Authors

1. Eddy, Kylie BAppSc (Speech Pathology)

Abstract

Review question/objective: The objective of this review is to identify the meaningfulness of health professionals' experiences of teamwork education in acute hospital settings.

Background: Team work in acute health care settings is recognized as being an integral factor in delivering high quality patient care.1 The Australian Government defines 'acute care' as

Care where the primary clinical purpose or treatment goal is to manage labor (obstetric), cure illness or provide definitive treatment of injury, perform surgery, relieve symptoms of illness or injury (excluding palliative care), reduce severity of an illness or injury, protect against exacerbation and/or complication of an illness and/or injury which could threaten life or normal function and perform diagnostic or therapeutic procedures.2^(p.2)

Service delivery in acute hospitals is characterized by increasing numbers of patients presenting with complex and serious conditions, rising numbers of patients developing chronic disease and ongoing changes to organizational structures within hospitals by government agencies.1

The division of labor among health professionals in hospitals means that no single professional can deliver a complete episode of health care.1 Health professionals with specific expertise often must work together to ensure that patients receive the care that they require.1 Even when they are not formally assigned to care teams, they still must engage in team work because it has become an essential part of health care practice today. Psychologist Eduardo Salas states that 'patient care is a team sport'.5^(p.1002)

In clinical areas, there are a range of health professionals with specific knowledge, skills and values that are related to their particular undergraduate training and chosen area of work. The Australian Institute of Health reports that doctors (13.3%) nurses (54.2%) and allied health professionals (10.5%) make up the dominant clinical workforce within an Australian hospital.6 Doctors, nurses, and midwives tend to specialize in clinical skills and work in one particular area of a hospital. Allied health professionals within an acute hospital setting are represented in smaller numbers and may often work across specialist areas and teams within a hospital. They may include the professions of audiology, dietetics and nutrition, exercise physiology, occupational therapy, podiatry, physiotherapy, psychology, social work, and speech pathology.6 Each health discipline continues with postgraduate training and ongoing work based education to develop clinical expertise in the area they have chosen to work in. It can be a challenge for health professionals who are trained with specific expertise to work together in teams to meet the goals of patient care and the organization.3

As well as clinical expertise, there are a range of identified competencies that are important for professional development of all health disciplines in developing skills that are 'non-technical'15, and foster collaboration across disciplines and team work. Medical education has identified that there are a number of teamwork related competencies that are important for success as a physician.7 They are interpersonal skills and professionalism, interaction with patients and family, fostering a team environment, and mentoring and educating other students and staff.7 The competencies, in addition to technical/clinical skills, are necessary for all professions who work in teams to be effective in the complex environments found in acute hospital settings. It is often people who don't utilize competent professional skills who are described as 'not being team players'. Health professionals who are not team players can be a risk to the performance of health teams in caring for patients.

Many health care organizations lack effective teamwork. The 'To Err is Human' report states that 'at least 44,000 people and perhaps as many as 98,000 people in the USA, die in hospitals each year as a result of medical errors that could have been prevented'.9^(p.1) The breakdown of communication is often cited as a common factor in causing errors.9 The South Australian Patient Safety Report 2011-2012 reports that '11.7% of communication and teamwork related incidents lead to notifications of harm being caused to the patient or the organization'.10^(p.72)

There are a range of reasons why teamwork and in particular communication within teams doesn't happen or can fail. Professional differences and hierarchies that exist currently in health settings, where members of the team may fear questioning or challenging perceived higher status team members such as medical personnel, can effect team functioning. Thomas et al. found that in their study on perceptions of teamwork, only 33% of nurses rated the quality of collaboration and communication with the physicians in their team as high or very high.11 In contrast, 73% of physicians rated their collaboration and communication with nurses as high or very high. In contrast to physicians, nurses reported that it is difficult to speak up, disagreements are not appropriately resolved, more input into decision making is needed, and nurse input is not well received.11 This study highlights that hierarchies within teams and differences in perceptions of team work behaviors can impact on relationships and performance within teams.

Frequent changes to personnel caring for patients, due to shift work, patient transfers and human resources procedures in hospitals can impact on teamwork function.10 In South Australian health organizations in 2012, the most common time for an adverse incident to occur to patients (through the delay or failure of communication within teams and with external teams), was when a patient was transferred within the health setting.10

Team work also requires people to deal with the challenges of relating to each other, dealing with conflict and compromise in often a stressful work environment.4 Lack of respect amongst health professionals has been identified as a significant barrier in creating a positive work environment and effective teams.4

Other barriers that lead to poor team work include different perceptions of what teamwork is, different skills levels in how to function as a team member, a lack of defined designated roles amongst team members including a team leader, and an unsafe culture where staff do not feel safe to challenge the actions of others and prevent mistakes happening.4

Teamwork can be defined by knowledge, skills and values that people use to accomplish interdependent work, including affective, cognitive, and motivation states that emerge during the course of that work.4 Behavioral processes include actions such as communication, coordination, sharing expertise, and helping. Emergent states include mutual respect and psychological safety.8

In 2008, Salas and colleagues5 sought to identify key principles of team training in health care using simulation technology. These principles are also valid with other forms of teamwork education. They undertook a quantitative and qualitative review of literature including a 'content analysis of team training in health care'. They developed the following principles from their findings:

* identify critical teamwork competencies and use these as a focus for training content

* emphasize teamwork over task work, design teamwork to improve team processes

* let the team-based learning outcomes desired, and organizational resources guide the process

* task exposure is not enough- provide guided, hands-on practice

* ensure training relevance to transfer environment

* feedback must be descriptive, timely and relevant

* go beyond reaction data and evaluate clinical outcomes, learning, and behaviors on the job

* reinforce desired teamwork behaviors through coaching and performance evaluation.5

Team work is important in all areas of the acute hospital environment. Studies in teamwork in acute settings have focused on teams in particular areas within hospital environments such as theatres, intensive care, delivery suites and emergency department teams.10 Health care services that show evidence of a safety culture demonstrate effective communication amongst team members, in particular the skills of situational awareness which impacts on the handling of unexpected or urgent events.10

There has been little research into the individual educational needs and training needs of healthcare professionals to enhance their participation in workplace teams.3 Health care team members may not understand the personal competencies required for team success.4 Teamwork may not happen naturally because of the ability of individual health professionals to function as effective members of a team. Individual factors that influence performance in teams will include the person's knowledge, attitude, motivation and personality.3 Therefore each team member comes with his/her own learning style, personality, skills, experience and values and these will determine his/her own ability to interact with a group, cooperate, follow group norms and contribute to team and organizational goals. Thus there is a need for teamwork education to focus on the individual abilities of people as a 'pre-requisite characteristic' of effective teamwork.3

Teamwork education can be delivered in core teams of the same profession such as nursing teams and it can also be delivered through an interprofessional focus. The definition of interprofessional education is when two or more professions learn from, with and about each other to improve collaboration and the quality of care. Experiences of teamwork education will be influenced by the support provided by organizations to integrate new learning into practice and in changing culture around team communication.1

There are a range of teamwork education options that can and have been utilized in post graduate education in acute hospital settings. These include formal training programs such as the TeamSTEPPS(R) program.17 The TeamSTEPPS(R) program originated in the aviation industry in the United States of America and the principles of teamwork and safety have been applied to teamwork in health settings. The program was introduced in 2008 in South Australia by the Department of Health and Ageing and in 2012, 60 wards or units were enrolled in the training across SA Health in diverse areas including emergency departments, rehabilitation and mental health.10 The TeamSTEPPS(R) program involves team members attending workshops and the designation of team coaches who provide mentoring and feed back to other team members. Teams assess the culture and practice of teamwork in their teams and implement strategies to improve and evaluate how team practices can change.17

Simulation training has been an educational tool for developing clinical skills and teamwork in acute hospital settings. It also originated in aviation and military training and was first introduced into medical training. Early simulation work focused on individual performance but it is now recognized that optimal health care can only be delivered by experienced interprofessional teams.5 This is particularly the case for teams in the operating theatre, intensive care and emergency departments.5 In simulation training, high fidelity human patient simulators and equipment in realistic clinical environments, replicate scenarios and they are played out in real time. Simulations can portray an environment (managing an acutely ill or injured patient that is high risk) where the problem for the patient may be unclear, information may be incomplete or conflicting, the situation can be rapidly changing, there may be multiple conflicting goals, there are time pressures and consequences of error are life threatening.5 Staff participate in the simulation debrief afterwards about clinical outcomes and also about the underlying team working processes such as cooperation, coordination, leadership and communication. More competent teams demonstrate closer sharing of mental models especially around what is happening to the patient and what is expected of other specialists when they arrive.5

There have been a number of systematic reviews on different interventions to improve team effectiveness including teamwork education programs. In 2008, Chakraborti, Boonsasai and Wright reviewed teamwork training interventions used in medical student and resident training.19 Buljac-Samardzic et al. reviewed interventions to improve team effectiveness.20 There have been a number of systematic reviews looking at the effectiveness of interprofessional education. Reeves, Zwarenstein and Goldmann reviewed the effectiveness of interprofessional education on patient and health outcomes22 and in 2007 Hammick et al. conducted a systematic review of interprofessional education.21 In each systematic review outlined above, the authors found it difficult to draw upon conclusions around teamwork education due to small numbers of studies and sample sizes, problems with conceptualizing and measuring collaboration, and the heterogeneity of interventions and settings. Currently in the literature, there is little evidence to prove that team work education strategies for teams of a specific profession such as a nursing team or for multidisciplinary teams (interprofessional education) is effective in improving outcomes for patients and organizations.12 There is no clear evidence of what interventions work with whom and why.

Health organizations in western countries including United Kingdom, United States of America, Canada and Australia are currently committed to improving team effectiveness in acute hospital settings.1 Teamwork education programs are integral to that commitment. It is therefore important to develop an insight into and an understanding of health professionals' experiences of teamwork education. While a significant amount of literature exists regarding health professionals' experiences of teamwork education, there has been no previous attempt to synthesize the results of these studies to inform practice. The findings of the review will have important implications for the development of planning and the implementation of continuing professional development programs that foster the knowledge, skills and values of team work that are based on evidence. The reviewer has searched the Cochrane Library, JBI library of Systematic Reviews, CINAHL, PubMed and Embase and not found any current or planned reviews on the topic.