Teaching and Learning in Nursing (2011) 6, 185–189

www.jtln.org

Development of team skills in novice nurses through anathletic coaching model1

Molly Johnson MSN, APRN-CPNP⁎, Mashawna Hamilton MSN,Beth Delaney MSN, APRN-FNP, Nicole Pennington MSN, RNC

Ohio University Southern, Center for Nursing Education (Academic 103), Ironton, OH 45638, USA

1 Previous Presentation of Paper: ApCoalition for Associate Degree Nurse Edu

*Corresponding author.E-mail addresses: johnsom4@ohio.e

delaneye@ohio.edu, penning@ohio.edu

1557-3087/$ – see front matter © 2011doi:10.1016/j.teln.2011.05.005

AbstractNursing is a team sport, and medical errors occur when members of the team fail to collaborate. Thepurpose of this project was to develop team leadership skills in entry-level nursing students through theintegration of team-focused activities in the classroom. The instructor's or coach's role was to facilitategroup activities that encourage communication, delegation, leadership, and adaptability. The result wasdevelopment of core competencies related to teamwork for students to use as an RN.© 2011 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.

KEYWORDS:Nursing leadership;Team building skills;Innovative teaching

1. Introduction

Quality and safety are important in every aspect of healthcare. Like members of a football team, each employee in ahealth care setting has a “position” and must play by “rules”according to regulations and directions of their “coach” andleague. Team dynamics are improved, which in turnproduces a higher level of satisfaction among memberswhen all players work together to achieve a common goal.Good team players have talent and a strong understandingof their position, as well as a good understanding of theroles of their teammates. Effective coaches use players tothe best of their ability to ensure the team runs efficiently.Championship winning teams are able to cooperate,

ril 2010 Poster Presentation, Ohiocators Conference, Columbus, OH.

du, hamiltom@ohio.edu,

National Organization for Associate Degre

coordinate, and work together. Nurses often act as the teamquarterback. To ensure a “touchdown” or positive patientoutcome, nurses must work with all members of the healthcare team to achieve safety and efficiency in patient care.

2. Background

The Institute of Medicine (IOM) previously published areport entitled To Err is Human: Building a Safer HealthSystem. The authors estimated that 44,000 to 98,000American's die each year as a result of preventable medicalerrors (IOM, 2000). A review of data by the JointCommission on Accreditation of Healthcare Organizations(2004) identified “breakdowns in communication” as criticalfactors in two thirds of all types of sentinel events (as cited inLeonard, Graham, & Bonacum, 2004). Knaus, Draper,Wagner, and Zimmerman (1986) found communicationbetween nurses and physicians to be the most significantfactor associated with excess hospital mortality in criticalcare settings. Donchin et al. (1995) cited verbal miscommu-nication between physicians and nurses as a causative factor

e Nursing. Published by Elsevier Inc. All rights reserved.

186 M. Johnson et al.

in 37% of all types of errors. Fortescue et al. (2003) foundthat tactics such as inclusion of nurses in physician workrounds and the order-writing process could potentiallyimprove communication between nurses and physiciansand prevent 17.4% of pediatric medical errors and 29.4% ofpotentially harmful errors.

High acuity of patients in hospitals coupled with rapidturnover requires that nurses be able to move fluidly throughvarious roles on a team, sometimes coaching and other timesreceiving direction. This concept is of particular importancein relation to interdisciplinary communication throughout theteam and its vital impact on patient safety. However,members of these interdisciplinary health care teams rarelytrain together and often learn the rules of the game using verydifferent play books. In fact, it may seem at times that thequarterback and his team are playing different offensesconcurrently. Recognizing that the best teams are not formedovernight and all leaders are not born with inherentleadership skills, it is imperative that nurses are providedtraining to develop team building, communication, andleadership skills.

Numerous agencies have provided guidelines gearedtoward improving patient safety and reducing deficiencies inthe delivery of quality health care. Each plan includes avariation of a mandate to improve communication withininterdisciplinary health care teams. The IOM's (2003)second core competency encourages institutions chargedwith educating health professionals to teach health careproviders to work as members of an interdisciplinary team.In response to the IOM competencies, the Robert WoodJohnson Foundation funded the Quality and Safety Educa-tion for Nurses (QSEN) project to develop nursing-specificsafety competencies for health care systems and to enhancenursing school curricula related to quality and safety (QSEN,2005). Teamwork and Collaboration was identified as thesecond of six areas of importance in the restructuring ofnursing education (Sherwood & Drenkard, 2007). EssentialElements II and VI from the American Association ofColleges of Nursing's (2008) The Essentials of BaccalaureateEducation for Professional Nursing Practice also addressesthe importance of the development of leadership skills,interdisciplinary communication, and collaboration inquality care and safety. Most recently, the IOM (2010), inThe Future of Nursing: Leading Change and AdvancingHealth, called on nurses to be full partners with physiciansand other health professionals in redesigning health care inthe United States. Achieving this task will require nurses tobe trained in leadership skills and perform competenciesvalidating training throughout their nursing education.

In 2006, Team Strategies and Tools to EnhancePerformance and Patient Safety (TeamSTEPPS) was re-leased as a joint effort by the Agency for HealthcareResearch and Quality (AHRQ) and the Department ofDefense as a national standard for team training in healthcare. The TeamSTEPPS program is an “evidence-basedteamwork system to improve communication and teamwork

skills among health professionals” (AHRQ, 2006). Clancyand Tornberg (2006) explained the four core competencyareas of the TeamSTEPPS program as follows:

1. Leadership—the ability to direct and coordinate activities ofteam members, assess team performance, assign tasks,develop team knowledge and skills, motivate team members,plan and organize, and establish a positive team atmosphere.

2. Mutual support (or back-up behavior)—the ability toanticipate other team members' needs and to shift workloadamong members to achieve balance.

3. Situation monitoring (or mutual performance monitoring)—the capacity to develop common understandings of the teamenvironment and apply appropriate strategies to monitorteammate performance accurately.

4. Communication—including the efficient exchange of infor-mation and consultation with other team members.

TeamSTEPPS also provides health care organizationswith the materials and training curriculum to utilize and teachthe key competencies/skills. See Table 1 for summary of keycompetencies, skills, and actions used in the TeamSTEPPscurriculum and how they were implemented in the classroom(AHRQ, 2006).

3. Implementation

In response to the prospect of a large number of entry-level associate degree nursing students (89 students in onesection), the authors developed an athletic coaching modelusing TeamSTEPPS as a framework. The athletic coachingmodel serves multiple purposes. First, it provides a team-learning experience in which students are actively engaged inlearning. Second, it shifts the focus of the classroom from theinstructor to the learner. Third, the athletic coaching modelallows students to form relationships with their teammates.Finally, opportunities are provided for students to practiceand apply communication and delegation skills.

Cottell and Millis (1993) described five key ingredientsfor a successful team-learning experience: (a) studentinterdependence, (b) individual accountability, (c) appropri-ate grouping, (d) social skills interaction, and (e) groupmonitoring. Springer, Stanne, and Donovan (1999) proposedthree interrelated perspectives to promote small-grouplearning: cognitive elaboration, affective collaboration, andmotivation. Cognitive elaboration means new information isbest retained when linked with information already inmemory. Affective collaboration is not only the allowanceto communicate with peers but also a desire to participate andshare ideas. Motivation occurs when individuals value thegoals and success of the group, thus supporting each otherindividually and collectively (Springer et al., 1999). In astudy regarding student perception of success in teamlearning, Rassuli and Manzer (2005) suggested teamassignments should be geared to support interdependenceand group input toward mastery of course material. In

Table 1 Summary of TeamSTEPPS key competencies, skills, actions, and methods of implementation in the classroom

TeamSTEPPS keycompetency

Skill Action Method of implementation in the classroom

1. Leadership Planning (brief) Prior to start discuss team and establishroles

–Meeting at beginning of each class period

Problem solving (huddle) Ad hoc team meeting to shareinformation and adjust plan

–Team huddles during each class period

Process improvement (debrief) After-action review to providefeedback

–Wiki pages–Online discussion forum–Survey regarding teams

2. Situationmonitoring

Cross-monitoring Monitoring the actions of others forpurpose of sharing workload orreducing or avoiding errors

–Monitoring group work on Wiki pages anddiscussion boards

–Use of clicker questions to verify studentunderstanding of content

Shared mental model Perception, understanding, andknowledge checked throughcommunication

–Morning report–Student understanding of content is verifiedthrough clicker questions

3. Mutual support Task assistance Giving and seeking help when needed –Instructor available during office hours, viae-mail, and online discussion board

–Students can answer one another's questions ondiscussion board

Feedback Sharing performance-relatedinformation with team members

–Team captains monitor student preparedness forclass weekly

–Students receive the results of their teamevaluation after the implementation of theservice-learning project

Advocacy and assertiveness Standing up for a person or idea in anonthreatening but firm manner

–Team captains are responsible for voicing theconcerns of their group to the instructor

–Students also use these skills when workingtogether on group project

Two-challenge rule Voicing your concern twice to makesure that it was heard and stopping anyaction you feel is unsafe

–Students were able to use this skill when workingtogether in group project

Collaboration Working together to ensure safety insatisfying process for all involved

–Students answered clicker questions together as agroup

–Required to work together for projectDESC Approach for managing and resolving

conflict–Students were asked to use this method whenresolving conflicts with group members andwhen complaints about the course arose

4. Communication SBAR Method for communicatinginformation in concise, clear, andtimely manner by stating the situation,background, assessment, and response

–This method was taught as a communication toolto use in e-mail and telephone correspondencewith the instructor

Call-out Strategy to communicate importantinformation

–Used by instructor when communicating vitalinformation such as changes in syllabus

Check-back Communication technique used toverify that the receiver understood thesender's message

–Clicker questions–Used by instructor to verify that important pointswere understood by the class

Hand-off Transfer of information duringtransitions that includes time forquestions and clarification

–Used at the end of every class to ensure thatquestions were answered

187Athletic coaching model

addition, instructors should be available to provide immedi-ate feedback to the team because students perceive success ifthe feedback enhances their retention of new concepts andproblem-solving skills (Rassuli & Manzer, 2005).

Implementing the team model in the classroom beganwith dividing students into teams according to their clinicalgroups, which were randomly assigned. Group sizes rangedfrom 7 to 10 members per group. Teams were assigned acolor by the instructor, and team members chose a namebased on that color. Examples of names selected include

Gang Green, Purple Parasites, and Code Blue. Teams wererequired to sit together in the classroom, compete as a unit ina weekly competition using classroom response clickers, andimplement a teaching–learning service project. Teamcaptains were assigned by the instructor or “coach” andalternated weekly so that each student had an opportunity topractice leadership and delegation skills.

Classes began with a brief instructor-led planning sessionin which announcements pertaining to the course and thenursing program were shared. Students were each given a

188 M. Johnson et al.

colored folder that corresponded with their assigned teamcolor and name. Student work such as examinations andother written work was sorted prior to the start of class andfiled in their individual folder. Folders were then sorted byteam colors. Team captains were responsible for assisting theinstructor with the distribution of folders and other coursematerials to team members at the beginning of each class.This process increased efficiency of tasks and provided timefor more meaningful activities.

Following the planning brief, teams participated in “teamhuddle.” During the huddle, teams summarized the keyconcepts from the assigned readings. In the TeamSTEPPSmodel, “huddles” consisted of a quick meeting of teammembers with a purpose of setting the day in motion, makingplans, or regrouping to move the team ahead (AHRQ, 2006).Captains were responsible for presenting key informationidentified during team huddle to the class in a “morningreport.” This action simulated the report a nurse might giveabout the clients under his or her care. As the students gave thereport, the instructor clarified the importance of selected topicsand elaborated when necessary, giving real-life examples asapplicable. This method of lecture and discussion allowedstudents to direct their own learning as the lecture becametailored around the concepts presented in team huddle.

Because of the large size of the class, team captains weregiven a yellow flag similar to those used by referees infootball games. The yellow flags were to be thrown if theteam didn't understand a concept being presented or ifquestions arose. The thrown flags were more effective thanraising hands because it caught the eye of the instructorquicker and created a fun, nonthreatening atmosphere. Thismethod also served to teach students assertiveness and gave

Table 2 Student responses to athletic coaching model in the classroo

Survey question % stronglyagree (n = 30)

1. Each teammember devoted his or her fair share of timeto the project.

20.0

2. The contributions of each team member werethoughtful and valuable.

26.7

3. Each team member gave the project a high priority andwillingly accepted responsibilities.

20.0

4. Each team member completed assigned tasks aspromised and on time.

36.7

5. Each team member saw what had to be done and did itwithout prompting or pressure.

26.7

6. The team members were willing to acceptdisagreement and adapt.

16.7

7. I would be pleased to work with these members onanother team in the future.

36.7

8. I would prefer to work on my own. 10.09. I felt that the team concept made the class more fun. 53.310. The team competition motivates me to be prepared

for class so that I don't let my teammates down.34.5

11. I ask my teammates questions first, rather than theinstructor, when I need clarification on a topic.

13.3

12. I enjoyed being the leader of my team. 10.013. I would have preferred not to be assigned teams. 6.7

them confidence to speak up in situations in which themessage was unclear. In turn, the instructor had a red penaltyflag to use when classroom noise was above an acceptablelevel or when students strayed from the task at hand.

The teams competed in weekly competitions usingaudience response clickers with NCLEX-style questions thatwere pertinent to content being learned in class. Scores fromeach student's responses were averaged for each team everyweek and were recorded. This process made it fairer for teamswho had fewer players. The final week of the quarter was savedfor a “Clicker Super Bowl,” in which the teams competed in acomprehensive Jeopardy-style clicker competition. The teamwith the most points for the quarter was allowed to select theday of their clinical for the next academic quarter.

Teams were also required to participate in a service-learning project at a local high school. Each team wasassigned a topic related to adolescent health and well-being,and they were required to develop a trifold poster and a 5-minute teaching presentation. Examples of topics includeddangers of texting while driving, depression and anxiety, andbullying. Clear guidelines for the project including a gradingrubric were included in the syllabus. Students were givenpoints for individual performance as rated by both the coachand their teammates. An online evaluation tool was createdso that students could provide feedback anonymously. Inaddition, the high school students were given the opportunityto vote for the presentation that they found most intriguingand helpful. The winning team was rewarded 5 bonus pointson the final examination.

In an effort to enhance team communication, Wiki pageswere created by the instructor at the beginning of the coursefor each team. Teams were encouraged to use the pages to

m

% agree(n = 30)

% neutral(n = 30)

% disagree(n = 30)

% stronglydisagree (n = 30)

53.3 10.0 16.7 0.0

56.7 16.7 0.0 0.0

46.7 16.7 16.7 0.0

43.3 13.3 6.7 0.0

50.0 10.0 13.3 0.0

50.0 16.7 16.7 0.0

36.7 13.3 13.3 0.0

10.0 40.0 26.7 13.336.7 10.0 0.0 0.034.5 17.2 13.8 0.0

63.3 16.7 6.7 0.0

36.7 43.3 10.0 0.06.7 26.7 50.0 10.0

189Athletic coaching model

work on their group assignment and to post helpfulinformation to their classmates. Team captains were requiredto post summaries of the assigned readings weekly on theirteam's Wiki page. A discussion board was also created foreach team. One thread of the discussion board was labeled“Questions for My Team,” and one thread was labeled“Questions for My Instructor.” This proved to be particularlyhelpful in reducing the volume of e-mails the instructorreceived, as most students were able to acquire answers totheir questions by posting on the discussion board.

4. Outcomes

The instructor using the athletic coaching model in theclassroom perceived it to be an effective management toolfor large student groups. Furthermore, the team approachserved to facilitate student relationships among each otherand with the instructor. These results are consistent withother research that has shown that team-based learningincreases student performance and increases studentengagement and satisfaction (Eun-Kyung, Jung-Ae,Young-Hong, & Oh-Sun, 2009). See Table 2 for studentresponses related to their experience with team learning inthe classroom. Using the TeamSTEPPS model in theclassroom gave novice nursing students exposure andexperience using tested strategies and tools currentlybeing used in health care to promote quality and safety.See Table 1 for a description of how each TeamSTEPPSskill was used in the classroom.

5. Conclusion

In today's medical environment, there is often consider-able uncertainty, rapidly changing circumstances, and a lackof clear communication among team members. Working asleader of an interdisciplinary team requires excellentcommunication skills, assertiveness, and adaptability, aswell as a knowledge of team functions. Acquiring these skillstakes practice and an environment such as the classroomwhere students can learn from their mistakes without fear ofharming a patient or their career. Future studies should focuson enhancing acquisition of team skills through structuredactivities in multiple settings that allow students todemonstrate learned knowledge and skills. Multidisciplinarysimulation exercises and structured opportunities in theclinical environment can offer students useful feedback toimprove their performance and help them gain confidenceand experience. In addition, research needs to be conducted

to assess the effects of team training on performanceoutcomes and patient safety criteria.

References

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