Mutual Support Two-Day Training

If you are teaching the Situation Monitoring Module as part of a two-day training, you should be able to perform all the activities noted below in around 90 minutes. Components you can include in this section for a two-day training include the following:

Introduction and Objectives: 5 minutes
Mutual Support Exercise: 5 minutes
Task Assistance: 7 minutes
Formative Feedback: 15 minutes
Feedback Exercise: 7 minutes
Advocacy and Assertion Tools: 25 minutes
Conflict in Teams: 10 minutes
DESC: 5 minutes
Summary: 3 minutes
Applying TeamSTEPPS Exercise: 5 minutes

Teaching Goals

It’s important to continuously reinforce your enthusiasm for TeamSTEPPS and its importance to patients and healthcare workers. You also should continue to foster mutual respect, fun, and transparency by using active learning and listening throughout the section. Specific objectives for this section include:

Describe how mutual support affects team processes and outcomes.
Discuss specific strategies to foster mutual support (e.g., task assistance, feedback).
Identify specific tools to facilitate mutual support.
Describe conflict resolution strategies.

Teaching Process

Introduction and Objectives

Image of slide: In this image a team of healthcare providers stand together discussing a patient.

Referring to Slide 1, "Mutual Support," welcome your class back from a break and acknowledge that they’re approaching the end of a long day of training. And note that even though mutual support is the last of the four main TeamSTEPPS modules, the tools it includes are some of the most important and frequently used. If you have time, ask a person to share a situation from the past few months where someone on their team went out of their way to support one of the other team members. Focusing on such a story will help to get the module off to a positive start.

Image of slide: The objectives of the mutual support training are to describe how it affects team processes and outcomes, discuss strategies to foster mutual support, and describe conflict resolution strategies.

Review Slide 2, "Objectives"; save time by displaying the slide without orally reviewing each objective. Stress the broad goal of acquiring insights and tools that will enable the participants to enhance mutual support within their teams. Objectives include:

Describe how mutual support affects team processes and outcomes.
Discuss specific strategies to foster mutual support (e.g., task assistance, feedback).
Identify specific tools to facilitate mutual support.
Describe conflict resolution strategies.

Mutual Support Exercise

Image of slide: Mutual support depends on information gathered through situation monitoring, facilitated by communication, enhanced by leaders who practice mutual support, and vital to supporting patients and providers.

For Slide 3, "Mutual Support Is," provide a very quick, high-level overview and reminder of the three modules you’ve already discussed. You may want to mention that the Pocket Guide or Pocket Guide App * is a useful resource for helping remember all the tools and major concepts in TeamSTEPPS. The four bullet points on that slide make the connections between each of the other three skills and mutual support.

*The app is being updated to match the new TeamSTEPPS 3.0 curriculum. A new version of the app will be available in fall 2023.

Image of slide: Mutual support involves team members that assist each other, provide and receive feedback, exert assertive advocacy behaviors when patient safety is threatened, and respond to conflict promptly and constructively.

Use Slide 4, "Mutual Support Involves…" as you review the four mutual support activities that team members should perform. Use this slide to reinforce the message that the patient is a key team member to be supported and to provide support to the rest of the team. Ask participants to share a situation where they felt supported by one of the patients or family caregivers they were caring for.

Image of slide: A mutual support discussion includes asking, listening, and acting.

When you display Slide 5, "Mutual Support Discussion," if time allows, ask the groups in your class to take 5 minutes to discuss the three questions on the slide. After the 5 minutes, have each group share the action they think is critical but sometimes overlooked.

Task Assistance

This slide introduces the concept of task assistance as an activity that involves both offering help to others and asking for help when needed. Poll the class to see how many think they do a better job of asking for help or offering help.

In reviewing Slide 6, “Task Assistance,” introduce the concept of task assistance as an activity that involves both offering help to others and asking for help when needed. Poll the class to see how many think they do a better job of asking for help or offering help.

Image of slide: This task assistance involves a nurse passing by a room where she hears a nurse call out regarding a patient who had a conscious sedation for a colonoscopy and her vitals were concerning.

In viewing Slide 7, “Task Assistance Example,” reinforce the meaning of task assistance. Share the scenario on this slide and ask class members to respond to the three questions. If you don’t think your class will respond or understand this example, you may want to substitute a different one from the curriculum or construct your own based on the backgrounds and work environments of class members.

Formative Feedback

Image of slide: Feedback is information provided that can positively or negatively impact team performance and could be nonverbal, verbal, intentional, or unintentional.

As you introduce Slide 8, “What Is Feedback?” note that feedback was discussed as a key part of the communication process in Module 1. Remind the class that it can be verbal or nonverbal and intentional or unintentional. If you have time, have a volunteer from the class attempt to convey three messages that you display to them. Tell them they can be creative but cannot make a sound. You can use the messages below or make up your own.

I’m hungry.
I’m tired.
I’m looking forward to tomorrow.

The first two messages should be easy to pantomime. If they get stumped by the third message, ask the class to give suggestions. Someone should realize that they could use their phone or email to convey the message. You can use this exercise to note the challenges associated with communicating and getting feedback using virtual communication technologies.

Image of slide: Types of formative feedback include formal, which is retrospective and scheduled in advance and has an evaluative quality; and informal, which is in real time and provided on an ongoing basis, focusing on knowledge and practical skills development.

In discussing Slide 9, “Types of Formative Feedback,” note that one type of feedback is formative feedback, which is designed to improve the team’s effectiveness. Explain that sometimes this feedback occurs formally and that more often it can be done informally in casual conversation or as part of a huddle or debrief.

Image of slide: Effective feedback is appreciative, timely, respectful, specific, directed toward improvement, considerate, and patient focused.

In displaying Slide 10, "Characteristics of Effective Formative Feedback," take time to address each of the seven characteristics of effective formative feedback. Each is important and frequently neglected, resulting in feedback that is ineffective or counterproductive. Ask a class member or two to give an example of a time when they received or provided feedback that didn’t meet one or more of the criteria. Use this example to reinforce their importance.

Feedback Exercise

Image of slide: A physician speaks to a nurse at the nurse's station to provide feedback.

For Slide 11, "Providing Effective Feedback Video," use the video to provide a full example of sharing feedback. Ask the class which of the criteria the feedback met.

Advocacy and Assertion Tools

Image of slide: Advocacy and assertion means advocating for the patient when team members' viewpoints don't coincide with the decision maker's and asserting a corrective action in a firm and respectful manner.

For Slide 12, "Advocacy and Assertion," explain that advocacy and assertion interventions are invoked when a team member's viewpoint does not coincide with that of a decision maker. In advocating for the patient or for another staff member and asserting a corrective action, the team member has an opportunity to correct errors or the loss of situation awareness. Note that the class will learn three mission-critical advocacy and assertion tools: assertive statements, the Two-Challenge Rule, and CUS. Also note that it’s important to learn both how to use the tools and how to respond when other team members use them.

Image of slide: The assertive statement is respectful and supportive of authority, clearly asserts concerns and suggestions, and is nonthreatening.

For Slide 13, “The Assertive Statement,” introduce the assertive statement and emphasize that assertive doesn’t mean rude or loud. Instead, it should be respectful, clear, and nonthreatening and use the five-step process. You may choose to make the point that assertive statements are also useful outside of work contexts. Ask the class to use the five-step process to address a teenager who isn’t doing their homework (or another nonwork scenario you’d prefer).

Image of slide: The Two-Challenge Rule empowers any team member to stop the line or action if they sense or discover a breach of safety.

For Slide 14, “Two-Challenge Rule,” introduce the rule as the second advocacy and assertion tool. Note that a challenge should stop whatever the action is that prompted it and that “stopping the line” when serious harm is imminent is a responsibility of every team member.

Make it clear that the use of this tool is likely to be uncommon but potentially very important. Ask the class whether they’ve ever seen the Two-Challenge Rule used or seen a situation where it should have been used to prevent harm to a patient. Use that story or stories to reinforce the importance of the Two-Challenge Rule.

Image of slide: The Two-Challenge Rule is invoked when an assertion is ignored. It includes voicing a concern assertively two times to ensure it has been heard. The member being challenged must acknowledge it.

For Slide 15, “Two-Challenge Rule (continued),” discuss the process of making the challenge and getting a response to the challenge, and what to do if the challenge isn’t resolved. Note that the first challenge should be in the form of a question, because questions are less confrontational and using them will allow many issues to be resolved without a direct challenge. Make the point that it’s just as important to train people on how to respond to the Two-Challenge Rule as it is to train them on how to use it.

Image of slide: Use CUS words only when appropriate - these are three assertive statements that can be used for mutual support: 1) I am concerned 2) I am uncomfortable and 3) This is a safety issue!

For Slide 16, “Please Use CUS Words ,” introduce CUS as a third assertion and advocacy tool and ask the class how many are familiar with it. CUS is widely used, so many people in the training may already know it. If they do, have two or three provide an example of how they’ve seen CUS used. Use these examples to reinforce the three steps in CUS.

Image of slide: This advocacy and assertion scenario occurs at point of discharge. A nurse checks the patient's vitals one last time and finds the blood pressure and heart rate are very elevated.

For Slide 17, “Advocacy and Assertion Scenario,” tell the trainees it’s time to apply their knowledge of the three advocacy and assertion tools to the scenario described on the slide.

Have trainees describe how assertive statements, the Two-Challenge Rule, and CUS could be used in this situation.
Ask them to discuss which approach they would use and why. If they say, “It depends,” have them explain what factors would cause them to choose a particular tool over the others.

As an alternative to this scenario, you may want to discuss a situation in which a patient with limited English proficiency is involved in an important team discussion without the support of a medical interpreter. You can use an available TeamSTEPPS video to encourage your class to explore how advocacy and assertion and the CUS tool can be used to support such patients, who are at greater risk of harm without a medical interpreter’s support. The link is available at:

Conflict in Teams

Image of slide: Conflict in teams falls into two categories: informational conflict and interpersonal conflict. The Two Challenge Rule is used in informational conflicts and the DESC script is used for both types.

As you introduce Slide 18, “Conflict in Teams,” ask trainees to rate the amount of conflict that exists in their teams on a scale from 1 (no conflict ever) to 10 (continuous, major conflict). See the range of ratings across your class. Ask people with very low and high scores how it feels to be in teams where there’s little conflict or lots of it. Use this to make the point that conflict is inevitable in teams but when conflict is continuous and not managed well, it’s very stressful and places patient safety at risk.

Once you’ve introduced the concept, note that some conflict is caused by having different information, while other conflict is interpersonal. Ask the class which type is a bigger challenge in their teams. It’s likely interpersonal will be more common.

Once the types of conflict have been introduced, note that the Two-Challenge Rule works well for informational conflict and the DESC script is an effective tool for interpersonal conflict.

DESC

Image of slide: Conflict resolution using the DESC script includes describing the specific situation or behavior, expressing how it makes you feel and your concerns, suggesting alternatives and seeking agreement, and stating consequences in terms of impact on team goals, while striving for consensus.

For Slide 19, “Conflict Resolution DESC Script,” introduce the four stages of the DESC script. Since conflict is stressful, choose a “light” example to illustrate the process: someone regularly leaves food in the breakroom refrigerator until it spoils and makes everyone else’s food smell bad. Have the group apply the DESC script to organizing a conversation with the person whose food is regularly abandoned.

For Slide 20, “DESC It,” note that discussions of interpersonal conflict can be tense and that the suggestions on this slide can help keep these conversations as constructive and positive as possible. Ask the class which of these suggestions seem particularly important to them. Note that it’s usually best to try to resolve issues with coworkers directly without involving others. But if a team member is very concerned about how the discussion will go, they may want to get advice or help from someone else.

Image of slide: In this scenario a nurse receives an order from the resident on call for a catheter for a patient with a distended bladder. The attending realizes the order was given without his consent and raises his voice to the resident in front of staff and the patient.

For Slide 21, “A DESC Scenario,” to help the class apply DESC, use the scenario on the slide or replace it with a different one that’s more relevant to your class members. Ask the class what they would say for the four phases of DESC. The messages should be similar to those shown below.

D: "I (resident) am sensing that you (attending) are upset with me for ordering the Foley catheter for your patient."
E: "When you question my judgment in front of others, it embarrasses me and makes me very uncomfortable. It also undermines my credibility with the patient."
S: "If you are concerned or have a question regarding my performance, I would appreciate it if you would speak to me in private."
C: "A private conversation would be more beneficial to me because I would feel less embarrassed and would be able to ask questions and supply information. Can we agree to follow such a procedure if this happens again?"

The TeamSTEPPS curriculum now includes a set of video-based simulation training activities that teach key concepts related to task assistance. You may want to use parts of or all of that resource to teach these concepts. Select to view videos on DESC.

Summary

Image of slide: Using the Mutual Support tools and strategies to address barriers helps teams achieve positive outcomes for their team and patients.

For Slide 22, “Tools and Strategies Summary,” once you’ve finished reviewing the mutual support tools, use the summary slide to reinforce the relationships among barriers to effective teamwork, tools and strategies the trainees have learned so far, and outcomes TeamSTEPPS was created to achieve. If you have time, ask the class which tool they’ve learned so far that they are most eager to try using.

Applying TeamSTEPPS Exercise

Image of slide: Apply TeamSTEPPS exercise to determine if the teamwork issue is related to mutual support. Ask is it related to mutual support? If so, what is the issue? Which mutual support tools or strategies might be implemented to address the issue.

For Slide 23, “Applying TeamSTEPPS Exercise,” if you have intact teams in your training with short-term implementation plans, you may want to use this slide to help them reflect on how mutual support relates to the challenge they are trying to address.

Otherwise, you can omit this slide and its discussion.

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