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INNOVATIONS IN EDUCATION
Interprofessional education in team
communication: working together to
improve patient safety
Douglas Brock,1 Erin Abu-Rish,2 Chia-Ru Chiu,2 Dana Hammer,3
Sharon Wilson,2 Linda Vorvick,1 Katherine Blondon,4 Douglas Schaad,5
Debra Liner,2 Brenda Zierler2
1
Department of Family Medicine
and MEDEX Northwest,
University of Washington,
Seattle, Washington, USA
2
Department of Biobehavioral
Nursing, University of
Washington, Seattle,
Washington, USA
3
Department of Pharmacy,
University of Washington,
Seattle, Washington, USA
4
Department of Health Services,
University of Washington,
Seattle, Washington, USA
5
Department of Biomedical
Informatics and Medical
Education, University of
Washington, Seattle,
Washington, USA
Correspondence to
Dr Douglas Brock, Department
of Family Medicine and MEDEX
Northwest, University of
Washington, 4311-11th Ave NE,
Suite 200; Seattle, WA 98195,
USA;
[email protected]
Received 1 March 2012
Revised 10 October 2012
Accepted 14 November 2012
Published Online First
4 January 2013
To cite: Brock D, Abu-Rish E,
Chiu C-R, et al. BMJ Qual Saf
2013;22:414–423.
414
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).
Conclusions Effective team communication is
important in patient safety. We demonstrate
positive attitudinal and knowledge effects in a
large-scale interprofessional TeamSTEPPS-based
training involving four student professions.
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.7–9 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
Brock D, et al. BMJ Qual Saf 2013;22:414–423. doi:10.1136/bmjqs-2012-000952
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Innovations in education
Figure 1 Team Strategies and Tools to Enhance Performance
and Patient Safety communications model.
provides a means to both learn and practise safe teamwork skills.
With this paper, we describe a sophisticated interprofessional team-based training, and take the important first step of demonstrating that participating
students can learn critical elements of team communication, and to value team functioning. We also demonstrate the utility of new self-report instruments.
Our study employs an established team communication framework,10 11 Team Strategies and Tools
to Enhance Performance and Patient Safety
(TeamSTEPPS),12 in teaching skills using manikin
simulators and standardised patients. While exceptions exist, training efforts commonly neglect to
provide evidence that learning has occurred, and that
learning is transferable to clinical settings. The
purpose of this paper is to describe and demonstrate
the effectiveness of an innovative interprofessional
training effort using 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 management13–15 (CRM).
Increasingly, there are calls for the incorporation of
team training into clinical settings16 stemming from
successful applications within surgery and traumafocused settings.17–19 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.20–22
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
together—and intraprofessional activities—where students work only with students within their discipline—
Brock D, et al. BMJ Qual Saf 2013;22:414–423. doi:10.1136/bmjqs-2012-000952
The overall goal of the interprofessional training was
for students to acquire effective interprofessional team
communication skills. Taking part in these exercises
allowed students the opportunity to practise and
observe interprofessional communication, and
through facilitated debriefings learn what proved most
effective. Our study goal sought to demonstrate that
interprofessional students would report enhanced
readiness23 through improved self-efficacy,24 25 motivation, positive attitudes and practice opportunities.
We proposed assessing testable research questions
aligned with our training goals. Following training,
would interprofessional students report
1. Improved attitudes, motivation and self-efficacy to
working within interprofessional healthcare teams?
2. Having observed and practised key team communication
skills?
3. Increased understanding of interprofessional team skills?
415
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Innovations in education
METHODS
Case development
Three adult acute cases (two adult males and one
teenage male) to demonstrate communication across
members of a healthcare team were developed collaboratively by a team of 9 interprofessional faculty, 19
student volunteers from various health profession programmes and 6 staff members. They were designed to
provide opportunities for an interprofessional team to
demonstrate team communication strategies and skills
in an acute situation, while delivering care to patients
and their families. The three adult acute cases were:
asthma exacerbation in a teenager (simulator with
standardised family member), congestive heart failure
in an elderly male (standardised patient) and supraventricular tachycardia in a male postsurgery (simulator with standardised family member). Each of the
three adult acute cases, and an adapted TeamSTEPPS
training, were tested with 49 students in June 2010.
Following the successful demonstration of the three
adult cases, we designed three paediatrics and three
obstetrics cases to reflect parallel skills requirements,
and provide comparable team communication skills
training in areas aligned with students’ career plans.
The paediatric cases were: severe asthma, acute
seizure and sepsis (each using a simulator). The three
obstetric cases were precipitous vaginal delivery, mild
postpartum haemorrhage and mild postpartum haemorrhage complicated by error (each using a standardised patient). Each of the cases are described and
available with toolkits for implementing and developing simulations on the Center for Health Sciences
Interprofessional Education, Practice and Research
website (http://www.collaborate.uw.edu).
Interprofessional Team Capstone
We used an existing capstone week held by the
University of Washington School of Medicine during
the last week of classes as an opportunity to bring
graduating medical bachelors of science in nursing,
PharmD and masters PA students together for interactive interprofessional training sessions. Participation
in the interprofessional training was required for all
students except for the PA students who were volunteers. Students participated in one 4 h training block
during the capstone week.
The Interprofessional Team Capstone experience
was designed to train students from four healthcare
professional programmes to practise together as a
team. Students had the option to participate in one of
three separate (focal area) trainings: (1) adult acute
care (2) paediatric, or (3) obstetric cases. This breakdown allowed students to select an area of practice
most similar to their anticipated specialty. The training
sessions occurred at two academic medical centre
training facilities across a 4-day period. In each
student focal area, the educational intervention
included a didactic session and three simulated
416
exercises. Following an icebreaker activity developed
to introduce interprofessional teamwork, students had
40 min of didactic instruction on patient safety and
TeamSTEPPS communication skills.
For the simulation sessions, students were divided
into interprofessional teams with balanced composition across healthcare programmes. The teams then
completed three simulated exercises (approximately
15 min each). Two exercises used a manikin simulator
and a standardised family member, and the third used
only a standardised patient. Each simulation was preceded by an introduction (eg, case materials and
ground rules), and was followed immediately by a
facilitated debriefing session. When not actively participating in a simulation, or when there were too
many students to accommodate, students were asked
to step back and observe. Students rotated through
observer and participant roles throughout the three
cases. All students (observers and participants) participated in the end-of-case debriefings. Student teams
met again as a large group for a final wrap-up with
the facilitators to review what they had learned.
Measuring the intervention’s impact
To assess the impact of the training on student learning,
we developed and selected instruments to assess attitudes, skills and knowledge (table 1). Instruments were
developed and reviewed by the UW Macy assessment
team, consisting of a physician and PA educator (LV), a
visiting physician fellow (KB), a nurse practitioner (SW),
a pharmacist (DH), two medical educators (DB, DS), a
nursing educator (BZ) and two nursing graduate students (CC, EAR). These instruments included attitudes
towards TeamSTEPPS communication skills, selfreported knowledge, motivation to implement these
skills, their value or utility and student self-efficacy in
being able to implement these skills in practice.
Student respondents were described by several
demographic variables. These included the student
educational programme, sex, age, healthcare experience prior to entering their current educational programme, and previous familiarity in working with
healthcare teams (eg, respiratory tech or medic).
Two instruments were administered, both pretraining and post-training. To assess attitudes towards team
communication we administered the TeamSTEPPS
Teamwork Attitudes Questionnaire (TAQ).26 The
TAQ is a validated instrument containing 30
Likert-type items assessing attitudes towards the five
dimensions (Team Structure, Leadership, Situational
Awareness, Mutual Support and Communication)
underlying the TeamSTEPPS communications model.
Attitudes were assessed by the Attitudes, Motivation,
Utility and Self-Efficacy (AMUSE); a 21 Likert-type
item instrument constructed to assess AMUSE. The
attitudes, motivation and utility items were developed
by the authors in consideration of existing instruments
to assess similar team constructs.23 27–30 The self-
Brock D, et al. BMJ Qual Saf 2013;22:414–423. doi:10.1136/bmjqs-2012-000952
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Innovations in education
Table 1
TeamSTEPPS communication behaviours and assessment instruments
Preinstruments and postinstruments
TeamSTEPPS: Teamwork Attitudes
Scale (TAQ)26
AMUSE*
Postonly instruments
Key communication behaviours:
frequency*
Key concepts: understanding*
Training program evaluation
Participant evaluations*
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
*Developed by study team.
†Copies of all instruments available at: http://www.collaborate.uw.edu/educators-toolkit/tools-for-evaluation.html-0
TeamSTEPPS, Team Strategies and Tools to Enhance Performance and Patient Safety.
efficacy items were guided by Bandura’s recommendations for developing scales to assess efficacy31 and following Bandura’s 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/toolsBrock D, et al. BMJ Qual Saf 2013;22:414–423. doi:10.1136/bmjqs-2012-000952
for-evaluation.html-0). The presurveys and postsurveys
were completed online and generally took between 10
and 15 min to complete. Pretraining surveys were open
to students for 2 weeks prior to training until 2 days
prior to the training. Post-training online surveys were
completed either on the day the subject completed
training, or approximately 2 weeks post-training. For
logistical reasons, we were unable to have students complete multiple postassessments. Students were randomly
assigned to the group that completed the survey on the
day of the training, or to the group that completed the
survey 2 weeks post-training. This allowed us to assess
degradation of training effects over time. All procedures
were approved by the University of Washington
Institutional Review Board.
Statistical analyses
Statistical analyses and instruments were selected to
align with the training goals. Within-group differences
(pre vs post) were analysed using paired t tests. Analysis
of variance (ANOVA) was used to explore differences
across interprofessional student groups (eg, medical).
Instrument internal consistency was assessed using
Cronbach’s α. All tests applied a p=0.05 level of significance. When multiple tests were performed simultaneously, the critical values were adjusted using the
Bonferroni criterion to reduce risk of Type I error.
RESULTS
Demographics
A total of 306 fourth-year medical, third-year nursing,
second-year pharmacy and second-year PA students
417
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Innovations in education
Table 2
Number and percent of students completing preassessment and postassessments
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 (χ²=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
Our first training goal focused on positive attitudinal
shifts (including motivation and self-efficacy). The
AMUSE was used to assess changes in student attitudes, motivation, utility and self-efficacy following
training. Each subscale (α=0.90–0.79) and the aggregate total (α=0.90) achieved acceptable levels of
Table 3
Demographics for students completing both the preassessment and postassessments (n=149)
Sex (n (%) female)
Age (mean, SD)
Healthcare experience (n (%) yes)
Team healthcare experience (n (%) most or Some)
PA, Physician assistant.
418
internal consistency. Change scores were used to
assess impact. Inspection of table 4 indicates that significant positive changes occurred for the AMUSE
total score ( p<0.001), and each of the four AMUSE
subscales ( p<0.001 to p=0.005). This provides evidence that training increased students’ positive attitudes towards working in teams, that students were
more motivated to work in teams, saw greater value
(utility) to this type of training and practice and felt
able to implement the skills they had learned (selfefficacy). The largest effect was seen for the AMUSE
utility score (mean=0.41, 95% CI 0.32 to 0.50). The
smallest effect was seen for the AMUSE self-efficacy
score (mean=0.12, 95% CI 0.04 to 0.21). Individual
students tended to show improvement in their attitudes, motivation, beliefs about utility and selfefficacy; this effect was relatively uniform across the
professional programme and focal area.
Table 4 also provides the prescores and postscores
for the TeamSTEPPS Attitude Questionnaire (TAQ).
One TAQ subscale (Mutual Support) exhibited marginal internal consistency (α=0.62). The other TAQ
subscales (α=0.85–0.94) and the TAQ aggregate
(α=0.93) achieved acceptable internal consistency.
Significant positive increases were noted for TAQ
Total Score ( p<0.001), TAQ Situation Monitoring
( p<0.001), TAQ Team Structure ( p=0.002), TAQ
Communication ( p=0.002) and TAQ Mutual Support
( p=0.003). There was no significant change in the
TAQ Leadership score ( p=0.062). The largest effect
was seen for the TAQ Situation Monitoring
(mean=0.19, 95% CI 0.10 to 0.38), and the smallest
significant
effect
was
for
Communication
(mean=0.13, 95% CI 0.05 to 0.21). Similar to the
AMUSE results, individual students showed improvements in most of the TAQ subscales, an effect which
was not differentially related to the student’s professional programme or the focal area of the training.
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)
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Innovations in education
Table 4 Pre-Attitudes and post-Attitudes, Motivation, Utility and Self-Efficacy (AMUSE) and the TeamSTEPPS Teamwork Attitudes
Questionnaire (TAQ) Totals and subscores
Instruments
Pre-Attitudes
Post-Attitudes
Paired
Effect
Mean (95% CI)
Mean (95% CI)
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
AMUSE Total (n=149)
3.92 (3.85 to 3.98)
4.21 (4.13
Attitudes
4.30 (4.20 to 4.40)
4.56 (4.46
Motivation
3.64 (3.55 to 3.73)
4.01 (3.90
Utility
4.05 (3.96 to 415)
4.46 (4.36
Self efficacy
3.68 (3.60 to 3.76)
3.80 (3.71
TeamSTEPPS Total (n=149)
4.02 (3.97 to 4.07)
4.16 (4.09
Team structure
4.34 (4.27 to 4.41)
4.48 (4.40
Leadership
4.55 (4.48 to 4.62)
4.63 (4.55
Situation monitoring
4.33 (4.25 to 4.40)
4.52 (4.43
Mutual support
3.01 (2.94 to 3.07)
3.14 (3.06
Communication
3.90 (3.84 to 3.96)
4.03 (3.95
*Effect size not computed for non-significant values.
All questions were scored on a scale from 1=‘Strongly Disagree’, to 5=‘Strongly Agree’.
TEAMstepps, Team Strategies and Tools to Enhance Performance and Patient Safety.
One-way ANOVAs were conducted on the change
scores of the TAQ and AMUSE aggregate total scores
and subscales to explore whether differences occurred
across student groups from different professions.
When conducting analysis by programme of study
(medical, nursing, pharmacy), robust statistical
Table 5 Post-training assessment of the frequency of seeing or
participating in specific behaviours
Item
Mean (95% CI)
Leaders assigned tasks to team members to help
4.16 (4.05 to 4.27)
team functioning
Leaders shared information with team members
4.14 (4.04 to 4.24)
Team member communication skills decreased the
4.01 (3.90 to 4.12)
risk of errors
Team members demonstrated a shared mental
3.92 (3.82 to 4.02)
model
Team members were consulted for their experience 3.87 (3.74 to 4.00)
Team members scanned the environment for
3.86 (3.75 to 3.97)
important situational cues
Leaders discussed the patient’s plan with their team 3.85 (3.73 to 3.97)
Team members exchanged information with the
3.85 (3.74 to 3.96)
patients and their families
Leaders created opportunities for team members to 3.78 (3.66 to 3.90)
share information
Team members asked for assistance
3.73 (3.60 to 3.86)
Team members anticipated needs
3.71 (3.60 to 3.82)
Team members asked questions about information
3.69 (3.57 to 3.81)
provided by other team members
Team members asserted patient safety concerns
3.64 (3.52 to 3.76)
until heard
Team members offered help to other team members 3.53 (3.38 to 3.68)
Patients and family members utilised as critical
3.51 (3.39 to 3.63)
components of the care team
Respondents (n=194–217 completed responses per item) reported the
frequency that the training cases allowed them to practise or observe
instances of specific communications skills.
Response options ranged from 1=‘Never’, to 5=‘Frequently’.
Brock D, et al. BMJ Qual Saf 2013;22:414–423. doi:10.1136/bmjqs-2012-000952
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)
differences between AMUSE subscales emerged only
for motivation ( p=0.010, η2=0.06) and self-efficacy
( p=0.005, η2=0.07). For motivation, this reflected
lower postscores for pharmacy students (mean=3.53,
SD=0.90) than for medical (mean=4.11, SD=0.46)
or nursing students (mean=4.13, SD=0.59). Medical
students (mean=3.89, SD=0.55) reported higher
postlevels of self-efficacy than did nursing
(mean=3.67, SD=0.43) or pharmacy students
(mean=3.56, SD=0.73).
Second training goal
Our second training goal sought to provide students
the opportunity to observe and practise team communication skills. In the postassessment, interprofessional
students were asked to rate the frequency with which
they saw or participated in a series of behaviours.
These behaviours are provided in table 5. Since these
questions could only be delivered post-training, we
have reported results for all students who completed
the postassessment (n=21 971.6%). Respondents
were significantly more likely (adjusted for Type I
error) to report having had the experience of team
leaders assigning tasks and sharing information with
team members, and to report examples of communication skills that served to reduce error. Observations
of team members effectively asserting patient safety
concerns, offering each other help, or utilising
patients and/or family members as critical members of
the care team were less likely to be reported.
Third training goal
Our third training goal focused on increasing student
understanding of team skills. As part of the postassessment, students reported levels of agreement that training
had increased understanding of key learning objectives
(table 6). The largest changes occurred in beliefs around
the benefits of implementing TeamSTEPPS (mean=1.48,
419
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Innovations in education
Table 6
Self-reported change between preunderstanding and postunderstanding of key TeamSTEPPS learning objectives
Learning objective
Before
After
Change with 95% CI
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=201–214) 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
At the conclusion of training, participants (n=292)
completed a brief evaluation of the experience. Overall,
students within each of the three focal areas reported
the trainings to be valuable (1=Not at all valuable, to
5=Highly valuable). They especially reported value in
the TeamSTEPPS introduction (mean=4.57, SD=0.70),
and the final debrief following the completion of the
three cases (mean=4.29, SD=0.95).
Participants were also asked their level of agreement
(1=Strongly Disagree, to 5=Strongly Agree) with specific aspects of the training. Participants were generally in agreement that materials were at an
appropriate level (mean=4.42, SD=0.78), provided
valuable team skills training (mean=4.66, SD=0.59),
provided a realistic experience of the challenges faced
when
working
in
interprofessional
teams
(mean=4.44, SD=0.78), and provided a valuable
opportunity to communicate with students from other
professions (mean=4.71, SD=0.56).
Students were also asked to describe their most
valuable learning experience in the training. Three
consistent themes emerged: (1) value in the opportunity to work with students from different professional
schools, (2) the value of learning and practising specific communication skills in a supportive environment and (3) value of practising skills within an
interprofessional team.
DISCUSSION
The Interprofessional Team Capstone was successful at
several levels. Initial successes are reflected in the
420
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.
considerable logistic challenges we addressed. These
included: recruiting and scheduling students from four
separate health professions; securing support from the
school deans and programme directors; recruiting sufficient volunteer faculty to staff the training sessions for
four full days; training the faculty using a
‘train-the-trainer’ approach; securing the physical space
necessary to conduct the simulation training. Other successes are reflected in the positive self-report from students and changes in their attitudes, beliefs and
confidence resulting from the training. This may result,
in part, from taking a multimodal approach to case
development that combined manikin simulators with a
standardised patient or standardised family member.
This allowed us to capitalise on the benefits of both
modes to provide a rich student learning experience.
The cases were considered realistic and engaging, the
communication challenges were important, and the
opportunity to work within interprofessional teams was
described as valuable. Students enjoyed the activities
and reported they had benefited professionally from
participation. This benefit was reflected in improved
attitudes towards interprofessional training, an increased
intrinsic and extrinsic motivation to participate in future
trainings, a perceived value for the utility of
TeamSTEPPS communication training, and an increased
sense of perceived self-efficacy in translating the skills
learned in training into practice. This was consistent
whether students were surveyed on the day of the training or 2 weeks following training.
Our cases, and our case development processes, parallel the recommendations of World Health
Organization (WHO)33 for the creation of multiprofessional patient safety education. We sought to develop
cases that were interesting, relevant, realistic and
readily applicable to practice. Most importantly, students were provided the opportunity to practise skills
learnt in multiple realistic simulations, and encouraged
to engage and receive feedback following each activity.
Students learnt by doing, not simply by observing.
Brock D, et al. BMJ Qual Saf 2013;22:414–423. doi:10.1136/bmjqs-2012-000952
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Innovations in education
We developed two new instruments for this study
and reported on a use of the previously unpublished
AMUSE instrument. These instruments were designed
to allow students to report experiences from interprofessional team trainings. While observer-based instruments for team training exercises have been reported,
similar self-report instruments have not been widely
discussed. Our instruments may prove of value to
other interprofessional trainings where educators
seek to better understand student attitudes and
perceptions.
One of the most consistent findings was reflected in
students’ written stated reports of the value of
working directly with students from other professions.
While most of the participating students had experience in clinical settings working with practitioners
from other professional programmes, the majority
had minimal experience working in interprofessional
activities with the people who would be their future
colleagues. Fellow students provide an opportunity
for learning to occur in lower stakes and a less stressful environment than working in interprofessional
healthcare teams caring for real patients.
Limitations
Our study has important limitations to consider. First,
this was a simple pre-post design, without a defined
control group. It is possible that student postresponses
resulted, in part, from other aspects of their ongoing
professional training. This concern is minimised by
the relatively short span of time between the preadministrations and postadministrations. However, it is
also possible that students were sensitised by the preassessment to be more alert and attuned to the
assessed elements of the team communication training. However, few studies meet the rigorous standards
necessary to draw causal relationships between the
various components of training and specific outcomes,34 35 and the empirical base for similar trainings has been questioned.36 Future work with
randomised controlled studies of students is needed
with outcomes that include later professional practice.
We have demonstrated that positive outcomes are
obtainable through a short introduction to the
TeamSTEPPS skillset, and the opportunity to practise
these skills and receive feedback from experienced
facilitators. However, interpretation of the findings is
confounded by unmeasured factors, which include the
effects of an individual’s assigned team members, and
different team facilitators on the team’s learning
experience. In addition, we have relied on selfassessment instruments that have not been fully validated. This is partly due to the paucity of validated
measurement assessment tools for use with students.
This is changing, especially with work around selfefficacy,37 and we are completing additional validation
efforts on the tools we have developed for the current
study.
Brock D, et al. BMJ Qual Saf 2013;22:414–423. doi:10.1136/bmjqs-2012-000952
This study does not directly address student skill
attainment, or the impact of newly learned skills on
practice. In addition, other researchers have questioned the impact of similar interventions.38 The
former can be understood to some extent through our
ongoing analysis of student performance from the
videos collected during the Capstone exercise. This
will provide some evidence that the skills have been
demonstrated, as well as the quality of the skills performed. Capturing downstream behaviour change,
and the impact of this change, are more difficult.
Demonstrating the effects of training will require longitudinal studies to capture the impact of attitudinal
changes on behaviour within clinical settings.
Future directions
Simulation training of interprofessional student teams
represents a first step in establishing improved communication skills within practising clinical teams. We
have shown that student teams can have significant
attitudinal shifts and practice, and observe important
team skills. Our work, funded through the Macy
Foundation, has allowed us to build distributable
resources, including interprofessional training cases
and a template model for the creation of new cases.
We encourage the development of multimodal simulations employing manikin simulators and standardised
patients, and standardised family members as a means
to leverage the benefits of both modes while optimising the student experience. Dissemination and the
application of these materials broadly across healthcare training programmes will demonstrate the
achievement of a principal goal underlying funding.
In addition, at the University of Washington, the trainings described in this paper have been integrated into
the ongoing curriculum.
Validation of the cases and interprofessional team
training tools will require close inspection and quantitative assessment of the impact such training will
ultimately have on the quality of healthcare delivered.
We do not report unequivocal evidence for the effectiveness of our trainings; we provide a foundation for
team-communication investigators to establish the
next steps to create best-practice training models. Our
team is currently establishing the validity of observational tools to assess team performance, as well as criteria for the assessment of videotaped team
interactions. The outcomes and successful training
activity reported here, when combined with the observational work in development, takes an important
step towards meeting the joint commission’s call that
measurement represents the ‘heart of safety,’ and that
improved care first requires the examination of highquality measures of outcomes.39
Acknowledgements The authors would like to
acknowledge funding from a Josiah Macy Foundation
Board Grant (B08–05), and all the members of the
421
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Innovations in education
University of Washington Macy Team that developed
and implemented the cases, simulations and trainings.
Contributors Each author contributed to the conception
of the study, the study design, writing and critical
review of the manuscript. Each author approved the
final version of the manuscript. Data collection and
analysis was conducted by DB, EAR and CRC.
Funding The authors would like to acknowledge
13
14
15
funding from a Josiah Macy Foundation Board Grant
(B08-05), and all the members of the University of
Washington Macy Team that developed and
implemented the cases, simulations and trainings.
16
Competing interests None.
17
Ethics approval University of Washington Internal
Review Board.
18
Provenance and peer review Not commissioned;
externally peer reviewed.
19
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Interprofessional education in team
communication: working together to
improve patient safety
Douglas Brock, Erin Abu-Rish, Chia-Ru Chiu, et al.
BMJ Qual Saf 2013 22: 414-423 originally published online January 3,
2013
doi: 10.1136/bmjqs-2012-000952
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