topic 4: being an effective team player

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Topic 4: Being an effective team player

Why teamwork is an essential elementof patient safety Effective teamwork in health-care delivery canhave an immediate and positive impact on patientsafety [1]. The importance of effective teams inhealth care is increasing due to factors such as: (i)the increasing complexity and specialization ofcare; (ii) increasing co-morbidities; (iii) increasingchronic disease; (iv) global workforce shortages;and (v) safe working hours initiatives. Paul M.Schyve, MD, senior vice president of the JointCommission has observed, “Our challenge … isnot whether we will deliver care in teams but ratherhow well we will deliver care in teams.”[2]

A typical example of complex care involvingmultiple teams would be a pregnant woman withdiabetes who develops a pulmonary embolus—her medical care team includes: an obstetrician,an endocrinologist and a respiratory physician.The doctors and nurses looking after her will bedifferent during the day compared to at night andon the weekend. In a teaching hospital, there willbe teams of doctors for each specialty area, all ofwhom need to coordinate care with each other,the nursing staff, allied health providers and thepatient’s primary care team.

This topic acknowledges that medical studentsare unlikely in their early years to have participatedas a member of health-care team themselves andoften have little understanding of how teams areconstructed and operate effectively. We aim in thistopic to draw on students' past experiences ofteamwork as well as look forward to the teamsthey will increasingly participate in as later yearstudents and practising clinicians.

Keywords:Team, values, assumptions, roles andresponsibilities, learning styles, listening skills,conflict resolution, leadership, effectivecommunication.

Learning objectives:• understand the importance of teamwork in

health-care;• know how to be an effective team player;• recognize you will be a member of a number

of health-care teams as a medical students.

Learning outcomes: knowledge andperformance

What students need to know (knowledgerequirements) Knowledge requirements in this module include a general understanding of:• the different types of teams in health care;• the characteristics of effective teams;• the role of the patient in the team.

What students need to do (performancerequirements) Use the following teamwork principles topromote effective health care including:• mindful of how one’s values and assumptions

affect interactions with others; • mindful of the of team members and how

psychological factors affect team interactions;• aware of the impact of change on teams;• include the patient in the team;• use communication techniques;• resolve conflicts;• use mutual support techniques;• change and observe behaviours.

WHAT STUDENTS NEED TO KNOW(KNOWLEDGE REQUIREMENTS)

The different types of teams in healthcare

What is a team? The nature of teams is varied and complex,they include: (i) teams that draw from a singleprofessional group; (ii) multiprofessional teams; (iii)

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teams that work closely together in one place; (iv)teams that are geographically distributed; (v)teams with constant membership; and (vi) teamswith constantly changing membership.

Regardless of the type and nature of the teamthey can be said to share certain characteristics.These include:• team members have specific roles and interact

together to achieve a common goal; [3]• teams make decisions; [4]• teams possess specialized knowledge and

skills and often function under conditions ofhigh workloads; [5,6]

• teams differ from small groups in as much asthey embody a collective action arising out oftask interdependency [7].

Salas defines teams as a “distinguishable set oftwo or more people who interact dynamically,interdependently, and adaptively towards acommon and valued goal/objective/mission, whohave been each assigned specific roles orfunctions to perform, and who have a limitedlifespan of membership” [8].

Examples of teams include choirs, sportingteams, military units, aircraft crew and emergencyresponse teams.

What different types of teams are foundin health care? There are many types of teams in healthcare. They include labour and delivery units, ICUs,medical wards, primary care teams in thecommunity, teams assembled for a specific tasksuch as an emergency response team ormultiprofessional teams such as multidisciplinarycancer care teams that come together to plan andcoordinate a patient’s care.

Teams in health care can be geographically co-located, as in an ICU or surgical unit, or

distributed as in a multidisciplinary cancer team orprimary health-care team.

Teams can include a single discipline or involvethe input from multiple practitioner types includingdoctors, nurses, pharmacists, physiotherapists,social workers, psychologists and potentiallyadministrative staff. The role these practitionersplay will vary between teams and within teams atdifferent times. Roles of individuals on the teamare often flexible and opportunistic such as theleadership changing depending on the requiredexpertise or the nurse taking on the patienteducation role as they are the ones that have themost patient contact.

In support of patient-centred care and patientsafety, the patient and their carers are increasinglybeing considered as active members of thehealth-care team. As well as being important interms of issues such as shared decision makingand informed consent, engaging the patient as ateam member can improve the safety and qualityof their care as they are a value information sourcebeing the only member of the team who is presentat all times during their care.

The TeamSTEPPS™ [9] programme developed inthe United States identifies a number of differentbut interrelated team types that support anddeliver health care:

1.Core teams Core teams consist of team leaders and memberswho are involved in the direct care of the patient.Core team members include direct care providers(from the home base of operation for each unit)and continuity providers (those who manage thepatient from assessment to disposition, forexample, case managers). The core team, suchas a unit-based team (physician, nurses,

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physiotherapist, and pharmacist) is generallybased where the patient receives care.

2. Coordinating teamsThe coordinating team is the group responsiblefor: • day-to-day operational management; • coordination functions; • resource management for core teams.

3. Contingency teams Contingency teams are: • formed for emergent or specific events; • time-limited events (e.g. cardiac arrest team,

disaster response teams, rapid responseteams);

• composed of team members drawn from avariety of core teams.

4. Ancillary servicesAncillary services consist of individuals such ascleaners or domestic staff who: • provide direct, task-specific, time-limited care

to patients; • support services that facilitate care of patients;• are often not located where patients receive

routine care.

Ancillary services are primarily a service deliveryteam whose mission is to support the core team.This does not mean that they should not share thesame goals. The successful outcome of a patientundergoing surgery requires accurate informationon catering and instructions in relation to “nil bymouth” orders so that a patient does notinadvertently receive a meal that may place themat risk of choking. In general, an ancillary servicesteam functions independently, however, there maybe times when they should be considered as partof the core team.

5. Support services Support services consist of individuals who:

• provide indirect, task-specific services in ahealth-care facility,

• are service-focused, integral members of theteam, helping to facilitate the optimal health-care experience for patients and their families.

Their roles are integrated in that they manage theenvironment, assets and logistics within a facility.Support services consist primarily of a service-focused team whose mission is to create efficient,safe, comfortable and clean health-careenvironments, which impact the patient careteam, market perception, operational efficiencyand patient safety.

6. Administration Administration includes the executive leadershipof a unit or facility, and has 24-hour accountabilityfor the overall function and management of theorganization. Administration shapes the climateand culture for a teamwork system to flourish by:• establishing and communicating vision; • developing and enforcing policies; • setting expectations for staff; • providing necessary resources for successful

implementation; • holding teams accountable for team

performance;• defining the culture of the organization.

How do teams improve patient care?Medical practice has traditionally focused onthe individual physician as solely responsible for apatients care. However, patients today are rarelylooked after by just one health professional.Patient safety, in the context of a complex medicalsystem, recognizes that effective teamwork isessential for minimizing adverse events caused bymiscommunication with others caring for thepatient and misunderstandings of their roles andresponsibilities.

The link between non-technical skills such as

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teamwork and adverse events is now wellestablished [10,11], as is the increasing burden ofchronic disease, co-morbidities and ageingpopulations that require a coordinated andmultidisciplinary approach to care [12].

Baker et al. [1], in a major review of team training,contended that the training of health professionalsas teams “constitutes a pragmatic, effectivestrategy for enhancing patient safety and reducingmedical errors”.

Teamwork has been associated with improvedoutcomes in areas such as primary care [13] andcancer care [14]. Teamwork has also been

associated with reduced medical errors [15,16].As summarized in Table 12, improving teamworkcan have benefits beyond improving patientoutcomes and safety that include benefits for theindividual practitioners in the team, the team as awhole as well as the organization in which theteam resides (adapted from Mickan, 2005) [12].

How do teams form and develop? Considerable research into how teams formand develop has been conducted in other highstakes industries. As detailed in Table 13,Tuckmann [17] identified four stages of teamdevelopment: forming, storming, norming andperforming.

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Outcome measures of effective teamwork

Individual benefits

Organizational benefits Team benefits Patients Team members

Reduced hospitalizationtime and costs

Improved coordination ofcare

Enhanced satisfaction Enhanced job satisfactionReduced unanticipatedadmissions

Efficient use of health-careservices

Acceptance of treatment Greater role clarity Better accessibility forpatients

Enhanced communicationand professional diversity

Improved health outcomesand quality of care

Reduced medical errors Enhanced well-being

Table 12: Measures of effective teamwork (adapted from Mickan, 2005)

Stage Definition

Forming Typically characterized by ambiguity and confusion when the team first forms. Team members may nothave chosen to work together and may be guarded, superficial and impersonal in communication, as wellas unclear about the task.

Storming A difficult stage when there may be conflict between team members and some rebellion against the tasksassigned. Team members may jockey for positions of power and frustration at a lack of progress in the task.

Norming Open communication between team members is established and the team starts to confront the task athand. Generally accepted procedures and communication patterns are established.

Performing The team focuses all of its attention on achieving the goals. The team is now close and supportive, openand trusting, resourceful and effective

Table 13: Stages of team development (modified from Flin [18])

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Similar to other industries, many health-careteams (such as surgical teams) are required towork together and need to be fully functioningwithout any time to establish interpersonalrelationships and go through the forming ornorming phases described above [18]. Thismakes team training essential for all members ofthe team prior to joining the team.

The characteristics of successfulteams

What makes for a successful team?There are many models describing effectiveteamwork. Historically these come from otherindustries such as aviation’s Crew ResourceManagement. Extensive studies have beenconducted into health-care teams and this has ledto the development of a number of models andtoolkits specific to health care.

Mickan and Roger [19] offer the following sixsimple characteristics that underpin effectivehealth-care teams:

1. Common purposeTeam members generate a common andclearly defined purpose that includescollective interests and demonstrates sharedownership.

2. Measurable goalsTeams set goals that are measurable andfocused on the team’s task.

3. Effective leadershipTeams require effective leadership that setand maintain structures, manage conflict,listen to members and trust and supportmembers. The authors also highlighted theimportance of teams to agree and shareleadership functions.

4. Effective communicationGood teams share ideas and informationquickly and regularly, keep written records aswell as allow time for team reflection. Some ofthe most in-depth analysis of interprofessionalteam communication has occurred in highstakes teams such as are found in surgery[20,21].

5. Good cohesionCohesive teams have a unique andidentifiable team spirit and commitment andhave greater longevity as teams memberswant to continue working together.

6. Mutual respectEffective teams have members who respectthe talents and beliefs of each person inaddition to their professional contributions. In addition, effective teams accept andencourage a diversity of opinion amongmembers.

Additional requirements for effective teamsinclude: [9,18,22]• demonstrating individual task proficiency

(both in terms of personal technical skills andteamwork skills);

• having task motivation;• being flexible;• monitoring their own performance; • effectively resolving and learning from conflict; • demonstrating situation monitoring.

Leadership Effective leadership is a keycharacteristic of an effective team. Effective teamleaders facilitate and coordinate the activities ofother team members by:• accepting the leadership role; • calling for help appropriately; • constantly monitoring the situation;• setting priorities and making decisions;

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• utilizing resources to maximize performance;• resolving team conflicts;• balancing the workload within a team;• delegating tasks or assignments;• conducting briefs, huddles, debriefs;• empowering team members to speak freely

and ask questions;• organize improvement activities and training

for the team;• inspire “followers” and maintain a positive

group culture.

Including the patient as a member of the health-care team is a new concept in health care.Traditionally the role of the patient has been morepassive as being a receiver of health care. But weknow that patients bring their own skills andknowledge about their condition and illness.Medical student can begin showing leadership inthis area by trying to include the patient or theirfamily as much as possible. Establishing eyecontact with patients, checking and confirminginformation and seeking additional information canall be done in the context of a ward round.Including the patient is a safety check to ensurethe correct information and complete informationis available to everyone on the team.

Communication techniques for health-care teams

George Bernard Shaw said, “The greatestproblem with communication is the illusion that ithas been accomplished.” Good communicationskills are at the core of patient safety and effectiveteamwork. The following strategies can assistteam members in accurately sharing informationand ensuring that the focus is on the informationbeing communicated. Use of a modified version ofthe "SBAR" called the "ISABAR" has recentlybeen demonstrated to improve telephone referralsby medical students in an immersive simulatedenvironment [23].

The following description of tools and caseexamples have been taken from The

TeamSTEPPS™ [9] programme and can be foundat http://www.ahrq.gov/qual/teamstepps/.

SBAR

SBAR is a technique for communicating criticalinformation about a patient’s concern that requiresimmediate attention and action. The technique isintended to ensure the correct information andlevel of concern is communicated in an exchangebetween health professionals.

SituationWhat is going on with the patient?“I am calling about Mrs Joseph in room 251. Chiefcomplaint is shortness of breath of new onset.”

Background

What is the clinical background or context?“Patient is a 62-year-old female post-op day onefrom abdominal surgery. No prior history ofcardiac or lung disease.”

Assessment What do I think the problem is?“Breath sounds are decreased on the right sidewith acknowledgement of pain. Would like to ruleout pneumothorax.”

Recommendation What would I do to correct it?“I feel strongly the patient should be assessednow. Are you available to come in?”

Call-out

Call-out is a strategy to communicate important orcritical information that:• informs all team members simultaneously

during emergent situations;• helps team members anticipate the next

steps;• directs responsibility to a specific individual

responsible for carrying out the task.

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An example of a call-out exchange between ateam leader and a resident would be:Leader: Airway status?Resident: Airway clear.Leader: Breath sounds?Resident: Breath sounds decreased on right.Leader: Blood pressure?Resident BP is 96/92.

Check-back

This is a simple technique for ensuring informationconveyed by the sender is understood by thereceiver, as intended:• sender initiates message;

• receiver accepts message and providesfeedback;

• sender double-checks, to ensure themessage is understood.

Doctor: Give 25 mg Benadryl IV push.Nurse: 25 mg Benadryl IV push?Doctor: That’s correct.

Handover or handoffHandover or handoff are crucial times whereerrors in communication can result in adverseoutcomes. " I pass the baton" is a strategy toassist timely and accurate handoff.

Resolving disagreement and conflict Key to successful teamwork is the ability toresolve conflict or disagreement in the team. Thiscan be especially challenging for junior membersof the team, such as medical students, or inteams that are highly hierarchical in nature.

However, it is important for all members of the teamto feel they can comment when they see somethingthat they feel will impact on the safety of a patient.

The following protocols have been developed tohelp members of a team express their concern ina graded manner.

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I Introduction Introduce yourself, your role and job and the name of the patient.

P Patient Name, identifiers, age, sex, location.

A Assessment Present chief complaint, vital signs, symptoms and diagnosis.

S Situation Current status/circumstances, including code status, level of (un)certainty,recent changes and response to treatment.

S Safety concerns Critical lab values/reports, socioeconomic factors, allergies and alerts(falls,isolation and so on).

The

B Background Co-morbidities, previous episodes, current medications and family history.

A Actions What actions were taken or are required? Provide brief rationale.

T Timing Level of urgency and explicit timing and prioritization of actions.

O Ownership Who is responsible (person/team), including patient/family.

N Next What will happen next?Anticipated changes?What is the plan?Are there contingency plans?

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Two-challenge ruleThe two-challenge rule is designed to empower allteam members to “stop” an activity if they senseor discover an essential safety breach. There maybe times when an approach is made to a teammember but is ignored or dismissed withoutconsideration. This will require a person to voicehis or her concerns by restating their concerns atleast twice, if the initial assertion is ignored (thusthe name “two-challenge rule”). These twoattempts may come from the same person or twodifferent team members:

• the first challenge should be in the form of aquestion;

• the second challenge should provide somesupport for the team members’ concern;

• remember this is about advocating for thepatient—the “two-challenge” tactic ensuresthat an expressed concern has been heard,understood, and acknowledged;

• the team member being challenged mustacknowledge the concerns;

• if this does not result in a change or is stillunacceptable, then the person with theconcern should take stronger action bytalking to a supervisor or the next person upthe chain of command.

CUSCUS is shorthand for a three-step process inassisting people in stopping the activity.

I am Concerned

I am Uncomfortable

This is a Safety issue

DESC ScriptDESC describes a constructive process forresolving conflicts.

Describe the specific situation or behaviourand provide concrete evidence or data.

Express how the situation makes you feel andwhat your concerns are.

Suggest other alternatives and seekagreement.

Consequences should be stated in terms ofimpact on established team goals or patientsafety. The goal is to reach consensus.

Barriers to effective teamworkA number of specific barriers exist toestablishing and maintaining effective teamwork inhealth care. These include:

Changing rolesThere are currently considerable change andoverlap in the roles played by different health-careprofessionals. Examples include radiographersreading plain film X-rays, nurses performingcolonoscopies and nurse practitioners havingprescribing rights. These changing roles canpresent challenges to teams in terms of roleallocation and acknowledgement.

Changing settingsThe nature of health care is changing includingincreased delivery of care for chronic conditionsinto community care and many surgicalprocedures to day-care centres. These changesrequire the development of new teams and themodification of existing teams.

Medical hierarchiesMedicine is strongly hierarchical in nature and thisis counterproductive in terms of establishing andeffectively running teams where all members’

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views are accepted and the team leader is notalways the doctor. While there has been a growingacknowledgement that teamwork is important inhealth care this has not necessarily beentranslated into changed practices, especially inemerging and developing nations where culturalnorms of communication may mitigate againstteamwork.

Individualistic nature of medicineThe practice of medicine is based on theautonomous one-on-one relation between thedoctor and patient. While this relationship remainsa core value, it is challenged by many concepts ofteamwork and shared care. This can be at manylevels including doctors being unwilling to sharethe care of their patients through to medico-legalimplications of team-based care.

Instability of teamsAs already discussed, health-care teams are oftentransitory in nature, coming together for a specifictask or event (such as cardiac arrest teams). Thetransitory nature of these teams places greatemphasis on the quality of training for teammembers, which raises particular challenges inmedicine where education and training is oftenrelegated at the expense of service delivery.

Accidents in other industries Reviews of high-profile incidents such as thecrash of Pan Am flight 401 have identified threemain teamwork failings as contributing toaccidents, namely: [18,24] • roles not being clearly defined;• lack of explicit co-ordination;• miscommunication/communication.

Assessing team performance Assessing the performance of a team is animportant step in improving team performance.

A number of teamwork assessment measures areavailable [18,25, 26]. Assessment of teams canbe carried out in a simulated environment, bydirect observation of their actual practice orthrough the use of teamwork exercises such asdescribed in the section below on teachingteamwork.

Assessment of teams can either be done at thelevel of individual performance within the team orat the level of the team itself. Assessment can beperformed by an expert or through peer rating ofperformance.

An analysis of the learning styles or problemsolving skills individuals bring to teamwork can beuseful following the assessment of teamperformance [27].

Summary Teamwork does not just happen. It requiresan understanding of the characteristics ofsuccessful teams, knowledge of how teamsfunction and ways to maintain effective teamfunctioning. There are a variety of team tools thathave been developed to promote teamcommunication and performance and theseinclude SBAR, call-out, check-back and I Passthe Baton.

WHAT STUDENTS NEED TO DO(PERFORMANCE REQUIREMENTS)

Using teamwork principles Medical students can use teamworkprinciples as soon as they start their medicalcourses. Many medical degrees are based on aproblem based learning (PBL) format and require

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students to work together in teams to buildknowledge and solve clinical problems. They canbegin to understand how those teams functionand what makes an effective PBL group. Learningto share information, textbooks and lecture notesis a forerunner to sharing information aboutpatients.

Be mindful of how one’s values andassumptions affect interactions with otherteam membersStudents learn by observing how different healthprofessionals interact with each other. They willrealize that even though a team can be made upof many personalities and practice styles, thisdoes not necessarily make the team less effective.Rather, it can show how the strengths andweaknesses of different members of the team canassist deliver quality and safe care.

Be mindful of the role of team members andhow psychosocial factors affect teaminteractions, recognize the impact of changeon team membersIt can often be difficult for medical students (andindeed practising clinicians) to appreciate thedifferent roles that health-care professionals playin teams, or how teams respond to change orpsychosocial factors. Students can beencouraged to make structured observations ofteams to observe what roles are played bydifferent individuals and how this relates to factorssuch as their personal characteristics as well astheir profession. Students can be encouraged totalk to different team members around theirexperience of working in a team. Faculty canthemselves ensure that students are included inteams and assigned roles so they can observethese processes from the inside.

Include the patient as a member of the teamMedical students can ensure that when they aretaking histories or performing procedures on

patients that they take the time to engage with thepatient. This can include discussing with thepatient the procedure they are undergoing or anyanxieties or concerns the patient or their carersmay have. They can actively include patients inward rounds by either inviting them at the time toparticipate or by discussing with the team howpatients might be included in ward rounddiscussions.

Using mutual support techniques andresolving conflicts, using communicationtechniques and changing and observingbehavioursMedical students can practise all ofthese competencies either in their work with theirpeers in study groups or within health-care teamsas they move through their programme and areincreasingly involved. As detailed below, manyteamwork activities can be used with groups ofstudents and practitioners to explore leadershipstyles, conflict resolution and communicationskills.

A number of practical tips exist to help medicalstudents improve their team communication skills.They can start practising good teamwork at thevery beginning of their medical course. Thefollowing activities and steps will promote goodteamwork in any situation whether as a medicalstudent or a hospital senior doctor. • Always introduce yourself to the team or

those you are working with even if it is for afew minutes.

• Reading back and closing the communicationloop in relation to patient care information.

• Stating the obvious to avoid confusion.

Nurse: Mr Brown is going to have an X-ray.

Student: So, we are taking Mr Brown to havean X-ray now.

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• Asking questions and continually clarifying.• Delegating tasks to people—look at them and

check they have the information to enablethem to do the task. Talking into the air is anunsafe practice because the person may notthink that it is they who have the responsibilityof the task.

• Clarifying your role in different situations.

Nurse: Mr Brown is going to have an X-ray.

Student: So, we are taking Mr Brown to havean X-ray now.

Nurse: Yes.Student: Who is taking Mr Brown for

his X-ray?

• Using objective language not subjectivelanguage.

• Learning the names of people who are in theteam and using them. Some doctors do notbother to learn the names of the nurses andother allied health-care workers thinking theyare not as important. However, doctor betterrelationships with other team members if theyuse people’s names rather than referring tothem by their profession, such as “nurse”.

• Being assertive when required. This isuniversally difficult, yet if a patient is at risk ofserious injury then the health professionals,including students, must speak up. Seniorclinicians will be grateful in the longer term if oneof their patients avoids a serious adverse event.

• If something does not make sense, ask forclarification.

• Briefing the team before undertaking a teamactivity and performing a debriefingafterwards.

This encourages every member of the team tocontribute to discussions about how it went andwhat can be done differently or better next time.

• When conflict occurs, concentrate on “what”is right for the patient not on establishing“who” is right or wrong.

CASE STUDIES

Right action, wrong result

A doctor was coming to the end of his first weekin the emergency department. His shift had endedan hour before, but the department was busy andhis registrar asked if he’d see one last patient.The patient was an 18-year-old man. He was withhis parents who were sure he’d taken anoverdose. His mother had found an empty bottleof paracetamol that had been full the day before.He had taken overdoses before and was underthe care of a psychiatrist. He was adamant he’donly taken a couple of tablets for a headache. Hesaid he’d dropped the remaining tablets on thefloor so had thrown them away. The parents saidthey’d found the empty bottle six hours ago andfelt sure that he couldn’t have taken theparacetamol more than ten hours ago. The doctorexplained that a gastric lavage would be of nobenefit. He took a blood test instead to establishparacetamol and salicylate levels. He asked thelab to phone the emergency department with theresults as soon as possible. A student nurse wasat the desk when the lab technician phoned. Shewrote the results in the message book. Thesalicylate level was negative. When it came to theparacetamol result, the technician said, “two”paused, and then, “one three”, “two point onethree” repeated the nurse, and put down thephone. She wrote “2.13” in the book. Thetechnician didn’t say whether this level was toxicand he didn’t check whether the nurse hadunderstood. When the doctor appeared at thedesk, the nurse read out the results. The doctorchecked a graph he’d spotted earlier on thenotice board. It showed when to treat overdoses.


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There was also a protocol for managingparacetamol overdoses on the notice board, but itwas covered by a memo. The graph showed that2.13 was way below treatment level. The doctorthought briefly about checking with the registrar, butshe looked busy. Instead, he told the student nursethat the patient would need admitting overnight sothat the psychiatrist could review him the next day.The doctor went off duty before the printout cameback from the lab. It read “paracetamol level: 213”.The mistake wasn’t discovered for two days, bywhich time the patient was starting to experiencethe symptoms of irreversible liver failure. It wasn’tpossible to find a donor liver for transplant and thepatient died a week later. If he’d been treated whenhe arrived at the emergency department, he mightnot have died.

The doctor was told what had happened by hisconsultant on Monday when he started his nextshift and, while still in a state of shock, explainedthat he had acted on what he thought was thecorrect result. He had not realised, he admitted,that paracetamol levels are never reported with adecimal point. Because he had not seen theprotocol he had also not appreciated that it mighthave been appropriate to start treatment beforethe paracetamol level had come back anyway,bearing in mind that the history, althoughcontradictory, suggested the patient might wellhave taken a considerable number of tablets. Itwould be unfair to blame the doctor or thestudent nurse individually. The real weakness isthe lack of safety checks in the system ofcommunicating test results. In fact, no-one madea really big mistake. At least three people made aseries of small ones, and the system failed to pickthese up.

ReferenceNational Patient Safety Agency 2005. Copyrightand other intellectual property rights in thismaterial belong to the NPSA and all rights are

reserved. The NPSA authorises healthcareorganisations to reproduce this material foreducational and non-commercial use.

A failure to relay information between staffand to confirm assumptions, resulting inadverse patient outcomeThis example highlights how the dynamicsbetween surgical trainees and staff and the flow ofstaff in and out of the operating roomcan allow adverse events to happen.

Before a roux-en-y gastric bypass patient wasbrought into the operating room, allow nursereported to a second nurse that the patient wasallergic to “morphine and surgical staples”. Thisinformation was repeated again to the staffsurgeon and the anaesthetist before the start ofthe procedure.

As the surgery was coming to an end, the staffsurgeon left the operating room, leaving a surgicalfellow and two surgical residents to complete theprocedure. The surgical fellow then also left theoperating room, leaving the two residents to closethe incision. The two surgical residents stapled along incision closed along the length of thepatient’s abdomen. They stapled the threelaparoscopic incisions closed as well. When theresidents began the stapling, a medical studentremoved a sheet of paper from the patient chartand took it over to the residents. The medicalstudent tapped one of the residents on theshoulder, held the paper up for her to read andtold her that the patient was allergic to staples.The resident looked at it and said “you cannot beallergic to staples.”

The staff surgeon returned to the operating roomas the residents were completing the stapling. Hesaw that the residents had stapled the incisionsand informed them that the patient did not wantstaples. He told them that they would have to


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take all the staples out and suture the incision. Heapologized for neglecting to inform them of thisallergy. One of the residents asked whether youcould be allergic to staples and the staff surgeonsaid: “It does not matter. The patient is convincedthat she is.” The staff surgeon told the residentsthey would have to remove all the staples andsew the incisions. This took an additional 30minutes.

Case from the WHO Patient Safety CurriculumGuide for Medical Schools working group.Supplied by Lorelei Lingard, University of Toronto,Toronto, Canada.

Emergency resuscitation requires teamworkThis case illustrates the importance of the teambeing prepared to carry out an effective code blueor emergency resuscitation.

Medical officer Simon was in the cafeteria eating alate lunch. Halfway through his meal, a cardiac arrestannouncement was made over the public addresssystem. He ran to get the lift up to the fifth floor wardwhere the emergency was. It was peak hour and thelifts were busy. By the time he reached the patient, anurse had wheeled in the cardiac arrest trolley andanother nurse had an oxygen mask on the patient.

“‘Blood pressure, pulse, heart rate?” yelled thedoctor. A nurse grabbed a blood pressure cuffand began to inflate it. The nurse holding theoxygen mask tried to find a pulse on the patient’swrist. The medical officer shouted for an ECGmonitor to be placed on the patient and for the ofthe bed head to be lowered. The nurses tried toobey his orders; one stopped trying to get theblood pressure and lowered the bed. This madethe oxygen mask fall off as the tubing gets caughtin the side panels of the bed.

Simon became agitated. He had no idea of theheart rate or rhythm. The patient did not seem to

be breathing. The heart monitor came on andshowed ventricular fibrillation.

“Pads and 50 joules”, called Simon. The nurseslook at him and say, “What?” “Pads and 50 joules,stat!” Simon replie. “Call a doctor, any doctor, tocome and assist me now!” he yelled. They couldnot revive the patient.

ReferenceCase from the WHO Patient Safety CurriculumGuide for Medical Schools working group.Supplied by Ranjit De Alwis, International MedicalUniversity, Kuala Lumpur,Malaysia.

Everyone on the team countsThis is an example of how an initiative such as apreoperative team briefing can provide anopportunity for individual members of theoperative team to provide information thatimpacts patient outcome. A preoperative teambriefing is a short gathering including nurses,surgeons and anaesthetists held before thesurgery with the goal of discussing importantpatient and procedure relevant issues.

In preparation for a low anterior resection andileostomy, the interprofessional team met to havea briefing. The surgeon asked a nurse whethershe had anything to contribute. The nursereported that the patient was worried about herhernia. In response to this the surgeon questionedthe patient (who was still awake) about the hernia.The surgeon then explains to the operating roomteam how he will proceed around the hernia andthat he might use mesh.

Case from the WHO Patient Safety CurriculumGuide for Medical Schools working group.Supplied by Lorelei Lingard, University of Toronto,Toronto, Canada.


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HOW TO TEACH THIS TOPIC

Teaching strategies and formatsThis module recommends a number of strategies tobuild education and experience around teamwork.

Effective teams do not just happen and there issubstantial body of underpinning theory that canbe appropriately delivered in a didactic manner.The knowledge requirements listed above canform the basis for didactic presentations.

Given that one of the most effective ways oflearning about teamwork is to participate in ateam, we include a number of team-basedactivities that can easily be run with small groupsof students with limited resources. Given thatmedical students will often have little experienceof participating in health-care teams, we includeactivities where students reflect on theirexperiences of teamwork outside of medicine.

To familiarize students with actual health-careteams we then include activities that anticipate thetypes of teams that students will increasinglyencounter as they move forward in their trainingand on to practice.

We conclude this section with a discussion ofinterprofessional education that may or may notbe an option for consideration within your medicalcurriculum.

A recent systematic review of teamwork trainingdeveloped for medical students and junior doctorsfound that teaching teamwork skills to studentsand young doctors was moderately effective overthe short term and appeared to be more effectivewhen more teamwork principles were addressedwithin the training [28].

Any team education and training programmedeveloped must consider local culturally

acceptable behaviour in regard to speaking out ina team and the nature of hierarchies in a givencountry.

Building teamwork education over thecourse of a programmeOver a four- or six-year medical programme thereis an opportunity to stratify teaching and learningaround teamwork. For instance, a programmecould be structured in the following ways.

Early years:

Didactic presentations around• basics of teamwork and learning styles;

• different types of teams in health care;• different learning styles.

Small group activities that focus on:• building fundamental team-based skills;

• appreciating different learning and problemsolving styles;

• reflecting on experience of participating inteams outside of health care;

• the roles of various health-care teams.

Middle and later years:

Didactic presentations around• the roles and responsibilities of different

health professionals in teams;• characteristics of effective teams;• strategies to overcome barriers to

effective teams.

Small group activities that include• interprofessional participation;

• refection on the experience of participating asa medical student in health-care teams;

• teamwork simulation in health-care context(high or low fidelity).


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Teaching activities

Engaging role modelsGiven that teamwork is not always recognized orvalued in the health-care delivery environmentsencountered by students, it is important toengage clinical role models the delivery ofteamwork education. If possible, identify clinicianswith good reputations for working inmultidisciplinary teams. Ideally, these role modelswould present different aspects of the theorybehind teamwork and give examples from theirown experiences. Wherever possible, role modelsshould be drawn from multiple health-careprofessions.

Reflective activities around experiences ofteamworkA simple way to introduce teamwork concepts tomedical students is to get them to reflect onteams they may have participated in during schoolor university. This may include sporting teams,work teams, choirs and so on. Reflectiveexercises can include the creation of simplesurveys that can be used to draw out questionsaround teamwork.

Reflective exercises can also be built aroundexamples of teamwork failures or successes thatmay be topical and/or current within the localcommunity. This may include the development ofquizzes or group discussions about newspaperarticles describing failures in sporting teamsassociated with teamwork failures or high-profileexamples of medical errors due to failures inteamwork. The case studies provided within theframework could also be used to reflect on failuresin teamwork.

High-profile examples of teamwork failures andsuccesses outside of health care such as planecrashes or nuclear power station failures are oftenused in the teaching of teamwork principles. A

number of these are described in detail by Flin etal. [18] and include the crashes of in the Pan Amand KLM 747s in Tenerife and the rescue of theApollo 13 mission.

Team building exercises There are a wide range of activities that can helppromote an understanding of team dynamics anddifferent learning styles. A simple search of theinternet will provide access to many examples.These can be useful for any level of teamparticipant and require no prior knowledge ofhealth care or teamwork. The intention is that theyare fun to take part in and often have a positiveside-effect of bonding student groups together.

Remember, one of the most important parts of anyteam building exercise is the debrief at the end ofthe exercise. The purpose of the debrief is to• reflect on what worked well for the team so

that effective team behaviours are reinforced; • reflect on what was difficult and what

challenges the team face—strategies tomanage the challenges should be exploredand then practised in subsequent sessions.

Free team building games can be found on thefollowing web site.http://www.businessballs.com/teambuildinggames.htm

Building newspaper towers: an example of ateam building exercise (taken from the web siteabove) An interactive exercise that requires no physicalcontact that can be varied depending on thegroup size, dynamics and available time.

Basic exercise:Split the group into smaller groups of 2–6 people.Issue each group with an equal number ofnewspaper sheets (the fewer the more difficult,20-30 sheets is fine for a 10-15 minute exercise),


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and a roll of sticky tape. The task is to constructthe tallest free-standing tower made only ofnewspaper and sticky tape in the allotted time. Thepoint of the exercise is to demonstrate importanceof planning (time, method of construction,creativity) and the motivational effect of a teamtask. The facilitator will need a tape measure.

Instructions need to be very clear. For instance,does the tower have to be free standing or can itbe braced? It does not matter which, it mattersonly that any issues affecting a clear result areclarified.

Tips for newspaper constructions exercisesYou can allocate as many sheets as you wish,depending on the main purpose of the exercise,and to an extent the duration and how many teammembers per team. As a general rule, the fewerthe sheets the smaller the teams and the shorterthe exercise. Short timescales, big teams, lots ofsheets = lots of chaos. This may be ideal fordemonstrating the need for leadership andmanagement. Unless the primary purpose isleadership and managing the planning stage,avoid small numbers of sheets with large teams.Small teams do not need lots of sheets unlessyou make a rule to use all materials in order to putpressure on the planning and design stage.

Examples of main purposes and numbers ofsheets: • very strong emphasis on preparation and

design;• 1-5 sheets in pairs or threes; • design, planning, preparation, teamworking:

5–10 sheets in team of three or four; • team building, time management, warm up,

ice-breaker, with some chaos management:20 sheets in teams of four, five or six;

• managing a lot of chaos: 30 sheets andupwards in teams of six or more.

Newspaper construction exercises are terrificallyflexible and useful. Once you decide the activitypurpose and rules, the important thing is to issuethe same quantity of materials to each team.

Other tips for newspaper construction activities:• Building tips: it does not matter how big the

sheets are, but large double pages offer thegreatest scope for the towers.

• Think about how much paper is issued as itchanges the type of challenge: lots of papermakes it much easier and places lessemphasis on planning. Very few sheets, oreven just one sheet, increases therequirement for planning.

• The main trick (do not tell the participantsbefore the exercise) is to make long thinround-section struts by rolling the sheets andfixing with sticky tape—Sellotape or Scotchtape, or narrow masking tape instead. Thestruts can then be connected using varioustechniques, rather like girders.

• Round struts (tubes), and any other design ofstruts or sections, lose virtually all theirstrength if flattened or bent. Very fewnewspaper exercise builders understand thisfundamental point, and some fail to realize iteven after completing the exercise, so it isworth pointing out during the review.

• Square sections are not very strong.Triangular or circular sections work best,although the former are difficult to make.

• It is possible to make a very tall tower (8–10feet) using a telescopic design, which requiresmany sheets to be stuck together end-to-end, rolling together and then pulling out fromthe centre.

• Most people make the mistake of forming bigsquare section lengths or spans, which areinherently very weak and unstable. This iswhy the newspaper constructions are suchgood exercises—each one needs thinkingabout and planning and testing or people fall


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into traps and make simple mistakes. • The best way of finding answers is to try it—

you should be doing that anyway if you arefacilitating and running the session. You willbe amazed at how strong paper can be if it isfolded and/or rolled and assembled with a bitof thought.

Simulated health-care environments Simulation is being increasingly used to learn andpractise teamwork in health care. This is an ideallearning environment for medical students, as itcombines safety—there is no “real” patient—andthe ability to increase or decrease the speed ofevolution of the scenarios to optimize learning,especially if using mannequin-based simulationtechniques. This is ideal for teamwork exercisesas the importance of sound teamwork behavioursis particularly manifest in “emergency”, time-critical situations. In addition, students get achance to experience what it is like to manage asituation in “real” time.

Ideally, simulated environments may be used toexplore teamwork using mixed groups of health-care professionals. When exploring teamwork thefocus should not be on the technical skills of thestudents but rather their interactions andcommunication with one another. The best way toensure this remains the focus of the exercise is toallow the students to learn and practise thetechnical aspects of the scenario together prior tothe actual scenario, usually through an initialprocedural workshop. If the team struggle withbasic knowledge and skills then the opportunity todiscuss teamwork may be lost as there may be somany important medical and technical issues todiscuss. However, if the students are well drilledon the technical aspects of the scenariobeforehand, the challenge for them is to put whatthey know into action as a team. The simulationthen becomes a powerful opportunity to explorethe “non-technical” aspects of the scenario,

namely the teamwork, leadership andcommunication issues that emerge as thescenario unfolds [18].

As with the non-health-care team buildingexercises discussed above, it is vital that astructured debriefing is conducted that exploresthe way the teams performed in the exercise:what worked well and why, what was difficult andwhy, and what could be done to improveperformance on subsequent occasions. If differenthealth-care students are working together in thesimulation, the different roles, perspectives andchallenges of each profession can be discussedduring the debriefing as well.

The major constraint with simulation exercises isthat they can be resource intensive, especially ifusing a computerized mannequin and attemptingto make a teaching setting look like a clinicalenvironment.

Participating in health-care teamsStudents, particularly in their later years, shouldbe encouraged to participate in a number ofdifferent types of health-care teams at everyopportunity. Just because the doctors and nursesfrom a particular ward or clinic maintain thetraditional silo approach to health care does notprevent medical students working with otherhealth professionals as part of a team.

The faculty should identify teams where studentswill be welcomed and ideally given some form ofparticipatory role. These teams may include well-established multidisciplinary care planning teamssuch as found in mental health or oncology ormore fluid teams as found in emergencydepartments. They should also include primaryhealth-care teams in the community.

It is important to get students to reflect on team-based experiences in health care and share these


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experiences with other students and faculty staff.This will allow then to discuss both the positiveand negative aspects of their experience.Students should be asked to identify model teamsand why they believe they can be identified assuch. They should be encouraged to askquestions such as:• What were the strengths of the team?• What professions were represented on the

team and what was their role?• Did the team have clear goals?• Was there a clear leader?• Were all team members permitted to

participate?• How did members of the team communicate

with one another?• How could the student see the team being

improved?• Was the patient part of the team?

Students should be asked to explore and reflecton areas of teamwork where errors are know tooccur such as communication between primaryand secondary care or during handover/hand off.

It may also be possible for students to take part ina panel discussion with an effectivemultidisciplinary team to discuss how the teamfunctions and works together.

Interprofessional educationWhile the focus of this Curriculum Guide is onmedical schools, teamwork in health care cannotbe discussed without discussing the importantrole of interprofessional education (IPE) inundergraduate health education.

At the heart of IPE is the preparation of futurepractitioners for effective team-based practicethrough bringing students from differentdisciplines together during undergraduateeducation to learn from and with each other.Undergraduate education is a good time to bring

different groups of students together to appreciateand respect the different roles of healthprofessionals before they have joined aprofessional group themselves.

While there is a compelling argument thatundergraduate IPE should improve subsequentteamwork in practice, the research to support thisargument is not yet conclusive.

Universities have taken different approaches tointroducing IPE depending on available resources,the available undergraduate programmes and thedegree of support for the concept at a seniorlevel. Approaches have ranged from a full re-engineering and alignment of all health curriculathrough to inserting IPE modules and activitiesinto existing curricula on a relatively opportunisticbasis.

The resources and activities included in this guideare intended to be useful either for programmesteaching only medical students or for thoseteaching multiprofessional student groups.

Below we include further reading on IPE and linksto universities that have introduced IPE into theircurricula.

ResourcesInstitute for Healthcare Improvement. Healthprofession education: a bridge to quality.Washington DC, National Academies Press, 2003.Almgren, G et al. Best practices in patient safetyeducation: module handbook. University ofWashington, Seattle, Center for Health SciencesInterprofessional Education, 2004.


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Universities that have introduced major initiativesin IPE include:• Health Care Innovation Unit, University of

Southampton, UKhttp://www.hciu.soton.ac.uk/

• Faculty of Health Sciences, LinkopingUniversity, Sweden.http://www.hu.liu.se/?l=en

• College of Health Disciplines, University ofBritish Columbia, Canada.http://www.chd.ubc.ca/

• Faculties of Health, The University of Sydney,Australiahttp://www.foh.usyd.edu.au/ipl/about/index.php

Summary In summary, team training for medical studentscan be effective using a variety of techniques,many of which can be delivered in the classroomor low-fidelity simulated environment.

Ideally, medical students should take part in realteams and learn through experience and guidedreflection.

As far as possible, team training should focus onas many principles of effective teamwork aspossible.

TOOLS AND RESOURCES

TeamSTEPPS™: Strategies and tools toenhance performance and patient safetyDepartment of Defense in collaboration with theAgency for Healthcare Research and Quality(AHRQ)(http://teamstepps.ahrq.gov/abouttoolsmaterials.htm).

TeamSTEPPS™ also includes free access to anumber of trigger tapes and videos.

SBAR ToolkitInstitute for Healthcare Improvement (IHI),Oakland, CA Kaiser Permanente(http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARToolkit.htm).

Teamwork in health care: promoting effectiveteamwork in health care in CanadaCanadian Health Services Research Foundation(CHSRF), 2006(http://www.chsrf.ca/research_themes/pdf/teamwork-synthesis-report_e.pdf).

How to assess this topic

Many different modalities can be used to assessteamwork.

MCQs and MEQs can be used to exploreknowledge components.

A portfolio to be maintained over the entirecurriculum can be used to record and reflect onteam activities encountered at medical school.

Assignments can be specifically designed torequire teamwork among students. This mayinclude students self-selecting a health- or non-health-related project to complete or facultysuggesting a project such as planning thedevelopment of an apartment for a person whouses a wheelchair or planning the development ofa rural outreach programme for oral health. Indeveloping the assignment, the emphasis is notso much on the outcome of the project but ratherthe manner in which the students approach theteamwork aspects of working together.

Later assessments can be more complex andrequire items such as a review of a team withwhich the student is working and thedevelopment of recommendations for how thatteam could be improved.


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A writing assignment could include tracking teamfunctions by following either a patient stay for adefined period of time or tracking a health-careprovider and reviewing how many teams theyintersect with and what there roles are on eachteam.

Depending on available resources, simulation canalso be used an effective formative andsummative assessment of health-care teamwork.

Ideally, some assessments would require studentsfrom different health professions to work together.

HOW TO EVALUATE THIS TOPIC

• As with any evaluation exercise, a number ofevaluation phases need to be considered.These would include

• a needs analysis (or prospective evaluation) tojudge how much teaching in teamworkcurrently exists and how much is needed;

• a process evaluation during the delivery ofany programmes to maximize itseffectiveness;

• an impact evaluation to track the impact ofthe programme on knowledge andcompetencies gained during the delivery ofthe programme.

See the Teacher’s Guide (Part A) for moreinformation on evaluation.

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Safety: the evidence-based relation. LiteratureReview. AHRQ Publication No. 05-0053.Rockville, MD, Agency for HealthcareResearch and Quality, 2005(http://www.ahrq.gov/qual/medteam/).

2. Schyve PM. The changing nature of

professional competence. Joint CommissionJournal on Quality and Patient Safety, 2005,31:185–202.

3. Salas E, Dickinson TL, Converse SA. Towardan understanding of team performance andtraining. In: Swezey RW, Salas E, eds. Teams:their training and performance. Norwood, NJ:Ablex, 1992:3–29.

4. Orasanu JM, Salas E. Team decision makingin complex environments. In: Klein GA et al.,eds. Decision making in action: models andmethods. Norwood, NJ, Ablex, 1993:327–345.

5. Cannon-Bowers JA, Tannenbaum SI, Salas E.Defining competencies and establishing teamtraining requirements. In: Guzzo RA, et al.,eds. Team effectiveness and decision-makingin organizations. San Francisco, Jossey-Bass,1995:333–380.

6. Bowers CA, Braun CC, Morgan BB. Teamworkload: its meaning and measurement. In:Brannick MT, Salas E, Prince C, eds. Teamperformance assessment and measurement.Mahwah, NJ, Erlbaum, 1997:85–108.

7. Brannick MT, Prince C. An overview of teamperformance measurement. In: Brannick MT,Salas E, Prince C, eds. Team performanceassessment and measurement. Mahwah, NJ,Erlbaum, 1997:3–16.

8. Salas E et al. Toward an understanding of teamperformance and training. In: Sweeney RW,Salas E, eds. Teams: their training andperformance. Norwood, NJ, Ablex, 1992.

9. Quality AfHRa. TeamSTEPPS™: strategiesand tools to enhance performance andpatient safety. Rockville, MD, November2007.

10. Bogner M. Misadventures in health care.Mahwah, NJ, Erlbaum, 2004.

11. Lingard L et al. Communication failures in theoperating room: an observationalclassification of recurrent types and effects[see comment]. Quality & Safety in Health


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Care, 2004, 13(5):330–334.12. Mickan SM. Evaluating the effectiveness of

health care teams. Australian Health Review,2005, 29(2):211–217.

13. Stevenson K et al. Features of primary healthcare teams associated with successful qualityimprovement of diabetes care: a qualitativestudy. Family practice, 2001, 18(1):21–26.

14. Junor EJ, Hole DJ, Gillis CR. Management ofovarian cancer: referral to a multidisciplinaryteam matters. British Journal of Cancer,1994, 70(2):363–370.

15. Morey JC, Simon R, Jay GD. Error reductionand performance improvement in theemergency department through formalteamwork training: evaluation results of theMedTeams project. Health Services Research,2002, 37(6):1553–1581.

16. Risser DT et al. The potential for improvedteamwork to reduce medical errors in theemergency department. The MedTeamsResearch Consortium. Annals of EmergencyMedicine, 1999, 34(3):373–383.

17. Tuckman BW. Development sequence insmall groups. Psycological Review, 1965,63:384–399.

18. Flin RH, O’Connoer P, Crichton M. Safety atthe sharp end: a guide to non-technical skills.Aldershot, UK, Ashgate Publishing Ltd, 2008.

19. Mickan SM, Rodger SA. Effective health careteams: a model of six characteristicsdeveloped from shared perceptions. Journalof Interprofessional Care, 2005, 19(4):358–370.

20. Lingard L et al. A theory-based instrument toevaluate team communication in theoperating room: balancing measurementauthenticity and reliability. Quality & Safety inHealth Care, 2006, 15(6):422–426.

21. Lingard L et al. Perceptions of operating roomtension across professions: buildinggeneralizable evidence and educationalresources. Academic Medicine, 2005,

80(Suppl. 10):S75–S79.22. West M. Effective teamwork: practical lessons

from organisational research. Leichester,Blackwell, 2004.

23. Marshall S, Harrison J, Flanagan B. Theteaching of a structured tool improves theclarity and content of inter-professional clinicalcommunication. Quality & Safety in HealthCare, 2008 (in press).

24. Rouse WB, Cannon-Bowers J, Salas E. Therole of mental models in team performance incomplex systems. IEEE Transactions onSystems, Man and Cybernetics, 1992,22:1295–1308.

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26. Salas E et al. Markers for enhancing teamcognition in complex environments: the powerof team performance diagnosis. Aviation,Space, and Environmental Medicine, 2007,78:5(Suppl. Sect 11):B77–B85.

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Slides for topic 4: Being an effectiveteam player

Didactic lectures are not usually the best way toteach students about patient safety. If a lecture isbeing considered, it is a good idea to plan forstudent interaction and discussion during thelecture. Using a case study is one way togenerate group discussion. Another way is to askthe students questions about different aspects ofhealth care that will bring out the issues containedin this topic.

The slides for topic 4 are designed to assist theteacher deliver the content of this topic. The slidescan be changed to fit the local environment andculture. Teachers do not have to use all of theslides and it is best to tailor the slides to the areasbeing covered in the teaching session.


topic 4: being an effective team player

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