In health care organizations, the main source of information about residents is
the medical record. In practice, however, care teams communicate
about residents in many ways. These include whiteboards
(with lists of residents that may change every day), notes that
one caregiver leaves for the next, and instructions for various
These are outside the official medical record, but they fill a need
In addition to these ways of documenting what is going on with
the resident, there are tools that can help with the process team
members use to communicate with each other. This section of
the module reviews two such tools: SBAR and CUS (see the
Additional Tools and Resources section of this workbook).
SBAR (Situation, Background, Assessment, Recommendation)
SBAR stands for Situation, Background, Assessment,
and Recommendation, and it should be used for general
communication among team members about patient updates.1
SBAR is an easy-to-remember framework for structuring
communication among team members. It should be the main
method used at shift-to-shift handoffs. SBAR is especially useful
in situations that require immediate attention and action.
- Identify yourself.
- Identify the resident.
- State the problem.
- Give a physical assessment report.
- Be brief and concise.
- Brief medical history.
- Health care already provided.
- Medications list.
- Vital signs.
- Lab results.
- Advance directive or code status.
- Life-threatening condition?
- What should happen next?
- What do you need?
Nursing assistants can use SBAR when communicating
with licensed nurses; licensed nurses can use SBAR when
communicating with doctors.
- Be sure to have the resident's situation in your mind before you start. If you NOTES
are a nursing assistant talking to a licensed nurse, this is usually what you have
noticed about the resident. If you are a licensed nurse talking to a doctor, this is
usually your physical assessment of the resident and a review of the chart.
- When you are ready, identify yourself, your organization or agency, and the
resident's name. Say what is going on with the resident that is a cause for
concern. Keep it short and to the point.
- Next, be sure you can describe the background. If you are a nursing assistant,
it may be how the resident was before the change (e.g., he/she was eating
normally or usually talkative). If you are a licensed nurse, it may include a
brief medical history, recent clinical findings, and advance directive or code
status (such as: "she has diabetes; her last hemoglobin A1C was [x]; and she
has a living will that she wants no resuscitation if it comes to that").
- In an SBAR assessment, you share the results of your clinical assessment of
the resident. If you are a nursing assistant, you could say: "I think you might
want to evaluate her" or "I don't know what this means but hope you
will take a look." If you are a licensed nurse, you may assess that the
problem is severe or life-threatening. For instance, you may say "I
think he may have had a stroke." or "Her Coumadin is well above the
- Then, in an SBAR recommendation, say what you think might need to
happen next. If you are a nursing assistant, you might say "I'm hoping
you will come and see her as soon as possible." If you are a licensed
nurse talking to a doctor, you might say the same thing or ask about something
that could be done in the meantime. For instance, you might say "Shall I take a
voice order for some vitamin K right away?"
Benefits of SBAR
- Critical thinking skills.
- Patient safety.
There are many benefits to using the SBAR tool. It helps ensure clear
communication. And clear communication helps to make a safe environment. It
makes for familiar expectations for everyone, and it encourages critical thinking
Tips for Using the SBAR Tool
- Review the chart before calling/communicating.
- Complete every section of the SBAR tool before calling/communicating.
- Speak clearly.
- Document the SBAR in progress notes.
An example of a complete SBAR communication from a nursing assistant to a
licensed nurse is:
"Ms. C fell asleep in her clothes this evening and cursed at me. She is the
85-year-old from room C6; she is usually pretty friendly and does her own
ADLs. She seems OK physically, but I'm worried. I'd feel better if you would take
a look at her and make an assessment."
CUS (Concerned, Uncomfortable, Safety)
CUS is a way to emphasize concern when it seems like someone is not
listening.2 If you are communicating with a fellow team member, and
worry that your communication is not getting through, CUS may be
helpful. It stands for:
- I am Concerned about my resident's condition.
- I am Uncomfortable with my resident's condition.
- I believe the Safety of the resident is at risk.
- I am Concerned.
- I am Uncomfortable.
- The Safety of the resident is at risk.
CUS can sometimes overcome barriers to communication by emphasizing our
personal stake in our residents' well-being. It should not be used routinely. Only
use CUS when the situation is urgent.
An example of a CUS communication from a nursing assistant to a licensed NOTES
"I'm concerned that Ms. C is not her usual self. I'm uncomfortable
that she is behaving so oddly. I believe she is not safe; she may have something
serious going on that we are missing."
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What Should Be Communicated
Types of Change to Be Reported
A list of changes to watch for in residents was described in detail in the
preceding module, "Detecting Change in a Resident's Condition." These include:
- Bowel and urination patterns.
- Level of weakness.
- Vital signs.
- Demeanor (appearance or way of acting).
- Confusion or agitation.
- Resident complaints of pain.
Information to Be Communicated
- Top physical and non-physical changes to watch for in residents.
- Nursing assistant communication tasks.
- Licensed nurse communication tasks.
Who Should Report About What
Each type of nurse (e.g., nursing assistant to licensed nurse) has his or her
own set of information to communicate. The next two sections present
communication action steps for nursing assistants and licensed nurses.
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Communication Action Steps for Nursing Assistants
In the case of nursing assistants, the important information is: what just
happened and what was it like before that is now different. For example, that
information may include:
- The nursing assistant's observations and concerns about the changes in the resident's condition.
- Any communication among nursing assistants about the resident's changing condition.
- Any previous communications between the nursing assistant and the licensed nurse, as well as any previous communication with a supervisor.
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Communication Action Steps for Licensed Nurses
Licensed and especially charge nurses have communication action steps that go in several directions:
- In communications with nursing assistants, licensed nurses can summarize communication between nursing assistants, keep nursing assistants up-to-date on the nursing assessment of the situation, and respond to a nursing assistant's concerns about a resident.
- In communications with other licensed nurses, they should provide a shift-toshift report and communicate with a supervisor about changes in a resident's condition.
- In communications with primary care providers (nurse practitioners or doctors), they could use the SBAR tool described above to structure their report and set in motion whatever action may be necessary.
- If the SBAR communication does not seem to work, the licensed nurse can move to the CUS model to help ensure his or her message gets across.
1. Haig KM, Sutton S, Whittington J. SBAR: A shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf 2006; 32:167-175.
2. TeamSTEPPS®: Strategies and Tools to enhance performance and patient safety. Department of Defense and Agency for Healthcare Research and Quality. Rockville, MD: Agency for Healthcare Research and Quality; 2008. Available at http://teamstepps.ahrq.gov/. Accessed January 19, 2012.
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