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 Table of Contents  
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 145-153

Parallel-group randomized study on the impact of a modified TeamSTEPPS training on resident and nurse attitudes toward teamwork and their adherence to patient safety protocols

1 Office of Medical Education, St. Luke's University Health Network, Bethlehem, PA 18015; Graduate School of Education, University of Pennsylvania, Philadelphia, PA, USA
2 Office of Academic Affairs, Einstein Healthcare Network, Philadelphia, PA 19141, USA
3 Center for Research in Education and Social Policy, Newark, DE; School of Education, University of Delaware, 201A Willard Hall, Newark, DE 19716, USA

Date of Submission26-Mar-2016
Date of Acceptance11-Jul-2016
Date of Web Publication28-Dec-2016

Correspondence Address:
James P Orlando
5653 Covenant Court, Allentown, PA 18106
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2455-5568.196870

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Introduction: Gaps remain in what constitutes optimal healthcare team training in terms of design and impact. This study utilizes a parallel group randomized design to study the impact of a modified TeamSTEPPS training on resident and nurse attitudes toward teamwork and their adherence to patient safety (PS) protocols.
Methods: The intervention randomized 76 participants (38 nurses and 38 1st year residents) equally into one of four parallel training groups to receive central venous catheter (CVC) lines simulation training with and without a modified 1-h TeamSTEPPS training. Both groups participated in video-based CVC instruction and a simulation CVC case scenario using high-fidelity mannequins. Participants were randomized twice: Initially into TeamSTEPPS and non-TeamSTEPPS training groups using a computer-generated randomization list, and then into resident-nurse pairs prior to the simulation CVC case scenario by selecting room assignments out of a hat. At the conclusion of a training session, participants completed the TeamSTEPPS questionnaire to measure perceptions for teamwork. Resident/nurse pairs' adherence to PS protocols during the simulation CVC case were recorded by the laboratory's audio/video system to measure team performance. Three trained and blinded postdoctoral research associates scored all recordings independently. Residents were eligible for the study if they were a 1st year postgraduate trainees with no prior TeamSTEPPS training. Nurses were eligible if they had <5 years of Intensive Care Unit experience and no prior TeamSTEPPS training. The principal investigator recruited volunteers through the hospital's E-mail system. Consent was obtained prior to training via E-mail and again at the start of each session. The setting was an independent teaching hospital in an urban setting that trains approximately 400 house staff.
Results: Repeated-measures analyses of variance showed significant differences in attitudes of teamwork between groups. However, there was no significant difference in adherence to safety markers between groups. There was high, >70% exact agreement among the three raters. Exploratory analyses revealed that team behaviors predicted adherence to PS protocols. No adverse events or side effects were observed or reported.
Conclusions: This study found that a modified TeamSTEPPS training improved resident and nurse attitudes of teamwork. However, this improvement did not translate into differences between groups with and without the TeamSTEPPS training in their adherence to PS protocols. Additional research is needed to determine the optimal team-training designs that improve PS. This research was funded by a research grant from the Albert Einstein Society, Philadelphia, PA, and was approved for exemption by Einstein Medical Center Philadelphia campus's Institutional Review Board. The authors report no declarations of interest.
The following core competencies are addressed in this article: Medical knowledge, interpersonal and communication skills, patient care, practice-based learning and improvement, professionalism, and systems-based practice.

Keywords: Interprofessional, randomized, simulation, team training, TeamSTEPPS

How to cite this article:
Orlando JP, Joshi A, Carter M, May H, Bortle C, White P. Parallel-group randomized study on the impact of a modified TeamSTEPPS training on resident and nurse attitudes toward teamwork and their adherence to patient safety protocols. Int J Acad Med 2016;2:145-53

How to cite this URL:
Orlando JP, Joshi A, Carter M, May H, Bortle C, White P. Parallel-group randomized study on the impact of a modified TeamSTEPPS training on resident and nurse attitudes toward teamwork and their adherence to patient safety protocols. Int J Acad Med [serial online] 2016 [cited 2023 Jan 29];2:145-53. Available from: https://www.ijam-web.org/text.asp?2016/2/2/145/196870

  Introduction Top


The importance of healthcare providers learning how groups work is accepted as an important strategy to improve team performance, patient safety (PS), and clinical outcomes. However, gaps remain in what constitutes optimal team-training design and delivery to produce these outcomes (Salas et al. 2013). [1],[2],[3],[4],[5] The design and delivery of team-training are critical in light of increasing clinical demands and financial pressures placed on healthcare systems. Training programs must make efficient and often creative use of limited resources while still producing measurable results. Previous reviews of the team-training literature report the need for studies to include greater detail regarding depth, breadth, and impact of training programs (Salas et al. 2013;; Harvey, Echols, et al. 2013; Patterson et al. 2013; Latif et al. 2012; Lewis et al. 2012; Rabo et al. 2012; Pernar et al. 2011; Wolf et al. 2010; Rodriguez-Paz et al. 2009). [1],[5],[6],[7],[8] This study was setup to address these current gaps about the relationship between design and impact of team training. Finally, the existing body of research on team training calls for higher quality research designs that include multiple performance measures (Salas et al. 2013). [9],[10],[11] Accordingly, this study utilizes a parallel group randomized design to compare the impact of a team-training intervention using two measures of performance: Teamwork perceptions and team adherence to a PS protocol.


This study utilizes a parallel group randomized design to study the impact of a modified TeamSTEPPS training on resident and nurse attitudes toward teamwork and their adherence to PS protocols. TeamSTEPPS is an evidence-based system, incorporating over 20 years of scientific research, aimed at optimizing performance among members of healthcare teams (Harvey, Wright, et al. 2013, Clancy and Tornberg 2007). [12] The research team hypothesized that 1 st year residents and inexperienced Intensive Care Unit (ICU) nurses, who participated in a modified, 1-h TeamSTEPPS training, as part of a 2-h interprofessional central venous catheter (CVC) insertion simulation course, would have greater adherence to CVC PS protocols because they had better attitudes and behaviors of teamwork, as compared to those who did not receive TeamSTEPPS training.

  Methods Top

Setting, participants, and sample size

This was a single site, randomized, parallel group study conducted at an independent, urban teaching hospital in north Philadelphia, PA, with over 400 house staff, 750-bed tertiary hospital, and level 1 trauma center. Participants sample size was established through a convenience sample from the general surgery, emergency medicine, urology, and internal medicine intern class and the ICU's nurse pool at the study site. Residents were eligible for the study if they were a 1 st year postgraduate trainees with no prior TeamSTEPPS training. Nurses were eligible if they had <5 years of ICU experience and no prior TeamSTEPPS training. The principal investigator recruited 76 volunteers (38 nurses and 38 1 st year residents) through the hospital's E-mail system from April to June 2013. The study protocol did not require follow-up with participants. All participants were asked about these eligible requirements in a recruitment E-mail. Consent was obtained prior to training via E-mail and again at the start of each session via a consent form.

Design and randomization sequence

As illustrated in [Figure 1], four parallel training sessions occurred over the course of a 2-week period in July. Participants flow through the study is illustrated in [Figure 1]. The intervention group shaded GRAY in [Figure 1], participated in a modified TeamSTEPPS training.
Figure 1: Study's parallel group randomized design flow sheet

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Participants were assigned to one of the four training sessions. Each session was carefully scripted to allow for a consistent and controlled delivery of educational material and to reduce variability. Each session included 18-20 participants (residents and nurses split equally so that we could pair them up later). Participants were given a brief lecture on hospital-specific central lines infection data and watched approximately 40 min of three instructional videos on CVC access and PS protocols. [13],[14],[15] At the conclusion of the first module, residents, and nurses were equally split, then randomized by a computer-generated randomization list into one of two groups: An intervention group with TeamSTEPPS training and a control group without TeamSTEPPS training. The control group went on to complete a CVC insertion simulation scenario only. The interventional group went on to complete TeamSTEPPS training and then to complete a CVC insertion simulation scenario.

For the control group, participants were again equally split, then randomized into resident-nurse pairs by having participants' select their simulation room number out of a hat prior to starting their CVC insertion simulation scenario. Each resident/nurse pair was considered a team (or unit) in this study. After receiving instructions about the case, resident/nurse pairings when to a simulation room where they found a high fidelity mannequin and supplies suitable for CVC insertion placement. Right-sided subclavian placement was required to ensure consistency among the CVC case. If a team member had a question or required assistance (aka called for help), she/he was asked to step outside the scenario room where a simulation center staff member was immediately available to provide assistance. If a team member requested a radiograph to confirm proper line placement, they were provided a complication in the form of a chest radiograph showing a pneumothorax. The case was considered complete when the team confirmed proper line placement, cleared the catheter for use, and completed the appropriate documentation. This process for the control group was repeated for the intervention group at the completion of their TeamSTEPPS training. Immediately following the case, each participant completed an online version of the TeamSTEPPS teamwork attitude questionnaire (T-TAQ). [16]


For the intervention group, we modified the TeamSTEPPS essentials curriculum to fit within a 1-h time frame, to try to make the experiment more broadly applicable to resource-limited instructions. A certified TeamSTEPPS trainer delivered the training. Instructional objectives were: (a) To identify key components of TeamSTEPPS framework, (b) to describe communication within the TeamSTEPPS framework, and (c) to describe how specific TeamSTEPPS tools can be integrated into everyday clinical use to ensure PS and improve patient outcomes. The certified trainer customized the TeamSTEPPS Essentials curriculum into relevant CVC team communication tools that included briefing, huddles, debriefing, situation monitoring, concern, uncomfortable, safety issue (CUS), call-outs, and check-backs. The instructor delivered the curriculum with didactic, videos, small group discussions, and role-playing activities. After TeamSTEPPS training, the intervention group participants went to complete their CVC insertion simulation scenario.


This study utilized a parallel group randomized design to study the impact of a modified TeamSTEPPS training on resident and nurse attitudes toward teamwork and their adherence to PS protocols. The T-TAQ was used to measure participants' attitudes on TeamSTEPPS dimensions of teamwork including team structure, leadership, situation monitoring, and mutual support, and communication. Responses were collected via SurveyMonkey, Inc Palo Alto, California, USA, www.surveymonkey.com. A nontechnical (NT) skills for surgeons (NOTSS) behavioral marker scoring sheet was modified to measure resident/nurse pairings' adherence to PS protocols. [17],[18] Observations were collected through the simulation laboratory's EMS' SIMULATIONiQ™ enterprise solution system and rated by three trained and blinded research associates, using a modified version of the NOTSS rating system.

NOTSS is a behavior rating system for surgeons. NOTSS was developed using task analysis with subject matter experts and evaluated using standardized video scenarios. [19],[20] The research team adopted the NOTSS approach for this study and created an NOTSS-based checklist consisting of thirty behavioral markers relevant to central line insertion (15 technical and 15 NT behavioral indices). The research team identified a subset of behaviors for the PS protocol based on the CVC bundle (eight behavioral indices). Like T-TAQ, the NOTSS-based checklist measured dimensions of CVC teamwork such, team structure, leadership, situation monitoring, and mutual support, communication, and adherence to the CVC bundle. The checklist was used to link NT behavioral indices of the central line procedure to those taught during TeamSTEPPS training. For example, we defined the TeamSTEPPS tool of "Briefing" on the observational instrument as "Nurse and resident briefly discuss what they will be doing." We linked and defined other TeamSTEPPS tools such as huddles, debrief, situation monitoring, CUS, call-outs, and check-backs to other NT behavioral markers of central lines insertion. The checklist scoring codes, titled, "CVC Simulation Team-training Rater Scoring Codes" is shown in [Figure 2]. The three raters were trained to score teams using a four-point, performance scale (above expectations = 4, meets expectations = 3, needs improvement = 2, and not observed = 1). Results were tabulated in an ordinal and categorical manner. Each rater independently watched, scored, and tabulated results of all 38 team video recordings (for a total of 114 recordings viewed and scored). Clinical research associates received training on a modified NOTSS-behavioral marker scoring system.
Figure 2: CVC Simulation Team-Training Rater Scoring Code

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Statistical methods

Statistical analyses aligned with the primary research goal were selected. The reliability of the T-TAQ was calculated using Cronbach alpha. Agreement and reliability among raters were also calculated using Cronbach alpha. Agreement shows stability of ratings for a participant from different raters; whereas, reliability shows consistency of ratings across multiple participants from different raters (Liao et al. 2010). [21] Correlation analysis was undertaken to understand the relationship between NT behaviors and adherence to PS protocols, specifically the IHI Central Lines Bundle. Repeated-measures analysis of variance (ANOVA) was used to determine any differences between the control group (TeamSTEPPS-trained) and study group (not TeamSTEPPS-trained). Study participants' perceptions of teamwork and team performance were compared to raters' team scores to evaluate whether any differences between groups exist and the degree to which these differences may be meaningful. Some exploratory analyses were conducted to see what the data could tell the research team beyond formal hypothesis testing.

Of note, the team-level scores were averaged across the three raters and across items. Because of this, each outcome has dozens of unique values. Therefore, the scales are on more of continuous scale and were not analyzed using nonparametric methods for an ordinal Likert scale. Outcome scores were aggregated across respondents and items to produce continuous scales.

  Results Top

TeamSTEPPS teamwork attitude questionnaire

Cronbach alphas on T-TAQ survey subscale reliability were good for four of five domains including leadership (0.77), situational monitoring (0.84), mutual support (0.73), and communication (0.74). Overall survey reliability was 0.90. Subscale reliability for team structure was low (i.e., 0.43) due to ceiling effects on items.

TeamSTEPPS teamwork attitude questionnaire differences between groups

A repeated-measures ANOVA was conducted to compare any differences between the TeamSTEPPS-trained and non-TeamSTEPPS-trained groups. As shown in [Table 1], there was significant differences between TeamSTEPPS-trained and untrained groups on the T-TAQ survey in teamwork-related behaviors (F (5, 38) =8.58, P < 0.001) for team structure (P = 0.01), leadership (P = 0.02), situational monitoring (P = 0.009), and communication (P < 0.001). TeamSTEPPS group had better attitudes and understanding of teamwork than the non-TeamSTEPPS-trained group.
Table 1: One-way analysis of variance of TeamSTEPPS teamwork attitude questionnaire domains by untrained and trained TeamSTEPPS groups

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Reliability and agreement among raters

The majority of rated indicators among the three blinded raters had a high agreement but mixed reliability. Average agreement across all indicators was 77%. Indicators with low agreement tended to be those that were difficult to observe on video (e.g., venous blood obtained during the procedure). Indicators with high agreement sometimes had low reliability due to a lack of variance across teams, meaning that every team demonstrated the task, so the indicator is unable to differentiate team performance. Reliability of rating scores ranged from very low to very high (i.e., 0.89 was the highest for mean ratings).

Team performance differences between groups

Analyses of rated indicators between untrained TeamSTEPPS and trained TeamSTEPPS groups mixed results. As shown in [Table 2], t-tests showed no significant differences between untrained TeamSTEPPS and trained TeamSTEPPS groups in terms NT behavioral markers (e.g., resident and nurse discuss what they will be doing), CVC insertion technical makers (e.g., hand hygiene), application of CVC bundle (e.g., full patient drape), or other PS protocols (e.g., time-out).
Table 2: One-way analysis of variance of central venous catheter simulation case performance domains by untrained TeamSTEPPS and trained TeamSTEPPS groups

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Overall, there was a significant difference in attitudes of teamwork between groups (based on T-TAQ questionnaire), but no significant difference in their adherence to PS CVC bundle markers (based on raters' scores).

Exploratory analyses

Exploratory analysis of each rated indicator suggested significant differences in the ability of the TeamSTEPPS groups to assert their concerns when there were two unsuccessful line attempts more often than the nontrained group (P = 0.0763). This difference may be due to chance given the number of tests run. In addition, as shown in [Table 3], correlation analyses of study domains (i.e., T-TAQ and performance domains) showed that NT team behaviors were strongly positively correlated to adherence to PS CVC bundle protocols, r = 0.52 regardless of a group's participation in TeamSTEPPS training. However, these additional analyses did not show any correlation between perceptions of teamwork and greater adherence to central lines PS protocols.
Table 3: Exploratory correlation analyses of study domains

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  Discussion Top


Results of this study suggest TeamSTEPPS training significantly improves perceptions of teamwork but did not have effective on teamwork behaviors and performance. Those who participated in TeamSTEPPS training reported an improvement of their perceptions of teamwork attitudes as a result of training when compared to the group who did not receive TeamSTEPPS training. This was an expected finding in our study, as numerous other studies reported similar results regardless of the methodological design. However, our study results also suggest TeamSTEPPS training neither lead to improved teamwork behaviors, nor greater adherence to PS protocols when comparing TeamSTEPPS-trained teams and nontrained teams. This was an unexpected finding as the TeamSTEPPS literature suggests a positive relationship between training and clinical performance (Salas et al. 2013).

One explanation is that the design and delivery of our modified TeamSTEPPS training may have been too general and not sufficient in length to replicate results of previous studies. TeamSTEPPS training was delivered in a 1-h, face-to-face format and by design, did not include objectives related to the central lines procedure. The research team wanted to see if a generic adaption of TeamSTEPPS would suffice because it was unclear from our literature review how tailored TeamSTEPPS training was designed to address a given problem. Our review of the literature indicated that organizations implement the TeamSTEPPS curriculum differently, and it was not clear how tailored these curricula are (Salas et al. 2013, Wolf et al. 2010). [1],[5],[6],[7],[8],[22],[23],[24] In this study, the trainer did not teach TeamSTEPPS tools within the context of the CVC procedure except for the Two-Challenge Rule. Interestingly, exploratory analyses found that TeamSTEPPS participants stated concerns about safety significantly more often than non-TeamSTEPPS participants. The CVC simulation scenario contained several opportunities for participants to state concerns about safety. Based on our findings, it may have been more effective to tailor TeamSTEPPS training objectives and learning activities to address clinical outcomes.

Another explanation for our study's lack of producing better adherence to PS protocols is that the scenario of simulated CVC insertion may not have been "real" enough, and the video-based CVC instruction may have insufficient. According to a literature review of simulation, high fidelity simulators provide a better learning experience to develop NT skills and provide teams to practice assessment and treatment of deteriorating patients. [25],[26],[27] We designed the study to allow for adaptation at other institutions that may not have significant resources for high-fidelity simulators and/or financial means to allow for multi-hour team-training sessions. Accordingly, we used low-fidelity mannequin simulators in this study. In addition, our contrived pneumothorax complication may not have seemed realistic without real-time physiologic decompensation. The research team debated what complication should be introduced into the case and how to incorporate this complication to provoke communication, situational awareness, mutual support of team members, and debriefing. Pneumothorax was chosen as an easily diagnosed, reproducible, and treatable complication after CVC placement. According to our posttraining T-TAQ questionnaire, a majority of participants commented that the mannequins were difficult to use and that contrived complication was not real enough (even though we used actual radiographs showing pneumothorax) because the scenario did not include real-time physiologic decompensation. Another theme from the posttraining questionnaire suggested that video-based instruction should be provided before the session so that participants can review them prior to the instruction led training. Participants said that this would help them be "somewhat familiar with" the content. Participants also suggested that video-based CVC instruction should be coupled with a live demonstration prior to the scenarios. Perhaps a "flipped classroom" approach coupled with high fidelity mannequins may be more effective in designing a more realistic scenario for procedure training. Furthermore, the lack of a real enough scenario may have compromised the use of TeamSTEPPS techniques because scenario did not induce reflection and recognition of the severity of the clinical situation. According to the literature, simulated scenarios are most effective when they are real enough to induce reflection and recognition.

A final explanation for why the study did not produce the expected result may have to do with contextual factors. The literature suggests that contextual factors impact the effectiveness of TeamSTEPPS training, as team-training alone may not produce the desired effect. For example, Jones et al. found that the impact of team-training decreased if the organization did not have (or if participants were not aware of or did not use) an error reporting system, an explicit culture of teamwork, nor an explicit teamwork competency found in the institutions performance management system, such as job descriptions or evaluation and promotions criteria (Salas et al. 2013). [2] As half of the team (i.e., the residents) were interns and less than a month into their residency, it is possible that they were not oriented properly to the institution's error reporting system or to the importance of teamwork during their medical school training or during the initial week of residency orientation. Two studies reported improved team performance and patient outcomes of team-training, specifically TeamSTEPPS when introduced as part of new personnel orientation strategy. TeamSTEPPS training may be more effective if new people are oriented in teamwork competencies and/or education on the institution's error reporting system. [22],[23] At the time of the study, new residents did not receive any formal education on the institution's error reporting system.


The study had several limitations. We developed a new observational instrument for this study. Our instrument may prove valuable to faculty who supervise central line placements in a simulation or clinical environment because it uses technical and NT behavioral markers. However, its reliability and validity are not clear. In hindsight, we would have developed the instrument using the DEEP guidelines for building simulation-based team assessment; [28] however, the study was published after our literature review and study intervention. Another study limitation is the quality of our rater training with the three clinical research associates. Even though we trained the raters on the instrument using a video excluded from the study (because the video included a PGY-2), we did not train all raters all at once due to scheduling conflicts and clinical demands. In hindsight, we should have trained them together and all at once to ensure consistency and encourage group discussion on the more challenging behavioral markers.


The study's findings are limited because the authors sought a convenience sample based on the number of incoming interns rather than a probability sample. Many studies on team-training do not seek statistical power let alone have a randomized design. [1] Fortunately, we received 100% participation from all interns because they saw the training as important and were given time in their orientation schedule to participate if they so choose. The research team acknowledges the fact that statistical tests are meant to work within the probability sampling theory framework. The research team chose a parallel group randomized designed to offset some of the inherent limitations of doing statistical testing in a convenience sample.

  Conclusion Top

The study was unique in several ways. We had 100% participation rate on the post-T-TAQ questionnaire, we used three clinical research associates, each who rated all 38 videos; and we evaluated the impact of TeamSTEPPS intervention on multiple measures (e.g., individual perceptions of teamwork and team adherence to a PS protocol). However, the most unique aspect of this study was its blinded randomized controlled group comparison design. Few studies on team-training, let alone TeamSTEPPS, include a randomized design. [29] Furthermore, the existing research on team training calls for higher quality research designs. [1],[7],[29] Based on this study's findings, future team-training should investigate design features that include specific rather than general teamwork objectives, flipped classroom delivery approach, DEEP guidelines for instrument design, more attention to rater training procedures, and high fidelity mannequins to make simulation scenarios more realistic for procedure training.

Financial support and sponsorship

Albert Einstein Society Research Grant.

Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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