Using SBAR and KSA to Promote Critical Thinking Among Graduating BSN Students Patti Connor Ballard PhD, MSN, BSN, RN, ACNS-BC Clinical Assistant Professor,

Using SBAR and KSA to Promote Critical Thinking Among Graduating BSN

Students

Patti Connor Ballard PhD, MSN, BSN, RN, ACNS-BCClinical Assistant Professor, School of Nursing

The Catholic University of America (CUA)Washington DC, USA

Pope Francis Visits CUA 23 Sept 2015

CUA School of Nursing

• Started in 1935• 1967 CUA was 1/13 US SONs selected to

develop/offer cardiac critical care training for CCU RNs (#4 US CCU at nearby HCH)

• Currently offers BSN (traditional and accelerated 2nd degree), MSN, Nurse Practitioner, DNP, and PhD

• Famous nursing alumni and nursing faculty include nursing deans, chief nursing officers, military nurse corps chiefs, VA nursing chiefs, nurse researchers, and nursing theorists (eg. Dorothea Orem of the Self-Care Model)

SBAR: Situation, Background, Assessment and Recommendation

• Originally designed by the US Navy for use during high-risk communications on deployed nuclear submarines

• Adapted for the US aviation industry• Modified for use in the US healthcare setting by Kaiser

Permanente for use by rapid response teams (RRTs)• Common patient “hand-over” communication strategy that is

clear, concise, focused, standardized, and appropriate for team approach to patient care

• Endorsed by The Joint Commission as a risk mitigation strategy for communication in the clinical setting, especially regarding patient status

…But what if the SBAR communication strategy was used as a teaching/learning strategy?

SBAR and KSA Student Population

• 71 nursing students in their final semester of a 4-year traditional BSN program at CUA• NURS 426 Medical-Surgical Nursing Leadership course

(90-hr group-based, faculty-supervised clinical practice)• Three (3) SBARs and two (2) KSAs per student weighted

into final course grade• SBAR piloted tested with same cohort in Fall 2014• Students invited to attend optional SBAR and KSA

workshops before assignment submission• SBAR and KSA reviewed during general clinical

orientation at Spring 2015 semester onset

SBAR Assignment Template: Situation (S)

• What are you most worried about right now?• Introduce self and patient as if communicating

with eg. MD (but remove patient identifiers)• Brief statement of #1 nursing concern

regarding patient (justify)• Patient stability per vital signs and oxygen

saturation

SBAR Assignment Template:Background (B)

• What happened up to this point?• Past medical history, allergies, ETOH use, smoking

status• Chief complaint and medical diagnosis at

admission• Major procedures done during hospitalization• Prescribed medications chart (including indication)• Baseline patient status (LOC, VS, O2 sat%, pain,

labs…)

SBAR Assignment Template:Assessment (A)

• What is happening now?• Targeted assessment based upon “S” concern• Labs (follow-up/repeat, change from baseline,

explain at least 1 abnormal lab value)• Risk assessment (infection/sepsis, bleeding,

aspiration, DVT, fall, seizure)• NANDA nursing diagnosis/ses (Dx/DT/AEB) for

“S” concern

SBAR Assignment Template:Recommendation (R)

• What needs to be done?• Nursing interventions targeted at “S” concern• #1 nursing intervention (justify)• Delegation of nursing interventions to NAP

(justify)• Necessary MD actions (justify)• Necessary referrals (justify)

SBAR Assignment: Positive Outcomes

• Provided structure for student contemplation and action in the clinical setting

• Led to academic and clinical performance improvement among marginal BSN students

• Prioritization of patient needs • Connect background information to #1 concern• Targeted assessment and recommendations• Risk assessment• Delegation/collaboration with non-RN staff• Prep for NCLEXRN pre-licensure exam

SBAR Assignment: Opportunities for Improvement

• Inconsistent compliance to assignment directions

• Persistent difficulty with prioritizing #1 concern and targeted assessment/interventions

• Identified gaps in student knowledge (eg clinical conditions, medications, risk…)

• Identified potential gaps in curriculum for BCC follow-up

Quality and Safety Education in Nursing (QSEN)

• Developed in response to the 2005 Institute of Medicine (IOM) report, To Err is Human, Building a Safer Health System

• Funded by the Robert Wood Johnson Foundation • Aims to introduce health care quality/safety

concerns and risk mitigation strategies into both nursing academia and RN clinical practice

• KSA format used to identify/teach the essential elements of a competency

QSEN KSA Assignment TemplateKnowledge (K) Skill (S) Attitude (A)

What is the knowledge needed to perform this skill safely? Such as…

• Clinical indications• Normal v abnormal

findings• VS and lab parameters• Drug onset/peak

action/duration/side effects

• Allergy risk• Contraindications• Complications• Equipment/supplies• Policy/procedure

What actions do you need to know to perform this clinical nursing action safely? Such as…

• Assessment• Procedure technique• Medication

administration• Documentation• Pre/post-procedure care• Use of

equipment/supplies

What action towards the patient must you initiate and maintain in order to perform this clinical nursing action safely? Such as…

Increased risk for _______Risk mitigation strategiesFollow-up assessmentPrecautionsIsolationPatient/family teachingDischarge preparation

KSA Assignment: Positive Outcomes

• Brief simple KSA tool• Increased student awareness of risk associated

with common nursing actions (medications, procedures)

• Increased student awareness of risk mitigation strategies for daily use in the clinical setting

• NGT, airway suctioning, ostomy care, bladder catheterization, tracheostomy care, medications, dressing change etc KSAs discussed at post-clinical conferences

KSA Assignment: Opportunities for Improvement

• QSEN not consistently incorporated into every BSN course

• Inconsistent faculty knowledge and experience regarding QSEN and KSA

• “KSA” saturation of small number of topics