course materials

1. Essay: Mixed methods research design
Essay: Mixed methods research designEssay: Mixed methods research designJONA Volume
46, Number 4, pp 201-207 Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.
THE JOURNAL OF NURSING ADMINISTRATION Promoting Patient Safety A Results of a
TeamSTEPPS Initiative Teresa Gaston, DNP, RN Nancy Short, DrPH, MBA, RN Christina
Ralyea, DNP, MS-NP, MBA, OCN, NE-BC Gayle Casterline, PhD, RN Teamwork is an essential
component of communication in a safety-oriented culture. The Joint Commission has
identified poor communication as one of the leading causes of patient sentinel events. The
aim of this quality improvement project was to design, implement, and evaluate a
customized TeamSTEPPS training program. After implementation, staff perception of
teamwork and communication improved. The data that TeamSTEPPS is a practical,
effective, and low-cost patient safety endeavor. nication has been gaining momentum in
healthcare. In 2006, the Department of Defense and the Agency for Healthcare Research and
Quality (AHRQ) partnered to develop a teamwork program designed specifically for
healthcare called Team Strategies and Tools to Enhance Performance and Patient Safety
(TeamSTEPPS ). TeamSTEPPS promotes the use of standardized communication tools and
addresses 5 areas of teamwork including leadership, communication, situational
monitoring, team structure, and mutual .8 Positive improvements have been reported in
the 18 TeamSTEPPS research studies reviewed by the authors. Staff perceptions regarding
teamwork and/or communication were the most common areas in which measurable
improvement occurred.9-22 TeamSTEPPS implementation has demonstrated improved
outcomes in a variety of specialty areas and settings including the operating room,22
pediatric and adult intensive care units,15 emergency department,23 mental health,18
neonatal intensive care,24 a combat hospital,25 and outpatient oncology.10 Essay: Mixed
methods research designORDER NOW FOR CUSTOMIZED, PLAGIARISM-FREE PAPERSOne
study reported a 13% increase in positive staff perceptions of teamwork and a 20%
increase in positive staff perceptions of communication measured by the Hospital Survey on
Patient Safety Culture (HSOPSC) 1 month after implementation.22 Several studies16-18
measured knowledge, reporting anywhere from a 6% to 9% increase following the training
program. In addition, decreased patient incident events have been reported following
training.25,26 The aims of this quality improvement project (QIP) were to improve staff
perceptions of teamwork and communication by customizing and implementing
TeamSTEPPS training for the oncology service line (OSL) in an academic health center and
to evaluate A Following the momentous report To Err Is Human,1 the Institute of Medicine

2. and The Joint Commission (TJC) recommended teamwork and communication training in
healthcare to assist in decreasing medical errors.2 Although teamwork is cited as an
essential component of both communication and a safetyoriented culture,3 effective
teamwork is often absent in healthcare settings4 and requires cultivation.5 According to
TJC,6 communication is one of the leading causes of patient sentinel events. For decades, the
aviation industry and the US military have enforced training in teamwork and
communication as a means to decrease errors and increase positive outcomes.7 The goal of
improving patient safety with highly effective teams and coordinated commuAuthor
Affiliations: Nurse Informatics Educator (Dr Gaston), Information Services, Carolinas
HealthCare System, Charlotte; Associate Professor (Dr Short), School of Nursing, Duke
University, Durham; and Assistant Vice President (Dr Ralyea), Patient Care Services
Oncology Division, and Nursing Research & Evidence Based Practice (Dr Casterline),
Carolinas HealthCare System, Charlotte, North Carolina. The authors declare no conflicts of
interest. Correspondence: Dr Gaston, Carolinas HealthCare System, 5039 Airport Center
Pkwy, Charlotte, NC 28208 (teresagaston2@gmail.com). DOI:
10.1097/NNA.0000000000000333 A JONA Vol. 46, No. 4 April 2016 Copyright © 2016
Wolters Kluwer Health, Inc. All rights reserved. 201 the overall effectiveness. Based on
previously reported 2013 HSOPSC results, nursing leaders identified teamwork and
communication on the OSL as an improvement opportunity. Important stakeholders,
including nursing leadership and the Quality and Patient Safety (QPS) team, were highly
ive. Targeted outcomes for implementation included the following: 1. observe an
improvement in staff perceptions of team structure and communication as measured by the
TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ);27 2. observe an increase in
positive staff perceptions of teamwork by 13% and communication openness by 20% as
measured by the HSOPSC28; 3. observe a 5% increase in staff knowledge as measured by
the TeamSTEPPS Learning Benchmark Test (LBT)29; and 4. discover and describe staff
perceptions toward the application of TeamSTEPPS tools and behaviors into clinical
practice as measured by the focus groups. Methods Design This QIP incorporated a mixed-
methods approach including both quantitative and qualitative data collection.Essay: Mixed
methods research designA preimplementation/postimplementation design measured
perceptions of teamwork, perceptions of communication, knowledge, and number of patient
incident reports. In addition, the design measured course evaluations, focus groups, and exit
surveys after training only. Qualitative information was gathered from the focus groups.
The settings were 3 oncology acute patient care units (total of 72 beds) within the OSL of an
874-bed academic health center located in the southeast United States. At project onset, 95
RNs, 35 clinical nurse assistants (CNAs)/healthcare technicians (HCTs), and 14 physicians
were eligible to participate. Each received an e-mail invitation to voluntarily sign up for a
TeamSTEPPS training session. RNs and CNAs/ HCTs received 2 hours_ pay outside their
scheduled shift work to attend 1 training session. Nurses who completed the training course
received 2.0 contact hours, whereas physicians did not receive any continuing medical
education. The convenience sample of voluntary staff included full- and part-time staff (n =
92 RNs, n = 12 CNAs/HCTs, n = 6 physicians) who work within the OSL. Of the participating
staff, 94% (n = 103) denied ever attending a formal TeamSTEPPS training prior to this QIP.

3. 202 Project Implementation Training Because the TeamSTEPPS program was purposely
designed to be customizable by healthcare organizations,8 a few studies have successfully
provided 2-hour training sessions in lieu of the 6-hour session promoted by the
AHRQ.10,15,30 Therefore, in collaboration with the QPS team, the content was customized
to a 2-hour training session. Essay: Mixed methods research designThese training sessions
included didactic instruction along with an audiovisual slide presentation containing videos,
discussion questions, scenarios, and oncology-specific examples. Seven staff members
volunteered to become TeamSTEPPS Master Trainers (MTs) and attended a 1-day course.
The project team scheduled 10 TeamSTEPPS sessions with 1 make-up session to implement
during September 2014. Coaching Coaching is an essential element of sustainability,18
although not well studied. The MTs provided coaching on each of the patient care units after
training for 3 months. The latest version of the TeamSTEPPS program has a new coaching
guide, and this module was reviewed by all MTs. The nurse managers or the MTs either e-
mailed staff or verbally reviewed with staff a Tool of the Month for 3 months following
training. Focus Groups During the training sessions, all participants (n = 110) received a
thank-you card, and of those participants, a randomized 40% (n = 44) received a special
thankyou card containing a focus group invitation. Three focus groups met 1 month after
the completion of all training sessions to answer specific questions. Data Collection and
Measures Data were obtained during 4 time periods: immediately prior to and immediately
following each of the 11 training sessions, approximately 1 month after the final training
session was conducted, and at the conclusion of this project. Data collection included the
following: demographics, T-TPQ, HSOPSC, LBT, focus group questions, exit survey, training
course evaluation, and number of patient incident reports. The T-TPQ, HSOPSC, and the LBT
are open-access tools and available on the AHRQ Web site, whereas the demographic
survey, focus group questions, exit survey, and training course evaluation were created for
this QIP (Table 1). Demographic data included patient care unit(s) to ensure employment
by the OSL, professional credentials, and a yes/no question to identify JONA Vol. 46, No. 4
April 2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. Table 1. Data
Collection Detail Types of Data Collected Time Periods of Data Collection Administered
immediately prior to the start of each training session (September 2014) September
2014VIntervention Essay: Mixed methods research designAdministered immediately
following each training session (September 2014) Focus groups (October 2014) Paper
surveys made available for a 2-wk period 1 mo following the completion of the last training
sessions (October 2014) Patient incident report no. (January 2015) Demographics T-TPQ
¾ ¾ HSOPSC LBT ¾ Course Evaluation Exit Survey ¾ 11 TeamSTEPPS training sessions ¾
¾ ¾ 3 Small group sessions ¾ ¾ ¾ ¾ Retrospective data collection upon completion of this
project including 3-mo pretraining (June, July, August 2014) then 3-mo posttraining
(October, November, December 2014) numbers those who had previously completed
TeamSTEPPS training. Individual participant responses were not identifiable by
demographic data. AHRQ developed the T-TPQ tool to measure the effectiveness of the
TeamSTEPPS training program. This tool can be administered in conjunction with the
HSOPSC tool.27 For the purpose of this QIP, we selected only 2 subscales, team structure
and communication from the T-TPQ (Likert scale 1-5). The reliability values of team

4. structure (Cronbach_s ! = .89) and communication (Cronbach_s ! = .88) subscales have been
reported to be good and have construct validity.31 For the purpose of this QIP, we selected
only 2 subscales from the HSOPSC tool (Likert scale 1-5) including staff perceptions of
teamwork within the units (Cronbach_s ! = .83) and communication openness (Cronbach_s !
= .73). Given these values, the HSOPSC has acceptable reliability.32 The items and subscales
are psychometrically sound.33 The HSOPSC has been administered across hundreds of
healthcare organizations ing its validity with national benchmarking data that are also
available.28 AHRQ developed the LBT specific to the educational content of the training
program to measure participant knowledge. This was modified by decreasing the number of
multiple-choice questions from 23 to 10 and by selecting questions specific to the revised 2-
hour course content. Three focus groups were conducted to gather staff_s perceptions
regarding the application of training to clinical practice. See Table 2 for focus group
questions. Resources regarding how to plan and conduct focus groups, as well as how to
create questions, and analyze the results were utilized.34,35 Gift cards were given to those
who participated. Only summative information was reported to protect participants_
anonymity and confidentiality. An exit survey was designed to gather more information
about the application to clinical practice, and the questions were created specifically for this
QIP, thereby lacking reliability and validity. A training course evaluation tool assessed staff
satisfaction following each of the training sessions. This was based on the standard
evaluation tool used for in-services by the academic health center. In addition, 2 additional
questions were created to illicit more information from staff regarding future application of
the newly learned tools. Patient incident report counts were obtained to indirectly observe
if the training impacted staff behaviors and patient events in the clinical setting. Data
Analysis Data were analyzed using SPSS version 22 software (IBM, Armonk, New York). The
quantitative data were normally distributed. Descriptive statistics were used for the
demographics, T-TPQ, HSOPSC, LBT, exit survey, and course evaluation data. An unpaired,
2-sample t test was conducted for the T-TPQ, HSOPSC, and LBT.Essay: Mixed methods
research designIn addition, a comparison was made from the previously reported 2013
HSOPSC data for the entire health center and the 2013 AHRQ 75th percentile comparative
database versus the 2014 HSOPSC data from this QIP. The qualitative data from 3 focus
groups were organized by major themes and coded by 2 individuals separately. Patient
JONA Vol. 46, No. 4 April 2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights
reserved. 203 Table 2. Focus Group Information Questions Asked Most Common Themes 1.
What facilitators do you see in your work area that promote or the use of TeamSTEPPS? 2.
Describe a time or an experience when you used a TeamSTEPPS tool. 3. Tell me some ideas
on how we can better integrate TeamSTEPPS tools into everyday practice. 4. Describe how
we can keep TeamSTEPPS going for newly hired staff. 5. Tell me about some of the barriers
that you may have experienced when applying the TeamSTEPPS tools in your work area. &
Huddle time & BI need clarity[ and CUSa tool used for medication orders, communication
between nurses and physicians, and electronic chemotherapy orders & Verbal reminders
during huddle time and team meetings & Visual reminders on the nursing unit bulletin
boards and in the break rooms & Written reminders via e-mail and communication books &
More educational in-services & Add to general hospital orientation program & Add to

5. nursing unit-specific orientation & Personal attitudes of staff & Nurse-physician
communication a CUS: “I am Concerned! I am Uncomfortable! This is a Safety issue!”
(TeamSTEPPS). incident report numbers were compared 3 months pre/post. Statistical
significance was set at P < .05. Results TeamSTEPPS Teamwork Perceptions Questionnaire
The 2 selected subscales of the T-TPQ (n = 107 pre, n = 73 post) were calculated using a 2-
sample t test based on the user manual.27 The mean for the team structure subscale before
training on a 1- to 5-point Likert scale was 3.89 and at 1 month after training was 4.43
(t178 = j5.62, P = .000). The mean for the communication subscale from pretraining was
4.08 and at 1 month after training was 4.58 (t180 = j 6.22, P = .000). Both subscales
measured demonstrated an improvement in staff perceptions for team structure and
communication with statistical significance (Figure 1). tile and (b) communication openness
at 67% for the overall health center and 66% for the AHRQ comparative database 75th
percentile benchmark. The 2 selected safety culture subscales of the HSOPSC (n = 109 pre, n
= 73 post) were calculated using a 2-sample t test based on the mean percent positive
responses utilizing the HSOPSC survey user_s guide.28 Staff perceptions for the teamwork
within unit subscale increased from 74% before training to 91% at 1 month after training
(t182 = j3.66, P = .000), and the communication openness subscale increased from 58%
before training to 79% at 1 month after training (t176 = j4.43, P = .000); both demonstrated
improved staff perceptions with statistical significance (Figure 2). Hospital Survey on
Patient Safety Culture Baseline 2013 retrospective data obtained from the academic health
center showed (a) teamwork within units at 85% for the overall health center and 84% for
the AHRQ comparative database 75th percen- Essay: Mixed methods research
designLearning Benchmark Test A 2-sample t test (n = 110 each sample) showed a
pretraining mean score of 92% (range, 40%-100%; median, 100%) and an immediate
posttraining mean score of 94% (range, 30%-100%; median, 100%) on a scale of 0% to
100%. Although staff knowledge increased by 2%, this was not statistically significant (P =
.207). The t test was selected based on a Figure 1. T-TPQ results: mean scores for team
structure and communication. *Statistical significance at P < .05. Figure 2. HSOPSC results:
mean % positive responses. *Statistical significance at P < .05. 204 JONA Vol. 46, No. 4 April
2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. sufficient sample
size and only slightly skewed data for the immediate posttraining group. Focus Groups
Another aim of this project was to describe staff perceptions toward the application of
TeamSTEPPS into clinical practice. Three focus groups (n = 20) were conducted to gather
this qualitative information. Table 2 displays the common themes that resulted from a
content analysis of the responses. Exit Survey All eligible participants (n = 74) who
completed the exit survey 1 month after training (67% response rate) reported that they
attended a training session prior to answering these questions. Improved teamwork was
reported by 81% (n = 60) of staff, and improved communication was reported by 85% (n =
63) of staff. Following the training sessions, 89% (n = 66) of staff reported that they used a
TeamSTEPPS tool or demonstrated a behavior at work during the past month since their
training. The top 3 reported tools that were used following training included huddle Essay:
Mixed methods research design