TeamSTEPPS Learning Benchmarks

TeamSTEPPS Long-Term Care Instructor Guide

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.

INSTRUCTIONS: These questions focus on resident care teamwork and communication and their effect on quality and safety in resident care. For each of the following questions, please circle the letter next to the one best answer.

  1. A nurse is called to the phone to receive a telephone order from the doctor about a resident she is taking care of today. After clearly establishing the resident and physician identities, the BEST procedure for the nurse would be:

    1. Listening to the order, calling the pharmacist, writing the details on the order sheet, and bringing the drug to the bedside.
    2. Refusing to take this telephone order and indicating that she can't be sure of the physician's thought process.
    3. Listening to the order, repeating back what the doctor said, and then writing it down in the resident's medical record.
    4. Listening to the order, asking the charge nurse how to spell the drug's name, asking the family member if that was in the plan for today, and carrying out the order.
    5. Listening to the order, writing it on the order page, reading the order back to the physician, and seeking his verification of the order's accuracy.
  2. A nurse is very concerned about a resident he is taking care of and feels it would be best to have the attending APRN (Advanced Practice Registered Nurse) come to the bedside immediately to evaluate. Checking around the unit, he locates the APRN, but she is busy dictating her notes. The nurse's BEST action is to:

    1. Wait quietly, but tap his foot rhythmically to indicate urgency.
    2. Quickly explain the resident's worrisome appearance and state, "I need you right now!"
    3. Walk away, planning to check back in a few minutes.
    4. Interrupt, shake her shoulder, and pull her quickly toward the room.
    5. Leave his extension number with the clerk with instructions to have her call.
  3. A loud crash is heard inside a resident room. The charge nurse, nursing assistant, and physical therapist come running. The resident has fallen in the bathroom and is crying in pain. The charge nurse, as team leader, should:

    1. Tell the nursing assistant to "find a few more strong nursing assistants for lifting the resident."
    2. Reassure the new team that she had plenty of experience with falls like this one and not to worry, and say, "I'll tell you what to do."
    3. Introduce herself, briefly describe the resident's diagnosis and history, explain the plan for assessing the resident, and ask for input from the team members.
    4. Explain the need for extra speed getting the resident off the floor before family members arrive.
    5. Pull out the resident's medical record and check for recent vital signs and lab results.
  4. The unit charge nurse receives and order for a medication that is clearly a dangerous mistake as the dose is 10 times the usual dose. Very concerned, she asks the doctor if he's sure that this is what he wants. Giving her a nasty look, he growls, "Well, that's what I ordered, isn't it?" Confident that the dose is way off base, her next action should be to:

    1. Walk away and indicate discouragement at being treated so rudely.
    2. Say loudly, "That's a huge mistake, Doctor; nobody uses a dose like that!"
    3. Not say anything for fear of making the doctor even angrier.
    4. Stat page the nursing supervisor.
    5. Say, "I'm very concerned about the safety of that dose, Doctor; it's much higher than I've ever seen given."
  5. For the real-life situation in question 4 above, a nurse in the same circumstances, but NOT confident and NOT positive that the dose is too high, but still very concerned about the resident's safety, should take the following course of action:

    1. Walk away and indicate discouragement at being treated so rudely.
    2. Say loudly, "That's a huge mistake, Doctor; nobody uses a dose like that!"
    3. Not say anything for fear of making the doctor even angrier.
    4. Stat or emergency page the nursing supervisor.
    5. Say, "I'm very concerned about the safety of that dose, Doctor; it's much higher than I've ever seen given."
  6. The doctor (questions 4 and 5), upon being challenged by the nurse about the potentially dangerous medication dose, and realizing she is right, should respond by:

    1. Demanding that this nurse be replaced immediately.
    2. Saying, "You're right. Thanks for watching my back; it's been a bad day."
    3. Saying, "I'm the doctor. Do what I say."
    4. Calling his partner on his cell phone to discuss the case.
    5. Telling the worried nurse, "Sometimes these dosages are confusing."
  7. If the doctor, in fact, is correct in his dosage (question 4) and the nurse was incorrect in her memory of the proper medication dosage, when this is suspected, the doctor's BEST action would be to:

    1. Call the pharmacist and ask her to send a package insert to review.
    2. Let the nurse know, in no uncertain terms, how it is inappropriate to challenge a physician.
    3. Request that the nurse be sent for retraining and put a notation in her file.
    4. Stop action, verify the correct dose, and thank the nurse for her concern regarding resident safety.
    5. Call the team together afterward and have the nurse explain her mistake.
  8. A night nurse is concerned about the changing circumstances for a resident and knows it will be necessary to call and awaken the covering physician. Getting his thoughts and information together, he plans to structure the phone call using a proven structured communication technique, SBAR. He plans to introduce himself, identify the resident, and describe:

    1. Situation, Background, Assessment, Recommendations.
    2. Sleep, Bathroom Activities, Results.
    3. Systems, Background, Alimentary, Respiratory.
    4. His pleasant memories of summer vacation at the S-BAR Ranch.
    5. Social Background, Assurance, Reassurance.
  9. The medical director is evaluating a resident who likely will need an urgent transfer to the hospital emergency department (ED). Continuity of care and resident safety are usually enhanced by all of the following EXCEPT:

    1. Considering the hospital ED physician to be part of the treatment team and sharing information.
    2. Withholding the reason for referral from the resident to decrease fear.
    3. Using a structured and detailed handoff document.
    4. Creating a reminder to forward any pending lab and x-ray results.
    5. Requesting the hospital to call if the resident hasn't yet been seen within a certain timeframe.
  10. After a resident fall with injury requiring a trip to the emergency department, the most helpful pathway toward team performance improvement involves:

    1. The leader telling everyone what they did wrong.
    2. Meeting as a team to debrief the events.
    3. Explaining the protocol deviations.
    4. Blaming the people who made mistakes.
    5. Visiting the resident in the ED.
  11. A housekeeper notices that a resident who is usually alert and oriented is confused and lethargic. She communicates this to the nursing assistnat caring for the resident, but the nursing assistant dismisses her concern. The BEST action for the concerned housekeeper would be to:

    1. Express her concern to the nursing assistant again, saying she was concerned, uncomfortable, and thought that there may be a safety issue with this resident.
    2. Tell the housekeeping supervisor.
    3. Tell the nursing supervisor.
    4. Walk away and forget about it because the resident is the nursing assistant's responsibility.
    5. Check back later to see if the resident is any better.
  12. The new nurse working on the rehab unit is having real difficulties interacting with the unit nurse manager (who has been working there for a decade). The unit manager continually is telling her what to do, in front of the residents and other staff. The BEST course of action for the new nurse is to:

    1. Tell the unit manager to stop undercutting her.
    2. Ask the unit manager for a quick meeting to discuss the problem of giving criticism in front of residents and other staff.
    3. Tell the nursing supervisor to have a talk with the unit manager.
    4. Complain to the director of nursing that the unit manager is hypercritical and ineffective.
    5. Just let everyone know that the unit manager is having a bad day.
  13. The director of nursing services (DNS) and the medical director are making rounds on the rehab unit. The nursing assistant overhears the DNS telling the medical director that her resident has been ambulating everyday in the hallway without pain. The nursing assistant knows that the resident has been complaining of severe pain for the past 2 days. The DNS is very short tempered because she is having family issues. The BEST action for the nursing assistant is to:

    1. Call for the administrator to come into the room.
    2. Quietly observe and hope that the doctor notices.
    3. Hope the resident speaks up about the pain.
    4. Interrupt the DNS and medical director and respectfully state her knowledge about the resident's pain.
    5. Wait until after rounds are over and speak with the DNS privately.
  14. A physical therapist working on the subacute unit overhears the doctor on the team make a misstatement about a sick resident, a comment that could result in a medical error and poor outcome. The therapist's correction of the misstatement is BEST interpreted as:

    1. A HIPAA violation on the subacute unit.
    2. An interference in the doctor's business.
    3. An action of cross-monitoring that makes teamwork safer.
    4. An action the doctor will likely get defensive about.
    5. A wrong-headed approach to teamwork.
  15. In the interest of resident care quality and safety, it is expected and mandatory that:

    1. Conflict be avoided at all cost.
    2. People always do the right thing.
    3. Members speak up if they are concerned.
    4. Leaders not make mistakes.
    5. Everyone agree with the plan.

INSTRUCTIONS: For each of this series of questions, based on your knowledge of communication, teamwork, and resident care quality and safety, select the one BEST answer.

B-1.  The attribute LEAST likely to be found in a team that is functioning in a HIGHLY EFFECTIVE manner is:

  1. Adaptability.
  2. Complacency.
  3. Trust.
  4. Respect.
  5. Information sharing.

B-2.  Recent research about the causes of errors in health care delivery focuses increasingly on:

  1. Outdated equipment.
  2. Incompetent providers.
  3. System problems.
  4. Lack of caring.
  5. Stupidity.

B-3.  Who is the leader in medical teams?

  1. Doctor.
  2. Nurse.
  3. Supervisor.
  4. Depends on circumstances.
  5. Resident.

B-4.  The best communication tool or method to get critical information to the whole team during an emergency or complex procedure is:

  1. Call-out.
  2. Check-back.
  3. Write it on the 24-hour report.
  4. Write it in the orders.
  5. Time-out-Write an extensive and thorough nursing note.

B-5.  The main reason hierarchy can be a problem in a team setting is that:

  1. The team leader may be obnoxious.
  2. Members having important information may not speak up or be heard.
  3. Staff of different levels or departments may disagree.
  4. Residents may be upset at the team being bossed around.
  5. Some staff may not feel respected.

B-6.  A shared mental model is key for team members primarily because:

  1. They need to have vision.
  2. They all need to have the same understanding of the plan.
  3. A mind is a terrible thing to waste.
  4. Otherwise, leaders may go adrift.
  5. Otherwise, residents will be confused.

B-7.  The following are human factor problems that research has identified as contributing to medical error EXCEPT:

  1. High workload.
  2. Fatigue.
  3. Distractions.
  4. Friendship in the workplace.
  5. Conflict and anger.

B-8.  The BEST method of conflict resolution for teams in the workplace is:

  1. Compromise.
  2. Accommodation.
  3. Avoidance.
  4. Collaboration using the DESC script.
  5. Dominance.

TeamSTEPPS Learning Benchmarks — Answer Key

This matrix presents the BEST ANSWER and relates the question to specific TeamSTEPPS Curriculum, including tools and strategies.

QATools, Strategies or Concepts Covered
1E
  • Check-back
  • Communication accuracy
  • Correct sequence
2B
  • Express version of SBAR
  • Explicit communication
  • Action oriented
  • Team priorities
3C
  • Team brief
  • Create a shared mental model
  • Respect for the input from all
  • Sharing the right information
4E
  • Two-Challenge rule
  • CUS (Concerned-Resident Safety)
  • Error reduction strategy
  • Maybe cross-monitoring
5E
  • Ditto above
  • Tries to emphasize that the nurse didn't have to know for sure that it was wrongℓips;needs to speak up anyway if concerned
  • Team dynamics
6B
  • Response to two challenges by the nurse
  • Team dynamics
  • Acknowledgment
  • Respect for team input
  • Focus on the resident and safety
7D
  • Proper response to the question and concern for resident safety
  • Stop the line; resolve the confusion
  • Respect the input
  • Team dynamic
  • Focus on the safety, not the error
  • A debrief would be good, but not to have the nurse "explain her mistakes"
8A
  • SBAR
9B
  • Nursing home-hospital referral
  • Handoff
  • Considering strategies to avoid likely errors in primary care, such as followup
  • Resident as part of the team
10B
  • Debrief—the word more than the concept
  • Deals with issues of blame and error
11A
  • Conflict
  • Unreasonable behavior
  • Solve it within the team if possible
  • Could DESC-IT, but probably not necessary
  • CUS
12B
  • Conflict resolution
  • Solve it at the team level
  • Power differential
  • Knowledge differential
  • Criticism undermining resident relationship
  • Action: meet to discuss (in private)
13E
  • Team dynamics
  • Speaking up despite the hierarchy and difficult director of nursing
  • Anyone can call for clarification
14C
  • Cross-monitoring
  • Protecting the resident
15C
  • Speak up about any resident concerns (mandatory
  • The other choices speak to reality issues for teams, differences from the ideal
B-1B
  • Complacency is not an attribute for highly effective teams; the others generally are seen in high-performing teams
B-2C
  • System problems and complexity
B-3D
  • It depends: the nurse may be the team leader in some instances, whereas the physician/nurse practitioner/physician's assistant may be the team leader in other situations. All disciplines have the opportunity to lead, depending on the situation or issue. The resident could be the team leader in the home or rehab setting.
B-4A
  • Call-out
B-5B
  • Hierarchy
  • Speak up
  • Be heard
  • Leadership, decisionmaking needs input from the whole team
B-6B
  • Need to have the same understanding of the plan and situation
  • Shared mental model
B-7D
  • Human factors
  • High workload
  • Distractions
  • Conflict
  • Anger
B-8D
  • Conflict resolution
  • DESC script
  • Collaboration

Return to Contents

Page last reviewed October 2008
Internet Citation: TeamSTEPPS Learning Benchmarks: TeamSTEPPS Long-Term Care Instructor Guide. October 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/longtermcare/sitetools/learnbench.html