Feedback Form: Coaching Workshop

TeamSTEPPS® Long-Term Care Version, Module 9

The Long-Term Care version of TeamSTEPPS adapts the core concepts of the TeamSTEPPS program to reflect the environment of nursing homes and other other long-term care settings such as assisted living and continuing care retirement communities. The examples, discussions, and exercises below are tailored to the long-term care environment.



While observing the scripted coaching role play, use this form to document the demonstrated competencies of the designated coach. The coach works through the designated issue with the team member, the team member acts out the particular scenario, and the observer watches the interaction and notes on the coaching observation form which competencies the coach exhibits and does not exhibit.

Coaching CriteriaDemonstrated
Communication Instructions   
Providing Feedback   
Listening for Understanding   
Performance Improvement
Setting Performance Goals   
Rewarding Improvement   
Dealing With Failure   
Assessing Strength and Weaknesses   
Building Rapport and Trust   
Motivating Others   
Working With Personal Issues   
Confronting Difficult Situations   
Responding to Requests   
Following Through   
Page last reviewed November 2012
Internet Citation: Feedback Form: Coaching Workshop: TeamSTEPPS® Long-Term Care Version, Module 9. November 2012. Agency for Healthcare Research and Quality, Rockville, MD.