Acta Anaesthesiol Scand 2009; 53: 143–151
Printed in Singapore. All rights reserved
Teamwork and patient safety in dynamic domains of
healthcare: a review of the literature
T. MANSER
ETH Zurich, Center for Organizational and Occupational Sciences, Zurich, Switzerland
Aims/Background: This review examines current re-
search on teamwork in highly dynamic domains of health-
care such as operating rooms, intensive care, emergency
medicine, or trauma and resuscitation teams with a focus
on aspects relevant to the quality and safety of patient
care.
Results: Evidence from three main areas of research sup-
ports the relationship between teamwork and patient
safety: (1) Studies investigating the factors contributing
to critical incidents and adverse events have shown that
teamwork plays an important role in the causation and
prevention of adverse events. (2) Research focusing on
healthcare providers’ perceptions of teamwork demon-
strated that (a) staff’s perceptions of teamwork and atti-
tudes toward safety-relevant team behavior were related to
the quality and safety of patient care and (b) perceptions of
teamwork and leadership style are associated with staff
well-being, which may impact clinician’ ability to provide
safe patient care. (3) Observational studies on teamwork
L EARNING from other high-risk industries has
inspired research efforts in healthcare and has
contributed to significant improvements. In recent
years, a number of articles on teamwork and team
training in high-risk industries other than health-
care have been published in medical and interdis-
ciplinary journals. Some of these articles have not
referred to any of the researches on teamwork that
have already been carried out in healthcare and
that are the focus of this review.
The process of providing healthcare is inherently
interdisciplinary, requiring physicians, nurses, and
allied health professionals from different special-
ties to work in teams. In the patient safety litera-
ture, it has been widely recognized that team
performance is crucial to providing safe patient
care.1 Poor coordination among providers at var-
ious levels of the organization appears to affect the
quality and safety of patient care (e.g. delays in
testing or treatment, conflicting information).2,3
Therefore, teamwork has become a focus of
r 2008 The Author
Journal compilation r 2008 The Acta Anaesthesiologica Scandinavica Foundation
ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/j.1399-6576.2008.01717.x
Review Article
behaviors related to high clinical performance have iden-
tified patterns of communication, coordination, and lea-
dership that support effective teamwork.
Conclusion: In recent years, research using diverse meth-
odological approaches has led to significant progress in
team research in healthcare. The challenge for future
research is to further develop and validate instruments
for team performance assessment and to develop sound
theoretical models of team performance in dynamic med-
ical domains integrating evidence from all three areas of
team research identified in this review. This will help to
improve team training efforts and aid the design of clinical
work systems supporting effective teamwork and safe
patient care.
Accepted for publication accepted 2 May 2008
r 2008 The Author
Journal compilation r 2008 The Acta Anaesthesiologica Scandinavica Foundation
system-based interventions to improve patient
safety and of medical education standards.
In general, teams are defined as two or more
individuals who work together to achieve specified
and shared goals, have task-specific competencies
and specialized work roles, use shared resources,
and communicate to coordinate and to adapt to
change.4 Compared with teams in other industries,
medical teams especially in the dynamic domains
of healthcare such as operating rooms, intensive
care, emergency medicine, or trauma and resusci-
tation teams5 work under conditions that change
frequently, may be assembled ad hoc, have a dyna-
mically changing team membership, often work
together for a short period of time, consist of
specialists or several specialist crews, and have to
integrate different professional cultures. In the
team literature, such teams are known as ‘action
teams’.6 When investigating effective teamwork in
medical teams, it is important to consider the
specific requirements a team is confronted with.
143
T. Manser

Not all medical teams are ‘action teams’ and team-
work requirements may vary depending on the
situation (e.g. routine vs. emergency).
Focusing on the dynamic domains of healthcare,
this review aims to provide an overview of (a) the
methods used and (b) the questions addressed by
teamwork research focusing on the time between
1998 and 2007, (c) identify aspects of teamwork that
have been shown to correspond to the quality and
safety of care, and (d) explore perspectives for
future research.
Materials and methods
A literature search was carried out consulting the
databases PubMed (1950–2007), MEDLINE via
OVID (1966–2007), ISI Web of Knowledge, and
PsychINFO. The following search terms were
used: teamwork, leadership, collaborative work,
collaborative activity, interdisciplinary practice,
team training, and cross training. In addition, the
initial database search was limited to the dynamic
domains of healthcare such as operating rooms,
intensive care, emergency medicine, or trauma and
resuscitation teams. Figure 1 provides an overview
of the process of identifying the publications in-
cluded in this review.
In a first step, references were screened for
relevance in the context of this review. The criteria
for inclusion in this review were (a) addresses
teamwork in the dynamic domains of healthcare,
(b) published journal article, and (c) published in
English.
In a second step, abstracts of the 277 articles
fulfilling the inclusion criteria were used to cate-
gorize publications; full-text articles were retrieved
when there was insufficient information in the
abstract. To assure reliability of this categorization,
an independent reviewer categorized a randomly
selected 20% subset of the abstracts (Cohen’s k.89).
The categorization showed that (a) the majority of
articles were empirical studies of teamwork, fol-
lowed by theoretical papers describing basic con-
cepts of teamwork and their relevance in healthcare
and (b) the relative importance of topics has shifted
over the years (see Fig. 2). For example, the propor-
tion of theoretical papers highlighting the impor-
tance of teamwork decreased whereas team
training became more prominent, first in terms of
Initial database search
Step 1:
Screening of references
according to inclusion criteria
Step 2:
Categorization
of the 277 publications
fulfilling inclusion criteria
Step 3:
Selection for detailed review:
101 publications
Fig. 1. Overview of the procedure for selecting publications for
this review.

100%
1
33 34
90% 5
3
80% 29 34

70%

60% 13
117
101
50%

40% 2
7
30% 24
22
20%
11
50 68
10%
Fig. 2. Distribution of 227 journal articles
0% on teamwork and team training in dynamic
Before 1987 1988-1997 1998-2007 total domains of healthcare across types of articles
and over time.

144

course descriptions (1988–1997) and then in terms
of evaluations of team training interventions (1998–
2007). Also, along with the increased number of
empirical studies of teamwork, an increase in
methodological papers describing, validating, or
discussing methods for team research can be noted.
Given these trends in the available literature, it was
decided to focus on recent empirical studies of
teamwork.
In a third step, a total of 101 empirical studies of
teamwork published between 1998 and 2007 were
sorted into thematic groups and reviewed in detail.
In the following, an overview of the studies in-
vestigating teamwork in relation to patient safety
will be given.
Results
Methods applied in studying the relationship
between teamwork and patient safety
The studies included in this review have applied a
broad spectrum of methodological approaches. Be-
sides retrospective case analysis based on docu-
ments such as patient records or incident reports
(sometimes in combination with interviews) that
have been used to identify factors contributing to
the causation and/or prevention of adverse events,
two main approaches can be distinguished.
(a) Methods used to study attitudes and percep-
tions: Interviews, focus groups, and (attitude) sur-
veys can provide useful diagnostic information
relating to the perception of teamwork behavior.
Over the past 10 years, a number of survey instru-
ments have been adapted to and applied in health-
care. Some of these instruments that measure safety
climate to diagnose the underlying safety culture7
include teamwork as one major aspect,8–11 whereas
others specifically measure the perceived quality of
teamwork.12–16
(b) Methods used to describe and assess beha-
vior: Although clinicians’ attitudes and perceptions
are very important aspects of teamwork, positive
attitudes toward teamwork are not necessarily
accompanied by appropriate behavior. Observation
studies of patient care teams provide complemen-
tary information on effective team behavior such as
coordination and leadership. For example, pro-
spective observational studies have been used to
identify medical errors and to describe the devel-
opment of critical incidents. Over the past 10 years,
significant progress has been made concerning the
development and evaluation of instruments to
Teamwork and patient safety
systematically describe team processes and assess
team performance. Two main approaches can be
identified: (a) systems to describe team processes
(either applying an ethnographic approach17–21 or
categorizing behaviors using a predefined observa-
tion system)22–25 and (b) rating systems to assess
teamwork skills (often referred to as behavioral or
non-technical skills) in various medical specialty
areas including anesthesia,26,27 surgery,28,29 operat-
ing room teams,30 intensive care,31 and neonatal
resuscitation.32 These instruments have been eval-
uated successfully as research tools but also as
feedback tools that can be used for teaching in
various clinical settings.33
Teamwork as an important contributing factor to
adverse events
This review identified a number of empirical stu-
dies investigating the role of teamwork issues in
the causation of adverse events in dynamic do-
mains of healthcare. These studies fall into two
main groups: (a) retrospective analyses of incident
and adverse event reports or malpractice claims
and (b) observational studies.
Retrospective analyses of incident and adverse
event reports found communication and teamwork
issues to be among the most frequent contributory
factors (i.e. in 22–32% of reports).34–36 These results
are not surprising because the provision of health-
care is an inherently communicative and team-
based activity.
Observational studies found similar results. In
the operating room, Lingard et al.,37 for example,
observed a failure in 30% of communication events
during surgical procedures. Of these failures, 36%
had observable consequences such as delay, ten-
sion among team members, or procedural error.
These results are supported by another observa-
tional study focusing on the effects of disruptions
of the surgical process (e.g. communication fail-
ures, equipment problems). The study found that
surgical errors increased significantly with in-
creased disruptions and that teamwork and com-
munication problems were the strongest predictors
of surgical errors.38 An observational study in
pediatric cardiac and orthopedic surgery found
that effective teamwork was associated with fewer
minor problems per operation (i.e. negative events
that were seemingly innocuous but many of which
contributed to major problems), higher intraopera-
tive performance (i.e. less key operating tasks were
disrupted), and shorter operating times.39
145
T. Manser
In summary, observational studies and retro-
spective analyses of incidents or adverse events
indicate that many of the contributing factors
originate from flawed teamwork rather than from
a lack of clinical skills. One difficulty is, however,
that most of these studies do not make it explicit
exactly which aspects of teamwork have to be
improved. In addition, few empirical studies sys-
tematically investigated the role of teamwork in
preventing minor problems from escalating to
more serious situations.38,39 Nevertheless, it is often
claimed that many adverse events could have been
prevented by improved teamwork.
Healthcare providers perceptions of teamwork in
dynamic medical domains
Surveys and interview studies regarding attitudes
toward teamwork indicate that – consistent with
many other high-risk industries – healthcare pro-
viders attribute a high degree of importance to
teamwork aspects such as communication or co-
ordination.9,14,40 In a qualitative study on the
meanings attached to teamwork in the operating
room, coordination, leadership, and its role in
assuring patient safety and staff well-being were
identified as the most prominent meanings.41
Different groups of healthcare providers perceive the quality
of teamwork differently. Studies investigating clini-
cians’ perceptions of teamwork found that the
quality of leadership, the openness of communica-
tion, etc. were generally rated positively.9,13,42,43
However, most studies identified marked differ-
ences in the perceived quality of teamwork between
professional groups (i.e. nurses reported lower le-
vels of quality of teamwork than doctors),10,13,15,42–46
within disciplines (i.e. trainee doctors reported
lower levels of quality of teamwork than senior
doctors),14,42,43,45 and between specialties.14,47 These
differences in the way members of different profes-
sional groups perceive interpersonal interactions are
also supported by a study investigating how differ-
ent members of an operating room team perceived
the same situation. The results of this study showed
that surgeons, nurses, and anesthesiologists inde-
pendently rated tension levels of three video-based
scenarios similarly, but rated each profession’s re-
sponsibility for creating and resolving tension dif-
ferently, often rating their profession as having
relatively less responsibility than the others.48
One aspect of teamwork for which most studies
identified differences between professional groups
146
is the quality of collaboration and communication
between team members. However, in some studies
healthcare providers rated a peer and in other
studies another type of caregiver. In one study,
nurses’ ratings of the quality of collaboration and
communication with physicians (33% positive rat-
ings) were compared with physicians’ ratings of the
quality of collaboration and communication with
nurses (73% positive ratings).44 Another study con-
trasted surgeons’ ratings of their collaboration with
other surgeons (85% positive ratings) with nurses’
ratings of their collaboration with surgeons (48%
positive ratings).47
Besides these methodological issues, there is no
consensus about the optimal level of cohesiveness
and shared understanding of team structure, team
tasks, and team roles in patient care teams. Human
factors research in other high-risk industries sug-
gests that a shared mental model of teamwork is
essential for effective team performance.49 There-
fore, the result that operating room teams deemed
the quality of the teamwork acceptable, despite
marked differences in team members’ understand-
ing of team roles, and team structure,16 may indicate
the need to raise awareness of the importance of
teamwork in patient safety.
Staff’s perceptions of teamwork are related to the quality
and safety of patient care. Little empirical evidence
exists on the relationship between staff’s percep-
tions of the quality of teamwork (or their attitudes
toward teamwork) and the perceived or objectively
measured quality and safety of patient care. For
example, studies using clinicians’ attitudes toward
safety-relevant behaviors as indicators of safety
found that although attitudes to these behaviors
were generally positive, staffs’ responses also in-
dicated a belief in personal invulnerability to stress
and fatigue.9,40,42 This result was more pronounced
in healthcare than in aviation.40 Research in inten-
sive care found that the perceived communication
openness among team members predicted the
degree to which individuals reported to under-
stand patient care goals.43,50
Studies using objective measures of the quality
and safety of patient care also indicate an associa-
tion with (certain aspects of) teamwork.11,12,51 For
example, relational coordination (measured by fre-
quency of communication, strength of shared
goals, degree of mutual respect among care provi-
ders, etc.) was found to be associated with im-
proved quality of care, reduced post-operative
pain, improved post-operative functioning, and

decreased lengths of hospital stay.12 Another study
in intensive care comparing the perceived quality
of team functioning with predicted and actual
mortality rates of the unit during the study period
found that for units with mortality rates that were
lower than predicted, staff’s perceptions of team-
work were more positive (e.g. team members were
seen as less dependent and more trusting).51
Perceptions of teamwork and leadership style impact staff
well-being. Besides known contributors to staff
well-being such as workload, time pressure, and
job control, perceptions of teamwork and leader-
ship behavior were found to be associated with
employee outcomes such as emotional exhaus-
tion,52 burnout,11,53 job satisfaction,11,54 and orga-
nizational commitment.54 For example, a survey of
ICU nurses showed that leadership styles that seek
and value contributions from staff promote a cli-
mate in which information is shared effectively,
promote decision making at the staff nurse level,
and influence coordination of work to provide a
milieu that increases nurses’ intent to stay.55
Although empirical results directly linking staff
well-being to patient safety are not available, hu-
man factors research indicates that, for example,
burnout symptoms such as emotional exhaustion,
fatigue, inability to concentrate, and aversion to
patients decrease clinicians’ ability to assure pa-
tient safety.5 In order to decrease the likelihood
for negative employee outcome, leadership beha-
vior creating an atmosphere where team members
feel they can communicate openly and participate
in decision making is essential.50,56 Moreover, first
studies on the effects of changes in the design
of work systems and processes indicate that re-
structuring toward a team-based approach im-
proves staff well-being and the quality and safety
of patient care.52,57
Teamwork behaviors related to patient safety
Observational studies of teamwork have identified
patterns of communication, coordination, and lea-
dership that support effective teamwork. However,
only a few studies could establish a direct link
between specific teamwork behaviors and clinical
performance or patient outcome.
Communication patterns supporting effective teamwork.
Among the most prominent themes in commu-
nication research in healthcare are the effects of
interruptions and tensions on effective team func-
Teamwork and patient safety
tioning. For example, ethnographic studies showed
that tensions in team communications in the oper-
ating room often evolve around the issues of time,
safety and sterility, resources, and work roles.17,58
Another focus of communication research is
concerned with the frames of reference that clin-
icians with different professional backgrounds re-
fer to when discussing patient care decisions.59–61
Studies in intensive care found that breakdowns in
teamwork were often related to different types of
knowledge referred to by nurses and physicians
when discussing clinical problems60 and that the
proximity to the patient played an important role
in shaping clinicians’ perspectives.59 A qualitative
study in an emergency room found that the use of
different frames of reference in patient care deci-
sions within a team decreases the recognition of
uncertainty and may compromise patient safety.61
So far, no direct link between communication
patterns and patient outcomes has been estab-
lished. However, Lingard et al.62 have proposed a
model of the relationships among specific commu-
nication practices (i.e. pre-operative team briefing),
intermediary processes (e.g. increased team mem-
ber knowledge, improved team behavior), and the
quality and safety of patient care. Theoretical mod-
els of communication in medical teams will enable
the development of training curricula that will
improve team functioning and patient safety.
Coordination strategies supporting effective teamwork.
Coordination is essential to teamwork because
different team members routinely perform multi-
ple interdependent tasks simultaneously. Ethno-
graphic research in anesthesia has highlighted
that teams coordinate not only through verbal
communication but also through their work envir-
onment (i.e. the precise alignment of team mem-
bers bodies, tools, and the patient’s body).18,20,21
This coordination strategy, which requires an in-
timate knowledge of work roles and procedures,
enables smooth team performance in most routine
situations. However, during unfamiliar, ill-struc-
tured, or critical situations, more explicit forms of
coordination may be necessary. Grote et al.,63 for
example, observed that anesthesia teams adapt to
situational requirements such as the levels of stan-
dardization of the work process. Higher levels of
standardization were associated with more implicit
coordination and less leadership behavior. These
results are in line with human factors research in
other high-risk industries, indicating that effective
teams adapt their coordination strategies to the
147
T. Manser
situational requirements (i.e. more implicit coordi-
nation during routine situations and more explicit
coordination during critical situations).64
Leadership behaviors supporting effective teamwork. Lea-
dership is a special means of coordination that
has received considerable attention in research
on trauma and cardiac arrest teams. These
teams are prototypical examples of action teams
because team members perform urgent and
highly consequential tasks while simultaneously
coping with frequent changes in team com-
position.6,65 In addition, these teams rarely com-
municate before attending to a cardiopulmonary
arrest.66
Video analyses of resuscitation attempts showed
that the degree to which resuscitation team leaders
built a structure within the team correlated signifi-
cantly with team dynamics and task perfor-
mance.22 If resuscitation team leaders participated
‘hands-on’, they were less likely to build a struc-
tured team, the team was less dynamic (i.e. less
adaptability and coordination), and the resuscita-
tion tasks were performed less effectively. These
results are supported by other studies, showing
that successful resuscitation teams exhibited sig-
nificantly more leadership behavior and explicit
task distribution67 and a positive effect of ‘directive
leadership behavior’ and ‘structuring inquiry’.25
Based on video analysis, Xiao et al.19 identified
six leadership functions in trauma teams (e.g.
information request, strategic planning, critiquing
plans) that were frequently triggered by specific
characteristics of the situation (e.g. arrival of a new
team member, completion of a sub-task, detection
of an error). The systematic mapping of leadership
functions to task situations provided evidence of
adaptive leadership in trauma teams. The impor-
tance of adaptive leadership is further supported
by observational research showing that senior team
leaders dynamically assign leadership tasks to team
members65 and that leadership roles change dyna-
mically when new team members join the team.25
These results suggest that adaptive leadership en-
hances teams’ ability to perform reliably in the face
of dynamically changing task requirements.
In summary, these studies provide evidence of
the importance of adaptive and effective leadership
in resuscitation teams. Survey results indicate that
many residents (50%) feel unprepared to take on a
leadership role in cardiac arrest teams due to
perceived deficits in their training, especially a
lack of leadership training (51%), and in their
148
Table 1
Overview of aspects of teamwork relevant to the quality and
safety of patient care in dynamical domains of healthcare.
Aspects of Examples of safety-relevant characteristics
teamwork
Quality of Mutual respect
collaboration Trust
Shared mental Strength of shared goals
models Shared perception of a situation
Shared understanding of team structure,
team task, team roles, etc.
Coordination Adaptive coordination (e.g. dynamic task
allocation when new members join the team;
shift between explicit and implicit forms of
coordination; increased information
exchange and planning in critical situations)
Communication Openness of communication
Quality of communication (e.g. shared
frames of reference)
Specific communication practices (e.g. team
briefing)
Leadership Leadership style (value contributions from
staff, encourage participation in decision-
making, etc.)
Adaptive leadership behavior (e.g. increased
explicit leadership behavior in critical
situations)
supervision including post-event debriefing and
performance feedback.68 Although trainees’ confi-
dence in their ability to lead a resuscitation team
often increases after advanced life support (ALS)
training, observational studies found no improve-
ment in leadership performance after ALS training
without specific leadership training.22
Conclusion
This review of teamwork demonstrates the critical
importance of teamwork in assuring patient safety
in the dynamic domains of healthcare. Table 1
summarizes safety-relevant aspects of teamwork
identified by the studies included in this review.
Research on attitudes toward teamwork indi-
cates that healthcare providers do not seem to fully
appreciate the impact of psychological factors on
clinical performance and that improved teamwork
may contribute to increased staff well-being as well
as improved patient outcome. Observational stu-
dies found weak to moderate associations between
ratings of teamwork skills and measures of techni-
cal and clinical performance.28,31,32,69,70 Empirical
evidence also supports the argument that system
improvements such as formal practices to
strengthen communication and relationships
among healthcare providers57,71 and specific team

training interventions have the potential to raise
clinicians’ awareness of these issues and to support
effective team behavior.72–74
Although there has been significant progress in
research on teamwork in healthcare, methodologi-
cal and theoretical challenges remain to be ad-
dressed by future research.75 In order to
effectively teach and reliably assess the quality of
teamwork, it is necessary to identify the behaviors
associated with effective teamwork and their inter-
play in relation to clinical performance ratings and
ultimately to patient outcome. Various research
groups have successfully developed instruments
to describe team processes and evaluate teamwork
skills. An important next step is to determine
whether there are generic team skills and behaviors
that contribute to effective team performance in
different domains of healthcare, to different types
of teams, and in different situations such as routine
and emergency patient care. So far, few of the
psychological concepts explaining successful team-
work in various high-risk industries such as team
situation awareness, shared mental models, and
adaptive coordination and leadership have been
investigated systematically in healthcare.76,77 How-
ever, these concepts provide useful heuristics to
understand effective coordination in dynamic
medical domains and a systematic comparison of
findings on effective teamwork across industries
may be an important next step. In addition, future
research should explicitly refer to theoretical
frameworks of teamwork.78,79 This approach
will allow for an integration and systematic com-
parison of available evidence on team behaviors
and their impact on patient safety. This will further
the development of refined models of team pro-
cesses in healthcare62 and of specific training con-
cepts that complement existing team training.
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Address:
Tanja Manser
ETH Zurich
Center for Organizational and Occupational Sciences
Kreuzplatz 5
8032 Zurich
Switzerland
e-mail: tmanser@ethz.ch
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