Facilitator's Notes

Training Guide: Using Simulation in TeamSTEPPS® Training

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.

Prepared by American Institutes for Research®, Washington, DC


  Session Overview
  Preparation Checklist
  Tips for Facilitators of Simulation Training
  Before the Training Session
Facilitator's Notes
  I. Welcome, Introduction, Objectives, Agenda
  II. Background
  III. Phase 1—Scenario Development
  IV. Phase 2—Development of Performance Measures
  V. Phase 3—Debriefing
Participant Handouts
Your Expectations for This Training
Objectives of Training
Developing Learning Objectives
Writing a Scenario for Your Learning Objectives
Developing Scenarios

Introduction to Using Simulation in TeamSTEPPS Training


The audience for this guide is health care team trainers who have been trained as TeamSTEPPS Master Trainers.


The purpose of this guide is to provide instruction on using simulation-based training when teaching TeamSTEPPS, as opposed to using TeamSTEPPS tools and strategies in simulation training for other purposes. The use of simulation, which has been proven to be a powerful strategy in team-based health care, affords excellent opportunities to enhance the quality of continuing education for health care professionals, as well as provide education and practice for students learning to become health care professionals.

The culture of medicine has traditionally valued technical proficiency over interpersonal skills, and this may not always be the most efficacious approach to ensuring patient safety. This TeamSTEPPS simulation guide integrates critical teamwork, interpersonal, and communication skills into simulation-based training, thereby offering strategies and tools that can improve team performance and enhance patient safety.

This training course can and should be adapted to meet the needs of specific health care teams and programs. It is intended as a train-the-trainer program in which key personnel become familiar with the materials and activities so that they can offer the simulation-based TeamSTEPPS training to local health care teams. Users of this training course are encouraged to adapt and augment activities accordingly, substituting their own scenarios in the training, when applicable.

Session Overview


By the end of this session, participants will be able to

  1. Apply the Event-Based Approach to Training.
  2. Develop TeamSTEPPS training scenarios.
  3. Develop TeamSTEPPS performance measures.
  4. Conduct effective debriefs of team performance.
  5. Determine the appropriate setting for TeamSTEPPS simulation training.

Return to Contents

Materials Checklist

___ Computer for use with flash drive or CD-ROM and LCD projector.
___ Copies of handouts for each participant.
___ Flash drive or CD-ROM containing the file of the PowerPoint presentation, “Using Simulation in TeamSTEPPS Training.”
___ Facilitator's notes.
___ Flipchart marking pens and masking tape for posting flipchart pages to walls.
___ Post-It® Note pads for participant tables

Return to Contents

Preparation Checklist

___ Reserve space for the training.
___ Duplicate handouts and assemble participant packets.
___ Ensure you have a flash drive or CD-ROM of the PowerPoint presentation, "Using Simulation in TeamSTEPPS Training."
___ Make nametags or name tents for participants.
___ Apply for CME/CEUs, if applicable, and prepare attendance sheet.
___ Arrange for food and beverage, as appropriate.
___ Arrive a half hour before training is scheduled to begin.
___ Check equipment to ensure that it is working properly.
___ Pre-label three flipchart pages using the following headings:

  • Expectations.
  • Parking Lot Issues.
  • Participant Feedback. This page should have two columns: one labeled pluses (+) and one labeled deltas (Δ).

Return to Contents

Tips for Facilitators of Simulation Training

  • Use questions to promote in-depth team participation.
  • Avoid closed-ended questions (i.e., those requiring "yes" or "no" answers). Instead, ask open-ended questions, such as those beginning with "what", "how", and "why" to encourage deeper discussion.
  • When a participant asks a question, direct the question back to the team, if possible. This encourages team discussion and interaction and encourages team members to discover their own answers.
  • Ensure that all team members are fully drawn into the discussion.
  • Allow time for participants to consider and formulate their answers after receiving a question. Do not be intimidated by a few moments of silence. Silence following a question often will prompt responses from the group.
  • Do not immediately provide answers when participants do not promptly respond to your questions. Instead, try rewording, rephrasing, or restating the questions.
  • Use active listening to indicate that you hear what participants are saying and to encourage continued participation.

Return to Contents

Before the Training Session

The following tasks should be completed before the session is held:

___ Arrange for a place to hold the course session and ensure that it has sufficient space and moveable chairs for break-out activities. Consider the room arrangement that will best facilitate your activities. For this course, it is suggested that the room have round tables that each seat from five to eight people.
___ Send out fliers or e-mails announcing the course and the dates.
___ Order all equipment (computer, LCD projector, screen, and flipcharts).
___ Arrange for refreshments and lunch, as appropriate.
___ Duplicate all handouts for the session (H-1 through H-5) and arrange them into participant packets. By providing a packet of materials to each participant, you can avoid the time-consuming task of distributing materials during the session.
___ Prepare nametags or name tents for participants.
___ Prepare a sign-in sheet to verify attendance (if providing CME or CEU, this is required for each session). Include spaces for participant name, program name, address, phone and fax numbers, and e-mail address. This will be useful if you need to make future contact with participants.
___ Read the Facilitator's Notes for the session, pages 1-17.
___ Review the handouts (H-1 through H-5) and the PowerPoint presentation, “Using Simulation in TeamSTEPPS Training,” (slides 1 through 48).
___ Load the PowerPoint presentation “Using Simulation in TeamSTEPPS Training” on the computer from the flash drive or CD-ROM.
___ Check the equipment to ensure that it is working properly. Check to ensure the slides can be seen clearly from the back of the room.
___ Pre-label flipchart pages with the headings below that correspond with the Facilitator's Notes:

  • Expectations.
  • Parking Lot Issues.
  • Participant Feedback. This page should have two columns: one labeled pluses (+) and one labeled deltas (Δ)

Return to Contents

Facilitator's Notes

Materials Activities Times
Using Simulation in TeamSTEPPS Training: Team Strategies and Tools to Enhance Performance and Patient Safety
I. Welcome, Introduction, Objectives, Agenda 40 min.
PPT slide 1 A. Welcome and Introduction

Begin with PPT slide #1 (title slide) on the screen. Welcome participants to this course on Using Simulation in TeamSTEPPS Training: Team Strategies and Tools to Enhance Performance and Patient Safety. Have each of the facilitators introduce themselves and make a brief statement about their backgrounds and expertise in simulation training and in the TeamSTEPPS approach. Tell participants that teamwork has been found to be one of the key initiatives within patient safety that can transform the culture of health care. TeamSTEPPS is an evidence-based program aimed at optimizing performance among teams of health care professionals, enabling them to respond quickly and efficiently to whatever situations arise.

Now ask participants to take no more than 1 minute each to introduce themselves, stating their names, positions, and prior experience, if any, with simulation training or with the TeamSTEPPS approach. If participants are few in number, they can introduce themselves one by one to the large group. Move the activity along, allowing each person to speak for only 1 minute. If the group is too large to complete the introductions in 15 minutes, ask participants to pair up and share background information (names, positions, and experience in simulation training or with TeamSTEPPS). Show that you are listening carefully to the introductions, which are important because they ensure from the start that every participant is acknowledged and included. However, there is sometimes a tendency for some people to speak for more than 1 minute; thus, you will need to be mindful of the time and not allow introductions to run longer than approximately 15 minutes.

(15 min.)

H-1; Flipchart page

B. Objectives and Agenda

Refer participants to Handout 1 (H-1) and ask them to picture themselves at the end of this training course: They are satisfied because they have learned new information that will help their teams perform more efficiently and effectively. Now ask them to think about two things they hope to gain from attending this course and write these on H-1. Sample responses from the group. List responses on the flipchart page that you pre-labeled “Expectations.” Continue listing expectations until there are no more responses. Post this flipchart page to a wall and allow it to remain there throughout the course. At the end of the course, you will revisit this list of participant expectations.

Note: It is not necessary that every participant respond to this question. It is likely that some participants will have expectations that have already been listed.

Refer to the flipchart list and identify those topics that will be addressed in this course; those that have not been planned for but can be addressed easily during the course; and those, if any, that are outside the realm of this course. To the extent possible, identify resources (both Web-based and print materials) that participants can access to address the issues that will not be covered in this course. Also identify other upcoming training opportunities, as appropriate, that will cover these topics.

(10 min.)
PPT slide 2; H-2 Now show participants PPT slide #2, Objectives, and refer to Handout 2 (H-2). Explain that there are two types of objectives: (1) Teamwork objectives that relate to the TeamSTEPPS approach that focuses on teamwork, interpersonal, and communication skills and (2) Technical/clinical objectives that relate to the specific medical procedure(s). Trainers should add their own specific objectives to PPT slide #2 to reflect the content of the simulation training they will conduct. They will also need to add the objectives to H-2 in participants' handout packets. (3 min.)
PPT slide 3 Trainers will need to develop an agenda for the training they will conduct (see sample agenda under Tab A, Appendix A, of the TeamSTEPPS Instructor Guide) and integrate the content and activities into the phases listed on PPT slide #3, Course Outline. Explain that for any course they develop, they will need to identify content for each of these three critical phases: Scenario development, measurement development, and debriefing. Be sure that the course outline focuses throughout on teamwork, interpersonal, and communication skills. It's helpful to create an agenda as a participant handout, including approximate times for each phase as well as breaks (e.g., morning, afternoon, and lunch breaks), as appropriate. If the course will be offered over a series of dates, be sure to include a multi-day agenda with dates and times of each session. Participants always appreciate having information on course content and meeting times. Now, referring to the PPT slide #3, quickly summarize the activities that will be part of this training and state their relationship to the expected outcomes. (5 min.)

Flipchart page

Parking Lot Issues

Post-It Note pads on tables

C. Parking Lot Issues

Tell participants that they will keep a “Parking Lot” of issues and questions that arise during training. The issues and questions may be tangentially related to simulation training or to medical procedures but not directly related to this course. Tell participants to write these questions on Post-It Notes (one question per note) and stick the notes on the flipchart page you pre-labeled “Parking Lot Issues.” Tell them that, to the extent possible, those questions and issues will be addressed at the end of this course.

Note: Post on the wall the flipchart page marked “Parking Lot Issues.” Also place a Post-It Note pad on each table. Throughout the course, ask participants to write their questions on the Post-It Notes, one question per note, and place the notes on the flipchart.

(2 min.)
Evaluation Form

D. Evaluation Form

Call participants' attention to the course evaluation form that you are using to collect information about participants' reactions to the course (See sample Course Evaluation Form under Tab B, Appendix A, of the TeamSTEPPS Instructor Guide). Remind them that they will be asked to complete the evaluation form at the end of the course but that they may wish to make notes on the form as the course progresses because it may be easier for them to keep a running commentary of their experiences throughout the course rather than try to remember everything at the end.

(5 min.)
II. Background 30 min.
PPT slide 4 Show PPT slide #4, Simulation. Explain that, as a training approach, simulation offers an opportunity to teach and engage health care professionals in a manner far superior to traditional methods of lecture and demonstration. Simulation provides opportunities for learners to practice TeamSTEPPS skills and strategies in a safe learning environment and, through practice and feedback, acquire teamwork skills needed for safe patient care. Simulation can take various forms, from simple role play to use of high-tech simulators. The point to emphasize here is that simulation is a method of instruction and not a technology. Simulation can be effective with low- or no-tech options. (2 min.)
PPT slide 5 Show PPT slide #5, Keys to Success, and explain that participants can have confidence that the design of their training will be successful if the course incorporates three primary elements: (1) Scenario design that focuses on specific learning objectives for their training and provides multiple opportunities for participants to practice team behaviors, (2) Measurement that includes both process and outcomes measures and accurately captures participant behaviors, and (3) Debriefing of practice activities to provide specific and detailed feedback to participants on behaviors that were performed according to acceptable standards and those that need improvement. Tell them that this course will cover these three phases plus a discussion of lessons learned. Remind participants that perhaps the most powerful learning occurs during debriefing when participants have a chance to review their performance with the training facilitator and identify those areas that need more work. (3 min.)
PPT slide 6 Show PPT title slide #6, TeamSTEPPS Resources, and remind participants that TeamSTEPPS Instructor Guide contains valuable resources that can be helpful in planning their training. Reinforce the point that participants should be clear in the behaviors that will be targeted and the goals to be accomplished in using simulation to train TeamSTEPPS. For example, Tab I contains scenarios that can be used or adapted for the training they develop and conduct. This tab contains 131 vignettes and is organized by department and by TeamSTEPPS skill and tool. If participants have not developed scenarios, they may wish to select from among those in the TeamSTEPPS Instructor Guide. Emphasize that they should be sure to embed TeamSTEPPS teamwork skills into scenarios they develop. You might want to spend a few minutes having participants skim through Tab I to become familiar with the scenarios it contains. Emphasize that these vignettes are not complete training scenarios but, with the methods described in this module, can serve as a stem to be developed. (5 min.)
In addition, Appendix C under Tab A contains a sample Team Performance Observation Tool that will be helpful for observing and measuring team performance during the simulation exercises. Observers should practice using this tool, which can be adapted to reflect a specific type of care. Reinforce the concept that these resources can be customized to fit their particular situations. Encourage participants to skim through Tab A. (5 min.)
PPT slide 7

Now show PPT slide #7, EBAT. Because it's important to acknowledge participants' prior knowledge and experiences, ask if anyone wishes to briefly share his or her knowledge of, or experiences with, EBAT.

(5 min.)
Explain that Event-Based Approach to Training (EBAT) offers a practical application for training teams to perform in naturalistic environments. Through the creation of effective scenario-based training, EBAT emphasizes linkages among learning objectives, scenario events, performance measures, instructional strategies, and feedback—all of which are critical elements of simulation training. This scenario- or vignette-based technique has proven highly effective as a strategy for training health care providers who must coordinate their efforts, especially in environments with multiple patient safety threats (e.g., emergency departments, intensive care units). It relies on controlled exercises or vignettes in which the trainee is presented with cues that are similar to those found in the actual task environment. The training objectives are accomplished by embedding specific "trigger" events into the scenario, and trainees receive feedback reflective of their responses. (5 min.)
Tell them that EBAT is not a new method. It has been used by the Department of Defense as well as the aviation industry. It is situation-based training (SBT) and is used to provide guided learning experiences that replicate real-world experiences as a means to build expertise. It has been applied to various U.S. military team-training efforts, including naval helicopter crews, teams that work in the combat information center onboard Navy ships, and attack center teams in the subsurface community, among others. In the airline industry during the 1980s, simulation became a cornerstone of Crew Resource Management (CRM), a team training program for airline pilots. Commercial aviation now relies heavily on SBT for pilot training and evaluation, particularly for simulating critical high-risk situations that cannot be performed in flight. In fact, the Federal Aviation Administration mandates that CRM scenarios be developed using an event-based method. (3 min.)

In health care, EBAT has been applied to both individual and teamwork training. The Simulation Module for Assessment of Resident Targeted Event Responses (SMARTER) approach is an event-based approach that links Accreditation Council for Graduate Medical Education, or ACGME, core competency-based assessment to SBT. The product of the EBAT process is a set of simulation scenarios and accompanying measurement tools that capture performance during SBT. EBAT has also been used for teamwork training in health care as well using the TeamSTEPPS curriculum. The EBAT approach is not the only solution, but it does offer one approach, in addition to others, in the toolbox of approaches to train and assess team performance.

Now explain that you will move into the heart of this course: The three phases of using simulation in TeamSTEPPS training. Ask if there are questions at this point before moving on to the three phases.

(2 min.)
Break 15 min.
III. Phase I—Scenario Development 2 hours
PPT slide 8

Welcome participants back from break and show PPT slide #8, Phase I. Explain that scenario development includes the following elements:

  1. Specifying teamwork skills.
  2. Defining learning objectives.
  3. Choosing the clinical context.
  4. Defining event sets.
  5. Defining targeted responses.

Tell participants that you will cover each of these in detail. Remind them that if they develop their own scenarios for use in training, the scenario should include the above five elements. Tell them that they will now explore each.

(3 min.)
PPT slide 9 Show PPT slide #9, Specify Teamwork Skills. Explain that “skills&##8221; refers to the categories of behavior for which they may want to provide training. Be sure they understand that teamwork is too encompassing and too complex to train using a single scenario. As a result, each course they offer should focus on a subset of competencies. The graphic on PPT slide #9 illustrate the four core competencies of TeamSTEPPS: Leadership, communication, situation monitoring, and mutual support. Tell them that it is important that they identify the teamwork skill and strategies they wish to target for training (e.g., conducting a pre-treatment briefing with their team). Ask if there are questions. (2 min.)
PPT slide 10

Show PPT slide #10, Define Learning Objectives. Explain that learning objectives state what participants will be able to do at the end of the training. They communicate to participants what is expected of them, and they help instructors/trainers focus their instruction and design appropriate learning activities for participants to apply and demonstrate their learning. Learning objectives also provide the basis for evaluating participant mastery of learning—in this case, mastery of performance expectations.

Learning objectives should be explicit, focusing on specific TeamSTEPPS behaviors, and they should be written in measurable terms. They should include the following information:

Performance—Specifies the behavior that is the focus of the training.
Condition(s)—Specifies the conditions under which the behavior occurs.
Standards—Specifies the level of expected performance.

(3 min.)
PPT slide 11

Review PPT slide #11, Example Objective. Also review the following examples of learning objectives relating to different teamwork skills:

  1. Upon completing this program of instruction on mutual support, participants, when using the feedback tool, will be able to communicate information in a way that allows for ongoing improvement.
  2. Upon completion of this program of instruction on team leadership, participants, when using the debrief checklist, will be able to summarize lessons learned and set goals for improvement.
  3. Upon completion of this program of instruction on situation monitoring, participants will be able to use cross monitoring to monitor behavior of other team members to ensure that mistakes or oversights are caught early.
  4. Upon completing this program of instruction on communication, participants will be able to use SBAR to communicate about a patient's condition using a standardized framework.
(5 min.)
H-3 Tell participants that it's now their turn to write some learning objectives. Referring to Handout 3 (H-3), ask them to develop learning objectives for a simulation course that they plan to deliver in the near future. They need first to consider the teamwork skills they want participants to learn. Remind them that the objectives should be explicit, be written in measurable terms, and include statements of performance, conditions, and standards. (2 min.)
Allow about 10 minutes for participants to develop learning objectives for the skills on which they plan to offer training. Provide assistance to those who indicate that they need help. When 10 minutes have elapsed, ask participants to form groups of three or four and to share their learning objectives with other members of their group. As each person shares his or her learning objectives, members of the group are to evaluate whether the objectives specify performance, conditions, and standards, and, if appropriate, they are to suggest ways to improve the learning objectives. Allow approximately 20 minutes for this small group activity. Then sample two or three learning objectives to share with the total group. Ask if there are questions. (30 min.)
PPT slide 12

Show PPT slide #12, Choose a Clinical Context. Explain to participants that after learning objectives have been set, it is important that they choose a clinical context to frame the scenario development and to assess the mastery of learning objectives. For example, if the learning objective is to examine whether health care professionals can communicate the four elements of an SBAR, the related scenario may be one centered on a trauma event involving cardiac arrest. Explain that although many clinical scenarios lend themselves to various learning objectives, not all contexts are equal for training purposes so participants should select a clinical context that affords participants opportunities to perform.

Remind participants that Tab I of the TeamSTEPPS Instructor Guide provides 131 scenarios from which they can select. Also remind them that the contexts selected should be appropriate for eliciting the team behaviors that are the focus of their training courses.

(5 min.)
PPT slides 13 and 14; H-4 Show PPT slide #13, TeamSTEPPS Scenario 86, then PPT slide #14, Clinical Context. Slide #13 presents a scenario. Slide #14 presents the clinical context of the same scenario. Encourage participants either to develop their own scenarios or to select scenarios from Tab I of the TeamSTEPPS Instructor Guide. Now refer participants to Handout 4 (H-4) and ask them to define the clinical context for the learning objectives they developed previously in this course. They should write both a descriptive scenario as well as the clinical context. Allow approximately 10 minutes for participants to work on their scenarios and clinical contexts, and then sample responses from the group. If time permits, you may wish to have participants in groups of three or four share their scenarios and clinical contexts and encourage members of their small groups to ask questions and offer suggestions for improving the scenarios.  
PPT slide 15

Show PPT slide #15, Define Event Sets. Explain that a scenario contains multiple reality-based event sets that trigger team responses, thereby creating engaging learning experiences for participants. Event sets are the building blocks of a scenario. An event set provides a framework for building scenarios and for examining and debriefing team performance. All event sets consist of a trigger—the condition under which the event becomes fully activated or the incident that elicits team behavior—and one or more distracters—conditions that are inserted into the event to divert the team's attention from other events that are occurring or are about to occur. Slide #15 presents an example of a trigger and a distracter for Team STEPPS Scenario 86 that was reviewed on slides #13 and #14.

Following is another example of a trigger and possible distracters in a scenario in which a patient is admitted to the telemetry floor to rule out myocardial infarction.

Trigger: Patient found apneic in hospital after central monitoring alarms sound.
     Team assembles in patient's room. Primary provider reports to team what he or she knows about the patient. Roles are assigned.
Distracters: Anxious family member enters room.
     Phone call announcing patient will not have ICU bed for at least 30 minutes

(10 min.)
PPT slide 16 Show PPT slide #16, Define Targeted Responses. Explain that each critical event needs to be linked to targeted responses, which are objectively observable behaviors exhibited by team members in response to the critical events. Each targeted response or behavior should meet expected levels of performance or standards as presented in the example on slide #16. Targeted responses indicate the extent to which a team member possesses explicitly defined knowledge, skills, and attitudes. See example on slide #16. (5 min.)
PPT slide 17 Show PPT slide #17, Guidance. Explain that, in developing scenarios, participants should keep the following points in mind:

  1. A simulation scenario should consist of three to five event sets to provide multiple opportunities for team members to demonstrate targeted responses.
  2. Each event set should include only one trigger event to avoid introducing too many variables and making it difficult to observe targeted responses to a specific trigger.
  3. It is helpful to break a clinical procedure into chunks and embed a trigger into each of the chunks.
(2 min.)
PPT slides 18 and 19 Now show PPT slides #18 and #19, Trauma Example. Each slide presents triggers and expected team behaviors of the same event set. The difference is that slide #18 represents a pre-hospital example while slide #19 represents primary survey. Review the triggers and expected team behaviors with participants. Explain that each slide can be chunked into two event sets, with one trigger for each event set. By combining the two trauma examples to make one scenario, you will have four event sets. (3 min.)
PPT slide 20; H-5 Show PPT slide #20, Scenario Development. Tell participants that it is now their turn to try their hands at scenario development. Refer them to Handout 5 (H-5) and ask them to work in groups of three to select a scenario from Tab I of the TeamSTEPPS Instructor Guide and then for their selected scenario to identify or develop the following items:

  • TeamSTEPPS skill.
  • TeamSTEPPS tool or strategy.
  • Learning objective(s).
  • Clinical context.
  • Event set with trigger and distracters.
  • Targeted responses

Allow participants 25 minutes for this exercise. Tell them to be prepared to make a 3-minute presentation in which they share their results with the total group.

(25 min.)

After about 25 minutes (longer, if participants need more time and your training schedule allows), ask each team to report to the total group the scenario they selected and the skills, learning objectives, clinical context, event set, and targeted responses they have identified or developed for their scenario. As a group completes its report, suggest that others in the room ask tactful questions, such as “What do you think the result would be if you changed the trigger to...?” and “Are there other learning objectives that might be related to this scenario?”, etc. After all groups report, give the groups about 5 minutes to make revisions to their scenarios.

Note: Keep in mind that the timing listed here for each part of the training is only a suggestion. You will need to modify the timing for exercises depending on the size of the group for which you are providing training as well as for the content of the training.

(25 min.)
Break or Lunch
Internet Citation: Facilitator's Notes. Content last reviewed July 2016. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/teamstepps/simulation/traininggd.html
Back To Top