Peer Review Articles About Individual Differences in the Classroom in the Last 5 Years
BMJ Open up. 2019; 9(9): e028280.
How effective is teamwork actually? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis
Jan B. Schmutz
i Department of Communication Studies, Northwestern University, Evanston, Illinois, USA,
Laurenz L. Meier
ii Department of Piece of work and Organizational Psychology, Academy of Neuchâtel, Neuchâtel, Switzerland,
Tanja Manser
3 FHNW School of Applied Psychology, University of Applied Sciences and Arts Northwestern Switzerland, Olten, Switzerland,
Received 2018 Nov 29; Revised 2019 Aug xiv; Accustomed 2019 Aug 16.
- Supplementary Materials
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Reviewer comments
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Author's manuscript
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Abstract
Objectives
To investigate the relationship between teamwork and clinical performance and potential moderating variables of this human relationship.
Design
Systematic review and meta-analysis.
Data source
PubMed was searched in June 2018 without a limit on the appointment of publication. Additional literature was selected through a manual backward search of relevant reviews, manual astern and forward search of studies included in the meta-analysis and contacting of selected authors via email.
Eligibility criteria
Studies were included if they reported a human relationship between a teamwork process (eg, coordination, non-technical skills) and a performance measure (eg, checklist based good rating, errors) in an acute care setting.
Data extraction and synthesis
Moderator variables (ie, professional person composition, team familiarity, average team size, task type, patient realism and type of performance mensurate) were coded and random-outcome models were estimated. Two investigators independently extracted information on study characteristics in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Results
The review identified 2002 articles of which 31 were included in the meta-analysis comprising 1390 teams. The sample-sized weighted mean correlation was r =0.28 (respective to an OR of 2.8), indicating that teamwork is positively related to performance. The examination of moderators was not significant, suggesting that the examined factors did not influence the average effect of teamwork on performance.
Conclusion
Teamwork has a medium-sized consequence on performance. The analysis of moderators illustrated that teamwork relates to performance regardless of characteristics of the team or chore. Therefore, healthcare organisations should recognise the value of teamwork and emphasise approaches that maintain and amend teamwork for the benefit of their patients.
Keywords: teamwork, non-technical skills, communication, teams, meta-analysis
Strengths and limitations of this report
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This systematic review evaluates bachelor studies investigating the effectiveness of teamwork processes.
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Xxx-one studies accept been included resulting in a substantial sample size of 1390 teams.
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The sample size of the principal studies included is usually depression.
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For some subgroup assay, the number of studies included was small.
Introduction
May it be an emergency team in the trauma room, paramedics treating patients afterward an accident or a surgical team in the operating room, teams are ubiquitous in healthcare and must work beyond professional, disciplinary and sectorial boundaries. Although the clinical expertise of private squad members is of import to ensure loftier performance, teams must be capable of applying and combining the unique expertise of team members to maintain prophylactic and optimal performance. In society for a team to be effective private team members need to interact and engage in teamwork. Today, experts concur that effective teamwork anchors safe and effective intendance at various levels of the healthcare systems1–4 leading to a relatively recent shift towards squad enquiry and preparation.5–vii
Healthcare is an evidence-based field and therefore administrators and providers are seeking evidence in the literature apropos the touch of teamwork on functioning outcomes like patient mortality, morbidity, infection rates or adherence to clinical handling guidelines. Having a closer look at the literature investigating healthcare teams we observe mixed and sometimes fifty-fifty contradicting results nearly the relationship between teamwork and clinical operation.8 Some studies notice a large event of teamwork on functioning outcomes (eg, Carlson et al 9) while others report pocket-sized or no relationships.ten 11 This inconsistency arises due to several reasons. First, the conceptual and empirical literature examining teamwork is fragmented and research examining teamwork effectiveness is spread across disciplines including medicine, psychology and system science. Therefore, researchers and practitioners often lack a mutual conceptual foundation for investigating teams and teamwork in healthcare. Second, research studies on teamwork in healthcare unremarkably showroom small sample sizes because of the challenges of recruiting bodily professional teams and advisedly balancing inquiry with patient intendance priorities. Small sample sizes, even so, increase the likelihood of reporting results that neglect to correspond true effect. Third, studies investigating healthcare teams often ignore important context variables of teams (eg, team composition and size, chore characteristics, squad environment) that likely influence the effect that teamwork has on clinical performance.12 13
These inconsistencies in the teamwork literature may lead to confusion about the importance of teamwork in healthcare, thus giving voice to critics who hinder efforts to improve teamwork. We aim to accost these problems with a meta-analytical study investigating the performance implications of teamwork. A meta-belittling arroyo moves beyond existing reviews on teamwork in healthcare8 14–17 and quantitatively tests if the widely advocated positive result of teamwork on operation holds true. In improver, this approach allows united states of america to investigate context variables equally moderators that may influence the upshot of teamwork on performance, meaning that this effect might be stronger or weaker under certain conditions. Previous meta-analysesxviii 19 focused mainly on the effectiveness of squad trainings but not on the effect of teamwork itself. This meta-analysis will generate quantitative evidence to inform the relevance of futurity interventions, regulations and policies targeting teamwork in healthcare organisations.
In the following we will outset institute an operational definition of teamwork, elaborate on relevant contextual factors and present our respective meta-analytical results and their estimation.
Teams, teamwork and team performance
In order to conspicuously understand the impact of teamwork on performance information technology is necessary to provide a brief introduction to teams, teamwork and team performance. We define teams as identifiable social piece of work units consisting of ii or more than people with several unique characteristics. These characteristics include (a) dynamic social interaction with meaningful interdependencies, (b) shared and valued goals, (c) a discrete lifespan, (e) distributed expertise and (f) clearly assigned roles and responsibilities.twenty 21 Based on this definition it becomes clear that teams must dynamically share data and resource among members and coordinate their activities in order to fulfil a certain task — in other words teams need to engage in teamwork.
Teamwork as a term is widely used and often difficult to grasp. However, we absolutely require a clear definition of teamwork peculiarly for team trainings that target specific behaviours. Teamwork is a process that describes interactions among team members who combine commonage resources to resolve job demands (eg, giving clear orders).22 23 Teamwork or team processes can be differentiated from taskwork. Taskwork denotes a team'south individual interaction with tasks, tools, machines and systems.23 Taskwork is contained of other team members and is oft described as what a team is doing whereas teamwork is how the members of a team are doing something with each other.24 Therefore, squad operation represents the accumulation of teamwork and taskwork (ie, what the squad really does).25
Team operation is ofttimes described in terms of inputs, processes and outputs (IPO).22 26–28 Outputs like quality of care, errors or performance are influenced past team related processes (ie, teamwork) like advice, coordination or decision-making. Furthermore, these processes are influenced by various inputs like team members' experience, task complexity, time pressure level and more. The IPO framework emphasises the critical function of team processes as the mechanism by which team members combine their resources and abilities, shaped past the context, to resolve team task demands. It has been the basis of other more advanced models27–29 only has also been criticised because of its simplicity.30 However, it is nonetheless the virtually popular framework to date and helps to systematise the mechanisms that predict squad performance and represents the basis for the pick of the studies included in our meta-analysis.
Contextual factors of teamwork effectiveness
Based on a large body of squad research from various domains, nosotros hypothesise that several contextual and methodological factors might moderate the effectiveness of teamwork, indicating that teamwork is more of import nether sure conditions.31 32 Therefore, we investigate several factors: (a) team characteristics (ie, professional person composition, team familiarity, team size), (b) task type (ie, routine vs non-routine tasks), (c) 2 methodological factors related to patient realism (ie, simulated vs real) and (d) the blazon of performance measures used (ie, process vs outcome performance). In the following we discuss these potentially moderating factors and the proposed effects on teamwork.
Professional composition
We distinguished between interprofessional and uniprofessional teams. Interprofessional teams consist of members from various professions that must piece of work together in a coordinated fashion.33 Diverse educational paths in interprofessional teams may shape respective values, behavior, attitudes and behaviours.34 As a outcome team members with dissimilar backgrounds might perceive and translate the environment differently and have a different agreement of how to work together. Therefore, nosotros presume that explicit teamwork is peculiarly important in interprofessional teams compared with uniprofessional teams.
Team familiarity
If team members have worked together, they are familiar with their individual working styles; and roles and responsibilities are ordinarily clear. If a squad works together for the first time, this potential lack of familiarity and clarity might make teamwork even more than important. Therefore, we differentiate between existent teams that besides piece of work together in their everyday clinical practice and experiential teams that only came together for study purposes.
Squad size
Another factor that may moderate the relationship between teamwork and operation is team size. Since larger teams exhibit more linkages among members than smaller teams, they also face greater coordination challenges. As well, with increasing size teams have greater difficulty developing and maintaining role structures and responsibilities. For these reasons, nosotros expect the influence of teamwork on clinical performance to be stronger in larger teams as compared with smaller teams.
Job blazon
Routine situations are characterised by repetitive and unvarying actions (eg, standard amazement induction).35 In contrast, non-routine situations exhibit more variation and dubiety, requiring teams to exist flexible and adaptive. Whereas squad members mostly rely on pre-learned sequences during routine situations, during non-routine situations nosotros assume that teamwork is more important in club for team members to resolve task demands.
Patient realism
Authors highlight the importance of using medical simulators in education.36 Therefore, we investigate the realism used in a study (fake vs real patients) equally a potential methodological factor that influences the relationship between teamwork and operation. Studies conducted with medical simulators might exist more standardised and less influenced by misreckoning variables than studies conducted with existent patients. Therefore, results from simulation studies might show stronger relationships between the 2 variables. Farther, using a simulator could cause individuals and teams to human action differently than in existent settings, thereby distorting the results. However, in the last decade high-fidelity simulators accept become increasingly realistic, suggesting that the results from simulation studies generalise to real environments. Including realism every bit a contextual factor in our analysis will reveal if the effects of teamwork observed in simulation compare with real life settings. Better understanding would provide important insights about simulation apply in teamwork studies.
Performance measures
As a second methodological factor, we expect that the type of functioning mensurate used in a study influences the reported teamwork effectiveness. The literature commonly differentiates between process-related and result-related aspects of performance.37 38 Process performance measures are action-related aspects and refer to adequate behaviour during procedures (eg, adhering to guidelines), making them easier to assess. Upshot performance measures (eg, infection rates after operations) follow team deportment, with assessment occurring later than procedure measures. Outcome performance measures suffer from several factors: greater sensitivity to confounding variables (eg, comorbidities), assessment challenges and greater difficulty linking team processes to outcomes. Looking at the predictors of the survival of cardiac abort patients illustrates the difference between the two types of performance measures. The main predictors for the survival (ie, performance effect) of a cardiac abort patient are 'duration of the abort' and 'age of the patient less than 70'.39 Although a squad delivers perfect basic life back up (ie, loftier process functioning) the patient can all the same die (ie, depression outcome performance). Due to these methodological considerations, we expect that studies assessing procedure performance report a stronger relationship betwixt teamwork and performance than studies assessing result performance.
Methods
The study was conducted based on the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses argumentxl also as established guidelines in social sciences.41 42 Through the combination of studies in the meta-analytical procedure, nosotros volition increase the statistical power and provide an accurate estimation of the true impact that teamwork has on performance.
Search strategy
Nosotros applied the post-obit search strategy to select relevant papers: (a) an electronic search of the database PubMed (no limit was placed on the date of publication, concluding search 19 June 2018) using the keywords teamwork, coordination, decision-making, leadership and communication in combination with patient safety, clinical performance, the final syntax for PubMed is available (online supplementary file), (b) a transmission backwards search for all references cited by 8 systematic literature reviews that focus on teamwork or non-technical skills in various healthcare domains,8 xv 17 43–47 (c) a manual backwards search for all references cited in studies we included in our meta-analysis, (d) a transmission forward search using Web of Scientific discipline to identify studies that cite the studies we included in our meta-assay, (eastward) identification of relevant unpublished manuscripts via email from authors currently investigating medical teams using specific mailing lists.
Inclusion criteria
Studies were included if a construct complied to the definition of teamwork processes outlined in the introduction (eg, coordination, communication). In addition, studies needed to investigate the human relationship between at least one teamwork process and a operation mensurate (eg, patient outcome). When studies reported multiple estimates of the same relationship from the same sample (eg, betwixt coordination and more than 1 indicator of performance), those correlations were examined separately just as appropriate for sub-analyses, just an average correlation was computed for all global meta-analyses of those relationships to maintain independence.41 We excluded manufactures investigating long-term care since the coordination of intendance for chronically sick patients has to consider the unique team task interdependencies in this setting.48 Also, teams working together over longer periods of time are more likely to develop emergent states (eg, team cohesion) that influence how a specific team works together.24 All manufactures included in this meta-analysis are listed in tables one and 2.
Table one
Descriptions of report objectives, settings and description of teamwork process and effect measures
| Authors | Year | Master study objectives | Participants and setting | Teamwork process measure | Result measure |
| Amacher et al 80 | 2017 | To compare female and male person rescuers in regard to cardiopulmonary resuscitation and leadership performance | Video observation of medical students managing cardiopulmonary resuscitation in a high-fidelity patient simulator | Structured observation of secure leadership statements within teams | Fourth dimension until start chest compression hands-on time within beginning 180 s |
| Brogaard et al threescore | 2018 | To investigate the relationship between non-technical skills and clinical performance in obstetrical teams | Video observation of obstetrical teams (obstetricians, obstetrical nurse, anaesthesiologists) managing real-life emergencies (postpartum haemorrhage) | Assessment of non-technical skills using a behaviourally anchored rating calibration (ATOP; Cess of Obstetric Team Performance) | Checklist tool for clinical performance (TeamOBS-PPH) |
| Burtscher et al 81 | 2011 | To investigate how team mental models and team monitoring behaviour interact to predict team performance in anaesthesia | Video observation of anaesthesia teams (residents, nurses) conducting a standard anaesthesia induction using a high-fidelity patient simulator | Structured observation of team monitoring behaviour | Checklist based expert rating |
| Burtscher et al 82 | 2011 | To investigate the relationship between adaptation of team coordination and clinical performance in response to a critical outcome | Video observation of anaesthesia teams (resident, nurse) conducting a standard anaesthesia induction including a critical upshot using a loftier-allegiance patient simulator | Structured observation of squad coordination | Reaction time related to the critical effect |
| Burtscher et al 83 | 2010 | To examine the office of anaesthesia teams' adaptive coordination in managing changing situational demands | Video observation of anaesthesia teams (residents, nurses, students) conducting standard anaesthesia inductions with non-routine events | Structured observation of squad coordination | Checklist based expert rating |
| Carlson9 | 2009 | To explore the relationship between team behaviour and the commitment of an appropriate standard of care specific to the false case | Video observation of trainees participating in a false event involving the presentation of acute dyspnoea | Assessment of team behaviour using a behaviourally anchored rating scale (leadership and team behaviour measurement tool) | Checklist based expert rating |
| Catchpole et al 62 | 2007 | To investigate if effective teamwork tin can prevent the development of serious situations and provide evidence for improvements in training and systems | Live observation of surgical teams conducting paediatric cardiac and orthopaedic surgeries | Observation of non-technical skills using a behaviourally anchored rating scale (NOTECHS scoring system) | Cess of pocket-size problems, intraoperative functioning and duration of surgery |
| Catchpole et al 63 | 2008 | To analyse the effects of surgical, aesthetical and nursing teamwork skills on technical outcomes | Ascertainment of surgical teams conducting laparoscopic cholecystectomies and carotid endarterectomies | Observation of non-technical skills using a behaviourally anchored rating calibration (NOTECHS scoring arrangement) | Operating time and errors in surgical technique |
| Cooper84 | 1999 | To examine the relationship between leadership behaviour, squad dynamics and task performance | Video ascertainment of emergency teams managing total cardiopulmonary arrests with a resuscitation attempt lasting longer than 3 min | Survey about leadership behaviour using the Leadership Behaviour Clarification Questionnaire | Checklist based expert rating |
| Davenport et al 85 | 2007 | To measure the impact of organisational climate condom factors on risk-adjusted surgical morbidity and mortality | Survey of staff on general and vascular surgery services | Survey about teamwork climate, level of communication and collaboration with surgeon | Surgical morbidity Surgical mortality |
| El Bardissi et al 86 | 2008 | To identify patterns of teamwork failures that would benefit from intervention in the cardiac surgical setting | Live observation of surgical teams conducting cardiac surgery | Structured observation of teamwork failures that disrupted the flow of the operation | Surgical technical errors |
| Gillespie et al 87 | 2012 | To investigate how various human factors variables, extend the expected length of an operation | Live observation of surgical teams beyond ten specialities | Structured observation of numbers of communication failures | Deviation from expected length of operation |
| Kolbe et al 88 | 2012 | To test the relationship between speaking upward and technical team operation in anaesthesia. | Observation of two-person (nurse, resident) advertizement hoc anaesthesia teams performing simulated inductions of general anaesthesia with modest non-routine events | Structured observation of speaking up behaviour | Checklist based adept rating |
| Künzle et al 89 | 2009 | To investigate shared leadership patterns during anaesthesia induction and to evidence how they are linked to team operation | Observation of two-person (nurse, resident) ad hoc anaesthesia teams performing simulated inductions of general amazement with a non-routine effect (asystole) | Structured observation of leadership behaviour | Reaction time to not-routine upshot |
| Manojlovich et al 90 | 2009 | To determine the relationships between patients' outcomes and nurses' perceptions of communication and characteristics of the practice environment. | A survey was conducted with nurses on various ICU wards | Survey nigh perception of nurse-physician communication using the ICU-nurse physician questionnaire | Ventilator-associated pneumonia Bloodstream infections Pressure ulcers Acute physiology and chronic health evaluation score |
| Manser et al 61 | 2015 | To investigate surgeons team direction skills and its influence on performance | Live observation of surgical teams managing a simulated laparoscopic cholecystectomy | Structured observation of team direction using the ComEd-Due east observation organisation | Checklist based practiced rating |
| Marsch et al 91 | 2004 | To decide whether and how human factors affect the quality of cardiopulmonary resuscitation | Observation of healthcare worker (nurse, physician) managing a cardiac arrest due to ventricular fibrillation using a high-fidelity patient simulator | Structured observation of job distribution, information transfer and leadership behaviour within the team | Checklist based adept rating |
| Mazzocco et al 92 | 2009 | To determine if patients of teams with adept teamwork had improve outcomes than those with poor teamwork | Live observation of surgical teams managing a diverseness of surgical procedures | Structured observation of information sharing, inquiry for relevant information and vigilance and awareness using a behaviourally anchored rating calibration | Postoperative complications and death |
| Mishra et al 93 | 2008 | To report on the development and evaluation of a method for measuring operating-theatre teamwork quality | Alive observation of surgical teams conducting laparoscopic cholecystectomy | Cess of non-technical skills using a behaviourally anchored rating scale (NOTECHS scoring system) | Surgical technical errors assessed with the OCHRA-tool |
| Schmutz et al 94 | 2015 | To investigate the moderating upshot of task characteristics on the human relationship between coordination and performance | Video observation of paediatric teams managing various paediatric emergencies using a high-allegiance patient simulator | Structured observation of closed loop communication, task distribution and provide data without request using the CoMeT-E ascertainment system | Checklist based expert rating |
| Siassakos et al 95 | 2012 | To investigate the relationship betwixt patient satisfaction and communication | Video observation of teams (physicians, midwives) managing obstetrical emergencies in secondary and tertiary maternity units | Structured ascertainment of airtight loop communication | Timely administration of magnesium sulfate |
| Siassakos et al 96 | 2011 | To determine whether team operation in a faux emergency is related to generic teamwork skills and behaviours | Video ascertainment of healthcare professionals (physician, midwives) managing various emergencies using a high-allegiance patient simulator | Assessment of generic teamwork using a behaviourally anchored rating scale (teamwork analytical tool) | Clinical efficiency score |
| Thomas et al 97 | 2006 | To investigate the human relationship of team behaviours during delivery room intendance and behaviours relate to the quality of care | Video observation of neonatal care teams managing a resuscitation during a caesarean section | Structured observation of advice, team management and leadership | Compliance with Neonatal Resuscitation Programme guidelines |
| Tschan et al 98 | 2006 | To investigate the influence of homo factors on squad functioning in medical emergency driven groups | Video observation of medical emergency teams (senior doctor, resident, nurse) managing a cardiac arrest in a high-fidelity patient simulator | Structured ascertainment of directive leadership and structuring inquiry | Clinical functioning assessed based on a fourth dimension-based coding of appreciable technical acts |
| Tschan et al 99 | 2009 | To investigate the influence of communication on diagnostic accuracy in ambiguous situations | Video ascertainment of groups of physicians diagnosing a hard patient with an anaphylactic daze in a loftier-fidelity patient simulator | Structured observation of the diagnostic information that take been considered, explicit reasoning and talking to the room | Accuracy of diagnosis |
| Westli et al 100 | 2010 | To investigate whether demonstrated teamwork skills and behaviour indicating shared mental models would be associated with improved medical management | Video observation of trauma teams (surgeons, anaesthesiologists, nurses, radiographers) in a high-fidelity patient simulator | Assessment of non-technical skills using a behaviourally anchored rating scale (ANTS and ATOM scoring system) | Checklist based expert rating |
| Wiegmann et al 101 | 2007 | To investigate surgical errors and their relationship to surgical flow disruptions to understand better the effect of these disruptions on surgical errors and patient safety | Live ascertainment of surgical teams conducting cardiac surgery operations | Structured observation of teamwork and communication failures | Structured observation of surgical errors during the operation |
| Williams et al 102 | 2010 | To describe relationships between teamwork behaviours and errors during neonatal resuscitation | Video observation of intensive care teams managing neonatal resuscitations | Structured ascertainment of teamwork behaviour (vigilance, workload management, information sharing, research, assertion) | Structured observation of errors (non-compliance with guidelines) |
| Wright et al 103 | 2009 | To test if observer ratings of team skills volition correlate with objective measures of clinical performance | Video observation of teams consisting of medical students performing low-fidelity classroom based patient assessment and high-allegiance simulation emergent care | Observation using a behaviourally anchored rating calibration for teamwork skills (assertiveness, controlling, situation assessment, leadership, communication) | Checklist based good rating |
| Yamada et al 104 | 2016 | To investigate the effect of standardised advice techniques on errors during resuscitation | Video observation of teams (Neonatologists, neonatal nurse practitioners, neonatology fellows) managing neonatal resuscitation | Structured observation of standardised communication | Error rate Time to initiate positive pressure ventilation Time to chest compression |
Tabular array 2
Studies, result sizes and moderator variables included in the meta-analytical database
| Authors | Year | Study goal | Setting | No. of teams | Professional person composition | Team famil-iarity | Average team size | Task type | Patient realism | Perfor-mance mensurate |
| Amacher et al 80 | 2017 | 0.11 | Emergency medicine | 72 | Uniprofessional | Experi-mental | 3 | Not-routine | Simulated | Process |
| Brogaard et al 60 | 2018 | 0.43 | Obstetrics | 99 | Interprofessional | Real | five | Non-routine | Existent | Process |
| Burtscher et al 81 | 2011 | −0.27 | Anaesthesia | 31 | Interprofessional | Experi-mental | 2 | Routine | Simulated | Procedure |
| Burtscher et al 82 | 2011 | 0.nineteen | Anaesthesia | 15 | Interprofessional | Experi-mental | two | Routine & non-routine | Faux | Process |
| Burtscher et al 83 | 2010 | 0.07 | Amazement | 22 | Interprofessional | Real | iii | Non-routine | Real | Process |
| Carlson et al*9 | 2009 | 0.83 | Emergency medicine | 44 | Uniprofessional | Experi-mental | 2.6 | Non-routine | Fake | Procedure |
| Catchpole et al 62 | 2007 | .45† | Surgery | 24 | Interprofessional | Real | nine | Non-routine | Real | Process |
| Catchpole et al 62 | 2007 | .29† | Surgery | 18 | Interprofessional | Real | v | Routine | Real | Process |
| Catchpole et al 63 | 2008 | .36† | Surgery | 26 | Interprofessional | Real | Routine | Real | Process | |
| Catchpole et al 63 | 2008 | .09† | Surgery | 22 | Interprofessional | Existent | Routine | Real | Procedure | |
| Cooper84 | 1999 | 0.fifty | Full general intendance | 20 | Interprofessional | Existent | 4 | Routine | Real | Process |
| Davenport et al 85 | 2007 | 0.17 | Surgery | 52 | Interprofessional | Real | Routine | Real | Outcome | |
| El Bardissi et al 86 | 2008 | 0.67 | Surgery | 31 | Interprofessional | Real | 7 | Routine | Real | Process |
| Gillespie et al 87 | 2012 | 0.23 | Surgery | 160 | Interprofessional | Real | vi | Routine | Real | Procedure |
| Kolbe et al 88 | 2012 | 0.33 | Anaesthesia | 31 | Interprofessional | Real | 2 | Not-routine | Simulated | Procedure |
| Künzle et al 89 | 2009 | 0.56 | Anaesthesia | 12 | Interprofessional | Real | 2 | Routine | Fake | Process |
| Manojlovich et al xc | 2009 | 0.11 | Intensive care | 25 | Uniprofessional | Real | 36 | Routine | Real | Outcome |
| Manser et al 61 | 2015 | 0.39 | Surgery | 19 | Interprofessional | Experi-mental | 5 | Routine | False | Process |
| Marsch et al 91 | 2004 | 0.23 | Intensive intendance | sixteen | Interprofessional | Experi-mental | iii | Non-routine | Simulated | Process |
| Mazzocco et al 92 | 2009 | 0.11 | Surgery | 293 | Interprofessional | Existent | 6 | Routine | Real | Outcome |
| Mishra et al 93 | 2008 | 0.05 | Surgery | 26 | Interprofessional | Real | 6 | Routine | Existent | Procedure |
| Schmutz et al 94 | 2015 | 0.12 | Emergency medicine | 68 | Interprofessional | Existent | six | Non-routine | Simulated | Process |
| Siassakos et al 95 | 2012 | 0.66 | Obstetrics | 19 | Interprofessional | Real | vi | Non-routine | Simulated | Process |
| Siassakos et al 96 | 2011 | 0.55 | Emergency medicine/ obstetrics | 24 | Interprofessional | Experi-mental | 6 | Not-routine | Fake | Process |
| Thomas et al 97 | 2006 | 0.23 | Neonatal intendance | 132 | Interprofessional | Existent | v | Not-routine | Real | Process |
| Tschan et al 98 | 2006 | 0.23 | Emergency medicine | 21 | Interprofessional | Experi-mental | 5 | Non-routine | False | Process |
| Tschan et al 99 | 2009 | 0.37 | Emergency medicine | 20 | Uniprofessional | Experi-mental | two.65 | Not-routine | Simulated | Event |
| Westli et al 100 | 2010 | 0.18 | Emergency medicine | 27 | Interprofessional | Real | 5.one | Non-routine | Fake | Process |
| Wiegmann et al 101 | 2007 | 0.56 | Surgery | 31 | Interprofessional | Real | Routine | Real | Process | |
| Williams et al 102 | 2010 | 0.xviii | Neonatal care | 12 | Interprofessional | Real | 5 | Non-routine | Real | Process |
| Wright et al 103 | 2009 | 0.81 | General care | 9 | Uniprofessional | Experi-mental | four | Non-routine | Simulated | Procedure |
| Yamada et al 104 | 2016 | 0.eleven | Emergency medicine | 13 | Interprofessional | Experi-mental | 3 | Not-routine | Simulated | Process |
For the criterion level of analysis, we included only effect sizes at the team level and non on an individual level. Therefore, the operation measure had to exist conspicuously linked to a team. This arroyo aligns with research that strongly recommends against mixing levels of analysis in meta-belittling integrations.49 50
Two reviewers independently screened titles and abstracts from articles yielded in the search. Afterwards full texts of all relevant manufactures were obtained and screened by the same ii reviewers. Understanding was above xc%. Whatsoever disagreement in the selection process was resolved through consensus discussion.
Data extraction
With the help of a jointly developed coding scheme, studies were independently coded past one of the authors (JS) and another rater, both with a groundwork in industrial psychology and human factors. 20 per cent of the studies were rated by both coders. Intercoder agreement was above 90%. Whatsoever disagreement was resolved through word. The data extracted comprised details of the authors and publication as well as important written report characteristics and statistical relationships between a teamwork variable and performance (table two).
Coding of squad characteristics
The professional composition of teams was coded either equally 'Interprofessional' if a team consisted of members from different professions (eg, nurses and physicians) or as 'Uniprofessional' if the members of the teams were of the same profession. Team size was coded as the number of members (boilerplate number if team size varied) of the investigated teams. Team familiarity was coded either equally 'experimental' or 'existent'. 'Real' indicates that the team members also worked together in their everyday clinical do. 'Experimental' means that the teams only worked together during the study.
Coding of task characteristics
Task blazon was coded either as 'Routine task' or 'Non-routine task'. Nosotros defined 'Non-routine tasks' every bit unexpected events that crave flexible behaviour frequently nether time-pressure (eg, emergency situations). 'Routine tasks' draw previously planned standard procedures (eg, standard anaesthesia consecration, planned surgery).
Coding of methodological factors
Patient realism was either coded as 'Real patient' or 'Imitation patient'. 'Simulated patient' included a patient simulator (manikin) whereas 'Real patient' included real patients in clinical settings.
Clinical performance measures were coded either equally 'Outcome functioning' or 'Process performance'.38 51 'Outcome performance' includes an outcome that is measured after the treatment process (eg, infection charge per unit, mortality). We focused merely on patient-related outcomes and not on team outcomes (eg, squad satisfaction). 'Process performance' describes the evaluation of the treatment process and describes how well the process was executed (eg, adherence to guidelines through expert rating). Procedure operation measures are often based on official guidelines and extensive proficient knowledge.52 Thus, we assumed that process performance closely relates to patient outcomes.
Statistical assay
Dissimilar types of effect sizes (eg, OR, F values and r) have been reported in the original studies. We therefore converted the different outcome sizes to a common metric, namely r using the formulas provided by Borenstein et al 53 and Walker.54 Moreover, some samples contained issue sizes of teamwork with two or more measures of performance. Considering independence of the included effects sizes is required for a meta-analysis,41 55 we used Fisher's z score to average the multiple correlations from the same sample (scholars have suggested to catechumen r to Fisher's z scores, to average the z'southward and then to backtransform it to r.56 Using simple arithmetic boilerplate (ie, correlations will be summed and divided by the number of coefficients) is problematic because the distribution of r becomes negatively skewed every bit the correlation is larger than zero. Every bit a result, the average r tends to underestimate the population correlation). The correlations were weighted for sample size. Even so, in dissimilarity to many meta-analyses in social sciences, the correlations were not adjusted for measurement reliability. This is considering information about the measurement reliability could not be compared (Kappa vs Cronbach's Alpha) or were non available at all for the majority of studies. Therefore, we study uncorrected, sample-size weighted mean correlation, its 95% CI, and the fourscore% credibility interval (CR). The CI reflects the accuracy of a point approximate and can exist used to examine the significance of the effect size estimates, whereas the CR refers to the deviation of these estimates and informs us about the existence of possible moderators.
Random-effects models were estimated based on two considerations.57 First, nosotros expected study heterogeneity to be high given the dissimilar written report design characteristics such every bit patient realism ('Real patient' vs 'Simulated patient'), job type ('Routine task' vs 'Not-routine chore') and unlike forms of operation measures. Second, we aimed to provide an inference on the average upshot in the entire population of studies from which the included studies are causeless to be a random selection of it. Therefore, random-effects models were estimated.57 These models were calculated by the restricted maximum-likelihood reckoner, an efficient and unbiased estimator.58 Since we included only descriptive studies and no interventions we simply included the sample size of the individual studies equally a potential bias into the meta-assay. To rule out a potential publication bias, we tested for funnel plot asymmetry using the random-effect version of the Egger test.59 The results betoken that there is no asymmetry in the funnel plot (z=i.79, p=0.074), suggesting that there is no publication bias.
The interpretation of meta-analytical models including the outlier analyses were performed with the bundle 'metafor' from the programming language and statistical environment R.58
Results
The online search resulted in 2002 manufactures (effigy i). Two studies were identified via contacting authors directly and have been presented at conferences in the past.60 61 After duplicates were removed 1988 articles were screened using title and abstruse. Sixty-seven articles were then selected for a full text review. Full text examination, forward and backward search of selected articles and relevant reviews resulted in 30 studies coming from 28 articles (ii publications presented 2 contained studies in one publication62 63). This led to a total of 32 studies coming from 30 articles. Following the recommendation by Viechtbauer and Cheung,64 nosotros screened for outliers using studentized deleted residuals. One example (Carlson et al,9 r=0.89, n=44, studentized deleted residuals=iv.26) was identified every bit outlier and therefore excluded from further analyses, resulting in a last sample size of g=31.
Systematic literature search.
Table 1 provides a qualitative description of the selected articles including study objectives, the setting in which the studies were carried out and a description of the teamwork processes as well as the outcome measures that were assessed. If a specific tool for the assessment of a teamwork process or event measure was used this is indicated in the corresponding cavalcade. Observational studies were virtually prevalent. Teamwork processes were assessed using either behaviourally anchored rating scales (n=viii) or structured observation (n=19) of specific teamwork behaviour. Structured ascertainment — as we describe it — is divers as a purely descriptive cess of certain behaviour ordinarily using a predefined observation system (eg, amount of speaking up behaviour). In contrast, behaviourally anchored rating scales consist of an evaluation of teamwork process behaviour by an practiced. Simply three studies used surveys to assess teamwork behaviours. The majority of the studies (due north=27) assessed procedure performance using either a checklist based proficient rating or assessing a reaction time measure after the occurrence of a sure event (eg, time until intervention). Only four studies assessed outcome performance measures. Measures included accurateness of diagnosis, postoperative complications and death, surgical morbidity and bloodshed, ventilator-associated pneumonia, bloodstream infections, pressure ulcers and astute physiology and chronic wellness evaluation score. Table 2 provides an overview of all variables included in the meta-analysis including the upshot sizes and moderator variables.
Effect of teamwork and contextual factors
Tabular array 3 and figure ii shows the relationship betwixt teamwork and squad functioning. The sample-sized weighted mean correlation was 0.28 (95% CI 0.20 to 0.35, z=6.55, p<0.001), indicating that teamwork is positively related to clinical performance. Results farther indicated heterogeneous consequence size distributions across the included samples (Q=53.73, p<0.05, I 2=45.96), signifying that the variability across the sample effect sizes was more than what would be expected from sampling error solitary.
Relationship between teamwork processes and functioning.
Table 3
Meta-analytical relationships between teamwork and clinical operation
| N | k | r | 95% CI | 80% CR | Q | Itwo | |
| Overall relationship | 1390 | 31 | 0.28* | (0.xx to 0.35) | (0.09 to 0.45) | 53.7* | 46.0 |
| Squad characteristics | |||||||
| Professional limerick | |||||||
| Interprofessional | 1264 | 27 | 0.28* | (0.20 to 0.36) | (0.09 to 0.46) | 47.1* | 48.2 |
| Uniprofessional | 126 | four | 0.28 | (−0.01 to 0.52) | (−0.04 to 0.54) | 6.5 | 47.1 |
| Team familiarity | |||||||
| Experimental team | 240 | 10 | 0.25* | (0.05 to 0.43) | (−0.05 to 0.51) | 17.two* | 47.2 |
| Real team | 1150 | 21 | 0.29* | (0.20 to 0.37) | (0.12 to 0.45) | 36.2* | 45.seven |
| Team size† | |||||||
| Job characteristics | |||||||
| Task type | |||||||
| Routine chore | 766 | xiv | 0.27* | (0.12 to 0.40) | (−0.01 to 0.50) | 30.9* | 65.0 |
| Non-routine task | 609 | 16 | 0.29* | (0.twenty to 0.39) | (0.16 to 0.42) | twenty.v | 24.6 |
| Methodological factors | |||||||
| Patient realism | |||||||
| Real patient | 993 | xvi | 0.28* | (0.18 to 0.38) | (0.x to 0.45) | 28.vii* | 49.iii |
| Imitation patient | 397 | xv | 0.28* | (0.xiii to 0.41) | (0.02 to 0.50) | 25.0* | 44.6 |
| Functioning measures | |||||||
| Upshot performance | 390 | iv | 0.13* | (0.03 to 0.23) | (0.06 to 0.xix) | 1.3 | 0.0 |
| Process performance | g | 27 | 0.30* | (0.21 to 0.39) | (0.10 to 0.49) | 45.half-dozen* | 45.6 |
To test for moderator effects of the contextual factors, we conducted mixed-effects models including the mentioned moderators: professional composition, team familiarity, team size, task type, patient realism and performance measures.
The omnibus test of moderators was not significant (F=0.18, df i=6, df ii=xviii, p>0.20), suggesting that the examined contextual factors did not influence the average effect of teamwork on clinical functioning. To provide greater detail about the function of the contextual factors, we conducted separate analyses for the categorical contextual factors and written report them in table iii.
Discussion
With this study, we aimed to provide bear witness for the functioning implications of teamwork in healthcare teams. By including diverse contextual factors, nosotros investigated potential contingencies that these factors might have on the relationship between teamwork and clinical performance. The analysis of 1390 teams from 31 different studies showed that teamwork has a medium sized effect (r=0.2865 66;) on clinical performance beyond diverse care settings. Our study is the kickoff to investigate this relationship quantitatively with a meta-belittling procedure. This finding aligns with and advances previous work that explored this relationship in a qualitative way.viii 15 17 43–47
At start glance a correlation of r=0.28 might not seem very high. However, we would like to highlight that r=0.28 is considered a medium sized effect65 66 and should not be underestimated. To meliorate illustrate what this effect means nosotros transformed the correlation into an OR of 2.8.53 Of course, this transformation simplifies the correlation because teamwork and often the outcome measures are non simple dichotomous variables that can exist divided into an intervention and control grouping. All the same, this transformation illustrates that teams who engage in teamwork processes are 2.8 times more probable to achieve high performance than teams who are non. Looking at the performance measures in our study we see that they either describe patient outcomes (eg, mortality, morbidity) or are closely related to patient outcomes (eg, adherence to handling guidelines). Thus, we consider teamwork a operation-relevant process that needs to be promoted through training and implementation into treatment guidelines and policies.
The included studies used a variety of dissimilar measures for clinical operation. This variability resulted from the different clinical contexts in which the studies were carried out. There is no universal measure for clinical performance considering the consequence is in well-nigh cases context specific. In surgery, common performance measures are surgical complications, bloodshed or morbidity.67 In anaesthesia, studies oft employ skilful ratings based on checklists to appraise the provision of amazement. Expert ratings are also the common class of functioning assessment in simulator settings where patient outcomes like morbidity or mortality cannot be measured. Future studies demand to be aware that clinical performance measures depend on the clinical context and that the development of valid performance measures requires considerable attempt and scientific rigour. Guidelines on how to develop performance assessment tools for specific clinical scenarios be and need to be accounted for.52 68 69 Furthermore, depending on the clinical setting researchers demand to evaluate what specific clinical functioning measures are suitable and if and how they tin exist linked to team processes in a meaningful style.
The analysis of moderators illustrates that teamwork is related with functioning under a variety of weather condition. Our results suggest that teams in unlike contexts characterised by different team constellations, team size and levels of acuity of care all benefit from teamwork. Therefore, clinicians and educators from all fields should strive to maintain or increase effective teamwork. In recent years, there has been an upsurge in crisis resource management (CRM).19 These trainings focus on team direction and implement various teamwork principles during crunch situations (eg, emergencies).70 Our results suggest that team trainings should not only focus on non-routine situations like emergencies but also on routine situations (eg, routine anaesthesia induction, routine surgery) because based on our information teamwork is equally important in such situations.
A closer wait at methodological factors of the included studies revealed that the observed relationship between teamwork and performance in simulation settings does not differ from relationships observed in real settings. Therefore, nosotros conclude that teamwork studies conducted in simulation settings generalise to existent life settings in astute care. Further, the analysis of different performance measures reveals a trend towards procedure functioning measures existence more strongly related with teamwork than outcome functioning measures. A possible caption of this finding relates to the difficulty of investigating outcome performance measures in a manner isolated from other variables. Nevertheless, we still found a meaning relationship between teamwork and objective patient outcomes (eg, postoperative complications, bloodstream infections) despite the methodological challenges of measuring outcome operation and the pocket-size number of studies using outcome performance (thousand=four).
Our results are in line with previous meta-analyses investigating the effectiveness of team training in healthcare.eighteen nineteen Like to our results, Hughes et al highlighted the effectiveness of team trainings nether a variety of conditions — irrespective of team limerick,18 simulator fidelity or patient vigil of the trainee's unit also as other factors.
Nosotros were unable to discover a moderation of task type in our written report, potentially explained by task interdependence, which reflects the degree to which team members depend on i another for their effort, information and resources.71 A meta-analysis including teams from multiple industries (eg, project teams, management teams) found that task interdependence moderates the relationship between teamwork and operation, demonstrating the importance of teamwork for highly interdependent team tasks.72 Nearly studies included in our analysis focused on rather short and intense patient intendance episodes (eg, a surgery, a resuscitation task) with high task interdependence, which may explicate the loftier relevance of teamwork for all these teams.
Limitations and future directions
Despite greater attending to healthcare team research and squad training over the terminal decade, we were only able to identify 32 studies (31 included in the meta-analysis). Of note, over two-thirds of the studies in our analysis emerged in the terminal 10 years, reflecting the increasing interest in the topic. The rather modest number of studies might relate to the difficulties in quantifying teamwork, the considerable theoretical and methodological cognition required and the challenges of capturing relevant consequence measures. Likewise, besides the manual searches of selected articles and reviews and contacting authors in the field we did only search the database PubMed. PubMed is the most common database to admission papers that potentially investigate medical teams and includes approximately 30 000 journals from the field of medicine, psychology and management. Nosotros are fairly confident that through the additional inclusion of relevant reviews and forward and backwards search, our results represent an accurate representation of what tin be found in the literature.
Hereafter enquiry should build on recent theoretical and applied work24 26 28 73 almost teamwork and apply this current meta-analysis as a signpost for future investigations. In order to move our field forward, we must employ existing conceptual frameworks22 24 26 and establish standards for investigating teams and teamwork. This tin can frequently just be accomplished with interdisciplinary research teams including experts from the medical fields only equally important from health professions education, psychology or communication studies.
Another limitation relates to the unbalanced analysis of subgroups. For example, we only identified iv studies that used outcome performance variables compared with 27 using process performance measures. Uneven groups may reduce the power to detect pregnant differences. Therefore, we encourage hereafter studies to include result operation measures despite the effort required.
Finally, more than factors may influence the relationship between teamwork and functioning that we were unable to extract from the studies. While nosotros tested for the effects of team familiarity by comparing experimental teams and real teams, this does not fully capture team member familiarity. The extent to which team members actually worked together during prior clinical practice might predict of how finer they perform together. Nonetheless, even two people working in the same ward might really not accept interacted much during patient care depending on the setting. Also team climate on a ward or in a hospital may exist an important predictor of how well teams work together, especially related to sharing information or speaking up within the team.74 75
Finally, the clinical context might play a part in how squad members interact. In unlike disciplines, departments or healthcare institutions different norms and routines exist on how to work together. Therefore, report results and recommendations about teamwork need to be interpreted in the light of the respective clinical context. There are empirical indications that a one-size-fits-all approach might not be suitable and team training efforts cannot ignore the clinical context, especially the routines and norms almost collaboration.76 We acknowledge that there might be other factors surrounding healthcare teams that might potentially influence teamwork and clinical performance. All the same, in this review we could merely extract data that was reported in the chief studies. Since these were limited in the healthcare contexts studied, the results might not generalise to long-term intendance settings or mental wellness, for example. Time to come work needs to consider and besides document a broader range of potentially influencing factors.
Decision
The electric current meta-assay confirms that teamwork across diverse team compositions represents a powerful procedure to better patient intendance. Good teamwork tin can be achieved by articulation reflection nearly teamwork during clinical event debriefings77 78 as well every bit team trainings79 and system improvement. All healthcare organisations should recognise these findings and place continuous efforts into maintaining and improving teamwork for the benefit of their patients.
Supplementary Material
Acknowledgments
The authors thank Manuel Stühlinger for his help with written report choice and information extraction and Walter J. Eppich, MD, PhD for a critical review and proofreading the manuscript.
Footnotes
Contributors: All authors substantially contributed to this study and were involved in the study design. JS drafted the paper. LM analysed the information and revised the manuscript for content. TM revised the manuscript for content and language. All authors approved the final version.
Funding: This work was funded by the European Society of Anaesthesiology (ESA) and the Swiss National Science Foundation (SNSF, Grant No. P300P1_177695). The ESA provided resource for an additional enquiry assistant helping with literature search and selection. Function of the salary of JS was funded by the SNSF.
Competing interests: None declared.
Patient and public involvement statement: Patients and public were non involved in this report.
Patient consent for publication: Non required.
Provenance and peer review: Not commissioned; externally peer reviewed.
Information availability statement: Information are bachelor upon reasonable asking.
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