Nurses recognize and promote the importance of advocacy for nurses at all levels of practice. Despite increased involvement of nurses in policy arenas in recent years, existing evidence suggests a continued practice gap in nurse advocacy, particularly related to approaching national policy stakeholders. The reason for this gap are nurses’ perceived lack of personal free time to engage in policy activities and perceived lack of skill in communicating with policymakers. The situation, background, assessment and recommendation (SBAR) situational briefing tool is an evidence-based communication tool familiar to many nurses. 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. The author discusses the history of SBAR communication, provides an exemplar of SBAR application in policy settings, and offers future research and educational implications. Using SBAR when engaging in activities with policy makers may help nurses overcome perceived barriers and more effectively engage with key policy stakeholders.
Key Words: Hospital policy, organizational policy, political participation, politics, advocacy, consumer advocacy, SBAR, policymaker, communication, nursing
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
Corresponding Component in Communication with Policymaker
Identify self and your (Advocacy and Communication Solutions [ACS], 2015; American Public Health Association, n.d.):
Personal qualifications to speak on this issue (American Public Health Association, n.d.; Brownson et al., 2006; Teater, 2009)
Association with significant stakeholder or stakeholder group (if applicable) (ACS, 2015; American Public Health Association, n.d.; Teater, 2009)
Summarize the concern (ACS, 2015; American Public Health Association, n.d.; Brownson et al., 2006)
Educate the policymaker regarding the issue (ACS, 2015; American Public Health Association, n.d.; Kingdon, 2003; Brownson et al., 2006)
Policymakers are often not aware of a healthcare related issue or may not understand its details or ramifications of policy decisions
Need for action
Immediate relevance: Explain why the status quo is unacceptable (ACS, 2015; Kingdon, 2003; Teater, 2009)
When sharing this information, it is more impactful if it is:
This is your personal recommendation or, if applicable, the recommendation of a larger group with which you are affiliated (ACS, 2015; Kingdon, 2003; Teater, 2009)
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
Hello Senator Smith:
(I) As an RN who has lived and practiced in your district at X facility for 15 years,
Thank you for your time and attention.
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.
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.
Carolyn Jurns, DNP, MSN, RN
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.
Accreditation Commission for Education in Nursing. (2017). Comparison of the 2017 and 2013 standards and criteria. Retrieved from http://www.acenursing.org/comparison-2017-2013-standards/
Advocacy and Communication Solutions. (2015). Key tips for meeting with policymakers. Retrieved from http://www.advocacyandcommunication.org/wp-content/themes/acs/docs/resources/policy_maker_engagement_December_2015/ACS_Key_Tips_Policymaker_Meeting_Tips_.pdf
American Academy of Nursing. (2015). 2017-2020 strategic plan. Retrieved from http://www.aannet.org/about/strategic-plan-2017-20
American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. Retrieved from https://www.aacnnursing.org/Portals/42/Publications/DNPEssentials.pdf
American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice [Educational standards]. Retrieved from https://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf
American Association of Colleges of Nursing. (2011). The essentials of master’s education in nursing [Educational standard]. Retrieved from https://www.aacnnursing.org/Portals/42/Publications/MastersEssentials11.pdf
American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Retrieved from http://nursingworld.org/DocumentVault/Ethics-1/Code-of-Ethics-for-Nurses.html
American Nurses Association. (n.d.). Advocacy. Retrieved from http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy
American Public Health Association. (n.d.). Tips for making a visit to your policy-maker. Washington, DC: Author. Retrieved from http://ties.prevenmed.com/bibliografia/tips_policy.pdf
Brenan, M. (2017, December 26). Nurses keep healthy lead as most honest, ethical profession. Gallup.Retrieved from http://news.gallup.com/poll/224639/nurses-keep-healthy-lead-honest-ethical-profession.aspx
Brownson, R. C., Royer, C., Ewing, R., & McBride, T. D. (2006). Researchers and policy makers: Travelers in parallel universes. American Journal of Preventive Medicine, 30(2), 164-172. doi:10.1016/j.amepre.2005.10.004
Candela, L. (2012). From teaching to learning: Theoretical foundations. In D. M. Billings & J. A. Halstead (Eds.), Teaching in nursing: A guide for faculty (4th ed., pp. 202-243. St. Louis, MO: Elsevier, Saunders.
Cramer, M. E. (2002). Factors influencing organized political participation in nursing. Power, Politics, and Policymaking, 3(2), 97-107. doi:10.1177/152715440200300203
Disch, J., Keller, M., & Weber, E. (2015). Applying a nursing lens to shape policy. In R. M. Patton, M. L. Zalon, & R. Ludwick (Eds.), Nurses making policy, From bedside to boardroom (pp. 359-394). New York, NY: Springer.
Grol, R., & Grimshaw, J. (1999). Evidence based implementation of evidence-based medicine. Joint Commission Journal on Quality Improvement, 25(10), 503-513.
Jansson, S. B., Nyamathi, A., Heidermann, G., Ward, R. C., Brown-Saltzman, K., Duan, L., & Kaplan, C. (2016). Predicting levels of policy advocacy engagement among acute-care health professionals. Policy, Politics & Nursing Practice, 17(1), 43-55. doi:10.1177/1527154416644836
Joint Commission. (n.d.). Transitions of care: The need for a more effective approach to continuing patient care. Retrieved from https://www.jointcommission.org/assets/1/18/Hot_Topics_Transitions_of_Care.pdf
Jurns, C. S. (2017). Promoting policy advocacy in nursing via education (Doctoral dissertation). Available from ProQuest Dissertations and Theses database. (UMI No. 10280307)
Kaiser Permanente of Colorado. (2017). SBAR technique for communication: A situational briefing model. Retrieved from http://www.ihi.org/resources/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.aspx
Kingdon, J. W. (2003). Agendas, alternatives, and public politics (2nd ed.). New York, NY: Addison-Wesley Education Publishers.
Kirpatrick, D. (2014). From the president. Ohio Nurses Review, 89(5), 3.
Knowles, M. (1973). The adult learner: A neglected species. Retrieved from http://eric.ed.gov/?id=ED084368
Kreitzer, M. J., & Koithan, M. (2014). Integrative nursing. New York, NY: Oxford University Press.
Marshall, S., Harrison, J., & Flanagan, B. (2008). The evaluation of structured communication tools in healthcare. Retrieved from Proceedings of the Human Factors and Ergonomics Society 52nd Annual Meeting-2008. doi:10.1177/154193120805201221
National Academies Press. (2011). The future of nursing: Leading change, advancing health. Retrieved from https://www.nap.edu/read/12956/chapter/1
Patton, R. M., Zalon, M. L., & Ludwig, R. (2015). Nurses making policy: From bedside to boardroom. New York, NY: Springer Publishing.
Porter-O’Grady, T., & Malloch, K. (2016). Leadership in nursing practice, Changing the landscape of health care (2nd ed.). Burlington, MA: Jones & Bartlett Learning.
Robert Wood Johnson Foundation. (2015, September 9). In historic shift, more nurses graduate with bachelors degrees [Press release]. Retrieved from https://www.rwjf.org/en/library/articles-and-news/2015/09/more-nurses-with-bachelors-degrees.html
Robert Woods Johnson Foundation. (2010, January 9). Groundbreaking new survey finds that diverse opinion leaders say nurses should have more influence on health systems and services. Retrieved from http://www.rwjf.org/en/library/articles-and-news/2010/01/groundbreaking-new-survey-finds-that-diverse-opinion-leaders-say.html
Stokowski, L. A., Sansoucie, D. A., McDonald, K. Q., Stein, J., Robinson, C., & Lovejoy, A. (2010). Advocacy: It is what we do. Advances in Neonatal Care, 10(2), 75-82. doi:10.1097/ANC.0b013e3181d50db8
Teater, B. (2009). Influencing state legislators: A framework for developing effective social work interest groups. Journal of Policy Practice, 8, 69-86. doi:10.1080/15588740802282540
Vandenhouten, C. L., Malakar, C. L., Kubsch, S., Block, D. E., & Gallagher-Lepak, S. (2011). Political participation of registered nurses. Policy, Politics, & Nursing Practice, 12(3), 159-167. doi:10.1177/1527154411425189
Westwood, J. D., Westwood, S. W., Fellander-Tsai, L., Haluck, R. S., Robb, R. A., Senger, S., ... Dev, P. (2012). SBAR ’flattens the hierarchy’ among caregivers. Studies in Health Technology & Informatics, 173