The University of Alabama Communication Within Healthcare Organizations Paper

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Question 1: How could TeamSTEPPS be incorporated into the various areas in which you practice? Would this type of culture change be welcomed? From an organizational view, would these concepts be easy to introduce? What would be the concerns? From a clinical view, would these concepts be easy to introduce? What would be the concerns?

Question 2: How would these methods of communication benefit patient safety, conflict resolution, teamwork, and/or a shared mental model?
Please locate an additional resource (published within the last five (5) years) that addresses the measurement impact of one of these elements in a specific clinical or administrative area of your interest (Psyhiatry/Mental health) to support your thoughts.
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JONA Volume 46, Number 4, pp 201-207 Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved. THE JOURNAL OF NURSING ADMINISTRATION Promoting Patient Safety A Results of a TeamSTEPPS Initiative Teresa Gaston, DNP, RN Nancy Short, DrPH, MBA, RN Christina Ralyea, DNP, MS-NP, MBA, OCN, NE-BC Gayle Casterline, PhD, RN Teamwork is an essential component of communication in a safety-oriented culture. The Joint Commission has identified poor communication as one of the leading causes of patient sentinel events. The aim of this quality improvement project was to design, implement, and evaluate a customized TeamSTEPPS training program. After implementation, staff perception of teamwork and communication improved. The data support that TeamSTEPPS is a practical, effective, and low-cost patient safety endeavor. nication has been gaining momentum in healthcare. In 2006, the Department of Defense and the Agency for Healthcare Research and Quality (AHRQ) partnered to develop a teamwork program designed specifically for healthcare called Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS ). TeamSTEPPS promotes the use of standardized communication tools and addresses 5 areas of teamwork including leadership, communication, situational monitoring, team structure, and mutual support.8 Positive improvements have been reported in the 18 TeamSTEPPS research studies reviewed by the authors. Staff perceptions regarding teamwork and/or communication were the most common areas in which measurable improvement occurred.9-22 TeamSTEPPS implementation has demonstrated improved outcomes in a variety of specialty areas and settings including the operating room,22 pediatric and adult intensive care units,15 emergency department,23 mental health,18 neonatal intensive care,24 a combat hospital,25 and outpatient oncology.10 One study reported a 13% increase in positive staff perceptions of teamwork and a 20% increase in positive staff perceptions of communication measured by the Hospital Survey on Patient Safety Culture (HSOPSC) 1 month after implementation.22 Several studies16-18 measured knowledge, reporting anywhere from a 6% to 9% increase following the training program. In addition, decreased patient incident events have been reported following training.25,26 The aims of this quality improvement project (QIP) were to improve staff perceptions of teamwork and communication by customizing and implementing TeamSTEPPS training for the oncology service line (OSL) in an academic health center and to evaluate A Following the momentous report To Err Is Human,1 the Institute of Medicine and The Joint Commission (TJC) recommended teamwork and communication training in healthcare to assist in decreasing medical errors.2 Although teamwork is cited as an essential component of both communication and a safetyoriented culture,3 effective teamwork is often absent in healthcare settings4 and requires cultivation.5 According to TJC,6 communication is one of the leading causes of patient sentinel events. For decades, the aviation industry and the US military have enforced training in teamwork and communication as a means to decrease errors and increase positive outcomes.7 The goal of improving patient safety with highly effective teams and coordinated commuAuthor Affiliations: Nurse Informatics Educator (Dr Gaston), Information Services, Carolinas HealthCare System, Charlotte; Associate Professor (Dr Short), School of Nursing, Duke University, Durham; and Assistant Vice President (Dr Ralyea), Patient Care Services Oncology Division, and Nursing Research & Evidence Based Practice (Dr Casterline), Carolinas HealthCare System, Charlotte, North Carolina. The authors declare no conflicts of interest. Correspondence: Dr Gaston, Carolinas HealthCare System, 5039 Airport Center Pkwy, Charlotte, NC 28208 (teresagaston2@gmail.com). DOI: 10.1097/NNA.0000000000000333 A JONA  Vol. 46, No. 4  April 2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. 201 the overall effectiveness. Based on previously reported 2013 HSOPSC results, nursing leaders identified teamwork and communication on the OSL as an improvement opportunity. Important stakeholders, including nursing leadership and the Quality and Patient Safety (QPS) team, were highly supportive. Targeted outcomes for implementation included the following: 1. observe an improvement in staff perceptions of team structure and communication as measured by the TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ);27 2. observe an increase in positive staff perceptions of teamwork by 13% and communication openness by 20% as measured by the HSOPSC28; 3. observe a 5% increase in staff knowledge as measured by the TeamSTEPPS Learning Benchmark Test (LBT)29; and 4. discover and describe staff perceptions toward the application of TeamSTEPPS tools and behaviors into clinical practice as measured by the focus groups. Methods Design This QIP incorporated a mixed-methods approach including both quantitative and qualitative data collection. A preimplementation/postimplementation design measured perceptions of teamwork, perceptions of communication, knowledge, and number of patient incident reports. In addition, the design measured course evaluations, focus groups, and exit surveys after training only. Qualitative information was gathered from the focus groups. The settings were 3 oncology acute patient care units (total of 72 beds) within the OSL of an 874-bed academic health center located in the southeast United States. At project onset, 95 RNs, 35 clinical nurse assistants (CNAs)/healthcare technicians (HCTs), and 14 physicians were eligible to participate. Each received an e-mail invitation to voluntarily sign up for a TeamSTEPPS training session. RNs and CNAs/ HCTs received 2 hours_ pay outside their scheduled shift work to attend 1 training session. Nurses who completed the training course received 2.0 contact hours, whereas physicians did not receive any continuing medical education. The convenience sample of voluntary staff included full- and part-time staff (n = 92 RNs, n = 12 CNAs/HCTs, n = 6 physicians) who work within the OSL. Of the participating staff, 94% (n = 103) denied ever attending a formal TeamSTEPPS training prior to this QIP. 202 Project Implementation Training Because the TeamSTEPPS program was purposely designed to be customizable by healthcare organizations,8 a few studies have successfully provided 2-hour training sessions in lieu of the 6-hour session promoted by the AHRQ.10,15,30 Therefore, in collaboration with the QPS team, the content was customized to a 2-hour training session. These training sessions included didactic instruction along with an audiovisual slide presentation containing videos, discussion questions, scenarios, and oncology-specific examples. Seven staff members volunteered to become TeamSTEPPS Master Trainers (MTs) and attended a 1-day course. The project team scheduled 10 TeamSTEPPS sessions with 1 make-up session to implement during September 2014. Coaching Coaching is an essential element of sustainability,18 although not well studied. The MTs provided coaching on each of the patient care units after training for 3 months. The latest version of the TeamSTEPPS program has a new coaching guide, and this module was reviewed by all MTs. The nurse managers or the MTs either e-mailed staff or verbally reviewed with staff a Tool of the Month for 3 months following training. Focus Groups During the training sessions, all participants (n = 110) received a thank-you card, and of those participants, a randomized 40% (n = 44) received a special thankyou card containing a focus group invitation. Three focus groups met 1 month after the completion of all training sessions to answer specific questions. Data Collection and Measures Data were obtained during 4 time periods: immediately prior to and immediately following each of the 11 training sessions, approximately 1 month after the final training session was conducted, and at the conclusion of this project. Data collection included the following: demographics, T-TPQ, HSOPSC, LBT, focus group questions, exit survey, training course evaluation, and number of patient incident reports. The T-TPQ, HSOPSC, and the LBT are open-access tools and available on the AHRQ Web site, whereas the demographic survey, focus group questions, exit survey, and training course evaluation were created for this QIP (Table 1).  Demographic data included patient care unit(s) to ensure employment by the OSL, professional credentials, and a yes/no question to identify JONA  Vol. 46, No. 4  April 2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. Table 1. Data Collection Detail Types of Data Collected Time Periods of Data Collection Administered immediately prior to the start of each training session (September 2014) September 2014VIntervention Administered immediately following each training session (September 2014) Focus groups (October 2014) Paper surveys made available for a 2-wk period 1 mo following the completion of the last training sessions (October 2014) Patient incident report no. (January 2015)     Demographics T-TPQ ¾ ¾ HSOPSC LBT ¾ Course Evaluation Exit Survey ¾ 11 TeamSTEPPS training sessions ¾ ¾ ¾ 3 Small group sessions ¾ ¾ ¾ ¾ Retrospective data collection upon completion of this project including 3-mo pretraining (June, July, August 2014) then 3-mo posttraining (October, November, December 2014) numbers those who had previously completed TeamSTEPPS training. Individual participant responses were not identifiable by demographic data. AHRQ developed the T-TPQ tool to measure the effectiveness of the TeamSTEPPS training program. This tool can be administered in conjunction with the HSOPSC tool.27 For the purpose of this QIP, we selected only 2 subscales, team structure and communication from the T-TPQ (Likert scale 1-5). The reliability values of team structure (Cronbach_s ! = .89) and communication (Cronbach_s ! = .88) subscales have been reported to be good and have construct validity.31 For the purpose of this QIP, we selected only 2 subscales from the HSOPSC tool (Likert scale 1-5) including staff perceptions of teamwork within the units (Cronbach_s ! = .83) and communication openness (Cronbach_s ! = .73). Given these values, the HSOPSC has acceptable reliability.32 The items and subscales are psychometrically sound.33 The HSOPSC has been administered across hundreds of healthcare organizations supporting its validity with national benchmarking data that are also available.28 AHRQ developed the LBT specific to the educational content of the training program to measure participant knowledge. This was modified by decreasing the number of multiple-choice questions from 23 to 10 and by selecting questions specific to the revised 2-hour course content. Three focus groups were conducted to gather staff_s perceptions regarding the application of training to clinical practice. See Table 2 for focus group questions. Resources regarding how to plan and conduct focus groups, as well as how to create questions, and analyze the results were utilized.34,35 Gift cards were given to those who participated. Only summative information was reported to protect participants_ anonymity and confidentiality.  An exit survey was designed to gather more information about the application to clinical practice, and the questions were created specifically for this QIP, thereby lacking reliability and validity.  A training course evaluation tool assessed staff satisfaction following each of the training sessions. This was based on the standard evaluation tool used for in-services by the academic health center. In addition, 2 additional questions were created to illicit more information from staff regarding future application of the newly learned tools.  Patient incident report counts were obtained to indirectly observe if the training impacted staff behaviors and patient events in the clinical setting. Data Analysis Data were analyzed using SPSS version 22 software (IBM, Armonk, New York). The quantitative data were normally distributed. Descriptive statistics were used for the demographics, T-TPQ, HSOPSC, LBT, exit survey, and course evaluation data. An unpaired, 2-sample t test was conducted for the T-TPQ, HSOPSC, and LBT. In addition, a comparison was made from the previously reported 2013 HSOPSC data for the entire health center and the 2013 AHRQ 75th percentile comparative database versus the 2014 HSOPSC data from this QIP. The qualitative data from 3 focus groups were organized by major themes and coded by 2 individuals separately. Patient JONA  Vol. 46, No. 4  April 2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. 203 Table 2. Focus Group Information Questions Asked Most Common Themes 1. What facilitators do you see in your work area that promote or support the use of TeamSTEPPS? 2. Describe a time or an experience when you used a TeamSTEPPS tool. 3. Tell me some ideas on how we can better integrate TeamSTEPPS tools into everyday practice. 4. Describe how we can keep TeamSTEPPS going for newly hired staff. 5. Tell me about some of the barriers that you may have experienced when applying the TeamSTEPPS tools in your work area. & Huddle time & BI need clarity[ and CUSa tool used for medication orders, communication between nurses and physicians, and electronic chemotherapy orders & Verbal reminders during huddle time and team meetings & Visual reminders on the nursing unit bulletin boards and in the break rooms & Written reminders via e-mail and communication books & More educational in-services & Add to general hospital orientation program & Add to nursing unit-specific orientation & Personal attitudes of staff & Nurse-physician communication a CUS: "I am Concerned! I am Uncomfortable! This is a Safety issue!" (TeamSTEPPS). incident report numbers were compared 3 months pre/post. Statistical significance was set at P < .05. Results TeamSTEPPS Teamwork Perceptions Questionnaire The 2 selected subscales of the T-TPQ (n = 107 pre, n = 73 post) were calculated using a 2-sample t test based on the user manual.27 The mean for the team structure subscale before training on a 1- to 5-point Likert scale was 3.89 and at 1 month after training was 4.43 (t178 = j5.62, P = .000). The mean for the communication subscale from pretraining was 4.08 and at 1 month after training was 4.58 (t180 = j 6.22, P = .000). Both subscales measured demonstrated an improvement in staff perceptions for team structure and communication with statistical significance (Figure 1). tile and (b) communication openness at 67% for the overall health center and 66% for the AHRQ comparative database 75th percentile benchmark. The 2 selected safety culture subscales of the HSOPSC (n = 109 pre, n = 73 post) were calculated using a 2-sample t test based on the mean percent positive responses utilizing the HSOPSC survey user_s guide.28 Staff perceptions for the teamwork within unit subscale increased from 74% before training to 91% at 1 month after training (t182 = j3.66, P = .000), and the communication openness subscale increased from 58% before training to 79% at 1 month after training (t176 = j4.43, P = .000); both demonstrated improved staff perceptions with statistical significance (Figure 2). Hospital Survey on Patient Safety Culture Baseline 2013 retrospective data obtained from the academic health center showed (a) teamwork within units at 85% for the overall health center and 84% for the AHRQ comparative database 75th percen- Learning Benchmark Test A 2-sample t test (n = 110 each sample) showed a pretraining mean score of 92% (range, 40%-100%; median, 100%) and an immediate posttraining mean score of 94% (range, 30%-100%; median, 100%) on a scale of 0% to 100%. Although staff knowledge increased by 2%, this was not statistically significant (P = .207). The t test was selected based on a Figure 1. T-TPQ results: mean scores for team structure and communication. *Statistical significance at P < .05. Figure 2. HSOPSC results: mean % positive responses. *Statistical significance at P < .05. 204 JONA  Vol. 46, No. 4  April 2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. sufficient sample size and only slightly skewed data for the immediate posttraining group. Focus Groups Another aim of this project was to describe staff perceptions toward the application of TeamSTEPPS into clinical practice. Three focus groups (n = 20) were conducted to gather this qualitative information. Table 2 displays the common themes that resulted from a content analysis of the responses. Exit Survey All eligible participants (n = 74) who completed the exit survey 1 month after training (67% response rate) reported that they attended a training session prior to answering these questions. Improved teamwork was reported by 81% (n = 60) of staff, and improved communication was reported by 85% (n = 63) of staff. Following the training sessions, 89% (n = 66) of staff reported that they used a TeamSTEPPS tool or demonstrated a behavior at work during the past month since their training. The top 3 reported tools that were used following training included huddles, I need clarity, and debriefs. Course Evaluation Questions 1 to 9 (n = 110) pertained to overall staff satisfaction with the training sessions, and staff selected good or excellent 96% to 100% of the time. Question 10 (n = 97) asked how likely they are to use the training materials in their clinical practice, and staff reported 66% (n = 64) definitely, 33% (n = 32) likely, and 1% (n = 1) not likely. Question 11 asked which tools or behaviors staff plan to use immediately following the training, and the top 3 reported tools included briefs, 2-challenge rule, and debriefs. Patient Incident Reports The number of patient incident reports voluntarily reported by staff via the electronic reporting system 3 months before training was 87 and 3 months after training was 87. Discussion The results indicate that TeamSTEPPS training improved staff perceptions of teamwork and communication as measured by both the T-TPQ and the HSOPSC tools, supporting previous findings.9-26 A comparison of these 2014 HSOPSC results to baseline 2013 HSOPSC results shows the OSL exceeded both the overall academic health center results and the AHRQ comparative database 75th percentile benchmarking results. Although the primary outcome measures (T-TPQ and HSOPSC) showed statistical significance, the LBT and the patient incident report numbers were basically unaffected by the training. The LBT had only a 2% knowledge increase and did not support the results of previous studies.16-18 The pretraining scores were higher than expected with a 92% mean, possibly indicating either the test was too easy or the staff already had sufficient baseline knowledge of teamwork, communication, and patient safety. The number of patient incident reports, although a broad measure of how teamwork training can impact staff behaviors and patient care, surprisingly remained unchanged, thus not substantiating 2 previous studies25,26 from the literature. In addition, other positive outcomes included staff satisfaction, behavior change, and staff input. The course evaluation showed that staff were satisfied with the training, which can be helpful in the momentum and sustainment of a QIP. Signifying a positive behavior change, 89% (n = 64) of staff reported that they used a tool in clinical practice that they learned from their training session. Without TeamSTEPPS research studies including focus groups to reflect upon, the benefits of staff insight regarding facilitators, barriers, and sustainability ideas are key. This information can be beneficial for nursing leadership moving forward. Overall, QIP outcomes 1, 2, and 4 were met, whereas outcome 3 was not met. Limitations There are several limitations that may affect the interpretation and application of these results. As with many QIPs, the health center_s OSL self-selected to participate. A convenience sample was used, therefore lacking a control group. Direct behavioral observation of posttraining behaviors and a longer evaluation time frame were beyond the scope of this project, which limits a thorough evaluation of training. The electronic patient incident reporting system lacks a specific category for incidents related to poor teamwork and/or communication. Lastly, the LBT results may not be comparative to other studies because the test was modified. Conclusions Promoting and sustaining a culture of patient safety remain challenging for nurse leaders. The data from this QIP support the effectiveness of the 2-hour TeamSTEPPS training with coaching for improving staff perceptions for both teamwork and communication. Future efforts to promote sustainability of the tools and behaviors within the OSL may include adding JONA  Vol. 46, No. 4  April 2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. 205 this training program to the patient care unit_s orientation program, including physicians in the training, maintaining an adequate supply of MTs, supporting direct observational methods with coaching, promoting visual/written/verbal reminders about the patient safety program, and providing more ongoing, educational in-services. TeamSTEPPS information is available at http://www.ahrq.gov/professionals/ education/curriculum-tools/teamstepps/index.html. Nurse leaders can use the information from this QIP to better guide their future implementation and evaluation efforts. The customized 2-hour TeamSTEPPS curriculum proved to be a practical, effective, and low-cost training program with high acceptance by participants. Acknowledgment The authors thank Dr Julie Thompson (statistician at Duke University School of Nursing) for her significant contribution to the data analysis. References 1. Kohn L, Corrigan J, Donaldson M. To Err Is Human: Building a Safer Health System. Institute of Medicine. Washington, DC: National Academies Press; 1999. 2. Thomas EJ, Sexton JB, Helmreich RL. Translating teamwork behaviours from aviation to healthcare: development of behavioural markers for neonatal resuscitation. Qual Saf Health Care. 2004;13(Suppl 1):i57-i64. 3. Pfrimmer D. Teamwork and communication. J Contin Educ Nurs. 2009;40(7):294-295. 4. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(S1): i85-i90. 5. Clancy CM, Tornberg DN. TeamSTEPPS: assuring optimal teamwork in clinical settings. Am J Med Qual. 2007;22(3): 214-217. 6. The Joint Commission. Sentinel event data: root causes by event type 2004-2Q2014. http://www.jointcommission.org/ assets/1/18/Root_Causes_by_Event_Type_2004-2Q_2014.pdf. Accessed March 2015. 7. Contratti F, Ng G, Deeb J. Interdisciplinary team training: five lessons learned. Am J Nurs. 2012;112(16):47-52. 8. King H, Battles J, Baker D, et al. TeamSTEPPS: team strategies and tools to enhance performance and patient safety. In: Henriksen K, Battles JB, Keyes MA, et al. eds. Advances in Patient Safety: New Directions and Alternative Approaches. Rockville, MD: AHRQ; 2008. 9. Brock D, Abu-Rish E, Chia CR, et al. Interprofessional education in team communication: working together to improve patient safety. BMJ Qual Saf. 2013;22(5):414-423. 10. Bunnell CA, Gross AH, Weingart SN, et al. High performance teamwork training and systems redesign in outpatient oncology. BMJ Qual Saf. 2013;22(5):405-413. 11. Goliat L, Sharpnack P, Madigan E, Baker J, Trosclair M. Using TeamSTEPPS resources to enhance teamwork attitudes in baccalaureate nursing students. West J Nurs Res. 2013;35(9): 1239-1240. 12. Guidry M, Rothwell W, Conkerton B. Integrated multidisciplinary training and practiced coaching of TeamSTEPPS improves reporting of teamwork in code blue and rapid response performance. J Hosp Med. 2011;6(4):S32. 13. Harvey E, Ranson S, Clark R, Lee E. Comparison of two TeamSTEPPS training methods on nurse failure to rescue performance. Clin Simulat Nurs. 2014;10(2):e57-e64. 14. Jones KJ, Skinner AM, High R, Reiter-Palmon R. A theorydriven, longitudinal evaluation of the impact of team training on safety culture in 24 hospitals. BMJ Qual Saf. 2013;22: 394-404. 206 15. Mayer CM, Cluff L, Lin WT, et al. Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units. Jt Comm J Qual Patient Saf. 2011; 37(8):365-374. 16. Meier AH, Boehler ML, McDowell CM, et al. A surgical simulation curriculum for senior medical students based on TeamSTEPPS. Arch Surg. 2012;147(8):761-766. 17. Sawyer T, Laubach VA, Hudak J, Yamamura K, Pocrnich A. Improvements in teamwork during neonatal resuscitation after interprofessional TeamSTEPPS training. Neonatal Netw. 2013; 32(1):26-33. 18. Stead K, Kumar S, Schultz T, et al. Teams communicating through STEPPS. Med J Aust. 2009;190(suppl 11):S128-S132. 19. Thomas L, Galla C. Building a culture of safety through team training and engagement. BMJ Qual Saf. 2013;22(5):425-434. 20. Tibbs SM, Moss J. Promoting teamwork and surgical optimization: combining TeamSTEPPS with a specialty team protocol. AORN J. 2014;100(5):477-488. 21. Vertino KA. Evaluation of a TeamSTEPPSB initiative on staff attitudes toward teamwork. J Nurs Adm. 2014;44(2):97-102. 22. Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamwork improve performance in the operating room? A multilevel evaluation. Jt Comm J Qual Patient Saf. 2010;36(3): 133-142. 23. Capella J, Smith S, Philp A, et al. Teamwork training improves the clinical care of trauma patients. J Surg Educ. 2010; 67(6):439-443. 24. Brodsky D, Gupta M, Quinn M, et al. Building collaborative teams in neonatal intensive care. BMJ Qual Saf. 2013;22: 374-382. 25. Deering S, Rosen MA, Ludi V, et al. On the front lines of patient safety: implementation and evaluation of team training in Iraq. Jt Comm J Qual Patient Saf. 2011;37(8):350-356. 26. Johnson HL, Kimsey D. Patient safety: break the silence. AORN J. 2012;95(5):591-601. 27. Battles JKing H, Agency for Healthcare Research and Quality (AHRQ). TeamSTEPPS Teamwork Perceptions Questionnaire Manual. 2010. http://teamstepps.ahrq.gov/Teamwork_Perception_ Questionnaire.pdf. Accessed March 2015. 28. Agency for Healthcare Research and Quality (AHRQ). Hospital Survey on Patient Safety Culture (HSOPSC): form and user_s guide. 2004. http://www.ahrq.gov/professionals/qualitypatient-safety/patientsafetyculture/hospital/index.html. Accessed March 2015. 29. Agency for Healthcare Research and Quality (AHRQ). Team STEPPS Learning Benchmarks. http://www.ahrq.gov/professionals/ education/curriculum-tools/teamstepps/instructor/reference/ learnbench.pdf. Accessed March 2015. JONA  Vol. 46, No. 4  April 2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. 30. Stafford R, Willis T, Mayer C, et al. Interdisciplinary TeamSTEPPS training for critical care high stakes events: implications for patient safety. Crit Care Med. 2009;37(12):SA299. 31. Keebler JR, Dietz AS, Lazzara EH, et al. Validation of a teamwork perceptions measure to increase patient safety. BMJ Qual Saf. 2014;23(9):718-726. 32. Blegen MA, Gearhart S, O_Brian R, Sehgal NL, Alldredge BK. AHRQ_s hospital survey on patient safety culture: psychometric analyses. J Patient Saf. 2009;5(3):139Y144. 33. Sorra JS, Dyer N. Multilevel psychometric properties of the AHRQ hospital survey on patient safety culture. BMC Health Serv Res. 2010;10:199. 34. Eliot & Associates. Focus group tutorial: Duke University. 2005. http://assessment.aas.duke.edu/documents/How_to_ Conduct_a_Focus_Group.pdf. Accessed March 2015. 35. NOAA Office for Coastal Management. Introduction to Conducting Focus Groups. 2009. http://coast.noaa.gov/digitalcoast/ publications/focus-groups. Accessed March 2015. JONA  Vol. 46, No. 4  April 2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. 207 PRACTICE IMPROVEMENT CHANGING TEAM MEMBER PERCEPTIONS BY IMPLEMENTING TEAMSTEPPS IN AN EMERGENCY DEPARTMENT Authors: Connie Obenrader, DNP, RN, NE-BC, Marion E. Broome, PhD, RN, FAAN, Tracey L. Yap, PhD, RN, CNE, WCC, FAAN, and Florame Jamison, DNP, APRN, CNP, Tahlequah, OK and Durham, NC Earn Up to 7.5 Hours. See page 115. Methods: The ED team consisted of 57 employees, including Contribution to Emergency Nursing Practice  The purpose of this practice improvement project was to improve communication and the team’s perceptions of communication among ED staff.  The primary outcome of this practice improvement project was the team’s improved perceptions of communication and teamwork within the emergency department.  Key implications for ED nursing practice-based on this project are implementation of the TeamSTEPPS program improves perceptions of teamwork and communication among ED staff. Abstract Introduction: The emergency department is an environment where teamwork and communication are of utmost importance and are the foundation for improved patient satisfaction, staff satisfaction, patient safety, and the reduction of clinical errors. An ED staff perceptions of communication and teamwork influences their ability to provide efficient, high quality care to patients. Connie Obenrader is Nurse Practitioner at Northeastern Health System, Tahlequah, OK. Marion E. Broome is Dean and Ruby F. Wilson Professor, School of Nursing, Duke University, Durham, NC. Tracey L. Yap is Associate Professor, School of Nursing, Duke University, Durham, NC. Florame Jamison is Nephrology Nurse Practitioner, Northeastern Health System, Tahlequah, OK. For correspondence, write: Connie Obenrader, DNP, RN, NE-BC, 13899 N 510 Road, Tahlequah, OK 74464; E-mail: connie.obenrader@gmail.com. J Emerg Nurs 2019;45:31-7. Available online 12 October 2018 0099-1767 Copyright Ó 2018 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jen.2018.08.006 January 2019 VOLUME 45  ISSUE 1 nurses, mid-level providers, and non-licensed individuals, who work within, or directly with, the department. This quality improvement project trained 57 members of the ED staff using the TeamSTEPPS training program. Forty-six of the participants completed assessments at all 3 time points (baseline, 2 weeks and one month): Team STEPPS Teamwork Perceptions and Attitudes Questionnaires and The Nursing Culture Assessment Tool (NCAT). Results: Formal group TeamSTEPPS training improved the emergency department team members’ perceptions of, and attitudes about, communication and teamwork. Discussion: As a result of TeamSTEPPS training in an Emergency Department, the staff of that department perceived that both teamwork and communication improved. The TeamSTEPPs program should be made sustainable by incorporating the verbiage and tools from the program into policy and culture within the department. Key words: Communication; Teamwork; Perception; TeamSTEPPS; Hospital; Community hospital; Emergency department E very health care entity strives to maintain a safe environment. To accomplish this, the workplace culture must value patient safety and quality care. Essential components of a culture of safety include communication, resources, commitment, and openness to creating structures that promote safety within the organization. 1 Nurses feel empowered when those components, including effective communication, exist as was documented in an exploratory study based on Kanter’s theory of structural empowerment.2 There are acquired assumptions—which are actually values and beliefs— about communication that are shared among occupational subgroups within every organization. Those assumptions influence the perceptions, and therefore the actions, of the individual members of the group. Mutual trust, as well as confidence in the efficacy of WWW.JENONLINE.ORG 31 PRACTICE IMPROVEMENT/Obenrader et al preventive measures—including communication and an environment where everyone feels responsible—are components of a culture of safety.3 The emergency department is an environment in which teamwork and communication are of utmost importance and are the foundations for improved patient satisfaction, staff satisfaction, patient safety, and the reduction of clinical errors.4 Each department within the hospital has a unique nursing culture. The Association of Operating Room Nurses (AORN) promotes an organizational structure that “encourages reporting, ends blame, involves senior leadership, and focuses on systems and offers standard communication as an underpinning.”5 Teamwork is enhanced by communication containing the effective exchange of information.6 Effective communication can be arduous and challenging in a high-paced, complex environment such as the emergency department, where numerous staff members are caring for patients as part of the health care team.7 Communication may be improved by structures or protocols that aid individuals in standardizing the order in which information is shared.8 One method for improving communication and team processes around safety is the use of the TeamSTEPPS program. TeamSTEPPS was developed by the Agency for Research and Quality between 2002 and 2005. The program has been used in health care across a variety of settings to improve teamwork.9 Using structured training, a work environment can be built so it may transfer new knowledge enhancing communication, and hence safety.10 Setting The setting for this project was an emergency department within a 99-bed health system in the Midwest United States. The department sees an average of 55 patients daily. There were challenges experienced among staff members during the communication processes related to patient care. The care team had developed a complacent attitude regarding communication. For example, during emergent situations, the team did not communicate with others involved in the emergency care of patients when tasks were completed. They believed that other members of their team knew them so well that they could adequately communicate by exception: meaning that unless otherwise stated, the task had been completed. Poor communication, a risky behavior, can develop as a result of a team working together daily and believing that clarifications are not needed. The emergency nurse must be diligent in communicating all care and treatments in the emergency department. Without intentional clarification, the receiving nurse may 32 JOURNAL OF EMERGENCY NURSING inadvertently duplicate or omit a treatment. Implementing structured communication tools can aid the team in improving the quality of their communication. Therefore, the primary aim of this quality improvement project was to improve the perception of communication among ED team members before and after implementation of the TeamSTEPPS program and tools. A secondary aim was to improve the perception of teamwork in the emergency department. Methods The ED team consisted of 57 employees including nurses, nurse practitioners, physicians assistants, and non-licensed individuals who work within, or directly with, the department. This group made up the convenience sample used in this project. Exclusion criteria included those individuals who did not complete all 3 assessments. Physicians were not included in the convenience sample owing to physician staff changes that occurred midway through the project. For this repeated measures-designed project, TeamSTEPPS initial training and data collection took place during a 1-week period. Fifteen and then 30 days later, the participants were asked to complete the tools again for the data collection. To sustain the program, TeamSTEPPS was included in policy verbiage, and additional TeamSTEPPS tools were slated for implementation at a future time across selected units in the institution. New employees are introduced to TeamSTEPPS during orientation and are provided training for TeamSTEPPS tools, which are in use within the emergency department. TeamSTEPPS is an evidence-based teamwork system derived from more than 20 years of Crew Resource Management by the Department of Defense. The program was designed to influence the following: (1) Expand the team’s ability to adapt to changing situations; (2) create a shared understanding of team plans; (3) develop positive attitudes about being part of the team; and (4) establish a safe and reliable environment in which to practice.9 The components of TeamSTEPPS have proven effective in improving communication and teamwork in many work settings including aviation, medical, nuclear power plants and community emergency agencies. The Team STEPPS Fundamentals course was conducted in person for the ED staff.9 The course was presented by a Master Trainer. The fundamentals course consists of video vignettes, table discussions, and role playing to learn and practice new communication skills. The new communication skills were supported by tools from the Team STEPPs program, which were selected by the ED leadership and core staff members. VOLUME 45  ISSUE 1 January 2019 January 2019 TABLE 1 Communication VOLUME 45  ISSUE 1 Instrument TTAQ TTPQ NCAT a Mauchly’s Test of Sphericity Time of Measurement Before training Time 1 met, x2(2, N¼43) T1M¼.3.77, ¼ .91, P ¼ .63 SD¼ .03 a 2 Violated , x (2, N¼43) T1M¼4.09, _ .001 ¼ 27.79, P < SD¼.01 met, x2(2, N¼22) ¼ 5.338, P ¼ .07 Significance Result Fifteen days after training Time 2 Thirty days after training Time 3 Time 1 and time 2 Time 1 and time 3 Time 2 and time 3 T2M¼3.91, SD¼ .07 T2M¼3.92, SD¼.02 T2M¼3.91, SD¼ .07 T3M¼4.58, SD¼ .02 P ¼ .03 P ¼ .001 P ¼ .04 _ .001 P< _ .001 P ¼
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Explanation & Answer

Attached.

Running head: COMMUNICATION WITHIN HEALTHCARE ORGANIZATIONS

Communication within Healthcare Organizations

Student’s name:
Institutional affiliation:

1

COMMUNICATION WITHIN HEALTHCARE ORGANIZATIONS

2

Communication within Healthcare Organizations
Question 1: How could TeamSTEPPS be incorporated into the various areas in which you
practice? Would this type of culture change be welcomed? From an organizational view,
would these concepts be easy to introduce? What would be the concerns? From a clinical
view, would these concepts be easy to introduce? What would be the concerns?
According to Obenrader et al. (2019), TeamSTEPPS has had invaluable success in
transforming employee perception and engagement in teamwork and work-related
communication in various spheres of healthcare. In my current area of practice, the
TeamSTEPPS can be implemented by appointing an educator or mentor who would be the coach
of the other employees. Coaching and teaching are at the core of effective application of
TeamSTEPPS and having a dedicated influencer of this program would help to improve its
effectiveness at the organization.

Question 2: How would these methods of communication benefit patient safety, conflict
resolution, teamwork, and/or a shared mental model?
Achievement of better communication among staff members has many benefits to patient
safety. Firstly, better communication would help to reduce possible errors at the workplace.
Errors related with double administration of medication, failure to administer medication on
time, and administration of the wrong medication and procedures would all reduce due to
improve communication at the workplace. This has a great impact in guaranteeing better patient
safety to the hospitalized as well as better care quality, which would lead to higher patient
satisfaction.
At the workplace, conflicts tend to thrive due to poor communication and

COMMUNICATION WITHIN HEALTHCARE ORGANIZATIONS

3

miscommunication. These two are the leading cause of poor attitudes among workmates as well
as development of strife between colleagues. This is mainly because poor communication and
miscommunication leads to development of personal opinions and beliefs about a situation or a
person, which escalates strife and conflicts. Developing open, effective, timely, and reliable
communication at the workplace would greatly help to reduce workplace conflict, as well as help
remedy existing conflicts. Open and reliable communication is ultimately a cure to existing
conflicts as it helps to clear doubts, avoid development of personal opinions, and ensure that
individuals have the same understanding on an issue.
Communication is at the core of developing great teams. Only teams that have embraced
open, reliable, consistent, and free communication can form consensus on issues and move
together as a group. The communication strategies put forth by Obenrader et al. (2019) would
help in developing strong teams by ensuring that all team members have the same understanding
of an issue.

COMMUNICATION WITHIN HEALTHCARE ORGANIZATIONS

4

References
Gaston, T., Ralyea, C., Short, N., & Casterline, G. (2016). Promoting Patient Safety; Results of a
TeamSTEPPSA Initiative. The Journal of Nursing Administration, 201-207.
Obenrader, C., Broome, M. E., Yap, T. L., Jamison, F., Ok, T., & Durham. (2019). Changing
Team Member Perceptions by Implementing TeamSTEPPS in an Emergency
Department. Journal of Emergency Nursing , 31-37.

Attached.

Running head: COMMUNICATION WITHIN HEALTHCARE ORGANIZATIONS

Communication within Healthcare Organizations

Student’s name:
Institutional affiliation:

1

COMMUNICATION WITHIN HEALTHCARE ORGANIZATIONS

2

Communication within Healthcare Organizations
Question 1: How could TeamSTEPPS be incorporated into the various areas in which you
practice? Would this type of culture change be welcomed? From an organizational view,
would these concepts be easy to introduce? What would be the concerns? From a clinical
view, would these concepts be easy to introduce? What would be the concerns?
According to Obenrader et al. (2019), TeamSTEPPS has had invaluable success in
transforming employee perception and engagement in teamwork and work-related
communication in various spheres of healthcare. In my current area of practice, the
TeamSTEPPS can be implemented by appointing an educator or mentor who would be the coach
of the other employees regarding effective communication strategies. The mentor will need to
undertake training on communication strategies and teamwork engagement to ensure that there is
enhanced team cohesion and shared vision. Coaching and teaching are at the core of effective
application of TeamSTEPPS and having a dedicated influencer of this program would help to
improve its effectiveness at the organization (Gaston et al., 2016). The implementation of the
TeamSTEPPS program would necessitate the training of team members to be flexible and
adaptable, to ensure there is group understanding of plans and vision, changing employee
attitudes about work and the company, as well as assuring employees of a safe work
environment.
The culture change of enhance teamwork and collaboration will be welcome as it would
help to reduce workplace errors and enhance efficiency at the workplace. It is expected that
enhanced communication and collaboration between the employees would also reduce conflicts
and enhance productivity (Curtsinger, 2018). It is expected that employees will support the
change initiative because it focusses on enhancing their capacity to do their work, as well as

COMMUNICATION WITHIN HEALTHCARE ORGANIZATIONS

3

reduce barriers to better work turnarounds. It is also expected...


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