Introduction

Safe and efficient care involves the coordinated activities of multiple teams of healthcare professionals. For example, while one team may focus on treating an underlying condition (e.g., cancer), other teams may address other health needs (e.g., catheter care and associated infections, unrelated heart problems). Still other teams may support the patient’s broader care needs, including those provided in non-hospital care settings. A team consists of two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal, have specific roles or functions, and have a time-limited membership.

Interprofessional Collaborative Skills

Teams with strong communication, leadership, situation monitoring, and mutual support skills typically achieve superior outcomes, reduce stress levels, and derive more satisfaction from their work and relationships with peers as well as with patients and their families or caregivers. The interrelationships are the foundation of a strong continuous improvement model: the knowledge, skills, and performance of a team will complement clinical excellence and improve patient outcomes because teams will use feedback cycles and clearly defined tools to communicate, plan, and deliver better-quality care.

• Knowledge: Teams whose members have strong communication, leadership, situation monitoring, and mutual support capabilities achieve important team outcomes such as shared awareness about what is going on with the team and progress toward its goal. Team members are also familiar with the roles and responsibilities of their teammates.
• Attitudes: When patients, healthcare professionals, and staff work in teams in which members have strong communication, leadership, situation monitoring, and mutual support skills, team members are more likely to have a positive team orientation, enjoy working with their teammates, and trust those teammates’ intentions.
• Performance: High-functioning teams will be able to adapt to changes in the care plan. Team members will know when and how to back up each other. They will be more efficient in providing care, will have a plan, and will know who is supposed to do what and how they are supposed to do it. High-performing teams will also be safer, allowing the team to more readily identify and correct errors if they occur. Adaptability, accuracy, productivity, efficiency, safety, and high reliability are hallmarks of high-functioning teams.

All healthcare students must prepare to deliberately work together in clinical practice with a common goal of building a safer, more effective, patient-centered healthcare system. The World Health Organization (WHO) (2010) defines interprofessional collaborative practice as multiple health workers from different professional backgrounds working together with patients, families, caregivers, and communities to deliver the highest quality of care.

Effective teamwork and communication are key to improving patient safety and achieving team outcomes (Agency for Healthcare Research and Quality [AHRQ], 2023). The importance of effective interprofessional collaboration has become even more important as healthcare professionals advocate to reduce health disparities related to social determinants of health (SDOH). In these efforts, healthcare professionals work with people from a variety of professions, such as physicians, social workers, educators, policymakers, attorneys, faith leaders, government employees, community advocates, and community members. Healthcare students must be prepared to effectively collaborate interprofessionally after graduation (National Academies of Sciences, Engineering, and Medicine, 2021).

Common Types of HealthCare Teams

Primary care is the fundamental level of health services and contacts a patient has with the healthcare system. Primary healthcare teams are composed of healthcare providers who provide comprehensive healthcare within the community. As an example, a primary team could consist of a group of family physicians, nurse practitioners, practice managers, pharmacists, and healthcare administrators (HCAs) working to support the team. Primary care teams work to meet public and patient expectations, optimize health outcomes, and work to support and sustain the healthcare delivery systems.

Secondary care is concentrated health services. Secondary healthcare teams are composed of specialized healthcare providers who provide expert and specific care to patients who are often referred to them by a primary healthcare provider or team. Secondary healthcare teams are often found in a hospital setting. As an example, a patient is referred to a hospital outpatient clinic for care or inpatient emergency care. The team composition can include specialized physicians such as a cardiologist, technicians, nurses, dieticians, and HCAs.

Tertiary care is advanced and highly specialized health services. Tertiary healthcare teams are found in healthcare settings focusing on advanced treatments and extended procedures such as cancer treatment or neurosurgery. Patients are referred to tertiary healthcare teams by either the primary or secondary health team. Tertiary team composition typically, includes medical specialists, nurses, technicians, and HCAs.

Teams and Teamwork

Now that we have reviewed the first three IPEC competencies related to valuing team members, understanding team members’ roles and responsibilities, and using structured interprofessional communication strategies, let us discuss strategies that promote effective teamwork. The fourth IPEC competency states, “Apply values and the principles of the science of teamwork to adapt one’s own role in a variety of team settings” (Interprofessional Education Collaborative, 2023). See the following box for the components of this IPEC competency.

Developing effective teams is critical for providing healthcare that is patient-centered, safe, timely, effective, efficient, and equitable (Interprofessional Education Collaborative Expert Panel, 2011). Healthcare professionals collaborate with the interprofessional team by not only assigning and coordinating tasks but also by promoting solid teamwork in a positive environment. A healthcare leader, such as a charge nurse, identifies gaps in workflow, recognizes when task overload is occurring, and promotes the adaptability of the team to respond to evolving patient conditions. The qualities of a successful team are described in the following box.

TeamSTEPPS

TeamSTEPPS® is an evidence-based framework used to optimize team performance across the healthcare system. It is a mnemonic standing for Team Strategies and Tools to Enhance Performance and Patient Safety. The Agency for Healthcare Research and Quality (n.d.) and the Department of Defense (DoD) developed the TeamSTEPPS® framework as a national initiative to improve patient safety by improving teamwork skills and communication.

Team structure

A healthcare leader establishes team structure by assigning or identifying team members’ roles and responsibilities, holding team members accountable, and including patients and families as part of the team.

Communication

Communication is the first skill of the TeamSTEPPS® framework. It is defined as a “verbal and nonverbal process by which information can be clearly and accurately exchanged among team members” (AHRQ, 2023). All team members should use these skills to ensure accurate interprofessional communication:

• Provide brief, clear, specific, and timely information to team members.
• Seek information from all available sources.
• Use check-backs to verify information that is communicated.
• Uses SBAR, call-outs, and handoff techniques (I-PASS) to communicate effectively with team members (AHRQ, 2023).

Leadership

Leadership is the second skill of the TeamSTEPPS® framework. It is defined as the “ability to lead teams to maximize the effectiveness of team members by ensuring that team actions are understood, changes in information are shared, and team members have the necessary resources” (AHRQ, 2023). An example of a healthcare team leader in an inpatient setting is the charge nurse.

Effective team leaders demonstrate the following responsibilities:

• Organize the team.
• Identify and articulate clear goals (i.e., the plan).
• Assign tasks and responsibilities.
• Monitor and modify the plan; communicate changes.
• Review the team’s performance; provide formative feedback and critique when needed.
• Manage and allocate resources.
• Facilitate information sharing.
• Encourage team members to assist one another.
• Foster a learning and psychologically safe environment.
• Keep conflict healthy through the use of tools such as DESC.
• Reinforce patient-centeredness of all team members and actions.
• Model effective teamwork (AHRQ, 2023).

Three major leadership tasks include sharing a plan, monitoring and modifying the plan according to situations that occur, and reviewing team performance. Tools to perform these tasks are discussed in the following subsections.

Sharing the plan

Healthcare team leaders identify and articulate clear goals to the team at the start of the shift during inpatient care using a “brief.” The brief is a short session to start to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, and anticipate outcomes and likely contingencies (AHRQ, 2023)

Monitoring and modifying the plan

Throughout the shift, it is often necessary for the team leader to modify the initial plan as patient situations change on the unit. A huddle is an ad hoc meeting to ensure continual progression of care to the goal; to re-establish or affirm situational awareness, reinforce the plan in place, or assess the need to augment or adjust to optimize outcomes (AHRQ, 2023). Read more about situational awareness in the “Situation Monitoring” subsection below.

Reviewing the team’s performance

When a significant or emergent event occurs during a shift, such as a “code,” it is important to later review the team’s performance and reflect on lessons learned by holding a “debrief ” session. A debrief is a structured, intentional yet informal, quick information exchange session designed to improve team performance and effectiveness through lessons learned and reinforcement of positive behaviors (AHRQ, 2023).

Situation Monitoring

Situation monitoring is the third skill of the TeamSTEPPS® framework and is defined as the “process of actively scanning and assessing situational elements to gain information or understanding, or to maintain awareness to support team functioning (AHRQ, 2023). Situation monitoring is an individual skill that refers to the process of continually scanning and assessing the situation to gain and maintain an understanding of what is going on around you. Situation awareness is an individual outcome that refers to a team member knowing what is going on around them regarding the patient, other team members, the environment, and progress toward goals. The team leader creates a shared mental model (a team outcome) to ensure all team members have situation awareness and know what is going on as situations evolve. The STEP tool is used by team leaders to assist with situation monitoring (AHRQ, 2023).

STEP

The STEP tool is a situation monitoring tool used to know what is going on with you, your patients, your team, and your environment. STEP stands for Status of the patient, Team members, Environment, and Progress toward the goal (AHRQ, 2023).

Cross-monitoring

As the STEP tool is implemented, the team leader continues to cross-monitor to reduce the incidence of errors. Cross-monitoring includes the following:

• Monitoring the actions and stress levels of other team members.
• Providing a safety net within the team.
• Ensuring that mistakes or oversights are caught quickly and easily.
• “Watching each other’s back” (AHRQ, 2023).

I’M SAFE checklist

The I’M SAFE mnemonic is a tool used to assess one’s own safety status, as well as that of other team members in their ability to provide safe patient care. See the I’M SAFE Checklist in the following box (AHRQ, 2023). If a team member feels their ability to provide safe care is diminished because of one of these factors, they should notify the charge nurse or other supervisor. In a similar manner, if a healthcare professional notices that another member of the team is impaired or providing care in an unsafe manner, it is an ethical imperative to protect clients and report their concerns according to agency policy.

Mutual Support

Mutual support is the fourth skill of the TeamSTEPPS® framework and is defined as the “ability to anticipate and support team members’ needs through accurate knowledge about their responsibilities and workload (AHRQ, 2023). Mutual support includes providing task assistance, giving formative feedback, and advocating for patient safety by using assertive statements to correct a safety concern. Managing conflict is also a component of supporting team members’ needs.

Task assistance

Helping other team members with tasks builds a strong, trusting team. Task assistance includes the following components:

• Team members foster psychological safety and protect each other from work overload.
• Effective teams place all offers and requests for assistance in the context of patient safety.
• Team members foster a climate where it is expected that assistance will be actively sought and offered.
• Resilient teams are willing to ask for help and lean into being responsible for facing challenges and finding solutions.
• Assistance is sought from and provided to patients and family caregivers (AHRQ, 2023).

Formative Feedback

Formative is shared to improve team performance. Effective feedback should follow these parameters:

• Appreciative: Expresses gratitude and notes actions that team members do well.
• Timely: Given soon after the target behavior has occurred.
• Respectful: Focuses on behaviors, not personal attributes.
• Specific: Relates to a specific task or behavior that requires correction or improvement.
• Directed towards improvement: Provides directions for future improvement.
• Considerate: Considers a team member’s feelings and delivers negative information with fairness and respect.
• Patient-focused: Addresses the impact of team behaviors on the patient’s well-being (AHRQ, 2023).

Advocating for safety with assertive statements

When a team member perceives a potential patient safety concern, they should assertively communicate with the decision-maker to protect patient safety. This strategy holds true for all team members, no matter their position within the hierarchy of the healthcare environment. The message should be communicated to the decision-maker in a firm and respectful manner using the following steps:

• Make an opening.
• State the concern.
• State the problem (real or perceived).
• Offer a solution.
• Reach agreement on next steps (AHRQ, 2023).

Two-challenge rule

When an assertive statement is ignored by the decision-maker, the team member should assertively voice their concern at least two times to ensure that it has been heard by the decision-maker. This strategy is referred to as the two-challenge rule. When this rule is adopted as a policy by a healthcare organization, it empowers all team members to pause care if they sense or discover an essential safety breach. The decision-maker being challenged is expected to acknowledge that they heard and understand your concern (AHRQ, 2023).

CUS assertive statements

During emergent situations, when stress levels are high or when situations are charged with emotion, the decisionmaker may not “hear” the message being communicated, even when the two-challenge rule is implemented. It is helpful for agencies to establish assertive statements that are well-recognized by all staff as the implementation of the two-challenge rule. These assertive statements are referred to as the CUS mnemonic: “I am Concerned – I am Uncomfortable – This is a Safety issue!” (AHRQ, 2023).

Using these scripted messages may effectively catch the attention of the decision-maker. However, if the safety issue still isn’t addressed after the second statement or the use of “CUS” assertive statements, the team member should take a stronger course of action and utilize the agency’s chain of command. For the two-challenge rule and CUS assertive statements to be effective within an agency, administrators must support a culture of safety and emphasize the importance of these initiatives to promote patient safety.

Managing conflict

Conflict is not uncommon on interprofessional teams, especially when there are diverse perspectives from multiple staff regarding patient care. Healthcare leaders must be prepared to manage conflict to support the needs of their team members. When conflict occurs, the DESC tool can be used to help resolve conflict by using “I statements.” DESC is a mnemonic that stands for the following:

• D: Describe the specific situation or behavior; provide concrete data.
• E: Express how the situation makes you feel/what your concerns are using “I” statements.
• S: Suggest other alternatives and seek agreement.
• C: Consequences should be stated in terms of impact on the patient and established team goals while striving for consensus (AHRQ, 2023).

The DESC tool should be implemented in a private area with a focus on what is right, not who is right.

References and attributions

Introduction

Module 2: Team Leadership: Section 2: Explanation of Key Team Leadership Concepts and Tools from TeamSTEPPS® Curriculum developed by the Agency for Healthcare Research and Quality. Published under public domain for noncommercial use. Lightly edited for brevity, clarity, and flow. For more information, visit https://www.ahrq.gov/teamstepps-program/index.html

Interprofessional Collaborative Skills

“Introduction to Curriculum: Section 2: Explanation and Value of the TeamSTEPPS Curriculum” from TeamSTEPPS® Curriculum developed by the Agency for Healthcare Research and Quality. Published under public domain for noncommercial use. For more information, visit https://www.ahrq.gov/teamstepps-program/index.html

“Collaboration Within the Interprofessional Team Introduction” in Nursing Management and Professional Concepts by Chippewa Valley Technical College. Published by the Wisconsin Technical College System under a CC BY 4.0 license. Lightly edited to update TeamSTEPPS content.

Agency for Healthcare Research and Quality. (2023, July). Section 2: Explanation and Value of the TeamSTEPPS Curriculum. https://www.ahrq.gov/teamstepps-program/curriculum/intro/explain.html 

National Academies of Sciences, Engineering, and Medicine. (2021). The future of nursing 2020-2030: Charting a path to achieve health equity. The National Academies Press. https://doi.org/10.17226/25982

World Health Organization. (2010). Framework for action on interprofessional education & collaborative practice. https://www.who.int/publications/i/item/framework-for-action-on-interprofessional-education-collaborative-practice

Common Types of Healthcare Teams

“Health Care Teams and Communication” in Therapeutic Communication for Health Care Administrators by Kimberlee Carter, Marie Rutherford, and Connie Stevens. Published by Conestoga College under a CC BY-NC-SA 4.0 license. Lightly edited for brevity and to change to American spelling conventions.

Teams and Teamwork

“Teams and Teamwork” in Nursing Management and Professional Concepts by Chippewa Valley Technical College. Published by the Wisconsin Technical College System under a CC BY 4.0 license. Lightly edited for consistency with its new context and to update TeamSTEPPS content.

Interprofessional Education Collaborative Expert Panel. (2023). Core competencies for interprofessional collaborative practice: Version 3. https://www.ipecollaborative.org/assets/core-competencies/IPEC_Core_Competencies_Version_3_2023.pdf

Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. https://ipec.memberclicks.net/assets/2011-Original.pdf

O’Daniel, M., & Rosenstein, A. H. (2011). Professional communication and team collaboration. In: Hughes R.G. (Ed.). Patient safety and quality: An evidence-based handbook for nurses. Agency for Healthcare Research and Quality (US); Chapter 33. https://www.ncbi.nlm.nih.gov/books/NBK2637

TeamSTEPPS

“Teams and Teamwork” in Nursing Management and Professional Concepts by Chippewa Valley Technical College. Published by the Wisconsin Technical College System under a CC BY 4.0 license. Lightly edited for clarity, consistency with its new context, and to update TeamStepps content.

Agency for Healthcare Research and Quality. (n.d.). TeamSTEPPS 2.0 Course Management Guide 2.0. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/coursemgmt.pdf

Agency for Healthcare Research and Quality. (2023). TeamSTEPPS Pocket Guide. https://www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/teamstepps-pocket-guide.pdf

AHRQ Patient Safety. (2015). TeamSTEPPS overview [Online video]. YouTube. https://www.youtube.com/watch?v=p4n9xPRtSuU

Image description

Image 5.1: A photo of a group of healthcare workers placing hands together as a team. [Return to Image 5.1].