Team up! Linking teamwork effectiveness of clinical teaching teams to residents’ experienced learning climate

Abstract

Background: Supportive learning climates are key to ensure high-quality residency training. Clinical teachers, collaborating as teaching team, have an important role in maintaining such climates since they are responsible for residency training. Successful residency training is dependent on effective teamwork within teaching teams. Still, it remains unclear whether this team effort benefits residents’ perceptions of the learning climate. We, therefore, investigated to what extent teamwork effectiveness within teaching teams is associated with (1) the overall learning climate, and (2) its affective, cognitive and instrumental facets?

Methods: This study used a web-based platform to collect data in clinical departments in the Netherlands from January 2014 to May 2017. Teamwork effectiveness was measured with the TeamQ questionnaire, administered amongst clinical teachers. The learning climate was measured with the D-RECT, applied amongst residents. Associations were analyzed using multilevel models and multivariate general linear models.

Results: Teamwork effectiveness was positively associated with the overall learning climate as well as with the affective and the instrumental facets of the learning climate. No significant associations were found with the cognitive facet.

Conclusion: Effective teamwork within teaching teams benefits learning climates in postgraduate medical education. Therefore, departments aiming to improve their learning climate should target teamwork within teaching teams.

Introduction

Learning climates in postgraduate medical education (PGME) are increasingly recognized as a cornerstone in ensuring high-quality residency training and subsequently patient care (Silkens, Arah, et al. 2018; Smirnova et al. 2018). These climates, which are embedded in clinical departments, reflect residents’ collective experience of the formal and informal aspects regarding their training such as departments’ practices and policies as well as the overall atmosphere (Silkens et al. 2016). Learning climates that are experienced as supportive benefit residents’ well-being (Van Vendeloo et al. 2018), professional competence development (Hoff et al. 2004) and medical knowledge (Shimizu et al. 2013). Clinical teachers have an important role in creating and maintaining a supportive learning climate since they are responsible for training residents (Slootweg et al. 2013; Stalmeijer et al. 2013). Efforts aimed at strengthening this crucial role of clinical teachers have mainly focused on improving teaching skills (Boor et al. 2008; Lombarts et al. 2014) and supervisory styles (Goldszmidt et al. 2015) of individuals. However, residency training is not merely the effort of individuals, as it should also be considered the collective endeavor of clinical teachers—referred to as the teaching team (Slootweg et al. 2013; Stalmeijer 2015; Steinert et al. 2017). Still, it remains unclear whether this team effort by teaching teams is linked to supportive learning climates in postgraduate medical education.

Table

Practice points

Supportive learning climates in residency training are important to ensure high-quality training and subsequently patient care. Teaching teams have an important role in creating and maintaining supportive learning climates, which requires effective teamwork within these teaching teams. Teamwork effectiveness benefits the overall learning climate, as well as its affective and instrumental facets. To improve learning climates in postgraduate medical education, departments should promote teamwork effectiveness within teaching teams. We suggest a holistic approach to faculty development to improve teamwork effectiveness within teaching teams as it might provide a more comprehensive view of teaching and learning in the clinical workplace.

Clinical teachers collaborate as a teaching team to fulfill educational tasks and activities regarding residency training (Steinert et al. 2016), such as discussing residents’ professional development, dividing teaching tasks and monitoring the quality of training. Successful execution and alignment of these activities requires effective teamwork (Slootweg et al. 2013) and might be essential for a supportive learning climate. Such teamwork within teaching teams has several key characteristics (Mickan and Rodger 2005), including effective communication (e.g. regular and adequate), mutual respect among members (e.g. value diversity in opinions) and having a common goal (e.g. organization of residency). Within healthcare, positive outcomes of effective teamwork are widely demonstrated for, amongst others, the safety and quality of patient care as well as the well-being of professionals (Rosen et al. 2018). Concerning PGME, however, we only assume that learning climates benefit from effective teamwork within teaching teams.

In this study, we, therefore, investigated the association between teamwork effectiveness within teaching teams and learning climates in PGME. The learning climate concept can be divided into three discrete facets (Ostroff 1993; Silkens et al. 2016). Each facet reflects residents’ experiences regarding a specific dimension of the learning climate. The affective facet is concerned with social interactions, for example how residents experience collaborating with colleagues and their feeling about the overall departmental atmosphere. The cognitive facet represents residents’ personal development, for example, whether residents are guided in reflecting on their performance. The instrumental facet comprises the formal aspects of residency training, evaluating aspects as planned education and the availability and accessibility of supervisors. Due to the multi-dimensional character of the learning climate, we furthermore aim to identify to what extent the separate facets are associated with teamwork effectiveness to provide insight for specific learning climate improvements. In sum, we pose the following research questions: To what extent is teamwork effectiveness within teaching teams associated with (1) the overall learning climate, and (2) its affective, cognitive and instrumental facets?

Methods

Study setting

In the Netherlands, residency training is regionally provided by the eight academic medical centers in collaboration with multiple affiliated teaching hospitals. The duration of residency training generally varies between three to six years and residents rotate every one to two years to another hospital. Each residency program is coordinated by a program director: an experienced clinical teacher who is formally responsible for the quality and delivery of residency training as well as the functioning of the teaching team (KNMG 2009).

Study population and data collection

As part of mandatory Dutch quality requirements (KNMG 2009), clinical departments use several tools to monitor and improve the quality of their residency training. Two widely-used tools are (1) the TeamQ questionnaire, measuring teamwork effectiveness as perceived by clinical teachers collaborating in teaching teams (Slootweg, Lombarts, et al. 2014), and (2) the Dutch Residency Educational Climate Test (D-RECT) questionnaire, measuring the perceived quality of the residents’ learning climate (Silkens et al. 2016). Many teaching departments use both questionnaires periodically as part of their on-going quality improvement processes (KNMG 2015).

For the current multicentre study, we used data from departments that completed the TeamQ evaluation and the D-RECT evaluation at the same time or within one year apart between January 2014 and May 2017. Both the TeamQ and the D-RECT evaluation were administered through a web-based system called Professional Performance Online (PPO). Using PPO, program directors of each residency program could request a TeamQ and/or D-RECT evaluation. For both questionnaires, participants were invited and reminded up to three times through automatically generated e-mails. Typically, participants had one month to complete the questionnaire.

Measures

Teamwork effectiveness

The TeamQ questionnaire was developed and validated in 2014 to evaluate the perceived teamwork effectiveness of teaching teams within clinical departments (Slootweg, Lombarts, et al. 2014). The TeamQ consists of 48 items grouped into eight domains: task expertise, team expertise, team decision-making, program directorship, feedback culture, team results, engaging residents and residents’ empowerment. All items are rated on a 5-point Likert scale (1 = not at all applicable, 2 = applicable to a small extent, 3 = somewhat applicable, 4 = applicable, 5 = very applicable and an additional option ‘not applicable’ is provided). All members of a teaching team fill out the TeamQ questionnaire individually.

Learning climate

The validated D-RECT questionnaire aims to evaluate residents’ experienced learning climate (Silkens et al. 2016). Residents, junior doctors not in training and fellows complete the questionnaire. The D-RECT has 35 items grouped into nine learning climate domains. Based on climate theory, the nine domains can be categorized into three higher order facets: affective, cognitive and instrumental facets (Ostroff 1993; Silkens et al. 2016). The affective facet contains the D-RECT domains of educational atmosphere, resident peer collaboration, and teamwork. The cognitive facet encompasses coaching and assessment, work is adapted to residents’ competence and patient sign-out. The instrumental facet includes formal education, the role of the specialty tutor and accessibility of supervision. All 35 items are rated on a 5-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree, and an additional option ‘not applicable’ is provided).

Covariates

In this study, we included covariates when their relevance was demonstrated in previous research and/or hypothesized by the researchers. We adjusted for type of specialty (surgical/nonsurgical) (Schultz et al. 2004) and constructed department level ratio’s for the following potential covariates: years of clinical teacher experience (0 to 15 years/16 to 30 years), gender of clinical teachers and residents (male/female) (Arah et al. 2012), year of residency training (years 1 to 3/years 4 to 6) (Schultz et al. 2004; Arah et al. 2012; Piek et al. 2015). We used the number of completed evaluations within one department as proxy for the group size of teaching teams and resident groups (Colquitt et al. 2001; Schneider et al. 2013).

Analysis

First, we described the study sample using descriptive statistics and frequencies. Based on previous research we determined a cutoff of 50% missing data (Silkens et al. 2016), meaning that TeamQ evaluations missing more than 24 questions and D-RECT evaluations missing more than 17 questions were excluded for further analysis. For the remaining evaluations of both questionnaires, missing values were assumed to be missing at random and therefore imputed separately by using expectation-maximization (EM). If departments used the TeamQ or D-RECT evaluation more than once during the study period the most recent data collection was included. However, we included evaluations of an earlier period (n = 9), when the most recent data yielded insufficient data per department. To obtain a reliable overall score, at least five TeamQ evaluations (Slootweg, Lombarts, et al. 2014) and three D-RECT evaluations (Silkens et al. 2016) per department were needed.

To evaluate teamwork effectiveness, we first calculated individual mean scores using the total set of item scores of the completed TeamQ evaluations. Then, we aggregated these individual mean scores to the team level. The overall learning climate score was calculated as mean score using the total set of item scores of the D-RECT evaluations. The three separate learning climate facets were calculated using the mean of the corresponding item scores. We then aggregated these mean scores to the department level, resulting in three separate aggregated mean scores per department.

To address our first research question we built an unadjusted and adjusted random intercept multilevel model. We used teamwork effectiveness as the predictor and the overall learning climate as outcome. By using the random intercept multilevel model with a Maximum-Likelihood estimation, hierarchical clustering of residents (level 1) nested within departments (level 2), was taken into account. To address our second research question we built unadjusted and adjusted multivariate general linear models. In these models we used the same predictor (teamwork effectiveness) and the three aggregated learning climate facets (affective, cognitive and instrumental) as outcome variables. Both multilevel and multivariate-adjusted models controlled for specialty, clinical teachers gender, and experience, size of the teaching team, residents’ gender, year of training and size of the resident group.

Associations were reported as regression coefficients (b), their 95% confidence interval (95% CI), and p-values (the significance threshold was set at .05). We used SPSS version 24 (IBM Corp. 2016) for the statistical analysis.

Ethics

The institutional ethical review board of the Amsterdam UMC of the University of Amsterdam provided a waiver declaring the Medical Research Involving Human Subjects Act (WMO) did not apply to the current study (reference number W18_222 # 18.226). Filling out the D-RECT and TeamQ was anonymous for all participants.

Results

In total, 47 teaching teams within 47 clinical departments in 16 hospitals used the TeamQ questionnaire. Teaching teams consisted on average of 14 clinical teachers (range 5–31) and rated their teamwork effectiveness as a 3.7 out of 5.0 (SD = 0.24; range = 3.3–4.3). Within teaching teams, the average variation of scores among clinical teachers was 1.3 points on a 5-point Likert scale. The lowest variation of scores within teaching teams was 0.6 points (range 3.2–3.8) and the highest variation 2.2 points (range 2.4–4.6). Within the same 47 clinical departments, 47 resident groups used the D-RECT questionnaire. On average resident groups counted 8 residents (range 3–28) and scored their learning climate a 3.9 out of 5.0 (SD = 0.4; range = 2.5–5.0). The average variation of scores within resident groups was 1.0 point, ranging from 0.1 to 2.2 points. Detailed information is presented in Table 1.

Table 1. Characteristics of the study population.

General characteristics	N (%)
Number of teaching hospitals
Academic	3 (19)
Non-academic	13 (81)
Number of departments
Surgical	16 (34)
Nonsurgical	31 (66)
Characteristics (non)residents
Number of resident evaluations	315 (100)
Male	117 (37)
Female	198 (63)
Years of training
Junior	178 (56)
Senior	137 (44)
Number of nonresident evaluations	85 (100)
Characteristics clinical teachers
Number of clinical teacher evaluations	578 (100)
Male	329 (57)
Female	249 (43)
Years of clinical experience
Junior	435 (75)
Senior	143 (25)

Associations with the overall learning climate

We found a positive, significant association between teaching teams’ teamwork effectiveness and the overall learning climate for the unadjusted and adjusted model (b = 0.33; 95% CI = 0.06–0.60) (Table 2). Detailed information on all the covariates is provided in the Supplementary Material.

Table 2. Unadjusted and adjusted associations of teamwork effectiveness with the overall learning climate score.

	Unadjusted model		Adjusted model^a
	Regression coefficient (95% CI)	p-Value	Regression coefficient (95% CI)	p-Value
Teamwork effectiveness	0.43 (0.16–0.70)	0.00	0.33 (0.06–0.60)	0.02

^a Adjusted for specialty, clinical teachers gender and experience, size teaching team, residents’ gender, year of training, and size resident group.

Associations with separate learning climate facets

The unadjusted model showed a significant association between teaching teams’ teamwork effectiveness and all three separate learning climate facets. Within the adjusted model, teamwork effectiveness was significantly associated with the affective (b = 0.49; 95% CI = 0.05–0.93) and instrumental (b = 0.43; 95% CI = 0.12–0.74) learning climate facets. The association with the cognitive facet was non-significant (b = 0.35; 95% CI = −0.07–0.77) (Table 3).

Table 3. Unadjusted and adjusted associations of teamwork effectiveness with the separate learning climate facets.

	Unadjusted model		Adjusted model^a
	Regression coefficient (95% CI)	p-Value	Regression coefficient (95% CI)	p-Value
Teamwork effectiveness on affective facet	0.52 (0.11–0.93)	0.01	0.49 (0.05–0.93)	0.03
Teamwork effectiveness on cognitive facet	0.48 (0.12–0.85)	0.01	0.35 (-0.07–0.77)	0.10
Teamwork effectiveness on instrumental facet	0.51 (0.24–0.79)	0.00	0.43 (0.12–0.74)	0.01

^a Adjusted for specialty, clinical teachers gender and experience, size teaching team, residents’ gender, year of training and size resident group.

Discussion

Main findings

This study suggests that teamwork effectiveness within teaching teams is positively associated with the overall learning climate as perceived by residents. More specifically, teamwork is positively associated with the affective and instrumental learning climate facets. The association between teamwork effectiveness and the cognitive facet of the learning climate was not found to be significant in this study.

Explanation of main findings

Our results suggest that learning climates in PGME benefit from effective teamwork within teaching teams. This finding resonates with the literature on positive outcomes of effective teamwork within healthcare teams (Rosen et al. 2018). Mazzocco et al. (2009) showed, for example, that patients were less likely to experience complications or even death if treated by teams demonstrating effective teamwork. Processes such as adequate information sharing and constructive briefings characterized these teams during handoffs.

The affective facet reflects learning climate domains that focus on how well residents work together with peers, supervisors and other professionals as well as residents’ perceptions of the overall atmosphere (Silkens et al. 2016). Effective teamwork is characterized by mutual respect among team members (Mickan and Rodger 2005), reflected by TeamQ items asking whether or not clinical teachers are able to discuss opinions honestly and address problems adequately (Slootweg, Lombarts, et al. 2014). If teaching teams perceive such positive team dynamics, it cultivates a positive departmental atmosphere (Silkens, Arah, et al. 2018). As residents work and learn within that same department, it is likely they inhabit this positive atmosphere (Genn 2001) and experience a supportive learning climate (e.g. to asks questions or seek guidance) which is crucial for their professional development (Silkens, Chahine, et al. 2018).

Next, the instrumental facet reflects the formal aspects of residency training such as the organization of formal education and supervision (Silkens et al. 2016). We consider that TeamQ items reflecting the organization of residency training (Slootweg, Lombarts, et al. 2014) explain the association with the instrumental facet. In most countries, PGME is increasingly organized on the basis of prescribed structures, regulations and professional standards (KNMG 2009; Slootweg et al. 2013; ACGME 2017), which might facilitate teaching teams in the organization of residency training. This is illustrated by Slootweg et al. (2013), who showed that teamwork within teaching teams is mainly concerned with discussing organizational elements of residency training such as the division of teaching tasks and the process of resident assessment. We might assume that such discussions contribute to clarifying expectations for residents (e.g. how they are assessed), as is known that clear expectations are associated with positive learning climate perceptions (Mickan and Rodger 2005; Hexter et al. 2018).

Finally, our study did not show a significant association between teamwork effectiveness and the cognitive learning climate facet. This facet reflects, for example, how supervisors stimulate residents to reflect on their own performance and to what extent work of residents is adapted to their level of competence (Silkens et al. 2016). Stimulating reflection on learning and aiding residents in formulating appropriate learning goals, are known teaching methods that can be used by supervisors to guide residents’ learning in the workplace (Stalmeijer et al. 2009; Stalmeijer et al. 2010; Olmos-Vega et al. 2015). Specifically focusing on reflection and exploration of learning goals is assumed to enhance residents’ learning climate experience (McConnell and McKay 2018). TeamQ items that reflect reflection and exploration evaluate whether or not teams follow residents’ individual teaching plan and if teachers refer residents to other—more skilled—colleagues when appropriate (Slootweg, Lombarts, et al. 2014). We speculate that the non-significant finding might be due to teaching teams using other teaching strategies (e.g. modeling) more effectively compared to reflection and exploration. This is also suggested by previous research, indicating that reflection and exploration were less (effectively) used teaching methods (Stalmeijer et al. 2009; Ravindra et al. 2013). Teaching methods such as modeling are facilitated by clinical teachers, while the teaching methods reflection and exploration aim to stimulate residents’ self-regulated learning (Stalmeijer et al. 2010). The latter methods might be more difficult to perform for clinical teachers due to time constraints or a lack of teaching skills (Stalmeijer et al. 2009). Hence, research indicated that residents (especially in higher years of training) emphasize the importance of reflection and exploration as it facilitates their professional development (Olmos-Vega et al. 2015). Strategies to improve teaching methods should focus on the teaching team as a collective within the clinical workplace (Steinert et al. 2016; Strand 2017). This aligns with the current competency-based approach embraced in medical education (CBME), as its main goal is to monitor residents’ progress and to create individualized learner approaches by teaching teams (Orr and Sonnadara 2019).

Implications for practice and research

Our study implies that departments aiming to improve their learning climate should pay attention to teamwork effectiveness within teaching teams. This move from an ‘individualistic perspective’ on clinical teaching to a ‘team perspective’ resonates with the growing body of literature in medical education stressing the importance of a holistic view on faculty development (Boud and Brew 2013; Steinert et al. 2016). Faculty development refers to all activities aimed at improving knowledge, skills, and behaviors of teachers (Steinert et al. 2016). Faculty development, underpinned by a holistic approach, suggests that improving teaching qualities of clinical teachers should be in collaboration with team members and located the clinical workplace (Boud and Brew 2013). Such an approach is more contextual sensitive to the everyday work of teaching teams and might facilitate continuing professional development (Strand 2017). Therefore, if clinical departments aim to foster a supportive learning climate, we suggest, in line with Steinert et al. (2016) that teamwork interventions should be located in the workplace and have a longitudinal design. Hence, interventions aimed at enhancing the cognitive learning climate facet might address teaching skills necessary to perform reflection and exploration within a prolonged team training. Specifically, this could entail teachers sharing experiences about, and reflecting on how to evaluate residents’ progress in relation to learning goals, as it is known that such skills (e.g. providing adjusted feedback) stimulate residents’ engagement in reflection and exploration (Stalmeijer et al. 2010). Furthermore, on-going team training might result in clear and stable communication between residents and teaching teams; creating a supportive environment for dialogs concerning learning goals and needs (Orr and Sonnadara 2019). Moreover, if teaching teams effectively stimulate reflection and exploration, residents’ learning needs—given their level of training—may be better met by their clinical teachers both as a team and individually. This is necessary to ensure optimal learning opportunities for residents while providing high-quality care. Future research could build on the findings in this study by investigating mechanisms that tie teamwork within teaching teams to residents’ experienced learning climate.

Strengths and limitations

A strength of this study is the use of two widely applied, validated questionnaires measuring teamwork effectiveness (TeamQ) and residents’ learning climate (D-RECT), to assure valid and reliable results. Furthermore, we gathered data from academic and nonacademic hospitals representing various specialties within the Netherlands. Therefore, we argue that the results may also apply to other residency programs within the Netherlands. Results may even be applicable beyond the Netherlands as, with the shift towards competency-based medical education (CBME), teaching has become a team effort in various postgraduate training programs around the world (Orr and Sonnadara 2019). However, more research is necessary to confirm our results in these other CBME training programs. Although the TeamQ aims to involve program directors’ evaluations in addition to clinical teachers’ evaluations, the role of participants could not yet be distinguished within the data. We consider this a limitation since studies suggest that the leadership style of program directors contribute to teamwork effectiveness of teaching teams (Slootweg, van der Vleuten, et al. 2014). Therefore, future research could address this by examining the moderating effect of the programs directors’ leadership style on the association between teamwork effectiveness and the departments’ learning climate. Furthermore, due to the cross-sectional design of this study, we cannot draw conclusions about causality or rule out reverse causality. However, we ensured that administration of the D-RECT was paralleled by the administration of the TeamQ within the same department: residents completed the questionnaire within one year after completion of the TeamQ by clinical teachers to minimize the possibility that associations might be explained by unmeasured variables (e.g. like residents rotating in and out of departments).

Conclusion

This study showed that teamwork effectiveness within teaching teams contributes to learning climates in PGME. Teamwork effectiveness especially benefits a supportive departmental atmosphere and positive team interactions, as reflected by the affective learning climate facet. Also, residents’ experiences of the formal aspects of residency training (instrumental facet) benefit from teamwork effectiveness within teaching teams. Finally, in our study, we did not find an association between teamwork effectiveness and residents’ experiences of professional development (cognitive facet), such as stimulating reflection and adapting work to residents’ competence level. Our results could encourage departments to promote teamwork effectiveness within teaching teams as a way to improve their learning climate.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Glossary

Learning climate: Residents’ perceptions of the formal and informal aspects of education, including perceptions of the overall atmosphere as well as policies, practices, and procedures within the teaching hospital (Silkens et al. 2016).

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Additional information

Notes on contributors

Iris Jansen

Iris Jansen, MSc, is a PhD-candidate at the Professional Performance and Compassionate Care Research Group, University of Amsterdam, Amsterdam UMC, the Netherlands.

Milou E. W. M. Silkens

Milou Silkens, MSc, PhD, is a postdoc researcher at the Professional Performance and Compassionate Care Research Group, University of Amsterdam, Amsterdam UMC, the Netherlands.

Renée E. Stalmeijer

Renée Stalmeijer, MSc, PhD, is an Assistant Professor in de Department of Educational Development and Research and the School of Health Professions Education at Maastricht University, the Netherlands.

Kiki M. J. M. H. Lombarts

Kiki Lombarts, MSc, PhD, is a Professor and head of the Professional Performance and Compassionate Care Research Group, Amsterdam UMC, University of Amsterdam, the Netherlands.