Enhancing teamwork across care provider levels: ?The manager of a medical-surgical unit has observed and had complaints about, lack of teamwork between the RNs and the patient care te

1Ballangrud R, et al. BMJ Open 2020;10:e035432. doi:10.1136/bmjopen-2019-035432

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Longitudinal team training programme in a Norwegian surgical ward: a qualitative study of nurses’ and physicians’ experiences with teamwork skills

Randi Ballangrud ,1 Karina Aase ,2 Anne Vifladt 1

To cite: Ballangrud R, Aase K, Vifladt A. Longitudinal team training programme in a Norwegian surgical ward: a qualitative study of nurses’ and physicians’ experiences with teamwork skills. BMJ Open 2020;10:e035432. doi:10.1136/ bmjopen-2019-035432

► Prepublication history and additional material for this paper are available online. To view these files, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2019- 035432).

Received 31 October 2019 Revised 27 April 2020 Accepted 18 May 2020

1Department of Health Science Gjøvik, Norwegian University of Science and Technology, Gjøvik, Norway 2Center for Resilience in Healthcare (SHARE), University of Stavanger, Stavanger, Norway

Correspondence to Dr Randi Ballangrud; randi. [email protected] ntnu. no

Original research

© Author(s) (or their employer(s)) 2020. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ.

Strengths and limitations of this study

► In this study, the sample of both nursing staff and physicians contributes to interprofessional experi- ences in the implementation of a team training pro- gramme in a surgical ward.

► The study intervention was based on an evidence- based team training programme with a standardised curriculum.

► A longitudinal design enables data collection on three occasions.

► The sample size was small, leading to a relatively limited number of participants in the focus group interviews.

AbStrACt Objectives Teamwork and interprofessional team training are fundamental to ensuring the continuity of care and high- quality outcomes for patients in a complex clinical environment. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence- based team training programme intended to facilitate healthcare professionals’ teamwork skills. The aim of this study is to describe healthcare professionals’ experiences with teamwork in a surgical ward before and during the implementation of a longitudinal interprofessional team training programme. Design A qualitative descriptive study based on follow- up focus group interviews. Setting A combined gastrointestinal surgery and urology ward at a hospital division in a Norwegian hospital trust. Participants A convenience sample of 11 healthcare professionals divided into three professionally based focus groups comprising physicians (n=4), registered nurses (n=4) and certified nursing assistants (n=3). Interventions The TeamSTEPPS programme was implemented in the surgical ward from May 2016 to June 2017. The team training programme included the three phases: (1) assessment and planning, (2) training and implementation and (3) sustainment. results Before implementing the team training programme, healthcare professionals were essentially satisfied with the teamwork skills within the ward. During the implementation of the programme, they experienced that team training led to greater awareness and knowledge of their common teamwork skills. Improved teamwork skills were described in relation to a more systematic interprofessional information exchange, consciousness of leadership- balancing activities and resources, the use of situational monitoring tools and a shared understanding of accountability and transparency. Conclusions This study suggests that the team training programme provides healthcare professionals with a set of tools and terminology that promotes a common understanding of teamwork, hence affecting behaviour and communication in their daily clinical practice at the surgical ward. trial registration number ISRCTN13997367.

IntrODuCtIOn Teamwork is fundamental to ensuring the continuity of care and high- quality outcomes for patients in a complex clinical environment, necessitating training across professional silos.1 2 Team training has been described as a learning strategy in which a learner or group of learners systematically acquire(s) team- work knowledge, skills and abilities to impact cognition, affect and behaviours of a team.3 Teamwork is found to positively affect clinical performance.4

In hospitals, many adverse events are asso- ciated connected to surgery.5–7 A system- atic review by Johnston et al8 documented that a delayed escalation of patient care after surgical complications is associated with higher mortality rates, identifying poor communication, hierarchical barriers and high workloads as causal factors. Previous research has provided evidence for strategies such as team training to improve the surgical culture9 and have a positive effect on postop- erative patient outcomes.10–12

Several team training programmes have been developed in healthcare.13 In this paper,

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we studied the implementation of the Team Strategies and Tools to Enhance Performance and Patient Safety (Team- STEPPS) in a surgical ward. TeamSTEPPS is a publicly released, evidence- based programme based on teamwork theory14 and change theory.15 The programme was devel- oped by the Agency for Healthcare Research and Quality in collaboration with the US Department of Defense and was released in 2006.16 17 TeamSTEPPS, which is trans- ferable to any healthcare setting, intends to facilitate healthcare professionals’ teamwork by optimising team structure and the team’s communication, leadership, situation monitoring and mutual support skills. The basic assumption of the programme is that these five teamwork principles are critical for safe patient care.16

Systematic reviews have confirmed that team training affects outcomes related to the team knowledge, atti- tudes, behaviours of healthcare professionals3 18–20 and results in improved quality.3 Furthermore, increased confidence and motivation to apply learned teamwork skills in daily practice have been experienced by health- care professionals.21

Quantitative studies of the TeamSTEPPS programme have confirmed improvements in teamwork and commu- nication,22 23 patient safety culture,24–27 efficiency inpa- tient care,24 25 28 complications and mortality,29 falls23 and frequency of wrong- site/side/person surgery.22 Most of the TeamSTEPPS studies are carried out in the USA30 without any longitudinal follow- up, and there are currently only a few qualitative studies18—for example, in surgical and paediatric intensive care25 and cardiotho- racic surgery telemetry.31 However, a need persists for qualitative studies in surgical ward settings because the team structure in wards is different from that in intensive care unit (ICU) settings; physicians are not situated in the ward for extended periods, thus restricting the possibili- ties for interprofessional reflections.32 This study is a part of a larger research project, comprising mainly substudies with a quantitative design, to evaluate an interprofes- sional team training intervention in a surgical ward.33 34 In this context, a qualitative study will provide in- depth knowledge of healthcare professionals’ experiences with learned teamwork skills in a longitudinal perspective.

We aimed to describe healthcare professionals’ experi- ences with teamwork in a surgical ward before and during the implementation of a longitudinal interprofessional team training programme. The following research ques- tion guided the study: how do healthcare professionals experience teamwork skills communication, leadership, situation monitoring and mutual support before and during the implementation of an interprofessional team training programme?

MethODS Design The study used a qualitative descriptive design35 based on semistructured focus group interviews with healthcare professionals at three- time intervals.

Setting The study was carried out at a 20- bed combined gastro- intestinal surgery and urology ward at a hospital divi- sion (198 beds) in a Norwegian hospital trust. The surgical ward was selected based on practical issues and the management’s interest and motivation for improve- ment initiatives after experiencing several patient safety incidents. The study occurred from April 2016 to June 2017. At baseline (November 2015 to March 2016), the ward statistics indicated an average bed occupancy rate of 87%, a mean patient length- of- stay value of 3.46 days and an admissions rate of 192.2 patients per month. Moreover, the ward’s number of full- time positions was 13 physicians, 17.25 registered nurses (RNs), 4.95 certified nursing assistants (CNAs), 1.0 head nurse and 1.0 clinical nurse specialist.

The patient care was organised into two interprofes- sional teams, where the primary members were RNs, CNAs and physicians. The composition of the teams and their duties were predetermined by a daily worklist for the nursing staff, while the physicians had their worklist, clarifying weekly duties such as surgery, polyclinic and doctors’ rounds.

Sample A convenience sample36 of 11 healthcare professionals divided into three professionally based focus groups comprising physicians (n=4), RNs (n=4) and CNAs (n=3) were recruited from the surgical ward. The inclusion criterion for participation in the study was that healthcare professionals from the surgical ward had participated at a minimum of 1 day of the interprofessional team training programme (41 participants). The ward management decided which professional groups participated in the TeamSTEPPS training programme. A request for infor- mation about the study and researchers was distributed to all healthcare professionals, where 11 confirmed their participation, thus constituting the study sample. The sample comprised eight women and three men with varying work experiences and employment within the ward. To secure the participants’ anonymity, no specifica- tion of their background is presented.

team training programme The longitudinal interprofessional team training programme was planned and implemented according to the TeamSTEPPS- recommended ‘model of change’ and was organised into three phases16 (see table 1 and box 1). A research group initiated the programme as part of a larger research project.34 Two nurses (one leader) and two physicians (leaders) from the surgical ward had the main responsibility for the training and implementation of the programme. Before the training, the four health- care professionals conducted the TeamSTEPPS V.2.0 Master Training Course and were certified as instructors. A more detailed description of the programme can be found in Aaberg et al.37

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Table 1 Implementation of tools at phase 2 and phase 3 of the team training programme

Phase 2 Phase 3

2016 Tools Implementation arena 2017 Tools Implementation arena

May

Closed- loop Communication

Exchange of critical information

January

Debriefs Leadership

Once a week— manager with nursing staff

Task Assistance Mutual support

Distribution of workload

June ISBAR Communication

Communicating critical information

February STEP Situation monitoring

Updated in electronic care plan

August Briefs Leadership

Start of every shift March Two- Challenge Rule Mutual support

When an initial assertive statement is ignored

September Huddles Leadership

At patient safety whiteboard meetings

May I- PASS Communication

Handoffs with focus on patient safety risks

October Cross- monitoring Situation monitoring

Double control by intravenous medication administration

I- PASS, illness severity, patient summary, action list, situation awareness and contingency planning; ISBAR, introduction, situation, background, assessment, recommendation; STEP, status of the patient, team members, environment, progress towards the goal.

box 1 team training programme based on teamStePPS

Phase 1: set the stage and decide what to do—assessment and planning (January 2016–April 2016)

► Site assessment. ► A lesson about teamwork in relation to promoting patient safety was conducted with all nurses and physicians to create an awareness of the need for improvement.

► A training and implementation plan was developed. Phase 2: making it happen—training and implementation (May 2016–December 2016)

► One day of interprofessional team training in a simulation centre was completed for all healthcare professionals (n=41) in the surgi- cal ward, comprising 6 hours of classroom training (lectures, videos, role plays and discussions) and 2 hours of high- fidelity simulation.

► A change team with members from all ward professions and a for- mer patient was assigned.

► An action plan was established, based on identified patient safety issues in the ward.

► The TeamSTEPPS tool was systematically implemented every month (see (table 1)).

Phase 3: making it stick—sustainment (January 2017–June 2017) ► The initiatives from the action plan were coached, monitored and integrated.

► Implementation of a monthly TeamSTEPPS tools continued. ► Small victories were celebrated. ► TeamSTEPPS refresher courses were held after four (nurses and physicians) and 11 months (nurses).

TeamSTEPPS, Team Strategies and Tools to Enhance Performance and Patient Safety.

Data collection Ten focus group interviews of healthcare professionals were conducted before the team training implementation

(baseline=T0), with follow- up interviews after 6 months (T1) and 12 months (T2) (see figure 1).

All the interviews occurred in a meeting room at the hospital during the daytime. A pilot interview was conducted to validate the thematic interview guides developed from a literature review on teamwork (online supplementary files 1 and 2). The interviews were conducted as a dialogue and started with a clarification of the study aim. The thematic interview guides, including the four teamwork skills at T1 and T2, were used to ensure that all themes were explored during each focus group interview. The participants were encouraged to complete an open collective activity with a reflection on common experiences.38 The same questions were posed to all focus groups, and follow- up questions were used to encourage the participants to elaborate and/or clarify their responses.39 One moderator and one observer (who made field notes) were responsible for conducting the interviews, with the third author (AV) as a moderator at T0 and the first author (RB) as a moderator at T1 and T2. At T0, the interview referred to generic questions about teamwork at the ward (see online supplementary file 1); at T1 and T2, the interview questions referred to learned teamwork skills based on the TeamSTEPPS framework (see online supplementary file 2). The field notes were approved by the participants after the interview. The interviews lasted from 25 to 60 min (mean=33 min). All the interviews were digitally recorded, transcribed verbatim and anonymised before the analysis.

Data analysis Based on the aim and research question of our study focusing on healthcare professionals’ experiences with teamwork skills during a team training programme, a

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T0 Interview, April 2016 Profession (focus groups 1–3)

T1 Interview follow up after six months, November 2016 Profession (focus groups 4–7)

T2 Interview follow up after 12 months, June 2017 Profession (focus groups 8–10)

RNs (n=4) CNAs (n=2) Physicians (n=3)

RNs (n=3) CNAs (n=2) Physicians (n=2) Physicians (n=2)

RNs (n=3) CNAs (n=2) Physicians (n=1)

Start of team training programme, May 2016 Figure 1 An overview of participants, and times of the interviews in relation to the implementation of a team- training

programme; n=11 healthcare professionals (four physicians, four RNs and three CNAs). CNA, certified nursing assistant; RN, registered nurse.

Table 2 Description of the four TeamSTEPPS teamwork skills

Communication Structured process by which information is clearly and accurately exchanged among team members

Leadership Ability to maximise the activities of team members by ensuring that team actions are understood, changes in information are shared and team members have the necessary recourses

Situation monitoring Process of actively scanning and assessing situational elements to gain information or understanding, or to maintain awareness to support team functioning

Mutual support Ability to anticipate and support team members’ needs through accurate knowledge about their responsibilities and workload

Agency for Healthcare Research and Quality. TeamSTEPPS V.2.0: Core Curriculum.16

TeamSTEPPS, Team Strategies and Tools to Enhance Performance and Patient Safety.

deductive manifest content analysis approach grounded on Elo and Kyngäs40 was used. The data were analysed according to the TeamSTEPPS framework,41 42 focusing on the four teamwork skills of communication, lead- ership, situation monitoring and mutual support. The description of the four teamwork skills is shown in table 2.

The analysis process was organised according to three phases: preparation, organising and reporting. The first (RB) and third (AV) authors conducted the first two phases with input from the second author (KA), while all three authors conducted the third phase. In the preparation phase, each interview was defined as one unit of analysis, and data from T0, T1 and T2 were analysed separately. All the interviews were read several times by all three authors to become familiar with the data, and, guided by the aim and research questions, the researchers obtained intimate knowledge of the participants’ experiences with teamwork skills. In the organisation phase, the authors established a structured analysis matrix, with columns representing the categories of communication, leadership, situation monitoring and mutual support. Based on the concep- tual description of each TeamSTEPPS teamwork skill in the TeamSTEPPS programme (see table 2),16 all the data were reviewed for content and coded according to the four teamwork categories (without using any software

tool), first individually by RB and AV, and then together by all three authors until agreement was reached. Exam- ples from the codebook at T1 are shown in table 3. The matrix revealed 514 codes representing the four team- work categories. In the reporting phase, the results were described using the contents of each of the four team- work categories. Quotations were used to enhance and illuminate the categories.43 To help secure a presentation of results representing the information provided by the participants, continuous discussion among the authors was prominent throughout the reporting phase. Finally, the results were reported according to the Consolidated Criteria for Reporting Qualitative Research (online supplementary file 3).44

Patient and public involvement Patients or the public were not involved in the design, conduct, reporting or dissemination plans of our research.

reSultS teamwork at t0 The healthcare professionals’ experiences of the four teamwork skills in the surgical ward before the team training programme (T0) are described in table 4.

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Table 3 Codebook examples from the qualitative deductive content analysis at T1

Communication Leadership Situation monitoring Mutual support

T1:RN,24. Everyone participates using a closed loop.

T1:RN,94. We allocate the tasks now so that they are distributed more evenly.

T1:RN,80. We have become more vigilant about medication administration.

T1:RN,35. When you know the purpose, you have a greater understanding for reporting a second time concern.

T1:CNA,5. On the classroom training day, we learnt to repeat messages—for example, when we take the phone—which is already done.

T1:CNA,36. The ward management is aware that the whiteboard meetings will take place.

T1:CNA,30. The most important thing about the whiteboard meetings is that there is a proper review of patients after the doctor’s rounds.

T1:CNA,56. It is not so easy to say so if there is something that we disagree about, compared with when there is something positive.

T1:Ph1,26. Seemed like the nurses were confident about how to present patient information to us.

T1:Ph2,84. If one is to think we are a team, it is natural that the physician who does the round is the leader.

T1:Ph1,69. Whiteboard meetings generate awareness about—for example, safety routines, nutrition, medication administration, etc—that is, such things that are good to check.

T1:Ph,43. It is now easier to ask each other since we know each other better after being in classroom training together.

CNA, certified nursing assistant; Ph, physician; RN, registered nurse.

teamwork during the 12-month (t1–t2) interprofessional team training programme A summary of healthcare professionals’ experiences with the four teamwork skills during the 12- month team training programme is described in table 5.

Communication, t1–t2 The RNs experienced a common set of tools that promote patient safety. Everyone emphasised the ‘closed loop’ tool as important to ensure a common understanding within the team. Using the tool, the RNs detected misunder- standings that could have caused consequences for the patient. Both the CNAs and RNs emphasised that, after the 12- month implementation of the team programme, they used the ‘closed loop’. They perceived the tool as important, simple to use and promoting patient safety, as exemplified by a CNA:

If there is a phone call and you receive a message then you repeat the message … to make sure you have got it right—don’t you? (T2:CNA,2)

The RNs found it valuable to have a common under- standing of communication skills with physicians at the surgical ward. However, they experienced that physicians from other wards, who were not included in the Team- STEPPS programme, expressed the feeling that the RNs were criticising them when using the ‘closed loop’.

During the implementation period, both the physicians and CNAs experienced the RNs as being more confident in their information exchange and found ‘introduction, situation, background, assessment, recommendation (ISBAR)’ useful when communicating important or crit- ical information over the phone. The RNs experienced the use of ‘ISBAR’ as somewhat challenging but easier to use when they had enough time. The physicians high- lighted that their medical education taught them how to

provide information systematically. However, they became more aware of systematic communication and repeating messages:

Well, I think everyone … everyone involved has re- flected … and raised one’s consciousness regarding it [communication] to a greater extent than if they didn’t attend the course. (T2:Ph,11)

With ‘ISBAR’, it had become more natural for the RNs to take an active part in patient treatment. They referred to common, established expectations toward more active participation, with ‘ISBAR’ focusing on their perception of the problem and how to handle it. One RN said:

When we call about a deteriorating patient … I pre- viously thought I shouldn’t mention anything regard- ing my ideas on the causes of deterioration. I always thought that was the physician’s task. (T2:RN,13)

The ‘handoff’ tools for information exchange during shifts had been introduced late and were not properly integrated at the ward. One RN said:

Well, then at least you will need sufficient time to re- flect before starting to use them [tools]… and that is not always the case, right. (T2:RN,45)

Even though it is an easy … an easy tool, I actually think it is one of the hardest as well. (T2:RN,46)

leadership, t1–t2 The RNs experienced that TeamSTEPPS had led to an increased awareness in using ‘huddling’ and ‘briefing’ at the patient safety whiteboard meetings. One RN explained:

We use huddling at the patient safety whiteboard meetings regarding the redistribution of tasks if

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Table 4 Teamwork skills at T0

Teamwork skills categories

Communication All healthcare professionals were mostly satisfied with the information exchange within the ward, with the nurse team leader possessing a central position. A busy schedule allowed the RNs, who often had patient responsibility within both teams, to acquire patient information in different ways, from participation in regular team meetings to ad- hoc meetings with the team leaders. The CNAs appreciated the ‘quiet handover’ used between shifts. When calling up the physicians on duty, the RNs often checked the phone list ahead of the phone call to be prepared, indicating that some physicians needed to have more background information than others. The physicians also emphasised the importance of proper and relevant information from the RNs who can be trusted.

Leadership The two core teams each had a team leader throughout the week, allowing the team leader to become better acquainted with a patient’s medical history and thereby increasing continuity and simplifying the hospital discharge. Not all of the RNs enjoyed being team leaders due to a heavy workload; however, the physicians were satisfied with the arrangement.

Situation monitoring

The physicians became familiar with the patients during rounds and through the patient’s medical record, mostly discussing patient- related issues in physicians’ meetings. Similarly, the RNs discussed issues related to patients’ care in nurse meetings, although this may also have resulted in contact with the physicians. Both RNs and CNAs had an active role in the observation of the patients and updating each patient’s care plan, and they were encouraged to stay bedsi

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