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What Makes Teams Work? Monitor on Psychology August/2018 IN SECTION: COVER STORY Psychologists are pinpointing the factors that make teams gel—research that has far-reaching implications for health care, education, research, industry and more

The lone wolf is becoming an endangered species. In fields from health care to hospitality, startups to big business, teamwork has become the favored way to get things done. "The world is so complex, no one person has the skills or knowledge to accomplish all that we want to accomplish," says Susan McDaniel, PhD, a psychologist at the University of Rochester Medical Center and 2016 APA president known for her dedication to team-based work. "Interdisciplinary teams are the way to make that happen." ¶ While humans have always joined forces with one another to achieve shared goals, psychologists are zeroing in on the methods and processes that make those collaborations more efficient and successful. "What’s changing is the understanding and appreciation that there is a science behind how to manage teams," says Suzanne Bell, PhD, an associate professor of industrial/organizational (I/O) psychology at DePaul University in Chicago. ¶ Now, a special issue of American Psychologist (Vol. 73, No. 4, 2018) details what psychologists have learned—and need to learn—about working in teams. "The Science of Teamwork," co-edited by McDaniel and colleague Eduardo Salas, PhD, of Rice University in Houston, in cooperation with American Psychologist editor-in-chief Anne E. Kazak, PhD, offers 21 articles that delve into the theory, research and applications of team science. Here, we look at some of the most significant findings in the special issue, particularly the ways that team processes matter for psychologists, whether they’re working in health care, research, industry, the military or education.

BUILDING A DREAM TEAM Sometimes teams seem to click without too much effort, working together seamlessly and producing great work as a result. Other collaborations crash and burn. A team’s success often depends on its composition, as Bell and her co-authors describe in their contribution to the special issue. Surface-level attributes of individual team members—such as age, gender and reputation—can be important to the team’s overall function, but they aren’t necessarily the factors that matter most, Bell says. Instead, it’s the "deep-level" factors you can’t see at a glance, such as the members’ personality traits, values and abilities, that tend to have a much bigger impact on work teams, studies suggest. Those deep-level factors shape what researchers call the ABCs of teamwork: the attitudes, behaviors and cognitive states that collectively influence whether a team achieves its goals. Those elements depend to some degree on the context and on the team’s objectives, Bell says. If the goal is to design an innovative new digital device, it’s a good idea to build a team with diverse thinkers who bring a range of knowledge, skills and abilities to the project. But if a team’s goal is to be more efficient, diverse attitudes might be less critical. Team success also hinges on some basic tenets of team composition, say Bell and her co-authors. One person’s mood and outlook can spread within a team, so a pessimistic team member could negatively influence the way the whole group views its goals. Individuals who value working in groups tend to be both more confident and more cooperative in a team setting. When team members are high in conscientiousness, they are better at self-regulating their teamwork. And groups composed of high-ability members who are able to learn, reason, adapt and solve problems are more likely to work well together. Researchers are working to design algorithms that help organizations create effective teams for specific goals. In a project with NASA, for instance, Bell and colleagues are developing algorithms to identify crew members suited to working together on long-distance space missions.  i Viewable Image - Image Caption Research on military teams has led to several core ideas that inform our understanding of how teams work best in both military and civilian settings. WAVEBREAKMEDIA/GETTY IMAGES Ultimately, such tools can help organizations create the best possible teams from the outset and tailor interventions for the unique needs of a team with a specific composition. "Teams are complex systems," Bell says. "The more you can manage them using a scientific basis, the better your teams will be."

THE SECRET SAUCE: COOPERATION IN THE MILITARY Using scientific methods to understand teams isn’t a new trend. Military researchers have been studying teamwork systematically for more than half a century, as Gerald F. Goodwin, PhD, of the U.S. Army Research Institute for the Behavioral and Social Sciences, and colleagues describe in an article in the special issue. "The military has been really central in supporting and executing research on teams since the 1950s," he says. "That support has been critical to moving this science forward." Research on military teams has led to several core ideas that inform our understanding of team processes in both military and civilian settings, Goodwin says. One such idea is the distinction between taskwork and teamwork. Taskwork is the work that teams must do to complete a mission or assignment. Teamwork, by contrast, is the interrelated thoughts, feelings and behaviors of team members—comparable to the ABCs—that enable them to work effectively together. That distinction might seem obvious, says Goodwin, but understanding the elements that allow teams to function well—team cohesion and shared mental models, for example—is important for training teams as well as evaluating their performance. "How well people work together may be more important than how well they work on the tasks," he says. "The secret sauce comes from the teamwork." Research from military settings has also clarified the importance of team cognition—what teams think, how they think together and how well synchronized their beliefs and perceptions are. Team cognition is what allows team members to understand intuitively how their teammates will think and act, whether on the battlefield, in a surgical suite or on a basketball court. "Team cognition is really important for teams that have to quickly adapt to dynamic circumstances without having the opportunity to communicate a lot," Goodwin says. Many of the empirical findings from military research apply to civilian teams as well. From the earliest studies, military and civilian researchers have openly shared findings and worked together to grow the science of teamwork, Goodwin says. The military, for instance, has made use of results from team research in aviation. Meanwhile, findings from military-funded research have informed processes in many industries, health care in particular.

TEAMING UP FOR BETTER HEALTH Teams in the military and in health care share an important commonality: They can be operating in situations in which team coordination can be a matter of life or death. Some of the earlier research on healthcare teams focused on hospital settings, where teamwork failures can lead to patient harms such as misdiagnoses, medication mistakes, surgical errors and hospital-acquired infections. In a paper for the special issue, Michael Rosen, PhD, an associate professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine, and colleagues describe how medical team coordination affects patient safety and the quality of patient care. Unlike teams in a business setting that might collaborate with one another for months at a time, health-care teams are often fluid, especially in hospitals. Medical personnel including physicians, nurses, surgical assistants and pharmacists might have to jump into a new care team at each shift change or for each new patient. The fundamentals of good collaboration are the same no matter how transient the team, Rosen says: "It’s about having clear roles, clear goals and a clear plan of care." Hospitals can also put procedures in place to boost the effectiveness of acute-care teams. One example is multidisciplinary rounds. Instead of a cardiologist, a surgeon and a pharmacist each visiting a patient individually, the physicians, nurses and other medical professionals might team up to consult with the patient together. Multidisciplinary rounds have been shown to improve communication between physicians and nurses, decrease length of stay for trauma patients, and improve quality measures for patients with congestive heart failure and pneumonia, Rosen and his co-authors note. Teams are also becoming increasingly important in primary-care settings. "I think the industry is recognizing that we don’t have a choice. Health care has become too complex, and the current model isn’t working very well," says Kevin Fiscella, MD, a professor of family medicine at the University of Rochester Medical Center who co-authored a special issue article with McDaniel on the science of primary-care teams. "It’s not a question of whether we adopt teamwork [in primary care], but how we do it—and how we begin addressing the barriers to teams."  i Viewable Image - Image Caption JACOBLUND/GETTY IMAGES RESEARCH SHOWS THAT MULTIDISCIPLINARY ROUNDS IMPROVE COMMUNICATION BETWEEN PHYSICIANS AND NURSES AND DECREASE STAYS FOR TRAUMA PATIENTS. Unfortunately, those barriers are not insignificant, Fiscella adds. One challenge is simply changing the way that many physicians think about primary care. "I graduated from medical school in 1980, and our whole training was that care is about me and the patient, and everybody else is there to support that relationship," he says. While that mentality is changing, it’s not dead yet. "That unfortunate mental model of what it means to provide primary care can make it difficult" to move toward team thinking, he adds. Systemic challenges also make collaboration difficult in primary-care settings. Clinicians such as family physicians, specialists and mental health professionals might be spread out in different locations. "It makes it harder to support other team members who are making important contributions," Fiscella says. The traditional fee-for-service payment model also makes it difficult for medical professionals to prioritize teamwork, Fiscella and McDaniel add. Research has shown, for example, that when primary-care teams have short "huddles" before a visit to coordinate their care plans, they routinely report better teamwork and more supportive practice climates. Similarly, short team debriefings at the end of the day to hash out what worked and what didn’t can boost learning and performance among team members and improve outcomes for patients. Yet due to scheduling challenges, it can be tough for primary-care teams to find even a few minutes to come together for huddles or debriefings. "Time is money. If you take time out for a team meeting, that’s lost revenue," Fiscella says. TEAMWORK IN THE LAB Academia is famous for its departmental silos, but that, too, is changing as multidisciplinary research becomes the norm across all fields of science. Team science is gaining momentum for good reason, says Kara Hall, PhD, director of the Science of Team Science Team at the National Cancer Institute and co-author of a special issue article about collaboration in science. Globalization and technology have made the pressing problems of society ever more complex, Hall says. Take the public health problem of reducing tobacco use, for instance. To address that challenge, you need an understanding of the genetic, neural, psychological and behavioral factors related to tobacco dependence, not to mention related social forces and the public policy context. "If you want to solve an applied global health problem, you need people who can bring their specialized knowledge to bear," she says. "Multidisciplinary teams can really [create] movement on these big problems." Research on team science has found that collaborating across organizational and geographic boundaries increases productivity and scientific impact. And cross-disciplinary teams produce more academic publications and publish in more diverse outlets, Hall and her colleagues report. Despite proven benefits, it can be hard for a researcher to wrap his or her head around team science. Most scientists were trained in an apprenticeship model, learning the ropes from a single mentor. "Historically, our scientists haven’t been trained to work in teams or to lead teams," Hall says. Even if scientists are prepared to take the leap to team-based research, their institutions might not be. Tenure and promotion are usually based on outputs such as academic publications, with more weight given to a paper’s lead author and to articles published in journals in a researcher’s own discipline. That model rewards competition, with the potential for tension as team members hash out who should be credited as first author. Team science is built instead on interdisciplinary cooperation—but so far, only a few academic institutions reward those cooperative efforts. Because of the lack of team training and the institutional hurdles, Hall says, a research project may be technically and scientifically well-conceived yet fail to yield anticipated outcomes. If a cross-disciplinary team fails to meet its goals, was it because the topic was better suited to intradisciplinary science? Was it a problem with the way the team was composed? Or could the team have succeeded if members had received more institutional support and training? Still, some early patterns are emerging to guide the way toward improved science teams, Hall and her co-authors report. Some studies have found that small teams are best for generating ideas that shake up the status quo, for instance, while larger teams are better at further developing those big ideas. And while cultural diversity can increase a science team’s impact, diverse teams might benefit from more team science principles to head off challenges such as miscommunication. MULTICULTURAL QUESTIONS The role of diversity in teamwork is a topic that needs a lot more attention, not just for scientific teams but in all areas of teamwork, says Jennifer Feitosa, PhD, an assistant professor of I/O psychology at the City University of New York, Brooklyn College. In the special issue, Feitosa and her co-authors describe the ways in which multicultural teams may function differently from teams in which all members share the same cultural background. As with cross-disciplinary science teams, multicultural teams offer key benefits. "Companies are seeking innovation and creativity," Feitosa says. "One of the pros of having team members from different cultures is that they can each bring in something unique, which can result in a better team product than any one person could have thought about on their own," she says. Yet it can take longer for a diverse team to find its groove than a team with similar backgrounds and mindsets. Individuals in multicultural teams are more likely to have different ways of doing things and might not understand where their fellow team members are coming from. "If you take a snapshot of a multicultural team at the beginning, it doesn’t look so promising. They often need more time to all get on the same page," Feitosa says. In both multicultural teams and more homogenous teams, trust is a key component for effective collaboration, Feitosa and her colleagues reported. But because of their differences, members of multicultural teams might have difficulty trusting each other at first. "Focusing on shared goals can really help to develop that trust," she says. In other ways, diverse teams operate quite differently from teams with cultural similarities. In the general teamwork literature, for example, research suggests that it’s important to address and manage team conflict head-on. But when team members come from cultures that emphasize harmony and avoid conflict, calling out the elephant in the room can make people extremely uncomfortable and interfere with the teamwork dynamic, Feitosa says.  i Viewable Image - Image Caption While multicultural teams can generate unique solutions, it can take longer for a diverse team to find its groove compared with a team made up of people with similar backgrounds and mindsets. ROOSTERHD/GETTY IMAGES Differences in leadership style can also hinder multicultural teams. In North America, organizations are moving toward giving individuals greater autonomy and opportunities for self-management, Feitosa notes. "In very collectivistic and high power-distance cultures, people might rely more heavily on direction from team leaders and might rather be told what to do." Fortunately, teams can prevent cultural differences from becoming obstacles by creating a "hybrid" culture, the authors report. "It’s about establishing team norms that aren’t entirely your culture or entirely my culture, but a little bit of everyone’s," Feitosa says. The research on multicultural teams can guide those looking to create collaborations that are both diverse and high-functioning. But to fully harness the value of cross-cultural perspectives and talents, Feitosa and her colleagues conclude, much more needs to be done to integrate findings from research on single-culture teams and multicultural teams. "Teamwork is a complex phenomenon, so we need to get more creative in how we look at this," she says. INTERVENING TO IMPROVE TEAMWORK Although researchers have more work to do to fully understand team processes, especially in multicultural contexts, it’s not too early to apply what we know, Salas says. For the special issue, Salas and colleagues described evidence-based approaches for improving teamwork. Organizations are clamoring for tools to make their teams more effective. "Team building is probably the No. 1 human resources intervention in the world," Salas says. Yet the results of such programs are mixed. If you send a group of executives into the wilderness for two days, they might have fun and learn something about one another—but it doesn’t mean they’ll magically develop new teamwork skills. Put them into evidence-based team trainings, however, and the story is different. "Team training works," Salas says. "We know how to design, develop and evaluate it." In particular, Salas and his colleagues describe four types of team development interventions that have been shown to benefit team performance: team training, team building, leadership training and debriefing. Team training describes formalized learning experiences that aim to improve specific team skills or competencies. Structured team training has been shown to improve teamwork functioning and outcomes in industries such as education, engineering and health care. A prime example is TeamSTEPPS, an intervention to reduce medical errors by improving communication and teamwork skills among health-care professionals (see sidebar). Team-building interventions, meanwhile, aim to better teams by improving interpersonal relationships, clarifying roles and improving problem-solving. Such interventions might focus on increasing trust or setting challenging yet specific goals, for example. Leadership training targets a team leader’s knowledge, skills and abilities, and improvements to these areas have been shown to support effective overall team processes. When leaders are trained in occupational safety, for instance, their teams exhibit safer behaviors on the job. Finally, team debriefings of the sort used in primary-care settings have been shown to improve performance in a variety of settings, including aviation and military teams. There’s power in numbers, and high-performing teams can be more than the sum of their parts. It’s fortunate, then, that teamwork processes can be measured and improved with targeted interventions. But to keep sharpening the science, psychologists must continue exploring the conditions that allow teams to succeed, Salas says. There’s certainly no shortage of demand, he adds. "There’s a tremendous amount of interest in trying to understand collaboration and teamwork—in health care, aviation, academia, the military, space exploration, the corporate world. I hope this special issue will inspire people to improve their teams, and to look for new ways of motivating their teams using psychological science." To read the full American Psychologist special issue on teamwork, go to http://psycnet.apa.org/PsycARTICLES/journal/amp/73/4. FURTHER RESOURCES APA: A Curriculum for an Interprofessional Seminar on Integrated Primary Care www.apa.org/education/grad/curriculum-seminar.aspx National Cancer Institute: Team Science Toolkit www.teamsciencetoolkit.cancer.gov APA Interdisciplinary Research Awards www.apa.org/about/awards/interdisciplinaryresearch.aspx. Training For Teams One of the largest evidence-based teamwork training programs is TeamSTEPPS, a set of teamwork tools jointly developed by the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense. TeamSTEPPS aims to optimize patient outcomes by improving communication and teamwork skills among health-care professionals. The curriculum leads health-care employees through a series of modules designed to improve communication, lead teams, improve situation monitoring and increase mutual support for team members. After implementing the program, one California health system reduced the dosage of labor-inducing drugs by 15 percent, without increasing C-section rates, and a Wisconsin hospital association that used the program to improve clinical quality and safety reduced the number of hospital readmissions by 22 percent in 18 months, according to AHRQ data. TeamSTEPPS got its start in hospitals, but it also offers a curriculum for officebased care. From major academic medical centers to small-town family medicine practices, it’s catching on: More than 1.5 million health-care workers have completed the TeamSTEPPS program, using evidence-based practice to strengthen teams. —Kirsten Weir ADVENTURES IN INTEGRATED CARE A Haven For Immigrant Teens IN SECTION: ADVENTURES IN INTEGRATED CARE A clinical psychologist helped establish a medical-legal partnership to assist unaccompanied minors with mental health, medical and legal needs BY AMY NOVOTNEY I t’s a Wednesday evening in the South Bronx, and scores of teenage boys and girls are playing soccer, learning English and filling up on a nutritious home-cooked meal. The event is being hosted by Terra Firma, an innovative medical-legal partnership affiliated with Montefiore Medical Center and supported by the Children’s Health Fund. Terra Firma has become a weekly gathering place and support center for these teens, many of whom have recently immigrated to New York from one of several Central American countries, including El Salvador, Guatemala and Honduras. Their journey to the United States typically involves traveling alone or in small groups and can include walking for days or riding atop freight trains. Once they reach the U.S. border, they may have to swim across the Rio Grande or travel through the desert in Texas, Arizona or New Mexico, where they either turn themselves in or are apprehended by authorities. After spending some time in an immigration processing center—often ice-cold and offering only cursory medical services at best—the teens are transferred to an Office of Refugee Resettlement shelter, located in cities across the country, including New York City, before they join family or friends. The voyage may be dangerous, but staying in their home countries is more perilous: Nearly all of the teens are fleeing poverty, community violence, gangs and often abuse or neglect in their own homes, says psychologist Cristina Muñiz de la Peña, PhD, one of the three co-founders of Terra Firma, and the program’s mental health director. "The vast majority of these youth come to the U.S., and then to our organization in New York, with a history of complex trauma, and also likely trauma they faced during their journey here," she says.