TeamSTEPPS Fundamentals Course: Module 6. Mutual Support
Instructor Outline: Mutual Support
In this module, you will present information about mutual support within teams. Participants will learn how to cultivate and maintain mutual support, as well as how to address conflict when it arises.
|#||Content||Page #||Approx. Time|
|1.||Introduction||5 - 7||4 mins|
|2.||Task Assistance||8 - 10||6 mins|
|3.||Feedback||11 - 14||8 mins|
|4.||Feedback Exercise||15||5 mins*|
|5.||Advocacy and Assertion Tools||16 - 23||15 mins|
|6.||Conflict in Teams||24 - 28||10 mins|
|7.||Tools and Strategies Summary||29||2 mins|
|8.||Applying TeamSTEPPS Exercise||30||5 mins|
|*Although all instructional content and activities are recommended to ensure that participants achieve the learning objectives, these activities may be considered "optional" if time is constrained.|
The Mutual Support module includes the content provided in the outline below. More content is available than can be covered in the time provided; therefore, optional content and activities are noted. It is strongly recommended that instruction not focus solely on lecture, but also include exercises, videos, and other activities. As such, instructors should use the information below to plan how the module will be taught within the time available.
Additional Resources: Below are sources of additional information and videos you may wish to use to customize this module to your participants.
- TeamSTEPPS DVD: The TeamSTEPPS DVD includes Specialty Scenarios and additional videos that can be used to customize your instruction.
- TeamSTEPPS Long-Term Care Version: Includes videos specific to the use of the mutual support tools and strategies in long-term care.
- TeamSTEPPS Primary Care Version: Includes videos specific to the use of the mutual support tools and strategies in the primary care setting.
- TeamSTEPPS Rapid Response Systems Module (RRS): Includes videos specific to the use of the mutual support tools and strategies by Rapid Response Teams.
- Comprehensive Unit-Based Safety Program (CUSP) "Implement Teamwork and Communication" Module: Includes information on some of the mutual support tools and strategies taught in TeamSTEPPS.
|Module Time: 50 Minutes|
- TeamSTEPPS Teamwork Skills
- Mutual Support
- Task Assistance
- Task Assistance Example
- What is Feedback?
- Types of Feedback
- Characteristics of Effective Feedback
- Video: Providing Feedback Effectively
- (Optional) Feedback Exercise
- Advocacy and Assertion
- The Assertive Statement
- The Two-Challenge Rule
- The Two-Challenge Rule, continued
- The Two-Challenge Rule, continued
- An Advocacy and Assertion Scenario
- Conflict in Teams
- Conflict Resolution: DESC Script
- DESC It!
- A DESC Scenario
- Tools and Strategies Summary
- Exercise: Applying TeamSTEPPS
Following this module, you will be able to:
- Describe how mutual support affects team processes and outcomes.
- Discuss specific strategies to foster mutual support (e.g., task assistance, feedback).
- Identify specific tools to facilitate mutual support.
- Describe conflict resolution strategies.
So far, we have covered the following in the TeamSTEPPS framework:
- Team Structure, which facilitates teamwork by identifying the individuals among which information must be communicated, a leader must be clearly designated, and mutual support must occur.
- Communication, which facilitates teamwork by enabling team members to effectively relay relevant information in a manner that is known and understood by all.
- Leadership, which facilitates teamwork through leaders' effective communication with their team members to ensure that a plan is conveyed, reviewed, and updated; continuous monitoring of the situation to better anticipate team members' needs and effectively manage resources; and fostering of an environment of mutual support through role modeling and reinforcement.
- Situation Monitoring, which facilitates teamwork by providing skills to ensure that new or changing information about the environment or the patient is identified for communication and decisionmaking by the leader; and leads to the effective support of fellow team members.
In this module, we will cover the final TeamSTEPPS skill, which is Mutual Support.
Mutual support is moderated by communication, which influences the delivery and ultimate effectiveness of the mutual support.
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 these "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.
Mutual support, which is commonly referred to as "back-up behavior" in the teamwork literature, is critical to team performance. Mutual support involves team members (1) assisting one another; (2) providing and receiving feedback; and (3) exerting assertive and advocacy behaviors when patient safety is threatened. Mutual support is the essence of teamwork. For example, in a health care 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.
What types of behavior do you think constitute mutual support?
- 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.
In this module, we'll focus specifically on task assistance, feedback, and advocacy and assertion as three strategies that can be used to foster mutual support.
One method of providing mutual support is through task assistance. This includes both asking for assistance when needed and offering assistance to team members when the opportunity arises. Task assistance is guided by situation monitoring, because situation monitoring allows team members to effectively identify when they, or other team members, need assistance.
To a certain degree, some of us have been conditioned to avoid asking for help because we fear that this would suggest a lack of knowledge or confidence. Many people refuse to seek assistance when overwhelmed or unsure of tasks. In support of patient safety, however, seeking task assistance is expected.
In addition, when it is recognized that a team member needs assistance, offering to help should be a cultural norm. Offering assistance should be verbally articulated so that each team member has a shared understanding of what will be done and by whom. Offering assistance may include helping team members to perform their tasks; correcting task performance when needed; 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.
- What can happen when we are overwhelmed and we do not seek task assistance?
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.
Several factors influence task assistance:
- 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.
- Attitudes and beliefs: Some attitudes restrict team members from offering or requesting assistance.
- 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.
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.
Let's review a brief example of task assistance:
Two members of the GI Laboratory are assessing an elderly patient who has just had conscious sedation for a colonoscopy. The monitor shows SVT at a rate of 150 and a BP of 76/48. The nurse calls out the vital signs while the physician continues to monitor the rhythm. A nurse passing by the room hears the call-out.
- How would you offer task assistance in this example?
- How would you request task assistance in this example?
Another strategy to foster 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 leadership roles or formal evaluation mechanisms. Effective feedback benefits the team in several ways, including:
- Fostering improvement in work performance.
- Meeting the team's and individuals' need for growth.
- Promoting better working relationships.
- Helping the team set goals for ongoing improvement.
- Can you describe a situation in which you had to give feedback to another team member?
- What was the situation?
- What was the result?
Feedback can be provided by anyone on the team at any time and can be either formal or informal.
- 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 discussions, case conferences, and individual performance reviews.
- Informal feedback typically occurs in real time and on an ongoing basis and focuses on knowledge and practical skills development. Examples include huddles and debriefs.
- Can someone share an example of when he or she provided or received formal feedback?
- How was the feedback helpful?
- Can someone share an example of when he or she provided or received informal feedback?
- How was the feedback helpful?
Feedback is a method of providing rich and useful information to enhance teamwork processes and increase patient safety. Ultimately, the aim is to provide feedback that it is effective.
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. Delivering feedback several weeks after poor performance has occurred is too late for it to be effective.
- Respectful—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. When providing negative feedback, it should never be delivered to individuals in front of other team members as this could lead to the individual feeling humiliated.
- 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.
Positive feedback should also be provided to team members 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. Providing feedback acknowledging a job well done will also communicate to an individual that he or she is valued and viewed as an important part of the team.
The next video will provide an example of a doctor providing feedback to a medical tech. Think about the guidelines for giving effective feedback as you watch the video.
Play the video by selecting the director icon on the slide.
- What was effective in the feedback provided?
- Appears to be timely.
- Respectful and related to behavior.
- Why would it be a good practice to share the experience with other team members?
- Sharing the effective communication technique with others will promote continuous learning.
|Video Time: 0:29 seconds|
We are now going to take a few minutes to think about providing effective feedback. In this scenario, an attending watches an intern start to place a chest tube in an obese patient in an incorrect location.
- How would you provide effective feedback? (i.e., timely, respectful and related to behavior, specific, directed, and considerate). Take a few minutes to plan how you would provide feedback in this example.
Instructor Note: After about 5 minutes, ask individuals to share how they would provide feedback. Allow a few individuals to share with the group, then present the following example of action taken.
Example Action Taken:
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.
- Yes. It is immediate.
- Respectful and related to behavior?
- Yes. The behavior is the focus and criticism is not directed at the intelligence of the intern.
- Yes. It suggests specific considerations to be aware of in the future.
- Yes. It is directed in showing the intern how to evaluate future patients and to be sure the anatomy is not distorted.
- 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.
|Time: 5 Minutes|
The third strategy used to facilitate mutual support is advocacy and assertion. Advocacy and assertion interventions are invoked when a team member's viewpoint does not coincide with that of a decisionmaker. 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 use 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.
We will discuss three tools to empower team members to advocate for the patient and be assertive when needed.
- The Assertive Statement.
- The Two-Challenge Rule.
Each of these tools provides a mechanism whereby team members are able to bring up ideas and concerns using language that is mutually understood by all team members. We will now go through each of these tools in more detail.
The Assertive Statement is one tool used to facilitate speaking up when there is concern for patient safety.
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 at all levels must always feel their input is valued. More important, their input should be expected, especially in situations that threaten patient safety.
Team members must respect and support the authority of the team leader while clearly asserting suggestions or communicating concerns. When the situation dictates that the 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 can easily be taught to patients and their families as a structured way to communicate their concerns to the rest of the care team.
The Assertive Statement involves a five-step process:
- Open the discussion.
- State the concern.
- State the problem—real or perceived.
- Offer a solution.
- Obtain an agreement.
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?
- 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?"
The Two-Challenge Rule is another tool used to facilitate team members' speaking up. In the clinical environment, team members should challenge colleagues if they have requested clarification, but the response or confirmation does not alleviate the concern regarding potential harm to a patient.
The Two-Challenge Rule is a way to help team members frame communications about thoughts, and reasoning about plans and decisions, related to patient care. The goal is to create a teamwork culture where team members respectfully challenge one another when the plan is unclear or of concern.
It is important to voice your concern by advocating and asserting your statement at least twice if the initial assertion is ignored (thus the name, "Two-Challenge Rule"). These two attempts may come from the same person or two different team members.
- The first challenge should be in the form of a question.
- The second challenge should provide some support for your concern.
Remember this is about advocating for the patient. The Two-Challenge Rule ensures that an expressed concern has been heard, understood, and acknowledged.
There may be times when an initial assertion is ignored. If after two attempts the concern is still disregarded, but the member believes patient or staff safety is or may be severely compromised, the Two-Challenge Rule mandates taking a stronger course of action or using a supervisor or chain of command. This overcomes our natural tendency to believe the team leader must always know what he or she is doing, even when the actions taken depart from established guidelines. When invoking this rule and moving up the chain, it is essential to communicate to the entire medical team that additional input has been solicited.
It is important to have an agreed upon approach of delivering the Two-Challenge Rule within your institution and to obtain buy-in from all involved (e.g., nurses, physicians, administration). As with any of the tools and strategies discussed throughout the TeamSTEPPS training, having a standardized method of delivery is critical for effectiveness. The chosen approach must be made known to all team members (i.e., everyone must be on the same page and speaking the same language).
If you personally are challenged by a team member, it is your responsibility to acknowledge the concerns instead of ignoring the person. Any team member should be empowered to "stop the line" if he or she senses or discovers an essential safety breach. This is an action that should never be taken lightly, but requires immediate cessation of the process to resolve the safety issue.
Let me provide an example of what a successful use of the Two-Challenge Rule might look like.
It is late at night during a particularly hectic shift. A distressed young female having an allergic reaction arrives in the ED. She has developed a rash and is beginning to wheeze. Dr. Andrew, who is new to the ED, orders Benadryl 125 mg IV. Clara, an experienced pharmacy technician, questions the drug dosage. Dr. Andrew repeats his order for Benadryl 125 mg IV. Clara pursues her challenge a second time, stating, "Dr. Andrew, that dose seems high. I've never dispensed more than 50 mg IV at a time before." "Yes, you're right. I was confusing the dose with that for Solu-Medrol," states Dr. Andrew. Dr. Andrew changes his order, she repeats the correct order back to him, and the correct dose of Benadryl is administered.
- Can anyone think of a situation in which you used or could have used the Two-Challenge Rule?
Using the CUS technique provides another tool for advocacy, assertion, and mutual support. Signal words, such as "danger," "warning," and "caution" are common in the medical arena. They catch the reader's attention. In verbal communication, "CUS" and other signal phrases have a similar effect. If all team members have a shared mental model and are on the same page, when these words are spoken, all team members will clearly understand the issue and its magnitude.
To use CUS:
- First, state your concern.
- Then state why you are uncomfortable.
- If the conflict is not resolved, state that there is a safety issue. Discuss in what way the concern is related to safety. If the safety issue is not acknowledged, a supervisor should be notified.
A few other phrases in use are:
- I would like some clarity about...
- Would you like some assistance?
We are now going to watch a video clip of the CUS technique in action.
Do: Play the video by selecting the director icon on the slide.
- How was the "challenge" presented?
- In the form of a statement, "I am concerned ..."and then followed up with additional patient vitals.
- The nurse was uncomfortable with the late decelerations.
- She became concerned and uncomfortable that the patient's safety may be at risk.
|Video Time 10 seconds|
Let's analyze this 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.
Before the patient is discharged, 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.
- If you were in this situation, what would you do to address the problem?
- How might you raise this issue to the physician?
- What TeamSTEPPS tools could you use to help?
Advocating for the patient and asserting your viewpoint are both important aspects of engaging in mutual support. However, even when used correctly the techniques and tools presented may still lead to conflict. Conflict resolution is a skill team members need to develop and cultivate in order to overcome challenges that will arise.
Conflict can occur in teams and it is important to know how to handle such situations when they occur. The two types of conflict we will address are informational and interpersonal.
- Informational conflict involves differing views, ideas, and opinions related to information. This is task-related and could involve disagreement about the best method to proceed with the plan of care.
- Interpersonal conflict stems from interpersonal compatibility and is not usually task related. This type of conflict tends to revolve around the team members themselves, not the actions or information. Tension, annoyance, and animosity are common and interactions can become very argumentative.
Attempts should be made to resolve both types of conflict before they interfere with work and undermine quality and patient safety. Informational conflicts left unresolved may evolve into interpersonal 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.
Resources are available to help address disruptive behavior. For example, the Department of Defense's Professional Conduct toolkit provides information on this topic.
For more information, go to: http://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Quality-And-Safety-of-Healthcare/Patient-Safety/Patient-Safety-Products-And-Services/Toolkits/Professional-Conduct-Toolkit.
- Can you provide an example of an informational conflict you've encountered?
- How did you resolve it?
- Can you provide an example of an interpersonal conflict you've encountered?
- How did you resolve it?
Two tools can be used to address conflict in teams: the Two-Challenge Rule and DESC script.
- Two-Challenge Rule:
- As we have already discussed, the Two-Challenge Rule can serve as a method to advocate and assert for patient safety; but it can also be used as a conflict resolution strategy. When team members have different information, the Two-Challenge Rule can be used to bring up the differing information so it can be addressed.
- DESC script:
- The DESC script can be used for both informational and interpersonal conflict but is most effective when conflict is of a personal nature.
Next we will discuss DESC script in more detail.
The DESC script can be used to communicate effectively during all types of conflict and is most effective in resolving interpersonal conflict. The DESC script can be used in situations involving greater conflict, such as when hostile or harassing behaviors are ongoing and safe patient care is suffering.
DESC is a mnemonic for:
D = Describe the specific situation.
E = Express your concerns about the action.
S = Suggest other alternatives.
C = Consequences should be stated.
Ultimately, consensus should be reached.
There are some crucial things to consider when using the DESC script:
- Time the discussion.
- Work on win-win—Despite your interpersonal conflict with the other party, team unity and quality of care depend on coming to a solution that all parties can live with.
- Frame problems in terms of personal experience and lessons learned.
- Choose the location—A private location that is not in front of the patient or other team members will allow both parties to focus on resolving the conflict rather than on saving face.
- Use "I" statements rather than blaming statements.
- Critique is not criticism.
- Focus on what is right, not who is right.
Let's examine a scenario with conflict.
A nurse feels that a patient has abdominal distension and pain secondary to a distended bladder and needs a Foley catheter. The nurse receives the order from the resident on call. When the attending later realizes that the order was given without his consent, he raises his voice to the resident in front of staff and the patient.
- How could the DESC script be used here?
D: "I (resident) am sensing that you (attending) are upset with me for ordering the Foley catheter for your patient."
E: "When you question my judgment in front of others, it embarrasses me and makes me very uncomfortable. It also undermines my credibility with the patient."
S: "If you are concerned or have a question regarding my performance, I would appreciate it if you would speak to me in private."
C: "A private conversation would be more beneficial to me because I would feel less embarrassed and would be able to ask questions and supply information. Can we agree to follow such a procedure if this were to occur again?"
Effectively communicating, having active leadership, and continually monitoring the situation will all affect the ability of team members to support one another. Continuous mutual support behaviors among team members will ultimately foster a shared mental model, adaptability, team orientation, and mutual trust.
Tools and strategies to enhance mutual support include task assistance, feedback, the Assertive Statement, the Two-Challenge Rule, CUS, and DESC script. Use of these tools will lead to more adaptive and effective patient care.
Instructor Note: This slide is intended for the Master Training course only. The previous slide should be the last one shown to staff participants at your organization.
Return once again to your TeamSTEPPS Implementation Worksheet. Answer the questions related to Mutual Support as you consider your own teamwork issue.
- Whether your teamwork issue is related to Mutual Support.
- If so, how you might address the issue using the TeamSTEPPS tools or strategies taught in this module.
Ask a few individuals to report on their issue as it relates to Mutual Support and which TeamSTEPPS tools or strategies they might consider in their implementation planning to address it.