Advocacy is an essential aspect of fundamental nursing practice and is an expected component of the nursing role. Advocacy is an essential aspect of fundamental nursing practice and is an expected component of the nursing role (American Nurses Association [ANA], n.d.). Multiple and varied healthcare organizations and nursing leaders urge nurse advocacy at all policy levels, ranging from bedside units to international healthcare venues (Kirpatrick, 2014; Patton, Zalon, & Ludwig, 2015; Porter-O’Grady & Malloch, 2016; Stokowski et al., 2010). The ANA (2015) Code of Ethics describes influencing social and healthcare policy as an ethical duty of all nurses; furthermore, the organization continuously promotes advocacy through example and resource offerings (ANA, n.d.). The American Academy of Nursing (2017) stresses the necessity of nurse advocacy to accomplish national healthcare goals. The Institute of Medicine of the National Academies appeals to nurses to be fully involved in, and sometimes lead, healthcare modeling and decision-making to optimize healthcare delivery and to advance the nursing profession (National Academies Press, 2011). The American Association of Colleges of Nursing (AACN) promotes advocacy (political and otherwise) as essential to professional nursing education, research, and practice (AACN, 2006; 2008; 2011).

...nurses consistently advocate for patients in healthcare settings, [but] they too often neglect advocacy in the policy arena. While it is well documented that nurses consistently advocate for patients in healthcare settings, they too often neglect advocacy in the policy arena (Disch, Keller, & Weber, 2015; Patton et al., 2015). Nurses have the potential to impact healthcare for several reasons. Nursing, identified by surveys as the most trusted profession (Brenan, 2017), the largest healthcare profession (Kreitzer & Koithan, 2014), and a profession which stands at the crossroads between healthcare policy and healthcare delivery, is potentially the most powerful profession to impact healthcare policy. Nurses’ expertise, experience, knowledge and skills are essential to contributing to meaningful and relevant healthcare policy decisions. However, a substantial barrier to this influence is the lack of the profession’s voice in the national healthcare policy arena (Robert Woods Johnson Foundation [RWJF], 2010). Two primary barriers to nurse advocacy include a perceived lack of personal free time and a perceived lack of skill when addressing policymakers (Cramer, 2002; Jansson et al., 2016; Jurns, 2017; Marshall et al., 2008; Vandenhouten, Malakar, Kubsch, Block, & Gallagher-Lepak, 2011). The SBAR communication tool can be an effective strategy for nurses to address these barriers and effectively interact with key policy stakeholders in a variety of policy venues.

The purpose of this article is to discuss nurse advocacy and to examine SBAR as a means by which nurses can effectively and confidently interact with policymakers. I discuss the history of SBAR communication, provides an exemplar of SBAR application in policy settings, and offer future research and educational implications.

History of SBAR Communication

The SBAR communication tool was initially developed by the United States Navy to improve communication... The SBAR communication tool was initially developed by the United States Navy to improve communication among personnel (Westwood et al., 2012). Sometimes preceded with an “I” for identify, SBAR neatly segments communication into the categories of situation, background, assessment, and recommendation. An evidence-based tool, SBAR has been demonstrated to guide effective and efficient verbal and/or written communication regarding patients’ conditions (Marshall, Harrison, & Flanagan, 2008). Clinical use of SBAR has been promoted by the Joint Commission (n.d.); the Institute for Healthcare Improvement (in association with Kaiser Permanente) (Kaiser Permanente of Colorado, 2017); and numerous other healthcare organizations and facilities. The SBAR briefing tool was specifically developed to aid in sharing vital information in time-pressured scenarios and demonstrates positive effects on communication’s flow and pace (Marshall, Harrison, and Flanagan, 2008).

SBAR Application in Healthcare Settings
In healthcare, (I)SBAR is used to organize communication about a patient in the following way:

(I)dentify – Stating who you are and of whom you speak
(S)ituation – Briefly describing what is happening with, or the concern regarding, a patient
(B)ackground – Sharing pertinent information and a concise patient history
(A)ssessment – Giving your expert professional assessment of what is occurring
(R)ecommendation/ Request – Offering your professional recommendation for a course of action.

Given that healthcare organizations employ the clinical application of the SBAR format, use of the tool in the policy arena would likely be relatively straightforward process.

Benefits of SBAR to Policy Advocacy
Nurses’ perceived lack of available personal time is a significant barrier to policy advocacy. Time Optimization. There are significant benefits to using SBAR’s focused, time-efficient, evidence based, and familiar communication format to promote policy advocacy among nurses. Nurses’ perceived lack of available personal time is a demonstrated barrier to advocating (Cramer, 2002; Vandenhouten, Malakar, Kubsch, Block, & Gallagher-Lepak, 2011). Cramer’s (2002) work found it to be the leading barrier. Using the SBAR tool addresses this need in several ways. Because many nurses are familiar with the tool, no additional learning is required. Additionally, because templates guide communicators, they can serve to lessen the burden of communication and potentially optimize user time.

Receiving SBAR communications is also practical from the policymakers’ perspective. Policymakers have limited time to examine issues and interact with stakeholders (Brownson, Royer, Ewing, & McBride, 2006; Kingdon, 2003). Using SBAR communication provides the template for nurses to effectively and succinctly describe issues and provides policymakers with the pertinent information required to make informed healthcare policy decisions. See Table 1 for additional information about applying (I)SBAR in communication with policymakers.

Effective Communication. Nurses’ perceived ability to speak and present effectively is positively correlated with increased political advocacy, while perceived lack of skill contributes to decreased advocacy involvement (Jansson et al., 2016; Jurns, 2017; Vandenhouten et al., 2011). The SBAR tool provides nurses a comfortable template for efficient and effective communication with policymakers. Applying the SBAR tool in the policy arena allows even nurses inexperienced in policy issues to stand upon the familiar ground of past experience as a seasoned communicator, enhancing their self-perception within the policy realm. Nurse comfort level in this application is explained and supported by both constructionist learning theory (Candela, 2012), which holds that new knowledge is built by viewing it through the interpretive lens of existing foundational knowledge, and Knowles (1973) adult education theory which recognizes adults thrive when connecting new knowledge with past experiences. Using SBAR may foster nurses’ perceptions of competence and efficiency, thus promoting participation in future advocacy activities.

Table 1. Applying (I)SBAR in Communicating with Policymakers

Communicating efficiently and succinctly has been identified as a key factor in influencing and interacting with policymakers. Effective Communication. Nurses’ perceived ability to speak and present effectively is positively correlated with increased political advocacy, while perceived lack of skill contributes to decreased advocacy involvement (Jansson et al., 2016; Jurns, 2017; Vandenhouten et al., 2011). Communicating efficiently and succinctly has been identified as a key factor in influencing and interacting with policymakers (Brownson et al., 2006; Kingdon, 2003).

The SBAR tool provides nurses a template for efficient communication with policymakers. As many nurses are familiar with the SBAR communication strategy, perceptions of effectiveness using SBAR is explained by constructionist learning theory which posits that new knowledge is built by viewing it through the interpretive lens of existing foundational knowledge (Candela, 2012) and adult education theory (Knowles, 1973) which suggests adults thrive when connecting new knowledge with past experiences. Applying the SBAR tool in the policy arena may support nurses, especially those inexperienced in political advocacy, to stand upon the familiar ground of past experience as effective communicators and enhance self-efficacy in political advocacy arenas. Using SBAR may foster nurses’ perceptions of competence and efficiency, thus promoting continued participation in future advocacy activities.

SBAR Application in Policy Settings: Exemplar

Table 2 provides an example of using (I)SBAR in written communication with a policymaker. A brief in-person conversation using SBAR would be similarly modeled.

Table 2. Sample Communication with Policymaker

Future Research and Educational Implications

While the SBAR communication tool is well documented in clinical and military literature (Marshall et al., 2008), continued research is necessary to demonstrate the efficacy of applying SBAR-modeled communication in policy arenas. Existing literature suggests that SBAR as a useful strategy to decrease barriers to nurse advocacy, including a perceived lack of personal free time and perception of inadequate skill when addressing policymakers (Cramer, 2002; Jansson et al., 2016; Jurns, 2017; Marshall et al., 2008; Vandenhouten et al., 2011). Established learning theories provide support for SBAR use by nurses familiar with the tool (Candela, 2012; Knowles, 1973). Future research should include examination of nurses’ perceptions of self-efficacy when using the tool in political advocacy situations.

...it is advantageous for those already comfortable with the SBAR tool to know that they possess a policy advocacy skill as well. Another future application of this work is to incorporate SBAR advocacy use into nursing education. As policy coursework is not mandatory until the baccalaureate level, and a large percentage of nurses in the United States have not yet earned a bachelor’s degree in nursing, many nurses may have never taken policy-related coursework (Accreditation Commission for Education in Nursing, 2017; AACN, 2006; 2008; 2011; RWJF, 2015). Education is a key step when implementing change (Grol & Grimshaw, 1999). Incorporating this application of SBAR into nursing curriculum at all levels may help to educate new generations of nurses who are not well-versed in this skill, possibly leading to increased participation in advocacy among these cohorts. Nurses’ perceptions of preparedness for political participation relates to frequency of advocacy (Vandenhouten et al, 2011). Therefore, it is advantageous for those already comfortable with the SBAR tool to know that they possess a policy advocacy skill as well. Continuing education forums, whether in workplaces or through professional organizations, may promote the use of SBAR as an efficient strategy in various policy arenas for practicing nurses.

Summary

The importance of nurse advocacy in policy matters and the current gap in this practice area is well established. Using SBAR, an evidence-based, time efficient communication tool known to many nurses and nursing students, is a logical approach to overcoming barriers to participating in policy advocacy. Nurses must find their voice in order to promote the nursing profession and to optimize population health endeavors in policy arenas.

Acknowledgment: The author would like to express appreciation to Mark McClelland DNP, RN, CPHQ Director, Quality International Operations, The Cleveland Clinic Foundation, for his encouragement and guidance in the early stages of writing this manuscript.

Errata Notice: Carolyn Jurns, author of "Using SBAR to Communicate with Policymakers" published November 28, 2018, recently advised us that a sentence in the sample letter to Senator Smith was omitted from the publication. This article was amended on July 9, 2020 to add the missing sentence addressing the (A) part of the acronym SBAR to the sample letter.

Author

Carolyn Jurns, DNP, MSN, RN
Email: cjurns@gmail.com

Carolyn Jurns DNP, MSN, RN has extensive experience related to nurse advocacy in state nursing organization and campaign manager capacities, as well as clinical experience in adult medical surgical critical care. Her doctoral research at Walden University in Minneapolis, Minnesota focused on understanding variables correlated with nurses’ advocacy frequency.