S.A.F.E 3: Structured communication


A key component of introducing situation awareness is having reliable mechanisms for communicating within the team. This section provides an outline of the importance of structured communication and some tools that can help embed it.

Using structured communication

In order to achieve non-hierarchichal communication within a microsystem, it is useful to agree on a structured approach to communication.

The main benefit is to help embed a reliable transfer of information, providing a framework for the information that needs to be communicated. This approach can also be used to allow individuals who may not fully understand what has been said to pause the conversation and have the information repeated.

The underlying principle is to introduce and embed a structured way for staff to provide accurate information and to be able to challenge potentially unsafe processes in a protected and constructive way.

Some examples of structured communication

Can I have clarity?: This indicates that the process or communication is not clear and provides a pause. This allows the process to be rechecked and reviewed, or the conversation to be repeated, before being restarted once everything is clear.

SBAR (Situation Background Assessment Recommendation): As shown in the diagram below, this provides a non-threatening and easy-to-follow framework to improve communication and lead to a decision.

ISBAR is a variation, where I stands for Identify.

SBAR - Situation; Background; Assessment; Recommendation

Figure 1: SBAR Communication Model


This presentation provides a brief introduction to ISBAR and how it can be implemented. Introducing ISBAR is like learning a new language and as such, will require practice, role-play and an adherence to a new way of communicating.

Presentation 3 - Using Structured Communication (PPT, 787KB)

Tools and worked examples

Implementing structured communication can be difficult, especially to get to a position where it is used reliably and consistently.

S.A.F.E recommends two key tools, SBAR and CUSS, but we recognise that there are many variations on the same themes. The main message is to understand structured communications and find a tool that suits you.

Tool 1: Situation, Background, Assessment, Recommendation (SBAR)

The NHS Institute for Innovation and Improvement (NHS III) described SBAR as a structured method for communicating critical information that requires immediate attention and action, contributing to effective escalation and increased patient safety. Used with PEWS (covered in the next section), it can help staff to escalate a concern when the PEWS indicates the need for additional intervention.

The way in which SBAR is introduced will determine the extent to which it is adopted. SBAR can be used effectively to enhance handovers between shifts, or between staff in the same or different clinical areas.

SBAR is an area where you may see some variation. You may find it prefaced with an I (Identify) to prompt an active introduction at the start of the handover. Or, a D (Decision) to ensure any decision taken is repeated and noted down. You may see both.


NHS III SBAR Teaching Guide

Tool 2: Concern, Uncomfortable, unSafe, Stop (CUSS)

Similar in some ways to the "Can I have clarity" question, in that it allows someone to express concern regarding an instruction or process in a non-threatening way, CUSS provides a levelled and assertive approach to raising concern.

Presentation - The CUSS Tool (PPT, 76KB)


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