Teamwork and Teamwork Training in Health care: An Integration and a Path Forward

Although teamwork is prevalent and important in almost every industry, this is particularly the case within the health care industry (e.g., Leonard & Frankel, 2011). Enhancing teamwork has been heralded as a prime factor in addressing the troubling pronouncement made by the Institute of Medicine’s (IOM) 1999 report, “To Err is Human: Building a Safer Health System,” which found that as many as 98,000 deaths occur annually as a result of medical errors (Kohn, Corrigan, & Donaldson, 1999). In fact, the Quality Interagency Coordination Task Force (which was established in response to the IOM 1999 report) suggested that improving teamwork dynamics was a key way to improve patient safety.

In response, there has been a wealth of research over the past two decades examining teamwork within the context of health care (e.g., Koberg, Boss, Senjem, & Goodman, 1999) and investigating the underlying ways to improve teamwork. In particular, teamwork training has been a primary means that has been studied as increasing coordination among health care team members (e.g., Salas & Rosen, 2013). However, when looking at the research that has been conducted over the last 20 years on teamwork and teamwork training in health care, the scientific evidence is rather scattered in part due to the different types of performance measures examined (e.g., patient safety, quality of care, innovation, efficiency, productivity, learning) and the fact that study designs are highly variable. In addition, the subjects and the settings (e.g., operating theaters, hospital wards, nursing homes, and long-term care facilities) considered within these studies vary and consider a diverse set of teams (e.g., small specialized teams, large teams providing routine care, teams with varying levels of functional diversity, as well as teams that are stable and some are quite ad hoc). As such, the diversity in the types of teams being studied, the differing evidence provided by such research, and the varied contexts in which they function make it difficult for both practitioners and academic audiences to know how best to create effective teamwork within health care and design interventions that return the highest teamwork gains.

In response, the intent of this special issue is to highlight what is known about teamwork and teamwork training in health care, provide examples of cutting edge research within this context, as well as emphasize some fruitful research opportunities that exist in the area of health care teamwork and teamwork training. To accomplish these aims, our special issue consists of six papers. We start our special issue with a review conducted by Salas, Zajac, and Marlow (2018) that highlights what is currently known about teamwork and teamwork training in health care. Themes and related factors that were found to be facilitative in improving effective teamwork and team training from both the literature and the authors’ extensive practical experience are discussed. As such, this article provides a nice starting point to our understanding of the current state of the literature as well as highlighting some directions for future research in this area. For instance, these authors advocate for future work to give more attention to multi-team systems (MTS), increasingly leverage novel performance measurement systems, and studying the effectiveness of various modalities of training interventions being used in health care. Although each of these recommendations is certainly fruitful, we see great promise in the area of MTS and call on researchers to explore what teamwork looks like across units/departments within a health care facility and how MTS training needs to be distinct from traditional teamwork training. Interestingly, several of the other research directions identified by Salas and colleagues (2018) are addressed by some of the other articles included in our special issue.

Salas and colleagues (2018) suggest that research is needed to understand the climate that exists within the particular health care organization and how this may impact teamwork. Lyubovnikova, West, Dawson, and West (2018) examined the perceived organizational support for teamwork training and its effect on team productivity and innovation by means of shared objectives. They demonstrate the important role that teamwork climate has on the productivity and innovation of acute health care teams. Ogbonnaya, Tillman, and Gonzalez (2018) also examine the value of organizational support and their study showed that, in addition to improved knowledge and skills, organizational support improves employee satisfaction and indirectly affects patient satisfaction.

Salas and colleagues (2018) also highlight the importance of examining ways to sustain the benefits of teamwork training. We agree with this sentiment wholeheartedly and advocate for more work examining whether and how various teamwork training interventions that have been evidenced to be valuable retain their benefits over time. As such, this would require longitudinal studies that examine the efficacy of teamwork interventions over time. Within our special issue, Reiter-Palmon, Kennel, Allen, and Jones (2018) provide an example of a longitudinal study in which they examine the impact that an intervention had on reflexivity, innovation, and patient fall rates over the course of a 2-year period.

Salas and colleagues (2018) call for more focus on patient-centered outcomes, which has been advocated by others as well (e.g., Manser, 2009). Within our special issue, we have studies that have examined quality of patient care via leader ratings (e.g., Johnson, Nguyen, Groth, & White, 2018), patient satisfaction (e.g., Ogbonnaya and colleagues, 2018), and patient fall data (e.g., Reiter-Palmon and colleagues, 2018). Although these represent cutting edge work in terms of patient-centered outcomes, there are certainly additional steps that can be taken here. For instance, many advocate that the patient and caregivers need to be members of the team but more work is needed to truly understand the role of the patient, how best to motivate patients to take an active role in their care, and how to encourage the health care team to let this happen.

Salas and colleagues (2018) also highlight the importance of multidisciplinary collaboration in health care. Primarily, they leverage the term multidisciplinary to advocate for partnerships between clinicians and scientists as well as scientists across a variety of fields. However, we think this point also applies to considering the multidisciplinary nature of teams that are functioning within health care. To this point, Johnson and colleagues (2018) examined multidisciplinary teams and investigated the impact that the functional diversity of these teams had on team performance via its effect on role conflict. Likewise, Reiter-Palmon and colleagues (2018) look at interdisciplinary teams and how a multifaceted fall-reduction intervention could increase team reflexivity, which was in turn, related to lower patient fall rates. This study emphasizes the complexity of the implementation processes involved in improvement initiatives, which include implementation strategies for behavioral, system and context-related factors and requires interdisciplinary collaboration (Foy et al., 2011).

Although not specifically highlighted by Salas and colleagues (2018), we were pleased that several of the studies in the special issue consider the actual functioning or processes used within the context of health care teams. For instance, Johnson and colleagues (2018) focus on team processes that are important to reduce role conflict and argue that teams with high functional diversity need different team processes (i.e., interpersonal conflict management) as opposed to teams with low functional diversity (i.e., back-up and helping behavior). Next, Ogbonnaya and colleagues (2018) provide evidence that training positively moderates the relationship between individual perceptions of teamwork and patient satisfaction through employee well-being and intention to remain. Based on the results of their study, they state that “effective teamwork is fundamental for shaping employees’ experience of meaningful work” (p. 496). Likewise, Henrickson Parker, Schmutz, and Manser (2018) sought to identify common coordination characteristics of health care teams by conducting task analyses that resulted in three coordination themes that they suggest should be considered when implementing teamwork training interventions so that such trainings could become more responsive to the dynamic and variable nature of work in health care (Laidlaw & Hart, 2011).

Beyond these general themes, we are pleased with the global nature of the studies included in our special issue as teamwork is essential within health care regardless of geographical locations. To this end, we have samples drawn from the United Kingdom (e.g., Ogbonnaya and colleagues, 2018; Lyubovnikova and colleagues, 2018), the United States (e.g., Reiter-Palmon and colleagues, 2018), Australia (e.g., Johnson and colleagues, 2018) and Germany (e.g., Henrickson Parker and colleagues, 2018). Similarly, we want to highlight some of the other strengths of the studies included in our special issue. For instance, we have studies that examined teamwork phenomenon by leveraging multi-level studies (e.g., Ogbonnaya and colleagues, 2018), data obtained via a large-scale multi-study investigation of an entire national health care system (e.g., Lyubovnikova and colleagues, 2018), and studies that include teams across three distinct health care settings (i.e., cardiac anesthesia, pediatric resuscitation, and trauma resuscitation) (e.g. Henrickson Parker and colleagues, 2018)

In conclusion, we are confident that this special issue provides a greater understanding of where the literature currently exists regarding teamwork and teamwork training within health care. In addition, the studies included here provide some solid examples of how to conduct research in the challenging and dynamic context of health care. Likewise, the articles included in the special issue start to address several of the gaps that currently exist in the literature and highlight where the literature can proceed over the next couple of decades.

In particular, we want to encourage researchers to think more about how they can examine the long-term efficacy of interventions designed to improve teamwork within health care. Obviously, this would require longitudinal research and as we noted before, Reiter-Palmon and colleagues (2018) examined the effects of an intervention to reduce patient fall rates over the course of 2 years. Such research designs require extensive time, effort, and collaboration on the part of both the research team and the health care facility but are necessary to truly understand the long-term effects of teamwork interventions. Such an approach would also allow researchers to examine the implementation process and the trajectory of effects that interventions can have and compare these trajectories for various outcomes across Kirkpatrick’s (1994) learning levels.

In addition, we want to push researchers to try to leverage the vast amount of performance data that exists within hospitals. As an example, within this special issue, Ogbonnaya and colleagues (2018) were able to assess performance by using an industry-wide patient satisfaction survey. As another example (Luciano et al., 2018) recently examined the performance of surgical teams by looking at the percentage of time that a procedure took to complete versus the budgeted time set for that procedure by the hospital. Such creative approaches will allow researchers to overcome some of the concerns raised when research only utilizes a single source of data. Accordingly, we would like to challenge scholars to approach performance as a multifaceted construct. However, the complexity comes from the fact that these facets may at times contradict. For example, training that increases innovation could diminish patient safety, and training that enhances productivity could harm care quality. By approaching performance as a multifaceted construct, a holistic picture of the effect of training on performance could be painted.

Finally, we advocate for considering team dynamics in the field. Fortunately, this special issue includes numerous examples of studies examining “real” health care teams across various specialties. As such, we contend that this special issue provides a nice roadmap for future research on teamwork within the health care context and our hope is that research going forward will examine the various types of teams that exist across the full continuum of care within health care organizations. As such, research can consider the teamwork dynamics necessary within emergency medical teams that bring patients to hospitals, the various types of teams that exist within hospitals, teams at recovery and rehabilitation facilities, as well as teams in the numerous medical offices and inpatient facilities that exist. We would like to challenge scholars to have an open-mind regarding what is the “team” of interest across the continuum of care. By doing so, more research attention may be dedicated to understand the connections that may exist across different organizations involved in a single patient’s care. For example, how should a surgeon and a primary care doctor collaborate and what types of training enhance the teamwork that is displayed across these differing entities?

We are looking forward to seeing how those interested in teamwork and teamwork training in health care can build upon the foundation that this special issue creates!