Robertson, Bethany DNP, CNM; Kaplan, Barbara MN; Atallah, Hany MD; Higgins, Melinda PhD; Lewitt, Mary Jane MN, CNM; Ander, Douglas S. MD
The failure of members of the healthcare team to collaborate and communicate can result in negative health outcomes.1 Patient care is a complex activity that requires effective teamwork skills between health care providers to assure quality and safety.1 Research and practical experience in many high-stakes professions including those in health care have shown that optimal, efficient team communications and interactions are essential to human error reduction.2 Despite the importance of teamwork and communication in the delivery of quality patient care, these critical skills are not typically taught and modeled in health professions education.3
Creating healthy teams entails interactive educational experiences early in a student's career within a system that values the diversity of professional knowledge.4,5 It is during the last year of nursing school and the third year of medical school, that students are learning the cultural norms, attitudes, and values that will affect their future roles in interdisciplinary teams.6–8 Active and experiential learning techniques facilitate students' acquisition of team skills, and many studies have shown that students view simulation learning experiences as relevant and immediately useful.9,10 Other researchers have demonstrated that students are able to gain improvements in knowledge, skills, attitudes, and beliefs from interdisciplinary educational experiences.11
The educational framework for our team skills curriculum was developed out of a collaboration between the medical and nursing schools to address the absence of interdisciplinary team training. As in most institutions, the education system of healthcare providers at our university is divided into silos. We have begun the process of changing this axiom, and this educational intervention was the first step to transform how all health professions students are educated. The philosophy at both the school of medicine and school of nursing is to teach and concurrently develop a culture around the importance of interprofessional teams and its role in the provision of patient-centered care. These objectives have been incorporated into the curricular changes at both schools.
Many researchers have demonstrated that students are able to gain improvements in knowledge, skills, attitudes, and beliefs from interdisciplinary educational experiences.10,11 This study is based on a collaboration to address issues in the provision of health care that result in significant safety concerns, as published in the 1999 Institute of Medicine report—To Err is Human.2 The MedTeams Project has provided evidence that formal teamwork training can improve team behaviors, decrease medical errors, and improve attitudes toward teamwork.12,13 This was achieved through a curriculum that focused on team structure, problem-solving strategies, team communication, workload management, and team skills. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program for teaching interdisciplinary teamwork was created by the Agency for Healthcare Research and Quality and the Department of Defense multiyear research and development project to create a national standard for team training in health care.14 The TeamSTEPPS program focuses on teaching competencies in team leadership, mutual performance monitoring, backup behaviors, adaptability, team/collective orientation, shared mental models, mutual trust, and closed loop communication. The core competencies of leadership, situation monitoring, mutual support, and communication are seen as the teachable integral components of the program. When these competencies are used by the health care team in the implementation of patient care, positive outcomes can be measured in the areas of performance, knowledge, and attitudes. We describe our adaptation of TeamSTEPPS for our curriculum and its use as an educational intervention for medical and nursing students. Our adaptation of content and design was based on adult learning theory and our assessment of appropriate content for the student's level of study. We hypothesized that participation of nursing and medical students in a team training program using the modified TeamSTEPPS program would positively affect knowledge and attitudes toward teamwork skills and the students' ability to recognize the presence and quality of team skills.
DESCRIPTION OF EDUCATIONAL PROGRAM
Faculty from the school of medicine and school of nursing met to bring students together for a program that focused on team training skills and patient safety, with the premise that they will be practicing in an interdisciplinary environment. Our overarching educational objective was to incorporate interdisciplinary team training for the first time at our institution using a modification of a well-established curriculum and doing so in an experiential format. We had several specific learning objectives that students should attain by the end of the course:
* Students would be able to recognize the effect of medical error and the importance of communication and teamwork in preventing errors.
* Students would be able to recall teamwork and communication strategies.
* Students would be able to recognize team skills or restate.
* Students would be able to put into practice those team skills that they have encountered during the course in a simulated clinical environment.
The educational intervention consisted of a half-day workshop for all the first-year nursing students and third-year medical students. The day was composed of lecture followed by small group sessions and ended with a summary lecture. We chose to employ several teaching modalities for the workshop. It is well documented that adult learners find active learning to be more appealing. We created a workshop that promoted active learning based on clinical experiences and provided our learners with practical knowledge. Our workshop involved our learners in problem-solving activities and included them in the learning process. In addition, inclusion of multiple teaching strategies accommodated multiple learning styles.
The workshop used the TeamSTEPPS program as a foundation to create our curriculum. We used components of the TeamSTEPPS program described below that our study group felt were relevant to learners at a nursing and medical student level and could be implemented in a half-day workshop.
The opening presentation of the program focused on providing the students with a history behind the quality and safety movement, the effect of medical error and the importance of teamwork skills/tools found in the TeamSTEPPS curriculum. In addition, the lecture provided multiple communication strategies that can be used in the healthcare arena to improve teamwork and decrease the occurrence of medical errors.
The small groups comprised nursing and medical students in proportion to the class sizes. Each small group was led by a nurse and physician facilitator. The objective of the small groups was to develop communication and team skills through multiple modalities, including interactive play, medical simulations, and review of video vignettes. The interactive play session, “ice breaker” that entailed teams making a construction paper chain with various barriers, allowed students who had never worked together to apply leadership skills such as brief (initial meeting of a team to establish the plan), huddle (ad hoc meeting of team members to ensure all are aware of the plan or to create a new plan), and general communication techniques.
The medical simulation allowed students to practice the team skills. Students self-selected their roles in the simulation, which were bedside assistant, documenter, treatment leader, procedure provider, or runner. We incorporated the Crisis Team Training approach that builds on Crisis Resource Management by adding defined roles and tasks for team members.15 Students received a written description of these roles and corresponding tasks. The simulation was divided into two portions of the simulated patients care. In the first part, the students had to resuscitate a trauma patient who sustained a femur fracture after a heavy object fell on his leg. After completion of this section, the case was “signed out” to another team of students, and they continued to manage the patient on the inpatient service where he developed an ST elevation myocardial infarction. The scenario began with the patient report followed by time for the students to “brief” and “huddle” with one another to determine the plan of care. Students were required to appropriately assess the patient's current status and ongoing monitoring of the changes in the patient's condition. This gave the opportunity for practice of situational awareness, cross-monitoring, and support of team roles. Closed-loop communication skills were used through verbal orders that were required for therapeutic treatment. Consultation was also inherent in the case, which required students to practice using standardized communication tools, such as situation, background, assessment, and recommendation (SBAR) and check back.
The final teaching methodology was the use of video vignettes. We created a module during which the student teams watched two video vignettes created by TeamSTEPPS “opportunity” and “success.” Each video was an identical labor and delivery patient care scenario; however, one displayed superb team skills with a positive patient outcome (success) and the other poor team skills, leading to a critical patient care situation (opportunity). Although students were at various stages of training and may or may not have fully understood the clinical content, students should be able to recognize good team skills and opportunities for improvement. Role modeling and observation of actions during their clinical rotations is an important component of their education. Developing skills that allow students to observe both good and bad team skills is an important component of the educational intervention.
After completion of both the video vignettes and simulation, facilitators used the standardized debriefing process, adapted from the study by DeVita et al15 to lead the discussions focused on the use or absence of teamwork skills. Facilitators were provided with a debriefing tool that included specific questions that highlighted team skills and critical actions. Student's ability to demonstrate team skills during the simulation and strategies for future improvement were discussed.
The final component of the curriculum was a short lecture to review all the major concepts. This lecture concentrated on the team communication skills that could be used in clinical venues and was aimed at summarizing the day's events and the relevance of the content to the participant's learning experience and practice.
Facilitators for the ITTD were recruited from across the health science centers. Forty facilitators from the academic and clinical setting attended a 2-hour training session held in advance of the ITTD so that they could orient to the training content, course materials, and their role. A facilitator training resource manual was developed by the authors, which contained all the course material and facilitator guides. The faculty training session paralleled the training event by beginning with a PowerPoint (Microsoft, Redmond, WA) presentation that contained similar but abbreviated content to the actual training day lecture. Facilitators participated in the actual “icebreaker” (paper chain) exercise. The facilitators viewed the video vignettes and reviewed the debriefing points. Training for the simulation component consisted of a general description of the cases' critical actions at various stages of the simulation case, and debriefing points were summarized. A description of the schedule of events, orientation to the simulators, and the debriefing process were also discussed. Six facilitators were also recruited and trained to run the software for the simulations.
We modeled team leadership skills by conducting a huddle with the facilitators for 15 minutes before the small group sessions. The objectives were to review the learning objectives, logistics, and answer any questions. At the conclusion of the course, we had a 15-minute debrief session to gather comments and their reactions to the training event.
Impact of the Intervention
After receiving Emory Institutional Review Board approval, the 213 students completed several forms to assess knowledge and attitudes before the educational intervention. This was a mandatory educational session for all students, but they were able to opt out of having their survey information included in the data analysis. No students requested this exemption.
A 12-item teamwork knowledge test was used assess knowledge related to leadership, situation monitoring, mutual support, and communication.16 Questions are situational, requiring participants to apply knowledge of these concepts and skills to correctly answer the question.
Attitudes of our students to teamwork were assessed using the 14-item Collaborative Healthcare Interdisciplinary Relationship Planning (CHIRP) Scale. The scale has seven subscales that comprise the overall teamwork attitudes construct (a) Interdependence, (b) Recognition, (c) Empathy, (d) Sharing, (e) Dominance, (f) Organizational climate, and (g) Respect.16
Because of the size of the class, students were proportionally assigned based on their school to either the morning or afternoon session. Groups of 10 predetermined interprofessional student teams along with their nurse and physician facilitator team convened after the lecture to begin the small group sessions. Room, time, and simulator operator logistics required us to assign half the groups to the video vignette session first and the other groups to the simulator session.
While viewing the “success” and “opportunity” versions of the video vignettes, the students completed the Team Skills Checklist Video Rating, a newly developed 24-item instrument constructed by a panel of 12 medical and nursing school clinical and research faculty from University of North Carolina and Duke University; project staff members, and TeamSTEPPS trainers who reviewed the content and made revisions over a 3-month period.16 Participants identify (“yes/no”) if a skill is present and then rate how well it was performed (Likert scale 1 [poor] to 5 [outstanding]).16 Because of its length and common anchor items, the number of items was reduced to 17 after collaboration with the original authors. The checklist has five constructs of (1) team structure “The team had a recognizable leader”; (2) leadership activities “Team huddles were used for impromptu problem solving”; (3) central team concepts “Individuals monitored specific actions of other team members”; (4) communication tools “Team members shared important or critical information when it became available”; and (5) conflict resolution “Team members asked for clarification on decisions.” The reliability of the 17-item instrument for the success video was 0.587 (standardized Cronbach's alpha) and 0.674 for the opportunity video.
Immediately after the educational session, students completed the postcourse questionnaires. This included the 12-item Team work Knowledge Test, CHIRP, and a postcourse evaluation—a 15-item survey to assess training satisfaction from the Medical Team Training Program Evaluation Tool.7 The instrument had an adequate internal consistency reliability (standardized Cronbach's alpha was 0.86) consistent with previous findings.17
All pre-to-post differences within subjects were analyzed with paired t tests. However, differences between groups were analyzed using independent t tests on the subjects' change scores (post − pre). Groups were defined as student type (nursing vs. medical students), gender (male vs. female), and training order (video first vs. simulation first). In addition, χ2 tests were used to determine whether there were differences between the proportions of subjects who are able to recognize team skills or not between groups. The statistical level of significance (alpha) was set at 0.05.
Two hundred thirteen students participated in the course. There are missing demographic data on 21 students, but we had 104 (54%) medical students and 88 (46%) nursing students complete the surveys. Eight-six percent of the students had minimal to no experience with simulators.
Team Skills Knowledge
After training, participants had more knowledge (P < 0.001) of team skills. The improvements in knowledge were significant regardless of grouping (all within-group differences were significant) and no significant differences were seen between groups (Table 1).
Team Skills Attitudes
Training resulted in a statistically significant improvement in attitudes toward teamwork (Table 2). Nursing students significantly increased their attitudes toward teamwork (P = 0.004), whereas medical students' attitudes toward teamwork did not significantly increase (P = 0.195). In addition, nursing students came into training with higher scores than medical students (P = 0.003). Because most of the nursing students were female, a similar significant increase in scores was also seen for females (P = 0.002) but not for the males (P = 0.800). As noted earlier, half the group participated in the simulation scenarios before watching and debriefing the videos. This group of students had a significant increase in attitudes toward teamwork (P = 0.037), whereas for the participants who viewed the video first, no significant change in attitudes was seen (P = 0.225).
Recognition of Team Skills
With regard to identifying team skills in the video vignettes, there was a significant association between the video watched (“success” vs. “opportunity”) and whether team skills were observed. For the success video, 97.6% (2024/2074) of the team skills were recognized, whereas only 27.7% (575/2074) of the team skills were recognized for the opportunity video (χ2 = 2163.3, df = 1; P < 0.001). This overwhelming difference in the better recognition of team skills for the success video was consistent regardless of student type. Nursing students (77.0%; 793 of 1030) compared with the medical students (78.5%; 1048 of 1335) recognized team skills in the success video (χ2 = 0.770, df = 1; P = 0.380). This was consistent regardless of training order (χ2 = 1.951, df = 1; P = 0.162).
In identifying the quality of the team skill when present, participants rated the success video significantly higher than the opportunity video (Table 3). There were no differences between student type and the training order. However, there was a difference by gender, the difference between ratings for the success versus opportunity videos was larger for females than for males.
Overall, participants were very satisfied with training. Average scores of satisfaction ranged from 80% to 97% (M = 4.18, SD = 0.46), with participants feeling “the training was well organized” (M = 4.34, SD = 0.57), and the lowest scoring item being “the scenarios were believable” (M = 3.95, SD = 0.88). Of all the teaching strategies used, simulation was rated the highest 96% (M = 4.49, SD = 0.63).
We feel that this event was successful on many levels; the collaboration that developed between the study team and facilitators across disciplines, exposure of students to one another within the context of quality and safety through interdisciplinary team training, the acquisition of knowledge, attitude and skills related to teamwork, and the successful use of simulation in interprofessional team training with 213 students. We adapted a TeamSTEPPS curriculum originally designed for healthcare providers and successfully used it for medical and nursing students.
After the TeamSTEPPS half-day team training program, interprofessional students from medicine and nursing had higher knowledge and attitudes related to team skills. Students could recognize the difference between the standardized video vignettes and the quality of the team skills when present. Nursing students entered into training with higher attitude scores and showed more significant improvements in their postattitude scores. Because nursing students enter the clinical environment earlier in their training, we believe this additional experience affected their attitudes toward teamwork. This also likely explains the differences in gender because the majority of nurses were female. Training order, in terms of simulation first versus watching the videos first, did not influence knowledge or ability to identify team skills. Participants, who viewed the simulation first, showed statistically significant improvement in their attitudes toward teamwork compared with those who viewed the video first. Whether simulation impacts attitudes as an active pursuit compared with the passive viewing of videos is questionable because although this was a statistical improvement, it might not be clinically relevant but it may suggest an instructional method of choice.
The use of TeamSTEPPS as the framework for interprofessional team training with undergraduate health professions students was successful, and the use of simulation proved to be instrumental in impacting outcomes. Interprofessional teamwork education was shown in this study to improve the knowledge skills and attitudes needed to provide safe patient care. Critical to the program's success is a commitment from both schools within the institution to tackle logistical barriers to teach quality and safety competencies in collaborative ways using unique teaching methodologies such as simulation. Each school provided time in the curriculum and space for multiple small group rooms and two simulation centers. We trained approximately 40 facilitators from the healthcare systems who required a significant time commitment.
Because of unanticipated computer issues, the postdata collection sample size was considerably smaller and variable. This may have affected the results, but the missing students were random, so we believe that mitigated the bias it may have caused in interpreting the results.
TeamSTEPPS is designed for training practicing healthcare professionals, thereby making it challenging to directly use the resources in teaching teamwork in undergraduate health care professional education. This required us to adapt the curriculum for use with our students. With current curricula, senior nursing students and third-year medical students entered this course with varying degrees of clinical experience and content knowledge. Despite creating simulation scenarios that required minimal medical knowledge and experience, the gap in clinical experience did create opportunities for the more experienced nursing student to assume the role as team leader. Although not necessarily a bad situation, it did create a distraction for the medical students who expected to be in charge. Our future aim will be to capitalize on this opportunity to debrief around this expectation because it relates to the science of teams and hierarchy. We did not evaluate teamwork skills during the simulation, thereby giving us little data on performance of skill as a result of training.
We used the TeamSTEPPS videos for our educational intervention. They were chosen based on the quality and the ability to highlight key team skills that we wanted the students to be able to recognize. We realize that these videos present the success and opportunities at their extremes, but at this novice level they met our educational aims. With development of a longitudinal curriculum and training of more advance level students with more clinical experience, a different set of videos with more subtle errors would need to be developed.
Teamwork skills are complex and require as much time and energy to master, if not more so, than typical technical skills incorporated in health professions education. To assume that participants will be able to replicate these skills in the real world environment only after 4 hours of training is an unrealistic expectation and was not the purpose of this study. However, the results demonstrated that as little as 4-hour exposure to teamwork concepts/skills did improve knowledge and attitudes and the ability to observe team skills.
Changing knowledge and attitudes is only the first step in development of team skills. Future work needs to examine how interprofessional team training impacts transference and retention of teamwork knowledge, attitudes, and skills. We need to determine which teaching strategy can obtain the most significant impact on this transference and retention. This can be difficult to study in students who have limited clinical responsibilities. Possible solutions are to study this cohort in a simulated environment or develop healthcare teams in a controlled, supervised clinical environment that might provide a setting in which team skills could be studied.
Future projects, for which we have already collected data in subsequent interdisciplinary courses, include examining the role of personality on teamwork attitudes and the ability of teams to translate team skill knowledge into practice in the simulated environment. We are also in the process of developing a longitudinal curriculum that may help answer more questions regarding the ability of educational interventions to create meaningful long-term change knowledge, skills, and attitudes.
Teamwork education is an interdisciplinary pursuit that we believe should start in medical and nursing school. We successfully adapted TeamSTEPPS for use with our students, educated a diverse group of facilitators, implemented the course to a large group of students, and demonstrated positive outcomes. Our students improved their knowledge of vital team and communication skills, attitudes toward working as teams, and were able to identify effective team skills. We believe that this should be a model curriculum for future interdisciplinary team skill education.