Posted: September 20th, 2022


Due 6pm Chicago time 

Pls follow the prompt 

 Topic: Enhancing Teamwork across care provider levels. The manager of a medical surgical unit has observed and had complaints about, lack of teamwork between the RN’s and the patient care techs  (PCT’s). Your task is to propose a plan to enhance teamwork on the unit. 

Pls use the article provided for this assignment 

Student Name:

EBP Journal Article in APA format:

.2 points

.4 points

.4 points

Is this an Evidence Based Article?

Name of Journal

and Year article was written?


Name of Journal


.2 points

State the problem

What was the goal of the project in the article?

Does this project correlate with your problem? State how?

What are you trying to achieve? Does this article support this goal?



State how this article correlates with your group problem and goal.

Strengths (Internal)

What’s was good about your article?

Why was this project successful?

List attributes of the article, i.e. support from administration, councils, colleagues, institutions. 

Did this implementation take place on a unit or area like yours?

.4 points

Weakness (Internal)- issues

Example: lack of education, lack of staffing, staff readiness, lack of support; size, managerial style.

.4 points

Opportunities (External)

Example: Lack of supplies, educational needs, stakeholders, baseline (your baseline data), what needs to be improved?

Threats – (External)

Staff buy in, support, limitations and barriers, supply cost, cost of implementation, time, money, realistic?

Total Points = 2 points

Student Name: XXXXXXXX

EPB Journal Article in APA format:

Sánchez, M., Suárez, M., Asenjo, M., & Bragulat, E. (2018). Improvement of emergency department patient flow using lean thinking. 
International Journal For Quality In Health Care: Journal Of The International Society For Quality In Health Care, 
30(4), 250–256.

.2 points

.4 points

.4 points

Is this an Evidence Based Article? Name of Journal and Year article was written?


Name of Journal: International Journal for Quality in Health Care

Year: 2018

.2 points

State the problem

What was the goal of the project?

Does this project correlate with your problem? State how?

What are you trying to achieve? Does this article support this goal?

Problem: Delays in the ED compromise quality of care and patient safety while simultaneously increasing mortality and healthcare costs. Internal inefficiencies and poor resource utilization may contribute to delays in care and overcrowding.

Goal: The goal of this project was to achieve a target time of 160 minutes (total), per patient in the ED.

· 80 minutes of “added value” (i.e. specific amount of time with a nurse and doctor for assessment, treatment, and education)

· 60 minutes for lab results

· 20 minutes for treatment steps that could not be eliminated using the Lean process

The goal of our group project is to propose a plan to decrease wait times and improve flow to care areas. The study outlined in this article directly correlates with our group project in that its aim was to tackle the issue of increased wait times leading to delay of care and negative outcomes, including decreased patient satisfaction and the increased risk for mortality. The goal of our group project is to propose a plan to reduce wait times in order to improve patient outcomes, which is exactly what the article’s researchers set out to do by proposing the use of lean principles to eliminate the unnecessary steps/processes that add to wait times.

Strengths (Internal)

What’s was good about your article?

Staff Input: This project was heavily supported by the ED staff and administration. In fact, the ED staff were empowered to make the necessary changes by identifying steps (waste) that slowed flow and hindered the care process. They were also tasked with recognizing processes that could be standardized to improve efficiency in care.

Leadership Style: Furthermore, the researchers encouraged a “bottom-up” approach (democratic leadership) to achieve a more enthusiastic acceptance and implementation of the plan. The ED executive team acted as consultants to help support and foster the new process to reduce internal resistance.

Cost: The implementation of the entire project was inexpensive because it did not require third party support or additional supplies.

Did this implementation take place on a unit or area like yours: Yes, this project was implemented in an ED unit.

.4 points

Weakness (Internal)

Staff Support: According to the researchers, the most difficult problem they faced was staff reluctance to abandon their old practices and proceed with implementing the new process of standardization (which required 3 weeks of constant surveillance).

Size: This study was performed in a single ED unit that did not provide services to pediatric or obstetric patients, so it is unknown how well these results might carry over to other specialized ED units. Furthermore, to ensure proper control, the study was limited to a specific unit in the ED, MAT-3, which was the busiest unit in the ED and designated solely for urgent cases.

.4 points

Opportunities (External)

Patient Satisfaction: The results of this study showed that the ED staff was able to reduce wait times, overall care times, and improve patient flow using the lean process to eliminate wasteful steps. However, the researchers could have also measured patient satisfaction to determine if the lean process also improved the correlation between wait times and patient satisfaction.

Staff Satisfaction: The authors recognized that additional research should be completed to analyze how the lean process affects staff members in terms of work satisfaction, turnover, and improved use of skills.

Baseline Data: The researchers found no significant differences in the revisit rate, mortality rate, or leave without being seen rate (LWBS) after implementing the lean process. Suggestions for additional research meant to address these variables were not provided but should be explored, especially due to their relationship with patient safety.

Threats – (External)

Validity: The researchers acknowledged that one of the greatest limitations of their study was its external validity since the study was performed in only one ED unit. Their methodology might not produce the same results in a more efficiently run ED unit.

Time: The researchers also agreed that the cultural change needed to fully adapt to this new standardized process would be an ongoing endeavor that would require additional time after the conclusion of the study. The researchers discounted the first 6 months of data because they anticipated that the staff would be more willing to embrace the new process, resulting in a false-positive outcome. Their aim was to observe how time also impacted the lean process in the ED unit in the following months.

Staff Buy In: Finally, the researchers also felt that the cultural/local interpretation of lean principles might differ depending upon location and/or unit. Previous studies concluded that the lean process did not provide clinically relevant results in ED units due to lack of staff buy in resulting from misinterpretation of lean principles. In other words, the staff must understand that the lean process is not a solution but a methodology.

Total Points = 2 points

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

Open access

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

Randi Ballangrud ,1 Karina Aase ,2 Anne Vifladt 1

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

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

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

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

Correspondence to
Dr Randi Ballangrud;
randi. ballangrud@ ntnu. no

Original research

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

Strengths and limitations of this study

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

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

► A longitudinal design enables data collection on
three occasions.

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

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

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

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

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


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

Open access

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

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

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

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

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

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

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

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

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

3Ballangrud R, et al. BMJ Open 2020;10:e035432. doi:10.1136/bmjopen-2019-035432

Open access

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

Phase 2 Phase 3

2016 Tools Implementation arena 2017 Tools Implementation arena


Closed- loop

Exchange of critical



Once a week—
manager with nursing

Task Assistance
Mutual support

Distribution of workload


Communicating critical

February STEP
Situation monitoring

Updated in electronic
care plan

August Briefs

Start of every shift March Two- Challenge Rule
Mutual support

When an initial
assertive statement is

September Huddles

At patient safety
whiteboard meetings


Handoffs with focus on
patient safety risks

October Cross- monitoring
Situation monitoring

Double control by
intravenous medication

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

box 1 team training programme based on teamStePPS

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

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

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

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

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

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

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

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

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

TeamSTEPPS, Team Strategies and Tools to Enhance Performance and Patient

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

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

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

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

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

Open access

Interview, April 2016

Profession (focus groups 1–3)

Interview follow up after
six months, November 2016

Profession (focus groups 4–7)

Interview follow up after
12 months, June 2017

Profession (focus groups 8–10)

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

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

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

Start of team training programme, May 2016

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

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

Table 2 Description of the four TeamSTEPPS teamwork skills

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

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

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

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

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

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

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

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

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

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

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

5Ballangrud R, et al. BMJ Open 2020;10:e035432. doi:10.1136/bmjopen-2019-035432

Open access

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

Communication Leadership Situation monitoring Mutual support

T1:RN,24. Everyone
participates using a closed

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Table 4 Teamwork skills at T0

Teamwork skills

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

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


The physicians became familiar with the patients during rounds and through the patient’s medical record,
mostly discussing patient- related issues in physicians’ meetings. Similarly, the RNs discussed issues related
to patients’ care in nurse meetings, although this may also have resulted in contact with the physicians.
Both RNs and CNAs had an active role in the observation of the patients and updating each patient’s
care plan, and they were encouraged to stay bedside during the rounds. The Modified Early Warning
Score (MEWS)* was recently applied, and the physicians were pleased with the new routines, which was
highlighted as an excellent tool to quickly determine the degree of illness of a patient. Moreover, the ward
was in the initial phase of using a patient safety whiteboard; thus, these meetings did not work optimally
with a frequent absence of physicians.

Mutual support The RNs and CNAs stated that they were flexible in helping each other in the event of an uneven distribution
of work, both within the team and between the teams. However, the teamwork was dependent on
openness and that team members spoke out when they needed help. They felt listened to and respected
by the physicians. All three healthcare professionals groups stated that knowing each other and having
fun together strengthened a good working environment and good teamwork. The physicians highlighted
that, for the best interest of the patient, good teamwork requires nurses with medical knowledge, clinical
experience and continuity with the patient. Nonetheless, the RNs experienced that they did not always have
the expected response from the physicians, and the physicians stressed that a large workload requires
prioritisation of multiple issues at one time, which may affect the teamwork. According to the RNs, this
rarely causes conflicts among healthcare professionals in the ward. Nevertheless, there have been real
conflicts, and some have been perceived as a personal attack.

*MEWS is a tool for bedside evaluation of the systolic blood pressure, pulse rate, respiratory rate, temperature and Alert, Reacting to Voice,
Reacting to Pain, Unresponsive score.57

CNA, certified nursing assistant; RN, registered nurse.

anyone feels they have too much work, while others
have available capacity. (T2:RN,58)

The redistribution of work tasks resulted in a more
even workload between the two core teams at the ward.

At T1, the mid- day nurse meeting was led by the RN
team leaders, whereas the physicians initially led the
interprofessional patient safety whiteboard meetings.
The RNs experienced it as natural that the physicians
led the meetings whenever they were present. However,
at T2, the mid- day nurse meeting was replaced with the
interprofessional patient safety whiteboard meeting, led
by the RN team leader. The physicians could not always
attend the patient safety whiteboard meeting due to activ-
ities in the operating theatre, being called for and so on.
While whiteboard meetings occurred daily, the weekly
‘debriefing’ occurred on Fridays. The ward head nurse
usually led the ‘debriefing’, which was experienced as
useful, as exemplified by a CNA:

It is good to talk things through, expressing issues
that are on your mind when it has been a busy week
… also experiencing that debriefing can be funda-
mental for change. (T3:CNA,30)

The physicians were more uncertain whether the team
training programme had led to an increased awareness of
team leadership.

Situation monitoring, t1–t2
The use of the term ‘situation monitoring’ was new for
healthcare professionals. The RNs realised that they had
always monitored the work system without being aware
of the term. By using the tools, they detected patient
safety incidents that could have resulted in unnecessary
harm to the patients. Cross- monitoring of the intravenous
medication administration had been implemented. The
RNs experienced the use of situation monitoring skills
depended on their role in the team. As team leaders, they

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Table 5 Experiences with teamwork skills at T1 and T2 of the team training programme

Categories T1 (6 months) T2 (12 months)

Communication Increased awareness in using the closed loop
and ISBAR tools.


Challenges with using ISBAR when
communicating critical information (RNs).

RNs are more confident in information exchange using
ISBAR. ISBAR forms a basis for a more active role for
RNs in decision- making.

Challenges still exist when using ISBAR during busy

The included tools are seen as a common
initiative to promote patient safety.


Misunderstandings in work practice are discovered
when using the tools.

The tools provide information in a more systematic

Handoff not properly incorporated.

Leadership Distribution of work tasks using huddling. ———————————————————→
RN team leader runs the mid- day nurse

Mid- day nurse meeting replaced with patient safety
whiteboard meeting.

Physician runs the interprofessional patient
safety whiteboard meeting when present,
otherwise an RN.

RN runs the interprofessional patient safety whiteboard

Head nurse runs the Friday debriefing, evaluating the
weekly activities.

Situation monitoring Double control in intravenous medication
administration using cross- monitoring.


Risk assessment at whiteboard meetings
provides awareness of new and/or important
patient issues.

Risk assessment at interprofessional patient safety
whiteboard meetings established on weekdays,
challenges on weekends.

Nursing plans less prioritised due to patient
safety whiteboard meetings.


MEWS prioritised. MEWS a well- established routine.

Mutual support Transparency and openness across the
healthcare team.


Legitimate to express safety concerns. ———————————————————→
Use of the Two- Challenge Rule to resolve


Increased awareness of speaking up for the patients.

Increased awareness of giving and receiving feedback.

*The arrow expresses continuity in healthcare professionals’ experiences throughout T1 and T2.
CNA, certified nursing assistant; ISBAR, introduction, situation, background, assessment, recommendation; MEWS, Modified Early Warning
Score; RN, registered nurse.

had to scan what was going on at the ward; however, if
they were situated inside the patient room, they lost sight
of other ongoing issues.

Six months into the team training programme, health-
care professionals experienced a better functioning of
the patient safety whiteboard meetings, though still not
optimal because physicians did not always attend. After
12 months, everyone experienced the meeting as a useful
and well- established arena to monitor patient risks. They

also experienced that the meeting created an awareness
of tasks that needed attention, as described by a physician:

Yes, fall prevention, nutrition, medication reconcili-
ation. Well, that’s the type of issue that … it’s con-
venient to check, reminding us of issues that need
attention. (T1:Ph,69)

Despite the benefit of the whiteboard meetings, they
were not prioritised on busy shifts during the weekends.

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

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Both the RNs and CNAs were responsible for updating
the patient safety whiteboard according to their patients’
needs and realised that the increased whiteboard focus
negatively affected the updating of the nursing plans.

During the team training programme, the ‘Modified
Early Warning Score (MEWS)’ became a well- established
and systematic routine appreciated by all healthcare
professionals. Nevertheless, the physicians experienced
that some nurses did not relate the ‘MEWS’ measure-
ments to the patient’s condition, only using ‘MEWS’ as
a recipe. Some experienced that the RNs called them
without getting into the patient’s anamnesis from the
medical record seen as their common information
exchange system. It was expected that both RNs and
CNAs scored their patients with ‘MEWS’ and exchanged
the results with the team leader. They now measured
the patient’s pulse and blood pressure more frequently,
although it was described that the parameters might be
overlooked, as pointed out by one CNA:

Well, it is worth mentioning regarding MEWS that
people tend to forget to measure the pulse them-
selves. They see the number and then refer to this
… without acknowledging that the pulse can be as
irregular and deviating as ever. (T2:CNA,47)

Mutual support, t1–t2
The RNs perceived mutual support to the teamwork skill
creating the most influential changes at the ward, also
considered the most effective to implement. At T1, RNs
experienced increased transparency and openness across
the healthcare team. Colleagues raised problems more
directly. It became more legitimate to express concerns
and speak up because the contents could be addressed
in relation to the tools and strategies of the training
programme. With a common understanding in place,
it was easier to use a tool such as the ‘Two- Challenge
Rule’. A physician referred to an episode, where the RN
disagreed with him and used the tool:

There was a patient with … urine retention with
300 mL of residual urine and you are not supposed
to send them home without a catheter … but on that
occasion I meant that we could do so. And she [RN]
was absolutely right in her judgment … there are
routines for not having that much [residual urine],
and since I thought it was right I tried to explain it.


It was, of course, ok, she did what she was supposed to
do and it is commendable that they raise it, that they
are not afraid of voicing it. (T1:Ph,62)

The physicians emphasised that it became easier to
collaborate on patient treatment with mutual and open
communication, and they felt that the team programme
had impacted this. At T2, the ‘Two- Challenge Rule’ was

used frequently, a strategy they probably used prior to the
programme, but as an RN expressed it:

Yes we did it [open communication, Two- Challenge
Rule] … it was just that we did not have a notion for
it. (T2:RN,40)

Hence, increased awareness of using different mutual
support tools had been created:

You don’t accept the response you are given; you
rather rephrase the question once or twice if neces-
sary. (T2:RN,102)

Both the RNs and CNAs had become more aware of
the importance of feedback. They evaluated the tools as
useful when adverse events occurred and, in that context,
experienced a high degree of support across the inter-
professional team. They experienced colleagues being
less concerned with raising issues through feedback,
and, according to RNs, the ‘go to the leader’ mentality
when dissatisfied was less prominent. The RNs had also
seen inexperienced RNs who now dared to speak up
for the patient. However, they still felt that healthcare
professionals held back on different occasions, implying
a continued room for improvement within giving and
receiving feedback.

We aimed to describe healthcare professionals’ experi-
ences with teamwork in a surgical ward before and during
the implementation of a longitudinal interprofessional
team training programme. The results described that RNs,
CNAs and physicians were highly satisfied with the team-
work at the ward before the team training programme.
Nevertheless, they experienced that the implementation
of the programme, where they were trained together, led
to greater awareness and knowledge of their common
teamwork skills. Changes were described related to more
systematic information exchange, increased conscious-
ness of team leadership balancing activities and resources,
increased use of situation monitoring tools and a common
understanding of accountability and transparency.

Communication: towards a systematic information exchange
When RNs used the communication tool ‘ISBAR’, the
physicians experienced a more systematic exchange
of patient information, which was highly appreciated.
The RNs experiencing challenges using the tool in the
first phase and eventually became more confident.
This finding is in accordance with results from a study
in surgical wards, where both nurses and physicians
perceived ‘ISBAR’ as effective in obtaining a structure of
the contents of patient reports.45 Nurses and physicians
traditionally communicate using different styles appro-
priate to the needs and processes of their respective
professions.46 47 This gap may be bridged using ‘ISBAR’,
establishing a common communication style. Hierar-
chical culture has been experienced by nurses as having

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a negative effect on interactions with some physicians.31
According to De Meester et al,48 the use of ‘ISBAR’ may
flatten the hierarchical structure by nurses experiencing
being empowered, thereby resulting in more effective
communication channels. The RNs in our study referred
to a positive change with expectations towards more active
participation in patient decision- making. Open commu-
nication with a common language of how to present key
patient information can prevent misunderstandings and
communication failures.49 Interprofessional teamwork
is generally found to motivate and empower staff when
team members feel their roles are acknowledged.50

leadership: balancing activities and resources
Leadership was seen as an essential teamwork skill to
increase the continuity of patient care, with an even distri-
bution of work tasks and debriefing as essential activities.
According to Salas et al,14 team leadership coordinates
and organises team members’ activities. Considering that
the team leader possesses knowledge of team resources,51
they have the opportunity to ‘balance the workload within
the team’.16 In this study, the redistribution of work tasks
was completed at the daily patient safety whiteboard
meeting led by the RN team leader. At these meetings, the
use of the tool ‘huddling’ was implemented and found
useful when balancing work tasks within and between
the two ward teams—the intention using huddles.16 The
leader’s overview of team activities is essential, with the
weekly debriefing meeting described as ‘fundamental for
change’ due to the opportunity for healthcare profes-
sionals to share their experiences related to patient care as
a basis for improvement in procedures or work routines.

Situation monitoring: towards a conscious use of tools and
interprofessional meetings
Our study confirmed that using the term ‘situation moni-
toring’ was new for healthcare professionals at the surgical
ward, although they realised they had previously used the
skill unconsciously. According to Benner,52 knowledge
development in healthcare consists of spreading practical
knowledge and the mapping of existing practical knowl-
edge developed through clinical experience, to which the
team training programme may have contributed. RNs,
CNAs and physicians all experienced increased attention
towards situation monitoring skills throughout the use
of MEWS, as well as at the daily interprofessional patient
safety whiteboard meetings established during the team
training programme period. These meetings were expe-
rienced as useful opportunities to monitor patients and
create an awareness of necessary tasks. This finding is in
accordance with Sehgal et al,53 where nurses were seen
as responsible for accurate and updated information
on whiteboards, whereas the goals for the day should
be created jointly by nurses and physicians. The physi-
cians in the current study appreciated that the nursing
staff referred to MEWS when calling them. Early warning
scores are known to have a good prognostic value for
patient deterioration and have been shown to improve

patient outcomes, partly because they facilitate communi-
cation among healthcare professionals.54 Like the physi-
cians, the nurses also saw the importance of gathering the
MEWS but also emphasising the importance of using their
clinical eye and mind. In their integrative review, Massey
et al55 found that assessing and knowing the patient, nurse
education and the use of specialised equipment were all
factors with an impact on ward nurses’ ability to recognise
patient deterioration.

Mutual support: towards accountability and transparency
In our study, mutual support was considered the most
effective teamwork skill to implement and, according to
the RNs, contributed to the most comprehensive positive
change at the ward during the team training programme.
This was despite healthcare professionals referring to a
ward culture with open communication, including before
the training programme. Mayer et al25 found that, by using
pre- implementation and post implementation interviews
of staff in surgical ICUs, the informants described an
overall improved mutual support with a more positive
team morale across physicians and nurses post imple-
mentation. In a qualitative study conducted by Baik and
Zierler,31 the nurses reported improved changes in inter-
professional relationships and being more satisfied with
their work because they felt included as a member of
an interprofessional team training intervention. In our
study, both physicians and nurses experienced that when
having a common understanding, it was easier to use tools
such as the ‘Two- Challenge Rule’. Both RNs and CNAs
described that they had become more aware of giving
each other feedback. When adverse events occurred,
they experienced a high degree of support across the
interprofessional team, a situation that is in accordance
with Weller et al,56 who interviewed a surgical team in
an operating room and described a positive change in
information sharing and improved confidence, as well
as a greater awareness of the other team members and
working environment, after conducting a simulation-
based team training programme.

There are several limitations in our study that need to
be recognised. The results may be influenced by the
relatively limited number of participants in each of the
focus group interviews and a possible bias in the sample
of participants based on possible positive perceptions of
teamwork at the surgical ward. The study is not suitable
for generalisation; however, the results based on our
qualitative design provide a deeper understanding of the
health professionals’ experiences with learned teamwork
skills that may be relevant at other hospital wards. Due to
time pressure and workload in their daily practice at the
surgical ward, the healthcare professionals had to repeat-
edly change their interview times, which may have affected
the results. Two groups of two physicians participated in
the interviews after 6 months, whereas only one physi-
cian had the opportunity to participate after 12 months.

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

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A larger group of physicians might have provided other
experiences with the teamwork skills that may also impact
the results because mostly the nursing staff attended the
refresher courses. The results may also be influenced
by the patient safety initiatives recently initiated at the
ward ahead of the team training programme, such as the
MEWS and patient safety whiteboard meetings.

Our study suggests that, during a team training
programme, healthcare professionals were provided with
a set of tools and terminology that promoted a common
understanding of teamwork, hence affecting behaviour
and communication in their daily clinical practice at
a surgical ward. The findings contribute to the qual-
itative evidence base of the implementation of team
training programmes. More specifically, the study docu-
mented the role of a systematic information exchange,
a consciousness of leadership and situation monitoring
skills and the importance of creating a culture of account-
ability and transparency in a surgical ward. Further
research should study the effect of the implementation
of the TeamSTEPPS programme in hospitals, including
various departments. Moreover, a study on the long- term
sustainability of team training programmes on healthcare
professionals’ behaviour is necessary.

Contributors RB, KA and AV were responsible for the study design. RB and AV
performed the data collection. RB, KA and AV contributed to the analysis of the
data, drafting of the manuscript, critical revision of the manuscript for important
intellectual content and final approval of the version to be published. All the authors
read and approved the final manuscript.

Funding This study was supported by the Norwegian Nurses Organisation
(15/0018), the Norwegian University of Science and Technology in Gjøvik and the
University of Stavanger.

Competing interests None declared.

Patient consent for publication Not required.

ethics approval The study was approved by the Norwegian Center for Research
Data (Ref. 46872) and permission was given by the head administration in the
participating hospitals. The Committee for Medical and Health Research Ethics of
South- East Norway reviewed the study (Ref. 2016/78) and responded that approval
was not necessary according to Norwegian law, since the study did not involve
patients. Information and an invitation to participate in the study were given to
healthcare professionals in written and verbal forms, referring to the principle of
autonomy addressed by confidentiality and voluntariness. Written consent was
obtained from the healthcare professionals who agreed to participate. The study
was conducted in accordance with the principles of the Declaration of Helsinki.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement No data are available. No additional unpublished data
are available from this study.

Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non- commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.

Randi Ballangrud http:// orcid. org/ 0000- 0003- 0403- 0509
Karina Aase http:// orcid. org/ 0000- 0002- 5363- 5152
Anne Vifladt http:// orcid. org/ 0000- 0001- 6594- 9725

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






    Team training programme

    Data collection

    Data analysis

    Patient and public involvement


    Teamwork at T0

    Teamwork during the 12-month (T1–T2) interprofessional team training programme

    Communication, T1–T2

    Leadership, T1–T2

    Situation monitoring, T1–T2

    Mutual support, T1–T2


    Communication: towards a systematic information exchange

    Leadership: balancing activities and resources

    Situation monitoring: towards a conscious use of tools and interprofessional meetings

    Mutual support: towards accountability and transparency




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