TeamSTEPPS Fundamentals Course: Module 5. Mutual Support: Instructor's Materials

TeamsTEPPS Fundamentals Course

TeamSTEPPS is a teamwork system developed jointly by the Department of Defense (DoD)and the Agency for Healthcare Research and Quality (AHRQ) to improve institutional collaboration and communication relating to patient safety.

One penguin is standing on the shoulders of another to look over an obstacle.

"A chain is only as strong as its weakest link." –Author Unknown


Contents


Exercise: Mutual Support—Optional

Mutual Support. One penguin is standing on the shoulders of another to look over an obstacle. 'A chain is only as strong as its weakest link. -Author Unknown'

Mutual Support. One penguin is standing on the shoulders of another to look over an obstacle. 'A chain is only as strong as its weakest link. -Author Unknown'

Mutual Support. One penguin is standing on the shoulders of another to look over an obstacle. 'A chain is only as strong as its weakest link. -Author Unknown'

Module Time: 50 Minutes

Materials: Mutual Support Exercise Sheet

 Customizable Content:

 You have the option of using the following scenario if you want.

Say:

The focus of this module is mutual support and the behaviors that make up this core team skill. To begin this module, we are going to read through a scene involving three nurses. Please think about how the members of this team work together in the following scenario.

Do:

Use the scenario below or select another from the specialty section. Ask for three volunteers to perform the parts for the rest of the participants.

Say:

Two nurses are at the desk during a brief lull in a busy day. They notice another nurse racing busily from the supply area to the gurneys, glancing over at them as she passes.

Scenario Script:

Nurse #1: "Let's see whether Maureen can use some help."

Nurse #2: "My patient will be back from X-ray in just a few minutes, and I hate to get tied up. Besides, Maureen doesn't usually accept help from anyone."

Nurse #1: "Come with me. I'll show you how it's done."

(Nurse #1 approaches Nurse #3.)

Nurse #1: "Maureen, I can see you're busy. I have about 5 minutes before my patient gets back from X-ray. I can start this IV for you while you tend to your other patient if you like."

Nurse #3: "Thanks. The IV is set up. You just need to start the line."

(Nurse 3 exits.)

Nurse #1: "The key to offering assistance is being clear about how much time you have and what tasks you're able to pick up."

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Objectives

Objectives: Define mutual support; Discuss task assistance and the types of feedback; Describe advocacy, assertion, and the Two-Challenge rule; Discuss "CUS" and "DESC script" techniques; Discuss common approaches to conflict resolution; List barriers, tools, strategies, and outcomes of mutual support
 

Say:

In this module, we'll:

  • Define mutual support.
  • Discuss task assistance and the types of feedback.
  • Describe advocacy, assertion, and the Two-Challenge rule.
  • Discuss "CUS" and "DESC script" techniques.
  • Discuss common approaches to conflict resolution.
  • List barriers, tools, strategies, and outcomes of mutual support.

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TeamSTEPPS Team Skills

TeamSTEPPS logo. For details, go to [D] Text Description.

[D] Select for Text Description

Time: 5 minutes

Materials:
  • Flipchart or Whiteboard (Optional)
  • Markers (Optional)

Say:

Mutual support is a key component of the teamwork process and is intimately linked to the other three essential elements of teamwork:

  • Because mutual support involves the willingness and preparedness to assist other team members during operations, it is enhanced by team leadership, given that team leaders encourage and role model "back-up" behaviors.
  • Mutual support is derived from situation monitoring through the ability to anticipate patient needs, as well as other team members' needs with accurate knowledge of their responsibilities. (Recall that a clear assessment of the situation is requisite to providing support.)
  • Mutual support is also moderated by communication that influences the delivery and ultimate effectiveness of the mutual support.

There are many situational factors that influence workload and the need for mutual support. Break off into groups for a 4-minute brainstorm on the situational factors that influence workload and the need for mutual support. At the end of the 4-minute period, your group will present one factor from your list to the group.

Do:

Break off groups and supply whiteboards/paper to record ideas to report to the whole class. Below is a list of some of the situational factors influencing workload that should be captured or mentioned.

Possible Answers:

  • Planning—planning can decrease workload.
  • Unexpected events—can quickly generate work that overwhelms people.
  • Patient volume—extremes and high flows.
  • Environmental design—location of resources.
  • Skill mix—experience levels.
  • Performance of other departments—delays and wrong equipment.
  • Patient state.
  • Lack of or malfunctioning equipment.

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Mutual Support

Mutual support. Mutual support is the essence of teamwork: Protects team members from work overload situations that may reduce effectiveness and increase the risk of error

Materials:
  • Flipchart or Whiteboard (Optional)
  • Markers (Optional)

Say:

Mutual support, which is commonly referred to as "back-up behavior" in the teamwork literature, is critical to the social and task performance aspects of teams. The construct suggests some degree of task interchangeability among members because they must fully understand what each one of the others does. To compensate for individual differences in team performance, constant vigilance is required of all team members.

Mutual support enables teams to function effectively. It is the essence of teamwork. In a healthcare environment, one team member's work overload may result in fatal consequences. Mutual support provides a safety net to help prevent errors, increase effectiveness, and minimize strain caused by work overload. Over time, continuous mutual support fosters team adaptability, mutual trust, and team orientation.

 Discussion:

What types of behavior do you think constitute mutual support or team back-up behavior?

Potential Answers:

Below are some team backup behaviors that could be captured on the final list.

  • Monitoring other team members' performance to anticipate assistance requests.
  • Offering or requesting assistance.
  • Filling in for a member who is unable to perform a task.
  • Cautioning team members about potentially unsafe situations.
  • Self-correcting, as well as helping others correct their mistakes.
  • Distributing and assigning work thoughtfully.
  • Rerouting/delaying work so that the overburdened team member can recover.
  • Regularly providing feedback to each other .
  • Providing encouragement.

** We'll focus specifically on task assistance, feedback, advocacy and assertion, and conflict resolution as tools for mutual support.

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Task Assistance

Task Assistance. Team members foster a climate in which it is expected that assistance will be actively sought and offered as a method for reducing the occurrence of error. 'In support of patient safety, it's expected!'

Say:

One method of providing mutual support is through task assistance. Task assistance is guided by situation monitoring because situation awareness allows team members to effectively identify the need for assistance by others on the team. To a certain degree, some of us have been conditioned to avoid asking for help because of the fear of suggesting lack of knowledge or confidence. Many people refuse to seek assistance when overwhelmed by tasks. In support of patient safety, however, task assistance is expected. What can happen when we are overwhelmed and we do not seek task assistance?

Ask:

What can happen when we are overwhelmed and we do not seek task assistance?

Say:

Error vulnerability is increased when people are under stress, are in high-task situations, and when they are fatigued. One of the most important concepts to remember with regard to Task assistance is that assistance should be actively given and offered whenever there is a concern for patient safety related to workload. Always remember the focus should be on patient safety rather than the individuals need for task assistance.

Task assistance may involve asking for assistance when overwhelmed or unsure; helping team members to perform their tasks, shifting workload by redistributing tasks to other team members, delaying/rerouting work so the overburdened member can recover, and/or filling in for overburdened team members when necessary.

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Task Assistance (continued)

One penguin is standing on the shoulders of another to look over an obstacle.

Say:

There are several factors that influence task assistance.

  1. Type of situation: Some team members react differently to offers and requests for help during emergent versus routine situations. Effective teams place all offers and requests for assistance in the context of patient safety and progress toward team goals, regardless of the situation.
  2. Attitudes and beliefs: Some attitudes restrict team members from offering or requesting assistance. What examples of attitudes and beliefs can you think of that could affect task assistance?

    Effective teams replace these attitudes with a strong value for patient safety. Team members foster a climate in which it is expected that assistance will be actively sought and offered as a method for reducing the occurrence of error.

  3. Style of communication: Personal style can have a significant influence on support actions taken by the team. A person's tone of voice or use of avoidance behaviors (e.g., being inaccessible or elusive) may inhibit others from asking for help. Effective teams demonstrate a willingness to engage in support behaviors wherever there is a need, and they communicate the information necessary to achieve that objective.

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Discussion: Task Assistance

Discussion-ask Assistance: In which situations can task assistance be used?; How can you make this a daily practice on your unit?; and How can you build it into your system to achieve cultural change? 'Ask for help... Offer help'

Say:

Task assistance completes an activity or solves a problem. In regard to task assistance, remember to—

  • Communicate clear and specific availability of time and skills when offering assistance.
  • Foster a climate supportive of task assistance-helping each other may have a domino effect.
  • Use common courtesy when asking for help.
  • Close the loop on task communication-ensure the task was completed correctly.
  • Account for experience level.

 Discussion:

  • Where can task assistance be used when you have someone to help and someone willing to receive help?
  • When is it appropriate to offer or ask for task assistance?
  • How can you build task assistance into your system to achieve cultural change?

Say:

Culture is affected by behavior. If behavior is exhibited consistently, it becomes part of the culture.

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What is Feedback?

What Is Feedback? 'Feedback is the giving, seeking, and receiving of performance-related information among the members of a team.' (Dickinson and McIntyre 1997)

Say:

Another type of mutual support is feedback. Feedback is information provided for the purpose of improving team performance. The ability to communicate self-improvement information in a useful way is an important skill in the team improvement process. Feedback can be given by any team member at any time. It is not limited to management roles or formal evaluation mechanisms. Performance feedback benefits the team in several ways:

  • Fosters improvement in work performance.
  • Meets the team's and individual's need for growth.
  • Promotes better working relationships.
  • Helps the team set goals for ongoing improvement.

 Discussion:

What are examples of giving feedback?

  • Cautioning team members about potentially unsafe situations. Example: "Your patient's blood pressure appears to be dropping. Do you think we should address this?" or "It looks like you're having some difficulty getting an IV inserted. I have a few minutes and will get a central line set up in case you need one."
  • Providing necessary information. Example: "I've brought you the file containing the patient's medical history and old EKGs. I think the patient has a strong family history of hyperlipidemia and heart disease."
  • Providing encouragement. Example: After she worked her first major trauma, she was told by the head trauma nurse that she did a great job and stayed cool and composed under the stress of the situation.

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Types of Feedback

Types of Feedback: Can be formal or informal; Constructive feedback: -Is considerate, task-specific, and focuses attention on performance and away from the individual (Baron 1988); and -Is provided by all team members ;Evaluative feedback: -Helps the individual by comparing behavior to standards or to the individual's own past performance (London, Larson, and Thisted 1999); and -Most often used by an individual in a coaching or mentoring role

Say:

Feedback can be provided by anyone on the team, it can be formal or informal, and it can be constructive or evaluative. Formal feedback tends to be retrospective in nature, is typically scheduled in advance and away from the clinical area, and has an evaluative quality. Examples include collaborative discussion, case conferences, and individual performance reviews. Typically, informal feedback occurs in real time and on an ongoing basis and focuses on knowledge and practical skills development. Examples include huddles and debriefs.

Constructive feedback is task-specific, focuses attention on the performance and not on the individual, usually is provided by all team members regardless of their role on the team, and is most beneficial when it is focused on team processes and is provided regularly. Evaluative feedback helps the individual understand performance by comparing behavior with standards or with the individual's own past performance. It is not a comparison of the individual's performance with that of other team members, and most often it is provided by individuals in a mentoring or coaching role.

 Discussion:

Could someone provide an example of when he or she effectively provided feedback?

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Characteristics of Effective Feedback

Good Feedback is-: Timely; Respectful; Specific; Directed toward improvement: -Helps prevent the same problem from occurring in the future; and Considerate. 'Feedback is where the learning occurs.'

Say:

Feedback is the facet of team communication in which learning occurs. Rules of effective feedback include the following:

  • Timely—If you wait too long, facts are forgotten and the feedback loses its "punch." Feedback is most effective when the behavior being discussed is still fresh in the mind of the receiver.
  • Respectful-The feedback should not be personal, and it should not be about personality. It should be about behavior. Never attribute a team member's poor performance to internal factors because such destructive feedback lowers self-efficacy and subsequent performance.
  • Specific—The feedback should relate to a specific situation or task. Imagine that you are receiving feedback from a peer who tells you that your surgical techniques need work. That statement is too general to use as a basis for improvement. The person receiving feedback will be better able to correct or modify performance if specific actions are mentioned during feedback.
  • Directed—Goals should be set for improvement.
  • Considerate—Be considerate of team members' feelings when delivering feedback, and remember to praise good performance. A feedback message will seem less critical if you provide information on the positive aspects of a person's performance as well as how the person may improve. Generally, fairness and respect will cushion the effect of any negative feedback.

Feedback may also be used to reinforce positive behaviors. All of us benefit from knowing that we've done a good job and that it has been recognized by others. Unacceptable negative feedback would include the following:

  • Delayed feedback—Feedback must be timely enough for an individual to be able to readily associate it with the behavior. Delivering feedback several weeks after a poor performance has occurred is too late for it to be effective.
  • Publicly delivered feedback—Negative feedback should never be expressed to individuals in front of other team members. The outcome of this approach is that individuals could possibly feel humiliated.

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A Feedback Scenario

An attending watches an intern start to place a chest tube in an obese patient. The attending corrects the placement of the planned incision by pulling the intern aside, showing the intern the landmarks to use, and demonstrating how the patient's position on the table is slightly distorting the anatomy.

Say:

An attending watches an intern start to place a chest tube in an obese patient. The attending corrects the placement of the planned incision by pulling the intern aside, showing the intern the landmarks to use, and demonstrating how the patient's position on the table is slightly distorting the anatomy.

 Discussion:

  • Is the feedback timely?
    — Yes. It is immediate and keeps patient safety of primary concern.
  • Is the feedback respectful and related to behavior?
    — Yes. It is behavioral in nature and not criticism directed at the intelligence of the intern.
  • Is it specific?
    — Yes. It suggests specific considerations to be aware of in the future.
  • Is it directed?
    — Yes. It is directed in showing the intern how to evaluate future patients and to be sure the anatomy is not distorted.
  • Is it considerate?
    — Yes. It is considerate to show that this is an abnormal situation and one the intern had not yet been trained to consider. Also, pulling the intern aside and not embarrassing him in front of the patient was appropriate.

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Providing Feedback Effectively

Female doctor shaking hand of male technician. At bottom right is penguin director icon to denote a video link.

Video Time: 29 seconds
 
Materials:
Feedback.Doc
ToMedTech.
INPTMED Video

 Customizable Content:

Say:

Here we will see an example of a doctor providing feedback to medical tech. Please think about the guidelines for giving effective feedback as you watch the video.

Do:

 Play the video by selecting the director icon on the slide.

 Discussion:

What was effective in the feedback provided?

  • Appears to be timely.
  • Respectful and related to behavior.
  • Specific.
  • Directed.
  • Considerate.
  • Effective communication technique will be shared with others for continuous learning.

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Advocacy, Assertion, and Conflict Resolution

Image 1 of 3: Penguin doctor at patient's bedside. Image 2 of 3: A small agitated penguin in scrubs with a larger penguin doctor. Image 3 of 3: Two penguins arguing over a rock on the ice.

Say:

Advocating for the patient and asserting your viewpoint are both important aspects of engaging in mutual support. However, even when used correctly, these techniques may lead to conflict. Conflict resolution is a skill team members need to deal with interactions that reflect both system and patient care problems that tend to pull them apart.

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An Advocacy and Assertion Scenario

A medical floor nurse is assigned to a patient following a myocardial infarction. The attending physician provides the final treatment, reviews the clinical situation, and determines that the patient is well enough to be discharged.

 Customizable Content:

Say:

A medical floor nurse is assigned to a patient following a myocardial infarction. The attending physician provides the final treatment, reviews the clinical situation, and determines that the patient is well enough to be discharged. Before discharge, the nurse checks the patient's vitals one last time. The nurse finds it unusual that the blood pressure and heart rate are substantially elevated. Despite concerns, the nurse discharges the patient because the physician made it clear that the patient is well enough to go home. Besides, the physician is a well-respected authority at the hospital.

 Discussion:

  • What might the outcome be?
  • Why didn't the nurse discuss his concerns with the physician?
  • If you were in this situation, what would you have done differently?
  • What should the nurse do if he voices his opinion and is not taken seriously?

Say:

We're now going to discuss the format and tools of effective advocacy and assertion, and several tools of conflict resolution.

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Advocacy and Assertion

Advocacy and Assertion: Advocate for the patient: -Invoked when team members' viewpoints don't coincide with that of a decision maker; and Assert a corrective action in a firm and respectful manner. Two images to right of text: Penguin doctor at patient’s bedside; and A small agitated penguin in scrubs with a larger penguin doctor.

Say:

Advocacy and assertion interventions are invoked when a team member's viewpoint does not coincide with that of a decision maker. In advocating for the patient and asserting a corrective action, the team member has an opportunity to correct errors or the loss of situation awareness. Failure to employ advocacy and assertion has been frequently identified as a primary contributor to the clinical errors found in malpractice cases and sentinel events.

You should advocate for the patient even when your viewpoint is unpopular, is in opposition to another person's view, or questions authority. When advocating, assert your viewpoint in a firm and respectful manner. You should also be persistent and persuasive, providing evidence or data for your concerns.

In the next section, we will address conflict and conflict resolution. But first, let's talk about the assertive statement.

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The Assertive Statement

The Assertive Statement: Respect and support authority; Clearly assert concerns and suggestions; Use an assertive statement (nonthreatening and ensures that critical information is addressed) Make an opening: -State the concern; -State the problem; -Offer a solution; -Reach an agreement.

Say:

Hospital and medical team leadership must foster an atmosphere in which the participation of every medical team member can flourish. This is accomplished by maintaining an environment that is predictable, but at the same time retaining the ability to respond to changing clinical situations. Team members must always feel their inputs are valued, at any level. More important, their inputs should be expected, especially in situations that threaten patient safety. Medical team members must respect and support the authority of the team leader while clearly asserting their suggestions or communicating concerns. These two concepts actually go hand in hand; respect for team members means speaking up when patient safety is at stake. When the clinical situation dictates that the medical team member must be assertive and address concerns regarding patient care, the assertive statement is the action. It is a nonthreatening, respectful way to make sure the concern or critical information is addressed. It is a five-step process:

  • Open the discussion.
  • State the concern.
  • State the problem-real or perceived.
  • Offer a solution.
  • Obtain an agreement.

Say:

Here's an example. Let's say we're in the endoscopy suite, and a patient is undergoing a colonoscopy. The endoscopy nurse thinks she sees a possible lesion that may have been missed. What should she say?

Possible Answers:

  • Opening: Say the person's name to whom the concern is addressed: "Dr. Myers..."
  • State concern: An owned emotion: "I thought I saw something abnormal looking in the cecum just as you started to withdraw the scope."
  • State the problem: Real or perceived: "I can't be certain but the mucosa looked abnormal."
  • Offer a solution: "Since you're so close, it would be easy to check the area."
  • Obtain an agreement: "Would you advance the scope back into the cecum and I'll point out the area I thought might be abnormal?"

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Conflict Resolution Options

Penguin in white coat speaking softly to penguin doctor who is ignoring the speaker; 2) Penguin speaks more forcefully and the doctor reacts.

Say:

Let's address the two types of conflict. Information conflict tends to be more impersonal. It involves differing views, ideas, and opinions. It could be a disagreement about the content of a decision. Personal conflict stems from interpersonal compatibility and is not usually task related. Tension, annoyance, and animosity are common. It can be very argumentative. Attempts should be made to resolve both types of conflict before they interfere with work and undermine quality and patient safety. Information conflicts left unresolved may evolve into personal conflicts in the long run and severely weaken teamwork.

Disruptive behavior among staff should be actively discouraged. Organizations should develop guidelines for acceptable behaviors to assist staff in better identifying, reporting, and managing behaviors that cause disruption to patient safety.

Types of disruptive behavior include condescending language or voice intonation, impatience with questions, reluctance or refusal to answer questions or telephone calls, strong verbal abuse or threatening body language, and physical abuse.

 Discussion:

  • How have you resolved conflict in the past?
  • What are some situations in which you found yourself in a conflict, and how did you resolve it?
  • How did the resolution affect team relationships and the quality of patient care?

Say:

Now we're going to cover two useful conflict resolution strategies: The Two-Challenge rule, which is used to address information conflict; and the DESC script, which is used to address personal conflict.

Select to proceed to the next section of this presentation/module.

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Current as of November 2008
Internet Citation: TeamSTEPPS Fundamentals Course: Module 5. Mutual Support: Instructor's Materials: TeamsTEPPS Fundamentals Course. November 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module5/igmutualsupp.html