Teamwork: Building Healthier Workplaces and Providing Safer Patient Care 
Paul R. Clark MSN, MA, RN 

Critical Care Nursing Quarterly
July/September 2009 
Volume 32 Number 3
Pages 221 - 231


A changing healthcare landscape requires nurses to care for more patients with higher acuity during their shift than ever before. These more austere working conditions are leading to increased burnout. In addition, patient safety is not of the quality or level that is required. To build healthier workplaces where safe care is provided, formal teamwork training is recommended. Formal teamwork training programs, such as that provided by the MedTeams group, TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), or participatory action research programs such as the Healthy Workplace Intervention, have decreased errors in the workplace, increased nurse satisfaction and retention rates, and decreased staff turnover. This article includes necessary determinants of teamwork, brief overviews of team-building programs, and examples of research programs that demonstrate how teamwork brings about healthier workplaces that are safer for patients. Teamwork programs can bring about these positive results when implemented and supported by the hospital system.

THAT the level of patient safety afforded patients during the provision of healthcare is not at the level it should be is not in doubt. The lack of high-quality, safe patient care came to light when the Institute of Medicine published the study To Err Is Human. This seminal study revealed that between 44 000 and 98 000 patients die in a year because of preventable errors in the healthcare system.1 Several reports outlining this gap in patient safety followed, along with studies and journal articles on solutions.2–7

Almost 10 years have passed since the publication of the Institute of Medicine report. During this decade, there has been significant patient safety research and implementation of creative, effective solutions. However, is the patient care environment any safer? As well, with the implementation of these patient safety solutions amidst staff shortages, an aging nursing workforce, cutbacks in Medicare and private insurance reimbursements, and higher patient acuity, is the workplace any healthier?

The answer appears to be yes. Researchers and healthcare experts have found that safer patient care and a healthier work environment occur when the healthcare team (doctors, nurses, technicians, respiratory therapists, unit secretaries, and anyone with direct or indirect involvement in the care of the patient) is trained and empowered in teamwork skills. This healthier, team-based workplace is one with a lower vacancy rate, a decreased staff turnover, and increased staff satisfaction levels. In addition, inadvertent and unintentional errors that impact patient care also decrease.

Building and training this functional healthcare team can occur in a number of ways. Team-building programs such as the United States Department of Defense/Agency for Healthcare Research and Quality TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) program or the Emergency Team Coordinator Course can be implemented. In addition, there are programs that build teamwork through participatory action research (PAR).8–12 The aviation industry has discovered lessons about team building in the form of a program called Threat and Error Management that can be adapted to the healthcare setting as well.13,14

Workplace team building is a solution that improves patient safety and creates a healthy workplace. As with any solution, there are caveats. Implementation of these interventions requires training, buy-in from important stakeholders (like physicians, upper-level hospital management, change agents in the patient care environment), and, in some cases, retraining or reimplementation of the program when a critical mass of those involved in the original program implementation move on from the unit or department. However, with the promise of improved staff satisfaction (and accompanying higher retention rates) along with improved patient safety, staff team building holds great promise for building safer patient care environments and healthier workplaces.


Before reviewing specific team-building programs, which lead to healthy workplaces and safe patient care, the concepts that define teamwork will be reviewed. These concepts are found in many sources of teamwork and healthy workplace literature, and are a necessary part of any team (healthcare or other). An analysis of these healthcare and nonhealthcare sources reveals teamwork concepts and the relationships between them. These common concepts include shared goals, norms, roles, horizontal leadership, communication, and collocation.

Goals are ends that (1) provide direction activities, (2) focus individuals with professional and personal talents on specific work, and (3) provide benchmarks helpful in measuring progress.15,16 This last point is important because progress toward a goal can be measured, and a determination can be made regarding its accomplishment.

A highly diverse group of people will begin to form into a team when they have goal(s) toward which they are directed.15 Other authors as well note that goals are necessary for effective teamwork.16–20 There are 6 key processes that are necessary in all group works, and the first in this list is goals or a mission: “The team must have clearly defined and measurable goals.”15(p34)

A team requires basic ground rules to operate. These ground rules are called norms. Norms are unwritten rules that govern any group and influence other areas of group work.15 These unwritten rules involve communication (how to, manners, etc) decision making, problem solving, conflict resolution, planning, etc.17 Norms are thus the guideposts and expectations for team behavior that identify and maintain the team.10,18 They direct team members how to interact with each other so as to focus team members' efforts on task completion. Healthy norms build relationships and encourage interdependence of team members. In her book on nursing management, Gillies19 notes that a group is an entity that shares common interests, values, and norms. Several authors note the presence and function of norms as a determinant in teamwork.15,17,18

In her research with communities and work teams, Dr Mickey Parsons utilizes specific ground rules when developing team norms. (Dr Mickey Parsons, PhD, oral communication, September 2005). When developing a team intervention, the team decides on its own ground rules during its initial meeting, conference, or retreat. These ground rules are synonymous with norms. These norms or ground rules involve communication, participation, etc, and are expected be used as the team interacts. In one research study, Dr Parsons noted the norms one unit established as its members formed their work teams: communication (work together to resolve conflicts), positive attitude (acknowledge others' feelings and points of view), and individual accountability (we teach each other and are taught).10 As can be seen, norms are the rules under which a team operates so as to maintain its focus and sustain its relationships.

Carrying out work involving norms does not occur by happenstance. Team norms need to be practiced. As Fry et al15 note, “(one) can't bring together a highly diverse group of people and expect that by calling them a team they will in fact behave as a team.”15(p56) Sports teams practice many, many more hours than they spend actually playing the game for which they prepare.

Practicing this teamwork involves performing individual teamwork components, including norms.9,21 As teams “practice” norms in their accomplishment of goals, they make mistakes, find behaviors that support their norms, roles, and leadership, and learn when and how boundaries are broken or maintained. However, it is with “practicing” or repeating/improving positive norms and correcting destructive/negative norms that a team strengthens itself.21

Beyond the external norms there are internal functions that all people in the team abide by to maintain teamwork and relationships. These internal functions are roles: clearly defined responsibilities each team member assumes, which are specific to his or her expertise, training, experience, natural talent, predilection, and education.16–18 Some roles are assigned on the basis of professional expertise or job title and not by group consensus.18 Others are chosen by consensus (such as the social organizer). In an ideal team situation, members' roles are complimentary and are not exactly duplicated by other team members.

An important aspect of a role is that no one role is more important than another. The even and level nature of roles can be understood as role equity. If one person pushes his or her agenda forward and disregards others' viewpoints and work, then he or she has placed his or her role at a higher status than others. Teamwork suffers.22 In a healthy team, a productive, supportive team climate is built, one in which the viewpoints of all roles are considered equally.20 There is no one vital role team members undertake; all roles are equally vital.23

Roles are clearly defined, but that does not mean that they are the same for each team, nor are they exclusively assigned to one person. In a qualitative study of interprofessional teams, Molyneux24 notes that creatively developing methods and guidelines (roles) specific to the needs of each particular team was helpful in working around the needs of each team. This sharing or flexibility of roles is known as role bending. In role bending, one has a clearly defined role, but one does not become so limited by this role that the responsibility of another's role cannot be undertaken temporarily when appropriate. In fact, limiting oneself or being restricted only to an assigned role only limits teamwork.25,26 A positive example of this role bending occurs when a team member who is not the assigned leader undertakes a leadership role so as to accomplish a project, which is part of the team's goal.

Role overlap is another example of how roles are not exclusively assigned to one person. Some roles on the inter- and intraprofessional level will overlap. Interprofessionally, registered nurses' roles may overlap each other. Intraprofessionally, a registered nurse may be the leader of a healthcare team that would traditionally have been led by a physician.24 This role overlap is important because it provides seamless care and/or consistent problem identification and resolution.25

As with norms, practice is an important part of developing and maintaining one's roles in a team so as to effectively carry out those responsibilities, learn of the roles' boundaries, and learn how and when to appropriately bend those roles.27 Practicing also allows the team to learn how the others' roles affect teamwork.

In any endeavor requiring the collaborative efforts of a team of people, leadership is necessary. Team leadership is required from the outset of the teamwork to assist in the acquisition of a clear, shared, and attainable vision.25 Leadership facilitates team consensus, leads task-oriented and social-emotional (relation building) functions, coordinates/focuses the efforts of the team toward goal accomplishment, maintains team roles, assesses progress toward goal attainment, and is not autocratic or hierarchical.9,15,18,20,25,28

Team leadership oftentimes is carried out by every team member because of the changing nature of the task.15,18 This is similar to role bending discussed earlier. Leadership is not exclusive to one person because one persons' efforts are probably unlikely to meet all of the teams' leadership requirements.15 Others in the team will take on various leadership roles; for instance, a group of nurses within the team may collaborate on a specific task, and one of these nurses may take a leadership role in this subgroup. Others in the team may be better at certain leadership roles such as conflict resolution or creative problem solving. These persons would then take on this leadership role without actually becoming the leader of the team.

Parsons'10 Healthy Workplace Intervention (HWI) framework, which is used in her healthy workplace program (discussed later in this article), describes this leadership role bending as “shared leadership.” In this shared leadership, all members of the team (in this case the clinical staff) participate in leadership. There is one defined leader, but all members participate in the leadership roles by sharing expertise and knowledge specific to their roles.

The role of team leader does not place the leader in a position of power or dominance, and there are no senior team members.23,24 This equitable leadership style is understood as horizontal leadership. Horizontal leadership is in contrast to a top down, pyramidal style of leadership known as a hierarchical leadership style. Hierarchical leadership places most of the team's power in the leader role, allowing the leader to guide and direct with little group input. This is not an effective leadership style as it impedes valuable group input, does away with equitable team roles, and diminishes the group's ability to work as a team. Many studies have shown that a hierarchical leadership style impedes teamwork.22,24,29

The leader utilizing a horizontal style builds consensus and helps the team come to a mutual understanding and agreement on decisions necessary for goal attainment. The leader brings team members to understand (not necessarily agree with) all viewpoints of the team, and assists the team to reach a mutually agreed upon decision.16,17 The leader stands on equal footing with all of the other team members in their various roles carrying out his or her specific role by helping the team reach consensus. In fact, leaders should turn to team members and allow the team to provide the leader with information to help the leader decide how to best lead the team.26

Communication is the channel through which the team learns team norms and roles, seeks and receives information required for task completion and goal attainment, and addresses issues of conflict. Through the communication channel, idea generation, encoding of information, message transmission through one or more channels, message receipt, and information feedback to the sender occur.19 These channels may be centralized and/or directed by the leader. Other channels may be decentralized and occur between individuals.18

Communication is essential for team members to learn team strengths and weaknesses, as well as for acknowledging and accepting diversity. When team strengths, weaknesses, and diversity are given due attention, a positive working relationship develops. Positive working relationships deepen as team members know to whom to communicate issues so as to assist in problem solving. Thus communication strengthens teamwork through an increase in team interdependence and information sharing. It also fosters positive working relationships through relational building and conflict management. Without communication, teamwork shudders to a halt.18,20

One aspect of teamwork that appears in a number of studies is “collocation.” Collocation is defined as the location of the team in the same physical facility so that they share resources and a common arena, which provides the setting for individual team interaction. Teamwork involves pooling of resources.23 Teamwork thrives when teams can share their knowledge, skills, expertise, and information, develop interpersonal relationships, and address team issues.22 The genius of teamwork is the sharing of resources that result in team members accomplishing tasks allowing them to reach their goal(s). Collocation facilitates this process.

Collocation leads to rich networking, and thus better outcomes.23 Rich networking, sharing space, and working in close physical proximity “reduces professional territoriality and atavistic behaviors, and facilitates communication.”23(p139) Differences are resolved through mutual understandings that occurred when those who were located in the same place reached mutual understandings. These mutual understandings may not have been attained had these team members been located at different sites and not had a chance to communicate directly and work out their differences. Collocation thus facilitates communication.22,29 When teams are located in the same space, they are more likely to interact because of their close proximity. Both formal communications (directed toward the goal of the team) and informal interactions (social interface “around-the-water-cooler”) sharpen overall communication. The collocated team has a better idea of shared issues and has more opportunity to share resources.

However, it should be noted that collocation is not absolutely necessary for teamwork to occur. Even if individual members do not work in one place or have “face-to-face” meetings often, teamwork occurs.18 However, team effectiveness and relationship building are certainly impacted positively by collocation. A safe assumption would be that, even if it is not necessary, collocation certainly improves teamwork.

There are other facets of teamwork that could be discussed, including commitment to the group/goals, norms for attitudes, mutual accountability, etc.25,30,31 It is beyond the scope of this article to discuss all characteristics that make up teamwork. The 7 concepts listed above are the major teamwork concepts consistently included in the literature. The concepts of teamwork are important to know, as they are the backbone for building teams that are the centerpiece of healthy workplaces.


Now that some basic concepts of teamwork are understood, it would be helpful to appreciate why implementation of team-building programs, which use these concepts, is important. It is one thing to say that successful team building makes for a healthier workplace and safer patient care provision. It is another to produce the evidence that team building does hold such promise. Fortunately, the link between teamwork and healthy workplaces and safer patient care is clear.

The healthcare system changes constantly. There was a time when patients could count on a same-day physician's office visit to care for an ailment. Hospitals took care of scheduled patient care, such as surgeries or care of chronic illnesses. Emergency and intensive care was reversed for a patient who had developed an acute illness or experienced a trauma and needed same-day, high-acuity care at a level beyond what a physician's office could provide. However, healthcare has now morphed into something drastically different with hospitals (and their staff) bearing the brunt of the change. Physicians with heavy office case loads often rely on hospitals for initial care of their patients who arrive as direct hospital admits or emergency department patients. Additional burdens to hospitals are those patients who, because of insufficient or nonexistent healthcare coverage or because of a desire to avoid a hospital visit, arrive at the hospital much sicker. These same under- or noninsured patients cannot afford or are turned away from physician's offices, and they use the emergency departments for primary healthcare (waiting until the acuity of their illness or trauma is much higher).

The result is that hospitals now have a heavier volume of much sicker patients. This greater volume of high-acuity patients creates emotional and physical stress on the hospital staff (nurses, physicians, technicians, therapists, clerks, housekeeping, management, etc). This increased stress is particularly felt by nurses who care for an expanded number of patients during a shift.12 Stress among staff can result in higher absentee rates, high staff turnover rates, and lower retention rates. Higher staff turnover and lower staff retention rates exacerbate the stress, as nurses who continue to work on a floor or in a unit must care for an even greater number of patients.

Making matters more troubling are reports from the Institute of Medicine and Agency for Healthcare Research and Quality, as well as researchers who are now reporting significant patient safety problems. In a study of patient healthcare quality, over twice the number of patients in the United States as in Great Britain reported a medical or medication error, which led to serious consequences (18% vs 9%).32 Although US healthcare spending outstripped all other countries in terms of gross domestic product, the United States is not in the list of top 30 countries that provide safe, reliable healthcare.32 More than 1 study found poor or insufficient communication contributing to patient errors and poor patient outcomes.33–35 What is clear is that the lack of sufficient patient safety is not only dangerous to patients but also holds the United States back from providing premier healthcare.

However, the significant problems of staff stress and a lack of safer patient care provision, which are the result of this changing healthcare landscape, are not without solutions. Building teamwork skills and creating healthcare teams have provided evidence of improved workplace conditions and safer patient care provision. Units and departments, which have carried out specific teamwork programs with measurable outcomes, have demonstrated a statistically significant decrease in clinical errors.36 An implementation of specific teamwork programs has made such a positive impact on stroke care that such programs are recommended by the National Stroke Clinical Guidelines.25 In addition, higher nurse assessed levels of quality of care, perceived quality improvement over the past year, and increased confidence that patients could manage their own care after discharge were found in one study examining a healthcare environment with high levels of teamwork.37 Even industries outside healthcare, such as the aviation industry which after some very unsafe decades leading to unnecessary passenger deaths, have lessons that can be (with adaptation) used by healthcare to avoid and manage errors.14

Healthier workplaces occur in units and departments where teamwork programs have been implemented. These workplaces have been shown to increase job satisfaction of staff and particularly of physicians and nurses, increase retention rates, decrease staff turnover rates, and lower nurse burnout.10,37–40


The team concepts listed earlier in this article are necessary aspects of teamwork. Knowing that these concepts are present among staff can provide some confidence that a group is operating as a team. However, can a department or unit be certain that their staff is working as a team? Is it possible for a manager or unit staff to assess the level of teamwork in their workplace and then determine whether the staff is operating as a team? The answer to this question would seem to be “no” for 2 reasons: (1) teamwork perceptions among staff are oftentimes subjective, as studies demonstrate; and (2) teamwork is effective if a program is implemented in the workplace to train teamwork basics to staff.

Teamwork concepts are important to know for an objective understanding of teamwork. Any concept, such as teamwork, needs to be clearly defined so that an accurate assessment of the concept can be made. As studies have demonstrated, without clearly understanding the building blocks of teamwork, it is very difficult to objectively assess the presence of teamwork.

Critical care nurses and physicians were queried regarding their attitudes toward teamwork. This study demonstrated that physicians and nurses clearly perceived their teamwork climate differently, as physicians were much happier with collaboration and communication (both with each other and with nurses) than nurses were with physicians.41 In a study of surgical staff, physicians rated teamwork with nurses much higher than nurses did with physicians: high levels of teamwork with consultant surgeons were reported by 73% of the surgical staff and 28% of surgical nurses.42 These results point to the fact that teamwork is not necessarily present or functional when those involved with the teams feel it is present. Undoubtedly to be objective, specific measures are required to determine the level of teamwork. In addition, for a group to work as a team, teamwork training is required.


A number of years ago, this author was working in a patient care setting where “team nursing” was implemented. To enhance patient care delivery, managers decided that 3 nurses would be assigned to 12 patients rather than 1 nurse being assigned to 4 patients. Since we all knew nursing and patient care, it was assumed that no more direction was required. The team concepts were present: our common goal was patient care, our roles as nurses were clear, the external norms were in place, horizontal leadership (both in the 3-nurse team and the shift charge nurse) was present, we communicated well and often, and we were all obviously colocated. However, the experiment failed, and within 3 weeks, regular assignments (1 nurse to 4 patients) recurred. Even with the concepts of teaming in place, this teaming experiment was doomed to fail. The missing element was a specific program designed to provide more specific roles, more clearly defined norms, and clear processes by which 3 nurses could care for 12 patients as opposed to 1 nurse being assigned to 4 patients. Clearly calling a team a “team” does not make it so. Teamwork needs to be trained.

In earlier team training studies, statistically significant data provided reliable evidence that staff can be trained in teamwork.43 In addition, specific, behavior-based training has been shown to bring about true teamwork better than a group which becomes a “team” through experience and familiarity by working together.21,43 Building teams using a specific process also develops and sharpens operational processes (processes that would have helped in the failed teamwork experiment mentioned above).10 In later studies, teamwork training has proven very effective not only in developing solid teams but also in creating a healthier work environment and providing higher-quality, safer patient care.


Several team-building interventions have been researched in clinical settings, which have improved patient safety and made the workplace healthier for the staff. These interventions include simulations, teamwork training programs, and participatory research programs designed to let the staff build itself into a team while focusing on solving department or unit problems of their choice.

Aviation safety principles applied in the healthcare setting are the basis for the MedTeams behavioral-based teamwork system, created by the Dynamics Research Corporation and sponsored by the Army Research Laboratory.13 A specific application of this program is the Emergency Team Coordinator's Course for nurses, physicians, technicians, and other emergency department staff.36 Both classroom and simulator training were used to develop 5 team dimensions (maintenance of team structure and climate, application of problem-solving strategies, communication with the team, execution of plans managing workload, and improvement of team skills). This intervention led to an improvement of teamwork attitudes among staff, an increase in observed quality of teamwork behaviors, and a decrease in observed clinical errors.36

A second team-building program developed by the US Department of Defense along with the Agency for Healthcare Research and Quality is called TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety). This extensive program is adaptable to every care setting from intensive care units to medical/surgical departments. TeamSTEPPS program develops communication and teamwork by promoting competency in 4 teachable/learnable areas: leadership, mutual support, situation monitoring, and communication.8,44 Developing these 4 competencies builds on the knowledge, skills, and attitudes required for good teamwork.8,44 The TeamSTEPPS training program provides interactive learning and practice sessions, coaching and facilitation skills, and strategies for sustainment of the team-building competencies that are customized for the unit.8,44 Upon implementation of this program in the patient care setting, the Agency for Healthcare Research and Quality found that teamwork improved, with many of the staff involved noting that there was better communication at all levels along with much less anger and more respect among staff.8,44


There are many other programs that have been created to build teamwork.38 However, one other team-building process is worth mentioning. This approach is less of a formal program and more a specialized research process that helps departments build teamwork through use of the skills and human capital that each staff member of a department possesses. The research process is called PAR and, in at least 2 studies, has been shown to bring about positive results.

PAR is a subset of action research in which researchers work actively with participants or stakeholders to plan and implement workplace change identified by the stakeholders as important.45 As opposed to management implementing solutions to problems and relying on staff to follow the solution process in a top-down approach, PAR allows a “bottom-up” approach. PAR recognizes that staff has the capacity to identify issues and develop solutions.12 Utilizing PAR empowers staff to identify problems, create solutions, and implement the new processes. With staff driving the change process, team building is supported. Likewise, with staff identifying problems and developing and implementing solutions, it: 1) experiences empowerment; 2) builds community; and, 3) creates, implements, evaluates, and changes practices. The result is an improvement of the health of the workplace.45

In this PAR process, researchers work with the group to build a creative, safe environment in which mutual trust and empowerment occur. In this environment, all healthcare staff (unit secretaries, technicians, registration personnel, physicians, nurses, housekeepers, management, etc) of a particular unit or department gathers to discuss issues that are perceived as problematic in a unit or department. Once the problems are identified, the staff with various job descriptions (including department management) self-selects into committees and creates and implements solutions. These solutions have a great rate of success because they are peer driven and peer supported.

Dr Mickey Parsons has created a PAR-driven project called the HWI. Researchers or those who have been trained as HWI facilitators meet with each department participating in the HWI, obtain buy-in from management (especially hospital administration), and then establish an initial meeting of the staff. The initial meeting is called a future search conference and occurs in a location off-site from the facility.10 This conference provides the space in which the group comes together and builds community and trust. Through the facilitation of the HWI facilitator/researcher, the assembled staff identifies departmental issues, prioritizes these issues, decides on 2 to 4 issues to tackle, and then self-selects into committees to confront these issues. Those who participate in the future search conference then return to the department or unit, and present their work to their peers in a future search conference report. Immediately those involved in the future search conference personally invite the staff that was unable to participate in the future search conference to join the committees. These committees then develop an action plan and implement solutions. Committees meet at a future search conference booster at 6 and 12 months to evaluate their work and decide on continuing, changing, ending, and/or developing new directions/committees.11

A process also utilizing the PAR process is the participatory organizational intervention, developed by Dr Lavoie-Tremblay.12 This intervention involves a process of organizational commitment, identification of work constraints by staff, a development of an action plan to address the work constraint, and implementation and evaluation of the action plan. Dr Lavoie-Tremblay's initial intervention involved focus groups and collection of anonymous comments. The staff was then assembled into work teams, which met once a day over 6 days to develop their action plan. Implementation and evaluation of the action plan occurred as the facilitator assisted the staff in the PAR process. This PAR process develops skills in communication, professional collaboration, problem conception, responsibility for solutions, and carrying out the plan of action.12

What is most important about both of these PAR interventions is that they assist the staff in solving problems in their department by developing and creating behaviors and positive workplace perceptions. These programs create the atmosphere for team building where the staff feels empowered and where they have control over their working environment. Empowering staff to identify problems, create and implement solutions, and push for staff support creates a healthier work environment. Having control over their work environment along with the development of behaviors that build better staff teamwork has outcomes that are distinctly measurable. One study demonstrated that after the PAR intervention, there were increases in staff job satisfaction, physician and nurse satisfaction, and retention rate, as well as a sharpening of operational processes.10,40


Amidst a changing healthcare landscape, which puts additional burdens upon nurses, physicians, and other healthcare staff and which needs to be much safer for patients, there is reason for hope. The bedrock of this hope is teamwork. Training healthcare staff in teamwork basics establishes a healthier workplace and creates the conditions for safer patient care provision. Using any number of teamwork training programs in a department or unit setting will provide staff with the empowerment and control that can lower costs associated with low retention and high turnover rates, while reducing the number of errors. Patients are safer and nurses are more satisfied with their workplace.


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