Communication, SBAR, Simulation, Student Anxiety, Student Confidence, Undergraduate Nursing Students



  1. Stevens, Natalie
  2. McNiesh, Susan
  3. Goyal, Deepika


Abstract: This study evaluated the effectiveness of the Situation-Background-Assessment-Recommendation (SBAR) technique to reduce anxiety and increase self-confidence levels regarding health care communication among undergraduate nursing students. Baccalaureate nursing students (n = 35) completed anxiety and self-confidence questionnaires before and after an SBAR communication workshop and subsequent simulation. A statistically significant increase in postintervention self-confidence scores was noted with no significant difference in anxiety levels. The findings support the use of SBAR as an organizing tool to promote nursing students' self-confidence during communication; however, further efforts are needed to qualitatively examine how this tool promotes these changes.


Article Content

According to The Joint Commission (2018), poor communication is associated with an increased risk of sentinel events, making effective communication the essential cornerstone of safe nursing care. Novice nursing students have limited knowledge, experience, and few opportunities to practice communication in critical situations, which can negatively impact self-confidence (Yu & Kang, 2017) and their learning ability in the clinical setting (White, 2014).


Research supports the use of standardized communication frameworks, such as Situation-Background-Assessment-Recommendation (SBAR), as an organizing framework to promote safe delivery of care through the systematic delivery of information that is clear and understandable to all individuals involved in the care of the patient (Kostiuk, 2015; Yu & Kang, 2017). The integration of standardized communication frameworks during the education process allows students opportunities to practice, preparing them to communicate effectively as part of the health care team (McComb & Simpson, 2014). Using a mixed-methods design, Kostiuk (2015) noted decreased anxiety (p = .001) and higher perceived confidence (p = .01) among 28 nursing students after students were taught use of a standardized communication framework during handover report. Yu and Kang (2017) noted communication clarity ratings of 62 undergraduate nursing students in Korea significantly increased compared to the control group (p = .001) after participating in multiple clinical simulation scenarios utilizing SBAR handovers; although not statistically significant, higher confidence scores were achieved in the experimental group.


Bedside nurses are responsible for recognizing signs and symptoms of clinical significance and communicating them effectively and accurately to the rest of the health care team. Therefore, it is critical for nursing students to develop confidence in conveying information concisely to others on the team. The use of standardized communication frameworks has been shown to improve nursing students' communication capacity and clarity (Institute for Healthcare Improvement [IHI], 2016; Lancaster, Westphal, & Jambunathan, 2015). The purpose of this study was to build upon the work of previous researchers (Kostiuk, 2015; Yu & Kang, 2017) and evaluate the effect of an SBAR communication workshop on the anxiety and self-confidence levels of undergraduate nursing students when participating in subsequent simulation scenarios.



This study was guided by Benner's (1982) novice-to-expert theory of clinical skill acquisition. According to Benner, nurses move along a continuum of five skill levels (novice, advanced beginner, competent, proficient, and expert) through exposure to patient care situations and experiences. Benner emphasized that nurses must repeatedly practice skills in order to develop knowledge and pass through to higher levels of proficiency. In this study, practice of the SBAR tool was implemented during peer role-play interactions and simulated real-life scenarios to promote skill development.


University institutional review board approval and participant consent were obtained prior to data collection. Using a quantitative, descriptive pretest and posttest design, a convenience sample of junior-level BSN students attending a public university in California were invited to participate in the study. Students provided demographic data and completed the Nursing Anxiety and Self-Confidence With Clinical Decision-Making Scale (NASC-CDM; White, 2014) before and after the intervention; forms were numerically coded for anonymity. Scored on a 6-point Likert-type tool (1 = not at all/do not agree to 6 = totally/agree), the NASC-CDM includes two subscales measuring anxiety and self-confidence. Subscale scores range between 27 and 162, with higher scores indicative of increased anxiety and self-confidence. Reliability for the subscales produced alpha values of .97 and .96, respectively.


The study intervention included two parts. The first part consisted of an SBAR communication workshop; the second part included a simulation session to practice using the SBAR format in clinical scenarios. Training materials for the workshop were developed by the primary investigator from evidence-based literature, IHI (2016) guidelines, and SBAR-related material in the nursing curriculum. The primary investigator presented a 20-minute lecture that included SBAR format review and detailed examples of how to prioritize and organize assessment findings into the format. Working in small groups, the students then applied the SBAR technique to a series of case studies.


Six to eight weeks after the SBAR communication workshop, students attended a regularly scheduled obstetrical simulation session in the nursing laboratory. Groups of eight to nine students participated in three simulation scenarios that focused on acute obstetrical events: postpartum hemorrhage, neonatal sepsis, and precipitous vaginal delivery. Students rotated through the scenarios as either observers or active participants with an overall objective to use SBAR when reporting patient information to the charge nurse or physician in each scenario. At the end of the simulation session, participants completed the NASC-CDM posttest questionnaire.



Of a possible 60 students, 35 (58 percent) completed both the pre- and posttest NASC-CDM. The majority were female (n = 25, 71.4 percent) between 20 and 37 years of age; the majority self-identified as Asian (n = 20, 57.2 percent), Hispanic (n = 5, 14.3 percent), or Caucasian (n = 4, 11.4 percent). Participant characteristics, anxiety, and self-confidence scores were analyzed using descriptive statistics and inferential tests.


Paired t-test analysis revealed a statistically significant increase in mean self-confidence from pre- (range = 70 to 140) to postintervention (range = 75 to 157), p = <.05, t = -2.434. No significant difference was noted in anxiety scores before and after the intervention.



Findings support the use of an SBAR communication workshop to enhance students' self-confidence levels with regard to health care communication. Our findings are in accord with Kostiuk (2015), who also noted a significant increase in nursing students' confidence levels (p = .01) after completing a standardized communication framework workshop. However, Kostiuk's findings have limited generalizability given all 28 participants were female and of European descent, whereas our sample was more diverse with regard to gender and race.


The findings should be interpreted with caution given the small sample size, convenience sampling, and time lapse (six to eight weeks) between the SBAR communication workshop and simulation session. A post hoc power analysis indicated the sample size was sufficient to detect a change in self-confidence but not in anxiety; a sample size >100 would have been required to note a change in anxiety. The time lapse between the communication workshop and simulation session, where students practiced SBAR, further limits our findings. It is unknown whether other factors influenced self-confidence, for example, more time spent in clinical and/or more exposure to clinical experiences.


Nurses must be able to competently assess and communicate patient care needs to others on the health care team; yet nursing students often harbor high levels of anxiety and lack self-confidence when communicating with the team. Therefore, it is critical for nurse educators to integrate the use of standardized communication frameworks into all levels of undergraduate nursing curricula to assist students with organizing and disseminating information. The use of SBAR can promote nursing students' self-confidence during health care communication; however, more efforts are needed to examine the effect of SBAR utilization on students' anxiety levels. Future researchers should strive to recruit more diverse samples in order to increase the generalizability of findings. In addition, more qualitative inquiry is needed to examine how standardized communication frameworks enhance knowledge, skills, and attitudes regarding health care communication (Anderson & Nelson, 2015).




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