Abstract
Background
Clear communication and cohesive teamwork are critical for ensuring safe, high-quality patient care, especially within the demanding environment of the labor ward. Pakistan faces some of the worst pregnancy outcomes globally. The TeamSTEPPS® is a validated curriculum for teaching interprofessional communication to healthcare professionals. Given the unique contexts of maternity care in Pakistan, there is a need to test the effectiveness of the TeamSTEPPS® program in interprofessional team involved in provision of care.
Methods
This quasi experimental study was conducted at Services Institute Medical Sciences/Services hospital Lahore, Pakistan. All the nursing students, pharmacist, obstetric, anesthesia and pediatric residents posted in labour room for two months were included. A core team of faculty taught the participants using TeamSTEPPS® framework. Participants knowledge, perceptions and attitudes were checked pre-training, one week and one month post-training using TeamSTEPPS® questionnaire of Teamwork Attitudes Questionnaire, Teamwork Perceptions Questionnaire and learning benchmarks. Team performance using Team Performance Observation Tool was also assessed after a month by simulation scenarios. Data were entered and analyzed using SPSS version 25. Descriptive statistics were used to summarize demographic characteristics and Chi-square test was applied to evaluate the association between pre- and post-intervention scores related to attitude, perception, benchmark and team performance. P-value of less than 0.05 was considered statistically significant.
Results
Total of 25 participants were imparted training. Significant improvements in team knowledge were seen in understanding the role of a team leader, shared mental model identifying the best method for conflict resolution at one week and one month post training (P<0.05). Changes in attitudes was observed in Team Structure, leadership and communication after one month (p<0.05). The intervention was effective in enhancing perceptions of team structure, situation monitoring, mutual support, and communication (p<0.05). The team performance assessment showed that all teams scored from acceptable to excellent implying that training had positive impact on their ability to work as interprofessional team.
Conclusion
The study demonstrated improvements in knowledge, attitudes, perceptions, and observed behaviors of healthcare professionals, affirming the relevance and effectiveness of structured teamwork training in a maternity care setting. This advocates for integration of TeamSTEPPS® into medical curricula, institutional policy, and national health programs.
Background
Collaborative teamwork and efficient communication form the foundation of safe and high-standard patient care, particularly in dynamic environments like labour wards where emergencies such as postpartum haemorrhage or fetal distress demand rapid, coordinated responses.1,2 Delays in care, unclear roles, and communication failures have been consistently linked to preventable maternal and neonatal morbidity and mortality.3,4 Addressing these systemic challenges requires structured team-based training models that go beyond traditional siloed professional education.
Interprofessional Education (IPE) enables learners from diverse healthcare professions to collaborate, promoting mutual understanding and shared mental models essential for safe clinical practice. 5 One evidence-based approach to operationalize IPE is developed by the Agency for Healthcare Research and Quality (AHRQ), TeamSTEPPS®—Team Strategies and Tools to Enhance Performance and Patient Safety that serves as a structured approach to improving teamwork. 6 TeamSTEPPS® is a standardized, evidence-based teamwork training program specifically designed for healthcare settings, with a strong emphasis on communication, leadership, situation monitoring, and mutual support. 7 TeamSTEPPS® has shown measurable improvements in teamwork attitudes, perceptions, and clinical performance across diverse healthcare settings. 8 Unlike broader interprofessional education frameworks, such as the World Health Organization (WHO) Framework for Interprofessional Education and Collaborative Practice, which primarily provide conceptual guidance, TeamSTEPPS® offers structured, practical tools that can be readily integrated into clinical workflows. In addition, TeamSTEPPS® has been widely used in acute care and maternity settings, aligns well with simulation-based training, and is freely available, making it particularly suitable for implementation in resource-constrained healthcare environments.
Pakistan continues to face a high maternal mortality ratio (MMR) of 186 per 100,000 live births—among the highest in South Asia. 9 Contributing factors include understaffing, hierarchical team structures, and lack of formal team training within health education curricula. Despite the urgency, structured IPE initiatives especially those adapted for local contexts remain scarce. There is a clear need to embed teamwork competencies into pre-service and in-service training to foster psychological safety and encourage all team members to “speak up” when patient lives are at risk. 10
This study addresses that need by designing and piloting a TeamSTEPPS®-based IPE module for multidisciplinary trainees in a tertiary maternity unit in Pakistan. It seeks to evaluate the programme’s effectiveness in improving teamwork knowledge, attitudes, perceptions, and observed behaviour thereby aligning with WHO’s Framework for Action on Interprofessional Education and the Sustainable Development Goal 3.1 of reducing maternal mortality. 11
TeamSTEPPS® incorporates several structured communication tools designed to enhance clarity and safety in clinical communication. One commonly used tool is SBAR (Situation, Background, Assessment, Recommendation), which provides a standardized framework for communicating critical patient information. Another tool is DESC (Describe, Express, Suggest, Consequences), a structured method for addressing conflict and promoting respectful assertive communication among healthcare team members. These tools support the development of shared mental models and effective interprofessional collaboration in high-risk clinical environments such as maternity care.
Methods
This study employed a quasi-experimental single-group pretest–posttest design to evaluate the impact of TeamSTEPPS® training on teamwork and interprofessional communication in maternity care. The TeamSTEPPS® 2.0 curriculum developed by the Agency for Healthcare Research and Quality (AHRQ) was selected because it is freely available, well validated, and adaptable to simulation-based training in resource-constrained settings. The study was conducted in the Department of Obstetrics and Gynecology at the Services Institute of Medical Sciences, Services Hospital, Lahore, a public-sector teaching hospital affiliated with the University of Health Sciences from January 2025 to February 2025. Ethical approval was obtained from the Institutional Review Board (Ref: IRB/2025/1513/SIMS). It was conducted in compliance with the Declaration of Helsinki 12 ensuring voluntary participation, informed consent, and confidentiality.
A multidisciplinary cohort of obstetrics, anesthesia, and pediatric residents, nursing students, and pharmacists posted in the labour ward over a two-month period was recruited using convenience sampling. Due to operational constraints, including duty rosters and limited availability of staff for training sessions, all eligible participants present during the study period were included. As this study was designed as a pilot quasi-experimental study, a formal a priori sample size calculation was not performed. The final sample size of 25 participants was therefore determined based on feasibility and is consistent with similar interprofessional education and simulation-based studies. While this sample size allowed detection of meaningful changes in key outcomes, the absence of formal sample size estimation may limit statistical power and generalizability.
Participation was guided by clinical duty rosters and rotation schedules, as all eligible staff could not be released simultaneously due to service requirements. During the study period, 15 obstetrics residents were posted in the department; however, only those assigned to labour ward duties during the scheduled training sessions were able to participate. Nursing students were similarly distributed across morning, evening, and night shifts, and participation was limited to those on duty during training sessions. All pharmacists posted in the department were included. Written informed consent was obtained from all participants.
Simulation scenarios were based on common labour ward emergencies, including postpartum haemorrhage, eclampsia, and neonatal resuscitation. These scenarios were conducted using low-fidelity obstetric mannequins and simulated ward environments due to resource constraints, reflecting realistic training conditions in many low- and middle-income healthcare settings. The intervention was conducted over five days (6 hours per day) and consisted of didactic lectures, PowerPoint presentations, and video vignettes from the TeamSTEPPS® online curriculum. Participants received TeamSTEPPS® pocket guides to reinforce key concepts. They were divided into interprofessional teams and engaged in structured simulation scenarios designed to elicit teamwork behaviors such as leadership, communication, and conflict resolution. These activities were followed by facilitated debriefing and group discussion.
Teamwork knowledge was assessed using the TeamSTEPPS® Learning Benchmarks Questionnaire. Perceptions and attitudes toward teamwork were measured using the TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ) and the Teamwork Attitudes Questionnaire (T-TAQ), respectively,6,13 appendix I-III. All instruments are part of the TeamSTEPPS® curriculum developed by AHRQ and have demonstrated validity and reliability in previous studies.
A 35-item validated questionnaire, the TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ) evaluates participants’ perceptions of teamwork. 6 It assesses individuals’ perceptions of the level of teamwork within their specific work unit. Responses are rated on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree), with 3 representing a neutral response. The T-TPQ has demonstrated strong internal consistency, with Cronbach’s alpha values ranging from 0.786 to 0.844 across the five domains.14,15
The TeamSTEPPS® Teamwork Attitudes Questionnaire (T-TAQ) is a 30-item self-administered instrument that uses a 5-point Likert scale to assess participants’ attitudes toward key teamwork competencies addressed in the TeamSTEPPS® program. 16 Ballangrud et al have reported strong reliability for the TTAQ, including Cronbach’s alpha coefficients supporting its internal consistency. 17
All participants completed the Learning Benchmarks, T-TPQ, and T-TAQ at three time points: pre-training, one-week post-training, and one-month post-training. In addition to self-reported measures, team performance was evaluated one month post-training using the Team Performance Observation Tool (TPOT), a validated observational rubric developed by AHRQ to assess actual teamwork behaviors in simulated clinical settings. The The TPOT evaluates 23 performance items on a 5-point Likert scale across domains such as team leadership, mutual support, and situation monitoring. It has been shown to have high inter-rater reliability and internal consistency. 18 Two trained observers independently assessed each team across 12 structured simulation scenarios to enhance reliability and permit triangulation of findings (Appendix IV).
The TeamSTEPPS® Learning Benchmarks questionnaire was used to evaluate healthcare providers’ (HCPs) knowledge of team-based behaviors. Comprising multiple-choice and scenario-driven items, the assessment is designed to gauge understanding of fundamental teamwork and communication concepts.
Participants were divided into three interprofessional teams of 8–9 members each. Each team underwent 12 structured simulation scenarios designed to elicit observable teamwork behaviors aligned with TeamSTEPPS® domains. Two trained observers independently assessed each team using the TPOT. These assessments allowed for triangulation of data between self-reported changes and observed performance, adding rigor to the evaluation process. Following simulation assessments, participants again completed the T-TAQ, T-TPQ, and Learning Benchmarks as final posttests.
The reporting of this study conforms to the TREND (Transparent Reporting of Evaluations with Nonrandomized Designs) Statement for non-randomized intervention studies. 19 The completed TREND checklist has been provided as a supplementary file. The reporting of this study conforms to the TREND (Transparent Reporting of Evaluations with Nonrandomized Designs) Statement, and the completed checklist is provided as a supplementary file (Appendix V).
Statistical Analysis
The data were entered and analyzed using SPSS v26. Age was presented as the mean and standard deviation (SD). Gender and all domains were presented as frequencies and percentages. Descriptive statistics were used to summarize demographic and outcome variables. Normality of distribution was assessed using the Shapiro–Wilk test. Likert-scale responses from the T-TPQ and T-TAQ were treated as ordinal variables. Changes across three time points (pre-training, one-week post-training, and one-month post-training) were analyzed using the Friedman test, with Wilcoxon signed-rank tests applied for post hoc pairwise comparisons where appropriate. Categorical variables were compared using the chi-square test. A p-value < 0.05 was considered statistically significant. Paired sample t-tests and chi-square tests were used to assess the significance of changes at three time points: pre-training, one week post-training, and one month post-training. A p-value< 0.05 was considered statistically significant.
Results
Baseline Characteristics of Study Participants (n = 25)
Comparison of Knowledge About Teamwork Before, at One Week and One Month Post Training
p-values represent within-group comparisons between pre-training and one-month post-training assessments.
Domain-Level Perception and Attitude Towards Interprofessional Teamwork Before, at One Week and One Month Post-Training
Values represent weighted mean Likert-scale scores (Disagree = 1, Neutral = 2, Agree = 3).
†p-values represent within-group comparisons between pre-training and one-month post-training assessments.
Similarly, attitudes toward teamwork improved significantly in the domains of team structure (p = 0.027), leadership (p = 0.01), and communication (p = 0.048). No statistically significant changes were observed for situation monitoring (p = 0.14) and mutual support (p = 0.58). Improvements were evident at one week and were largely sustained at one month across most domains. Detailed category-level distributions are provided in the Supplementary Appendix (Tables S2 and S3).
Team performance was assessed one month post-training using the Team Performance Observation Tool (TPOT) across 12 simulated clinical scenarios (Appendix 2). When considered in aggregate, teams demonstrated ratings ranging from acceptable to excellent across all five TeamSTEPPS® domains, team structure, leadership, communication, situation monitoring, and mutual support—indicating effective application of teamwork behaviors following training. Detailed sub-domain and team-wise TPOT results are provided in the Supplementary Appendix (Tables S3–S7).
Discussion
The results of this study are consistent with international literature supporting the efficacy of TeamSTEPPS® in improving interprofessional communication and teamwork, particularly in high-risk clinical settings such as maternity care.20,21 The significant improvement observed in domains such as team structure, leadership, and communication emphasized the role of structured teamwork interventions in reducing medical errors and enhancing patient outcomes.
Our observed improvements in communication and leadership echo those of who implemented TeamSTEPPS®, in labor and delivery units and reported improved team cohesion, confidence, and efficiency during obstetric emergencies. Similarly, demonstrated enhanced communication accuracy and team morale among maternity staff after simulation-based TeamSTEPPS®, sessions.22,23
Notably, our findings regarding the non-significant improvements in attitudes of mutual support and situation monitoring mirror limitations found by Weaver who noted that while knowledge and perceptions often improve after short-term training, certain behaviors especially those requiring assertiveness or peer-to-peer feedback require prolonged cultural reinforcement and institutional support. 24
Moreover, our TPOT findings, which reflect improvements in accountability and environmental monitoring, provide rare quantitative evidence of behavioral change post-intervention. These align with a study who highlighted that observable behavioral changes such as clear delegation, situational awareness, and mutual performance monitoring are critical indicators of effective teamwork training. 25 This study not only corroborates existing global evidence on the benefits of TeamSTEPPS but also contributes new data from a low-resource, culturally diverse setting. It underscores the potential for such interventions to enhance team function and, ultimately, maternal safety in under-resourced healthcare environments where there is high patient volumes with limited staff availability, reliance on low-fidelity simulation equipment rather than high-fidelity simulators, limited protected time for structured training due to clinical workload, and financial constraints that restrict access to proprietary training programs. These factors necessitate the use of feasible, low-cost, and easily implementable interprofessional training models that can be integrated into routine clinical practice. Cultural and hierarchical norms within Pakistani healthcare settings are important contextual factors influencing teamwork behaviors. Clinical environments are traditionally characterized by strong professional hierarchies, particularly between senior physicians, junior trainees, nurses, and allied health professionals. 26 These hierarchies may discourage junior staff from speaking up, questioning decisions, or providing peer-to-peer feedback, which directly challenges TeamSTEPPS® principles such as assertive communication, mutual support, and closed-loop communication. As a result, behaviors related to “speaking up” and situation monitoring may require sustained reinforcement beyond short-term training to achieve meaningful change.
The findings of this study carry significant implications for both clinical practice and health professional education, especially in the context of low- and middle-income countries like Pakistan. The demonstrated improvement in interprofessional communication, leadership, and team structure underscores the potential of TeamSTEPPS® to be institutionalized within maternity care systems to promote patient safety and team efficiency.
Firstly, the results strongly support the integration of TeamSTEPPS® training into ongoing professional development programs. Maternity wards, known for their time-critical decisions and high acuity, benefit from clearly defined team roles, structured communication protocols, and mutual performance monitoring. Effective communication and collaborative teamwork among obstetric care providers significantly reduce adverse maternal outcomes in Pakistani tertiary care settings. 27
Secondly, the results call for curricular innovation in both undergraduate and postgraduate medical and nursing education. Embedding IPE and structured communication tools like SBAR into core curricula can help inculcate these skills early in professional formation. Recent studies have shown improved collaboration, respect for professional roles, and student satisfaction when IPE was implemented using interactive modules and scenario-based learning. 28
Institutionally, the findings highlight the need for leadership to endorse and support regular simulation-based training. These exercises not only reinforce knowledge but also provide a psychologically safe space for practicing assertiveness, especially for junior staff. The improvement in accountability and conflict resolution behaviors in our study mirrors similar findings in literature who emphasized the value of leadership buy-in in sustaining behavior change after team training programs. 29
Moreover, interprofessional teamwork plays a crucial role in workforce morale and retention. In high-pressure maternity environments, poor communication and lack of support contribute to burnout and job dissatisfaction. 30 Implementing TeamSTEPPS can foster a culture of shared responsibility, improving job satisfaction and reducing staff turnover, which is critical in under-resourced hospitals.
Lastly, from a policy perspective, the incorporation of TeamSTEPPS® into national maternal health safety initiatives, such as those outlined in Pakistan’s MNCH strategic framework, could standardize communication and reduce preventable errors. The establishment of interprofessional training hubs in teaching hospitals could act as catalysts for wider systemic change. This study illustrates the practical value of structured teamwork interventions and provides a replicable model for enhancing collaboration in high-risk maternity care environments in resource-constrained settings.
This study offers several notable strengths. It is one of the first to evaluate TeamSTEPPS® in a tertiary maternity setting in Pakistan, demonstrating the framework’s applicability in low-resource, high-volume environments. A key strength is its multi-dimensional evaluation, incorporating clinical vignettes, validated questionnaires, and direct behavioral observation via TPOT enhancing the study’s internal validity. The intervention used realistic, maternity-specific scenarios and simulation-based role-plays, promoting active learning aligned with adult learning principles. The inclusive training approach, involving residents, nurses, and allied staff, strengthened interprofessional collaboration. Evaluations at three time points enabled assessment of both immediate and short-term retention. Finally, its alignment with national maternal health priorities enhances policy relevance. These strengths establish the study as a practical and theory-informed contribution to teamwork training in resource-limited maternity care settings.
Several limitations should also be acknowledged. The study assessed outcomes only up to one month after training and therefore did not evaluate long-term retention of teamwork behaviors. Self-reported measures of attitudes and perceptions may be subject to social desirability bias, and observer bias in TPOT assessments was not formally assessed. The study was not designed to detect differences between individual teams, and results should therefore be interpreted descriptively. Additionally, objective clinical outcomes such as maternal or neonatal morbidity were not measured. Another limitation of this study is the absence of an a priori sample size calculation, which may reduce the statistical power to detect smaller differences and limit the generalizability of findings.
Although the TeamSTEPPS® instruments used in this study have demonstrated strong validity and reliability internationally, formal cultural validation of these tools in the Pakistani healthcare context has not yet been established, which may influence interpretation of participant responses. Another limitation is the non-randomized single-group quasi-experimental design, which restricts causal inference. The use of convenience sampling and recruitment from a single tertiary hospital may further limit generalizability.
Future research should include multi-center randomized studies to evaluate the effectiveness and long-term sustainability of TeamSTEPPS® training across diverse healthcare settings. Evaluation using higher levels of the Kirkpatrick Model, including team leaders’ perceptions of team performance and institutional outcomes such as maternal and neonatal morbidity and mortality, would further strengthen the evidence linking teamwork training to patient safety. Incorporating clinical outcome metrics (e.g., maternal and neonatal morbidity) would help link team training to patient safety. Additionally, qualitative research is needed to explore participants’ experiences and contextual barriers. Multi-center and comparative studies could assess generalizability across diverse settings, while cost-effectiveness analyses would guide policy and resource allocation. Finally, integrating TeamSTEPPS® into medical and nursing education warrants exploration to assess long-term impact on professional development. These directions will strengthen the evidence base and support wider adoption of interprofessional teamwork training.
Overall, implementation of the TeamSTEPPS® framework led to measurable improvements in teamwork knowledge, attitudes, perceptions, and observed behaviors among maternity healthcare professionals. These findings support broader adoption of structured teamwork training within maternity care systems to strengthen collaboration and improve maternal and neonatal safety.
Conclusion
This study enabled a holistic assessment of interprofessional collaboration, combining attitudinal, perceptual, cognitive, and behavioral outcomes. The use of validated tools and structured simulations provided robust evidence for the impact of TeamSTEPPS® on team functioning in maternity care.
Supplemental Material
Supplemental Material - Impact of TeamSTEPPS® Training on Teamwork and Interprofessional Communication in Maternity Care: A Quasi-Experimental Study
Supplemental Material for Impact of TeamSTEPPS® Training on Teamwork and Interprofessional Communication in Maternity Care: A Quasi-Experimental Study by Tayyiba Wasim, Lubna Ansari Baig, Saima Rafique, Natasha Bushra and Usman Ahmad in Journal of Medical Education and Curricular Development.
Footnotes
Ethical Considerations
The Institutional Review Board of the Services Institute of Medical Sciences, Lahore, Pakistan, approved this study (Ref: IRB/2025/1513/SIMS). All procedures were performed in compliance with the Declaration of Helsinki.
Consent to Participate
Written informed consent was obtained from every participant before study enrollment.
Consent for Publication
All participants provided written informed consent to take part in the study and agreed to the publication of anonymized data in an open-access journal.
Author Contributions
TW conceptualized and designed the study, collected, analyzed, and interpreted the data, prepared the initial draft, made critical revisions, approved the final version, and takes full responsibility for the accuracy and integrity of the work, ensuring that any concerns were properly addressed. LB assisted in study design and overall supervision, provided critical revisions for intellectual content, approved the final manuscript, and ensured that any issues related to the integrity of the work were appropriately resolved. SR contributed to the study design and data interpretation, provided key revisions to the manuscript, approved the final draft, and remains accountable for the reliability and integrity of the findings. NB was involved in data collection and interpretation, contributed to drafting and reviewing the manuscript, approved the final version, and is responsible for maintaining the accuracy and integrity of the reported work. UK supported the development of study materials and data analysis, reviewed the manuscript for essential content, approved the final submission, and is accountable for the overall accuracy and integrity of the work.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The datasets generated and analyzed during the present study are available from the corresponding author upon reasonable request. Supplementary materials—including the TeamSTEPPS® training module, simulation scenarios, pre- and post-intervention questionnaires (TTAQ, TTPQ, Learning Benchmarks), and the TPOT assessment tool—are provided as supplementary files.
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
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