A Mapping Review of Teamwork Training and Assessment in Pharmacy Education

INTRODUCTION

A growing body of health sciences literature emphasizes the importance of teamwork. Health care experts increasingly agree that including pharmacists on health care teams can improve patient outcomes.^1,2 Similarly, employers of pharmaceutical sciences graduates recognize collaboration as a key skill for success in today’s workplace.³ Effectively preparing students for the realities of team-based care and other collaborative environments remains a key focus and challenge as pharmacy schools work to develop curricula aligned with the health care needs of society.^4-6

Teamwork in pharmacy education is prevalent and diverse, varying in its context, purpose, and structure. Students may encounter teamwork through the use of classroom-based pedagogies such as project-based learning or team-based learning (TBL).^7,8 Experiential education, such as introductory pharmacy practice experiences (IPPEs) or advanced pharmacy practice experiences (APPEs) may also involve collaboration with technicians, pharmacists, or other members of the health care team.^9,10 Further, students may experience teamwork within educational environments and groups, such as research laboratories, academic committees, and cocurricular organizations.¹¹

Research studies on group-based pedagogies, such as TBL and interprofessional education (IPE), generally describe positive outcomes. Compared to traditional lecture formats, TBL can result in increased student engagement and improved learning outcomes.^12-14 Similarly, interprofessional immersion can improve learner views of collaborative ability, confidence, and importance.¹⁵ While clear consensus exists concerning the importance of teamwork, there is a lack of literature and related research describing strategies for teaching pharmacy students how to work in teams (ie, how teamwork is taught, measured, and assessed).

The purpose of this manuscript was to review published research in pharmacy education that described how students were taught to work in teams and/or assessed as collaborators. The following questions were explored: How is teamwork taught (ie, skills and format) within pharmacy education? How is teamwork measured and assessed within pharmacy education?

METHODS

The protocol for this mapping review was developed to provide the most comprehensive selection of articles and to specifically capture how teamwork is taught, measured, and assessed within pharmacy education. To be included in this paper, studies had to meet the following criteria: included students enrolled in a PharmD curriculum at an accredited pharmacy school, were peer reviewed, were published between 2000-2019, and described teaching teamwork and/or how teamwork is measured and assessed within pharmacy education. Furthermore, specific outcomes related to teamwork skills and behaviors, attitudes, and/or knowledge as defined by Baker and colleagues needed to be reported in the study to be eligible for inclusion. Studies were excluded if they were only a review of the literature (eg, meta-analysis, systematic review, literature review), had not been peer reviewed (eg, commentaries, dissertations, book chapters), focused solely on survey development (ie, studies on developing a survey to be used to assess teamwork ), only assessed student readiness but not how teamwork was taught, or had only been published as an abstract.

The databases selected for this review included PubMed/Medline, SCOPUS, PsychINFO, EMBASE, and ERIC. PubMed/Medline, SCOPUS, and EMBASE are databases commonly used to identify studies that are related to health care and interventions; ERIC was selected to find additional education articles as it is the largest education database in the world; and PsycINFO was selected to capture interdisciplinary research in education and the social sciences.^16-18 The search terms selected for this review were “pharmacy education” AND “teamwork” to provide the most comprehensive, inclusive, and broad selection of articles related to teamwork in pharmacy.

Journal articles were cataloged in Mendeley Reference Manager (Mendeley) and were uploaded to Covidence, a software used for abstract and article screening, data extraction, and quality assessment. The abstract of each of the articles identified by the search was screened by two reviewers to determine which articles should be included in the full article screening. Conflicts were resolved by a third reviewer. Subsequently, the full version of each of the selected articles was screened by two individuals to determine whether the study would be included in the review. Again, conflicts were resolved by a third reviewer. For the full review, data extraction was completed by two individuals, who each extracted data from half of the included articles for the 13 different variables of interest. Ten percent of the articles were then randomly selected for review and audit by a third reviewer, with more than 95% agreement found across variables.

Variables of interest for this study included the teamwork training program design or intervention; duration of the program; learner characteristics or demographics; teaching methods used; teamwork knowledge, skills, and behaviors emphasized as defined by Baker and colleagues; teamwork model/instrument used; outcomes expected/measured; individual(s) performing the assessment; and intervention results, among others (Table 1).¹⁹ The teamwork framework created by Baker and colleagues was used as these knowledge, skills, and behaviors had previously been determined to meet the Institute of Medicine’s recommendation for organizations to develop effective, evidence-based interdisciplinary team training programs.¹⁹ A review with similar methodology used the Baker and colleagues framework to assess teamwork training in medical student and resident education.²⁰ All variable information and related data were cataloged using Excel.

RESULTS

Of the 114 references initially identified, 21 duplicate articles were removed. Of the remaining 93 articles identified, 50 were deemed irrelevant during the initial screening phase and an additional 25 were excluded based on the eligibility criteria. This resulted in 18 studies which described teaching teamwork and/or how teamwork was measured and assessed within pharmacy education and fulfilled all criteria for inclusion and data extraction.^9,21-37 The included studies represented 17 different pharmacy schools. Pharmacy student involvement in the programs ranged from first-year to fourth-year students. Nine studies (50%) described programs that included students from other health professions, with the most common being nursing (n=7, 39%) and medicine (n=6, 33%).

The characteristics of the teamwork training programs published within pharmacy education are presented in Table 2. Ten studies (56%) described how teamwork training was integrated into courses, while other programs included workshops (n=2, 11%), clinical rotations (n=2, 11%), modules (n=1, 6%), interprofessional simulations (n=1, 6%), long-term projects (n=1, 6%), and retreats (n=1, 6%). Learning activities involving patient cases were the most common teaching methods described with patient simulations, role-play exercises, and patient encounters included in 12 articles (67%). Duration of programs ranged from a one-day workshop to a semester-long course.

With regards to the teamwork principles that were taught, all of the programs described in the studies included leadership training or evaluation of students’ leadership skills. Specifically, 16 (89%) articles described programs addressing the solicitation of team member ideas in defining goals and objectives, and 13 (72%) described programs addressing fostering trust between team members. Nine studies (50%) did not describe a specific teamwork model used to teach teamwork within the program designs (Table 2).

The reported outcomes of the teamwork training programs are described in Appendix 1. Seventeen (94%) of the programs used self-reported measures of skills and behaviors, attitudes, and/or knowledge. No standardization existed between the skills and behaviors, attitudes, and knowledge attributes assessed or the method in which these attributes were assessed. Examples of skills and behaviors measured included communication, ability to integrate information into a therapeutic plan, and ability to work cohesively as a team. Attitude measures used in the studies included assessing the importance students placed on collaboratively working with peers or as part of a team, and whether students believed that teamwork skills could be learned. Of the five studies that reported on knowledge-related outcomes, four (80%) assessed student understanding of roles within a team and the roles of other health care professions.

Six (33%) programs used instruments that had undergone reliability testing and had been previously validated, including the Interdisciplinary Education Perception Scale (IEPS), the Readiness for Interprofessional Learning Scale (RIPLS), the Performance Assessment of Communication and Teamwork (PACT), and the Student Perceptions of Physician-Pharmacist Interprofessional Clinical Education (SPICE) instrument. Fourteen studies (78%) demonstrated improvements in students’ attitude-related outcomes, 13 (72%) studies demonstrated improvements in students’ skills-related outcomes, and six studies (33%) described improvements in students’ knowledge-related outcomes.

DISCUSSION

Within the pharmacy profession, increased emphasis has been placed on the importance of teamwork across health professions to improve patient care and patient safety.³⁸ Previous studies have demonstrated that teamwork and successful team performance can be developed in health professions students through training, specifically when team members learn key tenants of teamwork, as well as practice and continuously develop their teamwork skills.³⁹ To encourage the incorporation of teamwork training within pharmacy curricula, this review examined programs that were designed to teach, measure, and assess teamwork within pharmacy education.

As stated previously, literature within the health professions emphasizes the importance of effective teamwork, and the articles we identified through our review demonstrate the various collaborative learning approaches used within pharmacy curricula.^7,40 While group-based pedagogies such as team-based learning or project-based learning are commonly used within health professions curricula and have been shown to enhance student knowledge, retention, and problem-solving skills, our findings suggest that there is not a consistent way in which pharmacy schools teach teamwork to students (ie, different concepts of teamwork, skills taught, and assessment strategies are used within pharmacy education ).⁴¹

While specific teamwork training programs exist for specific purposes, such as TeamSTEPPS for interprofessional teamwork training, there is not a standardized format or program used to teach teamwork skills within pharmacy education. Additionally, most teamwork formats were incorporated within an isolated course in the curriculum, which only accounted for approximately half of the programs described in the literature. This mapping review can be used by others in the Academy to determine formats used to teach teamwork and outcomes used to measure and assess teamwork. However, given the importance of being able to effectively work within a team in the pharmacy profession, educators should consider whether it is more prudent and feasible to adapt an existing standardized teamwork training program for pharmacy education or create a new one. Baker outlines principles to include within the teamwork format, explaining that teamwork should be distinct from taskwork and that formats which allow individuals to function with only the knowledge and skill of the task at hand is not enough.¹⁹ Teamwork depends on each group member being able to anticipate the needs of others, adjust to each other’s actions and the changing environment, and to have a shared understanding of how a procedure should happen. Based on the teamwork formats described in the articles included in our mapping review, a format that includes all of Baker’s principles may not currently exist within pharmacy education.

Under the theory of social regulation of learning, optimal collaborative learning includes students monitoring and controlling for their own, their peers’, and the group’s cognition, motivation, and emotions during a group task.⁴² While our review indicates that some programs that use teamwork formats incorporate some of these principles, there still appears to a deficiency informats, which teach students how to regulate within groups. A study by Lyons and colleagues introduced a new web-based tool for fostering social regulation of learning within collaborative learning.⁴² Tools such as this may be beneficial to use within a variety of teamwork formats in order to help create metacognitive awareness and allow students to identify and develop strategies to overcome challenges within teams.

One reason for the lack of standardization among teamwork training in pharmacy education may be the limited consensus within the Academy regarding core competencies in this area for pharmacists. The Center for the Advancement of Pharmacy Education (CAPE) 2013 Educational Outcomes state that, to meet patient care needs, pharmacists should actively participate and engage as a health care team member by demonstrating mutual respect, understanding, and values.³⁸ However, the CAPE educational outcomes do not provide guidance on specific teamwork skills pharmacy curricula should emphasize to meet the associated outcome and instead defer to each school to determine their own interpretation. All of the programs described in the published articles we reviewed incorporate some combination of the eight teamwork principles outlined by Baker, but the emphasis and priority placed on each principle is not known.¹⁹ This suggests there is an opportunity to define core competencies related to teamwork to guide how pharmacy schools achieve the CAPE educational outcome.

In addition to defining teamwork core competencies for the pharmacy profession, our findings indicated that variability exists among pharmacy schools in how students’ teamwork skills are assessed. Published studies demonstrate that teamwork skills are widely self-assessed by students using surveys or questionnaires.^{9,21,23-26,28,29,31-33,35,36} While self-assessment of teamwork skills may prompt crucial self-reflection in students about their need for improvement, having pharmacy educators complete student evaluations may also foster growth in students in these areas. The findings from our mapping review also suggest that assessments measuring the degree to which participants were able to apply what they learned while in a training environment to their behavior post-training are lacking. We postulate that the development of pharmacy core competencies related to teamwork may serve as the impetus for the creation of best practices in teaching teamwork skills with standardized and holistic assessments.

Several of these points were addressed in 2019 by pharmacy educators at the University of Florida College of Pharmacy.⁴³ Farland and colleagues reasoned that teamwork should be developed and evaluated longitudinally across the pharmacy curriculum rather than within a single course or program. Additionally, teamwork assessment plans should incorporate a process to assess individual contributions and team dynamics. To address these points, Farland and colleagues implemented a model of Continuous Development of Teamwork skills using longitudinal self, peer, and team feedback processes across multiple courses. The researchers found that the program identified individual students and teams that met the teamwork standards established by the school as well as those students and teams that needed further coaching to achieve the designated learning outcomes. This model may serve as a starting point to address the teamwork training needs that we identified in our review.

This review is not without limitations. First, publication bias may have occurred as our review included only articles published in peer-reviewed journals. Therefore, other effective designs related to teamwork training may exist in unpublished papers or in published articles that did not align with our designated inclusion or exclusion criteria. Second, we only determined whether Baker’s teamwork principles were present in or absent from the articles identified in our search. We did not determine the quality of the content or extent to which Baker’s principles had been included in a school’s teamwork program as this information was not described in the majority of articles.. Finally, our literature search only identified articles describing activities embedded within the PharmD curriculum. As teamwork skills are taught in other educational environments, such as research laboratories, academic committees, and co-curricular organizations, looking only within the PharmD curriculum, as we did in this study, could be perceived as a limitation. For example, pharmacy students have reported that communication, collaboration, and influence were skills emphasized in co-curricular activities in which they participated.¹¹ This suggests that future research focusing on how teamwork is taught, measured, and assessed in other settings is needed.

CONCLUSION

Although teamwork is regarded as an integral component of effective health care, there is a paucity of literature describing strategies for teaching pharmacy students how to work effectively in teams. This mapping review describes the approaches taken to teach, measure, and assess teamwork within pharmacy education. The findings from this review highlight an opportunity to further explore and identify core competencies for teamwork in pharmacy, with corresponding standardized teamwork training programs and assessments.