A review of the literature on teamwork competencies in healthcare practice and training: Implications for undergraduate medical education

Successful teamwork is being recognized as a necessity for many aspects of effective healthcare and team training has proved effective in improving teamwork in healthcare. Therefore it is important to recognize the competencies of teamwork relevant to undergraduate medical education. This review of the literature draws on the teamwork competencies as discussed through diverse contexts of healthcare practice and health professions education and summarizes the competencies that are required with emphasis on undergraduate medical education. It highlights some practice points to medical educators; such as understanding the contexts of healthcare teams, understanding generic competencies of healthcare teamwork and understanding the specific team contexts and teamwork competencies required of trainees that should be emphasized in undergraduate education


Introduction
The world in which healthcare professionals practice is changing and patient-care is becoming team based rather than managed by individuals.The increasing trends in specialization and division of labour in health professions training and practice, as well as the expanding scope of the concept of health and the corresponding interdisciplinary work it thus encompasses, have resulted in the emergence of such team based healthcare (Nagi, 1975;Baldwin Jr, 1996).In this background, successful teamwork is being recognized as a necessity for many aspects of effective healthcare, from acute care settings to shared care in primary or chronic care settings.
Purported benefits of effective teamwork in healthcare include reduced medical errors, improved quality of patient care, enhanced patient satisfaction, improved staff satisfaction and retention, addressing of workload issues and reduced burnout of healthcare professionals (Clements et al., 2007;Estryn-Behar et al., 2007;Williams et al., 1999;Mickan, 2005).Teamwork is vital for some of these benefits.For instance, many of the errors in healthcare provision, especially among trainees, have been the result of teamwork breakdowns (Risser et al., 1999;Singh et al., 2007;Walton, 2004).Therefore successful teamwork is an essential aspect of successful practice as a health professional and should be inculcated during basic professional education.
In this context, the concepts of collaborative learning and inter-professional education are being increasingly emphasized and team training from other domains such as aviation is being drawn upon to improve teamwork among healthcare teams.Such programmes have been successful in error reduction, improved technical performance and team member satisfaction in dynamic domains of healthcare such as emergency medicine, surgery and obstetrics (Morey et al., 2007;Risser et al., 1999;Pratt et al., 2007;McCulloch et al., 2008).Further, a review of teamwork training, including training of medical teams, suggest that moderately positive relationships exist between team training interventions and achievement of cognitive, affective, process and performance outcomes (Salas et al., 2008).Thus team training has proved effective in improving teamwork in healthcare and thus should be implemented during basic professional education.
However, members of healthcare teams are rarely trained together (Baker et al., 2005a).Even in such inter-professional learning, many successful interventions have focused on improvement in learner's reactions, knowledge and skills, while only a few successful interventions, mostly in post basic education, assessed improvements in behaviour and patient care outcomes (Hammick et al., 2007).Therefore, though teamwork is emerging as a key area in medical education, opportunities for implementing team training and evidence of achieving improved healthcare outcomes through such training in undergraduate education are limited.In this context, this review will focus on some of the concerns in teamwork competencies required for undergraduate medical students, which it is hoped will aid medical educators to address the challenges in teamwork learning and assessment.

Teams and teamwork in healthcare
In today's context, as explained above, health professionals are almost always required to work in teams to provide comprehensive, continuing and quality healthcare.Healthcare 'teams' and 'teamwork' have been identified as such only in the last century.According to Cooter (2004) it was only in the early 20 th century that the term 'surgical teams' was used in USA to refer to the group of individuals known till then as a 'surgical firm '. Baldwin Jr (1996) describes the historical development of interdisciplinary practice after the World War II; from the establishment of Community Health Centers to provide primary care to the underprivileged, to the establishment of multidisciplinary teams in specialty oriented fields in both acute (surgery, burns) and chronic (rehabilitation, geriatrics, mental health) domains as well as in generalist primary care.To describe teamwork in healthcare it is necessary to understand the setting and function of these teams of health professionals and define teamwork in such a context.

Types of healthcare teams
Types of teams in healthcare have been described from a healthcare management perspective by Fried et al. (2000) as: work teams, i.e. continuing work units including treatment teams, emergency care teams, research teams and home care teams; parallel teams, i.e. teams to perform functions that the regular organization is not equipped to perform well such as hospital quality improvement teams; project teams i.e. time limited teams such as a team to plan a new hospital; and management teams such as hospital management boards.
Although healthcare professionals are involved in all such teams in professional practice they would mostly be working in continuing work units, or work teams.In clinical practice Black and Craft (2004) suggest that the term 'clinical team' is usually understood to mean the group of people with responsibilities for the direct clinical care of individual patients in a particular setting.They further elaborate that in hospital practice, the team has ceased to resemble the small close-knit medical firm of the past and is an extended body which is multidisciplinary (including specialists from different medical disciplines) and multiprofessional, who must all work together for the best possible patient outcome.Therefore the 'ward team' consisting of physicians at different levels of expertise (from interns to the specialist) and other ward staff, function as a part of a wider team as well.Hall and Weaver (2001) summarize team function in healthcare in a continuum from multidisciplinary to trans-disciplinary depending on the degree of interaction among team members and the degree of responsibility for patient care.In crossprofessional teams Thylefors et al. (2005) andD'Amour et al. (2005) define the term 'multiprofessional' as individuals from different professions working in parallel to provide care to a patient; the term 'inter-professional' as these individuals working towards a shared goal which cannot be achieved without interdependency on their complimentary skills; and the term 'trans-professional' as a blurring/ overlapping of professional boundaries in performance of such team roles.
In describing healthcare teams especially in the 'dynamic domains of healthcare' such as operating rooms, intensive care, emergency medicine, or trauma and resuscitation teams, Manser (2009) identifies that such teams work under conditions that change frequently, may be assembled ad hoc, have a dynamically changing team membership, often work together for a short period of time and have to integrate different professional cultures.These are known as 'action teams' in team literature.Saltman et al. (2006) argue that health professionals practice in both 'groups' focused on individual tasks and performance goals (e.g.clinical networks, academic departments, professional bodies) and 'teams' focused on shared tasks and performance goals (e.g.rural health, emergency setting).They suggest that a health professional should be able to seamlessly oscillate between individual and team effort according to the type of group or team.
In summary, healthcare teams, either ad hoc or in continuing units, function in a continuum from multidisciplinary to trans-professional, and can be found in all aspects of healthcare from acute care in central settings including emergency medicine, surgery, obstetrics, trauma and intensive care to continuing care in central or distributed settings including community care, primary care, rural health, mental health, general practice, geriatrics and rehabilitation.The teamwork competencies of their members should be understood according to the demands in the context of such settings and functions.

Defining 'Teamwork in Healthcare'
Researchers have attempted to define 'teamwork in healthcare' as applicable to healthcare teams described above.In management literature a 'team' has been defined as a small number of people with complementary skills who are committed to a common purpose, set of performance goals, and approach for which they hold themselves mutually accountable (Katzenbach & Smith, 1993).It is evident from the above discussion that teams in healthcare with patient-centred goals conform to this definition.
A concept analysis by Xyrichis and Ream (2008) proposes teamwork in healthcare as a dynamic process involving two or more healthcare professionals with complementary backgrounds and skills, sharing common health goals and exercising concerted physical and mental effort in assessing, planning, or evaluating patient care.Another dynamic view of teamwork through systems theory is offered in a literature review on team characteristics by Mickan and Rodger (2000), which describes teamwork as input conditions transformed via optimum throughput processes into maximal output.
In a comprehensive review of the literature on medical teams and patient safety Baker et al. (2005b) draw from the team training literature and the 'action teams' in healthcare to define teamwork as performance of two or more individuals, with specific roles, performing specific tasks, and interacting or coordinating to achieve a common goal or outcome.They elaborate that teams make decisions; possess specialized knowledge and skills; embody a collective action arising out of task interdependency; and teamwork characteristically mandates an adjustment on the part of team members to one another, in an effort to accomplish team goals.
These definitions and the actual practice of healthcare teams highlight that teamwork requires health professionals, mostly from different professional backgrounds and complementary skills to coordinate, communicate and collaborate in order to perform interdependent tasks and make mutually accountable decisions towards a shared goal of improved patient care.According to the context of the teams to which they belong, health professionals should be able to recognize and perform independent tasks requiring competencies that maybe specific to their profession but which requires coordination as well as tasks requiring interdependency.
Medical educators should focus on these varied contexts and the different roles medical graduates will encounter as they progress in their professional career in teaching teamwork.

Research on teamwork competencies in healthcare
A number of 'competencies' to become a successful team member in health professions learning and practice have been identified in literature.From a management perspective, a competency is defined as a "cluster of knowledge, skills and attitudes" (Parry, 1998).In education, Spady (1977) defines competencies as "indicators of successful performance in life-role activities (e.g.political citizen, life-long learner)" and distinguishes them "from the discrete cognitive, manual, and social capacities that serve as their enablers".He later defines outcome based education as "basing what we do instructionally on the outcomes we want to achieve, where practitioners start by determining such competencies" (Spady, 1988).Educational competencies identified in the literature on teamwork in healthcare are either the 'curriculum outcomes', or the 'knowledge, skills and attitudes' that are their 'enablers'.

Competencies in team training literature and their application in healthcare
Teamwork competency has been well described in the literature on management/ organizational behaviour.Katzenbach and Smith (1993) describe four elements essential for effective team performance; common commitment and purpose, performance goals, complementary skills, and mutual accountability.Stevens and Campion (1994) categorize the knowledge, skills and abilities required for teamwork as interpersonal (conflict resolution, collaborative problem solving, communication) and self-management (goal setting and performance management, and planning and task coordination) competencies.These competencies are similar to the healthcare related teamwork competencies described below.
Parallel to these developments, team performance has been extensively studied in high reliability contexts such as aviation, nuclear power plants and military teams.These researchers have identified competencies and developed frameworks and taxonomies (table 1) in constructing and validating teamwork measures (Fleishman & Zaccaro, 1992;Dickinson & McIntyre, 1992;Brannick et al., 1995).Extending such team training research to healthcare; through reviews of the literature, surveys, observations, and analysis of critical incidents, researchers have identified required competencies (table 2) and even developed tools of assessment in dynamic domains of healthcare (Thomas et al., 2004;Cole & Crichton, 2006;Undre et al., 2006;Healey et al., 2006;Frankel et al., 2007;Fernandez et al., 2008;Reader et al., 2009).

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A systematic literature review on medical team training literature by Baker et al. (2005a) summarizes these competencies as knowledge (shared task models, situational awareness, teammate characteristic familiarity, knowledge of team goals and task specific responsibilities); skills (monitoring, adaptability, backup behaviour, team leadership, conflict resolution, feedback, closed-loop communication) and attitude (team orientation, collective efficacy, shared vision, team cohesion, mutual trust, importance of teamwork) competencies.loop communication).Thus a team member should establish and maintain a shared understanding of the team context and tasks, should perform team processes where leadership is important, should also perform team processes where support is important, and effectively communicate to perform these.This grouping is neither hierarchical or context specific but rather describes different, though sometimes interrelated, 'life-role activities' a team member encounters which may require varied combinations of knowledge, skills and attitude competencies.For instance, attitudes of trust and team orientation, based on which the skills of mutual performance monitoring and backing up at times of high workload should be practiced, are required to support other team members.

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There are several issues that need to be recognized in identifying these competencies through the team training literature.Militello et al. (1999) in evaluating existing team performance models, correctly identify that the competencies have been described at different levels of abstraction.This is evident even in the studies and frameworks described above and the subsequent grouping derived is an attempt to classify them at a higher but equal level of abstraction.Further, in a review of team training studies of competencies from aviation team training Lenne (2003) cautions that very little seem to be understood about processes in distributed teams.In the next section competencies in distributed teams will be described according to the above grouping where appropriate.

Table 3: Teamwork competencies in interprofessional practice and education
While illustrating the significant overlap of these with the teamwork competencies described in the dynamic domains of health care, these highlight competencies required to cross professional boundaries and resolve associated issues of leadership and professional roles; and manage communication issues in dispersed teams.Thus there is more emphasis on aspects such as understanding each other's professional background and its impact on roles and responsibilities in the team and understanding when and how to involve other healthcare professionals in dispersed teams (shared understanding of context), willingness to collaborate with other professions (team support), communicating with respect/ clarity and regular review (communication), teaching other professions and patient centred integrative care.
Medical educators in undergraduate education should focus on preparing students with such generic competencies to effectively function in teams in different settings.

The relevance of teamwork competencies for trainees
Most teamwork contexts and competency frameworks described above are broadly addressed at all health professions and many are applicable for medical professionals at all levels of expertise.However, some contexts and competencies may be more relevant than others to trainees.Hughes et al, (2008) state that teamwork skills in undergraduate medical education may include, among others, group work skills, skills of reflection and analysis and skills of effective feedback.Singh et al. (2007) highlight the significance of patient safety for trainees through a study of malpractice claims that conclude that teamwork breakdowns contributed to 70% of errors among trainees, with lack of supervision, handoff problems and lack of clear lines of responsibility significantly higher among such trainee errors.Burke et al. (2000) discuss that role ambiguity and uncertainty about degree of competence, leadership and responsibility effects trainee performance in multidisciplinary mental health teams.Outcome statements and teamwork competencies for trainees and medical students attempt to further clarify these.

Competency statements in undergraduate education
Table 6 lists competencies of teamwork in healthcare identified for undergraduate education by researchers and educators through review of curricula for the changing practice environment (Halpern et al., 2001), through review of quality standards for interprofessional capability (Walsh et al., 2005), through application of an outcome based model for medical schools curricula (Simpson et al., 2002) and through stakeholder surveys in acute care (Perkins et al., 2005).

Table 5: Teamwork competencies in outcome/ competency frameworks by professional and educational organizations
In summary these studies and competency statements on trainees draws attention to some specific and challenging teamwork contexts encountered by interns and residents, such as patient handovers, acute and critical care situations such as cardiac arrests, ensuring continuity of care through distributed teams and learning while performing.Further, in addition to highlighting the well explored competencies in team training and interprofessional practice, these also emphasize some of the aspects important to recent graduates and postgraduate trainees such as assertiveness, negotiation, coping with uncertainty and valuing others' expertise in decision making (leadership); knowing one's responsibilities and limitations (shared understanding), dealing with other team members in the context of patient interests (team support) and teaching/ learning together in healthcare team environments.
Medical educators should focus specifically on these team contexts that a graduate will encounter and the relevant competencies.

Conclusion
Teamwork in healthcare is becoming increasingly emphasized in healthcare practice and health professions education, as improved teamwork have resulted in many benefits including improved quality of care and error reduction.Therefore team training is essential for medical education, especially from a perspective of improving inter-professional collaboration and patient safety.Researchers and educators have identified teamwork competencies relevant to healthcare from acute, centralized settings to continuing care in dispersed settings through research in team training in high reliability contexts and in interprofessional practice.A summary of such competencies, highlighting competencies in inter-professional practice and undergraduate medical education where further emphasis was found, is given below.
Educators in undergraduate medical education need to distinguish the teamwork contexts and competencies required as a medical professional and which of those are essential for a trainee.They need to focus especially on these team contexts that a graduate will encounter and the relevant competencies, while preparing the students with generic competencies applicable to the variety of team contexts in healthcare.
of similar studies in high reliability contexts and further quantitative and qualitative analyses,Salas et al. (2005) identify five core components and three supporting coordinating mechanisms of teamwork; namely the components of team leadership, mutual performance monitoring, back up behaviour, adaptability, team orientation and their coordination through shared mental models, closed-loop communication and mutual trust.

Table 2 : Teamwork competencies in dynamic domains of healthcare Neonatal resuscitation Truama care Surgery Intensive care Emergency medicine Thomas et al, 2004 Cole & Crichton, 2006 Undre et al, 2006 Healey et al, 2006 Frankel et al, 2007 Reader et al, 2009 Fernandez et al, 2008
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