The Journal of Continuing Education in Nursing

Teaching Tips 

Quality and Safety Education for Nurses Teamwork and Collaboration Competency: Empowering Nurses

Gail Armstrong, PhD, DNP, ACNS-BC, CNE


Improving the safety of health care continues to be a high priority for U.S. health care systems. One of the core competencies identified to improve health care safety focuses on improving teamwork. This article focuses on tools nurses can employ to improve health care team communication, thereby enhancing health care teamwork. [J Contin Educ Nurs. 2019;50(6):252–255.]


Improving the safety of health care continues to be a high priority for U.S. health care systems. One of the core competencies identified to improve health care safety focuses on improving teamwork. This article focuses on tools nurses can employ to improve health care team communication, thereby enhancing health care teamwork. [J Contin Educ Nurs. 2019;50(6):252–255.]

In 2000, The Institute of Medicine ([IOM], now The National Academy of Medicine) identified that the U.S. health care system is a system that is prone to errors; it calculated that 44,000 to 98,000 preventable deaths occur in U.S. hospitals each year. Error in health care continues to be a concern, as 2013 statistics indicate that as many as 400,000 deaths occur as a result of preventable errors (James, 2013; Landrigan et al., 2010). The IOM's follow-up report, Health Professions Education, identified team-work as one of the five necessary competencies for all members of the health care team (IOM, 2003). Continuing to train nurses in the skills necessary for effective teamwork in health care remains important to the priority of making health care safer. Improving teamwork in health care improves the overall safety of health care.

Teamwork in health care is inherently a complex phenomenon, as the systems in which care is provided are complex. Breaking teamwork down into discrete knowledge, skills, and attitudes facilitates effective assessment of the competency, as educators can use identified knowledge, skills, and attitudes in evaluation tools. Furthermore, breaking the competency into knowledge, skills, and attitudes expedites the development of targeted education for continued development in this competency. Soon after the IOM's Health Professions Education report, the nurse-led initiative, Quality and Safety Education for Nurses (QSEN), operationalized the recommended competencies into distinct knowledge, skills and attitudes (Cronenwett et al., 2007). The QSEN knowledge, skills, and attitudes for quality and safety competencies can be found on the QSEN website (, as well as in Table 1.

Quality and Safety Education for Nurses Knowledge, Skills, and Attitudes Necessary for Teamwork and Collaboration Competency

Table 1:

Quality and Safety Education for Nurses Knowledge, Skills, and Attitudes Necessary for Teamwork and Collaboration Competency

Current Thinking About Teamwork in Health Care

A common focus in the current health care teamwork literature is the vital role of effective communication on health care teams, and the many barriers to successful development of strong team communication practices. Leonard, Graham, and Bonacum (2004) estimated that 70% of all errors in health care stem from a miscommunication etiology. A widely cited 2010 study estimates that only 21% to 31% of nurses speak up when they have concerns about dangerous shortcuts, mistakes, or disrespect because of the hierarchy of team structure and the fear of punishment (Maxfield, Grenny, Lavandero, & Groah, 2011). Current evidence suggests a significant mismatch in team members leading interprofessional communications. A 2019 study in a pediatric intensive care unit measured participation of an interprofessional team in preparing for case meetings with families. Physicians spoke for an average of 83.9% of each meeting's duration (Walter et al., in press). Other evidence indicates that training teams in common skills and team-based practices are more valuable than introducing new technology to address ineffective team communication. When new innovations focus on the use of electronic tools in the electronic health record, recent evidence suggests that non-technology team factors have the most significant influence on teamwork and communication (Tang et al., 2019). Effective teamwork strategies focus on empowering all members of the team to fully employ their agency as patient advocates.

Strategies for Training Nurses About Effective Teamwork

Many of the most effective strategies to improve health care teamwork focus on communication. Two teamwork categories lead educational opportunities: (a) using standardized language to reduce the influence of hierarchy on health care teams, and (b) using predictable team communication structures so team communication can be anticipated.

Strategies to Increase Psychological Safety of Health Care Teams

The hierarchical structure of health care interferes with members of the health care team feeling safe in speaking up (Maxfield et al., 2011; Weller, Boyd, & Cumin, 2014). Many physicians are trained to use direct commands, and other team members are often not trained to challenge decisions or offer suggestions to challenges. Team training that uses standardized team language flattens the hierarchy and provides the same communication tools to all members of the health care team, regardless of rank. Table 2 offers specific standardized communication strategies that can facilitate more effective communication on a health care team. Use of standardized language allows all health care team members to have access to the same communication tools for clear and efficient communication (De Meester, Verspuy, Monsieurs, & Van Bogaert, 2013).

Team Tools to Standardize Communication

Table 2:

Team Tools to Standardize Communication

Structured Communication Occurrences to Improve Team Communication

The fast pace of health care delivery and the complexity of health care systems are barriers to effective and efficient communication among all team members. Missed information, incorrect information, or the absence of any communication are frequent causes to errors in health care. Utilization of standardized communication tools can lead to timely, efficient, and coordinated communication, especially in fast-paced health care environments (Turner, 2012). TeamSTEPPS® offers teaching materials, checklists, and resources for establishing standardized team communication before care, during care, or after care. Briefs (sometimes called rounding) are a precare team communication where plans for care are reviewed. Huddles occur during care and when an emerging event or critical issue needs to be discussed because of safety concerns before care can proceed. Debriefs offer the team an opportunity for retrospective review and analysis. Teams are encouraged to tailor the structure and content of briefs, huddles, or debriefs to the specific needs of their team and practice setting. Table 3 offers outlines for these three structures.

Structured Team Communication Options

Table 3:

Structured Team Communication Options

Empowering Nurses to Improve Teamwork

Nurses are well positioned to introduce communication strategies or suggest standardized occurrences of team communication, as they often serve as the connecting communicator between the patient, family, and members of the health care team. Providing nurses with evidence-based strategies to improve team communication may serve as an effective catalyst for improvement of health care teams. In all health care settings, improved communication among team members serves to improve the quality of care provided, as well as team member satisfaction.


Team communication is the foundation of all health care team functions. When team communication is poor, team functioning is poor. When health care teams communicate in a coordinated, timely, efficient, and aligned manner, there are benefits to the patient, patient outcomes, and members of the team. This article shared a variety of tools nurses can use in leading teams to improved communication. Nurses are well equipped to lead teams in adopting effective communication strategies and communication structures, especially with the right tools.


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  • De Meester, K., Verspuy, M., Monsieurs, K.G. & Van Bogaert, P. (2013). SBAR improves nurse–physician communication and reduces unexpected death: A pre and post intervention study. Resuscitation, 84, 1192–1196. doi:10.1016/j.resuscitation.2013.03.016 [CrossRef]
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  • Weller, J., Boyd, M. & Cumin, D. (2014). Teams, tribes and patient safety: Overcoming barriers to effective teamwork in healthcare. Postgraduate Medical Journal, 90, 149–154. doi:10.1136/postgradmedj-2012-131168 [CrossRef]

Quality and Safety Education for Nurses Knowledge, Skills, and Attitudes Necessary for Teamwork and Collaboration Competency

Knowledge ElementsSkills ElementsAttitude Elements
Describe own strengths, limitations, and values in functioning as a member of a teamDemonstrate awareness of own strengths and limitations as a team memberAcknowledge own potential to contribute to effective team functioning

Describe scopes of practice and roles of health care team members

Describe strategies for identifying and managing overlaps in team member roles and accountabilities

Initiate plan for self-development as a team memberAppreciate importance of intra-and interprofessional collaboration
Recognize contributions of other individuals and groups in helping patient and family achieve health goalsAct with integrity, consistency, and respect for differing viewsValue the perspectives and expertise of all health care team members
Analyze differences in communication style preferences among patients and families, nurses, and other members of the health care teamFunction competently within own scope of practice as a member of the health care teamRespect the centrality of the patient and family as core members of any health care team
Describe impact of own communication style on othersAssume role of team member or leader, based on the situationRespect the unique attributes that members bring to a team, including variations in professional orientations and accountabilities
Discuss effective strategies for communicating and resolving conflictInitiate requests for help when appropriate to situationValue teamwork and the relationships it is based on
Describe examples of the impact of team functioning on safety and quality of careClarify roles and accountabilities under conditions of potential overlap in team member functioningValue different styles of communication used by patients, families, and health care providers
Explain how authority gradients influence teamwork and patient safetyIntegrate the contributions of others who play a role in helping the patient and family achieve health goalsContribute to resolution of conflict and disagreement
Identify system barriers and facilitators of effective team functioningCommunicate with team members, adapting own style of communicating to needs of the team and situationAppreciate the risks associated with hand-offs among providers and across transitions in care
Examine strategies for improving systems to support team functioning

Demonstrate commitment to team goals

Solicit input from other team members to improve individual, as well as team, performance

Initiate actions to resolve conflict

Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care

Assert own position/perspective in discussions about patient care

Choose communication styles that diminish the risks associated with authority gradients among team members

Value the influence of system solutions in achieving effective team functioning

Team Tools to Standardize Communication

Tools and ResourcesTool DescriptionWhen to Use
ISBAR: Institute for Healthcare Improvement offers an SBAR toolkitIdentify: Identify yourself and your role on the team Situation: A concise statement of the problem Background: Relevant and brief information specific to the situation Assessment: Speaker's analysis of what is occurring in the situation Recommendation: What the speaker wants, action that is being requestedEffectively used when updating a team or team members on current status, asking for input or orders, or handoffs (Institute for Healthcare Improvement, n.d.).
Two challenge rule: Agency for Healthcare Research and Quality Team Strategies & Tools to Enhance Performance & Patient SafetyWhen a team member has a concern about a safety situation:

It is that team member's responsibility to voice concern at least two times to encure that it has been heard.

The challenged team member must acknowledge that the concern has been heard.

If the safety issue has not been addressed, use one's chain of command.

When a team member has a concern about an essential safety breach (
CUSStandardized approach for all team members to make an assertive statement:

“I am Concerned”

“I am Uncomfortable.”

“This is a Safety issue.”

When all team members are training in the use of CUS, the use of these three “alert” words informs the entire team of a safety concern by a team member (

Structured Team Communication Options

BriefsTeam briefs are a planning communication tool. Occurring before care, they may be held as rounding in the hospital, or a preclinical team meeting in the outpatient setting. Inclusion of all team members in the briefing process enhances team engagement.
HuddlesTeam huddles are called only when needed, on an ad hoc basis. This communication tool is used during care, to address important concerns that cannot be postponed. Huddles address alterations in plans or modifications where the whole team needs to be updated. Anyone on the team can call a huddle. Because of the interruptive nature of huddles, this team communication tool is used only when vital communication is needed.
DebriefsTeam debriefs are used after an event, after care, or after a specified amount of time (e.g. every week, every month, or every quarter). The structure focused on a brief recounting of the event or time frame, with attention to improving teamwork. Providing an opportunity for all team members to contribute to the retrospective analysis enriches collaboration.

Dr. Armstrong is Associate Professor, University of Colorado College of Nursing, Aurora, Colorado.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Gail Armstrong, PhD, DNP, ACNS-BC, CNE, Associate Professor, University of Colorado College of Nursing, 13120 East 19th Ave., Box C288-19, Aurora, CO 80045; e-mail:


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