally is crucial for health­ in clinical practice. Quality and Safety in Health Care, 15(6), 447.
care professionals to engage with the tool and incorporate it https://doi.org/10.1136/qshc.2005.016824
Compton, J., Copeland, K., Flanders, S., Cassity, C., Spetman, M., Xiao, Y.,
into their workplace routines. Future research should focus on & Kennerly, D. (2012). Implementing SBAR across a large multihospi­
how the organization can help professionals to cross profes­ tal health system. Joint Commission journal on quality and patient
sional boundaries and exchange their needs and expectations safety, 38(6), 261–268. https://doi.org/10.1016/s1553-7250(12)38033-1
 JOURNAL OF INTERPROFESSIONAL CARE 9

Curtis, J. R., Back, A. L., Ford, D. W., Downey, L., Shannon, S. E., professional boundaries between nursing students and medical
Doorenbos, A. Z., Kross, E. K., Reinke, L. F., Feemster, L. C., students. Academic Medicine, 90(6), 732–737. https://doi.org/10.1097/
Edlund, B. E., Arnold, R. W., O’Connor, K., & Engelberg, R. A. acm.0000000000000714
(2013). Effect of communication skills training for residents and Luettel, D., Beaumont, K., & Healy, F. (2007). Recognising and responding
nurse practitioners on quality of communication with patients with appropriately to early signs of deterioration in hospitalised patients.
serious illness: A randomized trial. JAMA, 310(21), 2271–2281. https:// National Patient Safety Agency. https://www.patientsafetyoxford.org/
doi.org/10.1001/jama.2013.282081 wpcontent/uploads/2018/03/NPSA-DeteriorPatients.pdf
De Meester, K., Verspuy, M., Monsieurs, K. G., & Van Bogaert, P. (2013). Marshall, A. P., Tobiano, G., Murphy, N., Comadira, G., Willis, N.,
SBAR improves nurse-physician communication and reduces unex­ Gardiner, T., Hervey, L., Simpson, W., & Gillespie, B. M. (2019).
pected death: A pre and post intervention study. Resuscitation, 84(9), Handover from operating theatre to the intensive care unit: A quality
1192–1196. https://doi.org/10.1016/j.resuscitation.2013.03.016 improvement study. Australian Critical Care, 32(3), 229–236. https://
Donahue, M., Miller, M., Smith, L., Dykes, P., & Fitzpatrick, J. J. (2011). doi.org/10.1016/j.aucc.2018.03.009
A leadership initiative to improve communication and enhance safety. Mehta, A., Goldstein, S. D., & Makary, M. A. (2017). Global trends in
American Journal of Medical Quality, 26(3), 206–211. https://doi.org/ center accreditation by the Joint Commission International: Growing
10.1177/1062860610387410 patient implications for international medical and surgical care. Journal
Eid, A., & Quinn, D. (2017). Factors predicting training transfer in health of Travel Medicine, 24(5). https://doi.org/10.1093/jtm/tax048
professionals participating in quality improvement educational Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W. E., &
interventions. BMC Medical Education, 17(1), 26. https://doi.org/10. Stock, S. (2018). Impact of the communication and patient hand-off
1186/s12909-017-0866-7 tool SBAR on patient safety: A systematic review. BMJ Open, 8(8),
Eva, K. W., Armson, H., Holmboe, E., Lockyer, J., Loney, E., Mann, K., & e022202–e022202. https://doi.org/10.1136/bmjopen-2018-022202
Sargeant, J. (2012). Factors influencing responsiveness to feedback: On Pope, B. B., Rodzen, L., & Spross, G. (2008). Raising the SBAR: How better
the interplay between fear, confidence, and reasoning processes. communication improves patient outcomes. Nursing2008, 38(3),
Advances in Health Science Education Theory and Practice, 17(1), 41–43. https://doi.org/10.1097/01.NURSE.0000312625.74434.e8
15–26. https://doi.org/10.1007/s10459-011-9290-7 Randmaa, M., Martensson, G., Leo Swenne, C., & Engstrom, M. (2014).
Gover, L., & Duxbury, L. (2012). Organizational faultlines: Social identity SBAR improves communication and safety climate and decreases inci­
dynamics and organizational change. Journal of Change Management, dent reports due to communication errors in an anaesthetic clinic:
12(1), 53–75. https://doi.org/10.1080/14697017.2011.652375 A prospective intervention study. BMJ Open, 4(1), e004268. https://
Grol, R., & Grimshaw, J. (2003). From best evidence to best practice: doi.org/10.1136/bmjopen-2013-004268
Effective implementation of change in patients’ care. Lancet, 362 Raymond, M., & Harrison, M. C. (2014). The structured communica­
(9391), 1225–1230. https://doi.org/10.1016/s0140-6736(03)14546-1 tion tool SBAR (situation, background, assessment and recommen­
Grol, R. P., Bosch, M. C., Hulscher, M. E., Eccles, M. P., & Wensing, M. dation) improves communication in neonatology. South African
(2007). Planning and studying improvement in patient care: The use of Medical Journal, 104(12), 850–852. https://doi.org/10.7196/SAMJ.
theoretical perspectives. Milbank Quarterly, 85(1), 93–138. https://doi. 8684
org/10.1111/j.1468-0009.2007.00478.x Reader, T. W., Flin, R., Mearns, K., & Cuthbertson, B. H. (2007).
Guimond, M. E., Foreman, S. E., & Werb, M. (2019, August). Evaluation Interdisciplinary communication in the intensive care unit. British
of an unfolding obstetric experience simulation in an undergraduate Journal of Anaesthesia, 98(3), 347–352. https://doi.org/10.1093/bja/ael372
nursing program. Nurse Education Today, 79, 124–128. https://doi.org/ Reeves, S., Perrier, L., Goldman, J., Freeth, D., & Zwarenstein, M. (2013).
10.1016/j.nedt.2019.05.003 Interprofessional education: Effects on professional practice and
Hattie, J., & Timperley, H. (2007). The power of feedback. Review of healthcare outcomes. The Cochrane Database of Systematic Reviews
Educational Research, 77(1), 81–112. https://doi.org/10.3102/ (3), CD002213. https://doi.org/10.1002/14651858.CD002213.pub3
003465430298487 Renz, S. M., Boltz, M. P., Wagner, L. M., Capezuti, E. A., & Lawrence, T. E.
Hazen, A. C. M., de Groot, E., de Bont, A. A., de Vocht, S., de Gier, J. J., (2013). Examining the feasibility and utility of an SBAR protocol in
Bouvy, M. L., de Wit, N. J., & Zwart, D. L. M. (2018). Learning through long-term care. Journal of Geriatric Nursing, 34(4), 295–301. https://
boundary crossing: Professional identity formation of pharmacists doi.org/10.1016/j.gerinurse.2013.04.010
transitioning to general practice in the Netherlands. Acadamic Riesenberg, L. A., Leitzsch, J., Massucci, J. L., Jaeger, J., Rosenfeld, J. C.,
Medicine, 93(10), 1531–1538. https://doi.org/10.1097/acm. Patow, C., Padmore, J. S., & Karpovich, K. P. (2009). Residents’ and
0000000000002180 attending physicians’ handoffs: A systematic review of the literature.
Horwitz, I. B., Horwitz, S. K., Daram, P., Brandt, M. L., Academic Medicine, 84(12), 1775–1787. https://doi.org/10.1097/ACM.
Brunicardi, F. C., & Awad, S. S. (2008). Transformational, transac­ 0b013e3181bf51a6
tional, and passive-avoidant leadership characteristics of a surgical Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the
resident cohort: Analysis using the multifactor leadership question­ facilitation of intrinsic motivation, social development, and
naire and implications for improving surgical education well-being. American Psychologist, 55(1), 68–78. https://doi.org/10.
curriculums. Journal of Surgical Research, 148(1), 49–59. https:// 1037/0003-066X.55.1.68
doi.org/10.1016/j.jss.2008.03.007 Sachdeva, A. K. (1996). Use of effective feedback to facilitate adult
Hotho, S. (2008). Professional identity product of structure, product of learning. Journal of Cancer Education, 11(2), 106–118. https://doi.org/
choice. Journal of Organizational Change Management, 21(6), 721–742. 10.1080/08858199609528405
https://doi.org/10.1108/09534810810915745 Shahid, S., & Thomas, S. (2018). Situation, background, assessment,
Joffe, E., Turley, J. P., Hwang, K. O., Johnson, T. R., Johnson, C. W., & recommendation (SBAR) communication tool for handoff in health
Bernstam, E. V. (2013). Evaluation of a problem-specific SBAR tool to care – A narrative review. Safety in Health, 4(1), 7. https://doi.org/10.
improve after-hours nurse-physician phone communication: 1186/s40886-018-0073-1
A randomized trial. Joint Commission Journal on Quality and Patient Stalmeijer, R. E., McNaughton, N., & Van Mook, W. N. (2014). Using
Safety, 39(11), 495–501. https://doi.org/10.1016/S1553-7250(13)39065-5 focus groups in medical education research: AMEE Guide No. 91.
King, N., Horrocks, C., & Brooks, J. (2019). Interviews in qualitative Medical Teacher, 36(11), 923–939. https://doi.org/10.3109/0142159x.
research (2nd ed.). Sage. 2014.917165
Kostoff, M., Burkhardt, C., Winter, A., & Shrader, S. (2016). An inter­ Taylor, J. R. A. (2010). The handbook of quality and service improvement
professional simulation using the SBAR communication tool. tools. NHS Institute for Innovation and Improvement. http://www.
American Journal of Pharmaceutical Education, 80(9), 157. https:// miltonkeynesccg.nhs.uk/resources/uploads/files/NHS%20III%
doi.org/10.5688/ajpe809157 20Handbook%20serviceimprove.pdf
Langendyk, V., Hegazi, I., Cowin, L., Johnson, M., & Wilson, I. (2015). Thomas, C. M., Bertram, E., & Johnson, D. (2009). The SBAR commu­
Imagining alternative professional identities: Reconfiguring nication technique: Teaching nursing students professional
10 E. H. A. J. COOLEN ET AL.

communication skills. Nurse Education, 34(4), 176–180. https://doi. interprofessional feedback. Medical Education, 50(2), 181–188.
org/10.1097/NNE.0b013e3181aaba54 https://doi.org/10.1111/medu.12850
Uhm, J. Y., Ko, Y., & Kim, S. (2019). Implementation of an SBAR West, M., & Richter, A. (2010). Team climate and effectiveness outcomes.
communication program based on experiential learning theory in In N. M. Ashkansay, C. P. Wiklderom, & M. F. Peterson (Eds.), The
a pediatric nursing practicum: A quasi-experimental study. Nurse handbook of organizational culture and climate (pp. 249–270). SAGE.
Education Today, 80, 78–84. https://doi.org/10.1016/j.nedt.2019. https://doi.org/10.4135/9781483307961.n14
05.034 West, M. A. (1990). The social psychology of innovation in groups. In
Van Schaik, S. M., O’Sullivan, P. S., Eva, K. W., Irby, D. M., & Regehr, G. M. A. West & J. L. Farr (Eds.), Innovation and creativity at work:
(2016). Does source matter? Nurses’ and physicians’ perceptions of Psychological and organizational strategies (pp. 309–333). John Wiley.