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Original research article, overcoming challenges to teamwork in healthcare: a team effectiveness framework and evidence-based guidance.

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  • 1 University of Texas MD Anderson Cancer Center, Houston, TX, United States
  • 2 Rice University, Houston, TX, United States
  • 3 Group for Organizational Effectiveness, Albany, NY, United States

Background: Safe and effective patient care depends on the teamwork of multidisciplinary healthcare professionals. Unfortunately, the field currently lacks an evidence-based framework for effective teamwork that can be incorporated into medical education and practice across health professions. We introduce a comprehensive framework for team effectiveness. Common challenges to teamwork in healthcare are identified along with evidence-based strategies for overcoming them.

Methods: The framework was developed in four steps: 1) grounding in the existing team science literature, 2) semi-structured interviews ( N = 13), 3) thematic analysis and initial framework development, and 4) revision of the framework through input from healthcare professionals representative of different functions across the healthcare system ( N = 13). A diagnostic tool consisting of one survey item per team competency was developed to complement the framework. The survey was then administered to healthcare teams across clinical and administrative functions ( N = 10 teams, 96 individuals), and results were compiled and then used to conduct debriefs with individual team members and teams. A set of common teamwork challenges were identified using the survey and qualitative data. Qualitative data was analyzed to explore the unique ways these challenges manifest in both clinical and administrative teams.

Results: The five most common challenges that face healthcare teams relate to accountability, conflict management, decision-making, reflecting on progress, and coaching. These challenges were similar across both clinical and administrative team types. Based on the authors' collective experience designing and implementing Team Development Interventions (TDIs), strategies for managing each challenge are provided.

Conclusions: The proposed framework is unique in two ways. First, it's generally applicable across the many types of teams that contribute to the quality and safety of patient care. Second, the levels of the framework build upon each other to contribute to the development of the ideal team states. The framework and accompanying strategies can provide guidance for where and how to target developmental efforts.

Introduction

Multidisciplinary teams have been established as best practice for optimal patient care across many disciplines in healthcare ( Haward, 2008 ; Tripathy, 2003 ; Merién, et al., 2010 ). In fact, advancements in medicine and the complex regulatory and economic factors affecting healthcare necessitate the use of multidisciplinary teams across the clinical, research, and administrative sectors of health systems. Although teamwork has been integrated into core competency models of health professional education, there is still an imbalance with a stronger focus on individual skill development, individual contribution, and accountability ( Leggat, 2007 ). Given the decades of evidence that have borne out that teamwork skills contribute to performance (e.g., LePine et al., 2008 ), this lack of focus on teaming represents an important gap in professional preparation.

While the potential benefits of multidisciplinary teams are clear (e.g., a larger source of knowledge and skill from which the team can draw), working with team members from a wide variety of backgrounds can be challenging ( Fleissig, et al., 2006 ). The practical barriers to these teams reaching their full potential can include differences in training, professional values, approaches to problem solving, and understanding of critical issues ( Hall, 2005 ). Each team member also brings with them their unique personality, values, and communication preferences, which affects how team members interact and ultimately their ability to reach shared goals ( Bell et al., 2018 ). Considering the context in which these teams work, there are a number of challenges inherent to healthcare that can also hinder performance, including psychological barriers (e.g., professional silos, hierarchies, power differentials) and organizational barriers (e.g., distributed teams, hybrid working models; Weller et al., 2014 ).

It is not surprising then, that teamwork breakdowns continue to be a primary cause of errors and near misses in healthcare, with root cause analysis suggesting lack of effective teamwork (e.g., communication) is involved in 60–70% of serious patient incidents ( Rabøl, 2011 ). In the field, teamwork can affect clinical (e.g., diagnostic accuracy, time to response/treatment), patient (e.g., complications, length of stay; e.g., Schmutz and Manser, 2013 ), and employee (e.g., well-being and patient satisfaction; Ogbonnaya et al., 2018 ) outcomes. Fortunately, there is ample evidence to suggest that team interventions in the field can improve teamwork and team performance ( Hughes et al., 2016 ; Weaver, et al., 2014 ).

For teamwork interventions in healthcare to reach their full potential, we need to first identify what drives or contributes to performance. While we have an understanding of the broad teamwork competencies that contribute to effective performance (e.g., shared mental models, mutual respect and trust, communication; Weller et al., 2014 ), the healthcare field lacks an evidence-based, comprehensive framework to better understand what facilitates and hinders effective multidisciplinary teamwork. Also lacking is an understanding of the most common teamwork challenges for multidisciplinary teams, how they can manifest in the field, and how they can be addressed.

This effort set out to accomplish two primary objectives, both of which hold implications for research and practice: 1) to develop a comprehensive, evidence-based framework for healthcare team effectiveness, and 2) to generate a practical assessment tool that aligns with the framework and use this tool to identify common teamwork challenges. Towards the accomplishment of Objective 1, a framework for team effectiveness, informed by team science and grounded in data from the field, is introduced and critical team competencies defined. At present, the field has yet to establish a robust, evidence-based multidisciplinary framework for effective teamwork that can be integrated into current medical education curriculum. Limited extant team effectiveness research has attempted to generate integrative models that span across multiple healthcare contexts, and incorporate aspects of task design and organizational context ( Lemieux-Charles and McGuire, 2006 ). While we acknowledge these contributions as valuable to the field, existing models fail provide a sufficient, in-depth perspective of teamwork essential to multidisciplinary team effectiveness. In addition, existing frameworks that address teamwork fail to span across multiple health professions (e.g., neonatal resuscitation, Thomas et al., 2004 ; emergency medicine, Fernandez et al., 2008 ; and healthcare governance, Brown et al., 2018 ). Our framework addresses both of these concerns by defining components to team effectiveness that are essential to multidisciplinary teams across healthcare contexts (i.e., clinical, administrative, research).

To achieve our second objective, we created and administered a diagnostic tool aligned with the framework. Follow-up qualitative inquiry was used to provide a case study or enriched interpretation of how teams experience these challenges, potential root causes, and the consequences for team outcomes. Despite the significant progress that has been made in understanding the difficulties healthcare teams face, challenges unique to multidisciplinary teams and how they manifest in the field remain less understood ( Hall, 2005 ). As a result, the increase in multidisciplinary team care in healthcare settings has come with a tradeoff of placing teams in uncharted territory, encountering problems specific to interdependent multidisciplinary work that members are less equipped to navigate effectively. Finally, we complement these two objectives by providing evidence-based strategies or solutions, drawing from both the literature and our collective experience with team development, for addressing these common challenges.

In the sections that follow, we provide a brief discussion of relevant background research and report the development of the unified framework (Objective 1) created through interviews, focus groups, and extant literature. We also outline the development and refinement of a practical tool corresponding to the framework informed by team and healthcare subject matter experts or SMEs (Objective 2). In addition, we discuss deployment of this tool with a diverse sample of healthcare teams spanning multiple contexts within a larger hospital system. Following this, we present teamwork challenges identified through survey data and further explored through follow-up debriefs. We conclude by presenting illustrative case studies exemplifying five of the most common teamwork and evidence-based approaches to address these challenges.

We grounded this effort in the research literature on team effectiveness in healthcare. Below we provide a brief overview of this literature, drawing from three overarching streams of research that informed the present work. Specifically, we introduce the concept of team effectiveness and highlight research supporting three distinct dimensions of team effectiveness: team performance, team functioning, and team viability.

Team Effectiveness

Team effectiveness can remain elusive and ill-defined if not clearly operationalized and consistently measured. Towards this end, team effectiveness is best understood as the combination of 1) team performance (results), 2) team functioning, and 3) team viability ( Hackman and Lorsch, 1987 ). Essentially, effectiveness is a combination of what the team is able to accomplish (results – also referred to as team performance outcomes), how the team functions while working together on a daily basis (team functioning), and whether the team believes they would be able to continue successfully working together in the future (viability; Hackman and Lorsch, 1987 ). This multidimensional conceptualization is critical as it is not only present-focused, but takes into account future outcomes and members' beliefs about the team.

Team Performance (Results)

Team performance is regarded as a process reflective of individual and team-level teamwork, taskwork, and emergent team-level processes that arise when working towards a shared goal ( Kozlowski and Klein, 2000 ; Salas et al., 2007 ; Salas et al., 2008 ). Based on this definition, team performance is often captured through objective production metrics (quotas, rates of production, etc.) in an effort to substantiate assertions of team performance improvement with tangible results ( Barrick et al., 1998 ). Other subjective metrics have also proven useful in capturing team performance, such as peer and supervisor ratings ( Barrick et al., 1998 ). The healthcare industry operates in a high-reliability context, and has a critical need to continually enhance team performance due to the nature and gravity of sub-optimal performance (i.e., patient quality of care and safety). Importantly, patient outcomes are impacted by clinical, administrative, and research teams alike. Thus, understanding factors that underpin team performance across different healthcare functions is essential to promoting team effectiveness in healthcare.

Team Functioning

Team performance results from the combination of two streams of team functioning (i.e., how the team performs on a day-to-day basis): teamwork and taskwork ( Salas et al., 2004 ). Taskwork encompasses actions required for successful task completion contributing towards goal accomplishment ( Bowers et al., 1997 ), and teamwork consists of the interrelated attitudes, behaviors, and cognitions (ABCs) needed to carry out interdependent actions required of the team ( Salas et al., 2007 ). Although taskwork is acknowledged as important, researchers argue the linchpin to team performance is effective teamwork ( Weaver et al., 2010 ). Seminal research on teams in healthcare has established the linkage between teamwork and team performance outcomes. For example, Manser (2009) synthesized multiple streams of research, finding that research on adverse events, healthcare provider perceptions, and clinical performance all supported the positive relationship between teamwork and patient safety. Better teamwork is associated with lower patient morbidity and mortality, as well as other critical outcomes such as reduced nursing turnover and increased patient satisfaction. Taken together, teamwork has proven instrumental to healthcare performance outcomes, meriting efforts to clarify how best to facilitate effective teamwork.

Team Viability

The final component of team effectiveness, team viability , pertains to future predictions of team functioning. A team’s perception of viability is subject to change after each performance episode and can be based on a broad number of factors – team processes, inputs, outcomes, and context – making it a more dynamic feature of effectiveness to capture ( Bell, and Marentette, 2011 ). Despite the higher level of dynamism and fluidity in viability, researchers have asserted it is a critical criterion of effectiveness ( Sundstrom et al., 1990 ), as it can be used to forecast the likelihood of a team operating successfully in the future. As with the preceding criteria, supervisor ratings ( Barrick et al., 1998 ) and self-report measures (e.g., survey items) ( Bushe and Coetzer, 2007 ; Bell and Marentette, 2011 ) have been used to capture team viability. In sum, many methods have been deployed to assess each facet of team effectiveness; it is with this in mind that we endeavor to provide and pilot test both a framework and a practical diagnostic measure that is carefully aligned with the framework to capture team effectiveness in healthcare.

As previously mentioned, we aimed to achieve two objectives: 1) to develop a comprehensive, evidence-based framework for healthcare team effectiveness, and 2) create a practical assessment tool that aligns with the framework and use this tool to identify common teamwork challenges. Specifically, the framework was informed from multiple sources, including the literature on team science, interviews, and focus groups. Next, a practical tool that aligns with the framework was developed and refined based on input from team and healthcare SMEs. The tool was deployed with a diverse sample of teams across different healthcare functions in a large healthcare system. Finally, teamwork challenges were identified from both quantitative survey data and post-survey follow-up debriefs to add context and rich detail. In the sections that follow, the above process is outlined in more detail, followed by presentation of five of the most common teamwork challenges across the teams, rich illustrative cases studies of each challenge, and evidence-based solutions for addressing these challenges. This study received Institutional Review Board exemption and did not require informed consent (Protocol 2020-0627).

Participants

Objective 1.

For development of the Team Effectiveness Framework, participants included 26 (76.9% F, 23.1% M) employees from a large healthcare organization in the Southwest United States. Of all participants, 69.2% were White, 11.5% were Black, and 7.7% were Asian, 3.8% were Hispanic, and 7.7% were other or non-disclosed. These participants included 10 healthcare leaders representing a variety of functional areas (including Nursing Education, Pharmacy, Communications, Interprofessional Education, Performance Improvement, and Leadership Development), three team science SMEs, and 13 frontline healthcare employees.

Objective 2

Survey participants were 96 healthcare professionals ( N = 10 teams, 96 individuals; 66.7% F, 32.3% M) from a large healthcare organization in the Southwest United States employed across a variety of clinical and administrative functions. Of all participants, 31.3% were White, 30.2% were Black, and 22.9% were Asian, 12.5% were Hispanic, and 3.1% were other or non-disclosed (note that 13 participants contributed to both Objectives 1 and 2). A subset of 35 participants contributed to further qualitative data collection (20 individual interviews, one 15 person debrief). All participants were involved in an administrative team performance improvement program that was open to all members of the institution across clinical, research, and administrative sectors. The leaders of the teams opted in to the performance improvement program.

Research Design and Procedures

Development of the framework utilized a qualitative research design similar to a grounded theory, which is well-suited to the present effort because it allows for drawing from the vast knowledge on team science (i.e., a deductive approach) as well as for the capture of data unique to multidisciplinary healthcare teams (i.e., an inductive approach). Specifically, the literature on team science was used to create an initial framework based on existing theory. Competencies that have proven critical to teams were drawn from the literature to create an initial list for inclusion in the framework. Team science experts then conducted interviews and focus groups to develop and refine the framework to the unique context. Specifically, input was sought both from individuals who work together in teams in the field and from SMEs who work extensively with a variety of healthcare teams to ensure the framework would be applicable across different aspects of healthcare. The framework was developed through three steps.

Grounding in the Existing Team Science Literature

To identify potential team competencies of interest, we first scanned the literature on teams and team performance models in healthcare. Two team science SMEs reviewed these to establish a preliminary list of critical team competencies.

The two team science SMEs then conducted semi-structured interviews with a group of multidisciplinary healthcare professionals ( N = 13 ). The interview protocol addressed the structure and purpose of teams, individual roles and responsibilities, and factors that facilitate and hinder team performance.

Thematic Analysis and Initial Framework Development

Qualitative interview data were then thematically analyzed. Competencies identified through the interview process were integrated with the preliminary competencies identified from the literature to create an initial framework.

Refinement of the Framework Though Iterative Feedback and Revision

The initial framework was then presented to a working group of key stakeholders representative of the different functions across a healthcare system, including Nursing Education, Pharmacy, Communications, Interprofessional Education, Performance Improvement, and Leadership Development ( N = 13). Through a series of focus groups facilitated by two team science SMEs, stakeholders provided feedback that was incorporated into framework revisions. Specifically, stakeholders refined competency terms to aid in understanding and added key components not identified through the literature (e.g., Assume Positive Intent). The final framework contains 27 competencies that are critical to team effectiveness in healthcare ( see Figure 1 for framework and Appendix A for a description of competencies). Teams that exhibit these competencies demonstrate more effective team functioning (e.g., exchanging information effectively) and vitality (e.g., believing they can succeed) and experience conditions that enable team results (e.g., adequately staffed).

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FIGURE 1 . Comprehensive Team Effectiveness Framework.

Team Diagnostic Tool (Objective 2.1)

For Objective 2.1, we first needed to create a practical assessment tool to measure each of the 27 components of the framework (see Appendix A for a description). The Team Diagnostic Tool, designed to capture a snapshot of team effectiveness and reduce the survey fatigue common in healthcare, was developed in three steps:

Initial Item Development

First, one subject matter expert (SME) drafted one survey item per competency in the framework. Survey items were based on the competency definitions available in the literature.

Item Quality Review

Next, each item was independently reviewed by two subject matter experts for clarity and content. Item edits suggested by the SMEs were incorporated into the next iteration of the survey.

Item Comprehension Review

Finally, one expert in the field of employee development, but not in teams and teamwork, reviewed the items to ensure they were easily understandable by healthcare professionals across disciplines (i.e., free from jargon). Final item edits were made after this review, and items were uploaded to Qualtrics survey platform.

The final tool contained a set of 27 items that assess various aspects of team effectiveness. Items were rated on a Likert-type scale with the anchors: 1) Does Not Describe my Team at All to 9) Describes my Team Very Well. Example items include: 1) Both leaders and team members hold individuals accountable for their commitments and for behaving professionally, 2) Roles are defined clearly on this team, including responsibilities, reporting structure, and decision-making authority, and 3) Team members communicate effectively by exchanging information that is clear, accurate, timely, and unique.

Identification of Teamwork Challenges (Objective 2.2)

For Objective 2.2 , the identification of common teamwork challenges, we used a mixed method, explanatory design. Quantitative data collection and analysis (i.e., deployment of the Team Diagnostic Tool) was followed up by qualitative data collection (i.e., interviews and focus groups; see Appendix B for sample items) and analysis to aid in deeper interpretation of the data. Average interview and focus group length was approximately 1 h per interview/focus group.

Diagnosing Team Effectiveness

The Team Diagnostic Tool described above was deployed to each of the teams ( N = 10 teams, 96 individuals) that participated in the study. These healthcare teams represented both clinical and administrative functions. The purpose of the tool was to provide a practical and quantitative diagnosis of each team’s competencies as depicted in the framework and assess its strengths and potential challenges to team effectiveness.

Initial Presentation of Results

Once the data from the Team Diagnostic Tool was analyzed (i.e., team averages were calculated for each item), results were presented to the team leader and then team members (de-identified and aggregated to the team level) of each team.

Follow Up Debriefs

Following the presentation of Team Diagnostic Tool data, individual semi-structured interviews ( N = 20 individuals) and one focus group ( N = 15 individuals) were held. The purpose of the interviews and focus group was to operationalize or provide rich detail around the challenges identified by the initial Team Diagnostic Tool.

In sum, using data aggregated across all teams, teamwork competencies consistently among the lowest rated were identified and represent a set of common challenges to healthcare team performance. Qualitative data from semi-structured interviews and group debriefs were thematically analyzed to explore the unique ways these challenges manifest in both clinical and administrative teams. Below, we introduce the framework, present the common challenges for healthcare teams, and provide evidence-based guidance on how to address the challenges and create high-performing teams.

Framework Introduction

The proposed framework is unique in at least two ways ( see Figure 1 ; Zajac et al., in press ). First, it is broadly applicable across the many types of teams that contribute to the quality and safety of patient care. While the importance of teamwork across all types of healthcare teams (e.g., administrative and research teams; Leggat, 2007 ) has been recognized, the majority of research is conducted with clinical teams. We aim for the framework to be adopted to create and study team development interventions (TDIs) across all sectors of healthcare, and to be integrated into healthcare professional education. Second, the levels of the framework build upon each other to contribute to the development of the ideal team states. This point is critical when determining where to target limited resources for team development. If gaps exist in lower levels of the framework, efforts may be maximized by focusing there first.

The framework delineates 27 competencies that are essential for high-performing teams functioning in large healthcare systems. Specifically, we present a blueprint for fostering team effectiveness through a hierarchical structure of building blocks organized by overarching themes (i.e., levels). While we acknowledge the importance of individual level traits (e.g., assertiveness, personal cultural traits) on team effectiveness, we did not include them in our framework as we focus specifically on team level variables. The Foundations of team effectiveness can be thought of as laying the groundwork for successful teamwork (e.g., Supportive Culture); if these elements are not in place initially, it can have a negative bottom-up impact on components at higher levels of the framework. Often termed enabling conditions , these critical aspects of teams have been evidenced to account for up to half of the variation in team performance ( Hackman, 2012 ). The attitudes, behaviors, and cognitions, or ABCs of teamwork, refer to how teams think, feel, and act. Some ABCs are team-specific competencies in that they are associated with a specific team and context (e.g., clear roles, shared mental models), while others are generic or transportable and can be trained and brought to any team or situation (e.g., closed-loop communication; Weaver et al., 2010 ). Finally, the Ideal Team States are emergent properties that arise from individual team member characteristics and the ABCs, or how teams interact over time. According to Kozlowski and Klein (2000) , “A phenomenon is emergent when it originates in the cognition, affect, behaviors, or other characteristics of individuals, is amplified by their interactions, and manifests as a higher-level, collective phenomenon’’ (p. 55). Because these ideal team states are emergent and built from the ABCs and foundations, we focus our identification of team challenges at the first two levels of this framework ( see Appendix A for a description of each competency).

Identification of Teamwork Challenges

To identify common challenges, we began by calculating descriptive statistics including the average score of each competency within each team. Further analyses were then conducted to identify the five competencies consistently rated the lowest across all teams (i.e., which competencies were ranked lowest across teams with the highest frequency). The team-level competency ratings were dichotomized such that items rated within the five lowest competencies on the team indicated the presence of a challenge. The dichotomized variables were dummy coded across teams with challenging competencies valued as 1 and not challenging as 0. Frequencies were then generated to identify the five most challenging competencies (i.e., competencies that appeared in the bottom five most frequently). A comparison of clinical and non-clinical teams revealed the top challenges remained largely the same across the different functions.

To build upon these findings, qualitative data was collected in the form of field notes from free response questions embedded in the survey, interviews, and focus groups. This allowed for triangulation of the data and identification of the different ways in which challenges associated with each competency can manifest on teams. Researchers have supported the value of qualitative analyses in healthcare to capture underlying phenomena experienced by healthcare providers and patients ( Vaismoradi et al., 2013 ). The qualitative analyses were carried out by two researchers with expertise in team science. All qualitative data was analyzed by both researchers separately using Atlas.ti (a qualitative data analysis software). Specifically, using the list of team competencies derived from Objective 1 and the Team Effectiveness Framework as a codebook, each coder read through interview or focus group transcripts. Excerpts from the transcripts were coded or labeled with the representative team competency, and extensive notes were captured on how the competency manifested itself. The researchers met to discuss discrepancies at the midpoint and conclusion of the coding process. Taken together, our methodological approach aligns with the literature on teams, by utilizing multiple modalities to capture team-level phenomenon ( Salas et al., 2017 ), providing a quantitative foundation for revealing common challenges, and the qualitative insight to enrich our interpretation and provide examples of how the challenges manifest in the healthcare context. Below, we present five common teamwork challenges along with case studies that were derived from the qualitative data collection effort (i.e., from the interviews and focus groups conducted during the team development activities).

Accountability

Accountability has been regarded as a key feature that enables teams to effectively outperform independent individual efforts ( Katzenbach and Smith, 2005 ). Accountability is often defined in terms of an employee or team accepting responsibility or answering for certain deliverables, for example as, “the means by which individuals and organizations report to a recognized authority (or authorities) and are held responsible for their actions” ( Edwards and Hulme, 1996 ; p. 967). While there is no doubt that following through on commitments is important to performance, accountability can also be defined as something a leader fosters more proactively. Bregman (2016) asserts that getting angry, frustrated, or pleading when goals are not met rarely works as a strategy for holding team members accountable. Instead, the author urges leaders to provide the following to create accountability and set employees up for success: 1) clear expectations around the desired outcome, the desired approach to achieving the outcome, and how success will be measured (2), the skills and resources needed to meet expectations, 3) clear, measurable targets with associated milestones, 4) open and ongoing feedback, and 5) clear consequences for success or failure. The employee or team can help co-create these conditions, but they need to be in place up front.

In the context of healthcare, accountability is of particular importance as the tasks teams engage in ultimately affect patient safety and quality of care. Unfortunately, efforts examining accountability have revealed that many teams face challenges; specifically, Brown et al. (2011) examined conflict in primary healthcare teams (PHCTs), finding that accountability was one of three main sources of conflict. Many of these challenges arise out of incongruences between current approaches to patient care and assignment of accountability ( Leggat, 2007 ; Bell et al., 2011 ). Put differently, from a multilevel perspective, the accountability structures in many healthcare organizations are seemingly at odds with the team-level care healthcare providers are expected to deliver to patients, and the individual level to which accountability is assigned ( Leggat, 2007 ). This can be problematic as medical errors often occur through multiple breakdowns in teamwork, wherein responsibility falls on several members of the team ( Bell et al., 2011 ).

Below, we examine how accountability challenges manifested on one such team and follow this with recommendations for interventions.

Case Example: Accountability vs. Punishment and Blame

The exemplar team for accountability functioned on the administrative side of processing clinical trials. Because the output of this team directly influenced the research activities and financial outcomes of the institution, expectations for timely and high-quality work were high. To encourage accountability, each member of the team was required to sign an individual accountability contract, holding them to a standard output of quality and quantity. Accountability measures in and of themselves may not be problematic and are commonplace in organizations; they can take the form of formal reporting relationships, individual and team performance evaluations, and group norms ( Frink and Klimowksi, 1998 ). Implemented under the right circumstances, these measures can result in positive outcomes. For example, Thoms et al. (2002) found accountability measures increased employee perception that coworkers and managers were aware of their work, and ultimately improved job satisfaction.While the accountability document was intended to increase motivation and follow-through, it was perceived as a way to place blame and punish those who did not meet goals. Essentially, this effort fell short because it ignored the pre-conditions for success or the proactive establishment of accountability delineated by Bergman (2016). First, clear, challenging (yet achievable) expectations were not established or consistent. Priorities of the team changed rapidly, and changes (although necessary) were implemented without a strong or cohesive message from leadership, leading to the perception by some that change was “optional” or that leadership was enforcing change inconsistently or unfairly. For example, a new policy was implemented and no clear expectations for how it would be enforced were established, leading some team members to wonder if everyone was being held accountable – was everyone actually adhering to the new policy, and moreover was anyone going to check for compliance? Second, not all team members had the capability or skills needed to meet the expectations (i.e., in terms of the Team Effectiveness Framework, they were not trained). Specifically, because the team was in a fast-paced, high-pressure environment, new employees were not receiving the onboarding training they needed to be successful. As is common in many teams, members were required to “figure it out as they go." This resulted in new members working longer hours, missing their performance goals despite these long hours, and making numerous mistakes. In addition to this, qualitative data revealed employees felt they lacked the needed continuing education (e.g., around new processes and procedures) and cross-training to understand how their work affected the group that received it.Ultimately, the end result was a detriment to team morale when members were held accountable for goals they felt they could not achieve. Mistakes led to the threat of additional accountability measures from an institutional body outside of the department, and the formation of an internal accountability team that raised tension and conflict. The department experienced a significant amount of turnover from both managers and frontline staff.

Solutions for Accountability

Accountability is an enormous and sometimes complicated concept; teams presenting with a concern around accountability could be experiencing a number of underlying issues. Often additional information is needed to pinpoint the contributing factors (for example, in the previous case, causes included unclear expectations and lack of training). One such intervention that can provide more insight is the Start, Stop, and Continue (SSC) exercise. The SSC exercise can be thought of as a dedicated time or opportunity for the team to debrief on their collective experience. According to Ciccarelli (2016) , the “Start” bucket is the best place to begin—this includes generating new ideas around where the team should invest time, new initiatives, or improved processes that could move the team forward. The “Stop” bucket includes items that get in the team’s way, including activities that cost a great deal of time with little return, distract from the core purpose of the team, or cause undue stress or conflict. Finally, identify the activities that result in positive outcomes, and that the team should “Continue” moving forward.

To create clear expectations and a shared awareness of changes to policy and procedures (and importantly, how changes impact the team’s work) leadership teams should be intentional about creating strategic communication plans. The literature on change management provides a wealth of advice on communicating change. For example, Balogun (2003) examined the complexity of change and how this affects choice of communication media. Routine changes communicated via individual, personal methods (e.g., face-to-face, telephone) may be overly complicated, while complex changes communicated more general (i.e., employee announcements) may lack depth and sensitivity. While a review of the literature around communicating change is beyond the scope of this article, we provide key points that can be used as a checklist when creating a communication strategy (See Table 1 ).

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TABLE 1 . Elements of a strategic communication plan.

Conflict Management

Conflict is inherent to working in diverse teams, and under certain circumstances can be beneficial to team outcomes. Conflict in teams is often broken down into two distinct categories delineated by Jehn (1999) , and each has its own unique influence on performance. Relationship Conflict , which arises from interpersonal issues and differences in personality, values, and beliefs, almost universally has a negative influence on team member attitudes and team effectiveness (e.g., motivation, commitment, performance; Chen at al., 2011 ; Shaw et al., 2011 ). On the other hand, the association between Task Conflict , defined as disagreements among ideas, opinions, and approaches to the task ( Jehn, 1999 ), and team outcomes is much more complicated. De Dreu (2006) suggests there may be a curvilinear relationship among task conflict and outcomes such as innovation, such that moderate levels of task conflict result in the best outcomes. We argue, whether or not the positive aspects of task conflict are realized may depend largely on how the conflict is managed.

Conflict management has been defined by DeChurch and Marks (2001) as “strategies implemented by group members aimed at reducing or solving conflict” (p. 6). The authors find that task conflict can lead to greater performance and satisfaction; however, this only holds true if managed actively (i.e., open discussion of differences and firm pursuit of one’s ideas) and agreeably (i.e., pleasant, relaxed). The conflict management literature has since steadily grown to include the importance of cooperation and competition styles ( Somech et al., 2009 ). In DeChurch et al. (2013) , the authors theoretically separate conflict states (i.e., what teams are disagreeing about) and conflict process (i.e., how teams incorporate disagreements), and find meta-analytic support for this distinction. The authors assert it is the latter, conflict process, which directly influences performance; findings suggest that when conflict states are controlled, processes used to manage conflict predicted more variance in team outcomes than did the states themselves.

Task conflict management strategies are essentially reflective of the way dissent is processed at the team level and have indeed been linked to team outcomes ( Behfar et al., 2008 ). Regardless of what a specific management style is called, taxonomies of conflict style have one underlying theme; effective styles result in sincere consideration and integration of other’s input while ineffective styles lead to dismissal of ideas and lost information ( Janssen et al., 1999 ). Lencioni (2012) describes at one end of extreme teams can experience artificial harmony, where team members don’t engage in open, constructive conflict (e.g., because of low levels of trust, desire to appear agreeable, discomfort with confrontation) and strive to keep a level of peace. On the other end of the conflict continuum, teams can experience abrasive personal attacks during disagreements. To be effective, teams need to find a middle ground characterized by psychological safety, where members can openly disagree, respect each other’s input, and walk away without taking things personally ( Edmondson, 1999 ).

Case Study: Extreme Ends of the Conflict Continuum

At either end of the conflict continuum, artificial harmony or personal attacks, consequences can occur for open exchange of ideas; essentially, under these conditions teams are unable to capitalize on the wider pool of knowledge and experience from diverse members. Healthcare attracts many individuals who are passionate about the purpose and mission of their work. Furthermore, these individuals are well-trained experts in their field, and they are working in an environment where their team’s performance can affect patient care and mistakes hold serious consequences. Because of the combinations of these factors, this exemplar team, a senior leadership team (SLT) involved in clinical care, experienced strong, vocal disagreements between members on one end of the continuum. Each member was enthusiastic and entrenched in their positions, and without the right set of skills to uncover them, mutually satisfying solutions were not sought.

On the opposite end of the continuum, the strong hierarchy inherent in the medical field has been evidenced to present barriers to speaking up, or what Weiss et al. 2017 term voice behavior. The authors note that while research shows employees with lower hierarchical status are often hesitant to speak up because of fear of negative outcomes, the complex, ill-structured nature of problems in healthcare make voicing concerns or opinions even more important. Individual characteristics of employees, including personality (e.g., assertiveness; Weiss et al., 2014 ) and directness of conflict expression ( Weingart et al., 2015 ) can also create differences in how people speak up, and how comfortable they are doing so. Taken together, these factors can lead to silence being interpreted as agreement when team members are avoidant of conflict. They can also lead to conflict initially focused on the task bleeding over into relationship conflict when conflict styles don’t match (e.g., a direct conflict individual approaches a colleague who prefers indirect expression). In this team, the members varied widely on assertiveness and directness of conflict expression, leaving the less assertive, less direct members to disengage from conflict. Silence from these members was interpreted as agreement.

For this team, experiencing both strong task conflict that turned personal as well as artificial agreement led to a number of different negative team outcomes. First, significant time and energy was lost. Specifically, SLT members not directly involved in the conflict spent time that could have been directed toward the task and accomplishing shared goals instead trying to maintain harmony on the team. Second, the valuable contribution of team members, especially direct frontline staff, was lost. These members were hesitant to speak up with an idea or experiment with the unknown or new and innovative processes. Watching the SLT model behaviors perceived as attacking, or hearing their own leaders express a desire to avoid confrontation, strongly influenced their behavior. Poor conflict management between SLT members also led to each of the units within the department feeling siloed. Areas where collaboration between units may have benefited both parties were evident but not taken advantage of. Overall, otherwise well-intentioned, talented leaders created a culture that was prohibiting the open exchange of team members’ diverse perspectives and getting in the way of this team and their staff achieving their full potential.

Solutions for Conflict Management

To foster constructive task conflict, include courses on negotiation in leadership and team development interventions. According to Allred et al. (1997) , negotiation is the primary process by which conflict can be managed. The authors define effective negotiation as generating mutually satisfying solutions that build or integrate different interests in innovative ways, with the dimensions of claiming value, creating value, and maintaining the ongoing relationship. Solutions that meet the needs of both parties, or create value, include 1) Bridging solutions (i.e., solutions that meet the needs or interest of both people without compromise or tradeoff) and 2) Trade-offs (i.e., strategic trade-offs where one gives up something of lesser importance to obtain something viewed as more important; Rubin et al., 1994). To reach these integrative solutions, team training can include the following behaviors ( Allred et al., 1997 ):

• Free exchange of information between negotiators (being forthcoming about one’s own interests and preferences)

• Actively listening and seeking to understand the other side’s perspective

• Asking more questions about the other's position and making less statements about one's own position

• Considering or negotiating for multiple issues rather than each issue separately

• Avoiding fixed-pie bias and assumption of the other party’s key interests and priorities

Use simulation to get team members comfortable with conflict. Simulation is a powerful tool for teaching teamwork or interpersonal skills (e.g., Shapiro et al., 2004 ), including conflict management. Moreover, as long as psychological fidelity (e.g., the degree to which trainees believe the simulation to be a comparable substitute; Rehmann et al., 1995 ) is high, simulations need not be costly. The design and development of the simulation, however, plays a large role in the efficacy of this intervention (see Table 2 for best practices).

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TABLE 2 . Simulation best practices.

Decision Making

Research on individual vs. team decision making bears out that teams can outperform individual decision makers in terms of decision accuracy, and that process gains cannot be explained by the most knowledgeable member or even the average level of knowledge across the team (i.e., there’s a synergistic gain; Michaelsen et al., 1989 ). Given these benefits, there has been ample research on the factors that contribute to accurate, high-quality team decisions. For example, Hollenbeck et al. (1995) identify three individual characteristics that affect decision accuracy, including how informed each individual member of the decision making team is, the validity of individual member recommendations, and the ability of the team leader to weigh recommendations appropriately. Urban et al. (1996) emphasize the importance of the work environment, including time pressure, resource demand, and workload. In working with teams in the field, however, challenges to decision making most often arise when individual team members must combine their expertise and experience to come to a collective decision.

According to Rogers and Blenko (2006) , ambiguity in decision making roles and accountability for decisions are the root causes of decisions stalling inside organizations. The authors present the RAPID model that delineates team decision roles, standing for Recommend, Agree, Perform, Input, and Decide. Those who recommend a course of action are responsible for interpreting relevant data and proposing a course of action. Those who provide input present the facts and the practicality or feasibility of different courses of action. Importantly, both of these can be distinct from those who must agree or sign off on a decision before it can move forward. Finally, the person(s) with the authority to decide makes the final decision, and those who perform carry out the decision.

Equally important is clearly defining what level of agreement those with final decision authority need to achieve. Desired level of agreement depends on a number of factors, including level of risk involved, uncertainty or complexity in the environment, and commitment needed to the implementation. Decision consensus occurs when all members with responsibility for making the final decision agree. Often this level of agreement can be time consuming or difficult to achieve. Further, while this level of consensus may be appropriate in some situations, at the extreme level this can result in loss of individual perspectives and groupthink ( Janis, 1982 ). Majority rule occurs when the decision is put to a vote. In teams where power or influence is distributed unequally, majority rule can have a potential for reducing these inequalities ( Falk and Falk, 1981 ). Majority rule can also be used in situations with time constraints or ambiguous, incomplete information; however, this can leave the dissenting group with less commitment to the outcomes. Finally, leader-made decisions occur when a formal or informal leader is solely responsible for the decision. While Holloman and Hendrick (1972) find decision adequacy increases with the direct participation of more group members, the leader must carefully consider the situation (e.g., sensitivity of the data) and constraints (e.g., time pressure).

Case Example: Unclear Decision Roles

Dyad leadership is defined by Sanford (2015) as two people working together as a team to co-lead a specific department, division, or clinical service line. According to the authors, this model consists of two people with different backgrounds (e.g., professional field, training, education, skill sets) that are paired together with the assumption that they can perform above and beyond what either could individually. Importantly, the dyad members do not report to or work for one another; rather, each has their own responsibilities and accountability for their joint work. Oostra (2016) describes how the dyad leadership structure has evolved from a rigid, largely separate dual reporting system to an interdependent, situationally distributed model with shared roles and responsibilities. For this model to be effective, both leaders must draw from each other’s complementary strengths, be included in decision making, and present as a united front supporting and maintaining any decision made. Saxena et al. (2018) found support for this integrated leadership structure, with the majority of dyad leaders indicating that hybrid leadership, with well-defined responsibilities in both individual and shared domains, is preferred. While the majority of respondents agreed joint-decision making was preferable, nearly all endorsed the importance of presenting a united front to healthcare team members.

In this exemplar of a physician and physician assistant (PA) dyad leadership team, ambiguity in decision roles created a strict division in accountability and confusion that permeated throughout the rest of the team. Instead of clearly defining what fell into shared and individual responsibility (i.e., who held the “Decision” role in the RAPID model), the pair had loosely defined the PA leader as the final decision maker on administrative duties, and the physician leader on clinical duties. This left decision authority on a number of issues that cross those domains (e.g., scheduling for the staff, managing performance issues, resource allocation) unclear and the message to the team divided.

The outcomes the team experienced ranged from uncertainty in how to perform their roles to interpersonal conflict and detriments to team morale. Decisions on how policies and procedures (e.g., billing, covering shifts) should be carried out were often decided by one member of the leadership without involvement from the other dyad leader. Sometimes, each leader made a separate decision on the same issue that did not align, and therefore gave conflicting information to team members. The result left team members unsure of how to carry out key functions or carrying out the same function in different ways. Additionally, as team members became aware that they would receive different answers depending on which leader they approached first, they began to approach the leader who most often provided them with the answer they were seeking. As these consequences unfolded, it created a level of interpersonal conflict that began at the leadership level and had a top-down effect on the team’s morale. Because of this uncertainty at the top level, participative decision making was also low and left members unheard or unappreciated. As the leaders grappled with their own accountability, the team was rarely consulted to provide input or recommendation. Ultimately, this dyad leadership team that had the capability of being a successful partnership instead created what Saxena et al. (2018) warn about as the potential dark side of shared leadership—parallel structures of responsibility characterized by power struggles between leaders.

Solutions for Decision Making

Turpin (2019) shared strategies for building a successful dyadic relationship. The relationship must begin with intentional discussion around how decisions will be made, how to engage in effective communication, and how disagreements will be handled. Corroborating the findings of Saxena and colleagues (2016), the authors also emphasize the importance of 1) clarity around roles and responsibilities that are shared and held individually, and 2) presenting a united front. Presenting a united front includes negotiating and debating before, leaving any lingering disagreements solely between the two leaders, and presenting the same message. Finally, acknowledging that in all situations we are sometimes the mentor and sometimes the learner goes a long way toward the leaders recognizing and appreciating each other’s unique expertise. Although in its nascent stages, there is evidence to suggest that leadership training specifically around improving leadership skills (e.g., coaching) and communication in dyad pairs can positively influence team outcomes (e.g., engagement; James, 2017 ).

Procedural justice is defined by Cropanzano et al. 2001 as employee perception or judgement regarding the fairness of work-related processes. According to the authors, justice perceptions are not necessarily based on a final outcome, but how the outcome was reached (e.g., whether the process to assign an outcome was fair, if an acceptable justification was given). Applied to decision making, Phillips (2002) asserts that one factor that may influence procedural justice is the perceived decision control, or level of influence the leader gives a team member’s input relative to others. In our collective experience with teams in the field, another factor we suggest may influence justice perceptions (above and beyond the final decision outcome) is the transparency or level of clarity around not only decision roles and level agreement (as discussed above), but also the status of the decision-making process and what is and is not included in the decision.

For example, when team members have a different understanding of the intent of a decision making discussion, it can create problems for the team. As a leader or team member tasked with making a final decision, you can avoid confusion and the potential feeling of lack of voice by being clear with your purpose prior to any team discussion. A simple tool to provide clarity around the status of a decision, or where the decision stands in terms of timeline, is the Update-Input-Decide (UID) Framework. For each agenda item, specify the intent: 1) Update (to simply inform the team about progress of plans), 2) seek Input (to request other’s perspective or feedback), or 3) Decide (to make the decision or determine who will make the decision).

As another example, research on Participation in Decision Making (PDM) suggests that greater inclusion of team members, including those with diverse backgrounds and the dissenting minority, can improve decisions outcomes (e.g., creativity), satisfaction with the process, and organizational commitment ( Black and Gregersen, 1997 ; De Dreu and West, 2001 ; Elele and Fields, 2010 ). Scott-Ladd and Chan (2004) echo the importance of PDM, however, they note that not all employees will be able to participate at the same level or time, and there will be times when this participation will not be possible (e.g., critical or urgent decisions). In these circumstances, the authors stress the importance of realistic involvement expectations and clear boundaries of when, what, and how employees will contribute. Toward this end, negotiables (i.e., items the team can weigh in on) and non-negotiables (i.e., items decided at a later point or restricted by external circumstances) can help the team avoid confusion, unmet expectations, and wasted time discussing points that are not within decision limits.

Reflecting on Progress

American philosopher, psychologist, and leader in early educational reform John Dewey underscored that while our experiences are an integral part to learning, we truly learn or learn more deeply from reflecting on that experience ( Rodgers, 2002 ). The education and training field emphasizes learning by doing, whether it be “experiential learning”, “active learning”, or “action learning” (e.g., Kolb, 1984 ; Bell and Kozlowski, 2008 ). But an often left out piece is that we also learn by reflecting on what we’ve done—what worked, what didn’t work, and what could be done better next time. In this sense reflection deepens learning, it allows us to develop at a faster pace. This is true in an individual setting, and maybe even more important in a team setting where we’re learning not only how to improve and develop ourselves, but where we’re also learning how to interact effectively with others.

At the team level, team reflexivity is defined as the extent to which team members set aside time to specifically reflect upon the team’s objectives and strategies or processes to meet these objectives, as well as the extent to which teams adapt strategies to current or future situations ( West and Beyerlein, 2000 ). This includes taking time out from performing work to pause, reflect, and plan for future success. Reflexivity has been evidenced to predict team effectiveness, creativity, and innovation (e.g., De Dreu, 2006 ; Tjosvold et al., 2003 ; Tjosvold et al., 2004 ). Schippers et al. (2008) argue team reflexivity may be especially beneficial under high levels of work demands (e.g., high patient-to-clinician ratio, time pressure). The authors tested and found support for their hypothesis with 98 multidisciplinary primary health care teams, including physicians, practice managers, nurses, and administrators. Under high demands, teams who reflect gain a greater awareness of these demands and their consequences and the gap between their current and desired state. This in turn focuses attention and team discussion on ideas for new and innovative ways to work.

Recognizing that medical knowledge and technology in healthcare change rapidly (e.g., Densen, 2011 ), team reflection plays an essential role in effectively implementing continuous change. In investigating healthcare teams undergoing adoption of new technology, Edmondson et al., 2001 found that teams with successful implementation went through a qualitatively different process for team learning. Specifically, the authors found that organization size, resources, support from senior management, and academic status were not associated with implementation success. Instead, success depended on an implementation process that included reflection. Teams were successful when they took the time to collect and review data, initiate discussions with the whole team, go over what happened immediately after an event, set aside regular time to review activities, review errors, and discuss how to change team process to improve in the future.

Case Example: High Work Demands & Time Pressure

The exemplar team for reflecting on progress was comprised of multi-disciplinary clinical professionals, including physicians and staff members, who were highly interdependent. Specifically, they had a team workflow, meaning there was a simultaneous, multidirectional exchange ( Saavedra et al., 1993 ). In order to manage this interdependency in clinical care, Taplin et al. (2015) point to the importance of workflow reappraisal across the team, fostering situational awareness and flexibility, and awareness of the overall operation. As this team was in the process of hiring physicians to bring them up to a full level of staffing, time to engage in these highly important but non-clinical team duties was limited and was not emphasized as a priority, and the factors below served to compound the issue.

According to Emanuele and Koetter (2007) , healthcare organizations are constantly facing the challenge of improving quality of care while reducing overall costs. To address this, many are turning to workflow technology as a way to improve efficiency and quality of care in a cost-effective manner. While the authors highlight the many potential benefits (e.g., automated steps, greater access to information when and where it is needed, decision support, integrated care plan), they also acknowledge potential drawbacks, including issues with communication (i.e., access to the technology, overloading members with messages). What we witnessed in this team is the negative impact this technology can have on the quality of communication if the team does not take the dedicated time to reflect and reappraise. This electronic patient management system made the reactions and stress levels of teammates hard to interpret, and there was less opportunity to get questions answered quickly. Perhaps more importantly, there was little opportunity to discuss cases and reflect as a team to learn collectively, surface concerns, and find ways to communicate more effectively.

Furthermore, this technology reduced the need for the team to experience patient cases together, and therefore understand each other’s roles and responsibilities, how the actions of one group affects the work of the other, and the stressors and pressures each groups faces. In short, there was a lack of a shared mental model or clarity around what each group does and thinks (e.g., how long it takes to do certain tasks, the effect of changes to the patient plan) and awareness of how the situation impacts each group. This not only affects operations, such as how tasks are prioritized and the time allotted for tasks, but is also detrimental to team morale and understanding and empathy between team members.

Solutions for Reflecting on Progress

Team coaching, which focuses on helping the team as a whole, is defined as direct interaction with an intact team to help members coordinate, make use of collective resources, and review and refine strategies ( Hackman and Wageman, 2005 ). According to Clutterbuck et al. (2010) , an essential piece of team coaching is assisted reflection and analysis. While research is still in its nascent stages, this type of coaching has been evidenced to improve interpersonal teamwork skills (e.g., communication) and team outcomes including effectiveness and innovation ( Peters and Carr, 2013 ; Rousseau et al., 2013 ). The coaching process allows teams to engage in the reappraisal of team strategies, building of mental models and situational awareness, and awareness of others roles and responsibilities that Taplin et al. (2015) pointed out as essential to managing interdependencies.

Team coaching is often overlooked or given little attention by team leaders. One reason for the underutilization is that leaders don’t understand the process or know how to engage in coaching effectively ( Hackman and Wageman, 2005 ). Fortunately, Brown and Grant (2010) put forth a practical model for team coaching based on the popular GROW (Goal-Reality-Options-Way Forward) model for individual coaching. The extended framework, called GROUP (Goal-Reality-Options-Understand Others-Perform), includes the importance of shifting both individual and group awareness and treating issues at a systemic and not symptom level (i.e., getting to the root cause of performance issues). The authors include example questions for each phase that can be asked by the team leader or a facilitator in an iterative process (e.g., How have you handled problems in the past? What worked? What didn’t?). Drawing from the literature on a similar group process (i.e., team debriefs), teaming coaching sessions may also be more effective when the development, non-punitive, and non-administrative intent is stressed, when teams reflect on specific events rather than general performance or competencies, and when multiple sources of information are used (e.g., multiple team members, objective data source).

Additionally, individual and team assessments can be useful tools to raise each team member’s level of self-awareness, which at the collective level has been shown to influence team functioning (e.g., coordination, conflict, cohesion, and team performance; Dierdoff et al., 2019 ). These tools can focus on personality, emotional intelligence, 360 feedback or a number of other critical performance areas. In essence, they help an individual become more aware of their own strengths and how they can be leveraged, as well as areas that represent opportunities for development. These tools can also be used for developmental discussions around how a team member interacts with others on the team. At the team level, these tools can be utilized for coaching sessions around team dynamics (e.g., the roles each members contributes to on the team; Driskell et al., 2017 ).

Coaching and Development

While team coaching can help teams reflect on and improve team processes, individual coaching is foundational to an employee’s personal development plan. Coaching has received considerable attention from the literature ( Smither, 2011 ; Grant, and Hartley, 2013 ; Bozer, and Jones, 2018 ), and has been found to be instrumental to employee learning and development ( Ladyshewsky, 2010 ; Liu and Batt, 2010 ; Jones et al., 2016 ). The primary function of workplace coaching is to support the coachee in the achievement of professional outcomes they deem important ( Smither, 2011 ; Jones et al., 2016 ). This involves one-on-one relationships that are developmental in nature, and characterized as goal-focused, collaborative, and reflective ( Smither, 2011 ; Jones et al., 2016 ). Dasborough et al. (2009) shed light on how differential attention on behalf of leaders can influence team climate, such that when team members perceive that leaders are treating certain members with favoritism this could act as a contagion to the team invoking negative affective responses. We draw upon this evidence to support our argument as to the influence one-on-one relationships can have on team-level challenges in the context of coaching. Specifically, coaching serves as yet another resource that leaders can provide to the team, and lack of this resource can impede employee development and perceptions of fairness.

In healthcare, coaching is of significant importance ( Stapleton et al., 2007 ; Grant et al., 2017 ; Wolever et al., 2017 ). The notion of continual development aligns with the overarching mission of healthcare institutions to strive for continual improvement in quality of care and patient safety, and teams often depend on coaching to provide them with opportunities to grow and improve. Specifically, Chatalalsingh and Reeves (2014) emphasize the importance of coaching to inspire collective learning to enhance task-related knowledge and relational aspects of the team. Coaching responsibilities can often reside with leadership and have been regarded as a critical in directing efforts towards developing others ( Calhoun et al., 2008 ). Challenges with many aforementioned outcomes and processes central to the healthcare context can be addressed through effective coaching strategies ( Chatalalsingh and Reeves, 2014 ; Grant, et al., 2009 ). Coaching can positively impact goal attainment, resilience, morale, and well-being ( Stapleton et al., 2007 ; Grant et al., 2009 ). Moreover, leader coaching interventions have been found to be effective at enhancing resilience, self-efficacy, and perspective taking among healthcare providers implementing change ( Grant et al., 2017 ).

However, the healthcare industry has faced challenges with coaching, requiring a cultural shift among healthcare organizations to first recognize the value of providing individuals with opportunities to promote their capacity to attain their own professional goals ( Thorn and Raj, 2012 ). Thorn and Raj (2012) identify four core coaching behaviors: 1) be authentic, 2) ask powerful questions, 3) establish trust, and 4) challenge beliefs. In addition, Thorn and Raj (2012) assert that in valuing professional pursuits a leader can enhance performance in teams. Taken together, healthcare is a domain that strives for continual improvement, and in this context, coaching can serve as a linchpin for improvement on the team and individual level. Thus, this work further supports the importance of coaching in healthcare while noting the challenges many organizations face with facilitating coaching-centered relationships.

Case Example: Lack of Leader Accessibility

Leader accessibility, defined in part by approachability and commitment, has been identified as a top quality of effective leaders ( Olanrewaju and Okorie, 2019 ). This exemplar team, which performed a critical regulatory function within the institution, depicts the consequences of lack of accessibility on employee perception of coaching and development. Importantly, lack of accessibility may have little to do with individual leader characteristics and can be a result of external factors inherent in the field of medicine (e.g., time pressure, heavy workloads) and leadership needs of the institution. However, these factors may not be readily perceptible to the team and can engender perceptions of leader unfairness. If leader accessibility is limited or unequal across members, then the attention leaders devote to certain members of the team could be perceived by other members of the team as being exclusionary, negatively impacting overall team climate ( Dasborough et al., 2009 ).

This exemplar team had experienced frequent changes in leadership over the previous five years. As research bears out, while a change in leadership can enhance team reflection and adaption ( Kalmanovich-Cohen et al., 2018 ), frequent changes in leadership can add to the perception of a lack of coaching and development. In addition, the executive leader of the team had their role expanded to meet the needs of the institution. This left the mid-level manager in charge of implementing new technology that was being integrated into the team’s process as well as the day-to-day functions of the team, requiring they block their schedule to complete a heavy workload—and furthering the perceptions of lack of leader accessibility.

Team members experienced a number of missed opportunities for development. Broadly, these consisted of a general lack of one-on-one meetings with leadership and an absence of feedback on work-related activities and progress. Unfortunately, there were many areas that the team would have benefited from either protected meeting time or feedback. For example, in terms of affect and morale, team members showed considerable concern regarding negative external perceptions of their team; they felt that others in the department did not respect them and voiced their aspiration to change these perceptions. This is a situation where a developmental opportunity allowing them to improve inter-departmental dynamics as well as their collective efficacy was deprived as a result of lack of one-on-one meetings with leadership to address these concerns through coaching. Members also expressed an inclination to improve upon their work and an overall growth mindset; however, this served as another missed opportunity wherein feedback and development was not prioritized and therefore not provided to them.

Solutions for Coaching and Development

To address these challenges, we offer two readily implementable potential solutions: leader–member meetings and creating protected time before meetings to check in with members and build rapport. While we acknowledge that time is a scarce resource in healthcare, oftentimes one-on-one meetings can take place in 15 minutes or less and can be as infrequent as once a month. However, we would encourage leaders to discuss temporal needs amongst their team to ascertain the ideal length and frequency of one-on-one meetings to ensure that the team’s learning and developmental needs are adequately addressed.

Given time constraints, exercises that build familiarity with developmental goals (i.e., “get to know you” exercises) can also take place in shorter durations (e.g., 10 minutes), and could precede regular meetings. The purpose of these exercises would be to give team members an opportunity to share professional goals and aspirations with both the leader and the team. This could later be leveraged by the leader during one-on-one meetings to provide members with learning and developmental opportunities that align with their goals. Finally, researchers have generated evidence-based and theoretically grounded steps to guide coaching efforts: 1) pre-coaching (e.g., identify expectations), 2) self-discovery and awareness (e.g., determine follower motivation(s), needs, and approach to achievement of results), 3) goal setting and accountability (e.g., agree upon goals and objectives), 4) action learning and execution (e.g., provide developmental activities and feedback), and 5) evaluation and revision (e.g., continue to provide feedback and evaluate progress; Harper, 2012 ).

The effectiveness of these solutions relies heavily on the level of buy-in and commitment from leadership; without this commitment, these efforts could lack follow-through. Hence, prior to the implementation of coaching efforts, it is critical to ascertain this information (i.e., leadership buy-in and commitment). This can be accomplished through a set of structured interview questions prior to the launch of any effort and will help shape expectations and strategies for improvement up front. For example, a leader can be asked if they have the bandwidth to make themselves available to their team and carry out some of these potential solutions. If the leader expresses that they are not available, an important follow-up response to this would be to have the leader identify someone who can champion the implementation of these solutions. Relatedly, it is equally important to present an accurate depiction of what these efforts could entail to the leader to facilitate informed decision making.

In this investigation into healthcare team effectiveness, we provided a comprehensive, evidence-based framework that is generalizable across team types. The findings reveal that teams in healthcare face similar challenges, regardless of whether they operate in the clinical, research, or administrative realm. Qualitative inquiry was used to provide rich detail about how each one of these challenges may manifest in the field and the impact of these challenges on team outcomes including performance, functioning, and viability. Finally, we pulled from the literature on team science and our collective experience in the field to provide potential solutions to address these challenges.

Qualitative data analysis made evident the numerous factors, internal and external to the team, that can influence effectiveness, emphasizing that a team of experts does not automatically create an expert team. The healthcare environment itself is characterized by high workloads, time pressure, and continuous change (e.g., new technology, new organizational structures) that can have a top-down effect on how teams perform. At the team level, combining the expertise necessary to tackle the complex and ambiguous problems that healthcare teams often face represents a significant barrier. Finally, characteristics of the team members themselves, including personality and communication or conflict style can create further barriers, even when members are passionate, talented, and working toward the same goal. The solutions presented help teams manage these challenges that manifest across different levels and emphasize the importance of targeting the root cause (and not the symptom) of team issues. They center on being intentional about setting up and carrying through team processes, setting aside dedicated time to develop the team, and practicing team skills just as you would technical skills.

Practical Implications

The Team Effectiveness Framework was designed to inform both research and practice, and as such presents three unique contributions for those that lead and develop teams. First, it is generally applicable across the many types of teams that contribute to the quality and safety of patient care. The development of this framework synthesized literature on teamwork competencies and overall team effectiveness across multiple disciplines within healthcare. This synthesis was bolstered by both quantitative and qualitative analyses of healthcare teams across multiple domains embedded in a larger healthcare organization. The integration of two metrics that capture different aspects of team dynamics, and challenges teams face as a result of breakdowns in teamwork as they occur in different healthcare settings, support the ecological validity of our findings and the applicability of our framework throughout the entire system. Additionally, this supports the practical utility of our framework in that it can be used as a common language or message about team effectiveness across the organization. It can also serve as a solid foundation for any team training program.

Second, the framework is structured to reflect a scaffolded process towards the development of ideal team states, such that each level builds upon the preceding one. The lowest level comprises competencies that provide the foundation and shape emergent attitudes, behaviors, and cognitions. If the team feels, acts, and thinks (i.e., the ABCs of teamwork; Weaver et al., 2010 ) in accordance with the framework this facilitates the development of ideal team states of psychological safety and trust, and adaptability and resilience. These states are what are ultimately needed in order for the team to successfully perform and accomplish shared goals at present (performance and results) and possess the capacity to continue working together effectively in the future (viability), thereby enabling overall team effectiveness.

Finally, the framework can provide guidance for when and where to target developmental efforts. As discussed, the framework’s hierarchical nature is structured such that each level is dependent on the preceding one, and within each level the competencies are clearly defined. This provides a blueprint leaders and practitioners can use to diagnose challenges and determine where interventions are needed. Specifically, given the scarcity of resources that often faces healthcare teams (e.g., time, financial resources), a team effectiveness measurement tool can guide efforts and maximize effects of any intervention. The potential solutions we generate to address challenges as they arise provide additional insight for leaders and practitioners to tailor their efforts to address the team’s unique needs and determine approaches to improving overall team effectiveness.

The team diagnostic used in this effort, like any cross-sectional measure, is based on a point in time and the framework includes elements that should be monitored on an ongoing basis. Membership changes, or team member fluidity, are quite common in healthcare (e.g., shift changes, membership loss and replacement). As membership changes, it can be helpful to re-assess the team on the framework components. However, in general, teams should be trained on transportable or generalizable teamwork skills (e.g., sharing just enough of the right information, shared leadership) to enable effective adaptation and resiliency throughout membership changes ( Bedwell et al., 2012 ). As specific developmental interventions are conducted overtime, a re-assessment can help clarify if the intended improvements have resulted.

Limitations

The present research effort took place in a larger academic-teaching hospital, thus presenting contextual limitations to the generalizability of our findings and framework. Academic medical institutions are a unique environment in the healthcare domain, and it is the aim of this effort to generalize this framework across institutions. As such, we encourage future research to replicate these findings across different healthcare institutions and care settings. In the same vein, the focal institution was larger in size, warranting needs for replicability across different institution sizes. Size can present an important boundary condition to teams operating as components of a larger system (i.e., teams nested within teams working towards a shared goal). Hence, institutional size could influence the present findings. From a different perspective, our effort does not account for the “nestedness” of teams in larger systems, referred to as multiteam systems (MTSs), which involve collectives of teams working towards a shared goal ( Mathieu et al., 2001 ). It would be both interesting and valuable for future research to expand upon this framework to consider multidisciplinary teams in the context of MTSs.

Future Research

While there have been several reviews of the efficacy of team training or TDIs in healthcare (e.g., Weaver et al., 2014 ; Hughes et al., 2016 ), empirical studies have focused largely on clinical teams. While there is no doubt teams with direct patient care responsibilities greatly influence critical outcomes for healthcare organizations (e.g., patient safety, quality of care), research and administrative teams often directly or indirectly influence patient outcomes as well. For example, organizational development teams that train clinical leaders to better manage their teams ultimately impact how these teams care for the patient. Non-clinical teams also play a key role in keeping the organization operating smoothly, including the management of clinical trials, ensuring regulatory guidelines are followed, and caring for the health and well-being of employees. While the competencies that are important for teams across different functions remain the same, how to effectively engage in teamwork (e.g., communication, coordination) may look very different depending on team characteristics like skill differentiation, authority differentiation, and temporal stability ( Hollenbeck et al., 2012 ). For example, effective communication norms of an operating room team, with the surgeon as a clear leader and high skill differentiation between members (e.g., anesthesiologists, nurses, surgical techs), will look very different than that of a more homogenous team managing employee recruitment. Because of this, more research is needed into the efficacy of different training interventions for non-clinical healthcare teams.

Specific developmental interventions have gained more attention in recent years, one of which that stands out is individual leader and team coaching. The benefits of coaching have been touted to be everything from increased goal attainment, professional growth, improved interpersonal relationships, improved productivity, and greater resilience, but strong empirical evidence lags far behind the use of coaching in the field ( Jones et al., 2016 ). This issue is even greater for investigations into team coaching. While there are many practical resources for team coaching best practices (e.g., Thorton, 2010 ; Hawkins, 2017 ), more empirical research into overall effectiveness and the specific techniques that work best, the length of engagements, the impact of team types, and specific desired outcomes that are most amenable to coaching is needed.

Finally, as the dyad leadership structure becomes more prevalent in healthcare, leadership training best practices specific to this group are needed. As a starting point, research on the training needs of the dyadic pair and the development of a competency model (essentially, what makes a dyadic pair effective) could help inform leadership development programs. As dyadic pairs can take many forms (e.g., physician and registered nurse, physician and operations manager), uncovering the challenges specific to each of these team types would also move research forward. Finally, the enabling conditions, or what the dyadic pair needs from the organization and environment in which they operate, can add to the overall picture of dyadic leadership team effectiveness.

The very nature of teamwork gives rise to complex, dynamic processes that arise over time from the interactions of team members. While the field of team science has made tremendous progress over the last several decades, researchers note that to move forward we need to “embrace the complexity” of current team-based designs (Mathieu, et al., 2008). Therefore, we encourage future research to look beyond the methodologies traditionally used in teams research and to seek underutilized approaches that may be able to further advance our understanding of multidisciplinary teams in healthcare (e.g., integrated qualitative and quantitative research paradigms, participatory action research (PAR); Baum et al., 2006 ; Paoletti et al., 2021 ).

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by University of Texas MD Anderson IRB Committee. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

Author Contributions

SZ, CH, ES, and ST all contributed to the activities related to the development of the framework. SZ and CH developed the diagnostic tool. SZ conducted interviews and debriefs for follow-up to the diagnostic tool. AW contributed substantially to data analysis and manuscript development/writing. All authors contributed to the development, writing, and review of the manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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TABLE A1 . Framework Competency Descriptions

Sample in-field interview items

1 What is your role on the team?

2 How effectively do team members work together?

a What is helping your team? What are your team’s strengths?

b What do you think may be hindering your team’s effectiveness? What are your team’s weaknesses?

3 If you could change on thing on this team, what would it be?

4 What do you need to able to succeed as a member of this team?

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Keywords: teams and groups, leadership, communication, decision making, coaching, reflection, conflict management, accountability

Citation: Zajac S, Woods A, Tannenbaum S, Salas E and Holladay CL (2021) Overcoming Challenges to Teamwork in Healthcare: A Team Effectiveness Framework and Evidence-Based Guidance. Front. Commun. 6:606445. doi: 10.3389/fcomm.2021.606445

Received: 15 September 2020; Accepted: 06 January 2021; Published: 17 March 2021.

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Copyright © 2021 Zajac, Woods, Tannenbaum, Salas and Holladay. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Stephanie Zajac [email protected]

This article is part of the Research Topic

Team and Leader Communication in the Healthcare Context: Building and Maintaining Optimal Transdisciplinary Teams

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Interventions to improve team effectiveness within health care: a systematic review of the past decade

  • Martina Buljac-Samardzic 1 ,
  • Kirti D. Doekhie 2 &
  • Jeroen D. H. van Wijngaarden 3  

Human Resources for Health volume  18 , Article number:  2 ( 2020 ) Cite this article

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A high variety of team interventions aims to improve team performance outcomes. In 2008, we conducted a systematic review to provide an overview of the scientific studies focused on these interventions. However, over the past decade, the literature on team interventions has rapidly evolved. An updated overview is therefore required, and it will focus on all possible team interventions without restrictions to a type of intervention, setting, or research design.

To review the literature from the past decade on interventions with the goal of improving team effectiveness within healthcare organizations and identify the “evidence base” levels of the research.

Seven major databases were systematically searched for relevant articles published between 2008 and July 2018. Of the original search yield of 6025 studies, 297 studies met the inclusion criteria according to three independent authors and were subsequently included for analysis. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence.

Three types of interventions were distinguished: (1) Training , which is sub-divided into training that is based on predefined principles (i.e. CRM: crew resource management and TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety), on a specific method (i.e. simulation), or on general team training. (2) Tools covers tools that structure (i.e. SBAR: Situation, Background, Assessment, and Recommendation, (de)briefing checklists, and rounds), facilitate (through communication technology), or trigger (through monitoring and feedback) teamwork. (3) Organizational (re)design is about (re)designing structures to stimulate team processes and team functioning . (4) A programme is a combination of the previous types. The majority of studies evaluated a training focused on the (acute) hospital care setting. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements.

Over the last decade, the number of studies on team interventions has increased exponentially. At the same time, research tends to focus on certain interventions, settings, and/or outcomes. Principle-based training (i.e. CRM and TeamSTEPPS) and simulation-based training seem to provide the greatest opportunities for reaching the improvement goals in team functioning.

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Introduction

Teamwork is essential for providing care and is therefore prominent in healthcare organizations. A lack of teamwork is often identified as a primary point of vulnerability for quality and safety of care [ 1 , 2 ]. Improving teamwork has therefore received top priority. There is a strong belief that effectiveness of healthcare teams can be improved by team interventions, as a wide range of studies have shown a positive effect of team interventions on performance outcomes (e.g. effectiveness, patient safety, efficiency) within diverse healthcare setting (e.g. operating theatre, intensive care unit, or nursing homes) [ 3 , 4 , 5 , 6 , 7 ].

In light of the promising effects of team interventions on team performance and care delivery, many scholars and practitioners evaluated numerous interventions. A decade ago (2008), we conducted a systematic review with the aim of providing an overview of interventions to improve team effectiveness [ 8 ]. This review showed a high variety of team interventions in terms of type of intervention (i.e. simulation training, crew resource management (CRM) training, interprofessional training, general team training, practical tools, and organizational interventions), type of teams (e.g. multi-, mono-, and interdisciplinary), type of healthcare setting (e.g. hospital, elderly care, mental health, and primary care), and quality of evidence [ 8 ]. From 2008 onward, the literature on team interventions rapidly evolved, which is evident from the number of literature reviews focusing on specific types of interventions. For example, in 2016, Hughes et al. [ 3 ] published a meta-analysis demonstrating that team training is associated with teamwork and organizational performance and has a strong potential for improving patient outcomes and patient health. In 2016, Murphy et al. [ 4 ] published a systematic review, which showed that simulation-based team training is an effective method to train a specific type of team (i.e. resuscitation teams) in the management of crisis scenarios and has the potential to improve team performance. In 2014, O’Dea et al. [ 9 ] showed with their meta-analysis that CRM training (a type of team intervention) has a strong effect on knowledge and behaviour in acute care settings (as a specific healthcare setting). In addition to the aforementioned reviews, a dozen additional literature reviews that focus on the relationship between (a specific type of) team interventions and team performance could be mentioned [ 7 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. In sum, the extensive empirical evidence shows that team performance can be improved through diverse team interventions.

However, each of the previously mentioned literature reviews had a narrow scope, only partly answering the much broader question of how to improve team effectiveness within healthcare organizations. Some of these reviews focus on a specific team intervention, while others on a specific area of health care. For example, Tan et al. [ 7 ] presented an overview on team simulation in the operating theatre and O’Dea et al. [ 9 ] focused on CRM intervention in acute care. Other reviews only include studies with a certain design. For instance, Fung et al. [ 13 ] included only randomized controlled trials, quasi-randomized controlled trials, controlled before-after studies, or interrupted time series. Since the publication of our systematic review in 2010 [ 8 ], there has been no updated overview of the wide range of team interventions without restrictions regarding the type of team intervention, healthcare setting, type of team, or research design. Based on the number and variety of literature reviews conducted in recent years, we can state that knowledge on how to improve team effectiveness (and related outcomes) has progressed quickly, but at the same time is quite scattered. An updated systematic review covering the past decade is therefore relevant.

The purpose of this study is to answer two research questions: (1) What types of interventions to improve team effectiveness (or related outcomes) in health care have been researched empirically, for which setting, and for which outcomes (in the last decade)? (2) To what extent are these findings evidence based?

Methodology

Search strategy.

The search strategy was developed with the assistance of a research librarian from a medical library who specializes in designing systematic reviews. The search combined keywords from four areas: (1) team (e.g. team, teamwork), (2) health care (e.g. health care, nurse, medical, doctor, paramedic), (3) interventions (e.g. programme, intervention, training, tool, checklist, team building), (4) improving team functioning (e.g. outcome, performance, function) OR a specific performance outcome (e.g. communication, competence, skill, efficiency, productivity, effectiveness, innovation, satisfaction, well-being, knowledge, attitude). This is similar to the search terms in the initial systematic review [ 8 ]. The search was conducted in the following databases: EMBASE, MEDLINE Ovid, Web of Science, Cochrane Library, PsycINFO, CINAHL EBSCO, and Google Scholar. The EMBASE version of the detailed strategy was used as the basis for the other search strategies and is provided as additional material (see Additional file 1 ). The searches were restricted to articles published in English in peer-reviewed journals between 2008 and July 2018. This resulted in 5763 articles. In addition, 262 articles were identified through the systematic reviews published in the last decade [ 3 , 4 , 7 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ]. In total, 6025 articles were screened.

Inclusion and exclusion criteria

This systematic review aims to capture the full spectrum of studies that empirically demonstrate how healthcare organizations could improve team effectiveness. Therefore, the following studies were excluded:

Studies outside the healthcare setting were excluded. Dental care was excluded. We did not restrict the review to any other healthcare setting.

Studies without (unique) empirical data were excluded, such as literature reviews and editorial letters. Studies were included regardless of their study design as long as empirical data was presented. Book chapters were excluded, as they are not published in peer-reviewed journals.

Studies were excluded that present empirical data but without an outcome measure related to team functioning and team effectiveness. For example, a study that evaluates a team training without showing its effect on team functioning (or care provision) was excluded because it does not provide evidence on how this team training affects team functioning.

Studies were excluded that did not include a team intervention or that included an intervention that did not primarily focus on improving team processes, which is likely to enhance team effectiveness (or other related outcomes). An example of an excluded study is a training that aims to improve technical skills such as reanimation skills within a team and sequentially improves communication (without aiming to improve communication). It is not realistic that healthcare organizations will implement this training in order to improve team communication. Interventions in order to improve collaboration between teams from different organizations were also eliminated.

Studies with students as the main target group. An example of an excluded study is a curriculum on teamwork for medical students as a part of the medical training, which has an effect on collaboration. This is outside the scope of our review, which focuses on how healthcare organizations are able to improve team effectiveness.

In addition, how teams were defined was not a selection criterion. Given the variety of teams in the healthcare field, we found it acceptable if studies claim that the setting consists of healthcare teams.

Selection process

Figure 1 summarizes the search and screening process according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) format. A four-stage process was followed to select potential articles. We started with 6025 articles. First, each title and abstract was subjected to elimination based on the aforementioned inclusion and exclusion criteria. Two reviewers reviewed the title/abstracts independently. Disagreement between the reviewers was settled by a third reviewer. In case of doubt, it was referred to the next stage. The first stage reduced the number of hits to 639. Second, the full text articles were assessed for eligibility according to the same set of elimination criteria. After the full texts were read by two reviewers, 343 articles were excluded. In total, 297 articles were included in this review. Fourth, the included articles are summarized in Table 1 . Each article is described using the following structure:

Type of intervention

Setting: the setting where the intervention is introduced is described in accordance with the article, without further categorization

Outcomes: the effect of the intervention

Quality of evidence: the level of empirical evidence is based in the Grading of Recommendations Assessment Development, and Evaluation (GRADE) scale. GRADE distinguishes four levels of quality of evidence

High: future research is highly unlikely to change the confidence in the estimated effect of the intervention.

Moderate: future research is likely to have an important impact on the confidence in the estimated effect of the intervention and may change it.

Low: future research is very likely to have an important impact on the confidence in the estimated effect of the intervention and is likely to change it.

Very low: any estimated effect of the intervention is very uncertain.

figure 1

PRISMA flowchart

Studies can also be upgraded or downgraded based on additional criteria. For example, a study is downgraded by one category in the event there are important inconsistencies. Detailed information is provided as additional material (see Additional file 2 ).

Organization of results

The categorization of our final set of 297 articles is the result of three iterations. First, 50 summarized articles were categorized using the initial categorization: team training (subcategories: CRM-based training, simulation training, interprofessional training, and team training), tools, and organizational intervention [ 8 ]. Based on this first iteration, the main three categories (i.e. training, tools, and organizational interventions) remained unchanged but the subcategorization was further developed. Training, related to the subcategory “CRM-based training”, “TeamSTEPPS” was added as a subcategory. The other subcategories (i.e. simulation training, interprofessional training, and team training) remained the same. Tools, the first draft of subcategories, entailed Situation, Background, Assessment, and Recommendation (SBAR), checklists, (de)briefing, and task tools. Two subcategories of organizational intervention (i.e. programme and (re)design) were created, which was also in line with the content of this category in the original literature review. Second, 50 additional articles were categorized to test and refine the subcategories. Based on this second iteration, the subcategories were clustered, restructured and renamed, but the initial three main categorizations remained unaffected. The five subcategories of training were clustered into principle-based training, method-based training, and general team training. The tools subcategories were clustered into structuring, facilitating, and triggering tools, which also required two new subcategories: rounds and technology. Third, the remaining 197 articles were categorized to test the refined categorization. In addition, the latter categorization was peer reviewed. The third iteration resulted in three alterations. First, we created two main categories based on the two subcategories “organizational (re)design” and “programme” (of the third main categorization). Consequently, we rephrased “programme-based training” into “principle-based training”. Second, the subcategories “educational intervention” and “general team training” were merged into “general team training”. Consequently, we rephrased “simulation training” into “simulation-based training”. Third, we repositioned the subcategories “(de)briefing” and “rounds” as structuring tools instead of facilitating tools. Consequently, we merged the subcategories “(de)briefing” and “checklists” into “(de)briefing checklists”. Thereby, the subcategory “technology” became redundant.

Four main categories are distinguished: training, tools, organizational (re)design, and programme. The first category, training , is divided in training that is based on specific principles and a combination of methods (i.e. CRM and Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS)), a specific training method (i.e. training with simulation as a core element), or general team training, which refers to broad team training in which a clear underlying principle or specific method is not specified. The second category, tools , are instruments that are introduced to improve teamwork by structuring (i.e. SBAR (Situation, Background, Assessment, and Recommendation), (de)briefing checklists, and rounds), facilitating (through communication technology), or triggering (through monitoring and feedback) team interaction. Structuring tools partly standardize the process of team interaction. Facilitating tools provide better opportunities for team interaction. Triggering tools provide information to incentivize team interaction. The third category, organizational (re)design , refers to (re)designing structures (through implementing pathways, redesigning schedules, introducing or redesigning roles and responsibilities) that will lead to improved team processes and functioning. The fourth category, a programme , refers to a combination of the previous types of interventions (i.e. training, tools, and/or redesign). Table 2 presents the (sub)categorization, number of studies, and a short description of each (sub)category.

Overall findings

The majority of studies evaluated a training. Simulation-based training is the most frequently researched type of team training.

Most of the articles researched an acute hospital setting. Examples of acute hospital settings are the emergency department, operating theatre, intensive care, acute elderly care, and surgical unit. Less attention was paid to primary care settings, nursing homes, elderly care, or long-term care in general.

Interventions focused especially on improving non-technical skills, which refer to cognitive and social skills such as team working, communication, situational awareness, leadership, decision making, and task management [ 21 ]. Most studies relied on subjective measures to indicate an improvement in team functioning, with only a few studies (also) using objective measures. The Safety Attitude Questionnaire (SAQ) and the Non-Technical Skills (NOTECHS) tool are frequently used instruments to measure perceived team functioning.

Quality of evidence

A bulk of the studies had a low level of evidence. A pre- and post-study is a frequently used design. In recent years, an increasing number of studies have used an action research approach, which often creates more insight into the processes of implementing and tailoring an intervention than the more frequently used designs (e.g. Random Control Trial and pre-post surveys). However, these valuable insights are not fully appreciated within the GRADE scale.

The findings per category will be discussed in greater detail in the following paragraphs.

CRM and TeamSTEPPS are well-known principle-based trainings that aim to improve teamwork and patient safety in a hospital setting. Both types of training are based on similar principles. CRM is often referred to as a training intervention that mainly covers non-technical skills such as situational awareness, decision making, teamwork, leadership, coping with stress, and managing fatigue. A typical CRM training consists of a combination of information-based methods (e.g. lectures), demonstration-based methods (e.g. videos), and practice-based methods (e.g. simulation, role playing) [ 9 ]. However, CRM has a management concept at its core that aims to maximize the use of all available resources (i.e. equipment, time, procedures, and people) [ 324 ]. CRM aims to prevent and manage errors through avoiding errors, trapping errors before they are committed, and mitigating the consequences of errors that are not trapped [ 325 ]. Approximately a third of CRM-based trainings include the development, redesign or implementation of learned CRM techniques/tools (e.g. briefing, debriefing, checklists) and could therefore also be categorized in this review under programme [ 39 , 40 , 42 , 51 , 56 , 58 , 59 , 61 , 62 ].

The studies show a high variety in the content of CRM training and in the results measured. The majority of the studies claim an improvement in a number of non-technical skills that were measured, but some also show that not all non-technical skills measured were improved [ 43 , 47 , 66 ]. Moreover, the skills that did or did not improve differed between the studies. A few studies also looked at outcome measures (e.g. clinical outcomes, error rates) and showed mixed results [ 49 , 52 , 53 ]. Notable is the increasing attention toward nursing CRM, which is an adaptation of CRM to nursing units [ 66 , 67 ]. Most studies delivered a low to moderate quality level of evidence. Although most studies measured the effect of CRM over a longer period of time, most time periods were limited to one or two evaluations within a year. Savage et al. [ 58 ] and Ricci et al. [ 56 ] note the importance of using a longer time period.

As a result of experienced shortcomings of CRM, Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) has evolved (since 2006). TeamSTEPPS is a systematic approach designed by the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD) to enhance teamwork skills that are essential to the delivery of quality and safe care. Some refer to TeamSTEPPS as “CRM and more”. TeamSTEPPS provides an approach on preparing, implementing, and sustaining team training. It is provided as a flexible training kit and facilitates in developing a tailored plan. It promotes competencies, strategies, and the use of standardized tools on five domains of teamwork: team structure, leadership, communication, situational monitoring, and mutual support. In addition, TeamSTEPPS focuses on change management, coaching, measurement, and implementation. Notable is that even though the TeamSTEPSS training is most likely to differ across settings as it needs to be tailored to the situational context, articles provide limited information on the training content. All studies report improvements in some non-technical skills (e.g. teamwork, communication, safety culture). Combining non-technical skills with outcome measures (e.g. errors, throughput time) seemed more common in this category. Half of the studies delivered a moderate to high quality of evidence.

Simulation-based training uses a specific method as its core, namely, simulation, which refers to “a technique to replace or amplify real-patient experiences with guided experiences, artificially contrived, that evokes or replicates substantial aspects of the real world in a fully interactive manner” [ 326 ]. The simulated scenarios that are used can have different forms (e.g. in situ simulation, in centre simulation, human actors, mannequin patients) and are built around a clinical scenario (e.g. resuscitation, bypass, trauma patients) aiming to improve technical and/or non-technical skills (e.g. interprofessional collaboration, communication). We only identified studies in a hospital setting, which were mostly focussed on an emergency setting. All studies reported improvements in some non-technical skills (e.g. teamwork behaviour, communication, shared mental model, clarity in roles and responsibilities). In addition, some studies report non-significant changes in non-technical skills [ 98 , 137 , 140 , 155 ]. Some studies also looked at technical skills (e.g. time spend) and presented mixed results [ 63 , 112 , 152 , 159 ]. Sixty-nine studies focused on simulation-based training, of which 16 studies delivered a moderate to high quality of evidence.

General team training does not focus on one specific training principle or method. It often contains multiple educational forms such as didactic lectures, interactive sessions, and online modules. General team training focuses on a broad target group and entails for example team building training, coaching training, and communication skills training. Due to the broad scope of this category, high variation in outcomes is noted, although many positive outcomes were found. Most studies have a low to very low level of evidence.

Tools are instruments that could be implemented relatively independently in order to structure , facilitate or trigger teamwork.

Structuring tools

Teamwork can be structured by using the structured communication technique SBAR (Situation, Background, Assessment, and Recommendation), (de)briefing checklists, and rounds.

SBAR is often studied in combination with strategies to facilitate implementation, such as didactic sessions, training, information material, and modifying SBAR material (e.g. cards) [ 202 , 204 , 206 , 207 , 208 , 211 ]. In addition, this subcategory entails communication techniques similar or based on SBAR [ 203 , 205 , 209 , 210 , 212 ]. One study focused on nursing homes, while the remaining studies were performed in a hospital setting. Most studies found improvements in communication; however, a few found mixed results [ 208 , 209 ]. Only (very) low-level evidence studies were identified.

Briefings and debriefings create an opportunity for professionals to systematically communicate and discuss (potential) issues before or after delivering care to a patient, based on a structured format of elements/topics or a checklist with open and/or closed-end questions. Studies on (de)briefing checklists often evaluate the implementation of the World Health Organization surgical safety checklist (SSC), a modified SSC, SSC-based checklist, or a safety checklist in addition to the SSC. The SSC consists of a set of questions with structured answers that should be asked and answered before induction of anaesthesia, before skin incision, and before the patient leaves the operating theatre. In addition, several studies presented checklists aiming to better manage critical events [ 221 , 223 , 233 ]. Only one study on SSC was conducted outside the surgery department/operating theatre (i.e. cardiac catheterization laboratory [ 222 ]). However, similar tools can also be effective in settings outside the hospital, as shown by two studies that focused on the long-term care setting [ 249 , 260 ]. Overall, included studies show that (de)briefing checklists help improve a variety of non-technical skills (e.g. communication, teamwork, safety climate) and objective outcome measures (e.g. reduced complications, errors, unexpected delays, morbidity). At the same time, some studies show mixed results or are more critical of its (sustainable) effect [ 215 , 222 , 231 , 242 ]. Whyte et al. [ 262 ] pointed out the complexity of this intervention by presenting five paradoxical findings: team briefings could mask knowledge gaps, disrupt positive communication, reinforce professional divisions, create tension, and perpetuate a problematic culture. The quality of evidence varied from high to very low (e.g. Whyte et al. [ 262 ]), and approximately one third presented a high or moderate quality of evidence. Debriefings can also be used as part of a training, aiming to provide feedback on trained skills. Consequently, some articles focused on the most suitable type of debriefing in a training setting (e.g. video-based, self-led, instructor-led) [ 245 , 246 , 253 , 263 ] or debriefing as reflection method to enhance performance [ 258 , 261 ].

Rounds can be described as structured interdisciplinary meetings around a patient. Rounds were solely researched in hospital settings. Five studies found improvements in non-technical skills, one study in technical skills, and one study reported outcomes but found no improvement. Three studies presented a moderate level of evidence, and the others presented a (very) low level.

Facilitating tools

Teamwork can be facilitated through technology. Technology, such as telecommunication, facilitates teamwork as it creates the opportunity to involve and interact with professionals from a distance [ 271 , 272 , 273 ]. Technology also creates opportunities to exchange information through information platforms [ 276 , 277 ]. Most studies found positive results for teamwork. Studies were performed in a hospital setting and presented a level of evidence varying from moderate to very low.

Triggering tools

Teamwork could be triggered by tools that monitor and visualize information, such as (score) cards and dashboards [ 278 , 279 , 281 , 283 , 284 ]. The gathered information does not echo team performance but creates incentives for reflecting on and improving teamwork. Team processes (e.g. trust, reflection) are also triggered by sharing experiences, such as clinical cases and stories, thoughts of the day [ 280 , 282 ]. All seven studies showed improvements in non-technical skills and had a very low level of evidence.

Organizational (re)design

In contrast with the previous two categories, organizational (re)design is about changing organizational structures. Interventions can be focused on several elements within a healthcare organization, such as the payment system [ 292 ] and the physical environment [ 299 ], but are most frequently aimed at standardization of processes in pathways [ 286 , 288 ] and changing roles and responsibilities [ 287 , 289 , 298 ], sometimes by forming dedicated teams or localizing professionals to a certain unit or patient [ 290 , 291 , 295 , 300 ]. Most studies found some improvements of non-technical skills; however, a few found mixed results. Only four studies had a moderate level of evidence, and the others had a (very) low level.

A programme most frequently consists of a so-called Human Resource Management bundle that combines learning and educational sessions (e.g. simulation training, congress, colloquium), often multiple tools (e.g. rounds, SBAR), and/or structural intervention (e.g. meetings, standardization). Moreover, a programme frequently takes the organizational context into account: developing an improvement plan and making choices tailored to the local situation. A specific example is the “Comprehensive Unit-Based Safety Program” (CUSP) that combines training (i.e. science of safety training educational curriculum, identify safety hazards, learn from defects) with the implementation of tools (e.g. team-based goal sheet), and structural intervention (i.e. senior executive partnership, including nurses on rounds, forming an interdisciplinary team) [ 309 , 319 , 322 ]. Another example is the medical team training (MTT) programme that consists of three stages: (1) preparation and follow-up, (2) learning session, (3) implementation and follow-up. MTT combines training, implementation of tools (briefings, debriefing, and other projects), and follow-up coaching [ 5 , 304 , 305 , 316 ]. MMT programmes are typically based on CRM principles, but they distinguish themselves from the first category by extending their programme with other types of interventions. Most studies focus on the hospital setting, with the exception of the few studies performed in the primary care, mental health care, and healthcare system. Due to the wide range of programmes, the outcomes were diverse but mostly positive. The quality of evidence varied from high to very low.

Conclusion and discussion

This systematic literature review shows that studies on improving team functioning in health care focus on four types of interventions: training, tools, organizational (re)design, and programmes. Training is divided into principle-based training (subcategories: CRM-based training and TeamSTEPPS), method-based training (simulation-based training), and general team training. Tools are instruments that could be implemented relatively independently in order to structure (subcategories: SBAR, (de)briefing checklists, and rounds), facilitate (through communication technology), or trigger teamwork (through information provision and monitoring). Organizational (re)design focuses on intervening in structures, which will consequently improve team functioning. Programmes refer to a combination of different types of interventions.

Training is the most frequently researched intervention and is most likely to be effective. The majority of the studies focused on the (acute) hospital care setting, looking at several interventions (e.g. CRM, TeamSTEPPS, simulation, SBAR, (de)briefing checklist). Long-term care settings received less attention. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements; objective outcome measures also received attention (e.g. errors, throughput time). Looking at the quantity and quality of evidence, principle-based training (i.e. CRM and TeamSTEPPS), simulation-based training, and (de)briefing checklist seem to provide the biggest chance of reaching the desired improvements in team functioning. In addition, programmes, in which different interventions are combined, show promising results for enhancing team functioning. The category programmes not only exemplify this trend, but are also seen in principle-based training.

Because this review is an update of our review conducted in 2008 (and published in 2010) [ 8 ], the question of how the literature evolved in the last decade arises. This current review shows that in the past 10 years significantly more research has focused on team interventions in comparison to the previous period. However, the main focus is on a few specific interventions (i.e. CRM, simulation, (de)briefing checklist). Nevertheless, an increasing number of studies are evaluating programmes in which several types of interventions are combined.

Training : There has been a sharp increase in research studying team training (from 32 to 173 studies). However, the majority of these studies still look at similar instruments, namely, CRM-based and simulation-based training. TeamSTEPPS is a standardized training that has received considerable attention in the past decade. There is now a relatively strong evidence for the effectiveness of these interventions, but mostly for the (acute) hospital setting.

Tools : There is also a substantial increase (from 8 to 84 studies) in studies on tools. Again, many of these studies were in the same setting (acute hospital care) and focused on two specific tools, namely, the SBAR and (de)briefing checklist. Although the level of evidence for the whole category tools is ambiguous, there is relatively strong evidence for the effectiveness of the (de)briefing checklist. Studies on tools that facilitate teamwork ascended the past decade. There is limited evidence that suggests these may enhance teamwork. The dominant setting was again hospital care, though triggering tools were also studied in other settings such as acute elderly care and clinical primary care. Moreover, most studies had a (very) low quality of evidence, which is an improvement compared to the previous review that solely presented (very) low level of evidence.

Organizational (re)design : More attention is paid to organizational (re)design (from 8 to 16 studies). Although the number of studies on this subject has increased, there still remains unclarity about its effects because of the variation in interventions and the mixed nature of the results.

Programmes : There seems to be new focus on a programmatic approach in which training, tools, and/or organizational (re)design are combined, often focused around the topic patient safety. The previous review identified only one such study; this research found 24 studies, not including the CRM studies for which some also use a more programmatic approach. There seems to be stronger evidence that this approach of combining interventions may be effective in improving teamwork.

Limitations

The main limitation of this review is that we cannot claim that we have found every single study per subcategory. This would have required per subcategory an additional systematic review or an umbrella review, using additional keywords. As we identified a variety of literature reviews, future research should focus on umbrella reviews in addition to new systematic literature reviews. Note that we did find more studies per subcategory, but they did not meet our inclusion criteria. For example, we excluded multiple studies evaluating surgical checklists that did not measure its effect on team functioning but only on reported errors or morbidity. Although this review presents all relevant categories to improve team functioning in healthcare organizations, those categories are limited to team literature and are not based on related research fields such as integrated care and network medicine. Another limitation is that we excluded grey literature by only focusing on articles written in English that present empirical data and were published in peer-reviewed journals. Consequently, we might have excluded studies that present negative or non-significant effects of team interventions, and such an exclusion is also known as publication bias. In addition, the combination of the publication bias and the exclusion of grey literature has probably resulted in a main focus on standardized interventions and a limited range of alternative approaches, which does not necessarily reflect practice.

Implication for future research

This review shows the major increase in the last decade in the number of studies on how to improve team functioning in healthcare organizations. At the same time, it shows that this research tends to focus around certain interventions, settings, and outcomes. This helped to provide more evidence but also left four major gaps in the current literature. First, less evidence is available about interventions to improve team functioning outside the hospital setting (e.g. primary care, youth care, mental health care, care for disabled people). With the worldwide trend to provide more care at home, this is an important gap. Thereby, team characteristics across healthcare settings vary significantly, which challenges the generalizability [ 327 ]. Second, little is known about the long-term effects of the implemented interventions. We call for more research that monitors the effects over a longer period of time and provides insights into factors that influence their sustainability. Third, studies often provide too little information about the context. To truly understand why a team intervention affects performance and to be able to replicate the effect (by researchers and practitioners), detailed information is required related to the implementation process of the intervention and the context. Fourth, the total picture of relevant outcomes is missing. We encourage research that includes less frequently used outcomes such as well-being of professionals and focuses on identifying possible deadly combinations between outcomes.

Availability of data and materials

Not applicable

Abbreviations

Agency for Healthcare Research and Quality

Crew resource management

Comprehensive Unit-Based Safety Program

Department of Defense

Grading of Recommendations Assessment Development, and Evaluation

Medical team training

Non-Technical Skills

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Safety Attitude Questionnaire

Situation, Background, Assessment, and Recommendation

Surgical safety checklist

Team Strategies and Tools to Enhance Performance and Patient Safety

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lack of teamwork in healthcare essay

What is Teamwork in Nursing? (With Examples, Importance, & How to Improve)

lack of teamwork in healthcare essay

Are you a nurse searching for ways to build strong relationships, improve patient care, and promote a good work environment? If so, the key to making this happen is teamwork. Perhaps you know teamwork is essential but find yourself asking, "Where can I start, and what are some ways to know how to improve teamwork in nursing?” In this article, I will share some insight from my nursing career, including 15 expert tips to improve teamwork in nursing. As you read further, you will find reasons why teamwork is so important in nursing and learn the consequences of lack of teamwork. I’ll also share some sample scenarios using teamwork in nursing with examples of poor teamwork and good teamwork.

What Is Teamwork In Nursing?

5 reasons why teamwork is so important in nursing, 1. teamwork in nursing results in better patient care, which improves patient outcomes., 2. teamwork and collaboration in nursing help build strong professional relationships., 3. when nurses work together as a team, there is a reduced risk to patient safety., 4. the increased efficiency in patient care due to effective teamwork in nursing leads to lower healthcare costs., 5. teamwork in nursing promotes efficiency in patient care, conducive to a healing environment for patients, and job satisfaction for nurses., what are the 7 key elements of good teamwork in nursing, 1. communication:, 2. collaboration:, 3. coordination:, 4. accountability:, 5. integrity:, 6. sharing ideas with one another:, 7. being supportive of others:, examples of poor teamwork vs. good teamwork in nursing, 1. scenario: demonstrating leadership in teamwork, poor teamwork:, good teamwork:, 2. scenario: collaborative teamwork to reduce patient anxiety, 3. scenario: unusually heavy patient load, how to improve teamwork in nursing, 1. learn effective communication skills., 2. give credit to others for a job well done., 3. avoid trying to micro-manage other team members., 4. two ears, one mouth., 5. volunteer to be a mentor., 6. adopt and promote a patient-centered mindset., 7. grow your skills., 8. be willing to be the first person to promote teamwork between yourself and your colleagues., 9. embrace the diversity that makes up your team., 10. understand the role and responsibilities of each team member., 11. practice integrity., 12. encourage others to grow and expand their professional skills., 13. be willing to accept change., 14. make personal connections with your team members., 15. promote a holistic approach to patient care., 4 consequences of poor teamwork in nursing, 1. increased stress in the workplace:, 2. increased risk of errors in patient care:, 3. conflict among team members:, 4. poor management of time and resources:, useful resources to improve teamwork in nursing, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. will lack of teamwork impact my nursing career, 2. usually, how long does it take for a nurse to improve their teamwork skills, 3. do all types of nurses require good teamwork skills, 4. are nurses with good teamwork skills happier.

lack of teamwork in healthcare essay

The Effects of the Lack of Teamwork in Healthcare

Introduction, reference list.

Interprofessional collaboration is necessary for medical institutions because it promotes successful cooperation and the formation of consensus about the design of care plans and the quality of healthcare. Numerous research in health and social care has substantially enhanced the ability for cooperation and interprofessional collaboration to carry out diverse parts of healthcare procedures (Karam et al., 2018). Teamwork can make a difference in healthcare quality, the practice of medicine, and the persistence of harmful practices and organizations (Anderson et al., 2017). As a result, lack of teamwork is a well-recognized human element that negatively influences interprofessional collaboration and may lead to worse patient outcomes (service users).

A lack of teamwork impairs interprofessional collaboration and has significant adverse effects, leading to worse patient outcomes. For instance, it results in ineffective communication, the creation of factions, a rise in distrust, and the inability to use current knowledge effectively, hence raising the risk of medical mistakes and decreasing treatment quality. According to the Care Quality Commission (2018), 96 percent of identifiable, preventable, yet medical severe care errors (commonly known as “never events”) in NHS (National Health Service), England, between 2017 and 2018 were caused by human factors, including a lack of teamwork and assertiveness (Dahlke et al., 2018; Cohen et al., 2018). These data suggest that most occurrences in healthcare settings are highly impacted by rigid hierarchical structures, which severely influence team communication methods and cooperative efforts among team members. Consequently, there is a lack of teamwork, which negatively impacts healthcare delivery to patients.

Communication is strained or poor due to a lack of collaboration. Consequently, interprofessional collaboration is injured, and current knowledge cannot be used to attain the desired patient outcomes. Lack of cooperation in organizations, social systems, and relationships leads to poor communication and a disorganized system, and the healthcare system is no exception (Anderson et al., 2021). Another study by Cohen et al. (2020) indicated that the needs of different patients vary, as does the level of cooperation required to carry out their treatment plan. Due to a lack of collaboration in such complicated circumstances, communication gaps develop, hence raising the risk of medical mistakes and reducing the quality of treatment (Caffrey & Munro, 2017). Therefore, a lack of collaboration and teamwork leads to common issues such as strained or inadequate communication, resulting in challenges such as substandard care, medical errors, and avoidable patient deaths (Rosen et al., 2018). Consequently, insufficient, or strained communication harms interprofessional collaboration, hurting healthcare teamwork.

Multiple studies have shown that a culture of underperformance in healthcare systems is intimately linked to a lack of cooperation among healthcare professionals. For instance, in the healthcare system, the absence of interprofessional communication and disregard for the viewpoint of non-clinical workers is one of the critical causes (Rosen et al., 2018). When cooperation is not acknowledged, specialized employees within interprofessional teams are more likely to encounter potential dangers and discrepancies (Dahlke et al., 2018). Contrary to common assumptions, functioning as a (multidisciplinary team) MDT enhances patient care and the quality of life for everyone involved (Kenny & Helpingstine, 2021). The problem needs to be solved because when there is a strong culture of collaboration, patients are happier with the healthcare process/plan, communication is more effective, safety is enhanced, and interprofessional cooperation is more cohesive. Additionally, Hanegraaff and Pritoni (2019) highlighted the importance of fostering a supportive work environment to increase team cohesion, communication, and care delivery. Effectively communicating (multidisciplinary team) MDTs promote patient care teamwork and transparency. It also supports interprofessional collaboration and patient and client safety. Thus, working as a team is critical to the long-term success of a healthcare organization and protection of its patients.

Anderson, E. S., Gray, R., and Price, K. (2017). Patient safety and interprofessional education: A report of key issues from two interprofessional workshops. Journal of Interprofessional Care , 31(2), pp.154-163.

Anderson, J. E., Lavelle, M., and Reedy, G. (2021). Understanding adaptive teamwork in health care: Progress and future directions. Journal of Health Services Research & Policy , 26(3), pp. 208-214.

Caffrey, L., and Munro, E. (2017). A systems approach to policy evaluation. Evaluation , 23(4), pp. 463-478.

Care Quality Commission. (2018). Learning from Never Events | CQC Public Website .

Cohen, D. J., Wyte-Lake, T., Dorr, D. A., Gold, R., Holden, R. J., Koopman, R. J…. and Warren, N. (2020). Unmet information needs of clinical teams delivering care to complex patients and design strategies to address those needs. Journal of the American Medical Informatics Association , 27(5), pp. 690-699.

Dahlke, S., Stahlke, S. and Coatsworth-Puspoky, R., 2018. Influence of teamwork on health care workers’ perceptions about care delivery and job satisfaction. Journal Of Gerontological Nursing , 44(4), pp. 37-44.

Hanegraaff, M. and Pritoni, A. (2019). United in fear: Interest group coalition formation as a weapon of the weak? European Union Politics , 20(2), pp. 198-218.

Karam, M., Brault, I., Van Durme, T. and Macq, J. (2018). Comparing interprofessional and interorganizational collaboration in healthcare: a systematic review of the qualitative research. International Journal of Nursing Studies , 79, pp. 70-83.

Kenny, M.C. and Helpingstine, C. (2021). The collaborative efforts of a multidisciplinary community-based team to address victims of commercial sexual exploitation. Psychological Trauma: Theory, Research, Practice, and Policy . Web.

Rosen, M.A., DiazGranados, D., Dietz, A.S., Benishek, L.E., Thompson, D., Pronovost, P.J. and Weaver, S.J. (2018). Teamwork in healthcare: Key discoveries enabling safer, high-quality care. American Psychologist , 73 (4), p.433.

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Aspects of Teamwork in Healthcare Essay

High-quality healthcare depends on various factors, and one of the most essential of them is the successful teamwork process between the medical personnel. Rosen et al. (2018) analyzed the secondary data on this topic and identified that effective group behaviors, decent quality of knowledge, teamwork interventions, performance, and collaboration help medical professionals enhance patient outcomes. It is essential in the United States to optimize the communication between all the employees of the organizational unit to provide medical aid according to the standards of care. The researchers state that failure in one of the steps directly led to patient harm or inappropriate therapies (Rosen et al., 2018). To maintain better results in teamwork, the teams of professionals should be first divided by structure and context. Then, inside each group, members should divide their tasks to achieve interdependence and logical group composition (Rosen et al., 2018). Learning to work in multidisciplinary conditions, developing skills, and sharing competencies and leadership is also important step for the amelioration of teamwork.

Fast absorption of information, constant active education, and adaptation are the conditions of medical learning. Practicing teamwork by being involved in various training is essential for the speed and efficiency of teamwork. Productivity of the interdisciplinary approach and high-speed communications inside the group of medical professionals lead to the positive patient, staff, and hospital outcomes (Rosen et al., 2018). Finally, the researchers propose the future directions of the studies involving the telemedicine impact in a multidisciplinary approach, investigation of professional mistakes, and science measurement for teams (Rosen et al., 2018). Finally, the researchers suggest examining Electronic Health Records (HERs) as agent-based team members (Rosen et al., 2018). In conclusion, the authors of the study underline the up-to-date importance of teamwork that can contribute to general science and enhance the results of the treatment.

Rosen, M. A., DiazGranados, D., Dietz, A. S., Benishek, L. E., Thompson, D., Pronovost, P. J., & Weaver, S. J. (2018). Teamwork in healthcare: Key discoveries enabling safer, high-quality care. The American psychologist, 73 (4), 433–450. Web.

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Essay on Teamwork In The Workplace

Students are often asked to write an essay on Teamwork In The Workplace in their schools and colleges. And if you’re also looking for the same, we have created 100-word, 250-word, and 500-word essays on the topic.

Let’s take a look…

100 Words Essay on Teamwork In The Workplace

Teamwork – the foundation of success.

Teamwork is when people come together to achieve a common goal. In the workplace, teamwork is essential for success. When people work together, they can accomplish more than they could if they worked alone.

Benefits of Teamwork

There are many benefits to teamwork, such as:

  • Increased productivity
  • Improved quality of work
  • Enhanced creativity
  • Better problem-solving
  • Stronger relationships

How to Foster Teamwork

There are many things that employers and employees can do to foster teamwork in the workplace, such as:

  • Creating a team culture that values teamwork
  • Setting clear goals and objectives for teams
  • Providing teams with the resources and support they need to succeed
  • Celebrating team successes

Teamwork is essential for success in the workplace. When people work together, they can accomplish more than they could if they worked alone. Employers and employees can promote teamwork by creating a team culture that values teamwork, setting clear goals and objectives for teams, providing teams with the resources and support they need to succeed, and celebrating team successes.

250 Words Essay on Teamwork In The Workplace

Teamwork: the key to workplace success.

In the bustling world of work, teamwork shines as a beacon of productivity and innovation. When employees join forces, they create a synergistic blend of skills, knowledge, and perspectives, propelling the organization towards its goals with remarkable efficiency.

Building Bridges of Communication

Effective teamwork hinges on open and honest communication. Team members who actively listen, express their thoughts clearly, and embrace diverse ideas foster an environment of trust and respect. This healthy dialogue leads to better decision-making, as everyone’s input is valued and considered.

Embracing Diversity: A Tapestry of Strengths

A diverse team resembles a vibrant tapestry, where each individual’s unique talents, backgrounds, and experiences intertwine to create a rich and dynamic work environment. By embracing this diversity, teams can tap into a broader pool of knowledge, perspectives, and solutions, leading to innovative breakthroughs and exceptional outcomes.

Synergy: The Power of Collaboration

When teamwork is truly effective, something extraordinary happens: synergy emerges. Synergy is the magic that occurs when the collective output of a team far surpasses the sum of individual contributions. It’s the spark that ignites creativity, fuels productivity, and drives organizations to unprecedented heights.

Conclusion: The Path to Success

Teamwork is the linchpin of workplace success. By fostering open communication, celebrating diversity, and harnessing the power of synergy, teams become unstoppable forces, capable of achieving remarkable feats and leaving an indelible mark on the business landscape.

500 Words Essay on Teamwork In The Workplace

What is teamwork.

Teamwork is when a group of people come together to work towards a common goal. They work together to achieve something that they could not do individually. Teamwork is important in the workplace because it allows companies to be more efficient and productive. It can also help to improve communication and cooperation between employees.

There are many benefits to teamwork in the workplace. Some of the benefits include:

  • Increased productivity: When people work together, they can often get more done than they would if they were working alone. This is because they can share ideas and resources, and they can help each other to overcome challenges.
  • Improved quality: Teamwork can also help to improve the quality of work. This is because people can learn from each other and they can help each other to identify and correct mistakes.
  • Enhanced creativity: Teamwork can also help to enhance creativity. This is because people can share different perspectives and ideas, which can lead to new and innovative solutions to problems.
  • Stronger relationships: Teamwork can also help to build stronger relationships between employees. This is because people who work together learn to trust and respect each other. They also learn to communicate effectively and to work together to resolve conflict.

Challenges of Teamwork

While teamwork can be very beneficial, there are also some challenges that can arise. Some of the challenges of teamwork include:

  • Communication problems: One of the biggest challenges of teamwork is communication problems. This can happen when people have different communication styles or when they come from different cultural backgrounds. It can also happen when people are not clear about their roles and responsibilities.
  • Conflict: Another challenge of teamwork is conflict. This can happen when people have different opinions or when they feel that their needs are not being met. Conflict can be destructive if it is not managed properly.
  • Lack of motivation: Another challenge of teamwork is lack of motivation. This can happen when people are not engaged in their work or when they do not feel like they are making a contribution to the team.

How to Promote Teamwork

There are a number of things that managers can do to promote teamwork in the workplace. Some of these things include:

  • Create a clear and shared goal: One of the most important things that managers can do to promote teamwork is to create a clear and shared goal for the team. This goal should be something that is challenging but achievable, and it should be something that everyone on the team can agree on.
  • Provide the right resources: Managers also need to provide the team with the right resources to achieve their goal. This includes things like the right tools, equipment, and training.
  • Encourage communication: Managers also need to encourage communication between team members. This can be done by creating opportunities for team members to talk to each other, such as through team meetings or social events.
  • Manage conflict: Managers also need to be prepared to manage conflict when it arises. This means being able to identify the root cause of the conflict and to help team members to resolve their differences.
  • Celebrate success: Finally, managers need to celebrate the team’s successes. This shows team members that their work is valued and it motivates them to continue working together.

By following these tips, managers can help to create a collaborative and productive work environment where teamwork can thrive.

That’s it! I hope the essay helped you.

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Poor communication by health care professionals may lead to life-threatening complications: examples from two case reports

Abhishek tiwary.

1 Department of Internal Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal

Ajwani Rimal

Buddhi paudyal, keshav raj sigdel, buddha basnyat.

2 Oxford University Clinical Research Unit, Patan hospital, Lalitpur, Nepal

Associated Data

All data underlying the results are available as part of the article and no additional source data are required.

Peer Review Summary

We report two cases which highlight the fact how poor communication leads to dangerously poor health outcome. We present the case of a 50-year-old woman recently diagnosed with rheumatoid arthritis from Southern Nepal presented to Patan hospital with multiple episodes of vomiting and oral ulcers following the intake of methotrexate every day for 11 days, who was managed in the intensive care unit. Similarly, we present a 40-year-old man with ileo-caecal tuberculosis who was prescribed with anti-tubercular therapy (ATT) and prednisolone, who failed to take ATT due to poor communication and presented to Patan Hospital with features of disseminated tuberculosis following intake of 2 weeks of prednisolone alone. These were events that could have been easily prevented with proper communication skills. Improvement of communication between doctors and patients is paramount so that life-threatening events like these could be avoided.

Introduction

Communication refers to exchanging information with the help of different mediums, such as speaking, writing or body language 1 . It is of great importance in the field of medicine. Effective physician-patient communication is vital as it is related with favourable health outcomes such as increased patients satisfaction, compliance and overall health status 2 . A study in 2008 by Bartlett G et al. concluded that communication problems with patients lead to increased preventable adverse effects which were mostly drug-related 3 . It has been estimated that 27% of medical malpractice is the result of the communication failures. Better communication can reduce medical errors and patient injury 4 . Poor communication can result in various negative outcomes, such as decreased adherence to treatment, patients dissatisfaction and inefficient use of resources 5 . The cases discussed here highlight the importance of proper communication, how such unfortunate events could have been prevented with good communication skills. The traditional medical education curriculum in South Asia usually focuses more on technical expertise than teaching communication skills. This fact has hindered the capacity of technically expert health professionals to effectively communicate with their patients regarding the disease and treatment approach 6 , 7 . Thus, a concerted effort needs to be made to improve the communication skills of health professionals in South Asia.

Case reports

A 50-year-old woman diagnosed with rheumatoid arthritis (RA) 3 weeks previously presented to Emergency Department of Patan Hospital in June of 2018 with complaints of multiple episodes of vomiting and oral ulcers for 5 days. She had a history of multiple joint pain for a year, for which she sought medical attention in New Delhi, India as her son used to work there. She visited New Delhi with her neighbour, and there was diagnosed with RA. As per the standard treatment of RA, her treating rheumatologist prescribed her 15 mg methotrexate once weekly and 5 mg folic acid twice weekly without emphasizing that methotrexate is to be taken weekly and not daily. The pharmacist also failed to stress the weekly dose schedule. Unfortunately, she consumed methotrexate 15 mg daily for 11 days. At 11th day, she presented with those above complaints to the National Medical College and Teaching Hospital near her home in Birgunj, in the southern plains of Nepal. There she was managed conservatively with folic acid and fluids for 2 days, then referred to our centre for further management. She had ongoing vomiting and her examination of the oral cavity revealed multiple erythematous and ulcerative lesions. Her total white blood cell count (WBC) was 2400/µl (normal range, 4000–11000/µl), with an absolute neutrophil count (ANC) of 1200/µl (normal range, 1500–8000/µl), haemoglobin of 9 g/dl (12–15 g/dl) and platelets of 84000/µl (150,000–450,000/µl). She was immediately admitted to the intensive care unit (ICU) for methotrexate toxicity (myelosuppression and mucositis). Her methotrexate was stopped and she was managed with leucovorin (15 mg once daily), GM-CSF (300 µg once daily) and nasogastric feeding as she was unable to eat anything because of the oral ulcers.

After 3 days in the ICU, she was transferred to the ward, where treatment with leucovorin and GM-CSF was continued at the same dose. She was discharged after a total of 11 days of hospital stay when her blood counts came back to within the normal range (WBC, 12300/µl; ANC, 6888/µl). Her haemoglobin increased to 13 g/dl and her platelet reached 340,000/µl. Her oral lesions subsided, and she was able to feed orally. She was started back on the correct dosage of methotrexate (15 mg once weekly) and counselled about the disease, medications (dosage and adverse effects) and was advised to follow up in rheumatology clinic. She has been followed-up every 3 months since then, is in remission and is taking medications properly.

A 40-year-old man from hills of Nepal presented to the emergency department of Patan Hospital in August 2018 with complaints of weakness in the right half of the body, deviation of the left side of the face and slurring of speech for 4 days. At 3 weeks prior to this, he had visited another tertiary level hospital in Kathmandu for pain in the lower abdomen and fever, where he was diagnosed as having ileo-cecal tuberculosis based on colonoscopy and biopsy with positive Ziehl-Neelson staining. He was then prescribed with antitubercular therapy (ATT) that included 3 tablets of Fixed dose combination consisting of isoniazid 75 mg, rifampicin 150 mg, pyrazinamide 400 mg and ethambutol 275 mg once daily and prednisolone 40 mg once daily. He was advised to take ATT from a health centre near his residence, whereas prednisolone was dispensed from the hospital pharmacy. Unfortunately, he just took prednisolone, but no ATT. As a result, he ended up in emergency with the aforementioned complaints. On evaluation, his chest x-ray showed features of pulmonary tuberculosis. Cerebral spinal Fluid (CSF) analysis was done which showed red blood cells (RBC) 200/µl (normal value, 0/µl), WBC 64/µl (normal range, 0–5/ µl), neutrophil 24%, lymphocytes 64%, protein 294 mg/dl (normal range, 15–45 mg/dl) and sugar 49 mg/dl (normal range, 50–80 mg/dl). Cerebrospinal fluid GeneXpert testing was positive for Mycobacterium tuberculosis . He was then diagnosed as disseminated tuberculosis with meningeal involvement and was admitted to Patan Hospital with ATT (3 tablets of fixed-dose combination consisting of Isoniazid 75mg, Rifampicin 150 mg, Pyrazinamide 400 mg and Ethambutol 275mg once daily) and dexamethasone (6 mg three times a day) for 3 days. He was then discharged with ATT (same dose as above) and prednisolone (40 mg once daily) after proper counselling about the nature of the disease and site of availability of anti-tubercular drugs. He came in for follow-up after 2 weeks with improvement in the symptoms and has been taking all medications properly.

In the discussed cases, the treating physicians had used the standard treatment protocol to best serve their patients. They used their medical knowledge in an appropriate manner to treat the disease condition, but proper communication with clear-cut emphasis on how and when to take the therapy, which is of utmost importance in achieving an overall positive health impact, was lacking. Had the doctors properly counselled and educated the patients regarding the disease, treatment options and the correct way of taking medications, these mishaps could have been prevented. Another major part of the communication involves the judgment of the doctor in figuring out how much the patient understood. As our patients were not literate, they could have explained about the disease and especially the weekly dosing of methotrexate and the availability and importance of ATT very clearly to the patient family. In South Asian countries like Nepal, the patient seldom is alone and therefore making things clear to the patient’s family is obviously a very important option that needs to be utilized to improve communication against the background of rampant illiteracy. In Nepal, only 48.6% of the population is literate; hence this fact needs to be kept in mind when explaining about diseases and prescribing drugs, especially regarding medicines that have dangerous side-effects 8 .

In Nepal, 25.2% population fall below the poverty line and 3.2% population are unemployed 9 . The young working generation have to leave their house for better employment opportunities, meaning they aren’t able to take care of their parents. In one of our cases, the son had to work in India for better employment opportunities and the patient came with her neighbour with whom the treating physician did not spend any time. It is possible that if the son had been there, he may well have been more concerned and asked more questions to the doctor. However, it is the responsibility of the health care professional to try to make sure the patient and their family have understood the matter clearly. There was also no caution mentioned by the pharmacy where the patient bought the medicine explaining the weekly (and not daily) dosing schedule of methotrexate. Hence there was failure of clear communication at various levels that led to this mishap.

Problems in doctor‐patient communication have received little attention as a potential but a remediable cause of health hazards, especially in a setting like this one in South Asia. Communication during the medical interaction among the health practitioner and the patient has a pivotal role in creating a positive health impact that includes drug adherence, future decision making on the interventions and modifying the health behaviours of the patient. We consider the cost and the negative impact on the outcome of the health from poor communication, which includes non-adherence to drugs regimens that will increase the burden of the cost of the total drug therapy, poor health outcomes, and unnecessary treatment and investigations. Different measures need to be considered to improve the communication between doctors and patients which would improve the overall health outcome. The measures include providing communication skills training to health care professionals and regular evaluation of communication skills of these professionals by interviewing the patients after a consultation.

Clear communication is vital in the proper treatment of the patient especially against the background of rampant illiteracy in countries such as Nepal in South Asia. Poor Communication may lead to life-threatening complications, as in our patients. For better communication practice, proper communication training to health care professionals including pharmacists is paramount.

Informed consent for publication of their clinical details, in the form of a fingerprint, was obtained from the patients.

Data availability

[version 1; peer review: 2 approved]

Funding Statement

This study was supported by the Wellcome Trust (106680).

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Reviewer response for version 1

Jill allison.

1 Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada

  • This article provides two cases where a lack of information and clear understanding of prescription medication contributed to morbidity and unnecessary suffering for the patients. The cases are linked to a lack of health professional engagement with the patient and failure to ensure full understanding of medication instructions. The cases and events surrounding are clearly described. The outcomes are also clearly described.
  • The clinical scenario is well described but it would be helpful to know what steps were taken with these two patients to prevent similar circumstances. There is no mention of what was done to educate and inform the patient or their families on discharge. Was there an interdisciplinary team involved to try to ensure the patient got sufficient information and how was their level of comprehension assessed?
  • There is a bit of repetition in the discussion and not many concrete suggestions for improving the skills of physicians in this area. Continuing medical education? Cultural competency teaching?
  • There are a few grammatical errors that could be corrected to improve the paper. 
  • Overall, an important concept for discussion and excellent examples of why the discussion must happen. 

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Sharad Onta

1 Department of Community Medicine and Public Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal

2 Nepal Public Health Foundation, Kathmandu, Nepal

Introduction:

  • This section should focus on contextual facts about the central issue of the manuscript, communication in clinical practice in the present context. It is better to avoid assessment of the contents of the cases and conclusion with recommendation. 
  • The statement “ The cases discussed here highlight the importance of proper communication, how such unfortunate events could have been prevented with good communication skills” indicates to the assessment of upcoming contents of the manuscript. It seems inappropriate in the introduction. (It better fits in the discussion).
  • The last phrase of this section “ Thus, a concerted effort needs to be made to improve the communication skills of health professionals in South Asia” carries a notion of recommendation, which seems premature for this section of the manuscript. (It can be moved to the conclusion).
  • It will be better to highlight the objective and rationale of presenting cases in this section. It provides the space for the authors to justify importance of communication in clinical practice.
  • Adequate exploration of the facts as the evidence of poor communication in health service/clinical practices and highlights of these facts (findings) are necessary in presentation of the cases for justification of explanations narrated in the section of discussion. The cases in the manuscript look weak, as the communication aspects are not adequately elaborated on. Elaboration of communication dimension in the case presentation is desirable and, hence, suggested.
  • As emphasized in the discussion section, and in the conclusion, of the manuscript, socio-economic characteristics of the service seekers are not clearly mentioned in the cases. Therefore, rationalization of importance of communication in the basis of these attributes is not well justifiable.  

Discussion:

Few examples:

  • In case 1 – it should be explored in depth whether the attitude and faith of patients to recover earlier by getting medicine in more (frequently) quantity than prescribed dose could be the reason for this situation.
  • In case 2 – role of poor communication is not established clearly. Other possible reasons for not taking ATT like unavailability of medicines, distance to the health centres, and so on should be excluded to establish the role of communication. If prednisolone was the underlying cause of complication of the case, it should be analyzed, whether dispensing prednisolone alone without AT medicines to the patient was a right practice/protocol and correlate with the communication.

Confidentiality:

  • In case 1 – name of the referring hospital as National Medical College and Teaching Hospital is mentioned whereas in the case 2 – it is mentioned as another tertiary level hospital in Kathmandu . It is better to maintain the consistency.

  

Conclusion:

  • The conclusion is not well based in facts of cases. The manuscript has justified the importance of communication (in Nepal) in the background of rampant illiteracy . However, literacy and other socio-economic status of the patients in both cases are not known.
  • Language could be improved.
  • Manuscript has addressed very relevant and useful issues. It should be considered for indexing after improvement incorporating all comments. 

     

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