SBAR Framework
What is SBAR?
SBAR (Situation, Background, Assessment, Recommendation) is a standardised communication framework endorsed by the WHO, JCI, and GCC health authorities. It ensures critical information is conveyed clearly, concisely, and completely — especially during handover, escalation, and nurse-to-doctor calls.
When to use SBAR
- Calling a doctor about a deteriorating patient
- Handing over at end of shift
- Requesting urgent review or medication order
- Activating Rapid Response Team
- Reporting a clinical concern to a senior nurse
- Transfer of care between departments
Key benefits
- Reduces miscommunication errors
- Creates shared mental model
- Ensures critical details are not omitted
- Reduces cognitive load under stress
- Supports less experienced nurses
- Meets JCI IPSG 2 communication standard
SBAR Components
S
B
A
R
ISBAR Introduction + SBAR
The I-SBAR variant adds a formal Introduction step, recommended when calling unfamiliar clinicians or across departments.
I
Then follow with S — B — A — R as normal.
I-PASS Paediatric Handover Mnemonic
Validated for paediatric handovers; also used in adult medicine. Focuses on shared understanding and synthesis.
I
P
A
S
S
✎ Interactive SBAR Builder
Fill in the fields below to generate a ready-to-use SBAR handover script.
Sample SBAR Call Scripts
Scenario 1 — Deteriorating Patient (respiratory)
"Good evening, Dr Hassan — this is Nurse Rania Mansour, Staff Nurse on Ward 6. I am calling about Mrs Leila Haddad in Bed 12, MRN 208741.
SITUATION: She has developed increased work of breathing over the last 45 minutes.
BACKGROUND: She was admitted yesterday with an exacerbation of COPD. She is on salbutamol nebs Q4H, IV hydrocortisone, and Augmentin. No known allergies.
ASSESSMENT: Her RR is now 32 breaths/min, SpO2 is 87% on 4L O2, HR 124, BP 95/58, temperature 38.6°C. NEWS2 score is 10. She is anxious and using accessory muscles.
RECOMMENDATION: I need you to review her immediately. I am preparing to activate the Rapid Response Team if she does not improve in the next few minutes."
Scenario 2 — Pain Management Request
"Dr Al-Farsi, this is Nurse Ahmed on Surgical Ward 3. Calling about Mr Tariq Suleiman in Bed 8, MRN 309112.
SITUATION: He is in significant pain following his laparotomy today, rating it 9/10.
BACKGROUND: Post-op Day 1, laparotomy for perforated duodenal ulcer. Currently on paracetamol 1g QID and tramadol 50mg PRN — last dose was 6 hours ago. Allergies: codeine (nausea).
ASSESSMENT: Pain score is 9/10. He is guarding his abdomen, unable to take deep breaths. Vitals stable: BP 138/86, HR 98, RR 20.
RECOMMENDATION: His current analgesia is insufficient. Could you review his pain management and consider adding a stronger analgesic or adjusting the tramadol dose?"
Scenario 3 — Family Concern
"Dr Khaled, this is Nurse Mariam on Medical Ward 2, calling about Mr Ibrahim Al-Zaabi, Bed 3, MRN 417823.
SITUATION: His family is very concerned — they feel he looks worse than yesterday and are requesting an urgent doctor review.
BACKGROUND: Admitted 5 days ago with stroke. Partial left hemiplegia. On aspirin, atorvastatin, amlodipine.
ASSESSMENT: Clinically, his vitals are currently stable, but I have noticed he is less responsive than this morning and GCS has dropped from 14 to 12. His family may have noticed this before us.
RECOMMENDATION: I would like you to come and review him and speak with his family, who are currently present at the bedside."
Scenario 4 — Medication Query
"Good morning, this is Nurse Priya Thomas, Pharmacy-Liaison Nurse on Ward 7. I have a query about Mrs Noura Hassan, MRN 519043.
SITUATION: I have a stat order for IV gentamicin 240mg but I cannot verify her recent renal function.
BACKGROUND: She is a 68-year-old with DM2, hypertension, and chronic kidney disease Stage 3. The last creatinine in the chart was from 4 days ago — 145 µmol/L.
ASSESSMENT: Given her CKD, this dose may need adjustment. I am concerned about nephrotoxicity.
RECOMMENDATION: Could you review and confirm the dose, or order an urgent creatinine before we administer?"
Shift Handover
Handover Methods Compared
| Feature | Bedside Handover | Written Handover | Recorded Audio |
|---|---|---|---|
| Patient involvement | High — patient can correct errors | Low | None |
| Error risk | Lower — real-time visual check | Moderate (transcription errors) | Higher (no confirmation) |
| Time required | Moderate | Low-moderate | Low |
| Legal standing | Must be backed by written record | Strong | Weak — not archivable in most systems |
| Information completeness | High | Depends on template | Prone to omissions |
| GCC recommendation | Preferred (DHA, JCI) | Required as backup | Not recommended alone |
Bedside Handover — PACE Mnemonic
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A
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E
Time-Out Principle: Never conduct a handover while simultaneously performing clinical tasks (medication administration, wound care, patient handling). Handover requires your full cognitive attention. Distraction during handover is a documented patient safety risk.
✎ Structured Handover Builder
Complete the fields below to generate a structured written handover summary.
Common Handover Errors
Errors to Avoid
- Incomplete or selective information transfer
- Conducting handover during clinical tasks
- Interruptions not managed (silence devices)
- Language barriers — assuming understanding
- No read-back to confirm accuracy
- Handing over to the wrong person
- Not including the patient's own report
- Relying on memory instead of written notes
Best Practices
- Use a standardised template every time
- Conduct at the bedside whenever possible
- Limit interruptions — use a quiet space
- Use professional interpreter if needed
- Ask incoming nurse to read back key points
- Confirm identity before beginning
- Check patient's wristband during handover
- Document that handover was completed
Escalation & Deterioration
Critical Principle: "Nurse concern" — your gut feeling that a patient "just doesn't look right" — is a VALID and recognised criterion for activating the Rapid Response Team. Do not wait for a specific threshold to be crossed if you are worried.
NEWS2 — National Early Warning Score 2
NEWS2 assigns scores to 7 physiological parameters. The aggregate score determines the escalation response.
| NEWS2 Score | Clinical Risk | Response |
|---|---|---|
| 0 | Low | Routine monitoring — continue scheduled obs |
| 1–4 | Low | Increase frequency of observations, inform charge nurse |
| 5–6 | Medium | Urgent review by ward doctor within 30 minutes |
| Score 3 in any single parameter | Medium–High | Urgent review — consider HDU referral |
| ≥7 | High | Immediate emergency response — RRT/MET activation |
NEWS2 parameters: Respiration Rate, SpO2, Supplemental O2 (yes/no), Blood Pressure, Pulse, Level of Consciousness (ACVPU), Temperature.
Rapid Response Team (RRT) / MET Activation Criteria
Activate immediately if ANY of the following are present:
Airway: Threatened or obstructed airway — stridor, unable to speak
Breathing: RR <8 or >30/min; SpO2 <90% despite supplemental O2
Circulation: HR <40 or >130 bpm; SBP <90 mmHg or fall >40 mmHg from baseline
Neurology: GCS fall ≥2 points; new agitation, confusion, or unresponsiveness
Urine output: <0.5 mL/kg/hr for 2 consecutive hours
Uncontrolled pain: pain score ≥8 not responding to prescribed analgesia
Acute change in skin: new mottling, pallor, cold clammy extremities
Nurse concern: "something is not right" — you are worried even if vitals appear normal
Code Blue — Your Role
When to call Code Blue
- Cardiac arrest (no pulse, unresponsive)
- Respiratory arrest (no breathing)
- Airway emergency not responding to basic manoeuvres
- Anaphylaxis with cardiovascular collapse
Nurse Roles During Code Blue
- First responder: call Code Blue via hospital emergency number
- Begin CPR immediately — 30:2 ratio or continuous chest compressions
- Attach AED / defibrillator as soon as available
- Assign roles: compressor, airway, IV, documentation, timekeeper
- Document timeline: time of arrest, time of call, time team arrived, interventions
- Prepare crash cart — ensure medication tray is accessible
Documentation of Escalation
- Time concern was first identified
- Observations that triggered concern (vitals, NEWS2)
- Time of call made and to whom
- Read-back of information provided (SBAR)
- Response time of clinician
- Orders received and actions taken
- Patient response to interventions
- Time of RRT arrival (if activated)
- Subsequent reassessment and outcome
SBAR Escalation Examples
Scenario — SpO2 drop, respiratory distress
S: "Mr Hassan in Bed 9 has developed acute shortness of breath. He is distressed and unable to complete sentences."
B: "He's a 62-year-old admitted for post-op monitoring after right hip replacement today. Background of COPD and hypertension. On enoxaparin, ramipril, and salbutamol nebs PRN."
A: "SpO2 has dropped to 86% on 4L O2. RR 34. HR 118. BP 142/88. He appears cyanotic. NEWS2 = 11. I am concerned about pulmonary embolism or acute COPD exacerbation."
R: "I need you here immediately. I am activating the Rapid Response Team now and applying a non-rebreather mask at 15L."
Scenario — Sudden confusion / GCS drop
S: "Mrs Aisha, Bed 4, has become acutely confused. She is not recognising her family and is pulling at her IV line."
B: "Admitted 2 days ago with UTI. Day 2 of IV ceftriaxone. No prior confusion documented. PMH: DM2, mild CKD. Last BGL was 5.4 mmol/L this morning."
A: "GCS has dropped from 15 to 11. ACVPU: Confused. Temp 38.8, HR 110, BP 105/65. I am concerned about sepsis or acute delirium secondary to infection."
R: "Please review her urgently. I am requesting blood cultures, lactate, and repeat BGL. I will hold her next dose of metformin pending review."
Difficult Communication Situations
Breaking Bad News — SPIKES Protocol
SPIKES is the internationally recognised framework for breaking bad news. Nurses are often present when bad news is delivered and must be familiar with this approach.
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P
I
K
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S2
Language Barriers — Non-English Speaking Patients
Critical rule: Never use a family member to interpret medical information. Family members may omit, modify, or emotionally filter critical clinical information. Use a professional medical interpreter for all clinical discussions.
Interpreter Resources — GCC
- MOHAP (UAE) — hospital-contracted interpreter services
- LanguageLine Solutions — telephone interpretation
- DHA-accredited hospital interpreter lists
- Saudi MOH interpreter services
- CBAHI facility language assistance policy
- In-person interpreter for high-stakes conversations (consent, end-of-life)
Practical Tips
- Request interpreter in advance when possible
- Speak directly to the patient, not the interpreter
- Use short sentences — pause for translation
- Use visual aids and written instructions
- Confirm understanding: "Can you explain back to me what we discussed?"
- Document that an interpreter was used and their name/ID
Angry or Aggressive Patients — De-escalation
De-escalation Techniques
- Stay calm — regulate your own voice and posture
- Do not argue or raise your voice
- Acknowledge the feeling: "I understand you are frustrated."
- Move to a private area where possible
- Maintain safe distance — do not block the exit
- Offer choices to restore sense of control
- Involve charge nurse early
Safety Triggers — Call Security If:
- Physical threats are made
- Patient becomes physically aggressive
- Property is damaged
- You or a colleague feels unsafe
- Patient attempts to leave against medical advice with risk to self or others
Document all incidents using your facility's Incident Reporting System (IRS). Record: time, behaviour, actions taken, persons involved, outcome.
Informed Consent — Nurse's Role
Witness vs Informer: The nurse's role is to WITNESS a consent signature — confirming the patient signed voluntarily, appeared competent, and was not coerced. The nurse does NOT provide the clinical information about the procedure — that is the doctor's responsibility. If a patient has questions about the procedure, refer them back to the doctor BEFORE signing.
- Confirm patient identity before witnessing consent (2 identifiers)
- Confirm patient appears competent and is not under duress
- Confirm patient has received information from the doctor
- Ensure patient has had an opportunity to ask questions
- Do not witness consent if patient expresses doubt or has unanswered questions
- Document that consent was obtained, who obtained it, and that patient appeared to understand
DNAR — Do Not Attempt Resuscitation
GCC/Islamic context: In many GCC countries, families (particularly senior male relatives) are culturally expected to be central to end-of-life decisions. While the patient's autonomy remains paramount, clinicians must be sensitive to family dynamics. Many Muslim scholars consider withdrawal of futile treatment permissible; however, DNAR decisions require explicit physician authorisation and clear documentation.
- DNAR must be ordered by the responsible physician — nurses do not issue DNAR orders
- Order must be clearly documented in the medical record with date, time, and reasoning
- DNAR does not mean "do not treat" — comfort care and active symptom management continue
- Communicate the DNAR status clearly during every handover
- Ensure DNAR documentation is visible at the bedside per facility policy
- If family challenges a DNAR: acknowledge distress, involve senior clinician and ethics if needed
- Nurses must know their own facility's DNAR documentation requirements (DHA, HAAD, MOH)
GCC Cultural Communication Tips
These are generalisations to inform sensitivity — always treat each patient and family as individuals. Cultural humility means asking, not assuming.
- Avoid delivering bad news to a patient alone if family is present and the patient has indicated family involvement is welcome
- In traditional Arab families, the eldest male relative may be approached as the family spokesperson — this does not override the competent patient's right to information and decision-making
- Prayer times are important — avoid non-urgent clinical tasks during prayer if the patient requests
- Modesty concerns: ensure same-gender care provider where possible, maintain dignity during examinations
- Ramadan fasting: medications and IV schedules may need to be adjusted — coordinate with the team
- Physical touch: ask before touching patients of the opposite gender for non-clinical interactions
- Eye contact norms vary: do not interpret avoidance of eye contact as disengagement or dishonesty
- Communication across teams: handover to doctors should include all clinical findings; to physiotherapists — mobility status, precautions; to dietitians — intake, cultural/religious dietary needs; to pharmacists — allergy history, compliance concerns
Documentation Standards & Quiz
Legal Principles of Nursing Documentation
Legal Principle: "If it is not documented, it was not done." In a legal dispute, only documented evidence can be relied upon. Verbal accounts without written records have no legal weight.
Core Documentation Standards
- Contemporaneous: document at or as close as possible to the time of the event
- Objective language: describe what you observe, not what you interpret — "Patient refused to take medication" not "Patient was non-compliant"
- No blank spaces: draw a line through empty spaces; no blanks left for later completion
- No deletions: cross through errors with a single line, write "Error", add date/time/signature
- Standardised abbreviations only: use only your facility-approved abbreviation list
What Must Be Documented
- All clinical assessments and reassessments
- Every medication given: drug, dose, route, time, site, nurse signature
- Patient teaching: what was taught, patient's response, understanding confirmed
- All escalation communications (SBAR calls, RRT activation)
- Consent obtained — who obtained it, patient's response
- Incidents and near-misses (both in notes and IRS)
- Patient and family communication
- Transfer and handover completion
GCC-Specific Standards
| Standard / Authority | Key Requirement | Jurisdiction |
|---|---|---|
| DHA Medical Records Standards | Entries must include: date, time, full name, designation, and signature. Electronic records require secure login audit trail. | Dubai, UAE |
| HAAD / DOH Standards | All nursing entries in the medical record are legal documents. Telephone orders must be countersigned by the physician within 24 hours. | Abu Dhabi, UAE |
| CBAHI Documentation Requirements | Nursing documentation must be part of the integrated patient record. Nursing care plans must reflect patient's individualised goals. Assessment every shift mandatory. | Saudi Arabia |
| JCI IPSG 2 | Communication of critical test results: must be documented within the defined timeframe. Verbal/telephone orders require read-back verification and documentation. | JCI-accredited facilities |
| JCI IPSG 1 | Patient identification: two identifiers must be confirmed before any procedure, medication, or blood product administration. | JCI-accredited facilities |
Common Documentation Errors
Errors That Create Legal Risk
- Documenting before performing the action
- Falsifying records (illegal — criminal offence)
- Using correction fluid (Tipp-Ex) on paper records
- Signing for another nurse's entry
- Using non-approved abbreviations
- Late entries without noting the delay
- Copying-and-pasting in electronic records without review
- Leaving entries unsigned
How to Correct Errors Properly
- Draw a single line through the error
- Write "Error" or "Mistake" next to it
- Add your initials, full name, date, and time
- Write the correct entry immediately after
- In electronic systems: use the "Addendum" or "Correction" function only
- Never delete original entries in electronic records
🎓 Knowledge Check — 10-Question Quiz
Test your knowledge of SBAR, escalation, documentation, and cultural communication. Select your answer then click Check.
1. In the SBAR framework, the "A" (Assessment) section should include:
2. A patient's NEWS2 score is 8. What is the appropriate action?
3. A patient's family member offers to interpret for a clinical consultation because "no one else is available." What should you do?
4. Under GCC and JCI documentation standards, when a nurse makes an error in a paper medical record, what is the correct procedure?
5. Which of the following is a valid criterion for activating the Rapid Response Team?
6. What is the nurse's role when witnessing a patient's informed consent signature?
7. According to NEWS2, a patient scores 3 in a single parameter (e.g., respiratory rate of 30/min). What does this require?
8. In the SPIKES protocol for breaking bad news, what does the "I" (Invitation) step involve?
9. A DNAR (Do Not Attempt Resuscitation) order is in place for a patient. The patient develops worsening pain. What is the appropriate nursing action?
10. Which JCI International Patient Safety Goal (IPSG) specifically addresses communication of critical test results?