A high variety of team interventions aims to improve team performance outcomes. In 2008, we conducted a systematic review to provide an overview of the scientific studies focused on these interventions. However, over the past decade, the literature on team interventions has rapidly evolved. An updated overview is therefore required, and it will focus on all possible team interventions without restrictions to a type of intervention, setting, or research design.
Objectives
To review the literature from the past decade on interventions with the goal of improving team effectiveness within healthcare organizations and identify the “evidence base” levels of the research.
Methods
Seven major databases were systematically searched for relevant articles published between 2008 and July 2018. Of the original search yield of 6025 studies, 297 studies met the inclusion criteria according to three independent authors and were subsequently included for analysis. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence.
Results
Three types of interventions were distinguished: [1] Training, which is sub-divided into training that is based on predefined principles [i.e. CRM: crew resource management and TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety], on a specific method [i.e. simulation], or on general team training. [2] Tools covers tools that structure [i.e. SBAR: Situation, Background, Assessment, and Recommendation, [de]briefing checklists, and rounds], facilitate [through communication technology], or trigger [through monitoring and feedback] teamwork. [3] Organizational [re]design is about [re]designing structures to stimulate team processes and team functioning. [4] A programme is a combination of the previous types. The majority of studies evaluated a training focused on the [acute] hospital care setting. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements.
Conclusion
Over the last decade, the number of studies on team interventions has increased exponentially. At the same time, research tends to focus on certain interventions, settings, and/or outcomes. Principle-based training [i.e. CRM and TeamSTEPPS] and simulation-based training seem to provide the greatest opportunities for reaching the improvement goals in team functioning.
Keywords: Systematic review, Healthcare teams, Intervention, Team training, Team tool, Team effectiveness, Team performance
Introduction
Teamwork is essential for providing care and is therefore prominent in healthcare organizations. A lack of teamwork is often identified as a primary point of vulnerability for quality and safety of care [, ]. Improving teamwork has therefore received top priority. There is a strong belief that effectiveness of healthcare teams can be improved by team interventions, as a wide range of studies have shown a positive effect of team interventions on performance outcomes [e.g. effectiveness, patient safety, efficiency] within diverse healthcare setting [e.g. operating theatre, intensive care unit, or nursing homes] [–].
In light of the promising effects of team interventions on team performance and care delivery, many scholars and practitioners evaluated numerous interventions. A decade ago [2008], we conducted a systematic review with the aim of providing an overview of interventions to improve team effectiveness []. This review showed a high variety of team interventions in terms of type of intervention [i.e. simulation training, crew resource management [CRM] training, interprofessional training, general team training, practical tools, and organizational interventions], type of teams [e.g. multi-, mono-, and interdisciplinary], type of healthcare setting [e.g. hospital, elderly care, mental health, and primary care], and quality of evidence []. From 2008 onward, the literature on team interventions rapidly evolved, which is evident from the number of literature reviews focusing on specific types of interventions. For example, in 2016, Hughes et al. [] published a meta-analysis demonstrating that team training is associated with teamwork and organizational performance and has a strong potential for improving patient outcomes and patient health. In 2016, Murphy et al. [] published a systematic review, which showed that simulation-based team training is an effective method to train a specific type of team [i.e. resuscitation teams] in the management of crisis scenarios and has the potential to improve team performance. In 2014, O’Dea et al. [] showed with their meta-analysis that CRM training [a type of team intervention] has a strong effect on knowledge and behaviour in acute care settings [as a specific healthcare setting]. In addition to the aforementioned reviews, a dozen additional literature reviews that focus on the relationship between [a specific type of] team interventions and team performance could be mentioned [, –]. In sum, the extensive empirical evidence shows that team performance can be improved through diverse team interventions.
However, each of the previously mentioned literature reviews had a narrow scope, only partly answering the much broader question of how to improve team effectiveness within healthcare organizations. Some of these reviews focus on a specific team intervention, while others on a specific area of health care. For example, Tan et al. [] presented an overview on team simulation in the operating theatre and O’Dea et al. [] focused on CRM intervention in acute care. Other reviews only include studies with a certain design. For instance, Fung et al. [] included only randomized controlled trials, quasi-randomized controlled trials, controlled before-after studies, or interrupted time series. Since the publication of our systematic review in 2010 [], there has been no updated overview of the wide range of team interventions without restrictions regarding the type of team intervention, healthcare setting, type of team, or research design. Based on the number and variety of literature reviews conducted in recent years, we can state that knowledge on how to improve team effectiveness [and related outcomes] has progressed quickly, but at the same time is quite scattered. An updated systematic review covering the past decade is therefore relevant.
The purpose of this study is to answer two research questions: [1] What types of interventions to improve team effectiveness [or related outcomes] in health care have been researched empirically, for which setting, and for which outcomes [in the last decade]? [2] To what extent are these findings evidence based?
Methodology
Search strategy
The search strategy was developed with the assistance of a research librarian from a medical library who specializes in designing systematic reviews. The search combined keywords from four areas: [1] team [e.g. team, teamwork], [2] health care [e.g. health care, nurse, medical, doctor, paramedic], [3] interventions [e.g. programme, intervention, training, tool, checklist, team building], [4] improving team functioning [e.g. outcome, performance, function] OR a specific performance outcome [e.g. communication, competence, skill, efficiency, productivity, effectiveness, innovation, satisfaction, well-being, knowledge, attitude]. This is similar to the search terms in the initial systematic review []. The search was conducted in the following databases: EMBASE, MEDLINE Ovid, Web of Science, Cochrane Library, PsycINFO, CINAHL EBSCO, and Google Scholar. The EMBASE version of the detailed strategy was used as the basis for the other search strategies and is provided as additional material [see Additional file ]. The searches were restricted to articles published in English in peer-reviewed journals between 2008 and July 2018. This resulted in 5763 articles. In addition, 262 articles were identified through the systematic reviews published in the last decade [, , , –]. In total, 6025 articles were screened.
Inclusion and exclusion criteria
This systematic review aims to capture the full spectrum of studies that empirically demonstrate how healthcare organizations could improve team effectiveness. Therefore, the following studies were excluded:
- Studies outside the healthcare setting were excluded. Dental care was excluded. We did not restrict the review to any other healthcare setting.
- Studies without [unique] empirical data were excluded, such as literature reviews and editorial letters. Studies were included regardless of their study design as long as empirical data was presented. Book chapters were excluded, as they are not published in peer-reviewed journals.
- Studies were excluded that present empirical data but without an outcome measure related to team functioning and team effectiveness. For example, a study that evaluates a team training without showing its effect on team functioning [or care provision] was excluded because it does not provide evidence on how this team training affects team functioning.
- Studies were excluded that did not include a team intervention or that included an intervention that did not primarily focus on improving team processes, which is likely to enhance team effectiveness [or other related outcomes]. An example of an excluded study is a training that aims to improve technical skills such as reanimation skills within a team and sequentially improves communication [without aiming to improve communication]. It is not realistic that healthcare organizations will implement this training in order to improve team communication. Interventions in order to improve collaboration between teams from different organizations were also eliminated.
- Studies with students as the main target group. An example of an excluded study is a curriculum on teamwork for medical students as a part of the medical training, which has an effect on collaboration. This is outside the scope of our review, which focuses on how healthcare organizations are able to improve team effectiveness.
In addition, how teams were defined was not a selection criterion. Given the variety of teams in the healthcare field, we found it acceptable if studies claim that the setting consists of healthcare teams.
Selection process
Figure 1 summarizes the search and screening process according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA] format. A four-stage process was followed to select potential articles. We started with 6025 articles. First, each title and abstract was subjected to elimination based on the aforementioned inclusion and exclusion criteria. Two reviewers reviewed the title/abstracts independently. Disagreement between the reviewers was settled by a third reviewer. In case of doubt, it was referred to the next stage. The first stage reduced the number of hits to 639. Second, the full text articles were assessed for eligibility according to the same set of elimination criteria. After the full texts were read by two reviewers, 343 articles were excluded. In total, 297 articles were included in this review. Fourth, the included articles are summarized in Table 1. Each article is described using the following structure:
- Type of intervention
- Setting: the setting where the intervention is introduced is described in accordance with the article, without further categorization
- Outcomes: the effect of the intervention
- Quality of evidence: the level of empirical evidence is based in the Grading of Recommendations Assessment Development, and Evaluation [GRADE] scale. GRADE distinguishes four levels of quality of evidence
- A. High: future research is highly unlikely to change the confidence in the estimated effect of the intervention.
- B. Moderate: future research is likely to have an important impact on the confidence in the estimated effect of the intervention and may change it.
- C. Low: future research is very likely to have an important impact on the confidence in the estimated effect of the intervention and is likely to change it.
- D. Very low: any estimated effect of the intervention is very uncertain.
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Table 1
Summary of results
Authors [year]InterventionSettingOutcome[s]GRADEPrinciple-based training: CRM-based trainingAllan et al. 2010 []A simulation-based in situ CRM training: game play, didactics, video review, hands-on high-fidelity simulation-based training and video-based debriefingPaediatric cardiac intensive careImprovement in participants’ perceived ability to function as a code team member and confidence in a code, likeliness to raise concerns about inappropriate management to the code leaderCBallangrud et al. 2014 []Simulation-based CRM team training: introductory theory inputs on safe team performance based on CRM and a team training in a simulation laboratoryIntensive careTraining increases awareness of clinical practice and acknowledges the importance of structured work in teamsDBank et al. 2014 []Needs-based paediatric CRM simulation training with post activity follow-up: plenary educational session, simulation and debriefingPaediatric emergency medicine residents [postgraduate year 1–5]Improvement in the ability to be an effective team leader in general, delegating tasks appropriately, and ability to ensure closed loop communication, and identification of CRM errorsCBudin et al. 2014 []CRM training: train-the-trainer programme and CRM training including videos, lecture, and role playingPerinatal careImprovement in nurse and physician perceptions of teamwork and safety climateCCarbo et al. 2011 []CRM-based training focusing on appropriate assertiveness, effective briefings, callback and verification, situational awareness, and shared mental modelsInpatient internal medicineImprovement in the percentage of correct answers on a question related to key teamwork principles, reporting “would feel comfortable telling a senior clinician his/her plan was unsafe”CCatchpole et al. 2010 []Aviation-style team training: classroom training of interactive modules including lectures and discussions, and coaching in theatreSurgeryMore time-outs, briefings, and debriefingsBClay-Williams et al. 2013 []CRM-based classroom training, CRM simulation training or classroom training followed by simulation trainingDoctors, nurses and midwivesImprovement in knowledge, self-assessed teamwork behaviour and independently observed teamwork behaviour when classroom-only trained group was compared with control, these changes were not found in the group that received classroom followed by simulation trainingACooper et al. 2008 []Simulation-based anaesthesia CRM trainingAnaesthesiologyNo difference between the trained and untrained cohortsCFrance et al. 2008 []CRM training: CRM introductory training course [i.e. lectures, case studies, and role playing] and perioperative CRM training [i.e. e-learning models and toolkit consisting of CRM process checklist, briefing scripts, communication whiteboard, implementation training]SurgeryShows potential to improve team behaviour and performanceDGardner et al. 2008 []Simulation-based CRM training with debriefingObstetrics departmentReduction in annual obstetrical malpractice premiums; improvement in teamwork and communication in managing a critical obstetric event in the intervalCGore et al. 2010 []CRM training: educational seminar [i.e. lectures and role-play exercises], development and expansion of time-out briefing, educational video on briefing, posters on content briefingOperating roomImprovement in teamwork, error reporting, and safety climateCHaerkens et al. 2017 []CRM training: CRM awareness training [i.e. lectures and multiple interactive sessions using case studies and video footage], implementation of toolsEmergency departmentImprovement in teamwork climate, safety climate and stress recognition. Increase in patient length of stayBHaller et al. 2008 []CRM training: video, discussion, [interactive] lectures, workshops, play roles, interactive courseObstetrical setting in hospitalImprovement in knowledge of teamwork, shared decision making, team and safety climate, stress recognitionBHefner et al. 2017 []CRM training: day-long retreats, during which participants underwent developed and tailored CRM safety tools and participated in role playing, development of system-wide internal monitoring processesMedical centre consisting of multiple hospitals and two campusesImprovement in [1] organizational learning and continuous improvement, [2] overall perceptions of patient safety, [3] feedback and communication about errors, and [4] communication openness.BHicks et al. 2012 []Crisis Resources for Emergency Workers [CREW]: a simulation-based CRM curriculum: precourse learning and a full-day simulation-based exercise with debriefingEmergency departmentBelieve that CREW could reduce errors and improve patient safety; no improvement toward team-based attitudesCHughes et al. 2014 []CRM adapted to Trauma Resuscitation with new cultural and process expectation: CRM course of 15 sessionsTrauma resuscitationImprovement in accuracy of field to medical command information, accuracy of emergency department medical command information to the resuscitation area, team leader identity, communication of plan, role assignment, likeliness to speak up when patient safety was a concernBde Korne et al. 2014 []Team Resource Management [TRM] programme [based on CRM concepts]: safety audits of processes and [team] activities, interactive classroom training sessions by aviation experts, a flight simulator session, and video recording of team activities with subsequent feedbackEye hospitalObservations suggests increase safety awareness and safety-related patterns of behaviour between professions, including communicationDKuy and Romero 2017 []CRM training: didactics, group discussions, and simulation trainingSurgical service staff at a VA HospitalAt T1 participants reported improvement in all 27 areas assessed. At T2 his improvement was sustained in 85% of the areas studied. Areas with largest improvement: briefing, collaboration, nursing input, and patient safety. Areas with regression: speaking up, expressing disagreement, level of staffing, and discussing errorsCLaPoint et al. 2012 []CRM training: core skills workshopsPerioperative staffImprovement in supervisor expectations, communication openness, teamwork within units, non-punitive response to error, hospital management support for safety, handoffs. No significant improvement in organizational learning, feedback communication about errors, teamwork across hospital units, number of eventsCMahramus et al. 2016 []Teamwork training based on CRM and TeamSTEPPS: simulations, debriefing, teamwork educationHospitalImprovement in perceptions of teamwork behavioursCMcCulloch et al. 2009 []Classroom non-technical skills training based on CRM: mixed didactic and interactive teaching [e.g. role play], follow-up feedback by trainersOperating roomImproved technical and non-technical performance: improvement in attitudes to safety, team non-technical performance and technical error ratesCMehta et al. 2013 []Multidisciplinary simulation course: CRM teaching, simulation with debriefing, closing session with feedbackOperating roomImprovement in clinical knowledge, teamwork, leadership and non-technical skills, as well as the mutual understanding and respect between related medical and non-medical team membersDMorgan et al. 2015a []CRM-based training and improving working processes through implementing morning briefing and WHO Surgical Safety ChecklistOperating room conducting elective orthopaedic surgeryImprovement in non-technical skills and WHO compliance; no significant improvement in clinical outcomesCMorgan et al. 2015b []Teamwork training course CRM-based interactive classroom teaching and on the job coachingOperating roomsImprovement in non-technical skills, but also with a rise in operative glitchesBMuller et al. 2009 []CRM training [i.e. psychological teaching including theoretical exercises and simulator scenarios and video-assisted debriefing] versus classic simulator training [MED]HospitalImprovement in clinical and non-technical performance after both training, but no difference between trainingCParsons et al. 2018 []Simulation-based CRM training: didactic presentation, series of simulation scenarios and structured debriefsEmergency medicineNo significant improvement in leadership, problem solving, communication, situational awareness, teamwork, resource utilization and overall CRM skillsDPhipps et al. 2012 []CRM-based training: didactic sessions, simulation and debriefingLabour and deliveryImprovement in patient outcomes [adverse outcomes], perceptions of patient safety including the dimensions of teamwork and communicationBRicci et al. 2012 []CRM training: Training [i.e. didactics, case study discussions, team-building exercises, simulated operating room brief and debrief sessions] and CRM techniques [e.g. pre-operative checklist and brief, post-operative debrief, read and initial files, feedback tools]Perioperative personnelWrong site surgeries and retained foreign bodies decreased, but increased after 14 months without additional training.BRobertson et al. 2009 []Obstetric Crisis Team Training: online module, training session [standardized, simulated crisis scenarios with simulator mannequin], and debriefingsMultidisciplinary obstetric providers in hospitalImprovement in attitude; perception of individual and team performance, and overall team performanceCSavage et al. 2017 []CRM safety programme: CRM training [i.e. didactic seminars, role playing], systematic risk assessments, and improving work practices [i.e. checklists, huddles or structured communication and meeting tools]Paediatric surgeryImprovement in non-technical skills, the use of safety tools, adherence to guidelines, safety culture [i.e. teamwork across and within units, supervisors’ expectations and actions, non-punitive response to adverse events, perceptions of overall patient safety]; unplanned readmissions following appendectomy declinedASax et al. 2009 []CRM training: video, team building exercises, open forum, and development and implementation of perioperative checklistHospitalsIncreased self-initiated error reports and perceived self-empowermentBShea-Lewis et al. 2009 []CRM-based training: real-life examples, feedback, SBAR, team meetings, briefing, and debriefingObstetric departmentImprovement in patient outcome, patient satisfaction, employee satisfactionCSchwartz et al. 2018 []Clinical Team Training [CTT] based on CRM principles: training [e.g. simulation] and implementation of improvement projects [e.g. briefing, huddles, checklists]Veterans Health Administration facilitiesImprovement in communication, teamwork and situational awareness for patient safety. Also decreased between T1 and T2 detected.BSculli et al. 2013 []Nursing CRM: interactive didactic training curriculum, features high-fidelity simulation, ongoing consultation, improvement project, refreshmentNursing unitsImprovement unit climate, teamwork, medication errors, HAPU, glucose control, FTR events, and care processesCSteinemann et al. 2011 []Crisis Team Training-based in situ team training: web-based didactic, simulations, and debriefingEmergency departmentImprovement in teamwork ratings, clinical task speed and completion rates, teamwork scores, objective parameters of speed and completeness of resuscitationBStevens et al. 2012 []CRM-based educational programme based on high realism acute crisis simulation scenarios and interactive workshopCardiac surgerySurvey: improvement in the concept of working as a team. Interview: improvement in personal behaviours and patient care, including speaking up more readily and communicating more clearlyDSuva et al. 2012 []CRM training: introductory course, interactive workshops, lecture, role playOperating roomImprovement in learning, knowledge regarding teamwork, safety climate, and stress recognition; improvement varies with participant specialtyCTschannen et al. 2015 []Nursing CRM training: educational sessions, podcasts, simulation and debriefingGeneral medicine telemetry unitNo significant improvement in communication openness and environmental values; RNs reported an increase in both synchronous communication and asynchronous communication with physicians whereas physicians noted a reduction in time spent in asynchronous communicationDWest et al. 2012 []Nursing CRM training: didactic session, simulation, implementation of a CRM technique: sterile cockpit ruleVeterans Affairs hospital on nursing unitsImprovement in efficiency [e.g. quicker follow-up on abnormal vital signs and blood glucose levels, rapid assessment of patients with changes in condition, and faster intervention when the condition was deteriorating] and perceived teamwork, communication, patient safetyCZiesmann et al. 2013 []STARTT [Standardized Trauma and Resuscitation Team Training]: lectures [on CRM], discussion based on CRM principles, simulations and debriefingTrauma teamsImprovement in overall CRM domains, teamwork, and safety climateDPrinciple-based training: TeamSTEPPSArmour Forse et al. 2011 []TeamSTEPPSOperating roomImprovement in communications, leadership first case starts, Surgical Quality Improvement Program measures, surgical morbidity and mortality, culture; not all improvement were sustained. No significant effect on PACU communication and teamworkBBridges et al. 2014 []Educational intervention: adapted TeamSTEPPS curriculum, discussion, practicing standardized communication toolsHospital Intermediate Care Unit serving adult medical cardiac patientsImprovement in awareness of teamwork and backupCBrodsky et al. 2013 []Multidisciplinary, small group, interactive workshop based on TeamSTEPPSNeonatal intensive careImprovement in the overall teamwork, communication, situation awareness, support, satisfaction, job fulfilment, respectBBui et al. 2018 []Video and live observation of TeamSTEPPS skills implementation during surgical briefs and debriefsOperating roomsLow compliance with TeamSTEPPS skills; compliance was under video observation than under live observationDCapella et al. 2010 []TeamSTEPPS [e.g. didactic session, simulation, 5 tools: briefing, STEP [situation monitoring tool], CUS [mutual support tool], call outs, and check backs]Level I trauma centreImprovement in leadership situation monitoring, mutual support, communication, and overall teamwork; decreasing the times from arrival to the CT scanner, endotracheal intubation and the operating roomBCastner et al. 2012 []TeamSTEPPSHospital inpatient bedside RNsImproved perceptions of leadershipCDeering et al. 2011 []TeamSTEPPSCombat support hospitalDecreases in the rates of communication-related errors, medication and transfusion errors, and needles tick incidents, the rate of incidents coded communication as the primary teamwork skill that could have potentially prevented the eventCFigueroa et al. 2013 []TeamSTEPPS-based simulation training: lecture [on TeamSTEPPS principles], simulation, checklist, and debriefingPaediatric cardiovascular intensive careImproving confidence, skills in the role of team leaders, and TeamSTEPPS conceptsBGaston et al. 2016 []Customized TeamSTEPPS training [of 2 instead of 6 h]Oncology acute patient careImprovement in staff perception of teamwork and communicationBGupta et al. 2015 []A selection of TeamSTEPPS toolsAcademic interventional ultrasound serviceImprovement in teamwork climate, safety climate, and teamworkCHarvey et al. 2014 []In situ simulation-based training [SBT] versus case study review, both incorporating TeamSTEPPS trainingMedical-surgical PCUsImprovement in knowledge and teamwork skills in both groups; SBT group showed greater improvement in all areas except knowledgeCJones et al. 2013 []TeamSTEPPS [e.g. TeamSTEPPS tools, fundamentals course]HospitalsImprovement in safety cultureAJones et al. 2013 []TeamSTEPPS [e.g. essentials course]Emergency departmentImprovement of staff perception related to a culture of safety [e.g. management support for patient safety, feedback and communications about error, communication openness]BLee et al. 2017 []After TeamSTEPPS, implementation of reinforcement activities regarding leadership and communication [i.e. lectures, self-paced learning programme, 1 page summary, and grand rounds on TeamSTEPPS principles]Orthopaedic surgeryNursing staff: improvement in leadership and communication behaviours. Surgical staff: improvement in leadership behaviours. Anaesthesia staff: no improvement in any teamwork behavioursCLisbon et al. 2016 []
TeamSTEPPS: brief, huddle, DESC [constructive approach for managing and resolving
Conflict] and CUS script
Academic emergency departmentImprovement in knowledge and improved communication attitudes; adoption of a specific behaviour, the huddle, also was observedBMahoney et al. 2012 []TeamSTEPPS [variation of tools: flyers, simulations, games, and sustainment tools such as luncheon debriefing, awards]Psychiatric hospitalImprovement in team foundation, functioning, performance, skills, climate, and atmosphereBMayer et al. 2011 []TeamSTEPPS [e.g. fundamental curriculum]Paediatric and surgical intensive careImprovement in experienced teamwork, team performance, communication openness and clinical outcomes [e.g. average time for placing patients on extracorporeal membrane oxygenation, average duration of adult surgery rapid response team eventsBRice et al. 2016 []Modified simulation-based TeamSTEPPS trainingIntensive careImprovement in teamwork attitudes, perceptions, and performanceDRiley et al. 2011 []TeamSTEPPS didactic training [e.g. webinar, video of simulated scenarios] versus full TeamSTEPPS training [e.g. series of in situ simulation training exercises including [de]briefing, rapid-cycle follow-through with process improvements, and repetitionHospitalsImprovement in perinatal morbidity between the pre- and post-intervention for hospital with simulation programme. No significant changes in safety cultureBSawyer et al. 2013 []TeamSTEPPS training [e.g. fundamental course] with medical simulationNeonatal intensive careImprovement in teamwork skills in team structure, leadership, situation monitoring, mutual support, and communication, the odds of a nurse challenging an incorrect medication dose, and detection and correction of inadequate chest compressionsCSonesh et al. 2015 []Adapted TeamSTEPPS [lecture-based interactive programme]Obstetrical settingImprovement in knowledge of communication strategies, decision accuracy, and length of babies’ hospital length of stay. Knowledge of other team competencies or self-reported teamwork did not significantly improveCSpiva et al. 2014 []Training curriculum based on TeamSTEPPS [e.g. didactic lecture, patient video vignettes, debriefing]HospitalImprovement on fall reduction and teamworkBStead et al. 2009 []TeamSTEPPS [e.g. redesign meetings, SBAR, coaching]Mental health facilitySubstantial impact on patient safety culture [i.e. frequency of event reporting, and curriculum learning], teamwork, communication, KSA score, rates of seclusion. Issues around staffing, teamwork across hospital units, and hospital management support remained unchangedDThomas et al. 2012 []TeamSTEPPS [e.g. master trainer course, fundamentals course, essentials course]HospitalImprovement in feedback and communication about error, frequency of events reported, hospital handoff and transitions, staffing, and teamwork across the unitsCTreadwell et al. 2015 []TeamSTEPPS [e.g. huddle, debrief, SBAR, briefing checklist]Medical homeImproved perception of team collaborationCVertino 2014 []TeamSTEPPS [e.g. formal presentation, discussion, role-play exercises embodying clinical scenarios]Inpatient [VHA] hospital unitPositive change in staff attitudes toward team structure, leadership, situation monitoring, mutual support, and communicationDWeaver et al. 2010 []TeamSTEPPS [e.g. didactic session, interactive role playing, multiple tools]Operating roomsImprovement in quality and quantity of briefings and the use of quality teamwork behaviours during casesBWong et al. 2016 []Interprofessional education course: adapted TeamSTEPPS curriculum, simulation scenarios, and structured debriefing, and wrap-up sessionEmergency departmentImprovement in team structure, leadership, situation monitoring, mutual support, frequency of event reporting, teamwork within hospital units, and hospital handoffs and transitionsBMethod-based training: Simulation-based trainingAbdelFattah et al. 2018 []Trauma-focus simulation training: trauma simulations with video-based debriefingTrauma surgeryImprovement in clinical management, leadership, communication, cooperation, professionalism and performance on trauma rotationDAmiel et al. 2016 []One-day simulation- based training with video-based debriefingEmergency department in trauma centreImprovement in teamwork, communication, patient handoff, and shock and haemorrhage controlCArora et al. 2014 []Full-hospital simulation across the entire patient pathway [with integration of teams in prehospital, through-hospital, and post-hospital care]HospitalImprovement in decision making, situational awareness, trauma care, and knowledge of hospital environment. Behavioural skills, such as teamwork and communication, did not show significant improvementCArora et al. 2015 []Simulation-based training for improving residents’ management of post-operative complications: ward-based scenarios and debriefing interventionSurgeryClinically, improvement in residents’ ability to recognize/respond to falling saturations, check circulatory status, continuously reassess patient, and call for help. Teamwork, improvement in residents’ communication, leadership, decision-making skills, and interaction with patients [empathy, organization, and verbal and nonverbal expression]BArtyomenko et al. 2017 []Simulation training sessions for urgent conditions with debriefingObstetrical anaesthesiologistsImprovement in speed and invasive techniques, teamwork and effectiveness after the fifth sessionCAuerbach et al. 2014 []In situ interdisciplinary paediatric trauma quality improvement simulation: simulated patient care followed by debriefingTertiary care paediatric emergency departmentImprovement in overall performance, teamwork, and intubation subcomponentsCBender et al. 2014 []Simulation-enhanced booster session [after Neonatal Resuscitation Program]: orientations session, simulation, and debriefingPaediatric and Family PracticeThe intervention group demonstrated better procedural skills and teamwork behaviours. The NICU programme demonstrated better teamwork behaviours compared with non-NICU programmeBBittencourt et al. 2015 []In centre simulation-based training [simulation and debriefing] and in situ simulation [simulation and debriefing]: comparison of actual paediatric emergencies, in-centre simulations, and in situ simulationsPaediatric level 1 trauma centreMean total TEAM scores were similar among the 3 settings. Simulation-based training improved communication, team interaction, shared mental models, clarifying roles and responsibilities, and task managementBBruppacher et al. 2010 []Training session with either high-fidelity simulation-based training [i.e. orientation session, simulation, and debriefing] or an interactive seminar [i.e. audiovisual aids such as PowerPoint slides, handouts, and face-to-face discussion of paper-based scenarios similar to the simulation training]Anaesthesiology for cardiopulmonary bypassBoth groups improved, the simulation group showed significantly higher improvement on situation awareness, team working, decision making, task management, and checklist performance compared with the seminar groupBBursiek et al. 2017 []Interdisciplinary [high-fidelity] simulation training with debriefingInterdisciplinary teamsImprovement in team work, perception of work environment and patient safetyCBurton et al. 2011 []Simulation-based training: simulation laboratory curriculum with video-assisted debriefingsExtracorporeal membrane oxygenation emergenciesNo improvement in timed responses or percent correct actions. Improvement in teamwork, knowledge, and attitudesCChung et al. 2011 []Conventional simulation-based training [i.e. lecture, videos, simulations, and debriefing] versus a script-based trainingCardiopulmonary resuscitation in emergency departmentsBoth type of training improved leadership scores, but no improvement in performanceBCooper et al. 2012 []Simulation team training: formative questionnaire, team-based videoed scenarios, photo elicitation, and expert feedback sessionsHospital nurse teamsImprovement in knowledge, confidence and competence; group debriefing session enhanced learningCCiporen et al. 2018 []Crisis management simulation training: instructions, simulation, and debriefingNeurosurgery and anaesthesiologyNo significant differences between groups in situation awareness, decision making, communication and teamworkCEllis et al. 2008 []High-technology training at a simulation centre versus low-tech training in local units [with and without teamwork theory]Midwives and obstetricians in hospitalsImprovement in rates of completion for basic tasks, time to administration of magnesium sulphate, and teamwork. Training in a simulation centre and teamwork theory had no effectBFernando et al. 2017 []Interprofessional simulation training with debriefingPrimary and secondary care doctorsImprovement in knowledge, confidence and attitudes. Qualitative data indicates improvement in clinical skills, reflective practice, leadership, teamwork and communication skillsCFouilloux et al. 2014 []Training based on an animal simulation modelCardiac surgeryImprovement in management of the adverse events and time spend per certain eventsDFransen et al. 2012 []Multiprofessional simulation team training: introduction video, simulation, and debriefingObstetric departmentsImprovement in teamwork performance and use of the predefined obstetric proceduresAFreeth et al. 2009 []Simulation-based interprofessional training with video-recorded debriefingDeliveryImprovement in knowledge and understanding of interprofessional team working, especially communication and leadership in obstetric crisis situationsCFrengley et al. 2011 []Simulation-based training: familiarization, teamwork session [presentation, video, and discussions], skills station, simulations or case-based trainingCritical careImprovement in overall teamwork, leadership, team coordination, verbalizing situational information, clinical management; no difference between simulation-based learning and case-based learningBGeorge and Quatrara 2018 []Interprofessional simulation training: introduction session, simulation, and debriefingSurgical trauma burn intensive care unitImprovement in perceptions of teamwork and knowledgeDGettman et al. 2009 []High-Fidelity Operating Room Simulation: introduction, simulation, and video-based debriefingOrology, operating roomImprovement in teamwork, communication, laparoscopic skills, and team performanceCGilfoyle et al. 2017 []Simulation-based training: lecture, group discussions, simulations, and debriefingPaediatric resuscitationImprovement in clinical performance and clinical teamwork [role responsibility, communication, situational awareness and decision making]BGum et al. 2010 []Interprofessional simulation training with video-based debriefingMaternity emergencyAbility for collaboration in team building [i.e. personal Role Awareness, interpositional knowledge, mutuality and leadership]DHamilton et al. 2012 []High-fidelity simulated trauma resuscitation with video-assisted debriefingSurgeryImprovement in team function score and the feeling of being more competent as team leaders and team membersBHoang et al. 2016 []Training course: classroom didactic sessions and hand-on simulation sessions[U.S. Navy Fleet] surgeryImprovement in time to disposition and critical errorsDJames et al. 2016 []Simulation-based interprofessional team training: simulation followed by debriefing and performance feedbackOncologyAcquired new knowledge, skills, and attitudes to enhance interprofessional collaborationCKalisch et al. 2015 []Virtual simulation training with introduction sessionMedical–surgical patient care unitImprovement in overall teamwork, trust, team orientation, and backupDKhobrani et al. 2018 []Boot camp curriculum with high-fidelity paediatric simulations with debriefing[Paediatric] emergency medicineImprovement in teamwork performance [leadership, cooperation, communication, assessment and situation] and basic knowledgeDKilday et al. 2012 []Team intervention: didactic curriculum with skill lab practice sessions, simulations, debriefingHospitalsImprovement in team performance, knowledge, and emergency teamworkCKirschbaum et al. 2012 []Multidisciplinary team training: assessments, high-fidelity simulation sessions, and debriefingObstetricians and anaesthesiologistsImprovement in teamwork cultural attitudes and perceptions, communication climate; decreases in autonomous cultural attitudes and perceptionsCKoutantji et al. 2008 []Simulations with debriefing and in between an interactive workshop on briefing, check-listing methods and protocolSurgeryImprovement in technical skills and no or negative effect on non-technical skillsDKumar et al. 2018 []Simulation-based Practical Obstetric Multi-Professional Training [PROMPT]: interactive lectures, scenarios based drills, debriefingObstetric care in hospitalsImprovement in clinical and non-technical skills highlighting principles of teamwork, communication, leadership and prioritization in an emergency situation. No significant change in clinical outcomesBLarkin et al. 2010 []Simulation-Based curriculum: video demonstrations, triggers, and simulated scenariosSurgeryImprovement in empathic communication. Higher levels of stress. No significant improvement in teamwork attitudesCLavelle et al. 2018 []Multidisciplinary simulation-based training designed to address Medical Emergencies in Obstetrics: lecture, orientation session, simulation, debriefing, didactic teachingHealthcare staff across organizationsImprovement in clinical skills and non-technical skills including teamwork, communication and leadership skillsDLavelle et al. 2017 []In situ, simulation training: introduction, simulation, and debriefingPsychiatric triage wardsImprovement in knowledge, confidence, and attitudes toward managing medical deterioration. Based on reflection: improved confidence in managing medical deterioration, better understanding of effective communication, improved self-reflection and team working, and an increased sense of responsibility for patients’ physical health. Incident reporting increased by 33%CLee et al. 2012 []Interdisciplinary high-fidelity simulation-based team training with debriefingUrologyUrology resident training correlated with technical performance but not with non-technical performance; anaesthesia resident training level did correlate with non-technical performanceDLorello et al. 2016 []Mental practice training [versus ATLS training] and simulation with debriefingTrauma resuscitationImprovement in teamwork behaviour, compared to traditional simulation-based trauma instructionBMager et al. 2012 []Expanded Learning and Dedication to Elders in the Region [ELDER]: simulated patient scenarios using mid-fidelity human patient simulators and debriefingLong-term care facilities and home care agencyEncouraging communication and teamworkCMaxson et al. 2011 []Interdisciplinary simulation team training with high-fidelity simulation scenarios, pre- and debriefing sessionInpatient surgical wardImprovement in collaboration between nurses and physicians and patient care decision making processCMcLaughlin et al. 2011 []Intensive trauma team training course [ITTTC]: didactic lectures, case studies, and clinical simulationsMilitary healthcare personnelCreates self-reported confidenceDMeurling et al. 2013 []Simulation-based team training: interactive seminars, simulation with debriefingIntensive careImprovement in self-efficacy. Improvement in nurse assistants’ perceived quality of collaboration and communication with physician specialists, teamwork climate, safety climate [also for nurses] and working conditionsDMiller et al. 2012 []In situ trauma simulation programme: didactic session, simulation, and debriefingEmergency departmentImprovement in teamwork and communication, this effect was not sustained after the programme was stoppedDvan der Nelson et al. 2014 []Multidisciplinary simulation training with team debriefing [with emphasizes on using clinical tools]SurgeryImprovement in safety culture, teamwork climate; deterioration in perceptions of hospital management and adequacy of staffing levelsCNicksa et al. 2015 []Simulation of high-risk clinical scenarios followed by debriefings with real-time feedbackGeneral surgery, vascular surgery, and cardiothoracic surgeryImprovement in communication, leadership, teamwork, and procedural ability. No significant improvement in decision making, situation awareness, and skillsCNiell et al. 2015 []Simulation-based training: didactic instruction, simulation, and debriefingRadiologyImprovement in their ability to manage an anaphylactoid reaction, their ability to work in a team, and knowledgeBOseni et al. 2017 []Training: video-based feedback and low-fidelity simulationResearch unit clinics and hospital [in low resource settings]Improvement in clinical knowledge, confidence and quality of teamwork [leadership, teamwork and task management]CPaige et al. 2009 []Repetitive training using high-fidelity simulation: Module 1 targeted teamwork competencies and Module 2 included a pre-operative briefing strategyOperating roomImprovement in the effectiveness of promoting attitudinal change toward team-based competenciesCPaltved et al. 2017 []In situ simulation: information, simulation, and debriefingEmergency departmentImprovement in teamwork climate and safety climateCPascual et al. 2011 []Human patient simulation training: introduction, simulation, and video-based debriefingIntensive careImprovement in leadership, teamwork, and self-confidence skills in managing medical emergenciesCPatterson et al. 2013a []Multidisciplinary in situ simulations with debriefingPaediatric emergency departmentAbility to identify latent safety threats, but changes in non-technical skillsCPatterson et al. 2013b []Simulation-based training: introduction [lectures, videotapes of simulated resuscitations and case studies], simulation, and video-assisted debriefingPaediatric emergency departmentSustained improvement in knowledge of and attitudes toward communication and teamwork behavioursCPennington et al. 2018 []Long distance, remote simulation training with Checklist for Early Recognition and Treatment of Acute Illness [CERTAIN]Interdisciplinary teams in emergency situationsImprovement in global team performance: “team’s ability to complete tasks in a timely manner” and in the “team leader’s communication to the team”CRao et al. 2016 []Simulation team tasks: presentation, live-demonstration, and simulationsOperating roomImprovement in mean non-technical skills and concomitant increase in technical skillsDReynolds et al. 2011 []Multidisciplinary simulation-based team training: introduction, presentation, simulation, and debriefingObstetrical emergenciesImprovement in knowledge, dealing with teamwork related issues, and [technical] skills [particularly relevant for obstetric nurses and for those who witness all trained obstetrical emergencies]CRoberts et al. 2014 []Team communication, leadership and team behaviour training: didactic presentations, simulation, and debriefingEmergency department [ad hoc emergency teams]Changed teamwork and communication behaviourCRubio-Gurung et al. 2014 []In situ simulation training: briefing, simulation, and debriefingDelivery roomImprovement in the technical skills and teamworkBSandahl et al. 2013 []Simulation team training: lectures, simulation, and debriefingIntensive careIncreased awareness of the importance of effective communication for patient safety, created a need to talk, led to reflection meetingsCShoushtarian et al. 2014 []Practical Obstetric Multi-Professional Training [PROMPT]: lectures, scenario-based simulation trainingMaternityImprovement in Safety Attitude [teamwork, safety and perception of management] and clinical measures [Apgar 1, cord lactates and average length of baby’s stay in hospital]BSiassakos et al. 2011 []Interprofessional training programme: updates on evidence-based guidelines and simple practical means of implementing them, high-fidelity simulationMaternity unitPositive safety culture, teamwork climate, and job satisfaction. Perceptions of high workload and insufficient staffing levels were the most prominent negative observationsDSiassakos et al. 2011 []Multiprofessional simulation trainingMaternity unitReduction in median diagnosis–delivery interval [as indicator of teamwork]CSilberman et al. 2018 []High-fidelity human simulation training: briefing, simulation, and debriefingIntensive careFacilitates teamwork, collaboration, and self-efficacy for ICU clinical practiceDStewart-Parker et al. 2017 []Simulation-based S-TEAMS course: lectures, case studies, interactive teamwork exercises, simulated scenarios, debriefingOperating roomIncrease in confidence for speaking up in difficult situations, feeling the S-TEAMS had prevented participants from making errors, improved patient safety and team workingCStocker et al. 2012 []Multidisciplinary in situ simulation programme [SPRinT] with debriefingPaediatric intensive careImpact on non-technical skills [teamwork, communication, confidence] and overall practice; less impact is perceived in technical skillsCSudikoff et al. 2009 []High-fidelity medical simulation: didactic teaching, hands-on skills stations, case simulation, video-enhanced debriefing [with and without supplemental education]Paediatric emergency careImproved performance and teamwork skills; reduction in harmful actionsDThomas et al. 2010 []Teamwork training: information session with examples and SBAR model, video clips, role playing, simulation, debriefingPaediatricImprovement in frequent teamwork behaviours, workload management and time to complete the resuscitationBWeller et al. 2016 []Multidisciplinary Operating Room Simulation [MORSim] intervention: simulation, debriefing, and discussionOperating roomImprovement in communication, culture and collaboration. But difficulties with uninterested colleagues, limited team orientation, communication hierarchies, insufficient numbers of staff exposed to MORSim and failure to prioritize time for team information sharingDWillaert et al. 2010 []Patient-specific virtual reality [VR] simulationOperating roomImprovement in sense of teamwork, communication, and patient safety; procedure time took longer in realityCYang et al. 2017 []Simulation-based interprofessional education course: preparation course, simulation, benchmarking, e-learningMedical centreImprovement in interprofessional collaboration attitude, self-reflection, workplace transfer and practice of the learnt skillsDGeneral team trainingAcai et al. 2016 []Educational creative professional development workshop: various interactive team building games, activities rooted in the dramatic arts, creative printmaking session, debriefing sessionsMental health and social carePositive impact on teams with low team cohesion prior to the intervention. Helps staff to bond, communicate, get to know each other better and accept each other’s mistakesDAgarwal et al. 2008 []McMaster Interprofessional Mentorship and Evaluation [MIME] programme to increase interprofessional interactions, learn more about the roles of other healthcare professionals and improve work-life satisfaction through intentional conversations at mutually agreed timesInterprofessional family health teamsNo significant improvement in the QWL Survey, but participant feedback from closing workshop focus groups and evaluations was positiveCAmaya-Anas et al. 2015 []Team training: workshops, virtual modules, time-out and checklist training, and institutional actionsOperating rooms and obstetrics suitesTwo or more points of improvement in the average OTAS-S scores in every phase, behaviours and sub-teamsCBarrett et al. 2009 []Intervention on lateral violence and team building: interactive groups sessions and skill-building sessionsAcute care hospitalImprovement in group cohesion and the RN-RN interactionCBleakley et al. 2012 []Complex education intervention: data-driven iterative education in human factors, establishing a local, reactive close call incident reporting system, and developing team self-review [briefing and debriefing]Operating roomImprovement in teamwork climate and reduction in stress recognition. No significant improvement in job satisfaction, perception of management, working conditions, safety climateBBlegen et al. 2010 []Multidisciplinary teamwork and communication training: presentations, videos, role playing, and facilitated discussionInpatient medical unitsImprovement in supervisor manager expectations, organizational learning,communication openness, hospital handoffs and transitions, and non-punitive response to errorBBrajtman et al. 2009 []Interprofessional educational intervention: interactive sessions consisting of a case study, discussions and presentationPalliative careImprovement in leadership, cohesion, communication, coordination and conflict domainsDBrajtman et al. 2012 []Interprofessional educational intervention: self-learning module [SLM] on end-of-life delirium and interprofessional teamwork, team objective structured clinical encounter [e.g. simulation team discussion and debriefing], and a didactic “theory burst”Long-term care facility and hospiceImprovement in knowledge and perceptions of IP competence, but does depend on the presences of the moduleDBrandler et al. 2014 []Team-based learning sessions: preparation reading, tests, and application-oriented activitiesPathologyAble to solve complex problems and work through difficult scenarios in a team settingDChan et al. 2010 []Intervention: educational workshop [e.g. case study using role play] and structured facilitation using specially designed materialsPrimary careImprovement in patient participation, empowerment in the care process, communication and collaborationCChristiansen et al. 2017 []Standardized Staff Development Program: educational session [i.e. lecture] and team building and resiliency session [e.g. simulation game, rounds]Burn centreContributed to perceived unit cohesion and increasing satisfaction and moraleDChiocchio et al. 2015 []Workshops integrating project management and collaboration: active, learner-centred, practice oriented strategies, feedback, and small group discussionsInterprofessional healthcare project teamsImprovement in satisfaction, perceptions of utility, self-efficacy for project-specific task work, teamwork, goal clarity, coordination, functional performance of projectsCCohen et al. 2016 []Allied Team Training for Parkinson [ATTP]: interprofessional education training on best practices and team-based careTargeted professionals [e.g. medicine, nursing, occupational, physical and music therapies]Improvement in self-perceived, objective knowledge, understanding role of other disciplines, attitudes toward healthcare teams, and the attitudes toward value of teamsBCole et al. 2017 []Elective rotation of operating room management and leadership training: curriculum consisting of leadership and team training articles, crisis management text, and daily debriefingsAnaesthesiologyImprovement in teamwork, task management and situational awarenessDEklöf and Ahlborg 2016 []Dialogue training: multiple dialogue rounds using standardized flashcards, group discussionsHospitalImprovement in participative safety [i.e. information sharing, mutual influence and sense of having a common task] and social support from managers. Qualitative data shows a positive tendency toward trust/opennessAEllis and Kell 2014 []Training: theory, group exercises, presentationsPaediatric wardImprovement in team cohesiveness, effectivity, and patient careDEricson-Lidman and Strandberg 2013 []Intervention to constructively deal with their troubled conscience related to perceptions of deficient teamwork: assist care providers in extending their understanding of the difficult situation and find solutions to the problem through participatory action researchElderly careSupport care providers to understand, handle and take measures against deficient teamwork. Using troubled conscience as a driving force can increase the opportunities to improve quality of careDFallowfield et al. 2014 []Communication skills training: workshop [e.g. presentations, exercises, discussion, role play]Breast cancer teamsImprovement in awareness and clarity about the trial[s] discussed during the trainingCFernandez et al. 2013 []Computer-based educational intervention: computer-based training module [e.g. presentations, clinical examples, simulation-based assessment] or a placebo training moduleEmergency care [and medical students]Improvement in teamwork and patient careBGibon et al. 2013 []Patient-oriented communication skills training module [e.g. information, role play] and team-resource oriented communication skills training module [e.g. information, role play]RadiotherapyImprovement in team members’ communication skills and their self-efficacy to communicateBGillespie et al. 2017 []Team training programme [TEAMANATOMY]: 1-h DVD [i.e. individual and shared situational awareness theory, filmed simulation pre-operative patient sign-in, and filmed simulation of time-out procedure]Operating roomImprovement in non-technical skills [communication and interactions, situational awareness, team skills, leadership and management skills and decision making]. Most significant improvement observed in surgeons. Improved use of the surgical safety checklistCGillespie et al. 2017 []Team training programme [TEAMANATOMY]: 1-h DVD [i.e. individual and shared situational awareness theory, filmed simulation pre-operative patient sign-in, and filmed simulation of time-out procedure]Operating roomImprovement in non-technical skills [communication and interactions, situational awareness, team skills, leadership and management skills and decision making] and the use of the surgical safety checklist. No improvement in perceived teamwork. No significant increase in perceived safety climateCHalverson et al. 2009 []Team training: classroom curriculum, intraoperative coaching on team-related behaviours, and follow-up feedback sessionsOperating roomImprovement in perception of teamworkCHowe et al. 2018 []Rural interdisciplinary team training programme: didactic mini-lectures, interactive case studies discussions, video presentations, role play demonstrations and the development of an action planVeteran affairs primary careImprovement in teamworkDKelm et al. 2018 []Mindfulness meditation training using a meditation device and smartphone application at home [e.g. education, demonstration, and practice in using device, one-page summary]Pulmonary and critical medicine physicians and ICU
Improvement in teamwork, task management, and overall performance
Change in how participants responded to work-related stress, including stress in real-code situations
DKhanna et al. 2017 []Training and refresher courses on the principles of the patient-centred care medical homes: participating patient-centred medical home received coaching, learning collaborative for improving teamwork, embedded care managerPrimary careNo significant difference in perceptions of teamworkDKörner et al. 2017 []Team coaching: identification of the expectations for team coaching [need-specific], definition of the coaching goals [task-related], development of the solution [solution-focused], maintenance of the solution [systemic]Rehabilitation teamsImprovement in team organization, willingness to accept responsibility and knowledge integration according to staff. No significant improvement in internal participation, team leadership, and cohesionBLavoie-Tremblay et al. 2017 []Transforming Care at the Bedside [TCAB] programme: learning modules combined with hands-on learningMultihospital academic health science centreImprovement in patient satisfaction focus, overall perceived team effectiveness, perceived team skill, perceived participation and goal agreement, perceived organizational support. No significant improvement in patient experienceCLee et al. 2012 []Communication and Patient Safety [CASP] training: practical exercises, video clips, small group discussion and other learning techniquesEmergency, outpatients, maternity, and special care nurseryChanges in behaviour at individual, team, and facility levelsCLing et al. 2016 []BASIC [Basic Assessment and Support in Intensive Care] Patient Safety Course: blended learning course with flipped classroom approach [e.g. lectures, formative assessment, interactive sessions]Intensive careImprovement in teamwork within hospital units and hospital management support for patient safety, but decreased in the frequency of reporting mistakesCLundén et al. 2017 []Drama Workshop [warm-up activities, improvizations and Forum Theatre, reflective discussions] as a learning mediumRadiographers and registered nurses specialized in areas such as radiography, operating room and anaesthesiaEnables participants to understand each other’s priorities better and find the best way to co-operateDMager et al. 2014 []Team-building activities: interactive activities, discussions, case studies, readings, and/or games to promote the application of teamwork skillsLong-term and home careQuantitatively: no statistical improvement; qualitatively: better understanding of other provider rolesCMagrane et al. 2010 []Learning in Teams model: interactive workshops, daily programme team meetings, conference calls, weekly online correspondence, and colloquiumAcademic health centresImprovement in team skills [clarifying team charge, exploring team purpose, and evaluating team process]and institutional team performanceCNancarrow et al. 2015 []Interdisciplinary Management Tool [IMT]: structured reflection through reflective exercises, facilitated sessions, evaluation conferenceCommunity based rehabilitation or community rehabilitation servicesproviding transitional care for older peopleEmpowers to understand and value their own, and others’ roles and responsibilities within the team; identify barriers to effective team work, and develop and implement appropriate solutions to theseDPrewett et al. 2013 []Team training: lecture, several role plays, and guided discussion for feedbackTrauma resuscitation teamsImprovement of behavioural choices for teamwork in the trauma room. More effective responses to teamwork issues , but no affect in case of already a positive attitudes toward teamworkDStephens et al. 2016 []Interprofessional training course: workshops, simulated a structured debriefing technique, facilitated discussion, and sustainability strategyPerioperative practitionersImprovement in team behaviours [communication, coordination, cooperation and backup, leadership, situational awareness]; recognizing different perspectives and expectations within the team; briefing and debriefingDWebb et al. 2010 []Emotional intelligence coaching: homework assignments, coaching sessions, goal settingFamily medicineDecline in teamwork rating and no improvement on competencesDTools: Structuring teamwork: SBARBeckett et al. 2009 []SBAR Collaborative Communication Education [e.g. didactic content, role play, and an original DVD demonstrating traditional and SBAR communication]Hospital paediatrics/perinatal services departmentImprovement in communication, collaboration, satisfaction, and patient safety outcomesCClark et al. 2009 []PACT [Patient assessment, Assertivecommunication, Continuum of care, Teamwork with trust] Project, aimed at improving communication between hospital staff at handover: 2 communication tools based on SBAR: Handover prompt card and reporting templatePrivate hospitalimprovement in communication, handover, and confidence in communicating with doctorsCCosta and Lusk 2017 []SBAR educational sessionBehaviour health clinicians in correctional facilitiesMarginal improvement in communication and team structureDDonahue et al. 2011 []EMPOWER project: an interdisciplinary leadership-driven communication programme [Educating and Mentoring Paraprofessionals On Ways to Enhance Reporting] using SBARHospitalImprovement in communication from paraprofessional staff to professional staff, no significant changes in rapid events reportsCMartin et al. 2015 []Huddles structured with SBAR with an educational sessionPaediatric emergency departmentImprovement in teamwork, communication, and nursing satisfactionCRandmaa et al. 2014 []SBAR and implementation strategies [e.g. modified SBAR card, in-house training course, information material and observation]Anaesthetic clinicsImprovement in between-group communication accuracy, safety climate, the proportion of incident reports due to communication errorsCRenz et al. 2013 []SBAR protocol and trainingNursing homesMixed results regarding the nurse satisfaction with nurse-medical provider communicationDRice et al. 2010 []Interprofessional intervention: semi-scripted four-step process during all patient-related interactions [i.e. name, role, issue, and feedback]General internal medicineNo changes in communication and collaboration between health professionalsDSculli et al. 2015 []Effective Followership Algorithm: 3Ws [what I see; what I’m concerned about; what I want], 4-Step Assertive Tool, Engage team, Chain of commandPaediatric and adult operating roomsImprovement in safety culture, teamwork, team performanceCTing et al. 2017 []SBAR Collaborative Communication Education: educational session, case-based discussion, video demonstration on traditional and SBAR communicationObstetrics departmentImprovement in teamwork climate, safety climate, job satisfaction, and working conditionsDWeller et al. 2014 []Video-intervention teaching SNAPPI tool: Stop the team; Notify of the patient’s status; Assessment of the situation; Plan what to do; Priorities for actions; and Invite ideasAnaesthesiologyImprovement in SNAPPI score, number of diagnostic options, information sharing. No significant improvement in information probe sharing and medical management [in intervention group]CTools: Structuring teamwork: [De]briefing checklist Berenholtz et al. 2009 []Standardized one-page briefing and debriefing toolOperating roomImprovement in interdisciplinary communication and teamworkC Bliss et al. 2012 []Comprehensive surgical safety checklist [using pre-operative briefing and post-operative debriefing checklists] and a structured team training curriculumSurgeryDecrease in 30-day morbidity. Cases with safety-compromising events [e.g. inadequate communication, decision making], had higher rates of 30-day morbidityB Böhmer et al. 2012 []Modified perioperative surgical safety checklistOperating roomImprovement in interprofessional coordination and communicationD Böhmer et al. 2013 []Perioperative safety checklistsAnaesthesiology and traumatologyImprovement in verification of written consent for surgery, clear marking of the surgical site, time management, better informed about the patients, the planned operation, and the assignment of tasks during surgery in both short and long terms. Decrease in communication over longer time periods.B Boet et al. 2011 []Self-debriefing versus instructor debriefingHospitalImprovement in situational awareness, teamwork, decision making, task management, total non-technical skills, regardless of the type of debriefing receivedB Boet et al. 2013 []Interprofessional within-team debriefing compared to an instructor-led debriefingOperating roomImprovement in team performance regardless of the type of debriefing. No significant difference in the degree of improvement between within-team debriefing and instructor-led debriefingC Cabral et al. 2016 []Standardized, comprehensive time-out and a briefing/debriefing process using surgical safety checklistSurgeryImprovement of nurses’ perception of communication. No significant improvement of surgeons and technologists perception of communicationC Calland et al. 2011 []Surgical safety checklists [intervention group included a basic team training using a pre-procedural checklist]SurgeryImprovement in team behaviour, defined as discrete, objective, observable shared communication behaviours; more likely to involve positive safety-related team behaviours such as case presentations, explicit discussions of roles and responsibilities, contingency planning, equipment checks, and post case debriefings; no significant differences in situational awarenessA Dabholkar et al. 2018 []Customized surgical safety checklistSurgeryImprovement in verification of patient’s identity, awareness of operating team members’ names and roles, practice of displaying radiological investigation during surgery, pre-check of equipment and communicationB Dubois et al. 2017 []Person-centred endoscopy safety checklist [introduces during seminars and training]Endoscopy unitImprovement in quality of collaboration with nurses and perception. No differences in teamworkD Einav et al. 2010 []Pre-operative team briefings [briefing protocol and poster]Operating room25% reduction in the number of non-routine events when briefing was conducted and a significant increase in the number of surgeries in which no non-routine event was observed. Team members evaluated the briefing as most valuable for their own work, the teamwork, and patient safetyC Erestam et al. 2017 []Revised surgical safety checklistOperating roomNo significant change in teamwork climate. Lack of adherence to the checklist was detectedC Everett et al. 2017 []Critical event checklistsSurgical daytime facilityNo improvement in medical management or teamwork [during simulation]C Gleicher et al. 2017 []Standardized handover protocol consisting of a handover content checklist and a “sterile cockpit” time-outCardiovascular intensive careImprovement in teamwork, content received and patient care planningC Gordon et al. 2014 []Pre-procedure checklistCardiac catheterization laboratoryNo improvement in complication rates, overall team and safety attitudesC Hardy et al. 2018 []Malignant hyperthermia checklistAnaesthesiologyImprovement in non-technical skills in the experiment group. Higher self-reported stress in the experiment groupC Haugen et al. 2013 []Surgical safety checklistOperating roomImprovement in frequency of events reported and adequate staffing. No significant improvement in patient safety, teamwork within units, communication on error, hospital management promoting safetyB Haynes et al. 2011 []Checklist-based surgical safety interventionOperating roomsImprovement in teamwork and safety climateC Helmiö et al. 2011 []Surgical safety checklistOperating roomImprovement in verification of the patient’s identity, awareness of the patient’s medical history, medication and allergies, knowledge of the names and roles among the team members, discussion about possible critical events, recording post-operative instructions, communication between team membersB Howe et al. 2014 []Long-term care team talk programme involved regularly scheduled 5-min debriefing sessions at the end of the day shift led by a rotating schedule of certified nurseTransitional care unit in long-term care facilityImprovement in co-worker and supervisor support, teamwork and communication, job demands and decision authority, characteristics of the unit and intent to leave/transfer unitC Jing and Honey 2016 []Robotic-assisted laparoscopic radical prostatectomy checklistOperating roomImprovement in teamwork, time efficiency, higher confidence levels and more comprehensive operating room setupD Kawano et al. 2014 []Surgical safety checklistSurgeryImprovement in the Safety Attitude ScoresC Kearns et al. 2011 []Modified surgical safety checklistObstetric theatreImprovement in interprofessional communication, familiarity with team members, and checklist complianceC Kherad et al. 2018 []Endoscopy checklist implementation [with lectures by quality officers]EndoscopyImprovement in team work and communication, patient perception of team communication and teamwork. No significant improvement in team perceptionC Khoshbin et al. 2009 []“07:35 huddles” [pre-operative OR briefing following 4 elements] and “surgical time-outs” [pre-operative OR briefing following 9 elements]Paediatric hospitalEspecially for the nursing personnel, change the notion of individual advocacy to one of teamwork and being proactive about patient safetyC Lepanluoma et al. 2014 []Surgical safety checklistOperating roomImprovement in communication between the surgeon and the anaesthesiologist. Safety-related issues were better covered. No improvement in awareness. Improvement in unplanned admission rates and number of wound complicationsD Lingard et al. 2008 []Team briefing structured by a checklistGeneral surgeryImprovement in number of communication failures and proactive and collaborative team communicationC Low et al. 2013 []“Flow checklists” at high-risk points in the patient surgical journey, in addition to the surgical safety checklistAmbulatory surgery centreImprovement in the perception of patient safetyD McLaughlin et al. 2014 []Time-Out Process: [1] team member introductions, [2] safety statement by the time-out leader, [3] addition of two supplemental items to the institutional checklist, and [4] pre-incision Surgical Care Improvement Project measuresNeurosurgery in operating roomImprovement in the perception of patient safety, team spirit, voice safety concerns. Does not necessarily reinforce teamwork.D Merrell et al. 2018 []Emergency manual consisting of a set of crisis checklists or cognitive aidsOperating roomEnabled perceived effective team functioning through reducing stress, fostering a calm working environment and improvement teamwork and communicationD Mohammed et al. 2013 []Obstetric safe surgery checklistAnaesthetists and obstetriciansImprovement in communication of caesarean section grade [urgency] between obstetricians and anaesthetistsC Molina et al. 2016 []Surgical safety checklistsOperating roomImprovement in respect, clinical leadership, assertiveness, coordination, and communicationA Nadler et al. 2011 []Debriefings using video recordingsNeonatal resuscitationImprovement in teamworkC Nilsson et al. 2010 []Pre-operative checklist during time-outOperating roomImprovement in “team feeling”D Norton et al. 2016 []Novel paediatric surgical safety checklistOperating room at paediatric hospitalReduced complications and errors and improved patient safety, communication among team members, teamwork in complex procedures, efficiency in the operating room, prevented or averted an error or a complicationC Nundy et al. 2008 []Pre-operative briefings using a standardized format [with training session]Operating roomReduction in unexpected delays and communication breakdowns leading to delaysB Paige et al. 2009 []Pre-operative briefing protocolOperating roomImprovement in pre-operative briefing and overall team interaction; no significant improvement in procedure timeD Pannick et al. 2017 []Prospective clinical team surveillance [PCTS]: structured daily interdisciplinary briefings to capture staff concerns, with organizational facilitation and feedbackMedical wardImprovement in safety and teamwork climates, reduction in excess length of stay [eLOS]B Papaconstantinou et al. 2013 []Surgical safety checklistSurgeryImprovement in the awareness of patient safety and quality of care, the perception of the value of and participation in the time-out process, surgical team communication, and in the establishment and clarity of patient care needsB Papaspyros et al. 2010 []Pre-operative briefing with checklist and debriefingCardiac operating roomImprovement in communicationD Sewell et al. 2011 []Educational programme focused on using the surgical safety checklistOrthopaedic surgeryIncrease in checklist use, believe that the checklist improved team communication; checklist use was not associated with a significant reduction in early complications and mortality in patients undergoing orthopaedic surgeryB Skåre et al. 2018 []Video-assisted, performance-focused debriefingsDeliveryImprovement in Neonatal Resuscitation Performance Evaluation [NRPE] score: group function/communication, preparation and initial steps and positive pressure ventilationC Steinemann et al. 2016 []Structured physician-led briefing [using a checklist]Trauma careImprovement in T-NONTECH leadership scale [not the other domains] and task completions [not for all scenarios]C Takala et al. 2011 []Surgical safety checklistOperating roomImprovement in confirming patient’s identity, knowledge of names and roles among team members, discussing critical events, and fewer communication failuresA Tscholl et al. 2015 []Anaesthesia pre-induction checklist, in addition to the surgical safety checklistAnaesthesiologyImprovement in information exchange, knowledge of critical information, perception of safety in anaesthesia teams, perceived teamworkA Urbach et al. 2014 []Surgical safety checklistOperating roomImplementation is not associated with significant reductions in operative mortality or complicationsB Wagner et al. 2014 []Mental health huddles [similar to safety briefings] to support staff in discussing and managing client responsive behavioursLong-term careimprovement in staff collaboration, teamwork, support, and communicationD Weiss et al. 2017 []After events reviews [AER]: assertiveness-specific AER [ASAER] versus teamwork-generic AER [TGAER]Healthcare teamsImprovement in nurses speaking up following the ASAER in comparison to TGAER and higher levels of hierarchy-attenuating beliefs following the ASAER in comparison to TGAERC White et al. 2017 []Four-day pilot course for implementation of surgical safety checklistHospital [low-income setting]Improvement in learning, behaviour and organizational change [not hierarchical culture]D Whyte et al. 2009 []Structured pre-operative team briefings [using a checklist]Pre-operative teamsFive types of negative events: the briefings could mask knowledge gaps, disrupt positive communication, reinforce professional divisions, create tension, and perpetuate a problematic cultureD Zausig et al. 2009 []Two different training groups: one included extensive debriefing of NTS [resource management, planning, leadership and communication] and medical management and the other included a simpler debriefing that focused solely on medical managementAnaesthesiologyImprovement in non-technical skills; no differences between the groupsDTools: Structuring teamwork: Rounds Genet et al. 2014 []Respiratory therapist [RT]-led interdisciplinary rounds using a scripted tool [with education session]Neonatal ICUImprovement in communication, teamwork, and timeliness of completing respiratory ordersB Henkin et al. 2016 []Bedside rounding: inclusion of nurses in morning rounds with the medicine teams at the patients’ bedside, using a checklistGeneral medicine inpatient teaching unitImprovement in the perceptions of nurse–physician teamworkC Li et al. 2018 []Interprofessional Teamwork Innovation Model [ITIM]: structured daily roundsAcademic medical centreImprovement in communication among team members and overall time savings. Reduction in 30-day same-hospital readmissions, no impact on 30-day same-hospital ED visits or costsB O’Leary et al. 2010 []Structured Interdisciplinary Rounds combined a structured format for communication and a forum for regular interdisciplinary meetingsTertiary care teaching hospitalImprovement in teamwork climate in intervention group [compared to control group]B O’Leary et al. 2011 []Structured Interdisciplinary Rounds: combined a structured format for communication with a forum for regular interdisciplinary meetingsGeneral medical unit in hospitalImprovement in quality of communication and collaboration with hospitalists, teamwork and safety climateC O’Leary et al. 2015 []Structured Interdisciplinary Rounds and prepared nurse–physician co-leadershipGeneral medical unitsImprovement in teamwork but no reduction in Adverse EventsC Young et al. 2017 []Multidisciplinary Bedside Rounding Initiative, which included creating nursing availability, streamlining provider communication, and performance monitoring and feedbackHospitalImprovement in teamwork climate, nurse job satisfaction, and early dischargesDTools: Facilitating teamworkButler et al. 2018 []Telemedicine technology in care deliveryEmergency careNo differences in teamwork between control and experiment groups. Higher workload in experiment groupBChu-Weininger et al. 2010 []Remote monitoring by intensivists using telemedicine technology [tele-ICU]Intensive careImprovement in teamwork climate and safety climateBDoyle et al. 2016 []Remote information technology [education session, teleconferences, web-based team case presentations]Mental health services for older peopleImprovement in professional development, perceived peer support, team building, cohesion, and reduce travel timeDFoo et al. 2015 []Mobile task management tool [digitize patient flow and provide real-time visibility over clinical decision making and task performance]Acute general surgical serviceImprovement in working efficiency of junior clinical staffCLetchworth et al. 2017 []MedNav; a decision support tool on a tablet or mobile phone with integrated vocal prompts and visual cuesMaternity teamsImprovement in teamwork based on all domains of Clinical Teamwork Scale and Global Assessment of Obstetric Team PerformanceBO’Connor et al. 2009 []Using wireless e-mail in order to send information-rich, specific, legible, and time-stamped messagesIntensive careImprovement in communication, team relationships, staff satisfaction, and patient careDYeh et al. 2016 []Ping-pong-type multidisciplinary reflective e-communication [within web-based integrated information platform]Radiation oncologyHigher Timeliness, Notating convenience, Information completeness, Feedback convenience, Communication confidence, Communication effectiveness, Review convenience and overall satisfactionCTools: Triggering teamworkAberdeen and Byrne 2018 []Concept mapping visually representing a patient’s situationResidential aged care facilitiesImprovement in effectiveness of care planning and knowledge increase of dementia careDAinsworth et al. 2013 []Door Communication Card [DCC] to improve goal alignmentSurgical ICU academic military medicalNo improvement in goal alignmentDBennett et al. 2015 []Sharing clinical cases and stories about patients [during workshops]Primary care clinical settingHelped in bonding around their shared mission of patient-centred care, build supportive relationships, enhance compassion for patients, communicate and resolve conflict, better understand workflows and job roles, develop trust, and increase moraleDDaley et al. 2012 []Clinical dashboard systemAcute elderly careImprovement in access to information, communication and information sharing, staff awareness, and data qualityDO’Neil et al. 2017 []Thought for the Day [TOD] intervention; a short reflection on a piece of poetry, music, or religious writingInpatient palliative careImprovement in perception of teamwork. Coming together as an interdisciplinary team for a time to reflect is valuedDSiegele 2009 []The Daily Goals Tool [DGT] and Daily Goals Tool Reference [DGTR]Surgical intensive careHelps in simplifying complex tasks, improving teamwork, promoting effective communication and shared decision making, and enhancing patient safetyDStoller et al. 2010 []Respiratory therapy [RT] business scorecard that compared target goals with actual monthly performanceRespiratory therapy departmentsImprovement in teamwork among RT departments and outcomesDOrganizational [re]designBarry et al. 2016 []Behavioural Health Interdisciplinary Program [BHIP] team model as an innovative approach to transform VHA general outpatient mental health delivery, include holding daily huddles and longer weekly interdisciplinary team meetingsVeterans Health Administration mental health careImprovement in teamwork and patient care and has potential to improve staff working relationships, communication, collaboration, morale, and veteran treatment consistencyDde Beijer et al. 2016 []Clinical pathways: standardizing treatment and communication methods, delegating tasks from medical specialists to nurses, and providing nurses with their own consultation roomOrthopaedic hand unit outpatient clinicImprovement in the actual communication and collaborative problem-solving skills concerning standard patientsDClements et al. 2015 []Allocating the most senior nurse as team leader of trauma patient assessment and resuscitationEmergency departmentImprovement in understanding of their role, “intimidating personality”, and nursing leadershipCDeneckere et al. 2013 []Care pathways: [1] Formative evaluation of the teams’ performance before implementation, [2] Evidence-based KI, and [3] Training in pathway developmentAcute hospitalImprovement in conflict management, team climate for innovation, level of organized care, risk of burnout, emotional exhaustion, and competence. No significant improvement in relational coordinationBFernandez et al. 2010 []Two models: The multifaceted Shared Care in Nursing [SCN] model of nursing careinvolved team work, leadership and professional development. In the Patient Allocation [PA] model one nurse was responsible for the care of a discrete group of patientsGeneral medical and surgical wards in tertiary teaching hospitalThe two models of care support most aspects of interdisciplinary and intra-disciplinary communicationCFogel et al. 2016 []Patient-focused primary care redesignContinuity clinic settingsImprovement in teamwork training, teamwork among residents, perception of overall quality of care in clinic, and that physicians, nurses, and administrative staff worked together to optimize patient flowCFrykman et al. 2014 []Multiprofessional teamwork involving changes in work processes, with task-generated feedback, managerial feedback, aimed at increasing interprofessional collaborationEmergency departmentEnabled teamworkCGreene et al. 2015 []Innovative compensation model: replaced fee-for-service payment with a largely team based, quality-focused payment, 40% of compensation was based upon the clinic-level quality performance, and an additional 10% was based upon the clinic-level patient’s experiencePrimary careMixed results: quality improvement for the team and less patient “dumping,” or shifting patients with poor outcomes to other clinicians, but also lack of control and colleagues riding the coattails of higher performers. mixed results: greater interaction with colleagues, but also an increase in tensionCHern et al. 2009 []Quality improvement intervention: creation of team structures linking faculty advisors and residents with patients, intra-team management of office tasks, and the implementation of multidisciplinary team meetingsFamily medicineImprovement in perceptions of continuity of patient care, office efficiency, and team communicationCHung et al. 2018 []Redesign consisting of multiple workflow changes: [1] “5S” standardization of medical equipment, supplies and education materials in patient exam rooms, [2] redesign of call centre functions, [3] co-location of existing care teams and [4] redesign of care team roles and workflowsAmbulatory care primary care departmentsImprovement in teamwork, participation in decisions to improve care by physicians, engagement among physicians and motivation among Non-physicians staffCO’Leary et al. 2009 []Localizing physicians to specific patient care unitsHospitalNurses and physicians wereable to identify one another and communicated more frequentlyBPan et al. 2017 []An operating room [OR] assistant using an instructional supervision programmeOperating roomImprovement in first cases that started on time, percentage of teamwork score and patient satisfactionBParush et al. 2017 []Employ technological cognitive aids at EDEmergency DepartmentImprovement in teamwork; overall communication, situational awareness [as measured by CTS and not SAGAT], and decision makingDPati et al. 2015 []Decentralized unit operations and the corresponding physical designInpatient unitsPotentially improvement in quality of workDStavroulis et al. 2013 []Integrated theatre environment: a superior operating environment in which the laparoscopic equipment and multiple flat-screen monitors are permanently installed to be operational on demand inside the theatreOperating roomImprovement in perceived efficiency, teamwork and stress levelsCStepaniak et al. 2012 []Fixed operating room [OR] teams for a day instead of OR teams that vary during the dayOperating room [bariatric surgery]Reduced procedure durations and improved teamwork and safety climate, without adverse effects on patient outcomesBProgrammeBasson et al. 2018 []Multifaceted intervention consisting of monthly walking rounds by the director and an interactive learning session focused of feedback of culture data, educational training programme, and unit-based programme for safetyVeterans administration hospital leadersNo improvement on most items of the SAQ and AHRQ Hospital Safety Survey. Improvement in responding to errors and expressing disagreement with physicians. Decrease of perception of leadership’s safety efforts and levels of staffingDBunnell et al. 2013 []For each identified risk area, agreements about roles, responsibilities and behaviours of each team member were made. Tools were developed and systems modified to enhance situational awareness and a shared mental model among team members, and to support implementation of the agreementsAmbulatory clinical oncology practiceImprovement in patient satisfaction scores regarding coordination of care, efficiency safety of care, more respectful behaviour, relationships among team members. No significant improvement in non-communicationCBraithwaite et al. 2012 []System-wide intervention promoting interprofessional collaboration; implementing educational workshops and seminars, feedback sessions, project, and other initiativesHealth professionals across entire health systemMost agreement on improvement in sharing of knowledge between professions and improved quality of patient care, and least agreement that between-professional rivalries had lessened and communication and trust between professions improvedBCarney et al. 2011 []Medical team training programme: preparations, learning sessions, implementing projects including briefing and debriefing, coachingOperating room in Veterans Health AdministrationImproved perceptions of safety climateBCarney et al. 2011 []Medical team training programme: preparations, learning sessions, implementing projects including briefing and debriefing, coachingVeterans Health AdministrationImprovement in teamwork climateBCostello et al. 2011 []OR Transformation Project: OR day redesign, workflow, human resources analysis, supply and technology, and quality of work lifeOperating roomImprovement in work practices, recognition/ compensation, communication, commitment, physical/environmental safety, teamwork, and respectCGinsburg and Bain 2017 []Multifaceted intervention programme to promote speaking up and teamwork consisting a role-playing simulation workshop, discussion briefings and other department-led initiatives such as 10-min staff huddlesEmergency department and intensive careImprovement in team climate score at follow-upBHilts et al. 2013 []The Quality in Family Practice [QIFP] programme encompasses clinical and practice management using a comprehensive tool of family practice indicatorsAcademic primary care clinicsImprovement in understanding of team roles and relationships, teamwork, flattening of hierarchy through empowermentDHsu et al. 2015 []Multifaceted intervention included Comprehensive Unit-based Safety Program [CUSP], the daily goals communication tool, and 5 evidence-based practices [i.e. hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site, and removing unnecessary catheters]Adult intensive careImprovement in safety climate, job satisfaction, and working conditionsBHsu et al. 2014 []Team Resource Management [TRM] programme: simulative learning workshop [e.g. lectures, videos, case-based interactive discussions], focus group interviews, develop TRM-based checklists, working sheets, and re-designed organ procurement and transplantation processes, video skill demonstration and training, case reviews and feedback activitiesHospitalNo significant improvement on teamwork [i.e. teamwork framework, leadership, situational awareness, communication, mutual support]; no error in communication or patient identification was notedCJe et al. 2013 []Hospital-wide quality improvement programme: forming committee to review the system, implemented a dedicated communication system, standardizationon of role, training, implementing a standard reporting systemHospitalImprovement in safety attitude [i.e. sharing information, training, medical error reporting, safety climate, job satisfaction, communication, hospital management quality]BKotecha et al. 2015 []Quality Improvement Learning Collaborative Program: learning sessions, action periods to develop improvement plans, and summative congresses supported by QI coaches, teleconferences, and a web-based virtual officePrimary careImprovement in trust and respect for each other’s clinical, administrative roles, collegial relationships, collapse professional silos, communication, and interdisciplinary collaborationDLin et al. 2018 []Safety Program for Surgery: Comprehensive Unit-based Safety Program [CUSP] and individualized bundles of interventionsHospitalsImprovement in overall perception/patient safety, teamwork across units, management support for patient safety, non-punitive response to error, communication openness, frequency of events reported, feedback/communication about error, organizational learning/continuous Improvement, supervisor/manager expectations and actions promoting safety, and teamwork within unitsBMcArdle et al. 2018 []Safety Program for Perinatal Care [SPPC, adapted CUSP]: TeamSTEPPS teamwork and communication framework and tools, applying safety science principles [standardization, independent checks, and learn from defects], and establishing an in situ simulation programmeLabour and deliveryImprovement in the se of shoulder dystocia safety strategies, in situ simulation, teamwork and communication, standardization, learning from defects, and independent checksBMcCulloch et al. 2017 []Four-month safety improvement interventions, using teamwork training [TT], systems redesign and standardization [SOP], Lean qualityimprovement, SOP + TT combination, or Lean+TT combinationOperating roomTT: improvement in non-technical skills and WHO compliance, but not technical performance. Systems interventions [Lean and SOP]: improvement in non-technical skills and technical performance, WHO compliance. Combined interventions: improvement in all performance measures except WHO time-out attempts, whereas single approaches improved WHO compliance less and failed to improve technical performanceBNeily et al. 2010 []Medical team training programme: preparation, learning session, implementing briefings, debriefings and other projects [i.e. SBAR, Interdisciplinary rounds, Fatigue management], follow-up coachingSurgical care in Veterans Health AdministrationImprovement in teamwork, efficiency, avoiding an undesirable eventCNeily et al. 2010 []Medical team training programme: preparation, learning session, implementing projects, follow-up coachingOperating room in Veterans Health AdministrationLower surgical mortality and improvement in open communication and staff awarenessAPettker et al. 2011 []Comprehensive Obstetrics Patient Safety Program: [1] obstetrics patient safety nurse, [2] protocol-based standardization of practice, [3] CRM training, [4] oversight by a patient safety committee, [5] 24-h obstetrics hospitalist, and [6] anonymous event reporting systemHospitalImprovement in proportion of staff members with favourable perceptions of teamwork culture, safety culture, job satisfaction, and management. No significant improvement in stress recognitionBPitts et al. 2017 []Comprehensive Unit-based Safety Program [CUSP]: training, safety assessment, select safety prioritiesPrimary careNo significant improvement in safety climate and teamworkDPronovost et al. 2008 []Comprehensive Unit-based Safety Program including implementing CUSP [i.e. 6-step iterative process], daily goals communication strategy, and toolkit included materials for staff education, redesign of work processes, support of local opinion leaders, and evaluation of performanceIntensive careImprovement in teamwork climateBSexton et al. 2011 []Comprehensive Unit-based Safety Program [CUSP]: educate teams, identify, prioritize, and eliminate patient safety hazards, senior leader’s role, tools for learning and improving communicationIntensive careImprovement in safety climateBStapley et al. 2017 []The Situation Awareness For Everyone [SAFE] programme: huddle, SBAR, and paediatric early warning systems [PEWS]Clinical wardsImprovement in awareness of important issues, communication, teamwork, and a culture of increased efficiency, anticipation and planning on the ward. But added pressure on staff time and workload, and the potential for junior nurses to be excluded from involvementDTimmel et al. 2010 []Comprehensive Unit-Based Safety Program [CUSP] including 6 steps: Science of safety training educational curriculum, Identify safety hazards, Senior executive partnership, Learn from defects, Implement improvement tools, such as team-based goals sheet, including nurses on rounds to form an interdisciplinary teamSurgical inpatient unitsImprovement in safety climate, teamwork climate, and nurse turnover ratesBWolf et al. 2010 []Medical team training programme: preparation, classroom learning session, checklist-guided briefings and debriefings, formation of a problem-solving Executive Committee, follow-up and feedbackOperating room in Veterans Health AdministrationImprovement in case delays, mean case score, frequency of pre-operative delays, handoff issues, equipment issues/delays, perceived management and working conditions. No significant improvement in teamwork climate, safety climate, job satisfaction, stress recognitionB
Studies can also be upgraded or downgraded based on additional criteria. For example, a study is downgraded by one category in the event there are important inconsistencies. Detailed information is provided as additional material [see Additional file ].
Organization of results
The categorization of our final set of 297 articles is the result of three iterations. First, 50 summarized articles were categorized using the initial categorization: team training [subcategories: CRM-based training, simulation training, interprofessional training, and team training], tools, and organizational intervention []. Based on this first iteration, the main three categories [i.e. training, tools, and organizational interventions] remained unchanged but the subcategorization was further developed. Training, related to the subcategory “CRM-based training”, “TeamSTEPPS” was added as a subcategory. The other subcategories [i.e. simulation training, interprofessional training, and team training] remained the same. Tools, the first draft of subcategories, entailed Situation, Background, Assessment, and Recommendation [SBAR], checklists, [de]briefing, and task tools. Two subcategories of organizational intervention [i.e. programme and [re]design] were created, which was also in line with the content of this category in the original literature review. Second, 50 additional articles were categorized to test and refine the subcategories. Based on this second iteration, the subcategories were clustered, restructured and renamed, but the initial three main categorizations remained unaffected. The five subcategories of training were clustered into principle-based training, method-based training, and general team training. The tools subcategories were clustered into structuring, facilitating, and triggering tools, which also required two new subcategories: rounds and technology. Third, the remaining 197 articles were categorized to test the refined categorization. In addition, the latter categorization was peer reviewed. The third iteration resulted in three alterations. First, we created two main categories based on the two subcategories “organizational [re]design” and “programme” [of the third main categorization]. Consequently, we rephrased “programme-based training” into “principle-based training”. Second, the subcategories “educational intervention” and “general team training” were merged into “general team training”. Consequently, we rephrased “simulation training” into “simulation-based training”. Third, we repositioned the subcategories “[de]briefing” and “rounds” as structuring tools instead of facilitating tools. Consequently, we merged the subcategories “[de]briefing” and “checklists” into “[de]briefing checklists”. Thereby, the subcategory “technology” became redundant.
Results
Four main categories are distinguished: training, tools, organizational [re]design, and programme. The first category, training, is divided in training that is based on specific principles and a combination of methods [i.e. CRM and Team Strategies and Tools to Enhance Performance and Patient Safety [TeamSTEPPS]], a specific training method [i.e. training with simulation as a core element], or general team training, which refers to broad team training in which a clear underlying principle or specific method is not specified. The second category, tools, are instruments that are introduced to improve teamwork by structuring [i.e. SBAR [Situation, Background, Assessment, and Recommendation], [de]briefing checklists, and rounds], facilitating [through communication technology], or triggering [through monitoring and feedback] team interaction. Structuring tools partly standardize the process of team interaction. Facilitating tools provide better opportunities for team interaction. Triggering tools provide information to incentivize team interaction. The third category, organizational [re]design, refers to [re]designing structures [through implementing pathways, redesigning schedules, introducing or redesigning roles and responsibilities] that will lead to improved team processes and functioning. The fourth category, a programme, refers to a combination of the previous types of interventions [i.e. training, tools, and/or redesign]. Table 2 presents the [sub]categorization, number of studies, and a short description of each [sub]category.
Table 2
Categorization of results
InterventionsnDescription1. Training174“A systematic process through which a team is trained to master and improve different aspects of team functioning.” [] 1.1 Principle-based training a. CRM-based training40“Training based on a management concept used in the aviation industry to improve teamwork. CRM encompasses a wide range of knowledge, skills, and attitudes including communication, situational awareness, problem solving, decision making, and teamwork.” [] b. TeamSTEPPS28A specific set of strategies and techniques, aimed at optimizing patient outcomes by improving communication and teamwork skills among healthcare professionals. [//www.ahrq.gov/teamstepps/index.html] 1.2 Method-based training: Simulation-based training69“Training that recreates characteristics of the real world.” [] 1.3 General team training37General team training includes studies that each has a unique combination of principles and learning methods.2. Tools83Specific instruments that teams can use to improve teamwork [] 2.1 Structuring toolsTools that are used to partly standardize the process of team interaction. a. SBAR11The SBAR [Situation, Background, Assessment, Recommendation] is a framework for communication between team members about a patient’s condition. [www.ihi.org] b. [De]briefing checklist51A tool that creates an opportunity for professionals to systematically communicate and discuss [potential] issues before or after delivering care to a patient, based on a structured format of elements/topics; checklist. c. Rounds7A structured interdisciplinary meeting around a patient. 2.2 Facilitating tools7Tools [often technology] that facilitate communication between team members. 2.3 Triggering tools7Tools that help provide information [e.g. dashboards] to incentivize team interaction.3. Organizational [re]design16Design or redesign of organizational structures with the aim of improving team processes and team functioning.4. Programme24A combination of interventions [training, tools, and/or organizational [re]design] bundled in a program that aims to improve team functioning.Total297
Overall findings
Type of intervention
The majority of studies evaluated a training. Simulation-based training is the most frequently researched type of team training.
Setting
Most of the articles researched an acute hospital setting. Examples of acute hospital settings are the emergency department, operating theatre, intensive care, acute elderly care, and surgical unit. Less attention was paid to primary care settings, nursing homes, elderly care, or long-term care in general.
Outcome
Interventions focused especially on improving non-technical skills, which refer to cognitive and social skills such as team working, communication, situational awareness, leadership, decision making, and task management []. Most studies relied on subjective measures to indicate an improvement in team functioning, with only a few studies [also] using objective measures. The Safety Attitude Questionnaire [SAQ] and the Non-Technical Skills [NOTECHS] tool are frequently used instruments to measure perceived team functioning.
Quality of evidence
A bulk of the studies had a low level of evidence. A pre- and post-study is a frequently used design. In recent years, an increasing number of studies have used an action research approach, which often creates more insight into the processes of implementing and tailoring an intervention than the more frequently used designs [e.g. Random Control Trial and pre-post surveys]. However, these valuable insights are not fully appreciated within the GRADE scale.
The findings per category will be discussed in greater detail in the following paragraphs.
Training
CRM and TeamSTEPPS are well-known principle-based trainings that aim to improve teamwork and patient safety in a hospital setting. Both types of training are based on similar principles. CRM is often referred to as a training intervention that mainly covers non-technical skills such as situational awareness, decision making, teamwork, leadership, coping with stress, and managing fatigue. A typical CRM training consists of a combination of information-based methods [e.g. lectures], demonstration-based methods [e.g. videos], and practice-based methods [e.g. simulation, role playing] []. However, CRM has a management concept at its core that aims to maximize the use of all available resources [i.e. equipment, time, procedures, and people] []. CRM aims to prevent and manage errors through avoiding errors, trapping errors before they are committed, and mitigating the consequences of errors that are not trapped []. Approximately a third of CRM-based trainings include the development, redesign or implementation of learned CRM techniques/tools [e.g. briefing, debriefing, checklists] and could therefore also be categorized in this review under programme [, , , , , , , , ].
The studies show a high variety in the content of CRM training and in the results measured. The majority of the studies claim an improvement in a number of non-technical skills that were measured, but some also show that not all non-technical skills measured were improved [, , ]. Moreover, the skills that did or did not improve differed between the studies. A few studies also looked at outcome measures [e.g. clinical outcomes, error rates] and showed mixed results [, , ]. Notable is the increasing attention toward nursing CRM, which is an adaptation of CRM to nursing units [, ]. Most studies delivered a low to moderate quality level of evidence. Although most studies measured the effect of CRM over a longer period of time, most time periods were limited to one or two evaluations within a year. Savage et al. [] and Ricci et al. [] note the importance of using a longer time period.
As a result of experienced shortcomings of CRM, Team Strategies and Tools to Enhance Performance and Patient Safety [TeamSTEPPS] has evolved [since 2006]. TeamSTEPPS is a systematic approach designed by the Agency for Healthcare Research and Quality [AHRQ] and the Department of Defense [DoD] to enhance teamwork skills that are essential to the delivery of quality and safe care. Some refer to TeamSTEPPS as “CRM and more”. TeamSTEPPS provides an approach on preparing, implementing, and sustaining team training. It is provided as a flexible training kit and facilitates in developing a tailored plan. It promotes competencies, strategies, and the use of standardized tools on five domains of teamwork: team structure, leadership, communication, situational monitoring, and mutual support. In addition, TeamSTEPPS focuses on change management, coaching, measurement, and implementation. Notable is that even though the TeamSTEPSS training is most likely to differ across settings as it needs to be tailored to the situational context, articles provide limited information on the training content. All studies report improvements in some non-technical skills [e.g. teamwork, communication, safety culture]. Combining non-technical skills with outcome measures [e.g. errors, throughput time] seemed more common in this category. Half of the studies delivered a moderate to high quality of evidence.
Simulation-based training uses a specific method as its core, namely, simulation, which refers to “a technique to replace or amplify real-patient experiences with guided experiences, artificially contrived, that evokes or replicates substantial aspects of the real world in a fully interactive manner” []. The simulated scenarios that are used can have different forms [e.g. in situ simulation, in centre simulation, human actors, mannequin patients] and are built around a clinical scenario [e.g. resuscitation, bypass, trauma patients] aiming to improve technical and/or non-technical skills [e.g. interprofessional collaboration, communication]. We only identified studies in a hospital setting, which were mostly focussed on an emergency setting. All studies reported improvements in some non-technical skills [e.g. teamwork behaviour, communication, shared mental model, clarity in roles and responsibilities]. In addition, some studies report non-significant changes in non-technical skills [, , , ]. Some studies also looked at technical skills [e.g. time spend] and presented mixed results [, , , ]. Sixty-nine studies focused on simulation-based training, of which 16 studies delivered a moderate to high quality of evidence.
General team training does not focus on one specific training principle or method. It often contains multiple educational forms such as didactic lectures, interactive sessions, and online modules. General team training focuses on a broad target group and entails for example team building training, coaching training, and communication skills training. Due to the broad scope of this category, high variation in outcomes is noted, although many positive outcomes were found. Most studies have a low to very low level of evidence.
Tools
Tools are instruments that could be implemented relatively independently in order to structure, facilitate or trigger teamwork.
Structuring tools
Teamwork can be structured by using the structured communication technique SBAR [Situation, Background, Assessment, and Recommendation], [de]briefing checklists, and rounds.
SBAR is often studied in combination with strategies to facilitate implementation, such as didactic sessions, training, information material, and modifying SBAR material [e.g. cards] [, , –, ]. In addition, this subcategory entails communication techniques similar or based on SBAR [, , , , ]. One study focused on nursing homes, while the remaining studies were performed in a hospital setting. Most studies found improvements in communication; however, a few found mixed results [, ]. Only [very] low-level evidence studies were identified.
Briefings and debriefings create an opportunity for professionals to systematically communicate and discuss [potential] issues before or after delivering care to a patient, based on a structured format of elements/topics or a checklist with open and/or closed-end questions. Studies on [de]briefing checklists often evaluate the implementation of the World Health Organization surgical safety checklist [SSC], a modified SSC, SSC-based checklist, or a safety checklist in addition to the SSC. The SSC consists of a set of questions with structured answers that should be asked and answered before induction of anaesthesia, before skin incision, and before the patient leaves the operating theatre. In addition, several studies presented checklists aiming to better manage critical events [, , ]. Only one study on SSC was conducted outside the surgery department/operating theatre [i.e. cardiac catheterization laboratory []]. However, similar tools can also be effective in settings outside the hospital, as shown by two studies that focused on the long-term care setting [, ]. Overall, included studies show that [de]briefing checklists help improve a variety of non-technical skills [e.g. communication, teamwork, safety climate] and objective outcome measures [e.g. reduced complications, errors, unexpected delays, morbidity]. At the same time, some studies show mixed results or are more critical of its [sustainable] effect [, , , ]. Whyte et al. [] pointed out the complexity of this intervention by presenting five paradoxical findings: team briefings could mask knowledge gaps, disrupt positive communication, reinforce professional divisions, create tension, and perpetuate a problematic culture. The quality of evidence varied from high to very low [e.g. Whyte et al. []], and approximately one third presented a high or moderate quality of evidence. Debriefings can also be used as part of a training, aiming to provide feedback on trained skills. Consequently, some articles focused on the most suitable type of debriefing in a training setting [e.g. video-based, self-led, instructor-led] [, , , ] or debriefing as reflection method to enhance performance [, ].
Rounds can be described as structured interdisciplinary meetings around a patient. Rounds were solely researched in hospital settings. Five studies found improvements in non-technical skills, one study in technical skills, and one study reported outcomes but found no improvement. Three studies presented a moderate level of evidence, and the others presented a [very] low level.
Facilitating tools
Teamwork can be facilitated through technology. Technology, such as telecommunication, facilitates teamwork as it creates the opportunity to involve and interact with professionals from a distance [–]. Technology also creates opportunities to exchange information through information platforms [, ]. Most studies found positive results for teamwork. Studies were performed in a hospital setting and presented a level of evidence varying from moderate to very low.
Triggering tools
Teamwork could be triggered by tools that monitor and visualize information, such as [score] cards and dashboards [, , , , ]. The gathered information does not echo team performance but creates incentives for reflecting on and improving teamwork. Team processes [e.g. trust, reflection] are also triggered by sharing experiences, such as clinical cases and stories, thoughts of the day [, ]. All seven studies showed improvements in non-technical skills and had a very low level of evidence.
Organizational [re]design
In contrast with the previous two categories, organizational [re]design is about changing organizational structures. Interventions can be focused on several elements within a healthcare organization, such as the payment system [] and the physical environment [], but are most frequently aimed at standardization of processes in pathways [, ] and changing roles and responsibilities [, , ], sometimes by forming dedicated teams or localizing professionals to a certain unit or patient [, , , ]. Most studies found some improvements of non-technical skills; however, a few found mixed results. Only four studies had a moderate level of evidence, and the others had a [very] low level.
Programme
A programme most frequently consists of a so-called Human Resource Management bundle that combines learning and educational sessions [e.g. simulation training, congress, colloquium], often multiple tools [e.g. rounds, SBAR], and/or structural intervention [e.g. meetings, standardization]. Moreover, a programme frequently takes the organizational context into account: developing an improvement plan and making choices tailored to the local situation. A specific example is the “Comprehensive Unit-Based Safety Program” [CUSP] that combines training [i.e. science of safety training educational curriculum, identify safety hazards, learn from defects] with the implementation of tools [e.g. team-based goal sheet], and structural intervention [i.e. senior executive partnership, including nurses on rounds, forming an interdisciplinary team] [, , ]. Another example is the medical team training [MTT] programme that consists of three stages: [1] preparation and follow-up, [2] learning session, [3] implementation and follow-up. MTT combines training, implementation of tools [briefings, debriefing, and other projects], and follow-up coaching [, , , ]. MMT programmes are typically based on CRM principles, but they distinguish themselves from the first category by extending their programme with other types of interventions. Most studies focus on the hospital setting, with the exception of the few studies performed in the primary care, mental health care, and healthcare system. Due to the wide range of programmes, the outcomes were diverse but mostly positive. The quality of evidence varied from high to very low.
Conclusion and discussion
This systematic literature review shows that studies on improving team functioning in health care focus on four types of interventions: training, tools, organizational [re]design, and programmes. Training is divided into principle-based training [subcategories: CRM-based training and TeamSTEPPS], method-based training [simulation-based training], and general team training. Tools are instruments that could be implemented relatively independently in order to structure [subcategories: SBAR, [de]briefing checklists, and rounds], facilitate [through communication technology], or trigger teamwork [through information provision and monitoring]. Organizational [re]design focuses on intervening in structures, which will consequently improve team functioning. Programmes refer to a combination of different types of interventions.
Training is the most frequently researched intervention and is most likely to be effective. The majority of the studies focused on the [acute] hospital care setting, looking at several interventions [e.g. CRM, TeamSTEPPS, simulation, SBAR, [de]briefing checklist]. Long-term care settings received less attention. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements; objective outcome measures also received attention [e.g. errors, throughput time]. Looking at the quantity and quality of evidence, principle-based training [i.e. CRM and TeamSTEPPS], simulation-based training, and [de]briefing checklist seem to provide the biggest chance of reaching the desired improvements in team functioning. In addition, programmes, in which different interventions are combined, show promising results for enhancing team functioning. The category programmes not only exemplify this trend, but are also seen in principle-based training.
Because this review is an update of our review conducted in 2008 [and published in 2010] [], the question of how the literature evolved in the last decade arises. This current review shows that in the past 10 years significantly more research has focused on team interventions in comparison to the previous period. However, the main focus is on a few specific interventions [i.e. CRM, simulation, [de]briefing checklist]. Nevertheless, an increasing number of studies are evaluating programmes in which several types of interventions are combined.
- Training: There has been a sharp increase in research studying team training [from 32 to 173 studies]. However, the majority of these studies still look at similar instruments, namely, CRM-based and simulation-based training. TeamSTEPPS is a standardized training that has received considerable attention in the past decade. There is now a relatively strong evidence for the effectiveness of these interventions, but mostly for the [acute] hospital setting.
- Tools: There is also a substantial increase [from 8 to 84 studies] in studies on tools. Again, many of these studies were in the same setting [acute hospital care] and focused on two specific tools, namely, the SBAR and [de]briefing checklist. Although the level of evidence for the whole category tools is ambiguous, there is relatively strong evidence for the effectiveness of the [de]briefing checklist. Studies on tools that facilitate teamwork ascended the past decade. There is limited evidence that suggests these may enhance teamwork. The dominant setting was again hospital care, though triggering tools were also studied in other settings such as acute elderly care and clinical primary care. Moreover, most studies had a [very] low quality of evidence, which is an improvement compared to the previous review that solely presented [very] low level of evidence.
- Organizational [re]design: More attention is paid to organizational [re]design [from 8 to 16 studies]. Although the number of studies on this subject has increased, there still remains unclarity about its effects because of the variation in interventions and the mixed nature of the results.
- Programmes: There seems to be new focus on a programmatic approach in which training, tools, and/or organizational [re]design are combined, often focused around the topic patient safety. The previous review identified only one such study; this research found 24 studies, not including the CRM studies for which some also use a more programmatic approach. There seems to be stronger evidence that this approach of combining interventions may be effective in improving teamwork.
Limitations
The main limitation of this review is that we cannot claim that we have found every single study per subcategory. This would have required per subcategory an additional systematic review or an umbrella review, using additional keywords. As we identified a variety of literature reviews, future research should focus on umbrella reviews in addition to new systematic literature reviews. Note that we did find more studies per subcategory, but they did not meet our inclusion criteria. For example, we excluded multiple studies evaluating surgical checklists that did not measure its effect on team functioning but only on reported errors or morbidity. Although this review presents all relevant categories to improve team functioning in healthcare organizations, those categories are limited to team literature and are not based on related research fields such as integrated care and network medicine. Another limitation is that we excluded grey literature by only focusing on articles written in English that present empirical data and were published in peer-reviewed journals. Consequently, we might have excluded studies that present negative or non-significant effects of team interventions, and such an exclusion is also known as publication bias. In addition, the combination of the publication bias and the exclusion of grey literature has probably resulted in a main focus on standardized interventions and a limited range of alternative approaches, which does not necessarily reflect practice.
Implication for future research
This review shows the major increase in the last decade in the number of studies on how to improve team functioning in healthcare organizations. At the same time, it shows that this research tends to focus around certain interventions, settings, and outcomes. This helped to provide more evidence but also left four major gaps in the current literature. First, less evidence is available about interventions to improve team functioning outside the hospital setting [e.g. primary care, youth care, mental health care, care for disabled people]. With the worldwide trend to provide more care at home, this is an important gap. Thereby, team characteristics across healthcare settings vary significantly, which challenges the generalizability []. Second, little is known about the long-term effects of the implemented interventions. We call for more research that monitors the effects over a longer period of time and provides insights into factors that influence their sustainability. Third, studies often provide too little information about the context. To truly understand why a team intervention affects performance and to be able to replicate the effect [by researchers and practitioners], detailed information is required related to the implementation process of the intervention and the context. Fourth, the total picture of relevant outcomes is missing. We encourage research that includes less frequently used outcomes such as well-being of professionals and focuses on identifying possible deadly combinations between outcomes.
Supplementary information
Acknowledgements
We would like to thank Wichor Bramer, Librarian at the Erasmus Medical Center Rotterdam, The Netherlands, for his support in conducting the search for this systematic review.
Abbreviations
AHRQAgency for Healthcare Research and QualityCRMCrew resource managementCUSPComprehensive Unit-Based Safety ProgramDoDDepartment of DefenseGRADEGrading of Recommendations Assessment Development, and EvaluationMTTMedical team trainingNOTECHSNon-Technical SkillsPRISMAPreferred Reporting Items for Systematic Reviews and Meta-AnalysesSAQSafety Attitude QuestionnaireSBARSituation, Background, Assessment, and RecommendationSSCSurgical safety checklistTeamSTEPPSTeam Strategies and Tools to Enhance Performance and Patient Safety
Authors’ contributions
MBS, KDD, and JDHW reviewed titles, abstracts, and full texts for the systematic review. MBS initiated the first draft of the manuscript and revised the manuscript on the basis of input of KDD and JDHW. MBS, KDD, and JDHW together categorized the results. All authors read and approved the final manuscript.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Availability of data and materials
Not applicable
Ethics approval and consent to participate
Not applicable
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Martina Buljac-Samardzic, Email: LN.RUE.MPHSE@CAJLUB.
Kirti D. Doekhie, Email: LN.RUE.MPHSE@EIHKEOD.
Jeroen D. H. van Wijngaarden, Email: LN.RUE.MPHSE@NEDRAAGNJIWNAV.
Supplementary information
Supplementary information accompanies this paper at 10.1186/s12960-019-0411-3.
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