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A systematic review of teamwork in the intensive care unit: What do we know about teamwork, team tasks, and improvement strategies?
A Systematic Review of Teamwork in the ICU: What do we know about Teamwork, Team Tasks, and Improvement Strategies? Aaron S. Dietz MA, Peter J. Pronovost MD, PhD, Pedro Alejandro Mendez-Tellez MD, Rhonda Wyskiel RN, BSN, Jill A. Marsteller PhD, MPP, David A. Thompson DNSc, MS, RN, Michael A. Rosen PhD PII: DOI: Reference:
S0883-9441(14)00226-3 doi: 10.1016/j.jcrc.2014.05.025 YJCRC 51539
To appear in:
Journal of Critical Care
Received date: Revised date: Accepted date:
9 January 2014 13 May 2014 27 May 2014
Please cite this article as: Dietz Aaron S., Pronovost Peter J., Mendez-Tellez Pedro Alejandro, Wyskiel Rhonda, Marsteller Jill A., Thompson David A., Rosen Michael A., A Systematic Review of Teamwork in the ICU: What do we know about Teamwork, Team Tasks, and Improvement Strategies?, Journal of Critical Care (2014), doi: 10.1016/j.jcrc.2014.05.025
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ACCEPTED MANUSCRIPT A Systematic Review of Teamwork in the ICU: What do we know about Teamwork, Team Tasks, and Improvement Strategies?
Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine Baltimore, MD USA
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The Armstrong Institute for Patient Safety and Quality The Johns Hopkins University School of Medicine Baltimore, MD USA
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Aaron S. Dietz, MA1 Peter J. Pronovost, MD, PhD1,2 Pedro Alejandro Mendez-Tellez, MD2 Rhonda Wyskiel, RN, BSN1 Jill A. Marsteller, PhD, MPP1,3 David A. Thompson, DNSc, MS, RN1,2 Michael A. Rosen, PhD1,2
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Department of Health Policy and Management The Johns Hopkins University Bloomberg School of Public Health Baltimore, MD USA
Address correspondence to:
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Michael A. Rosen, PhD Assistant Professor Armstrong Institute for Patient Safety and Quality, and Department of Anesthesiology & Critical Care Medicine Johns Hopkins University School of Medicine 750 East Pratt Street, 15th Floor Baltimore, MD 21202 Office: 1-443-637-6269 [email protected] Institution: This work was performed at Johns Hopkins University. Support: This work was supported by funding from the Gordon and Betty Moore Foundation (Grant #3186.01). The views expressed in this paper are those of the authors and not necessarily reflective of Johns Hopkins University or the Gordon and Betty Moore Foundation. Word Count: 3,564
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ACCEPTED MANUSCRIPT Key Words: Teamwork; Intensive Care Unit; Patient Safety; Group Processes
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ABSTRACT
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Purpose: Teamwork is essential for ensuring the quality and safety of healthcare delivery in the intensive care unit (ICU). This article addresses what we know about teamwork, team tasks, and
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team improvement strategies in the ICU to identify the strengths and limitations of the existing knowledge base to guide future research.
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Methods: A key word search of the PubMed database was conducted in February 2013. Key
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word combinations focused on three areas: (1) teamwork, (2) the ICU, and (3), training/quality improvement interventions. All studies that investigated teamwork, team tasks, or team
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interventions within the ICU (i.e., intradepartment) were selected for inclusion. Results: Teamwork has been investigated across an array of research contexts and task types.
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The terminology used to describe team factors varied considerably across studies. The most
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common team tasks involved strategy and goal formulation. Team training and structured protocols were the most widely implemented quality improvement strategies.
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Conclusions: Team research is burgeoning in the ICU, yet low hanging fruit remains that can further advance the science of teams in the ICU if addressed. Constructs must be defined and theoretical frameworks should be referenced. The functional characteristics of tasks should also be reported to help determine the extent to which study results might generalize to other contexts of work.
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ACCEPTED MANUSCRIPT INTRODUCTION Teamwork is essential for ensuring the quality and safety of healthcare delivery in the
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intensive care unit (ICU). In the ICU, patient care requires vigilant synchronization of efforts in a
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team with fluid membership including highly specialized clinicians with diverse knowledge, skills, and attitudes (KSAs).1-3 Patients and their families can also be conceptualized as part of
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the care team, not just the object of technical work.4 Emerging evidence from across clinical
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domains clearly demonstrates an association between the quality of teamwork and a broad variety of patient harms5,6 as well as the positive impact of team improvement strategies on
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perceptions of7,8 and objectively observed teamwork,9 safety culture,10 error rates and process efficiencies,11,12 and even patient outcomes such as mortality and complications.13
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ICUs are not immune to teamwork failures. In a classic single-center observational study
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in ICUs, 37% of errors identified involved verbal communication between nurses and physicians even though communication events comprised just 2% of all activities.14 A multi-center review
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of incident reports from 23 ICUs over one year replicated this finding and revealed team factors
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contributed to 32% of incidents.15 Several other studies have demonstrated significant associations between the level of teamwork and ICU outcomes. For example, positive caregiver interaction among ICU clinicians was associated with shortened length of stay.16 Better leadership, conflict resolution, and coordination were associated with lower incidents of periventricular/intraventricular hemorrhage or periventricular leukomalacia (PIVH/PVL).17 Positive perceptions of nurse-physician collaboration were associated with reduced likelihood of mortality and/or readmission.18 Given the rapid expansion of the teamwork literature in healthcare,19,20 this article systematically reviews the literature to answer three key questions about teamwork in ICUs.
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ACCEPTED MANUSCRIPT First, how have researchers conceptualized teamwork in ICUs? Understanding how investigators have applied teamwork to the ICU environment can provide guidance on what aspects of
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teamwork matter most in the ICU as well as how those concepts can be translated into practical
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guidance or interventions. Second, what is the context of ICU team research (i.e., what tasks are being investigated)? Reviewing the types of tasks or settings where teamwork has been
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investigated provides insight into where teamwork may be most important within an ICU, or
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what aspects of teamwork are most important under what conditions. Third, what interventions have been used to improve teamwork and what evidence of effectiveness exists? Answering
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these questions will provide practical guidance for improving teamwork in the ICU as well as outlining limitations of the existing knowledgebase to guide future research.
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BACKGROUND
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Over the past decades, a strong multidisciplinary science of teams has developed.21,22 This has been paralleled with active research of teamwork, team tasks, and interventions to foster
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teamwork in the ICU. 23-26 Several systematic and unsystematic reviews of teamwork have been
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conducted in this setting.27-31 Given the accelerated pace of this research since previous reviews, the greater variety of research allows us to provide a more detailed analysis of the types of team constructs under investigation, the clinical tasks that depend on teamwork, and interventions to optimize teamwork. To ensure a shared lexicon of information presented in this article, we briefly define key terms. We define a team as “a distinguishable set of two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal/object/mission, who have each been assigned specific roles or functions to perform, and who have a limited life span of membership.32(p.4) Team performance is a process consisting of individual taskwork
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ACCEPTED MANUSCRIPT activities (i.e., those independent of other team members) and teamwork activities (i.e., those involving exchanges with other team members) while team performance effectiveness is the
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quality and/or efficiency of team performance with respect to predetermined goals or standards.33
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Figure 1 serves as an organizational structure for this review, illustrating a general input, process/mediator, output framework for teamwork. The influence of input variables such as
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team, task, and environmental characteristics on focal performance outcomes (e.g., patient
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outcomes and team outcomes) is dependent on the effectiveness of team processes. Team processes are the dynamic interactions of team members and can broadly be categorized as
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transition (i.e., preparing for or reflecting on the team’s work), action (i.e., task execution), or interpersonal (i.e., managing personal relationships) in nature.21,34
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METHODS
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Figure 2 summarizes the article screening process, which was designed to capture the full spectrum of articles related to teamwork in the ICU. First, A Boolean key word search of the
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PubMed database was conducted in February 2013. Key word combinations consisted of MeSH
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terms and other key words that were selected in consultation with a Librarian at Johns Hopkins University to maximize the return of relevant articles. Key words focused on three areas: (1) teamwork, (2) the ICU, and (3), interventions (e.g., training, quality improvement initiatives). Next, 3,023 article titles were screened by a single author (A.S.D.) to jettison manuscripts that were conspicuously irrelevant to the present article. From the resulting list of 714 titles, abstracts were reviewed by a single author (A.S.D.) to confirm the article (1) focused on an ICU(s) as the context of research and (2) investigated teamwork, team tasks, or interventions to improve team performance, resulting in 296 possible articles for inclusion. Last, more stringent screening protocols involving the review of both abstracts and the full-text of the article were applied
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ACCEPTED MANUSCRIPT (A.S.D.). This final stage of screening resulted in 85 articles that were intradepartment (i.e., within ICU team processes), involved a primary data source, and described ICU team-related
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data when the articles’ focus was scale development (i.e., beyond a description psychometric
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properties) or when multiple unit types were discussed (e.g., an emergency department). Our coding scheme was iteratively developed and revised concurrently with the screening
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process, with the goal of ensuring extracted content was relevant and meaningful to the aims of
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this review. Key variables included information about team processes and emergent states, team tasks, team interventions, and study outcomes. Although articles were coded by a single
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individual (A.S.D.), questions raised during coding were resolved through consensus building discussions with another author (M.A.R.).
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RESULTS
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Table 1 provides an overview of key article characteristics. The majority of articles were empirical and quantitative (n=63; 74%). Sixty-two percent of articles (n=53) relied on a non-
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experimental design to examine the relationship(s) among constructs of interest while the
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remaining articles employed a quasi-experimental design (n=32; 38%). Unlike experimental research, quasi-experimental designs do not randomly assign participants to treatment conditions when evaluating the effect of an independent variable (e.g., training vs. no training) on a dependent variable(s) (e.g., perceived quality of teamwork).35 Twenty-nine percent (n=25) of studies cited uncertain generalizability as a key limitation to research findings and 18% of studies did not report study limitations (n=15). Thirty-seven percent of studies (n=31) involved more than one ICU and the majority of single ICU studies (n=38; 45%) had a unique clinical focus (e.g., pediatric, medical, surgical).
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ACCEPTED MANUSCRIPT One study examined attributes of leadership and leadership training at a workshop for pediatric intensivists.36
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How has teamwork been conceptualized in the ICU?
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Teamwork is a broad construct with varying definitions and conceptualizations.37 This reality highlights a need to understand how investigators have conceptualized teamwork
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constructs within the ICU environment to allow for comparisons of findings across studies.
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Additionally, understanding what aspects of teamwork matter most can serve to focus practical guidance or interventions around widely prevalent teamwork issues.
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Twenty-seven unique constructs were identified (Table 1). In some cases, unique teamwork constructs were collapsed into a single category because of similarity in focus (e.g.,
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team climate and culture). Seventeen percent of articles (n=14) did not explore any teamwork
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construct. These studies often examined a teamwork activity (e.g., rounds) or a teamwork intervention (e.g., documentation tool) in relation to patient, individual, or unit/organization
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outcomes. Many studies investigated more than one aspect of teamwork. The most widely
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studied construct was communication (n=44; 52%), followed by leadership (n=17; 20%), collaboration (n=16; 19%), coordination (n=12; 14%), and team climate/culture (n=7; 8%). Team constructs were also described with varying levels of specificity. For instance, many studies investigated or described communication as a unidimensional construct38,39 while other studies explored facets of communication such as closed-loop communication40 and the openness/quality of communication.41 Additionally, there was a great deal of overlap in how team constructs were operationalized. For instance, Boyle and Kochinda42 described collaborative communication to be the product of factors such as leadership, communication, coordination, problem-solving and
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ACCEPTED MANUSCRIPT conflict management, and team culture. Thomas et al.24 rated aspects of assertiveness, collaboration, cooperation, support, coordination, and conflict resolution to assess teamwork
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timeliness, and problem-solving to gauge collaborative interaction.
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climate. Last, Miller43 measured leadership, communication openness, satisfaction, and
What is the context of ICU team research?
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Team tasks investigated in ICU team research are summarized in Table 1. These tasks
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were examined in descriptive studies and as part of an intervention to improve team performance. Findings are organized around transition and action phases of team task
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accomplishment (see Fig. 1).34 Transition Phases
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Rounds were the most common type of team task described in articles (n=33; 39%).
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Rounds typically involve a 20-25 minute discussion of each patient in which the clinical team prioritizes a daily plan of care.44 Clinicians can spend as much as 75% of their time engaged in
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communication events during rounds.45 Rounds are a critical team task because they provide a
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forum in which the entire care team can communicate, yet are not necessarily the panacea for the formation of shared expectations for patient treatment.46 The effectiveness of rounds may be impeded by communication interruptions45 or the focus of conversation (e.g., provider-focused vs. goal-focused).44 Space constraints, time pressure, and inefficient access to patient information can further complicate the effectiveness of rounds.47 Handoffs primarily involve the coordination of patient care1 and were described in 20% of reviewed articles (n=17). During one type of handoff, clinicians from an outgoing shift brief oncoming clinicians on a patients’ status.48 The exchange of patient information is both complex and central to patient safety.48 Pronovost et al.15 found that 12% of incidents reported by 23 ICUs
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ACCEPTED MANUSCRIPT over a one year period resulted from breakdowns in verbal or written communication during handoffs. Ilan et al.49 observed that physicians spend about 3 minutes discussing each patient
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during end-of-week handovers and that the appropriate use of standardized communication tools
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(e.g., SBAR, SOAP, MAN) was inconsistent. Further, explicit recommendations were omitted in 60% of observations. Finally, Collins et al.48 reported that handoffs were generally a discipline-
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specific activity (e.g., nurse-nurse, physician-physician), which inherently limits information
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sharing across roles. Action Phases
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For the purpose of this review, clinical tasks are broadly defined as specific taskwork activities (i.e., directly engaged in patient care activities) such as cardiac arrest management40 or Clinical tasks were described in 20% of articles (n=17). In the ICU, work is
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‘routine care.’15
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often conducted at an accelerated pace to respond to changing patient conditions.1 Task diversity is a team input factor that magnifies the importance of teamwork processes such as
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communication and coordination.16 For example, the perceived effectiveness of caregiver
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interaction was associated with better perceptions of technical care and increased ability to meet patient-family needs.16 Communicating priorities and appropriate task delegation by leadership are also central to team performance.29 What interventions have been used to improve teamwork in the ICU and what evidence of effectiveness exists? Thirty-six articles described interventions to improve teamwork. As summarized in Table 1, many of these studies involved more than one intervention (e.g., multiple patient tools) and most were developed primarily to improve teamwork (n=22; 61%). The majority of interventions identified were standardized protocols (e.g., daily checklist, patient charts; n=15;
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ACCEPTED MANUSCRIPT 42%), implementation of daily rounds or modification to the rounding structure/process (n=7; 19%), and training (n=8; 22%).
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Standardized protocols are typically applied to augment the rounding or handover
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process.39,50,51 Pronovost et al.44 developed a daily goal sheet as a communication tool to increase clinician understanding of patient care objectives for that day. Daily goals help to make goals
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explicit and reduce ambiguity among team members, especially when nurses read back the
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patient’s goals. Prior to the intervention, daily patient goals were understood by less than 10% of residents and nurses. Following the intervention, daily patient goals were understood by more
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than 95% of nurses and residents. Patient length of stay was also reduced from 2.2 days to 1.1 days. Daily goal sheets have been applied in a number of ICUs, given their effectiveness as a
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mechanism to improve the communication of daily care plans,50,52,53 but ensuring clinician
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compliance is a key challenge for realizing the benefit of these tools.39 Rounds were described earlier as an important team task in which care plans are formally
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discussed and prioritized. Rounds led by an ICU physician have been associated with shorter
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hospital stays, reduced hospital costs, and fewer postoperative complications.54 An explicit approach to rounds increased confidence among clinicians that a long-term care plan was in place for patients as well as their overall satisfaction with rounding processes.55 The implementation of multidisciplinary rounds also contributed to decreased incidents of adverse clinical outcomes (e.g., ventilator associated pneumonia, bloodstream infections, and urinary tract infections).56,57 All training interventions were designed specifically to improve teamwork and 7 of 8 training articles described interventions to improve teamwork skills during clinical tasks. There was not enough information to determine a specific task for one training article.42 Simulation-
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ACCEPTED MANUSCRIPT based training was applied in 5 studies and in each case, high-fidelity simulators were used.40,5861
All studies reported improved team outcomes following team training. For example, Mayer et
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al.62 investigated team performance before and after a classroom-based course emphasizing the
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TeamSTEPPS® curriculum. Core competency areas such as communication, leadership, situation monitoring, and mutual support/assertion were significantly improved one-month following the
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intervention. Improvement was not significantly maintained for all of the competency areas 12-
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months after team training. Allan et al.60 applied Crew Resource Management (CRM) principles to improve teamwork skills during resuscitation events. Following training, participants were
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more confident in their ability to lead future resuscitations and indicated they were more likely to speak up if they believed the resuscitation was not being managed effectively.
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In sum, effective team interventions in the ICU include implementing rounds,
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standardizing the rounding process with daily goals, and enhancing teamwork skills through team training. No study evaluated the synergistic impact of all of three of these interventions.
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Evidence of intervention effectiveness has been demonstrated with respect to team factors
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(n=18; 50%; e.g., improved perception of communication after training),58 patient factors (n=14;39%; e.g., rates of ventilator associated pneumonia),63 task factors (n=21; 58%; e.g., perceived accuracy with a new sign-out document),64 individual factors (n=9; 25%; e.g., job satisfaction),42 and unit/organizational factors (n=4; 11%; e.g., safety climate).65 DISCUSSION The science of teams is bourgeoning in critical care and the importance of this topic cannot be understated. Clinical team members provide health services to extremely vulnerable patients by definition. The margin of error is thin and the consequences of errors are profound. Care delivery intrinsically demands a constant state of vigilance as multidisciplinary providers
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ACCEPTED MANUSCRIPT establish, implement, and revise patient care plans, respond to acute situations, and integrate data from diverse information streams.
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This review provides an overview of the type of team factors being investigated, the
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context of ICU team research, and what interventions have been used to improve teamwork in the ICU and evidence of intervention effectiveness. Supplementary figure E1 integrates key
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findings of this review by addressing which aspects of teamwork (team processes or
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competencies) have been investigated in different task settings and targeted by which improvement methods. The number of times a teamwork construct was specified in an article is
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noted in parentheses, with the exception of instances when a construct was only referenced once. A number of important conclusions can be gleaned from Supplementary figure E1 and Table 1.
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First, communication was singularly the most prominent teamwork construct identified. This it is
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not surprising because communication skills (e.g., clarity, completeness)66 are globally relevant during both transition (e.g., a handoff) and action phases (e.g., responding to a code) of
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teamwork. Second, the ICU teamwork literature emphasized transition oriented tasks compared
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to action oriented tasks. In turn, interventions to improve performance on such tasks were widely targeted. Third, team training interventions targeted a variety of competencies underlying performance during action phases of teamwork. Conversely, structured protocols were widely employed as an improvement strategy for transition phases. This review clearly demonstrates a rapid expansion of research dedicated to teamwork in critical care; investigations of this topic are not constrained to a specific context of work (i.e., clinical focus), type of team task, or type of teamwork construct. While increased attention to the variety of factors that underlie team performance is encouraging, this review also illuminates potential areas to advance the state of science and practice in this field, as described below.
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ACCEPTED MANUSCRIPT What is Being Measured Conceptualizations of teamwork constructs varied in the studies that were reviewed. This
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finding is consistent with the broader teamwork literature in healthcare67 and represents low
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hanging fruit that can yield significant dividends for future reviews seeking to conduct quantitative comparisons across studies. For example, communication has been conceptualized
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and operationalized in the ICU team literature as (1) a unidimensional construct, (2) a
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multidimensional construct, and (3) an attribute of other constructs. Teamwork constructs are also not orthogonal,21 which means teamwork cannot be explored in a silo. To avoid possible
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discourse and ensure a shared understanding of research findings, ICU team researchers should clearly delineate what attributes are being measured and report findings in relationship to a
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clearly defined theoretical and operational definition of the construct(s) under investigation. Such
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construct clarification will allow for more meaningful interpretation of study findings and provide a foundation on which to base future quantitative reviews of teamwork within the ICU.
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To this end, Manser68 called for future team research in healthcare to reference an existing
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theoretical framework of teamwork. Such practice will facilitate the integration existing findings to better understand the impact of teamwork on safety and performance .68 We agree with this appeal and encourage future ICU teamwork research to specifically cite the theoretical underpinnings of the constructs that are explored. It is also worth noting the majority of studies explored teamwork behaviors (e.g., communication, leadership, and coordination; Table 1). Although these attributes are central to teamwork, team functioning represents a constellation of attitudes, behaviors, and cognitions.69,70 Further study of cognitive and affective components of teamwork is encouraged. Where Teamwork is Being Measured
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ACCEPTED MANUSCRIPT Teamwork has been investigated across a wide range of ICU types and tasks, with research examining teamwork behaviors both in relation to a specific task as well as outside of a
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specific task. This is consistent with calls for both general and task specific interventions to
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improve teamwork69,71 and reinforces the conception of patient care in the ICU as a complex team endeavor. Depending on the type of team task, there may be variability in team
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composition, the degree of interdependence required, and the pace at which tasks must be
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completed. This reality requires team members to develop competencies that are not only specific to a particular task or team (e.g., implicit coordination, shared mental models), but also
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competencies that are transportable and can be generalized to different teams and different tasks (e.g., assertiveness, backup behavior).69 Future research would benefit from explicitly defining
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the functional characteristics of team tasks that are investigated, the competencies required for
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task execution, and whether the competencies are specific or generic to ICU teams and tasks.69 Such an understanding will help future researchers interpret the extent to which study results
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generalize to new ICU team contexts. This need is particularly important given the pervasiveness
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of limited generalizability being reported in ICU team research. One means to accomplish this objective is for researchers to conduct team training needs analyses (TTNA)72 of the ICUs under investigation. The outcome of such an analysis will be documentation of individual, team, and organizational characteristics likely to impact team performance effectiveness. How Teamwork is Improved Consistent with the broader healthcare literature,73 teamwork training, structured communication protocols, and organizational structure interventions have been implemented and evaluated in ICUs as well as more novel interventions (e.g., tele-robotic presence). While the variety and quality of studies prohibits quantitative synthesis, these interventions have shown an
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ACCEPTED MANUSCRIPT impact on a broad array of staff and patient outcomes as well as work processes. Given the effectiveness of several individual interventions, future research should seek to optimize
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teamwork by evaluating multifaceted interventions. Such investigations can also reveal the
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relative contribution of each intervention component on dependent variables of interest. Limitations
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Like the studies we reviewed, the present article is not without limitations. First the
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reliability and validity of the measurement systems and experimental design applied in studies that were reviewed were not scrutinized. Second, the frequency of teamwork constructs listed in
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Supplementary figure E1 may be artificially inflated in some cases. Several articles investigated more than one team task and in some cases included more than one intervention (e.g., two types
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of standardized protocols, implementing rounds and a checklist). The coding scheme did not
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allow us to directly map team constructs described in the methods and results section to a specific task or intervention when more than one was reported. The possible inflation of
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teamwork constructs was recognized in 12 articles. Last, only one literature database was used to
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identify articles for this review. Additional queries would certainly expand the pool of possible studies for this review. That said, we feel that the quantity of articles is an appropriate sample of ICU team research, which includes 50 more articles since the last review on teamwork in the ICU.27 ACKNOWLEDGEMENT This work was supported by funding from the Gordon and Betty Moore Foundation (Grant #3186.01). The views expressed in this paper are those of the authors and not necessarily reflective of Johns Hopkins University or the Gordon and Betty Moore Foundation.
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ACCEPTED MANUSCRIPT REFERENCES
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1. Douglas S, Cartmill R, Brown R, et al. The work of adult and pediatric intensive care unit
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nurses. Nurs Res. 2013;62(1):50-58.
2. Collins SA, Bakken S, Vawdrey DK, Coiera E, Currie L. Model development for EHR
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interdisciplinary information exchange of ICU common goals. Int J Med Inform.
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2011;80(8):e141-9.
MA
3. Hawryluck LA, Espin SL, Garwood KC, Evans CA, Lingard LA. Pulling together and pushing apart: Tides of tension in the ICU team. Acad Med. 2002;77(10 Suppl):S73-6.
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4. Carayon P, Friesdorf W. Human factors and ergonomics in medicine. In: Salvendy G, ed.
PT
Handbook of human factors and ergonomics. Third Edition ed. Hoboken, NJ, USA.: John Wiley
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& Sons, Inc.; 2006:1517-1537. 10.1002/0470048204.ch58.
5. Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes. Am J
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Surg. 2009;197(5):678-685.
6. Mardon RE, Khanna K, Sorra J, Dyer N, Famolaro T. Exploring relationships between hospital patient safety culture and adverse events. J Patient Saf. 2010;6(4):226-232.
7. Haynes AB, Weiser TG, Berry WR, et al. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf. 2011;20(1):102-107.
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ACCEPTED MANUSCRIPT 8. Brock D, Abu-Rish E, Chiu CR, et al. Interprofessional education in team communication:
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Working together to improve patient safety. BMJ Qual Saf. 2013;22(5):414-423.
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9. Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamwork improve performance in the operating room? A multilevel evaluation. Jt Comm J Qual Patient Saf. 2010;36(3):133-142.
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10. Jones KJ, Skinner AM, High R, Reiter-Palmon R. A theory-driven, longitudinal evaluation of
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the impact of team training on safety culture in 24 hospitals. BMJ Qual Saf. 2013;22(5):394-404.
MA
11. Deering S, Rosen MA, Ludi V, et al. On the front lines of patient safety: Implementation and evaluation of team training in iraq. Jt Comm J Qual Patient Saf. 2011;37(8):350-356.
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12. Schmutz J, Manser T. Do team processes really have an effect on clinical performance? A
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systematic literature review. Br J Anaesth. 2013;110(4):529-544.
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13. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical
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team training program and surgical mortality. JAMA. 2010;304(15):1693-1700.
14. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23(2):294-300.
15. Pronovost PJ, Thompson DA, Holzmueller CG, et al. Toward learning from patient safety reporting systems. J Crit Care. 2006;21(4):305-315.
16. Shortell SM, Zimmerman JE, Rousseau DM, et al. The performance of intensive care units: Does good management make a difference? Med Care. 1994;32(5):508-525.
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ACCEPTED MANUSCRIPT 17. Pollack MM, Koch MA. Association of outcomes with organizational characteristics of
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neonatal intensive care units. Crit Care Med. 2003;31(6):1620-1629.
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18. Baggs JG, Schmitt MH, Mushlin AI, et al. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Crit Care Med.
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1999;27(9):1991-1998.
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19. Weaver SJ, Rosen MA. Team training in healthcare: Brief update review. In: Shekelle PG, Wachter RM, Pronovost PJ, eds. Making healthcare safer II: An updated critical analysis of the
MA
evidence for patient safety practices. AHRQ Report No. 13-E001-EF ed. Rockville, MD: Agency for Healthcare Research and Quality; 2013:472-479.
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http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyII-full.pdf.
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20. Salas E, Rosen MA. Building high reliability teams: Progress and some reflections on
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teamwork training. BMJ Qual Saf. 2013;22(5):369-373.
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21. 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;61:273-307.
22. Kozlowski SWJ, Ilgen DR. Enhancing the effectiveness of work groups and teams. Psychological Science in the Public Interest. 2006;7(3):77-124.
23. Ohlinger J, Brown MS, Laudert S, Swanson S, Fofah O, CARE Group. Development of potentially better practices for the neonatal intensive care unit as a culture of collaboration:
Page 18 of 31
ACCEPTED MANUSCRIPT Communication, accountability, respect, and empowerment. Pediatrics. 2003;111(4 Pt 2):e471-
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81.
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24. Thomas EJ, Sexton JB, Helmreich RL. Discrepant attitudes about teamwork among critical care nurses and physicians. Crit Care Med. 2003;31(3):956-959.
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25. Stockwell DC, Slonim AD, Pollack MM. Physician team management affects goal
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achievement in the intensive care unit. Pediatr Crit Care Med. 2007;8(6):540-545.
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26. Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med. 2011;39(5):934-939.
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27. Reader TW, Flin R, Mearns K, Cuthbertson BH. Developing a team performance framework
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for the intensive care unit. Crit Care Med. 2009;37(5):1787-1793.
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28. Lin F, Chaboyer W, Wallis M. A literature review of organisational, individual and
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teamwork factors contributing to the ICU discharge process. Aust Crit Care. 2009;22(1):29-43.
29. Reader TW, Flin R, Cuthbertson BH. Communication skills and error in the intensive care unit. Curr Opin Crit Care. 2007;13(6):732-736.
30. Reader TW, Flin R, Lauche K, Cuthbertson BH. Non-technical skills in the intensive care unit. Br J Anaesth. 2006;96(5):551-559.
31. Baggs JG, Norton SA, Schmitt MH, Sellers CR. The dying patient in the ICU: Role of the interdisciplinary team. Crit Care Clin. 2004;20(3):525-40, xi.
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ACCEPTED MANUSCRIPT 32. Salas E, Dickinson TL, Converse S, Tannenbaum SI. Toward an understanding of team performance and training. In: Swezey RW, Salas E, eds. Teams: Their training and performance.
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Norwood, NJ: Ablex; 1992:3-29.
33. Salas E, Cooke NJ, Rosen MA. On teams, teamwork, and team performance: Discoveries and
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developments. Hum Factors. 2008;50(3):540-547.
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34. Marks MA, Mathieu JE, Zaccaro J. A temporally based framework and taxonomy of team
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processes. The Academy of Management Review. 2001;26(3):356-376.
35. Pedhazur EJ, Schmelkin LP. Measurement, design, and analysis: An integrated approach.
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Hillsdale, NJ, USA: Lawrence Erlbaum Associates, Inc.; 1991.
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36. Stockwell DC, Pollack MM, Turenne WM, Slonim AD. Leadership and management
2005;6(6):665-670.
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training of pediatric intensivists: How do we gain our skills? Pediatr Crit Care Med.
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37. Salas E, Cooke NJ, Rosen MA. On teams, teamwork, and team performance: Discoveries and developments. Hum Factors. 2008;50(3):540-547.
38. Sluiter JK, Bos AP, Tol D, Calff M, Krijnen M, Frings-Dresen MH. Is staff well-being and communication enhanced by multidisciplinary work shift evaluations? Intensive Care Med. 2005;31(10):1409-1414.
39. Newkirk M, Pamplin JC, Kuwamoto R, Allen DA, Chung KK. Checklists change communication about key elements of patient care. J Trauma Acute Care Surg. 2012;73(2 Suppl 1):S75-82. Page 20 of 31
ACCEPTED MANUSCRIPT 40. Figueroa MI, Sepanski R, Goldberg SP, Shah S. Improving teamwork, confidence, and collaboration among members of a pediatric cardiovascular intensive care unit multidisciplinary
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team using simulation-based team training. Pediatr Cardiol. 2013;34(3):612-619.
41. Jukkala AM, James D, Autrey P, Azuero A, Miltner R. Developing a standardized tool to
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improve nurse communication during shift report. J Nurs Care Qual. 2012;27(3):240-246.
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42. Boyle DK, Kochinda C. Enhancing collaborative communication of nurse and physician
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leadership in two intensive care units. J Nurs Adm. 2004;34(2):60-70.
43. Miller PA. Nurse-physician collaboration in an intensive care unit. Am J Crit Care.
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2001;10(5):341-350.
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44. Pronovost PJ, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving
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communication in the ICU using daily goals. J Crit Care. 2003;18(2):71-75.
45. Alvarez G, Coiera E. Interruptive communication patterns in the intensive care unit ward
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round. Int J Med Inform. 2005;74(10):791-796.
46. Custer JW, White E, Fackler JC, et al. A qualitative study of expert and team cognition on complex patients in the pediatric intensive care unit. Pediatr Crit Care Med. 2012;13(3):278284.
47. Ho D, Xiao Y, Vaidya V, Hu P. Communication and sense-making in intensive care: An observation study of multi-disciplinary rounds to design computerized supporting tools. AMIA Annu Symp Proc. 2007:329-333.
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ACCEPTED MANUSCRIPT 48. Collins SA, Mamykina L, Jordan D, et al. In search of common ground in handoff
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documentation in an intensive care unit. J Biomed Inform. 2012;45(2):307-315.
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49. Ilan R, LeBaron CD, Christianson MK, Heyland DK, Day A, Cohen MD. Handover patterns: An observational study of critical care physicians. BMC Health Serv Res. 2012;12:11-6963-12-
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11.
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50. Narasimhan M, Eisen LA, Mahoney CD, Acerra FL, Rosen MJ. Improving nurse-physician communication and satisfaction in the intensive care unit with a daily goals worksheet. Am J Crit
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Care. 2006;15(2):217-222.
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51. Abraham J, Kannampallil TG, Patel VL. Bridging gaps in handoffs: A continuity of care
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based approach. J Biomed Inform. 2012;45(2):240-254.
52. Rehder KJ, Uhl TL, Meliones JN, Turner DA, Smith PB, Mistry KP. Targeted interventions
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improve shared agreement of daily goals in the pediatric intensive care unit. Pediatr Crit Care
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Med. 2012;13(1):6-10.
53. Phipps LM, Thomas NJ. The use of a daily goals sheet to improve communication in the paediatric intensive care unit. Intensive Crit Care Nurs. 2007;23(5):264-271.
54. Dimick JB, Pronovost PJ, Heitmiller RF, Lipsett PA. Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection. Crit Care Med. 2001;29(4):753-758.
55. Dodek PM, Raboud J. Explicit approach to rounds in an ICU improves communication and satisfaction of providers. Intensive Care Med. 2003;29(9):1584-1588. Page 22 of 31
ACCEPTED MANUSCRIPT 56. Jain M, Miller L, Belt D, King D, Berwick DM. Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture
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change. Qual Saf Health Care. 2006;15(4):235-239.
57. Johnson V, Mangram A, Mitchell C, Lorenzo M, Howard D, Dunn E. Is there a benefit to
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multidisciplinary rounds in an open trauma intensive care unit regarding ventilator-associated
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pneumonia? Am Surg. 2009;75(12):1171-1174.
58. Meurling L, Hedman L, Sandahl C, Fellander-Tsai L, Wallin CJ. Systematic simulation-
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professions. BMJ Qual Saf. 2013.
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based team training in a swedish intensive care unit: A diverse response among critical care
59. Pascual JL, Holena DN, Vella MA, et al. Short simulation training improves objective skills
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in established advanced practitioners managing emergencies on the ward and surgical intensive
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care unit. J Trauma. 2011;71(2):330-7; discussion 337-8.
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60. Allan CK, Thiagarajan RR, Beke D, et al. Simulation-based training delivered directly to the pediatric cardiac intensive care unit engenders preparedness, comfort, and decreased anxiety among multidisciplinary resuscitation teams. J Thorac Cardiovasc Surg. 2010;140(3):646-652.
61. Nunnink L, Welsh AM, Abbey M, Buschel C. In situ simulation-based team training for post-cardiac surgical emergency chest reopen in the intensive care unit. Anaesth Intensive Care. 2009;37(1):74-78.
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ACCEPTED MANUSCRIPT 62. Mayer CM, Cluff L, Lin WT, et al. Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units. Jt Comm J Qual Patient Saf.
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2011;37(8):365-374.
63. Stone ME,Jr, Snetman D, O'Neill A, et al. Daily multidisciplinary rounds to implement the
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ventilator bundle decreases ventilator-associated pneumonia in trauma patients: But does it affect
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outcome? Surg Infect (Larchmt). 2011;12(5):373-378.
64. Palma JP, Sharek PJ, Longhurst CA. Impact of electronic medical record integration of a
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handoff tool on sign-out in a newborn intensive care unit. J Perinatol. 2011;31(5):311-317.
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65. Vigorito MC, McNicoll L, Adams L, Sexton B. Improving safety culture results in rhode island ICUs: Lessons learned from the development of action-oriented plans. Jt Comm J Qual
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Patient Saf. 2011;37(11):509-514.
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66. Smith-Jentsch KA, Cannon-Bowers JA, Tannenbaum SI, Salas E. Guided team self-
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correction: Impacts on team mental models, processes, and effectiveness. Small Group Research. 2008;39(3):303-327.
67. Baker DP, Gustafson S, Beaubien J, Salas E, Barach P. Medical teamwork and patient safety: The evidence-based relation. . 2005;05-0053.
68. Manser T. Teamwork and patient safety in dynamic domains of healthcare: A review of the literature. Acta Anaesthesiol Scand. 2009;53(2):143-151.
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ACCEPTED MANUSCRIPT 69. Cannon-Bowers JA, Tannenbaum SI, Salas E, Volpe CE. Defining competencies and establishing team training requirements. In: Guzzo R, Salas E, eds. Team effectiveness and
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decision making in organizations. San Francisco,CA: Jossey-Bass; 1995:333-380.
70. Salas E, Rosen MA, Burke CS, Goodwin GF. The wisdom of the collectives in organizations:
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An update of the teamwork competencies. In: Salas E, Goodwin GF, Burke CS, eds. Team
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effectiveness in complex organizations. New York, NY: Routledge; 2009:39-79.
BMJ Qual Saf. 2011;20(8):647-650.
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71. Thomas EJ. Improving teamwork in healthcare: Current approaches and the path forward.
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72. Salas E, Cannon-Bowers JA. The science of training: A decade of progress. Annu Rev
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Psychol. 2001;52:471-499.
73. Buljac-Samardzic M, Dekker-van Doorn CM, van Wijngaarden JD, van Wijk KP.
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2010;94(3):183-195.
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Interventions to improve team effectiveness: A systematic review. Health Policy.
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ACCEPTED MANUSCRIPT Table 1. Overview of Key Findings Article Information • Empirical-Quantitative (63; 74%)
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Type of article (n=85)
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• Empirical-Qualitative (22; 26%) Experimental design (n=85)
• Quasi-Experimental (32; 38%)
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• Non-Experimental (53: 62%)
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Key Research Questions
• Team (44; 52%)
research? ICU team (n=85)
• Task (43; 51%)
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What outcomes are being investigated in
• Patient (24; 28%)
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• Individual (20; 24%)
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How has teamwork been conceptualized
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and operationalized in the ICU? (n=85)
• Unit/Organization (13; 15%)
• Communication (44; 52%) • Leadership (17; 20%) • Collaboration (16; 19%) • Coordination (12; 14%) • Team Climate/Culture (7; 8%) • Information Exchange (3; 4%) • Conflict Management (3; 4%) • Cohesion (2; 2%) • SA/Team SA (2; 2%) • Shared Mental Model (2; 2%) • Assertion (1; 1%)
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ACCEPTED MANUSCRIPT • Caregiver Interaction (1; 1%) • Cooperation (1; 1%)
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• Empowerment (1; 1%)
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• Decision-making Inclusion (1; 1%)
• Joint Sense-Making (1; 1%)
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• Mutual Performance Monitoring (1; 1%)
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• Mutual Respect (1; 1%) • Mutual Support/Assertion (1; 1%)
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• Shared Goal Agreement (1; 1%) • Shared Problem Solving (1; 1%)
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• Situation Monitoring (1; 1%) • Team Commitment (1; 1%) • Team Satisfaction (1; 1%) • Trust (1; 1%) • Verbalizing Situational Information (1; 1%) • Not Specified (14; 17%)
Where has teamwork been investigated?
Research Context
(n=85)
• Multiple ICUs (31; 37%) • General ICU (15; 18%) • Pediatric ICU (10; 12%) • Medical ICU (5; 6%) • Medical-Surgical ICU (5; 6%) • Surgical ICU (4; 5%)
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ACCEPTED MANUSCRIPT • Neurovascular ICU (3; 4%) • Neonatal ICU (2; 2%)
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• Pediatric Cardiac ICU (2; 2%)
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• Cardiothoracic ICU (1; 1%)
• Medical-Surgical Pediatric ICU (1; 1%)
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• Neuro-ICU (1; 1%)
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• Neuroscience ICU (1; 1%) • Newborn ICU (1; 1%)
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• Neurosurgical ICU (1; 1%) • Trauma ICU (1; 1%)
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• Not Applicable (1; 1%)
Team Tasks • Rounds (33; 39%) 34 • Clinical (17; 20%) • Handoff (17; 20%) • Transfer (2; 2%) • Huddle/Debrief (1; 1%) • Multidisciplinary Meetings (1; 1%)
What interventions have been used to
• Standardized Patient Status Tool (15; 42%)
improve teamwork in the ICU? (n=36)
• Training (8; 22%) • Rounds/Change of Rounding Process (7; 19%) • Specialized Staffing (3; 8%) • Comprehensive Unit-Based Safety Program (2; 6%)
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ACCEPTED MANUSCRIPT • Robotic Tele-Presence (1; 3%) • Safety Attitude Questionnaire Action Plan (1; 3%)
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• Multidisciplinary Work Shift Evaluations (1; 3%)
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• Collaborative Communication Intervention (1; 3%)
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• Wireless Email (1; 3%)
• Developed primarily to improve teamwork (22; 61%)
to improve teamwork? (n=36)
• Not primary or only focus (14; 39%)
Where has evidence of intervention
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Were interventions developed primarily
• Team outcomes (18; 50%)
• Task outcomes (21; 58%)
• Patient outcomes (14; 39%) • Individual outcomes (9; 25%) • Unit/Organization outcomes (4; 11%)
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effectiveness been demonstrated? (n=36)
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S0883-9441(14)00226-3 doi: 10.1016/j.jcrc.2014.05.025 YJCRC 51539
To appear in:
Journal of Critical Care
Received date: Revised date: Accepted date:
9 January 2014 13 May 2014 27 May 2014
Please cite this article as: Dietz Aaron S., Pronovost Peter J., Mendez-Tellez Pedro Alejandro, Wyskiel Rhonda, Marsteller Jill A., Thompson David A., Rosen Michael A., A Systematic Review of Teamwork in the ICU: What do we know about Teamwork, Team Tasks, and Improvement Strategies?, Journal of Critical Care (2014), doi: 10.1016/j.jcrc.2014.05.025
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT A Systematic Review of Teamwork in the ICU: What do we know about Teamwork, Team Tasks, and Improvement Strategies?
Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine Baltimore, MD USA
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The Armstrong Institute for Patient Safety and Quality The Johns Hopkins University School of Medicine Baltimore, MD USA
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Aaron S. Dietz, MA1 Peter J. Pronovost, MD, PhD1,2 Pedro Alejandro Mendez-Tellez, MD2 Rhonda Wyskiel, RN, BSN1 Jill A. Marsteller, PhD, MPP1,3 David A. Thompson, DNSc, MS, RN1,2 Michael A. Rosen, PhD1,2
3
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Department of Health Policy and Management The Johns Hopkins University Bloomberg School of Public Health Baltimore, MD USA
Address correspondence to:
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Michael A. Rosen, PhD Assistant Professor Armstrong Institute for Patient Safety and Quality, and Department of Anesthesiology & Critical Care Medicine Johns Hopkins University School of Medicine 750 East Pratt Street, 15th Floor Baltimore, MD 21202 Office: 1-443-637-6269 [email protected] Institution: This work was performed at Johns Hopkins University. Support: This work was supported by funding from the Gordon and Betty Moore Foundation (Grant #3186.01). The views expressed in this paper are those of the authors and not necessarily reflective of Johns Hopkins University or the Gordon and Betty Moore Foundation. Word Count: 3,564
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ACCEPTED MANUSCRIPT Key Words: Teamwork; Intensive Care Unit; Patient Safety; Group Processes
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ABSTRACT
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Purpose: Teamwork is essential for ensuring the quality and safety of healthcare delivery in the intensive care unit (ICU). This article addresses what we know about teamwork, team tasks, and
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team improvement strategies in the ICU to identify the strengths and limitations of the existing knowledge base to guide future research.
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Methods: A key word search of the PubMed database was conducted in February 2013. Key
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word combinations focused on three areas: (1) teamwork, (2) the ICU, and (3), training/quality improvement interventions. All studies that investigated teamwork, team tasks, or team
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interventions within the ICU (i.e., intradepartment) were selected for inclusion. Results: Teamwork has been investigated across an array of research contexts and task types.
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The terminology used to describe team factors varied considerably across studies. The most
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common team tasks involved strategy and goal formulation. Team training and structured protocols were the most widely implemented quality improvement strategies.
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Conclusions: Team research is burgeoning in the ICU, yet low hanging fruit remains that can further advance the science of teams in the ICU if addressed. Constructs must be defined and theoretical frameworks should be referenced. The functional characteristics of tasks should also be reported to help determine the extent to which study results might generalize to other contexts of work.
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ACCEPTED MANUSCRIPT INTRODUCTION Teamwork is essential for ensuring the quality and safety of healthcare delivery in the
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intensive care unit (ICU). In the ICU, patient care requires vigilant synchronization of efforts in a
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team with fluid membership including highly specialized clinicians with diverse knowledge, skills, and attitudes (KSAs).1-3 Patients and their families can also be conceptualized as part of
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the care team, not just the object of technical work.4 Emerging evidence from across clinical
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domains clearly demonstrates an association between the quality of teamwork and a broad variety of patient harms5,6 as well as the positive impact of team improvement strategies on
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perceptions of7,8 and objectively observed teamwork,9 safety culture,10 error rates and process efficiencies,11,12 and even patient outcomes such as mortality and complications.13
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ICUs are not immune to teamwork failures. In a classic single-center observational study
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in ICUs, 37% of errors identified involved verbal communication between nurses and physicians even though communication events comprised just 2% of all activities.14 A multi-center review
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of incident reports from 23 ICUs over one year replicated this finding and revealed team factors
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contributed to 32% of incidents.15 Several other studies have demonstrated significant associations between the level of teamwork and ICU outcomes. For example, positive caregiver interaction among ICU clinicians was associated with shortened length of stay.16 Better leadership, conflict resolution, and coordination were associated with lower incidents of periventricular/intraventricular hemorrhage or periventricular leukomalacia (PIVH/PVL).17 Positive perceptions of nurse-physician collaboration were associated with reduced likelihood of mortality and/or readmission.18 Given the rapid expansion of the teamwork literature in healthcare,19,20 this article systematically reviews the literature to answer three key questions about teamwork in ICUs.
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ACCEPTED MANUSCRIPT First, how have researchers conceptualized teamwork in ICUs? Understanding how investigators have applied teamwork to the ICU environment can provide guidance on what aspects of
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teamwork matter most in the ICU as well as how those concepts can be translated into practical
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guidance or interventions. Second, what is the context of ICU team research (i.e., what tasks are being investigated)? Reviewing the types of tasks or settings where teamwork has been
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investigated provides insight into where teamwork may be most important within an ICU, or
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what aspects of teamwork are most important under what conditions. Third, what interventions have been used to improve teamwork and what evidence of effectiveness exists? Answering
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these questions will provide practical guidance for improving teamwork in the ICU as well as outlining limitations of the existing knowledgebase to guide future research.
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BACKGROUND
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Over the past decades, a strong multidisciplinary science of teams has developed.21,22 This has been paralleled with active research of teamwork, team tasks, and interventions to foster
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teamwork in the ICU. 23-26 Several systematic and unsystematic reviews of teamwork have been
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conducted in this setting.27-31 Given the accelerated pace of this research since previous reviews, the greater variety of research allows us to provide a more detailed analysis of the types of team constructs under investigation, the clinical tasks that depend on teamwork, and interventions to optimize teamwork. To ensure a shared lexicon of information presented in this article, we briefly define key terms. We define a team as “a distinguishable set of two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal/object/mission, who have each been assigned specific roles or functions to perform, and who have a limited life span of membership.32(p.4) Team performance is a process consisting of individual taskwork
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ACCEPTED MANUSCRIPT activities (i.e., those independent of other team members) and teamwork activities (i.e., those involving exchanges with other team members) while team performance effectiveness is the
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quality and/or efficiency of team performance with respect to predetermined goals or standards.33
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Figure 1 serves as an organizational structure for this review, illustrating a general input, process/mediator, output framework for teamwork. The influence of input variables such as
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team, task, and environmental characteristics on focal performance outcomes (e.g., patient
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outcomes and team outcomes) is dependent on the effectiveness of team processes. Team processes are the dynamic interactions of team members and can broadly be categorized as
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transition (i.e., preparing for or reflecting on the team’s work), action (i.e., task execution), or interpersonal (i.e., managing personal relationships) in nature.21,34
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METHODS
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Figure 2 summarizes the article screening process, which was designed to capture the full spectrum of articles related to teamwork in the ICU. First, A Boolean key word search of the
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PubMed database was conducted in February 2013. Key word combinations consisted of MeSH
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terms and other key words that were selected in consultation with a Librarian at Johns Hopkins University to maximize the return of relevant articles. Key words focused on three areas: (1) teamwork, (2) the ICU, and (3), interventions (e.g., training, quality improvement initiatives). Next, 3,023 article titles were screened by a single author (A.S.D.) to jettison manuscripts that were conspicuously irrelevant to the present article. From the resulting list of 714 titles, abstracts were reviewed by a single author (A.S.D.) to confirm the article (1) focused on an ICU(s) as the context of research and (2) investigated teamwork, team tasks, or interventions to improve team performance, resulting in 296 possible articles for inclusion. Last, more stringent screening protocols involving the review of both abstracts and the full-text of the article were applied
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ACCEPTED MANUSCRIPT (A.S.D.). This final stage of screening resulted in 85 articles that were intradepartment (i.e., within ICU team processes), involved a primary data source, and described ICU team-related
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data when the articles’ focus was scale development (i.e., beyond a description psychometric
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properties) or when multiple unit types were discussed (e.g., an emergency department). Our coding scheme was iteratively developed and revised concurrently with the screening
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process, with the goal of ensuring extracted content was relevant and meaningful to the aims of
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this review. Key variables included information about team processes and emergent states, team tasks, team interventions, and study outcomes. Although articles were coded by a single
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individual (A.S.D.), questions raised during coding were resolved through consensus building discussions with another author (M.A.R.).
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RESULTS
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Table 1 provides an overview of key article characteristics. The majority of articles were empirical and quantitative (n=63; 74%). Sixty-two percent of articles (n=53) relied on a non-
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experimental design to examine the relationship(s) among constructs of interest while the
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remaining articles employed a quasi-experimental design (n=32; 38%). Unlike experimental research, quasi-experimental designs do not randomly assign participants to treatment conditions when evaluating the effect of an independent variable (e.g., training vs. no training) on a dependent variable(s) (e.g., perceived quality of teamwork).35 Twenty-nine percent (n=25) of studies cited uncertain generalizability as a key limitation to research findings and 18% of studies did not report study limitations (n=15). Thirty-seven percent of studies (n=31) involved more than one ICU and the majority of single ICU studies (n=38; 45%) had a unique clinical focus (e.g., pediatric, medical, surgical).
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ACCEPTED MANUSCRIPT One study examined attributes of leadership and leadership training at a workshop for pediatric intensivists.36
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How has teamwork been conceptualized in the ICU?
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Teamwork is a broad construct with varying definitions and conceptualizations.37 This reality highlights a need to understand how investigators have conceptualized teamwork
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constructs within the ICU environment to allow for comparisons of findings across studies.
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Additionally, understanding what aspects of teamwork matter most can serve to focus practical guidance or interventions around widely prevalent teamwork issues.
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Twenty-seven unique constructs were identified (Table 1). In some cases, unique teamwork constructs were collapsed into a single category because of similarity in focus (e.g.,
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team climate and culture). Seventeen percent of articles (n=14) did not explore any teamwork
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construct. These studies often examined a teamwork activity (e.g., rounds) or a teamwork intervention (e.g., documentation tool) in relation to patient, individual, or unit/organization
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outcomes. Many studies investigated more than one aspect of teamwork. The most widely
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studied construct was communication (n=44; 52%), followed by leadership (n=17; 20%), collaboration (n=16; 19%), coordination (n=12; 14%), and team climate/culture (n=7; 8%). Team constructs were also described with varying levels of specificity. For instance, many studies investigated or described communication as a unidimensional construct38,39 while other studies explored facets of communication such as closed-loop communication40 and the openness/quality of communication.41 Additionally, there was a great deal of overlap in how team constructs were operationalized. For instance, Boyle and Kochinda42 described collaborative communication to be the product of factors such as leadership, communication, coordination, problem-solving and
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ACCEPTED MANUSCRIPT conflict management, and team culture. Thomas et al.24 rated aspects of assertiveness, collaboration, cooperation, support, coordination, and conflict resolution to assess teamwork
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timeliness, and problem-solving to gauge collaborative interaction.
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climate. Last, Miller43 measured leadership, communication openness, satisfaction, and
What is the context of ICU team research?
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Team tasks investigated in ICU team research are summarized in Table 1. These tasks
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were examined in descriptive studies and as part of an intervention to improve team performance. Findings are organized around transition and action phases of team task
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accomplishment (see Fig. 1).34 Transition Phases
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Rounds were the most common type of team task described in articles (n=33; 39%).
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Rounds typically involve a 20-25 minute discussion of each patient in which the clinical team prioritizes a daily plan of care.44 Clinicians can spend as much as 75% of their time engaged in
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communication events during rounds.45 Rounds are a critical team task because they provide a
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forum in which the entire care team can communicate, yet are not necessarily the panacea for the formation of shared expectations for patient treatment.46 The effectiveness of rounds may be impeded by communication interruptions45 or the focus of conversation (e.g., provider-focused vs. goal-focused).44 Space constraints, time pressure, and inefficient access to patient information can further complicate the effectiveness of rounds.47 Handoffs primarily involve the coordination of patient care1 and were described in 20% of reviewed articles (n=17). During one type of handoff, clinicians from an outgoing shift brief oncoming clinicians on a patients’ status.48 The exchange of patient information is both complex and central to patient safety.48 Pronovost et al.15 found that 12% of incidents reported by 23 ICUs
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ACCEPTED MANUSCRIPT over a one year period resulted from breakdowns in verbal or written communication during handoffs. Ilan et al.49 observed that physicians spend about 3 minutes discussing each patient
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during end-of-week handovers and that the appropriate use of standardized communication tools
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(e.g., SBAR, SOAP, MAN) was inconsistent. Further, explicit recommendations were omitted in 60% of observations. Finally, Collins et al.48 reported that handoffs were generally a discipline-
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specific activity (e.g., nurse-nurse, physician-physician), which inherently limits information
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sharing across roles. Action Phases
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For the purpose of this review, clinical tasks are broadly defined as specific taskwork activities (i.e., directly engaged in patient care activities) such as cardiac arrest management40 or Clinical tasks were described in 20% of articles (n=17). In the ICU, work is
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‘routine care.’15
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often conducted at an accelerated pace to respond to changing patient conditions.1 Task diversity is a team input factor that magnifies the importance of teamwork processes such as
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communication and coordination.16 For example, the perceived effectiveness of caregiver
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interaction was associated with better perceptions of technical care and increased ability to meet patient-family needs.16 Communicating priorities and appropriate task delegation by leadership are also central to team performance.29 What interventions have been used to improve teamwork in the ICU and what evidence of effectiveness exists? Thirty-six articles described interventions to improve teamwork. As summarized in Table 1, many of these studies involved more than one intervention (e.g., multiple patient tools) and most were developed primarily to improve teamwork (n=22; 61%). The majority of interventions identified were standardized protocols (e.g., daily checklist, patient charts; n=15;
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ACCEPTED MANUSCRIPT 42%), implementation of daily rounds or modification to the rounding structure/process (n=7; 19%), and training (n=8; 22%).
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Standardized protocols are typically applied to augment the rounding or handover
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process.39,50,51 Pronovost et al.44 developed a daily goal sheet as a communication tool to increase clinician understanding of patient care objectives for that day. Daily goals help to make goals
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explicit and reduce ambiguity among team members, especially when nurses read back the
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patient’s goals. Prior to the intervention, daily patient goals were understood by less than 10% of residents and nurses. Following the intervention, daily patient goals were understood by more
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than 95% of nurses and residents. Patient length of stay was also reduced from 2.2 days to 1.1 days. Daily goal sheets have been applied in a number of ICUs, given their effectiveness as a
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mechanism to improve the communication of daily care plans,50,52,53 but ensuring clinician
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compliance is a key challenge for realizing the benefit of these tools.39 Rounds were described earlier as an important team task in which care plans are formally
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discussed and prioritized. Rounds led by an ICU physician have been associated with shorter
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hospital stays, reduced hospital costs, and fewer postoperative complications.54 An explicit approach to rounds increased confidence among clinicians that a long-term care plan was in place for patients as well as their overall satisfaction with rounding processes.55 The implementation of multidisciplinary rounds also contributed to decreased incidents of adverse clinical outcomes (e.g., ventilator associated pneumonia, bloodstream infections, and urinary tract infections).56,57 All training interventions were designed specifically to improve teamwork and 7 of 8 training articles described interventions to improve teamwork skills during clinical tasks. There was not enough information to determine a specific task for one training article.42 Simulation-
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ACCEPTED MANUSCRIPT based training was applied in 5 studies and in each case, high-fidelity simulators were used.40,5861
All studies reported improved team outcomes following team training. For example, Mayer et
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al.62 investigated team performance before and after a classroom-based course emphasizing the
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TeamSTEPPS® curriculum. Core competency areas such as communication, leadership, situation monitoring, and mutual support/assertion were significantly improved one-month following the
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intervention. Improvement was not significantly maintained for all of the competency areas 12-
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months after team training. Allan et al.60 applied Crew Resource Management (CRM) principles to improve teamwork skills during resuscitation events. Following training, participants were
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more confident in their ability to lead future resuscitations and indicated they were more likely to speak up if they believed the resuscitation was not being managed effectively.
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In sum, effective team interventions in the ICU include implementing rounds,
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standardizing the rounding process with daily goals, and enhancing teamwork skills through team training. No study evaluated the synergistic impact of all of three of these interventions.
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Evidence of intervention effectiveness has been demonstrated with respect to team factors
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(n=18; 50%; e.g., improved perception of communication after training),58 patient factors (n=14;39%; e.g., rates of ventilator associated pneumonia),63 task factors (n=21; 58%; e.g., perceived accuracy with a new sign-out document),64 individual factors (n=9; 25%; e.g., job satisfaction),42 and unit/organizational factors (n=4; 11%; e.g., safety climate).65 DISCUSSION The science of teams is bourgeoning in critical care and the importance of this topic cannot be understated. Clinical team members provide health services to extremely vulnerable patients by definition. The margin of error is thin and the consequences of errors are profound. Care delivery intrinsically demands a constant state of vigilance as multidisciplinary providers
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ACCEPTED MANUSCRIPT establish, implement, and revise patient care plans, respond to acute situations, and integrate data from diverse information streams.
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This review provides an overview of the type of team factors being investigated, the
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context of ICU team research, and what interventions have been used to improve teamwork in the ICU and evidence of intervention effectiveness. Supplementary figure E1 integrates key
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findings of this review by addressing which aspects of teamwork (team processes or
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competencies) have been investigated in different task settings and targeted by which improvement methods. The number of times a teamwork construct was specified in an article is
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noted in parentheses, with the exception of instances when a construct was only referenced once. A number of important conclusions can be gleaned from Supplementary figure E1 and Table 1.
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First, communication was singularly the most prominent teamwork construct identified. This it is
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not surprising because communication skills (e.g., clarity, completeness)66 are globally relevant during both transition (e.g., a handoff) and action phases (e.g., responding to a code) of
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teamwork. Second, the ICU teamwork literature emphasized transition oriented tasks compared
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to action oriented tasks. In turn, interventions to improve performance on such tasks were widely targeted. Third, team training interventions targeted a variety of competencies underlying performance during action phases of teamwork. Conversely, structured protocols were widely employed as an improvement strategy for transition phases. This review clearly demonstrates a rapid expansion of research dedicated to teamwork in critical care; investigations of this topic are not constrained to a specific context of work (i.e., clinical focus), type of team task, or type of teamwork construct. While increased attention to the variety of factors that underlie team performance is encouraging, this review also illuminates potential areas to advance the state of science and practice in this field, as described below.
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ACCEPTED MANUSCRIPT What is Being Measured Conceptualizations of teamwork constructs varied in the studies that were reviewed. This
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finding is consistent with the broader teamwork literature in healthcare67 and represents low
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hanging fruit that can yield significant dividends for future reviews seeking to conduct quantitative comparisons across studies. For example, communication has been conceptualized
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and operationalized in the ICU team literature as (1) a unidimensional construct, (2) a
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multidimensional construct, and (3) an attribute of other constructs. Teamwork constructs are also not orthogonal,21 which means teamwork cannot be explored in a silo. To avoid possible
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discourse and ensure a shared understanding of research findings, ICU team researchers should clearly delineate what attributes are being measured and report findings in relationship to a
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clearly defined theoretical and operational definition of the construct(s) under investigation. Such
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construct clarification will allow for more meaningful interpretation of study findings and provide a foundation on which to base future quantitative reviews of teamwork within the ICU.
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To this end, Manser68 called for future team research in healthcare to reference an existing
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theoretical framework of teamwork. Such practice will facilitate the integration existing findings to better understand the impact of teamwork on safety and performance .68 We agree with this appeal and encourage future ICU teamwork research to specifically cite the theoretical underpinnings of the constructs that are explored. It is also worth noting the majority of studies explored teamwork behaviors (e.g., communication, leadership, and coordination; Table 1). Although these attributes are central to teamwork, team functioning represents a constellation of attitudes, behaviors, and cognitions.69,70 Further study of cognitive and affective components of teamwork is encouraged. Where Teamwork is Being Measured
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ACCEPTED MANUSCRIPT Teamwork has been investigated across a wide range of ICU types and tasks, with research examining teamwork behaviors both in relation to a specific task as well as outside of a
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specific task. This is consistent with calls for both general and task specific interventions to
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improve teamwork69,71 and reinforces the conception of patient care in the ICU as a complex team endeavor. Depending on the type of team task, there may be variability in team
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composition, the degree of interdependence required, and the pace at which tasks must be
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completed. This reality requires team members to develop competencies that are not only specific to a particular task or team (e.g., implicit coordination, shared mental models), but also
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competencies that are transportable and can be generalized to different teams and different tasks (e.g., assertiveness, backup behavior).69 Future research would benefit from explicitly defining
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the functional characteristics of team tasks that are investigated, the competencies required for
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task execution, and whether the competencies are specific or generic to ICU teams and tasks.69 Such an understanding will help future researchers interpret the extent to which study results
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generalize to new ICU team contexts. This need is particularly important given the pervasiveness
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of limited generalizability being reported in ICU team research. One means to accomplish this objective is for researchers to conduct team training needs analyses (TTNA)72 of the ICUs under investigation. The outcome of such an analysis will be documentation of individual, team, and organizational characteristics likely to impact team performance effectiveness. How Teamwork is Improved Consistent with the broader healthcare literature,73 teamwork training, structured communication protocols, and organizational structure interventions have been implemented and evaluated in ICUs as well as more novel interventions (e.g., tele-robotic presence). While the variety and quality of studies prohibits quantitative synthesis, these interventions have shown an
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ACCEPTED MANUSCRIPT impact on a broad array of staff and patient outcomes as well as work processes. Given the effectiveness of several individual interventions, future research should seek to optimize
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teamwork by evaluating multifaceted interventions. Such investigations can also reveal the
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relative contribution of each intervention component on dependent variables of interest. Limitations
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Like the studies we reviewed, the present article is not without limitations. First the
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reliability and validity of the measurement systems and experimental design applied in studies that were reviewed were not scrutinized. Second, the frequency of teamwork constructs listed in
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Supplementary figure E1 may be artificially inflated in some cases. Several articles investigated more than one team task and in some cases included more than one intervention (e.g., two types
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of standardized protocols, implementing rounds and a checklist). The coding scheme did not
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allow us to directly map team constructs described in the methods and results section to a specific task or intervention when more than one was reported. The possible inflation of
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teamwork constructs was recognized in 12 articles. Last, only one literature database was used to
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identify articles for this review. Additional queries would certainly expand the pool of possible studies for this review. That said, we feel that the quantity of articles is an appropriate sample of ICU team research, which includes 50 more articles since the last review on teamwork in the ICU.27 ACKNOWLEDGEMENT This work was supported by funding from the Gordon and Betty Moore Foundation (Grant #3186.01). The views expressed in this paper are those of the authors and not necessarily reflective of Johns Hopkins University or the Gordon and Betty Moore Foundation.
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ACCEPTED MANUSCRIPT REFERENCES
T
1. Douglas S, Cartmill R, Brown R, et al. The work of adult and pediatric intensive care unit
RI P
nurses. Nurs Res. 2013;62(1):50-58.
2. Collins SA, Bakken S, Vawdrey DK, Coiera E, Currie L. Model development for EHR
SC
interdisciplinary information exchange of ICU common goals. Int J Med Inform.
NU
2011;80(8):e141-9.
MA
3. Hawryluck LA, Espin SL, Garwood KC, Evans CA, Lingard LA. Pulling together and pushing apart: Tides of tension in the ICU team. Acad Med. 2002;77(10 Suppl):S73-6.
ED
4. Carayon P, Friesdorf W. Human factors and ergonomics in medicine. In: Salvendy G, ed.
PT
Handbook of human factors and ergonomics. Third Edition ed. Hoboken, NJ, USA.: John Wiley
CE
& Sons, Inc.; 2006:1517-1537. 10.1002/0470048204.ch58.
5. Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes. Am J
AC
Surg. 2009;197(5):678-685.
6. Mardon RE, Khanna K, Sorra J, Dyer N, Famolaro T. Exploring relationships between hospital patient safety culture and adverse events. J Patient Saf. 2010;6(4):226-232.
7. Haynes AB, Weiser TG, Berry WR, et al. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf. 2011;20(1):102-107.
Page 16 of 31
ACCEPTED MANUSCRIPT 8. Brock D, Abu-Rish E, Chiu CR, et al. Interprofessional education in team communication:
T
Working together to improve patient safety. BMJ Qual Saf. 2013;22(5):414-423.
RI P
9. Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamwork improve performance in the operating room? A multilevel evaluation. Jt Comm J Qual Patient Saf. 2010;36(3):133-142.
SC
10. Jones KJ, Skinner AM, High R, Reiter-Palmon R. A theory-driven, longitudinal evaluation of
NU
the impact of team training on safety culture in 24 hospitals. BMJ Qual Saf. 2013;22(5):394-404.
MA
11. Deering S, Rosen MA, Ludi V, et al. On the front lines of patient safety: Implementation and evaluation of team training in iraq. Jt Comm J Qual Patient Saf. 2011;37(8):350-356.
ED
12. Schmutz J, Manser T. Do team processes really have an effect on clinical performance? A
PT
systematic literature review. Br J Anaesth. 2013;110(4):529-544.
CE
13. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical
AC
team training program and surgical mortality. JAMA. 2010;304(15):1693-1700.
14. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23(2):294-300.
15. Pronovost PJ, Thompson DA, Holzmueller CG, et al. Toward learning from patient safety reporting systems. J Crit Care. 2006;21(4):305-315.
16. Shortell SM, Zimmerman JE, Rousseau DM, et al. The performance of intensive care units: Does good management make a difference? Med Care. 1994;32(5):508-525.
Page 17 of 31
ACCEPTED MANUSCRIPT 17. Pollack MM, Koch MA. Association of outcomes with organizational characteristics of
T
neonatal intensive care units. Crit Care Med. 2003;31(6):1620-1629.
RI P
18. Baggs JG, Schmitt MH, Mushlin AI, et al. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Crit Care Med.
SC
1999;27(9):1991-1998.
NU
19. Weaver SJ, Rosen MA. Team training in healthcare: Brief update review. In: Shekelle PG, Wachter RM, Pronovost PJ, eds. Making healthcare safer II: An updated critical analysis of the
MA
evidence for patient safety practices. AHRQ Report No. 13-E001-EF ed. Rockville, MD: Agency for Healthcare Research and Quality; 2013:472-479.
ED
http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyII-full.pdf.
PT
20. Salas E, Rosen MA. Building high reliability teams: Progress and some reflections on
CE
teamwork training. BMJ Qual Saf. 2013;22(5):369-373.
AC
21. 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;61:273-307.
22. Kozlowski SWJ, Ilgen DR. Enhancing the effectiveness of work groups and teams. Psychological Science in the Public Interest. 2006;7(3):77-124.
23. Ohlinger J, Brown MS, Laudert S, Swanson S, Fofah O, CARE Group. Development of potentially better practices for the neonatal intensive care unit as a culture of collaboration:
Page 18 of 31
ACCEPTED MANUSCRIPT Communication, accountability, respect, and empowerment. Pediatrics. 2003;111(4 Pt 2):e471-
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81.
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24. Thomas EJ, Sexton JB, Helmreich RL. Discrepant attitudes about teamwork among critical care nurses and physicians. Crit Care Med. 2003;31(3):956-959.
SC
25. Stockwell DC, Slonim AD, Pollack MM. Physician team management affects goal
NU
achievement in the intensive care unit. Pediatr Crit Care Med. 2007;8(6):540-545.
MA
26. Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med. 2011;39(5):934-939.
ED
27. Reader TW, Flin R, Mearns K, Cuthbertson BH. Developing a team performance framework
PT
for the intensive care unit. Crit Care Med. 2009;37(5):1787-1793.
CE
28. Lin F, Chaboyer W, Wallis M. A literature review of organisational, individual and
AC
teamwork factors contributing to the ICU discharge process. Aust Crit Care. 2009;22(1):29-43.
29. Reader TW, Flin R, Cuthbertson BH. Communication skills and error in the intensive care unit. Curr Opin Crit Care. 2007;13(6):732-736.
30. Reader TW, Flin R, Lauche K, Cuthbertson BH. Non-technical skills in the intensive care unit. Br J Anaesth. 2006;96(5):551-559.
31. Baggs JG, Norton SA, Schmitt MH, Sellers CR. The dying patient in the ICU: Role of the interdisciplinary team. Crit Care Clin. 2004;20(3):525-40, xi.
Page 19 of 31
ACCEPTED MANUSCRIPT 32. Salas E, Dickinson TL, Converse S, Tannenbaum SI. Toward an understanding of team performance and training. In: Swezey RW, Salas E, eds. Teams: Their training and performance.
RI P
T
Norwood, NJ: Ablex; 1992:3-29.
33. Salas E, Cooke NJ, Rosen MA. On teams, teamwork, and team performance: Discoveries and
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developments. Hum Factors. 2008;50(3):540-547.
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34. Marks MA, Mathieu JE, Zaccaro J. A temporally based framework and taxonomy of team
MA
processes. The Academy of Management Review. 2001;26(3):356-376.
35. Pedhazur EJ, Schmelkin LP. Measurement, design, and analysis: An integrated approach.
ED
Hillsdale, NJ, USA: Lawrence Erlbaum Associates, Inc.; 1991.
PT
36. Stockwell DC, Pollack MM, Turenne WM, Slonim AD. Leadership and management
2005;6(6):665-670.
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training of pediatric intensivists: How do we gain our skills? Pediatr Crit Care Med.
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37. Salas E, Cooke NJ, Rosen MA. On teams, teamwork, and team performance: Discoveries and developments. Hum Factors. 2008;50(3):540-547.
38. Sluiter JK, Bos AP, Tol D, Calff M, Krijnen M, Frings-Dresen MH. Is staff well-being and communication enhanced by multidisciplinary work shift evaluations? Intensive Care Med. 2005;31(10):1409-1414.
39. Newkirk M, Pamplin JC, Kuwamoto R, Allen DA, Chung KK. Checklists change communication about key elements of patient care. J Trauma Acute Care Surg. 2012;73(2 Suppl 1):S75-82. Page 20 of 31
ACCEPTED MANUSCRIPT 40. Figueroa MI, Sepanski R, Goldberg SP, Shah S. Improving teamwork, confidence, and collaboration among members of a pediatric cardiovascular intensive care unit multidisciplinary
RI P
T
team using simulation-based team training. Pediatr Cardiol. 2013;34(3):612-619.
41. Jukkala AM, James D, Autrey P, Azuero A, Miltner R. Developing a standardized tool to
SC
improve nurse communication during shift report. J Nurs Care Qual. 2012;27(3):240-246.
NU
42. Boyle DK, Kochinda C. Enhancing collaborative communication of nurse and physician
MA
leadership in two intensive care units. J Nurs Adm. 2004;34(2):60-70.
43. Miller PA. Nurse-physician collaboration in an intensive care unit. Am J Crit Care.
ED
2001;10(5):341-350.
PT
44. Pronovost PJ, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving
CE
communication in the ICU using daily goals. J Crit Care. 2003;18(2):71-75.
45. Alvarez G, Coiera E. Interruptive communication patterns in the intensive care unit ward
AC
round. Int J Med Inform. 2005;74(10):791-796.
46. Custer JW, White E, Fackler JC, et al. A qualitative study of expert and team cognition on complex patients in the pediatric intensive care unit. Pediatr Crit Care Med. 2012;13(3):278284.
47. Ho D, Xiao Y, Vaidya V, Hu P. Communication and sense-making in intensive care: An observation study of multi-disciplinary rounds to design computerized supporting tools. AMIA Annu Symp Proc. 2007:329-333.
Page 21 of 31
ACCEPTED MANUSCRIPT 48. Collins SA, Mamykina L, Jordan D, et al. In search of common ground in handoff
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documentation in an intensive care unit. J Biomed Inform. 2012;45(2):307-315.
RI P
49. Ilan R, LeBaron CD, Christianson MK, Heyland DK, Day A, Cohen MD. Handover patterns: An observational study of critical care physicians. BMC Health Serv Res. 2012;12:11-6963-12-
SC
11.
NU
50. Narasimhan M, Eisen LA, Mahoney CD, Acerra FL, Rosen MJ. Improving nurse-physician communication and satisfaction in the intensive care unit with a daily goals worksheet. Am J Crit
MA
Care. 2006;15(2):217-222.
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51. Abraham J, Kannampallil TG, Patel VL. Bridging gaps in handoffs: A continuity of care
PT
based approach. J Biomed Inform. 2012;45(2):240-254.
52. Rehder KJ, Uhl TL, Meliones JN, Turner DA, Smith PB, Mistry KP. Targeted interventions
CE
improve shared agreement of daily goals in the pediatric intensive care unit. Pediatr Crit Care
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Med. 2012;13(1):6-10.
53. Phipps LM, Thomas NJ. The use of a daily goals sheet to improve communication in the paediatric intensive care unit. Intensive Crit Care Nurs. 2007;23(5):264-271.
54. Dimick JB, Pronovost PJ, Heitmiller RF, Lipsett PA. Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection. Crit Care Med. 2001;29(4):753-758.
55. Dodek PM, Raboud J. Explicit approach to rounds in an ICU improves communication and satisfaction of providers. Intensive Care Med. 2003;29(9):1584-1588. Page 22 of 31
ACCEPTED MANUSCRIPT 56. Jain M, Miller L, Belt D, King D, Berwick DM. Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture
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change. Qual Saf Health Care. 2006;15(4):235-239.
57. Johnson V, Mangram A, Mitchell C, Lorenzo M, Howard D, Dunn E. Is there a benefit to
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multidisciplinary rounds in an open trauma intensive care unit regarding ventilator-associated
NU
pneumonia? Am Surg. 2009;75(12):1171-1174.
58. Meurling L, Hedman L, Sandahl C, Fellander-Tsai L, Wallin CJ. Systematic simulation-
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professions. BMJ Qual Saf. 2013.
MA
based team training in a swedish intensive care unit: A diverse response among critical care
59. Pascual JL, Holena DN, Vella MA, et al. Short simulation training improves objective skills
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in established advanced practitioners managing emergencies on the ward and surgical intensive
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care unit. J Trauma. 2011;71(2):330-7; discussion 337-8.
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60. Allan CK, Thiagarajan RR, Beke D, et al. Simulation-based training delivered directly to the pediatric cardiac intensive care unit engenders preparedness, comfort, and decreased anxiety among multidisciplinary resuscitation teams. J Thorac Cardiovasc Surg. 2010;140(3):646-652.
61. Nunnink L, Welsh AM, Abbey M, Buschel C. In situ simulation-based team training for post-cardiac surgical emergency chest reopen in the intensive care unit. Anaesth Intensive Care. 2009;37(1):74-78.
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ACCEPTED MANUSCRIPT 62. Mayer CM, Cluff L, Lin WT, et al. Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units. Jt Comm J Qual Patient Saf.
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2011;37(8):365-374.
63. Stone ME,Jr, Snetman D, O'Neill A, et al. Daily multidisciplinary rounds to implement the
SC
ventilator bundle decreases ventilator-associated pneumonia in trauma patients: But does it affect
NU
outcome? Surg Infect (Larchmt). 2011;12(5):373-378.
64. Palma JP, Sharek PJ, Longhurst CA. Impact of electronic medical record integration of a
MA
handoff tool on sign-out in a newborn intensive care unit. J Perinatol. 2011;31(5):311-317.
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65. Vigorito MC, McNicoll L, Adams L, Sexton B. Improving safety culture results in rhode island ICUs: Lessons learned from the development of action-oriented plans. Jt Comm J Qual
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Patient Saf. 2011;37(11):509-514.
CE
66. Smith-Jentsch KA, Cannon-Bowers JA, Tannenbaum SI, Salas E. Guided team self-
AC
correction: Impacts on team mental models, processes, and effectiveness. Small Group Research. 2008;39(3):303-327.
67. Baker DP, Gustafson S, Beaubien J, Salas E, Barach P. Medical teamwork and patient safety: The evidence-based relation. . 2005;05-0053.
68. Manser T. Teamwork and patient safety in dynamic domains of healthcare: A review of the literature. Acta Anaesthesiol Scand. 2009;53(2):143-151.
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ACCEPTED MANUSCRIPT 69. Cannon-Bowers JA, Tannenbaum SI, Salas E, Volpe CE. Defining competencies and establishing team training requirements. In: Guzzo R, Salas E, eds. Team effectiveness and
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decision making in organizations. San Francisco,CA: Jossey-Bass; 1995:333-380.
70. Salas E, Rosen MA, Burke CS, Goodwin GF. The wisdom of the collectives in organizations:
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An update of the teamwork competencies. In: Salas E, Goodwin GF, Burke CS, eds. Team
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effectiveness in complex organizations. New York, NY: Routledge; 2009:39-79.
BMJ Qual Saf. 2011;20(8):647-650.
MA
71. Thomas EJ. Improving teamwork in healthcare: Current approaches and the path forward.
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72. Salas E, Cannon-Bowers JA. The science of training: A decade of progress. Annu Rev
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Psychol. 2001;52:471-499.
73. Buljac-Samardzic M, Dekker-van Doorn CM, van Wijngaarden JD, van Wijk KP.
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2010;94(3):183-195.
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Interventions to improve team effectiveness: A systematic review. Health Policy.
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ACCEPTED MANUSCRIPT Table 1. Overview of Key Findings Article Information • Empirical-Quantitative (63; 74%)
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Type of article (n=85)
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• Empirical-Qualitative (22; 26%) Experimental design (n=85)
• Quasi-Experimental (32; 38%)
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• Non-Experimental (53: 62%)
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Key Research Questions
• Team (44; 52%)
research? ICU team (n=85)
• Task (43; 51%)
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What outcomes are being investigated in
• Patient (24; 28%)
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• Individual (20; 24%)
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How has teamwork been conceptualized
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and operationalized in the ICU? (n=85)
• Unit/Organization (13; 15%)
• Communication (44; 52%) • Leadership (17; 20%) • Collaboration (16; 19%) • Coordination (12; 14%) • Team Climate/Culture (7; 8%) • Information Exchange (3; 4%) • Conflict Management (3; 4%) • Cohesion (2; 2%) • SA/Team SA (2; 2%) • Shared Mental Model (2; 2%) • Assertion (1; 1%)
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ACCEPTED MANUSCRIPT • Caregiver Interaction (1; 1%) • Cooperation (1; 1%)
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• Empowerment (1; 1%)
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• Decision-making Inclusion (1; 1%)
• Joint Sense-Making (1; 1%)
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• Mutual Performance Monitoring (1; 1%)
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• Mutual Respect (1; 1%) • Mutual Support/Assertion (1; 1%)
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• Shared Goal Agreement (1; 1%) • Shared Problem Solving (1; 1%)
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• Situation Monitoring (1; 1%) • Team Commitment (1; 1%) • Team Satisfaction (1; 1%) • Trust (1; 1%) • Verbalizing Situational Information (1; 1%) • Not Specified (14; 17%)
Where has teamwork been investigated?
Research Context
(n=85)
• Multiple ICUs (31; 37%) • General ICU (15; 18%) • Pediatric ICU (10; 12%) • Medical ICU (5; 6%) • Medical-Surgical ICU (5; 6%) • Surgical ICU (4; 5%)
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ACCEPTED MANUSCRIPT • Neurovascular ICU (3; 4%) • Neonatal ICU (2; 2%)
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• Pediatric Cardiac ICU (2; 2%)
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• Cardiothoracic ICU (1; 1%)
• Medical-Surgical Pediatric ICU (1; 1%)
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• Neuro-ICU (1; 1%)
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• Neuroscience ICU (1; 1%) • Newborn ICU (1; 1%)
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• Neurosurgical ICU (1; 1%) • Trauma ICU (1; 1%)
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• Not Applicable (1; 1%)
Team Tasks • Rounds (33; 39%) 34 • Clinical (17; 20%) • Handoff (17; 20%) • Transfer (2; 2%) • Huddle/Debrief (1; 1%) • Multidisciplinary Meetings (1; 1%)
What interventions have been used to
• Standardized Patient Status Tool (15; 42%)
improve teamwork in the ICU? (n=36)
• Training (8; 22%) • Rounds/Change of Rounding Process (7; 19%) • Specialized Staffing (3; 8%) • Comprehensive Unit-Based Safety Program (2; 6%)
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ACCEPTED MANUSCRIPT • Robotic Tele-Presence (1; 3%) • Safety Attitude Questionnaire Action Plan (1; 3%)
T
• Multidisciplinary Work Shift Evaluations (1; 3%)
RI P
• Collaborative Communication Intervention (1; 3%)
SC
• Wireless Email (1; 3%)
• Developed primarily to improve teamwork (22; 61%)
to improve teamwork? (n=36)
• Not primary or only focus (14; 39%)
Where has evidence of intervention
MA
NU
Were interventions developed primarily
• Team outcomes (18; 50%)
• Task outcomes (21; 58%)
• Patient outcomes (14; 39%) • Individual outcomes (9; 25%) • Unit/Organization outcomes (4; 11%)
AC
CE
PT
ED
effectiveness been demonstrated? (n=36)
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