TeamSTEPPS Fundamentals Course: Module 6. Evidence-Base: Mutual Support

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.

 Mutual support is a core team skill and a crucial component in any teamwork process. Mutual support is also commonly referred to as "back-up behavior" in the teamwork literature. Porter, et al., define backup behavior as "the discretionary provision of resources and task-related effort to another member of one’s team that is intended to help that team member obtain the goals as defined by his or her role when it is apparent that the team member is failing to reach those goals."1 Backup behavior is considered critical to the social and task performance aspects of teams and essentially involves helping other team members to perform their tasks.1,2

Backup behaviors often include filling in for a team member who cannot perform a task (e.g., inexperienced, incapable, overburdened, about to make an error), helping others correct their mistakes, or redistributing work to a fellow team member who is underused. This behavior results in more adaptive teams.1 The construct suggests some degree of task interchangeability, situation monitoring, and coordination among members, since they must fully understand each other’s roles and be willing to provide and seek assistance when needed.3,4

Mutual support in health care has significant importance as it is a skill that has the potential to improve the quality of patient care.5-13 The health care context is often characterized by high workload, as well as acute and time-sensitive situations; thus, task assistance and backup behavior are crucial to adequate patient care. Mutual support provides a safety net to help prevent errors, increase effectiveness, and minimize strain due to workload. In fact, health care training curricula that include mutual support training have been shown to reduce length of patient stays by 50 percent,14 reduce hospital costs by 19 percent,15 increase staff understanding of goals,16 reduce patient adverse events,15,17 reduce mortality,18 and reduce malpractice suits by 50 percent.15

Research has demonstrated that TeamSTEPPS® training can enhance mutual support among health care teams. Such training emphasizes how to provide timely, respectful, specific, directed, and considerate feedback; how and when to engage in effective task assistance; and how to advocate for a patient even when it is an unpopular view.

Brock, et al., examined participant attitudes before and after a TeamSTEPPS training session.  Significant attitudinal shifts for teamwork skills were observed for mutual support, team structure, situation monitoring, and communication.19  Moreover, Capella, et al., found that the TeamSTEPPS intervention as applied to training trauma resuscitation teams was effective in improving mutual support and other relevant team competencies.20 Similar research has found that TeamSTEPPS training was associated with significant increases in the quantity and quality of mutual support behaviors, specifically feedback and task assistance.21 These findings taken together further illustrate the effectiveness of TeamSTEPPS for training mutual support and the importance of mutual support in ensuring effective patient care.

In summary, mutual support is a core skill that enables teams to function effectively and improve teamwork and patient care.5,6 Teams that exhibit effective mutual support typically:

  • Back up and fill in for each other in performing tasks.22
  • Self-correct.
  • Reallocate functions.
  • Compensate for each other when overloaded.22
  • Distribute and assign work thoughtfully.
  • Engage in conflict management, resolving personal and interpersonal conflict.3
  • Engage in patient advocacy.3
  • Regularly provide feedback to each other (both individual and team oriented).3,22


  1.  Porter CO, Hollenbeck JR, Ilgen DR, et al. Backing up behaviors in teams: the role of personality and legitimacy of need. J Appl Psychol 2003;88(3):391-403.
  2.  Dickinson TL, McIntyre RM. A conceptual framework for teamwork measurement. In: Brannick MT, Salas E, Prince C, eds. Team performance assessment and measurement. Mahwah, NJ: Lawrence Erlbaum Associates; 1997. p. 19-43.
  3.  Salas E, Sims DE, Burke SC. Is there a "Big Five" in teamwork? Small Gr Res 2005;36(5):555-99.
  4.  Andersen P, Jensen M, Lippert A, et al. Identifying non-technical skills and barriers for improvement of teamwork in cardiac arrest teams. Resuscitation 2010;81(6):695-702.
  5.  Baxter S, Brumfitt S. Benefits and losses: a qualitative study exploring healthcare staff perceptions of teamworking. Qual Saf Health Care 2008;17(2):127-30.
  6.  Shea-Lewis A. Teamwork: crew resource management in a community hospital. J Healthc Qual 2009;31(5):14-8.
  7.  Barrett J, Gifford C, Morey J, et al. Enhancing patient safety through teamwork training. J Healthc Risk Manag 2001;21(4):57-65.
  8.  Morey JC, Simon R, Jay GD, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res 2002;37(6):1553-81.
  9.  DuBose JJ, Inaba K, Shiflett A, et al. Measurable outcomes of quality improvement in the trauma intensive care unit: the impact of a daily quality rounding checklist. J Trauma 2008;64(1):22-9.
  10.  Hicks CM, Bandiera GW, Denny CJ. Building a simulation-based crisis resource management course for emergency medicine, phase 1: results from an interdisciplinary needs assessment survey. Acad Emerg Med 2008;15:1136-43.
  11.  Stead K, Kumar S, Schultz TJ, et al. Teams communicating through STEPPS. Med J Aust 2009;190(11 Suppl):S128-32.
  12.  Castner J, Foltz-Ramos K, Schwartz D, et al. A leadership challenge: staff nurse perceptions after an organizational TeamSTEPPS initiative. J Nurse Admin 2012;42:467-72.
  13.  Sawyer T, Laubach VA, Hudak J, et al. Improvements in teamwork during neonatal resuscitation after interprofessional TeamSTEPPS training. Neonatal Netw 2013;32(1):26-33.
  14.  Pronovost P, Berenholtz S, Dorman T, et al.  Improving communication in the ICU using daily goals. J Crit Care 2003;18(2):71-5.
  15.  Mann S, Marcus R, Sachs B. Grand Rounds: Lessons from the cockpit: how team training can reduce errors on L&D. Contemporary OB/GYN 2006 Jan;51:31-45.
  16.  Young MP, Gooder VJ, Oltermann MH, et al. The impact of a multidisciplinary approach on caring for ventilator-dependent patients. Int J Qual Health Care 1998 Feb;10(1):15-26.
  17.  Pronovost P, Needham D, Berenholtz, S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Eng J Med 2006 Dec; 355(26):2725-32.
  18.  Uhlig PN, Brown J, Nason AK, et al. System innovation: Concord Hospital. Jt Comm J Qual Improv 2002 Dec;28(12):666-72.
  19.  Brock D, Abu-Rish E, Zierler B, et al. Interprofessional education in team communication: working together to improve patient safety. BMJ Qual Saf 2013;22(5):414-23.
  20.  Capella J, Smith S, ReMine S, et al. Teamwork training improves the clinical care of trauma patients. J Surg Educ 2010;67(6):439-43.
  21.  Weaver S, Rosen M, DiazGranados D, et al. Does teamwork improve performance in the operating room? A multilevel evaluation. Jt Comm J Qual Pat Saf 2010;36(3):133-42.
  22.  Marks MA, Mathieu JE, Zaccaro SJ. A temporally based framework and taxonomy of team processes. Acad Manage Rev 2001;26(3):356-76.

Additional Resources

Baron RA. Negative effects of destructive criticism: impact on conflict, self-efficacy, and task performance. J Appl Psychol 1988;73(2):199-207.

Katzenbach JR, Smith DK. The discipline of teams. Harv Bus Rev 1993 Mar-Apr;71(2):111-20.

London M, Larson HH, Thisted LN. Relationship between feedback and self-development. Group Organ Manage 1999;24(1):5-27.

McIntyre RM, Salas E. Measuring and managing for team performance: emerging principles from complex environments. In: Guzzo RA, Salas E, eds. Team effectiveness and decision making in organizations. San Francisco, CA: Jossey-Bass; 1995. p. 9-45.

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Page last reviewed March 2014
Page originally created September 2012
Internet Citation: TeamSTEPPS Fundamentals Course: Module 6. Evidence-Base: Mutual Support. Content last reviewed March 2014. Agency for Healthcare Research and Quality, Rockville, MD.