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ABSTRACT
Background Communication failures in
healthcare teams are associated with medical errors
and negative health outcomes. These findings have
increased emphasis on training future health
professionals to work effectively within teams. The
Team Strategies and Tools to Enhance Performance
and Patient Safety (TeamSTEPPS) communication
training model, widely employed to train
healthcare teams, has been less commonly used
to train student interprofessional teams. The
present study reports the effectiveness of a
simulation-based interprofessional TeamSTEPPS
training in impacting student attitudes,
knowledge and skills around interprofessional
communication.
Methods Three hundred and six fourth-year
medical, third-year nursing, second-year pharmacy
and second-year physician assistant students took
part in a 4 h training that included a 1 h
TeamSTEPPS didactic session and three 1 h team
simulation and feedback sessions. Students worked
in groups balanced by a professional programme in
a self-selected focal area (adult acute, paediatric,
obstetrics). Preassessments and postassessments
were used for examining attitudes, beliefs and
reported opportunities to observe or participate in
team communication behaviours.
Results One hundred and forty-nine students
(48.7%) completed the preassessments and
postassessments. Significant differences were
found for attitudes toward team communication
(p<0.001), motivation (p<0.001), utility of training
(p<0.001) and self-efficacy (p=0.005). Significant
attitudinal shifts for TeamSTEPPS skills included,
team structure (p=0.002), situation monitoring
(p<0.001), mutual support (p=0.003) and
communication (p=0.002). Significant shifts were
reported for knowledge of TeamSTEPPS (p<0.001),
advocating for patients (p<0.001) and
communicating in interprofessional teams
(p<0.001).
INTRODUCTION
An increased focus on interprofessional
education (IPE) has resulted from several
influences. Among the most compelling is
the growing recognition and evidence
that improved communication and collaboration by interprofessional teams
leads to better delivery and access to care.
In its 2004 sentinel event data report,1
the Joint Commission listed leadership,
communication, coordination and human
factors as among the leading root causes
of sentinel events. Failures in communication within interprofessional healthcare
teams are established causes of medical
error2 and negative health outcomes,1 3 4
including death.5 In addition, team communication failures have significant economic impacts that may reduce quality
and safety, or access to care.1 6
The relationship between team communication and patient safety4 has increased
the emphasis placed on training future
health professionals to work within
teams.79 However, few studies have
sought to demonstrate that prepractice
interprofessional team training is effective
in building the foundations for later practice within healthcare teams. Increasingly,
educators have sought to create interprofessional trainings that teach the key elements of effective teamwork in simulated
settings that allows for the practise of skills
in a stimulus-rich but controlled environment. Interprofessional team simulation
designed to promote incorporation of team communication into programme curricula across the health profession schools.
Interprofessional team communication is defined by
skills learned and later modified and reinforced when
healthcare workers work collaboratively to provide
competent care. Competence to practise safely
requires effective communication with patients and
colleagues, active listening, assertiveness, respect and
timeliness. Failures occur when vital information is
not communicated between team members, or team
members incorrectly interpret messages. Failures to
communicate information may result from adversarial
relationships, roles that are not clearly defined, or
insufficiently developed communication pathways
within teams. Incorrect interpretations occur when
providers use different terms to convey information,
accept incomplete information, or assign different
weights to communications. In each case, the result
may be an error.
The educational framework for the development of
the training content was based on TeamSTEPPS.12
TeamSTEPPS was developed from research and development collaborations between the Department of
Defense (DoD) Patient Safety Program and the Agency
for Healthcare Research and Quality (AHRQ), and is
rooted in crew resource management1315 (CRM).
Increasingly, there are calls for the incorporation of
team training into clinical settings16 stemming from
successful applications within surgery and traumafocused settings.1719 More recently, clinician educators have sought to integrate TeamSTEPPS tools11 16)
into healthcare education. Simulation-based training
provides an excellent vehicle for student teams to work
collaboratively in a realistic yet structured environment
without risks to patients.2022
Study goals
BACKGROUND
The curriculum and assessment tools described in this
study were developed as part of a grant funded through
the Josiah Macy Jr Foundation for the purpose of
improving communication within learning teams,
enhancing team-based care, increasing awareness of
respective roles and responsibilities, and promoting an
understanding of interprofessional values and ethics.
Faculty from the schools of medicine, nursing, pharmacy and the MEDEX Northwest Physician Assistant
(PA) Training Program worked to create novel and distributable training tools for team communication aimed
at reducing errors and improving patient safety. The
goal was to create new collaborations, while strengthening and leveraging existing interprofessional activities
where students from different disciplines work
togetherand intraprofessional activitieswhere students work only with students within their discipline
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30 Likert-type items (1=Strongly Disagree, to 5=Strongly Agree) assessing attitudes towards the five dimensions
(Team Structure, Leadership, Situational Awareness, Mutual Support and Communication) underlying the
TeamSTEPPS communications model
21 Likert-type items (1=Strongly Disagree, to 5=Strongly Agree) assessing Attitudes, Motivation, Utility and
Self-Efficacy toward interprofessional team skills
15 self-report frequency items, asking the extent to which the training cases provided the opportunity to practice
or observe key communication behaviours. Response options ranged on a 5-point scale from Never to
Frequently. Examples included whether team members were consulted for their experience or asked
for assistance
10 Likert-type item pairs (1=Strongly Disagree, to 5=Strongly Agree). Instrument asked respondents to rate their
understanding of key concepts both before and after training (eg, BEFORE participating in training I had a good
understanding of the benefits and application of SBAR and AFTER completing the training I have a BETTER
understanding of the benefits and application of SBAR)
Completed by all students following the simulation training.
1. Report of training value by programme segment (eg, TeamSTEPPS introduction, final debrief) (1=Not at all
valuable, to 5=Highly valuable)
2. Likert-type items (1=Strongly Disagree, to 5=Strongly Agree) addressing level of agreement with specific
aspects of the training. For instance, whether the programme provided a realistic experience of the challenges
faced when working in interprofessional teams
3. Students were also asked to describe their most valuable learning experience in the training
efficacy items were guided by Banduras recommendations for developing scales to assess efficacy31 and following Banduras theory of agency,25 32 that people
act on their environment, set goals and monitor progress, learning both through direct experience as well
as vicariously through observing others.
Two new instruments and the AMUSE were developed
specifically to assess whether students had the opportunity to practise or observe specific team behaviours, and
whether these training opportunities were positively
regarded, and represented skills that students believed
would be of value to carry forward, and for which they
had sufficient familiarity to successfully implement in
practice. One instrument asked students to report the
frequency with which the training cases provided the
opportunity to practise or observe key communication
behaviours. Examples included whether team members
were consulted for their experience or asked for
assistance. This scale consisted of 15 items with
response options ranging on a 5-point scale from
Never, to Frequently. A second instrument asked
respondents to rate their understanding of key concepts
both before and after training (eg, BEFORE participating in training I had a good understanding of the benefits
and application of Situation, Background, Assessment,
Recommendation (SBAR) and AFTER completing the
training I have a BETTER understanding of the benefits
and application of SBAR). This instrument consisted of
10 item-pairs on a five-point scale from Strongly
Disagree to Strongly Agree. Copies of each of the
instruments are available at the following website:
(http://www.collaborate.uw.edu/educators-toolkit/tools-
645
Medicine
Nursing
Pharmacy
Physician assistant
Total
Total n (%)
Completed
preassessment
Completed
postassessment
Completed preassessment
and postassessment
Completed
neither
174 (56.9)
88 (28.8)
32 (10.5)
12 (3.9)
306 (100.0)
89 (51.1)
58 (65.9)
27 (84.4)
11 (91.7)
185 (60.5)
122 (70.1)
62 (70.5)
27 (84.4.)
8 (66.7)
219 (71.6)
73 (42.2)
46 (52.3)
23 (71.9)
7 (58.3)
149 (48.7)
36 (20.7)
14 (15.9)
1 (3.1)
0 (0.0)
51 (16.7)
completed the training. Of the total, 255 (83.3%) students completed the preassessment and/or the postassessment, of which 149 (48.7%) students completed
both the preassessment and postassessments (completers). Table 2 provides a breakdown of the student
completers by professional programme. There was no
significant difference, by profession, for completer
classification (=5.33, p=ns). Completers did not
differ significantly from non-respondents or students
completing only one assessment component on profession, sex, age or previous healthcare experience (each
p=ns). Therefore, the analyses reported here reflect
those students who completed both preassessment and
postassessments, allowing for a preassessment vs postassessment comparison on study variables. Table 3 provides a breakdown of the completers by sex, age and
healthcare, and healthcare team experience.
Postassessments were completed in one of two
groups: day of the training, or 2 weeks post-training.
Change scores for aggregate measures between preassessment and postassessment were compared using
one-way ANOVA. After adjusting for the possibility of
an inflated Type I error rate, no significant differences
were discovered as a function of the date of the postadministration survey (each p>0.10). The staggered postmeasures were, therefore, aggregated to a single set of
postmeasures. Only seven PA students completed both
the preassessment and the postassessment. This number
was not sufficient to treat as a separate subgroup, and
the PA students were excluded from group analyses.
First training goal
Demographics for students completing both the preassessment and postassessments (n=149)
646
Medicine (n=73)
Nursing (n=46)
Pharmacy (n=23)
PA (n=7)
Total (n=149)
39 (53.4)
28.7, 3.3
23 (31.5)
21 (91.3)
41 (89.1)
26.7, 6.5
23 (50.0)
16 (70.0)
15 (65.2)
26.6, 3.7
5 (21.7)
1 (20.0)
5 (71.4)
34.6, 5.9
7 (100.0)
6 (85.6)
100 (67.1)
28.0, 4.9
58 (38.9)
44 (75.8)
Instruments
Pre-Attitudes
Post-Attitudes
Paired
Effect
t test
Size d
0.000
0.000
0.000
0.000
0.005
0.000
0.002
0.062
0.000
0.003
0.002
0.70
0.65
0.40
0.70
0.23
0.32
0.26
*
0.35
0.24
0.26
to 4.29)
to 4.65)
to 4.11)
to 4.56)
to 3.89)
to 4.23)
to 4.57)
to 4.72)
to 4.61)
to 3.23)
to 4.10)
647
Self-reported change between preunderstanding and postunderstanding of key TeamSTEPPS learning objectives
Learning objective
Before
After
TeamSTEPPS
2.82
4.29
1.48 (1.33 to 1.63)
Advocate
3.06
4.33
1.27 (1.13 to 1.41)
Communication
3.42
4.50
1.08 (0.94 to 1.22)
Briefs and huddles
3.40
4.46
1.06 (0.93 to 1.19)
SBAR
3.45
4.46
1.03 (0.88 to 1.18)
Shared mental model
3.44
4.45
1.02 (0.88 to 1.16)
IPE benefits
3.55
4.54
0.99 (0.85 to 1.13)
Importance of sharing information
3.49
4.42
0.93 (0.81 to 1.05)
Patient safety
3.95
4.55
0.60 (0.49 to 0.71)
Offer help
4.01
4.40
0.39 (0.29 to 0.49)
Respondents (n=201214) reported whether they had a good understanding before training and whether they had
Items were scored from 1=Strongly Disagree, to 5=Strongly Agree.
TeamSTEPPS, Team Strategies and Tools to Enhance Performance and Patient Safety.
95% CI 1.33 to 1.63) and ability to advocate withinteams (mean=1.27, 95% CI 1.13 to 1.41). The least
change occurred in student understanding of the
association between interprofessional teams and patient
safety (mean=0.60, 95% CI 0.49 to 0.71), and of the
importance of offering assistance and seeking help
(mean=0.39, 95% CI 0.29 to 0.50).
Evaluation data
648
Paired t test
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
a better understanding
Effect size
1.37
1.22
1.07
1.10
0.92
0.97
0.98
1.03
0.71
0.51
after training.
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13
14
15
16
17
Review Board.
18
19
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doi: 10.1136/postgradmedj-2012-000952rep
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