Adaptation of the Norwegian version of the TeamSTEPPS Teamwork Perceptions Questionnaire for use in ambulance services: A validation study

Adaptation of the Norwegian version of the TeamSTEPPS Teamwork Perceptions Questionnaire for use in ambulance services: A validation study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Adaptation of the Norwegian version of the TeamSTEPPS Teamwork Perceptions Questionnaire for use in ambulance services: A validation study Tore Karlsen, Randi Ballangrud, Kjetil Myhr, Jan Porthun, Stephen J.M. Sollid, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9444718/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Well-functioning teamwork is essential for providing quality of care in healthcare organizations and is acknowledged globally as a patient safety core competency for health professionals. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) Teamwork Perceptions Questionnaire has been validated to measure health professionals’ perception of teamwork in hospital settings in several countries, however, as far as we know, never within an ambulance service. The aim of this study is to test the psychometric properties of the Norwegian version of the TeamSTEPPS Teamwork Perceptions Questionnaire among ambulance professionals. Methods A total of 154/199 (77%) ambulance professionals responded to the questionnaire. The Norwegian version of the questionnaire was tested for face validity by an expert group representing the target population and was semantically adapted. Cronbach’s alpha was used to establish the questionnaire`s internal consistency. Confirmatory factor analysis was conducted with one modified- and one unmodified model to assess the questionnaire’s factor structure. Results The confirmatory factor analysis demonstrates an adequate fit for the five - factor structure consistent with the original English language version of the questionnaire. The confirmatory factor analysis of both models revealed satisfactory fit of the questionnaire with fit indexes of Root Mean Square Error of Approximation = 0.059, Comparative Fit Index = 0.958, Tucker - Lewis Index = 0.955 and Standardized Root Mean Square Residual = 0.068. Chi-square was statistically significant p < 0.05. Factor loading of items to the predefined latent factors ranged from 0.608–0.920, except for one item with a loading of 0.181. Cronbach’s alpha values ranged from 0.77 to 0.87 for the five dimensions. Conclusion The results indicate that the Norwegian version of TeamSTEPPS Teamwork Perception Questionnaire demonstrates good psychometric properties, including internal consistency. The questionnaire serves as a valuable tool for assessing teamwork, identifying areas for improvement, and guiding implementations of interventions aimed at enhancing teamwork and patient safety when used in a sample of ambulance professionals. This study also found that one item within the Team Structure dimension likely did not reflect the perception of Team Structure among ambulance professionals and should therefore be interpreted with caution. Trial registration ClinicalTrials.gov-ID: NCT05244928 Confirmatory factor analysis Ambulance professionals Teamwork Patient safety Figures Figure 1 Figure 2 Figure 3 Figure 4 Background The importance of teamwork for quality of care and patient safety is acknowledged globally and is highlighted by the World Health Organization (WHO) as a core patient safety competency for healthcare professionals [ 1 , 2 ]. Effective teamwork is essential for mitigating patient safety issues and for improving patient outcomes [ 3 , 4 ]. Teamwork is defined by Oandasan [ 5 , p. 3] as “The interaction or relationship of two or more health professionals who work interdependently to provide care for patients”. Ambulance professionals primarily work in teams of two and regularly interact and collaborate with other first responders and healthcare professionals within multi-team systems [ 6 ]. These include nurses in municipal care settings, operators at Emergency Medical Call Centres, general practitioners, emergency critical care doctors, firefighters, police officers, and emergency personnel at the hospital. Patients and their next of kin are considered integral members of the team [ 7 ]. In 2005, the Agency for Health Research and Quality (AHRQ), in collaboration with the Department of Defence, developed a team training program aimed at enhancing team performance and patient safety within healthcare settings [ 7 ]. This program, Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), emphasizes Team Structure and four core, teachable skills: Communication, Leadership, Situation Monitoring, and Mutual Support [ 7 ]. Team Structure reflects how members identify and organize the components of a multi-team system, ensuring effective collaboration to maintain patient safety. Communication encompasses structured processes for the clear and accurate exchange of information among team members. Leadership focuses on optimizing team performance by clarifying actions, sharing updated information, and ensuring access to necessary resources. Situation Monitoring involves actively scanning and assessing situational elements to maintain situational awareness and support team functioning. Mutual Support builds on Situation Monitoring and reflects the ability to anticipate and assist team members’ needs through accurate knowledge about their responsibilities and workload [ 7 ]. These four skills are interdependent and equally critical for safe and effective patient care. Their application fosters shared awareness of team activities and progress toward goals, enhances understanding of roles and responsibilities, and promotes positive attitudes toward teamwork [ 7 , 8 ]. The TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) [ 9 ] was developed as a part of the TeamSTEPPS measurement package to assess perception of teamwork in the organization or units where teamwork occurs. The T-TPQ has been widely applied in hospital settings among multiprofessional teams [ 10 – 16 ] among nurses [ 17 – 19 ], and residents [ 20 ]. Keebler et al. [ 13 ] conducted the first study to examine the psychometric properties of the T-TPQ in its original language. Since then, the questionnaire has been translated, adapted, and validated across diverse healthcare contexts and among various professional groups. T-TPQ has undergone adaptation and psychometric testing in Norway [ 15 ], Sweden [ 12 ], Japan [ 21 ], Colombia [ 10 ], Belgium [ 14 ], Tunisia [ 22 ], and Thailand [ 23 ] among multidisciplinary healthcare professionals working in hospitals. T-TPQ has also been tested in China with hospital residents [ 20 ] and among hospital nurses in Turkey [ 17 ], Korea [ 18 ], and Iran [ 19 ]. This broad adaptation and validation of T-TPQ underscore the global emphasis on teamwork in healthcare. Confirmatory factor analyses across these studies generally supported the five-factor structure of the T-TPQ, although some fit indices varied. Test-retest reliability was reported as fair to good in the Norwegian [ 15 ], French and Belgian [ 14 ], Chinese [ 20 ], French and Tunisian versions [ 22 ]. Furthermore, the questionnaire demonstrated concurrent validity with other teamwork measures, including the Hospital Survey on Patient Safety Culture and the Safety Attitudes Questionnaire [ 20 ]. The context of ambulance services differs significantly from that of hospital settings, characterized by fewer resources and a more unpredictable Team Structure. Therefore, testing the questionnaire among ambulance professionals is of considerable interest. To our knowledge, an adaptation of T-TPQ for use in ambulance services, along with an assessment of its psychometric properties in this context, has not previously been conducted. The aim of this study is to test the psychometric properties of the Norwegian version of the T-TPQ among ambulance professionals for use within ambulance services. Methods Design This study employs a cross-sectional design to test the psychometric properties of the Norwegian version of the T-TPQ among ambulance professionals for use within ambulance services. This study is a part of a longitudinal, multimethod research project to evaluate medication administration and the implementation of the team training program TeamSTEPPS in an ambulance service (TEAM-AMB) [ 24 ]. Setting and Sample The questionnaire was distributed within a Norwegian hospital trust comprising 24 ambulance stations, serving a population of about 370,000 inhabitants across an area of more than 52,000 km². The TEAM-AMB study included seven of the 24 ambulance stations and were divided into group 1 and group 2. The other ambulance stations were invited to participate in this validation study of the T-TPQ. Based on the sample size calculation, a target of 386 participants was calculated. However, due to technical issues, only 199 ambulance professionals ultimately received the questionnaire. Participant Characteristics A total of 154 ambulance professionals, representing various professional roles within the ambulance services, responded to the questionnaire. Most participants were emergency medical technicians or paramedics, predominantly male, aged 25–39 years, and had between 0 and 10 years of work experience in the ambulance service, as summarized in Table 1 . Table 1 Characteristics of the sample. Characteristics of sample (N = 154). n (%) Ambulance professionals (n = 153) Emergency medical technicians Paramedics Nurse Other 65 (42.5) 51 (33.3) 9 (5.9) 28 (18.3) Gender (n = 152) Male Female 94 (61.8) 58 (38.2) Age (n = 153) ≤24 years 25–39 years 40–54 years ≥55 years 19 (12.4) 67 (43.8) 54 (35.3) 13 (8.5) Work experience in the ambulance services (n = 153) 0–10 years 11–20 years >20 years 67 (43.8) 53 (34.6) 33 (21.6) The questionnaire The T-TPQ measures the individual healthcare professional’s perception of group-level team skills and behaviour and includes the TeamSTEPPS dimensions Team Structure, Communication, Leadership, Situation Monitoring, and Mutual Support. The questionnaire is a self-report instrument consisting of 35 items, with seven items representing each dimension (see Table 2 ). Responses are scored on a five-point Likert scale from 1 = strongly disagree to 5 = strongly agree [ 9 ]. Table 2 T-TPQ dimensions and items adapted for a Norwegian ambulance setting. Team Structure (T) T1 The skills of ambulance professionals overlap sufficiently so that work can be shared when necessary T2 Ambulance professionals are held accountable for their actions T3 Ambulance professionals within the station share information that enables timely decision making by the direct patient care team T4 The ambulance station makes efficient use of resources (e.g., staff, equipment, and information) T5 Ambulance professionals understand their roles and responsibilities T6 The ambulance station has clearly articulated goals T7 The ambulance station operates at a high level of efficiency Leadership (L) L1 Team leaders consider the ambulance professionals` input when making decisions about patient care L2 The management provides opportunities to discuss the ambulance professionals performance after an event L3 The management takes time to meet the ambulance professionals at the ambulance station to develop plans/procedures/guidelines for patient care. L4 The management ensures that adequate resources are available (e.g., staff, supplies, equipment, information) L5 The management resolves conflicts successfully L6 The management models appropriate team behaviour L7 The management ensures that ambulance professionals at the station are aware of any situations or changes that may affect patient care Situation Monitoring (S) S1 Ambulance professionals effectively anticipate each other`s needs S2 Ambulance professionals observe each other`s performance S3 Ambulance professionals exchange relevant information as it becomes available S4 Ambulance professionals continuously scan the environment for important information S5 Ambulance professionals share information regarding potential complications (e.g., changes in the patient`s condition) S6 Ambulance professionals meet to reevaluate patient care goals when aspects of the situation have changed S7 Ambulance professionals correct each other`s mistakes to ensure that procedures are followed properly Mutual Support (M) M1 Ambulance professionals assist fellow staff during high workload M2 Ambulance professionals request assistance from fellow staff when they feel overwhelmed M3 Ambulance professionals caution each other about potentially dangerous situations M4 Feedback between the ambulance professionals is delivered in a way that promotes positive interactions and future change M5 Ambulance professionals advocate for patients even when their opinion conflicts with that of a senior member of the unit M6 When ambulance professionals have a concern about patient safety, they challenge others until they are sure the concern has been heard M7 Ambulance professionals resolve their conflicts, even when the conflicts have become personal Communication (C) C1 Information regarding patient care is explained to patients and their families in lay terms C2 Ambulance professionals relay relevant information to patients and their families in a timely manner C3 When communicating with patients, ambulance professionals allow enough time for questions C4 Ambulance professionals use common terminology when communicating with each other C5 Ambulance professionals verbally verify information that they receive from one another C6 Ambulance professionals follow a standardized method of sharing information when handing off patients (e.g. in the emergency department or to other departments) C7 Ambulance professionals seek information from all available sources (e.g. the patient, relatives, the team, medical records, lab results, research) Adaptation of T-TPQ for use in Norwegian ambulance services The Norwegian version of the T-TPQ underwent an adaptation process to fit the ambulance service context. Members of the research group adjusted the item wording to ensure relevance without altering the original content. Face and content validity were assessed by 30 ambulance professionals from the target population, following the recommendation of Polit and Yang [ 25 ], which emphasize sampling diversity within the target group. The test group evaluated the questionnaire on a five-point scale regarding relevance, precision, articulation, and understandability of the 35 items. Overall, the expert panel considered the items understandable and easy to score from “strongly disagree” to “strongly agree”. Minor clarifications were added to some items to improve specificity. Item T2 was perceived as understandable but overly general, and comments indicated a lack of context; however, no changes were made based on these remarks. Further, this item was perceived as insufficiently context-specific and therefore open to interpretation. No modifications were made. The translation and adaptation process is illustrated in Fig. 1 . Data collection The survey was conducted as follows: Data collection for group 1 was carried out from January 25, 2022, and for group 2 from September 5, 2022. Additionally, data collection for the other ambulance stations was carried out at the same time as group 1. Two reminders were sent to non-responders at two and seven days after the initial distribution. The survey was administrated electronically. One questionnaire was excluded because it was incomplete, resulting in a final response rate of 154 out of 199 (77%). Data analysis Data were examined for missing item responses before further analysis. We planned to replace missing data with median score when missingness was random and accounted for less than 2%, however, no missing data were observed for the items within the dimensions. Descriptive statistics were used to describe the sample characteristics and to calculate the mean, SD, skewness, kurtosis, and floor and ceiling effects of items and dimensions. The normality of the endogenous variables was visually inspected, and skewness and kurtosis were calculated. Further, the data were checked for outliers. Internal consistency within dimensions was explored with Cronbach’s alpha coefficient. Internal consistency was deemed to be acceptable when the value was higher than 0.7 [ 25 ]. A confirmatory factor analysis (CFA) was employed to evaluate the fit of two pre-defined models to our collected data [ 26 ]. The two different models were tested: an unmodified model, corresponding to model 1 in Keebler et al. [ 13 ] and Ballangrud et al. [ 15 ], and a modified model, corresponding to the final model of Keebler et al.`s [ 13 ] and model 2 in the study by Ballangrud et al. [ 15 ]. Keebler et al. [ 13 ] arguments for modifying the model were to test if the modifications improved the fit. In accordance with Keebler et al. [ 13 ], the modification in our study was done by adding a correlation between error terms for four pairs of items in the same dimension, Leadership item L5 and L6, Mutual Support item M1 and M2 and M5 and M7, and finally between Communication item C1 and C3, as these items contained highly similar contents [ 13 ]. The model fit was estimated utilizing the recommended fit indices across all models. The chi-square test (χ²) and the Standardized Root Mean Square Residual (SRMR) served as the absolute fit indices. Furthermore, the Root Mean Square Error of Approximation (RMSEA) was used [ 26 ]. The χ² -test should be nonsignificant with a p-value > 0.05, the RMSEA has a threshold value of ≤ 0.06, and SRMR should have a value close to 0.08 to reflect a relatively good fit of the model to the observed data [ 27 ]. Comparative fit indexes were calculated by using comparative fit index (CFI) and Tucker - Lewis fit index (TLI). CFI compares the model with a null model where all the variables are uncorrelated. CFI and TLI should have values close to 0.95 or greater [ 26 , 27 ]. Correlation between the latent dimensions were analysed. A positive correlation was assumed as all dimensions are supposed to reflect aspects of teamwork perceptions [ 25 ]. P-value ≤ 0.05 was considered as statistically significant. The statistical analyses were conducted using IBM SPSS AMOS 26 and MPlus Version 8.11 software. Language editing Language editing support was provided using an AI-based tool (Microsoft Copilot, powered by GPT technology). Results Test of normal distribution of responses All items demonstrated an approximately normal distribution on the five-point rating scale (1 = Strongly disagree to 5 = Strongly agree), indicating no floor or ceiling effect in this sample (Fig. 2). The least frequently selected option was “strongly disagree” (1). Notably, no participants selected “strongly disagree” for the items T2-3, T5, S1-2, S4-7, M1, M3, and C1-3. Item 1 to Item 7 = Items per dimension; Numbers on the bar charts: 1 = Strongly disagree; 2 = Disagree; 3 = Neutral; 4 = Agree; 5 = Strongly agree Figure 2. Distribution of answers to all questions in percent. Test of reliability Internal consistency for the dimensions ranged from 0.77 to 0.87, as measured by Cronbach’s alpha: Team Structure α = 0.77, Communication α = 0.85, Mutual Support α = 0.86, Leadership α = 0.87, and Situation Monitoring α = 0.87. Intercorrelation between the latent dimensions Our analysis revealed positive correlations among all dimensions. Intercorrelation between the latent dimensions ranged from r = 0.41 to r = 0.75, as illustrated in Fig. 3. The strongest correlation was observed between Mutual Support and Communication (r = 0.75) and Mutual Support and Situation Monitoring (r = 0.75), while the weakest correlation occurred between Leadership and Situation Monitoring (r = 0.41). *p-value < 0.001. All Correlations (Corr) with 95% Confidence Intervals (CI) in parentheses. The diagonal displays density plots that illustrate the distributions. The scatter plots depict the correlation among the T-TPQ dimensions. Figure 3. Intercorrelations between dimensions illustrated with Pearson correlations, scatterplots and graph. Test of construct validity Goodness of fit was assessed using CFA. Both model 1 (unmodified) and model 2 (modified) yielded significant chi-square value (p < 0.05). Table 3 presents the goodness-of-fit indexes of the two models. Table 3 Goodness of fit indexes model 1 (unmodified) and model 2 (modified model). Goodness-of -fit statistics Threshold values Model 1 Model 2 df = 550 df = 546 Chi-Square Χ 2 P > 0.05 P < 0.05 P < 0.05 RMSEA (90% CI) 0.90 0.958 0.961 TLI > 0.90 0.955 0.957 SRMR < 0.08 0.068 0.067 RMSEA= Root mean square error of approximation, CFI = Comparative fit Index, TLI = Tucker - Lewis Index, SRMR = Standardized Root Mean Square Residual, df = Degree of freedom Fit indices for the unmodified model indicated acceptable values and the modified model demonstrated marginally improved fit. However, the chi-square test remained significant for both models (p < 0.001), as shown in Table 4 and Fig. 4 . The CFA indicated regression weights (factor loading) for the five dimensions in the unmodified model ranged from 0.608 to 0.920 across 35 items. High factor loading reflects a strong relationship between the items and their corresponding latent dimension. However, item T2 exhibited an unacceptable loading of 0.181. In Model 2, where error terms were correlated in accordance with the final model of Keebler et al. [ 13 ], factor loadings were slightly lower than in the unmodified model and did not improve overall goodness of fit. Table 4 Factor loading Model 1 and Model 2. Parameter Model 1 (unmodified model) Model 2 (modified model) Factor loading SE Factor loading SE Team Structure T1 0.643 0.055 0.644 0.055 T2 0.181 0.080 0.181 0.080 T3 0.723 0.053 0.723 0.053 T4 0.679 0.050 0.679 0.050 T5 0.800 0.037 0.800 0.037 T6 0.676 0.055 0.676 0.055 T7 0.697 0.045 0.697 0.045 Leadership L1 0.617 0.059 0.615 0.060 L2 0.794 0.042 0.795 0.042 L3 0.795 0.037 0.798 0.038 L4 0.789 0.041 0.790 0.041 L5 0.779 0.039 0.721 0.047 L6 0.811 0.035 0.760 0.042 L7 0.735 0.051 0.738 0.051 Situation Monitoring S1 0.646 0.060 0.646 0.060 S2 0.627 0.055 0.627 0.055 S3 0.775 0.037 0.775 0.037 S4 0.833 0.034 0.833 0.034 S5 0.857 0.027 0.856 0.027 S6 0.850 0.029 0.850 0.029 S7 0.877 0.032 0.877 0.032 Mutual Support M1 0.776 0.040 0.775 0.039 M2 0.722 0.039 0.721 0.040 M3 0.785 0.042 0.783 0.042 M4 0.870 0.027 0.867 0.027 M5 0.661 0.044 0.642 0.046 M6 0.804 0.033 0.788 0.035 M7 0.643 0.052 0.641 0.052 Communication C1 0.920 0.029 0.916 0.030 C2 0.877 0.036 0.876 0.036 C3 0.751 0.042 0.745 0.043 C4 0.737 0.046 0.737 0.046 C5 0.802 0.035 0.802 0.035 C6 0.608 0.050 0.607 0.050 C7 0.628 0.056 0.623 0.055 SE=standard error Discussion Discriminant validity Findings in this study indicate there are a discriminant difference between the dimensions Team Structure, Communication, Leadership, Situation Monitoring, and Mutual Support. The correlation between the latent dimensions ranged from 0.48 to 0.88 in the CFA analysis and from 0.41 to 0.75 using the Pearson correlation equation. A high correlation (> 0.9) indicates low discrimination between dimensions [ 28 ]. Additionally, the analysis showed no floor or ceiling effect and suggests the possibility of change in perception of teamwork when the T-TPQ is used to evaluate teamwork or results of interventions aimed at improving teamwork in a unit or institution. Reliability The analysis showed acceptable internal consistency within the latent dimensions. The Team Structure dimension exhibited the lowest internal consistency, with a value of 0.77, which is still considered acceptable [ 25 ]. Previous studies have reported varying internal consistency values for the Team Structure dimension, ranging from 0.78 in the French and Belgian version [ 14 ] to 0.92 in the original English version [ 13 ]. These variations may be attributed to differences in the sample sizes and to the fact that the French and Belgian version removed two items from the Team Structure dimension [ 14 ], resulting in five items instead of seven. Construct validity Correlations between dimensions were all positive and significant, as they are designed to represent aspects of perceptions of teamwork [ 9 ]. However, the highest correlation coefficient was observed between the dimensions Mutual Support and Communication, with a value of 0.88. A change in the Communication dimension is associated with a change in the Mutual Support dimension and vice versa. This could indicate that ambulance professionals could improve Mutual Support skills by improving Communication skills. This aligns with the vision of the TeamSTEPPS team training program [ 7 ]. In previous research, the English, Turkish, and Iranian versions demonstrated a high correlation between Mutual Support and Communication with a value above 0.80 [ 13 , 17 , 19 ]. The Norwegian version reported correlation between Mutual Support and Communication with a value of 0.66 [ 15 ], and the Thai version a value of 0.61 [ 23 ], both within a sample of interprofessional healthcare personnel in hospital. The correlation between Mutual Support and Communication in the French and Tunisian version was 0.54 [ 22 ] and, and the Swedish version 0.56 [ 12 ], also within a hospital-based interprofessional sample. These variations in intercorrelation between latent dimensions may indicate that different samples in different countries interpret the latent dimensions differently, depending on their teamwork experience and the context in which teamwork occurs. Comparison of correlations between the latent dimensions from previous studies may be of limited value, as some studies use correlation equations with Pearson correlation and some use CFA-based correlations. The higher correlations observed between the latent dimensions in the CFA (Fig. 4 ) compared with Pearson correlations of the dimensions (Fig. 3) are attributable to the fact that CFA estimates relationships between latent constructs after accounting for measurement error. In contrast, Pearson correlations are based on observed scores and are therefore attenuated by unreliability, leading to systematically lower estimates of association. CFA correlation equations between latent dimensions account for latent variables which are not directly observed and reflect relationships that consider measurement error and the structure of the specified model [ 25 ]. Factor loading of the items to their respective latent dimensions were strong ranging from 0.60 to 0.92. Acceptable values should be > 0.3–0.4 to reflect aspects of the latent construct [ 26 ]. Item T2 was an outlier, with a factor loading of 0.18 in both models, and should be interpreted with caution when the questionnaire is used in ambulance services. Previous studies have not reported similar low factor loadings for item 2 [ 13 , 14 , 19 ]. The Thai version of T-TPQ showed low factor loadings for item T1 [ 23 ], and the French and Belgian version reported low factor loading on item T1 and T2 in the Team Structure dimension [ 14 ], leading to removal of the item. The TeamSTEPPS 3.0 curriculum has moved the Team Structure to the Leadership module [ 7 ]. This change may indicate that Leadership and establishing the Team Structure are more closely related within teamwork than initially assumed by the designer of the original TeamSTEPPS program. However, the AHRQ website has not yet updated the T-TPQ instruments to align with the revised curriculum [ 7 ]. Based on our study and the others that have found low factor loading of items for the Team Structure dimension, a revision of the questionnaires could be considered to match the updated TeamSTEPPS curriculum. Our analysis showed a significant chi-square value, as previous studies, regardless of the model tested [ 12 , 13 , 15 , 23 ]. A chi-square test should ideally be non-significant to indicate a good model fit. However, this test is highly sensitive to sample size [ 29 ]. Therefore, a significant result does not necessarily suggest poor model fit. Goodness of fit Both the unmodified model and the model with post hoc modification demonstrated acceptable or good model fit. This indicates that the original structure of the T-TPQ provides a satisfactory fit when applied to a sample of ambulance professionals. The unmodified model, which assumes no correlation between error terms and is based on Keebler et al.`s [ 13 ] initial model, demonstrated a superior fit compared to Keebler’s analysis of their unmodified model, as evidenced by the TLI, CFI, and RMSEA indices. Our modified model (model 2) exhibited a better fit in terms of CFI and TLI in comparison to Keebler`s final model; however, it did not show an improvement in the RMSEA index. Model 2 in our study exhibits as good or better fit for ambulance professionals compared to its performance in a sample of Norwegian interprofessional hospital healthcare personnel [ 15 ], as well as the findings reported in the Swedish version by Hall-Lord et al. [ 12 ]. Keebler et al.’s [ 13 ] modified model (Model 2) was tested in the two previous Scandinavian studies and in the French and Tunisian version, and it demonstrated a good factor structure [ 12 , 15 , 22 ]. Later studies have reported good model fit without the need for modification [ 10 , 17 ]. The modifications applied to the model were based on similarities among items within the same dimension. Strengths and limitation The study has some limitations. In this study the sample size was 154, which is lower than recommended. Polit and Yang suggest a sample of 10 participants per item [ 25 ]. Due to a technical issue, only 199 of the 386 planned participants received the questionnaire. This technical failure affected ambulance stations that were not part of the TeamSTEPPS intervention. When the issue was discovered, data collection had already begun, and the team training intervention was underway. Sending a new invitation was considered inappropriate due to the considerable time that had passed and because the questionnaire was conducted anonymously. The expert group who commented on the clarity and ease to respond to the T-TPQ items, found some items too generic and difficult to answer, as the context was not specified. This comment applied to item T2 and may explain its low factor loading. These comments were not implemented in the adaptation process, but providing examples of relevant contexts should be considered carefully when adapting the questionnaire to new settings and samples. Despite these limitations, our findings show goodness of fit similar to, and in some cases better than, previous studies. Our analysis demonstrated an RMSEA index with a narrow confidence interval, which strengthens the findings despite the low sample size [ 26 ]. A strength in our study was that the model did not require modification to achieve acceptable fit for the targeted sample. However, we did not conduct a test-retest reliability assessment, which could have strengthened our findings for the reliability of our results. The preparation of this manuscript has been inspired by the COSMIN checklist [ 30 ]. Conclusions The Norwegian version of the T-TPQ demonstrated acceptable reliability and construct validity for measuring ambulance professionals’ individual perceptions of teamwork in ambulance service. Item T2 showed low factor loading in both models, indicating that this item does not adequately reflect the Team Structure construct when applied in a Norwegian ambulance context. A reformulation of the translation to better fit the ambulance setting should be considered. Our study showed that the model provides a good fit for representing the five dimensions of teamwork perception when used in a sample of ambulance professionals. The Norwegian version of the T-TPQ is a valuable tool for assessing teamwork, identifying areas for improvement, and implementing interventions to enhance teamwork and patient safety in ambulance services. Further research with a larger sample of ambulance professionals and in ambulance services in other countries is recommended to provide additional insight into the findings of this study. Abbreviations CFI Comparative fit index CFA Confirmatory factor analysis RMSEA Root Mean Square Error of Approximation SRMR Standardized Root Mean Square Residual TLI Tucker - Lewis fit index TeamSTEPPS The Team Strategies and Tools to Enhance Performance and Patient Safety T-TPQ The TeamSTEPPS Teamwork Perceptions Questionnaire Declarations Ethics approval and consent to participate The study was approved by the Data Protection Officer at the Hospital Trust (reference no: 16797830), and the head of the Prehospital Division at the Hospital Trust. The study was reviewed by the Regional Committees for Medical and Health Research Ethics Central Norway (reference no: 250950). All the participants received written information about the study. Participation in the survey was voluntary and confirmed by answering and submitting questionnaires electronically. Consent for publication Not applicable. Availability of data and materials The data are not publicly available. However, the dataset analyzed during the current study can be made available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests and no financial disclosures. Funding This study was funded by the Norwegian University of Science and Technology and Innlandet Hospital Trust. Authors` contribution For this study, RB, KM, JP, SJMS, KRO and AV contributed to the planning of the study concept and design. KM carried out the data collection. TK and JP had the main responsibility for to the data analysis. TK and AV had the main responsibility for drafting the manuscript, and all authors TK, RB, KM, JP, SJMS, KRO and AV reviewed and revised the manuscript. The final version of the manuscript to be published is approved by the authors. Acknowledgements The authors would like to acknowledge the ambulance professionals for participating in the study, as well as the support from the leaders of the units and the division. We would also like to thank Eystein Grusd (EG), Pål Anders Mæhlum (PAM), and Karina Aase (KA) for their contributions to the planning of the study. Furthermore, we would like to acknowledge the hospital trust and the Norwegian University of Science and Technology for the support and the opportunity to carry out the project. Finally, we are grateful for the collaboration with the SHARE - Centre for Resilience in Healthcare at the University of Stavanger. Authors` information 1 Department of Health Sciences Gjøvik, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Gjøvik, Norway. 2 Department of Acute Care Medicine, Division Elverum-Hamar, Innlandet Hospital Trust, Norway. 3 Department of Prehospital Care, Division Prehospital, Innlandet Hospital Trust, Brumunddal, Norway. 4 Center for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, 5 Department of Research, Innlandet Hospital Trust, Brumunddal, Norway. Norway. References World Health Organization. Organisation for Economic Co-operation and Development, The World Bank, Delivering quality health services: a global imperative for universal health coverage [Internet]. Geneva: WHO;2018. https://www.who.int/publications/i/item/9789241513906 . Accessed 2 Oct 2024 World Health Organization. Global patient safety action plan 2021–2030: towards eliminating avoidable harm in health care [Internet]: Geneva: WHO (2021) https://www.who.int/teams/integrated-health-services/patient-safety/policy/global-patient-safety-action-plan . Accessed 2 Oct 2024 Rosen MA, DiazGranados D, Dietz AS, Benishek LE, Thompson D, Pronovost PJ et al (2018) Teamwork in healthcare: Key discoveries enabling safer, high-quality care. AM Psychol 73(4):433. http://dx.doi.org/10.1037/amp0000298 Schmutz JB, Meier LL, Manser T (2019) How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis. BMJ Open 9(9):e028280. https://doi.org/https://10.1136/bmjopen-2018-028280 Oandasan I, Baker GR, Barker K, Bosco C, D`Amour D, Jones LC et al (2006) Teamwork in healthcare: Promoting effective teamwork in healthcare in Canada. Policy synthesis and recommendations. Ontario: Canadian Health Services Research Foundation, Ottawa Patterson PD, Weaver MD, Hostler D (2017) Teams and teamwork in emergency Medical Services. Human factors and ergonomics of prehospital emergency care. edn.: CRC, pp 95–108 Agency for Healthcare Research and Quality (AHRQ). TeamSTEPPS 3.0 [Internet]. Content last reviewed March 2025. Rockville (MD): Agency for Healthcare Research and Quality (2023) https://www.ahrq.gov/teamstepps-program/index.html . Accessed 1 May 2025 King HB, Battles J, Baker DP, Alonso A, Salas E, Webster J et al (2008) TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety. In: Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Rockville (MD); Agency for Healthcare Research and Quality; https://www.ncbi.nlm.nih.gov/books/NBK43686/ Accessed 2 Oct 2024 Battles J, King HB (2010) Teamstepps teamwork perceptions questionnaire (T-TPQ) manual. American Institute for Research, Washington (DC) Amaya-Arias AC, García-Valencia J, Jaimes F (2024) Cross-Cultural Validation of the TeamSTEPPS Teamwork Perceptions Questionnaire-Spanish in Colombia. J Nurs Care Qual 39(2):E23–E29. https://doi.org/10.1097/ncq.0000000000000755 Dener H, Elçin M (2025) Use of the measurement tools of TeamSTEPPS®: a scoping review. BMC Med Educa 25(1):172. https://doi.org/10.1186/s12909-025-06759-x Hall-Lord ML, Skoogh A, Ballangrud R, Nordin A, Bååth C (2020) The Swedish version of the teamstepps® teamwork perceptions questionnaire (T-tpq): A validation study. J Multidiscip Healthc 13:829–837. https://doi.org/10.2147/JMDH.S261768 Keebler JR, Dietz AS, Lazzara EH, Benishek LE, Almeida SA, Toor PA et al (2014) Validation of a teamwork perceptions measure to increase patient safety. : BMJ Publishing Group Ltd 718. https://doi.org/10.1136/bmjqs-2013-001942 Diep AN, Paquay M, Servotte J-C, Dardenne N, Istas L, Van Ngoc P et al (2022) Validation of a French-language version of TeamSTEPPS® T-TPQ and T-TAQ questionnaires. J Interprof Care 36(4):607–616. https://doi.org/10.1080/13561820.2021.1902293 Ballangrud R, Husebø SIE, Hall-Lord ML (2017) Cross-cultural validation and psychometric testing of the Norwegian version of the TeamSTEPPS® teamwork perceptions questionnaire. BMC Health Serv Res 17:799. https://doi.org/10.1186/s12913-017-2733-y Lakatamitou I, Lambrinou E, Kyriakou M, Paikousis L, Middleton N (2020) The Greek versions of the TeamSTEPPS teamwork perceptions questionnaire and Minnesota satisfaction questionnaire short form. BMC Health Serv Res 20(1):587. https://doi.org/10.1186/s12913-020-05451-8 Yerköy Ateş A, Yıldırım A (2024) Adaptation of the TeamSTEPPS® Teamwork Perceptions Questionnaire into Turkish for a Nurse Sample: A Methodological Study. J Educ Res Nurs 21(2):99–106. https://doi.org/10.14744/jern.2023.81236 Hwang J-I, Ahn J (2015) Teamwork and clinical error reporting among nurses in Korean hospitals. Asian Nurs Res 9(1):14–20 Kakemam E, Rouzbahani M, Rajabi MR, Roh YS (2021) Psychometric testing of the Iranian version of the TeamSTEPPS teamwork perception questionnaire: a cross-cultural validation study. BMC Health Serv Res 21(1):1–705. https://doi.org/10.1186/s12913-021-06739-z Qu J, Zhu Y, Cui L, Yang L, Lai Y, Ye X et al (2020) Psychometric properties of the Chinese version of the TeamSTEPPS teamwork perceptions questionnaire to measure teamwork perceptions of Chinese residents: a cross-sectional study. BMJ Open 10(11):e039566–e039566. https://doi.org/10.1136/bmjopen-2020-039566 Unoki T, Matsuishi Y, Tsujimoto T, Yotsumoto R, Yamada T, Komatsu Y et al Translation, reliability and validity of Japanese version the TeamSTEPPS® teamwork perceptions questionnaire. Nurs Open 2021, 8(1):115–122. https://doi.org/10.1002/nop2.609 Idoudi M, Tlili MA, Mellouli M, Zedini C (2024) Cross-cultural validation and psychometric testing of the French version of the TeamSTEPPS teamwork perceptions questionnaire. J Health Organ Manag 38(6):923–941. https://doi.org/10.1108/JHOM-01-2023-0004 Rojnawee S, Thanomlikhit C, Narajeenron K, Kheawwan P (2025) Translation and psychometric evaluation of the Thai version of TeamSTEPPS® teamwork attitudes and teamwork perceptions questionnaires. J Interprof Care 39(2):267–274. https://doi.org/10.1080/13561820.2025.2452965 Vifladt A, Ballangrud R, Myhr K, Grusd E, Porthun J, Mæhlum PA et al (2023) Team training program's impact on medication administration, teamwork and patient safety culture in an ambulance service (TEAM-AMB): a longitudinal multimethod study protocol. BMJ Open 13(1):e067006. https://doi.org/http://dx.doi.org/10.1136/bmjopen-2022-067006 Polit DF, Yang F (2016) Measurement and the measurement of change: a primer for health professionals. Wolters Kluwer, Philadelphia (PA) Brown TA, Moore MT Confirmatory factor analysis. Handbook of structural equation modeling 2012, 361:379. https://www.researchgate.net/publication/251573889_Hoyle_CFA_Chapter_-_Final Lt H, Bentler PM (1999) Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct Equ Model 6(1):1–55. https://doi.org/10.1080/10705519909540118 Rönkkö M, Cho E (2022) An updated guideline for assessing discriminant validity. Organ Res Methods 25(1):6–14. https://doi.org/10.1177/1094428120968614 Kline RB (2011) Principles and practice of structural equation modeling, 3rd edn. Guilford Press, New York (NY) Mokkink LB, Terwee CB, Knol DL, Stratford PW, Alonso J, Patrick DL et al (2010) The COSMIN checklist for evaluating the methodological quality of studies on measurement properties: a clarification of its content. BMC Med Res Methodol 10:22. https://doi.org/10.1186/1471-2288-10-22 Additional Declarations The authors declare no competing interests. Supplementary Files Additionalfile1.TheNorwegianlanguageversionofTeamSTEPPSTeamworkPerceptionsQuestionnaireTTPQforuseinambulanceservices.docx Additional file 1. The Norwegian-language version of TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) for use in ambulance services. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9444718","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":625977780,"identity":"64328806-09c0-4ae0-8ae6-c19067e37ac3","order_by":0,"name":"Tore Karlsen","email":"","orcid":"https://orcid.org/0000-0002-1389-3472","institution":"Department of Health Sciences Gjøvik, Norwegian University of Science and Technology. Norway","correspondingAuthor":false,"prefix":"","firstName":"Tore","middleName":"","lastName":"Karlsen","suffix":""},{"id":625977781,"identity":"e6340d62-7566-41c1-b422-859b03e47fc9","order_by":1,"name":"Randi Ballangrud","email":"","orcid":"https://orcid.org/0000-0003-0403-0509","institution":"Department of Health Sciences Gjøvik, Norwegian University of Science and Technology. Norway","correspondingAuthor":false,"prefix":"","firstName":"Randi","middleName":"","lastName":"Ballangrud","suffix":""},{"id":625977782,"identity":"63ebedff-1789-4509-a564-a19d01cbb7b2","order_by":2,"name":"Kjetil Myhr","email":"","orcid":"https://orcid.org/0000-0002-3254-4171","institution":"Department of Health Sciences Gjøvik, Norwegian University of Science and Technology / Department of Acute Care Medicine, Innlandet Hospital Trust. 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Norway","correspondingAuthor":true,"prefix":"","firstName":"Anne","middleName":"","lastName":"Vifladt","suffix":""}],"badges":[],"createdAt":"2026-04-17 06:10:19","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9444718/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9444718/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108411419,"identity":"47d75578-7380-4966-9ebc-7d6b34020735","added_by":"auto","created_at":"2026-05-04 10:21:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":54917,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of the T-TPQ translation and validation process to a Norwegian ambulance service.\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-9444718/v1/1d74ab8687e740e3431f4965.png"},{"id":108411421,"identity":"d8250a61-4f2a-4370-a09d-3e38d73b8c40","added_by":"auto","created_at":"2026-05-04 10:21:43","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":128137,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of answers to all questions in percent.\u003c/p\u003e","description":"","filename":"image2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9444718/v1/0142d6e5a68346c1557dd514.jpeg"},{"id":108411422,"identity":"45926c8c-e6cf-4db2-91a3-491dc80f1b8a","added_by":"auto","created_at":"2026-05-04 10:21:43","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":154898,"visible":true,"origin":"","legend":"\u003cp\u003eIntercorrelations between dimensions illustrated with Pearson correlations, scatterplots and graph.\u003c/p\u003e","description":"","filename":"image3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9444718/v1/099c5943faa7833dbca216f7.jpeg"},{"id":108411423,"identity":"85a8d2d3-e5c1-4f1e-83fc-0f1214668e50","added_by":"auto","created_at":"2026-05-04 10:21:43","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":33576,"visible":true,"origin":"","legend":"\u003cp\u003eFactor loading and correlation between dimensions.\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-9444718/v1/4573b1cbaa158f7adddfb9e0.png"},{"id":108809068,"identity":"493d8208-d1a5-4ea1-80bc-f7a82b45020d","added_by":"auto","created_at":"2026-05-08 15:49:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":844704,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9444718/v1/27649019-4897-42fa-ba9e-767825213d13.pdf"},{"id":108803824,"identity":"ceeaad53-c19b-4573-aea8-418a488e9d08","added_by":"auto","created_at":"2026-05-08 15:08:32","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":26809,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 1\u003cstrong\u003e.\u003c/strong\u003e The Norwegian-language version of TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) for use in ambulance services.\u003c/p\u003e","description":"","filename":"Additionalfile1.TheNorwegianlanguageversionofTeamSTEPPSTeamworkPerceptionsQuestionnaireTTPQforuseinambulanceservices.docx","url":"https://assets-eu.researchsquare.com/files/rs-9444718/v1/b7535a2b135d610b79d16703.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eAdaptation of the Norwegian version of the TeamSTEPPS Teamwork Perceptions Questionnaire for use in ambulance services: A validation study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eThe importance of teamwork for quality of care and patient safety is acknowledged globally and is highlighted by the World Health Organization (WHO) as a core patient safety competency for healthcare professionals [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]. Effective teamwork is essential for mitigating patient safety issues and for improving patient outcomes [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e]. Teamwork is defined by Oandasan [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e, p. 3] as “The interaction or relationship of two or more health professionals who work interdependently to provide care for patients”. Ambulance professionals primarily work in teams of two and regularly interact and collaborate with other first responders and healthcare professionals within multi-team systems [\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]. These include nurses in municipal care settings, operators at Emergency Medical Call Centres, general practitioners, emergency critical care doctors, firefighters, police officers, and emergency personnel at the hospital. Patients and their next of kin are considered integral members of the team [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 2005, the Agency for Health Research and Quality (AHRQ), in collaboration with the Department of Defence, developed a team training program aimed at enhancing team performance and patient safety within healthcare settings [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]. This program, Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), emphasizes Team Structure and four core, teachable skills: Communication, Leadership, Situation Monitoring, and Mutual Support [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTeam Structure reflects how members identify and organize the components of a multi-team system, ensuring effective collaboration to maintain patient safety. Communication encompasses structured processes for the clear and accurate exchange of information among team members. Leadership focuses on optimizing team performance by clarifying actions, sharing updated information, and ensuring access to necessary resources. Situation Monitoring involves actively scanning and assessing situational elements to maintain situational awareness and support team functioning. Mutual Support builds on Situation Monitoring and reflects the ability to anticipate and assist team members’ needs through accurate knowledge about their responsibilities and workload [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]. These four skills are interdependent and equally critical for safe and effective patient care. Their application fosters shared awareness of team activities and progress toward goals, enhances understanding of roles and responsibilities, and promotes positive attitudes toward teamwork [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e] was developed as a part of the TeamSTEPPS measurement package to assess perception of teamwork in the organization or units where teamwork occurs. The T-TPQ has been widely applied in hospital settings among multiprofessional teams [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e] among nurses [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e], and residents [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Keebler et al. [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e] conducted the first study to examine the psychometric properties of the T-TPQ in its original language. Since then, the questionnaire has been translated, adapted, and validated across diverse healthcare contexts and among various professional groups.\u003c/p\u003e \u003cp\u003eT-TPQ has undergone adaptation and psychometric testing in Norway [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e], Sweden [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e], Japan [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e], Colombia [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e], Belgium [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e], Tunisia [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e], and Thailand [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e] among multidisciplinary healthcare professionals working in hospitals. T-TPQ has also been tested in China with hospital residents [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e] and among hospital nurses in Turkey [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e], Korea [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e], and Iran [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. This broad adaptation and validation of T-TPQ underscore the global emphasis on teamwork in healthcare. Confirmatory factor analyses across these studies generally supported the five-factor structure of the T-TPQ, although some fit indices varied. Test-retest reliability was reported as fair to good in the Norwegian [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e], French and Belgian [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e], Chinese [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e], French and Tunisian versions [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. Furthermore, the questionnaire demonstrated concurrent validity with other teamwork measures, including the Hospital Survey on Patient Safety Culture and the Safety Attitudes Questionnaire [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe context of ambulance services differs significantly from that of hospital settings, characterized by fewer resources and a more unpredictable Team Structure. Therefore, testing the questionnaire among ambulance professionals is of considerable interest. To our knowledge, an adaptation of T-TPQ for use in ambulance services, along with an assessment of its psychometric properties in this context, has not previously been conducted. The aim of this study is to test the psychometric properties of the Norwegian version of the T-TPQ among ambulance professionals for use within ambulance services.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eDesign\u003c/p\u003e\n\u003cp\u003eThis study employs a cross-sectional design to test the psychometric properties of the Norwegian version of the T-TPQ among ambulance professionals for use within ambulance services. This study is a part of a longitudinal, multimethod research project to evaluate medication administration and the implementation of the team training program TeamSTEPPS in an ambulance service (TEAM-AMB) [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eSetting and Sample\u003c/p\u003e\n\u003cp\u003eThe questionnaire was distributed within a Norwegian hospital trust comprising 24 ambulance stations, serving a population of about 370,000 inhabitants across an area of more than 52,000 km\u0026sup2;. The TEAM-AMB study included seven of the 24 ambulance stations and were divided into group 1 and group 2. The other ambulance stations were invited to participate in this validation study of the T-TPQ. Based on the sample size calculation, a target of 386 participants was calculated. However, due to technical issues, only 199 ambulance professionals ultimately received the questionnaire.\u003c/p\u003e\n\u003cp\u003eParticipant Characteristics\u003c/p\u003e\n\u003cp\u003eA total of 154 ambulance professionals, representing various professional roles within the ambulance services, responded to the questionnaire. Most participants were emergency medical technicians or paramedics, predominantly male, aged 25\u0026ndash;39 years, and had between 0 and 10 years of work experience in the ambulance service, as summarized in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of the sample.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics of sample (N\u0026thinsp;=\u0026thinsp;154).\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals (n\u0026thinsp;=\u0026thinsp;153)\u003c/p\u003e\n \u003cp\u003eEmergency medical technicians\u003c/p\u003e\n \u003cp\u003eParamedics\u003c/p\u003e\n \u003cp\u003eNurse\u003c/p\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e65 (42.5)\u003c/p\u003e\n \u003cp\u003e51 (33.3)\u003c/p\u003e\n \u003cp\u003e9 (5.9)\u003c/p\u003e\n \u003cp\u003e28 (18.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGender (n\u0026thinsp;=\u0026thinsp;152)\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e94 (61.8)\u003c/p\u003e\n \u003cp\u003e58 (38.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (n\u0026thinsp;=\u0026thinsp;153)\u003c/p\u003e\n \u003cp\u003e\u0026le;24 years\u003c/p\u003e\n \u003cp\u003e25\u0026ndash;39 years\u003c/p\u003e\n \u003cp\u003e40\u0026ndash;54 years\u003c/p\u003e\n \u003cp\u003e\u0026ge;55 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19 (12.4)\u003c/p\u003e\n \u003cp\u003e67 (43.8)\u003c/p\u003e\n \u003cp\u003e54 (35.3)\u003c/p\u003e\n \u003cp\u003e13 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWork experience in the ambulance services (n\u0026thinsp;=\u0026thinsp;153)\u003c/p\u003e\n \u003cp\u003e0\u0026ndash;10 years\u003c/p\u003e\n \u003cp\u003e11\u0026ndash;20 years\u003c/p\u003e\n \u003cp\u003e\u0026gt;20 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e67 (43.8)\u003c/p\u003e\n \u003cp\u003e53 (34.6)\u003c/p\u003e\n \u003cp\u003e33 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe questionnaire\u003c/p\u003e\n\u003cp\u003eThe T-TPQ measures the individual healthcare professional\u0026rsquo;s perception of group-level team skills and behaviour and includes the TeamSTEPPS dimensions Team Structure, Communication, Leadership, Situation Monitoring, and Mutual Support. The questionnaire is a self-report instrument consisting of 35 items, with seven items representing each dimension (see Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Responses are scored on a five-point Likert scale from 1\u0026thinsp;=\u0026thinsp;strongly disagree to 5\u0026thinsp;=\u0026thinsp;strongly agree [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eT-TPQ dimensions and items adapted for a Norwegian ambulance setting.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eTeam Structure (T)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe skills of ambulance professionals overlap sufficiently so that work can be shared when necessary\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals are held accountable for their actions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals within the station share information that enables timely decision making by the direct patient care team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe ambulance station makes efficient use of resources (e.g., staff, equipment, and information)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals understand their roles and responsibilities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe ambulance station has clearly articulated goals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe ambulance station operates at a high level of efficiency\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeadership (L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTeam leaders consider the ambulance professionals` input when making decisions about patient care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe management provides opportunities to discuss the ambulance professionals performance after an event\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe management takes time to meet the ambulance professionals at the ambulance station to develop plans/procedures/guidelines for patient care.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe management ensures that adequate resources are available (e.g., staff, supplies, equipment, information)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe management resolves conflicts successfully\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe management models appropriate team behaviour\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe management ensures that ambulance professionals at the station are aware of any situations or changes that may affect patient care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSituation Monitoring (S)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eS1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals effectively anticipate each other`s needs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eS2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals observe each other`s performance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eS3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals exchange relevant information as it becomes available\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eS4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals continuously scan the environment for important information\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eS5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals share information regarding potential complications (e.g., changes in the patient`s condition)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eS6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals meet to reevaluate patient care goals when aspects of the situation have changed\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eS7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals correct each other`s mistakes to ensure that procedures are followed properly\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMutual Support (M)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals assist fellow staff during high workload\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals request assistance from fellow staff when they feel overwhelmed\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals caution each other about potentially dangerous situations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFeedback between the ambulance professionals is delivered in a way that promotes positive interactions and future change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals advocate for patients even when their opinion conflicts with that of a senior member of the unit\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhen ambulance professionals have a concern about patient safety, they challenge others until they are sure the concern has been heard\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals resolve their conflicts, even when the conflicts have become personal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunication (C)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInformation regarding patient care is explained to patients and their families in lay terms\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals relay relevant information to patients and their families in a timely manner\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhen communicating with patients, ambulance professionals allow enough time for questions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals use common terminology when communicating with each other\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals verbally verify information that they receive from one another\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals follow a standardized method of sharing information when handing off patients (e.g. in the emergency department or to other departments)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmbulance professionals seek information from all available sources (e.g. the patient, relatives, the team, medical records, lab results, research)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdaptation of T-TPQ for use in Norwegian ambulance services\u003c/p\u003e\n\u003cp\u003eThe Norwegian version of the T-TPQ underwent an adaptation process to fit the ambulance service context. Members of the research group adjusted the item wording to ensure relevance without altering the original content. Face and content validity were assessed by 30 ambulance professionals from the target population, following the recommendation of Polit and Yang [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e], which emphasize sampling diversity within the target group. The test group evaluated the questionnaire on a five-point scale regarding relevance, precision, articulation, and understandability of the 35 items. Overall, the expert panel considered the items understandable and easy to score from \u0026ldquo;strongly disagree\u0026rdquo; to \u0026ldquo;strongly agree\u0026rdquo;. Minor clarifications were added to some items to improve specificity. Item T2 was perceived as understandable but overly general, and comments indicated a lack of context; however, no changes were made based on these remarks. Further, this item was perceived as insufficiently context-specific and therefore open to interpretation. No modifications were made. The translation and adaptation process is illustrated in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData collection\u003c/p\u003e\n\u003cp\u003eThe survey was conducted as follows: Data collection for group 1 was carried out from January 25, 2022, and for group 2 from September 5, 2022. Additionally, data collection for the other ambulance stations was carried out at the same time as group 1. Two reminders were sent to non-responders at two and seven days after the initial distribution. The survey was administrated electronically. One questionnaire was excluded because it was incomplete, resulting in a final response rate of 154 out of 199 (77%).\u003c/p\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eData were examined for missing item responses before further analysis. We planned to replace missing data with median score when missingness was random and accounted for less than 2%, however, no missing data were observed for the items within the dimensions.\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were used to describe the sample characteristics and to calculate the mean, SD, skewness, kurtosis, and floor and ceiling effects of items and dimensions. The normality of the endogenous variables was visually inspected, and skewness and kurtosis were calculated. Further, the data were checked for outliers. Internal consistency within dimensions was explored with Cronbach\u0026rsquo;s alpha coefficient. Internal consistency was deemed to be acceptable when the value was higher than 0.7 [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eA confirmatory factor analysis (CFA) was employed to evaluate the fit of two pre-defined models to our collected data [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. The two different models were tested: an unmodified model, corresponding to model 1 in Keebler et al. [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e] and Ballangrud et al. [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e], and a modified model, corresponding to the final model of Keebler et al.`s [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e] and model 2 in the study by Ballangrud et al. [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]. Keebler et al. [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e] arguments for modifying the model were to test if the modifications improved the fit. In accordance with Keebler et al. [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e], the modification in our study was done by adding a correlation between error terms for four pairs of items in the same dimension, Leadership item L5 and L6, Mutual Support item M1 and M2 and M5 and M7, and finally between Communication item C1 and C3, as these items contained highly similar contents [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThe model fit was estimated utilizing the recommended fit indices across all models. The chi-square test (\u0026chi;\u0026sup2;) and the Standardized Root Mean Square Residual (SRMR) served as the absolute fit indices. Furthermore, the Root Mean Square Error of Approximation (RMSEA) was used [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. The \u0026chi;\u0026sup2; -test should be nonsignificant with a p-value\u0026thinsp;\u0026gt;\u0026thinsp;0.05, the RMSEA has a threshold value of \u0026le;\u0026thinsp;0.06, and SRMR should have a value close to 0.08 to reflect a relatively good fit of the model to the observed data [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eComparative fit indexes were calculated by using comparative fit index (CFI) and Tucker - Lewis fit index (TLI). CFI compares the model with a null model where all the variables are uncorrelated. CFI and TLI should have values close to 0.95 or greater [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eCorrelation between the latent dimensions were analysed. A positive correlation was assumed as all dimensions are supposed to reflect aspects of teamwork perceptions [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]. P-value\u0026thinsp;\u0026le;\u0026thinsp;0.05 was considered as statistically significant. The statistical analyses were conducted using IBM SPSS AMOS 26 and MPlus Version 8.11 software.\u003c/p\u003e\n\u003cp\u003eLanguage editing\u003c/p\u003e\n\u003cp\u003eLanguage editing support was provided using an AI-based tool (Microsoft Copilot, powered by GPT technology).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTest of normal distribution of responses\u003c/p\u003e \u003cp\u003eAll items demonstrated an approximately normal distribution on the five-point rating scale (1\u0026thinsp;=\u0026thinsp;Strongly disagree to 5\u0026thinsp;=\u0026thinsp;Strongly agree), indicating no floor or ceiling effect in this sample (Fig.\u0026nbsp;2). The least frequently selected option was \u0026ldquo;strongly disagree\u0026rdquo; (1). Notably, no participants selected \u0026ldquo;strongly disagree\u0026rdquo; for the items T2-3, T5, S1-2, S4-7, M1, M3, and C1-3.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eItem 1 to Item 7\u0026thinsp;=\u0026thinsp;Items per dimension; Numbers on the bar charts: 1\u0026thinsp;=\u0026thinsp;Strongly disagree; 2\u0026thinsp;=\u0026thinsp;Disagree; 3\u0026thinsp;=\u0026thinsp;Neutral; 4\u0026thinsp;=\u0026thinsp;Agree; 5\u0026thinsp;=\u0026thinsp;Strongly agree\u003c/p\u003e \u003cp\u003eFigure 2. Distribution of answers to all questions in percent.\u003c/p\u003e \u003cp\u003eTest of reliability\u003c/p\u003e \u003cp\u003eInternal consistency for the dimensions ranged from 0.77 to 0.87, as measured by Cronbach\u0026rsquo;s alpha: Team Structure α\u0026thinsp;=\u0026thinsp;0.77, Communication α\u0026thinsp;=\u0026thinsp;0.85, Mutual Support α\u0026thinsp;=\u0026thinsp;0.86, Leadership α\u0026thinsp;=\u0026thinsp;0.87, and Situation Monitoring α\u0026thinsp;=\u0026thinsp;0.87.\u003c/p\u003e \u003cp\u003eIntercorrelation between the latent dimensions\u003c/p\u003e \u003cp\u003eOur analysis revealed positive correlations among all dimensions. Intercorrelation between the latent dimensions ranged from r\u0026thinsp;=\u0026thinsp;0.41 to r\u0026thinsp;=\u0026thinsp;0.75, as illustrated in Fig.\u0026nbsp;3. The strongest correlation was observed between Mutual Support and Communication (r\u0026thinsp;=\u0026thinsp;0.75) and Mutual Support and Situation Monitoring (r\u0026thinsp;=\u0026thinsp;0.75), while the weakest correlation occurred between Leadership and Situation Monitoring (r\u0026thinsp;=\u0026thinsp;0.41).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e*p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001. All Correlations (Corr) with 95% Confidence Intervals (CI) in parentheses. The diagonal displays density plots that illustrate the distributions. The scatter plots depict the correlation among the T-TPQ dimensions.\u003c/p\u003e \u003cp\u003eFigure 3. Intercorrelations between dimensions illustrated with Pearson correlations, scatterplots and graph.\u003c/p\u003e \u003cp\u003eTest of construct validity\u003c/p\u003e \u003cp\u003eGoodness of fit was assessed using CFA. Both model 1 (unmodified) and model 2 (modified) yielded significant chi-square value (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the goodness-of-fit indexes of the two models.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGoodness of fit indexes model 1 (unmodified) and model 2 (modified model).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGoodness-of -fit statistics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThreshold values\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModel 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModel 2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003edf\u0026thinsp;=\u0026thinsp;550\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003edf\u0026thinsp;=\u0026thinsp;546\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChi-Square \u003cem\u003eΧ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRMSEA\u003c/p\u003e \u003cp\u003e(90% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003cp\u003e(0.051\u0026ndash;0.067)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.058\u003c/p\u003e \u003cp\u003e(0.049\u0026ndash;0.065)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCFI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.958\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.961\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTLI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.955\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.957\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSRMR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.067\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRMSEA= Root mean square error of approximation, CFI\u0026thinsp;=\u0026thinsp;Comparative fit Index, TLI\u0026thinsp;=\u0026thinsp;Tucker - Lewis Index, SRMR\u0026thinsp;=\u0026thinsp;Standardized Root Mean Square Residual, df\u0026thinsp;=\u0026thinsp;Degree of freedom\u003c/p\u003e \u003cp\u003eFit indices for the unmodified model indicated acceptable values and the modified model demonstrated marginally improved fit. However, the chi-square test remained significant for both models (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe CFA indicated regression weights (factor loading) for the five dimensions in the unmodified model ranged from 0.608 to 0.920 across 35 items. High factor loading reflects a strong relationship between the items and their corresponding latent dimension. However, item T2 exhibited an unacceptable loading of 0.181. In Model 2, where error terms were correlated in accordance with the final model of Keebler et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], factor loadings were slightly lower than in the unmodified model and did not improve overall goodness of fit.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactor loading Model 1 and Model 2.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eModel 1\u003c/p\u003e \u003cp\u003e(unmodified model)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eModel 2\u003c/p\u003e \u003cp\u003e(modified model)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003cp\u003eloading\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003cp\u003eloading\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eTeam Structure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.643\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.644\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.723\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.053\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.723\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.053\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.679\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.050\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.679\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.050\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.800\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.800\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.676\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.676\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.697\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.697\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eLeadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.617\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.615\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.060\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.794\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.795\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.795\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.798\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.789\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.041\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.790\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.779\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.721\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.811\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.760\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.735\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.738\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eSituation Monitoring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eS1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.646\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.060\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.646\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.060\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eS2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.627\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.627\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eS3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.775\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.775\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eS4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.833\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.833\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eS5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.857\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.856\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eS6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.850\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.850\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eS7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.877\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.877\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eMutual Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.776\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.040\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.775\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.039\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.722\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.721\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.040\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.785\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.783\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.870\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.867\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.661\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.044\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.642\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.804\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.788\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.643\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.641\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eCommunication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.920\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.916\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.877\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.876\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.751\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.745\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.737\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.737\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.802\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.802\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.608\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.050\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.607\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.050\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.628\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.623\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eSE=standard error\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDiscriminant validity\u003c/p\u003e \u003cp\u003eFindings in this study indicate there are a discriminant difference between the dimensions Team Structure, Communication, Leadership, Situation Monitoring, and Mutual Support. The correlation between the latent dimensions ranged from 0.48 to 0.88 in the CFA analysis and from 0.41 to 0.75 using the Pearson correlation equation. A high correlation (\u0026gt;\u0026thinsp;0.9) indicates low discrimination between dimensions [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Additionally, the analysis showed no floor or ceiling effect and suggests the possibility of change in perception of teamwork when the T-TPQ is used to evaluate teamwork or results of interventions aimed at improving teamwork in a unit or institution.\u003c/p\u003e \u003cp\u003eReliability\u003c/p\u003e \u003cp\u003eThe analysis showed acceptable internal consistency within the latent dimensions. The Team Structure dimension exhibited the lowest internal consistency, with a value of 0.77, which is still considered acceptable [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Previous studies have reported varying internal consistency values for the Team Structure dimension, ranging from 0.78 in the French and Belgian version [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] to 0.92 in the original English version [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These variations may be attributed to differences in the sample sizes and to the fact that the French and Belgian version removed two items from the Team Structure dimension [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], resulting in five items instead of seven.\u003c/p\u003e \u003cp\u003eConstruct validity\u003c/p\u003e \u003cp\u003eCorrelations between dimensions were all positive and significant, as they are designed to represent aspects of perceptions of teamwork [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, the highest correlation coefficient was observed between the dimensions Mutual Support and Communication, with a value of 0.88. A change in the Communication dimension is associated with a change in the Mutual Support dimension and vice versa. This could indicate that ambulance professionals could improve Mutual Support skills by improving Communication skills. This aligns with the vision of the TeamSTEPPS team training program [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In previous research, the English, Turkish, and Iranian versions demonstrated a high correlation between Mutual Support and Communication with a value above 0.80 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The Norwegian version reported correlation between Mutual Support and Communication with a value of 0.66 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and the Thai version a value of 0.61 [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], both within a sample of interprofessional healthcare personnel in hospital. The correlation between Mutual Support and Communication in the French and Tunisian version was 0.54 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and, and the Swedish version 0.56 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], also within a hospital-based interprofessional sample. These variations in intercorrelation between latent dimensions may indicate that different samples in different countries interpret the latent dimensions differently, depending on their teamwork experience and the context in which teamwork occurs. Comparison of correlations between the latent dimensions from previous studies may be of limited value, as some studies use correlation equations with Pearson correlation and some use CFA-based correlations. The higher correlations observed between the latent dimensions in the CFA (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e4\u003c/span\u003e) compared with Pearson correlations of the dimensions (Fig.\u0026nbsp;3) are attributable to the fact that CFA estimates relationships between latent constructs after accounting for measurement error. In contrast, Pearson correlations are based on observed scores and are therefore attenuated by unreliability, leading to systematically lower estimates of association. CFA correlation equations between latent dimensions account for latent variables which are not directly observed and reflect relationships that consider measurement error and the structure of the specified model [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFactor loading of the items to their respective latent dimensions were strong ranging from 0.60 to 0.92. Acceptable values should be \u0026gt;\u0026thinsp;0.3\u0026ndash;0.4 to reflect aspects of the latent construct [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Item T2 was an outlier, with a factor loading of 0.18 in both models, and should be interpreted with caution when the questionnaire is used in ambulance services. Previous studies have not reported similar low factor loadings for item 2 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The Thai version of T-TPQ showed low factor loadings for item T1 [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and the French and Belgian version reported low factor loading on item T1 and T2 in the Team Structure dimension [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], leading to removal of the item. The TeamSTEPPS 3.0 curriculum has moved the Team Structure to the Leadership module [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This change may indicate that Leadership and establishing the Team Structure are more closely related within teamwork than initially assumed by the designer of the original TeamSTEPPS program. However, the AHRQ website has not yet updated the T-TPQ instruments to align with the revised curriculum [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Based on our study and the others that have found low factor loading of items for the Team Structure dimension, a revision of the questionnaires could be considered to match the updated TeamSTEPPS curriculum.\u003c/p\u003e \u003cp\u003eOur analysis showed a significant chi-square value, as previous studies, regardless of the model tested [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. A chi-square test should ideally be non-significant to indicate a good model fit. However, this test is highly sensitive to sample size [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Therefore, a significant result does not necessarily suggest poor model fit.\u003c/p\u003e \u003cp\u003eGoodness of fit\u003c/p\u003e \u003cp\u003eBoth the unmodified model and the model with post hoc modification demonstrated acceptable or good model fit. This indicates that the original structure of the T-TPQ provides a satisfactory fit when applied to a sample of ambulance professionals. The unmodified model, which assumes no correlation between error terms and is based on Keebler et al.`s [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] initial model, demonstrated a superior fit compared to Keebler\u0026rsquo;s analysis of their unmodified model, as evidenced by the TLI, CFI, and RMSEA indices. Our modified model (model 2) exhibited a better fit in terms of CFI and TLI in comparison to Keebler`s final model; however, it did not show an improvement in the RMSEA index. Model 2 in our study exhibits as good or better fit for ambulance professionals compared to its performance in a sample of Norwegian interprofessional hospital healthcare personnel [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], as well as the findings reported in the Swedish version by Hall-Lord et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Keebler et al.\u0026rsquo;s [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] modified model (Model 2) was tested in the two previous Scandinavian studies and in the French and Tunisian version, and it demonstrated a good factor structure [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Later studies have reported good model fit without the need for modification [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The modifications applied to the model were based on similarities among items within the same dimension.\u003c/p\u003e \u003cp\u003eStrengths and limitation\u003c/p\u003e \u003cp\u003eThe study has some limitations. In this study the sample size was 154, which is lower than recommended. Polit and Yang suggest a sample of 10 participants per item [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Due to a technical issue, only 199 of the 386 planned participants received the questionnaire. This technical failure affected ambulance stations that were not part of the TeamSTEPPS intervention. When the issue was discovered, data collection had already begun, and the team training intervention was underway. Sending a new invitation was considered inappropriate due to the considerable time that had passed and because the questionnaire was conducted anonymously.\u003c/p\u003e \u003cp\u003eThe expert group who commented on the clarity and ease to respond to the T-TPQ items, found some items too generic and difficult to answer, as the context was not specified. This comment applied to item T2 and may explain its low factor loading. These comments were not implemented in the adaptation process, but providing examples of relevant contexts should be considered carefully when adapting the questionnaire to new settings and samples.\u003c/p\u003e \u003cp\u003eDespite these limitations, our findings show goodness of fit similar to, and in some cases better than, previous studies. Our analysis demonstrated an RMSEA index with a narrow confidence interval, which strengthens the findings despite the low sample size [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. A strength in our study was that the model did not require modification to achieve acceptable fit for the targeted sample. However, we did not conduct a test-retest reliability assessment, which could have strengthened our findings for the reliability of our results.\u003c/p\u003e \u003cp\u003eThe preparation of this manuscript has been inspired by the COSMIN checklist [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe Norwegian version of the T-TPQ demonstrated acceptable reliability and construct validity for measuring ambulance professionals\u0026rsquo; individual perceptions of teamwork in ambulance service. Item T2 showed low factor loading in both models, indicating that this item does not adequately reflect the Team Structure construct when applied in a Norwegian ambulance context. A reformulation of the translation to better fit the ambulance setting should be considered.\u003c/p\u003e \u003cp\u003eOur study showed that the model provides a good fit for representing the five dimensions of teamwork perception when used in a sample of ambulance professionals. The Norwegian version of the T-TPQ is a valuable tool for assessing teamwork, identifying areas for improvement, and implementing interventions to enhance teamwork and patient safety in ambulance services. Further research with a larger sample of ambulance professionals and in ambulance services in other countries is recommended to provide additional insight into the findings of this study.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCFI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComparative fit index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCFA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfirmatory factor analysis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eRMSEA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRoot Mean Square Error of Approximation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSRMR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandardized Root Mean Square Residual\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eTLI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTucker - Lewis fit index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eTeamSTEPPS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe Team Strategies and Tools to Enhance Performance and Patient Safety\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eT-TPQ\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe TeamSTEPPS Teamwork Perceptions Questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Data Protection Officer at the Hospital Trust (reference no: 16797830), and the head of the Prehospital Division at the Hospital Trust. The study was reviewed by the Regional Committees for Medical and Health Research Ethics Central Norway (reference no: 250950). All the participants received written information about the study. Participation in the survey was voluntary and confirmed by answering and submitting questionnaires electronically.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe data are not publicly available. However, the dataset analyzed during the current study can be made available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests and no financial disclosures.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Norwegian University of Science and Technology and Innlandet Hospital Trust.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors` contribution\u003c/p\u003e\n\u003cp\u003eFor this study, RB, KM, JP, SJMS, KRO and AV contributed to the planning of the study concept and design. KM carried out the data collection. TK and JP had the main responsibility for to the data analysis. TK and AV had the main responsibility for drafting the manuscript, and all authors TK, RB, KM, JP, SJMS, KRO and AV reviewed and revised the manuscript. The final version of the manuscript to be published is approved by the authors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge the ambulance professionals for participating in the study, as well as the support from the leaders of the units and the division. We would also like to thank Eystein Grusd (EG), Pål Anders Mæhlum (PAM), and Karina Aase (KA) for their contributions to the planning of the study. Furthermore, we would like to acknowledge the hospital trust and the Norwegian University of Science and Technology for the support and the opportunity to carry out the project. Finally, we are grateful for the collaboration with the SHARE - Centre for Resilience in Healthcare at the University of Stavanger.\u003c/p\u003e\n\u003cp\u003eAuthors` information\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of Health Sciences Gjøvik, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Gjøvik, Norway. \u003csup\u003e2\u003c/sup\u003eDepartment of Acute Care Medicine, Division Elverum-Hamar, Innlandet Hospital Trust, Norway.\u003csup\u003e\u0026nbsp;3\u003c/sup\u003eDepartment of Prehospital Care, Division Prehospital, Innlandet Hospital Trust, Brumunddal, Norway. \u003csup\u003e4\u003c/sup\u003eCenter for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, \u003csup\u003e5\u003c/sup\u003eDepartment of Research, Innlandet Hospital Trust, Brumunddal, Norway.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNorway.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. 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Guilford Press, New York (NY)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMokkink LB, Terwee CB, Knol DL, Stratford PW, Alonso J, Patrick DL et al (2010) The COSMIN checklist for evaluating the methodological quality of studies on measurement properties: a clarification of its content. BMC Med Res Methodol 10:22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1471-2288-10-22\u003c/span\u003e\u003cspan address=\"10.1186/1471-2288-10-22\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Norwegian University of Science and Technology","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Confirmatory factor analysis, Ambulance professionals, Teamwork, Patient safety","lastPublishedDoi":"10.21203/rs.3.rs-9444718/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9444718/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eWell-functioning teamwork is essential for providing quality of care in healthcare organizations and is acknowledged globally as a patient safety core competency for health professionals. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) Teamwork Perceptions Questionnaire has been validated to measure health professionals\u0026rsquo; perception of teamwork in hospital settings in several countries, however, as far as we know, never within an ambulance service. The aim of this study is to test the psychometric properties of the Norwegian version of the TeamSTEPPS Teamwork Perceptions Questionnaire among ambulance professionals.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 154/199 (77%) ambulance professionals responded to the questionnaire. The Norwegian version of the questionnaire was tested for face validity by an expert group representing the target population and was semantically adapted. Cronbach\u0026rsquo;s alpha was used to establish the questionnaire`s internal consistency. Confirmatory factor analysis was conducted with one modified- and one unmodified model to assess the questionnaire\u0026rsquo;s factor structure.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe confirmatory factor analysis demonstrates an adequate fit for the five - factor structure consistent with the original English language version of the questionnaire. The confirmatory factor analysis of both models revealed satisfactory fit of the questionnaire with fit indexes of Root Mean Square Error of Approximation\u0026thinsp;=\u0026thinsp;0.059, Comparative Fit Index\u0026thinsp;=\u0026thinsp;0.958, Tucker - Lewis Index\u0026thinsp;=\u0026thinsp;0.955 and Standardized Root Mean Square Residual\u0026thinsp;=\u0026thinsp;0.068. Chi-square was statistically significant p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Factor loading of items to the predefined latent factors ranged from 0.608\u0026ndash;0.920, except for one item with a loading of 0.181. Cronbach\u0026rsquo;s alpha values ranged from 0.77 to 0.87 for the five dimensions.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe results indicate that the Norwegian version of TeamSTEPPS Teamwork Perception Questionnaire demonstrates good psychometric properties, including internal consistency. The questionnaire serves as a valuable tool for assessing teamwork, identifying areas for improvement, and guiding implementations of interventions aimed at enhancing teamwork and patient safety when used in a sample of ambulance professionals. This study also found that one item within the Team Structure dimension likely did not reflect the perception of Team Structure among ambulance professionals and should therefore be interpreted with caution.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003eClinicalTrials.gov-ID: NCT05244928\u003c/p\u003e","manuscriptTitle":"Adaptation of the Norwegian version of the TeamSTEPPS Teamwork Perceptions Questionnaire for use in ambulance services: A validation study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 10:21:35","doi":"10.21203/rs.3.rs-9444718/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6410f5fb-1b9f-456d-be51-b6baf46eb06e","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T10:21:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 10:21:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9444718","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9444718","identity":"rs-9444718","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}