Team training is an effective method to improve frontline healthcare personnel’s teamwork competencies . Team training is defined as “a set of tools and methods that form an instructional strategy,” and is a methodology designed to educate team members with the competencies necessary for optimizing teamwork . Teamwork competencies refer to the attitudes, behaviors and cognitions necessary for effective teamwork . In this context, the attitudes are the affective attributes essential for effective team performance, behaviors are the skills and procedures needed for teamwork and cognitions are the necessary elements of knowledge and experience necessary for effective teamwork . Interprofessional team training in hospitals has a positive impact on team behavior [9, 13], patient safety culture  and patient outcome .
Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS)  was chosen as the team training program in this study. This generic program is one of a few standardized training and research-based programs that address the impact of human factors on healthcare teams . The program aims to optimize patient safety and the quality of care by enhancing team structure and four teamwork competencies; communication, leadership, situation monitoring, mutual support [17-19]. Each of the four teamwork competencies has a set of tools or strategies that the interprofessional team members are supposed to utilize to ensure effective teamwork [17, 20]. The AHRQ gave permission to translate and use the program in Norway.
Despite previous research which shows that interprofessional team training interventions improve the quality of clinical practice, there is little knowledge about its impact on hospital wards. The overall objective of the study was therefore to explore the impact of an interprofessional teamwork intervention in a surgical ward on structure, process and outcome. Here, we report on the implementation of the TeamSTEPPS program as additional data to facilitate a better understanding of the evaluation results of this study.
Research setting and sample
The interprofessional teamwork intervention was carried out in a surgical ward at hospital in eastern Norway. The ward was selected for convenience, and based on the management`s interest to participate in the study. The target group was frontline healthcare personnel healthcare personnel consisting of physicians, registered nurses and nurse assistants working at the ward. A consecutive sample of elective and emergency patients with the inclusion criteria being 18 years or older, understanding Norwegian, and being in a mental and physical health condition that made it ethically justifiable to participate, were included in the study. Furthermore, healthcare personnel in a surgical ward at a hospital in southern Norway constituted the control group.
Description of the intervention
The intervention was initiated by a research group consisting of four researchers from two universities in Norway. Two of the researchers and four of the leaders at the ward had attended a TeamSTEPPS master training. The TeamSTEPPS program and teaching materials were translated into Norwegian by a translation agency, and approved by three faculty members. The intervention was conducted according to the recommended TeamSTEPPS implementation plan , which is built on John Kotter`s change model with eight steps for organizational change . The TeamSTEPPS intervention is described in three phases, with Kotter`s eight steps incorporated in the different phases. The study period lasted for 12 months after the initial interprofessional team training.
Phase I. Setting the stage and deciding what to do - assessment and planning
Multiple actions occurred to assess organizational readiness for a TeamSTEPPS initiative [17, 21]. After collection of the assessment profile of the surgical ward, the leaders decided that the ward was ready for the TeamSTEPPS intervention. A comprehensive planning for an interprofessional TeamSTEPPS training and implementation was jointly conducted by the leaders and the researchers. In advance of the team training, the physicians and nursing staff attended information meetings organized by the researchers.
Phase II: Make it happen - training and implementation
The onset for the TeamSTEPPS intervention was six hours of compulsory interprofessional team training conducted for all frontline healthcare personnel during work hours (n=41). TeamSTEPPS leaflets and pocket guides were distributed to all healthcare personnel. The team training was conducted by the leaders of the ward in collaboration with two of the researchers (RB and ORA), and completed over three days (three interprofessional groups) during three weeks in May 2016. The team training consisted of didactics, videos, role-play and high-fidelity simulation training with debriefing sessions. The first lecture aimed to create a sense of urgency (Kotter’s step 1) by presenting the Sue Sheridan video  and by presenting the hospital`s reports of adverse events. The two simulation sessions consisted of two scenarios: “A postoperative urology patient with infection” and “A postoperative gastroenterological patient with acute deterioration,” both with a focus on communication and teamwork. At the end of the course, all healthcare personnel were asked to identify patient safety issues in the ward, and to suggest TeamSTEPPS tools to solve the problem. Moreover, immediately after the training the participants responded to “The TeamSTEPPS Course Evaluation Survey  to evaluate the training and learning outcomes. The six hours of team training was accredited for continuing education by for general surgery by the Norwegian Medical Association and for clinical advancement by the Norwegian Nurse Organization.
The initial team training was followed by an implementation phase in the intervention ward. A Change Team was established (Kotter’s step 2) consisting of multi-professional healthcare personnel from the ward (two registered nurses, two assistant nurses and four physicians), in addition to the Chair of the surgical department, a former patient and a researcher serving as a coach (ORA). The Change Team served as a guiding coalition and was led by the Nurse Unit Manager. A vision of “Zero errors” (0 patient harm errors) was set, and an action plan was developed based on the identified patient safety risk areas in the ward and approved by the Chair of the surgical department (Kotter’s step 3). The action plan was communicated in unit staff meetings and by email to all employees (Kotter’s step 4). The leaders empowered a broad-based action to make the implementation as smooth as possible, and to remove obstacles that could undermine the changes (Kotter’s step 5). Posters with explanations of the TeamSTEPPS tools were placed in working stations at the ward. In addition, posters for patients and visitors were placed in the ward corridors, with a request to speak up if they perceived something that might be a threat to patient safety. One of the authors (ORA) coached the implementation by giving and gathering input from site visits and e-mail communications with the leaders and the clinical nurse specialist, and as a member of the Change Team throughout the study period.
The Nurse Unit Manager and the Clinical Nurse Specialist led the implementation of tools and strategies. Five TeamSTEPPS tools were implemented during the first six months of the study period (see Table 1). Each tool was launched as “The tool of the month,” and communicated in the weekly newsletters sent to the nursing staff and physicians. The introduction of new tools was marked in inventive ways. An example of structural changes that followed the training were implementation of interprofessional huddles held beside the patient safety whiteboard after the daily interprofessional rounds.
The frontline healthcare personnel and their leaders celebrated short-term wins together (Kotter’s step 6). Five months after the initial team training, the master-trained Unit Nurse Manager and the clinical nurse specialist organized 75 minute TeamSTEPPS refresher training for the nursing staff. The master-trained Chief Surgeon conducted a 20 minute refresher training for the physicians.
Phase III: Make it stick – sustainment
The implementation of the tools and structural changes continued into the sustainment phase, with five more tools implemented during the next six months. After 11 months, one more 75 minute TeamSTEPPS refresher training was conducted for all the nursing staff. The leaders and the frontline healthcare staff used the tools in their daily work, and the changes were consolidated (Kotter’s step 7). They anchored the change to let the change effort to become a lasting part of the organizational culture (Kotter’s step 8). This step is the final leg of Kotter’s leading change model. The implementation period was 12 months.
An overview of the intervention is illustrated in Figure 1, and more details are given in Table 1.