Sounding the Call for Team Training in Health Care: Some Insights and Warnings

Abstract

Health care is changing. Nearly a decade after initial calls regarding the importance of teamwork in optimizing patient safety,1 team training efforts to enhance both interdisciplinary and intradisciplinary medical teamwork are being integrated into formal standards, regulations, and curricula. For example, the Joint Commission's second National Patient Safety Goal for 2009 was to “improve the effectiveness of communication among caregivers,” a core component of teamwork. The National Quality Forum's3(pVI) third safe practice for 2009 directed health care organizations was to “establish a proactive, systematic, organization-wide approach to developing team-based care through teamwork training, skill building, and team-led performance interventions that reduce preventable harm to patients,” and in 2002 the Accreditation Council for Graduate Medical Education4 formally recognized communication and interpersonal skills as core requirements for residents by creating the interpersonal and communication skills competency. This recognition of teamwork as a key factor in quality patient care and working environment has catapulted quality interventions such as team training into the spotlight as a means for optimizing teamwork in health care. From the organizational and human factors psychology literature, two recent quantitative reviews examined the effects of team training on team performance. These two reviews examined empirical data across all industries and assessed the effectiveness of team training. Moreover, a qualitative review of team training was conducted which focused on the health care industry. In the following section we will review these meta-analyses and provide the reader with an overview of their findings. The Evidence The evidence of the impact of team training was illustrated in two meta-analyses conducted by Salas and colleagues.5,6 Salas et al5 examined three specific training strategies as used by intact teams. Their results indicated that overall team training strategies did improve performance. Broken down by the type of strategy, Salas and colleagues found that Team Coordination and Adaptation Training, a form of team training similar to Crew Resource Management (CRM) training, accounted for 37% of the variance in team performance. Similarly, Guided Team Self-Correction training accounted for 20% of the variance in team performance. Cross-training, the third strategy examined, did not result in an effect on performance. However, more recent work7 has reexamined the effect of cross-training and has found that it accounts for 15% of the variance in performance. A second, more robust meta-analysis by Salas and colleagues6 examined all forms of team training—that is, team training conducted on both taskwork and teamwork. Their findings indicated that overall team training had a positive effect on team functioning (ρ = 0.34). Moreover, their analysis reviewed the impact of team training on different outcomes. Team training impacted cognitive, affective, process, and performance outcomes. In summary, these quantitative reviews are evidence that team training does impact performance. Similar findings have also been reported in other reviews.8–10 In health care, this can mean the reduction of medical errors, saving a life, or overall providing better care to patients. Building on these quantitative results, the current paper is based on a qualitative review focused on team training implementations in health care. A content analysis was conducted of the empirical team training literature in health care with a focus on answering such questions as how training was designed, what content was included in the training, what instructional strategies were used, how was the training implemented, and how was it evaluated. The focus on team training articles in health care resulted in 37 articles being analyzed to determine principles and best practices for team training in health care. The review of team training in health care illustrated a positive picture, but it has also highlighted some areas which need attention. First, team training is not limited to any one specialty. Team training conducted in health care is targeting anesthesia (16% of studies), emergency medicine (14% of studies), pediatrics (5% of studies), and a mix of other specialties, such as radiology, surgery, and labor and delivery. It is positive to see that team training is not being limited to a specific area. Second, the review identified that the most-used team training strategy implemented in health care is Crisis Resource Management, modeled after the aviation training intervention Crew Resource Management. CRM focuses on training the ability to distribute the workload when needed, knowing the environment, cross-checking, and using cognitive aides.11 In addition to CRM being implemented, general teamwork is the primary focus of team training in health care. General teamwork training emphasizes team concepts such as communication, coordination, and cooperation. Third, a surprising finding from the qualitative review of team training in health care was that out of the 37 articles, 19% conducted team training in an individually based training environment (e.g., individuals participating in didactic lecture-based training) versus actually using team-based training strategies and exercises (e.g., team-based simulation activities). On the other hand, an extremely positive picture was painted when the use of practice was assessed during the implementation of team training. Eighty-six percent of the empirical articles reviewed used practice or simulation and provided the trainees opportunities to practice. Fifth, equally important during training is to provide trainees with feedback during their opportunities to practice. The content analysis of these articles resulted in a finding that 81% of the studies explicitly reported that feedback was provided during practice sessions. Sixth, a large range of the duration of team training interventions was found. That is, the training interventions that have been implemented and studied in health care have ranged from 30 minutes to 5 days. The lower end of the range is of some concern. Thirty minutes may not be enough time to train teams effectively on teamwork-related concepts. Lastly, 78% of the team training interventions which were implemented and studied in health care settings were evaluated beyond that of trainee reactions. This is a critical step in a team training implementation program. Evaluating the effectiveness of a program to change behaviors and organizational outcomes is crucial in determining the impact of an intervention. Some Insights Build team training on the foundation of the science of training and learning … then recognize that all teams in health care are not created equal To be effective, team training programs must be grounded in the science of training12,13 and adult/team learning.14,15 Programs should focus on optimizing teamwork-relevant behaviors, thoughts, and attitudes. They should also strive to focus on the core competencies of teamwork,16 such as communication (i.e., briefings, debriefings, closed loop), coordination (i.e., backup behavior, mutual performance monitoring), and cooperation (i.e., psychological safety, collective efficacy, cohesion). However, the principles, competencies, and content of the program must be chosen with a clear understanding of the task and the interdependencies of the teams/units/specialties targeted for training. The level of interdependence among team members varies widely across the spectrum of units and specialties. Different teams require different behaviors at different times. Therefore, effective team training tends to focus on both general and team-specific KSAs within a program contextualized to the targeted medical specialty. Team training must go beyond awareness … it must be practice-based As the saying goes, knowing and doing can sometimes be two very separate things. Team training is not a one-day event, a place where people are sent, or simply saying “do better” at an M&M conference. Adult learners are highly experience-oriented and prefer programs that draw heavily on the application of trained concepts to immediate, practical problems17; therefore, effective team training programs include opportunities for active learning, modeling, and practice. Furthermore, effective programs ensure that this practice is guided. From an instructional design standpoint, this means that practice scenarios are scripted to elicit desired, training-relevant behaviors. Additionally, effective programs do not only expose trainees to “ideal” behavioral examples and practice scenarios in which everything goes according to plan. Team training must include opportunities for trainees to see and experience examples of bad teamwork and near misses. Merge simulation with any team training strategy … guide the practice Effective medical team training programs are built heavily on active learning strategies, such as simulation, which incorporate real-life scenarios likely to create time pressure and stress. These are the times that team breakdowns leading to significant adverse events are most likely to occur during patient care. Training that provides the opportunity to practice teamwork skills under conditions that mirror those experienced on a daily basis heightens the transfer of trained skills to the actual work environment. Furthermore, the science of training demonstrates that opportunities to apply training in varied situations leads to the generation of usable knowledge structures (i.e., mental models) which enhance performance.18,19 Simulation-based training (SBT), however, is not merely a group of people in front of a mannequin. Simulation scenarios must be built on the science which indicates that effective SBT (1) is built on clear and precise learning outcomes, (2) includes trigger events embedded in the scenario, (3) uses diagnostic measures of performance and detailed observation protocols, (4) is developed as part of a comprehensive instructional system, and (5) is implemented from a systems perspective.20 Feedback in itself doesn't matter … to matter it must be timely and diagnostic Feedback is at the very core of the purpose of training, to build and refine KSAs, and its positive influence on trainee performance has been supported empirically. However, not all feedback is created equal. Poorly structured and/or executed attempts at feedback can actually hinder performance as exemplified by Kluger and DeNisi.21 Effective feedback (1) pertains to familiar tasks and addresses task-specific goals, (2) avoids a focus on the self, (3) addresses changes in performance from previous trials, (4) sets expectations and goals for performance, and (5) aids in refining strategies to meet these expectations and goals. For example, work regarding Guided Team Self-Correction, a team training technique predominantly focused on providing developmental feedback via postaction debriefings known as After Action Reviews, has been found to positively impact shared mental models among team members, thus enhancing their task understanding and team performance.22 Some Warnings Team training is not a panacea … it cannot solve all of your patient safety problems Health care must be wary of approaching team training as a catch-all cure for a broken system. To be effective, team training must be integrated as part of a larger culture/climate change. Current evidence suggests that team training accounts for approximately 20% of the variance in team performance.6 The remaining 80% is accounted for by other factors, such as safety culture, leadership, and incentives. Teamwork and participation in team training must be a valued component of organizational culture focused on patient safety and quality of care. It must be only part of a broad, systematic approach to optimizing patient safety and personnel outcomes. Similarly, for team training to be effective there must be a clear link between outcomes targeted for improvement and teamwork. Although this may sound intuitive, expectations must be realistically based on the degree to which targeted outcomes are related to actual teamwork processes. First and foremost, administrators, regulators, and providers must make sure that teamwork is the correct “medicine” for the issues targeted within a particular unit, department, or facility. Talk is cheap … signals before, during, and after training must indicate that teamwork matters The organization as a whole must be prepared to approach team training from a comprehensive, systematic perspective. Organizations must be prepared to invest in team training both culturally and financially, while being prepared to address other related issues. Specifically, the messages and policies emphasized before, during, and after training must convey the value the organization places on team training and support teamwork as an organizational norm. To demonstrate that team training is valued, both time and resources (e.g., paid time for training, CME) must be allocated to the team training implementation process. Additionally, all organizational members must be involved in team training initiatives. Everyone, from providers to housestaff, administrators, and regulators, plays an essential role in quality care. Therefore, for team training to be effective they must be initiative champions who actively support, enact, and call others to the cause. This also means actively reinforcing teamwork behaviors on the job and enforcing policies when someone does not agree to be a team player. Physicians MUST think of themselves as part of the team For team training to be effective, we must progress beyond the “me versus them” mentality that is prevalent in health care. Not to pick on them, but take some physicians for example. Even though they are often team leaders, some physicians still tend to see themselves as separate from the hospital staff “team.” Their leadership role, however, makes their buy-in and active participation vital for the success of any team training initiative and broader cultural shift. If the physician and nurse leaders in the room, on the floor, and in the unit do not actively champion teamwork and reinforce it among their team members, then team training will fail—no matter how much time, effort, or money is invested. The idea of “my responsibility” versus “someone else's responsibility” must be replaced by a collective perspective on care. Equally as important, the patient must also be considered as an integral part of the team. For example, many hospitals have integrated the patient into the Joint Commission's universal protocol by having patients write their initials on the part of their body targeted for the procedure. Patients should also be encouraged to ask questions, provide information openly, and take ownership in their care. Patients must be integrated as active partners in their health care, not simply passive recipients. Teamwork must be included in formal risk assessment The evidence demonstrates that teamwork contributes to adverse events. The Joint Commission statistics continue to demonstrate that nearly 70% of sentinel events are related to communication, a core component of teamwork.23 Despite such a significant impact, teamwork is rarely (if ever) included in traditional risk analysis. Probabilistic risk models should be formulated to include teamwork in order to account for the probability of teamwork failures. This will ensure that team training initiatives are linked to important outcomes valuable to patients, providers, and the larger organization. Team training must be treated with the same rigor as a clinical trial Initial evaluation evidence has generally supported the positive impact of team training on important patient safety and provider outcomes,6,10,24 but our evidence base considering the long-term impact must continue to grow. Robust evaluation should be built into team training programs from the early preplanning stages, and quasi-experimental designs should be leveraged to develop effective team training evaluation studies. Additionally, evaluations must strive beyond reaction data to better explore the impact of training on job behaviors and important patient safety/organizational outcomes (e.g., near misses, events, turnover, etc.). Evaluations should also be approached with a long-term focus. Drawing from the available literature and our own experiences working with health care facilities to develop, implement, and evaluate team training, a vital need exists for long-term evaluations in order to understand those factors which promote long-term sustainment and culture change. Additionally, these experiences and results must be openly shared throughout the health care community both scientifically and practically. Unless medical training programs report means, SDs, and other metrics, we will not be able to meaningfully quantify the impact of team training on patient safety. Addressing this issue, Davidoff and colleagues25 recently published comprehensive publication guidelines for reporting health care quality improvement initiatives. These guidelines provide a tool for initiative preplanning by listing important considerations and items to report in final publications. Conclusions Overall, the evidence to date indicates that team training positively impacts team performance. Existing evaluations indicate that health care providers demonstrate positive reactions to team training, view it as a viable means for improving patient safety, and demonstrate more high-quality teamwork behavior as a result of training.9 Emerging evidence also suggests that team training can positively impact important patient safety outcomes10,26; however, for team training to be effective, its design and implementation must be scientifically rooted. Additionally, there must be buy-in and active support, especially from senior leaders, physicians, and senior nurses. When these leaders promote, reward, and reinforce teamwork on the job, in the long term, there can be a clear connection between teamwork and meaningful outcomes. Disclaimer All opinions expressed in this article are those of the authors and do not necessarily reflect the opinions or position of the University of Central Florida, the Department of Defense, or TRICARE Management.