Implementing a TeamSTEPPS® Team-training Program in a Bachelor of Nursing Education to Enhance Teamwork Attitudes and Skills

The aim of this paper is to describe the implementation process of the TeamSTEPPS® intervention in the education of Bachelor of Nursing students Results. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) program was implemented in three phases according to an implementation plan built on seven of Kotter’s eight-step model for leading change. The rst phase consisted of establishing a sense of urgency to implement team training in the education program, establishing a change team and creating a vision and plan for implementation of the program as well as providing information and training for faculty. The second phase consisted of the various team training activity as lectures, videos, and posters in the simulation environment and learning platform that were introduced to students. The goal of the third phase was to consolidate the teamwork skills for retention and to challenge students to use the teamwork skills in more complex situations. 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’ rst clinical placement in nursing homes. Structured reection-hours were arranged during clinical placements. The TeamSTEPPS® skills were used to so that the students could reect upon the perceived challenges of being a nursing student in the patient care team.


Introduction
The healthcare system is rapidly changing, and the development of new technology with increased complexity and specialization creates a need to work in teams (Disch, 2017; White Paper Nr 10, 2012; White Paper Nr 13, 2012). Teamwork performance is a core competency of all healthcare professionals to meet the needs of the twenty-rst-century health system (Greiner Ann C & Knebel Elisa, 2003) and to offer safe and effective care (WHO, 2011). Teamwork has to be emphasized in theoretical and practical studies in the education of nurses as well as in the education of other healthcare professionals (Aase & Hansen, 2018; Norwegian Ministry of Health and Care Services, 2019). Team training has been implemented in the education of nurses in Norway to a limited extent (Aase et al., 2013). Research has revealed that team training among healthcare students shows positive changes in attitudes towards teamwork (Goliat et al., 2013;Maguire et al., 2015) and increases knowledge of teamwork skills (Robertson et al., 2010), which indicate that students enjoy attending team training (Welsch et al., 2018). The overall objectives of this study are to explore the impact of implementing a Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) team training intervention. The aim of this paper is to describe the implementation process of the TeamSTEPPS® intervention in the education of Bachelor of Nursing students.

Main Text
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(Hughes et al., , 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. 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 rst four semesters, and phase 3 involved the fth 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 rst 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, brie ngs and debrie ngs were used consistently as strategies before and after each training session of nursing skills in the simulation center. See Additional le 1 for the description of the skill, tools and strategies implemented. The faculty had access to notes with questions to facilitate re ections 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' rst clinical placement in nursing homes. Structured re ection-hours were arranged during clinical placements. The TeamSTEPPS® skills were used to so that the students could re ect 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 rst-aid simulation day. The student teams had to take care of seven cases who needed rst-aid care. Team structure, communication, leadership, situation monitoring, and mutual support skills were all part of the debrie ng session after each scenario. The students were encouraged to provide a short brie ng before each scenario after the case had been announced. A short-time-win (Step 6) was established after the rst-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 debrie ng 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, speci cally their leadership skills, as one part of the assignment.

Phase 3. Make it stick -sustainability
Year 3: In the fth semester (fall 2020), the intervention consisted of training sessions in con ict-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 re ections concerning teamwork, use of teamwork skills, lack of teamwork skills and how disagreements were solved in the team (step 7).
Additional le 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.

Limitations
This research project has some limitations. Cross-cultural aspects of the TeamSTEPPS® concept may in uence the implementation process in a Norwegian health educational culture. One limitation is that the Declarations Ethics approval and consent to participate The study was approved by the Norwegian Social Science Data Service (NSD project number758392) and by the head of the department. The students received written information about the studies, voluntary nature of taking part in the evaluation, right to withdraw at any time, and con dentiality of participating according to the General Data Protection Regulations (GDPR) and the Declaration of Helsinki (WMA, 2013). The students signed a written consent form before attending the studies, either by pen and paper or electronically.

Consent for publication
Not applicable Availability of data and materials Not Applicable Competing interests Table 1 Overview of the implementation of TeamSTEPPS® team training tools and strategies in the education of Bachelor of Nursing students Year Month A description of the intervention Year 1