NARRATIVE REVIEW Team-training in healthcare: a narrative ... · team-based care through teamwork training, skill building, and team-led performance improvement interventions that

Team-training in healthcare:a narrative synthesis of the literature

Sallie J Weaver,1 Sydney M Dy,2 Michael A Rosen1

▸ Additional material ispublished online only. To viewplease visit the journal online(http://dx.doi.org/10.1136/bmjqs-2013-001848).

1Department of Anesthesiologyand Critical Care Medicine,Johns Hopkins University Schoolof Medicine, Armstrong Institutefor Patient Safety & Quality,Baltimore, Maryland, USA2Department of Health Policy &Management, Oncology, andMedicine, Johns HopkinsUniversity, Baltimore, Maryland,USA

Correspondence toSallie J Weaver, Department ofAnesthesiology and Critical CareMedicine, Johns HopkinsUniversity School of Medicine,Armstrong Institute for PatientSafety & Quality, 750 E. PrattSt., 15th Floor, #1544,Baltimore, MD 21202, USA;[email protected]

Received 22 January 2013Revised 6 December 2013Accepted 12 January 2014Published Online First5 February 2014

To cite: Weaver SJ, Dy SM,Rosen MA. BMJ Qual Saf2014;23:359–372.

ABSTRACTBackground Patients are safer and receivehigher quality care when providers work as ahighly effective team. Investment in optimisinghealthcare teamwork has swelled in the last10 years. Consequently, evidence regarding theeffectiveness for these interventions has alsogrown rapidly. We provide an updated reviewconcerning the current state of team-trainingscience and practice in acute care settings.Methods A PubMed search for review articlesexamining team-training interventions in acutecare settings published between 2000 and 2012was conducted. Following identification ofrelevant reviews with searches terminating in2008 and 2010, PubMed and PSNet weresearched for additional primary studies publishedin 2011 and 2012. Primary outcomes includedpatient outcomes and quality indices. Secondaryoutcomes included teamwork behaviours,knowledge and attitudes.Results Both simulation and classroom-basedteam-training interventions can improveteamwork processes (eg, communication,coordination and cooperation), andimplementation has been associated withimprovements in patient safety outcomes.Thirteen studies published between 2011 and2012 reported statistically significant changes inteamwork behaviours, processes or emergentstates and 10 reported significant improvementin clinical care processes or patient outcomes,including mortality and morbidity. Effects werereported across a range of clinical contexts.Larger effect sizes were reported for bundledteam-training interventions that included toolsand organisational changes to supportsustainment and transfer of teamworkcompetencies into daily practice.Conclusions Overall, moderate-to-high-qualityevidence suggests team-training can positivelyimpact healthcare team processes and patientoutcomes. Additionally, toolkits are available tosupport intervention development andimplementation. Evidence suggests bundledteam-training interventions and implementationstrategies that embed effective teamwork as a

foundation for other improvement efforts mayoffer greatest impact on patient outcomes.

INTRODUCTION

…It has become necessary to developmedicine as a cooperative science; theclinician, the specialist, and the labora-tory workers uniting for the good of thepatient, each assisting in elucidation ofthe problem at hand, and each depend-ent upon the other for support. –

William J. Mayo, Commencementspeech at Rush Medical College, 1910

Deficiencies in communication and team-work have long been cited as a frequentcontributor to adverse events. Precise esti-mates of the extent of the problem are dif-ficult to make, given definitional,reporting and measurement inconsisten-cies. However, a variety of studies supportthe notion that teamwork and communi-cation are critical components of safehealthcare systems. Previous reviewsreport linkages between various aspects ofteamwork (eg, situational monitoring,communication, leadership, trust, sharedmental models) and clinical perform-ance.1–3 Meta-analytic results suggest therelationship between team processes andclinical performance indicators has gener-ally been characterised by medium tolarge effect sizes.4 5 For example, studiesin surgery have shown increased odds ofcomplications and death (OR 4.82; 95%CI 1.30 to 17.87) when surgical teamsexhibit less frequent teamwork behaviours(eg, less information sharing duringintraoperative and handoff phases, andless briefing).6 Reviews of malpracticeclaims further underscore that communi-cation problems are major contributingfactors in 24% of cases.7 Other studiesfound teamwork and communicationissues cited as root causes in 52–70% ofadverse events.8 9 Additionally, teamworkand communication dimensions of safety

Open AccessScan to access more

free content

NARRATIVE REVIEW

Weaver SJ, et al. BMJ Qual Saf 2014;23:359–372. doi:10.1136/bmjqs-2013-001848 359

on May 28, 2020 by guest. P

rotected by copyright.http://qualitysafety.bm

j.com/

BM

J Qual S

af: first published as 10.1136/bmjqs-2013-001848 on 5 F

ebruary 2014. Dow

nloaded from

http://dx.doi.org/10.1136/bmjqs-2013-001848



http://crossmark.crossref.org/dialog/?doi=10.1136/bmjqs-2013-001848&domain=pdf&date_stamp=2014-4-11

http://qualitysafety.bmj.com/

culture have been significantly related to adverse clin-ical events.10 11

The 2001 Making Health Care Safer report12 pro-vided one of the early reviews concerning the topic ofhealthcare team-training in a chapter entitled ‘CrewResource Management and Its Application inMedicine’. This review discussed early conceptualisa-tions of team-training in other high-reliability indus-tries such as aviation and summarised early studiesattempting to translate team-training principles devel-oped elsewhere into healthcare settings. The develop-ment and implementation of team-trainingprogrammes in acute care settings has grown dramat-ically in the last decade with improvements incontent, methods and evaluation desgins.13–15

Advances in training content, implementation andevaluation have increasingly drawn on over 30 yearsof evidence examining team performance processesand team-training across a wide variety of high-riskenvironments.16 While previous reviews described thestate of team-training in healthcare through2009,13 14 the prevalence of peer-reviewed literatureevaluating team-training interventions continues togrow. Publication trends suggest that in the last5 years, over 448 papers examining teamwork topicsin a variety of languages, across a variety of care set-tings, have appeared in PubMed (see figure 1).Additionally, team-training was formally identified in2013 as a top patient safety strategy encouraged foradoption in acute care settings.17 Therefore, ourobjective is to provide an updated narrative synthesisof the body of evidence evaluating team-training inacute care settings, including implementation trends,evidence for effectiveness and potential boundaryconditions (ie, factors that may enhance or inhibiteffectiveness). In providing this updated review, wehope to also highlight fruitful areas for future researchand innovative practice.

Types of team-training strategiesTeam-training is defined as a constellation of content(ie, the specific knowledge, skills and attitudes thatunderlie targeted teamwork competencies), tools (ie,team task analysis, performance measures) and deliv-ery methods (ie, information, demonstration andpractice-based learning methods) that together forman instructional strategy.18 In this sense, team-trainingis a systematic methodology for optimising the com-munication, coordination and collaboration of health-care teams that combines specific content withopportunities for practice, formative feedback andtools to support transfer of training to the daily careenvironment.As described by the National Quality Forum19:

Health care organizations must establish a proactive,systematic, organization-wide approach to developingteam-based care through teamwork training, skill

building, and team-led performance improvementinterventions that reduce preventable harm topatients…training programs should systematicallyaddress and apply the principles of effective team lead-ership, team formation [and team processes].

Borrowing from other high-reliability communities,team-training in healthcare originated largely in theform of Crew Resource Management (CRM), a spe-cific team-training strategy focused on developing asubset of teamwork competencies including hazardidentification, assertive communication and collectivemanagement of available resources.20–23 However, thepractice of team-training is much broader. Today,team-training is an overarching term that encompassesa broad range of learning and development strategies,methods and teamwork competencies. Table 1 out-lines several types of team-training strategies.The critical element defining team-training is that

the learning activity focuses on developing, refiningand reinforcing knowledge, skills or attitudes thatunderlie effective teamwork behaviours such as com-munication, coordination and collaboration. Priorreviews found that the most commonly targeted team-work competencies include communication, situ-ational awareness, leadership, role clarity andcoordination.14 24–27 To this end team-trainingactivities are often designed to develop generalisable,transportable teamwork competencies that learnerscan apply across different settings and teams. Thisdifferentiates team-training from learning activitiesfocused on technical clinical skills (eg, differentialdiagnosis and procedural skills), as well as teambuilding exercises focused on developing emergentstates such as trust or cohesion among members of anintact team.

METHODSA PubMed search for key review articles examiningteam-training interventions in acute care settings pub-lished between January 2000 and December 2012was conducted. Key search terms included ‘team-training’, ‘teamwork training’, ‘teamwork traininginterventions’, ‘crew resource management’,‘TeamSTEPPS’ and related terms. Following identifica-tion of relevant reviews with searches terminating in2008,13 200912 21 and 2010,24 25 a search of PubMedand PSNet was completed to identify additionalprimary studies published between 1 January 2011and 31 December 2012. Studies were excluded if theywere only descriptive in nature, if conducted innon-English-speaking populations or if primarily tar-geting students or trainees. Narrative summaries ofindividual studies and shared themes are presented.This review was supported by Agency for HealthcareResearch and Quality (AHRQ), which had no role inthe selection or review of the evidence or the decisionto submit this manuscript for publication.

Narrative review

360 Weaver SJ, et al. BMJ Qual Saf 2014;23:359–372. doi:10.1136/bmjqs-2013-001848



j.com/

BM

J Qual S


ebruary 2014. Dow

nloaded from


RESULTSSeveral previous reviews have examined the effective-ness and implementation of healthcare team-training.2 13–15 23–33 For example, one systematicreview of interventions to improve team effectivenessin healthcare found that the majority involved someform of team-training (42 of 48 reviewed studies).13

Other reviews investigated the effectiveness of team-training for obstetric emergencies,33 for enhancingcommunication in surgery and anaesthesia,20 25 31

classroom-based interventions27 and simulation-basedinterventions.15 24 30 Additionally, several reviewsinvestigated the content, design and delivery of team-training and the impact of team processes on clinicalprocesses and outcomes.2 14 24 26 29 31 32 34 We drawon results from these reviews and 26 articles publishedsince their searches terminated in order to describe thecurrent body of evidence regarding the effectiveness ofteam-training in acute care settings, the contexts inwhich it has been evaluated and effects of differentdesign and delivery methods. Findings from 26 studiespublished after previous reviews concluded theirsearches are summarised in table 2 and discussed ingreater detail in subsequent sections (see online supple-mentary appendix for detailed evidence summary).

What is the context for team-training?Previous reviews highlight that team-training has beenimplemented across a broad range of acute care con-texts.2 13 14 27 30 This includes academic hospitals35

and community-based hospitals,36 37 as well as medicalcentres affiliated with the Veterans Administration (VA)and the Military Health System.38–40 Though ourfocus is on current practitioners,41–44 team-trainingprogrammes have focused on a variety of audiencesincluding students and clinical trainees.45 46 Themajority of studies have focused on evaluating team-training efforts among frontline clinicians working inobstetric or perioperative care areas; however, studies

have also been conducted in emergency and criticalcare, procedural areas (eg, endoscopy) and administra-tion. For example, table 2 demonstrates that 9 studiesof the 26 published between 2011 and 2012 were con-ducted in surgical work areas, 5 were conducted incritical care or inpatient nursing units and 4 were con-ducted in obstetrical or emergency/trauma settings,respectively. Four studies were conducted in otherareas, including procedural areas or administration, orwere conducted across multiple types of care areas.Team-training programmes for hospital leaders have

also demonstrated positive effects. Individual execu-tive leadership development programmes fall outsidethe scope of traditional team-training initiatives;however, team-training programmes for executiveleaders is an area ripe for further research as manyhealthcare organisations move towards enterpriseaffiliations and Accountable Care Organization (ACO)models. In this way administrators, service lineleaders, division leaders and frontline providersincreasingly manage and work not only in teams, butas part of teams-of-teams, or multiteam systems(MTS).47 48 MTSs are defined as two or more teamsthat work interdependently towards at least onecommon goal.49 Initial work has begun to examinethe leadership competencies that matter most in thesecontexts and to test interventions to cultivatethem.50 51 However, further development and evalu-ation of team-training interventions targeting MTSswithin the healthcare context are needed.

Team typeTeamwork in healthcare is often characterised byhighly dynamic team membership, participation onmultiple teams and rapid team formation. As opposedto intact teams who have a history and future workingtogether, some types of healthcare teams, particularlyin acute care settings, may not have ever workedtogether before, form under stressful conditions (eg, a

Figure 1 PubMed publication trends from 2000 through October 2013 for team-training and related concepts.

Narrative review




j.com/

BM

J Qual S


ebruary 2014. Dow

nloaded from


Table 1 Team-training strategies

Team-trainingstrategy Definition

Primary teamworkcompetencies targeted Best practices

Assertiveness training Dedicated to developing communicationstrategies that support task-relevant andteam-performance relevant assertiveness

▸ Backup behaviour▸ Closed-loop

communication▸ Conflict management▸ Mutual trust▸ Psychological safety▸ Team leadership

▸ Clearly define training objectives aroundtask-relevant and team performanceassertiveness rather than generalassertive behaviours and differentiatefrom aggressive behaviours.

▸ Compare and contrast effective andineffective assertive behaviours

▸ Provide opportunities to practiceappropriate assertiveness that includefeedback. Practice should also strive toinclude realistic time pressures or otherstressors to allow practice using andreacting to appropriate assertivenessunder such conditions.

Cross -training Team members learn the roles that comprisethe team, as well as the tasks, duties, andresponsibilities fulfilled by fellow teammembers.

▸ Accurate and sharedmental models (SMMs) ofteam roles andresponsibilities

▸ Include information about the roles andresponsibilities of other team membersand how they operate to achieve these.

▸ Explain the why— clarify who membersdepend on for information.

▸ Provide opportunities to shadow anotherrole if possible.

▸ Provide feedback during cross-trainingthat facilitates the formation ofreasonable expectations of one another.

Error managementtraining

Participants are encouraged to make errorsduring training scenarios, analyse these errorsand practice error recognition andmanagement skills.

▸ Collective efficacy▸ Cue-strategy associations▸ SMMs▸ Team adaptation

▸ Ensure trainees understand the purposeof this training strategy is to encountererrors and to have the opportunity topractice managing them in a safeenvironment.

▸ Frame errors as positive opportunities forlearning.

▸ Embed the opportunity to make errorsinto training scenarios by providingminimal guidance during the scenario.

▸ Follow the scenario with immediatefeedback and discussion to facilitatelearning.

Guided teamself-correction

Strategy designed around a cycle of facilitatedbriefings and debriefings that occur around atraining scenario or live event.

▸ Backup behaviour▸ Collective orientation▸ Closed-loop

communication▸ Cue-strategy associations▸ Mission analysis▸ Mutual trust▸ SMMs▸ Team adaptation▸ Team leadership

▸ Define the team self-correction skills tobe trained prior to team self-correctiontraining.

▸ Record positive and negative examplesof teamwork dimensions during teamperformance episode.

▸ Classify and prioritise observations,diagnose strengths and weaknesses, andidentify goals for improvement beforebeginning debrief.

▸ Set the stage for team participation andsolicit examples of teamwork behaviourduring debrief.

Continued

Narrative review




j.com/

BM

J Qual S


ebruary 2014. Dow

nloaded from


code) and may not have great likelihood of workingtogether closely in the future. Such teams are knownas ad hoc teams or action teams and are defined byrapid formation, an abbreviated lifespan and oftenlimited experience working together previously. Giventhis context, can team-training be effective for such adhoc teams? Previous reviews indicate that healthcareteam-training has been conducted with intact (ie,teams who work together currently or on a regularbasis) and ad hoc teams (ie, teams formed quickly forbrief periods of performance or for training purposesonly). For example, Weaver14 found eight studies thatreported training intact teams and five studies thatreported training in ad hoc teams. One meta-analysisthat examined team-training effectiveness across avariety of industries including healthcare foundsimilar effect sizes for teams who worked together ona regular basis (intact teams ρ=0.48) and teams whodid not (ad hoc teams ρ=0.44).4 A secondmeta-analysis that also examined the effects of team-training on overall team performance across a rangeof settings found that team-training had a greaterpositive impact on the performance of ad hoc teams(dIntact=0.62; dAdhoc=0.92); however, the differencewas not statistically significant.52 Within healthcare,several of the most robust studies have used trainingstrategies allowing teams to train together (eg, closingthe operating room for 1 day so that team members

could attend training together); however, this is not aboundary condition for training effectiveness.

What have we learned about team-training design anddelivery?Several reviews of team-training and team processes inhealthcare have also examined training design anddelivery.13 14 24 27 31 These reviews find variationamong programmes in the teamwork competenciestargeted, curriculum used, how much time learnersspend in training, how often clinicians and staff areparticipating, and other details regarding content,delivery strategies and evaluation efforts.

Training contentAs described earlier, many different types of trainingstrategies fall under the umbrella of team-training.Previous reviews found communication, situationalawareness, leadership and situation monitoring as themost common teamwork competencies targeted.14 27

Table 2 emphasises that similar competencies havealso been the focus of more recent primary studies,particularly as the adoption of teamwork training cur-riculums built around these competencies (eg,TeamSTEPPS, CRM, VA Medical Team Training (VAMTT)) has grown. For example, 9 of the 26 studiesreviewed used some form of CRM, 7 reported usingcomponents of the TeamSTEPPS curriculum and 3

Table 1 Continued

Team-trainingstrategy Definition

Primary teamworkcompetencies targeted Best practices

Metacognitiontraining

Focuses on developing cognitive aspects ofteam performance by teaching strategiesdedicated to analysing, updating and aligningmental models of the s task, coordinationstrategy, and contingencies.

Cue-strategy associationsMission analysisSMMsTeam adaptation

Develop training objectives around cognitiveprocesses such as planning, monitoring andre-analysis.Structure metacognitive practice tasks arounda subject that trainees have pre-existingknowledge about.

Team adaptation andcoordination training

Focuses on how to effectively use all availableresources (ie, people, information, etc.) througheffective team communication, coordinationand cooperation. Crew or Crisis ResourceManagement is a form of TACT.

▸ Backup behaviour▸ Closed-loop

communication▸ Cue-strategy associations▸ Mission analysis▸ Mutual performance

monitoring▸ Leadership▸ Shared mental models

▸ Develop training objectives that addressaround transportable teamworkcompetencies for ad-hoc teams (nohistory or future).

▸ Training team-specific competencies canalso be incorporated for intact teams.

▸ Train intact teams together if possible.▸ Create opportunities for both guided

and unguided practice.▸ Develop feedback mechanisms that

engage self-reflection and teamself-correction following practiceopportunities.

▸ Develop tools that support effectiveteamwork, but recognise that toolsalone (eg, checklists) cannot optimiseteam performance (and alone maynegatively impact performance).

Adapted from Salas et al.32

Narrative review




j.com/

BM

J Qual S


ebruary 2014. Dow

nloaded from


Table 2 Studies examining team-training effects on clinical process or patient outcomes

Study characteristics

Curriculum Setting Design Clinical processes or patient outcomes

Andreatta 201141 OBEMAN OB Descriptive ▸ Five types of incongruent hospital policies or proceduresgoverning clinical practice identified

Armour 201142 TS OR Time series ▸ Significant reduction in surgical morbidity (20.2% vs 11%*) and mortality (2.7% vs 1%*)

▸ Significant improvement in 4 of 6 SQIP measures*▸ Room turnover time decreased significantly (43 vs 35.5

min*), percentage of on-time first case starts improved(69% to 81%+)

▸ Patient willingness to recommend significantly improved(77% to 89.3%*)

▸ Evidence of some decay over 1 year post-trainingfollow-up for mortality, morbidity, on-time starts andpatient satisfaction, while SQIP remained improved

Carney 201169 VA MTT OR Pre-post

Castner 201285 TS Multiple NCGPT

Cooper 201153 Leadership TT Hospitalmanagement

Post only

Deering 201139 TS Combat supporthospital

Pre-post ▸ Decreased number of adverse events (22.2 vs 18.2events+)

▸ 83% decrease in medication and transfusion errors (7.1 vs1.2*), 70% decrease in needlestick injury and exposures(4.0 vs 1.2*), 65% decrease communication incidents(5.2 vs 1.8*)

▸ No significant decrease in incidents related to three otherteamwork competencies

Figueroa 201265 TS ICU Time series

Fransen 201243 Multidisciplinary OB Cluster RCT ▸ Trained teams adhered to predefined obstetric proceduresmore frequently than non-trained teams (83% vs 46%*)

Frengley 201186 CRM ICU NCGPPT ▸ Regardless of modality that clinical management skillswere also taught, all participating teams improved clinicalmanagement scores*

Heard 201187 CRM Endoscopy Time series

Kirschbaum 201288 Multidisciplinary OR Pre-post

Maxson 201189 TS Surgery Time series

Mayer 201135 TS PICUSICU

Longitudinal withnon-equivalent control

▸ Nosocomial infections decreased slightly+

▸ Average time for placing patients on extracorporealmembrane oxygenation (ECMO) decreased (23 vs 14min*)

▸ No significant change in length of rapid response teamevents

McLaughlin 201144 Trauma TT Trauma Post-only

Neily 201138 VA MTT OR RCC ▸ 50% greater reduction in risk-adjusted surgical mortalityfor MTT group versus control (RR=1.49)*

▸ Reduction of 0.5 deaths per 1000 procedures associatedwith every quarter that teamwork intervention was inplace*

▸ Qualitative interviews suggested improvements in overallperioperative efficiency, reduced length of procedures,improved first case on-time start times and equipment use

Continued

Narrative review




j.com/

BM

J Qual S


ebruary 2014. Dow

nloaded from


studies used VA MTT. Seven studies reported usingother team-training curriculums.More narrowly defined programmes targeting deep

development of specific teamwork skills (eg, leader-ship) in the healthcare context have also been evalu-ated. Two53 54 of the twenty-six studies reviewedspecifically evaluated an intervention designed todevelop teamwork competencies among hospitalleaders and administrators. Such programmes maydiffer from those focused on frontline providers inthe level of emphasis on certain teamwork competen-cies (eg, transformational leadership, conflict manage-ment and mediation, broader internal and externalenvironment awareness, boundary spanning activitiesthat facilitate coordination with other internal orexternal teams, etc., may be of greater emphasis),55 56

as well as design (eg, greater use of table-top simula-tions or game-based approaches).57

Training modality and methodsThe evidence to date demonstrates that healthcareteam-training programmes vary in the instructional

modalities and methods used. Instructional methodscan be conceptualised in terms of three broad categor-ies: (1) information-based methods (eg, didacticlecture), (2) demonstration-based methods (eg, behav-ioural modelling, videos) and (3) practice-basedmethods (eg, simulation, role playing). Previousreviews found that the majority (83%) of team-training programmes integrated both information andpractice-based methods, while only 35% reportedincorporated demonstration-based activities.14

Simulation-based versus classroom-based training.Simulation is a broad training modality that mayinclude physical simulation of clinical care environ-ments, standardised patients, cognitive simulationsand role play. It includes both centre-based learningactivities and in situ activities that occur in the actualenvironment where care is provided.Simulation is a common modality for team-training

in healthcare. Previous reviews found 68% of pro-grammes using simulation-based activities.14 Severalreviews have examined simulation-based team-trainingexclusively.15 24 30 In terms of outcomes, previous

Table 2 Continued

Study characteristics

Curriculum Setting Design Clinical processes or patient outcomes

Patterson 2013 (online2012)66

MultidisciplinaryTT

Paediatric ED Time series ▸ Patient safety event rate decreased (2–3 annually vs1000 days since safety event, 12 m post)

Phipps 201270 CRM L&D Pre-post ▸ Decrease in adverse outcome index (AOI) (0.052 pre vs0.043 post)

▸ No significant change in patient satisfactionRiley 201136 TS L&D NCGPPT ▸ Weighted adverse outcome score (WAOS)—an index of

perinatal harm—decreased 37% for full interventiongroup only (1.15 pre vs 0.72 post*)

▸ Variability in WAOS scores was decreased post-training forfull intervention group only

Singer 201154 Leadership TT Hospital mgmt. Qual. Longitudinal

Steinemann 201190 CRM Trauma Prospective cohort ▸ 16% reduction in ED resuscitation time*, 76% increase incompleteness of clinical tasks*

▸ No significant changes in mean hospital length of stay,ICU days or deaths

Stevens 201271 CRM Cardiac surgery Pre-post

Stocker 201291 CRM PICU Time series

Tapson 201180 CRM Surgery Longitudinal ▸ Significantly more post-training than pretraining chartsmet guideline recommendations and standards of care fortiming, inpatient duration and prophylaxis use beyonddischarge*

van Schaik 201192 CRM PICU Cross-sectional

Volk 201193 CRM OR Post-only

Young-Xu 201158 VA MTT OR RCC ▸ 20% greater reduction in risk-adjusted surgical morbidityin the MTT group versus control (RR=1.20)*

+, improvement, but not statistically significant; CBT, case based learning; CRM, Crew or Crisis Resource Management; L&D, labor and delivery; NCGPT,non-equivalent comparison group post-test only; NCGPPT, non-equivalent comparison groups pre-test/post-test; OB, obstetrics; OBEMAN, obstetrics,emergency medicine, anesthesiology, and neonatology program; OR, operating room; Peds, pediatrics; PICU, pediatric intensive care unit; RCC, retrospectivecontrolled cohort study; SBT, simulation based training; SICU, surgical intensive care unit; TS, TeamSTEPPS; VA MTT, VA Medical Team Training. *p<0.05.

Narrative review




j.com/

BM

J Qual S


ebruary 2014. Dow

nloaded from


reviews examining simulation-based team-training15 24 30 and classroom-based team-training27

separately reported similar positive effects on learnerreactions, knowledge or skills, and clinical practices. Interms of patient outcomes, both simulation studies andclassroom-based studies have shown a positive impacton patient outcomes. Though simulation is powerfullearning activity, particularly for teamwork competen-cies, some of the most robust studies published sincethese previous reviews were completed did not useelaborate simulation methods, but still achieved signifi-cant reductions in both mortality and morbidity.38 58

Direct comparison studies also provide insight. Riley36

compared perinatal work areas in three different hospi-tals; one participated in a didactic team-training pro-gramme, one participated in an in situ simulationprogramme and one served as a control. Results indi-cated that significantly greater reductions in patientharm were achieved by the group that participated inthe in situ simulation programme compared with boththe didactic and control groups (37% reduction vs 1%reduction vs 43% increase in harm, respectively).Training duration. Programme duration is an area in

which team-training programmes in healthcare vary. Areview of 18 studies evaluating classroom-based team-training interventions found course duration variedfrom 4 h to 3 days with several studies describinglonger train-the-trainer programmes.27 Anotherreview found that 53% of 40 reviewed team-trainingprogrammes were designed to last less than 1 day.14

Intervention design and implementation strategyOverall, no comprehensive meta-analysis to date hasdirectly examined variations in design or implementa-tion strategy as boundary conditions influencing theeffectiveness of healthcare team-training programmes.However, current evidence supports the notion thatthe most effective team-training programmes leveragea bundled intervention design that pairs learningactivities and practice, with tools designed to supporteffective teamwork during daily clinical care (eg,checklists, reminders, peer coaches). This bundleddesign aligns with a systems-based approach to train-ing that emphasises a comprehensive strategy fordeveloping and sustaining expert team performance.32

These strategies view training as one piece of thepuzzle that will support effective team performanceunder stressful conditions over time. For example,Buljac-Samardzic’s13 descriptive systematic review ofstrategies to optimise team effectiveness found thatthe majority involved some form of team-training;however, other interventions also included tools tosupport team performance during care (eg, checklists,goal lists; 8 studies), as well as broader organisationalinterventions (eg, redesign of care processes or teamstructures, 8 studies).Implementation strategy. In terms of implementation

strategy, both train-the-trainer and direct train-the-staff

strategies have been used. For example, atrain-the-trainer model formed the foundation for theNational Implementation of TeamSTEPPS Project,59 acollaborative effort by the U.S. Department of Defense(DoD), the AHRQ and the American Institute forResearch (AIR) designed to create a national trainingand support infrastructure for healthcare entitiesimplementing team-training. Through a nationalnetwork of team resource centres, individuals inter-ested in leading the implementation of team-trainingwithin their organisation could become TeamSTEPPSMaster Trainers by participating in an intensive 3-daytraining session. Master Trainers then return to trainadministrators and frontline personnel within theirown organisation using the customisable TeamSTEPPScurriculum. A slightly different approach was used inthe large-scale implementation of team-trainingthroughout the VA. As part of the VA National Centerfor Patient Safety Medical Team-training (MTT)Programme, learning sessions for participating VAmedical centres were facilitated directly by an interdis-ciplinary team of dedicated MTT faculty.38 Both strat-egies, however, include local facility change teams,implementation of on-the-job tools (eg, process check-lists, scripts) to support training transfer, as well asmeasurement and evaluation processes as integralimplementation components.Transfer of training. Overall, systems-based models

of team-training share an implementation approachthat strategically considers what happens before,during and after training in order to facilitate transferof effective teamwork into daily care processes. Thesemodels are rooted in classic transfer of trainingmodels, which stipulate that transfer, generalisation ofteamwork skills developed in training and mainten-ance of these skills over time is the product of thework environment (ie, support for using teamworkskills, opportunities to use these skills in practice),training design and individual trainee characteristics.60

This suggests that the most effective team-trainingefforts include readiness assessment and preparation,learning activities that bring together multidisciplinarypractitioners, deployment of performance supporttools (eg, checklists or structured communicationtools) and post-training support through coaching,reinforcement and recognition for improved team-work, and ongoing measurement paired with con-structive feedback concerning teamwork processes.61

For example, the VA MTT programme was led by anational coordinating entity (the VA National Centerfor Patient Safety) who worked with local implemen-tation teams through 2 months of preplanning andreadiness preparation prior to implementation.38

Transfer of training was also supported by structuredcommunication tools and quarterly follow-up coach-ing. The TeamSTEPPS programme similarly offersreadiness assessment and evaluation planning, andfacilitator training as part of the TeamSTEPPS Master

Narrative review




j.com/

BM

J Qual S


ebruary 2014. Dow

nloaded from


Trainer curriculum, as well as coaching and deploy-ment support.Organisational policies and procedures have also

been changed to facilitate transfer of trained team-work skills. For example, one study of team-trainingin surgery found significant improvements in on-timefirst case starts and operating room turnover times fol-lowing training.42 To sustain these improvements, theorganisation implemented policy changes and incen-tives around these two processes. The combination ofteam-training and these organisational changesresulted in continued improvement in both processesover the 4 years following training implementation.Specifically, on-time starts increased 42% across thetotal 5-year period reported (69–98%) and there was a38% decrease in OR turnover time (mean2006=43 minto mean2010=27 min). Such examples reinforce thenotion that effective team-training initiatives gobeyond training alone to proactively address aspectsof the organisational work environment that supportteam members in sustaining effective teamwork prac-tices over time, as well as generalisation of skills tonew teams and new situations.62

What have we learned about team-training effectiveness?Team-training has demonstrated the capacity toimprove both how teams do their work and resultingoutcomes across a wide variety of industries. Forexample, one meta-analysis of team-training thatincluded 93 effect sizes across a broad range of indus-tries found that participation in team-training canaccount for nearly 20% of the variance in team pro-cesses (ρ=0.44) and outcomes (ρ=0.39).4

Several reviews also support the notion that team-training can meaningfully improve participant knowl-edge or attitudes, teamwork processes, clinical careprocesses and even patient outcomes.5 13 14 27 31

Though local customisation of team-training curricu-lum is common and evaluation metrics are heteroge-neous, we attempt to summarise findings in theremainder of this section in terms of participant reac-tions, changes in knowledge, attitudes or skill, team-work processes or behaviours in clinicalenvironments, and clinical processes or patient out-comes. This organising structure is based uponKirkpatrick’s framework for training evaluation thatorganises training outcomes across the four levelsdescribed below.63

Level 1: learner reactions to trainingPrevious reviews demonstrate that learner reactions areone of the more common, yet least robust, evaluationmetrics reported. One review found that 60% of 40reviewed articles reported learner reactions to training(eg, perceptions of training utility, applicability andgeneral satisfaction with training).14 The sample of 26studies summarised in table 2 demonstrates a shifttowards more comprehensive evaluation of team-

training programmes, however. Ten studies explicitlyreported trainee reactions; while 7 studies examinedtrainee knowledge, attitudes or self-efficacy; 16 studiesevaluated team behaviours, processes or emergentstates (eg, teamwork climate, safety climate, trust); and13 studies evaluated clinical processes or patient out-comes (see online supplementary appendix).Overall, learner reactions to team-training have

been shown to be positive, often with 80% or moreof training participants, indicating that the topicscovered during training were applicable to their worksetting (see online supplementary appendix).Reactions can be important factors in shaping learnermotivation to use effective teamwork strategies on thejob and should be considered for that reason;however, they are not highly correlated with othertraining outcomes64 and are not generally consideredstrong indicators of training effectiveness. Increasinglyevaluation efforts have moved away from reportingparticipant reactions as primary outcomes, focusinginstead on evaluating effects on provider behavioursand patient outcomes.

Level 2: learner knowledge, self-efficacy and attitudesThis second level of evaluation examines the impactof training on learner knowledge, self-efficacy andattitudes. Previous reviews indicate that such out-comes were reported in 50%13 to 78%27 of studies.Self-efficacy or confidence in one’s ability to engagein effective teamwork behaviours during future clin-ical events was the most commonly reported outcomeat this level among the studies reviewed in table 2.Self-efficacy is an important antecedent that shapesintentions to use effective teamwork skills during clin-ical practice and has been related to increased use ofeffective teamwork behaviours.65 Overall, previousreviews and the additional seven primary articles thatevaluated these outcomes provide evidence that team-training can positively impact these types of outcomes(see online supplementary appendix). Of the sevenarticles, five reported significant improvements inteamwork attitudes, self-efficacy or knowledge follow-ing training and the majority of these used CRM orTeamSTEPPS training curriculums. Several studieshave also investigated the duration of these effectsover time or differential effects among various typesof clinicians. For example, Figueroa65 found thatincreases in leadership and clinical skills confidenceachieved immediately post-training were sustained at a3-month post-training evaluation. SimilarlyPatterson66 found gains in teamwork knowledge sus-tained at follow-up conducted 8–10 monthspost-training.

Level 3: teamwork behaviours, processes and emergent statesChanges in teamwork behaviours and processes arearguably the primary criteria by which the effective-ness of team-training programmes in healthcare hasbeen evaluated. Previous reviews found that 44%28 to

Narrative review




j.com/

BM

J Qual S


ebruary 2014. Dow

nloaded from


63%14 of studies reported evaluating the impact ofteam-training on team behaviour or performance.Sixteen of the twenty-six studies (62%) reviewed (seeonline supplementary appendix) evaluated the impactof team-training at this level, of which 12 reportedsignificant improvements (ie, statistically significantimprovement on one or more process measures or atleast one dimension of safety culture/climate, or statis-tically significant differences between participatingteams and controls). The methods used to assess teamperformance range from team self-ratings to blindedobservational ratings using validated measurementtools. A number of observational tools and behav-ioural marker systems have been developed to evaluateteamwork in both simulated and live practice environ-ments (eg, the Oxford Non-Technical Skills(NOTECHS) scale,67 the Anesthetists’ Non-TechnicalSkills (ANTS) system68), which have greatly improvedthe strength and validity of findings in studies thathave used them. For example, one high-quality studythat used a modified version of the NOTECHSadapted for the trauma care setting found significantimprovements in observed teamwork processes bothduring simulated cases and live cases following an insitu simulation-based team-training programme thatincluded both a brief web-based didactic learningsession and multidisciplinary clinical simulations.In addition to team behaviours, evaluations of team-

training have also often included measures of emer-gent, affective aspects of team performance such asteamwork climate or safety climate. Teamwork climateand safety climate reflect shared perceptions regardingcommunication openness, mutual support and otheraspects of team functioning. Previous reviews also indi-cate that such measures may be used as part of pretrain-ing needs analysis.27They are often measured with asafety culture or climate survey; however, reporting ofresults is highly heterogeneous. Some studies reportcomposite scores that aggregate several survey itemsinto one domain or dimension (eg, Carney,69 Phipps70)while others report item-level results (eg, Stevens71).Overall, there is some moderate evidence that team-training may positively impact teamwork climate orsafety climate outcomes; however, conclusions arelimited by variation in reporting.

Level 4: clinical processes and patient outcomesMore recently, studies demonstrate the impact ofteam-training programmes on clinical processes, aswell as indices of care safety and quality. Previousreviews found that only a few studies had attemptedto evaluate the impact of team-training on such out-comes.5 13 14 27 72 However, effect sizes have tendedto fall in the medium to large range (eg, d=0.63,73 ascited in5), indicating that team-training has beenrelated to meaningful improvements in clinical processand patient outcomes. Thirteen of the twenty-sixstudies summarised in table 2 evaluated the impact of

team-training at this level, of which ten reported stat-istically significant improvement. Additionally, severalrobust studies offer high-quality evidence that com-prehensive team-training programmes can improveboth clinical processes and patient outcomes. Forexample, an evaluation of the VA MTT programmedemonstrated significant and sustained decreases inpreoperative delays (from 16% to 7% of cases,p=0.004), increased antibiotic prophylaxis compli-ance (from 85% to 97%, p<0.0001), decreases inequipment issues/case delays (from 24% to 7% ofcases, p<0.0001), decreased handoff issues (from5.4% to 0.3% of cases, p<0.0001) and most notablysignificantly greater reductions in both mortality(RR=1.49) and morbidity (RR=1.20) for facilitiesthat implemented team-training.38 58 Furthermore, adose–response relationship was established such thatfor each quarter the programme was in place at a facil-ity, a decrease of 0.5 deaths per 1000 procedures(p=0.001) was observed. Implementation ofTeamSTEPPS has been associated with increased effi-ciency in clinical processes for multidisciplinarytrauma teams (eg, decreased times from arrival tosurgery from 130.1 to 94.5 min (p<0.05), endo-tracheal intubation from 10.1 to 6.6 min (n.s.) andCT scan from 26.4 to 22.1 min (p<0.01),74 as well asan 83% reduction in medication and transfusionerrors (p<0.001) and a 70% reduction in needlestickinjuries and exposures (p<0.05) in a U.S. CombatSupport Hospital deployed in Iraq.39 Other studieshave also reported significant reductions in clinicaldecision time (p<0.05)40 associated with team-training, as well as one study showing a reductionin adverse clinical events and a 50% reduction inhigh-severity malpractice claims (pretraining 11 high-severity claims, post-training 5 high-severity claims,no statistics reported).75

Strength of evidenceOverall, the body of evidence concerning the effect-iveness of team-training in healthcare spans the con-tinuum of low-quality, medium-quality andhigh-quality studies. The majority of previous reviewsdid not systematically rate study quality. However,Buljac-Samardzic13 concluded that the majority ofstudies reviewed were of low-level to moderate-levelquality even though eight of the reviewed team-training studies were categorised as high or moderatequality (ie, RCT or high-quality pre-post study).Similar conclusions were drawn by McCulloch.28

Significant homogeneity among studies, both in train-ing content and strategy, as well as reported outcomeslimited conclusions. In the review by Rabøl27 ofclassroom-based team-training interventions, 15 of the18 reviewed studies were uncontrolled and 17 studieswere rated at a moderate or high risk for bias.A number of high-quality primary studies have been

published since these reviews were completed. These

Narrative review




j.com/

BM

J Qual S


ebruary 2014. Dow

nloaded from


include the VA studies38 58 69 and several studies ofthe TeamSTEPPS curriculum.35 39 42 These studiesused high-quality retrospective controlled designs orhigh-quality pre-post designs that examined the effectsof training across multiple outcomes including team-work processes and patient outcomes. Several veryrecent studies published after our search windowended have also employed strong quasi-experimentaldesigns, larger sample sizes, robust analytical methods(eg, multilevel analyses) and different outcomes (eg,care coordination practices across teams, communica-tion with patients and families) to further strengthenconclusions regarding team-training effectiveness.76–79

Are the effects of team-training sustained over time?Sustainability of team-training effects over time is acommon question among both improvement scientistsand practitioners. Many early evaluations of team-training limited follow-up evaluations to 6 monthspost-training or less.27 28 Recent studies have includedlonger follow-up evaluation periods with multiplemeasurement points. Of the 26 papers summarised intable 2, 11 included follow-up evaluations examiningat least one of the Kirkpatrick levels more than6 months after the training activity. For example,Mayer and colleagues35 found significant improve-ments in observed team processes 1 month post-training that were sustained at 6 months and 12months post-training in a sample of critical care provi-ders. Findings regarding changes in survey measuresof patient safety culture over time were mixed,however. In studies examining the implementation ofthe VA’s team-training programme, results indicatedboth significant improvements in perceptions of team-work climate 9–11 months following implementa-tion69 and statistically significant reductions insurgical mortality 1 year post.38 58 Several studies alsodemonstrated that variability in aggregate indices ofpatient harm were reduced following implementationof a team-training programme delivered using a com-bination of both didactic learning activities and in situsimulation.36 70 Overall, there is evidence forimprovements in teamwork knowledge, attitudes andteam processes during shorter term evaluationwindows (eg, less than 6 months) and increasinglymore robust evidence for longer term impact onaggregate indices of real or potential patient harm.There are also indications of skill decay over time,however, with several studies demonstrating that allshort-term improvements in knowledge, skills andpractices were not maintained over longer timeperiods.66 80 While a great deal of work has beendedicated to examining optimal refresher trainingintervals for clinical procedural skills (eg, resuscitationor intubation skills81 82), relatively minimal work hasbeen done to understand optimal refresher intervalsfor teamwork competencies.

DISCUSSIONIn summary, previous reviews of team-training inhealthcare and recent studies have found that theseprogrammes can improve teamwork processes andpatient outcomes (eg, reductions in adverse events,reductions in mortality and morbidity). Current evi-dence also offers detailed insight into team-trainingdesign and implementation strategies relevant forresearchers and practitioners alike.13 14 24 27–32

Additionally, over three decades of research examiningteam-training in a wide variety of contexts exists thatboth researchers and practitioners can draw from.In terms of the strength of evidence, previous sys-

tematic reviews included several studies that used RCTor controlled pre-post designs. Several robust studiesexamining team-training strategies have been publishedsince previous reviews concluded. However, it isimportant to note that previous reviews and recentstudies reflect a wide range in quality of evidence—with several studies limited by small sample sizes, weakstudy design and limited detail regarding the team-training curriculum or implementation strategy.Overall, our synthesis suggests that there is moderateto high-quality evidence that team-training can posi-tively impact healthcare team processes and, in turn,clinical processes and patient outcomes. These effectshave been demonstrated across a variety of acute careareas, including critical care, surgery and emergencycare. A key finding is that the studies demonstrating themost robust evidence for effectiveness35 38 58 haveimplemented team-training as a bundled interventionthat includes preplanning, readiness assessment, inter-disciplinary learning activities and tools to supportactive transfer and sustained use of effective teamworkpractices into daily care. Additionally, evaluationefforts undertaken in the most robust studies leveragedlarge care systems and strong quasi-experimental evalu-ation designs. This is not to say that every attempt toimplement team-training should be compelled tofollow similar evaluation efforts. These findings dounderscore the value of implementing bundled inter-ventions that match learning activities with activities toactively practice effective teamwork strategies andtools to support effective teamwork in daily practice.This underscores that team-training is most effectivewhen paired with other methods to improve teamworkand also that team-training is one of several interven-tions that has proven effective at reducing patient harmand improving patient safety.62 83

Additionally, our synthesis underscores that there ismeaningful heterogeneity and local adaptation in bothtraining design and implementation across studies.While the studies reviewed used similar general trainingstrategies (eg, CRM), the details of specific competencyareas targeted and delivery methods were highly hetero-geneous. As noted in previous reviews13 14 28 and in themore recent work reviewed here, training programmesvaried in duration, activities and modality.

Narrative review




j.com/

BM

J Qual S


ebruary 2014. Dow

nloaded from


The importance of local customisation is also reflectedin the toolkits available to support team-training imple-mentation. For example, a customisable version of theTeamSTEPPS curriculum is available publically throughAHRQ (http://teamstepps.ahrq.gov/). Additionally, theVA MTT programme is available to VA MedicalCenters through the National Center for Patient Safety(http://www.patientsafety.gov/mtt/). Both programmesprovide customisable content while emphasising localadaptation of learning materials and implementationstrategies. Best practices for team-training developmentand evaluation61 84 can also provide guiderails forimplementation and evaluation design.To continue building this evidence base, future work

should continue to evaluate team-training effortsacross time and outcomes. This includes continuing toexamine the impact on patient safety outcomes usingrobust implementation designs, evaluating team-training effects in multiteam system contexts (eg,chronic disease management, comprehensive cancercare), examining the comparative effectiveness of dif-ferent methods of training implementation and exam-ining implementation methods to support sustainmentof behaviour changes achieved through training. Forexample, there is currently limited evidence that pro-vides insight into the frequency of retraining or dedi-cated practice needed to develop and maintaineffective teamwork skills. Additionally, there is a needto examine how dynamic team composition (ie,changes in team membership) moderate team processesand the effects of team-training. Methodologically,robust validation studies can continue to strengthenthe evidence regarding team-training effectiveness andthe factors or conditions that influence effectiveness.Finally, longitudinal studies and studies addressing theintegration of team-training concepts throughout thecareer development of healthcare professionals areneeded to continue building our understanding ofteam-training in healthcare.

Contributors SJWand MAR were responsible for study concept,design, analysis, interpretation and preparation of themanuscript. SMDy was responsible for study concept,interpretation and preparation of the manuscript.

Funding This work was supported by funding from the Agencyfor Healthcare Research and Quality (AHRQ), U.S. Departmentof Health and Human Services (contract no. HHSA-290-2007-10062I). AHRQ reviewed contract deliverables to ensureadherence to contract requirements and quality, and a copyrightrelease was obtained from AHRQ prior to submission of thismanuscript. The authors of this report are responsible for itscontent. Statements in the report should not be construed asendorsement by the AHRQ or the U.S. Department of Healthand Human Services.

Competing interests None.

Provenance and peer review Not commissioned; externallypeer reviewed.

Open Access This is an Open Access article distributed inaccordance with the Creative Commons Attribution NonCommercial (CC BY-NC 3.0) license, which permits others todistribute, remix, adapt, build upon this work non-commercially,and license their derivative works on different terms, provided

the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/

REFERENCES1 Baker DP, Gustafson S, Beaubien J, et al. Medical teamwork

and patient safety: the evidence-based relation. Rockville, MD:Agency for Healthcare Research and Quality, 2005. http://www.ahrq.gov/research/findings/final-reports/medteam/index.html

2 Manser T. Teamwork and patient safety in dynamic domains ofhealthcare: a review of the literature. Acta Anaesthesiol Scand2009;53:143–51.

3 Sorbero M, Farley D, Mattke S, et al. Outcome measures foreffective teamwork in inpatient care: final report. Santa Monica,CA: RAND Corporation, 2008. http://www.rand.org/content/dam/rand/pubs/technical_reports/2008/RAND_TR462.pdf

4 Salas E, DiazGranados D, Klein C, et al. Does team trainingimprove team performance? A meta-analysis. Hum Factors2008;50:903–33.

5 Schmutz J, Manser T. Do team processes really have an effecton clinical performance? A systematic literature review. Br JAnaesth 2013;110:529–44.

6 Mazzocco K, Petitti DB, Fong KT, et al. Surgical teambehaviors and patient outcomes. Am J Surg 2009;197:678–85.

7 Rogers SO, Gawande AA, Kwaan M, et al. Analysis of surgicalerrors in closed malpractice claims at 4 liability insurers.Surgery 2006;140:25–33.

8 Rabøl LI, Andersen ML, Østergaard D, et al. Descriptions ofverbal communication errors between staff. An analysis of 84root cause analysis-reports from Danish hospitals. BMJ QualSaf 2011;20:268–74.

9 Singh H, Thomas EJ, Petersen LA, et al. Medical errorsinvolving trainees: a study of closed malpractice claims from 5insurers. Arch Intern Med 2007;167:2030–6.

10 Mardon RE, Khanna K, Sorra J, et al. Exploring relationshipsbetween hospital patient safety culture and adverse events.J Patient Saf 2010;6:226–32.

11 Singer S, Lin S, Falwell A, et al. Relationship of safety climateand safety performance in hospitals. Health Serv Res2009;44:399–421.

12 Shojania KG, Duncan BW, McDonald KM, et al. MakingHealth Care Safer: Summary. 2001. In: AHRQ EvidenceReport Summaries. Rockville (MD): Agency for HealthcareResearch and Quality (US); 1998-2005. http://www.ncbi.nlm.nih.gov/books/NBK11945/

13 Buljac-Samardzic M, Dekker-van Doorn CM, vanWijngaarden JDH, et al. Interventions to improve teameffectiveness: a systematic review.Health Policy 2010;94:183–95.

14 Weaver SJ, Lyons R, DiazGranados D, et al. The anatomy ofhealth care team training and the state of practice: a criticalreview. Acad Med 2010;85:1746–60.

15 Cumin D, Boyd MJ, Webster CS, et al. A Systematic review ofsimulation for multidisciplinary team training in operatingrooms. Simul Healthc 2013;8:171–9.

16 Salas E, Cooke NJ, Gorman JC. The science of teamperformance: progress and the need for more…. Hum Factors2010;52:344–6.

17 Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patientsafety strategies that can be encouraged for adoption now. AnnIntern Med 2013;158:365–8.

18 Cannon-Bowers J, Tannenbaum S, Salas E, et al. Definingcompetencies and establishing team training requirements. In:Guzzo R, Salas E, eds. Team effectiveness and decision making

Narrative review




j.com/

BM

J Qual S


ebruary 2014. Dow

nloaded from

http://teamstepps.ahrq.gov/

http://teamstepps.ahrq.gov/

http://www.patientsafety.gov/mtt/

http://www.patientsafety.gov/mtt/

http://creativecommons.org/licenses/by-nc/3.0/


in organizations. San Francisco, CA: Jossey-Bass Publishers,1995:333–80.

19 National Quality Forum. Safe practices for better healthcare2010 update: A consensus report. 2010.

20 Gaba DM. Crisis resource management and teamwork trainingin anaesthesia. Br J Anaesth 2010;105:3–6.

21 Salas E, Burke CS, Bowers CA, et al. Team training in theskies: does crew resource management (CRM) training work?Hum Factors 2001;43:641–74.

22 Reznek M, Smith-Coggins R, Howard S, et al. Emergencymedicine crisis resource management (EMCRM): pilot study ofa simulation-based crisis management course for emergencymedicine. Acad Emerg Med 2003;10:386–9.

23 Maynard MT, Marshall D, Dean MD. Crew resourcemanagement and teamwork training in health care: a review ofthe literature and recommendations for how to leverage suchinterventions to enhance patient safety. Adv Health Care Manag2012;13:59–91.

24 Weaver SJ, Salas E, Lyons R, et al. Simulation-based teamtraining at the sharp end: a qualitative study of simulation-based team training design, implementation, and evaluation inhealthcare. J Emerg Trauma Shock 2010;3:369–77.

25 Gillespie BM, Chaboyer W, Murray P. Enhancingcommunication in surgery through team training interventions:a systematic literature review. AORN J 2010;92:642–57.

26 Baker DP, Gustafson S, Beaubein JM, et al. Medical team trainingprograms in health care. In: Henriksen K, Battles JB, Marks ES,et al. eds. Advances in patient safety: from research toimplementation (volume 2: concepts and methodology). Rockville,MD: Agency for Healthcare Research and Quality (US), 2005.

27 Rabøl LI, McPhail M, Bjørn B, et al. Outcomes of a classroom-based team training intervention for multi-professional hospitalstaff. Med Teach 2012;34:868–9.

28 McCulloch P, Rathbone J, Catchpole K. Interventions toimprove teamwork and communications among healthcarestaff. Br J Surg 2011;98:469–79.

29 Thomas EJ. Improving teamwork in healthcare: currentapproaches and the path forward. BMJ Qual Saf2011;20:647–50.

30 Eppich W, Howard V, Vozenilek J, et al. Simulation-based teamtraining in healthcare. Simul Healthc 2011;6(Suppl):S14–19.

31 Sevdalis N, Hull L, Birnbach DJ. Improving patient safety inthe operating theatre and perioperative care: obstacles,interventions, and priorities for accelerating progress. Br JAnaesth 2012;109(Suppl):i3–i16.

32 Salas E, Weaver SJ, Gregory ME. Team training for patientsafety. In: Carayon P. ed Handbook of human factors andergonomics in health care and patient safety. Boca Raton, FL:CRC Press, 2012:627–48.

33 Merién AER, van de Ven J, Mol BW, et al. Multidisciplinaryteam training in a simulation setting for acute obstetricemergencies: a systematic review. Obstet Gynecol2010;115:1021–31.

34 Salas E, Gregory ME, King HB. Team training can enhancepatient safety—the data, the challenge ahead. Jt Comm J QualPatient Saf 2011;37:339–40.

35 Mayer CM, Cluff L, Lin W-T, et al. Evaluating efforts to optimizeTeamSTEPPS implementation in surgical and pediatric intensivecare units. Jt Comm J Qual Patient Saf 2011;37:365–74.

36 Riley W, Davis S, Miller K, et al. Didactic and simulationnontechnical skills team training to improve perinatal patientoutcomes in a community hospital. Jt Comm J Qual Patient Saf2011;37:357–64.

37 Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamworkimprove performance in the operating room? A multilevelevaluation. Jt Comm J Qual Patient Saf 2010;36:133–42.

38 Neily J, Mills PD, Young-Xu Y, et al. Association betweenimplementation of a medical team training program andsurgical mortality. JAMA 2010;304:1693–700.

39 Deering S, Rosen MA, Ludi V, et al. On the front lines ofpatient safety: implementation and evaluation of team trainingin Iraq. Jt Comm J Qual Patient Saf 2011;37:350–6.

40 Nielsen PE, Goldman MB, Mann S, et al. Effects of teamworktraining on adverse outcomes and process of care in labor anddelivery: a randomized controlled trial. Obstet Gynecol2007;109:48–55.

41 Andreatta P, Frankel J, Boblick Smith S, et al. Interdisciplinaryteam training identifies discrepancies in institutional policiesand practices. Am J Obstet Gynecol 2011;205:298–301.

42 Armour Forse R, Bramble JD, McQuillan R. Team training canimprove operating room performance. Surgery2011;150:771–8.

43 Fransen AF, van de Ven J, Merién AER, et al. Effect ofobstetric team training on team performance and medicaltechnical skills: a randomised controlled trial. BJOG2012;119:1387–93.

44 McLaughlin T, Hennecke P, Garraway NR, et al. Apredeployment trauma team training course creates confidencein teamwork and clinical skills: a post-Afghanistan deploymentvalidation study of Canadian Forces healthcare personnel.J Trauma 2011;71:S487–93.

45 Thomas EJ, Williams AL, Reichman EF, et al. Team training inthe neonatal resuscitation program for interns: teamwork andquality of resuscitations. Pediatrics 2010;125:539–46.

46 Chakraborti C, Boonyasai RT, Wright SM, et al. A systematicreview of teamwork training interventions in medical studentand resident education. J Gen Intern Med 2008;23:846–53.

47 Zaccaro SJ, Marks MA, DeChurch LA. Multiteam systems: anintroduction. In: Zaccaro SJ, Marks MA, DeChurch LA. edsMultiteam systems: an organizational form for dynamic andcomplex environments. New York, NY: Taylor & Francis,2011:3–32.

48 Marks MA, DeChurch LA, Mathieu JE, et al. Teamwork inmultiteam systems. J Appl Psychol 2005;90:964–71.

49 Mathieu JE, Marks MA, Zaccaro SJ. Multi-team systems. In:Anderson N, Ones DS, Sinangil H, et al. eds. Handbook ofindustrial, work, and organizational psychology, vol 2:organizational psychology. London, UK: Sage, 2001:289–313.

50 DeChurch LA, Marks MA. Leadership in multiteam systems.J Appl Psychol 2006;91:311–29.

51 Asencio R, Carter DR, Dechurch LA, et al. Charting a coursefor collaboration: a multiteam perspective. Transl Behav Med2012;2:487–94.

52 Delise LA, Allen Gorman C, Brooks AM, et al. The effects ofteam training on team outcomes: a meta-analysis. PerformImprov Q 2010;22:53–80.

53 Cooper JB, Singer SJ, Hayes J, et al. Design and evaluation ofsimulation scenarios for a program introducing patient safety,teamwork, safety leadership, and simulation to healthcareleaders and managers. Simul Healthc 2011;6:231–8.

54 Singer SJ, Hayes J, Cooper JB, et al. A case for safetyleadership team training of hospital managers. Health CareManage Rev 2011;36:188–200.

55 Calhoun JG, Dollett L, Sinioris ME, et al. Development of aninterprofessional competency model for healthcare leadership.J Healthc Manag 2008;53:375–89; discussion 390–1.

Narrative review




j.com/

BM

J Qual S


ebruary 2014. Dow

nloaded from


56 Storey J, Holti R. Towards a new model of leadership for theNHS.

57 Hemmasi M, Graf LA. Managerial skills acquisition: a case forusing business policy simulations. Simul Gaming1992;23:298–310.

58 Young-Xu Y, Neily J, Mills PD, et al. Association betweenimplementation of a medical team training program andsurgical morbidity. Arch Surg 2011;146:1368–73.

59 Agency for Healthcare Research and Quality. TeamSTEPPS:National Implementation. http://teamstepps.ahrq.gov/aboutnationalIP.htm (accessed 30 Nov 2011).

60 Baldwin TT, Ford KJ. Transfer of training: a review anddirections for future research. Pers Psychol 1988;41:63–105.

61 Salas E, Almeida SA, Salisbury M, et al. What are the criticalsuccess factors for team training in health care? Jt Comm JQual Patient Saf 2009;35:398–405.

62 Salas E, Rosen MA. Building high reliability teams: progressand some reflections on teamwork training. BMJ Qual Saf2013;22:369–73.

63 Kirkpatrick DL, Kirkpatrick JD. Evaluating training programs:the four levels. Third edn. San Francisco, CA: Berrett-Koehler,2006.

64 Alliger GM, Tannenbaum SI, Bennett W, et al. A meta—analysis of the relations among training criteria. Pers Psychol2006;50:341–58.

65 Figueroa MI, Sepanski R, Goldberg SP, et al. Improvingteamwork, confidence, and collaboration among members of apediatric cardiovascular intensive care unit multidisciplinaryteam using simulation-based team training. Pediatr Cardiol2013;34:612–19.

66 Patterson MD, Geis GL, LeMaster T, et al. Impact ofmultidisciplinary simulation-based training on patient safety in apaediatric emergency department. BMJ Qual Saf 2013;22:383–93.

67 Mishra A, Catchpole K, McCulloch P. The Oxford NOTECHSSystem: reliability and validity of a tool for measuringteamwork behaviour in the operating theatre. Qual Saf HealthCare 2009;18:104–8.

68 Fletcher G, Flin R, McGeorge P, et al. Anaesthetists’Non-Technical Skills (ANTS): evaluation of a behaviouralmarker system. Br J Anaesth 2003;90:580–8.

69 Carney BT, West P, Neily JB, et al. Improving perceptions ofteamwork climate with the Veterans Health Administrationmedical team training program. Am J Med Qual 2011;26:480–4.

70 Phipps MG, Lindquist DG, McConaughey E, et al. Outcomesfrom a labor and delivery team training program withsimulation component. Am J Obstet Gynecol 2012;206:3–9.

71 Stevens L-M, Cooper JB, Raemer DB, et al. Educational programin crisis management for cardiac surgery teams including highrealism simulation. J Thorac Cardiovasc Surg 2012;144:17–24.

72 McCulloch P, Mishra A, Handa A, et al. The effects ofaviation-style non-technical skills training on technicalperformance and outcome in the operating theatre. Qual SafHealth Care 2009;18:109–15.

73 Morey JC, Simon R, Jay GD, et al. Error reduction andperformance improvement in the emergency departmentthrough formal teamwork training: evaluation results of theMedTeams project. Health Serv Res 2002;37:1553–81.

74 Capella J, Smith S, Philp A, et al. Teamwork training improvesthe clinical care of trauma patients. J Surg Educ2010;67:439–43.

75 Mann S, Pratt S, Gluck P, et al. Assessing quality obstetricalcare: development of standardized measures. Jt Comm J QualPatient Saf 2006;32:497–505.

76 Jones KJ, Skinner AM, High R, et al. A theory-driven,longitudinal evaluation of the impact of team training on safetyculture in 24 hospitals. BMJ Qual Saf 2013;22:394–404.

77 Bunnell CA, Gross AH, Weingart SN, et al. High performanceteamwork training and systems redesign in outpatientoncology. BMJ Qual Saf 2013;22:405–13.

78 Fouilloux V, Gsell T, Lebel S, et al. Assessment of team trainingin management of adverse acute events occurring duringcardiopulmonary bypass procedure: a pilot study based on ananimal simulation model (Fouilloux, Team training in cardiacsurgery). Perfusion 2014;29:44–52m.

79 Shaw DJ, Davidson JE, Smilde RI, et al. Multidisciplinary teamtraining to enhance family communication in the ICU. CritCare Med 2014;42:265–71.

80 Tapson VF, Karcher RB, Weeks R. Crew resource managementand VTE prophylaxis in surgery: a quality improvementinitiative. Am J Med Qual 2011;26:423–32.

81 Mancini ME, Soar J, Bhanji F, et al. Part 12: education,implementation, and teams: 2010 International consensus oncardiopulmonary resuscitation and emergency cardiovascularcare science with treatment recommendations. Circulation2010;122:S539–81.

82 Effect of Recent Refresher Training on in Situ Simulated PediatricTracheal Intubation Psychomotor Skill Performance. 2008.

83 Weaver SJ, Lubomksi LH, Wilson RF, et al. Promoting aculture of safety as a patient safety strategy: a systematic review.Ann Intern Med 2013;158:369–74.

84 Weaver SJ, Salas E, King HB. Twelve best practices for teamtraining evaluation in health care. Jt Comm J Qual Patient Saf2011;37:341–9.

85 Castner J, Foltz-Ramos K, Schwartz DG, et al. A leadershipchallenge: staff nurse perceptions after an organizationalTeamSTEPPS initiative. J Nurs Adm 2012;42:467–72.

86 Frengley RW, Weller JM, Torrie J, et al. The effect of asimulation-based training intervention on the performance ofestablished critical care unit teams. Crit Care Med2011;39:2605–11.

87 Heard LA, Fredette ME, Atmadja ML, et al. Perceptions ofsimulation-based training in crisis resource management in theendoscopy unit. Gastroenterol Nurs 2011;34:42–8.

88 Kirschbaum KA, Rask JP, Brennan M, et al. Improvedclimate, culture, and communication through multidisciplinarytraining and instruction. Am J Obstet Gynecol 2012;207:200.e1–7.

89 Maxson PM, Dozois EJ, Holubar SD, et al. Enhancing nurseand physician collaboration in clinical decision making throughhigh-fidelity interdisciplinary simulation training. Mayo ClinProc 2011;86:31–6.

90 Steinemann S, Berg B, Skinner A, et al. In situ, multidisciplinary,simulation-based teamwork training improves early trauma care.J Surg Educ 2000;68:472–7.

91 Stocker M, Allen M, Pool N, et al. Impact of an embeddedsimulation team training programme in a paediatric intensivecare unit: a prospective, single-centre, longitudinal study.Intensive Care Med 2012;38:99–104.

92 Van Schaik SM, Plant J, Diane S, et al. Interprofessional teamtraining in pediatric resuscitation: a low-cost, in situ simulationprogram that enhances self-efficacy among participants. ClinPediatr (Phila) 2011;50:807–15.

93 Volk MS, Ward J, Irias N, et al. Using medical simulation toteach crisis resource management and decision-making skills tootolaryngology housestaff. Otolaryngol Head Neck Surg2011;145:35–42.

Narrative review




j.com/

BM

J Qual S


ebruary 2014. Dow

nloaded from

http://teamstepps.ahrq.gov/aboutnationalIP.htm




NARRATIVE REVIEW Team-training in healthcare: a narrative ... · team-based care through teamwork training, skill building, and team-led performance improvement interventions that

Documents