ORIGINAL RESEARCH

Application Effects of SBAR Communication

Mode in ICU Nursing Physical Restraint Shift
Yanzhi Ding, BM; Guoying Wang, MM; He Chen, BM; Jin Kang, BM; Zhaochun Wu, BM

ABSTRACT
Context • Correct and effective handovers of patients’ hospital’s routine communication mode for the physical
information during shift changes can ensure patients’ restraint of a patient during a nursing shift.
safety and can help an incoming shift of nurses to Outcome Measures • The study measured the differences
continuously monitor patients’ psychological problems between the groups in the nurses’ passing rates based on
and avoid unnecessary physical restraints. Development standards for the use of physical restraints, the quality of
of a standard procedure for handover of patients who have handover of information during shift changes about
been physically restrained has important clinical patients under physical restraint, the quality of the
significance related to the smooth continuation of nursing documentation written by nurses about the physical
work and assurance of the quality of care. restraint, and the nurses’ satisfaction with the handover of
Objective • The study intended to investigate the clinical information during a shift change.
effects of the situation-background-assessment- Results • Among the patient, 112 in the intervention group
recommendation (SBAR) communication mode on the (92.56%) and 92 in the control group (77.97%) were
quality of the information passed during shift changes qualified for physical restraint. A statistically significant
about patients in intensive care units (ICUs) who had been difference existed between the two groups in the passing
physically restrained and to compare it to the clinical effects rate for the use of physical restraints (P = .001). The quality
obtained using traditional methods of communication. score for the handovers during shift changes of patients
Design • The study was a retrospective analysis of the under physical restraint in the intervention group was 95.46
process used by nurses who were passing patient’s ± 2.50 and for the control group was 91.08 ± 3.57, with the
information during shift changes when caring for patients difference being statistically significant (P = .030). The
who had been physically restrained. quality score for the nursing documentation for the
Setting • The study took place in an ICU at the Second intervention group, at 97.21 ± 1.49, was higher than that of
Hospital of Hebei Medical University in Shijiazhuang, the control group, at 90.78 ± 3.42, and the difference was
Hebei, China. statistically significant (P < .001). The nurses’ satisfaction
Participants • Participants were 21 nurses caring for 239 score for the intervention group, at 98.14 ± 1.01 was higher
ICU patients under physical restraint at the Second Hospital. than that of the control group, at 92.57 ± 1.86, and the
Intervention • Of the 239 patients, 118 had been hospitalized difference was statistically significant (P = .006).
between March 1 and March 15, 2018 and were assigned to Conclusions • The use of the SBAR communication mode
the control group, and 121 had been hospitalized between to improve the information passed to nurses about patients
June 1 and June 15, 2018 and were assigned to the under physical restraint during a shift change can improve
intervention group. An ICU Physical Restraint Handover the quality of the physical restraint and nurses’ satisfaction
Order was established according to the SBAR communication and has a better clinical-application effect than the
mode. The intervention group used the SBAR traditional methods used during shift changes. (Altern
communication mode and the control group used the Ther Health Med. 2022;28(6):112-117)

Yanzhi Ding, BM, nurse-in-charge; He Chen, BM, nurse-in- nurse, ICU Department, the Second Hospital of Hebei
charge; Jin Kang, BM, senior nurse; and Zhaochun Wu, BM, Medical University, Shijiazhuang, Hebei, China.
nurse-in-charge, ICU Department, the East Branch of the
Second Hospital of Hebei Medical University, Shijiazhuang, Corresponding author: Yanzhi Ding, BM
Hebei, China. Guoying Wang, MM, co-chief superintendent E-mail: [email protected]

112 ALTERNATIVE THERAPIES, SEPTEMBER 2022 VOL. 28 NO. 6 Ding—SBAR Communication Mode in ICU Nursing
 The concept of a shift change is important in nursing events but may have caused adverse consequences, such as skin
work and plays an important role in the transmission of damage, constipation, depression, and anger, which might
patient-care information.1 At the same time, the shift system increase the mortality rate and hospital stays of patients.8 Chang
is one of the core systems of nursing and plays an important et al’s study suggested that 25.6% to 80% of patients with
role in ensuring the quality of nursing care.2 unplanned extubations were under physical restraint.18
Patients in intensive care units (ICUs) are usually in a The smooth transfer of patients’ information has been
serious condition, and most patients experience anxiety or found to be the primary factor in a safe transition of patients to
delirium, which is a common clinical syndrome in the ICU. new nursing staff, ensuring that they receive good follow-up
It’s an acute brain dysfunction, characterized by transient and treatment and continuous care.20 The correct assessment of the
widespread cognitive impairment, with acute onset and rapid patient’s condition requires comprehensive knowledge and
development.13 These characteristics of patients can affect the comprehensive analysis of a patient’s information, while effective
smooth progress of treatment and even lead to adverse advice depends on the application of critical thinking. One study
events. For example, unplanned extubation is a serious found that patients who weren’t evaluated for physical restraint
adverse event in nursing that can bring serious harm to had three times as much agitation as those who weren’t.17
patients, and physical restraints are aimed at reducing such The development of a standard procedure for handover of
adverse events. Therefore, clinical nurses usually use physical patients who have been physically restrained has important
restraints to ensure safety during the nursing process.3 clinical significance related to the smooth continuation of
Benbenbishty et al reported that the average rate of nursing work and assurance of the quality of care. In January
usage of physical restraints in the care of 34 comprehensive 2016, the Australian Center for Evidence-based Healthcare
ICU patients in Europe was 39%.4 In China, Zhu et al and released the Physical Restraint Standards, which state that “the
Chen et al found that the rate of physical restraint for ICU patient’s needs, risks, and benefits should be considered in the
patients was 39.4% to 45.7%.5,6 best interests of the patient,” and advocated that “the use of
Use of physical restraints requires continuous work, and physical restraint should be avoided as far as possible and the
the reasons for physical restraints are complex, so the patient’s withdrawal of restraint (should be ) as early as possible.”23
consciousness, treatment mode, and degree of ability to
cooperate need to be considered comprehensively. The reasons SBAR
for physical constraints are diverse and complex, which can The situation-background-assessment-recommendation
lead to issues regarding the transfer of information during (SBAR) communication mode is an evidence-based, standardized
nursing handovers at shift changes and poor time continuity. form of communication and refers to a communication process
Physical restraints aim to prevent accidents and maintain that focuses on what happened, what caused it, what the problem
patients’ safety by restricting their activities.10 Patients under is, and what should be done to solve it.9
physical restraint often are unconscious or have trouble SBAR ensures the effective transmission of information,16
expressing their needs. These factors make it difficult for thus ensuring the continuity of use of physical restraints.
nurses to smoothly transfer patients’ care during a shift Evaluation of the process of handovers during shift change
change, but because of the particularities of ICU patients, the based on the SBAR mode for patients under physical restraint
handover between nurses is especially important. Correct can help nurses in the process of information transmission to
and effective handovers of patients’ information during shift form a consensus about the use of restraints. Chang et al
changes can ensure patients’ safety and can help an incoming found that the application of the SBAR communication
shift of nurses to continuously monitor patients’ psychological mode during the nursing shift change in the ICU could
problems and avoid unnecessary physical restraints. Poor reduce the rate of unplanned extubation and improve the
communication between doctors and nurses has been found quality of nursing care through a standardized process.2
to be the main cause of patients’ accidental injuries.11 The SBAR communication mode can play a positive role
According to Xin et al and Rose et al, nurses use physical in improving the comprehensive quality of nursing care. The
restraint in clinical practice to ensure the safety of patients required detailed description of the current situation depends
with delirium and the smooth progress of treatment and on an accurate grasp of a patient’s information, and the
nursing while a patient is restrained, but they have indicated accurate description of the background during the shift
that physical restraint can aggravate the degree of delirium.14,15 depends on a nurse’s comprehensive grasp of the patient’s
Sone studies have suggested that patients can experience treatment and nursing situation.
depression, irritability, and humiliation after physical The standardized communication mode of SBAR has
restraint; some patients feel that their personality and dignity been found to be helpful in improving the critical thinking
have been violated and have even developed delirium and ability and communication ability of nurses and improving
posttraumatic stress disorder.12 the quality of their decisions to use physical restraints by
One study found that 81.75% of ICU nurses believe that improving the collaborative ability of the nursing team, to
physical restraint was effective in preventing unplanned ensure patients’ safety.19
extubation.7 However, another study found that physical In clinical work, communication barriers are often caused
restraints had little effect on reducing the occurrence of adverse by differences in communication modes among medical staff.

Ding—SBAR Communication Mode in ICU Nursing ALTERNATIVE THERAPIES, SEPTEMBER 2022 VOL. 28 NO. 6 113
The SBAR mode standardizes the communication mode, nurses received training regarding the established ICU
which can help nurses to clarify communication content, Physical Restraint Order and followed its procedures for
highlight key points, and reduce communication barriers.21 handovers, and the control group’s nurses received no
Smooth communication can ensure the transmission of training and performed handovers following the procedures
information, and a standardized communication mode can in the hospital’s routine communication mode.
increase the benefits of the information-transmission process. Establishment of ICU Physical Restraint Handover
Gou et al found that a succession schedule created using the Order according to the tenets of the SBAR communication
SBAR communication mode had allowed standardization of the mode. An order was designed and established for use by the
succession order and content, helping the nurses at a shift’s end nurses in the intervention group.
to fully grasp the patients’ information, and the succession With respect to the situation (S), the SBAR requires that
nurses to understand a patient’s condition and treatment in a the nurses document their patients’ bed numbers, names,
short time and to determine the follow-up nursing focus, so as and current physical restraints.
to avoid the occurrence of a poor handover.2 With respect to the background (B), the SBAR requires
Wang and Gao also found that the application of the that the nurses document: (1) the reason why a patient was
SBAR communication mode strengthened nurses’ placed under physical restraint, including the patient’s
understanding of patients’ overall situations, improved nurses’ awareness of the restraint; (2) the patient’s ability to take care
ability to observe and summarize patients’ conditions, reduced of his or her personal needs, such as urination; (3) the
the differences caused by different communication modes patient’s degree of cooperation; (4) the patient’s mobility; and
among the nurses, and effectively reduced the incidence of (5) the patient’s complaints about the restraint.
adverse events during shift changes and patient transport.22 With respect to the assessment (A), the SBAR requires
Therefore, the current study intended to investigate the that the nurses: (1) assess patients’ current states of physical
clinical effects of the SBAR communication mode on the restraint, if any, and (2) describe the main nursing problems
quality of the information passed during shift changes about and measures to be taken.
patients who had been physically restrained and to compare With respect to the recommendation (R), the SBAR
it to the clinical effects obtained using traditional methods of requires that the nurses suggest what their successors for the
communication. next shift should focus on for each patient, such as medical
indicators that need to be continuously assessed and
METHODS monitored and a plan of care that communicates what the
Participants need for physical restraint is during the next shift.
The study was a retrospective analysis of the process Training of nurses to follow the established ICU
used by nurses who were passing patient’s information Physical Restraint Order. A training team for the
during shift changes when caring for patients who had been intervention group was set up, comprising one head nurse,
physically restrained. Prospective participants were nurses three senior nurses, and two doctors. The training content
caring for patients who had been admitted to the ICU of the included: (1) the meaning of the SBAR communication
Second Hospital of Hebei Medical University in Shijiazhuang, mode, (2) theoretical knowledge of and operational skills for
Hebei, China and who underwent a shift change during the physically restraining patients, including the correctness of
period in which their patients were physically restrained. tool selection and (3) the methods to use the ICU Physical
Potential patients were included if they: (1) had been Restraint Handover Order according to SBAR mode.
hospitalized in the ICU for ≥24h; (2) were ≥18 years or age; Data collection. According to the SBAR model, a
and (3) had no damage to, loss of integrity in, or edema of the Physical Restraint Handover Checklist was created, and the
skin at the restraint site before restraint occurred. Potential clinical application of the order in the ICU was monitored.
patients were excluded if they had: (1) a bleeding tendency or To enable quality control, the training team evaluated
skin disease or (2) a history of mental illness. whether: (1) the description of the current situation as
The study was approved by the ethics committee of the documented was consistent with a patient’s real situation,
Second Hospital of Hebei Medical University, and written (2) any omissions had occurred, (3) the reason for the physical
informed consent was obtained from all participants. restraint of a patient was valid, (4) the comprehensiveness of
the situation’s description, (5) the correctness of the physical-
Procedures restraint assessment, (6) the rationality of the use of physical
Groups. The patients who had been hospitalized between restraint, and (6) the rationality of the follow-up nursing
March 1 and March 15, 2018 were included in the control suggestions about the physical restraint.
group, and patients who had been hospitalized between June The responsible team leader checked the nurses’
1 and June 15, 2018 were included in the intervention group. compliance with the checklist twice a day. The head nurse
The nurses were the study’s participants, with their assigned randomly checked the compliance of two nurses per week,
groups being those of the patients for whom they cared. and the nurse participants checked their own compliance
Intervention. For the handovers during shift changes of once a week, forming a three-level, quality-control mechanism
patients under physical restraints, the intervention group’s related to physical restraints during shift changes in the ICU.

114 ALTERNATIVE THERAPIES, SEPTEMBER 2022 VOL. 28 NO. 6 Ding—SBAR Communication Mode in ICU Nursing
 Outcome measures. The research team performed an Table 1. Comparison of Eligibility of Patients for Physical
assessment of the effects of the order on the outcomes of shift Restraint Between the Groups (N = 239)
changes. The clinical effects for each shift were evaluated using
the following indicators: (1) an evaluation of the passing rate Patients Qualified Unqualified
for the use of physical restraint—the reasonableness of the Group n n (%) n (%)
justifications for the physical restraints, and the correctness of Intervention group 121 112 (92.56) 9 (7.44)
the use of the restraint methods, with a nurse failing to follow Control group 118 92 (77.97) 26 (22.03)
the order if he or she didn’t meet any of the three requirements; χ2 10.182
(2) use of a self-designed quality table regarding the handover P value .001a
during shift change of patients under physical restraint, which
included the physical-restraint status, background, evaluation, a
Indicates a significant difference in the eligibility for the
and suggestions, with a maximum possible score of 100 points; intervention group compared to the control group’s eligibility
(3) an examination of the written nursing records documenting
the physical restraints used for the two groups of patients Table 2. Comparison of the Quality of the Nurses Handovers
during their hospitalizations, based on the quality standards of During Shift Change for Patient’s Under Physical Restraint
the hospital, with a maximum possible score of 100 points; (N = 239). The maximum possible score was 100 points.
(4) administration of a self-designed questionnaire to
investigate the 21 nurses’ satisfaction with the shift changes for Patients Quality Score
their patients’ who were under physical restraint, with a Group n Mean ± SD
maximum possible score of 100 points. Intervention group 121 95.46 ± 2.50
Control group 118 91.08 ± 3.57
Intervention t 10.994
The training included theoretical learning and skill P value 0.030a
training, and the training period was one month, 2 times per
week and 2 hours at a time. During the training process, a
Indicates a significantly better quality for the handovers for
theoretical assessment, skill assessment, and scenario- the intervention group than for the control group
simulation assessment were adopted to help the nurses to
master the SBAR mode and conduct a handover of patients were examined by Student t test. Categorical variables were
under physical restraint at a shift change. presented as numbers with percentages and compared with
Problems that nurses encountered in the implementation the Chi-square tests. Statistical significance was set at P < .05.
of a handover order were collected for one month, and the
training was conducted again at that time to optimize the use RESULTS
of the established order. Participants
Of 239 patients who were admitted to the hospital and
Outcome Measures who underwent physical restraint, 118 were assigned to the
Passing rate. the reasonableness of physical restraint control group, and 121 were assigned to the intervention
reasons, the correctness of tool selection and the correctness of group. No significant differences existed in the demographics
restraint methods. If one of them fails, the option is disqualified between the patients in the two groups, with P > .05.
Self-designed quality table. Self-designed physical The shift nurses involved in the study were 21 ICU
restraint handover quality table, including physical restraint nurses, including one male and 20 females. Their ages ranged
status, background, evaluation and suggestions, with a full from 26 to 39 years, with a mean age of 30.42 ± 2.97 years
score of 100 points. (data not shown). Their number of years of working as an
Examination of written nursing records documenting ICU nurse ranged from 4 to 20 years, with a mean number of
physical restraints. according to the quality standard of years of 6.42 ± 3.55 years.
nursing document writing in our hospital, physical restraint
nursing records of the two groups of patients during Shift Changes
hospitalization were examined, with a full score of 100 In terms of the nurses’ passing rates regarding the use of
Nurses’ satisfaction questionnaire. the self-designed physical restraints, 112 patients in the intervention group
questionnaire was calculated with a score of 100 points to (92.56%) and 92 patients in the control group (77.97%) were
investigate 21 nurses’ satisfaction with physical restraint shift. qualified for physical restraint, and the difference was
statistically significant (P = .001) (Table 1).
Statistical Analysis Regarding the quality of the handovers of patients under
Statistical analysis was performed using the SPSS physical restraint, the score was 95.46 ± 2.50 for the
software program, version 17.0 (IBM Corp, LA, CA, USA). intervention group’s nurses, while that for the control group’s
Normally distributed measurement data were expressed as nurses was 91.08 ± 3.57. The difference between the two
means ± standard deviations (SDs), and the comparisons groups was statistically significant, with P = .030 (Table 2).

Ding—SBAR Communication Mode in ICU Nursing ALTERNATIVE THERAPIES, SEPTEMBER 2022 VOL. 28 NO. 6 115
 The comparison of the quality of written nursing Table 3. Comparison of Quality of Written Documentation
documentation for patients under physical restraint between by Nurses About Physical Restraints (N = 239). The maximum
the two groups showed that the intervention group’s quality possible score was 100 points.
score was 97.21 ± 1.49, which was higher than that of the
control group, at 90.78 ± 3.42, and the difference was Patients Quality Score
statistically significant, with P < .001 (Table 3). Group n Mean ± SD
In the comparison of the nurses’ satisfaction with the Intervention group 121 97.21 ± 1.49
transfer of information about patients under physical Control group 118 90.78 ± 3.42
restraint during shift changes for the two groups, the score of t 18.916
the intervention group’s nurses was 98.14 ± 1.01, which was P value 0.001a
higher than that of the control group’s nurses, at 92.57 ± 1.86,
and the difference was statistically significant, with P = .006 a
Indicates a significantly better quality for the documentation
(Table 4). for the intervention group than for the control group

DISCUSSION Table 4. Comparison of Nurses’ Satisfaction With Physical-

In the current study, the research team applied the SBAR restraint Handovers (N = 21) The maximum possible score
communication mode for the first time to the handovers of was 100 points.
patients under physical restraint during shift changes in the
ICU. The use of the SBAR communication mode improved Nurses Quality Score
the quality of the handovers and the nurses’ satisfaction with Group n Mean ± SD
the handovers, which indicated that the mode might be able Intervention group 21 98.14 ± 1.01
to play an important role in improving the quality of nursing Control group 21 92.57 ± 1.86
in the ICU. t 12.055
The results of the current study suggested that after the P value 0.006a
establishment of the ICU Physical Restraint Handover Order
based on the SBAR communication mode, the qualified rate a
Indicates a significantly greater satisfaction for the nurses
of patients’ physical restraint and the handover quality score caring for the intervention group compared to those caring
both improved, suggesting that the adoption of the SBAR for the control group
communication mode was helpful to the successful
completion of handover during shift changes of patients AUTHORS’ DISCLOSURE STATEMENT
This study was supported by the Hebei Provincial Medical Science Research Key Project
under physical restraint. Plan (No. 20170121). The authors declare there is no conflict of interest.
The results of the current study indicated that the
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