Translation and psychometric validation of the Thai version of TeamSTEPPS® team performance observation tool

ABSTRACT

In healthcare, effective communication and teamwork are pivotal in reducing medical errors. Integrating team training into health professions education is crucial. Accurate measurement of team performance during training requires reliable assessment tools. The TeamSTEPPS® Team Performance Observation Tool (TPOT), recently updated by the Agency for Healthcare Research and Quality, serves this purpose. However, it had not been translated and validated for use in Thailand. We aimed to translate and assess the psychometric properties of the Thai version of TPOT. Employing a back-translation process, TPOT was adapted to the Thai context. The resulting Thai TPOT instrument was administered to 518 healthcare professionals who had undergone TeamSTEPPS® training. Participants were asked to evaluate two prerecorded, 7-minute simulated team emergency scenarios using the Thai TPOT instrument. Results exhibited high internal consistency (Cronbach’s alpha = .96) and inter-rater reliability (ICC = .98). Confirmatory factor analysis affirmed the construct validity of the Thai TPOT. These findings establish the Thai TPOT as useful for evaluating teamwork within healthcare teams.

KEYWORDS:

• Healthcare professionals
• psychometric properties
• team performance
• Team performance observation tool
• TeamSTEPPS
• teamwork
• Thailand

Introduction

In modern healthcare, team performance is pivotal for patient safety. Adverse events occur in approximately 14.2% of hospital admissions, and a substantial portion – up to 83%—of these errors are recognized as preventable (Zanetti et al., 2020). A systematic review identified ineffective communication as a primary obstacle to a positive patient safety culture while highlighting strong teamwork as a key strength factor contributing to patient safety (Albalawi et al., 2020). Consequently, team training has emerged as an indispensable facet of interprofessional health professions education (Interprofessional Education Collaborative, 2023).

In healthcare education, the use of simulation-based interprofessional education has gained prominence. Employing the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) curriculum has proven effective in fostering teamwork within diverse health professions (Chen et al., 2019; Thomas & Galla, 2013). The TeamSTEPPS® curriculum is designed to improve team structure and team competencies, such as communication, leadership, situation monitoring, and mutual support to promote quality, and patient safety. Tangible impacts of implementing the TeamSTEPPS® curriculum on patient outcomes have been well-documented (Alsabri et al., 2020; Bogne Kamdem et al., 2021), reinforcing its efficacy. The integration of simulation team training, guided by the TeamSTEPPS® curriculum, has gained widespread traction across clinical practice and healthcare education. This approach effectively heightens awareness and proficiency in teamwork competencies.

In the effort to assess improvements in team performance during simulation sessions, educators need to employ tools that are both valid and reliable. These tools serve as a crucial yardstick for the effectiveness of training initiatives. Ensuring the competence of teams through comprehensive training and measurement is paramount for safeguarding patient safety and elevating the quality of care. Existing research indicates that tools relying on observer assessments are more reliable than self-assessments for appraising team performance (Andersson et al., 2017). Therefore, the development of an observation tool tailored to the study context is imperative to enhance the effectiveness of team performance training.

Background

Teamwork is characterized as a “dynamic process involving two or more healthcare professionals with complementary backgrounds and skills, sharing common health goals and exercising concerted physical and mental effort in assessing, planning, or evaluating patient care” (Xyrichis & Ream, 2008, p. 238). Its significance lies in its potential to elevate healthcare quality and enhance patient safety. Effective teamwork not only boosts patient satisfaction but also mitigates burnout among healthcare professionals. Institutions such as the Agency for Healthcare Research and Quality (AHRQ) and the Joint Commission have underscored teamwork as a robust catalyst for augmenting healthcare quality (Kronick, 2016). Beyond this, teamwork is touted as a vital competency for bolstering healthcare services, while its absence can amplify medical errors and compromise patient safety. Given the pressing imperative to enhance patient safety and healthcare quality, the widespread adoption of team training is a key driver in fortifying teamwork.

Numerous scholars have observed favorable correlations between teamwork and patient safety. Proficient teamwork and effective communication play pivotal roles in clinical patient outcomes, as well as healthcare provider well-being, including factors such as burnout and job satisfaction (Dinius et al., 2020). The reported outcomes encompass heightened risk identification, reduced incidents of falls, improved relationships, increased incident reporting, the capacity to voice concerns, and decreased length of hospital stays (Dinius et al., 2020; Roemer et al., 2016). Enhanced teamwork strategies have been linked to shorter hospital stays (Potts et al., 2017; Toledo et al., 2013). Furthermore, stronger inter-professional teamwork corresponded to a more favorable perception of patient safety (Potts et al., 2017).

Enhancing the quality of care and minimizing the potential for medical errors necessitates team training for healthcare professionals. Simulation-based training is a recognized strategy that adeptly elevates team performance. A multitude of research findings underscore the substantial enhancements in participants’ non-technical skills, clinical team processes, and overall team performance from simulation-based training interventions (Gjeraa et al., 2014; Lee et al., 2020; Liaw et al., 2020).

Simulation training, founded upon a theoretical framework, integrates feedback, debriefing, or guided reflection to facilitate optimal outcomes. When assessing enhancements in team performance through formative assessments and evaluating real-world performance, the use of measurement tools that are both valid and reliable is pivotal. These tools should align with the theoretical underpinnings of the curriculum. This evaluation serves three key purposes. Firstly, the assessment of team performance functions as a navigational tool for structured and progressive learning. Secondly, it serves as a summative assessment, offering an evaluation of the team’s progress at a given point for both trainers and team members. Thirdly, the establishment of behavioral and outcome criteria within the evaluation process serves to substantiate the effectiveness of team training. The inclusion of evaluation within simulation-based team training is imperative. It provides tangible benchmarks to assess program success and serves as a platform to identify areas for enhancement.

The TeamSTEPPS® curriculum is an empirically grounded framework designed to optimize team performance within a healthcare delivery system. Some key theoretical foundations of TeamSTEPPS include the input-process-output model, crew resource management (CRM), and human factors theory. The input-process-output model underscores the importance of refining communication and coordination processes for enhanced team performance. CRM focuses on improving communication, situational awareness, and decision-making within teams, while human factors and ergonomics (HFE) consider how individuals interact with their environments, taking into account their capabilities and limitations (King et al., 2008).

The TeamSTEPPS® assessment tool has five cardinal principles, including team structure and four key skills. Team structure refers to the composition of an individual team or of a multi-team system, serving as a fundamental element in the teamwork process. A well-organized patient care team both facilitates and manifests effective communication, leadership, situation monitoring, and mutual support. Recognizing that a patient care team is incomplete without the patient, it is crucial to embrace and value patients and their families as essential contributors to the care process.

The four skills are (a) communication, a verbal and nonverbal process facilitating clear and accurate information exchange among team members; (b) team leadership, the ability to lead a team within a multi-team system, maximizing the effectiveness of team members by ensuring understanding of team actions, sharing changes in information, and providing necessary resources; (c) situation monitoring, the process of actively scanning and assessing situational elements to gain information or understanding, or to maintain awareness to support team functioning; and (d) mutual support, the ability to anticipate and support team members’ needs through accurate knowledge about their responsibilities and workload (Agency for Healthcare Research and Quality, 2023a). The TeamSTEPPS® framework reflects the connections among these four skills and how they contribute to the knowledge, attitudes, and sustained high performance needed to achieve highly reliable, safe, and effective care for every patient.

Integration of TeamSTEPPS® principles has demonstrated efficacy in mitigating adverse patient outcomes. Various investigators have reported a reduction in medication error rates and instances of patient falls following the implementation of TeamSTEPPS® training (Aldawood et al., 2020; Jones et al., 2019; Motycka et al., 2018). Combining simulation with the TeamSTEPPS® curriculum emerges as a potent pedagogical approach, affording learners the chance to partake in experiential learning encompassing knowledge, skills, and interpersonal interactions, all while practicing team strategies within a secure and replicable setting. Nevertheless, even with TeamSTEPPS® as the gold standard for healthcare team training, the assessment of team performance, a pivotal determinant of the training program’s success, remains a crucial endeavor.

In Thailand’s medical care teams, four commonly employed instruments include the Anesthesia Non-Technical Skills (ANTS) System, the TeamSTEPPS® 2.0 Team Performance Observation Tool (TPOT), the Ottawa Global Rating Scale (GRS), and Non-Technical Skills for Surgeons (NOTSS). The ANTS and GRS have been translated into the Thai language and employed in simulation scenarios within the anesthetic curriculum. The Ottawa GRS has demonstrated superior practicality and reliability in this context (Jirativanont et al., 2017). However, both tools have been limited use outside of anesthetic practice settings. The NOTSS has not undergone translation into Thai, and similar to the ANTS, the NOTSS has not been extensively utilized for evaluating team performance beyond the perioperative setting.

Although the ANTS, GRS, and NOTSS instruments were designed for specific practice contexts, the TPOT stands out as it was directly derived from the TeamSTEPPS® curriculum, making it adaptable to all healthcare teams. Given that the TeamSTEPPS® program aims to enhance team functionality across medical teams, the TPOT has greater utility among interprofessional teams regardless of specialty or setting.

AHRQ released an updated version of the TPOT in 2004. The initial TPOT employed a 5-point Likert-type scale to evaluate the general team proficiencies. Focusing on observable behaviors can curtail subjectivity in observations, augmenting the reliability and validity of assessment measures. The original version of TPOT was approved as a validated tool for appraising teamwork competencies in simulation-based interprofessional education activity (Maguire, 2016). A literature review indicated that the TPOT was translated into the Persian language, demonstrating acceptable face and content validity, as well as internal consistency, within the military care community (Zaeri et al., 2021). However, its adaptation and examination within the Thai context are unexplored.

In summary, TeamSTEPPS® offers an empirically grounded framework for enhancing team performance in healthcare delivery, with the use of an observational team performance assessment tool, relying on observer assessments for greater reliability. The TPOT directly derived from the TeamSTEPPS® curriculum, emerges as the most suitable tool, ensuring adaptability across all healthcare teams. The lack of adaptation and examination of TPOT within the Thai context is a gap in existing research. Therefore, we sought to address this gap by translating and evaluating the psychometric properties of the Thai version of TPOT. The findings from this study can contribute valuable insights to interprofessional education (IPE) and healthcare in Thailand. Our results are anticipated to enhance understanding of teamwork dynamics within Thai healthcare teams, providing a foundation for improving interprofessional collaboration and ultimately impacting the overall quality of healthcare delivery in the Thai context.

Methods

Design

The process of translating the original TPOT into Thai involved a rigorous process. This study adopted a cross-sectional design with a substantial sample size to comprehensively assess the content validity, construct validity, inter-rater reliability, and internal consistency of the translated tool.

Instrument

The original, English version TeamSTEPPS® 2.0 TPOT is a 23-item, 5-point Likert-type scale observational tool. Its primary objective is to yield data on team performance grounded in five core teamwork process principles. These domains are Team Structure, Leadership, Situation Monitoring, Mutual Support, and Communication. Each domain encompasses between four to six variables corresponding to the respective team process facet. The scale’s rating ranges from 1 (Very poor) to 5 (Excellent). A well-defined scoring mechanism must be employed consistently during each TPOT administration. Participants were instructed to exclusively consider observed behaviors. In assessing each item on the scale, a holistic evaluation of overall performance was encouraged, emphasizing collective team performance over individual contributions. The maximum attainable score on the TPOT is 125 points. A higher score indicates better teamwork performance. There are no predefined criteria for overall team performance assessment. To assess the improvement in team performance for each dimension at each time point during team training, the average score for each dimension should be calculated.

Several researchers have demonstrated the effectiveness of the TeamSTEPPS® tool, including its use of the TPOT (Borckardt et al., 2020; Clapper et al., 2018; Maguire, 2016; Matzke et al., 2021; Shortridge et al., 2019; Zaeri et al., 2021). The psychometric properties of the original TPOT version were evaluated by Maguire (2016). The TPOT demonstrated good content validity, internal consistency and good construct validity. Test-retest reliability indicated stability over time, with a significant proportion of scores remaining consistent after 2 weeks (Maguire, 2016).

Translation of TPOT

The original English version of TPOT was translated to Thai language with the permission of the United States AHRQ from the TeamSTEPPS® 2.0 National Implementation (accessible at http://teamstepps.ahrq.gov/). The translation process adhered to established guidelines for translation and cultural adaptation as advocated by the ISPOR task force (Wild et al., 2005). The procedure is detailed as follows:

Step 1 Preparation

The primary investigator obtained formal permission from AHRQ to initiate the translation process in an e-mail communication. Following this authorization, the English version of the TeamSTEPPS® 2.0 TPOT was prepared for subsequent translation phases.

Step 2 Forward translation

Two proficient bilingual translators, both native Thai speakers with different linguistic backgrounds, independently translated the original English version of the TeamSTEPPS® 2.0 TPOT into Thai. One translator came from the Translation and Interpretation Services Unit, Chalermprakiat Center of Translation and Interpretation, Faculty of Arts, Chulalongkorn University. The second translator was a bilingual nurse with an in-depth understanding of English-speaking culture who was a native Thai speaker. The aim of this step was to achieve conceptual equivalency, rather than literal translation, by ensuring the most relevant translation of instruments. The authors addressed transcultural adaptation in the translation process by ensuring clarity with the forward translator, emphasizing that the translations should convey the conceptual meaning of the questions rather than focusing solely on literal translation.

Step 3 Reconciliation

Three expert panelists were asked to compare the two forward translations and reconcile them via discussions with the second forward translator for difficult items. Some modifications were made. After final reconciliation, forward translation was ready for back translation.

Step 4 Backward translation

The reconciled version from the previous step was subjected to a conceptual back translation approach. A bilingual translator, a native English speaker fluent in Thai, back-translated the reconciled version into English. The translator, raised in the US and having lived there for two decades, had no prior knowledge of the measure, source language, or any other language versions.

Step 5 Back translation review

The backward-translated version was thoroughly compared against the original English version by the research team to ensure conceptual and semantic equivalence. Discrepancies were addressed, and a pre-final version was formulated.

Step 6 Harmonization

A harmonization meeting was convened among the research team to address any disparities that emerged between the various language versions. Conceptually complex items were discussed and clarified, ensuring consistency of Thai words throughout the tool. This stage resulted in the creation of a final consensus version of the Thai TPOT.

Step 7 Cognitive debriefing

To assess comprehensibility and cognitive equivalence, a cognitive debriefing phase was carried out involving interprofessional healthcare providers, including a physician, a nurse, a medical technologist, a pharmacist, and a radiologic technologist. Five reviewers used the Thai TPOT to evaluate team performance skills during IPE simulations, providing feedback for further refinement.

Step 8 Review of cognitive debriefing results and finalization

The feedback from cognitive debriefing was reviewed by the primary investigator. Translation modifications were made based on respondents’ suggestions to enhance translation performance.

Step 9 Proofreading

The final translation underwent thorough proofreading by the primary investigator and the research team members to rectify any remaining errors, including spelling, diacritical marks, grammar, or other issues.

Step 10 Final report

A comprehensive final report was compiled, detailing the methodology employed and providing an item-by-item representation of all translation decisions. With the completion of these steps, the final Thai translation version of the TeamSTEPPS® 2.0 TPOT was ready for subsequent testing of psychometric properties.

Psychometric properties testing of Thai TPOT

The psychometric evaluation phase involved assessments of validity and reliability for the scale. These included evaluations of content validity, construct validity, internal consistency, and inter-rater reliability.

Participants and setting

The research was conducted at a university hospital in Thailand. The study samples were selected using convenience sampling. Inclusion criteria consisted of (a) had age ≥18 years; (b) over 5 years of working experience; (c) proficient in spoken and written Thai and capable of effective communication; and (d) attended TeamSTEPPS® training.

The selection of healthcare professionals trained in TeamSTEPPS® was vital to establish the study’s reliability and validity. Participants underwent TeamSTEPPS® training sessions to ensure their shared comprehension of key curriculum constructs, including TPOT variables such as huddle, the Concerned-Uncomfortable-Safety (CUS) tool, and the Describe, Express, Suggest, Consequences (DESC) tool. These in-person training sessions each lasted 2 hours and encompassed the following components: (a) a didactic review, focusing on fundamental team concepts and the critical role of team performance in patient safety to establish a common baseline understanding; (b) an exploration of TeamSTEPPS® principles, illuminating the correlation between each Thai TPOT item and these principles; (c) a pitfall case, demonstration of common rating pitfalls to enhance the accuracy of assessments; (d) a practical session, engaging participants in practice ratings using prerecorded video simulations of IPE scenarios; and (e) a discussion, encouraging discussion to address any discrepancies in rating scores. This rigorous approach aimed to equip participants with the requisite knowledge and skills to effectively engage with the study’s objectives and assessment tools.

The determination of sample size was guided by factor analysis criteria. Established literature provided a benchmark wherein a sample size of 50 was categorized as very poor, 100 as poor, 200 as fair, 300 as good, 500 as very good, and 1,000 as excellent for conducting factor analyses (Comrey & Lee, 1992).

To assess the inter-rater reliability of the Thai version of TPOT, three faculty members from diverse professions were invited to participate. This observer group included a nurse, a physician, and a medical technologist. The inclusion criteria the inter-rater reliability testing were as follows: (a) age ≥18 years; (b) current employed as faculty; (c) engage in professional activities related to TeamSTEPPS® education; and (d) proficiency in both spoken and written Thai for effective communication.

Data collection

Upon obtaining IRB approval, the researcher disseminated informational posters to eligible participants. Permission for data collection was sought from the hospital, followed by distribution of research participation invitation posters within hospital departments.

Eligible participants were engaged through a scannable QR code, inviting their participation in the study. These QR codes directed them to a study document, where the initial page encompassed a participant information sheet and informed consent. Participants were able to indicate their willingness or unwillingness to partake in the study. Those willing to participate were subsequently led to the second page housing a demographic data sheet for screening inclusion criteria.

Participants meeting the inclusion criteria were guided to the third survey page, offering a link to schedule their attendance for the TeamSTEPPS® training session. The TeamSTEPPS® training sessions were conducted on participants’ chosen dates. Following the culmination of the training sessions, participants were asked to assess a pair of prerecorded, 7-minute simulated team emergency scenarios using the Thai version of the TPOT.

For evaluating inter-rater reliability, invitations were extended to faculty members comprising nurses, physicians, and medical technologists through posters that targeted eligible faculty staff. Potential participants meeting the inclusion criteria received e-mail invitations. These faculty members were subsequently instructed to evaluate two prerecorded, 7-minute video sessions using the Thai version of the TPOT instrument.

Data analysis

Analysis of the study’s data involved descriptive statistics, assessment of internal consistency reliability, and determination of inter-rater reliability. These procedures were conducted using The Statistical Package for the Social Sciences version 22. Assessment of the TPOT’s internal consistency reliability was carried out using Cronbach’s alpha coefficient. For evaluating inter-rater agreement, the intraclass correlation coefficient (ICC) was computed. Based on a 95% confidence interval of the ICC estimate, values less than .50, between .50 and .75, between .75 and .90, and greater than .90 indicate poor, moderate, good, and excellent reliability, respectively (Koo & Li, 2016).

Content validity was established using the content validity index. To assess the construct validity of the Thai TPOT, a confirmatory factor analysis (CFA) was performed with Mplus version 8.3. The fit of each model was evaluated using three fit indices: the Root Mean Square Error of Approximation (RMSEA), the Tucker Lewis Index (TLI), and the Comparative Fit Index (CFI). RMSEA, an absolute fit index, accounted for error estimates in the population. A RMSEA value close to .06 indicates a well-fitting model (Hu & Bentler, 1999), while values up to .08 suggest reasonable approximation errors within the population. The TLI and CFI, both indicative of comparative fit, demonstrate strong model fit with values near .95 (Hu & Bentler, 1999).

Ethical consideration

This research study received approval from the Ethical Review Committee for Research Involving Human Research Subjects, Faculty of Medicine, Chulalongkorn University, under Certificate of Approval No. 0782/2022.

Results

Participant demographics

A total of 518 participants enrolled in the study. Each participant was asked to review two prerecorded video sessions, resulting in a dataset of 1,036 samples for analysis. The predominant occupation among participants was nursing (94.2%), physicians (4.1%), pharmacists (0.8%), medical technologists (0.6%), and radiologists (0.4%). A significant majority of the sample identified as female (97.7%, n = 506). Participants’ ages ranged from 28 to 59 years, with an average age of 38.24 years (standard deviation = 7.98).

Content validity

Assessment of content validity involved a panel of five experts. This group comprised an emergency medicine physician well-versed in TeamSTEPPS®, three experienced nurses skilled in instrument development and emergency care, and a proficient pilot specializing in crew resource management and team training. The evaluation encompassed all item content. Each item was appraised using a four-point Likert scale (1 = not relevant to 4 = very relevant). The Content validity index (CVI) was computed by calculating the proportion of items rated 3 or 4 by the expert panel. Across the items, the CVI scores ranged from .80 to 1.00, with an average CVI of .83, confirming the content validity of the Thai TPOT (Polit et al., 2007).

Internal consistency reliability

The Cronbach’s alpha for the overall Thai TPOT was notably high. Individual dimension coefficients showed good reliability. One item of the team structure dimension (1d), including patients and families as part of the team, exhibited a slightly low corrected item-total correlation coefficient. The details of corrected item-total correlations and Cronbach’s alpha values for each dimension, along with information about deleted items, are provided in Table 1.

Table 1. Reliability for Thai TPOT items and dimensions (n = 1,036).

Items	Corrected item-total correlation	Cronbach alpha if item deleted	Cronbach alpha
1.Team structure			.82
a. Assembles a team	.71	.97
b. Assigns or identifies team members’ roles and responsibilities	.78	.97
c. Holds team members accountable	.77	.97
d. Includes patients and families as part of the team	.41	.98
2. Communication			.89
a. Provides brief, clear, specific and timely information to team members	.79	.97
b. Seeks information from all available sources	.71	.97
c. Uses check-backs to verify information that is communicated	.80	.97
d. Uses SBAR, call-outs, and handoff techniques to communicate effectively with team members	.82	.97
3. Leadership			.95
a. Identifies team goals and vision	.73	.97
b. Utilizes resources efficiently to maximize team performance	.84	.97
c. Balances workload within the team	.87	.97
d. Delegates tasks or assignments, as appropriate	.84	.97
e. Conducts briefs, huddles, and debriefs	.84	.97
f. Role models teamwork behaviors	.86	.97
4. Situation Monitoring			.94
a. Monitors the status of the patient	.82	.97
b. Monitors fellow team members to ensure safety and prevent errors	.79	.97
c. Monitors the environment for safety and availability of resources (e.g., equipment)	.80	.97
d. Monitors progress toward the goal and identifies changes that could alter the plan of care	.86	.97
e. Fosters communication to ensure team members have a shared mental model	.85	.97
5. Mutual Support			.92
a. Provides task-related support and assistance	.84	.97
b. Provides timely and constructive feedback to team members	.82	.97
c. Effectively advocates for patient safety using the Assertive Statement, Two-Challenge Rule, or CUS	.73	.97
d. Uses the Two-Challenge Rule or DESC Script to resolve conflict	.73	.97

Inter-rater reliability

The ICC value for the overall scale was found to be .96, with a 95% confidence interval ranging from .89 to .99. Furthermore, ICC values were computed for the five individual dimensions: team structure (.70), communication (.82), leadership (.90), situation monitoring (.89), and mutual support (.86).

Construct validity

A confirmatory factor analysis was performed to evaluate the validity of the factor structure of the Thai TPOT. The CFA model is displayed in Figure 1, demonstrating an excellent fit with the data.

Figure 1. Confirmatory Factor Analysis Model of Thai Team Performance Observation Tool.

Note. χ² = 193.40, df = 173, p = .14, CFI = 0.999, TLI = 0.998, RMSEA = 0.011, SRMR = 0.013

All items had factor loadings over .70, indicating an excellent factor loading. Only one item (Q4_TS: Includes patients and families as part of the team) had a lower factor loading of .46, which indicates a moderate loading score. Nevertheless, the ratios of factor loadings to their corresponding standard errors surpassed 2.00, underscoring substantial factor loadings.

Discussion

We aimed to translate and evaluate the psychometric properties of the Thai version of the TeamSTEPPS® 2.0 TPOT. Our findings demonstrate that the translated Thai TPOT exhibits favorable psychometric characteristics in terms of content validity, internal consistency reliability, inter-rater reliability, and construct validity.

The content validity assessment involving a panel of experts indicated strong agreement on the relevance of items within the Thai TPOT. The calculated CVI supports the appropriateness of the translated items, indicates that they align with the original tool’s intended constructs, and underscores the tool’s robust content validity.

The high Cronbach’s alpha coefficient for the overall Thai TPOT reflects strong internal consistency. This suggests that the translated instrument consistently measures the same underlying construct across items (Polit et al., 2007). These findings are consistent with earlier research that demonstrated high internal consistency for the original English TPOT (Maguire, 2016), indicating that the Thai TPOT maintains reliability across languages.

An exception was observed with one item within the team structure dimension (Q4_TS: Includes patients and families as part of the team), which had a slightly low coefficient. In a prior study by Maguire (2016); this item exhibited a slightly low I-CVI, and was excluded, resulting in an improved overall S-CVI. The remaining 22 items were recommended. In our study, a particular item had a higher I-CVI and was not excluded from analyses. However, our reliability assessment indicated a slightly lower coefficient.

We chose not to delete this item due to its alignment with the theoretical foundation of TeamSTEPPS® 2.0 TPOT, which emphasizes the significance of family involvement in care process (Agency for Healthcare Research and Quality, 2023b). The rationale behind this decision is supported by a strong theoretical framework and its consistency with the overarching healthcare objectives in Thailand, emphasizing the significance of patients and families as crucial components of quality and safe care. Several underlying reasons are suspected for the suboptimal item-total correlation of this particular item. Firstly the remaining items within the TPOT predominantly focus on tasks specific to healthcare providers directly engaged in patient care. Within this context, healthcare providers might not commonly perceive patients and family members as active participants in the care process. Although family-centered care has demonstrated its potential to enhance patient outcomes (Backman et al., 2021; Kokorelias et al., 2019), its effective implementation has also posed challenges.

Second, the prerecorded video scenarios might not adequately have elucidated the roles of patients and families. This lack of clarity might have contributed to the diminished relevance of this item within the context of evaluating healthcare team performance from a TeamSTEPPS® perspective. It’s important to note that the TeamSTEPPS® curriculum suggests the integration of patients and families into the healthcare team. Although the internal consistency of the TPOT was strong overall, the item assessing the inclusion of patients and families in the team displayed limited alignment with the other items. Factors such as healthcare providers’ perceptions, the role of patients and families in care delivery, and the presentation of this role in the video scenarios might collectively contribute to this discrepancy. This item’s relevance within the TeamSTEPPS® framework and its practical implementation in healthcare settings warrant further exploration. Incorporating patients and family caregivers into care processes and decision-making is a critical aspect of ensuring patient safety in Thailand. Retaining the specific scale item of Thai TPOT could serve as a promising initial step for evaluating and improving the engagement of patients and their families within the clinical setting in Thailand.

Our findings indicate excellent inter-rater reliability among the faculty observers. These findings align with earlier studies that documented strong inter-rater reliability for the original English TPOT (Maguire, 2016), as well as the Persian version TPOT (Zaeri et al., 2021).

The CFA results demonstrated an excellent fit for the factor structure of the Thai TPOT, indicating that the five core teamwork process principles (team structure, communication, leadership, situation monitoring, and mutual support) are well-represented in the translated version. The fit indices—χ2/df, CFI, TLI, RMSEA, and SRMR – all supported the congruence of the model with the data. This suggests that the Thai TPOT’s factor structure is consistent with the theoretical framework of the original TPOT and is suitable for assessing team performance in the Thai context.

In comparing the Persian and Thai versions of the TPOT, it is evident that both adaptations underwent rigorous validation processes, demonstrating strong psychometric properties. In the Persian version, the high CVI scores, along with good face validity, underscore the strong agreement on item relevance. Furthermore, the robust internal consistency suggests a reliable measurement of underlying constructs. The acceptable correlation between all dimensions of the questionnaire and favorable results from the ICC evaluation further enhances the Persian TPOT’s credibility (Zaeri et al., 2021).

In the Thai version, the content validity assessment, reflected in a good CVI, signifies strong agreement among experts regarding item relevance, aligning well with the original tool’s intended constructs. The high Cronbach’s alpha coefficient for the overall Thai TPOT and individual dimension coefficients demonstrate strong internal consistency and reliability. The item-total correlations confirm the scale’s internal consistency and homogeneity. Both the Persian and Thai versions exhibit robust psychometric properties, validating their use as reliable tools for assessing team performance within their respective contexts.

Although this study contributes valuable insights into the cross-cultural adaptation of the TPOT, certain limitations must be acknowledged. The participant demographic in this study exhibited a notable gender and professional imbalance, with a substantial majority identifying as female. The vast majority of participants were nurses, while physicians and other professions represented a much smaller proportion. This gender and professional imbalance can have implications for the generalizability of the study findings. Participation from physicians and other professions showed a lower response rate than that of nurses, possibly due to the study being conducted in a setting where these professions, particularly physicians and others, were underrepresented. Furthermore, the utilization of invitation posters with QR code for recruiting participants might have contributed to the low response rate. Enhancing participation might be achieved by employing diverse strategies, such as implementing multiple reminders or sending individualized e-mail invitations.

Moreover, the study was conducted at a single university hospital, potentially limiting the generalizability of the findings to other healthcare settings. Future research could involve multi-center studies to enhance the external validity of the findings. Additionally, the diminished internal consistency and factor loading observed for the item concerning the inclusion of patients and families as part of the team, several factors could potentially account for this discrepancy. These factors encompass healthcare providers’ perceptions, the evolving role of patients and families in care delivery, and the portrayal of this role within the video scenarios. The interplay of these factors might collectively contribute to the observed outcomes. Consequently, there is a compelling need to delve deeper into the relevance of this item within the context of the TeamSTEPPS® framework and its real-world application within healthcare settings. Further investigation is warranted to unravel the intricacies surrounding this item and its implications for enhancing team performance and patient-centered care.

Conclusion

The findings of this study substantiate the robustness of the Thai version of the TPOT’s psychometric properties, establishing its viability as an instrument for assessing team performance in interprofessional collaborative practice. These findings validate the Thai TPOT as a valid and reliable instrument for assessing team performance in the context of healthcare education and practice. The utilization of this tool in simulation-based interprofessional education holds promise for enhancing teamwork and promoting patient safety among healthcare professionals in Thailand

Acknowledgments

The authors would like to express sincere gratitude to the participants, faculty observers, and experts who dedicated their time and insights to support the research. Additionally, the authors acknowledge the funding support provided by the Second Century Fund at Chulalongkorn University.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The work was supported by the The Second Century Fund, Chulalongkorn University [none].

Notes on contributors

Pataraporn Kheawwan

Dr. Pataraporn Kheawwan, PhD, RN, serves as the Senior Nurse Manager overseeing human resource development at King Chulalongkorn Memorial Hospital. In this role, Dr. Kheawwan is dedicated to advancing the professional development of nursing staff within the organization. Her responsibilities encompass evaluating the competency needs of nursing professionals, delivering competency-based training, engaging in scholarly activities, research activities, and participating as a member of the Continuing Nursing Education Committee of the Thailand Nursing and Midwifery Council. Dr. Kheawwan’s contributions extend beyond her hospital, as she pioneered the implementation of a nurse residency program, setting a national standard. She now serves as a consultant at the national level. Her areas of expertise include cardiothoracic surgery and critical care nursing, health behavior change, scale development, psychometric testing, and simulation training for patient safety.

Chanya Thanomlikhit

Chanya Thanomlikhit, MNS, RN, ENP, holds certification as a Nurse Specialty in Emergency Nurse Practitioner and serves as the Head of the Nursing Professional Development Center within the Human Resource Development division of the Nursing Department at King Chulalongkorn Memorial Hospital. In her role, she oversees clinical nurse practice within the hospital and is particularly dedicated to advancing the field through clinical teaching for nurse educators and the implementation of the Nurse Residency Program for newly graduated nurses. Ms. Thanomlikhit has contributed to this field with several publications on these topics.

Khuansiri Narajeeenron

Khuansiri Narajeenron, MD, MHPE, MSc, FTCEP, CHSE, is a faculty member specializing in emergency medicine and cardiology at the Emergency Department, Chulalongkorn University, and King Chulalongkorn Memorial Hospital in Bangkok, Thailand. As the Academic Director and a Certified Healthcare Simulation Educator, she instructs EM residents, medical students, EM nurses, pharmacists, and paramedics, focusing on non-technical skills enhancement, TeamSTEPPS, and simulation-based interprofessional education. Dr. Narajeenron actively contributes to the EM curriculum, serves on the Thai EM committee, and works on smartphone applications for national EM residency program evaluation. In 2023, she graduated with an MHPE from the University of Illinois at Chicago. She also engages in an international research and education fellowship at the University of California, Irvine, focusing on the development and validation of FEED-ER for feedback quality assessment in the ED workplace. Recognized for her dedication, she received the ACEP Teaching Fellowship certification in 2017. Dr. Narajeenron holds a Master of Science degree from Chulalongkorn University and achieved a gold medal, first-class honors in her Doctor of Medicine degree from Thammasat University.

Suwimon Rojnawee

Suwimon Rojnawee, PhD, RN, is a distinguished Assistant Professor at Chulalongkorn University’s Faculty of Nursing, celebrated for her dedication to education, research, and nursing service. Actively engaging in scholarly activities, she enriches both her knowledge and that of her students, specializing in children’s health with a focus on chronic respiratory and urinary conditions. Additionally, she is an expert in research instrument development. Her commitment to tobacco control reflects her dedication to creating a healthier society. With a wealth of knowledge and experience, she has authored several publications in her areas of expertise.