Citation: McEwan D, Ruissen GR, Eys MA, Zumbo BD, Beauchamp MR (2017) The Effectiveness of Teamwork Training on Teamwork Behaviors and Team Performance: A Systematic Review and Meta-Analysis of Controlled Interventions. PLoS ONE 12(1): e0169604. https://doi.org/10.1371/journal.pone.0169604
Editor: Nico W. Van Yperen, Rijksuniversiteit Groningen, NETHERLANDS
Received: September 15, 2016; Accepted: December 19, 2016; Published: January 13, 2017
Copyright: © 2017 McEwan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files. Raw data (taken from the studies in our meta-analysis) are available upon request from the corresponding author.
Funding: The authors received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
From road construction crews and professional soccer squads to political parties and special operations corps, teams have become a ubiquitous part of today’s world. Bringing a group of highly-skilled individuals together is not sufficient for teams to be effective. Rather, team members need to be able to work well together in order for the team to successfully achieve its purposes [1, 2]. As a result, there has been a proliferation of research assessing whether, and how, teams can be improved through teamwork training. A wide range of studies have shown positive effects of teamwork interventions for improving team effectiveness across several contexts such as health care (e.g., ), military (e.g., ), aviation (e.g., ), and academic (e.g., ) settings. Similarly, improvements in teamwork have been observed as a result of training with a variety of team types including new teams (e.g., ), intact teams (e.g., ), and those created for laboratory-based experiments (e.g., ). In sum, the extant empirical evidence to date appears to suggest that teams can be improved via teamwork training.
What is Teamwork?
Within teams, members’ behaviors can be categorized in terms of both taskwork and teamwork processes . Marks et al.  differentiated between the two by suggesting that “taskwork represents what it is that teams are doing, whereas teamwork describes how they are doing it with each other” (p. 357). Specifically, while taskwork involves the execution of core technical competencies within a given domain, teamwork refers to the range of interactive and interdependent behavioral processes among team members that convert team inputs (e.g., member characteristics, organizational funding, team member composition) into outcomes (e.g., team performance, team member satisfaction) [2, 10]. Some examples of teamwork (and respective comparisons to taskwork) include: the seamless communication between a surgeon, nurse, and anaesthesiologist, rather than the technical competencies of these practitioners; the synergy between a quarterback and receiver to complete a passing play, rather than their respective skill sets related to throwing or catching a football; the collaborative adjustments a flight crew makes in response to adverse weather or system problems, rather than each individual’s aviation skills; and so forth. Research from an assortment of studies indicates that teamwork—the focus of the current paper—is positively related to important team effectiveness variables, including team performance, group cohesion, collective efficacy, and member satisfaction .
Teamwork has been conceptualized within several theoretical models. For example, in their review, Rousseau et al.  reported that 29 frameworks related to teamwork have been published. Although there is much overlap across these models, there are also some notable differences. These relate to the number of dimensions of teamwork being conceptualized as well as the specific labelling of these dimensions. One thing that is generally agreed upon, however, is that teamwork is comprised of multiple observable and measurable behaviors. For instance, two highly cited frameworks by Marks et al.  and Rousseau et al.  consist of 10 and 14 dimensions of teamwork, respectively. In general, teamwork models focus on behaviors that function to (a) regulate a team’s performance and/or (b) keep the team together. These two components coincide with the two respective processes that Kurt Lewin, the widely recognized father of group dynamics, originally proposed all groups to be involved in: locomotion and maintenance .
With regard to regulating team performance (i.e., locomotion), teamwork behaviors include those that occur (a) before/in preparation for team task performance, (b) during the execution of team performance, and (c) after completing the team task . First, with regard to teamwork behaviors that occur before/in preparation for team task performance, these include the active process of defining the team’s overall purpose/mission, setting team goals, and formulating action plans/strategies for how goals and broader purposes will be achieved. These behaviors help ensure that all team members are clear in terms of what is required of them in order for the team to function effectively. Second, teamwork behaviors that occur during the execution of team tasks include actions that correspond to members’ communication, coordination, and cooperation with each other. At this stage, team members translate what they have previously planned (during the preparation phase) into action. Third, in terms of teamwork behaviors that occur after completing the team task (i.e., reflection), these include monitoring important situations and conducting post-task appraisals of the team’s performance and system variables (e.g., internal team resources, broader environmental conditions), solving problems that are precluding team goal attainment, making innovative adjustments to the team’s strategy, and providing/receiving verbal and behavioral assistance to/from teammates. Hence, team members determine whether their actions have moved them closer towards accomplishing the team goals and objectives, and whether any modifications are required in order to facilitate future success. In addition to these three dimensions concerned with the regulation of team performance, a fourth dimension of teamwork involves behaviors that function to keep the team together (i.e., maintenance). These behaviors focus on the team’s interpersonal dynamics, and include the management of interpersonal conflict between members and the provision of social support for members experiencing personal difficulties. Managing interpersonal dynamics is critical as it is theorized that teams cannot operate effectively when these issues are present .
How Can Teamwork Be Trained?
Teamwork interventions have utilized a number of training methods in order to target the regulation of team performance (i.e., preparation, execution, reflection) and management of team maintenance (i.e., interpersonal dynamics) dimensions. These intervention strategies generally fall under one of four categories. First, the most basic approach to training and developing teamwork involves providing didactic education to team members in a classroom-type setting, such as lecturing about the importance of providing social support within the team or promoting ways to manage interpersonal conflict among teammates. This type of training has been found to be useful for enhancing team effectiveness (e.g., ). A second category of team training involves utilizing a more interactive workshop-style format, wherein team members take part in various group activities, such as having discussions about the team’s purposes and goals (e.g., ) or working through case studies together (e.g. ). The third broad category of team training involves simulation training, wherein teams experientially enact various teamwork skills, such as interpersonal communication and coordination, in an environment that mimics upcoming team tasks (e.g., airline simulators or medical patient manikins). Although often used as a means of fostering taskwork competencies (e.g., teaching new surgeons how to perform the technical skills of a medical operation), simulation training has been found to be an efficacious approach to teamwork intervention (e.g., ). In addition to these three training approaches that occur outside of the team task environment (i.e., training within classroom and simulation settings), teamwork can also be fostered by incorporating team reviews in-situ (i.e., where the team actually performs its tasks), which allows teams to monitor/review their quality of teamwork on an ongoing basis. These team reviews involve some form of team briefs before (e.g., creating action plans), during (e.g., monitoring team members’ actions), and/or after (e.g., assessing the team’s performance) team task execution, and have also been shown to be efficacious in previous studies (e.g., ).
The effectiveness of teamwork interventions can be determined with an assortment of criteria, including team- and individually-based behaviors, cognitions, and affective states. Hackman and Katz 2010  posit that team effectiveness can be determined by examining the extent to which the team has achieved its a priori objectives. Since the broad purpose of forming a team is to produce something of value, it is perhaps unsurprising that the most widely tested criterion of team effectiveness has been team performance [18–20]. Thus, although teams come from an array of settings and are idiosyncratic in their own ways, one question that essentially all teams address at some point during their tenure is whether they are performing well. For example, is that road construction crew fixing potholes adequately? Does the local soccer squad have a respectable winning percentage? Has an elected political party successfully completed the tasks for which they campaigned? Did a special operations corps achieve the mission it set out to accomplish? When taken in concert, questions related to team performance are often of central interest when characterizing a team’s effectiveness.
In addition to assessing the outcome variable of team performance, researchers have also been interested in whether teamwork training actually improves teamwork itself. The efficacy of these interventions can be determined with a number of objective (e.g., products produced by an industry team), self-report (e.g., questionnaires regarding perceived social support amongst team members), and third-party assessments (e.g., expert ratings of team behaviors). Both general/omnibus measures of teamwork (e.g., ) as well as those assessing specific dimensions of teamwork (e.g., communication ) have been operationalized to examine the effectiveness of these interventions. For example, do team goal setting activities actually result in members creating and pursuing effective team goals? Does simulation training improve the requisite coordination processes among aviation cockpit crews? Has a didactic lecture contributed to improved conflict management among team members? Answering these types of questions is important for determining whether an intervention is actually efficacious in changing the variable that is targeted for improvement (i.e., teamwork behaviors).
The Current Review
Prior to outlining the purposes of this systematic review, it is important to recognize that previous quantitative reviews have been conducted that addressed—to some degree—teamwork training. In preparation for this systematic review, we conducted a scoping review which revealed that eight previous meta-analyses have assessed teamwork intervention studies in some way. However, these reviews were delimited based on various sample and/or intervention characteristics. For example, some reviews included studies that were only conducted with certain team types (e.g., intact teams ) or within a particular context (e.g., sports ; medical teams ). Others were delimited to specific training programs/strategies that were restricted to a narrow range of teamwork strategies (e.g., [23, 25–29]). Finally, studies that used a combination of teamwork and taskwork intervention components have been systematically reviewed ; however, these types of interventions result in a limited ability to determine the extent to which the resulting effects were due to teamwork training versus taskwork training.
It should also be noted that all but one  of these previous reviews pooled together studies that included a control condition (i.e., wherein teams do not receive any type of teamwork training) and those that did not (as mentioned above, that study only analyzed the effects of certain teamwork strategies). This is an important consideration, as it has been suggested that controlled and uncontrolled studies should not be combined into the same meta-analysis due to differences in study quality (which is a major source of heterogeneity) and since stronger conclusions can be derived from controlled interventions compared to uncontrolled interventions (e.g., ). Therefore, while previous systematic reviews have provided valuable contributions to the teamwork literature, a systematic review that assesses the effects of controlled teamwork interventions across a range of contexts, team types, and involving those that targeted diverse dimensions of teamwork appears warranted. In doing so, a more comprehensive assessment of the efficacy of these teamwork interventions is provided, while also having the capacity to look at the potential moderating effects of various sample, intervention, and measurement characteristics. Moreover, by including only controlled studies, one is able to make stronger conclusions regarding the observed effects.
The overall purpose of this study was to better understand the utility of teamwork training for enhancing team effectiveness. Specifically, a meta-analysis was conducted on controlled studies (i.e., comparing teams who have received teamwork training with those who have not) that have examined the effects of teamwork interventions on teamwork processes and/or team performance. To better disentangle the effectiveness of these studies, we also sought to assess potential moderators of these main effects; that is, to determine whether there are certain conditions under which the independent variable of teamwork training more strongly (or weakly) causally influences the dependent variables of teamwork behaviors or team performance . The specific moderators that we assessed included: (a) the team context/field of study, (b) the type of teams that were trained, (c) the primary type of intervention method employed, (d) the dimensions of teamwork that were targeted in the intervention, (e) the number of dimensions targeted, (f) the types of measures used to quantify the training effects, and (g) in studies where teamwork was assessed as an outcome variable, the dimensions of teamwork that were measured. It was hypothesized that teamwork training would have a positive and significant effect on both teamwork and team performance and that these effects would be evident across a range of the aforementioned sample, intervention, and measurement characteristics/conditions.
Searches for potential articles were conducted in the following databases: PsycInfo, Medline, Cochrane Central Register of Controlled Trials, SportDiscus, and ProQuest Dissertations and Theses. Hand searches were also conducted across thirteen journals that typically publish articles on group dynamics (e.g., Group Dynamics: Theory, Research, and Practice; Small Group Research, Journal of Applied Psychology; Personnel Psychology, Human Factors; Academy of Management Journal, Journal of Sport & Exercise Psychology). In each database and journal search, the following combination of search terms were used: (team OR interprofessional OR interdisciplinary) AND (intervention OR training OR building OR simulation) AND (teamwork OR mission analysis OR goal specification OR goal setting OR planning OR strategy OR coordination OR cooperation OR communication OR information exchange OR information sharing OR monitoring OR problem solving OR backing up OR coaching OR innovation OR adaptability OR feedback OR support OR conflict management OR situation awareness OR confidence building OR affect management). These terms were based on various models of teamwork that exist within the literature (see Rousseau et al.  for an overview of these models). An additional search was conducted within these databases and journals using the search terms (TeamSTEPPS OR Crew Resource Management OR SBAR [Situation-Background-Assessment-Recommendation]), as several articles in the initial search used these specific training programs. We also searched the reference sections of the articles from past teamwork training review papers as well as from articles that initially met inclusion criteria to determine if any additional articles could be retrieved. The searches were conducted in September 2015 and no time limits were placed on the search strategy. Each article was first subjected to title elimination, then abstract elimination, and finally full-text elimination.
To be included in the meta-analysis, a study needed to examine the effects of teamwork training by comparing teams in an experimental condition (i.e., those who received teamwork training) with those in a control condition (i.e., where teams did not receive teamwork training). Cross-sectional/non-experimental studies were excluded, as were intervention studies that did not include a control condition. As this review was only concerned with teamwork interventions, studies that focused on training taskwork—whether independent of, or in addition to, a teamwork intervention—were excluded. For example, as previously mentioned, simulation-based training (SBT) has been used as a means of training individuals to perform technical skills and also to enhance teamwork. In order for a SBT intervention to be included in this meta-analysis, it had to be clear that only teamwork (not technical skills) was being targeted during training. In order to address our primary research question, the study had to provide data on at least one teamwork dimension and/or team performance. The study also needed to provide sufficient statistics to compute an effect size. In cases of insufficient data, corresponding authors were contacted for this information. The articles were delimited to those published in the English language.
Articles that met the aforementioned eligibility criteria were extracted for effect sizes and coded independently with respect to seven moderators by two of the authors (DM and GR). Interrater reliability for the coding of these moderators was over 90%, kappa (SE) = 0.80 (0.01). The moderators examined were based on a scoping review (the purpose of which included identifying pertinent characteristics that were commonly reported in previous teamwork intervention research), which was conducted in preparation for this systematic review. The moderators that were examined in this review included (1) the context within which an intervention was conducted (health care, aviation, military, academia, industry, or laboratory experiment), (2) the type of team targeted (intact or new), (3) the primary training method applied to conduct the intervention (didactic education, workshop, simulation, or team reviews), (4) the dimension(s) of teamwork (preparation, execution, reflection, and/or interpersonal dynamics) targeted in the intervention as well as (5) the number of dimensions targeted (between one and four), (6) the type of measure used to derive effect sizes (self-report, third party, or objective measures), and—when teamwork was assessed as the criterion variable—(7) the specific dimension(s) of teamwork that were measured (general, preparation, execution, reflection, and interpersonal dynamics).
Once coded, data were entered into the software Comprehensive Meta-Analysis, Version 2  and analyzed as a random-effects model (DerSimonian and Laird approach). This type of model assumes that there is heterogeneity in the effect sizes across the included studies and is the appropriate model to use in social science research, as opposed to a fixed-effects model (which assumes that effect sizes do not vary from study to study) [34, 35]. Where possible, effect sizes for each study were derived from means, standard deviations, and sample sizes at baseline and post-intervention [34, 36]. If these statistics were not fully provided, they were supplemented with F-statistics, t scores, correlations, and p-values to compute the effect size. Each study was given a relative weight based on its precision, which is determined by the study’s sample size, standard error, and confidence interval (i.e., the more precise the data, the larger the relative study weight) .
In instances where a study provided data to calculate multiple effect sizes (such as when several measures of the criterion variable—teamwork or team performance—were examined), these effects were combined into one overall effect size statistic (i.e., a weighted average) for that study. This was done to ensure that those studies that had multiple measures of teamwork or team performance were not given greater weight compared to studies that only provided one effect size (i.e., only had one measure of performance or teamwork), which could potentially skew the overall results . The exception to this was when articles reported the effects of more than one intervention (i.e., had multiple experimental conditions), each of which had a unique teamwork training protocol. In these cases, an effect size from each intervention was computed. Thus, these articles would contribute multiple effect sizes to the total number of comparisons within the meta-analysis. To correct for potential unit-of-analysis errors in these particular articles, the sample size of the control condition was divided by the number of within-study comparisons . For example, if three different types of teamwork interventions were compared to one control condition (e.g., which had a sample size of 30 participants), the n of the control condition was divided by 3 (i.e., 30/3 = 10) when calculating the effect sizes of those interventions. Cohen’s d was used as the effect size metric to represent the standardized effect (i.e., the average magnitude of effectiveness) of teamwork interventions on teamwork and team performance . Standard errors and 95% confidence intervals were computed to test for the accuracy of the standardized effects obtained.
To reduce heterogeneity and improve the interpretability of the results, we pooled studies into those that measured teamwork as its criterion variable and those that measured team performance. Pooling studies in this manner not only reduces heterogeneity but also allowed us to identify the extent to which teamwork interventions impact team performance and, separately, the extent to which they affect teamwork processes. Heterogeneity within the meta-analysis was also assessed by computing a Q value—which estimates the variability in the observed effect sizes across studies—and an I2 statistic—which estimates the ratio of the true heterogeneity to the total observed variation across studies. High Q and I2 statistics can be problematic for interpreting the results of a meta-analysis and can also indicate that the meta-analysis includes outlier studies. We also planned to identify and exclude outliers from subsequent moderator analyses in two ways. First, sensitivity analyses were carried out by removing a single intervention from the meta-analysis and noting the resulting effect size—this estimates the impact that each individual intervention has on the overall effect size of teamwork or team performance. If the resulting effect size with an intervention removed (i.e., K– 1) is substantially different than the effect size with that intervention present, this may suggest that it is an outlier and needs to be removed . Second, we noted any studies that had abnormally high effect sizes and standardized residuals (above 3.0), especially when these values were accompanied by narrow confidence intervals. If heterogeneity (Q and I2) is substantially reduced upon removal of a study, this further confirms that the study is an outlier and should be omitted from subsequent subgroup/moderator analyses.
Once the two pools of studies were produced, bias within each pool was assessed. First, publication bias was examined by calculating a fail-safe N statistic, which estimates the number of unpublished studies with null findings that would have to exist to reduce the obtained effect size to zero . If this number is sufficiently large—Rosenberg  recommends a critical value of 5N+10—then the probability of such a number of studies existing is considered to be low. For example, if 20 studies were included in a meta-analysis, then the resulting fail-safe N should be larger than 110 (i.e., 5*20 + 10); if this value was not larger than 110, then publication bias is likely within this pool of studies. We also obtained two funnel plots (one for studies where teamwork was the outcome variable and one for team performance as the outcome) to provide a visual depiction of potential publication bias. We then conducted an Egger’s test as a measure of symmetry for these two funnel plots. If this test statistic is significant (p < 0.05), this denotes that the distribution around the effect size is asymmetric and publication bias is likely present .
The literature search from the five databases returned 22,066 articles, while the hand searches of the 13 journals returned 3797 articles, vetting of studies from previous team training reviews returned 191 articles, and the ancestry search of reference lists returned 471 articles (see Fig 1). After removing duplicates, 16,849 articles were subject to title and abstract screening, where they were dichotomously coded as ‘potentially relevant’ or ‘clearly not relevant’. 1517 potentially relevant articles were then full-text reviewed and coded as meeting eligibility criteria or as ineligible for the following reasons: (1) not a teamwork intervention; (2) teamwork-plus-taskwork intervention; (3) insufficient statistics to compute an effect size; (4) not including a measure of teamwork or team performance; or (5) not including a control group. As a result of this eligibility coding, 51 articles were included in the meta-analysis. 13 of these studies reported results on two or more interventions, bringing the total number of comparisons (k) to 72 with 8439 participants (4966 experimental, 3473 control). See S1 Table for descriptions of each study with regard to study context, type of team and participants, targeted teamwork dimensions of the intervention, number of effect sizes, the criteria measured, and an overview of the intervention.
Results of the overall effect of teamwork interventions on teamwork processes along with summary statistics and sensitivity analyses (i.e., the final column marked ‘ES with study removed’) for this pool of studies are presented in Table 1. This pool included a total of 39 interventions from 33 studies. The results revealed that teamwork interventions had a significant, medium-to-large effect on teamwork, d (SE) = 0.683 (0.13), 95% CI = 0.43–0.94, Z = 5.23, p < 0.001; Q (df) = 660.7 (38), I2 = 94.2. The funnel plot for this pool of studies is shown in Fig 2. The fail-safe N was 3598, which is sufficiently large, as it exceeds the critical value of 205 (5*39+10). The funnel plot for this pool of studies is presented in Fig 2. Egger’s value for this funnel plot was not significant (B = 0.364, SE = 1.30, 95% CI = -2.26–2.99, t = 0.28, p = 0.78), which also suggests that bias was not present. Two studies were identified as outliers within this pool of studies: Morey et al.  and Marshall et al. . The resulting effect size when these studies were excluded was d (SE) = 0.550 (0.08), 95% CI = 0.39–0.71, Z = 6.73, p < 0.001; Q (df) = 187.53 (36), I2 = 80.8. Subsequent moderator analyses were conducted with these two outlier studies being omitted.
Results of the overall effect of teamwork interventions on team performance as well as summary statistics and sensitivity analyses (i.e., the final column marked ‘ES with intervention removed’) for this pool of studies are presented in Table 2. This pool of studies included a total of 50 interventions from 32 studies. It was shown that teamwork interventions had a significant, large effect on team performance—d (SE) = 0.919 (0.14), 95% CI = 0.65–1.19, Z = 6.72, p < 0.001; Q (df) = 851.3 (49), I2 = 94.2. The funnel plot for this pool of studies is shown in Fig 3. The fail-safe N was 6692, which is sufficiently large, as it exceeds the critical value of 260 (5*50+10). The funnel plot for this pool of studies is presented in Fig 3. Egger’s value for this funnel plot was not significant (B = 0.131, SE = 1.19, 95% CI = -2.26–2.54, t = 0.11, p = 0.91), which also implies that bias was not present. There were five outlier interventions (from four studies) in this pool of studies that assessed team performance: Morey et al. , Smith-Jentsch et al. , one of the interventions from Buller and Bell ; teambuilding condition), and both interventions from Bushe and Coetzer . When these outliers were removed, the resulting effect size was d (SE) = 0.582 (0.06), 95% CI = 0.47–0.69, Z = 10.30, p < 0.001; Q (df) = 101.1 (44), I2 = 56.5. Subsequent moderator analyses were conducted with these five interventions omitted.
The results of the moderator analyses are shown in Table 3 (for teamwork behaviors) and Table 4 (for team performance). With respect to sample characteristics, significant positive effects of teamwork interventions were found for enhancing teamwork across all contexts (ds = 0.46–1.23) except for the single effect size from an industry setting (d = 0.50). In terms of team performance, significant effects were evident across all settings (ds = 0.40–1.76). In addition, interventions were effective for enhancing teamwork with intact teams (d = 0.33) and newly-formed teams (d = 0.67), with the effect size for new teams being significantly larger (Q = 4.04, p = 0.004) than that for existing teams. Teamwork training was also effective at fostering team performance for both team types; however, in contrast to the findings on teamwork, the effect size for intact teams (d = 0.99) was significantly larger (Q = 6.04, p = 0.02) than that for new teams (d = 0.54).
Three intervention characteristics were analyzed as potential moderators. First, with regard to the intervention method utilized, significant effects on teamwork were found for workshop training (d = 0.50), simulation-based teamwork training (d = 0.78), and team reviews (d = 0.64) but not for didactic education (d = 0.19). All training methods were effective for enhancing team performance (ds = 0.41–0.69). Second, significant effects of training on teamwork were evident when two or more dimensions of teamwork were targeted (ds = 0.65–0.98) but not when only one dimension was targeted (d = 0.05). Team performance, however, improved significantly as a result of teamwork training regardless of the number of teamwork dimensions that were targeted (ds = 0.46–0.67). Third, significant effects were shown regardless of which dimension (i.e., preparation, execution, reflection, interpersonal dynamics) was targeted for both teamwork (ds = 0.64–0.75) and team performance (ds = 0.52–0.60).
With regard to measurement characteristics, significant improvements on teamwork emerged when either third-party (d = 0.80) or self-report (d = 0.38) measures of teamwork were utilized; the effect size for third-party measures was significantly larger (Q = 6.02, p = 0.014) than the effect size for self-report measures. For team performance outcomes, significant effects were shown for both objective (d = 0.61) and third-party measures (d = 0.56). Finally, significant effects on teamwork were found when general/omnibus measures of teamwork were taken (d = 0.71), as well as when a specific dimension of teamwork was measured (ds = 0.45–0.70).
The purpose of this systematic review and meta-analysis was to quantify the effects of the extant controlled experimental research of teamwork training interventions on teamwork and team performance. We found positive and significant medium-to-large sized effects for these interventions on teamwork and large effects on team performance. When outlier studies were removed, medium-sized effects were found for both criteria. Additional subgroup/moderator analyses also revealed several notable findings, each of which will be discussed in turn. The paper concludes with a discussion of the limitations associated with this meta-analysis as well as considerations for future teamwork training research.
Who Can Benefit From Teamwork Training?
With regard to sample characteristics, teamwork interventions were shown to be effective at enhancing both teamwork and team performance across a variety of team contexts, including laboratory settings as well as real-world contexts of health care, aviation, military, and academia. This highlights the efficacy of teamwork training as a means of improving teams; this is an important finding as effective teams (i.e., those that work well together and perform at a high level) are vital in many of the aforementioned contexts. For example, it has been estimated that approximately 70% of adverse events in medical settings are not due to individuals’ technical errors but, rather, as a result of breakdowns in teamwork . Thus, there is a critical need to ensure that teams are effective across these settings, as these teams greatly impact (among other things) the welfare of others. The results of this meta-analysis suggest that teamwork training can indeed be a useful way of enhancing team effectiveness within these contexts.
We also examined whether there were differential effects of teamwork training for new teams compared to intact teams. It was shown that these interventions were effective for both team types. The effects of teamwork training on teamwork outcomes were significantly larger for new teams (who showed a medium-to-large effect size) compared to existing teams (who had a small-to-medium effect size). Interestingly, when we examined team performance as the criterion variable, the training effects were significantly larger for intact teams (who showed a large effect size) compared to newly-formed teams (who again showed a medium-to-large effect size). It should be noted that there were many more studies conducted with new teams compared to intact teams—thus, caution should be exercised in directly comparing these findings. Nonetheless, at this point, the existing research seems to suggest that teamwork interventions work particularly well at enhancing teamwork processes for newly established teams—and also work with existing teams—but not the same extent. It is possible that teamwork processes might be more malleable and display greater potential for improvement with new teams compared to more established teams whose teamwork processes may be more entrenched. On the other hand, it is notable that the effects of teamwork training on team performance were stronger for established teams. In line with this, it is plausible that, while intact teams may show less pronounced changes in teamwork, they might be better able to translate their teamwork training into improved team performance outcomes.
What Type of Training Works?
Three moderator variables were assessed with regard to intervention characteristics. First, with regard to the training method utilized, it was shown that all four training methods were effective for enhancing team performance. These included the provision of didactic lectures/presentations, workshops, simulation training, and review-type activities conducted in situ. Although significant effects were shown for the latter three training methods for teamwork outcomes, those interventions that targeted didactic instruction did not result in significant improvements in teamwork itself. This suggests that simply providing educational lectures wherein team members passively learn about teamwork is not an effective way of improving teamwork. When taken together these findings suggest that teamwork training should incorporate experiential activities that provide participants with more active ways of learning and practising teamwork. These may include various workshop-style exercises that involve all team members, such as working through case studies of how teams can improve teamwork, watching and critiquing video vignettes of teams displaying optimal versus suboptimal teamwork, discussing and setting teamwork-related goals and action plans, or other activities that help stimulate critical thinking and active learning of effective teamwork. Teams may also find it useful to conduct simulations of specific team tasks that the group is likely to encounter in-situ, such as aviation teams using an airplane simulator, surgical teams conducting mock-surgeries on medical manikins, military teams practising various field missions, and so on. Teamwork can be also fostered by having team members participate in team reviews/briefings before, during, and/or after the execution of team tasks that occur in-situ. In summary, simply lecturing about the importance of teamwork is not sufficient to create meaningful improvements in teamwork; rather, substantive positive effects can be derived by having team members engage in activities that require them to actively learn about and practise teamwork.
We also sought to assess how comprehensive an intervention should be—specifically, the number of teamwork dimensions that need to be targeted—in order to be effective. With regard to improving team performance, there were significant effects when one or more dimensions were targeted. However, in terms of improving teamwork behaviors, significant effects only emerged when two or more dimensions were targeted. From an applied perspective, individuals concerned with intervention (e.g., team consultants, coaches, managers, team leaders) can utilize these findings by targeting more than one dimension of teamwork within their training protocol. For instance, if the purpose of an intervention is to improve a health care team’s communication, greater effects may be derived by not merely targeting communication during the execution phase alone (e.g., with a structured communication tool), but by also incorporating strategies that target other dimensions of teamwork, such as setting goals and action plans for how communication will be improved (i.e., the preparation dimension of teamwork) as well as monitoring progress towards those goals, resolving any communication-related problems that arise, and making adjustments to action plans as necessary (i.e., the reflection dimension).
Relatedly, we sought to address whether there were differential effects of teamwork interventions on teamwork and team performance based on the dimensions of teamwork that were targeted. It was found that interventions had a significant effect on both teamwork behaviors and team performance when any dimension of teamwork was targeted. This is important as it means that if those concerned with intervention target any one of the four dimensions of teamwork, this will likely result in improvements in team functioning. While the preparation (i.e., behaviors occurring before team task performance such as setting goals and action plans), execution (i.e., intra-task behaviors such as communication and coordination), and reflection (i.e., behaviors occurring following task performance such as performance monitoring and problem solving) dimensions have each been theorized to be implicated in fostering team performance [2, 79], is particularly noteworthy that interventions targeting the interpersonal dynamics of a team (i.e., managing interpersonal conflict and the provision of social support between members) also displayed significant effects in relation to team performance. Specifically, efforts to enhance interpersonal processes have generally been theorized to be related to supporting team maintenance more so than supporting team performance [2, 79]. However, the results from the current review provide evidence that training teams with regard to social support and interpersonal conflict management processes may actually be a useful way to enhance team performance. While the exact reason for this effect is not immediately clear from this review, it may be that improving interpersonal dynamics has an indirect relationship with team performance. That is, teamwork training focused on improving social support and conflict management may improve the functioning of a team, which, in turn, improves the team’s performance. As Marks et al.  contend, these interpersonal processes “lay the foundation for the effectiveness of other processes” (p. 368). Relatedly, Rousseau et al.  suggest that problems related to social support and conflict management “may prevent team members from fully contributing to task accomplishment or from effectively regulating team performance” (p. 557). Further research examining this potential relationship is required as this would have implications in both research and applied teamwork settings.
Does It Matter How Criterion Variables Are Measured?
Two measurement characteristics were examined as moderators within this meta-analysis. First, significant, large- and small-to-medium sized effects were found for third party and self-report measures of teamwork, respectively. Significant medium effects were also evident for third party and objective measures of team performance. It is worth noting that significantly larger effect sizes emerged for third party assessments of teamwork compared to self-report measures. Taken together, these findings suggest that the positive effects that were found for teamwork interventions are not merely perceptive and/or due to individuals’ self-report biases (i.e., social desirability). Rather, these results indicate that the effects of these interventions on both teamwork and team performance are clearly observable with measures beyond self-report indices.
Finally, we sought to assess whether the effects of teamwork training varied based on which teamwork dimension(s) were measured. Medium-to-large effects emerged when general/omnibus measures of teamwork—that is, those that provided an overall score of teamwork as opposed to examining individual dimensions of teamwork—were taken. Measures that tapped into the specific dimensions of teamwork (e.g., those that provided individual scores on preparation, execution, reflection, and interpersonal dynamics) also yielded comparable effect sizes. Hence, teamwork interventions appear to have a somewhat similar effect on each of the components of teamwork. In summary, the results of the above two moderators (i.e., type of measure and dimension of teamwork examined) suggest that teamwork training has a positive impact on teamwork and team performance regardless of the way in which these variables are assessed.
Despite the contributions of this meta-analytic review, it is not without limitations. First, there were additional variables that we had planned to analyze as moderators a priori including team size and length of/contact time within the intervention. However, there was an insufficient amount of reliable data across the studies on these variables to conduct these subgroup analyses appropriately. For instance, although many studies noted the total number of participants within an organization (e.g., a hospital) that took part in an intervention, information on the size of the teams within the organization (e.g., various units within the hospital) was often missing. Team composition variables such as this have been noted as important factors to take into account when examining teams (e.g., [30, 80]). Similarly, although some studies were explicit about the total length of the intervention and the contact time between interventionists and participating teams, this information was not provided consistently. This too would have been a valuable feature to analyze in order to provide more specific recommendations about how teamwork training programs should be designed—that is, how long an intervention should last? Unfortunately, due to the paucity of information available in the included manuscripts, we were unable to determine whether these variables moderated the observed effects of teamwork training on teamwork and team performance in the current meta-analysis.
Furthermore, there was a considerable amount of variability within some of the moderator categories that were coded. For instance, with regard to intervention methods, ‘workshops’ consisted of many different types of activities including team charter sessions, strategy planning meetings, case study activities, and so on. Combining these activities into one category was done for the sake of being adequately powered to conduct moderator analyses (i.e., include a sufficient number of studies within each of the resulting categories). However, while the above examples are indeed activities that teams do together, they are of course each different in their own ways. Hence, although it is evident that workshop-type activities are effective overall, it is unclear if specific workshop activities are more effective than others. This example underscores the difficulty that can occur when trying to balance statistical power with accuracy for each moderator category when conducting subgroup analyses in a meta-analysis.
Relatedly, effect sizes were only computed with the statistics that were provided from baseline and post-intervention, even if studies provided additional data on teamwork and/or performance at some other point in between or at a follow-up point in time (although it is worth noting that relatively few studies actually did this). This was done in order to minimize heterogeneity within the meta-analysis and improve the interpretability of the results (i.e., determining the effects of teamwork training from pre- to post-intervention). However, by not taking these measurement time-points into consideration, two questions in particular are raised. First, do certain dimensions of teamwork and team performance evolve differently over time and, if so, how? For instance, do improvements in teamwork occur immediately in response to training and then plateau; or do they improve in a slower, more linear fashion from the onset of training? Second, what are the long-term implications of teamwork training? That is, does teamwork training result in sustained improvements in teamwork and team performance beyond the intervention period or do these effects eventually wane? Answers to these types of research questions would certainly be of interest to teamwork researchers and applied practitioners.
In addition to summarizing the previous research on teamwork interventions for improving teamwork and team performance, the findings from this systematic review also highlight several potential avenues of future research. First, with regard to sample characteristics, the majority of studies that examined the effects of teamwork interventions on team performance were conducted within laboratory settings, with relatively fewer controlled studies having been conducted in real-world settings. Thus, although significant effects on team performance (and teamwork) were found in health care, aviation, military, and academic settings, the extant literature would be strengthened by conducting further controlled intervention research within these contexts. It was also shown that teamwork training was less effective for improving teamwork for intact teams compared to new teams. Since many teams seeking teamwork training are likely to be intact, it is important that future research continue to test various training strategies that can be utilized with these types of teams. In addition, there are other contexts in which controlled interventions have not yet been conducted such as with police squads, firefighting crews, sports teams, political parties, and so on. Research in these areas is clearly ripe for future inquiry.
Further research on the ideal combination of teamwork dimensions (i.e., preparation and/or execution and/or reflection and/or interpersonal dynamics) targeted in an intervention would also enhance our current knowledge in terms of how to train teamwork most effectively and efficiently. We had originally planned to further assess this moderator by conducting a method co-occurrence analysis . Specifically, since there would likely be a variety of combinations of dimensions that were targeted in the teamwork interventions (e.g., preparation only; preparation and execution; preparation, execution, reflection, and interpersonal dynamics; etc), we had hoped to examine if there would be differential effects of these combinations with regard to intervention effectiveness. Unfortunately, since there were such a large number of combinations of dimensions targeted in the included studies, there was an insufficient number of interventions that fell into each category. We were, therefore, unable to pursue this method co-occurrence analysis  of the various combinations of dimensions. Thus, although our findings suggest that interventions are more effective when two or more dimensions are targeted, further research that examines the effects of the ideal combinations of these dimensions would certainly enhance our current knowledge of teamwork training. For example, if the objective of teamwork training is to improve the coordination and cooperation of the team, should the training also target (in addition to targeting these execution behaviors) both the preparation and reflection dimensions of training (or simply one or the other)? Answering such complex questions will help to advance our understanding of what makes for an effective teamwork training program.
Balanced against the contributions and insights provided by the various moderator analyses conducted in this study, the overall take-home message is that teamwork training is an effective way to foster teamwork and team performance. These effects appear to be evident across a range of samples, utilizing numerous intervention methods, and when considering various measurement characteristics. Interventions appear to be particularly effective when they target multiple dimensions of teamwork and include experiential activities for team members to actively learn about, practise, and continually develop teamwork.
- Conceptualization: DM ME BZ MB.
- Data curation: DM.
- Formal analysis: DM.
- Investigation: DM GR.
- Methodology: DM MB.
- Project administration: DM MB.
- Resources: DM MB.
- Supervision: MB.
- Validation: DM GR MB.
- Visualization: DM GR ME BZ MB.
- Writing – original draft: DM MB.
- Writing – review & editing: DM GR ME BZ MB.
- 1. Lepine JA, Piccolo RF, Jackson CL, Mathieu JE, Saul JR. A Meta-Analysis Of Teamwork Processes: Tests Of A Multidimensional Model And Relationships With Team Effectiveness Criteria. Personnel Psychology. 2008;61(2): 273–307.
- 2. Rousseau V, Aubé C, Savoie A. Teamwork behaviors: A review and an integration of frameworks. Small Group Research. 2006Jan;37(5): 540–70
Organizations are increasingly becoming dynamic and unstable. This evolution has given rise to greater reliance on teams and increased complexity in terms of team composition, skills required, and degree of risk involved. High-reliability organizations (HROs) are those that exist in such hazardous environments where the consequences of errors are high, but the occurrence of error is extremely low. In this article, we argue that teamwork is an essential component of achieving high reliability particularly in health care organizations. We describe the fundamental characteristics of teams, review strategies in team training, demonstrate the criticality of teamwork in HROs and finally, identify specific challenges the health care community must address to improve teamwork and enhance reliability.
Keywords: High-reliability organization, teams, teamwork, health care, patient safety, training
A healthy 38-year-old woman was admitted to a major medical center to deliver her first child. Although she was a low-risk patient with only mildly elevated blood pressure, her admission ended tragically when she underwent an emergency cesarean after a failed forceps delivery. Once inside the abdominal cavity, the uterus was found to have ruptured, and the placenta was in the abdomen. She delivered a stillborn fetus. After an unsuccessful attempt to repair her uterus, she received a full hysterectomy, underwent blood transfusions, and endured endless complications resulting in a 3-week hospital stay, including 18 days in intensive care. What went wrong? According to root cause analyses, lack of teamwork played a significant role. Specifically, communication was poor; there was a lack of mutual performance cross-monitoring, inadequate conflict resolution, poor situational awareness, and work overload. A major response to the tragedy was the initiation of team training at the medical center (Sachs 2005).
Safety is a fundamental patient right, though not a certainty (Knox and Simpson 2004). When patients arrive at a health care organization, they expect to leave that institution in equal or better health. Patients and their families do not expect physicians, nurses, and other hospital staff to make mistakes, or worse yet cover up as opposed to communicate errors. The publication of To Err Is Human by the Institution of Medicine (IOM) highlighted the fact that the delivery of care is not error free. The report concluded that medical errors cause up to 98,000 deaths annually. The IOM report brought national focus to this important issue and has since spawned significant research on the causes of medical errors and the effectiveness of different strategies for making health care a more reliable system (Kohn, Corrigan, and Donaldson 1999).
The IOM issued a number of recommendations designed to move health care institutions toward high reliability. HROs are institutions that operate in complex, hazardous environments making few mistakes (i.e., medical errors) over long periods of time. Recommendations related to voluntary error reporting, systems changes, safety systems design, and standard for health care professionals were presented in To Err Is Human. The IOM also pointed toward the need for enhanced teamwork. Historically physicians, nurses, and other health care professionals have functioned as discrete parts. The IOM recommended that interdisciplinary team training programs be established, based on sound principles of team management, to improve coordination and communication among health care staff (Kohn et al. 1999).
The Agency for Healthcare Research and Quality (AHRQ) is the lead federal agency in supporting and implementing the recommendations of the IOM in its effort to reduce medical error and improve patient safety. As part of this agenda, AHRQ established the HRO network to support patient safety leaders by providing them with a forum for learning about promising practices and identifying new and innovative ways to implement research findings. AHRQ's goal is to create high-reliability health care organizations. In support of that goal, AHRQ will launch Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) during 2006 and distribute this team training curriculum to members of the HRO network (Alonso et al. 2006).
The purpose of this paper then is to demonstrate that teamwork is an important component of HROs. While moving health care toward team-based work will not automatically result in high reliability, there are many parallels between teams and HROs (Knox and Simpson 2004; Wilson et al. 2005). To justify our argument, we begin by providing an overview of teams, teamwork, and strategies for promoting team effectiveness. Much has been written about these topics in domains where high reliability is critical because the consequences of error are great (e.g., the military, commercial aviation, and air traffic control) (Salas and Cannon-Bowers 2000; Davies 2001; Baker et al. 2003; Salas Sims and Kleien 2004). Later in this document, we describe the key characteristics of HROs. The concept of HROs has been around for more than 20 years, but has only recently begun to take hold in health care with the publication of To Err Is Human and AHRQ's patient safety agenda. In this section, we compare the fundamental features of teamwork and the critical characteristics of HROs and demonstrate how these characteristics are interwoven as well as how and why the HRO environment demands teamwork. Finally, although the science of teamwork has been around for over 30 years, it is only recently that this concept has begun to take hold in health care. In the last section we present a series of challenges researchers and practitioners need to address to advance the health care community's understanding of team performance and instantiate these practices as part of health care's quest to achieved high reliability.
TEAMS, TEAMWORK, AND TRAINING
Teams and Teamwork
There is a general consensus in the research literature that a team consists of two or more individuals, who have specific roles, perform interdependent tasks, are adaptable, and share a common goal (Salas et al. 1992). To work effectively together, team members must possess specific knowledge, skills, and attitudes (KSAs), such as the skill in monitoring each other's performance, knowledge of their own and teammate's task responsibilities, and a positive disposition toward working in a team. Such KSAs comprise teamwork (Cannon-Bowers et al. 1995;, Sims, Salas, and Burke 2004).
Based on its definition alone, it is easy to see how teamwork is critical for the delivery of health care. Physicians, nurses, pharmacists, technicians, and other health professionals must coordinate their activities to deliver safe and efficient patient care. As specified in our definition of a team, health care workers perform interdependent tasks (e.g., a surgeon cannot operate until a patient is anesthetized) while functioning in specific roles (e.g., surgeon, surgical assistant, anesthesiologist) and sharing the common goal of safe care. However, despite the importance of teamwork in health care, most clinical units continue to function as discrete and separate collections of professionals (Knox and Simpson 2004). This is partially due to the fact that members of these teams are rarely trained together; furthermore, they often come from separate disciplines and diverse educational programs.
Given the interdisciplinary nature of the work and the necessity of cooperation among the workers who perform it, teamwork is critical for ensuring patient safety. Teams make fewer mistakes than do individuals, especially when each team member knows his or her responsibilities, as well as those of other team members (Smith-Jentsch, Salas and Baker 1996;Volpe et al. 1996, Sims et al. 2004,). However, simply installing a team structure does not automatically ensure it will operate effectively. Teamwork is not an automatic consequence of co-locating people together and depends on a willingness to cooperate for a shared goal. Teamwork does not require that team members work together on a permanent basis. Teamwork is sustained by a commitment to a shared set of team KSAs rather than permanent assignments that carry over from day to day (Morey et al. 2002).
Critical Components of Teamwork
Extensive research on teamwork during the past 20 years (McIntyre, Salas, and Glickman 1989;Howard et al. 1992; Helmreich and Foushee 1993;Holzman et al. 1995)suggests that teamwork is defined by a set of interrelated KSAs that facilitate coordinated, adaptive performance (Cannon-Bowers et al. 1995;, Salas, Bowers and Cannon-Bowers 1995;Baker et al. 2003). Teamwork is distinct from taskwork (e.g., surgical skill) but both are required for teams to be effective in complex environments (Morgan et al. 1986). Furthermore, in health care, knowledge and skill at the task are not enough. Teamwork depends on each team member being able to anticipate the needs of others; adjust to each other's actions, and have a shared understanding of how a procedure should happen (e.g., knowing the steps in an appendectomy
Recently, researchers have begun to identify skills that define team performance in health care. This line of research began with the work of Gaba et al. (2001) who developed Anesthesia Crisis Resource Management (ACRM). ACRM was designed to help anesthesiologists effectively manage crises by working in multidisciplinary teams that include physicians, nurses, technicians, and other medical professionals (Howard et al. 1992; Gaba et al., 1998, 2001). ACRM uses patient simulators to provide training in specific technical and generic teamwork skills. The simulated anesthesia environment consists of a real operating room with standard equipment and situations requiring actual performance of clinical interventions. A life-like mannequin with appropriate breath and heart sounds permits team members to perform clinical procedures such as endotracheal intubation and infusion of intravenous drugs. Scenarios presented include overdose of inhalation anesthetic, cardiac arrest, and complete power failure (Holzman et al. 1995). The team skills trained in this simulated environment include making inquiries and assertions, communicating, giving and receiving feedback, exerting leadership, maintaining a positive group climate, and reevaluating actions.
In addition to anesthesia, a number of researchers have recently begun to identify the KSA requirements of teamwork in other health disciplines. For example, Healey, Undre, and Vincent (2004) have developed the Observational Assessment for Teamwork in Surgery (OTAS) to assess cooperation, leadership, coordination, awareness, and communication in surgical teams (Healeyet al. 2004). Thomas, Sexton, and Helmreich (2004) developed 10 behavioral markers for teamwork in neonatal resuscitation teams and Flin and Maron (2004) have identified nontechnical skill requirements for teams in acute medicine.
These studies encapsulate the core KSA requirements for physicians, nurses, and other health care professionals to function effectively in a wide variety of health care teams. Although different researchers use different terminology to define these KSA requirements (e.g., Thomas et al. 2004) identify one of their behavioral markers as “Information Sharing,” while others identify a requirement for “Communication” (Leonard, Tarrant 2001; Flin and Maron 2004; Healey et al. 2004), we argue, much as have Salas and colleagues, that these generic KSAs can be clustered into eight broad competencies of teamwork (Sims et al. 2004). These competencies must be possessed by health care professionals so they can perform (1) in the variety of teams of which they are part and (2) a variety tasks requiring coordination in day-to-day practice. Table 1 presents each KSA, its definition, and behavioral examples.
Team KSA Competencies and Outcomes
Characteristics of Effective Teams
Teams whose members possess a shared commitment to the KSAs presented in Table 1 have been shown to out perform teams whose members do not possess these attributes (Smith-Jentsch et al. 1996; Leonard, Tarrant 2001; Salas et al. 2001; O'Shea et al. 2003). One important fact to note about these KSAs is that they are all individual as opposed to team-level competencies. In other words, team members bring these KSAs to each team task they engage in; the competencies are not unique to the task or the team. When team members work together on a more permanent basis, these competencies are refined over time (they are tailored within the team) and some additional competencies emerge (e.g., knowledge of teammate characteristics).
Regardless of whether a team has consistent membership or not, when team members possess the KSAs in Table 1 they are able to perform as a highly reliable and efficient system. Table 2 presents a list of characteristics of effective teams that make them reliable and efficient. These characteristics are similar to the properties that embody HROs, which we describe in the next section. However, before our review of HROs, we describe the mechanisms by which effective team performance can be achieved.
Characteristics of Effective Teams
How to Promote Teamwork
There are three basic strategies by which effective teamwork can be achieved. First, specific individuals, who have the correct KSAs, can be selected to participate in a team or to perform team-based work (Klimoski and Mohammed 1994). This strategy requires precise measurement of individual-level team competencies and a correct balancing of task-oriented and team-oriented KSAs among team members. Second, teamwork can be enhanced by modifying tasks, workflow, or structure (Campion, Medsker and Higgs 1993;). In other words, one can examine the environmental conditions in which team-based work occurs and reengineer these conditions accordingly. Finally, individual team member competencies can be developed through training (Cannon-Bowers et al. 1995, 1989;, Cannon-Bowers and Salas 1997; Leonard, Graham, and Bonacum 2004,). Team training has been the most widely applied strategy to improve team performance.
Team training is defined as applying a set of instructional strategies that rely on well-tested tools (e.g., simulators, lectures, videos) (Salas et al. 1999;, Salas, Rhodenizer and Bowers 2000). Effective team training reflects general principles of learning theory, presents information about requisite team behaviors, affords team members the opportunity to practice the skills they are learning, and provides remedial feedback.
A great deal of research has been devoted to the most effective strategies and techniques for training specific team KSAs. A comprehensive review of this research has presented an extensive collection of principles and guidelines concerning the design and delivery of team training. For example, guidelines exist for assertiveness training (Smith-Jentsch et al. 1996), cross-training (Volpe et al. 1996), stress management training (Driskell and Johnston 1998), and team self-correction (Smith-Jentsch et al. 1998).
Team training programs have been an essential component of the airline industry's efforts to achieve high reliability. For over 30 years, crew resource management (CRM) has been a critical part of most airlines' efforts to improve their margin of safety. Recent research suggests that CRM training results in heightened safety-related attitudes; improved communication, coordination, and decision-making behaviors; and enhanced error-management skills (Wiener, Kanki and Helmreich 1993;). Helmreich and Merrit 1998;). CRM training has also demonstrated consistently positive results across a wide range of team structures, including pilot crews, maintenance crews, dispatch crews, and air traffic control teams (Helmreich, Foushee 1993; Oser et al. 2001; Smith-Jentsch et al. 2001
Interestingly, CRM's effect on the ultimate criterion—a reduction in the number of accidents—has yet to be empirically established (Salas et al. 2001). However, accidents represent a poor criterion methodologically because they exhibit an extremely low base rate (Helmreich and Foushee 1993). Thus, researchers have relied on surrogate measures—like improvements in team-related knowledge and skills, behavioral demonstrations of CRM skills on simulated flights, instructor evaluations of trained versus untrained crews, and changes in an organization's safety culture—to demonstrate the effectiveness of CRM training Helmreich and Foushee 1993; Hansberger and Holt, Boehm-Davis 1999; Ikomi et al. 1999; Incalcaterra and Holt 1999; Holt, Boehm-Davis, and Hansberger 2001).
Similar to the airline industry, some type of formal team training is now a major component of training in most branches of the United States Armed Forces. For example, all branches of the Armed Forces give their aircrews a military version of CRM, ranging from Fighter Resource Management (FRM) for single-seat fighter pilots to CRM training for the large crews that staff transport and patrol aircraft (Spiker et al. 1998). In addition, many sailors, soldiers, airmen, and marines receive team training. For example, the Navy, having tested several team-training approaches (Serfaty, Entin, and Johnston 1998), has adopted an approach called Team Dimensional Training (TDT), which resulted from the TADMUS program (Cannon-Bowers and Salas 1998). TDT addresses team-related knowledge and skills, provides practice in briefing and debriefing, and trains trainers and team leaders to evaluate and critique team skills (Tannenbaum, Smith-Jentsch, and Behson 1998).
TEAMS AND HROs
The characteristics of HROs dictate that teamwork is an essential component of such organizations. HROs will not achieve high reliability unless its members are able to effectively and efficiently coordinate their activities. In the previous section, we have spent considerable time clarifying what we mean by “teams” and “teamwork.” In this section we define the concept of high reliability, review the key characteristics of HROs, and demonstrate why teamwork is so critical in such organizations.
HROs are defined by their potential for causing failures that lead to catastrophic consequences. If the potential is high (thousands of dramatic failures), but the actual number of failures is low, the organization is an HRO (Roberts 1990a). For example, a nuclear power plant failure could result in horrific consequences for its surrounding community, although such failures are extremely rare. The same can be said for many U.S. hospitals—there are thousands of opportunities for major accidents everyday. Although the IOM estimated that 98,000 preventable deaths occur per year, the actual occurrence of medical error resulting in deaths is extremely low (Kohn et al. 1999).
HROs are those organizations that function in hazardous, fast-paced, and highly complex technological systems essentially error-free for long periods of time (Roberts 1990a, b). Roberts and Rousseau (1989) identified eight characteristics of HROs: (1) hypercomplexity, (2) tightly coupled, (3) extreme hierarchical differentiation, (4) many decision makers working in complex communication networks, (5) high degree of accountability, (6) frequent, immediate feedback regarding decisions, (7) compressed time factors, and (8) synchronized outcomes (Roberts and Rousseau 1989). Below we review each of these characteristics, demonstrate how teamwork is an essential component of effective performance in such organizations, and provide a health care example, where appropriate.
Hypercomplexity is defined as an extreme variety of components, systems, and levels, each having their own standard procedures, training routines, and command hierarchy (Roberts and Rousseau 1989;). Based on its definition alone, successful performance in hypercomplex environments relies upon multiteam systems and teamwork is an essential component of such environments. For example, Roberts and Rousseau describe aircraft carrier operations is indicative of hypercomplexity. Pilots, air traffic controllers, dispatchers, ground crews, and many others must work collectively to launch and recover aircraft. These interdependent teams (e.g., air traffic control team, aircrews, maintenance teams, etc.), must coordinate their activities and efficiently monitor each other's performance.
Similarly, the delivery of health care occurs in a hypercomplex environment that is dependent on multiteam systems. Even though health care workers have historically operated in distinct silos and have been trained in separate professions and possess distinct expertise, these individual must coordinate to deliver safe care. At the most basic level, physicians must accurately communicate treatment information to the nurse based, in part, on information the nurse presents to the physician regarding the patient's condition. Orders are written on the basis of this discussion and the physician's examination of the patient. These orders are distributed to the pharmacy, X-ray, labs, physical therapy, etc., so that other health care professionals can collect additional information to provide insight regarding the patients or initiate treatment.
Tight coupling is defined as reciprocal interdependence across many units and levels. Tight coupling relates to task interdependence, which is the defining characteristic of teams. That is, tasks performed by one member of the team are dependent on tasks performed by other members of the team and the performance of these tasks must be coordinated among team members for effective team performance (delivery of safe care). For example, in health care an emergency C-section is a tightly coupled event that involves several different members of the labor and delivery team. The nurse handling the case is typically the first to observe fetal distress and must communicate this information to the attending physician. The doctor must decide if a C-section is necessary based upon the information the nurse provides and review of information collected from the fetal heart rate monitor. If the attending decides to operate, appropriate staff must be notified (anesthesiologist, neonatologist, or pediatrician), and the patient must be moved to surgery. Before making the initial incision, the patient must be properly anesthetized and the staff should be briefed as to the status of the patient and the baby. This process, which involves a series of interdependent steps, can take place in a matter of minutes depending on the history of the case and the level of fetal distress observed. For such a sequence to run smoothly, teams must use effective communication and have a shared understanding of the mother's and baby's condition. The Joint Commission (JCAHO) reported that ineffective communication resulted in 70 percent of all preventable errors involving death or serious injury from 1995 to 2003 (JCAHO 2004).
Extreme hierarchical differentiation is defined as an organizational structure in which levels and roles are clearly differentiated. This characteristic is also true of most health care teams. Physicians tend to be at the top of this hierarchy with the case or treatment resulting from their directions. Therefore, a great deal of coordination is necessary to keep physicians, nurses, and technicians working together as a cohesive unit. Unfortunately hierarchy often makes it more difficult for medical teams to achieve this level of coordination and cohesiveness. In fact, research suggests that the extreme hierarchical difference between physicians and nurses in particular can contribute to dysfunctional communication yielding less than optimal patient care Keenan Cooke and Hillis,1998; Knox and Simpson 2004).
Although most medical teams are hierarchical, high-reliability teams trained in teamwork exhibit characteristics such as assertiveness and mutual trust, which reduce the negative effects of hierarchy. Mutual trust, an essential teamwork KSA, involves a shared belief that team members will protect and support the interests of their team (Sims et al. 2004). Team members with mutual trust are willing to admit to mistakes and accept and appreciate feedback Bandow 2001; Webber 2002). This allows team members to firmly assert their concerns even to a higher-ranking team member without fear of reprisal.
Another key characteristic of HROs is that they contain many decision makers working in complex communication networks (Roberts and Rousseau 1989). This characteristic personifies most health care teams. First, team members continually need to make important decisions concerning patient care (e.g., start an IV, induce labor, administer narcotics, admit patient). Consequences of these decisions clearly have implications on the ultimate well being and safety of patients. As most teams in health care are comprised of four to six unique individuals, however, decisions are not always unanimous. Second, as different team members are trained separately in their respective professions (e.g., medical school and nursing school), they have learned to communicate differently and have varying styles of conveying information depending on their role. Fortunately, new and emerging techniques like the Situation Background Assessment Recommendation (SBAR) strategy have been used in health care to overcome such communication difficulties with positive results (Leonard et al. 2004). This particular strategy facilitates clear and concise communication among members of health care teams by providing an easy-to-remember acronym used for framing critical conversations.
A high degree of accountability in HROs is characterized by the severe consequences that can result from errors (Roberts and Rousseau 1989). Although serve consequences may be characteristic of all teams (e.g., project teams), in health care, the consequence of a mistake can often be death the patient. Preventable medical errors that result in loss of human life eternally affect the patient's family, the staff that tended to the patient, the community, and the hospital's reputation. However, even small mistakes resulting in patient harm yield grave consequences, yet not all medical team members are held equally accountable when errors do occur. More often then not, it is the physician in charge of the patient's care that gets the brunt of the blame for any mistakes made. Malpractice lawsuits or the possibility of losing one's license are very real outcomes that add to pressures felt by already stressed physicians. Consequences may also be present for the hospital such as loss of accreditation, and negative media attention.
HROs are also characterized by “immediate feedback” resulting from their decisions; the plane crashes; there is a nuclear disaster; the patient is injured (Roberts and Rousseau 1989). In other words, there is an identifiable, measurable outcome associated with HRO performance. Such outcomes are typically an indicator of poor team and/or system processes within the HRO. For example, in aviation 60–80 percent of all accidents are attributed to human error as opposed to anything technically wrong with the aircraft. Similarly, the IOM report points to human error as a major contributor in patient deaths (Foushee 1984; Kohn et al. 1999).
Immediate feedback is also a characteristic of effective team performance. Team members must monitor each other and provide each other feedback to maximize team functioning. However, feedback here focuses on team process and its improvement rather than solely on team outcomes. To ensure that feedback occurs, team members must be trained to deliver timely, behavioral, and specific feedback to one another (using such strategies as TDT). The ability to monitor each other's performance and effectively provide feedback to other team members is a critical facet of achieving higher reliability in health care and elsewhere.
Major HRO activities often occur under compressed time, as in the case of naval flight operations where aircraft are launched and recovered in 48–60-second intervals (Roberts and Rousseau 1989). Somewhat different than the other characteristics, the extent to which this variable is related to team performance is a function on the environment in which the team operates as opposed to the team itself. Some teams operate under compressed time while others do not. The same is true of health care, with a slightly different twist. Routine procedures like childbirth can quickly become a stressful, time compressed situation should a problem arise with the mother or baby. In such cases, teams need to be able to quickly adapt. Team members may have to be quickly added and integrated into the team and task—anesthesiologist, emergency response team—or existing members may have to take on new roles—OB-GYN converts from coaching the mother through a normal delivery to conducting an emergency C-section.
The last characteristic of HROs is that critical outcomes occur simultaneously (Roberts and Rousseau 1989). As discussed earlier, team members work together on interdependent tasks. This is what separates teams from groups or individuals working in isolation. Interdependency creates the need for synchronization of activities and outcomes. For instance, when delivering a baby, each member of a labor and delivery team is actively engaged in different aspects of the process yet their actions are synchronized.
As can be seen from the description above, the HRO environment demands teamwork. Teamwork, or the KSAs that comprise it (refer to Table 1), are critical for successful performance in organizations that are hypercomplex, tightly coupled, hierarchical, time compressed, and rely upon synchronized outcomes (Sims et al. 2004). Aviation, the military, and now health care acknowledge the criticality of teamwork in achieving high reliability despite data that show a direct relation between team training and the ultimate criterion, a reduction in errors (e.g., accidents, deaths, etc.) (Salas et al. 2001). However, the science of teamwork and team training is still evolving, particularly in health care. The IOM report did much to stimulate research on health care teams, but much of this early work relied upon direct transitions from the commercial airlines to health care. Despite the work of Gaba and colleagues, it is only within the last 3 years that the science of health care teams has really begun to emerge and take hold (Baker et al. 2003). As a result, a number of questions remain that health care must address to have a firm understanding of teamwork and its relation to patient safety and high reliability. Direct transitions from aviation without additional study are insufficient. In the next section, we outline a series challenges the health care community must address to better understand health care team performance, how to maximize this performance, and ultimately improve patient safety.
Throughout this paper we focused on three basic themes. First, the delivery of health care, by its nature, requires that organizations providing such services act as HROs. Patients expect error-free care (Knox and Simpson 2004). Second, teamwork is an essential component of HROs. Although not the sole determinant of high reliability, HROs are typically comprised of teams embedded in multiteam systems and effective teamwork is critical for success in environments that demand high reliability (Wilson et al. 2005). Finally, the easiest way of improving teamwork is through training. Team training has been effectively implemented in the commercial airlines and the military with positive results (Salas et al. 2001). Such training programs are now emerging in health care with potentially similar benefits (Baker, Beaubien, and Holtzman 2003).
Nonetheless, teamwork in health care is an emerging science. To move this science forward so that findings can be transitioned and implemented, we recommend that health researchers, quality improvement specialists, regulatory bodies, and others seek to address the following challenges.
Challenge 1: A Theoretical Model of Team Performance in Health Care Should Be Developed
To date, research has not developed a comprehensive model of team performance in medical settings; consequently, existing and emerging team training programs are not grounded in a scientific understanding of what comprises effective teamwork in health care (Baker et al. 2003, 2003). In our review of the team literature, we recommend the teamwork framework advocated by Salas and colleagues and this framework serves as the foundation for AHRQ's TeamSTEPPS training program. However, the Salas model needs to be tested in health care to determine (1) the relations among predictors of performance (team KSAs) and (2) the relations between predictors (KSAs) and outcome criteria (e.g., quality of care, error management, efficiency, etc.).
Challenge 2: Proven Instructional Strategies Should Be the Basis for Team-Training Programs in Health Care
Team training is the most practiced strategy for enhancing team performance and improving team outcomes. Most HROs provide some form of team training and the science of team training has developed and validated numerous training strategies. Through a variety of formats and objectives, these strategies extend beyond CRM training. However, health care seems to be focused on adapting CRM programs derived directly from aviation (Baker et al. 2003) and not implementing other strategies which have been shown to be effective and may by more appropriate (i.e., team dimensional training). Therefore, we challenge health care to (1) move beyond CRM and look to other validated methods, (2) use these strategies wherever possible as the foundation for team training programs, and (3) test and refine these strategies to ensure that they effectively generalize to health care teams. It is only through implementation, testing, and refinement that health care will be able to understand and demonstrate how to enhance teamwork.
Challenge 3: Team-Training Strategies Must Be Further Adapted to Specific Health Care Needs
Similar to our previous recommendation, we are convinced that no single model of team training, like CRM, can be applied across all health care services and contexts when attempting to achieve high reliability. For purposes of this discussion, we define a “service” as a medical specialty or subspecialty, such as emergency medicine, general or family medicine, intensive care, general surgery, obstetrics, etc. Medical services differ dramatically across a variety of criteria: size, purpose, duration, redundancy of expertise, decision time, and consequence of error, to name but a few.
In addition, services operate in a number of diverse contexts. As an example, emergency medicine providers function in hospital emergency departments, in emergency-response mobile units, and on battlefields. Similarly, urban and rural providers operate in independent or multipractitioner offices, as well as in community walk-in clinics. Neither the competencies that impel successful teamwork nor an optimal team-training strategy can be expected to generalize across all these contexts. And, of course, not all members within the same team will necessarily need the same KSAs.
Therefore, in addition to the core competency taxonomy, the science of teamwork in health care must seek to develop service-specific taxonomies. These putative taxonomies would not be redundant with the generic, core competency taxonomy. Rather, a specific taxonomy would denote the specific KSA requirements that are central to teamwork in a given service, thus maximizing team performance within that service. The task content and procedures that define this service would drive the identification of relevant team competencies.
Virtually no previous research has addressed the manner in which differences within and among health care services should be reflected in service-specific taxonomies and customized training. Yet we find this issue sufficiently compelling, particularly with the context of HROs, because it suggests that customized solutions are warranted to achieve high reliability. Therefore, while a generic taxonomy of team KSAs is the foundation to teamwork in health care, we argue that these competencies must be refined and training must be tailored to a specific service to maximize team performance and safety.
Challenge 4: Team Training Must Be Institutionalized throughout Health Care and Professional Training
Finally, health care must work to integrate teamwork throughout every level of training and education of health care professionals. By “integrated” we mean instruction, measurement, and feedback on critical team KSAs occurs as part of a health care professional's technical education and training. Using this approach, team concepts become a part of everyday practice.
Several initiatives by physician education, certification, and licensing boards have already begun to move health care toward integrating team concepts. For example, the ACGME has identified several teamwork-related competencies that residents must master as part of the ACGME outcomes project (http://www.acgme.org). Similarly, AAMC funded a “critical incident” analysis to investigate the behaviors that result in successful and unsuccessful performance during medical school and residency (Adams et al. 2001). Although not originally targeted toward team performance, the results revealed the importance of a number of teamwork-related competencies.
Building off existing initiatives, we believe that the structure of health care, as currently conceptualized, offers appropriate junctures where teamwork skills could be evaluated. For example, like the examinations that are constructed for board certification in medical specialties, it might ultimately be useful to develop a board certification test for teamwork. Such an exam might combine a written test of knowledge and situational judgment with performance in a simulated scenario. Because the board examinations are practice-specific, their teamwork component could assess practice-specific teamwork competencies. In addition, the JCAHO currently evaluates hospitals on criteria that range from medical practices to managerial systems to facilities maintenance. At some point in the future, folding team competency criteria into the JCAHO evaluation might focus providers' attention on the importance of teamwork in medical settings, as well as yielding valuable research data.
In summary, we have argued that teamwork is an essential component of achieving high reliability for health care organizations. HRO environments demand teamwork and, as a result, the science of team training can provide great insights and proven techniques for improving performance within such organizations. In closing, we recommend that health care gain traction from the more than 20 years of research on team performance and training and that these principles be first tested and then integrated into the practice of health care and the training of health professionals. Although this will take considerable time, perhaps spanning a generation, this approach has been one of the key drivers in other industries achieving the highest reliability possible. We believe that the challenges we have presented here provide a roadmap with which health care can continue.
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