Patients depend on health workers working well together for their recovery. If health-care providers have training in teamwork, however, there is less risk that they will make mistakes.

“As health services become more specialized, it’s even more important for health care providers to be good at working together. But to get good at this, you need training and education,” says Tore Karlsen.

Karlsen is an associate professor and study programme leader for the master’s degree in specialist nursing at the Department of Health Sciences at NTNU in Gjøvik.

Karlsen's focus has been a Norwegian version of a programme called TeamSTEPPS. His colleagues in this effort have been assistant professors Marit Sund Storlien and Tone Stomlien and Professor Randi Ballangrud from the same department.

The researchers followed a cohort of nursing students (in Norwegian) for three years. Teamwork skills were a topic in all relevant courses. What did the students learn, and what were the experiences of the teachers? The researchers have now investigated this.

The focus on patient safety increased sharply after the 1999 US report “To Err is Human“. This report showed that nearly 100 000 patients died each year in American hospitals due to adverse events. Poor communication and teamwork were among the most important reasons.

This is how TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) was born. The programme was released in November 2006 and was developed by the US Department of Defense and the Agency for Healthcare Research and Quality to integrate teamwork into practice.

The purpose is to strengthen teamwork, and is based on four skills:

• Communication
• Management
• Situation monitoring
• Mutual support

These skills are taught through tools and strategies such as briefing, debriefing, and a programme called ISBAR, which is a patient safety communication structure and other methods to ensure safe and structured communication.

The TeamSTEPPS was translated into Norwegian in 2015 and is currently used in education and clinical practice.

A cohort of nursing students at NTNU in Gjøvik used TeamSTEPPS throughout their bachelor’s education.

They carried out the team training using simulations, and studied practices and theory. The programme included reflection exercises, short lectures, films and digital learning resources.

Twenty-two students participated in interviews, while the students in the entire cohort answered the TeamSTEP questionnaire about attitudes towards teamwork. They did this before the programme started, after ten months and after 24 months.

The researchers compared the responses from the students with a group of students on another campus who did not receive this training. They also interviewed 12 teachers.

The students said it took time to learn good cooperation. At the start of their education, they found it difficult to understand why teamwork was important. It was both theoretical and complicated.

As they were able to practice their team skills in various learning activities at school and in practice, they gained a better understanding of its relevance and importance.

“Getting good at teamwork takes time, but it can be learned – and should be part of the education from start to finish,” says Karlsen.

Teamwork is about more than communication and leadership. The students and teachers raised their awareness of the complexity of the healthcare system and the importance of teamwork for patient safety. This was a key lesson learned throughout the project.

The list of what can be considered a healthcare team is long. A team can be the patient, a nurse and relatives. Or a nutritionist, kitchen staff and nurse. Or the oncologist and palliative care team. Physiotherapists and occupational health services have to work together. Occupational therapists and employees in home care are other examples.

Many educational offerings have programmes or projects in which nursing students participate in interprofessional teamwork. These may last from a few days to several weeks.

“However, there is often a general lack of emphasis on teamwork throughout educational programmes,” says Karlsen.

It can also be difficult to coordinate the various health education programmes in order to carry out interprofessional activities and training over time. This may be due to differences in course structure, timetables, collegial relationships and location.

Teamwork is based on the same principles regardless of how the team is composed, and there is no difference in effect between profession-specific and interprofessional teams when it comes to team training

This is how the nursing students completed four skills in team training:

Good communication within the team is fundamental to all other team skills. The students started by practising clear communication. This was followed up in all simulations throughout the education.

The students used simulations to train for leadership roles. In the beginning, they worked on leadership with their own work and included the “patient” as an active participant in the team, for example in connection with transfers or personal hygiene. An important part of the leadership role was to prepare the team through a briefing before the task started. Afterwards, the team leader was responsible for carrying out a debriefing: What worked well, what could be improved?

Situation monitoring is not only about monitoring the patient and having background knowledge about them, but also about observing the behaviour and competence of colleagues and fellow students. This could include whether hygiene is taken care of, assessing whether the team’s actions are having the desired effect and helping to ensure that errors are detected quickly.

Giving each other both positive and constructive feedback to improve practice and patient safety was demanding. Addressing disagreements and resolving conflicts in the team was also difficult to train through simulation. The teachers consequently made a video in which they themselves played roles in a team that had professional disagreements. The video was used as a starting point for reflection on how conflicts can be resolved in a way that does not impair teamwork or patient safety.

“In all of this, psychological safety is important. Without this, it is difficult for the students to use teamwork skills in practice,” Karlsen says.

“National guidelines for nursing education place great emphasis on learning outcomes in health, illness and nursing. Unfortunately, there is a vaguer description of the learning outcomes of teamwork skills,” he said.

References:
Karlsen, Tore (2025) Learning teamwork is not an event, it’s a journey: Implementing the TeamSTEPPS team training program in bachelor of nursing education to enhance patient safety. PhD dissertation, NTNU

Karlsen, T., Hall-Lord, M. L., Wangensteen, S., & Ballangrud, R. (2023). Bachelor of nursing students’ experiences of a longitudinal team training intervention and the use of teamwork skills in clinical practice—A qualitative descriptive study. Nursing Open, 10, 5616–5626. https://doi.org/10.1002/nop2.1806

Tore Karlsen, Marie Louise Hall-Lord, Sigrid Wangensteen, Randi Ballangrud (2022) Bachelor of nursing students’ attitudes toward teamwork in healthcare: The impact of implementing a teamSTEPPS® team training program — A longitudinal, quasi-experimental study, Nurse Education Today, Vol. 108, 2022, 105180, ISSN 0260-6917,
https:// doi.org/10.1016/j.nedt.2021.105180