SBARs for industrial case studies

The image shows three buckets: one with a smiley face one, one with a neutral face and one with a sad face. The buckets have counters beside them.

The problem of presentations

One of the undergrad activities I run is a case study workshop. I originally designed it so that the students would split into six groups, analyse the case studies and present it to the rest of the class. Part of my plan was that after the presentation another group (called the review group) would question those presenting the case, adding additional facts they had gleamed from the case notes and perhaps challanging the overall analysis. In addition we’d planned to assess the presentation skills of the students as well.

In practise, the presentation parts of the workshop didn’t work very well. I was unusual for the review group to offer additional comments. Sometimes the presentations didn’t always effectively communicate the salient points for the case studies. At time the students who were presenting the cases appeared to be reluctant volunteers. On top of that there was never any time to assess and feedback on the non-technical attributes of presentations.

Upon reflection this is perhaps not surprising: the students in the workshop had a very short space of time to examine the case study and design an effective presentation. A quick look at the literature hints that these sort of student-lead presentations are unfavourable recieved (1).

For me, the final nail on the coffin of the presentations idea, was a conversation I had with a student on one of our other courses. They commented that many workshops seemed to end with group presentations, and that it was generally felt among the class that these presentations were an ineffective way of communicating ideas and that they wasted the last third or quarter of the workshop. I immediately thought of my case study workshop, and felt challanged, but unsure of what to do to avoid the ‘student-lead presentations’.

SBAR format

In one of the MSc classes I’m teaching on, we’ve recently set an assignment centred upon an SBAR. SBAR is the acronym for ‘Situation, Background, Assessment and Recommendation’. SBAR is a briefing model and seems to be widely used in the healthcare industries as a structured method of communication allowing staff to pass on essential facts about a patient in a style and sequence that everyone is familiar with.

It has taken me quite some time to the bottom of how and where SBAR was developed. There seems to be quite a few references to it being developed by the US Navy for use in submarines, and then being further refined in the aviation industry. This ‘lineage’ can be found in the SBAR wikipedia entry , and several healthcare related references. (See footnote 1.)

For the MSc assignment the SBAR isn’t being used for patients but for a scenario focussed on a drug supply problem. Although the SBAR format need a bit of tweaking for that assignment, the overall format sits nicely with the idea of a ‘recommendation’ – that is a future action which should be carried out on the basis of observations and understanding. However, for my undergrad case studies workshop, the SBAR idea need some significant alteration because the recommendations have already been described, that is the SBAR becomes entirely retrospective.

So, if I think of SBAR as a briefing model, I can tweak the format as follows:

Healthcare Quality Managment/
Risk analysis
Case Studies
Situation What has the patient presented for?
What is the key information about the patient?
What is the situation you are describing?
What have been the outcomes of the situation?
What is the situation you are describing?
What were the outcomes of the situation?
Background What is the patient’s relevant medical status and history? What are the relevant regulations and guidelines for this situation? What guidelines, or scientific knowledge, has to be communicated for the assessment to be understood?
Assessment What is the diagnosis? What is the assessment of the situation compared to the background regulations?
Does the situation align with, or contradict, the guidelines?
What was the ‘root cause’ of the situation, and how did this contradict the information given in the background
Recommendation What is the recommended future action? What is the recommendation to resolve the situation according to the guidelines? What steps had to be put in place because of the situation?

In each of the above cases the learning outcomes for a class would be that the students can access, understand and apply the information required in each of the SBAR sections (as given in the table above), and present that in a suitable format.

I thought it might be worth expanding a few of the ideas above. For example, for case studies that involve microbiological contamination might include background information about the contaminating bacteria, the disease they cause and where they originate from. Failures in formulation (or production) may have to include information linking the failure to the underlying physico-chemistry of the problem. Essentially, the SBAR must include an understanding of the problem so that the recommendation makes sense.

Community driven learning

The evening before my workshop I thought about swapping the student presentation section out for an SBAR exercise. However, I thought I could give the class the choice of whether to keep the original format, or try the SBARs. I did, after all, only have my observations and the comment of one student from another class, so it seemed fair to give the class to whom the decision affected some say. When given the choice, both the morning and afternoon classes, approved the SBAR choice conclusively with head nodding (and there were no students who expressed a preference for the presentation-based format).

So what’s the data?

I want to be data driven in my teaching. To do this I try to gather data on all my teaching activities (although so far this is only in my workshops and labs) and I do this through my ‘counter-buckets’. This works by giving each student a counter and asking them to place it in one of three buckets on the way out. I take a photo of the buckets giving me data to go back to. (See an example below.) The advantage of getting this data on every lesson is that if I alter something I have a clear idea if it’s made a difference.

The image shows three buckets: one with a smiley face one, one with a neutral face and one with a sad face. The buckets have counters beside them.
The counter buckets (home-made!) that I use to survey activity class (labs and workshops)

The data compared to last year is here:

Format Happy
face
Neutral
face
Sad
face
No. of
counters
Presentations
(2019 class)
65% 21% 14% 96
SBAR
(2020 class)
92% 8% 0% 37

In 2019 I survey both classes, however in 2020 I only surveyed the afternoon class because I forgot my counter set for the morning session. Grrrr! That said, the counter data provides quantitative values to the observation that the class prefers SBAR to student led presentations.

Postscript 18th May 2020

The legal proffession has an equivalent system: IRAC. Standing for Issue, Rule Analysis and Conclusion it allows lawyers to identify and structure legal arguments.

—————————–

Footnotes:

  1. I’m was initially skeptical about the origins of the SBAR. All the papers that I could find pointed to the origins of the SBAR model as coming from the aviation, aerospace or naval industries are healthcare references and where those papers do provide citations, those citations are to other healthcare papers. I can find no evidence that SBAR has any links to the aviation industry. There is some suggestion that SBAR may have originated from Situation Briefing Models (SBM) used in aviation settings (3), and may be linked to Cockpit Resource Management systems (4, 5). However, SBM’s are not mentioned in aviation literature in a manner that links them directly to SBAR. A old school friend of mine who’s been a pilot for over 30 years has never heard of them. There is more evidence connecting SBAR with the US Navy: Doug Bonacum of Kaiser Permanente wrote about adapting his experience as a submariner here. The widely accepted (and recycled) narrative about the uncertain creation of SBAR, contrasts with other quality improvement tools such as the Ishikawa/fishbone diagrams, where the environment where they were developed are well known. I do not doubt that SBAR is a useful tool, and spread memetically (and here I refer to the concept originally proposed by Richard Dawkins regarding the spread of useful ideas), but the widely accepted (and published) narrative about the source of SBAR appears to have an uncertian basis in the peer-reviewed literature.

References:

  1. Sander et al, “Engaging the learner: Reflections on the use of student presentations”, Psychology Teaching Review (2002) 10, 1. Available on 15FEB2020 here. My comment comes from the open line of the abstract. The authors appear to come to this conclusion by citing their own research in the paper. They go on to discuss a program of ‘staff-supported’ student led presentations, which would not be applicable to this single workshop.
  2. Rodgers K., “Using the SBAR Communication Technique To Improve Nurse-Physician Phone Communication: A Pilot Study”, AAACN Viewpoint; Vol. 29, Iss. 2, (Mar/Apr 2007): 7-9. Available on 15FEB2020 in part here.
  3. Curry Narayan, Mary. ” Using SBAR communications in efforts to prevent patient rehospitalizations”. Home Healthcare Nurse. 31(31), 504-517. Available on 15FEB2020 in part here.
  4. Helmreich RL. “On error management: lessons learned from aviation” BMJ 2000;320:781–5
  5. Romijn A, et al. “Complex social intervention for multidisciplinary teams to improve patient referrals in obstetrical care: protocol for a stepped wedge study design”. BMJ Open 2016;6: e011443. Available on 15FEB2020 in part here.
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