Applied Sciences

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versity curricula. It has been applied at academic institutions, including Harvard University’s Beth Israel Deaconess Hospital and Duke University Health System’s Pediatric Intensive Care Unit. Military operational units continue to request training to enhance their ability to support any mission at a moment’s notice. Forward surgical teams have received training to increase the precision of care provided both on the battlefield and in the combat support hospitals in Iraq and Afghanistan. A front-page article on TeamSTEPPS in the June 1, 2007, issue of Internal Medicine News (Vol 40, No 11, www.internal confirmed the widespread attention enjoyed by TeamSTEPPS. The prestigious M. Scott Myers Award for Applied Re- search from The Society for In- dustrial and Organizational Psych- ology went to TeamSTEPPS in 2007.

Tools and Strategies The TeamSTEPPS program pro-

vides tools and strategies to in- crease team awareness through a shared mental model (see Figure 1). It clarifies team roles and re- sponsibilities, and creates an atmosphere of mutual trust. Co- hesive teamwork will enhance per- formance through increased adapt- ability, accuracy, productivity, effi- ciency, and safety. The core of the TeamSTEPPS framework comprises four key principles/skills/core competencies that are integrated to foster delivery of safe, quality care as a cohesive patient care team, which includes the patient,

TeamSTEPPS: Integrating Teamwork Principles Into Adult Health/Medical-Surgical Practice

staff satisfaction. The TeamSTEPPS approach has met with great suc- cess in a variety of high-risk set- tings such as emergency depart- ments and labor and delivery. It is now time to embrace TeamSTEPPS strategies in the medical-surgical setting.

TeamSTEPPS Goal The goal of TeamSTEPPS is to

produce highly effective medical teams that optimize the use of information, people, and re- sources to achieve the best clini- cal outcomes for patients. To achieve this goal, the HCTCP will work to institutionalize team-driv- en care, solidify collaborative partnerships, and support re- search demonstration projects to improve patient safety.

TeamSTEPPS Impact to Date TeamSTEPPS was implement-

ed in 2005-2007 in over 68 military treatment facilities (MTFs) world- wide. Approximately 1,500 partici- pants have attended the train-the- trainer course, and over 22,000 continuing education (CE/CME) credits have been awarded. The train-the-trainer approach has saved the DoD $1.4 million in train- ing and travel costs. TeamSTEPPS has been introduced in 24 peer- reviewed publications and was the topic of conversation in over 10 in- terviews. In January 2008, the Military Health System Conference featured a 2-hour TeamSTEPPS training session for over 100 par- ticipants. TeamSTEPPS tools and strategies have been incorporated in simulation exercises and in uni-

In collaboration with the Healthand Human Services Agency for Healthcare Research and Quality (AHRQ), the Department of De- fense (DoD) Health Care Team Coordination Program (HCTCP) developed an initiative that stress- es teamwork and communication among physicians, nurses, and other health care personnel to make the delivery of health care safer for all patients. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS™) principles were designed to be incorporated into the daily activities of patient care provision in an effort to reduce clinical errors, and improve pa- tient outcomes and patient and

Sheri L. Ferguson, MSN, MBA, MSEd, BSN, CMSRN, is a Colonel, Army Nurse Corps, and Chief, Nursing Admini- stration, Carl R. Darnall Army Medical Center, Fort Hood, TX. She is also Medical Surgical Nursing Consultant to The Surgeon General.

Disclaimer: The opinions and views expressed in this article are those of the author and do not necessarily rep- resent those of the U.S. Army Nurse Corps, nor those of the U.S. Depart- ment of Defense.

Note: Military nursing offers unique practice opportunities. Share your per- spectives on your practice as a nurse in the Armed Forces with the readers of MEDSURG Nursing by submitting a manuscript in consideration for this column. Questions and submissions can be directed to the Editor, Dottie Roberts, at

Sheri L. Ferguson

MEDSURG Nursing—April 2008—Vol. 17/No. 2 123

direct caregivers, and those who play a supportive role within the health care delivery system. The four key skill areas are: 1. Leadership. Involves the abili-

ty to coordinate the activities of team members by ensuring team actions are understood, changes in information are shared, and team members have the necessary resources. TeamSTEPPS tools include: ➤ Planning – Brief: A short

session prior to start to dis- cuss team and establish roles.

➤ Problem solving – Huddle: An ad hoc team meeting to share information and adjust plans.

➤ Process improvement – Debrief: After-action review to provide feedback and improve team perform- ance.

2. Situation Monitoring. The pro- cess by the individual of active- ly scanning behaviors and ac- tions of those around him or her to assess the situation or environment. Situation monitor- ing fosters mutual respect and team accountability, and pro- vides a safety net for the team and the patient. TeamSTEPPS tools include: ➤ Cross monitoring – A process

of monitoring the actions of other team members for the purpose of sharing the workload and reducing or avoiding errors. It ensures mistakes or oversights are caught quickly and easily. It is a way of “watching each other’s back.”

➤ Shared mental model – The perception of, understanding of, or knowledge about a sit- uation or process that is shared among team mem- bers through communica- tion. Having team members “on the same page” is the desired team outcome.

3. Mutual Support. The ability to anticipate and support other team members’ needs through accurate knowledge about their responsibilities and work- load, mutual support protects team members from work over- load situations that may reduce effectiveness and increase the risk of error. TeamSTEPPS tools include: ➤ Task assistance – Team

members foster a climate where it is expected that assistance will be actively sought and offered.

➤ Feedback – Information for the purpose of improving team performance should be

timely, respectful, specific, directed toward improve- ment, and considerate.

➤ Advocacy and assertion – Invoked when team mem- bers’ viewpoints do not coincide with that of a deci- sion maker. The team mem- ber asserts a corrective action in a firm and respect- ful manner.

➤ Two-challenge rule – Invoked when an initial assertion is ignored. It is the team mem- ber’s responsibility to voice his or her concern asser- tively at least two times to ensure that it has been heard. The member being challenged must acknow- ledge the challenge; if the outcome is still not accept- able, a stronger course of action, such as notifying the supervisor, must be taken.

➤ Collaboration – Achieves a mutually satisfying solution resulting in the best out- come. The patient care team (individual team members, team, and patient) all win!

➤ DESC script – A constructive approach for managing and resolving conflict. Ultimate- ly, consensus shall be reached. • D – Describe the specific

situation. • E – Express your concerns

about the action. • S – Suggest other alterna-

tives. • C – Consequences should

be stated. 4. Communication. A process by

which information is clearly and accurately exchanged among team members. TeamSTEPPS strategies for providing clear and accurate communication include: ➤ SBAR – a technique that

requires immediate atten- tion and action concerning a patient’s condition. • S – Situation • B – Background • A – Assessment • R – Recommendation

➤ Call-out – A strategy used to communicate important or critical information. Exam- ple: resuscitations.

Figure 1. TeamSTEPPS Teamwork Training System




Communication SituationMonitoring


Mutual Support

124 MEDSURG Nursing—April 2008—Vol. 17/No. 2

➤ Check-Back – A process of employing closed-loop com- munication to ensure that information conveyed by the sender is understood by the receiver as intended. Ex- ample: all verbal orders.

➤ Handoff – The transfer of information (along with authority and responsibili- ty) during transitions in care across the continuum; to include an opportunity to ask questions, clarify, and confirm responses. Ex- amples: shift changes, phy- sicians transferring com- plete responsibility, and pa- tient transfers.

TeamSTEPPS Transforms Culture

The AHRQ and DoD are engaged in an extensive awareness campaign targeted at hospitals, hospital associations, health care trade associations, professional organizations, and medical and nursing schools. As TeamSTEPPS and team training are embraced by MTFs across the military health system (MHS), they also have real- ized considerable growth in the private sector since their release to the public domain on November 2, 2006. The ability to export TeamSTEPPS to many different health care settings and popula- tions is an indication that team- work can transform the culture of an organization through a variety of different ways: 1. Establishes names for behav-

iors and a common language for talking about communica- tion failures.

2. Bridges the professional divide and levels the hierarchy often seen in health care.

3. Provides teachable-learnable skills and actions to practice.

4. Increases mindfulness, or “knowing what is going on around you.”

5. Enlists the patient as a valued team member.

TeamSTEPPS in the Medical- Surgical Setting

Medical-surgical health care personnel often operate in silos and become frustrated because their voices and opinions are not

heard. Their priorities may be dif- ferent, often causing frustration. The interdisciplinary plan of care often is difficult to orchestrate when nurses, physicians, respira- tory therapists, and other health care personnel do not have a shared mental model. The tools found in TeamSTEPPS can advance culture change by providing the health care workforce with a shared simple set of words to describe critical communication behaviors. As TeamSTEPPS is spread to large numbers of health care workers, the issues that are supporting those silos begin to dis- appear and culture change is seed- ed. With a common language and focus, the introduction to a series of common behaviors gives health

care workers a way to break out of constraints of current cultures and express what they see and think more freely; the cultural outcome is collective mindfulness.

Implementation across an organization is one thing; sustain- ability is more difficult. For a change to a shift of culture to be successful, a powerful group must lead the change, and members of that group must work together as a team. Culture change is hard work. It takes leadership commitment, time resources, and focused im- provement. Medical-surgical nurs- es are a powerful group of profes- sionals who, in collaboration with other health care providers, can lead that change.

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Table 1. Resources Available

TeamSTEPPS™ Instructor Guide. [TeamSTEPPS™: Team Strategies & Tools to Enhance Performance and Patient Safety; developed by the Department of Defense and published by the Agency for Healthcare Research and Quality.] AHRQ Publication No. 06-0020. Rockville (MD): Agency for Healthcare Research and Quality; September 2006.

TeamSTEPPS™ Pocket Guide. [Team Strategies & Tools to Enhance Performance and Patient Safety; developed by the Department of Defense and published by the Agency for Healthcare Research and Quality.] AHRQ Publication No. 06-0020-2. Rockville (MD): Agency for Healthcare Research and Quality; June 2006.

TeamSTEPPS™ Multimedia Resource Kit. [TeamSTEPPS™: Team Strategies & Tools to Enhance Performance and Patient Safety; developed by the Department of Defense and published by the Agency for Healthcare Research and Quality.] AHRQ Publication No. 06-0020-3. Rockville (MD): Agency for Healthcare Research and Quality; September 2006.

TeamSTEPPS™ Guide to Action. [TeamSTEPPS™: Team Strategies & Tools to Enhance Performance and Patient Safety; developed by the Department of Defense and published by the Agency for Healthcare Research and Quality.] AHRQ Publication No. 06-0020-4. Rockville (MD): Agency for Healthcare Research and Quality; September 2006.

TeamSTEPPS™ Poster. [TeamSTEPPS™: Team Strategies & Tools to Enhance Performance and Patient Safety; developed by the Department of Defense and published by the Agency for Healthcare Research and Quality.] AHRQ Publication No. 06-0020-5.Rockville (MD): Agency for Healthcare Research and Quality; September 2006.

Table 2. TeamSTEPPS Citations

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TeamSTEPPS in the Military Health System The MHS mission is to provide optimal health

services in support of the nation’s military mission (see Tables 1 & 2). The MHS is prepared to respond anytime, anywhere, with comprehensive medical capability to military operations, natural disasters, and humanitarian crises around the globe, and to ensure delivery of world-class health care to all DoD service members, retirees, and their families. Effective teamwork and communication are vital to the success- ful completion of this mission. A part of the MHS vision is to have an integrated team ready to go in harm’s way to meet the nation’s challenges at home or abroad; with the help of TeamSTEPPS, the vision has become reali- ty. As a source of innovative education, medical train- ing, research, technology and policy, the MHS strives to provide a bridge to peace. Dr. M. Ward Casscells, assistant secretary of Defense for Health Affairs, reported at the end of 2006 that “medical teams were still saving an unbelievable 90% of soldiers wounded in battle…They did so through a commitment to mak- ing a science of performance, rather than waiting for new discoveries. And they did it under extraordinari- ly demanding conditions and with heroic personal sacrifices.” Exceptional teamwork has resulted in the unprecedented outcomes that military health care has achieved during this most recent conflict. The MHS leadership believes such impressive results are a consequence of a culture based on innovation, service to others, and an unrelenting persistence to achieve excellence. ■

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