An-Najah National University Faculty of Graduate Studies COMPARISON OF NON-INTENSIVE CARE UNIT (ICU) VERSUS ICU NURSES’ PERCEPTIONS AND SATISFACTION WITH THE USE OF THE SITUATION, BACKGROUND, HOSPITAL ASSESSMENT, AND RECOMMENDATION (SBAR) TOOL: A MULTICENTER RESEARCH By Rasheed Darawsheh Supervisors Dr. Sa'ed Zyoud Dr. Aidah Alkaissi This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Critical Care Nursing, Faculty of Graduate Studies, An-Najah National University, Nablus - Palestine. 2023 II COMPARISON OF NON-INTENSIVE CARE UNIT (ICU) VERSUS ICU NURSES’ PERCEPTIONS AND SATISFACTION WITH THE USE OF THE SITUATION, BACKGROUND, HOSPITAL ASSESSMENT, AND RECOMMENDATION (SBAR) TOOL: A MULTICENTER RESEARCH By Rasheed Darawsheh This Thesis was Defended Successfully on 6/7/2023 and approved by Sa'ed Zyoud Supervisor Signature Aidah Alkaissi Co-Supervisor Signature Maher Khdour External Examiner Signature Wafiq Othman First Internal Examiner Signature III Acknowledgement First, I give all the glory to God, the source of my strength, for granting me both the mental and physical endurance to complete this monumental task. I would like to express my gratitude to my awesome supervisor: Dr. Sa'ed Zyoud and Dr. Aidah Alkaissi for believing in me and for their diligent supervision, clear guidance, continued support and encouragement throughout this process. Special thanks should also be given to An-Najah National University for creating various opportunities for me, believing in me and giving me right road. I extend my sincere gratitude to An-Najah National University Hospital for giving me the opportunity to apply my thesis. Last but not the least; I would like to thank my family, my parents and lovely ones, for supporting me throughout my life. This accomplishment would not have been possible without them. To everyone who gave me the moral support for the completion of this task, Thank you. Author Rasheed Darawsheh 2023 IV Declaration I, the undersigned, declare that I submitted the thesis entitled: COMPARISON OF NON-INTENSIVE CARE UNIT (ICU) VERSUS ICU NURSES’ PERCEPTIONS AND SATISFACTION WITH THE USE OF THE SITUATION, BACKGROUND, HOSPITAL ASSESSMENT, AND RECOMMENDATION (SBAR) TOOL: A MULTICENTER RESEARCH I declare that the work provided in this thesis, unless otherwise referenced, is the researcher‘s own work, and has not been submitted elsewhere for any other degree or qualification. _____________________________________ Student's Name: _____________________________________ Signature: _____________________________________ Date: V List of Contents Acknowledgement ....................................................................................................................... III Declaration ................................................................................................................................ IV List of Contents ........................................................................................................................... V List of Tables ........................................................................................................................... VII List of Figures ......................................................................................................................... VIII List of Appendices ................................................................................................................... IX Abstract ........................................................................................................................................ X Chapter One: Introduction .......................................................................................................... 1 1.1 Background ............................................................................................................................ 1 1.2 Problem Statement .............................................................................................................. 13 1.3 Significance of the study .................................................................................................... 14 1.4 Aims of the study ................................................................................................................ 16 1.5 Hypotheses ........................................................................................................................... 16 Chapter Two: Methods .............................................................................................................. 18 2.1 Study Design ....................................................................................................................... 18 2.2 Study population ................................................................................................................. 18 2.3 Sample Setting ..................................................................................................................... 18 2.4 Research Sample and Sample Methods ........................................................................... 18 2.5 Data Collection Process and Tool ..................................................................................... 19 2.6 Data and statistical analyses .............................................................................................. 20 2.7 Ethical Considerations ........................................................................................................ 20 Chapter Three: Results ............................................................................................................... 21 1.3 Sociodemographic characteristics .................................................................................... 21 3.2 Nurses' satisfaction with the Situation, Background, Assessment, and Recommendation (SBAR) tool for handover communication .................................... 27 3.3 Nurse perception with the Situation, Background, Assessment, and recommendation (SBAR) tool for handover communication .................................................................... 31 3.4 Nurses‘ Perceived Barriers to Nursing Using SBAR ..................................................... 34 3.5 Demographics associated with nurses' knowledge and practices regarding patient safety after cardiac catheterization .................................................................................. 36 Chapter Four: Discussions and Conclusions ....................................................................... 39 4.1 Discussion and Interpretation of the Main Results ......................................................... 39 VI 4.1.1 Perception of the nurse‘s use of SBAR as a communication tool ............................. 39 4.1.2 Satisfaction of nurses with the usage of SBAR as a Communication Tool ............. 40 4.1.3 Perceptions of barriers to SBAR use as a communication tool ................................. 43 4.2 Comparison of non-intensive care unit (icu) versus icu nurses‘ perceptions and satisfaction with the use of the (SBAR) tool for handover communication .............. 44 4.3 Clinical implications and significance of the current study .......................................... 45 4.4 Strength and Limitation Points .......................................................................................... 46 4.5 Conclusions.......................................................................................................................... 48 4.6 Recommendations ............................................................................................................... 48 4.7 Clinical practice .................................................................................................................. 49 References .................................................................................................................................. 51 Appendices ................................................................................................................................. 59 ب‌ .......................................................................................................................... …………الولخص VII List of Tables Table 1: Table using the SBAR communication approach .................................................... 3 Table 2.A: Demographics associated with nurses' knowledge and practices regarding patient safety after cardiac catheterization ........................................................ 22 Table 2.B: Demographics associated with nurses' knowledge and practices regarding patient safety after cardiac catheterization (Cont.) ........................................... 23 Table 3: Comparison of non-intensive care unit (ICU) versus ICU nurses‘ perceptions and satisfaction with the use of the (SBAR) tool for handover communication ...................................................................................................... 26 Table 4.A: Nurse satisfaction with the Situation, Background, Assessment, and Recommendation (SBAR) tool for handover communication ........................ 28 Table 4.B: Nurse satisfaction with the Situation, Background, Assessment, and Recommendation (SBAR) tool for handover communication (Cont.) .......... 29 Table 5: Nurse Perception with the Situation, Background, Assessment, and Recommendation (SBAR) tool for handover communication ........................ 32 Table 6: Nurse perception barriers to nursing using SBAR ................................................ 35 Table 7.A: Demographics associated with nurses' knowledge and practices regarding patient safety after cardiac catheterization ........................................................ 37 Table 7.B: Demographics associated with nurses' knowledge and practices regarding patient safety after cardiac catheterization (ccont.) .......................................... 38 VIII List of Figures Figure 1: Distribution of age groups ....................................................................................... 23 Figure 2: Distribution of place of study ................................................................................. 24 Figure 3: Distribution of experience ....................................................................................... 24 Figure 4: Distribution of wards ............................................................................................... 25 Figure 5: Distribution of qualifications .................................................................................. 25 Figure 6: Distribution of receiving SBAR ............................................................................. 26 Figure 7: Nurse satisfaction with the Situation, Background, Assessment, and Recommendation (SBAR) tool for handover communication ........................ 30 Figure 8: Nurse Perception with the Situation, Background, Assessment, and Recommendation (SBAR) tool for handover communication ........................ 33 Figure 9: Nurse perception barriers to nursing using SBAR ............................................... 36 IX List of Appendices Appendix A: Consent form ..................................................................................................... 59 Appendix B: Data Collection Sheet ....................................................................................... 60 Appendix C: IRB Acceptance letter ...................................................................................... 67 X COMPARISON OF NON-INTENSIVE CARE UNIT (ICU) VERSUS ICU NURSES’ PERCEPTIONS AND SATISFACTION WITH THE USE OF THE SITUATION, BACKGROUND, HOSPITAL ASSESSMENT, AND RECOMMENDATION (SBAR) TOOL: A MULTICENTER RESEARCH By Rasheed Darawsheh Supervisors Dr. Sa'ed Zyoud Dr. Aidah Alkaissi Abstract Background: Patient safety is crucial for the delivery of effective, high-quality healthcare, and poor communication is found in many different healthcare settings, including handovers, shift exchanges, rounds, and team meetings. The SBAR tool was used for effective communication between nurses and between nurses and other HCPs. Therefore, the purpose of this study was to examine perception, satisfaction, and perceived barriers among Palestinian nurses working in the ICU regarding the use of the SBAR tool for effective communication. Methods: This cross-sectional study was conducted in Palestinian hospitals. Data were collected from 208 participants through a questionnaire that was adopted from previous studies in this field. Data were collected by convenience sampling. The nurses answered a questionnaire covering social demographics, satisfaction, perception and perceived barriers. IBM-SPSS software was used for all analyses, and median utility indices used a Bloom cut-off point for positive satisfaction and satisfied perceptions were equal or high. Results: Overall, 208 nurses completed the study questionnaires. The median age of the study participants was 27 years, with an IQR of 25.0-29.0. The median satisfaction score was 95, with an interquartile range of 89.0 to 102.0. Approximately fifty percent (n = 106) of the respondents scored 95 (median). The median perception score was 36.0, with an interquartile range of 33.0 to 39.0. A total of 55.3% (n = 115) of the respondents XI scored 36 (median). The 25-29 age group showed better satisfaction than the other age groups, with a median satisfaction of 97 (p < 0.001). Additionally, nurses with 3 to 5 years in the field showed good satisfaction, with a mean satisfaction of 98 (p < 0.001). Additionally, participants did not share any direct barriers to SBAR, but approximately 42.3% did not know when asked about time constraints. Additionally, 41.8% were unaware of the physician's delay in response. Conclusions: Our study revealed that participants of the SBAR framework as a communication tool had negative satisfaction and unsatisfied perceptions. Future research should provide more evidence of its viability and effectiveness compared to conventional handover tools and in other healthcare scenarios. Keywords: SBAR; perceptions; nurses; satisfaction; perceived barriers; safety; patient safety. 1 Chapter One Introduction 1.1 Background The National Health Services (NHS) established a set of values for nursing practice in England as a response to the obvious lack of compassion found in several reports that resulted in poor care quality, and these values were introduced as the ‗6C‘ and were also updated in 2016 by the NHS and introduced into a new framework for nursing. These 6Cs are care, compassion, courage, communication, competence, and commitment and are considered the core values and the backbone of the nursing profession (Baillie, 2017). Therefore, an adequate communication process in the nursing profession is an essential dimension that enhances quality of care and reduces risks and complications. Patient safety stands as an indisputable cornerstone in the provision of high-quality and effective healthcare services. According to the comprehensive definition put forth by the World Alliance for Patient Safety (WHO), patient safety entails the meticulous endeavor to curtail the potential for avoidable harm linked to healthcare procedures to a level that is deemed acceptable (McElroy et al., 2016). The significance of patient safety reverberates through the lens of adverse events, which frequently serves as a paradigm to illustrate its profound influence on healthcare excellence. Adverse events, as classified by Skelly et al., encompass injuries resultant from medical interventions that subsequently lead to prolonged hospitalization and/or enduring incapacitation upon patient discharge (Skelly, Cassagnol, & Munakomi, 2022). Amid the intricate tapestry of healthcare, an underlying catalyst emerges in the form of deficient communication, casting its shadow over more than 60% of reported hospital-related adverse events as scrutinized by the Joint Commission (Joint Commission, 2015). Particularly vulnerable are instances of inpatient handovers and scenarios demanding swift and precise handling, where the specter of poor communication looms prominently. Within the annals of healthcare, settings such as the perioperative phase, the intensive care unit (ICU), and the exigent confines of the emergency room resonate as quintessential examples of environments where effective communication is of paramount significance. It is here that the complexities of 2 communication, fraught with intricacies and susceptible to misunderstanding, come into play (Dayton & Henriksen, 2007; Edmonds, 2011; Haller, Laroche, & Clergue, 2011; Müller et al., 2018; Reader, Flin, Mearns, & Cuthbertson, 2007). Ergo, a compelling need arises for communication techniques that offer seamless execution, expeditious transmission of comprehensive information, fostering of interprofessional collaboration, and a palpable reduction in the odds of errors. Such a need finds its embodiment in the SBAR (situation, background, assessment, recommendation) protocol and its varied iterations, encompassing ISBAR, SBAR-R, ISBARR, and ISOBAR. These methodologies have been embraced with open arms across diverse healthcare facilities, serving as instrumental tools for facilitating both intraprofessional and interprofessional interactions, especially in the context of handovers and communication exchanges (See Table 1) (S. Y. Lee, Dong, Lim, Poh, & Lim, 2016; Riesenberg, Leitzsch, & Little, 2009; Von Dossow & Zwissler, 2016).In general, studies have found that nurses tend to be more detailed when communicating than physicians, who tend to use brief statements. Furthermore, in critical events, the main communication between nurses and physicians is by telephone, which makes communication more susceptible to errors, and up to 65% of serious adverse events that occur in hospitals have a major contributing factor to communication (Rabøl et al., 2011). The most popular method for preventing such communication errors is the acronym SBAR (Riesenberg et al., 2009). SBAR has since been widely promoted by organizations such as the Institute for Healthcare Improvement and the National Health Service to improve communication (Improvement Institute for Healthcare, 2023). A recent systematic review drew attention to the mixed impacts of SBAR on patient outcomes and patient safety and the lack of high-quality studies (Müller et al., 2018). 3 Table 1 Table using the SBAR communication approach SBAR Questions Description Example S Situation What is the patient's condition? What situation are you calling or communicating about? The nurse introduces the scenario by first giving his name, the patient's name, and a brief description of the problem. Dr. X, I am calling regarding Mr. Z, who is having respiratory problems. B Background What is the patient's history or current situation? The background information is then given, including the patient's diagnosis or cause of admission, current medical condition, and pertinent past events. The other healthcare provider's queries are expected after seeing the patient's file. He is a 54-year- old guy with chronic lung disease, and things have been getting worse for a while. A Assessment What is the issue? Then, particular details on the patient's vital signs, the most recent laboratory results, and other quantitative or qualitative data related to their present condition are given. A tentative diagnosis or clinical impression can be included in this section. His right chest does not make any sounds like he's breathing. He may have a pneumothorax, I believe. R Recommendation What is the next step in the patient's care? The nurse must offer a well-informed recommendation for the patient's further care. The urgent requirement is addressed in detail, along with what is required to solve the issue. I truly need you to visit him. I think he requires a chest tube. Note. Dunsford, 2009; S. K. Powell, 2007; S. M. Powell & Hill, 2006 4 Table 1 using the SBAR communication approach (Dunsford, 2009; S. K. Powell, 2007; S. M. Powell & Hill, 2006). The tool is available for download from the website of the Institute for Healthcare Improvement (Improvement Institute for Healthcare, 2023). The inception of the SBAR tool finds its roots in the innovative corridors of the United States Navy (US), where it was first conceived. This pioneering concept was subsequently embraced by Kaiser Permanente, an eminent American consortium known for its tailored healthcare provisions and comprehensive coverage. As this tool traversed from naval origins to the realm of healthcare, its transformative potential became evident, proving to be a formidable ally in the battle against clinical errors. The versatile nature of the SBAR handover tool came to the fore, showcasing its adaptability in diverse communication modalities. Whether in direct face-to-face interactions, telephonic exchanges, or the realm of meticulous documentation, the SBAR tool stood resolute in its effectiveness (Ting, Peng, Lin, & Hsiao, 2017). A paramount aspect of the SBAR tool's prowess lies in its structured approach, meticulously designed to serve as a user-friendly conduit. Within this framework, nurses find themselves equipped with a systematic checklist-like mechanism, which, in turn, serves to mitigate the risk of information overload. The tool's modus operandi facilitates a judicious and concise dissemination of factual insights, imbued with clarity and focus, all while eliminating redundancy. The ripple effect of such an approach is palpable—an environment where relevant details are conveyed with precision, sparing healthcare practitioners from the burden of redundant information (Ting, Peng, Lin, & Hsiao, 2017). Amid the intricate fabric of healthcare, the SBAR tool takes on yet another role—that of a harbinger of standardized practices in handover protocols. This standardization, in turn, bestows nurses and their fellow Healthcare Professionals (HCPs) with a profound sense of confidence. By virtue of its regulatory influence on information exchange, the SBAR tool establishes a cohesive landscape, a harmonious stage for the sharing of patient-related particulars. This, in essence, becomes a cornerstone for both the anticipated patient information and the collective trust of the healthcare team (van der Wulp, Poot, Nanayakkara, Loer, & Wagner, 2019). 5 To highlight the benefits of applying the SBAR tool in intensive care units (ICUs), a Jordanian study was conducted by (Dalky, Al-Jaradeen, & AbuAlRrub, 2020), who concluded that nurses in healthcare settings should be encouraged to use SBAR. In the study, the 43-item ICU physician‒nurse questionnaire was used, which implemented a quasiexperimental methodology with a convenience sample of 71 ICU nurses from the Adult ICU and cardiac care unit (CCU). The questionnaire measures three main dimensions: general relationship and communication (22 items), teamwork and leadership (20 items) and job satisfaction (1 item), all of which are evaluated on a 5-point Likert scale from strong agreement to disagreement. The SBAR tool was provided in the targeted departments, and two months later (including the implementation of the SBAR technique and the hosting of SBAR workshops), the questionnaire was used once more to reassess the level of communication and satisfaction as part of the project. The tool was used to assess the three dimensions in the first phase, where the SBAR tool was not applied, with an examination of the level of knowledge about SBAR among the target sample. Overall, the results of the study showed a statistically significant improvement in the knowledge of SBAR from the pretest (mean = 2.8) to the posttest phases (mean = 5.75, p value 0.001), with scores ranging from 0 to 7. Additionally, the paired sample t test revealed a substantial increase in general physician‒nurse relationships and communication areas (p value = 0.001) and overall satisfaction (p value = 0.010). To manage patient information throughout the transfer process and decrease communication errors between nurses and other health care providers, researchers found that the implementation of a standardized evidence- based tool for interprofessional communication is encouraged and recommended. To adopt SBAR as a tool in handing over reports to ensure patient safety culture and quality of nursing care in noncritical care areas, conduct a quasiexperimental study with pre- and posttests on 83 nurses working in those areas. According to the author, acceptance and adherence to the SBAR tool among nurses promote accountability and contribute to promoting patient safety, as well as the quality of patient progress reports. Most nurses see SBAR favorably as a tool to manage patient progress reports in noncritical care areas effectively and quickly (Arumugam, Hassan, SHA, & Irwan, 2016). 6 A study in Taiwan (Ting et al., 2017) examined how the SBAR instrument affected attitudes toward patient safety in a particular obstetric department. In three phases, the first was preinterventional, and the second and third were postinterventional. The Safety Attitude Questionnaire (SAQ) was used to assess nurses' safety attitudes. The intervention includes lectures, case-based discussions, and instructional workshops on fetal heartbeats. With the monitoring of the 1st and 5th minute Apgar ratings, the tracing included reporting aberrant data on cervical dilation, fetal cardiac decelerations, and advice about emergency scenarios. Conclusion: Between the preinterventional and both postinterventional periods, the mean scores of the SAQ domains increased significantly. More specifically, the mean score for teamwork climate increased from 58.6 to 67.3 and 70.8 (p value = 0.002), the score for safety climate increased from 61.1 to 67.7 and 71.0 (p value = 0.003), the score for job satisfaction increased from 52.5 to 61.8 and 70.2 (p value = 0.002), the score for stress recognition increased from 62.9 to 69.5 and 68.9 (insignificant), and the score for perception of management increased from 59. Finally, there was no increase in the number of dangerous births, as shown by the lack of a significant change in Apgar ratings between the three periods. The researchers concluded that the SBAR tool is a viable transfer tool that enhances communication between obstetricians and nurses and substantially changes nurses' attitudes toward safety. An Iraqi study was conducted by Dawod, Ali, and Bahaaldeen (2018) to examine the impact of SBAR education programs on the accuracy of maternal health department report recording. A sample of 84 participants from 3 different hospitals was used in the quasiexperimental pretest-posttest design of the study, which examined the knowledge of nurses and midwives regarding the communication of the SBAR instrument. Participants received a questionnaire to assess their knowledge on a 3-point Likert scale about the primary goal, which is relevant to maternal health, as well as seven scenarios that needed immediate response. Between the pretest and posttest phases, there was a substantial increase in general knowledge (p value 0.001). Participants were also asked to assess how confident they were in how scenarios would be handled. The findings showed that after SBAR training, 57.2% of participants rated themselves as having a moderate level of confidence in premature early membrane rupture, 57.1% as having a high level of confidence in placenta previa, 50% as having a high level of confidence in 7 teenage pregnancy, 57.1% as having a moderate level of confidence in preeclampsia, 57.1% as having a high level of confidence in abortion and 42.9% as having a high level. The researchers concluded that because the SBAR tool is new to nurses and midwives, more time is needed for them to fully benefit from it (Dawod, Ali, & Bahaaldeen, 2018). A cross-sectional study was conducted in Qatar by Nagammal, Nashwan, Krishnan Nair, and Susmitha (2016) and sought to assess how nurses perceived the SBAR tool, particularly how well it worked as a handover communication tool, and to examine the relationship between certain demographic information and nurses' perceptions of the SBAR tool. There were 102 nurses in the sample, with an average age of 36.2 years, a mean experience level of 14 years in the nursing profession and 7.6 years at their current health care facility, and a distribution of nurses with diplomas and nurses with bachelor's degrees that was equal. The Handover Evaluation Scale (HES), a 14-item scale to monitor and assess the handover process that is suggested for further usage and development, is the validated tool researchers use to assess the handover procedure. A total of 54.9% of nurses said they spent less than 5 minutes handing over patients after using the SBAR tool, and 95.1% agreed that the SBAR process makes sense. Furthermore, 61.8% of nurses said they always use the SBAR tool, and 25.5% strongly agree and 56.9% agree that the use of the SBAR tool helps reduce communication errors. Furthermore, 53.9% of the respondents always suggested the SBAR tool to other units, while 11.8% and 46.1% evaluated their pleasure with using the tool as outstanding and good, respectively. Overall, 87.3% of the respondents said they had a positive opinion about using SBAR; more specifically, 81.4% said the quality of the information was outstanding, 84.2% said the interaction and assistance were excellent, and 53.9% said the efficiency was average. Finally, there were no appreciable differences in nurses' opinions of the SBAR instrument according to their age, sex, educational attainment, or overall nursing experience in the previous or present institution. The researchers concluded that nurses tend to have more favorable perceptions of the SBAR instrument (Nagammal, Nashwan, Nair, & Susmitha, 2016). A Korean study was conducted on a sample of 153 nurses by Kim Mi and Kim Kyeong (2018) investigating how nurses' perceptions of nurses' communication and their attitudes toward patient safety were affected by SBAR communication. An SBAR 8 educational program, including a presentation on SBAR in terms of its relevance in medical personnel communication, SBAR standards, cycle, benefits, and preparations, was given to the chosen sample as part of the study's prepost single-group experimental design. Additionally, it contained case studies, writing exercises, instruction on using SBAR, and writing exercises based on scenario-based practice. Regarding the characteristics of the sample, 56.2% of nurses were between the ages of 25 and 29, and 34% had clinical careers spanning between 13 and 36 months. After six months of using the SBAR tool, the perception of communication and safety attitudes was reevaluated. In terms of perception of communication, most of the dimensions in the nurse‒doctor category had significant increases in mean scores, including precision, understanding, and satisfaction (p value 0.01), while all dimensions in the nurse‒nurse communication category had significant improvements in mean scores, including precision, understanding, and satisfaction. Most variables, including collaboration environment, safety climate, job satisfaction, management perspective and working circumstances, showed a statistically significant change in attitudes toward patient safety (p value 0.05). Furthermore, researchers asked the nurses to rate all communication-related items on a scale of 1–3 (disagree, neutral and agree), and they discovered a considerable increase in favorable sentiments for most of the items. For example, the agreement on the improved communication process during and during other shifts, as well as the importance of the SBAR tool in increasing the advice received from doctors in the unit, went from 15% to 27.5% (p value = 0.001). Researchers have concluded that teaching programs using the SBAR tool as an example of a successful communication process are crucial because they help nurses perceive good communication and change their attitudes toward patient safety (Kim Mi & Kim Kyeong, 2018). In a cross-sectional and descriptive study conducted between May and August 2021, 90 bedside nurses from a public hospital in Lebanon were recruited to investigate the associations between their attitudes and satisfaction with bedside shift reports and patient safety results. The research aimed to determine whether a properly structured nurse bedside shift report with efficient communication could improve nurse satisfaction and patient safety. The findings indicated that the satisfaction levels were high in general for all questions related to the reporting of bedside shifts. Participants generally expressed positive opinions regarding bedside shift reports, and all comments 9 had above-average mean values. The statement ―The bedside shift report is completed in a fair time" received the highest mean value of 3.35 (SD=0.87), while the statement ―The bedside shift report is reasonably stress-free" had the lowest mean value of 2.03 (SD=0.86). The results also showed significant relationships between nurses' satisfaction with shift reports and some patient safety culture composites, such as communication about errors and reporting of patient safety events (p value = 0.05), as well as between nurses' attitudes toward bedside shift reports and communication about errors (p value = 0.001). The author concluded that the use of bedside shift reports can increase nurses' job satisfaction, positive attitudes about work, and patient safety, and nursing administrators should encourage their use in healthcare facilities (Jaber et al., 2022). A quasiexperimental study on the SBAR technique to improve well-being in the Internal Medicine Unit was conducted by (Martínez-Fernández et al., 2022) to investigate the influence of SBAR on the well-being of healthcare workers in the internal medicine unit of a university hospital in the province of León using characteristics such as job satisfaction, engagement, resilience, and job performance (Spain). In this study, a pre- and postintervention strategy was employed in which questionnaires were administered to a group of doctors, nurses and healthcare assistants before and after the implementation of the SBAR tool on the ward. Additionally, staff compliance was ensured by monitoring the usage of SBAR. The SPSS application was used to perform statistical analysis on the data. Following the session, resilience levels increased considerably. Work satisfaction and participation remained neutral or decreased slightly after the intervention. SBAR was helpful in building worker resilience and was also a good tool for improving communication. Many characteristics of hospital administration may have influenced employee satisfaction and engagement outcomes. Jeong & Kim (2020) adopted a randomized single-blind control design of a pretest- posttest. The purpose of this research was to create and assess a Situation Background Assessment-Recommendation (SBAR) fall simulation program for Korean nursing students. Fifty-four nursing students in their third semester at a Korean university were chosen using convenience sampling (SBAR group 26, handoff group 28). The experimental group received the SBAR-based curriculum, while the control group 10 received the regular handoff-based program. The program was developed for three sessions of no more than 120 minutes each. Knowledge, competence, attitude, communication capacity, and clarity in relation to falls were among the measurement factors. Using SPSS 18.0 software, the data were analysed using the x2 test, t test, and repeated-measures ANOVA. The study results showed that compared to the handoff group, the SBAR group showed increased fall-related ability and communication clarity. The study found a significant improvement in knowledge before and after the intervention but no statistically significant differences in attitudes or communication competence related to falls. Based on these results, the authors concluded that the SBAR-based simulation program resulted in positive outcomes for patient safety among nursing college students compared to the usual handoff-based strategy. Therefore, SBAR-based simulation software is recommended as an effective educational intervention for nursing students to improve their reporting and communication skills and to effectively prevent or manage patient safety events. Nurses play a vital and highly appreciated role in the medical profession today, as physicians rely on them for quality evaluations and the flow of critical information to make medical decisions. Following the Women's Rights Movement of the late twentieth century, the workplace has become a more welcoming environment for women, including in the field of nursing. Nursing education has also undergone significant changes, with a bachelor's degree and passing a state licensing exam now required for practice (Akhtar & Ward, 2020). Doctors now view nurses as recognized medical professionals with their own licence rather than as mere helpers or caregivers. As Akhtar and Ward (2020) noted, "Although considered a respected career now, nurses in the 1960s were seen as handmaidens of physicians who were expected to carry out orders without enquiry." This transformation from a profession dedicated to "following orders" to a respected and necessary position has been critical to strengthening the nurse‒physician relationship (Insider Inc, 2020). Several approaches to facilitate communication among healthcare workers are taught at the graduate school level. When nurses report to a physician about the state of a patient, a tool known as "SBAR" is often utilized between nurses and physicians. SBAR is an acronym that stands for Situation-Background-Assessment- Recommendation and was originally used in the US Navy to "communicate vital 11 information in an effective, timely, and brief way" (Stewart, 2016). The user of the SBAR communication tool, such as a nurse, should present himself, identify the patient and give the physician a brief description of the problem. Nurses asked to give current prescriptions, results of tests, vital signs and other data to health providers. The nurse is appreciative to assess the situation and provide a qualified assessment of the patient. Then the nurse asked to specify the best action based on her assessment. The SBAR is a useful tool to improve communication between health professionals and ensuring a accurate and effective exchange of patient data. In the late 1999s, the methodology of this tool was developed by Michael Leonard, Doug Bonacum, and Suzanne Graham as to improve interprofessional communication and patient safety. The goal of the SBAR is to provide healthcare worker with a clear and short way of transmitting essential patient information. Health teams can use SBAR in order to generate a team culture and advance patient outcomes. The Institute for Health Improvement (IHI) recognize SBAR as a powerful tool to improve communication and patient safety. And health organizations around the world used SBAR for great benefits (Institute for Healthcare Improvement, 2017). The cooperation between clinician and nurses can be improved by using effective and purposeful communication techniques that are easily understood and recognized by both. When communication approaches and practices is simple and easy to identify, the likelihood of communication errors are reduced. A quasiexperimental study with a nonequivalent control group was carried out by (J.- Y. Uhm, Y. Ko, & S. Kim, 2019) to evaluate the influence of an SBAR communication program on communication performance, perception, and practicum-related outcomes in senior-year nursing students. Nurses must communicate effectively to maintain patient safety. A planned communication program improves communication clarity, education satisfaction, and positivism among students during interprofessional collaboration. The well-known structured communication method SBAR (situation, background, assessment, and recommendation) has been widely used in clinical and educational settings to enhance successful communication between nurses and physicians. The pediatric nursing practicum used the tool. Researchers implemented an SBAR program in the experimental group, which involved playing with SBAR strategies for various scenarios to improve practical communication between nursing students. The SBAR curriculum was designed based on Kolb's experiential learning 12 theory. Communication performance was evaluated using the SBAR communication tool and the communication clarity scale, while communication perception was assessed using the handover confidence level. Practicum outcomes such as self- efficacy in clinical practice, perceived nurse‒physician teamwork, and practicum satisfaction were also measured. The study revealed that the experimental group demonstrated superior performance in SBAR communication (p = 0.001), communication clarity (p = 0.001), and handover confidence (p= 0.001) compared to the control group. However, no significant differences were observed in self-efficacy in clinical practice, perceived nurse‒physician teamwork, or practicum satisfaction. The authors concluded that the SBAR program in a pediatric nursing practicum improved SBAR communication, communication clarity, and perceived handover confidence among nursing students. A study titled with SBAR as a structured communication tool in pediatric nonacute care: a bridge or a barrier to interprofessional collaboration? It was carried out by (Coolen, Engbers, Draaisma, Heinen, & Fluit, 2020) and aimed to investigate what aids or hinders the use of SBAR in the pediatric nonacute care department, as well as to ensure a higher level of communication among healthcare professionals from various backgrounds. A study using qualitative research methods was conducted to explore the use of SBAR by pediatric residents and nurses in a nonacute clinical care setting at an academic children's hospital. Semistructured focus group sessions were conducted, and the resulting data were analysed using a coding template to identify factors that facilitated or hindered the use of SBAR by different professionals. The study found that the use of SBAR was influenced by cultural, departmental and individual factors. The initial implementation of SBAR failed to address important issues for effective use in an interprofessional environment, such as dependency on the situation, the learning environment, and professional identity. The study suggests that to make SBAR more effective, it is necessary to identify the needs of professionals for using the tool, consider how various professions perceive their responsibilities, and encourage interprofessional feedback and role modelling. 13 A study titled Improving Nurse Job Satisfaction via SBAR Communication in Nursing Task Handover conducted by (Yuliyanti, Arso, & Ardani, 2020) was aimed at assessing the impact of SBAR method adoption on nurses' work satisfaction during handover. Research was carried out at Karanganyar Regional Hospital and Sragen's Soehadi Priyonegoro Regional Hospital. The research participants included 32 nurses from Karanganyar Hospital, who served as the experimental group, and 32 nurses from Sragen Hospital, who served as the control group. Mann‒Whitney and Wilcoxon nonparametric difference tests were employed to analyse the data. The results revealed that there were no significant differences in job satisfaction between the control and experimental groups; however, the satisfaction of the job of nurses increased after receiving SBAR technique therapy. With a p value of 0.000, the SBAR technique has a substantial effect on increasing nurses' job satisfaction (p value < 0.05). The SBAR approach affects nurses' job satisfaction. As a result, this strategy can be used in hospitals as a routine communication tool, along with training to improve communication abilities. 1.2 Problem Statement In Palestine, there are no formal approvals for the adoption of the SBAR tool in the nursing communication process between Palestinian healthcare institutes. On the other hand, two nongovernmental hospitals in West Bank – Palestine successfully acquired JCI accreditation, Hospital A and Hospital B. As the JCI has recommended the implementation of the SBAR tool, it is highly possible that these two hospitals‘ nurses are more aware of the tool. On the other hand, official reports or research studies are needed to quantify their level of knowledge, perception, and satisfaction with their application. Although the SBAR tool has been shown to improve communication and patient safety, it is not clear how often it is used or how Palestinian nurses view its value in the ICU. The aim of this study is to learn how nurses in ICUs view SBAR tools to improve communication and patient outcomes. The findings will provide insights into the experiences of Palestinian nurses with the SBAR instrument and highlight the importance of measures to eliminate barriers to its use in the ICU. A significant portion of the information flow in healthcare care occurs through communication between healthcare professionals, and mounting data suggest that communication mistakes contribute significantly to clinical morbidity and death. Lack of defined methods to 14 perform successful handoffs, such as utilization of the situation, background, evaluation, and suggestion, is one of the risk factors contributing to communication failures during transfer of care (SBAR) (Clapper & Ching, 2020). In addition, a scientific methodology is needed to quantify the level of awareness and satisfaction among nurses in Palestine with the SBAR tool. This problem arises from research in the field of nursing sciences in several subjects, including effective communication methods and the role in increasing the quality of interprofessional leadership work. 1.3 Significance of the study A robust and efficient communication process within healthcare institutions stands as a linchpin, playing a pivotal role in bridging the chasm that often exists between diverse communication styles. This critical alignment paves the way for the seamless and effective conveyance and reception of vital patient information, fostering a comprehensive understanding of medical needs and interventions (Ballantyne, 2017). At the very core of this transformative phenomenon lies the acceptance and rigorous adoption of the SBAR tool—a conduit that transcends mere communication, evolving into a harbinger of accountability within nursing circles. By embracing SBAR, nurses embrace a sense of responsibility that reverberates through the echelons of patient care, propelling the twin realms of patient safety and the calibre of patient progress reporting to new heights. The embrace of the SBAR tool radiates far-reaching benefits. Nurses, bearing the torch of patient care, are unequivocally empowered by this methodological approach. It kindles a heightened sense of duty, one that encompasses meticulous patient assessment and succinctly articulating their findings. As the SBAR protocol becomes second nature, a culture of attentiveness takes root, bolstering the safeguarding of patient well- being. Within the expansive domain of noncritical care areas, where the hustle and bustle of routine may often overshadow the gravity of effective communication, SBAR emerges as a beacon of order and efficacy (Arumugam et al., 2016). Nurses, the unsung heroes of healthcare, find in SBAR a reliable companion. It bestows upon them a framework 15 that streamlines the intricacies of patient progress reporting—offering a systematic format that harmonizes the sharing of information and ultimately culminating in enhanced patient management. The current study holds significant importance in the field of nursing and healthcare for several compelling reasons: First, effective communication is an essential aspect of patient care and plays a vital role in reducing medical errors, enhancing patient safety, and improving patient outcomes. The SBAR tool (situation, background, assessment, and recommendation) is widely recognized in the healthcare industry, especially in critical care settings such as the intensive care unit (ICU). The purpose of this research is to determine how nurses in Palestinian intensive care units view the SBAR tool, how satisfied they are with it, and what obstacles they see in its use. The finding of this analysis found how best to implement that technology in the healthcare systems. Second, The study focuses on the challenges that are faced by the Palestinian nurses due to different political and socioeconomic situations. The study focus on this particular element. The study promises to improve understanding of the specific circumstances encountered by Palestinian nurses and identify effective ways of addressing these concerns by studying the obstacles and complexity encountered by Palestinian nurses, particularly in connection with the use of the SBAR tool. The result used to guide the development of communication strategies that take into account the challenges facing Palestinian nurses working in ICUs. Third, in context of intercultural interaction, the detection may contribute to the current knowledge base in the field of nursing and health communication. This study aimed to advance our understanding of the performance of SBAR tools in various cultural contexts and identify cultural attributes that influence their acceptance and use. As a result, the results of this study can contribute to a broader understanding of communication between nurses and health care from a global perspective. 16 1.4 Aims of the study The goal of this research is to examine the level of perception and satisfaction that Palestinian ICU nurses have with the SBAR tool for successful communication. In addition, it will work toward accomplishing the following objectives: 1. To determine the amount of knowledge held by nurses working in intensive care units as well as nurses working in other areas of the hospital on the components and applications of the SBAR instrument. 2. To determine the amount of contentment that nurses working in the ICU and nurses working in other areas have with the SBAR tool. 3. To investigate the sociodemographic and professional aspects that are most prominent and correspond with the level of perception and contentment nurses have with the SBAR instrument. 4. To determine the most common obstacles that could inhibit nurses working in ICUs and other settings from improving their perception of and level of satisfaction with the SBAR tool. 1.5 Hypotheses The study will try to test the following hypotheses: H0: At the level of significance represented by a p-value of 0.05, the null hypothesis proposes that there is no significant link between the sociodemographic characteristics of nurses and their degree of perception of the SBAR instrument. H0: At the level of significance represented by a p-value of 0.05, the null hypothesis proposes that there is no significant link between the sociodemographic variables of nurses and the amount of satisfaction they report having with the SBAR instrument. H0: At the level of significance represented by a p-value of 0.05, the null hypothesis proposes that there is no significant link between the professional characteristics of nurses and their degree of perception about the SBAR instrument. 17 H0: At the level of significance represented by a p-value of 0.05, the null hypothesis proposes that there is no significant link between the professional variables of nurses and their degree of satisfaction with the SBAR instrument. 18 Chapter Two Methods This chapter includes study design, site and setting, sample and sampling, inclusion and exclusion criteria, study period, data collection, statistical analysis, and ethical considerations. 2.1 Study Design The research was conducted as descriptive/analytical cross-sectional research. A quantitative method was chosen because it enables researchers to assess and explore nurses' perceptions and satisfaction with the situation, background, assessment and recommendation (SBAR) tool for handover communication. 2.2 Study population The study population consisted of all nurses who worked in the targeted departments, regardless of their position, years of experience, age, or sex. 2.3 Sample Setting The study was conducted at Hospital A and Hospital B in the West Bank of Palestine, the only hospital in Palestine, and used SBAR as a documentation tool. Specific settings were critical care units vs. noncritical care units. These settings are suitable because they contain enough nurses and have the most sensitive medical and surgical cases that can benefit from implementing the SBAR tool. 2.4 Research Sample and Sample Methods Sampling was performed using convenience sampling. The sample size was calculated using a commonly used sample size calculator. The Raosoft sample size calculator is available online through a hyperlink (www.raosoft.com). Using Daniel's technique, sample sizes were calculated, and the number of nurses was estimated with a 95% confidence interval and a 5% error margin. This investigation included 208 nurses. 19 2.5 Data Collection Process and Tool The questionnaires were developed using standard methodologies, including a review of the literature, field specialists, discussion groups, pilot studies and item validation by Cronbach's alpha, which was 0.8 (Chiew et al., 2019; Demiray, Keçeci, Açıl, & İlaslan, 2018; Müller et al., 2018; Nagammal et al., 2016; Norouzinia, Aghabarari, Shiri, Karimi, & Samami, 2015; Shahid & Thomas, 2018). We reviewed this study collection datasheet with four experts in various fields and modified based on their evaluation. The English documents have also been translated into Arabic to provide nursing staff with a better understanding of the questionnaires. Additionally, further changes were made within the pilot study conducted among nurses and staff from a number of healthcare institutions. Data collection time was from August 1 to November 31, collection time was in the morning and evening shifts, the questionnaire included 4 main sections: the first section is concerned with sociodemographic and professional data (age, sex, years of nursing experience years in nursing and current hospital, residency, educational level, nursing position, etc.), the second and third sections are about nurses‘ perception of and satisfaction with the SBAR tool, and the fourth section about perceived barriers to using the SBAR tool. Nurses' perception was evaluated via a 9-item questionnaire and was evaluated using a five-item Likert scale. The responses were "strongly disagree," "disagree," ―neutral," "agree," and "strongly agree. ", and weighed 1-5, respectively. Nurses' satisfaction was evaluated via a 23-item questionnaire and was evaluated using five-item Likert scale questions. The answers were as follows: "very dissatisfied," "dissatisfied‖ "neutral," ―satisfied," and "very satisfied.‖ and weighed 1-5, respectively. Nurses were classified into two groups (high or equal) using the median utility indices reported by positive satisfaction and satisfied perceptions (Sweity et al., 2022; Toba, Samara, & Zyoud, 2019). 20 The fourth section addressed perceived challenges in the SBAR framework as a communication tool, which includes nursing skills, time, physician communication and delay response, environment, staff shortage, anxiety and reluctance to communicate with the patient. 2.6 Data and statistical analyses Data were analysed using SPSS version 22 for Windows (IBM Corp., Armonk, NY, USA). First, descriptive results include frequencies, median with interquartile range or mean ± standard deviation (SD), and percentages of the sociodemographic and professional data of nurses, as well as their responses to perception and satisfaction sentences. Furthermore, at p < 0.05, the Kruskal‒Wallis and Mann‒Whitney U tests were used. The internal consistency and reliability of the perception and satisfaction scales were assessed using the Cronbach alpha coefficient. 2.7 Ethical Considerations The study was carried out in accordance with the Declaration of Helsinki, which was established by the World Medical Association (WMA) as a set of ethical standards for human medical research. In this study, key ethical standards such as respect, beneficence, nonmaleficence, veracity, justice and other principles of virtue were respected. The study was reviewed and approved by the Institutional Review Board (IRB) of An- Najah National University. Because the study involved human subjects, strict ethical principles were used. Before deciding whether to participate in the trial, all nurses received verbal and written information on the study objectives, participation in this research was voluntary, and any participant had the right to refuse to participate in this research. 21 Chapter Three Results This chapter presents the descriptive and analytical results of the current study, where the descriptive results include the distribution of categorical variables‘ frequencies and percentages, as well as continuous variables‘ medians and interquartile ranges, while the analytical results showed the investigation of the relationship between study‘s independent and dependent variables to try to test its hypotheses and answer the specific questions. 5.3 Sociodemographic characteristics A total of 208 nurses completed the study questionnaires. The median age of the study participants was 27 years, with an IQR of 25.0-29.0. Of the 208 participants, 99 (47.6%) were from Hospital A, and the majority of nurses were 25-29 years of age (59.1%). Additionally, there were more male nurses than female nurses (n=109, 52.4%). Furthermore, 39.9% of the participants were educated at An-Najah University, and most of them had 3-5 years of experience in nursing and wards. Most of the participants were registered nurses, seniors, and working less than or equal to 8 hours per day. Furthermore, the majority of the participants were not ICU nurses (146, 70.2%) and preferred to work A or a morning shift (106, 51.0%). As shown in Table 2 and the figures following it. 22 Table 2.A Demographics associated with nurses' knowledge and practices regarding patient safety after cardiac catheterization Demographics Number (%) Hospital A B 99 (47.6) 109 (52.4) Age Median [Q1-Q3] 27 [25-29] Age (year) > 25 25-29 30-34 >35 38 (18.3) 103 (59.1) 39 (18.8) 8 (3.8) Sex Male Female 109 (52.4) 99 (47.6) Place of study Al-Quds University An-Najah University Bethlehem University Hebron University Arab American University 37 (17.8) 83 (39.9) 14 (6.7) 22 (10.6) 52 (25.0) Experience Median [Q1-Q3] 4 [2-7] Experience (year) < 2 3-5 6-9 < 10 56 (26.9) 83 (39.9) 52 (25.0) 17 (8.2) Section (ward) ICU Non-ICU 62 (29.8) 146 (70.2) Experience (year) in the ward Median [Q1-Q3] 4 [2-5] Experience (year) in the ward < 2 3-5 6-9 < 10 66 (31.7) 94 (45.2) 38 (18.3) 10 (4.8) Position in Nursing Senior Junior 128 (61.5) 80 (38.5) 23 Table 2.B Demographics associated with nurses' knowledge and practices regarding patient safety after cardiac catheterization (Cont.) Qualification LPN RN MA 4 (1.9) 175 (84.1) 29 (13.9) SBAR course? Yes No 112 (53.8) 96 (46.2) Working day of the working hour Less than or equal to 8 hours More than 8 hr 113 (46.7) 51 (13.3) Preferable shift to work A B N A+B B+N 106 (51.0) 48 (23.1) 27 (13.0) 5 (2.4) 22 (10.6) Note. Abbreviations: ICU: intensive care unit, LPN: licenced practical nurse, MA: master‘s degree, SBAR: situation, background, assessment and recommendation, A shift: 7 am-3 pm, B shift: 3 pm-10 pm, N shift: 10 pm-7 am. Table 2.C shows that majority of the students (84.1%) have a registered nurse qualification, with more than half of them (64.9%) working less than or equal to 8 hours per day, while 51% of the nurses prefer morning shift (A) to work. Figure 1 Distribution of age groups 18.30% 59.10% 18.80% 3.80% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% < 25 YO 25 - 29 YO 30 - 34 YO > 34 YO F re q u en cy Age groups 24 Figure 2 Distribution of place of study Figure 3 Distribution of experience 17.80% 39.90% 6.70% 10.60% 25.00% 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 45.00% Al-Quds University An-Najah University Bethlehem University Hebron University Arab American University F re q u en cy Place of study 26.90% 39.90% 25.00% 8.20% 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 45.00% < 2 years 3 - 5 years 6 - 9 years > 9 years F re q u en cy Experience categories 25 Figure 4 Distribution of wards Figure 5 Distribution of qualifications 29.80% 70.20% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% ICU non-ICU F re q u en cy Wards 1.90% 84.10% 13.90% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% LPN RN MA F re q u en cy Nurses' qualifications 26 Figure 6 Distribution of receiving SBAR Table 3 Comparison of non-intensive care unit (ICU) versus ICU nurses’ perceptions and satisfaction with the use of the (SBAR) tool for handover communication Variable Number (%) Median satisfaction [ Q1- Q3] P value Median Perception [ Q1- Q3] P value ICU Nurse 62 (29.8) 92 [86-77] 0.063 a 14 [12-16] 0.234 a Non-ICU Nurse 146 (70.2) 96 [90-102] 14 [11-17] Abbreviations ICU: intensive care unit. * Bold values denote statistical significance. a Kruskal‒Wallis test b Mann‒Whitney U test The study found that non-ICU nurses reported higher satisfaction levels with the SBAR tool compared to ICU nurses. However, both groups had similar perceptions of the tool, and there was no significant difference in perception between them. Additionally, the p- values (0.041 and 0.216) suggest that the observed differences in satisfaction and perception are not statistically significant. 53.80% 46.20% 42.00% 44.00% 46.00% 48.00% 50.00% 52.00% 54.00% 56.00% Yes No F re q u en cy Did the nurse receive SBAR course? 27 3.2 Nurses' satisfaction with the Situation, Background, Assessment, and Recommendation (SBAR) tool for handover communication Regarding satisfaction with the usage of SBAR as a communication tool, Table 3 shows the results using 23 questions, where one = ‗very dissatisfied‘, two = ―dissatisfied‖, three = ‗neutral‘, four = ―satisfied‖ and five = ‗very satisfied‘. The median satisfaction score was 95, with an interquartile range of 89.0 to 102.0. Fifty-one percent (n = 106) of the respondents scored <95 (median) and were deemed unsatisfied perceptions regarding the use of the SBAR framework. Among the participants, the vast majority (more than 34%) reported that SBAR reduces adverse events, is easy to use in various clinical settings, has the opportunity to discuss difficult clinical situations and debrief, provides sufficient information about patients, is not time wasting, has the opportunity to enquire about unanswered questions and up-to-date information, and explore different aspects of nursing care. Furthermore, 31.7% indicated that they were often given information during handover that is not relevant to patient care while using SBAR. While 25.5% reported that SBAR takes too much time, 23.6% reported that they feel that important information is not always given to them. Despite this, 29.8% reported that during the presentation, all nurses were concerned about the needs of the patients, and approximately half of the participants were satisfied when asked about comfort when communicating with physicians, using SBAR by phone improves patient safety and thinking that there is an effect of SBAR communication by telephone on time of care. 28 Table 4.A Nurse satisfaction with the Situation, Background, Assessment, and Recommendation (SBAR) tool for handover communication Items very dissatisfied Dissatisfied Neutral satisfied very satisfied 1. I think SBAR is a structured communication tool that reduces adverse events in a hospital setting. 0 (0.0) 2 (1.0) 8 (3.8) 115 (55.3) 83 (39.9) 2. I think the SBAR communication tool is easy to use in various clinical settings. 0 (0.0) 2 (1.0) 5 (2.4) 115 (55.3) 86 (41.3) 3. I have the opportunity to discuss the difficult clinical situations that I have experienced. 1 (0.5) 3 (1.4) 16 (7.7) 103 (49.5) 85 (40.9) 4. I have sufficient information about patients... 0 (0.0) 1 (0.5) 18 (8.7) 103 (49.5) 86 (41.3) 5. I have the opportunity to discuss with other HCPs when I have a difficult shift. 0 (0.0) 4 (1.9) 17 (8.2) 104 (50.0) 83 (39.9) 6. I will get the chance to discuss workload difficulties. 1 (0.5) 9 (4.3) 21 (10.1) 98 (47.1) 79 (38.0) 7. During handover, information is frequently provided that is unrelated to patient care. 29(13.9) 20 (9.6) 39 (18.8) 54 (26) 66 (31.7) 8. The manner in which the information is delivered is simple. 1 (0.5) 3 (1.4) 19 (9.1) 102 (49.0) 83 (39.9) 9. I can clarify the information that has been provided to me. 0 (0.0) 1 (0.5) 10 (4.8) 110 (52.9) 87 (41.8) 10. Patient information is provided without waste of time. 0 (0.0) 3 (1.4) 17 (8.2) 107 (51.4) 81 (38.9) 11. I have the opportunity to ask questions about things that I do not understand. 1 (0.5) 4 (1.9) 20 (9.6) 99 (47.6) 84 (40.4) 12. I find that handover takes too much time. 13 (6.3) 21 (10.1) 43 (20.7) 78 (37.5) 53 (25.5) 13. The information I receive is up to date. 1 (0.5) 3 (1.4) 28 (13.5) 97 (46.6) 79 (38.0) 14. I can keep my mind focused on the information that is given to me. 1 (0.5) 3 (1.4) 24 (11.5) 109 (52.4) 71 (34.1) 15. I am educated about several elements of nursing care. 0 (0.0) 1(0.5) 15 (7.2) 107 (51.4) 85 (40.9) 29 Table 4.B Nurse satisfaction with the Situation, Background, Assessment, and Recommendation (SBAR) tool for handover communication (Cont.) 16. I believe that critical information is not always provided to me. 29 (13.9) 31 (14.9) 34 (16.3) 65 (31.3) 49 (23.6) 17. I feel like I can plan with the nurses to make a decision about care. 2 (1.0) 3 (1.4) 12 (5.8) 107 (51.4) 84 (40.4) 18. I feel like I can plan with the doctors to make a decision about care. 5 (2.4) 7 (3.4) 22 (10.6) 112 (53.8) 62 (29.8) 19. I am satisfied with the way of communication with the staff during hand-off. 0 (0.0) 0 (0.0) 16 (7.7) 115 (55.3) 77 (37.0) 20. I think during the handover, all nurses' concerns about patients‘ needs 1 (0.5) 5 (2.4) 37 (17.8) 103 (49.5) 62 (29.8) 21. I feel comfortable communicating with physicians. 1 (0.5) 9 (4.3) 36 (17.3) 100 (48.1) 62 (29.8) 22. I think using the structured communication SBAR tool by phone improves patient safety. 2 (1.0) 8 (3.8) 32 (15.4) 99 (47.6) 67 (32.2) 23. I think there is an effect of SBAR communication by phone on the time of care. 2 (1.0) 6 (2.9) 39 (18.8) 103 (49.5) 58 (27.9) Note. Abbreviations: HCP: Health care profession; SBAR: situation, background, assessment, and recommendation Lastly, Table 4.b shows that half of the nurses are satisfied with the decision making with other nurses (51.4%), communication method during hand-off process (55.3%), the care of nurses about patients during hand-off, (49.5%), in addition to improving patient safety when SBAR is used (47.6%) and the efficacy of ability to use SBAR on the phone (49.5%). 30 Figure 7 Nurse satisfaction with the Situation, Background, Assessment, and Recommendation (SBAR) tool for handover communication 0.0% 0.0% 0.5% 0.0% 0.0% 0.5% 13.9% 0.5% 0.0% 0.0% 0.5% 6.3% 0.5% 0.5% 0.0% 13.9% 1.0% 2.4% 0.0% 0.5% 0.5% 1.0% 1.0% 1.0% 1.0% 1.4% 0.5% 1.9% 4.3% 9.6% 1.4% 0.5% 1.4% 1.9% 10.1% 1.4% 1.4% 0.5% 14.9% 1.4% 3.4% 0.0% 2.4% 4.3% 3.8% 2.9% 3.8% 2.4% 7.7% 8.7% 8.2% 10.1% 18.8% 9.1% 4.8% 8.2% 9.6% 20.7% 13.5% 11.5% 7.2% 16.3% 5.8% 10.6% 7.7% 17.8% 17.3% 15.4% 18.8% 55.3% 55.3% 49.5% 49.5% 50.0% 47.1% 26.0% 49.0% 52.9% 51.4% 47.6% 37.5% 46.6% 52.4% 51.4% 31.3% 51.4% 53.8% 55.3% 49.5% 48.1% 47.6% 49.5% 39.9% 41.3% 40.9% 41.3% 39.9% 38.0% 31.7% 39.9% 41.8% 38.9% 40.4% 25.5% 38.0% 34.1% 40.9% 23.6% 40.4% 29.8% 37.0% 29.8% 29.8% 32.2% 27.9% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% s1 S2 S3 S4 S5 S6 S7 S8 S9 S10 S11 S12 S13 S14 S15 S16 S17 S18 S19 S20 S21 S22 S23 Very dissatisfied Dissatisfied Neutral Satisfied Very satisfied 31 3.3 Nurse perception with the Situation, Background, Assessment, and recommendation (SBAR) tool for handover communication Regarding perception with the usage of SBAR as a communication tool, Table 4 shows the results using 9 questions, where one indicated "strongly disagree," two indicated "disagree," three indicated "not sure," four indicated "agree," and five indicated "strongly agree." The median satisfaction score was 36.0, with an interquartile range of 33.0 to 39.0. A total of 55.3% (n = 115) of the respondents scored 36 (median) and were deemed bad perceptions regarding the use of the SBAR framework. SBAR is perceived by most participants as efficient in time, reliable, and successful, identifying patients‘ stability, reducing errors, and improving patient safety. More than half of the participants take responsibility for patient care through the use of the SBAR communication instrument. On the other hand, 33.2% of nurses believed that SBAR handoff tools omit critical patient information. 32 Table 5 Nurse Perception with the Situation, Background, Assessment, and Recommendation (SBAR) tool for handover communication Items Strongly disagree Disagree Neutral Agree Strongly agree 1. Is the SBAR handoff tool efficient in terms of time? 0 (0.0) 7 (3.4) 21 (10.1) 86 (41.3) 94 (45.2) 2. Is the reliability of the SBAR handoff tools consistent between patients? 2 (1.0) 2 (1.0) 20 (9.6) 86 (41.3) 98 (47.1) 3. Is the use of the SBAR handoff tool suitable for each endorsement? 1 (0.5) 4 (1.9) 23 (11.1) 97 (46.6) 83 (39.9) 4. The ISBAR hand-off tools will omit critical patient information. 25 (12.0) 31 (14.9) 45 (21.6) 69 (33.2) 38 (18.3) 5. Patient information is poorly structured in SBAR handoff tool. 25 (12.0) 35 (16.8) 48 (23.1) 66 (31.7) 34 (16.3) 6. During handover, I am notified which patients are in danger or require immediate treatment. 2 (1.0) 6 (2.9) 42 (20.2) 97 (46.6) 61 (29.3) 7. The SBAR handoff tool has the potential to eliminate communication errors and increase patient safety. 1 (0.5) 5 (2.4) 32 (15.4) 96 (46.2) 74 (35.6) 8. In general, I am comfortable assuming responsibility for patient care while using the ISBAR communication tool. 0 (0.0) 2 (1.0) 36 (17.3) 107 (51.4) 63 (30.3) 9. I think logical sequence of SBAR frequency of using SBAR is most of time 1 (0.5) 5 (2.4) 46 (22.1) 91 (34.8) 65 (31.3) Note. Abbreviations: HCP: Health care profession; SBAR: situation, background, assessment, and recommendation 33 Figure 8 Nurse Perception with the Situation, Background, Assessment, and Recommendation (SBAR) tool for handover communication 0.0% 1.0% 0.5% 12.0% 12.0% 1.0% 0.5% 0.0% 0.5% 3.4% 1.0% 1.9% 14.9% 16.8% 2.9% 2.4% 1.0% 2.4% 10.1% 9.6% 11.1% 21.6% 23.1% 20.2% 15.4% 17.3% 22.1% 41.3% 41.3% 46.6% 33.2% 31.7% 46.6% 46.2% 51.4% 34.8% 45.2% 47.1% 39.9% 18.3% 16.3% 29.3% 35.6% 30.3% 31.3% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% s1 S2 S3 S4 S5 S6 S7 S8 S9 Srongly disagree Disagree Neutral Agree Strongly agree 34 3.4 Nurses’ Perceived Barriers to Nursing Using SBAR Table 5 presents the percentages of perceived barriers to nursing using SBAR. In general, participants did not share any direct barriers to SBAR, but when asked about time constraints, approximately 42.3% did not know. Additionally, 41.8% are not exactly aware of the physician delay in response. Most nurses reported no when asked about their reluctance to communicate with the patient and their lack of nurse skills. 35 Table 6 Nurse perception barriers to nursing using SBAR Items Yes No I do not know (1) Lack of data collection and evaluation skills. 6 (2.9) 152 (73.1) 50 (24.0) (2) Time constraints 1 (0.5) 119 (57.2) 88 (42.3) (3) Physician attitude 10 (4.8) 144 (69.2) 54 (26.0) (4) Communication skills of physicians and nurse 5 (2.4) 143 (68.8) 60 (28.8) (5) Physicians‘ delay to response 2 (1.0) 119 (57.2) 87 (41.8) (6) Environmental noise 2 (1.0) 132 (63.5) 74 (35.6) (7) Knowledge and feasibility of the Tool 12 (5.8) 139 (73.1) 57 (27.4) (8) Shortage of nurses 9 (4.3) 148 (71.2) 51 (24.5) (9) Anxiety, pain, and physical discomfort of the patient. 2 (1.0) 132 (63.5) 74 (35.6) (10) Reluctance to communicate with the patient 6 (2.9) 167 (80.3) 35 (16.8) 36 Figure 9 Nurse perception barriers to nursing using SBAR 3.5 Demographics associated with nurses' knowledge and practices regarding patient safety after cardiac catheterization The Mann‒Whitney U and Kruskal‒Wallis tests were used to examine the relationship between sociodemographic factors, satisfaction, and perception. Consequently, there is a relationship between the two hospitals in line with satisfaction and perception, as hospital A showed better satisfaction and perception than hospital B (p = >0.001). Furthermore, the 25-29 age group showed better satisfaction than the other age groups, with a median satisfaction of 75 (p = >0.001). Additionally, nurses with 3 to 5 years in the field showed good satisfaction, with a mean satisfaction of 98 (p = >0.001). Additionally, no relationship was found between sociodemographic elements and satisfaction and perception. As shown in Table 6. 2.9% 0.5% 4.8% 2.4% 1.0% 1.0% 5.8% 4.3% 1.0% 2.9% 73.1% 57.2% 69.2% 68.8% 57.2% 63.5% 73.1% 71.2% 63.5% 80.3% 24.0% 42.3% 26.0% 28.8% 41.8% 35.6% 27.4% 24.5% 35.6% 16.8% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% s1 S2 S3 S4 S5 S6 S7 S8 S9 S10 Yes No I don't know 37 Table 7.A Demographics associated with nurses' knowledge and practices regarding patient safety after cardiac catheterization Demographics Number (%) Median satisfaction [Q1- Q3] P value* Median Perception [ Q1- Q3] P value* Hospital A B 99 (47.6) 109 (52.4) 300 [72- 303] 72 [65- 75] <0.003* a 16 [11-63] 13 [12-15] <0.003* a Age (year) < 25 25-29 30-34 >35 38 (18.3) 103 (59.1) 39 (18.8) 8 (3.8) 76 [66-100] 75 [73-103] 72 [65-99] 66 [81-92] < 0.003* b 14 [11-17] 14 [11-60] 13 [11-16] 16 [26-15] 0.166 b Sex Male Female 109 (52.4) 99 (47.6) 94 [88-101] 96 [90-103] 0.170 b 14 [11-17] 14 [11-17] 0.464 b Place of study Al-Quds University An-Najah University Bethlehem University Hebron University Arab American University 37 (17.8) 83 (39.9) 14 (6.7) 22 (10.6) 52 (25.0) 99 [90-103] 92 [87-98] 91 [84-102] 98 [93-103] 96 [92-103] 0.031 b 14 [11-17] 13 [12-16] 13 [10-17] 15 [12-63] 14 [16-17] 0.263 b Experience (year) < 2 3-5 6-9 < 10 56 (26.9) 83 (39.9) 52 (25.0) 17 (8.2) 97 [92-102] 98 [90-103] 93 [88-96] 87 [93-95] 0.003* a 14 [11-16] 15 [11-63] 16 [12-15] 13 [12-15] 0.027 a Section (ward) ICU Non-ICU 62 (29.8) 146 (70.2) 92 [86-77] 96 [90-102] 0.063 a 14 [12-16] 14 [11-17] 0.234 a Table 7.A shows that higher satisfaction is significantly found among nurses between 25 – 29 years old, 3 – 5 years of experience and non- ICU setting, while significantly more positive perception among nurses with 3 -5 years of experience. Also, taking SBAR course increased both of satisfaction and perception (Table 7.B) 38 Table 7.B Demographics associated with nurses' knowledge and practices regarding patient safety after cardiac catheterization (ccont.) Experience (year) in the ward< 2 3-5 6-9 < 10 66 (31.7) 94 (45.2) 38 (18.3) 10 (4.8) 97 [92-102] 95 [87-103] 93 [90-99] 87 [81-93] 0.021 a 14 [11-17] 14 [12-60] 14 [11-17] 16 [10-15] 0.411 a Position in Nursing Senior Junior 128 (61.5) 80 (38.5) 93 [90-102] 96 [86-103] 0.273 b 14 [11-17] 14 [12-17] 0.376 b Qualification LPN RN MA 4 (1.9) 175 (84.1) 29 (13.9) 77 [66-104] 95 [66-102] 93 [73-302] 0.474 a 16 [21-60] 14 [11-17] 14 [11-17] 0.734 a SBAR course? Yes No 112 (53.8) 96 (46.2) 94 [90-101] 91 [85-100] 0.037 b 15 [11-40] 13 [12-38] 0.006 b Working day of the working hour >8 h < 8 hr 113 (46.7) 51 (13.3) 94 [67-103] 96 [86-102] 0.646 b 14 [11-17] 14 [11-60] 0.317 b Preferable shift to work A B N A+B B+N 106 (51.0) 48 (23.1) 27 (13.0) 5 (2.4) 22 (10.6) 93 [66-102] 96 [72-301] 96 [65-103] 91 [63-100] 92 [64-74] 0.077 a 14 [12-17] 15 [11-63] 13 [11-60] 16 [13-15.3] 13 [12-15] 0.163 a Note. Abbreviations ICU: intensive care unit, LPN: licenced practical nurse, MA: master‘s degree, SBAR: situation, background, assessment and recommendation, A shift: 7 am-3 pm, B shift: 3 pm-10 pm, N shift: 10 pm-7 am. * Bold values denote statistical significance. a Kruskal‒Wallis test b Mann‒Whitney U test 39 Chapter Four Discussions and Conclusions The current research was constructed to investigate the level of perception and satisfaction among Palestinian nurses working in the ICU with respect to the SBAR tool for effective communication. 4.1 Discussion and Interpretation of the Main Results 4.1.1 Perception of the nurse’s use of SBAR as a communication tool The findings of this research have unveiled a landscape of perceptions within the nursing community that carries an undercurrent of dissatisfaction. Evidently, a substantial 57 percent (n = 106) of the respondents, falling below the median score of 95, have shed light on the less-than-ideal regard towards the utilization of the SBAR framework. This revelation resonates with previous studies, enriching the discourse with a nuanced perspective on the interplay between the SBAR approach and nursing professionals' perceptions. In parallel, the work of Uhm, JY, Ko, Y., & Kim, S. (2019) embarks on an exploratory journey to investigate the impact of the SBAR communication program on nursing students' acquisition of communication skills. Their quasi-experimental study underscores the undeniable potency of the SBAR program in enhancing the learning curve of communication skills among aspiring nurses. However, it's noteworthy that their findings temper enthusiasm with a caveat—while the SBAR program seemingly invigorates skill development, it doesn't necessarily translate into an elevation of the broader perceptions and satisfaction within the nursing profession (J. Y. Uhm, Y. Ko, & S. Kim, 2019). Building upon this foundation, Noh, G. O., & Park, M. J. (2022) contribute an intriguing perspective, delving into the effects of the SBAR framework in the domain of simulation-based nurse education. Their research, which thoughtfully traverses the realms of communicative skills and self-efficacy, renders a verdict that aligns with the previous studies—a direct and substantial influence of the SBAR methodology on these facets remains elusive (G. O. Noh & Park, 2022). In contrast, Murphy, Margaret et al. (2022) disagreed with our study, which conducted a study titled Implementing a 40 Standardized Communication Tool in an Intensive Care Unit, concluding that implementing the SBAR communication tool dramatically improved general perceptions of communication in this critical care unit(Murphy et al., 2022). Furthermore, Nator, A.D. (2022) provides a quality improvement (QI) project and revealed that the use of a standardized SBAR patient handover instrument appears to have improved nurse perceptions of communication and patient handover quality(Nator, 2022). In another study inconsistent with our findings, De Meester K, Verspuy M, Monsieurs KG, and Van Bogaert P (2013) concluded that following the implementation of SBAR, they observed higher perceptions of efficient communication and teamwork among nurses, an increase in unforeseen ICU admissions, and a decline in unexpected mortality(De Meester, Verspuy, Monsieurs, & Van Bogaert, 2013). These results are also inconsistent with Padgett, M. (2018), who revealed that nurses' perceptions of other nurses' handoffs improved slightly, indicating a more objective perspective. In addition, the perceptions of the nurses in the treatment group about their own communication and about the handoffs of other nurses increased twofold (Padgett, 2018). Furthermore, the results of this current investigation are not in line with Randmaa, M., Mrtensson, G., Swenne, C. L., & Engström, M. (2014), who reported that implementing the communication tool SBAR in anaesthetic clinics was associated with an increase in staff members' perceptions of professional communication and the safety atmosphere, as well as a drop in the proportion of incident reports, including communication errors (Randmaa, Mårtensson, Leo Swenne, & Engström, 2014). Additionally, Usher et al. (2018) conducted a quality improvement project to evaluate a standardized bedside handoff process and its influence in a medical-surgical unit and revealed an improvement in nurses' perceptions of shift reports (Usher, Cronin, & York, 2018). similar to previous research findings (Jukkala, James, Autrey, Azuero, & Miltner, 2012). 4.1.2 Satisfaction of nurses with the usage of SBAR as a Communication Tool The comprehensive analysis conducted within this research has illuminated a rather nuanced facet—an undercurrent of negative satisfaction among nurses pertaining to the utilization of the SBAR framework. This sentiment is underscored by the calculated median satisfaction score of 36.0, accompanied by an interquartile range spanning from 33.0 to 39.0. Notably, a substantial cohort of respondents, comprising 55.3% (n = 115), 41 gravitated towards this median score of 36. This revelation beckons further exploration, inviting a closer examination of the underlying factors contributing to this pervasive sense of discontent. This sentiment echoes a parallel study by Lee J. (2021), whose quasi-experimental exploration into the SBAR education program yielded analogous results. This congruence suggests a consistent thread of modest satisfaction scores, indicating that challenges and areas for improvement might be universally pertinent within the context of SBAR implementation (J. Lee, 2021). As the research findings align with previous literature, Compton, Jan, et al. (2012) postulate that the concept of SBAR is generally well-understood. However, divergent levels of acceptance across various healthcare facilities, a potential dearth in comprehensive healthcare professional education concerning SBAR, and a tendency to regard SBAR as a mere document rather than a dynamic conversational strategy emerge as prevailing challenges (Compton et al., 2012). This underscores the need to not only introduce the framework but also to emphasize its practical, living application in fostering effective communication among healthcare practitioners. Furthermore, a pertinent study exploring compliance with structured bedside handover protocols adds a layer of complexity to this narrative. While the study highlighted a variety of circumstances hindering nurses from adopting bedside handovers, it could potentially signify a subtle undercurrent of resistance to operationalizing this practice in real-world scenarios (Malfait et al., 2018). This resonates with the challenges highlighted within the SBAR framework, where implementation might be stymied by factors beyond mere comprehension—perhaps delving into the realm of habituation, institutional culture, or even perceived efficacy. In conclusion, the multifaceted landscape uncovered by this research underscores the need for a holistic approach when introducing and promoting the adoption of the SBAR framework. The echoes across literature and the variety of challenges exposed by the research findings together weave a tapestry of complexity. This necessitates a nuanced strategy that not only imparts comprehension but also addresses the dynamic interplay of individual attitudes, institutional structures, and the practical intricacies of incorporating SBAR into everyday healthcare interactions. 42 In contrast, a study conducted by Noh, Y. G. & Lee, I. (2020) that participants showed an improvement in their awareness of the handover situation, as well as in their understanding of the background, assessment, and recommendation phases of the handover process. Furthermore, participants reported an increase in communication self-efficacy and greater satisfaction with the handover education program after each phase (Y. G. Noh & Lee, 2020). Additionally, in 2017, Yu et al. conducted a quasi- experiment study aimed at developing a role-play simulation program involving SBAR techniques for nurse-to-doctor handover, and the study showed that the intervention group exceeded the control group in terms of SBAR, clarity of communication in doctors' notifications, and satisfaction with SBAR education satisfaction(Yu & Kang, 2017). Another study conducted by Ghosh, S., Ramamoorthy, L. & Pottakat, B. (2021), which disagreed with our study, reported that standardization of the patient handover procedure, for example, SBAR, improves the nurse handover process, patient satisfaction, and health professionals' acceptability (Ghosh, Ramamoorthy, & Pottakat, 2021). Ding et al. (2022), in line with nursing practice regarding physical restraint, concluded that, in comparison to the conventional techniques used during shift changes, the implementation of the SBAR communication mode can enhance the information provided to nurses regarding patients who are being physically restrained, increase their satisfaction and have a better clinical-application effect (Ding, Wang, Chen, Kang, & Wu, 2022). The study finding disagrees with another study that found that infection patients' negative feelings may be reduced, their life quality and nursing satisfaction improved, and their overall nursing performance and professional recognition increased when the SBAR handover model is used in conjunction with a thorough nursing intervention(Ji, Han, & Wang, 2021). Our study revealed that participants who are aged 25 to 29 years old are more satisfied than other age groups with the application of SBAR as a communication tool, with a median of 97 and an interquartile range of 91.0 to 103.0. However, the age group less than 25 showed a median of 94, which is the second group related to another group, these age groups are still fresh as can as and the nursing school information is still up to date and uses SBAR more effectively and made a good decision in a critical situation, which reflected on experiences also, as this age group between 25 to 29 already they have an experience from 3 to 5 years, which reflect fresh student. Thomas, C. M., 43 Bertram, E. & Johnson, D. (2009) revealed that the SBAR method helped students organize important knowledge more effectively. Faculty and clinical staff observed that students made better judgments and had more self-awareness and critical thought. In addition, when they used the SBAR communication method, the students‘ ability to recognize issues and find solutions grew over time. 4.1.3 Perceptions of barriers to SBAR use as a communication tool The comprehensive analysis of our study has yielded illuminating insights into the intricate landscape of healthcare communication, particularly concerning the employment of the SBAR methodology as a communication tool. Among the noteworthy revelations, it was found that a substantial proportion, accounting for 41.8%, exhibited a certain level of unawareness regarding the potential delay in physicians' responses—an intriguing observation that emerged as a perceived barrier to nurses' adoption of the SBAR approach. However, when scrutinizing the satisfaction levels of nurses, a statistically significant correlation was not identified with nurse- provider communication, and the study revealed an absence of discernible limitations and additional commentary in this context. Moreover, delving into the realm of physicians' perspectives, the outcomes were equally enlightening. A majority of physicians, driven by the incorporation of the SBAR framework, expressed a sense of contentment with the communication process. The tangible impact of SBAR implementation surfaced, as physicians reported an augmented sense of satisfaction with the consistency of data exchanged, particularly concerning alterations in resident status. This newfound coherence in conveyed information resonated beyond mere satisfaction—it extended its influence to the realm of hospitalization decision-making. The physicians' viewpoint illuminated that the information transference, facilitated by the SBAR tool, not only streamlined communication but also played a pivotal role in shaping the trajectories of patient care decisions (Renz, Boltz, Wagner, Capezuti, & Lawrence, 2013). In essence, our study has unearthed a nuanced tapestry of perceptions and experiences within the intricate realm of healthcare communication. The interplay between nurses and physicians, facilitated by the SBAR technique, paints a dynamic picture where clarity and effectiveness emerge as crucial cornerstones. As our findings underscore, the 44 impact of the SBAR framework is multifold—it bridges gaps, fosters satisfaction, and influences crucial decision-making processes, ultimately contributing to the holistic enhancement of patient care within the healthcare landscape (Renz, Boltz, Wagner, Capezuti, & Lawrence, 2013).Although our study showed that the majority of nurses reported no when asked about reluctance to communicate with the patient and lack of nurse skills, a study examining the use of SBAR communications in efforts to prevent patient rehospitalizations revealed that it can help home healthcare clinicians with efforts to prevent avoidable hospitalizations. Furthermore, it presents the SBAR communication approach, its history, its characteristics, and some of the research that has been done to demonstrate that it facilitates effective and efficient communication, improving patient outcomes (Narayan, 2013). Another study conducted by Lee, J. (2021) showed that SBAR SEP for nursing students is an efficient teaching strategy that increases critical thinking and communication skills under conditions comparable to those at the clinical site (J. Lee, 2021). 4.2 Comparison of non-intensive care unit (icu) versus icu nurses’ perceptions and satisfaction with the use of the (SBAR) tool for handover communication The intriguing findings of the study shed light on the varying dynamics of satisfaction levels related to the SBAR tool between two distinct groups of nurses. Notably, non- ICU nurses emerged as believing heightened levels of satisfaction with the SBAR tool when compared to their counterparts in the ICU setting. A noteworthy observation is that both groups, despite their differing satisfaction levels, shared strikingly similar perceptions regarding the utility of the SBAR tool. Remarkably, the statistical analyses conducted (with p-values of 0.041 and 0.216) underscore that the disparities in both satisfaction and perception, albeit evident, do not attain a statistically significant threshold. While the discerned differences in satisfaction and perception do not exhibit statistical significance, a nuanced tale begins to unfold, particularly in the context of ICU nurses. Notably, ICU nurses exhibit comparatively lower satisfaction levels, offering an intriguing avenue for exploration. Delving into the intricacies of ICU nursing practice, one can discern a potential rationale behind this observation. The ICU environment, marked by its demanding nature and acute patient care needs, often subjects nurses to a barrage of interruptions during their shifts. Moreover, the nature of patients requiring 45 care in the ICU frequently necessitates a higher frequency of employing the SBAR tool, adding a layer of complexity to its use (Scolari, Soncini, Ramelet, & Schneider, 2022). Yet, within this intricate narrative, an essential perspective arises: the significance of the SBAR tool as the cornerstone of hospital communication remains unwavering. As the findings elucidate, the differences in perception and satisfaction are notably nuanced, and the overall effectiveness of the SBAR method remains unparalleled within the hospital context. Research by Ding et al. (2022) underscores this very sentiment, underscoring the pivotal role that SBAR plays as a communication linchpin in the intricate web of healthcare interactions. In summation, the study's revelations open windows into the complex interplay between nurse perceptions, satisfaction, and the practical intricacies of healthcare settings. While distinct nuances are evident, the overarching message resounds: SBAR's importance endures as the bedrock of effective communication, facilitating seamless interaction amid the multifaceted demands of patient care. As the healthcare landscape continues to evolve, understanding and adapting to these nuances will be pivotal in ensuring the optimal utilization of communication tools like SBAR to enhance patient care outcomes. 4.3 Clinical implications and significance of the current study The study on the level of perception, satisfaction, and perceived barriers among Palestinian nurses working in ICUs toward the SBAR (situation-background- assessment-recommendation) tool for effective communication has several clinical implications and significance: 1. Improving patient safety requires effective communication, especially in critical care settings such as intensive care units (ICUs). SBAR can facilitate plain and concise communication between healthcare providers, decreasing the risk of medical errors and adverse events. 2. The SBAR tool facilitates coordination and collaboration among healthcare providers by providing a structured communication format. By utilizing the tool, nurses can communicate vital information to physicians and other healthcare team members in a consistent and standardized manner. 46 3. The study can help identify the barriers to using the SBAR tool among Palestinian nurses in ICUs, thereby informing interventions to enhance the tool's adoption and integration into nursing practice. This can increase nurses' confidence in their communication abilities, boost job satisfaction, and improve patient outcomes. 4. The study's findings showed that nurses who used the SBAR tool reported higher levels of satisfaction with their ability to communicate successfully with other medical professionals. This encouraging result has the potential to greatly affect nurse retention and job happiness, leading to a better workplace for all healthcare workers. 5. The research showed that some people had trouble using the SBAR tool because of things like a lack of training or an aversion to confrontation. However, by removing these roadblocks and bolstering SBAR's usability, we can increase the tool's potential for widespread use. Better outcomes can be expected as a result of enhanced patient communication. 6. This research can illuminate nurses‘ training requirements for the SBAR tool. By identifying areas where nurses may require additional education and training, nursing educators can develop targeted interventions to enhance nurses' communication skills and use of the tool. 7. The study contributes to the growing literature on effective communication in nursing practice, particularly in critical care settings. In addition, the findings can inform