Module 6

MUTUAL SUPPORT
(DRAFT)

SUBSECTIONS
•
•
•

•

Task Assistance
Feedback
Advocacy and Assertion:
Assertive Statement, TwoChallenge Rule, CUS
Conflict Resolution: DESC
Script

TIME: 50 minutes
VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION

INSTRUCTOR OUTLINE: MUTUAL SUPPORT

Mutual Support
Slide

Instructor Note: In this module, you will present information
about mutual support within teams. Participants will learn how to
cultivate and maintain mutual support, as well as how to address
conflict when it arises.
The Mutual Support module includes the content provided in the
outline below. More content is available than can be covered in
the time provided; therefore, optional content and activities are
noted. It is strongly recommended that instruction not focus solely
on lecture, but also include exercises, videos, and other activities.
As such, instructors should use the information below to plan how
the module will be taught within the time available.
Content

Page #

Approx. Time

1. Introduction

5- 7

4 mins

2. Task Assistance

8 - 10

6 mins

11 - 14

8 mins

15

5 mins*

5. Advocacy and Assertion
Tools

16 - 23

15 mins

6. Conflict in Teams

24 - 28

10 mins

3. Feedback
4. Feedback Exercise

7. Tools and Strategies
Summary

29

2 mins

8. Applying TeamSTEPPS
Exercise

30

5 mins

MODULE
TIME:
50 minutes

MATERIALS:
• Flipchart or
Whiteboard
(Optional)
• Markers
(Optional)
• Feedback LTC
Video
(Feedback_LTC.
mpg)
• CUS Subacute
Video
(CUS_Subacute.
mpg)
• TeamSTEPPS
Implementation
Worksheet

*Although all instructional content and activities are recommended to
ensure that participants achieve the learning objectives, these
activities may be considered “optional” if time is constrained.

Continued…

TeamSTEPPS for Long-Term Care | Mutual Support VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION

B-6-3

Mutual Support
Slide

INSTRUCTOR OUTLINE: MUTUAL SUPPORT
(Continued)
Additional Resources: Below are sources of additional
information and videos you may wish to use to customize this
module to your participants.
•

TeamSTEPPS for Long-Term Care DVD: The
TeamSTEPPS for Long-Term Care DVD includes Specialty
Scenarios and additional videos that can be used to
customize your instruction.

•

TeamSTEPPS 2.0: Includes videos specific to the use of
the mutual support tools and strategies in multiple hospital
settings.
• http://www.ahrq.gov/professionals/education/curriculumtools/teamstepps/instructor/fundamentals/index.html

•

TeamSTEPPS for Office-Based Care Version: Includes
videos specific to the use of the mutual support tools and
strategies in the primary care setting.
• http://www.ahrq.gov/professionals/education /curriculum tools/teamstepps/primarycare/

•

TeamSTEPPS Rapid Response Systems Module (RRS):
Includes videos specific to the use of the mutual support
tools and strategies by Rapid Response Teams.
• http://www.ahrq.gov/professionals/education /curriculum tools/teamstepps/rrs/

•

Comprehensive Unit-Based Safety Program (CUSP)
“Implement Teamwork and Communication” Module:
Includes information on some of the mutual support tools
and strategies taught in TeamSTEPPS.
• http://www.ahrq.gov/professionals/education /curriculum tools/cusptoolkit/modules/implement/index.html

B-6-4 VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION TeamSTEPPS for Long-Term Care | Mutual Support

OBJECTIVES

Mutual Support

SAY:
Following this module, you will be able to:
• Describe how mutual support affects team processes and
outcomes;
• Discuss specific strategies to foster mutual support (e.g., task
assistance, feedback);

Slide

• Identify specific tools to facilitate mutual support; and
• Describe conflict resolution strategies.

TeamSTEPPS for Long-Term Care | Mutual Support VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION

B-6-5

Mutual Support

TEAMSTEPPS TEAMWORK SKILLS
SAY:
So far, we have covered the following in the TeamSTEPPS
framework:
•

Team Structure, which facilitates teamwork by identifying the
individuals among which information must be communicated,
a leader must be clearly designated, and mutual support must
occur.

•

Communication, which facilitates teamwork by enabling team
members to effectively relay relevant information in a manner
that is known and understood by all.

•

Leadership, which facilitates teamwork through leaders’
effective communication with their team members to ensure
that a plan is conveyed, reviewed, and updated; continuous
monitoring of the situation to better anticipate team members’
needs and effectively manage resources; and fostering of an
environment of mutual support through role modeling and
reinforcement.

•

Situation Monitoring, which facilitates teamwork by
providing skills to ensure that new or changing information
about the environment or the resident is identified for
communication and decisionmaking by the leader; and leads
to the effective support of fellow team members.

Slide

In this module, we will cover the final TeamSTEPPS skill, which is
Mutual Support.
Mutual support is moderated by communication, which influences
the delivery and ultimate effectiveness of the mutual support.
Because mutual support involves the willingness and
preparedness to assist other team members during operations, it
is enhanced by team leadership, given that team leaders
encourage and role model these “back-up” behaviors.
Mutual support is derived from situation monitoring through the
ability to anticipate resident needs, as well as other team
members’ needs, with accurate knowledge of their responsibilities.

B-6-6 VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION TeamSTEPPS for Long-Term Care | Mutual Support

Mutual Support

MUTUAL SUPPORT
SAY:
Mutual support, which is commonly referred to as “back-up
behavior” in the teamwork literature, is critical to team
performance. Mutual support involves team members (1) assisting
one another; (2) providing and receiving feedback; and (3) exerting
assertive and advocacy behaviors when resident safety is
threatened. Mutual support is the essence of teamwork. For
example, in a health care environment, one team member's work
overload may result in fatal consequences. Mutual support
provides a safety net to help prevent errors, increase
effectiveness, and minimize strain caused by work overload. Over
time, continuous mutual support fosters team adaptability, mutual
trust, and team orientation.

Slide

MATERIALS:
• Flipchart or
Whiteboard
(Optional)
• Markers
(Optional)

DISCUSSION:
• What types of behavior do you think constitute mutual support?
Potential Answers:
– Monitoring other team members’ performance to anticipate
assistance requests
– Offering or requesting assistance
– Filling in for a member who cannot perform a task
– Cautioning team members about potentially unsafe
situations
– Self-correcting and helping others correct their
mistakes
– Distributing and assigning work thoughtfully
– Rerouting/delaying work so that the overburdened team
member can recover
– Regularly providing feedback to each other
– Providing encouragement
SAY:
In this module, we’ll focus specifically on task assistance,
feedback, and advocacy and assertion as three strategies that
can be used to foster mutual support.

TeamSTEPPS for Long-Term Care | Mutual Support

VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION B-6-7

Mutual Support

TASK ASSISTANCE
SAY:

Slide

One method of providing mutual support is through task
assistance. This includes both asking for assistance when needed
and offering assistance to team members when the opportunity
arises. Task assistance is guided by situation monitoring, because
situation monitoring allows team members to effectively identify
when they, or other team members, need assistance.
To a certain degree, some of us have been conditioned to avoid
asking for help because we fear that this would suggest a lack of
knowledge or confidence. Many people refuse to seek assistance
when overwhelmed or unsure of tasks. In support of resident
safety, however, seeking task assistance is expected.
In addition, when it is recognized that a team member needs
assistance, offering to help should be a cultural norm. Offering
assistance should be verbally articulated so that each team
member has a shared understanding of what will be done and by
whom. Offering assistance may include helping team members to
perform their tasks; correcting task performance when needed;
shifting workload by redistributing tasks to other team members;
delaying/rerouting work so the overburdened member can recover;
and/or filling in for overburdened team members when necessary.
ASK:
•

What can happen when we are overwhelmed and we do
not seek task assistance?

SAY:
Error vulnerability is increased when people are under stress, are
in high-task situations, and when they are fatigued. One of the
most important concepts to remember with regard to task
assistance is that assistance should be actively given and offered
whenever there is a concern for resident safety.

Continued…

B-6-8 VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION TeamSTEPPS for Long-Term Care | Mutual Support

TASK ASSISTANCE (Continued)

Mutual Support
Slide

SAY:
Several factors influence task assistance:
1. Type of situation: Some team members react differently to
offers and requests for help during emergent versus routine
situations. Effective teams place all offers and requests for
assistance in the context of resident safety and progress
toward team goals, regardless of the situation.
2. Attitudes and beliefs: Some attitudes restrict team members
from offering or requesting assistance.
3. Style of communication: Personal style can have a significant
influence on support actions taken by the team. A person’s
tone of voice or use of avoidance behaviors (e.g., being
inaccessible or elusive) may inhibit others from asking for help.
Effective teams demonstrate a willingness to engage in support
behaviors wherever there is a need, and they communicate the
information necessary to achieve that objective.

TeamSTEPPS for Long-Term Care | Mutual Support

VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION

B-6-9

Mutual Support

TASK ASSISTANCE EXAMPLE
SAY:
Task assistance completes an activity or solves a problem. In
regard to task assistance, remember to:

Slide

•

Communicate clear and specific availability of time and
skills when offering assistance;

•

Foster a climate supportive of task assistance—helping
each other may have a domino effect;

•

Use common courtesy when asking for help;

•

Close the loop on task communication—ensure the task
was completed correctly; and

•

Account for experience level.

Let’s review a brief example of task assistance:
Two members of the GI Laboratory are assessing a resident
who has just had conscious sedation for a colonoscopy. The
monitor shows SVT at a rate of 150 and a BP of 76/48. The
nurse calls out the vital signs while the physician continues to
monitor the rhythm. A nurse passing by the room hears the callout.

ASK:
•

How would you offer task assistance in this example?

•

How would you request task assistance in this example?

B-6-10VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION TeamSTEPPS for Long-Term Care | Mutual Support

WHAT IS FEEDBACK?

Mutual Support

SAY:
Another strategy to foster mutual support is feedback. Feedback
is information provided for the purpose of improving team
performance. The ability to communicate self-improvement
information in a useful way is an important skill in the team
improvement process.

Slide

Feedback can be given by any team member at any time. It is
not limited to leadership roles or formal evaluation mechanisms.
Effective feedback benefits the team in several ways, including:
• Fostering improvement in work performance;
• Meeting the team’s and individuals’ need for growth;
• Promoting better working relationships; and
• Helping the team set goals for ongoing improvement.
ASK:
•

Can you describe a situation in which you had to give feedback
to another team member?
•

What was the situation?

•

What was the result?

TeamSTEPPS for Long-Term Care | Mutual Support VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION

B-6-11

Mutual Support

TYPES OF FEEDBACK
SAY:
Feedback can be provided by anyone on the team at any time
and can be either formal or informal.
•

Formal feedback tends to be retrospective in nature, is
typically scheduled in advance and away from the clinical
area, and has an evaluative quality. Examples include
collaborative discussions, case conferences, and individual
performance reviews.

•

Informal feedback typically occurs in real time and on an
ongoing basis and focuses on knowledge and practical
skills development. Examples include huddles and debriefs.

Slide

ASK:
•

Can someone share an example of when he or she provided
or received formal feedback?
• How was the feedback helpful?

•

Can someone share an example of when he or she provided
or received informal feedback?
• How was the feedback helpful?

SAY:
Feedback is a method of providing rich and useful information to
enhance teamwork processes and increase resident safety.
Ultimately, the aim is to provide feedback that it is effective.

B-6-12VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTIONTeamSTEPPS for Long-Term Care | Mutual Support

CHARACTERISTICS OF EFFECTIVE
FEEDBACK

Mutual Support

SAY:
Feedback is the facet of team communication in which learning
occurs. Rules of effective feedback include the following:
• Timely—If you wait too long, facts are forgotten and the
feedback loses its “punch.” Feedback is most effective when
the behavior being discussed is still fresh in the mind of the
receiver. Delivering feedback several weeks after poor
performance has occurred is too late for it to be effective.

Slide

• Respectful—Feedback should not be personal, and it should
not be about personality. It should be about behavior. Never
attribute a team member's poor performance to internal factors,
because such destructive feedback lowers self-efficacy and
subsequent performance. When providing negative feedback, it
should never be delivered to individuals in front of other team
members as this could lead to the individual feeling humiliated.
• Specific—The feedback should relate to a specific situation or
task. Imagine that you are receiving feedback from a peer who
tells you that your surgical techniques need work. That
statement is too general to use as a basis for improvement.
The person receiving feedback will be better able to correct or
modify performance if specific actions are mentioned during
feedback.
• Directed—Goals should be set for improvement.
• Considerate—Be considerate of team members' feelings when
delivering feedback, and remember to praise good performance.
A feedback message will seem less critical if you provide
information on the positive aspects of a person’s performance
as well as how the person may improve. Generally, fairness and
respect will cushion the effect of any negative feedback.
Positive feedback should also be provided to team members to
reinforce positive behaviors. All of us benefit from knowing that
we’ve done a good job and that it has been recognized by others.
Providing feedback acknowledging a job well done will also
communicate to an individual that he or she is valued and viewed
as an important part of the team.

TeamSTEPPS for Long-Term Care | Mutual Support VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION

B-6-13

Mutual Support

VIDEO: PROVIDING FEEDBACK
EFFECTIVELY
SAY:
Please think about the guidelines for giving effective feedback as
you watch the video.

Slide

DO:
Play video by clicking the director icon on the slide.

VIDEO TIME:
0:11 seconds

DISCUSSION:
•

What was effective in the feedback provided?
– Appears to be timely

MATERIALS:

– Respectful and related to behavior

• Feedback LTC
Video
(Feedback_LTC.
mpg)

– Specific
– Directed
– Considerate
•

Why would it be a good practice to share the experience
with other team members?
– Sharing the effective communication technique with others
will promote continuous learning

B-6-14
VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTIONTeamSTEPPS for Long-Term Care | Mutual Support

(OPTIONAL) FEEDBACK EXERCISE

Mutual Support

SAY:
We are now going to take a few minutes to think about providing
effective feedback. In this scenario, a staff development nurse
watches a nursing assistant use a mechanical lift to transfer a
resident from the bed to a chair.
ASK:
• How would you provide effective feedback? (i.e., timely,
respectful and related to behavior, specific, directed, and
considerate). Take a few minutes to plan how you would
provide feedback in this example.
Instructor Note: After about 5 minutes, ask individuals to
share how they would provide feedback. Allow a few individuals to
share with the group, then present the following example of action
taken.

Slide

TIME:
5 minutes

Example Action Taken:
The nurse pulls the nursing assistant aside to remind her of the
proper positioning of the lift pad, demonstrating which
landmarks to use. She explains how the resident’s position can
affect the function of the lift and can also cause friction and
sheer to the resident’s skin when not positioned properly.
• Timely?
– Yes. It is immediate and keeps the resident safety of primary
concern.
• Respectful and related to behavior?
– Yes. It is behavioral in nature and not criticism directed at the
intelligence of the nursing assistant.
• Specific?
– Yes. It suggests specific considerations to be aware of in the
future.
•

Directed?
– Yes. It is directed in showing the nursing assistant how to
properly position residents for transfer using a mechanical lift.

•

Considerate?
– Yes. It is considerate to reeducate on proper technique for
the safety of both the resident and nursing assistant. Also,
pulling the nursing assistant aside and not embarrassing her
in front of the resident was appropriate.

TeamSTEPPS for Long-Term Care | Mutual Support VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION B-6-15

Mutual Support

ADVOCACY AND ASSERTION
SAY:

Slide

The third strategy used to facilitate mutual support is advocacy
and assertion. Advocacy and assertion interventions are invoked
when a team member’s viewpoint does not coincide with that of a
decisionmaker. In advocating for the resident and asserting a
corrective action, the team member has an opportunity to correct
errors or the loss of situation awareness. Failure to use advocacy
and assertion has been frequently identified as a primary
contributor to the clinical errors found in malpractice cases and
sentinel events.
You should advocate for the resident even when your viewpoint is
unpopular, is in opposition to another person's view, or questions
authority. When advocating, assert your viewpoint in a firm and
respectful manner. You should also be persistent and persuasive,
providing evidence or data for your concerns.
We will discuss three tools to empower team members to
advocate for the resident and be assertive when needed.
1. The Assertive Statement;
2. The Two-Challenge Rule; and
3. CUS.
Each of these tools provides a mechanism whereby team
members are able to bring up ideas and concerns using language
that is mutually understood by all team members. We will now go
through each of these tools in more detail.

B-6-16VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION TeamSTEPPS for Long-Term Care | Mutual Support

Mutual Support

THE ASSERTIVE STATEMENT
SAY:
The Assertive Statement is one tool used to facilitate speaking up
when there is concern for resident safety.
Team leadership must foster an atmosphere in which the
participation of every team member can flourish. This is
accomplished by maintaining an environment that is predictable,
but at the same time retaining the ability to respond to changing
clinical situations. Team members at all levels must always feel
their input is valued. More important, their input should be
expected, especially in situations that threaten resident safety.

Slide

Team members must respect and support the authority of the team
leader while clearly asserting suggestions or communicating
concerns. When the situation dictates that the team member must
be assertive and address concerns regarding resident care, the
Assertive Statement is the action. It is a nonthreatening, respectful
way to make sure the concern or critical information is addressed.
It can easily be taught to residents and their families as a structured
way to communicate their concerns to the rest of the care team.
The Assertive Statement involves a five-step process:
1. Open the discussion.
2. State the concern.
3. State the problem—real or perceived.
4. Offer a solution.
5. Obtain an agreement.

Continued…

TeamSTEPPS for Long-Term Care | Mutual Support VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION

B-6-17

Mutual Support

THE ASSERTIVE STATEMENT (Continued)

Slide
SAY:
Here’s an example of the Assertive Statement.
Let’s say a nurse and nursing assistant are conducting a skin
assessment on a newly admitted resident. The nursing assistant
thinks she sees a reddened area on the coccyx that the nurse may
have missed.
ASK:
• What should the nursing assistant say in this situation?
Possible Answers:
• Opening: Say the person’s name to whom the concern is
addressed: “Dianne…”
• State concern: An owned emotion: “I thought I saw redness on
the coccyx as we were turning Mrs. Myers over.”
• State the problem: Real or perceived: “I can’t be certain, but it
looks like she may have a reddened area.”
• Offer a solution: “I can help you turn her back over to recheck
the area.”
• Obtain an agreement: “When she is turned, I can show you the
area that I thought looked reddened.”

B-6-18
VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTIONTeamSTEPPS for Long-Term Care | Mutual Support

THE TWO-CHALLENGE RULE

Mutual Support

SAY:
The Two-Challenge Rule is another tool used to facilitate team
members’ speaking up. In the clinical environment, team
members should challenge colleagues if they have requested
clarification, but the response or confirmation does not alleviate
the concern regarding potential harm to a resident.

Slide

The Two-Challenge Rule is a way to help team members frame
communications about thoughts, and reasoning about plans and
decisions, related to resident care. The goal is to create a
teamwork culture where team members respectfully challenge
one another when the plan is unclear or of concern.

TeamSTEPPS for Long-Term Care | Mutual Support VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION

B-6-19

Mutual Support

THE TWO-CHALLENGE RULE
SAY:
It is important to voice your concern by advocating and asserting
your statement at least twice if the initial assertion is ignored (thus
the name, “Two-Challenge Rule”). These two attempts may come
from the same person or two different team members.

Slide

•

The first challenge should be in the form of a question.

•

The second challenge should provide some support for
your concern.

Remember this is about advocating for the resident. The TwoChallenge Rule ensures that an expressed concern has been
heard, understood, and acknowledged.
There may be times when an initial assertion is ignored. If after
two attempts the concern is still disregarded, but the member
believes resident or staff safety is or may be severely
compromised, the Two-Challenge Rule mandates taking a
stronger course of action or using a supervisor or chain of
command. This overcomes our natural tendency to believe the
team leader must always know what he or she is doing, even
when the actions taken depart from established guidelines. When
invoking this rule and moving up the chain, it is essential to
communicate to the entire medical team that additional input has
been solicited.
It is important to have an agreed upon approach of delivering the
Two-Challenge Rule within your institution and to obtain buy-in
from all involved (e.g., nurses, physicians, administration). As with
any of the tools and strategies discussed throughout the
TeamSTEPPS training, having a standardized method of delivery
is critical for effectiveness. The chosen approach must be made
known to all team members (i.e., everyone must be on the same
page and speaking the same language).

B-6-20 VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION
TeamSTEPPS for Long-Term Care | Mutual Support

THE TWO-CHALLENGE RULE

Mutual Support

SAY:
If you personally are challenged by a team member, it is your
responsibility to acknowledge the concerns instead of ignoring the
person. Any team member should be empowered to “stop the line”
if he or she senses or discovers an essential safety breach. This is
an action that should never be taken lightly, but requires immediate
cessation of the process to resolve the safety issue.

Slide

Let me provide an example of what a successful use of the TwoChallenge Rule might look like.
Example:
Mrs. Peters returned from the dentist after having a molar
extracted. The nurse let Mrs. Peters’ aide, Judy, know that she
should receive soft foods for a few days so as not to disturb the
clot. Judy takes Mrs. Peters to dinner and watches the dietary
aide deliver a regular meal. Judy stops the dietary aide, Matt, and
tells him that Mrs. Peters needs a soft meal. Matt replies that Judy
is wrong, as Mrs. Peters’ menu card says “regular diet.” Judy
explains to Matt that, “No, Mrs. Peters just returned from the
dentist, and the nurse said she needs soft foods.” Matt takes the
tray back to talk to his supervisor.
ASK:
•

Can anyone think of a situation in which you used or could
have used the Two-Challenge Rule?

TeamSTEPPS for Long-Term Care | Mutual Support VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION B-6-21

Mutual Support

CUS
SAY:

Slide

VIDEO TIME:
0:27 seconds

MATERIALS:
• CUS Subacute
Video
(CUS_Subacute.
mpg)

Using the CUS technique provides another tool for advocacy,
assertion, and mutual support. Signal words, such as “danger,”
“warning,” and “caution” are common in the medical arena. They
catch the reader's attention. In verbal communication, “CUS” and
other signal phrases have a similar effect. If all team members
have a shared mental model and are on the same page, when
these words are spoken, all team members will clearly understand
the issue and its magnitude.
To use CUS:
•

First, state your concern.

•

Then state why you are uncomfortable.

•

If the conflict is not resolved, state that there is a safety
issue. Discuss in what way the concern is related to safety.
If the safety issue is not acknowledged, a supervisor should
be notified.

A few other phrases in use are:
•

I would like some clarity about…

•

Would you like some assistance?

We are now going to watch a video clip of the CUS technique in
action.

DO:
Play the video by clicking the director icon on
the slide.

DISCUSSION:
•

How was the “challenge” presented?
– In the form of a statement, “I am concerned…”
– The physical therapy assistant was uncomfortable with how hard
the resident was breathing.
– She became concerned and uncomfortable that the
resident’s safety may be at risk.

B-6-22 VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION TeamSTEPPS for Long-Term Care | Mutual Support

AN ADVOCACY AND ASSERTION SCENARIO

Mutual Support

SAY:
Let’s analyze this scenario:
A high school senior working in the dietary department is
wheeling the steam-tray table down the hall after dinner. Ahead
of her, she sees a nursing assistant escort a resident into his
room and close the door. As she passes the room, she hears a
raised voice and believes it to be the nursing assistant. She
feels she should knock on the door or tell someone but doesn’t.

Slide

DISCUSSION:
• If you were in this situation, what would you do?
• How might you raise the issue with a staff member?
• What should the dietary worker do if she says something and
her observations are not taken seriously?
• What TeamSTEPPS tools could you use to help?
SAY:
Advocating for the resident and asserting your viewpoint are both
important aspects of engaging in mutual support. However, even
when used correctly the techniques and tools presented may still
lead to conflict. Conflict resolution is a skill team members need to
develop and cultivate in order to overcome challenges that will arise.

TeamSTEPPS for Long-Term Care | Mutual Support VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION

B-6-23

Mutual Support

CONFLICT IN TEAMS
SAY:
Conflict can occur in teams and it is important to know how to
handle such situations when they occur. The two types of conflict
we will address are informational and interpersonal.
•

Informational conflict involves differing views, ideas, and
opinions related to information. This is task-related and
could involve disagreement about the best method to
proceed with the plan of care.

•

Interpersonal conflict stems from interpersonal compatibility
and is not usually task related. This type of conflict tends to
revolve around the team members themselves, not the
actions or information. Tension, annoyance, and animosity are
common and interactions can become very argumentative.

Slide

Attempts should be made to resolve both types of conflict before
they interfere with work and undermine quality and resident
safety. Informational conflicts left unresolved may evolve into
interpersonal conflicts in the long run and severely weaken
teamwork.
Disruptive behavior among staff should be actively discouraged.
Nursing homes should develop guidelines for acceptable
behaviors to assist staff in better identifying, reporting, and
managing behaviors that cause disruption to resident safety.
Types of disruptive behavior include condescending language or
voice intonation, impatience with questions, reluctance or refusal
to answer questions or telephone calls, strong verbal abuse or
threatening body language, and physical abuse.
Resources are available to help address disruptive behavior. For
example, the Department of Defense’s Professional Conduct
toolkit provides information on this topic.
Please contact the Patient Safety team to receive the
Professional Conduct Toolkit via email at [email protected].

Continued…

B-6-24VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION TeamSTEPPS for Long-Term Care | Mutual Support

CONFLICT IN TEAMS (Continued)
DISCUSSION:

Mutual Support
Slide

• Can you provide an example of an informational conflict you’ve
encountered?
• How did you resolve it?
• Can you provide an example of an interpersonal conflict you’ve
encountered?
• How did you resolve it?
SAY:
Two tools can be used to address conflict in teams: the TwoChallenge Rule and DESC script.
• Two-Challenge Rule:
- As we have already discussed, the Two-Challenge Rule
can serve as a method to advocate and assert for resident
safety; but it can also be used as a conflict resolution
strategy. W hen team members have different information,
the Two-Challenge Rule can be used to bring up the
differing information so it can be addressed.
• DESC script:
- The DESC script can be used for both informational and
interpersonal conflict but is most effective when conflict is
of a personal nature.
Next we will discuss DESC script in more detail.

TeamSTEPPS for Long-Term Care | Mutual Support VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION

B-6-25

Mutual Support

CONFLICT RESOLUTION: DESC SCRIPT
SAY:
The DESC script can be used to communicate effectively during
all types of conflict and is most effective in resolving interpersonal
conflict. The DESC script can be used in situations involving
greater conflict, such as when hostile or harassing behaviors are
ongoing and safe resident care is suffering.

Slide

DESC is a mnemonic for:
D = Describe the specific situation.
E = Express your concerns about the action.
S = Suggest other alternatives.
C = Consequences should be stated.
Ultimately, consensus should be reached.

B-6-26 VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION TeamSTEPPS for Long-Term Care | Mutual Support

DESC IT!

Mutual Support

SAY:
There are some crucial things to consider when using the DESC
script:
• Time the discussion.
•

Work on win-win—Despite your interpersonal conflict with the
other party, team unity and quality of care depend on coming
to a solution that all parties can live with.

•

Frame problems in terms of personal experience and
lessons learned.

•

Choose the location—A private location that is not in front
of the resident or other team members will allow both
parties to focus on resolving the conflict rather than on
saving face.

•

Use “I” statements rather than blaming statements.

•

Critique is not criticism.

•

Focus on what is right, not who is right.

Slide

TeamSTEPPS for Long-Term Care | Mutual Support VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION B-6-27

Mutual Support

A DESC SCENARIO
SAY:
Let’s examine a scenario with conflict.

Slide

Two days ago, the charge nurse submitted a maintenance
request to fix a window unit air conditioner. While in the
resident’s room, the nurse realizes it is warm and the air
conditioner still isn’t working properly. She checks the logbook
and sees that the maintenance request has not been completed.
She doesn’t know that a new unit is being delivered today.
Worried about the comfort of her resident, who has difficulty
breathing in warm weather, she raises her voice at the director
of maintenance in front of staff and residents, criticizing his work
ethic.
ASK:
•

How could the DESC script be used here?

Example Answer:
DESC:
D

“I (maintenance director) realize that you (nurse) are

worried about the resident’s ability to breathe comfortably
in this warm weather and I am sensing that you don’t think I
have addressed your concern about her air conditioning
problem.”
E

“When you accuse me of not addressing the needs of
residents, especially in a timely fashion, it embarrasses me
and makes me very frustrated.”

S

“If you have a question about my performance, I would
appreciate your asking me about it before jumping to
conclusions.”

C

“Having a conversation with me would be better because I
would feel less embarrassed and would be able to supply
information. Can we agree to follow such a procedure if this
happens again? In the meantime, I can add a “pending”
column to the logbook to communicate such information.”

VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION TeamSTEPPS for Long-Term Care | Mutual Support
B-6-28

TOOLS AND STRATEGIES SUMMARY

Mutual Support

SAY:
Effectively communicating, having active leadership, and
continually monitoring the situation will all affect the ability of
team members to support one another. Continuous mutual
support behaviors among team members will ultimately foster a
shared mental model, adaptability, team orientation, and mutual
trust.

Slide

Tools and strategies to enhance mutual support include task
assistance, feedback, the Assertive Statement, the TwoChallenge Rule, CUS, and DESC script. Use of these tools will
lead to more adaptive and effective resident care.

TeamSTEPPS for Long-Term Care | Mutual Support VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION

B-6-29

Mutual Support

EXERCISE: APPLYING TEAMSTEPPS
Instructor Note: This slide is intended for the Master
Training course only. The previous slide should be the last one
shown to staff participants at your nursing home.
SAY:

Slide



Return once again to your TeamSTEPPS Implementation
Worksheet. Answer the questions related to Mutual Support as
you consider your own teamwork issue.

MATERIALS:

Think about:

TeamSTEPPS
Implementation
Worksheet

•

Whether your teamwork issue is related to Mutual Support;
and

•

If so, how you might address the issue using the
TeamSTEPPS tools or strategies taught in this module.

DO:
Ask a few individuals to report on their issue as it relates to Mutual
Support and which TeamSTEPPS tools or strategies they might
consider in their implementation planning to address it.

B-6-30VERSION FOR REVIEW ONLY; NOT FOR DISTRIBUTION TeamSTEPPS for Long-Term Care | Mutual Support