Team interventions in acute hospital contexts: a systematic search of the literature using realist synthesis

Measuring interprofessional collaboration in fluid healthcare teams through the lens of teamness

Health professionals often need to work together to provide team-based care. With increasing healthcare complexities and manpower shortages, more health professionals are working in multiple, fluid teams instead of one stable team, to provide care to patients. However, there is currently no validated instrument to measure the quality of interprofessional collaboration in fluid teams. One approach is to assess team members' perceived level of teamness (qualities that make clinical teams effective). This study aimed to examine the validity evidence of using the Assessment for Collaborative Environment (ACE-15) in fluid teams and investigate if teamness varies among health professions and clinical settings. Content and response process validity were gathered through consulting experts and cognitive interviews, resulting in revisions to 11 of 15 items in ACE-15. Through exploratory factor analysis of 194 responses on the revised ACE-15, a 13-item instrument, ACE-13F, with strong validity evidence for use in fluid teams was developed. A two-factor fixed effect ANOVA model revealed that the clinical setting that health professionals work in has a significant impact on the level of teamness (F[3,170] = 6.15, p < .001, η2 = 0.09). ACE-13F can be used as a rapid instrument to measure interprofessional collaboration in fluid healthcare teams.

Green Cross method in a postanaesthesia care unit: a qualitative study of the healthcare professionals' experiences after 3 years, including the COVID-19 pandemic period

OBJECTIVES

Unsafe medical care causes morbidity and mortality among the hospital patients. In a postanaesthesia care unit (PACU), increasing patient safety is a joint effort between different professions. The Green Cross (GC) method is a user-friendly incident reporting method that incorporates daily safety briefings to support healthcare professionals in their daily patient safety work. Thus, this study aimed to describe healthcare professionals' experiences with the GC method in a PACU setting 3 years after its implementation, including the period of the coronavirus disease 2019 pandemic's three waves.

DESIGN

An inductive, descriptive qualitative study was conducted. The data were analysed using qualitative content analysis.

SETTING

The study was conducted at a PACU of a university hospital in South-Eastern Norway.

PARTICIPANTS

Five semistructured focus group interviews were conducted in March and April 2022. The informants (n=23) were PACU nurses (n=18) and collaborative healthcare professionals (n=5) including physicians, nurses and a pharmacist.

RESULTS

The theme 'still active, but in need of revitalisation' was created, describing the healthcare professionals' experiences with the GC method, 3 years post implementation. The following five categories were found: 'continuing to facilitate open communication', 'expressing a desire for more interprofessional collaboration regarding improvements', 'increasing reluctance to report', 'downscaling due to the pandemic' and 'expressing a desire to share more of what went well'.

CONCLUSIONS

This study offers information regarding the healthcare professionals' experiences with the GC method in a PACU setting; further, it deepens the understanding of the daily patient safety work using this incident reporting method.

“When there's collective leadership, there's the power to make changes”: A realist evaluation of a collective leadership intervention (Co-Lead) in healthcare teams

There is accumulating evidence for collective approaches to leadership, where multiple individuals share leadership roles, but there remains a lack of theory-informed research on how collective leadership is fostered in practice. This study evaluated the impact of a collective leadership intervention, exploring what works for whom, how, and under what circumstances through a mixed-methods realist evaluation of four case studies. Eight context-mechanism-outcome configurations (theories) were extrapolated that elucidate the mechanisms triggered to drive outcomes in particular settings. This is the first study to apply a realist lens to understand collective leadership and articulate the generative mechanisms that enable/inhibit collective leadership in healthcare teams.

Which Attributes of Credibility Matter for Quality Improvement Projects in Hospital Care-A Multiple Case Study among Hospitalists in Training

Healthcare professionals have to give substance to the role of a champion in order to successfully lead quality improvement (QI) initiatives. This study aims to unravel how hospitalists in training shape their role as a champion within the context of QI projects in hospital care and why some are more effective in leading a QI project than others. We focus on the role of credibility, as it is a prerequisite for fulfilling the role of champion. This multiple-case study builds upon 23 semi-structured interviews with hospitalists in training: quality officers and medical specialists. We first coded data for each case and then described the different contexts of each case in detail to enable comparison across settings. We then compared the cases and contrasted the attributes of credibility. Four attributes of credibility emerged and were identified as essential for the hospitalist in training to succeed as a champion: (1) being convincing about the need for change by providing supportive clinical evidence, (2) displaying competence in their clinical work and commitment to their tasks, (3) generating shared ownership of the QI project with other healthcare professionals, and (4) acting as a team player to foster collaboration during the QI project. We also identified two contextual factors that supported the credibility of the hospitalist in training: (1) choosing a subject for the QI project that was perceived as urgently required by the group of stakeholders involved, and (2) being supported by the board of directors and other formal and informal leaders as the leader of a QI project. Further research is needed to gain a deeper understanding of the relationship between credibility and sustainability of change.

Conceptualising contexts, mechanisms and outcomes for implementing large-scale, multisite hospital improvement initiatives: a realist synthesis

DESIGN

Realist synthesis.

STUDY BACKGROUND

Large-scale hospital improvement initiatives can standardise healthcare across multiple sites but results are contingent on the implementation strategies that complement them. The benefits of these implemented interventions are rarely able to be replicated in different contexts. Realist studies explore this phenomenon in depth by identifying underlying context-mechanism-outcome interactions.

OBJECTIVES

To review implementation strategies used in large-scale hospital initiatives and hypothesise initial programme theories for how they worked across different contexts.

METHODS

An iterative, four-step process was applied. Step 1 explored the concepts inherent in large-scale interventions using database searches and snowballing. Step 2 identified strategies used in their implementation. Step 3 identified potential initial programme theories that may explain strategies' mechanisms. Step 4 focused on one strategy-theory pairing to develop and test context-mechanism-outcome hypotheses. Data was drawn from searches (March-May 2020) of MEDLINE, Embase, PubMed and CINAHL, snowballed from key papers, implementation support websites and the expertise of the research team and experts.

INCLUSION CRITERIA

reported implementation of a large-scale, multisite hospital intervention. RAMESES reporting standards were followed.

RESULTS

Concepts were identified from 51 of 381 articles. Large-scale hospital interventions were characterised by a top-down approach, external and internal support and use of evidence-based interventions. We found 302 reports of 28 different implementation strategies from 31 reviews (from a total of 585). Formal theories proposed for the implementation strategies included Diffusion of Innovation, and Organisational Readiness Theory. Twenty-three context-mechanism-outcome statements for implementation strategies associated with planning and assessment activities were proposed. Evidence from the published literature supported the hypothesised programme theories and were consistent with Organisational Readiness Theory's tenets.

CONCLUSION

This paper adds to the literature exploring why large-scale hospital interventions are not always successfully implemented and suggests 24 causative mechanisms and contextual factors that may drive outcomes in the planning and assessment stage.

Implementing a new emergency medical triage tool in one health region in Norway: some lessons learned

BACKGROUND

Acutely sick or injured patients depend on ambulance and emergency department personnel performing an accurate initial assessment and prioritisation (triage) to effectively identify patients in need of immediate treatment. Triage also ensures that each patient receives fair initial assessment. To improve the patient safety, quality of care, and communication about a patient's medical condition, we implemented a new triage tool (the South African Triage Scale Norway (SATS-N) in all the ambulance services and emergency departments in one health region in Norway. This article describes the lessons we learnt during this implementation process.

METHODS

The main framework in this quality improvement (QI) work was the plan-do-study-act cycle. Additional process sources were 'The Institute for Healthcare Improvement Model for improvement' and the Norwegian Patient Safety Programme.

RESULTS

Based on the QI process as a whole, we defined subjects influencing this work to be successful, such as identifying areas for improvement, establishing multidisciplinary teams, coaching, implementing measurements and securing sustainability. After these subjects were connected to the relevant challenges and desired effects, we described the lessons we learnt during this comprehensive QI process.

CONCLUSION

We learnt the importance of following a structured framework for QI process during the implementation of the SATS-N triage tool. Furthermore, securing anchoring at all levels, from the managements to the medical professionals in direct patient-orientated work, was relevant important. Moreover, establishing multidisciplinary teams with ambulance personnel, emergency department nurses and doctors with various medical specialties provided ownership to the participants. Meanwhile, coaching provided necessary security for the staff directly involved in caring for patients. Keeping the spirit and perseverance high were important factors in completing the implementation. Establishment of the regional network group was found to be important for sustainability and further improvements.

A Case Study of a Whole System Approach to Improvement in an Acute Hospital Setting

Changes in healthcare tend to be project-based with whole system change, which acknowledges the interconnectedness of socio-technical factors, not the norm. This paper attempts to address the question of whole system change posed by the special issue and brings together other research presented in this special issue. A case study approach was adopted to understand the deployment of a whole system change in the acute hospital setting along four dimensions of a socio-technical systems framework: culture, system functioning, action, and sense-making. The case study demonstrates evidence of whole system improvement. The approach to change was co-designed by staff and management, projects involving staff from all specialities and levels of seniority were linked to each other and to the strategic objectives of the organisation, and learnings from first-generation projects have been passed to second and third-generation process improvements. The socio-technical systems framework was used retrospectively to assess the system change but could also be used prospectively to help healthcare organisations develop approaches to whole system improvement.

A Realist Evaluation of Team Interventions in Acute Hospital Contexts-Use of Two Case Studies to Test Initial Programme Theories

BACKGROUND

Designing and implementing team interventions to improve quality and safety of care in acute hospital contexts is challenging. There is little emphasis in the literature on how contextual conditions impact interventions or how specific active ingredients of interventions impact on team members' reasoning and enact change. This realist evaluation helps to deepen the understanding of the enablers and barriers for effective team interventions in these contexts.

METHODS

Five previously developed initial programme theories were tested using case studies from two diverse hospital contexts. Data were collected from theory driven interviews (n = 19) in an Irish context and from previously conducted evaluative interviews (n = 16) in a US context. Data were explored to unpack the underlying social and psychological drivers that drove both intended and unintended outcomes. Patterns of regularity were identified and synthesised to develop middle-range theories (MRTs).

RESULTS

Eleven MRTs demonstrate how and why intervention resources introduced in specific contextual conditions enact reasoning mechanisms and generate intended and unintended outcomes for patients, team members, the team and organisational leaders. The triggered mechanisms relate to shared mental models; openness, inclusivity and connectedness; leadership and engagement; social identity and intrinsic motivational factors.

CONCLUSIONS

The findings provide valuable information for architects and facilitators of team interventions in acute hospital contexts, as well as help identify avenues for future research. Dataset: The data presented in this study are available on request from the corresponding author. The data are not publicly available due to their sensitive nature and potential identification of participants.

Longitudinal team training program in a Norwegian surgical ward: a qualitative study of nurses' and physicians' experiences with implementation

BACKGROUND

Team training interventions to improve team effectiveness within healthcare are widely used. However, in-depth knowledge of how healthcare professionals experience such team training curricula and their implementation processes, as well as how contextual factors impact implementation, is currently missing. The aim of this study is therefore to describe healthcare professionals' experiences with the implementation of a longitudinal interprofessional team training program in a surgical ward.

METHODS

A descriptive design was applied based on qualitative semi-structured focus group interviews with 11 healthcare professionals. A convenience sample of physicians (n = 4), registered nurses (n = 4), and certified nursing assistants (n = 3) was divided into three professionally based focus groups, which were interviewed at three time intervals over a period of 1 year.

INTERVENTION

The validated and evidence-based team training program Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) was implemented in a surgical ward at a hospital between January 2016 and June 2017. The team training program included three phases: 1) assessment and planning, 2) training and implementation, and 3) sustainment.

RESULTS

Healthcare professionals' experiences with the content of the team training program varied from valuing the different elements of it to seeing the challenges in implementing the elements in clinical practice. A one-day training course was found to be especially beneficial for interprofessional collaboration at the ward. Over time, the nursing staff seemed to maintain their motivation for the implementation of the tools and strategies, while the physicians became less actively involved. Contextual ward factors influenced the adoption and utilization of the tools and strategies of the program both positively and negatively. The healthcare professionals' experienced the implementation of the team training program as positive for the patient safety culture at the ward in the forms of increased awareness of teamwork and open communication.

CONCLUSIONS

The study suggests that the implementation of a team training program in a surgical ward is dependent on a set of factors related to content, process, context, and impact. Knowledge on how and why a team training program work supports the transferability to clinical practice in further planning of team training measures.

TRIAL REGISTRATION

The study is part of a larger research project with a study protocol that was registered retrospectively on 05.30.17, with the trial registration number ISRCTN13997367 .

Team interventions in acute hospital contexts: protocol for the evaluation of an initial programme theory using realist methods

Introduction: Literature on multi-disciplinary healthcare team interventions to improve quality and safety of care in acute hospital contexts tends to focus on evaluating the success of the intervention by assessing patient outcomes. In contrast, there is little focus on the team who delivered the intervention, how the team worked to deliver the intervention or the context in which it was delivered. In practice, there is therefore a poor understanding of why some interventions work and are sustained and why others fail. There is little emphasis in the literature on how the team delivering the intervention might impact success or failure.

Given that team is the vehicle through which these interventions are introduced, it is important to understand interventions from their perspectives.

This research seeks to deepen understanding of enablers and barriers for effective team interventions. Using two case studies, we will evaluate previously developed initial programme theories to understand, what worked for whom, in what conditions, why, to what extent and how?

Methods and analysis: A realist evaluation approach will be employed to test the previously formed set of initial programme theories. Two multi-disciplinary acute hospital team interventions in two different geographical and organisational contexts will be identified. In case study 1, a theory based approach to interviewing will be used. In case study 2, interview transcripts obtained using a semi- structured approach for primary research purposes will undergo secondary analysis.

This will enable a more sensitive look at patterns and variations in patterns of multi-disciplinary team interventions. Researchers will first iteratively interrogate each respective dataset to identify the characteristics or resources present within the specific context that influenced how the team intervention worked to produce particular outcomes. Data will then be synthesised across contexts in order to produce middle range theories and thereby more generalisable insights.

A human factors intervention in a hospital - evaluating the outcome of a TeamSTEPPS program in a surgical ward

BACKGROUND

Patient safety in hospitals is being jeopardized, since too many patients experience adverse events. Most of these adverse events arise from human factors, such as inefficient teamwork and communication failures, and the incidence of adverse events is greatest in the surgical area. Previous research has shown the effect of team training on patient safety culture and on different areas of teamwork. Limited research has investigated teamwork in surgical wards. The aim of this study was to evaluate the professional and organizational outcomes of a team training intervention among healthcare professionals in a surgical ward after 6 and 12 months. Systems Engineering Initiative for Patient Safety 2.0 was used as a conceptual framework for the study.

METHODS

This study had a pre-post design with measurements at baseline and after 6 and 12 months of intervention. The intervention was conducted in a urology and gastrointestinal surgery ward in Norway, and the study site was selected based on convenience and the leaders' willingness to participate in the project. Survey data from healthcare professionals were used to evaluate the intervention. The organizational outcomes were measured by the unit-based sections of the Hospital Survey of Patient Safety Culture Questionnaire, and professional outcomes were measured by the TeamSTEPPS Teamwork Perceptions Questionnaire and the Collaboration and Satisfaction about Care Decisions in Teams Questionnaire. A paired t-test, a Wilcoxon signed-rank test, a generalized linear mixed model and linear regression analysis were used to analyze the data.

RESULTS

After 6 months, improvements were found in organizational outcomes in two patient safety dimensions. After 12 months, improvements were found in both organizational and professional outcomes, and these improvements occurred in three patient safety culture dimensions and in three teamwork dimensions. Furthermore, the results showed that one of the significant improved teamwork dimensions "Mutual Support" was associated with the Patient Safety Grade, after 12 months of intervention.

CONCLUSION

These results demonstrate that the team training program had effect after 12 months of intervention. Future studies with larger sample sizes and stronger study designs are necessary to examine the causal effect of a team training intervention in this context.

TRIAL REGISTRATION NUMBER

ISRCTN13997367 (retrospectively registered).

Longitudinal team training programme in a Norwegian surgical ward: a qualitative study of nurses' and physicians' experiences with teamwork skills

OBJECTIVES

Teamwork and interprofessional team training are fundamental to ensuring the continuity of care and high-quality outcomes for patients in a complex clinical environment. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based team training programme intended to facilitate healthcare professionals' teamwork skills. The aim of this study is to describe healthcare professionals' experiences with teamwork in a surgical ward before and during the implementation of a longitudinal interprofessional team training programme.

DESIGN

A qualitative descriptive study based on follow-up focus group interviews.

SETTING

A combined gastrointestinal surgery and urology ward at a hospital division in a Norwegian hospital trust.

PARTICIPANTS

A convenience sample of 11 healthcare professionals divided into three professionally based focus groups comprising physicians (n=4), registered nurses (n=4) and certified nursing assistants (n=3).

INTERVENTIONS

The TeamSTEPPS programme was implemented in the surgical ward from May 2016 to June 2017. The team training programme included the three phases: (1) assessment and planning, (2) training and implementation and (3) sustainment.

RESULTS

Before implementing the team training programme, healthcare professionals were essentially satisfied with the teamwork skills within the ward. During the implementation of the programme, they experienced that team training led to greater awareness and knowledge of their common teamwork skills. Improved teamwork skills were described in relation to a more systematic interprofessional information exchange, consciousness of leadership-balancing activities and resources, the use of situational monitoring tools and a shared understanding of accountability and transparency.

CONCLUSIONS

This study suggests that the team training programme provides healthcare professionals with a set of tools and terminology that promotes a common understanding of teamwork, hence affecting behaviour and communication in their daily clinical practice at the surgical ward.

TRIAL REGISTRATION NUMBER

ISRCTN13997367.

Collaboration between parents and SLTs produces optimal outcomes for children attending speech and language therapy: Gathering the evidence

BACKGROUND

Collaboration between parents and speech and language therapists (SLTs) is seen as a key element in family-centred models. Collaboration can have positive impacts on parental and children's outcomes. However, collaborative practice has not been well described and researched in speech and language therapy for children and may not be easy to achieve. It is important that we gain a deeper understanding of collaborative practice with parents, how it can be achieved and how it can impact on outcomes. This understanding could support practitioners in daily practice with regard to achieving collaborative practice with parents in different contexts.

AIMS

To set a research agenda on collaborative practice between parents and SLTs in order to generate evidence regarding what works, how, for whom, in what circumstances and to what extent.

METHODS & PROCEDURES

A realist evaluation approach was used to make explicit what collaborative practice with parents entails. The steps suggested by the RAMESES II project were used to draft a preliminary programme theory about collaborative practice between parents and SLTs. This process generates explicit hypotheses which form a potential research agenda.

DISCUSSION & CONCLUSIONS

A preliminary programme theory of collaborative practice with parents was drafted using a realist approach. Potential contextual factors (C), mechanisms (M) and outcomes (O) were presented which could be configured into causal mechanisms to help explain what works for whom in what circumstances. CMO configurations were drafted, based on the relevant literature, which serve as exemplars to illustrate how this methodology could be used. In order to debate, test and expand our hypothesized programme theory for collaborative practice with parents, further testing against a broader literature is required alongside research to explore the functionality of the configurations across contexts. This paper highlights the importance of further research on collaborative practice with parents and the potential value of realist evaluation methodology. What this paper adds Current policy in education, health and social care advocates for family-centred care and collaborative practice with parents. Thereby, collaborative practice is the preferred practice for SLTs and parents. In this paper, we explore collaborative practice and use a realist evaluation approach to achieve the aim of setting a research agenda in this area. Researchers use realist evaluation, a methodology originally developed by Pawson and Tilley in the 1990s, to explore the causal link between interventions and outcomes, summarized as what works, how, for whom, in what circumstances and to what extent. Realist evaluation provides a framework to explore configurations between contexts (C), mechanisms (M) and outcomes (O). We used this methodology to take a first step at making explicit what collaborative practice is and how it might be achieved in different contexts. We did this by drafting a preliminary programme theory about collaborative practice, where we made explicit what context factors and mechanisms might influence outcomes in collaborative practice between parents and SLTs. Based on this programme theory, we argue for the need to develop a research agenda on collaborative practice with parents of children with speech, language and communication needs. The steps between a programme theory and a research agenda could entail exploring each CMO, or step in the programme theory, and evaluating it against the existing literature-both within and beyond speech and language therapy-to see how far it stands up. In this way, gaps could be identified that could be converted into research questions that would stimulate debate about a research agenda on collaborative practice. Understanding how collaborative practice can be achieved in different contexts could support SLTs to use mechanisms to optimise collaborative practice intentionally and tailor interventions to the specific needs of families, thereby enhancing collaborative practice between parents and SLTs.

Application of the critical incident technique in refining a realist initial programme theory

Background

As realist methodology is still evolving, there is a paucity of guidance on how to conduct theory driven interviews. Realist researchers can therefore struggle to collect interview data that can make a meaningful contribution to refining their initial programme theory. Collecting data to inform realist Inital Programme Theories (IPTs) in healthcare contexts is further compounded due to the healthcare workers’ busy work schedules.

In this case study of team interventions in acute hospital contexts, we explore the benefits of using the Critical Incident Technique (CIT) in order to build and refine an initial programme theory. We contend that use of the CIT helps to draw on more specific experiences of “Key Informants” and therefore elicits richer and more relevant data for realist enquiry.

Methods

The five steps of the CIT were mapped against realist methods guidance and adapted into an interview framework. Specifications to identify an incident as “critical” were agreed. Probes were embedded in the interview framework to confirm, refine and/or refute previous theories.

Seventeen participants were interviewed and recordings were transcribed and imported for analysis into NVivo software. Using RAMESES guidelines, Context-Mechanism-Outcomes configurations were extrapolated from a total of 31 incidents.

Results

We found that the CIT facilitated construction of an interview format that allowed participants to reflect on specific experiences of interest. We demonstrate how the CIT strengthened initial programme theory development as it facilitated the reporting of the specifics of team interventions and the contexts and mechanisms characteristic of those experiences. As new data emerged, it was possible to evolve previous theories synthesised from the literature as well as to explore new theories.

Conclusions

Utilising a CIT framework paid dividends in terms of the relevance and usefulness of the data for refining the initial programme theory. Adapting the CIT questioning technique helped to focus the participants on the specifics relating to an incident allowing the interviewers to concentrate on probes to explore theories during the interview process. The CIT interview format therefore achieved its purpose and can be adapted for use within realist methodology.

Understanding antibiotic prophylaxis prescribing in pediatric surgical specialties

BACKGROUND

Overuse of antibiotics has caused secondary poor outcomes and has led to a current rate of antibiotic resistant infections that constitutes a public health crisis. In pediatric surgical specialties, children continue to receive unnecessary antibiotics.

OBJECTIVE

To understand the factors that contribute to pediatric surgeons' decisions regarding the use of perioperative antibiotic prophylaxis.

METHODS

Focus groups included pediatric proceduralists/surgeons from the following specialties: interventional cardiology, otolaryngology, orthopedic surgery, cardiothoracic surgery, and general surgery.

RESULTS

A total of 23 surgeons with a median of 9 years of experience (range, 0.5-29 years) participated in the focus groups that lasted 30-90 minutes each. Five themes emerged influencing beliefs about antibiotic prescribing practices: (1) reliance on previous experience and early education, (2) balancing antibiotic use with risk of infection, (3) uncertainty about the state of the scientific evidence, (4) understanding importance of communication and team collaboration, and (5) a prevalence of hospital-level concerns.

CONCLUSIONS

Surgeons describe a complex set of factors that impact their antibiotic prescribing in pediatric surgical cases. They reported initial, but not ongoing, training and a use of individual weight of risk and benefit as a major dictator of prescribing practices. Antimicrobial stewardship programs should work with surgeons to develop acceptable implementation strategies to optimize antibiotic prescribing.

Identifying the context, mechanisms and outcomes underlying collective leadership in teams: building a realist programme theory

BACKGROUND

There is accumulating evidence for the value of collective and shared approaches to leadership. However, relatively little research has explored collective leadership in healthcare and thus, there is a lack understanding of the mechanisms that promote or inhibit the practice of collective leadership in healthcare teams. This study describes the development of an initial programme theory (IPT) to provide insight into the mechanisms underpinning the enactment of collective leadership.

METHODS

This IPT was informed by a multiple-method data collection process. The first stage involved a realist synthesis of the literature on collective leadership interventions in healthcare settings (n = 21 studies). Next, we presented initial findings to receive feedback from a realist research peer support group. Interviews with members of teams identified as working collectively (n = 23) were then conducted and finally, we consulted with an expert panel (n = 5). Context-mechanism-outcome configurations (CMOCs) were extrapolated to build and iteratively refine the programme theory and finalise it for testing.

RESULTS

Twelve CMOCs were extrapolated from these data to form the initial programme theory and seven were prioritised by the expert panel for focused testing. Contextual conditions that emerged included team training on-site, use of collaborative/co-design strategies, dedicated time for team reflection on performance, organisational and senior management support, inclusive communication and decision-making processes and strong supportive interpersonal relationships within teams. Mechanisms reported include motivation, empowerment, role clarity, feeling supported and valued and psychological safety which led to outcomes including improvements in quality and safety, staff and patient satisfaction, enhanced team working, and greater willingness to share and adopt leadership roles and responsibilities.

CONCLUSIONS

This study has identified preliminary support for the contexts, mechanisms and outcomes underpinning the practice of collective leadership. However, it must be noted that while they may appear linear in presentation, in reality they are independent and interlinked and generative of additional configurations. This paper contributes to the nascent literature through addressing an identified gap in knowledge by penetrating below the surface level inputs and outputs of an intervention to understand why it works or doesn't work, and for whom it may work.

Interventions to improve team effectiveness within health care: a systematic review of the past decade

BACKGROUND

A high variety of team interventions aims to improve team performance outcomes. In 2008, we conducted a systematic review to provide an overview of the scientific studies focused on these interventions. However, over the past decade, the literature on team interventions has rapidly evolved. An updated overview is therefore required, and it will focus on all possible team interventions without restrictions to a type of intervention, setting, or research design.

OBJECTIVES

To review the literature from the past decade on interventions with the goal of improving team effectiveness within healthcare organizations and identify the "evidence base" levels of the research.

METHODS

Seven major databases were systematically searched for relevant articles published between 2008 and July 2018. Of the original search yield of 6025 studies, 297 studies met the inclusion criteria according to three independent authors and were subsequently included for analysis. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence.

RESULTS

Three types of interventions were distinguished: (1) Training, which is sub-divided into training that is based on predefined principles (i.e. CRM: crew resource management and TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety), on a specific method (i.e. simulation), or on general team training. (2) Tools covers tools that structure (i.e. SBAR: Situation, Background, Assessment, and Recommendation, (de)briefing checklists, and rounds), facilitate (through communication technology), or trigger (through monitoring and feedback) teamwork. (3) Organizational (re)design is about (re)designing structures to stimulate team processes and team functioning. (4) A programme is a combination of the previous types. The majority of studies evaluated a training focused on the (acute) hospital care setting. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements.

CONCLUSION

Over the last decade, the number of studies on team interventions has increased exponentially. At the same time, research tends to focus on certain interventions, settings, and/or outcomes. Principle-based training (i.e. CRM and TeamSTEPPS) and simulation-based training seem to provide the greatest opportunities for reaching the improvement goals in team functioning.