“Teamwork in hospitals”: a quasi-experimental study protocol applying a human factors approach

On the basis of international studies, the World Health Organization (WHO) estimates that between 3 and 16% of all patients treated in hospitals are affected by adverse events [1]. Poor teamwork is an independent cause of many of the system failures that lead to patient harm [2‐4], which are considered as preventable [5, 6]. Despite improvements in the past 15 years, patient safety remains an important public health concern [7]. Effective teamwork and good communication are critical components essential to patient safety in today’s specialized and complex healthcare services [3, 8, 9]. A focus on teamwork competencies in complex healthcare systems such as leadership and coordination are identified by the WHO as a priority for research on patient safety in the Western world [10]. Teamwork is described in terms of behaviour, cognitions and attitudes that make interdependent performance possible [11], which is defined as: “The interaction or relationship of two or more health professionals who work interdependently to provide care for patients” ([12], p. 3). Teamwork is one of six core competencies seen as necessary for health professionals to master in order to meet the current and future demands for the quality of care [13].

Hospital units are representing frontline microsystems in hospitals where patients and healthcare professionals meet, and where care quality, patient safety and clinical outcomes are being produced [14]. These microsystems have the greatest opportunity to develop and improve work processes [15]. An extensive review of factors associated with team performance has identified shared mental models, mutual respect and trust, and closed-loop communication as the underpinning conditions required for effective teams [16]. However, various challenges exist within the frontline healthcare environment. For example, there are different perceptions and expectations of the roles and collaboration in teams among healthcare professionals [17, 18]. Moreover, studies have also demonstrated a variation in their perception of patient safety culture [19, 20], while another challenge to effective teamwork is the hierarchical structure among healthcare personnel [21, 22]. The association between adverse events and insufficient teamwork have been known for some time, but it is only in recent years that an evidence-based understanding of the problem has been developed, as well as an efficient programme to promote patient safety. Furthermore, it has been demonstrated that team training can improve efficiency in inter-professional teamwork within hospitals [23‐26]. Team training is recommended for those who are expected to work together in teams [27], which requires that health-care personnel across professions should train together. Although there is an increasing awareness regarding teamwork competencies, healthcare has implemented team training in healthcare education and clinical practice to a small extent [28‐30]. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) [31] is an evidence-based teamwork system based on research on teamwork, team training and cultural change [16, 32, 33]. The teamwork system is released from the US Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense as a national team training programme. TeamSTEPPS provides tools, strategies and measurements to promote team practice in all aspects of healthcare [34], and with the use of an implementation strategy based on Kotter’s model of organizational change [35].

The process of developing and evaluating complex interventions has a number of stages, although they may not follow a linear structure; however, the best practice is to develop interventions in a systematic way [47]. A first step is to identify existing evidence of similar interventions, in addition to which methods have been used to evaluate them [47]. This study consists of two parts with six sub-studies, each with a protocol based on a review of the literature. In the overall study protocol, the evidence is based on recent systematic reviews on teamwork and team training in hospitals. A theoretical framework and a theoretical understanding are needed to prevent weak links and to identify strengths. The SEIPS 2.0 model [36] provides a valuable lens to the theoretical understanding, which assists our research on inter-professional teamwork in a number of ways: 1) to reframe how to observe and monitor inter-professional teamwork, and interpret aspects of teamwork performance; 2) to explore more deeply what contextual factors influence the healthcare team’s performance; 3) to measure the effect of inter-professional teamwork on patient safety and patient outcomes, and 4) to help move the discussion beyond the teamwork training events (i.e. using simulation), and to provide evidence-based recommendations on the content, duration and frequency of teamwork training programmes associated with the clinical evidence [26].

It is important to understand the context in which the intervention is taking place. One challenge may be that there is still no consensus about a single definition or model of teamwork that can accommodate every feature of teamwork within a specific healthcare specialty [3]. Moreover, healthcare personnel may not be aware of the core competencies of teamwork [48, 49]. Therefore, a feasibility testing of the translated teamwork questionnaire conducted in a hospital setting is important. Moreover, the TeamSTEPPS programme [31] has to be translated and adapted into a Norwegian hospital setting.

The intervention in this study will be investigated using a quasi-experimental interventional design, which is useful where there are practical or ethical barriers to conducting a randomized experiment [50], although under an quasi-experimental design researchers have less control over confounding factors [50]. The intervention is taking place in a hospital ward, which is a small microsystem with a limited sample size that hampers the use of randomization. Quasi-experimental designs may include controlled and uncontrolled before-and-after studies and time-series design [50]. Such designs are often found in studies of improvement [51], and will also be used in this project. The decision making with regard to outcome measures is based on identifying existing evidence about similar interventions. Qualitative data from interviews will be used in process evaluations, and will contribute to exploring the way in which the intervention is implemented. It is important to understand how and why changes have taken place [51], and why an intervention has unexpected consequences or fails, or how a successful intervention works [47].

The intervention has been planned according to the TeamSTEPPS-recommended change model, and uses an implementation strategy based on Kotter’s model of organizational change. With the understanding that complex interventions may work best if they are tailored to local contexts [52], a project group comprising members of the research group and leaders from clinical practice is in collaboration responsible for the development. Moreover, a change team at the surgical intervention ward is responsible for the implementation in clinical practice.

The major strength of this study is its status as an intervention conducted in a real-world hospital setting with an opportunity to achieve changes in work processes and patient safety. However, there are methodological limitations in terms of isolation on the effect of the ongoing intervention.