Hrev_master
Healthcare in Low-resource Settings 2023; volume 11(s1):11163
The effects of TeamSTEPPS implementation by nurses on situation
monitoring in hospital
Ahsan, Imeldha Monitasari, Evi Harwiati Ningrum, Ike Nesdia Rahmawati, Linda Wieke
Noviyanti, Kuswantoro Rusca Putra
Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya, Malang, Indonesia
Abstract
Introduction: Patient safety is a healthcare system, which min-
imizes the occurrence and impact of side effects. It also helps to
facilitate full recovery in patients, and efforts to improve their
safety require teamwork, such as situation monitoring by nurses.
Therefore, this study aims to determine the effects of
TeamSTEPPS implementation by nurses on situation monitoring
in hospitals.
Design and Methods: A quasi-experimental pre-post test
design was used with a total of 56 nurses, which were selected
using the purposive sampling technique. They were then shared
equally into 2 groups, namely control and intervention groups.
Results: The unpaired t-test result shows that the value of |t
count| was lower than the t table (0.210 < 2.005), while the p-
value was greater than α (0.835 > 0.050). This result indicates that
implementing TeamSTEPPS by nurses have an insignificant effect
on situation monitoring in the hospital.
Conclusions: In conclusion, hospitals are advised to imple-
ment TeamSTEPPS regularly to improve teamwork, specifically
in situation monitoring by nurses.
Introduction
Hospital is a professional place that provides safe services,
which prioritize the patients’ needs, such as optimal safety during
the treatment.1 Patient safety is a system that involves risk assess-
ment, identification, incident reporting, and implementation of
solutions to minimize risks.2 The Institute of Medicine (IOM)
revealed that the rate of adverse effects in Utah and Colorado,
United States was 2.9% with a 6.6% mortality rate, while a preva-
lence and death rate of 3.7% and 13.6%, respectively were record-
ed in New York. Meanwhile, hospitals in Australia and Denmark
reported a prevalence rate of 3.2%-16.6% and 12% in Canada.3
Over the years, the prevalence of Patient Safety Incidents
(PSIs) in Indonesia has also increased with a total of 144 cases in
2009, 103 cases in 2010, and 34 cases between January-April
2011. Furthermore, at the province level, the reported rates in DKI
Jakarta, Central Java, Yogyakarta, and East Java as of 2007 were
37.9%, 15.9%, 12.8%, and 11.7%, respectively.4 In Malang, the
reported near misses and adverse events cases were 47.6% and
46.2%, respectively. An observation revealed that 30 PSIs were
not reported, which consist of 12 no harm cases and 18 reportable
circumstances.5
This high prevalence rate has several material and immaterial
impacts on the hospitals and patients. The material impacts are
caused by the high number of patient safety incidents, such as the
USD 37.6 billion financial loss experienced by the United States
annually due to these events.6 Other material impacts include
injuries, deformities, deaths, extension of the treatment period,
additional treatment costs, and similar events recurrence.
Meanwhile, the immaterial impacts include patients’ loss of moti-
vation to experience the treatments as well as declining trust in
health workers who provides health services due to the trauma
they experienced.7
These data revealed that all health workers, specifically nurs-
es, have the potential to contribute towards the increase in the
number of patient safety incidents. This is because nurses account
for approximately 40%-60% of health workers who provide health
care services in hospitals. They also have the most direct contact
with patients in 24 hours.6 Meanwhile, nurses can fail to under-
stand the patient’s declining condition because they often ignore
the clinical information reported by other team members,8 which
is also known as situation monitoring.
Situation monitoring is a process of actively assessing and
understanding the patient’s internal and external situations.9
Internal situation is the conditions of patients and team members,
while the external situation is the physical environment.9 Situation
monitoring helps to resolve issues that occur between team mem-
bers, understand the situation of the surrounding environment,
monitor the patient’s condition as well as to learn the appropriate
measures that can be used to avoid mistakes.10 Furthermore, it is
one of the major methods used to increase patient satisfaction and
the quality of teamwork.
TeamSTEPPS training has been proven to be an efficient
method that can be used to prevent patient safety incidents. The
method uses the concept of collaboration between teams and it
Article
Significance for public health
The nurse's ability to read changes in the patient's situation is critical in predicting potential worsening conditions that could endanger the patient's life.
Situation monitoring aids in the resolution of conflicts among team members, allowing them to learn the best practices for avoiding medical errors, adverse
events, and sentinel events. The adoption of modified TeamSTEPPS is expected to result in improved situation monitoring and, as a result, a reduction in the
occurrence of medical errors. This study investigated the impact of a modified TeamSTEEPS on Nurses' situation monitoring in the hospital. The findings could
lead to new ways to improve hospital and other healthcare facility safety.
[Healthcare in Low-resource Settings 2023; 11(s1):1163] [page 1]
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consists of four main components, namely leadership, communica-
tion, mutual support, and situation monitoring between the teams.11
Study revealed that TeamSTEPPS can improve patient safety
and healthcare quality, hence, it needs to be implemented in
Indonesia’s nursing services. Furthermore, previous studies report-
ed that poor situation monitoring or situation awareness accounts
for 80% of anesthesia patient safety incidence.12,13 Qualitative
review also showed that understanding of situation monitoring
improves nurses’ decision-making ability and health care quality.12
Therefore, this study aims to determine the effects of
TeamSTEPPS implementation by nurses on situation monitoring
in hospitals.
Design and Methods
This study used a quasi-experimental pre-post-test design to
examine the difference between situation monitoring in the control
group and the intervention group after the TeamSTEPPS treatment.
This study was carried out from November 2019 to February 2020
among nurses in the inpatient rooms of Muhammadiyah Malang
University (UMM) Hospital and Brawijaya University (UB)
Hospital, with a total of 75 and 50 nurses, respectively. The sam-
ples were then selected using the purposive sampling technique,
which was based on several inclusion and exclusion criteria.
Nurses that are willing to participate for a minimum of two months
and are ready to perform nursing care directly to the patients for
more than 7.5 hours/week were selected, while nurses on leave or
probation were excluded. A total of 28 samples were then obtained
from each hospital after the selection process. The UMM and UB
Hospitals samples were served as the control and intervention
groups, respectively.
The Situational Monitoring as part of the TeamSTEPPS
Teamwork Perceptions Questionnaire (T-TPQ) and TeamSTEPPS
Teamwork Attitudes Questionnaire (T-TAQ) from the AHRQ were
used for this study. They contain 13 questions, which consist of 7
perceptions dimension items, and 6 attitudes dimension items
(Table 1). The validity and reliability test was carried out using
Pearson’s correlation and Cronbach’s Alpha on 43 respondents
who were outside the sample population but had the same charac-
Article
[page 2] [Healthcare in Low-resource Settings 2023; 11(s1):1163]
Table 1. The situational monitoring perceptions and attitudes questionnaire.
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teristics as the sample. The validity and reliability test showed that
T-TPQ was 0.713 and 0.849, while TTAQ was 0.683 and 0.706.
Therefore, it was concluded that the situaional monitoring ques-
tionnaire items on T-TPQ and T-TAQ were valid.
Results and Discussions
Characteristics of respondents
The description of the respondents can be seen at Table 2. The
control group contains 16 female (57.1%), while the intervention
group has 23 female (82.1%). Furthermore, 23 respondents
(82.1%) in the control group are between the age of 20-30, while
20 respondents (71.4%) in the intervention group are in this age
range. The Diploma Nursing Program was the latest education of
15 respondents (53.6%) in the control group, while in the interven-
tion group, the Nurse Profession Program was the latest for 16
respondents (57.1%). 21 respondents (75.0%) are working in the
inpatient rooms in the intervention group, while all 28 respondents
(100.0%) in the control group work there. 22 respondents (78.6%)
in the control group and 18 (64.3%) respondents in the intervention
group have been working at the unit for one to five years. This
range of working periods is similar to that of the samples with 18
respondents (64.3%) in the control group and 20 respondents
(71.4%) in the intervention group.
Situation monitoring in the control group and interven-
tion group
Situation Monitoring in control group shows that the percep-
tions pretest scores median of 28.00 was equal to that of the
posttest scores. Also, the attitudes pretest scores median of 24.00
was equal to that of the posttest scores. However, Situation
Monitoring in intervention group shows that the perceptions
pretest scores median of 27.00 is less than the posttest which was
28.00. It also shows that the attitude pretest scores median of 24.50
is greater than the posttest which was 24.00 (Table 3).
Analysis of the difference in the situation monitoring
pretest and posttest scores
Table 4 reveals that the p-value of perceptions is 0.406, which
indicates that there is no significant difference in the perceptions
scores of the control group. Furthermore, the p-value of attitudes
was 0.737, which shows that there is no significant difference in
the attitudes scores of the control group. The p-value of percep-
tions was 0.732, which indicates that there was no significant dif-
ference between the pretest and posttest perceptions scores in the
intervention group. Furthermore, the attitudes had a p-value of
0.830, which shows that there was also no significant difference
between the pretest and posttest attitudes scores in the intervention
group.
Analysis of the difference in the situation monitoring
pretest and posttest scores in the control and
intervention groups
Table 5 shows that p-value of the Situation Monitoring
Perceptions was 0.610 (p > 0.05), which indicates that there was no
significant difference in the averages of both groups based on the
measured improvement. In the situation monitoring variable, the
average improvement of the intervention group was slightly higher
than the control, but the difference was insignificant. Moreover,
the p-value of the Situation Monitoring Attitudes was 0.835 (p >
0.05), which indicates that there was no significant difference in
the averages of both groups based on the measured improvement.
In the situation monitoring variable, the average improvement of
the intervention group was slightly lower than the control, but the
difference was insignificant. This indicates H0 was accepted,
meaning that the implementation of TeamSTEPPS by the nurses
has no significant effects on their situation monitoring.
The majority of nurses in this study are female and based on
psychological theories perspective, they adhere to the rules and
expect success at work more than male.14 However, there is no dif-
ference between the male and female nurses in terms of solving
problems, skills, competition drive, motivation, and ability to pro-
vide good nursing care to patients. Most of the samples were 20-
30 years old, which shows that the way of thinking as well as prob-
Article
[Healthcare in Low-resource Settings 2023; 11(s1):1163] [page 3]
Table 2. Characteristics of respondents.
Characteristic Control Group (n=28) Intervention Group (n=28)
F % F %
Age
20-30 y.o. 23 82.1% 20 71.4%
31-40 y.o. 5 17.9% 8 28.6%
Gender
Male 12 42.9% 5 17.9%
Female 16 57.1% 23 82.1%
Latest Education
Nurse Profession Program 13 46.4% 16 57.1%
D3 Nursing Program 15 53.6% 11 39.3%
Others 0 0% 1 3.6%
Years Working in the Unit
< 1 year 0 0% 10 35.7%
1-5 years 22 78.6% 18 64.3%
6-10 years 6 21.4% 0 0%
Years Working at the Hospital
< 1 year 0 0% 10 35.7%
1-5 years 22 78.6% 18 64.3%
6-10 years 6 21.4% 0 0%
Work Unit
Inpatient 28 100,0% 21 75.0%
ICU 0 0,0% 7 25.0%
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lem-solving ability increases along with age, and this improves
their performance, experience and knowledge.15
The latest education of most nurses in the control group was
the D3 Nursing Program, while the Nurse Profession Program was
the lastest in the intervention group. Therefore, it was assumed that
the nurses’ level of education affects their perception of nursing
care provision system as well as the need to implement their
knowledge and skills in patient safety.16
The nurses’ working period in the unit ranges between one to
five years. It was also observed that respondents with ≤ 6 years
working experience provided better nursing care because they are
more enthusiastic and have greater curiosity while performing
their duties. Therefore, the working period in the units and hospi-
tals significantly affected their performance while providing
healthcare services to patients.17 The majority of the respondents
work in inpatient units, and a previous study reported that nurses
working in different rooms in a hospital have no significant effects
on their performance.18
Situation monitoring in the control group
In the control group, the pretest scores of perceptions towards
situation monitoring were higher than their posttest scores.
Meanwhile, their attitudes pretest scores were lower than their
posttest scores because the control group was not given the
TeamSTTEPS treatment. This finding is consistent with a previous
study, which reported that there was no significant improvement in
the perceptions and attitudes posttest and pretest for the control
group. This was because they work in the same unit in the hospital
and they were not trained.19
Situation monitoring in the intervention group before
and after the TeamSTEPPS training
The pretest scores of the nurses’ perceptions towards situation
monitoring were lower than the posttest, while the pretest scores of
their attitudes were higher than the posttest scores. Furthermore,
King et al. (2015) stated that there was an improvement in nurses’
perceptions because the TeamSTEPPS training was administered
in accordance with the AHRQ guidelines. The training was then
monitored regularly by the High-Reliability Organization (HRO)
and supported by the AHRQ through teleconference for two
months.20 These findings are in line with Goebel (2016) that there
was an improvement of perceptions in the intervention group, but
it was insignificant with a p-value of 0.84.21
Meanwhile, the pretest scores of the nurses’ attitudes were
higher than the posttest, but it was insignificant. This is in line with
a similar study that the improvement of situation monitoring
observed through the teamwork attitude was caused by the poor
motivation and compliance while implementing the training in
real-life situations.22 Furthermore, Shaw (2015) reported that
TeamSTEPPS has several benefits, such as improving nurses’ per-
ceptions, although the employment rate before and after the train-
ing was constant.23
The effects of TeamSTEPPS
implementation by nurses on
situation monitoring in a hospital
Based on perceptions improvement, there was no significant
difference between the averages of the two groups. The interven-
Article
Table 3. Results of the situation monitoring pretest and posttest in the control group and intervention group.
Group Variable Median N IQR Min Max
Control Group Pretest
Perceptions 28.00 28 2.75 21.00 35.00
Attitudes 24.00 28 2.75 20.00 30.00
Posttest
Perceptions 28.00 28 2.00 21.00 35.00
Attitudes 24.00 28 1.00 20.00 30.00
Intervention Group Pretest
Perceptions 27.00 28 2.00 19.00 34.00
Attitudes 24.50 28 4.50 16.00 30.00
Posttest
Perceptions 28.00 28 2.75 22.00 35.00
Attitudes 24.00 28 0.00 21.00 30.00
Table 4. Situation monitoring in the control group using Wilcoxon test.
Group Variable Z p-value
Control Group Perceptions Pretest -0.832 0.406
Posttest
Attitudes Pretest -0.336 0.737
Posttest
Intervention Group Perceptions Pretest -0.342 0.732
Posttest
Attitudes Pretest -0.215 0.830
Table 5. Results of the unpaired T-Test on the situation monitoring perceptions and attitudes in the control and intervention groups.
Variables Group Mean N Std. Dev T P-value
Perceptions Control -0.4286 28 4.76429 0.513 0.610
Intervention 0.2143 28 4.60561
Attitudes Control 0.1429 28 3.80754 -0.210 0.835
Intervention -0.0714 28 3.83868
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tion group’s average perception was slightly higher than the con-
trol, but the difference was insignificant. Meanwhile, in terms of
the attitudes towards situation monitoring, the average improve-
ment of the intervention group was slightly lower than the control
group, and the difference was also insignificant. This study shows
that the improvement of average perceptions in the intervention
group was slightly higher than the control, but it was insignificant.
This finding is consistent with Shaw (2015) that there was no sig-
nificant difference in situation monitoring, but there was an
improvement of perceptions in the posttest.23 Furthermore, this
was caused by the limited time of training, which was conducted
for only four hours. It was also caused by the instructor’s inade-
quate skills while conducting the training, which led to the loss of
interest by the participants. In terms of the attitudes, the average
improvement in the intervention group was slightly lower than the
control group, and the difference was also insignificant. This is in
line with a previous study that there was a slight and insignificant
improvement in the nurses’ attitudes towards situation
monitoring.24 This was because the respondents had positive atti-
tudes before the TeamSTEPPS training, consequently, the change
after the training was insignificant.
The factor that caused the insignificant improvement of situa-
tion monitoring in this study was the poor commitment of the inter-
vention group respondents in attending the training. This lack of
commitment can be observed through the undisciplined partici-
pants that came late and left the training room during the
TeamSTEPPS training. The workshop lasted for only two hours,
after which the seminar was carried out on the same day.
Meanwhile, the AHRQ advised that the workshop needs to be
administered a day after the seminar for four to six hours.10 After
the training, advisory sessions and follow-ups regarding teamwork
were regularly conducted, but the nurses showed poor commitment
towards implementing the program in their units. Consequently,
the teamwork in situation monitoring after the training was subop-
timal.
Regular observation needs to be carried out for one month after
the implementation of TeamSTEPPS to monitor the improvement
of perceptions and attitudes.25 Another observation must be done 6
and 12 months after the implementation to monitor the significant
improvement of the competence in every PICU and SICU. The
improvement of situation monitoring scores of both control and
intervention groups was caused by various factors including the
age of most of the respondents and their working duration in the
units and hospital. The working period correlates with their expe-
riences in teamwork. Furthermore, these experiences help to devel-
op workplace comfort, which indirectly builds a trusting relation-
ship in nursing care and fosters effective teamwork. Based on the
results, the implementation of TeamSTEPPS had no significant
effects on situation monitoring by nurses at Brawijaya and
Muhammadiyah Malang Hospitals. This study found that
TeamSTEPPS had no significant effects on hospital situation mon-
itoring. TeamSTEPPS should also be improved through a more
effective method and training duration to achieve the best results.
After receiving TeamSTEPPS training, at least six months of
observation is required to track teamwork improvement in situa-
tion monitoring. These ongoing check-ins help to reinforce the
nurses’ commitment to the program’s implementation.
Conclusions
The improvement of the intervention group’s perceptions
towards situation monitoring was slightly higher than the control.
Meanwhile, the improvement of the intervention group’s attitudes
was slightly higher than the control group, but the difference was
insignificant. These findings indicate that there was an insignifi-
cant difference between the perceptions and attitudes towards situ-
ation monitoring after the TeamSTEPPS treatment in a hospital.
Article
Correspondence: Ahsan, Department of Nursing, Faculty of Health
Sciences, Universitas Brawijaya, Jl. Puncak Dieng, Kunci, Kalisongo,
Kec. Dau, Malang, East Java Indonesia 65151.
Tel.: +62 341 5080686, Fax: +62 341 5080686.
E-mail: ahsanpsik.fk@ub.ac.id
Key words: Patient safety; nursing management; nursing team; situa-
tional monitoring.
Contributions: AA and EHN verified the method and design of this
study, and they also supervised the findings. IM performed the statisti-
cal analysis and interpreted the data. INR drafted, wrote, and revised the
manuscript with the support of other authors. LWN conceived the idea
presentation and developed the theory as well as the concept. All
authors carried out the study and agreed to the arrangement of authors
as well as read and approved the final version of the manuscript and
agreed to be accountable for all aspects of the work.
Conflict of interest: The authors declare no conflict of interest.
Funding: Funds were provided by the Faculty of Medicine, Universitas
Brawijaya through the Professor and Doctor Grant Scheme (Number:
11/UN10.F08/PN/2019).
Acknowledgments: The authors are grateful to all that contributed to
this study, especially the respondents, students of the bachelor program
in nursing, Faculty of Medicine, Universitas Brawijaya.
Availability of data and materials: All data generated or analyzed during
this study are included in this published article.
Ethics approval and consent to participate: This study was approved by
the Health Research Ethics Commission of the Faculty of Medicine,
Universitas Brawijaya (Ethical Clearance letter No. 07/EC/KEPK/
01/2020).
Informed consent: Written informed consent was obtained from a legal-
ly authorized representative(s) for anonymized patient information to be
published in this article.
Conference presentation: Part of this paper was presented at the
2nd International Nursing and Health Sciences Symposium that took place
at the Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia.
Received for publication: 3 December 2021.
Accepted for publication: 10 May 2022.
This work is licensed under a Creative Commons Attribution 4.0
License (by-nc 4.0).
©Copyright: the Author(s), 2023
Licensee PAGEPress, Italy
Healthcare in Low-resource Settings 2023; 11(s1):11163
doi:10.4081/hls.2023.11163
Publisher's note: All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their affiliated organi-
zations, or those of the publisher, the editors and the reviewers. Any prod-
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manufacturer is not guaranteed or endorsed by the publisher.
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