Teamwork is a skill—it must be practiced

How do you talk to a colleague who is obviously making work-related mistakes? And how would you yourself want this kind of feedback? Patients depend on health workers working well together for their recovery. If health-care providers have training in teamwork, however, there is less risk that they will make mistakes.

"As health services become more specialized, it's even more important for health care providers to be good at working together. But to get good at this, you need training and education," says Tore Karlsen.

Karlsen is an associate professor and study program leader for the master's degree in specialist nursing at the Department of Health Sciences at NTNU in Gjøvik.

Need training

Karlsen has worked with assistant professors Marit Sund Storlien and Tone Stomlien and Professor Randi Ballangrud in the same department and with a Norwegian version of a program called TeamSTEPPS.

The researchers followed a cohort of nursing students (in Norwegian) for three years. Teamwork skills were a topic in all relevant courses. What did the students learn, and what were the experiences of the teachers? The researchers have now investigated this.

Patients died

The focus on patient safety increased sharply after the 1999 US report "To Err is Human." It showed that nearly 100,000 patients died each year in American hospitals due to adverse events. Poor communication and teamwork were among the most important reasons.

This is how TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) was born. The program was released in November 2006 and was developed by the US Department of Defense and the Agency for Health care Research and Quality to integrate teamwork into practice.

The purpose is to strengthen teamwork and is based on four skills:

• Communication
• Management
• Situation monitoring
• Mutual support

These skills are taught through tools and strategies such as briefing, debriefing, and a program called ISBAR, which is a patient safety communication structure and other methods to ensure safe and structured communication.

The TeamSTEPPS was translated into Norwegian in 2015 and is currently used in education and clinical practice.

Nursing students trained

A cohort of nursing students at NTNU in Gjøvik used TeamSTEPPS throughout their bachelor's education.

They carried out the team training using simulations, and studied practices and theory. The program included reflection exercises, short lectures, films and digital learning resources.

Twenty-two students participated in interviews, while the students in the entire cohort answered the TeamSTEP questionnaire about attitudes towards teamwork. They did this before the program started, after ten months and after 24 months.

The researchers compared the responses from the students with a group of students on another campus who did not receive this training. They also interviewed 12 teachers.

Takes time to learn cooperation

The students said it took time to learn good cooperation. At the start of their education, they found it difficult to understand why teamwork was important. It was both theoretical and complicated.

As they were able to practice their team skills in various learning activities at school and in practice, they gained a better understanding of its relevance and importance.

"Getting good at teamwork takes time, but it can be learned—and should be part of the education from start to finish," says Karlsen.

Teamwork is about more than communication and leadership. The students and teachers raised their awareness of the complexity of the health care system and the importance of teamwork for patient safety. This was a key lesson learned throughout the project.

Many types of teams

The list of health care teams is long. A team can be the patient, a nurse and relatives. Or a nutritionist, kitchen staff and nurse. Or the oncologist and palliative care team. Physiotherapists and occupational health services have to work together. Occupational therapists and employees in home care are other examples.

Many educational offerings have programs or projects in which nursing students participate in interprofessional teamwork. These may last from a few days to several weeks.

"However, there is often a general lack of emphasis on teamwork throughout educational programs," says Karlsen.

It can also be difficult to coordinate the various health education programs in order to carry out interprofessional activities and training over time. This may be due to differences in course structure, timetables, collegial relationships and location.

Across professions

Teamwork is based on the same principles regardless of how the team is composed, and there is no difference in effect between profession-specific and interprofessional teams when it comes to team training.

This is how the nursing students completed four skills in team training:

1. Communication: Good communication within the team is fundamental to all other team skills. The students started by practicing clear communication. This was followed up in all simulations throughout the education.

2. Leadership: The students used simulations to train for leadership roles. In the beginning, they worked on leadership with their own work and included the "patient" as an active participant in the team, for example in connection with transfers or personal hygiene. An important part of the leadership role was to prepare the team through a briefing before the task started. Afterwards, the team leader was responsible for carrying out a debriefing: What worked well, what could be improved?

3. Situation monitoring: Situation monitoring is not only about monitoring the patient and having background knowledge about them, but also about observing the behavior and competence of colleagues and fellow students. This could include whether hygiene is taken care of, assessing whether the team's actions are having the desired effect and helping to ensure that errors are detected quickly.

4. Mutual support: Giving each other both positive and constructive feedback to improve practice and patient safety was demanding. Addressing disagreements and resolving conflicts in the team was also difficult to train through simulation. The teachers consequently made a video in which they themselves played roles in a team that had professional disagreements. The video was used as a starting point for reflection on how conflicts can be resolved in a way that does not impair teamwork or patient safety.

"In all of this, psychological safety is important. Without this, it is difficult for the students to use teamwork skills in practice," Karlsen says.

"National guidelines for nursing education place great emphasis on learning outcomes in health, illness and nursing. Unfortunately, there is a vaguer description of the learning outcomes of teamwork skills," he said.

More information:
Learning teamwork is not an event, it's a journey: Implementing the TeamSTEPPS team training program in bachelor of nursing education to enhance patient safety. ntnuopen.ntnu.no/ntnu-xmlui/handle/11250/3024396

Provided by Norwegian University of Science and Technology