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Special Issue on Teamwork*
Building high reliability teams: progress and some reflections on teamwork training
  1. Eduardo Salas1,
  2. Michael A Rosen2
  1. 1Department of Psychology, Institute for Simulation & Training, University of Central Florida, Orlando, Florida, USA
  2. 2Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  1. Correspondence to Dr Eduardo Salas, Institute for Simulation & Training, University of Central Florida, UCF, Orlando, FL 11111, 32826 USA; esalas{at}


The science of team training in healthcare has progressed dramatically in recent years. Methodologies have been refined and adapted for the unique and varied needs within healthcare, where once team training approaches were borrowed from other industries with little modification. Evidence continues to emerge and bolster the case that team training is an effective strategy for improving patient safety. Research is also elucidating the conditions under which teamwork training is most likely to have an impact, and what determines whether improvements achieved will be maintained over time. The articles in this special issue are a strong representation of the state of the science, the diversity of applications, and the growing sophistication of teamwork training research and practice in healthcare. In this article, we attempt to situate the findings in this issue within the broader context of healthcare team training, identify high level themes in the current state of the field, and discuss existing needs.

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Teamwork training has been heralded as a transformative method for improving safety and quality in healthcare.1 Not too long ago, the argument for team training in healthcare relied heavily on the experiences of other industries: aviation, nuclear power generation and the military for example. Now, the story is different. We know that teamwork impacts clinical performance,2 and teamwork training can improve the teamwork of clinicians3 and even clinical outcomes.4 Evidence from a diverse range of sources, including reviews of adverse events and incidents of patient harm,5 reviews of closed claims malpractice cases,6 descriptive studies across clinical contexts7 and cross-sectional survey studies8 all highlight the pervasiveness of communication failures in healthcare. Comprehensively addressing breakdowns in communication requires a full systems approach, including the analysis and redesign of work processes and information technology.9 Such changes notwithstanding, the teamwork competencies of healthcare workers constitute a critical component for any efforts to reduce communication failures. Yet, the development of teamwork competencies has not been addressed in a systematic way by educational institutions, professional organisations or healthcare systems to date.

The articles in this special issue clearly demonstrate the extent to which a body of knowledge on teamwork in healthcare exists and upon which educational and training efforts could draw. The achievements detailed here are remarkable and encouraging. In this article, we take stock of what we know, what works, what are the insights and what needs to be done about the design, delivery and implementation of team training. These reflections encompass not only the articles included in the special issue but the broader scientific literature on team training and simulation as well as our own experience.

Team training works

The data are compelling and convincing. It is not perfect, but clearly team training impacts important processes and outcomes. These data come not only from the articles in this special issue, but from a growing literature base, which includes increasingly rigorous approaches to evaluation.9 ,10 Like many safety and quality interventions, evaluation of team training in healthcare is not easy. The unit of analysis for a teamwork training intervention is not typically a patient or even staff team, but an entire unit. The effects of teamwork on patient and safety outcomes are frequently indirect. Despite these challenges, the emerging picture clearly demonstrates that healthcare providers have positive reactions to teamwork training (ie, they believe it is important, relevant to their work and they intend to apply it in their practice), learn the concepts and use the new behaviours on the job. These multi-level training evaluations are important pieces of the puzzle as they outline all of the links in the chain of effects necessary to achieve the ultimate results desired. However, these are not the truly compelling issues. Team training must impact patient safety and quality of care. We now know that this is true. Teamwork training is associated with improvements in clinical performance2 and other important organisational outcomes (eg, efficiency, culture).3 Most importantly teamwork training improves patient outcomes.4

Team training works, but implementation strategies and organisational conditions matter

And these conditions matter more than we typically think. The conditions set the climate for how teamwork is perceived; for how it is reinforced; and for how it is valued. The signals that organisations send about what behaviours, attitudes or cognition are appropriate and accepted in the workplace will determine whether physicians, nurses, students and staff will exhibit them. It is clear that organisations get the behaviours, cognition and attitudes they reinforce.11 For example, in a follow-up article to the widely cited WHO safer surgery checklist study,12 almost 50% of the reduction in mortality and complications observed after implementing the checklist was associated with the pre-existing safety culture of the facilities where the checklist was implemented.13 Facilities high in safety culture realised much more benefit from the intervention than facilities with lower safety culture. This is rational, predictable and consistent with theories of organisational culture. An organisation's safety culture consists of the aggregate attitudes and values of its members. It reflects the degree to which individuals prioritise safety in relation to other competing demands (eg, financial and production pressures). If an organisation's members prioritise safety, they will more likely see the value of collaborating and invest effort in changing their own behaviours and patterns of interactions on the job.

In this special issue, Jones et al14 found that certain aspects of organisational structure and leadership moderated the relationship between teamwork training and cultural change. Specifically, the impact of teamwork training decreased if the organisation did not have a functioning error reporting system in place, leaders did not understand or reinforce the value of teamwork, and teamwork concepts were not institutionalised into job descriptions, or evaluation and promotion criteria. Taken as a whole, these characteristics indicate the degree to which the organisation takes teamwork training seriously. Do staff perceive the training as a ‘one and done’ episode, or as a part of the organisation's true values? To realise long-term and sustained change, organisations must provide the supportive context for teamwork and pervasive reminders that teamwork matters to the organisation.15

Team training works, but method of delivery matters

And practice is best. Guided practice. In contrast to other topics in healthcare education, traditional information-based methods of training delivery can improve teamwork in healthcare.16 The effectiveness of didactics and reading materials may reflect the fact that the content of teamwork training (ie, teamwork knowledge, skills, and attitudes) may be easier to learn relative to complex clinical topics. Or, perhaps, the novelty of the topic engages learners. Nonetheless, applying teamwork principles on the job remains challenging. It involves breaking old habits of communication and interaction, much of which we do under time pressure and without much conscious deliberation. Thus, practice-based training significantly enhances impact on the acquisition, application and retention of teamwork skills in healthcare.17 In this special issue, there are several examples of the use of simulation to improve teamwork and safety including the work of Patterson et al18 in the paediatric emergency department and the work of Brock et al19 in interprofessional education.

Team training is a cultural intervention and dependent upon leadership support at all levels

While behavioural and knowledge competencies are critical for effective teamwork, attitudinal competencies matter as well. These include belief in the importance of teamwork, mutual trust and comfort with taking interpersonal risks. These characteristics are tied to organisational climates and cultures, which are heavily influenced by leadership at all levels. Emerging evidence indicates that, much like other organisational change interventions in healthcare, the degree of leadership support for teamwork training in healthcare impacts sustainment.20 For example, when senior leaders attend, if only briefly, teamwork training sessions, sustainment of those interventions is markedly better than in facilities where leadership support is less visible.21 As discussed above, teamwork is tightly intertwined with culture, and leadership is perhaps the single most important driver of what an organisation's culture looks like.

Team training is best paired with other methods of improving teamwork

Team training represents just one of three main types of intervention that can improve teamwork in healthcare. The two others consist of standardised communication protocols (eg, briefing and debriefing checklists, and handoff protocols) and interventions at the structural level (eg, changes to team composition, information systems and support tools, role structure clarification).22 Each of these approaches has value in its own right, but each complements the others.23 With appropriate organisational design and communication protocols, the work environment supports rather than inhibits effective communication, coordination and collaboration. In this issue, Bunnell et al24 demonstrated significant impact on care processes as well as staff and patient reported outcomes. They achieved this benefit by pairing teamwork training with a workflow analysis and redesign for specific care communication challenges faced in outpatient oncology. General teamwork training combined with specific communication tools is an effective strategy, as the training provides a broad rationale for teamwork and general competencies while the tools provide scaffolding, support and reminders for using teamwork skills on the job.

Measurement driven feedback drives improvement

Feedback is essential to learning and improvement, specifically diagnostic feedback—information that helps team members understand the causes of effective and ineffective performance.25 But, measuring any type of process in healthcare is a challenge. The barriers and constraints are no different for teamwork measurement. Several robust measurement systems have been developed for teamwork in specific clinical areas.26 ,27 However, large gaps remain in the tools available for guiding learning in training events and on the job. In this issue, Grand et al28 provide a general teamwork measurement framework as well as a process for developing and validating measures for specific contexts and purposes. This approach of adapting an overarching measurement framework to multiple uses is a strong contribution as it is unlikely there will be a single global tool useful for measuring teamwork across all settings.

Becoming an expert team player is a career-long journey

Currently, team training programmes target practicing clinicians and last only a few hours.29 While this amount of training has proven effective, it is also unlikely that 2–4 h of training will equip a clinician with all of the teamwork skills he or she will need throughout their career. The interprofessional education movement emphasises teamwork among healthcare workers from the earliest stages of education, and alignment of team training programmes conducted in the operational setting with these early opportunities to learn will no doubt enhance their effects. Additionally, these competencies need to be integrated into ongoing continuing education programmes.30 Brock et al19 illustrate how a team training programme designed for practicing clinicians can be effectively implemented with medical, nursing and pharmacy students. Their work clearly demonstrates impact on teamwork attitudes and knowledge in these students, an experience they will hopefully carry forward in their professional development.

Team training is a solution to patient safety, not the solution

Teamwork training attempts to break the mythology of individual heroism in medicine, and broaden the views of clinicians to understanding and managing interdependencies between individuals. The emphasis on individual expertise and accountability in healthcare is critical and inspiring, but it is also limiting. The nature of work in healthcare demands a team approach to coordinate the diverse expertise of clinicians as well as better involving patients and their families in care processes and decisions.31 However, truly managing care in a coordinated and collaborative fashion requires more than good teamwork skills. The built environment, information systems, devices and work processes all influence the care provided. There is workload involved in coordinating with others and every human has inherent workload capacities and limitations. The work systems that reduce extraneous workload (eg, inefficient and duplicative documentation, overwhelming monitoring false alarms) provide more opportunities for healthcare workers to coordinate with one another and with patients and their families.32 Teamwork training alone will not resolve these issues, of course. The more fundamental and underlying physical, device, task and information system issues need to be addressed concurrently with teamwork training.

Sustainability: the next frontier

If team training is viewed solely as training, real change is not likely to happen and it is less likely to persist over time. As previously discussed, what happens in training sessions matters (eg, use of practice-based strategies, diagnostic measurement and feedback) but what happens after training is equally as important and frequently more challenging to manage. Brodsky et al33 demonstrated the long-term impact of a team training programme in neonatal intensive care on staff perceptions of teamwork and job fulfilment. Their approach involved focusing on teamwork training and including work process changes (ie, team meetings) to make enacting teamwork in the workplace easier for staff to accomplish. Thomas and Galla34 document a series of lessons learnt in a multi-year effort to spread and sustain teamwork training efforts throughout a large hospital system. These include building in accountability into the training plan for various roles and responsibilities, embedding the teamwork concepts into organisational policies and practices, engaging physician leaders as active partners in the training, and planning for refresher trainings.


Team training is no longer an approach that healthcare has adopted from other industries without careful adaptation. The articles in this special issue and the broader literature illustrate great maturation in designing, delivering and evaluating teamwork training in a way that reflects the unique needs of healthcare. However, we still have much to learn. There remain open questions about how to make team training work best. Issues of duration and timing of the training, how much practice is required, how frequently should refreshers occur, and many other practical considerations involved in integrating teamwork into the fabric of educational and operational institutions remain unanswered to the degree necessary to fully guide practice. Additionally, further advancements in rigorous yet practically feasible methods of measurement and evaluation that can drive diagnostic feedback at the individual, team, unit and higher levels of analysis are needed.



  • *Special Issue on Teamwork: Edited by Eduardo Salas and Michael Rosen in collaboration with Elizabeth Hunt (Johns Hopkins University, School Of Medicine, Division of Pediatric Critical Care Medicine, Baltimore, USA) and Pamela R Jeffries (The Johns Hopkins University, School of Nursing, Baltimore, USA)

  • Contributors Both authors equally contributed to the writing of this paper.

  • Funding This research received no specific funding.

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.