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BAB I

PENDAHULUAN

A. Latar Belakang
There are many different approaches to hand-off communication, including shift
report in a room, at the nurses station, by phone, and at the bedside. Much of the
literature indicates a need for a standardized communication method such as the
Situation-Background-Assessment-Recommendation (SBAR) technique. This technique
provides a framework for effective communication among members of the healthcare
team and helps create an environment that allows individuals to speak up and express
their concerns. This, in turn, reduces the risk of adverse events and ultimately fosters a
culture of patient safety.

B. Rumusan Masalah
1. Apa yang dimaksud dengan nursing report?
2. Apa sajakah langkah-langkah dari nursing report?
3. Apa sajakah perhatian komunikasi pada nursing report?
C. Tujuan
1. Untuk mengetahui apa yang dimaksud dengan nursing report
2. Untuk mengetahui langkah-langkah dari penulisan nursing report
3. Untuk mengetahui perhatian komunikasi pada nursing report

BAB II
PEMBAHASAN

A. Nursing Report
There are many different approaches to hand-off communication, including shift
report in a room, at the nurses station, by phone, and at the bedside. Much of the
literature indicates a need for a standardized communication method such as the
Situation-Background-Assessment-Recommendation (SBAR) technique. This
technique provides a framework for effective communication among members of the
healthcare team and helps create an environment that allows individuals to speak up
and express their concerns. This, in turn, reduces the risk of adverse events and
ultimately fosters a culture of patient safety.
Improving the communication between caregivers can prevent negative patient
outcomes and strengthen a teamwork approach to care. The SBAR technique provides
common expectations such as what will be communicated, how it’s structured, and
what are the required elements. It allows communication to be focused on the
problem and not the people. This is very important when staff members are
communicating hand-off information at the change of shifts.
The SBAR technique also provides a way to hand-off relevant information in the
presence of the patient, allowing active participation of the patient in his or her
care.the patient is central to allinformation surrounding care activities. Patient can ask
questions or add information to the discussion. Through this procces, the patient sees
the staff working as a team and is assured that all involved know and agree on the
plan of care. Evidence suggests that better-informed patients are less anxious and
more likely to follow medical advice.
Now let’s take a look at how following the steps in the SBAR acronym leads the
speaker to convey information in a methodical and logical way so that the listener can
easily follow.

B. Following The Steps


1. Situation. The “S” component should take about 8 to 12 seconds. The nurse
states what’s happening now. If giving a shift report to the next caregiver, the
nurse states the patient’s name, why the patient is on the unit, and introduces the
nurse coming on duty to the patient. For exemple: “Ms. J, this is Tina Jones, the
registed nurse who will be caring for you today. Tina, Ms. J is here to have rehab
after her right knee replacement. “To be effective you must be concise, clear, and
to the point when giving the report, leaving irrelevant information out of the
conversation.
2. Background. During the “B” compenent, the nurse gives the next caregiver brief
background information specific to the patient’s relevant history. This section sets
the context for what’s being discussed which may include the patient’s diagnosis,
history of procedures done, and family situation. For exemple: “Ms. J had a right
knee replacement on June 3rd by Dr. Smith. She has a history of hypertension,
diabetes, and arthritis. She lives with her husband who’s retired and able to care
for her at home when discharged.
3. Assessment. During the “A” compenent, the nurse report the current condition of
the patient. For exemple: “Blood glucose levels have been stable, vital signs witin
normal limits, and the incision line is clean and dry with no drainage noted. The
dressing was changed today. Ms. J is able to ambulate to the restroom with a
contact guard of one and the use of a walker. Her pain has been reported as a 7 on
a 0-to-10 scale and she was given two hydrocodone pills at 9 a.m. The hydrocone
appears to be helping her, especially when given before therapy”.
4. Recommendation. During the “R” component, the nurse states what he or she
thinks would be the nurse states what he or she thinks would be the desired
response to the pateint’s care of the day. She may suggest that discharge planning
be initiated by discussing needs with the patient, contacting the physician with
discharge plans, and conveying to the rest of the care team what needs to be done
before discharge. You don’t need to read the entire patient profile or orders. For
example: “Ms. J is scheduled for discharge this Friday and will need to speak to
the discharge planner today.”
Remember, not everything about the patient needs to be conveyed, just what’s
pertinent to the situation at that time. Also remember that effective
communication takes two: Ask if there are any questions and remind team
members and the patient that you’ll be available should further clarification be
needed.

C. Communication Concerns
Although nurses communicate all the time with their patient, it’s sometimes
difficult for them to conduct a report that includes the patient. One reason for this
uneasiness has been identified as fear of having to interrupt the patient if he or she
monopolized the report episode. Staff nurses who fell comfortable communicating in
the presence of and with patients can share their techniques to demonstrate best
practices to the nurses who are unsure of the procces.
Informing the patient of his or her role in the bedside report process is also
important. To guide patient participation and minimize the disclosure of irrelevant
information, remind your patient of the upcoming bedside report toward the end of
the shift. To minimize interruptions by the patientduring the report, use this time to
address the patient’s needs for pain relief, toileting, and other requests.
You should also discuss the bedside report process with the patient upon
admission to the unit. The patient can choose whether the family or significant other
can be present during the bedside report, and those wishesmust be passed from nurse
to nurse. One hospital made signs for each patient room that reminded the patient, as
well as the nurses, about the reporting process. Preparing patients proved to be a vital
part of this hospital’s implementation process successful bedside report.

D. As easy as S, B, A, R
As you continue to use the SBAR technique, you’ll enjoy the benefits of effective
communication with your coworkers at the bedside. These benefits include the
oncoming nurses ability to visualize patients immediately and prioritize care for the
shift. Nurses can also demonstrate equipment use and share information related to
individual patient needs. Accountability between shifts is promoted by immediate
visualization of patient needs by both shifts. And staff- reletionships are improved
because communication between shifts is face to face, which builds teamwork and
decreases blame. It’s that effective.
BAB III

PENUTUP

A. Kesimpulan
The nursing report is a standard report that is indispensable as communication
between nurses to nurses to know the patient’s development which includes Situation-
Background-Assessment-Recommendation.

B. Saran
Menyadari bahwa penulis masih jauh dari kata sempurna, kedepannya penulis
akan lebih focus dan details dalam menjelaskan tentang makalah di atas dengan sumber-
sumber yang lebih banyak yang tentunya dapat dipertanggung jawabkan.
DAFTAR PUSTAKA

Anderson CD, Mangino RR. Nurse Shift Report: who says you can’t talk in front of the patient?
Nurse Adm Q. 2006;30(2):112-122. dikutip dari googleweblight.com

Caruso EM. The Evolution Of Nurse to Nurse Bedside Report On A Medical-Surgical


Cardiology Unit. Medsurg Nurs. 2007;16(1):17-22 dikutip dari googleweblight.com

Institute for Healthcare Improvement. SBAR technique for communication: a situational briefing
model.