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Table 3 Relationships between teamwork and patient safety

From: Integrating teamwork, clinician occupational well-being and patient safety – development of a conceptual framework based on a systematic review

Study Topic Primary topic Sample & setting Design & data collection methods Assessment of variables Analyses Findings Outcomes & effect sizes Quality scored
a) observational studies
Burtscher et al., 2010 [61] Relationships between coordination activities and team performance under differing situational demands yes 19 anesthetists and 14 anesthesia nurses, 40 cases, teaching hospital, Switzerland Video observation of anesthesia induction Teamwork: observation system used for coding coordination activities & clinical work
Patient safety: team performance (self-developed checklist)
Paired-sample t-test 1) Compared to low-performing teams, high-performing teams increase task management during non-routine events
2) No changes in information management during non-routine events
1) t(20) = −2.75, p < 0.05, []b
2) NS
13.5 (15)
Burtscher et al., 2011 [12] Relationships between adaptive team coordination during non-routine events and clinical performance during anesthesia induction yes 15 anesthesia teams (1 resident, 1 nurse), teaching hospital, Switzerland Video observation of simulated anesthesia induction Teamwork: team coordination (structured observation)a
Patient safety: decisions and execution latency (expert rating)
Pearson’s correlation 1) Information management is
a) negatively correlated with decision latency
b) but not with execution latency
2) No correlations between task management and
a) decision latency
b) execution latency
1a) r = −0.49, p = 0.003
1b) NS
2a) NS
2b) NS
12.5 (15)
Burtscher et al., 2011 [5] Team mental model properties moderate link between monitoring behaviors and performance in anesthesia induction yes 31 teams (1 anesthesia resident, 1 anesthesia nurse), teaching hospital, Switzerland Video observation of simulated anesthesia induction Teamwork:
Team mental model similarity and accuracy (concept mapping), monitoring behavior (structured observationa)
Patient safety: adherence to anesthesia induction protocol (structured observationa)
Multiple hierarchical regression 1) Teams with similar mental models perform well irrespective of team monitoring level; teams with dissimilar mental models only perform well when team monitoring is low
2) Team mental model similarity is only related to performance when team mental model accuracy is also high
3) Team performance is high when either team or system monitoring is high and the other is low
4) Mental model accuracy does not moderate relationship between systems monitoring and performance
1) β = 0.36, p = 0.04, ΔR2 = 0.13, [ƒ2 = 0.21]b
2) β = 0.42, p = 0.02, ΔR2 = 0.17, [ƒ2 = 0.12]b
3) β = −0.36, p = 0.04, ΔR2 = 0.12, [ƒ2 = 0.28]b
4) NS
14 (15)
Catchpole et al., 2007 [64] Relationships between non-technical skills and adverse events in the OR yes 42 operations (24 pediatric, 18 orthopedic), 2 hospitals, UK Live & video observation Teamwork: non-technical skills (NOTECHSa)
Patient safety: Adverse events: minor problems, intraoperative performance, operating time
Multiple linear regression Non-technical skills negatively predict
1) minor problems but not
2) intraoperative performance or
3) operating time
1) B = −3.3, t = −2.2, p = 0.035, []b
2) NS
3) NS
8 (15)
Catchpole et al., 2008 [62] Relationships between non-technical skills and errors in the OR yes 54 surgeons, anesthetists, and nurses, 48 operations (26 laparoscopic cholecystectomies, 22 carotid endarterectomies), 1 hospital, UK Live observation of operation Teamwork: NOTECHSa
Patient safety: errors in surgical technique (observation clinical human reliability assessment technique), other procedural problems and errors (checklist), operating time
Multiple linear regression 1a) Surgical leadership and management negatively predicts operating time,
1b) whereas anesthetic leadership and management in carotid endarterectomy positively predicts operating time
2a) nursing leadership and management negatively predict other procedural problems and errors
2b) whereas nursing leadership and management in carotid endarterectomy positively predicts operating time (2 predictors)
3a) surgical situation awareness negatively predicts errors in surgical techniques (3 predictors)
3b) whereas surgical situation awareness in carotid endarterectomy positively predicts operating time (3 predictors)
4) Teamwork dimensions
a) leadership and management
b) teamwork and cooperation
c) problem solving and decision making
d) situation awareness
are not associated with patient safety dimensions
e) errors in surgical technique
f) other procedural problems and error
g) operating time
1a) β = −0.19, p = 0.023
1b) β = 0.81, p < 0.001, R2 = 0.717, [ƒ2 = 2.53]b,c
2a) β = −0.39, p = 0.012
2b) β = 0.41, p = 0.008, R2 = 0.69 [ƒ2 = 2.215]b,c
3a) β = −0.71, p < 0.001
3b) β = 1.97, p < 0.001, R2 = 0.19, [ƒ2 = 0.233]b,c
4ae-dg) 9 non-significant associations
9 (15)
Catchpole et al., 2008 [63] Relationships between non-technical skills and safety threats, errors, and operative duration yes Physicians and nurses, 44 operations (24 pediatric, 20 orthopedic), 2 hospitals, UK Live & video observation Teamwork: NOTECHSa
Patient safety: errors & threats (checklists and free observations)
Spearman’s rank correlation 1) Positive correlation between non-technical skills and
1a) safety threats
1b) operative duration
1c) but not technical errors in pediatric surgery
2) No correlations between non-technical skills and
1a) safety threats
1b) operating time
1c) technical errors in orthopedic surgery
1a) ρ = 0.58, p < 0.005
1b) ρ = 0.58, p < 0.005
1c) NS
2a) NS
2b) NS
2c) NS
10 (15)
Endacott et al., 2014 [81] Relationships between leadership, teamwork and performance in medical emergencies yes 42 nurses, 15 teams, 1 hospital, Australia Video observation of simulated emergency Teamwork: Team Emergency Assessment Measure (TEAM) a
Patient safety: performance of key treatment actions
Pearson correlation Teamwork correlates positively with patient safety in the
1) respiratory distress and
2) hypovolemic shock but not in the
3) chest pain scenario
1) r = .90, p < 0.001
2) r = .54, p < .05
3) NS
11.5 (15)
Kolbe et al., 2012 [65] Relationships between speaking up and technical team performance/team interaction no 31 anesthesia teams (1 nurse, 1 resident), teaching hospital, Switzerland Video observation of simulated anesthesia induction Teamwork: Coding scheme for (non-)verbal team interactions
Patient safety: technical team performance (adherence to checklist of standard anesthesia induction and target values)
Hierarchical linear regression 1) Technical team performance is predicted by nurses’ levels of speaking up
2) but not by residents’ levels of speaking up
1) β = 0.43, p = 0.017, R2 = 0.18, [f2 = 0.22]bc (2 predictors)
2) NS
14 (15)
Kuenzle et al., 2010 [67] Relationship between shared leadership and anesthesia team performance under high and low task load yes 12 anesthesia teams (1 resident, 1 nurse), teaching hospital, Switzerland Video observation of simulated anesthesia induction Teamwork: Coding scheme for content-oriented and structuring leadership behavior
Patient safety: performance (reaction time after non-routine event)
ANOVA 1a) No differences in shared leadership behaviors of high-performing teams between nurses and residents
1b) during high- and low task load situations
2a) Residents show more leadership behaviors than nurses in low performing teams
2b) independent of task load
1a) F(1, 20) = 0.00, p = 0.971, η2 = 0.000
1b) Interaction: NS
2a) F(1, 20) = 7.14, p = 0.015, η2 = 0.263
2b) Interaction: NS
12.5 (15)
Kuenzle et al., 2010 [66] Relationship between shared leadership and anesthesia team performance under high and low task load yes 12 anesthesia teams (1 resident, 1 nurse), 1 hospital, Switzerland Video observation of simulated anesthesia induction Teamwork: structuring and content oriented leadership: structured observation
Patient safety: performance (speed of correct management after non-routine event = high task load)
Spearman’s rank correlation
Kruskal-Wallis-test
1) Under high task load team performance and
a) structuring and
b) content-oriented leadership
are not correlated
2) Under low task load, team performance and
a) structuring,
b) but not content-oriented leadership
are negatively correlated
3) Interaction of leadership behavior and team experience is not associated with team performance
1a) NS
1b) NS
2a) ρ = −0.56, p < 0.05
2b) NS
3) NS
12 (15)
Lubbert et al., 2009 [68] Relationship between team organization and treatment errors yes 378 video registrations of patients treated in the emergency room, 1 hospital, The Netherlands Video observation Teamwork & patient safety: Self-developed checklist measuring adherence to advanced trauma life support (ATLS) guidelines t-test 1) Errors in team organization dimension evident leadership are associated with more deviations from treatment protocol, whereas
2) errors in team organization dimension effective leadership are not
1) p = 0.01 (no other indicators reported)
2) NS
6 (15)
Manser et al., 2009 [11] Relationships between different coordination patterns and team performance yes 46 anesthesia residents, 23 teams, USA Video observation of simulated anesthesia emergency Teamwork: self-developed coding scheme for coordination
Patient safety: clinical performance (adherence to malignant hyperthermia treatment guidelines)
Hierarchical regression analysis 1) Time spent on coordination dimensions
a) task management
b) but not information management
c) or coordination via work environment
negatively predicts performance
2) Time spent on task management categories
a) task distribution
b) but not planning
c) clarification
d) initiating action
e) or assistance
negatively predicts performance
3) Time spent on information management categories
a) situation assessment
b) but not information transfer
c) decision making
d) or feedback/acknowledgement
negatively predicts performance
1a) β = −0.47, p < 0.01, ΔR2 = 0.243, [f2 = 0.32]b
1b) NS
1c) NS
2a) β = −0.54, p < 0.01, ΔR2 = 0.340, [f2 = 0.52]b
2b) NS
2c) NS
2d) NS
2e) NS
3a) β = −0.57, p < 0.05, ΔR2 = 0.227, [f2 = 0.29]b
3b) NS
3c) NS
3d) NS
11.5 (15)
McCulloch et al., 2009 [6] Relationships between non-technical skills and technical errors yes 54 surgeons, anesthetists and nurses, 48 observations before and 55 observations after training, teaching hospital, UK Uncontrolled pre-post-training
Live observations of operations
Teamwork: NOTECHSa
Patient safety: technical errors (Observation Clinical Human Reliability Assessment, OCHRA)a
Spearman’s rank correlation 1) Negative correlation between
a) overall non-technical skills and technical errors
b) especially for surgical sub-team
2) Negative correlation between
a) situational awareness and technical errors
b) especially for surgical sub-team
1a) ρ = −0.215, p = 0.024
1b) ρ = −0.236, p = 0.013
2a) ρ = −0.300, p = 0.001
2b) ρ = −0.436, p < 0.0001
11.5 (18)
Mishra et al., 2008 [69] Relationships between non-technical skills and technical errors yes 26 observations (nurses, surgeons, anesthetists), teaching hospital, UK Live observation of operation Teamwork: NOTECHSa
Patient safety: OCHRAa
Spearman’s rank correlation 1) No correlation between technical errors and
a) leadership & management
b) teamwork & cooperation
c) problem-solving and decision-making in the
d) overall team, or
e) surgeon
f) anesthetists
g) and nurses subgroup
2) Negative correlation between situation awareness and technical errors for
a) overall team
b) surgeon subgroup
c) but not anesthetists
d) and nurses subgroup
1ad) NS
1ae) NS
1af) NS
1ag) NS
1bd) NS
1be) NS
1bf) NS
1bg) NS
1 cd) NS
1ce) NS
1cf) NS
1cg) NS
2a) ρ = −0.505, p = 0.009
2b) ρ = −0.718, p = 0.001
2c) NS
2d) NS
10 (15)
Ottestad et al., 2007 [70] Development and psychometric testing of tool to measure resuscitative skills and to compare interns and teams regarding ideal management of septic shock no 23 observations (ICU residents), USA Video observation of emergency simulation Teamwork: NOTECHSa
Patient safety: Adherence to Surviving Sepsis Campaign Guidelines
Pearson’s correlation Positive correlation between non-technical skills and team sepsis management r = 0.4, p = 0.05 7.5 (15)
Schmutz et al., 2015 [79] Relationships between coordination, task type and performance in medical emergencies yes 277 nurses, resident and senior physicians, 68 teams, 7 hospitals, Germany Video observation of simulated pediatric emergency Teamwork: Coordination behaviors via CoMeT–E (Coordination System for Medical Teams - Emergency) observation toola
Patient safety: Clinical performance via key treatment steps checklist
Hierarchical linear regression 1a) Coordination behavior closed-loop communication is positively associated with clinical performance, whereas
1b) coordination behaviors task distribution and
1c) providing information without request are not.
2a) Task type moderates relationship 1a) in that it is stronger in rule-based compared to knowledge-based tasks
2b) Task type did not moderate relationship 1b)
2c) Task type did not moderate relationship 1c)
1a) β = .25, p < .05
1b) NS
1c) NS
2a) β = −.52, p < .01
2b) NS
2c) NS
14 (15)
Schraagen et al., 2011 [85] Relationships between non-routine events, teamwork and patient outcomes yes 1 pediatric cardiac surgery team, 40 operations, The Netherlands Cross-sectional self-report questionnaire, live observation of operations, record review Teamwork: observation tool derived from NOTECHSa, ANTSa, NOTSSa, and OTASa
Patient safety: 30-day postsurgical complications, operating time
Pearson’s correlation,
ANOVA
1) Positive correlation between non-technical skills and
a) operating time
b) but not postsurgical complications
2) Explicit coordination of anesthetists is associated with higher levels of postsurgical complications
1a) r = 0.45, p < 0.05
1b) NS
2) Muncomplicated = 12.88, Mminor complications = 21.55, []b
Mmajor complications = 16.40, F(2,36) = 4.78, p < 0.01, []b
10 (16)
Schraagen et al., 2011 [86] Relationships between non-routine events, teamwork and patient outcomes yes 1 pediatric cardiac surgery team, 40 operations, The Netherlands Cross-sectional self-report questionnaire, live observation of operations, record review Teamwork: NOTECHSa
Patient safety: 30-day postsurgical complications
Pearson’s correlation,
ANOVA
Teamwork and cooperation is associated with higher levels of postsurgical complications Muncomplicated = 3.19, Mminor complications = 3.44, Mmajor morbidity = 3.28, F(2,36) = 3.85, p < 0.05, η2 = 0.18 8.5 (16)
Siassakos et al., 2010 [80] Relationships between individual team members’ knowledge, skills, and attitudes and team performance no 19 teams (physicians and midwives), 6 maternity units, UK Video observation of obstetric emergency simulation, self-report questionnaire Teamwork: SAQ subscale team climatea
Patient safety: team performance (magnesium administration)
Kendall’s rank correlation No correlation between teamwork climate and performance NS 8 (16)
Siassakos et al., 2011 [72] Relationships between teamwork skills and behaviors and team performance in emergency situations yes 47 teams (2 physicians and 4 midwives each), 6 maternity units, UK Video observation Teamwork: Team analytical toola
Patient safety: performing key actions
Kendall’s rank correlation 1) Positive correlation between speed of magnesium administration and
a) skills
b) behavior
c) and overall teamwork
2) Negative correlation between time needed to put patient in recovery position and
a) skills
b) behavior
c) but not overall teamwork
3) Negative correlation between time needed to administer oxygen and
a) skills
b) behavior
c) and overall teamwork
4) Negative correlation between time needed to sample blood and
a) skills
b) behavior
c) and overall teamwork
1a) τ = 0.54, p < 0.001
1b) τ = 0.41, p = 0.001
1c) τ = 0.51, p < 0.001
2a) τ = −0.29, p = 0.012
2b) τ = −0.25, p = 0.026
2c) NS
3a) τ = −0.39, p < 0.001
3b) τ = −0.28, p = 0.014
3c) τ = −0.41, p < 0.001
4a) τ = −0.35, p = 0.002
4b) τ = −0.35, p = 0.002
4c) τ = −0.35, p < 0.002
8.5 (15)
Siassakos et al., 2011 [71] Relationships between teamwork and clinical efficiency in emergency situations yes 114 physicians and nurses, 19 teams, 6 maternity units, UK Video observation Teamwork: self-developed observation system
Patient safety: performing key action (speed of magnesium administration)
Kendall’s rank correlation 1) Positive correlation between closed-loop communication and clinical efficiency
2) Positive correlation between unambiguous communication and clinical efficiency
3) No correlations between clinical efficiency and
a) SBAR communication style
b) team coordination
c) situational awareness
d) leadership style
e) supportive language
f) task support by senior clinician
1) τ = 0.46, p = 0.022
2) τ = 0.53, p = 0.004
3a) NS
3b) NS
3c) NS
3d) NS
3e) NS
3f) NS
8 (15)
Thomas et al., 2006 [73] Relationship between teamwork and quality of care yes 118 teams (physicians, nurses, respiratory therapists), resuscitation room, teaching hospital, USA Video observation of neonatal resuscitation Teamwork: Frequency of different teamwork behaviors
Patient safety: Neonatal Resuscitation Program (NRP) Guidelines
Spearman’s rank correlation 1) Negative correlation between team communication and
a) overall quality of resuscitation,
b) non-compliance with all NRP steps, and
c) non-compliance during preparation and initial steps
2) Negative correlation between team management and
a) noncompliance with all NRP steps, and
b) noncompliance during preparation and initial steps but not
c) overall quality of resuscitation,
3) Negative correlation between team leadership and
a) overall quality of resuscitation, but not with
b) noncompliance with all NRP steps, and with
c) non-compliance during preparation and initial steps
1a) ρ = −0.236, p = 0.007
1b) ρ = −0.214, p = 0.014
1c) ρ = −0.230, p = 0.008
2a) ρ = −0.201, p = 0.021
2b) ρ = −0.252, p = 0.003
2c) NS
3a) ρ = −0.288, p < 0.001
3b) NS
3c) NS
9.5 (15)
Tschan et al., 2006 [74] Relationships between directive leadership, structuring inquiry and performance regarding different phases yes 109 clinicians (nurses, residents, senior physicians), 21 teams, ICU, university hospital, Switzerland Video observation and transcription of emergency simulation Teamwork: directive leadership and structuring inquiry
Patient safety: clinical performance (key actions, hands-on time)
Pearson’s correlation 1) Phase 1 (nurses only): positive correlation between performance and
a) directive leadership and
b) structuring inquiry
2) Phase 2 (residents and nurses): positive correlation between performance and
a) resident directive leadership during first 30 s,
no correlation between performance and
b) resident directive leadership per second
c) resident structuring inquiry per second
d) resident structuring inquiry during first 30 s
3) Phase 3 (nurses, residents, senior physicians): positive correlation between performance and
a) senior physician structuring inquiry,
no correlation between performance and
b) resident structuring inquiry
c) senior physician
d) resident directive leadership
1a) r = 0.445, p < 0.05
1b) r = 0.216, p < 0.05
2a) r = 0.522, p < 0.05
2b) NS
2c) NS
2d) NS
3a) r = 0.428, p < 0.01
3b) NS
3c) NS
3d) NS
11.5 (15)
Tschan et al., 2009 [75] Relationships between team communication and perceptual biases of individuals and accuracy of diagnosis yes 53 physicians, 20 teams, university hospital, Switzerland Video observation of hand-over simulation Teamwork: coding of communication and behavior
Patient safety: diagnostic performance
ANOVA 1) Groups considering more diagnostic information are not more likely to find the correct diagnosis
2) Groups showing
a) more explicit reasoning
b) more talking to the room
are more likely to find the correct diagnosis
1) NS
2a) F(2, 15) = 5.750, p = 0.014
2b) χ2 = 8.598, df = 2, p = 0.007
11 (15)
Westli et al., 2010 [76] Relationship between teamwork skills/shared mental models and clinical performance yes 27 trauma teams, Norway Video observation of emergency simulations Teamwork: ANTSa and Anti-Air Teamwork Observation Measure (ATOM)
Patient safety: Team global medical management,
key actions of trauma management
Pearson’s correlation 1) Negative correlation between supporting behavior and performing key actions
2) Negative correlation between poor coordination and medical management
3) Positive correlation between information exchange and medical management
4) Negative correlation between poor situational awareness and performing key actions
5) Positive correlation between providing information and medical management
6a-u) 21 non-significant correlations between teamwork and patient safety variables
1) r = −0.37, p < 0.05
2) r = −0.36, p < 0.05
3) r = 0.34, p < 0.05
4) r = −0.40, p < 0.05
5) r = 0.51, p < 0.01
6a-u) NS
10.5 (15)
Wiegmann et al., 2007 [77] Relationship between (teamwork-related) surgical flow disruptions and surgical error yes 31 cardiac operations, 1 hospital, USA Live observation of operation Teamwork: teamwork-related surgical flow disruptions
Patient safety: surgical errors
Multiple regression Teamwork-related surgical flow disruptions positively predict surgical errors β = 0.692, p < 0.001, adj. R2 = 0.553, [f2 = 1.24]bc
(5 predictors altogether)
11 (15)
Williams et al., 2010 [78] Relationships between teamwork behaviors and resuscitation errors yes 12 resuscitation teams, NICU, teaching hospital, USA Video observation of resuscitation Teamwork: frequency of different teamwork behaviors
Patient safety: Neonatal Resuscitation Program (NRP) Guidelines
Spearman’s rank correlation, generalized linear mixed model (GLM) 1) Negative correlation between vigilance and NRP errors
2) No correlation between workload management and NRP errors
3) NRP errors are associated with
a) more assertions before the error
b) less teaching after the error
4) No associations between NRP errors and
a) information sharing before error
b) information sharing after error
c) inquiry before error
d) inquiry after error
e) assertion after error
f) teaching before error
1) ρ = −0.62, p = 0.031
2) NS
3a) OR = 1.44, p = 0.008, 95 % CI 1.10 – 1.89
3b) OR = 0.59, p = 0.028, 95 % CI 0.37 – 0.94
4a) NS
4b) NS
4c) NS
4d) NS
4e) NS
4f) NS
10 (15)
b) survey studies
Brewer, 2006 [87] Relationships between culture, team characteristics/processes and patient safety/hospital financial performance yes 430 nurses, physicians and other medical care providers, 16 surgical units, 4 acute care hospitals,
USA
Cross-sectional
self-report questionnaire, record review
Teamwork:
Positive team processes: Relational Coordination Scalea
Negative team processes scale
Patient safety: patient falls (incident reporting system), length of stay (hospital records)
Pearson’s correlation 1) Positive intra-team processes correlate positively with a) length of stay
b) but not with patient falls
2) No correlation between negative team processes and
a) length of stay
b) patient falls
1a) r = 0.59, p < 0.05
1b) NS
2a) NS
2b) NS
10 (16)
Chan et al., 2011 [88] Validity of a team-based tool to assess success of a team-based intervention to reduce central line associated blood stream infections (CLABSI) no 46 ICUs, 35 hospitals, USA Secondary analyses of longitudinal RCT, self-report questionnaire, record review Teamwork: Team check-up tool (TCT)
Patient safety: Central line associated bloodstream infections (CLABSI)
Cox regression No association between teamwork and duration to reach zero CLABSI’s after intervention NS 10 (19)
Chang & Mark, 2009 [89] Antecedents (teamwork, nurse & patient factors) of severe and non-severe medication errors yes 1 671 nurses, 279 units, 146 hospitals, USA Longitudinal self-report questionnaire, record review Teamwork: Relational Coordination Scalea
Patient safety: medication errors (hospital incident reports)
Generalized estimating equations (GEE) Relational coordination predicts neither
1) severe nor
2) non-severe medication errors
1) NS
2) NS
9 (16)
Edmondson, 2004 [10] Relationship between team/organizational characteristics, team leadership and medication errors yes 159 nurses, physicians and pharmacists, 8 hospitals, USA Cross-sectional self-report questionnaire, record review Teamwork: Team/organizational characteristics and team leadership (self-developed questionnaire)
Patient safety: medication error (hospital incident reports & self-reported)
Spearman’s rank correlation Positive correlation between
1) nurse manager coaching
2) nurse manager direction setting and
3) unit relationship quality
and
a) detected and
b) intercepted medication errors but not with
c) non-preventable drug complications
1a) ρ = 0.74, p < 0.03
1b) ρ = 0.71, p < 0.03
1c) NS
2a) ρ = 0.74, p < 0.03
2b) ρ = 0.83, p < 0.03
2c) NS
3a) ρ = 0.74, p < 0.03
3b) ρ = 0.76, p < 0.03
3c) NS
11 (16)
Fasolino et al., 2012 [90] Relationships between nurse characteristics, nurse practice environment, team member effectiveness and medication error yes 163 nurses, 11 surgical units, 1 hospital, USA Cross-sectional self-report questionnaire, record review Teamwork: team member effectiveness survey
Patient safety: medication errors (hospital incident reports)
Spearman’s rank correlation Team member effectiveness is positively correlated with medication error ρ = 0.19, p < 0.01 12 (16)
Hoffer Gittell et al., 2000 [9] Relationship between relational coordination and quality of care/length of stay yes 338 physicians, nurses, and other medical care providers, 9 hospitals, USA Cross-sectional self-report questionnaire, record review Teamwork: Relational Coordination Scalea
Patient safety: Length of stay
Hierarchical linear regression Relational coordination is associated with decreased length of stay B = −53.77, p < 0.001, []b 13 (16)
Hwang & Ahn, 2015 [83] Relationships between teamwork and error reporting yes 576 nurses, 2 acute care hospital, South Korea Cross-sectional self-report questionnaire Teamwork: Teamwork perceptions questionnaire (TPQ)a
Patient safety: occurrence of and reporting medical errors
Logistic regression Teamwork dimensions
1) team structure,
2) team leadership,
3) situation monitoring,
4) mutual support, and
5) communication
are positively associated with error reporting
No information on relationship between teamwork and occurrence of medical errors
1) OR = 0.92, 95 % CI 0.50 –1.692) OR = 1.13, 95 % CI 0.78 –1.623) OR = 0.96, 95 % CI 0.52 – 1.78
4) OR = 1.23, 95 % CI 0.66 – 2.30)
5) OR = 1.82, 95 % CI 1.05 - 3.14
12.5 (16)
Kalisch & Lee, 2010 [60] Relationship between teamwork and missed nursing care yes 2216 nurses, 40 acute care units, 4 hospitals, USA Cross-sectional self-report questionnaire Nursing Teamwork Surveya MISSCARE Surveya Pearson’s correlation
Multiple linear regression
1) Negative correlation between missed nursing care and
a) trust
b) team orientation
c) backup behavior
d) shared mental model
e) team leadership
2) After controlling for various covariates, overall teamwork scores negatively predict missed nursing care
1a) r = −0.31, p < 0.01
1b) r = −0.28, p < 0.01
1c) r = −0.31, p < 0.01
1d) r = −0.32, p < 0.01
1e) r = −0.29, p < 0.01
2) B = −0.254, p < 0.001, ΔR2 = 10.9, [f2 = 0.124]b
12.5 (16)
Leroy et al., 2012 [8] Mediation and moderation relationships between leader behavioral integrity for safety, team psychological safety, team priority of safety, and treatment errors yes 580 nurses and head nurses, 4 hospitals, Belgium Longitudinal self-report questionnaire Teamwork: Team Psychological Safety Scalea
Patient Safety: head nurses’ reports of treatment errors
Path analysis 1) Good overall model fit
2) Within path model, team psychological safety at time 1 positively predicts treatment errors at time 2
1) χ2 = 6.72, p = 0.03, SRMR = 0.07, RMSEA = 0.02, CFI = 0.98
2) β = 0.28, p = 0.02
14 (16)
Manojlovich et al., 2007 [82] Relationships between perceived work environments, nurse-physician communication and patient outcomes yes 462 nurses, 25 ICUs, 8 hospitals, USA Cross-sectional self-report questionnaire Teamwork: parts of ICU Nurse-Physician Questionnairea
Patient safety: nurse-reported adverse events (medication errors, ventilator-associated pneumonia, catheter-associated sepsis)
Random intercept multilevel models Nurse-physician communication negatively predicts
1) ventilator-associated pneumonia
2) catheter-associated sepsis and
3) medication errors
1) B = −0.045, p < 0.05, R2 = 0.09, [f2 = 0.1]b,c
2) B = −0.049, p < 0.05, R2 = 0.14, [f2 = 0.16]b,c 3) B = −0.047, p < 0.01, R2 = 0.11, [f2 = 0.12]b,c
 
Manojlovich et al., 2009 [91] Relationship between nurse-physician communication and patient outcomes yes 462 nurses, 25 ICUs, 8 hospitals, USA Cross-sectional self-report questionnaire, record review Teamwork: ICU Nurse-Physician Questionnairea Patient safety: adverse outcomes ventilator-associated pneumonia, bloodstream infections, and pressure ulcers Pearson’s correlation No correlation between nurse-physician communication subscales
1) timeliness
2) accuracy
3) openness and
4) understanding
and patient safety indicators
a) ventilator-associated pneumonia
b) bloodstream infections and
c) pressure ulcers
1a-4c) 12 non-significant associations 11 (16)
Ogbolu et al., 2015 [84] Relationships between nurse work environment and patient safety no 222 nurses, Nigeria Cross-sectional self-report questionnaire Teamwork: nurse-physician relationsa
Patient safety: Patient safety: one item from AHRQa
Generalized linear mixed modeling Relationship between nurse-physician relations and patient safety not reported (only relationship between aggregate NWI scale and patient safety) - 10 (16)
Taylor et al., 2012 [92] Relationships between safety climate, teamwork and patient adverse events no Nurses in 29 units, 1 hospital, USA Cross-sectional & longitudinal self-report questionnaire, record review Teamwork: SAQ subscale team climatea
Patient safety: patient falls & injuries, deep vein thrombosis and pulmonary embolism records
Multilevel logistic regression Positive team climate is associated with
1) fewer decubitus ulcers, but not
2) less patient falls & injuries or
3) pulmonary embolisms and deep vein thrombosis
one year later
1) OR = 0.56, 95 % CI 0.30 - 0.82, p < 0.01
2) NS
3) NS
13.5 (16)
Vogus et al., 2007 [93] Moderation of relationship between team safety organizing behaviors and medication errors by trust in manager and existence of care pathways yes 1033 nurses & 78 nurse managers, 78 units, 10 acute-care hospitals, USA Cross-sectional self-report questionnaire, record review Teamwork: Safety Organizing Scale (SOS)a
Trust in manager: 2 items
Care pathways: 1 item
Patient safety: medication errors (number of errors reported to unit’s incident reporting system up to 6 months after survey data collection)
Multilevel Poisson regression 1) Safety organizing negatively predicts medication errors
2) Trust in manager has no impact on reporting of medication errors when level of safety organizing is high. When safety organizing is low and trust in manager is high, more errors are reported
3) Use of care pathways has no impact on reporting of medication errors when safety organizing is low. When safety organizing is high and care pathways are extensively used, fewer errors are reported
1) β = −0.29, p < 0.01, 95 % CI −0.57 to −0.01
2) β = −0.68, p < 0.001, 95 % CI −1.03 to −0.32
3) β = −0.82, p < 0.001, 95 % CI −1.31 to −0.33
13 (16)
Wheelan et al., 2003 [94] Relationship between teamwork and patient mortality yes 349 healthcare providers, 17 ICUs, 9 hospitals, USA Cross-sectional self-report questionnaire, record review Teamwork: Group Development Questionnairea
Patient safety: Standardized mortality rates
Pearson’s correlation Level of group development correlates negatively with mortality rates r = −0.66, p = 0.004 12 (16)
Yun et al., 2005 [95] Moderation of relationship between contingent leadership and team effectiveness by severity of patient trauma and team experience yes 91 members of trauma resuscitation teams, 1 hospital, USA Cross-sectional self-report questionnaire, scenario method Teamwork & patient safety: Team Effectiveness Scalea,
Team leadership, severity of trauma and team experience manipulated across scenarios
General linear model (GLM) 1) Interaction of leadership/severity of injury: Team effectiveness dimension quality health care is high when patient was not severely injured/leadership is empowering or patient was severely injured/leadership was directive
2) Interaction of leadership/team experience: quality health care is highest when leadership is empowering, independent of team experience
3) 3-way-interaction: quality health care is highest when team is experienced and leadership is empowering, independent of patient condition. When team is inexperienced, quality health care is highest when leadership is empowering and patient is not severely injured, or when leadership is directive and patient is severely injured
1) Severely injured patient:
Mdirective leaders = 3.06, 95 % CI 2.83 – 3.27, Mempowering leaders = 2.72, 95 % CI 2.50 – 2.95. Non-severely injured patient: Mempowering leaders= 3.91, 95 % CI 3.69 – 4.13, Mdirective leaders = 2.16, 95 % CI 1.94 – 2.38, F = 119.48, p < 0.01, η2 = 0.26.
2) Experienced team: Mempowering leadership = 3.65, 95 % CI 3.42 - 3.82, Mdirective leadership = 2.48, 95 % CI 2.25 - 2.70. Inexperienced team: Mempowering leadership = 2.99, 95%CI 2.76 - 3.21, Mdirective leadership = 2.74, 95 % CI 2.51 - 2.96, F = 23.19, p < 0.01, η2 = 0.06.
3) Inexperienced team/severely injured patient: Mdirective leadership = 3.19, 95 % CI 2.89 - 3.49, Mempowering leadership= 2.13, 95 % CI 1.82 - 2.44. Inexperienced team/non-severely injured patient: Mempowering leadership= 3.85, 95 % CI 3.57 - 4.12, Mdirective leadership= 2.28, 95 % CI 2.00 - 2.56, F = 7.31, p < 0.01, η2 = 0.04.
14.5 (16)
  1. We report not only significant but also non-significant relationships between predictor and outcome variables of interest in this review as hypothesized in the reviewed studies; even if not explicitly stated in the original publication
  2. a validated instrument
  3. b effect sizes calculated by authors, calculation not possible if brackets empty
  4. c Cohen’sƒ2 based on R2 instead of ΔR2
  5. d in brackets: maximal possible score