Report-now: a critical change in condition or critical lab value should be escalated immediately using SBAR, not deferred.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A client who had a left-hemisphere stroke has expressive (Broca) aphasia. Which nursing approach is MOST appropriate?
Answer: B. In expressive aphasia the client understands speech but has difficulty producing it. The nurse should allow extra time for responses, ask yes/no questions, and use communication aids such as picture boards. Speaking loudly is unnecessary because hearing is intact, completing sentences for the client is frustrating, and avoiding communication promotes isolation.
Question 2 of 5
A nurse delegates obtaining a clean-catch urine specimen to a UAP. What is the nurse's responsibility regarding the right direction and communication?
Answer: B. The right direction/communication means giving clear, specific instructions: what to do, expected outcome, limits, and when to report back. The nurse should explain the procedure clearly and have the UAP report when the specimen is collected. Vague instructions, assuming prior knowledge, or no follow-up violate safe delegation.
Question 3 of 5
During a handoff (SBAR) report, the off-going nurse should include:
Answer: B. Handoff communicates current status, recent changes, pending tasks/results, and safety concerns so care continues safely. Omitting pending results or concerns risks errors.
Question 4 of 5
The nurse uses SBAR to call a provider. The 'R' stands for:
Answer: B. SBAR = Situation, Background, Assessment, Recommendation. The 'R' is the nurse's recommendation/request (e.g., 'I recommend you come evaluate' or 'I'd like an order for...').
Question 5 of 5
A nurse is using SBAR to call the rapid response team about a deteriorating client. Which statement correctly reflects the Recommendation component of SBAR?
Answer: A. In SBAR, Recommendation is the clear request or suggestion for what is needed. Stating I need a provider to evaluate the client now and recommend orders for the change in condition is a recommendation. Reporting the diagnosis is Background, current vital signs are Assessment, and the reason for calling is Situation.
Keep the streak going with more questions like these, each with a full rationale.
What is sbar handoff communication?
It ensures concise, complete, and consistent transfer of critical information. Memory aid: Situation, Background, Assessment, Recommendation.
Key points to remember
- Situation: state who you are, the client, and the immediate concern or reason for the communication.
- Background: provide relevant history, diagnosis, current treatments, and pertinent context.
- Assessment: give your current assessment findings, vital signs, and what you think the problem is.
- Recommendation: state what you need or recommend, and request specific orders or actions.
- SBAR standardizes communication, improves patient safety, and is used for shift handoffs, transfers, and provider notification.
- Some facilities add 'I' for Identify and 'R' for Read-back (ISBAR-R) to confirm accuracy.
Nursing priorities
- Gather current data (vital signs, recent labs, assessment, code status, allergies) before initiating the handoff.
- Communicate using the SBAR structure to deliver concise, complete information.
- State a clear recommendation or request rather than only describing the problem.
- Use read-back/repeat-back to verify verbal and telephone orders.
- Conduct handoffs in a setting that allows questions and clarification.
Patient teaching
- Have the chart, current vital signs, medications and code status in hand before you call.
- State your name, unit and the patient right away, then move through S-B-A-R without backtracking.
- End with a specific request ("I'd like you to see the patient now" or "Can I get an order for an ABG?"), not just data.
Red flags: report now
- Report-now: a critical change in condition or critical lab value should be escalated immediately using SBAR, not deferred.
- Never accept or give a verbal/telephone order without read-back confirmation.
- Do not omit allergies, code status, or high-alert medications from the handoff.
- Never bury an acute change — if the patient is deteriorating, say so in the first sentence.
References
Clinical references for this topic
