Appendix C Communication Strategies

Advocating for Safety with Assertive Statements

When a team member perceives a potential patient safety concern, they should assertively communicate with the decision-maker to protect patient safety. This strategy holds true for ALL team members, no matter their position within the hierarchy of the health care environment. The message should be communicated to the decision-maker in a firm and respectful manner using the following steps[1]:

  • Make an opening.
  • State the concern.
  • State the problem (real or perceived).
  • Offer a solution.
  • Reach agreement on next steps.

Examples of Using Assertive Statements to Promote Patient Safety

A nurse notices that a team member did not properly wash their hands during patient care. Feedback is provided immediately in a private area after the team member left the patient room: “I noticed you didn’t wash your hands when you entered the patient’s room. Can you help me understand why that didn’t occur?” (Wait for an answer.) “Performing hand hygiene is essential for protecting our patients from infection. It is also hospital policy and we are audited for compliance to this policy. Let me know if you have any questions and I will check back with you later in the shift.” (Monitor the team member for appropriate hand hygiene for the remainder of the shift.)

Two-Challenge Rule

When an assertive statement is ignored by the decision-maker, the team member should assertively voice their concern at least two times to ensure that it has been heard by the decision-maker. This strategy is referred to as the two-challenge rule. When this rule is adopted as a policy by a health care organization, it empowers all team members to pause care if they sense or discover an essential safety breach. The decision-maker being challenged is expected to acknowledge the concern has been heard.[2]

CUS Assertive Statements

During emergent situations, when stress levels are high or when situations are charged with emotion, the decision-maker may not “hear” the message being communicated, even when the two-challenge rule is implemented. It is helpful for agencies to establish assertive statements that are well-recognized by all staff as implementation of the two-challenge rule. These assertive statements are referred to as the CUS mnemonic: “I am Concerned – I am Uncomfortable – This is a Safety issue!”[3]

Using these scripted messages may effectively catch the attention of the decision-maker. However, if the safety issue still isn’t addressed after the second statement or the use of “CUS” assertive statements, the team member should take a stronger course of action and utilize the agency’s chain of command. For the two-challenge rule and CUS assertive statements to be effective within an agency, administrators must support a culture of safety and emphasize the importance of these initiatives to promote patient safety.

Read an example of a nurse using assertive statements in the following box.

Assertive Statement Example

A nurse observes a new physician resident preparing to insert a central line at a patient’s bedside. The nurse notes the resident has inadvertently contaminated the right sterile glove prior to insertion.

Nurse: “Dr. Smith, I noticed that you contaminated your sterile gloves when preparing the sterile field for central line insertion. I will get a new set of sterile gloves for you.”

Dr. Smith: (Ignores nurse and continues procedure.)

Nurse: “Dr. Smith, please pause the procedure. I noticed that you contaminated your right sterile glove by touching outside the sterile field. I will get a new set of sterile gloves for you.”

Dr. Smith: “My gloves are fine.” (Prepares to initiate insertion.)

Nurse: “Dr. Smith – I am concerned! I am uncomfortable! This is a safety issue!”

Dr. Smith: (Stops procedure, looks up, and listens to the nurse.) “I’ll wait for that second pair of gloves.”

Learn More

View a detailed video webinar describing the TeamSTEPPS® principles.[4]


A common format used by health care team members to exchange client information is ISBARR, a mnemonic for the components of Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.[5],[6]

  • Introduction: Introduce your name, role, and the agency from which you are calling.
  • Situation: Provide the client’s name and location, the reason you are calling, recent vital signs, and the status of the client.
  • Background: Provide pertinent background information about the client such as admitting medical diagnoses, code status, recent relevant lab or diagnostic results, and allergies.
  • Assessment: Share abnormal assessment findings and your evaluation of the current client situation.
  • Request/Recommendations: State what you would like the provider to do, such as reassess the client, order a lab/diagnostic test, prescribe/change medication, etc.
  • Repeat back: If you are receiving new orders from a provider, repeat them to confirm accuracy. Be sure to document communication with the provider in the client’s chart.

Nursing Considerations

Before using ISBARR to call a provider regarding a changing client condition or concern, it is important for nurses to prepare and gather appropriate information. See the following box for considerations when calling the provider.

Communication Guidelines for Nurses[7]

  • Have I assessed this client before I call?
  • Have I reviewed the current orders?
  • Are there related standing orders or protocols?
  • Have I read the most recent provider and nursing progress notes?
  • Have I discussed concerns with my charge nurse, if necessary?
  • When ready to call, have the following information on hand:
    • Admitting diagnosis and date of admission
    • Code status
    • Allergies
    • Most recent vital signs
    • Most recent lab results
    • Current meds and IV fluids
    • If receiving oxygen therapy, current device and L/min
  • Before calling, reflect on what you expect to happen as a result of this call and if you have any recommendations or specific requests.
  • Repeat back any new orders to confirm them.
  • Immediately after the call, document with whom you spoke, the exact time of the call, and a summary of the information shared and received.

Read an example of an ISBARR report in the following box.

Sample ISBARR Report From a Nurse to a Health Care Provider

I: “Hello Dr. Smith, this is Jane Smith, RN from the Med-Surg unit.”

S: “I am calling to tell you about Ms. White in Room 210, who is experiencing an increase in pain, as well as redness at her incision site. Her recent vital signs were BP 160/95, heart rate 90, respiratory rate 22, O2 sat 96% on room air, and temperature 38 degrees Celsius. She is stable but her pain is worsening.”

B: “Ms. White is a 65-year-old female, admitted yesterday post hip surgical replacement. She has been rating her pain at 3 or 4 out of 10 since surgery with her scheduled medication, but now she is rating the pain as a 7, with no relief from her scheduled medication of Vicodin 5/325 mg administered an hour ago. She is scheduled for physical therapy later this morning and is stating she won’t be able to participate because of the pain this morning.”

A: “I just assessed the surgical site and her dressing was clean, dry, and intact, but there is 4 cm redness surrounding the incision, and it is warm and tender to the touch. There is moderate serosanguinous drainage. Her lungs are clear and her heart rate is regular. She has no allergies. I think she has developed a wound infection.”

R: “I am calling to request an order for a CBC and increased dose of pain medication.”

R: “I am repeating back the order to confirm that you are ordering a STAT CBC and an increase of her Vicodin to 10/325 mg.”

Handoff Reports

Handoff reports are defined by The Joint Commission as “a transfer and acceptance of patient care responsibility achieved through effective communication. It is a real-time process of passing patient specific information from one caregiver to another, or from one team of caregivers to another, for the purpose of ensuring the continuity and safety of the patient’s care.”[8] In 2017 The Joint Commission issued a sentinel alert about inadequate handoff communication that has resulted in patient harm such as wrong-site surgeries, delays in treatment, falls, and medication errors.[9]

The Joint Commission encourages the standardization of critical content to be communicated by interprofessional team members during a handoff report both verbally (preferably face to face) and in written form. Critical content to communicate to the receiver in a handoff report includes the following components[10]:

  • Sender contact information
  • Illness assessment, including severity
  • Patient summary, including events leading up to illness or admission, hospital course, ongoing assessment, and plan of care
  • To-do action list
  • Contingency plans
  • Allergy list
  • Code status
  • Medication list
  • Recent laboratory tests
  • Recent vital signs

Several strategies for improving handoff communication have been implemented nationally, such as the Bedside Handoff Report Checklist, closed-loop communication, and I-PASS.


Closed-Loop Communication

The closed-loop communication strategy is used to ensure that information conveyed by the sender is heard by the receiver and completed. Closed-loop communication is especially important during emergency situations when verbal orders are being provided as treatments are immediately implemented.

  1. The sender initiates the message.
  2. The receiver accepts the message and repeats back the message to confirm it (i.e., “Cross-Check”).
  3. The sender confirms the message.
  4. The receiver notified the sender the task was completed (i.e., “Check-Back”).

See an example of closed-loop communication during an emergent situation in the following box.

Closed-Loop Communication Example

Doctor: “Administer 25 mg Benadryl IV push STAT.”

Nurse: “Give 25 mg Benadryl IV push STAT?”

Doctor: “That’s correct.”

Nurse: “Benadryl 25 mg IV push given at 1125.”


I-PASS is a mnemonic used to provide structured communication among interprofessional team members. I-PASS stands for the following components[11]:

I: Illness severity
P: Patient summary
A: Action list
S: Situation awareness and contingency plans
S: Synthesis by receiver (i.e., closed-loop communication)

See a sample I-PASS Handoff in Table 7.5b.[12]

Table C.1Sample I-PASS Verbal Handoff[13]

Table C.1 Sample I-PASS Verbal Handoff

I Illness Severity This is our sickest patient on the unit, and he’s a full code.
P Patient Summary AJ is a 4-year-old boy admitted with hypoxia and respiratory distress secondary to left lower lobe pneumonia. He presented with cough and high fevers for two days before admission, and on the day of admission to the emergency department, he had worsening respiratory distress. In the emergency department, he was found to have a sodium level of 130 mg/dL likely due to volume depletion. He received a fluid bolus, and oxygen administration was started at 2.5 L/min per nasal cannula. He is on ceftriaxone.
A Action List Assess him at midnight to ensure his vital signs are stable. Check to determine if his blood culture is positive tonight.
S Situations Awareness & Contingency Planning If his respiratory distress worsens, get another chest radiograph to determine if he is developing an effusion.
S Synthesis by Receiver Ok, so AJ is a 4-year-old admitted with hypoxia and respiratory distress secondary to a left lower lobe pneumonia receiving ceftriaxone, oxygen, and fluids. I will assess him at midnight to ensure he is stable and check on his blood culture. If his respiratory status worsens, I will repeat a radiograph to look for an effusion.


Accurate, timely, concise, and thorough documentation by interprofessional team members ensures continuity of care for their clients. It is well-known by health care team members that in a court of law the rule of thumb is, “If it wasn’t documented, it wasn’t done.” Any type of documentation in the electronic health record (EHR) is considered a legal document. Abbreviations should be avoided in legal documentation and some abbreviations are prohibited.

Learn More

Read the current list of error-prone abbreviations by the Institute of Safe Medication Practices. These abbreviations should never be used when communicating medical information verbally, electronically, and/or in handwritten applications. Abbreviations included on The Joint Commission’s “Do Not Use” list are identified with a double asterisk (**) and must be included on an organization’s “Do Not Use” list.

Nursing staff access the electronic health record (EHR) to help ensure accuracy in medication administration and document the medication administration to help ensure patient safety.


The electronic health record (EHR) contains the following important information:

  • History and Physical (H&P): A history and physical (H&P) is a specific type of documentation created by the health care provider when the client is admitted to the facility. An H&P includes important information about the client’s current status, medical history, and the treatment plan in a concise format that is helpful for the nurse to review. Information typically includes the reason for admission, health history, surgical history, allergies, current medications, physical examination findings, medical diagnoses, and the treatment plan.
  • Provider orders: This section includes the prescriptions, or medical orders, that the nurse must legally implement or appropriately communicate according to agency policy if not implemented.
  • Medication Administration Records (MARs): Medications are charted through electronic medication administration records (MARs). These records interface the medication orders from providers with pharmacists and are also the location where nurses document medications administered.
  • Treatment Administration Records (TARs): In many facilities, treatments are documented on a treatment administration record.
  • Laboratory results: This section includes results from blood work and other tests performed in the lab.
  • Diagnostic test results: This section includes results from diagnostic tests ordered by the provider such as X-rays, ultrasounds, etc.
  • Progress notes: This section contains notes created by nurses, providers, and other interprofessional team members regarding client care. It is helpful for the nurse to review daily progress notes by all team members to ensure continuity of care.
  • Nursing care plans: Nursing care plans are created by registered nurses (RNs). Documentation of individualized nursing care plans is legally required in long-term care facilities by the Centers for Medicare and Medicaid Services (CMS) and in hospitals by The Joint Commission. Nursing care plans are individualized to meet the specific and unique needs of each client. They contain expected outcomes and planned interventions to be completed by nurses and other members of the interprofessional team. As part of the nursing process, nurses routinely evaluate the client’s progress toward meeting the expected outcomes and modify the nursing care plan as needed.


  1. AHRQ. (2020, January). Pocket guide: TeamSTEPPS.
  2. AHRQ. (2020, January). Pocket guide: TeamSTEPPS.
  3. AHRQ. (2020, January). Pocket guide: TeamSTEPPS.
  4. AHRQ Patient Safety. (2017, July 26). Introduction to the fundamentals of TeamSTEPPS® concepts and tools. [Video]. YouTube. Video in the Public Domain.
  5. Institute for Healthcare Improvement (n.d.). ISBAR trip tick.
  6. Grbach, W., Vincent, L., & Struth, D. (2008). Curriculum developer for simulation education. QSEN Institute.
  7. Studer Group. (2007). Patient safety toolkit – Practical tactics that improve both patient safety and patient perceptions of care. Studer Group.
  8. Starmer, A. J., Spector, N. D., Srivastava, R., Allen, A. D., Landrigan, C. P., Sectish, T. C., & I-Pass Study Group. (2012). Transforming pediatric GME. Pediatrics, 129(2), 201-204.
  9. The Joint Commission. (n.d.). Sentinel event alert 58: Inadequate hand-off reports.
  10. The Joint Commission. (n.d.). Sentinel event alert 58: Inadequate hand-off reports.
  11. The Joint Commission. (n.d.). Sentinel event alert 58: Inadequate hand-off reports.
  12. Starmer, A. J., Spector, N. D., Srivastava, R., Allen, A. D., Landrigan, C. P., Sectish, T. C., & I-Pass Study Group. (2012). Transforming pediatric GME. Pediatrics, 129(2), 201-204.
  13. Starmer, A. J., Spector, N. D., Srivastava, R., Allen, A. D., Landrigan, C. P., Sectish, T. C., & I-Pass Study Group. (2012). Transforming pediatric GME. Pediatrics, 129(2), 201-204.


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Leading Change in Health Systems: Strategies for RN-BSN Students Copyright © 2023 by Kathy Andresen DNP, MPH, RN, CNE is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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