Introduction
Teamwork has been emphasized as essential to improving quality and safety in the healthcare delivery system. Teamwork has been defined as a dynamic interaction among healthcare providers that is aimed toward a common goal and refers to a set of interrelated knowledge, attitudes, and skills (Agency for Healthcare Research and Quality [AHRQ], 2019). Various types of healthcare providers work together to provide patient care within the complexity of healthcare systems (World Health Organization [WHO], 2011). Healthcare providers perform interdependent tasks but are rarely trained together (King et al., 2008). From this perspective, ensuring safe care is often difficult unless teamwork and effective communication exist among healthcare providers. Therefore, it is necessary to provide a strategy that strengthens teamwork to enhance patient safety.
Effective teamwork has been recognized as critical to preventing medical errors in the care process (WHO, 2011). A meta-analysis study has demonstrated that improving teamwork competency through team training in healthcare saves patient lives (Hughes et al., 2016). In addition, teamwork has been proposed in previous studies as affecting job performance positively in relation to patient safety and patient outcomes. Improving teamwork among nursing staff has been reported to reduce patients' fall rate (Kalisch et al., 2007), increase nurses' performance of missed care (Kalisch & Lee, 2010), and result in better error reporting (Hwang & Ahn, 2015). As nursing teams comprise the largest human resource in hospitals, improving teamwork competency in nurses may have financial and quality-of-care impacts across the healthcare sector (Barton et al., 2018).
Patient safety involves minimizing the incidence and impact of adverse events while maximizing recovery from these events (WHO, 2011). Patient safety competency consists of knowledge, skills, and attitudes toward patient safety (Cronenwett et al., 2007; WHO, 2011). To achieve patient safety and quality improvement goals, several international organizations have included teamwork competencies within core patient safety competencies (AHRQ, 2019; Australian Commission on Safety and Quality in Health Care, 2005; Canadian Patient Safety Institute, 2008; WHO, 2011). To ensure that nurses are competent in patient safety, education on patient safety in the nursing curriculum is required. However, because nurses receive little or no formal patient safety education in the university curriculum (Barton et al., 2018; Hwang, 2015), they may not be able to cope with patient safety issues adequately. Among patient safety competencies, nurses have demonstrated the lowest scores on teamwork competencies (Hwang, 2015). Therefore, the first step toward ensuring patient safety and quality in healthcare is to provide an education program that emphasizes teamwork competency.
Teamwork training enables healthcare providers to optimize their teamwork competencies with the teamwork knowledge, attitudes, and skills needed to become effective team members (Sherwood & Barnsteiner, 2017). The teamwork improvement program (TIP), Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) has been applied in various healthcare settings and has proven to be effective by using an evidence-based team training method developed for improving patient safety by enhancing both communications among healthcare professionals and teamwork competencies (Cooke, 2016; Gaston et al., 2016; Parker et al., 2019).
Nurses play an important role as part of the multidisciplinary team while providing 24-hour care for patients and interaction with them. Because nurses conduct their clinical practice based on cooperation and collaboration with other nurses (Kaiser & Westers, 2018), teamwork is a critical element in effective nursing practice. Particularly, of the patient care departments in the hospital, the operating room (OR) is one of the most intricate and high-risk environments (Sonoda et al., 2018), where healthcare is provided by a temporary interprofessional team and often performed using invasive treatments under anesthesia. Teamwork between nurses in the OR is especially important because two nurses work closely as a team performing the roles of scrub nurse and circulating nurse in each operation. While participating in the operation, the perioperative nurse cannot perform tasks such as counting, timeout, supplying of aseptic surgical materials, and coping with emergency situations as an individual nurse. Therefore, perioperative nurses are required to have teamwork competencies to minimize incidents during surgery.
To provide the best surgical nursing care to patients, nursing team members must communicate effectively and coordinate properly (Sonoda et al., 2018). Thus, applying a TIP that focuses on the nursing team in the OR environment and educating nurses to understand how to apply teamwork strategies in the clinical context of their specialty settings are necessary. To successfully apply these teamwork programs in specific clinical settings, it is important to include adequate materials and resources relevant to the department in the program design (Clapper & Ng, 2013) or to develop a customized program for the target area (Vertino, 2014). The TeamSTEPPS program has been applied in several intervention studies in the OR (Dahl et al., 2017; S.-H. Lee et al., 2021) for interprofessional teams, including nursing, surgical, and anesthesia staff. However, few studies have focused on the implementation of this program within the nursing team in the OR.
Therefore, in this study, we developed a TIP for perioperative patient safety and evaluated the effectiveness and satisfaction of this program in the context of perioperative nurses.
Methods
Study Design
In this study, a quasi-experimental research design was used to evaluate the effectiveness of the developed program.
Setting and Sample
This study was conducted at one tertiary hospital in South Korea. Participants were recruited using a convenience sampling method from two operating centers (cancer operating center, main operating center), which shared a similar safety culture, unit organization, nursing staffing level, and working conditions. The inclusion criteria were (a) > 6 months of clinical experience as a perioperative staff nurse and (b) understood the purpose of the study and agreed to participate. The nurses working in the cancer operating center were assigned to the experimental group, and the nurses working in the main operating center were assigned to the control group. The groups were located at separate centers to minimize treatment diffusion.
We calculated the appropriate sample size using G*Power 3.1 (Faul et al., 2009) by specifying an effect size of 0.5, a power of .7, and a probability of alpha error of .05 for a paired t test. The required sample size was 27 in each group. A sample of 63 perioperative nurses agreed to participate, and 60 nurses actually participated.
Program Development
The process used to develop the TIP consisted of four steps (Figure 1). In the first step, the researchers identified teamwork competencies using a literature review on patient safety competencies and then combined these competencies with team-based competencies that are specifically required of perioperative nurses (Australian Commission on Safety and Quality in Health Care, 2005; Canadian Patient Safety Institute, 2008; Cronenwett et al., 2007; WHO, 2011). The researchers categorized the teamwork competencies based on the educational objectives and core concepts described in the TeamSTEPPS educator's guide. The list of teamwork competencies was finalized after review by a panel of experts.
In the second step, the educational plan for the program was constructed in accordance with the educational content of the TeamSTEPPS fundamental modules, and additional content was added to reflect the specific needs of OR environments. In addition, teamwork education needs were assessed using interviews with three perioperative nurses, and the content validity for the final educational plan was verified with four clinical experts.
In the third step, the instructional structure, methods, and materials were developed based on the results of the established educational plan. After initial development, the educational content was reviewed by an expert panel composed of a perioperative nurse with more than 15 years of clinical experience in the OR and a nurse educator who had worked for more than 10 years in a hospital. The final program was developed after revising the content, structure, and teaching methods in accordance with the results of the validity test.
Comparisons of the structure and content between TeamSTEPPS and the developed TIP are described in Table 1. The focus in this study was on improving teamwork competencies among perioperative nurses and applying teamwork strategies to nursing practice to enhance perioperative patient safety. The content addressing patient safety concepts and teamwork was emphasized, and teaching materials (AHRQ, 2019; National Patient Safety Agency, 2011; The Joint Commission, 2016a, 2016b; WHO, 2009, 2011) included scenarios and examples closely related to daily surgical practice in OR settings. In addition, tools were integrated into the TIP that are part of the OR standard of practice, such as the surgical safety checklist, briefing, and debriefing. Moreover, handoff tools (WHO, 2009, 2011) were added to improve the communication skills of participants in actual situations.
Measures
Kirkpatrick's four levels of training evaluation model (reaction, learning, behavior, and outcomes; Kirkpatrick & Kirkpatrick, 2006) were adopted to evaluate the effectiveness of the program (Figure 1).
Program satisfaction evaluation (reaction evaluation)
Participant's satisfaction with the program was assessed using the program satisfaction questionnaire (N.-J. Lee, 2015). The program satisfaction questionnaire with modifications consisted of eight items scored using a 7-point Likert scale. The Cronbach's alpha value was .92 in this study.
Teamwork competencies (learning and behavior evaluation)
Teamwork competencies comprised teamwork knowledge, teamwork attitudes, communication self-efficacy, and teamwork skills and behavior. In the learning evaluation, teamwork knowledge, teamwork attitudes, and communication self-efficacy were measured. Teamwork skills and behavior were measured at the behavior level.
For teamwork knowledge, the Learning Benchmarks of 23 multiple-choice items was used (1 = correct answer, 0 = wrong answer), with higher total scores associated with better teamwork knowledge.
The Teamwork Attitudes Questionnaire (TAQ) was used to assess teamwork attitudes. The TAQ consists of 30 items in five subscales (team structure, leadership, situation monitoring, mutual support, and communication) scored using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Higher scores are associated with positive teamwork attitudes. The Cronbach's alpha values of the five subscales reported in previous research were .70, .81, .83, .70, and .74, respectively (AHRQ, 2017). The Cronbach's alpha values of the five subscales were .81, .82, .90, .60, and .67, respectively, in this study.
A 13-item questionnaire was developed in this study to measure communication self-efficacy based on the communication competencies selected in this study. This questionnaire uses a 5-point Likert scale, ranging from 1 = strongly disagree/not at all to 5 = strongly agree/very much, with higher scores associated with higher communication self-efficacy. The Cronbach's alpha value of this questionnaire was .82 in this study.
Teamwork skills and behavior were measured using the Teamwork Perceptions Questionnaire (TPQ). The TPQ consists of 35 items under the same five subscales as the TAQ that are scored using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), with higher scores associated with better teamwork skills and behavior. The TPQ psychometric test has been validated in the hospital setting (Keebler et al., 2014). The Korean language version of the TPQ, translated and revised by Ahn and Lee (2016), was used in this study. The Cronbach's alpha values of the five subscales were .82, .88, .76, .78, and .75, respectively, in this study.
The Learning Benchmarks, TAQ, and TPQ tools were developed by the AHRQ and the U.S. Department of Defense. Permission to use the scales was obtained from the AHRQ, and the authors of this study translated these scales from English to Korean using the committee approach. In the committee approach, all versions of a translation are reviewed by an expert team after initial translation (Tsang et al., 2017). In this study, the tools were initially translated independently by three experts, who then met together to review all of the translated versions in a reconciliation/consensus session to discuss discrepancies and reach an agreement on the translated tools. The clarity and readability of the items were tested by a group of nurses and doctoral students of nursing. After conducting a content validity test, the final questionnaire was completed for the Learning Benchmarks and TAQ.
Experience of participation in the teamwork improvement program and experience of surgical nursing errors (outcomes evaluation)
To assess the participants' experience of change after participating in the TIP, qualitative data were collected using focus group interviews (FGIs) and the program evaluation survey (PES). In addition, their experience of surgical nursing errors was investigated using pre- and postsurveys. A "surgical nursing error" refers to a nursing mistake experienced or perceived by the perioperative nursing team, which may result in unanticipated harm to a patient during an operation. In the survey, participants answered "yes" or "no" to having experienced these errors and indicated the number of error experiences encountered during the previous 4-week period.
Intervention
The program consisted of four 60-min sessions conducted twice per week over a 2-week period and participation in web-based learning. The TIP utilized a variety of educational methods, including lectures, presentations, feedback, watching videos, discussion, scenario-based discussion, and simulation. The educational materials were posted to a website so that participants could learn in advance. A research team member provided the TIP to the experimental group at a seminar room in the operating center. Based on the definition of a team (AHRQ, 2019), four or five nurses who worked together to perform the same operations with the aim of safe surgery were assigned to one team. To enhance team performance, team members participated together in team activities (e.g., teamwork games, scenario-based discussions, and a simulation) during the TIP.
Data Collection
Data were obtained between December 2016 and March 2017. After obtaining permission to collect data from a tertiary hospital, the researcher recruited nurses interested in participating by posting the recruitment poster in operating centers. This study was approved by the institutional review board at the Seoul National University (IRB No. 1608/003-010). All of the study participants read and signed the informed consent form.
The pre- and postsurveys were conducted at a 4-week interval with both control and experimental groups. In the pre-and postsurveys, we measured teamwork competencies and surgical nursing error experiences using a self-report questionnaire. After the presurvey, the experimental group underwent the TIP for 2 weeks and completed a postsurvey, including the program satisfaction questionnaire, after the 2-week intervention. In addition, the experimental group underwent a PES and FGIs.
The PES was conducted in the fourth session of the program to allow all of the participants to freely write their thoughts and feelings about the program participation experience, and we utilized the data as a basis for team discussion. We conducted two FGIs with eight nurses from the experimental group who agreed to participate in interviews 2 weeks after the intervention. The participants were divided into two groups, taking into account their duty schedule and duration of clinical career. The FGIs lasted 50-60 minutes for each group and were recorded after obtaining the consent of the participants. The key questions on the PES and FGIs were as follows: "Are there any changes in your overall thoughts about teamwork after participating in the program?" "Have you made any changes in clinical practice after participating in the program?" "Which tools or strategies that you have learned in the program would you like to try first in the OR?"
Data Analysis
SPSS 24.0 (IBM Inc., Armonk, NY, USA) was used to analyze the quantitative data in this study. The general characteristics of the experimental and control group participants were analyzed using descriptive statistics. Homogeneity tests for general and study variables were analyzed using an independent t test, [chi]2 test, and Fisher's exact test. The analyses of pretest and posttest differences between the experimental and control groups were performed using a paired t test. Differences in nursing error experiences between the two groups were analyzed using a chi-square test.
The qualitative data from the PES and FGIs were analyzed using a conventional content analysis based on Hsieh and Shannon (2005). The recorded data from the interview were transcribed as text. First, the overall meaning of the text was extrapolated by repeatedly reading and rereading the data. Next, meaningful sentences and words that contained key ideas were highlighted to identify associated codes, and similar codes were sorted into subcategories. At the end of the process, the subcategories were derived into categories. To enhance rigor, an analytical discussion between two researchers was undertaken until consensus was reached to determine whether the results of the analysis reflected the participants' experiences accurately.
Results
Data on participants' recruitment and retention are summarized in Figure 2. The baseline characteristics and premeasurement scores for the intervention and control groups are shown in Table 2. No statistically significant difference in the premeasurement scores of outcome variables was identified between the two groups with regard to teamwork knowledge (t = -1.21, p = .230), teamwork attitudes (t = -0.10, p = .920), communication self-efficacy (t = -1.00, p = .321), teamwork skills and behavior (t = -0.24, p = .808), and experience of surgical nursing errors ([chi]2 = 1.08, p = .406).
Program Satisfaction
Nearly all (96.4%) of the participants were satisfied with the overall content of the TIP, and the information provided in the program was identified as helpful to their clinical practice. The participants scored each of the eight items an average of >= 6 points (on a 7-point scale).
Teamwork Competencies
The pretest-posttest differences for the experimental and control groups were analyzed. The pretest-posttest differences in the experimental group were significantly higher than in the control group for teamwork knowledge (mean = 0.75 +/- 1.38 vs. -0.68 +/- 1.35, t = 4.07, p < .001), teamwork attitudes (mean = 0.51 +/- 0.31 vs. -0.00 +/- 0.33, t = 6.10, p < .001), communication self-efficacy (mean = 1.12 +/- 0.32 vs. 0.23 +/- 0.37, t = 9.90, p < .001), and teamwork skills and behavior (mean = 0.54 +/- 0.41 vs. -0.08 +/- 0.39, t = 6.04, p < .001).
Experience of Participation in the Teamwork Improvement Program
Based on the results of the conventional content analysis, seven subcategories under three categories were extracted (Table 3).
Recognizing the importance and content of teamwork
Participants experienced a turning point in rethinking teamwork in their workplace after training. They realized teamwork as crucial for improving patient safety in the OR and could demonstrate teamwork through participating in team activities. Involving patients and their caregivers as team members was a new concept for participants, and they felt proud to apply it in their work. In addition, the participants realized that, to achieve a safe operation, the team should have a common goal that encompasses all members of the team, including patients and caregivers. Working in the OR, they had previously perceived that they worked alone but changed their mind after the intervention to perceive their work in the context of their team.
Improving teamwork competencies
Participants realized that they already had knowledge of teamwork but did not know how to apply it in their workplace. They also had a positive experience of the education, in that they were glad to learn the strategies for applying their knowledge to practice. After the training, the participants employed tools and coping strategies when patient safety was threatened, and they had a positive experience of practicing the strategies they had learned in the training program while working in OR settings.
Contributing to safe surgery
With regard to safe surgery, leading a team effectively is important, but participants were not previously aware that they could play the role of leader. They learned that there were various types of team leaders, and they became aware of the leader's role and responsibility to prevent errors using standard OR practices, such as briefing, debriefing, and implementing the surgical safety checklist. The participants recognized that ineffective communication could impact patient safety and endeavored to use assertive strategies to ensure clear communication among team members.
Experience of Surgical Nursing Errors
In the postsurvey, 10 participants (35.7%) in the experimental group and 11 participants (34.4%) in the control group responded that they had experienced surgical nursing errors. There was not a significant difference between the two groups.
Discussion
Nurses' teamwork is an important factor in ensuring the quality of care and patient safety. To improve nursing teamwork, a competency-based education program is important to guide teaching and learning. The Quality and Safety Education for Nurses emphasizes the teamwork and collaboration competency as a core requirement of nursing education (Cronenwett et al., 2007). However, there is a lack of guidance in terms of how to teach nurses this competency. In this study, a TIP for perioperative patient safety was developed based on the teamwork competencies required for nurses, and the effectiveness of the program was assessed using Kirkpatrick's four-level evaluation model. The TIP for perioperative patient safety is the first nursing teamwork training program to be assessed as suitable for OR settings in South Korea.
The findings of this study provide evidence that teamwork training increases nurses' teamwork competencies in terms of teamwork knowledge, attitudes, skills and behavior, and communication self-efficacy, which is consistent with previous findings (Cooke, 2016; Gaston et al., 2016; Parker et al., 2019; Thomas & Galla, 2013). After participating in a teamwork program, the improvements in teamwork competency were found to affect various aspects of patient safety, including patient safety culture (Gaston et al., 2016; Staines et al., 2019; Thomas & Galla, 2013) and patient outcomes (Kalisch et al., 2007). In addition, increased teamwork competencies may impact nurses' job satisfaction and retention, which in turn may positively impact the healthcare work environment for nurses. Kalisch et al. (2010) found that nurses who scored higher on teamwork were more likely to be satisfied with their occupation. Moreover, teamwork interventions that include a 4-hour TeamSTEPPS training course and a simulation session were shown to increase the job satisfaction and slightly decrease the turnover rate among nurses (Baik & Zierler, 2019). Therefore, ongoing teamwork training is needed to improve patient safety, provide high-quality patient care, and ensure adequate nursing staffing.
Compared with previous studies that have applied the TeamSTEPPS program in OR settings (Dahl et al., 2017; S.-H. Lee et al., 2021), the TIP used in this study focused on knowledge of nursing teamwork in the perioperative setting, patient safety concepts, and the relationship between teamwork and patient safety in the healthcare system. Scenarios and examples were added in the teaching materials to supplement the concept-oriented materials of TeamSTEPPS and to help participants better understand the content. The qualitative data in this study indicate that participants showed improvement in recognizing the importance and content of teamwork. It is important that participants' attitudes and perceptions of teamwork improved. Teamwork depends on team members' willingness to cooperate and communicate together with the shared goal of achieving optimal outcomes for patients (King et al., 2008).
To develop teamwork competencies, nurses should not only be equipped with relevant knowledge, attitudes, and skills but also be supported to use the tools they have learned in clinical practice (Barton et al., 2018). The TIP developed in this study includes various tools that nurses may apply in actual work situations. It is particularly meaningful that participants perceived that their coping skills improved and that they applied communication tools based on teamwork knowledge, demonstrating positive changes in perioperative nurses' teamwork skills and behavior. This is consistent with previous findings that 89% of healthcare professionals used a tool in clinical practice after team training (Gaston et al., 2016). In terms of patient safety competencies, teamwork competencies have a critical impact on the safety climate (Hwang, 2015). Therefore, these outcomes may contribute to a positive safety climate and culture.
Showing the Speak-up video during the intervention and having the participants watch it repeatedly on the website/mobile applications is thought to be effective in improving communication self-efficacy and leadership. The qualitative data analysis in this study showed that the participants were willing to use assertiveness strategies and team-guided strategies such as the two-challenge rule, call-out, CUS (concern, uncomfortable, safety), briefing, and debriefing, all of which were emphasized in teamwork training. Effective communication and leadership skills are required to improve patient safety and teamwork in healthcare. Thus, teaching health professionals how to speak up and express themselves when they have safety concerns is a key factor in achieving safe patient care (WHO, 2011). In addition, assertive communication education is needed on an ongoing basis to prevent potential errors in the OR. Therefore, it is necessary to create an environment in which team members feel safe to encourage them to communicate effectively and speak up with each other.
To improve quality and safety competencies, it is necessary to use various teaching strategies that include not only didactic or web-based modules but also case studies and simulations (Cronenwett et al., 2007). This study incorporated various teaching methods such as teamwork games, videos, scenario-based small group discussions, and lectures to engage participants. Simulation using the TeamSTEPPS may be an effective way to improve the teamwork and collaboration competency proposed by Quality and Safety Education for Nurses (Sherwood & Barnsteiner, 2017). In this study, simulation training was performed using the OR scenarios in which participants could apply all of the teamwork competencies learned in the last lesson of the developed program. In the simulation, nurses not only integrated teamwork knowledge into practice but also took into account the attributes and performance of other team members participating in the scenario and made situational judgments (Barton et al., 2018). Therefore, using a scenario that reflects the clinical situation in teamwork training strengthens the learning effect and is effective in linking learned teamwork knowledge to teamwork skills and behavior.
This study has several limitations. First, this research was conducted at a tertiary hospital in a metropolitan city. Thus, the results may not be generalizable to other nurses. In future research, the sample size may be increased, and perioperative nurses working at different organizational levels and in different cultures may be recruited. Second, this research measured short-term outcomes using a self-reported questionnaire. Thus, the insignificant pretest-posttest difference in surgical nursing error experience may be due to the short time between intervention and postmeasurement or reflect a subjective measurement bias. Therefore, a long-term outcome measure using objective data will be necessary to examine the association between teamwork competencies and clinical errors.
Conclusions
Effective teamwork in nursing teams is an essential factor in the OR that may be learned using a systematic competency-based teamwork program. The TIP developed in this study was effective in improving the teamwork competencies of the perioperative nurses. The clinical application of teamwork strategies may be expected to contribute to patient safety by promoting effective communication, leadership, situation monitoring, and mutual support with other health professionals based on teamwork knowledge. When providing teamwork training, educational materials that reflect healthcare professionals' clinical settings should be used to strengthen the connection between patient safety concepts and teamwork. To promote a safe nursing practice, hospital executives and nurse managers should create an environment that supports the implementation of learned teamwork strategies. Finally, in the future, applying and evaluating the effectiveness of the TIP with not only nursing staff but also other healthcare professionals who work together in the OR will be necessary.
Acknowledgment
This research was supported by Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Education (No. 2014R1A1A2055166).
Author Contributions
Study conception and design: SA, NJL
Data collection: SA
Data analysis and interpretation: SA, NJL
Drafting of the article: SA, NJL
Critical revision of the article: SA, NJL
References