Enhancing Teamwork and Patient Safety Through TeamSTEPPS^®: A Scoping Review of Benefits in Academic and Clinical Settings

Round 1

Reviewer 1 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

See the attached file. 

 

Thank you.

Comments for author File: Comments.pdf

Author Response

Response to Reviewer 1 Comments

 

Dear reviewer,

It is a privilege to receive such constructive feedback. Please find our detailed responses to these points below.

 

Comment 1: The authors have adequately addressed my comments and made meaningful revisions to improve the clarity, rigor, and relevance of the manuscript.

Response: We sincerely thank the reviewer for this positive assessment.

 

Comment 2: The Methods section has been strengthened by providing a clearer and more transparent description of the scoping review methodology.

Response: We greatly appreciate this comment.

 

Comment 3: In response to concerns regarding the narrowness of the original search strategy, the authors have acknowledged this issue appropriately in the Limitations section.

Response: We sincerely thank the reviewer for this comment.

 

Comment 4: The Discussion has been substantially enhanced. The authors now move beyond descriptive synthesis by integrating findings across studies, identifying consistent patterns, contradictions, and contextual differences.

Response: Thank you for this positive feedback.

 

Comment 5: The Conclusions section has been revised to provide clearer practice- and policy-relevant implications. The authors now emphasize continuous training, leadership involvement, and organizational commitment, aligning the conclusions more closely with the objectives of the scoping review and increasing its relevance for educators, managers, and decision-makers.

Response: We are grateful to the reviewer for this favourable assessment.

Reviewer 2 Report (Previous Reviewer 4)

Comments and Suggestions for Authors

Points for Improvement

1. Structural & Editorial

• Remove duplication in the Data Extraction section (Page 7).

• Consider a visual summary table of key outcomes per theme to enhance readability.

• Improve flow between sections—some transitions between themes in the Discussion are abrupt.

2. Analytical Depth

• Subgroup analysis by study design or context (e.g., simulation vs. real-world) could provide finer insights.

• Critical appraisal of included studies (though optional in scoping reviews) would strengthen confidence in findings.

• Explicitly map gaps per PCC element (Population, Concept, Context) to guide future research.

3. Methodological Reporting

• Clarify grey literature search—though theses and unpublished studies were included, the search strategy seems database-focused.

• Justify exclusion of non-English studies beyond “linguistic limitations,” especially since TeamSTEPPS is implemented globally.

4. Implications & Recommendations

• Expand on “how” to implement sustained change—beyond stating the need for leadership, provide practical strategies.

• Link findings to existing implementation frameworks (e.g., CFIR, RE-AIM) to enhance utility for quality improvement teams.

• Recommend specific metrics for long-term evaluation in future studies.

Author Response

Dear reviewer,

We appreciate your insightful feedback and recommendations for improvement. We have carefully addressed each suggestion, and our point-by-point responses are provided below.

 

Comment 1: Remove duplication in the Data Extraction section (Page 7).

Response: We sincerely thank the reviewer for this positive assessment. We have addressed this issue.

 

Comment 2: Consider a visual summary table of key outcomes per theme to enhance readability.

Response: Thank you for this suggestion. We agree that a visual summary enhances readability. Please note that a table summarizing the outcomes per theme is already included on page 9.

 

Comment 3: Improve flow between sections—some transitions between themes in the Discussion are abrupt.

Response: Thank you for pointing this out. We’ve worked on the transitions between themes to make the Discussion flow more naturally. Beyond that, we took the opportunity to do a full English review of the entire paper to make sure everything is clear and easy to read.

 

Comment 4: Subgroup analysis by study design or context (e.g., simulation vs. real-world) could provide finer insights.

Response: We agree that subgroup distinctions by context add important interpretative depth. The Discussion has now been revised to present the subgroup insights more explicitly, with clearer differentiation between simulation-based and real-world studies.

 

Comment 5: Critical appraisal of included studies (though optional in scoping reviews) would strengthen confidence in findings.

Response: We appreciate the reviewer comment and we have addressed this issue.

 

Comment 6: Explicitly map gaps per PCC element (Population, Concept, Context) to guide future research.

Response: Thank you for this suggestion. A mapping of evidence gaps according to each PCC element has now been explicitly included in the Limitations section to better guide future research directions.

 

Comment 7: Clarify grey literature search—though theses and unpublished studies were included, the search strategy seems database-focused.

Response: Thank you for this observation. A clarification has now been added to the Methods section to better describe this aspect of the search strategy. The primary search was conducted in major bibliographic databases, grey literature was intentionally explored through additional sources, including the Portuguese Open Access Scientific Repository (RCAAP), to identify theses and dissertations.

 

Comment 8: Justify exclusion of non-English studies beyond “linguistic limitations,” especially since TeamSTEPPS is implemented globally.

Response: We thank the reviewer for this insightful comment, we have addressed this issue.

 

Comment 9: Expand on “how” to implement sustained change—beyond stating the need for leadership, provide practical strategies.

Response: Thank you. The manuscript has been revised to summarize the implementation strategies reported across the included studies. These strategies are now described in the Discussion section. Consistent with the JBI scoping review methodology, the purpose of this review was to map and summarize the range of evidence described in the literature rather than to formulate practical strategies; therefore, the added text focuses on synthesizing the strategies identified across studies. Thank you!

 

 

Comment 10: Link findings to existing implementation frameworks (e.g., CFIR, RE-AIM) to enhance utility for quality improvement teams.

Response: We thank the reviewer for this suggestion. It really helps bridge the gap between our findings and practical application. We have added a paragraph to the Discussion noting that the success factors for the TeamSTEEPS® align with frameworks like CFIR and RE-AIM. We believe this provides a much more practical lens for quality improvement teams looking to put this evidence into practice.

 

Comment 11: Recommend specific metrics for long-term evaluation in future studies.

Response: Thank you for this excellent suggestion. We agree that moving beyond immediate post-training assessments is vital for understanding the true impact of TeamSTEPPS®. To address this, we have updated the Discussion to recommend specific metrics for long-term evaluation in future research.

 

 

 

Reviewer 3 Report (New Reviewer)

Comments and Suggestions for Authors

Congratulations on conducting this extensive and interesting study. Scoping reviews represent a real challenge for researchers, as synthesizing the identified information is demanding and requires substantial effort. The study is relevant. However, from my perspective, it requires revision to achieve a clearer synthesis of the information. Therefore, I outline below my suggestions to improve the quality of the manuscript.

Abstract

In the methodological section, it would be appropriate to briefly report the criteria used for the selection of studies (if the text becomes too long, you may remove the following information: “Two independent reviewers performed the screening, selection, and data extraction processes”).

Introduction

1. Lines 156-162: I recommend including a reference that justifies what is appropriately reported regarding the suitability of the scoping review for addressing the research question.
2. Lines 165-176: To promote greater clarity for the reader and avoid redundancy, I recommend redrafting these lines by integrating all the information presented in: (1) the research question and (2) the aim of the scoping review (there are currently two aims/objectives).

Methods

1. The PRISMA checklist is missing from the supplementary file.
2. Line 246: I suggest replacing “paper selection” with “bibliographic source selection”.
3. I recommend moving the flow diagram as well as the search results (lines 246-255) to the “Results” section, as they represent outcomes derived from the application of the described methodology.
4. Lines 277-283: It would be appropriate to report, in the data extraction section, the same elements presented in the table, using identical wording. Additionally, I suggest numbering the supplementary files (e.g., Supplementary File 1, Supplementary File 2) and clearly referring to them in the text.

Results

1. Lines 285-286: The data are incomplete. Please revise accordingly.
2. It is important to explicitly state that all descriptive data of the included studies are presented in the supplementary material table, as this information is highly relevant. Nevertheless, I understand that, due to its length, the table has been placed in the supplementary material, which is common in scoping reviews.
3. Lines 301-312: Please consider adding specific numbers in parentheses when using expressions such as “most studies” or “some studies”.
4. I am sorry, as I know this represents a substantial amount of work, but I believe that if the first studies in the table are listed in alphabetical order, the same approach should also be applied to the remaining ones.
5. As the importance of the outcomes measured to demonstrate the effectiveness of TeamSTEPPS® is emphasized throughout the manuscript (e.g., lines 151-152, which methods were used to evaluate the benefits promoted by Team STEPPS®), I recommend adding a paragraph presenting a synthesis of these data.
6. In my opinion, it is necessary to describe here what was found across the different identified thematic categories. The most relevant findings identified in the analysis of the different thematic categories should be mentioned in order to subsequently discuss it. For example: Regarding Theme 1 “Academic Education, Interprofessional Education, and Simulation” both healthcare professionals (e.g., physicians, nurses, and pharmacists). This represents a result that can subsequently be discussed.

 

Discussion

In my opinion, in order to properly discuss the identified themes, it is first necessary to present in the Results section the findings related to these themes, which are currently reported in the Discussion. I therefore recommend revising the Discussion by moving the most of the data related to the studies included to the Results section and leaving in the Discussion the interpretation and discussion of these results.

Conclusion

Please clarify and verify the number of included studies reported.

Author Response

Dear reviewer,

We truly appreciate the insights you have provided. They were very helpful in polishing the final version of this manuscript. We have addressed all your recommendations point by point, as detailed below.

 

Comment 1: Abstract - In the methodological section, it would be appropriate to briefly report the criteria used for the selection of studies (if the text becomes too long, you may remove the following information: “Two independent reviewers performed the screening, selection, and data extraction processes”)..

Response: Thank you for your constructive suggestion. In accordance with your recommendation, we revised the abstract.

 

Comment 2: Lines 156-162: I recommend including a reference that justifies what is appropriately reported regarding the suitability of the scoping review for addressing the research question.

Response: Thank you for this suggestion. The suitability of the scoping review design for addressing the research question is explained in the manuscript (Lines 227–232).

 

Comment 3: Lines 165-176: To promote greater clarity for the reader and avoid redundancy, I recommend redrafting these lines by integrating all the information presented in: (1) the research question and (2) the aim of the scoping review (there are currently two aims/objectives).

Response: We thank for this helpful suggestion. In response, we revised lines 165–176 to improve clarity and reduce redundancy by integrating the research question and the objectives of the scoping review into a single, coherent aim.

 

Comment 4: The PRISMA checklist is missing from the supplementary file.

Response: We apologize if the supplementary file containing the PRISMA checklist was not accessible in the previous submission. We have now submitted a revised version in which the PRISMA checklist has been properly included in the supplementary materials.

 

Comment 5: Line 246: I suggest replacing “paper selection” with “bibliographic source selection”.

Response: Thank you for the suggestion. We have replaced “paper selection” with “bibliographic source selection” as recommended. We appreciate your helpful input.

 

Comment 6: I recommend moving the flow diagram as well as the search results (lines 246-255) to the “Results” section, as they represent outcomes derived from the application of the described methodology.

Response: Thank you very much for your thoughtful suggestion. After careful consideration, we have decided to keep the flow diagram and the search results in their current position. We believe that presenting them alongside the methodology helps readers better understand the process as it unfolds, ensuring greater clarity and continuity. We truly appreciate your valuable input and the opportunity to clarify our choices.

 

 

Comment 7: Lines 277-283: It would be appropriate to report, in the data extraction section, the same elements presented in the table, using identical wording. Additionally, I suggest numbering the supplementary files (e.g., Supplementary File 1, Supplementary File 2) and clearly referring to them in the text.

Response: Thank you for your valuable suggestion. We have now numbered the supplementary files (e.g., Supplementary File 1, Supplementary File 2) and clearly referred to them in the text as recommended. We appreciate your helpful feedback.

 

Comment 8: Lines 285-286: The data are incomplete. Please revise accordingly.

Response: Thank you very much for your comment. We appreciate your attention to detail. However, we kindly note that the line numbers you referred to do not correspond to the current version of the manuscript.

 

Comment 9: Results - It is important to explicitly state that all descriptive data of the included studies are presented in the supplementary material table, as this information is highly relevant. Nevertheless, I understand that, due to its length, the table has been placed in the supplementary material, which is common in scoping reviews.

Response: Thank you for your comment. We fully agree with your observation. For this reason, we have included all descriptive data of the included studies in the supplementary material, ensuring that this important information remains accessible to all readers. We appreciate your valuable feedback and support.

 

 

Comment 10: Lines 301-312: Please consider adding specific numbers in parentheses when using expressions such as “most studies” or “some studies”.

Response: Thank you for this comment. We have revised the manuscript to include specific numbers in parentheses when using expressions such as “most studies” or “some studies”.

 

Comment 11: I am sorry, as I know this represents a substantial amount of work, but I believe that if the first studies in the table are listed in alphabetical order, the same approach should also be applied to the remaining ones.

Response: Thank you for your comment. We have already made this change, and all studies in the table are now listed in alphabetical order.

 

Comment 12: As the importance of the outcomes measured to demonstrate the effectiveness of TeamSTEPPS® is emphasized throughout the manuscript (e.g., lines 151-152, which methods were used to evaluate the benefits promoted by Team STEPPS®), I recommend adding a paragraph presenting a synthesis of these data.

Response: We thank the reviewer for this suggestion. In response, we have added a synthesis paragraph in the conclusions section that integrates the outcomes used to demonstrate the effectiveness of the TeamSTEPPS® program.

 

Comment 13: In my opinion, it is necessary to describe here what was found across the different identified thematic categories. The most relevant findings identified in the analysis of the different thematic categories should be mentioned in order to subsequently discuss it. For example: Regarding Theme 1 “Academic Education, Interprofessional Education, and Simulation” both healthcare professionals (e.g., physicians, nurses, and pharmacists). This represents a result that can subsequently be discussed.

Response: We thank the reviewer for this helpful suggestion. In response, we have added a concise synthesis paragraph in the results section describing the main findings identified across the different thematic categories.

 

 

Comment 14: In my opinion, in order to properly discuss the identified themes, it is first necessary to present in the Results section the findings related to these themes, which are currently reported in the Discussion. I therefore recommend revising the Discussion by moving the most of the data related to the studies included to the Results section and leaving in the Discussion the interpretation and discussion of these results.

Response: We thank for this thoughtful comment. While we understand the concern raised, we respectfully consider that the current structure of the manuscript already clearly distinguishes between the presentation of results and their interpretation. The Results section focuses on describing the findings emerging from the thematic analysis, whereas the Discussion section is intended to contextualize and interpret these findings in light of existing literature and prior reviews. For this reason, we believe that moving most of the study-related data from the Discussion to the Results section would compromise the interpretative nature of the Discussion and reduce the analytical coherence of the manuscript. We therefore opted to maintain the current structure, which we believe ensures clarity and alignment with the objectives of a scoping review.

 

Comment 15: Conclusion - Please clarify and verify the number of included studies reported.

Response: We thank the reviewer for noting this issue. The number of included studies reported in the Conclusions section has been reviewed, clarified, and corrected accordingly to ensure consistency throughout the manuscript.

 

 

 

 

Round 2

Reviewer 3 Report (New Reviewer)

Comments and Suggestions for Authors

Dear Authors,

The majority of the requested changes have been appropriately addressed, resulting in an improvement in the overall quality of the manuscript. I have only two minor suggestions:

1. Sorry for insisting, but I still believe that the study flow diagram should be moved to the Results section, as it represents the outcomes obtained by applying the described methodology.
2. In the Results section, it is necessary to clearly specify in the text that the study characteristics are presented in the Supplementary File, as this information is currently indicated only in the Methods section.

Author Response

Dear reviewer,

We sincerely value the feedback received. Your comments were instrumental in refining the final version of the manuscript. We have carefully considered and responded to each of your suggestions individually, as outlined below.

 

Comment 1: Sorry for insisting, but I still believe that the study flow diagram should be moved to the Results section, as it represents the outcomes obtained by applying the described methodology.

Response: We thank the reviewer for the continued emphasis on this point. In response, the PRISMA flow diagram has been moved to the Results section.

 

Comment 2: In the Results section, it is necessary to clearly specify in the text that the study characteristics are presented in the Supplementary File, as this information is currently indicated only in the Methods section.

Response: We thank the reviewer for highlighting this point. In response, we have revised the Results section to explicitly indicate that detailed study characteristics are presented in the Supplementary File.

 

 

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript entitled “Enhancing teamwork and patient safety through Team-STEPPS®: A scoping review of benefits in academic and clinical settings” was interesting. The authors aimed to map the existing evidence on the benefits of implementing TeamSTEPPS® in educational and professional settings, emphasizing its contribution to sustainable teamwork, patient safety, and organizational learning. However, the following issues need further attentions.

• The manuscript has been revised and track changes are still visible. It was much better if the authors uploaded the clean version of the manuscript.
• In the abstract, the authors reported qualitative and quantitative research along with quality improvement. What do the researchers mean by quality improvement? Is it “action research”? Can we consider it under qualitative, quantitative or mixed-methods studies?
• Please choose the keywords using the MeSH Terms.
• Please use the full form of OECD in the text of the introduction.
• The number of searched databases is quite limited. PubMed and Web of Science are the main databases which need to be searched.
• The authors included studies with different settings and different target groups. However, team working may have several challenges in different settings and among various target groups. Therefore, the inclusion criteria should be refined.
• The search string is quite limited to a few terms which is unusual.
• After examining the full text of the papers, reasons for excluding irrelevant ones should be added to the PRISMA-ScR diagram.
• Table 2 is not easy to follow, clear and transparent, and needs to be re-designed.
• The details of each paper should be summarized in a table.

Author Response

Dear Reviewer,

Please see the attachment

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

• The authors address a highly relevant and timely topic in nursing, “Enhancing teamwork and patient safety through Team-STEPPS”. The authors used a rigorous scoping review methodology, followed PRISMA, and synthesized evidence across educational and clinical contexts. The manuscript is generally well-structured, comprehensive, and clearly written, with strong thematic synthesis. However, the Methods section would benefit from improved methodological clarity, particularly regarding the search strategies used to identify and include studies in this scoping review.
• Regarding the search strategy, the authors used relatively narrow keywords (“TeamSTEPPS AND outcomes”), which may have limited the retrieval of relevant studies. This represents a methodological limitation that is inconsistent with the exploratory and comprehensive nature of scoping reviews. N
• The authors discussed strength of evidence across themes. Identifying contradictions or inconsistent findings. I enjoyed reading this section.
• Conclusions are somewhat descriptive. I suggest that the authors can enhance the Conclusions in a way that would move the manuscript beyond synthesis toward practice-informed guidance, increasing its relevance for decision-makers and aligning it more closely with the objectives of this scoping review.

Author Response

Dear Reviewer,

Please see the attachment

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

1. The manuscript is well structured and redacted. English does not require more improvement.
2. The manuscript is interesting and explores the team-STEPPS current situation, well justified and exploring it in a worldwide perspective. 
3. Tables and figures are clear and contain enough information about the topic studied.
4. Discussion and conclusions are well redacted and justified that it can be important to develop further studies in this field.

 

The manuscript is well written and structured and it is ready to be published. No more comments are needed

Author Response

Dear Reviewer,

Please see the attachment

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

 

1. Correct Title and Abstract Typos:

   • Title: Change "Scopping Review" to "Scoping Review".

   • Abstract, Results: The phrase "Twenty-threattricks published" is unclear and appears to be a significant typographical error. Please correct it to state the accurate number of included studies (e.g., "Twenty-three studies published...").

   • Abstract/Main Text Consistency: In the Abstract, the study designs are listed as quantitative (n=15), qualitative (n=4), and quality-improvement (n=4). In the Results section (Page 6), the corresponding percentage for quality-improvement studies is given as (4.3%; n=4), which is a miscalculation (4 out of 23 is ~17.4%). Please correct the percentage in the main text to ensure numerical consistency.

2. Clarify and Polish Key Sentences:

   • Page 9, Lines 317-318: The sentence beginning "Umoren et al. [57] demonstrate some possible methods to reduce interprofessional attacks via simulating virtual computers..." is garbled and its meaning is obscure. It likely intends to describe using virtual simulation to reduce communication errors or interprofessional conflicts. Please rewrite this sentence for clarity and accuracy.

   • A careful proofread is recommended to catch other minor grammatical or phrasing issues that slightly affect flow (e.g., ensure consistent use of "client" vs. "patient" based on journal style, though this is generally well-managed).

3. Enhance Data Presentation:

   • Figure 2 (Summary of Included Articles): The "Scientific Journals" segment of the pie chart is currently not informative, showing only one journal title and "Others." To improve this figure's utility, please consider:

     • Listing the 2-3 most frequently occurring journals by name and grouping the remainder as "Others (n=XX)", or

     • If journal distribution is not a key finding, consider presenting a different, more relevant summary metric in this space.

   • Table 2 (Synthesis Table): In the provided draft, the cells of this table are empty. It is assumed this is a placeholder. This table is crucial. In the final manuscript, please ensure it is populated to indicate (e.g., with checkmarks, Xs, or brief notes) which of the 23 included studies provide evidence relevant to each of the four thematic categories. This will allow readers to visually trace the evidence supporting your synthesis.

4. Correct Structural Inconsistencies:

   • Section Numbering: The "Limitations" section is numbered "5" and the "Conclusions" is numbered "7," with no section "6." Please renumber the sections sequentially (e.g., 5. Limitations, 6. Conclusions) to avoid confusion.

   • Abbreviations List: The definition for "SWAT" is given as "Strengths, Weaknesses, Opportunities e Threats." Please change the "e" to "and" or "&" for consistency with common acronym presentation (i.e., "and Threats").

5. Strengthen the Limitations Section:

   • The current limitations are valid. Consider adding a brief mention of the potential for publication bias in the included literature (i.e., that studies with positive results are more likely to be published), which is a common consideration in reviews of intervention outcomes. This would further demonstrate critical appraisal.

Author Response

Dear Reviewer,

Please see the attachment

Author Response File: Author Response.pdf

Reviewer 5 Report

Comments and Suggestions for Authors

This manuscript presents a well-conducted scoping review examining the benefits of the TeamSTEPPS® program across academic and clinical settings. However, several minor issues should be addressed to strengthen clarity, rigor, and interpretive precision.

1. The authors are encouraged to more explicitly articulate what this review adds beyond existing reviews, particularly those published between 2018 and 2023. A clearer distinction between confirmation of known benefits and genuinely novel insights (e.g., sustainability, governance, leadership reinforcement) would strengthen the manuscript’s contribution.
2. Although this is a scoping review, some phrasing in the Discussion and Conclusions risks implying effectiveness or causal impact (e.g., “demonstrate clear benefits,” “proved to be more effective”). Given the heterogeneity of study designs and the absence of quality appraisal (appropriate for scoping reviews), conclusions should be framed more cautiously, emphasizing reported benefits rather than demonstrated effectiveness.
3. The manuscript repeatedly notes that short-term improvements are common and that sustainability requires reinforcement. This is an important finding, but it would benefit from a more explicit synthesis: Which outcomes appear most sensitive to decay over time? Which contextual factors (leadership, mandatory training, organizational embedding) are consistently associated with longer-term maintenance? Making these patterns more explicit would enhance the analytical value of the review.

Author Response

Dear Reviewer,

Please see the attachment

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I appreciate the authors for their time and efforts to revise the mnuscript. However, a number of my methodological comments have been addressed in the limitation section. In my opinion, the number of databses, search strings, and inclusion/exclusion criteria needed to be revised not just being mentioned in the limitation section.