Improving nursing documentation using the SBAR-D framework among nurses in an acute inpatient ward: a best practice implementation project

Abstract

Introduction: Nursing electronic documentation fulfills a vital legal and quality assurance role; however, nurses perceive it as a significant time and effort burden.

Objectives: This project aimed to improve the quality and effectiveness of nursing documentation by implementing a framework for free-text documentation using the SBAR-D framework in a general medicine ward.

Methods: This evidence implementation project used the JBI Evidence Implementation Framework. The JBI Framework follows a seven-phase approach and is grounded in an audit and feedback process, along with a structured method for identifying and managing barriers to compliance with recommended clinical practices. A novel translation of a communication tool was developed as a framework for nursing documentation. Time-saved data were collected from electronic medical record user reports and were presented descriptively.

Results: The project met the target 80% compliance with best practice recommendations. Three barriers were identified and seven strategies to overcome these barriers were successfully implemented. Time saved through the implementation was quantified.

Conclusion: Implementing the SBAR-D framework for free-text documentation has significantly improved compliance with best practice recommendations of logical, sequential nursing documentation, improving the quality of documentation in the pilot setting. This positive pilot has led to the successful expansion of the SBAR-D framework into four other acute wards. The study institution has also begun expanding the SBAR-D framework hospital-wide and codifying this evidence-based practice change as part of regular standard operating procedures, making it a core part of induction packages for new staff and an area of focus for continuing education.

Spanish abstract: http://links.lww.com/IJEBH/A531.

Keywords: electronic nursing documentation: free-text narratives: SBAR-D; evidence-based practice; standardization; time management.