In our exploration of teamwork, we have so far looked at the behavioural competencies, and the communication competencies, of effective healthcare teamwork. In this post we will review two of the practical and standardised tools that facilitate the effectiveness of communication within and between teams.
The SBAR technique is perhaps the most widely used structured communication method and it enhances communication by sorting the information to be conveyed under four headings: situation, background, assessment, and recommendation. The SBAR tool has many qualities that make it an effective communication tool, and one of the most important is its ability to overcome steep authority gradients. This point was made by Robert Wachter in his article titled Why diagnostic errors don’t get any respect – and what can be done about them. In this paper, he highlighted how authority gradients compromise communication within teams because of the power distance that exists between senior and the junior team members. Wachter argues that the SBAR technique, by providing a structure to communication, overcomes this barrier and reduces the risks of clinical error.
M. Leonard and colleagues, in their paper titled The human factor: the critical importance of effective teamwork and communication in providing safe care also explored the positive influence of the SBAR tool in flattening authority hierarchy. They noted that the tool reduces the power distance within teams, a phenomenon that tends to restrain junior members from ‘speaking up‘ when patient safety is at risk. They also pointed out that SBAR improves doctor-nurse communications by removing the limitations imposed on them by the different ways the two professional groups are trained to communicate.
A crucial element of healthcare communication is its ability to raise appropriate levels of concern about patient safety. One tool that helps to communicate the seriousness of clinical situations is the CUS word system, a technique advocated by Wachter. This tool aids the communication of three escalating levels of concern using the following phrases:
- First level: ‘I am Concerned‘
- Second level: ‘I am Uncomfortable‘,
- Third level: ‘This is a Safety issue‘
Leonard and colleagues also promoted the CUS word system which they said also overcomes power distance by creating ‘a clearly agreed upon communication model that helps avoid the natural tendency to speak indirectly and deferentially‘. Stressing the importance of appropriate assertiveness when raising concerns, they nevertheless advised that this should be done by stating the problem ‘politely and persistently‘ until a response is received. They emphasised that when the stakes are high, ‘the common practice of speaking indirectly – the ‘hint and hope‘ model – is risky for patient safety. They also advocated using the system to raise concerns even if this is just based on a feeling that the situation ‘doesn’t feel right‘.
In the next post, we will round up our exploration of the clinical foundations of human error with a review of the virtues of mindful practice.