Failures in teamwork and communication lead to treatment errors, inefficiency and workplace tension. To begin to address this, we need to know what good teamwork and communication look like and have some measure of progress toward that goal (i.e., a method of assessment).
The evidence on teamwork and communication draws from many industries(1,2) and comprises knowledge, skills or behaviors, and attitudes that lend themselves to different approaches to assessment.
Knowledge: Assessing knowledge could begin by incorporating the literature on effective team communication strategies in undergraduate, postgraduate and continuing education curricula and measuring it within existing assessment programs. The oft-quoted adage “assessment drives learning” is probably true, at least at the undergraduate level; if the material isn’t formally assessed, it may not be considered important by learners.
Skills/behaviors: The skills and behaviors required for effective teamwork are well described(1-4) and measurable. Key behaviors include managing the team (e.g., coordination, monitoring and supporting others); managing the task (e.g., role allocation, planning, prioritizing, identifying, and utilizing resources); and developing a shared team mental model (information sharing on task and role). The communication skills underpinning effective teamwork include closed-loop communication, structured handover,(5) callout(6) (e.g., Stop, Notify, Assessment, Plan, Priorities, Invite ideas [SNAPPI]), and graded assertiveness(7) (Table 1), which lend themselves to use as assessment criteria of teamwork and communication skills.
Teamwork behaviors can be measured by survey or observation. Survey instruments rely on self-report and are open to bias.(8) However, they are easier to administer than observational instruments and, by making explicit the components of teamwork, can potentially promote learning.
Dietz et al(9) recently undertook a review of behaviorally anchored rating scales for observer measurement of teamwork and reported that while the marker systems cover similar content, inconsistent terminology and different levels of granularity make comparisons difficult. These systems have often been developed around acute care events, and often in a simulated setting, probably for logistic reasons. In acute care events, good teamwork is required to avoid immediate, negative consequences for the patient, reducing the time required to observe and score teams. Simulation allows for scheduling, standardizing and repeating events, allowing for comparisons between teams and change over time. Surveys of teamwork may be more feasible in routine or chronic care settings.
Considerable effort has gone into establishing the validity and reliability of the teamwork measurement tools, with varying levels of evidence. However, the need for lengthy rater training (up to several days) to produce reliable scores affects their feasibility for high stakes assessment or research. These instruments may be more valuable in helping teams to know what they are aiming for in teamwork and communication. Linking the learning objectives with the assessment tool through explicit criteria for performance and descriptions of good and poor performance enables team members to consider each item against their own team performance. Reflection and feedback against these criteria identify gaps and strategies to address those gaps. For example, an item on leadership could be, “A leader was clearly established”; a descriptor of good performance could be, “One person was centralizing information and decision making and coordinating the actions of the team.” The descriptor for poor performance could be, “It was unclear who was taking the lead, information was not centralized, and no one was taking on the role of coordinating the team members.”
While self-assessment is prone to bias, there is some evidence that intensive care teams can reliably use teamwork rating scales to discriminate different levels of teamwork performance and thus recognize improvement.(10)
A partial list of potentially useful instruments for the critical care context is provided in Table 2.(3,10-16)
Attitudes: Attitudes are generally assessed through surveys or interviews and, because they must rely on self-report, results can be open to bias. Relevant instruments include the Safety Attitudes Questionnaire,(17) Assessment of Interprofessional Team Collaboration Scale,(8) the TeamSTEPPS attitudes to teamwork,(18) Collaboration and Satisfaction about Care Decisions in intensive care teams,(19) and Heinemann’s Attitudes Toward Health Care Teams Scale.(20) Some studies using these instruments have found that positive attitudes toward teamwork are linked to improved patient outcomes. Attitudes are more resistant to change than behaviors, and negative attitudes toward teamwork can undermine initiatives to improve it. Mutual trust and respect and a team orientation are fundamental requirements for effective teamwork.
Clinicians need to be convinced of the relevance of learning about teamwork and communication in order to change, but important barriers exist. Training professional silos limit opportunities to learn about the roles and capabilities of others and how they contribute to decision making and patient management. Patient care can be fragmented and responsibility delineated within professional boundaries, creating barriers to working as a whole team and monitoring and supporting each other.(21) Hierarchical attitudes persist, and where power differentials exist between team members, open communication is discouraged: the less powerful fear negative consequences, and the powerful fail to value the input of all team members.(22)
While an individual may be competent, what matters to the patient is the collective competence(23) of the team and their ability to perform, which depends on: individual competence; appropriate skill mix; prior experience working together; the environment and available resources; and the organizational support for teamwork. Furthermore, team membership is constantly changing. With multiple factors influencing the performance of teams, there seems little point in “failing” a particular individual or team. The focus should be on continuous improvement, which may require interventions at multiple levels.
So far we have considered the assessment knowledge, skills and attitudes of teams and individual members. The relevant outcome measures for overall team performance can be considered using the input-process-output framework(2) (Figure 1).
Measurable inputs influencing team performance include: attributes of team members, including their knowledge, skills and attitudes relevant to teamwork and communication; the task at hand; environmental resources (e.g., availability of checklists, scheduled team briefings); and the organizational culture in which the team functions (e.g., valuing democracy in teams). Observable behaviors, as measured by teamwork measurement tools, and compliance with established protocols are process measures. Output measures include: patient outcomes (complications, length of hospital stay, 30-day mortality); use of time and resources; and impact on staff (staff morale, staff retention). Mazzocco et al(24) developed the Behavioral Marker Risk Index, a simple instrument to measure teamwork in operating room teams, and found an association between index scores and the rate of adverse patient events, suggesting a clear link between teamwork process measures and patient outcomes.
The purpose of assessing teamwork and communication is to improve team performance. Effective teamwork and communication depend on the knowledge, skills and attitudes of individual team members, their ability to form teams, and an enabling environment and organizational culture. Instruments to measure teamwork can: 1) help individuals and workgroups acquire the skills and behaviors of effective teams, and 2) demonstrate improvement following interventions. The aim of improving team performance is to produce better outcomes for patients, and assessment of the quality and safety of patient care is the ultimate yardstick against which to measure and drive improvement in teamwork and communication.
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