SBAR Escalation Call Scenario With Model Answer

Nursing faculty teaching resource

Calling nurse case brief

Recognize the change

It is 1:58 p.m. on 3 East. You are Lee Harmon, RN, caring for Robert Hayes. You have just found the change below. The charge nurse is available nearby, but no emergency call has yet been made. Compare the trend and decide what help is needed immediately.

Patient / location

Robert Hayes, 67 years; fictional MRN 593824; 3 East, room 318

Admission

Hospital day 2 with pneumonia; receiving prescribed antibiotics.

History / status

Hypertension; no chronic lung disease or home oxygen use. No known medication allergies. Full code.

Respiratory change

Earlier: speaking in full sentences. Latest: more short of breath at rest, accessory-muscle use and short phrases; awake and responding.

The oximeter probe and signal have been checked; saturation remains 89% on 2 L/min by nasal cannula.

Exercise response pathway

For this exercise, severe breathing difficulty, saturation persistently below 90% despite oxygen, or serious staff concern requires immediate rapid response activation without provider permission. The standing emergency protocol authorizes nasal-cannula oxygen adjustment and continuous oximetry while help is summoned. Flow and target selection are not assessed.

If the patient becomes unresponsive and is not breathing normally (including only gasping), call the code team (local emergency response) and start BLS as trained; return to SBAR only when immediate care is covered.

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SBAR worksheet

Prepare and record the call

Nursing faculty teaching resource

Receiver role card

Play the covering clinician

You are Dr. Jordan Patel. Lee Harmon, RN, calls about Robert Hayes. Receiver: initially unavailable.

Before the call

Ask for immediate actions and the escalation decision. If activation is omitted or the learner would wait for permission, pause and clarify that emergency action cannot wait. The observer records the omission and prompt. Then give the call update card (page 2). Everyone uses the same update; it does not earn credit for the initial decision.

Opening

“This is the covering clinician. Tell me what is happening.” Let the learner finish the initial SBAR.

One realistic constraint

Say once: “I am tied up with another patient. Can this wait until I finish?” If the caller has already proposed the rapid response clinician as an alternative, say instead: “I cannot leave this patient. What response can we coordinate now?”

Accept either appropriate plan

Accept a clear request for immediate assessment. Choose your availability before the round and keep it the same for the retry. If unavailable, agree to response-team assessment with immediate covering-team contact. Accept equivalent wording; do not require your attendance or a diagnosis.

If a safe plan is not reached

End the conversation for debrief. Emergency help remains active; never withhold it to force the right words. Credit immediate coordination through the charge nurse and rapid response lead when a clinician is unavailable.

If asked for absent information, say “That information is not provided.” Do not invent orders, repeat measurements, arrival, or improvement. Keep this card separate from the calling learner.

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Release after the initial decision

Update for the SBAR call

RECEIVER: Keep this page until the learner states their initial decision. Then give it to the calling nurse to read and keep in view. This supplied update is the same for all learners, including anyone who needed a prompt.

Actions now underway

It is now 2:00 p.m. Rapid response was requested at 1:58 p.m., without waiting for the phone call. Bedside observation continued and the head of the bed was raised. After the oxygen equipment was checked, oxygen was increased to 4 L/min by nasal cannula under the standing emergency protocol. Continuous pulse oximetry is in place. The charge nurse now stays at the bedside while you call Dr. Jordan Patel; the rapid response team, including respiratory therapy and a clinician, is on its way. The 89% reading was on 2 L/min before this change. No post-adjustment reading is supplied in this exercise. Obtain and report current findings without delaying help; do not assume improvement.

Now make the call

Call Dr. Jordan Patel, the covering clinician, using SBAR. Communicate the change, your working concern, actions underway, and the response needed. Confirm the agreed plan.

Keep observations and actions separate

The chart readings describe the patient before the increase in oxygen. Do not report a new saturation or improvement. New treatment orders are outside this exercise; repeating the response plan is not medication-order read-back.

Response-team context

If the patient worsens or help is delayed, immediately alert the charge nurse and response lead.

If the patient becomes unresponsive and is not breathing normally (including only gasping), call the code team (local emergency response) and start BLS as trained; return to SBAR only when immediate care is covered.

Nursing faculty teaching resource

Observer reference

Facts for the observer

Keep this reference and the worksheet together. Use the facts to check the report; do not give the caller the model answer.

Patient / location

Robert Hayes, 67 years; fictional MRN 593824; 3 East, room 318

Admission

Hospital day 2 with pneumonia; receiving prescribed antibiotics.

History / status

Hypertension; no chronic lung disease or home oxygen use. No known medication allergies. Full code.

Respiratory change

Earlier: speaking in full sentences. Latest: more short of breath at rest, accessory-muscle use and short phrases; awake and responding.

Stage 1: initial decision

Before the update, no emergency call has occurred. Look for immediate help and rapid response, staying with the patient, upright positioning and oxygen/monitoring support under the standing emergency protocol. Do not require a specific oxygen flow at this stage. Record the learner’s words; the update does not earn retrospective credit.

Stage 2: supplied actions

At 2:00 p.m.: rapid response requested at 1:58 p.m.; head of bed raised; oxygen increased to 4 L/min after equipment check under the standing emergency protocol; continuous oximetry. Charge nurse remains at bedside. Team including clinician and respiratory therapy is on its way. No post-adjustment findings are supplied; obtain current readings without delaying help.

Nursing faculty teaching resource

Observer guidance

What to credit

If the patient worsens

If the patient worsens or help is delayed, immediately alert the charge nurse and response lead.

If the patient becomes unresponsive and is not breathing normally (including only gasping), call the code team (local emergency response) and start BLS as trained; return to SBAR only when immediate care is covered.

Acceptable response plans

Credit immediate assessment by an appropriate clinician: the covering clinician, or the rapid response clinician with covering-team coordination. Confirm who, timing, and the response to worsening or delayed help through the charge nurse/response lead. Do not require covering-clinician attendance.

Credit an uncertain concern about respiratory failure or sepsis tied to findings. Do not require a definitive diagnosis. A call confirms communication, not patient improvement.

Nursing faculty teaching resource

Observer worksheet

Observe the decision and call

Patient: Robert Hayes | Guided brief | Initially unavailable receiver

Calling learner: ____________________ Observer: ____________________

O = observed as described; N = not yet demonstrated; N/A = no opportunity (explain). Note missing parts and prompts (Y/N). Use the reference. No total score.

Nursing faculty teaching resource

Instructor guide

Run the escalation activity

Guided brief | Initially unavailable receiver. For final-semester students and new-graduate nurses with prior respiratory assessment and emergency-response teaching.

Learning objectives

• Recognize a concerning trend and verbalize immediate nursing support and escalation before the call.
• State a supported, uncertain clinical concern and request timely assessment.
• Confirm an appropriate response and contingency for worsening or delay; document the actual agreement.

Suggested timing: about 20 minutes

Distribution for 24 students in 8 groups

Provide 8 calling-nurse handouts, 8 sets of receiver/observer materials (5 pages per set; 40 single-sided sheets), and 1 guide per facilitator. Receiver: pages 1-2. Observer: pages 3-5. Give the update card on page 2 only after the initial decision.

Rotation

For three rotations: 24 calling handouts, 8 receiver cards and 8 update cards, 8 sets of observer reference/guidance pages, and 24 observer worksheets (page 5). The same learner makes both attempts before roles change. Later learners have heard the case; this is practice, not an unseen assessment.

The suggested timing is a starting point; adjust it for your group. Agree how to request faculty help, space groups so calls can be heard, and stagger rounds if needed.

Written for US practice settings; adapt terms and policies for your setting.

Nursing faculty teaching resource

Facilitator and observer preparation

Prebrief and observation

Read aloud: a short prebrief

“This is formative practice, not a graded assessment. We will discuss the words heard, then repeat the conversation with the same nurse learner. Equivalent wording is welcome.”

“Our goal is to recognize deterioration, summon help, and confirm an urgent response. Two chairs back to back represent the phone call.”

“The patient and chart are fictional. Work with the supplied facts as if they were real, and tell us if something prevents you from doing that. Everyone brings useful experience and is here to learn.”

“Treat one another respectfully. The receiver has a scripted role; resistance is part of the activity, not a judgment of the learner. Anyone may say pause. We will clarify the task, support the learner, and restart if needed. Keep identifiable comments within the learning group.”

“First state your immediate actions and how you would summon help. Then receive the update card and make the call. In real care, activate emergency help at once; the preparation time here is only for learning. Verbalize actions here; do not perform procedures or call emergency numbers.”

“If information is missing, say it is not provided and explain what you would check. Do not invent a new result, order, or patient response. The receiver should answer ‘That information is not provided.’ Faculty will clarify anything needed to continue.”

“The observer records all marks and prompts, using the reference to check facts and noting brief exact words. The receiver follows the role card and helps clarify what was said during debrief. Start with the learner’s view, then offer evidence and one useful next step.”

Observer only: calibrate privately before starting

Mark O when the behavior is observed and N when it is not yet demonstrated as described. Record any missing parts in the evidence notes; there is no partial category. Use N/A only when there was no scripted opportunity, and explain why. Mark a prompt when someone supplied a missing cue or suggested answer. A scripted challenge or request to repeat an unclear word is not a prompt. Do not total the marks or assign a pass score.

Focus detailed notes on one or two behaviors. For a row with several parts, mark N if a part is missing, then record what was present and what remains. Faculty resolve uncertain marks from the words heard. Binary marks keep feedback simple and consistent with the companion guide; this case checklist is not the validated SBAR-LA rubric.

Example

“Saturation fell from 96% to 89%” omits the oxygen setting and times: mark N and note “trend stated; setting and times missing.” Credit an appropriate response-team assessment even when the covering clinician cannot attend.

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Facilitation notes

Debrief and document

Start with the initial decision

Which cues made this urgent? Review the decision before the supplied update. If the learner waited for permission, use a coached restart; the update does not earn retrospective credit.

Use the words heard

• Ask the observer for the concern, evidence, requested response, and confirmation. Ask the receiver what responsibility was understood.
• Credit “I am worried about sepsis” supported by the findings. “This is definitely sepsis” overstates what the case establishes. Pneumonia and sepsis are not alternatives.
• If a clinician is unavailable, distinguish coordinated assessment from an unconfirmed promise to review later.
• What would you communicate if the patient worsened before help arrived?
• Which sepsis screen or early-warning tool does your unit use? Apply only a supplied tool with available inputs; screening must not delay emergency help.

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Documentation and transfer

Record the actual agreement

Clinical scope

The oxygen action is not a universal prescription. No new orders or later outcomes are simulated. Accept appropriate response-team assessment; the covering clinician does not have to attend.

Brief documentation practice

Write a short note during debrief: event/contact time, findings and concern, actions underway, whom you contacted, and the actual agreed response. Use the agreement reached in this attempt, not an assumed outcome. No new orders were given; plan confirmation is not order read-back.

Example: “2:00 p.m.: Called Dr. Jordan Patel, covering clinician, by phone. At 1:58 p.m.: RR 30 (18 at 1:30 p.m.), SpO2 89% on 2 L/min (96% on 2 L/min at 1:30 p.m.), HR 118, BP 104/64, temperature 100.8 °F; accessory muscles, short phrases, awake and responding. Concern for respiratory failure/possible sepsis. Rapid response requested 1:58 p.m.; head of bed raised, oxygen now 4 L/min under the standing emergency protocol, continuous oximetry, charge nurse at bedside. Agreed response-team clinician to assess on arrival and contact covering clinician, who is available by phone. Will alert charge nurse and response lead immediately if worsening or delay. Repeat SpO2 pending.”

Retry and transfer

Choose one target. Repeat both stages with the same learner and receiver behavior. Later roles have prior exposure. A different receiver adds a challenge, not an unseen clinical case. Use an unfamiliar case to explore transfer.

Nursing faculty teaching resource

Faculty reference

Curriculum links

Suggested connections for lesson planning. These are limited mappings by the resource author, not endorsement, competency certification, or a validated scoring framework.

AACN Essentials

Domain 6, Interprofessional Partnerships, 6.1b: “Use various communication tools and techniques effectively.” Evidence here is the learner’s SBAR, clarification, and confirmation of responsibilities.

QSEN

Teamwork and Collaboration: explain the concern, clarify roles, and agree next steps. Safety: distinguish known findings from assumptions and communicate unresolved needs. Observe these behaviors; do not infer an entire competency from one exercise.

NCSBN Clinical Judgment Measurement Model

Recognize and analyze cues: compare the respiratory trend. Prioritize hypotheses: state an uncertain clinical concern. Generate solutions and take action: verbalize immediate help and escalation, then negotiate the response. Actions are verbalized, not physically demonstrated. No later patient outcomes are supplied, so this activity does not test evaluation of clinical outcomes.

A clearer second conversation demonstrates improvement on this familiar task. It does not by itself establish transfer to an unseen patient or completion of the clinical judgment cycle.

Nursing faculty teaching resource

Sources and reuse

Sources, review and reuse

Sources and related teaching resources

AACN Essentials: Domain 6

QSEN: Prelicensure competencies

NCSBN: Clinical Judgment Measurement Model

INACSL: Simulation standards and prebriefing

AHRQ TeamSTEPPS: SBAR

AHRQ PSNet: Rapid Response Systems

SCCM: Surviving Sepsis Campaign 2026

American Heart Association: Adult basic life support

SBAR authoring guide: bedside report, critical results, orders and read-back

Before you teach

Written by the Lingua CoPilot Medical team from the sources listed. These cases have not been clinically reviewed. The model answer is one possible response, not a standard of care.

Lingua CoPilot Medical | Version 1.0 | Revised November 4, 2026.

Original case materials: CC BY 4.0. Copy, adapt and share with attribution to Lingua CoPilot Medical, a license link, and an indication of changes. External sources retain their own terms. Review adaptations before teaching; keep faculty answers separate during first attempts.

Creative Commons Attribution 4.0 International