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Teamwork and Clinical Error Reporting among Nurses in Korean Hospitals

  • Jee-In Hwang
    Affiliations
    College of Nursing Science, Kyung Hee University, Seoul, South Korea
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  • Jeonghoon Ahn
    Correspondence
    Correspondence to: Jeonghoon Ahn, PhD, Office of Research Planning, National Evidence-based healthcare Collaborating Agency (NECA), Jung-Gu Toegye-ro 173, Namsan Square Building, 7th Floor, Seoul, 100-705, South Korea.
    Affiliations
    Office of Health Services Research, National Evidence-based Healthcare Collaborating Agency, Seoul, South Korea
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Open AccessPublished:February 06, 2015DOI:https://doi.org/10.1016/j.anr.2014.09.002

      Summary

      Purpose

      To examine levels of teamwork and its relationships with clinical error reporting among Korean hospital nurses.

      Methods

      The study employed a cross-sectional survey design. We distributed a questionnaire to 674 nurses in two teaching hospitals in Korea. The questionnaire included items on teamwork and the reporting of clinical errors. We measured teamwork using the Teamwork Perceptions Questionnaire, which has five subscales including team structure, leadership, situation monitoring, mutual support, and communication. Using logistic regression analysis, we determined the relationships between teamwork and error reporting.

      Results

      The response rate was 85.5%. The mean score of teamwork was 3.5 out of 5. At the subscale level, mutual support was rated highest, while leadership was rated lowest. Of the participating nurses, 522 responded that they had experienced at least one clinical error in the last 6 months. Among those, only 53.0% responded that they always or usually reported clinical errors to their managers and/or the patient safety department. Teamwork was significantly associated with better error reporting. Specifically, nurses with a higher team communication score were more likely to report clinical errors to their managers and the patient safety department (odds ratio = 1.82, 95% confidence intervals [1.05, 3.14]).

      Conclusions

      Teamwork was rated as moderate and was positively associated with nurses' error reporting performance. Hospital executives and nurse managers should make substantial efforts to enhance teamwork, which will contribute to encouraging the reporting of errors and improving patient safety.

      Keywords

      Introduction

      The need for strong teamwork has been emphasized as being necessary for improving quality care, with the increasing complexity of healthcare systems. Healthcare teams vary in terms of team composition and size. Ineffective teamwork has been recognized as a major factor contributing to decreased patient safety [
      • Joint Commission
      Sentinel event data: root causes by event type 2004–2012 [Internet].
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      • Kohn L.T.
      • Corrigan J.M.
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      To err is human: building a safer health system.
      ,
      • Manser T.
      Teamwork and patient safety in dynamic domains of healthcare: a review of the literature.
      ]. Thus, strengthening teamwork worldwide is crucial for enhancing patient safety.
      Teamwork refers to a set of interrelated knowledge, skills, and attitudes that team members must possess in order to function as a team [
      • Salas E.
      • Sims D.E.
      • Burke C.S.
      Is there a big 5 in teamwork?.
      ]. The core components of this concept include leadership, situation monitoring, backup behavior, and communication [
      • Salas E.
      • Sims D.E.
      • Burke C.S.
      Is there a big 5 in teamwork?.
      ,
      • Alonso A.
      • Baker D.P.
      • Holtzman A.
      • Day R.
      • King H.
      • Toomey L.
      • et al.
      Reducing medical error in the military health system: how can team training help?.
      ,
      • Baker D.P.
      • Day R.
      • Salas E.
      Teamwork as an essential component of high-reliability organizations.
      ]. Previous studies have explored the levels of teamwork by observing team behaviors [
      • Cooper S.
      • Cant R.
      • Porter J.
      • Sellick K.
      • Somers G.
      • Kinsman L.
      • et al.
      Rating medical emergency teamwork performance: development of the Team Emergency Assessment Measure (TEAM).
      ,
      • Hull L.
      • Arora S.
      • Kassab E.
      • Kneebone R.
      • Sevdalis N.
      Observational teamwork assessment for surgery: content validation and tool refinement.
      ,
      • Steinemann S.
      • Berg B.
      • DiTullio A.
      • Skinner A.
      • Terada K.
      • Anzelon K.
      • et al.
      Assessing teamwork in the trauma bay: introduction of a modified “NOTECHS” scale for trauma.
      ] or by using teamwork surveys [
      • Battles J.
      • King H.B.
      TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) Manual [Internet].
      ,
      • Castner J.
      Validity and reliability of the Brief TeamSTEPPS Teamwork Perceptions Questionnaire.
      ,
      • Kalisch B.J.
      • Lee H.
      • Salas E.
      The development and testing of the nursing teamwork survey.
      ,
      • Lurie S.J.
      • Schultz S.H.
      • Lamanna G.
      Assessing teamwork: a reliable five-question survey.
      ]. While observational studies of teamwork are generally resource-intensive, it is frequently difficult to administer instruments to a large number of healthcare providers. Surveys can be used more efficiently to measure teamwork in clinical practice. However, a review of teamwork surveys has found that the conceptualizations of teamwork and psychometric properties varied considerably between instruments [
      • Valentine M.A.
      • Nembhard I.M.
      • Edmondson A.C.
      Measuring teamwork in health care settings: a review of survey instruments.
      ]. Among the surveys, the Teamwork Perceptions Questionnaire (TPQ) has been recently developed as part of the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) initiative supported by the Agency for Healthcare Research and Quality, which seems useful in teamwork-related studies in healthcare settings [
      • Battles J.
      • King H.B.
      TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) Manual [Internet].
      ,
      • Castner J.
      • Foltz-Ramos K.
      • Schwartz D.G.
      • Ceravolo D.J.
      A leadership challenge: staff nurse perceptions after an organizational TeamSTEPPS initiative.
      ]. The TPQ captures how healthcare providers perceive the current state of teamwork: teamwork is not affected by prior experience, nor limited to specific departments or specialties [
      • Battles J.
      • King H.B.
      TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) Manual [Internet].
      ]. It has broad applicability to various types of teams.
      Studies investigating the perceptions of teamwork among healthcare providers showed that the levels of teamwork varied depending on the workplace [
      • Kalisch B.J.
      • Lee K.H.
      Nursing teamwork, staff characteristics, work schedules, and staffing.
      ,
      • Kalisch B.J.
      • Lee K.H.
      The impact of teamwork on missed nursing care.
      ]. For instance, nurses working at intensive care units rated teamwork as higher than did those working in medical-surgical units [
      • Kalisch B.J.
      • Lee K.H.
      The impact of teamwork on missed nursing care.
      ]. In addition, there were differences in the dimension levels of teamwork [
      • Battles J.
      • King H.B.
      TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) Manual [Internet].
      ,
      • Castner J.
      • Foltz-Ramos K.
      • Schwartz D.G.
      • Ceravolo D.J.
      A leadership challenge: staff nurse perceptions after an organizational TeamSTEPPS initiative.
      ]. A study of US nurses showed that team leadership had the highest priority for improvement [
      • Castner J.
      • Foltz-Ramos K.
      • Schwartz D.G.
      • Ceravolo D.J.
      A leadership challenge: staff nurse perceptions after an organizational TeamSTEPPS initiative.
      ]. From this perspective, levels of teamwork may vary by healthcare systems and settings. In addition, diagnosing the current state of teamwork is necessary in order to enhance teamwork in the workplace.
      Researchers have proposed that teamwork positively influences staff performance regarding patient safety and patient outcomes [
      • Manser T.
      Teamwork and patient safety in dynamic domains of healthcare: a review of the literature.
      ,
      • Reader T.W.
      • Flin R.
      • Mearns K.
      • Cuthbertson B.H.
      Developing a team performance framework for the intensive care unit.
      ]. For instance, a study of nine emergency departments found that improved teamwork led to a significant decrease in clinical error rates [
      • Morey J.C.
      • Simon R.
      • Jay G.D.
      • Wears R.L.
      • Salisbury M.
      • Dukes K.A.
      • et al.
      Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project.
      ]. This reduction of errors and adverse events has also been reported in outpatient oncology [
      • Bunnell C.A.
      • Gross A.H.
      • Weingart S.N.
      • Kalfin M.J.
      • Partridge A.
      • Lane S.
      • et al.
      High performance teamwork training and systems redesign in outpatient oncology.
      ], labor and delivery [
      • Mann S.
      • Marcus R.
      • Sachs B.
      Lessons from the cockpit: how team training can reduce errors on L&D.
      ], and surgery [
      • Neily J.
      • Mills P.D.
      • Young-Xu Y.
      • Carney B.T.
      • West P.
      • Berger D.H.
      • et al.
      Association between implementation of a medical team training program and surgical mortality.
      ]. However, most of the existing research has concentrated on building teamwork and reducing clinical errors in specific workplaces. Other studies focusing on nursing teams, rather than teams including various healthcare professionals, showed that higher levels of nursing teamwork related to lower levels of patient falls leading to injury [
      • Kalisch B.J.
      • Curley M.
      • Stefanov S.
      An intervention to enhance nursing staff teamwork and engagement.
      ]. Inadequate nursing teamwork was an important predictor for missed nursing care [
      • Kalisch B.J.
      • Lee K.H.
      The impact of teamwork on missed nursing care.
      ]. However, to the best of our knowledge, very few studies explore the relationship of teamwork with error reporting in inpatient care settings.
      A clinical error is a preventable adverse event or a near miss within the current medical knowledge context [
      • World Health Organization
      The conceptual framework for the international classification for patient safety [Internet].
      ]. Clinical errors include both acts of commission and omission [
      • World Health Organization
      The conceptual framework for the international classification for patient safety [Internet].
      ]. One such error type, the near miss, is an event or situation that though potentially harmful, does not result in any harm to the patient [
      • Wachter R.M.
      Understanding patient safety.
      ]. The magnitude and severity of clinical errors have been reported in many studies [
      • Kohn L.T.
      • Corrigan J.M.
      • Donaldson M.S.
      To err is human: building a safer health system.
      ,
      • de Vries E.N.
      • Ramrattan M.A.
      • Smorenburg S.M.
      • Gouma D.J.
      • Boermeester M.A.
      The incidence and nature of in-hospital adverse events: a systematic review.
      ,
      • Sandars J.
      • Esmail A.
      The frequency and nature of medical error in primary care: understanding the diversity across studies.
      ]. The factors and conditions associated with error occurrence include individual characteristics (e.g., age, gender, years of nursing experience, and education level) and work environment characteristics (e.g., work unit, working conditions and workload, and hospital environment) [
      • Anoosheh M.
      • Ahmadi F.
      • Faghihzadeh S.
      • Vaismoradi M.
      Causes and management of nursing practice errors: a questionnaire survey of hospital nurses in Iran.
      ,
      • Brady A.M.
      • Malone A.M.
      • Fleming S.
      A literature review of the individual and systems factors that contribute to medication errors in nursing practice.
      ,
      • Chang Y.K.
      • Mark B.A.
      Antecedents of severe and nonsevere medication errors.
      ,
      • Kalisch B.J.
      • Landstrom G.
      • Williams R.A.
      Missed nursing care: errors of omission.
      ,
      • Mrayyan M.
      • Shishani K.
      • Al-Faouri I.
      Rate, causes and reporting of medication errors in Jordan: nurses' perspectives.
      ,
      • Walters J.A.
      Nurses' perceptions of reportable medication errors and factors that contribute to their occurrence.
      ]. Poor teamwork and communication failures have been identified as the most common causes of clinical errors in practice [
      • Joint Commission
      Sentinel event data: root causes by event type 2004–2012 [Internet].
      ,
      • Lo L.
      Teamwork and communication in health care: a literature review [Internet].
      ,
      • Rabøl L.I.
      • Andersen M.L.
      • Østergaard D.
      • Bjørn B.
      • Lilja B.
      • Mogensen T.
      Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals.
      ].
      Identifying the incidence and nature of clinical errors in real practice is necessary for effective error reduction. Many healthcare institutions have implemented error-reporting systems. Data and information that are built into, and analyzed through clinical error reporting help detect vulnerable processes behind patient safety incidents and provide opportunities that improve system performance and prevent future patient safety risks [
      • Anderson J.E.
      • Kodate N.
      • Walters R.
      • Dodds A.
      Can incident reporting improve safety? Healthcare practitioners' views of the effectiveness of incident reporting.
      ,
      • World Health Organization
      World Alliance for Patient Safety: WHO draft guidelines on adverse event reporting and learning systems [Internet].
      ]. Clinical error reporting is a crucial component of creating a safer healthcare system. However, the underreporting of clinical errors is a challenge to patient safety improvement. In this regard, we focus on teamwork and error reporting in this study.
      Specifically, we aimed to examine the levels of teamwork in Korean hospitals using a reliable, valid teamwork tool. In addition, we investigated the relationships between teamwork and nurses' error reporting. Identifying the strengths and weaknesses of the current state of teamwork and investigating its relationships with safety-relevant staff performances will help healthcare professionals develop strategies that enhance patient safety.

      Methods

      Study design

      This study employed a cross-sectional survey design. The data reported in this paper were collected as part of a larger study of human and organizational factors relevant to patient safety. The project included explorations of systems thinking and situational awareness, as well as teamwork.

      Setting and sample

      This study was conducted in two acute-care teaching hospitals in Seoul, Korea. The hospitals have different nurse staffing levels in terms of the ratio of the number of patient beds per nurse: 2.0 to less than 2.5 for one hospital and 2.5 to less than 3.0 for the other hospital. Both hospitals had three nursing shifts of 8 hours. Nurse managers in care units involve in direct patient care. The target population was nurses in adult patient care units, including operating rooms. We excluded psychiatric and ambulatory care departments. The sample consisted of 674 nurses (423 nurses from one hospital and 251 nurses from the other). To evaluate the appropriateness of this sample size, we considered the following recommendations: (a) at least 10 cases per item for factor analyses, (b) ability to obtain a power of 0.80 with a medium effect size (β2 = 0.06) and a significance criterion of .05 in analysis of variance, and (c) 10–20 cases per predictor in logistic regression analysis [
      • Polit D.F.
      Statistics and data analysis for nursing research.
      ]. The sample size met all these criteria.

      Ethical consideration

      This study was part of a larger research project on human and organizational factors relevant to patient safety. The overall study protocol was approved by the Institutional Review Boards of the two study hospitals (KHNMC-OH-IRB 2012-011, KOMCIRB-2012-19).

      Measurements and instruments

      Teamwork was measured using TPQ. The US Agency for Healthcare Research and Quality and the Department of Defense launched a multiyear research and development effort in 2006 to create TeamSTEPPS as the national standard for team training in healthcare. The TeamSTEPPS program has a publicly available toolkit that includes the TPQ [
      • Battles J.
      • King H.B.
      TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) Manual [Internet].
      ,
      • Keebler J.R.
      • Dietz A.S.
      • Lazzara E.H.
      • Benishek L.E.
      • Almeida S.A.
      • Toor P.A.
      • et al.
      Validation of a teamwork perceptions measure to increase patient safety.
      ]. This questionnaire has a sound theoretical basis, and its psychometric property has been validated in hospital settings [
      • Battles J.
      • King H.B.
      TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) Manual [Internet].
      ,
      • Castner J.
      Validity and reliability of the Brief TeamSTEPPS Teamwork Perceptions Questionnaire.
      ,
      • Keebler J.R.
      • Dietz A.S.
      • Lazzara E.H.
      • Benishek L.E.
      • Almeida S.A.
      • Toor P.A.
      • et al.
      Validation of a teamwork perceptions measure to increase patient safety.
      ]. The TPQ, which can be applied to various types of healthcare teams, is available in the public domain. It consists of 35 items under the five subscales of team structure, leadership, situation monitoring, mutual support, and communication. Each subscale has seven items. The TPQ was translated to Korean by the first author of the present study. The relevance and validity of the translated scale along with the fluency of the translation were reviewed by two bilingual nursing professors and one researcher in the National Evidence-based Healthcare Collaborating Agency. No adaptations were judged necessary for a Korean hospital setting, although minor description revisions were made. The resulting questionnaire was pilot-tested with 33 nurses for clarity and readability. Additional linguistic revisions were made for clarity on basis of their feedback.
      The participants were asked to indicate their degree of agreement with each statement using a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). The Cronbach's alpha coefficient of the entire TPQ was .96, and those for the five subscales were .86, .94, .90, .85, and .89, respectively. Item analysis demonstrated that the corrected item-total correlation coefficients ranged from .54 to .68. No items had average correlation coefficients of less than .30 [
      • Polit D.F.
      Statistics and data analysis for nursing research.
      ].
      Principal components analysis yielded five factors with eigenvalues of 1 or greater, together accounting for 64.1% of the total variance. Each factor corresponded with one of the five subscales. Factor 1 was “mutual support”, factor 2 was “team leadership”, factor 3 was “team communication”, factor 4 was “team structure”, and factor 5 was “situation monitoring”. These five factors accounted for 44.0%, 8.6%, 4.4%, 3.8%, and 3.3% of the variance, respectively. All the items had factor loadings greater than .40 [
      • Polit D.F.
      Statistics and data analysis for nursing research.
      ]. Although there were cross-loaded items onto multiple factors, they were retained based on theoretical framework [
      • Battles J.
      • King H.B.
      TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) Manual [Internet].
      ]. In addition, confirmatory factor analysis revealed that the 35-item five-factor model had acceptable fit to the data (comparative fit index = .891, root mean square error of approximation = .067, and standardized root mean square residual = .053). Thus, we retained all the items.
      We defined clinical error as a preventable adverse event, or near miss, such as a medication error or a fall [
      • World Health Organization
      The conceptual framework for the international classification for patient safety [Internet].
      ]. Nurses were asked to indicate whether they had experienced clinical errors in the last 6 months and whether they then reported the errors to their managers or the patient safety department. If the response was that they “always” or “usually” reported their clinical errors, this was regarded as an appropriate performance of error reporting based on the previous research regarding the categorization of positive responses to the frequency of events reported [
      • Haugen A.S.
      • Søfteland E.
      • Eide G.E.
      • Nortvedt M.W.
      • Aase K.
      • Harthug S.
      Patient safety in surgical environments: cross-countries comparison of psychometric properties and results of the Norwegian version of the Hospital Survey on Patient Safety.
      ]. The other responses (“sometimes”, “rarely”, and “never”) were coded as indicating “inappropriate” performance.
      We also collected general information on the participants. The general characteristics of the participants included age, gender, marital status, educational level, years of nursing experience, and job position. The organizational variables of their workplaces included specific clinical department, nurse staffing level, and hospital type. Employment status was not included since all the nurses worked full-time. Since nurse staffing levels were determined at the hospital level, we included only the type of hospital for the analysis.

      Data collection and procedure

      A questionnaire survey was conducted in November 2012. The questionnaires were distributed with return envelopes to nurses via the nursing departments of the study hospitals. The nurses invited to the survey received a small gift regardless of participation. The cover letter included an explanation of the purpose of this study, the voluntary nature of the participation, and assurances of both participant anonymity and data confidentiality.

      Data analysis

      Data were analyzed using SAS version 9.2 (SAS Institute, Cary, NC, USA). We summarized the general characteristics of participants using descriptive statistics, and calculated the TPQ and subscale scores by averaging related items. Thus, possible scores ranged from 1.0 to 5.0. A mean score of 3.0 or higher indicates that the teamwork is in an acceptable range [
      • Castner J.
      • Foltz-Ramos K.
      • Schwartz D.G.
      • Ceravolo D.J.
      A leadership challenge: staff nurse perceptions after an organizational TeamSTEPPS initiative.
      ]. To examine the internal consistency and reliability of the TPQ and its subscales, Cronbach's alpha coefficients were calculated. In item analysis, the cut-off values of average correlation coefficients were set to less than .30 [
      • Polit D.F.
      Statistics and data analysis for nursing research.
      ]. Construct validity was examined using principal components analysis and confirmatory factor analysis. Using principal components analysis with varimax rotation, we examined the number of factors with an eigenvalue of 1 or greater and the variance explained by such factors. We ran confirmatory factor analysis to confirm the five-factor structure. The cut-off values were set to comparative fit index ≥ .90, root mean square error of approximation ≤ .08, and standardized root mean square residual ≤ .10 [
      • Petrowski K.
      • Paul S.
      • Albani C.
      • Brähler E.
      Factor structure and psychometric properties of the trier inventory for chronic stress (TICS) in a representative German sample.
      ].
      Student's t tests and analysis of variance were conducted in order to identify differences in TPQ scores according to participants' general characteristics and error reporting. These tests are robust for non-normal distribution, especially if the number of cases per group is at least 20 [
      • Polit D.F.
      Statistics and data analysis for nursing research.
      ]. Post hoc tests were performed using Tukey's studentized range (honest significant difference) test. Logistic regression analysis was performed to determine the relationship between teamwork and error reporting. Odds ratios (OR) and 95% confidence intervals (CI) were examined. A value of p < .05 was considered statistically significant.

      Results

      General characteristics of participants

      Of the 674 nurses, 576 returned completed surveys with a response rate of 85.5%. Among these, 522 (90.6%) reported experiencing at least one clinical error in the previous 6 months. This study used only the responses of those who had had an experience with clinical error in the previous 6 months (n = 522). The general characteristics of participants are shown in Table 1. Most were female (99.0%), and their mean age was 30.9 (SD = 7.6) years. Of the participants, 177 (33.9%) were married, and 294 (56.3%) had a 4-year bachelor's degree.
      Table 1General Characteristics of Study Participants and Teamwork Scores (N = 522).
      Variablesn%Teamworkt/FPost-hoc test
      Analysis of variance with Tukey's Studentized range (honestly significant difference) test where values with the same character are not significantly different.
      p
      MSD
      Gender
       Male51.03.550.400.43.664
       Female51799.03.460.45
      Age (yr)
       ≤2928254.03.450.457.52B.001
       30–3917233.03.400.43B
       40≤6813.03.650.45A
      Marital status
       Yes17733.93.470.50−0.23.820
       No34566.13.460.43
      Education
       3-year college14227.23.450.481.57.209
       4-year university29456.33.440.43
       Graduate school or higher8616.53.540.48
      Years of nursing experience
       <3 years23745.43.450.430.99.399
       3 to less than 5 years5811.13.420.44
       5 to less than 10 years8816.93.440.50
       ≥10 years13926.63.520.47
      Job position
       Manager5310.23.690.463.91<.001
       Staff46989.93.440.45
      Clinical department
       Medical care units15028.73.540.456.96A<.001
       Surgical care units13024.93.510.40A
       Traditional medicine care units6913.23.460.46A
       Intensive care units9718.63.460.44A
       Operating rooms7614.63.220.48B
      Hospital
       A32762.63.460.46−0.18.855
       B19537.43.460.43
      a Analysis of variance with Tukey's Studentized range (honestly significant difference) test where values with the same character are not significantly different.
      The participating nurses had an average of 9.1 (SD = 7.7) years of nursing experience. Most (89.9%) were in a staff position. More nurses (n = 150, 28.7%) reported working in medical care units than in surgical care units (n = 130, 24.9%), traditional medicine care units (n = 69, 13.2%), operating rooms (n = 76, 14.6%), or intensive care units (n = 97, 18.6%).

      Levels of teamwork

      The mean score on the entire TPQ was 3.5 (SD = 0.5). Four hundred sixty-three nurses (88.7%) rated teamwork with a mean score of 3.0 or higher. There were significant differences in TPQ scores according to participants' ages (F = 7.52, p = .001), job positions (t = 3.91, p < .001), and the clinical departments in which they worked (F = 6.96, p < .001). Specifically, nurses aged 40 years or older rated their teamwork higher than did the others. The TPQ scores of the nurse managers were higher than those of the staff nurses. Nurses working in operating rooms rated their teamwork as lower than did the others (Table 1).
      At the subscale level, the mean score was 3.4 (SD = 0.5) for team structure, 3.3 (SD = 0.7) for team leadership, 3.5 (SD = 0.5) for situation monitoring, 3.6 (SD = 0.5) for mutual support, and 3.5 (SD = 0.5) for team communication (Table 2). The proportion of nurses who rated their teamwork with a mean of 3.0 or higher was 85.8% (n = 448) for team structure, 78.4% (n = 409) for team leadership, 90.4% (n = 472) for situation monitoring, 92.0% (n = 480) for mutual support, and 93.1% (n = 486) for team communication.
      Table 2Levels of Teamwork (N = 522).
      Subscale/Items%
      The proportions of the nurses who rated their teamwork as the mean of 3.0 or higher.
      MSD
      Team structure85.83.410.49
       The skills of staff overlap sufficiently so that work can be shared when necessary.95.23.400.61
       Staff are held accountable for their actions.96.43.660.62
       Staff within my unit share information that enables timely decision making by the patient care team.94.33.450.65
       My unit makes efficient use of resources (e.g. staff supplies, equipment, information).87.63.260.74
       Staff understand their roles and responsibilities.96.93.610.64
       My unit has clearly articulated goals.92.53.340.68
       My unit operates at a high level of efficiency.85.63.180.76
      Team leadership78.43.290.67
       My manager considers staff input when making decisions about patient care.89.13.390.75
       My manager provides opportunities to discuss the unit's performance after an event.87.93.340.76
       My manager takes time to meet with staff to develop a plan for patient care.83.53.200.80
       My manager ensures that adequate resources (e.g. staff supplies, equipment, information) are available.88.13.340.77
       My manager resolves conflict successfully.82.83.150.86
       My manager models appropriate team behaviour.85.13.270.83
       My manager ensures that staff are aware of any situations or changes that may affect patient care.89.93.340.76
      Situation monitoring90.43.490.52
       Staff effectively anticipate each other's needs.95.43.430.64
       Staff monitor each other's performance.96.43.570.65
       Staff exchange relevant information as it becomes available.96.03.580.65
       Staff continuously scan the environment for important information.95.83.520.64
       Staff share information regarding potential complications (e.g. patient changes, bed availability).96.03.570.64
       Staff meet to re-evaluate patient care goals when aspects of the situation have changed.86.63.240.74
       Staff correct each other's mistakes to ensure that procedures are followed properly.94.43.500.69
      Mutual support92.03.570.50
       Staff assist colleagues during high workload.96.63.800.73
       Staff request assistance from colleagues when they feel overwhelmed.95.83.760.69
       Staff caution each other about potentially dangerous situations.97.13.690.65
       Feedback between staff is delivered in a way that promotes positive interactions and future change.93.73.480.71
       Staff advocate for patients even when their opinion conflicts with that of a senior member of the unit.87.43.250.76
       When staff have a concern about patient safety, they challenge others until they are sure the concern has been heard.97.93.590.63
       Staff resolve their conflicts, even when the conflicts have become personal.93.53.420.67
      Communication93.13.540.51
       Information regarding patient care is explained to patients and their family in lay terms.97.73.680.64
       Staff relay relevant information in a timely manner.97.53.530.63
       When communicating with patients, staff allow enough time for questions.86.63.310.75
       Staff use common terminology when communicating with each other.96.93.540.65
       Staff verbally verify information that they receive from one another.98.33.600.63
       Staff follow a standardized method of sharing information when handling off patients.97.53.630.66
       Staff seek information from all available sources.95.03.520.67
      Note. SD = standard deviation.
      a The proportions of the nurses who rated their teamwork as the mean of 3.0 or higher.
      At the item level, the top five items with the highest scores were “staff assist colleagues during high workload,” “staff request assistance from colleagues when they feel overwhelmed,” “staff are held accountable for their actions,” “staff caution each other about potentially dangerous situations,” and “staff explain information regarding patient care to patients and their family in lay terms.” The five items with the lowest scores included “my manager resolves conflict successfully,” “my manager takes time to meet with staff to develop a plan for patient care,” “my unit operates at a high level of efficiency,” “staff meet to re-evaluate patient care goals when aspects of situations have changed,” and “staff advocate for patients even when their opinion conflicts with that of a senior member of the unit.”

      Relationship between teamwork and clinical error reporting

      Of the 522 nurses who experienced clinical errors, 277 (53.0%) responded that they had always or usually reported clinical errors to their managers and/or patient safety department. Not surprisingly, t tests showed that there were significant differences in the entire TPQ and in the subscale scores by error reporting (Table 3). Nurses who had appropriately reported clinical errors had a higher teamwork score than did those who had not.
      Table 3Levels of Teamwork by Clinical Error Reporting (N = 522).
      VariableAppropriate reportingPoor reportingtp
      (n = 277)(n = 245)
      MSDMSD
      Overall teamwork3.530.453.380.45−3.71.000
       Team structure3.470.493.350.49−2.81.005
       Team leadership3.360.693.210.65−2.43.016
       Situation monitoring3.550.523.420.52−2.98.003
       Mutual support3.640.493.490.49−3.27.001
       Team communication3.630.523.450.49−4.19<.000
      Logistic regression analyses were applied with a dependent variable, appropriate performance of error reporting. Appropriate error reporting was defined as responses of “always” or “usually” on reporting errors, according to previous research findings. The category of appropriate performance was coded as “1”, while inappropriate performance was coded as “0”. Teamwork was a significant factor associated with the high performance of error reporting (OR = 2.12, 95% CI [1.39, 3.23]; p = .001). At the subscale level, nurses with a higher team communication score were 1.82 times more likely to report clinical errors to their manager or patient safety department (OR = 1.82, 95% CI [1.05, 3.14]; p < .001; Table 4).
      Table 4Logistic Regression Analysis for Appropriate Error Reporting (N = 522).
      VariablesModel 1Model 2
      OR (95% CI)OR (95% CI)
      Gender(=female)1.79 (0.26–12.17)1.89 (0.27–13.14)
      Age
       ≤291.35 (0.56–3.23)1.29 (0.54–3.11)
       30–390.61 (0.28–1.30)0.58 (0.27–1.25)
       40≤ReferenceReference
      Marital status(=married)1.24 (0.76–2.04)1.26 (0.77–2.07)
      Educational level
       4-year university1.17 (0.75–1.81)1.17 (0.76–1.83)
       Graduate school or higher2.04 (1.06–3.92)1.93 (0.99–3.73)
       3-year collegeReferenceReference
      Years of nursing experience
       <3 years0.90 (0.48–1.71)0.89 (0.47–1.70)
       3 to less than 5 years0.64 (0.28–1.47)0.66 (0.29–1.53)
       5 to less than 10 years0.78 (0.41–1.47)0.77 (0.41–1.46)
       ≥10 yearsReferenceReference
      Clinical department
       Medical care unit1.67 (1.02–2.73)1.68 (1.03–2.76)
       Traditional medicine care unit1.45 (0.79–2.67)1.41 (0.76–2.61)
       Operating room1.70 (0.93–3.12)1.81 (0.98–3.36)
       Intensive care unit1.56 (0.90–2.71)1.50 (0.85–2.64)
       Surgical care unitReferenceReference
      Hospital (=A)0.78 (0.53–1.16)0.79 (0.53–1.18)
      Job position (=staff)1.58 (0.71–3.55)1.54 (0.69–3.48)
      Overall teamwork2.12 (1.39–3.23)
       Team structure0.92 (0.50–1.69)
       Team leadership1.13 (0.78–1.62)
       Situation monitoring0.96 (0.52–1.78)
       Mutual support1.23 (0.66–2.30)
       Communication1.82 (1.05–3.14)
      Note. CI = Confidence interval; OR = Odds ratio.

      Discussion

      Teamwork is an essential component of high quality care in the healthcare delivery system. This is the first study that investigates the relationship between teamwork and error reporting practice in a Korean inpatient care setting using a validated teamwork instrument. The findings show the necessity of improving teamwork. In addition, teamwork is linked to the safety-relevant performance of error reporting. Better team communication is associated with nurses' high error-reporting performance. Hospital executives and nurse managers should be actively involved in enhancing teamwork. Such efforts will also facilitate error reporting and contribute to a reduction of risks to patient safety through learning from errors.
      In this study, the level of teamwork is rated as moderate. The scores of the TPQ and its subscales are slightly lower than those of other studies [
      • Battles J.
      • King H.B.
      TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) Manual [Internet].
      ,
      • Castner J.
      Validity and reliability of the Brief TeamSTEPPS Teamwork Perceptions Questionnaire.
      ]. This finding may be attributable to the lack of substantial efforts for effective teamwork in most Korean hospitals, although the importance of teamwork has been widely recognized. Therefore, hospital executives and managers need to incorporate teamwork training programs as part of their in-service education efforts for effective team building and functioning.
      The score on team leadership is rated the lowest among the five components of teamwork. This is consistent with the previous findings for the US nurses [
      • Castner J.
      • Foltz-Ramos K.
      • Schwartz D.G.
      • Ceravolo D.J.
      A leadership challenge: staff nurse perceptions after an organizational TeamSTEPPS initiative.
      ]. The role of team leaders is critical in facilitating collaboration and coordination in team functioning. In particular, nurses indicate a lack of involvement of their team leaders in the planning and discussing of patient care and in constructively managing conflicts. Therefore, leadership development strategies and education for team leaders are emphasized as necessary components of better teamwork.
      This study also shows differences in the teamwork perceptions by nurses' characteristics. Nurses aged 40 years or older and those in managerial positions have more positive perceptions of teamwork than do the others. This may result from a better understanding of the complicated work processes involving various professionals and departments and the ways they work in teams over time. Another possible explanation is that the accumulated experience and job rank of these veteran nurses made them understand the importance of teamwork. Hence, younger staff nurses can be a priority group for teamwork training. Furthermore, levels of teamwork varied across clinical departments (Table 1). This is consistent with the previous finding that levels of teamwork are different in different workplaces and settings [
      • Kalisch B.J.
      • Lee K.H.
      Nursing teamwork, staff characteristics, work schedules, and staffing.
      ,
      • Kalisch B.J.
      • Lee K.H.
      The impact of teamwork on missed nursing care.
      ]. For instance, while a study of US nurses showed that teamwork in intensive care units was rated as being the highest [
      • Kalisch B.J.
      • Lee K.H.
      The impact of teamwork on missed nursing care.
      ], in this study teamwork in operating rooms was rated as the lowest, with no significant differences between the levels of teamwork in other departments. This may be related to the fact that the traditional hierarchy of surgery in operating rooms has often discouraged speaking up to a surgeon about patient safety concerns [
      • Makary M.A.
      • Sexton J.B.
      • Freischlag J.A.
      • Holzmueller C.G.
      • Millman E.A.
      • Rowen L.
      • et al.
      Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.
      ]. Formal processes that encourage nurses' engagement in patient care are needed for effective multidisciplinary surgical teamwork. For this purpose, a clinical pathway can be useful [
      • Deneckere S.
      • Euwema M.
      • Lodewijckx C.
      • Panella M.
      • Sermeus W.
      • Vanhaecht K.
      The European quality of care pathways (EQCP) study on the impact of care pathways on interprofessional teamwork in an acute hospital setting: study protocol: for a cluster randomised controlled trial and evaluation of implementation processes.
      ,
      • Deneckere S.
      • Euwema M.
      • Van Herck P.
      • Lodewijckx C.
      • Panella M.
      • SermeusW
      • et al.
      Care pathways lead to better teamwork: results of a systematic review.
      ]. For example, a clinical pathway on perioperative patient care may improve the overall process and information exchange among multidisciplinary team members by providing communication concerning what the teams complete, or what individual team members do at a given moment, thus reducing unnecessary complexity.
      Improved teamwork is positively linked to error reporting. Team communication is the only significant factor associated with the appropriate performance of error reporting. This finding supports the importance of communication for enhancing patient safety [
      • Joint Commission
      Sentinel event data: root causes by event type 2004–2012 [Internet].
      ,
      • Manser T.
      Teamwork and patient safety in dynamic domains of healthcare: a review of the literature.
      ]. Error reporting is generally a formal, upward communication. Better communication among team members promotes open, all-channeled communication; thus, it will facilitate communication even of clinical errors and patient safety concerns.
      Overall, the findings of this study indicate the necessity of improving teamwork. To this end, substantial efforts should be made to focus on the low-ranked items, such as resolving conflicts and having meetings for developing patient care plans, based on the findings of this study. Frontline managers as team leaders in inpatient care teams need to spend more time in staff meetings listening to nurses' concerns about patient care. They should coordinate and support the activities of the staff, and constructively manage possible team conflicts. In addition, hospital executives can provide and support leadership-training programs to facilitate effective team leadership. Generic comprehensive team training, task-specific team training, and quality improvement interventions can be designed in order to improve teamwork [
      • Thomas E.J.
      Improving teamwork in healthcare: current approaches and the path forward.
      ]. The best example of generic comprehensive team training is the TeamSTEPPS program, which is applicable to most providers and care sites, rather than specific healthcare tasks or activities [
      • Thomas E.J.
      Improving teamwork in healthcare: current approaches and the path forward.
      ]. To improve multidisciplinary teamwork, the aforementioned clinical pathway approach can also be useful [
      • Deneckere S.
      • Euwema M.
      • Lodewijckx C.
      • Panella M.
      • Sermeus W.
      • Vanhaecht K.
      The European quality of care pathways (EQCP) study on the impact of care pathways on interprofessional teamwork in an acute hospital setting: study protocol: for a cluster randomised controlled trial and evaluation of implementation processes.
      ,
      • Deneckere S.
      • Euwema M.
      • Van Herck P.
      • Lodewijckx C.
      • Panella M.
      • SermeusW
      • et al.
      Care pathways lead to better teamwork: results of a systematic review.
      ]. Improved teamwork will create a more positive work environment for error reporting. In particular, the study findings stress the importance of team communication in improving error reporting. Specifically, closed-loop communication needs to be incorporated to ensure safe team communication. In this type of information exchange, the receiver acknowledges the message by check-back, and the sender verifies that the intended message was received [
      • Salas E.
      • Sims D.E.
      • Burke C.S.
      Is there a big 5 in teamwork?.
      ,
      • Härgestam M.
      • Lindkvist M.
      • Brulin C.
      • Jacobsson M.
      • Hultin M.
      Communication in interdisciplinary teams: exploring closed-loop communication during in situ trauma team training.
      ]. The use of standardized methods of timely information sharing and a common terminology may lead to improved closed-loop communication among team members, which will encourage error reporting.
      This study has several limitations. First, it was conducted with only nurses in two teaching hospitals. Therefore, the generalizability of the findings is limited. Second, we measured nurses' error reporting by using self-administered questionnaire items because we had difficulty obtaining formal reporting documents; thus, recall bias is possible. Third, since this study was cross-sectional in nature, causal relationships cannot be inferred. Thus, we suggest that longitudinal studies, with nurses in different care settings, be conducted to investigate whether improved teamwork through interventions such as team training leads to better patient safety performance. In addition, this study did not include examinations of patient acuity or organizational culture that can contribute to teamwork and error occurrences. Although we included information on hospital type and clinical department in the analysis, further studies will need to include these work environment factors for a better understanding of the dynamics of teamwork and clinical error reporting. Furthermore, this study was conducted in an inpatient care setting with teams that had relatively stable roles as full-time nursing staff members. Future studies should include various healthcare professionals and consider different types of teams consisting of variable roles and personnel make up. On the other hand, this study's focus on teamwork and error reporting has the following implications: It is apparent that the weaknesses and strengths of teamwork in the current practice will provide a fundamental basis for better teamwork and higher-quality care. Furthermore, evidence concerning the relationship between teamwork and error reporting provide a practical strategy for reducing clinical errors and improving patient safety.

      Conclusion

      Teamwork is a core element of highly reliable organizations [
      • Baker D.P.
      • Day R.
      • Salas E.
      Teamwork as an essential component of high-reliability organizations.
      ]. The findings of this study of acute care hospital nurses indicate the need to improve teamwork by focusing on team leadership. Therefore, hospital executives and nurse managers should monitor both overall teamwork and subscale scores and identify areas requiring improvement. The teamwork scale validated in this study can be used as a reliable, economical tool. Furthermore, we also recommend a tailored approach considering the five components of teamwork to create interventions that effectively improve teamwork.
      Our results provide evidence that teamwork is related to the safety-relevant performance of error reporting. In particular, team communication is an important factor associated with error reporting. Therefore, in an inpatient setting, a series of efforts to enhance teamwork and communication facilitates learning from clinical errors, thereby contributing to improved patient safety.

      Conflict of Interest

      The authors declare no conflict of interest.

      Acknowledgment

      This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (grant no. NRF-2012R1A1A2008214 ).

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