Introduction

Teamwork has been emphasized as essential to improving quality and safety in the healthcare delivery system. Teamwork has been defined as a dynamic interaction among healthcare providers that is aimed toward a common goal and refers to a set of interrelated knowledge, attitudes, and skills (Agency for Healthcare Research and Quality [AHRQ], 2019). Various types of healthcare providers work together to provide patient care within the complexity of healthcare systems (World Health Organization [WHO], 2011). Healthcare providers perform interdependent tasks but are rarely trained together (King et al., 2008). From this perspective, ensuring safe care is often difficult unless teamwork and effective communication exist among healthcare providers. Therefore, it is necessary to provide a strategy that strengthens teamwork to enhance patient safety.

Effective teamwork has been recognized as critical to preventing medical errors in the care process (WHO, 2011). A meta-analysis study has demonstrated that improving teamwork competency through team training in healthcare saves patient lives (Hughes et al., 2016). In addition, teamwork has been proposed in previous studies as affecting job performance positively in relation to patient safety and patient outcomes. Improving teamwork among nursing staff has been reported to reduce patients’ fall rate (Kalisch et al., 2007), increase nurses’ performance of missed care (Kalisch & Lee, 2010), and result in better error reporting (Hwang & Ahn, 2015). As nursing teams comprise the largest human resource in hospitals, improving teamwork competency in nurses may have financial and quality-of-care impacts across the healthcare sector (Barton et al., 2018).

Patient safety involves minimizing the incidence and impact of adverse events while maximizing recovery from these events (WHO, 2011). Patient safety competency consists of knowledge, skills, and attitudes toward patient safety (Cronenwett et al., 2007; WHO, 2011). To achieve patient safety and quality improvement goals, several international organizations have included teamwork competencies within core patient safety competencies (AHRQ, 2019; Australian Commission on Safety and Quality in Health Care, 2005; Canadian Patient Safety Institute, 2008; WHO, 2011). To ensure that nurses are competent in patient safety, education on patient safety in the nursing curriculum is required. However, because nurses receive little or no formal patient safety education in the university curriculum (Barton et al., 2018; Hwang, 2015), they may not be able to cope with patient safety issues adequately. Among patient safety competencies, nurses have demonstrated the lowest scores on teamwork competencies (Hwang, 2015). Therefore, the first step toward ensuring patient safety and quality in healthcare is to provide an education program that emphasizes teamwork competency.

Teamwork training enables healthcare providers to optimize their teamwork competencies with the teamwork knowledge, attitudes, and skills needed to become effective team members (Sherwood & Barnsteiner, 2017). The teamwork improvement program (TIP), Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) has been applied in various healthcare settings and has proven to be effective by using an evidence-based team training method developed for improving patient safety by enhancing both communications among healthcare professionals and teamwork competencies (Cooke, 2016; Gaston et al., 2016; Parker et al., 2019).

Nurses play an important role as part of the multidisciplinary team while providing 24-hour care for patients and interaction with them. Because nurses conduct their clinical practice based on cooperation and collaboration with other nurses (Kaiser & Westers, 2018), teamwork is a critical element in effective nursing practice. Particularly, of the patient care departments in the hospital, the operating room (OR) is one of the most intricate and high-risk environments (Sonoda et al., 2018), where healthcare is provided by a temporary interprofessional team and often performed using invasive treatments under anesthesia. Teamwork between nurses in the OR is especially important because two nurses work closely as a team performing the roles of scrub nurse and circulating nurse in each operation. While participating in the operation, the perioperative nurse cannot perform tasks such as counting, timeout, supplying of aseptic surgical materials, and coping with emergency situations as an individual nurse. Therefore, perioperative nurses are required to have teamwork competencies to minimize incidents during surgery.

To provide the best surgical nursing care to patients, nursing team members must communicate effectively and coordinate properly (Sonoda et al., 2018). Thus, applying a TIP that focuses on the nursing team in the OR environment and educating nurses to understand how to apply teamwork strategies in the clinical context of their specialty settings are necessary. To successfully apply these teamwork programs in specific clinical settings, it is important to include adequate materials and resources relevant to the department in the program design (Clapper & Ng, 2013) or to develop a customized program for the target area (Vertino, 2014). The TeamSTEPPS program has been applied in several intervention studies in the OR (Dahl et al., 2017; S.-H. Lee et al., 2021) for interprofessional teams, including nursing, surgical, and anesthesia staff. However, few studies have focused on the implementation of this program within the nursing team in the OR.

Therefore, in this study, we developed a TIP for perioperative patient safety and evaluated the effectiveness and satisfaction of this program in the context of perioperative nurses.

Methods Study Design

In this study, a quasi-experimental research design was used to evaluate the effectiveness of the developed program.

Setting and Sample

This study was conducted at one tertiary hospital in South Korea. Participants were recruited using a convenience sampling method from two operating centers (cancer operating center, main operating center), which shared a similar safety culture, unit organization, nursing staffing level, and working conditions. The inclusion criteria were (a) > 6 months of clinical experience as a perioperative staff nurse and (b) understood the purpose of the study and agreed to participate. The nurses working in the cancer operating center were assigned to the experimental group, and the nurses working in the main operating center were assigned to the control group. The groups were located at separate centers to minimize treatment diffusion.

We calculated the appropriate sample size using G*Power 3.1 (Faul et al., 2009) by specifying an effect size of 0.5, a power of .7, and a probability of alpha error of .05 for a paired t test. The required sample size was 27 in each group. A sample of 63 perioperative nurses agreed to participate, and 60 nurses actually participated.

Program Development

The process used to develop the TIP consisted of four steps (Figure 1). In the first step, the researchers identified teamwork competencies using a literature review on patient safety competencies and then combined these competencies with team-based competencies that are specifically required of perioperative nurses (Australian Commission on Safety and Quality in Health Care, 2005; Canadian Patient Safety Institute, 2008; Cronenwett et al., 2007; WHO, 2011). The researchers categorized the teamwork competencies based on the educational objectives and core concepts described in the TeamSTEPPS educator’s guide. The list of teamwork competencies was finalized after review by a panel of experts.

Figure 1:

Stages of program development and evaluation.

In the second step, the educational plan for the program was constructed in accordance with the educational content of the TeamSTEPPS fundamental modules, and additional content was added to reflect the specific needs of OR environments. In addition, teamwork education needs were assessed using interviews with three perioperative nurses, and the content validity for the final educational plan was verified with four clinical experts.

In the third step, the instructional structure, methods, and materials were developed based on the results of the established educational plan. After initial development, the educational content was reviewed by an expert panel composed of a perioperative nurse with more than 15 years of clinical experience in the OR and a nurse educator who had worked for more than 10 years in a hospital. The final program was developed after revising the content, structure, and teaching methods in accordance with the results of the validity test.

Comparisons of the structure and content between TeamSTEPPS and the developed TIP are described in Table 1. The focus in this study was on improving teamwork competencies among perioperative nurses and applying teamwork strategies to nursing practice to enhance perioperative patient safety. The content addressing patient safety concepts and teamwork was emphasized, and teaching materials (AHRQ, 2019; National Patient Safety Agency, 2011; The Joint Commission, 2016a, 2016b; WHO, 2009, 2011) included scenarios and examples closely related to daily surgical practice in OR settings. In addition, tools were integrated into the TIP that are part of the OR standard of practice, such as the surgical safety checklist, briefing, and debriefing. Moreover, handoff tools (WHO, 2009, 2011) were added to improve the communication skills of participants in actual situations.

Table 1 - Structure of the Teamwork Improvement Program for Perioperative Patient Safety Theme TeamSTEPPS Modules TeamSTEPPS Content Applied in the TIP TeamSTEPPS Tools Content Added to the TIP Tools and Teaching Strategies Added to the TIP 〈Session 1〉
Understanding the importance of teamwork for perioperative patient safety and error prevention Introduction 1. Faculty and participant introductions ✓ • Concept and definition of patient safety
• Understanding of human factors, systems approach, and patient safety
• The importance of perioperative patient safety
• Understanding of surgical errors
• Perioperative patient safety and teamwork • Quiz on perioperative patient safety
• Watching the news about a wrong-site surgery
• Teamwork game
• Speak-up video: preventing errors in your care
• Speak-up video: asking your advocate to speak up
• Discussion (strategies for and experience of patient participation in the OR) 2. Overview of the master trainer course and materials 3. Sue Sheridan video and discussion 4. Barriers to team performance ✓ 5. Patient safety movement and team training ✓ 6. The TeamSTEPPS framework ✓ 7. Characteristics of high performing teams ✓ Team structure 1. Definition of a team ✓ 2. Teams and teamwork exercise 3. Partnering with patients and families ✓ 4. Multi-team system ✓ 5. Team structure video and discussion 〈Session 2〉
Understanding the concepts of communication and leadership for improving teamwork Communication 1. Importance of communication ✓ • SBAR • Communication failure in the OR
• Root causes of sentinel event data
• Importance of surgical safety checklist
• Tools and resources for improving team communication in the perioperative setting
• Team-guided strategies for safe perioperative clinical practice • Review quiz
• Scenario-based practice focusing on perioperative setting
• Team-based method
• Surgical safety checklist
• Handoff tools
• Discussion (experience of conflict and resolution in the OR) 2. Communication definition, standards, and challenges ✓ • Call-out 3. Information exchange strategies and tools ✓ • Check-back • Handoff Leadership 1. Types of and effective team leaders ✓ • Brief 2. Team leader strategies ✓ • Huddle 3. Conflict resolution ✓ • Debrief 4. Promoting and modeling teamwork ✓ 〈Session 3〉
Understanding the concepts of situation monitoring and mutual support for improving teamwork Situation monitoring 1. The STEP process ✓ • STEP • Understanding of situation monitoring and mutual support in the perioperative setting
• How to share important information to improve safety of perioperative care
• Patient advocacy and self-assessment on perioperative patient safety issues • Review quiz
• Scenario-based discussion
• Situation monitoring and mutual support scenario in the OR
• Practical exercise for assertiveness on patient safety issues
• Best practice video 2. Situation awareness ✓ • Cross-monitoring 3. Shared mental models ✓ Mutual support 1. Task assistance ✓ • The assertive statement 2. Feedback ✓ • Two-challenge rule 3. Advocacy and assertion ✓ • CUS 4. Conflict resolution ✓ • DESC script 〈Session 4〉
Summary: putting it all together to improve teamwork Summary 1. Review of teamwork skills, team effectiveness and TeamSTEPPS outcomes ✓ • Tools and strategies learned • Summary of teamwork components, tools and strategies for perioperative patient safety
• Teamwork training
• Discussion and evaluation • Speak-up video: preparing for surgery
• Wrong-site surgery scenario that could occur in the OR
• Teamwork training: scenario-based discussion and simulation 2. Skills practice exercise 3. Identifying opportunities to use TeamSTEPPS ✓ 4. Practice teaching session preparation

Note. The program was based on the fundamental modules of the TeamSTEPPS program, and modifications was made for application in the OR clinical environment. TeamSTEPPS = Team Strategies and Tools to Enhance Performance and Patient Safety; TIP = teamwork improvement program; OR = operating room; SBAR = situation, background, assessment, recommendation; STEP = status of the patient, team members, environment, progress toward the goal; CUS = concern, uncomfortable, safety; DESC = describe the specific situation, express your concerns about the action, suggest other alternatives, consequences should be stated.

Measures

Kirkpatrick’s four levels of training evaluation model (reaction, learning, behavior, and outcomes; Kirkpatrick & Kirkpatrick, 2006) were adopted to evaluate the effectiveness of the program (Figure 1).

Program satisfaction evaluation (reaction evaluation)

Participant’s satisfaction with the program was assessed using the program satisfaction questionnaire (N.-J. Lee, 2015). The program satisfaction questionnaire with modifications consisted of eight items scored using a 7-point Likert scale. The Cronbach’s alpha value was .92 in this study.

Teamwork competencies (learning and behavior evaluation)

Teamwork competencies comprised teamwork knowledge, teamwork attitudes, communication self-efficacy, and teamwork skills and behavior. In the learning evaluation, teamwork knowledge, teamwork attitudes, and communication self-efficacy were measured. Teamwork skills and behavior were measured at the behavior level.

For teamwork knowledge, the Learning Benchmarks of 23 multiple-choice items was used (1 = correct answer, 0 = wrong answer), with higher total scores associated with better teamwork knowledge.

The Teamwork Attitudes Questionnaire (TAQ) was used to assess teamwork attitudes. The TAQ consists of 30 items in five subscales (team structure, leadership, situation monitoring, mutual support, and communication) scored using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Higher scores are associated with positive teamwork attitudes. The Cronbach’s alpha values of the five subscales reported in previous research were .70, .81, .83, .70, and .74, respectively (AHRQ, 2017). The Cronbach’s alpha values of the five subscales were .81, .82, .90, .60, and .67, respectively, in this study.

A 13-item questionnaire was developed in this study to measure communication self-efficacy based on the communication competencies selected in this study. This questionnaire uses a 5-point Likert scale, ranging from 1 = strongly disagree/not at all to 5 = strongly agree/very much, with higher scores associated with higher communication self-efficacy. The Cronbach’s alpha value of this questionnaire was .82 in this study.

Teamwork skills and behavior were measured using the Teamwork Perceptions Questionnaire (TPQ). The TPQ consists of 35 items under the same five subscales as the TAQ that are scored using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), with higher scores associated with better teamwork skills and behavior. The TPQ psychometric test has been validated in the hospital setting (Keebler et al., 2014). The Korean language version of the TPQ, translated and revised by Ahn and Lee (2016), was used in this study. The Cronbach’s alpha values of the five subscales were .82, .88, .76, .78, and .75, respectively, in this study.

The Learning Benchmarks, TAQ, and TPQ tools were developed by the AHRQ and the U.S. Department of Defense. Permission to use the scales was obtained from the AHRQ, and the authors of this study translated these scales from English to Korean using the committee approach. In the committee approach, all versions of a translation are reviewed by an expert team after initial translation (Tsang et al., 2017). In this study, the tools were initially translated independently by three experts, who then met together to review all of the translated versions in a reconciliation/consensus session to discuss discrepancies and reach an agreement on the translated tools. The clarity and readability of the items were tested by a group of nurses and doctoral students of nursing. After conducting a content validity test, the final questionnaire was completed for the Learning Benchmarks and TAQ.

Experience of participation in the teamwork improvement program and experience of surgical nursing errors (outcomes evaluation)

To assess the participants’ experience of change after participating in the TIP, qualitative data were collected using focus group interviews (FGIs) and the program evaluation survey (PES). In addition, their experience of surgical nursing errors was investigated using pre- and postsurveys. A “surgical nursing error” refers to a nursing mistake experienced or perceived by the perioperative nursing team, which may result in unanticipated harm to a patient during an operation. In the survey, participants answered “yes” or “no” to having experienced these errors and indicated the number of error experiences encountered during the previous 4-week period.

Intervention

The program consisted of four 60-min sessions conducted twice per week over a 2-week period and participation in web-based learning. The TIP utilized a variety of educational methods, including lectures, presentations, feedback, watching videos, discussion, scenario-based discussion, and simulation. The educational materials were posted to a website so that participants could learn in advance. A research team member provided the TIP to the experimental group at a seminar room in the operating center. Based on the definition of a team (AHRQ, 2019), four or five nurses who worked together to perform the same operations with the aim of safe surgery were assigned to one team. To enhance team performance, team members participated together in team activities (e.g., teamwork games, scenario-based discussions, and a simulation) during the TIP.

Data Collection

Data were obtained between December 2016 and March 2017. After obtaining permission to collect data from a tertiary hospital, the researcher recruited nurses interested in participating by posting the recruitment poster in operating centers. This study was approved by the institutional review board at the Seoul National University (IRB No. 1608/003-010). All of the study participants read and signed the informed consent form.

The pre- and postsurveys were conducted at a 4-week interval with both control and experimental groups. In the pre-and postsurveys, we measured teamwork competencies and surgical nursing error experiences using a self-report questionnaire. After the presurvey, the experimental group underwent the TIP for 2 weeks and completed a postsurvey, including the program satisfaction questionnaire, after the 2-week intervention. In addition, the experimental group underwent a PES and FGIs.

The PES was conducted in the fourth session of the program to allow all of the participants to freely write their thoughts and feelings about the program participation experience, and we utilized the data as a basis for team discussion. We conducted two FGIs with eight nurses from the experimental group who agreed to participate in interviews 2 weeks after the intervention. The participants were divided into two groups, taking into account their duty schedule and duration of clinical career. The FGIs lasted 50–60 minutes for each group and were recorded after obtaining the consent of the participants. The key questions on the PES and FGIs were as follows: “Are there any changes in your overall thoughts about teamwork after participating in the program?” “Have you made any changes in clinical practice after participating in the program?” “Which tools or strategies that you have learned in the program would you like to try first in the OR?”

Data Analysis

SPSS 24.0 (IBM Inc., Armonk, NY, USA) was used to analyze the quantitative data in this study. The general characteristics of the experimental and control group participants were analyzed using descriptive statistics. Homogeneity tests for general and study variables were analyzed using an independent t test, χ2 test, and Fisher’s exact test. The analyses of pretest and posttest differences between the experimental and control groups were performed using a paired t test. Differences in nursing error experiences between the two groups were analyzed using a chi-square test.

The qualitative data from the PES and FGIs were analyzed using a conventional content analysis based on Hsieh and Shannon (2005). The recorded data from the interview were transcribed as text. First, the overall meaning of the text was extrapolated by repeatedly reading and rereading the data. Next, meaningful sentences and words that contained key ideas were highlighted to identify associated codes, and similar codes were sorted into subcategories. At the end of the process, the subcategories were derived into categories. To enhance rigor, an analytical discussion between two researchers was undertaken until consensus was reached to determine whether the results of the analysis reflected the participants’ experiences accurately.

Results

Data on participants’ recruitment and retention are summarized in Figure 2. The baseline characteristics and premeasurement scores for the intervention and control groups are shown in Table 2. No statistically significant difference in the premeasurement scores of outcome variables was identified between the two groups with regard to teamwork knowledge (t = −1.21, p = .230), teamwork attitudes (t = −0.10, p = .920), communication self-efficacy (t = −1.00, p = .321), teamwork skills and behavior (t = −0.24, p = .808), and experience of surgical nursing errors (χ2 = 1.08, p = .406).

Figure 2:

Flow diagram of participants.

Table 2 - General Characteristics and Premeasurement Scores of Participants (N = 60) Category Total (N = 60) Experimental Group (n = 28) Control Group (n = 32) t/χ2 p n (%) or M ± SD General characteristics  Age (year) 28.25 ± 4.48 28.36 ± 4.72 28.16 ± 4.33 0.17 .864  Gender   Female 58 (96.7) 28 (100.0) 30 (93.8) 1.81a .494   Male 2 (3.3) 0 (0.0) 2 (6.2)  Working hours per day 8.52 ± 0.67 8.59 ± 0.78 8.45 ± 0.56 0.77 .448  Education   Bachelor 59 (98.3) 27 (96.4) 32 (100.0) 1.16 a .467   Associate degree in nursing 1 (1.7) 1 (3.6) 0 (0.0)  Job position   Staff nurse 42 (70.0) 21 (75.0) 21 (65.6) 0.63 .574   Senior nurse 18 (30.0) 7 (25.0) 11 (34.4)  Clinical career (years)   < 5 38 (63.3) 19 (67.9) 19 (59.4) 1.34 .512   5–9 12 (20.0) 6 (21.4) 6 (18.7)   ≥ 10 10 (16.7) 3 (10.7) 7 (21.9)  Type of work   Day 31 (51.7) 13 (46.4) 18 (56.3) 0.58 .605   Evening 29 (48.3) 15 (53.6) 14 (43.7)  Patient safety education experience   Yes 54 (90.0) 24 (85.7) 30 (93.8) 1.07 a .404   No 6 (10.0) 4 (14.3) 2 (6.2)  Annual number of patient safety education experiences 1.48 ± 1.36 1.29 ± 0.85 1.66 ± 1.68 −1.05 .296  Teamwork education experience   Yes 17 (28.3) 5 (17.9) 12 (37.5) 2.84 .150   No 43 (71.7) 23 (82.1) 20 (62.5)  Annual number of teamwork education experiences 0.28 ± 0.45 0.18 ± 0.39 0.38 ± 0.49 −1.72 .090  Communication education experiences   Yes 38 (63.3) 16 (57.1) 22 (68.8) 0.87 .425   No 22 (36.7) 12 (42.9) 10 (31.2)  Annual number of communication education experiences 0.68 ± 0.57 0.61 ± 0.57 0.75 ± 0.57 −0.97 .335 Premeasurement scores  Teamwork knowledge 19.82 ± 1.16 20.19 ± 1.18 −1.21 .230  Teamwork attitudes 4.13 ± 0.35 4.14 ± 0.32 −0.10 .920  Communication self-efficacy 3.31 ± 0.41 3.43 ± 0.50 −1.00 .321  Teamwork skills and behavior 3.86 ± 0.39 3.88 ± 0.36 −0.24 .808  Experience of surgical nursing errors   Yes 7 (25.0) 12 (37.5) 1.08 .406   No 21 (75.0) 20 (62.5)
Program Satisfaction

Nearly all (96.4%) of the participants were satisfied with the overall content of the TIP, and the information provided in the program was identified as helpful to their clinical practice. The participants scored each of the eight items an average of ≥ 6 points (on a 7-point scale).

Teamwork Competencies

The pretest–posttest differences for the experimental and control groups were analyzed. The pretest–posttest differences in the experimental group were significantly higher than in the control group for teamwork knowledge (mean = 0.75 ± 1.38 vs. −0.68 ± 1.35, t = 4.07, p < .001), teamwork attitudes (mean = 0.51 ± 0.31 vs. −0.00 ± 0.33, t = 6.10, p < .001), communication self-efficacy (mean = 1.12 ± 0.32 vs. 0.23 ± 0.37, t = 9.90, p < .001), and teamwork skills and behavior (mean = 0.54 ± 0.41 vs. −0.08 ± 0.39, t = 6.04, p < .001).

Experience of Participation in the Teamwork Improvement Program

Based on the results of the conventional content analysis, seven subcategories under three categories were extracted (Table 3).

Table 3 - Category, Subcategory, and Quotes From Content Analysis Category Subcategory Quotes Recognizing the importance and content of teamwork Recognition of the need for teamwork improvement program I can now keep in mind that the most important thing for patient safety is teamwork. I had no idea about teamwork at all before, but through this teamwork training, I came to realize the importan