Team training has been described as a learning strategy in which a learner or group of learners systematically acquire(s) teamwork knowledge, skills and abilities to impact the cognition, affect and behaviors of a team (Hughes et al., 2016, p. 1267). TeamSTEPPS® is an evidence-based team training program developed by the Agency of Health Research and Quality (AHRQ) and the Department of Defence (DoD) in the U.S. The AHRQ has approved the Norwegian research team to translate and use the TeamSTEPPS® program in Norway. We decided to use the TeamSTEPPS® program in our study due to its evidence-based foundation and its unique package of learning material, implementation strategy and measurement instruments (AHRQ, 2017a; King et al., 2008). The TeamSTEPPS® curriculum emphasizes the team structure and four teamwork skills: communication, leadership, situation monitoring and mutual support. These four skills are mutually supportive and equally crucial to team success and to creating a culture of patient safety. The team structure is a fundamental of teamwork in clinical care. Communication skills emphasize the importance of structured, clear and accurate communication among team members. Team leadership skills focus on sharing information and plans of care to maximize the activities of team members. Situation monitoring is about the process of scanning and assessing situational elements to gain information or an understanding or to maintain awareness to support team functioning. The mutual support skill is about the ability to anticipate and support team members’ needs through accurate knowledge about their responsibilities and workload (AHRQ, 2014, 2017a, 2017c).
Research settings and sample
This teamwork intervention was carried out at a university in Norway. The study involved students starting their education in the fall of 2010 (N = 534). A total of 164 students from one campus were included as the intervention group (N = 164)
Description of the Implementation of the intervention
The intervention was implemented in three phases according to the TeamSTEPPS® implementation guide(AHRQ, 2017c) and incorporated seven out of Kotter’s eight steps for organizational change (Kotter, 2012) (AHRQ, 2017c). Figure 1 Phases in the implementation
Phase 1: Setting the stage and deciding what to do - assessment and planning.
The head of the department on the campus was informed about the project and approved it. The intervention idea was presented in a workshop with the faculty members in March 2018. This workshop (Step 1) was arranged to foster a sense of urgency among the faculty members. The workshop revealed that some teamwork skills were already implemented to a certain extent through learning objectives in clinical placements. The workshop contributed to a higher consciousness of the complexity of teamwork and highlighted teamwork skills in a clear context of patient safety, e.g., the importance of using closed loop communication to avoid a misunderstanding of patient information and the importance of speaking up if safety issues were discovered to avoid adverse events. A “change team” with four faculty members was established (TS, TK, RB and MHSS) (Step 2). Three members (TS, MHSS, TK) of the change team attended a TeamSTEPPS® master trainer course at Northwell Hospital, Long Island, NY, in May 2018. The fourth member was already a TeamSTEPPS master trainer®. The master training course provided a foundation for developing a change vision and strategy (Step 3). Learning outcomes were made to guide the implementation. Phase 2 was determined to involve the first four semesters, and phase 3 involved the fifth semester. The sixth semester was not included in the research project for practical reasons.
Phase 2: Make it happen - training and implementation
The vision and strategy were presented and rooted among the department leaders and key faculty members through several meetings and workshops in the spring and autumn of 2018 (Step 4). The implementation plan was continually evaluated and shared between key members of the faculty to meet the objectives and vision of the TeamSTEPPS® project throughout the implementation phase (Steps 4 and 5). An overview of the implementation is presented in Table 1. Overview of the implementation of TeamSTEPPS® team training tools and strategies in the education of Bachelor of Nursing students.
Year 1:
The first semester (Fall 2018) started with informing the students about the TeamSTEPPS® program and its implications. It was emphasized that the TeamSTEPPS® strategies and tools should be an integral part of the students’ learning activities. The TeamSTEPPS® team structure and teamwork skills were introduced as a part of the practical skill training to raise consciousness between teamwork and patient safety. It was stressed that “the patient” be included as a team member in any simulated or role-playing session.
In the second semester (Spring 2018), the students were offered a 6-hour TeamSTEPPS® essential course, in which the Norwegian version of the TeamSTEPPS® pocket-guide was distributed. Additional TeamSTEPPS® learning material was made available to the students through the learning platform (Blackboard). The second semester included extended use of the TeamSTEPPS® tools and strategies: the leadership tools, briefings and debriefings were used consistently as strategies before and after each training session of nursing skills in the simulation center. See Additional file 1 for the description of the skill, tools and strategies implemented. The faculty had access to notes with questions to facilitate reflections about the impact of using teamwork skills. These questions were used to raise the consciousness of the link between teamwork, quality of care and patient safety in the practice of nursing skills and in simulated patient care sessions. Communication skills were trained by using the Identity, Situation, Background, Assessment, Recommendation (ISBAR) structured communication in a simulated scenario. Mutual support skills were trained through a two-hour workshop with feedback exercises before the students’ first clinical placement in nursing homes. Structured reflection-hours were arranged during clinical placements. The TeamSTEPPS® skills were used to so that the students could reflect upon the perceived challenges of being a nursing student in the patient care team.
Year 2:
In the third semester (Fall 2019) a 30-minute lecture summary of the teamwork skills was given at the beginning of a seven-hour first-aid simulation day. The student teams had to take care of seven cases who needed first-aid care. Team structure, communication, leadership, situation monitoring, and mutual support skills were all part of the debriefing session after each scenario. The students were encouraged to provide a short briefing before each scenario after the case had been announced. A short-time-win (Step 6) was established after the first-aid training day, as all the student teams were required to use ISBAR communication when reporting to a supervisor. Successful completion was celebrated with ice cream bars given to all the students. (Ice-cream bar = IS-BAR in Norwegian). ISBAR was used to train in both the simulated scenario training and throughout the students’ second clinical placement. To focus on situation monitoring skills, the use of cross-monitoring among the team members in more complex nursing care situations was emphasized. These training sessions consisted of scenarios such as changing the dressing on a central venous catheter and bronchial suctioning. The use of communication skills, situation awareness and feedback to create a shared mental model in a psychiatric care scenario were trained. Peer-to-peer feedback was practiced and explicitly connected to patient safety during the debriefing after the simulation of two patient care scenarios during the students’ clinical placements in the second year of education.
In the fourth semester (Spring 2020), the interventions from the prior semesters were continued. Communication skills were expanded to focus on patient-handover tools. Videos of handoffs using the Illness, Patient summary, Action list, Situation awareness, Synthesis by receiver (IPASS) structure in two different settings was published. A one-hour lecture that emphasized the importance of mutual support before their fourth clinical placement was conducted. The students had access to several demonstration videos in Norwegian in which the TeamSTEPPS® teamwork skills were explained and demonstrated. Supervised clinical placements were canceled due to the Covid-19 pandemic. The students who did not have access to nursing-assistant jobs in that period received an assignment in which they had to focus on their own teamwork skills, specifically their leadership skills, as one part of the assignment.
Phase 3. Make it stick - sustainability
Year 3:
In the fifth semester (fall 2020), the intervention consisted of training sessions in conflict-situations management and how to approach disagreement as a part of the mutual support skill. The students had to rate their teamwork skills as displayed in a video of a simulated scenario by using the TeamSTEPPS® teamwork observation tool (TPOT). The TPOT-score was fundamental for reflections concerning teamwork, use of teamwork skills, lack of teamwork skills and how disagreements were solved in the team (step 7).
Additional file Table S1 show the implemented teamwork skills.
Evaluation
The evaluation of the outcomes of the intervention was based on three out of Kirkpatrick’s four levels of learning evaluation (Kirkpatrick & Kirkpatrick, 2006): Level 1, reactions to training (perceptions); Level 2, learning of training and attitudes; and Level 3, behavior (perception of application to clinical practice). See Table 2 Evaluation methods.
Level 1, reactions to training, explored the students’ perceptions to training by using focus group interviews. Level 2, learning of training, was measured by the students’ self-reported attitudes toward teamwork in healthcare, as measured by the Norwegian version of the TeamSTEPPS® Teamwork Attitude Questionnaire (T-TAQ) before the intervention, after one year and after two years of the intervention, compared with a control group.
Level 3, behavior due to training, explored the students’ perceptions and performance by observation and rated the students’ teamwork skills. One study explored the students’ perception of the transference of their learned skills into clinical placements by using focus group interviews, and one study observed and rated the students’ use of teamwork skills in a simulated scenario. The student’s teamwork skills were rated using the TPOT.