Delivery of the TeamSTEPPS^® communication module to the ophthalmatology operating room team: determining perceptions, experiences, and opinions

Abstract

Background

Interprofessional collaboration among healthcare teams has become essential to ensuring patient safety. Deficiencies in collaboration and ineffective communication among team members contribute significantly to the risk of patient harm. Communication-related issues are consistently identified as the predominant cause of medical errors across healthcare settings. The aim of the study was to implement the TeamSTEPPS^® Communication Module in the ophthalmology operating room at a university hospital in Turkey, and determine the perceptions, experiences, and opinions of the healthcare professionals regarding communication and teamwork to enhance collaboration and patient safety.

Methods

In this mixed-method study, the participants completed the TeamSTEPPS^® Teamwork Perceptions Questionnaire (T-TPQ) at three time points: immediately before the training, immediately after its conclusion, and one month post-training. Additionally, qualitative data were collected through focus group interviews conducted before the training.

Results

A total of 31 participants participated in the study. The analysis of the T-TPQ scores revealed no statistically significant differences between the pre-test, post-test, and retention test results (p > 0.05). The interview data underwent inductive content analysis, resulting in the identification of four key themes: team cohesion, support, leadership qualities, and communication. The participants’ feedback on the TeamSTEPPS^® Communication Module highlighted verifying understanding, avoiding errors, and applying lessons to improve collaboration, patient safety, and professional responsibility.

Conclusion

This study is significant as it represents the first implementation and evaluation of the TeamSTEPPS^® Communication Module in Turkey. These findings underscore the importance of assessing the specific educational needs of healthcare units and designing team-based training, and regular repetition of training to reinforce learning, enhance communication, and promote the delivery of safer healthcare services.

Trial registration

Clinical trial number: Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-08149-9.

Background

As the healthcare systems grow increasingly complex, interprofessional collaboration among healthcare teams has become essential to ensuring patient safety. Deficiencies in collaboration and ineffective communication among team members contribute significantly to the risk of patient harm, primarily due to the incomplete transfer of critical information. Communication-related issues are consistently identified as the predominant cause of medical errors across healthcare settings. Without a shared understanding of each team member’s role and responsibility, along with insufficient attention to patient-specific factors, further increases the risk of adverse events. The Joint Commission has identified communication failures as the leading cause of sentinel events [1–4]. An analysis of 23,658 medical malpractice cases from 2009 to 2013 documented in the Controlled Risk Insurance Company (CRICO) database—a risk management initiative affiliated with Harvard Medical Institutions—revealed that more than 7,000 cases involved communication errors that directly harmed patients. Notably, communication failures were a contributing factor in 30% of these cases, with intra-team communication breakdowns reported in 49% [5].

Operating rooms are highly specialized and dynamic clinical environments that demand coordination and synergy among healthcare professionals to optimize patient outcomes [6]. According to data from the World Health Organization, approximately 27% of all adverse patient events globally are associated with surgical interventions [7]. Moreover, in 2023, incidents involving procedural errors—such as wrong-patient or wrong-site surgeries—increased by 26% compared to the previous year, regardless of the invasiveness or severity of the procedure [8].

Fostering a strong culture of teamwork is key to advancing patient safety. This includes clear leadership accountability, organizational infrastructure that prioritizes safety, and a commitment to team-based care rooted in effective communication and collaboration [9, 10]. Educational initiatives aimed at enhancing communication competencies among healthcare professionals have shown promise in raising awareness and promoting safer clinical practices [11]. In this context, the Agency for Healthcare Research and Quality (AHRQ) and the U.S. Department of Defense (DoD) jointly developed Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS^®). This structured, evidence-based methodology facilitates the development of a shared communication framework among healthcare professionals and has been associated with improved patient safety outcomes [12].

The aim of the study was to implement the TeamSTEPPS^® Communication Module targeting the healthcare teams in the ophthalmology operating room at a university hospital in Turkey. to determine the perception levels, experiences, and opinions of the healthcare professionals regarding communication and teamwork to enhance collaboration and patient safety. The research questions under this aim are;

1. What are the levels of perception of team members regarding teamwork before and after the TeamSTEPPS^® training?

2. What are the opinions of team members about communication and teamwork before the TeamSTEPPS^® training?

3. What are the opinions of team members about the effectiveness of the training after the TeamSTEPPS^® training?

Methods

Researchers, study design, and participants

The first author (H.D.) is a nurse working in the ophthalmology outpatient clinic and was a doctoral candidate in medical education. The second author (M.E.) is a medical doctor with a master’s degree in educational sciences and served as a faculty member in the Department of Medical Education & Informatics. Both researchers had experience in interprofessional education and teamwork and received training in qualitative research methodologies.

Prior to this study, both researchers completed the TeamSTEPPS^® Master Trainer Course, conducted by the Johns Hopkins Medicine Armstrong Institute from October 4–6, 2022, and were awarded master trainer certificates. The content of TeamSTEPPS^® program was adapted into Turkish with the necessary permissions before this study.

This study employed a mixed-methods design, incorporating both qualitative and quantitative data collection. The study group included 23 ophthalmology residents, two anesthesiology residents, four nurses, four operating room technicians, and two anesthesia technicians—all working in the ophthalmology operating room. As the aim was to include the entire group, no sampling was performed; all eligible staff were invited to participate, resulting in a total of 31 participants. Participants were informed that their participation in the study was entirely voluntary, that choosing to participate or not would have no academic or administrative consequences, and that residents and employees who did not provide consent could opt out of the study. Written informed consent was obtained from those who agreed to participate.

The ophthalmology residents work in the same clinic as the primary researcher (H.D.). The researcher also has prior acquaintance with the nurses and technicians in the ophthalmology operating room. However, there is no educational or administrative hierarchical relationship between the researcher and the participants. The researcher had no prior relationship with the anesthesiology residents or technicians.

The study was conducted in the Department of Ophthalmology between December 2022 and January 2023.

Study workflow and data collection

Data collection instruments included a demographic questionnaire and the previously Turkish-adapted version of the TeamSTEPPS^® Teamwork Perceptions Questionnaire (T-TPQ). The Cronbach’s alpha coefficient calculated for the reliability of the entire Turkish adaptation of the questionnaire was 0.95, indicating internal consistency. The Cronbach’s alpha values for the subscales also demonstrated high reliability, ranging from 0.86 to 0.95. Due to interdependence among certain items and their overlap with communication-related items—which limited respondents’ ability to differentiate between them—the questionnaire was revised to include 29 items. Of these, three belong to the “Situation Monitoring” dimension, two to the “Mutual Support” dimension, and one to the “Team Structure” dimension. The 29-item version of the Turkish questionnaire was found to be more reliable and valid than the original 35-item version, particularly within the context of Turkish healthcare settings [13].

For the quantitative component, participants completed the 29-item, Likert-type T-TPQ at three time points: immediately before the training, immediately after its conclusion, and one-month post-training. This approach was used to assess baseline perceptions, immediate effects, and score retention over time.

The study was completed in 5 phases (Fig. 1). In the initial phase, a preliminary evaluation meeting was conducted with senior team members, including a senior ophthalmology resident, senior nurse, senior operating room technician, and senior anesthesia technician. This session focused on exploring current practices, expectations and concerns regarding collaboration, communication, and patient and staff safety. The meeting was guided by unstructured questions, lasted 25 min, and while notes were taken, no audio recordings were made.

Fig. 1.

Study workflow

The second phase involved focus group interviews and the administration of T-TPQ for the baseline evaluation. Semi-structured interview questions (Supplemantary Material 1.) were developed by the researcher, and reviewed by three medical education experts for relevance and clarity. A pilot study was also conducted. Informed written consent was obtained from all participants. Five focus group interviews, each with five participants, were conducted in the workplace and audio-recorded; six participants with time constraints due to clinical responsibilities provided written responses. Each session averaged 20 min in duration. No repeat interviews were conducted. T-TPQ adminpeistration occurred immediately before each session date on December 15 and 22.

The third phase encompassed the training intervention. To minimize disruption to operating room workflow, participants were divided into two interprofessional groups. The communication module was delivered by the primary researcher (H.D.) on December 15 and 22 in the department’s classroom. Each session lasted one hour. The TeamSTEPPS^® curriculum consists of non-editable, ready-to-use materials, including presentation slides and instructional guides. The communication module covers fundamental concepts and tools such as SBAR, Closed-Loop Communication, Call-Out, Check-Back, Handoff, and I-PASS, supported by pre-prepared video resources.

During the training sessions, these standardized slides and videos were utilized to promote active learning. To enhance engagement and relevance, examples related to ophthalmology—particularly scenarios posing potential threats to patient safety—were integrated into the content to capture participants’ interest.

The fourth phase involved post-training evaluation through the re-administration of the T-TPQ and collection of written feedback. This was conducted on immediately after each session date on December 15 and 22.

In the fifth and final phase, follow-up evaluation was carried out to assess the retention of training effects using the T-TPQ.

Data analysis

Descriptive statistics were used to summarize participants’ demographic characteristics. For the quantitative analysis, skewness and kurtosis values were obtained to determine whether the data showed a normal distribution (Supplemantary Material 2.), and the Paired Samples T-Test was employed to compare participants’ scores on the pre-test, post-test, and retention test. Effect sizes were calculated according to Cohen's d. Statistical analyses were conducted using Jamovi software (version 2.3.24).

Qualitative data were analyzed using an inductive content analysis approach to facilitate a comprehensive understanding of the phenomenon under investigation. This method enables the systematic classification of textual data by grouping words or phrases into content-related categories that reflect shared meanings [14, 15]. Given the availability of sufficient contextual information, an inductive approach was deemed appropriate.

Transcripts were anonymized by assigning unique three-digit identifiers to participants. The participants did not approve the transcribed interviews. Qualitative data analysis was performed manually without the use of specialized software.

Both researchers independently reviewed the interview transcripts multiple times to become familiar with the data and to identify recurring concepts. Meaningful units—words or phrases conveying similar ideas—were identified and coded. Codes with similar content were subsequently organized into broader themes. The researchers performed the coding and categorization independently, then convened to compare, discuss, and finalize the derived themes through consensus.

Results

Demographics

The study cohort consisted of 35 healthcare professionals, including 23 ophthalmology residents, two anesthesiology residents, four nurses, four operating room technicians, and two anesthesia technicians (Table 1). Of these, 31 participants took part in the study, comprising 22 females and nine males. Participants’ professional experience ranged from four months to 32 years, and their ages varied between 25 and 58 years. Only one individual reported prior participation in an interprofessional training program. All 31 participants completed the pre-test, post-test, and retention test assessments, and the study findings are based on this group.

Table 1.

Characteristics of the participants in the study based on their profession, gender, and years of work experience

Characteristics	Category	Participants (n:31)
Profession	Ophthalmology residents	22
	Anesthesiology residents	2
	Nurse	3
	Operating room technicians	2
	Anesthesia technicians	2
Gender	Female	22
	Male	9
Job experience (years)	0–10 years	24
	11–32 years	7

Teamwork perceptions

Teamwork perceptions, as measured by the TeamSTEPPS^® Teamwork Perceptions Questionnaire (T-TPQ), were evaluated among members of the ophthalmology operating room team. A comparison of T-TPQ scores before and immediately after the TeamSTEPPS^® training revealed no statistically significant difference (p >0.05, effect size < 0.2) (Table 2). Similarly, no statistically significant difference was observed between the post-test and the retention test scores (p >0.05, effect size < 0.2) (Table 3).The Cohen’s d effect size scores are less than 0.2. For Cohen’s d indicates 0.2 small effect, 0.5 medium effect, and 0.8 large effect size [16].

Table 2.

Comparison of the pre-post training scores of the opthalmology operating room team members perceptions regarding teamwork

Dimensions	Measurement Time	N	Mean	Sd	t	p	Effect Size
Team structure	Pre test Post test	31 31	21.0 20.5	4.42 5.43	0.3581	0.723	0.0643
Leadership	Pre test Post test	31 31	23.0 22.6	6.77 5.57	0.2624	0.795	0.0471
Situational monitoring	Pre test Post test	31 31	13.5 13.6	2.58 2.92	-0.0427	0.966	-0.0076
Mutual support	Pre test Post test	31 31	16.7 16.5	3.91 3.90	0.2021	0.841	0.0362
Communication	Pre test Post test	31 31	25.7 25.1	4.62 3.36	0.6035	0.551	0.1083
Overall	Pre test Post test	31 31	100.0 98.3	17.41 16.64	0.3514	0.728	0.0631

Table 3.

Comparison of the post training and retention test scores of the opthalmology operating room team members perceptions regarding teamwork

Dimensions	Measurement Time	N	Mean	Sd	t	p	Effect Size
Team structure	Post test Retention test	31 31	20.5 20.6	5.43 4.18	-0.1016	0.920	-0.0182
Leadership	Post test Retention test	31 31	22.6 22.4	5.57 5.61	0.1794	0.859	0.0322
Situational monitoring	Post test Retention test	31 31	13.6 13.8	2.92 2.57	-0.2891	0.775	-0.0519
Mutual support	Post test Retention test	31 31	16.5 17.1	3.90 3.47	0.6695	0.508	-0.1202
Communication	Post test Retention test	31 31	25.1 25.6	3.36 3.74	0.5615	0.579	-0.1008
Overall	Post test Retention test	31 31	98.3 99.5	16.64 16.25	0.2658	0.792	-0.0477

Initial phase meeting

During the initial phase meeting, senior team members emphasized key areas such as patient and staff safety, infection control, communication, and collaboration, particularly with regard to the implementation of surgical time-outs. A time-out is the surgical team’s short pause, just before incision, to confirm that they are about to perform the correct procedure on the correct body part of the correct patient [17]. Based on data from the Office of Quality Improvement, the Ophthalmology Operating Unit reported one of the highest rates of documented time-outs within the institution, with a rate of 71.4% compared to the institutional average of 61% in February 2022. Illustrative quotations addressing these key areas are presented below:

“The study was conducted in the Department of Ophthalmology between December 2022 and January 2023. “There is a lot of intensity. What’s done here is teamwork, and we must check each other. Sometimes someone else catches something that has been overlooked. The doctor, anesthetist, nurse, and technician all check. Because sometimes another patient’s name might be written on the patient form, verification must be done from the beginning. Medication checks are also necessary—medications prepared for another patient could be administered by mistake. For medication verification, the dose and name of the drug are written with a permanent marker.”

“It gets very crowded, and from the perspective of both staff and students, there’s a risk of breaking sterility. We pay attention to both this issue and expired materials.”

“Working without stress is very important. Everyone here knows what to do, and we can even understand each other through non-verbal communication.”

“Yes, we can all easily ask for help, and we help each other as much as we can.”

“We apply the time-out well, and our communication is good.”

“The work ethic of the staff is important. If you love your job and do it well, you pay attention to avoid mistakes. It’s also something that comes with experience.”

“The time-out should be applied in every unit, not left to personal preferences. Training might be lacking in the OR; sustainability can be achieved by providing this training to newcomers.”

Focus group interviews

In the presentation of findings, participant statements were anonymized and coded as K01 through K31. The interview data underwent inductive content analysis, resulting in the identification of four key themes: team cohesion, support, leadership qualities, and communication.

A representative sample of transcribed excerpts, coding units, and assigned codes is provided in Table 4. The overall distribution of codes across the identified themes is summarized in Table 5.

Table 4.

The example transcript, units, and codes from the focus group discussion conducted with the opthalmology opreating room team members

Transcribed interview text with identified meaningful statements	Units	Codes
“We pay great attention to sterility. Also, proper patient identification is well tracked (K10.4).After bringing the patient in, we ask about allergies, age, and name, and check the patient id wristband (K10.7). ” “Everyone working here is aware of their duties and comes in early in the morning to prepare for the day. Checks are done, such as verifying both lenses and equipment. Nurses, technicians, and we all do this (K18.5).” “As team members, if there is any dangerous situation, we warn each other. If the patient has hepatitis or another infectious disease, we make sure everyone is informed about it (K22.5).” “When we go to the operating room, we take turns going to eat. We think about each other and look out for one another’s needs (K02.5).” “At the end of the day, we’re working as a group. The leader has to assign roles. If that part is not clear, there are too many conflicts between people. He needs to organize things properly (K11.30).” “Time-out is really important here. We make sure to pay close attention to it in the OR (K23.27).”	K10.4 Correct patient tracking K10.7 Patient ID wristband and allergy verification K18.5 Verification of materials to be used K22.5 Warnings about potential dangers and infectious diseases K02.5 Taking care of basic needs K11.30 Task Allocation K23.27 Time-out practice	Patient and staff safety Social Assistance Team Collaboration Conditions Structured Processes During Procedures

Table 5.

Themes, codes and units from the focus group discussion with the ophthalmology operating room team members

Themes	Codes	Units
Team Cohesion	Patient and Staff Safety	18
	Roles and Responsibilities	14
	Experience	18
	Human Factors in the Work	43
	Environment
	Equipment in the Work Environment	9
	Collaboration and Interpersonal Communication	32
	Total	134
Support	Patient Advocacy	8
	Professional Support	32
	Social Assistance	36
	Total	76
Leadership Qualities	Scientific Competence	10
	Personality Traits `	48
	Team Collaboration Conditions	49
	Total	107
Communication	Structured Processes During	49
	Procedures Structured patient handovers	12
	Structured processes between teams	7
	Respectful communication	27
	Total	95

Team cohesion

The theme of team cohesion includes the codes of patient and staff safety, roles and responsibilities, experience, human factors in the work environment, equipment in the work environment, collaboration, and interpersonal communication.

“Everyone working here is aware of their duties and comes in early in the morning to prepare for the day. Checks are done, such as verifying both lenses and equipment. Nurses, technicians, and we all do this. The patient is also checked for allergies, etc.” (K18)

“There is compliance with teamwork in the operating room. It is highly valued, and everyone fulfills their duties properly. There is also harmony within the team. Everyone knows very well what they should do within their role and receives feedback from others when something is missing.” (K08)

“There can be communication breakdowns during handover times.” (K04)

“New technicians might not be very familiar with the workflow, and things get messy there. They don’t know the machines or the materials.” (K18)

“We work with a team spirit.” (K03)

Support

The support theme includes the codes of patient advocacy, professional support, and social assistance.

“If you ask for help or support on any issue from colleagues here, they will do their best.” (K05)

“Sometimes when I’m in surgery, there are maneuvers I hesitate to perform, but the nurses help me do them.” (K15)

“When we go to the operating room, we take turns sending each other to lunch. We think of one another and consider each other’s needs.” (K02)

Leadership qualities

The theme of leadership qualities includes the codes of scientific competence, personality traits, and team collaboration conditions.

“A leader should be experienced, communicative, and able to make clear and firm decisions.” (K30)

“A leader should be familiar with the workflow and able to assign roles to everyone.” (K04)

Communication

The communication theme includes structured processes during procedures, structured patient handovers, structured processes between teams, and respectful communication codes within and between teams. Among these, the use of structured processes during procedures has been the most emphasized.

“Effective and clear communication should be established, ensuring the other party understands and confirming that understanding.” (K04)

“Mutual confirmation is needed—that is, the information exchanged must be verified and approved. Some patients are very elderly and may not even know which eye will be operated on. We immediately check the surgery list or the exam notes to confirm. When it passes through two or three levels of checking, the error rate significantly drops. So, the time-out must be done properly.” (K11)

“Patient handovers should be done with predefined emergency plans and routine protocols.” (K30)

“Patient handovers must be done properly. It shouldn’t be like, ‘I finished my shift, I’m leaving.’ Patients must be handed over with complete and accurate information.” (K31)

“Our coordinated work is very important for the patient’s well-being. Communication among us is crucial—doctor, nurse, technician, anesthetist. Information verification should be done as a team to avoid mistakes.” (K09)

“Communication should be respectful and structured to prevent breakdowns within and between teams.” (K22)

“Everyone should politely point out any shortcomings or errors they notice and speak openly to help correct the situation.” (K29)

Participants’ feedback

The participants’ feedback on the TeamSTEPPS^® Communication Module highlighted verifying understanding, avoiding errors, and applying lessons to improve collaboration, patient safety, and professional responsibility.

“It was a practical and very useful training. It also helped me notice the things we usually do, overlook, or should do but actually don’t. Especially the importance of teamwork, making sure the other side understands during handovers, and confirming that understanding—this was very helpful and allowed me to recognize my own shortcomings. For example, in verbal handovers, we don’t go into such detail; someone just says something and leaves, but there’s no confirmation on how well the other person understood or if they understood correctly. This training helped me realize the importance of that. Maybe we can be more careful from now on. It also gave me a chance to reflect on the people I work with. I believe this is training every healthcare worker should receive.” (K08)

“It was a successful training. It could have been more effective with a broader range of participants and professions—not just the operating room and resident group. I think our professors should have attended as well. We spend more of our time in the outpatient clinic, but we’re also a team in the operating room, and communication is crucial in preventing errors. I had never considered some things from this perspective. We do things in the operating room that can affect the patient’s life. There needs to be a control mechanism and communication at every stage, and this training was effective in reminding us of that. It gave all the residents a new perspective.” (K11)

“It was an effective and beneficial training. Sometimes we understand each other through a glance here, but that’s actually not very reliable. I’ve once again realized how important it is to verify information. Especially verbal and face-to-face communication stuck with me, and I will pay more attention to that. Also, the points to watch for during patient handovers were very useful to me.” (K09).

“We can prevent errors with good and effective communication. Personal conflicts should not interfere with communication. The patient is what matters here. After working hours, what my colleague does is not my concern. It should be repeated from time to time, maybe every 5–6 months. These are things we already know, but it was an effective training to refresh our memories and keep them in focus.” (K06).

“It was very beneficial for me. We live in an age where we use “I-language” a lot, but even though we use it, we work as a team, and we need to be aware of that. These were things we paid attention to, but this training helped me see them from a different perspective. Timely communication is crucial in avoiding errors, both in giving and receiving information. Both my patients and colleagues in my unit need to do this, and I must do the same. It was great that these points were addressed.” (K23).

Discussion

Teamwork perceptions

In this study, an analysis of the teamwork scale scores of ophthalmology operating room team members in relation to the TeamSTEPPS^® training revealed no statistically significant differences between the pre-test, post-test, and retention test results (p >0.05). These results might be related to a few underlying reasons: the ophthalmology operating room has been reported as one of the units with higher levels of ranking in the hospital related to teamwork and patient safety. Furthermore, the relatively limited intensity of the intervention might not have a statistically significant impact on the test results. Meanwhile, the participants shared their positive perceptions on the training which highlighted certain details about teamwork in a formal way. Similar findings have been reported in the literature, where the implementation and evaluation of the TeamSTEPPS^® program showed no notable differences between pre- and post-test scores, with various explanations offered for these results. For instance, in a study by Aaberg et al., TeamSTEPPS^® training was conducted in a surgical ward in a Norwegian hospital. The professional and organizational outcomes were assessed using the TPQ, HSOPS, and CSACD-T instruments at baseline, six months, and 12 months post-intervention. While no significant changes were observed in any of the T-TPQ teamwork dimensions at the six-month mark, a statistically significant improvement in three dimensions—considered professional outcomes—was recorded at 12 months. These findings suggest that the effects of the training program may become evident only after a longer period, such as 12 months following implementation [18].

Experiences and opinions

Participants’ experiences and opinions on teamwork, particularly regarding communication and collaboration, prior to the TeamSTEPPS^® training were explored through focus group interviews.

Team cohesion

Team members engaging in safety-related practices, such as preoperative checks, time-out procedures, allergy screening, and verifying surgical materials, were seen as key contributors to both patient safety and a positive working environment. These findings are consistent with existing literature. For example, following the introduction of the Surgical Safety Checklist, studies reported several improvements, including increased familiarity among operating room staff regarding each other’s names and roles, verification of surgical consent, confirmation of antibiotic use prior to incision, and enhanced interprofessional collaboration [19].

Participants noted that clearly defined roles and responsibilities within the team fostered trust during surgical procedures. This aligns with findings by Weller and Boyd, who highlighted that a shared mental model—where team members possess a common understanding of objectives, plans, and individual roles—is essential for effective teamwork. They emphasized that preoperative briefings and checklists help develop this shared understanding and that mutual performance monitoring, supported by tools like checklists, reinforces team trust [20].

Conversely, participants identified several factors negatively impacting operating room efficiency and safety, including high staff turnover, challenges in patient turnover, inexperience, staffing shortages, lack of necessary materials, and poor coordination with the anesthesia team. These issues led to delays and compromised patient safety. Supporting literature demonstrates that consistent team composition throughout the day, as opposed to rotating team members, can reduce procedure times, enhance teamwork, and improve the overall safety climate without adversely affecting patient outcomes [21].

Additionally, participants emphasized that effective communication and collaboration strengthened team spirit and mutual support, contributing to a more positive work environment. This is echoed in research on perioperative communication failures, which suggests that addressing communication challenges is crucial for fostering team cohesion and improving job satisfaction [22].

Support

Participants emphasized that in high-pressure work environments, employees actively support one another by attending to physical needs, raising awareness about potential health risks, and using words and actions to boost team morale. Operating room staff were noted to serve as a bridge between faculty members and ophthalmology residents, helping to prevent potential conflicts—an example of the social dimension of mutual support. In terms of professional collaboration, participants described working together in areas such as the use of surgical materials and devices, managing procedures, sharing technical knowledge, responding collectively in emergencies, and exchanging experience and expertise. The participants’ thoughts highlighted that both social and professional support within the team contribute significantly to motivation, emotional well-being, and a sense of psychological safety among staff. Similar findings are supported in the literature, where psychological safety is defined as a shared belief that the team environment is safe for interpersonal risk-taking. Feeling psychologically secure, working toward shared goals, and learning collectively have all been shown to positively influence team performance [23].

Participants also reported that they monitor one another to prevent errors, offer timely warnings, and provide help when needed. This culture of mutual support not only enhances teamwork but also plays a critical role in ensuring patient safety. Supporting studies indicate that mutual support improves communication, reduces stress, and promotes safer clinical environments. For instance, in a study where TeamSTEPPS^®-based training was implemented through clinical simulation for intensive care staff, participants highlighted mutual support as essential for managing stressful situations and emphasized the importance of situational awareness to enable such support [24].

Leadership qualities

Participants identified the leader’s knowledge, experience, and command of the clinical case as essential qualities. According to the TeamSTEPPS^® framework, effective leadership—one of the core competencies of teamwork—entails optimizing team performance by promoting shared understanding, disseminating information, and ensuring the availability of necessary resources [25]. Responses related to working conditions and personal traits of the leader, particularly their ability to delegate tasks efficiently, align with existing literature. Participants also highlighted the importance of accurate and timely decision-making, problem-solving abilities, ensuring the availability of surgical materials, and demonstrating fairness and supportiveness as key leadership characteristics. While the department head was typically recognized as the primary leader responsible for task distribution, participants noted that leadership could also shift depending on the context. For instance, the surgeon performing the procedure or a senior resident could take on the leadership role. Supporting this perspective, research by McElroy et al. suggests that leadership effectiveness often depends more on an individual’s experience and communication skills than on their official title or specialty area [26]. Further evidence from a study on resuscitation team dynamics identified a leader’s most critical responsibilities as managing time, resources, and tasks. In this context, effective leaders are those who remain accessible, recognize personnel and equipment limitations, and respond adaptively to evolving clinical situations [27].

Communication

Participants frequently emphasized the use of structured processes during procedures, particularly ensuring mutual understanding through closed-loop communication (using verbal feedback, including call-outs, check-backs, and teach-backs, to ensure that recipients correctly understand messages), timely and accurate information transfer, and applying verification techniques. These included conducting the time-out procedure, confirming intraocular lens specifications against biometric data, and, when appropriate, verifying with the patient which eye was to undergo surgery. The proper implementation of these techniques, along with completing the time-out checklist, plays a critical role in preventing serious patient safety risks such as wrong-site surgery, operating on the wrong patient, or using incorrect materials. The findings are consistent with previous studies highlighting the benefits of surgical checklists, particularly the WHO’s Surgical Safety Checklist (SSC), which has been shown to significantly reduce surgical complications, mortality, hospital stay lengths, and adverse events [20, 28, 29].

Participants also stressed the importance of performing handovers, regarding pathology specimens, medications, and patient transfers, as a team and, where possible, in accordance with standardized protocols. Ensuring accurate and complete material handovers was seen as essential in preventing loss or degradation of surgical materials. Based on the responses, implementing routine protocols contributes not only to patient safety but also to decreasing team workload, cognitive burden, and the risk of material-related errors. Literature supports the effectiveness of standardized communication tools, with studies showing that the use of checklists during patient handovers reduces technical errors and verbal omissions [30–33].

Effective collaboration with all team members, including anesthesiologists, physicians, nurses, and technicians, was regarded as crucial for minimizing risks and enhancing patient outcomes. Numerous studies affirm that effective interprofessional teamwork and communication are essential to patient safety, noting that a failure in communication by any member of the care team can result in preventable complications [12].

Moreover, participants underlined the importance of respectful, polite, and open communication when addressing errors. They emphasized that maintaining professionalism and avoiding conflict through constructive dialogue helps prevent misunderstandings and reduces error rates. These observations are supported by the literature. For example, Holmes et al. found that constructive criticism, a willingness to learn, careful planning, and professional demeanor improved perioperative nursing performance. Conversely, distractions such as excessive communication, noise, stress, distrust, and irritability had negative impacts [34].

Feedback on the TeamSTEPPS^® communication module

The feedback revealed that the training was considered as effective, particularly in enhancing patient and material handovers, closed-loop communication, and the importance of timely, audible, and face-to-face communication. Literature supports the evaluation of team training programs over varying durations. For instance, a study conducted in Norway assessed the experiences of healthcare professionals in the urology and gastrointestinal surgery departments before and during the implementation of the TeamSTEPPS^® program. Findings indicated that, although participants initially expressed general satisfaction with existing teamwork skills, the training notably increased their awareness and understanding of shared teamwork competencies during the implementation phase [35].

Conclusion

This study is significant as it represents the first implementation and evaluation of the TeamSTEPPS^® Communication Module in Turkey.

The analysis of focus group interviews conducted prior to the training revealed four key themes, reflecting the core components of the TeamSTEPPS^® framework: team cohesion, support, leadership qualities, and communication.

Although both quantitative and qualitative findings indicated that many teamwork and patient safety practices were already in place, post-training feedback provided insights that the program effectively addressed previously unrecognized communication gaps. These findings underscore the importance of assessing the specific educational needs of the healthcare unit and designing team-based training aligned with institutional goals. Furthermore, the regular repetition of patient safety training is essential to reinforce learning, enhance communication, and promote the delivery of safer healthcare services.

The suggestions for the future work include;

• conducting a preliminary assessment of the educational needs of departments and units within healthcare institutions, and planning team training in alignment with institutional goals,

• increasing time and resources to enable the implementation of TeamSTEPPS^® training in larger groups, across different departments, and for longer follow-up terms,

• incorporating the TeamSTEPPS^® program into hospital training programs for all departments (internal medicine – surgery – pediatrics),

• establishing institutional policies to ensure the full and complete implementation of standard protocols (time-out form) in the operating room for patient safety.

Trustworthiness and Limitations

To ensure the study’s trustworthiness, four criteria (credibility, dependability, confirmability and transferability) were applied. Researcher H.D. had the opportunity to become familiar with the ophthalmology residents and opthalmology operating room staff, as they were also his colleagues. This familiarity contributed to a sense of trust during data collection and enhanced the internal consistency of the research findings. All data were collected by H.D. with adequate time allocated to the data collection process. Audio recordings were transcribed verbatim into Microsoft Word documents and subsequently checked for accuracy. Both researchers had prior training and experience in interprofessional education and qualitative research methodologies. Data analysis was conducted independently by each researcher, after which the findings were compared. Any discrepancies were discussed and resolved through consensus. Themes were supported with direct quotations from participants, and all data—including audio files and transcripts—were securely stored. The entire research process was documented in detail to ensure transparency and credibility.

This study was conducted with residents (opthalmaology and anesthesiology), nurses, operating room technicians, and anesthesia technicians working in the ophthalmology operating room of a university hospital, and the results are limited to this group. Qualitative data were collected in writing from some participants who had time constraints with time due to workload and clinical responsibilities.

Authors’ contributions

All authors contributed to the study conception and design. HD wrote the main manuscript text and prepared Tables 1, 2, 3, 4 and 5, and; ME prepared Fig. 1., and critically revised the manuscript. All authors read and approved the final manuscript.

Funding

No funding was received for this review.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

We confirm that our study was conducted in accordance with relevant ethical guidelines, including the Declaration of Helsinki. To conduct the study, ethical approval has been obtained from the Hacettepe University Ethics Committee (No: E-35853172-100-00002487028). Informed consent was obtained from all participants who agreed to participate in this study information about the study was provided, and participants’ questions were answered. Additionally, the voluntary participation forms given to individuals also included information about the study protocol. This manuscript was produced from the doctoral thesis accepted in 2025.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.