Can Team Coaching provide healthcare the remedy it needs?

Abstract

The healthcare industry is inadvertently a teamwork industry - and yet - little time is devoted to improving teamwork on the field. As a response to this issue, team development intervention (TDI) tools have flourished. Findings suggest the capability for TDIs to better team competencies (Lacerenza et al., 2018), and potentially mitigate prominent healthcare problems (Hughes et al., 2016). However, team coaching has been excluded as a potential TDI for healthcare. For this reason, we seek to 1) discuss existing team coaching models, integrating findings across the literature, 2) highlight the advantages of Hackman and Wageman (2005)’s model over others, 3) display its empirically-corroborated propositions, and finally, 4) provide general guidance on how to move forward. We move beyond extant literature by providing an outline on what outcomes team coaching can and cannot yield, accumulating evidence from fields outside of healthcare and incorporating team coaching into the TDI literature. By doing so, we hope empirical research on team coaching is incentivized, resulting in an efficient and accessible TDI for healthcare professionals and the field of interprofessional care.

Introduction

It is ironic, indeed, to realize that a football team spends 40 hours per week practicing teamwork for those 2 hours on a Sunday afternoon when their teamwork really counts. Teams in [healthcare organizations] seldom spend 2 hours per year practicing, when their ability to function as a team counts 40 hours per week - Wise (1974).

Teamwork is the defining characteristic of modern work: 90% of employees believe that teamwork is indispensable in order for their organization’s success (Tannenbaum and Salas, 2021). However, only 25% rate their own teams as effective (Tannenbaum and Salas, 2021). Teamwork has proliferated over the last couple of decades, and whilst this has led to positive organizational outcomes, many organizations have failed to realize that teamwork is not a default, it is not a given skill, and this lack of consideration has led to problems. In healthcare, examples include how interprofessional teams are more likely to experience communication problems (Kvarnstrom, 2008; Leonard et al., 2004) and how these so-called communication failures (which may involve other teamwork competencies beyond communication; see Clapper and Ching, 2020) are one of the leading causes of mistakes regarding patient care. Given the consequential impact of healthcare industry mistakes, researchers have spent significant time developing interventions, such as Deering et al. (2011)’s multidisciplinary teamwork and communication training. However, healthcare is not an easy field to intervene in - as there are many hurdles to overcome. Overall, healthcare organizations have three prominent problems with their working teams (e.g., surgical, physician, and nursing teams): an abundance of burnout (Rotenstein et al., 2021), a general lack of psychological safety (O’Donovan and McAuliffe, 2020), and other issues, most generally regarded as communication mistakes - a triple threat. As healthcare teamwork outcomes are directly related to people’s livelihoods, any interventions made need to be messing for the better (Hysong, S. J., personal communication, April 20, 2023).

These issues are further exacerbated by additional administrative issues: the main one being healthcare professionals’ lack of time (Ikenwilo & Skåtun, 2014) and the degree of specialization and prior training required to intervene in certain types of healthcare teams (i.e., surgical, nursing, and first-responder teams). Therefore, team development interventions (TDIs) in healthcare need to aid teams in overcoming issues as efficiently and quickly as possible, as there is no time to be wasted (and barely time to be made). Additionally, whatever the TDI (i.e., team training, leadership training) might be, if it involves external intervention of any kind (i.e., a team training with an outside specialist) those involved need to be sufficiently versed in healthcare jargon and the healthcare context to intervene. Therefore, interventions that use internal team members (who are already equipped with task knowledge) and are aimed at teamwork processes that can be implemented whilst the team works (instead of trainings that require time set aside) are likely to be more adept to healthcare’s immediate day-to-day teamwork needs. This is not to say there is no space for training interventions or outside experts, but in a matter of day-to-day team functioning, internal interventions fit better with the problems healthcare is currently facing.

Unlike other TDIs, such as team building (whose focus is on greater engagement and trust via a facilitator, see Clutterbuck et al., 2019; Lacerenza et al., 2019), or leadership training (which focuses on enhancing leader knowledge, skills, and abilities, without an explicit focus on team dynamics; Lacerenza et al., 2019); team coaching brings together two important components healthcare can greatly benefit from: leadership training and a process intervention focusing on team dynamics. For this reason, we argue that internal team leader coaching can be the remedy healthcare needs. It addresses healthcare’s triple threat by increasing group effort, bettering interpersonal processes, and improving team knowledge and learning, using an internal leader approach that targets teamwork processes; which we describe below.

Executive coaching has already been applied in healthcare (i.e., Henochowicz and Hetherington, 2006; Godfrey et al., 2014) and team coaching has shown success in improving teamwork in a multitude of other industries. These include the technology industry (Liu et al., 2009), the financial industry and the higher education industry (Schaubroeck et al., 2016; Graen et al., 2020) and even the healthcare industry (Schaubroeck et al., 2016; Maynard et al., 2021). However, the team coaching literature suffers from a problem of definition. Multiple authors conceptualize the intervention differently, leading to a crippling of the literature’s ability to truly derive the power of team coaching as a strategy (Jones et al., 2019). As one author notes,

Team coaching is, therefore, not a homogenous practice, with team coaches developing their own approach, choosing what they perceive to be useful and mixing and matching from the array of options on offer (Graves, 2021, p. 125).

More importantly, the problem of definition (in everything from team coaching models to who should implement the coaching) has led to further issues in solidifying the intervention’s ability to produce positive results, because research is lacking (Peters and Carr, 2013) and there is no classification systems for existing team coaching interventions (Traylor et al., 2020).

All of these factors weaken our ability to implement team coaching in healthcare settings, a field where any interventions made have clear ties to people’s lives. For this reason, we 1) discuss existing team coaching models, integrating findings across the literature, 2) highlight the advantages of Hackman and Wageman (2005)’s model over others, 3) display its empirically-corroborated propositions, and finally, 4) provide general guidance on how to move forward.. Our goal with this discussion paper is to summarize what we know about team coaching in healthcare and to offer a starting point for the intervention in the industry based on empirical evidence, highlighting what we know to be true and unnecessary for team coaching to be successful. Based on this, we give recommendations, messing with healthcare teams for the better.

The team coaching literature

Over the last couple of decades, executive coaching, a targeted intervention that helps individuals hold positive change throughout their professional lives, has flourished (Athanasopoulou & Dopson, 2018). As understood by the International Coaching Federation (ICF), coaching is a continuum, including coaches who practice coaching as a profession and individual workers who implement some coaching skills throughout their careers (ICF, 2020). However, to be considered a coaching practitioner, the ICF holds that coaches should go through extensive training and professional certifications (ICF, 2020). This type of coaching has been consistently linked to multiple positive individual and organizational-level outcomes, such as increased work satisfaction, better time management, increased employee productivity, and more (Athanasopoulou & Dopson, 2018; de Haan et al., 2019). Yet, interventions that have focused on teaching coaching skills to employees within an organization have also yielded positive and impactful results (Küllenberg et al., 2021). Regardless of the type of implementation, executive coaching is a practice that is incredibly widespread, raising the question of team coaching’s ability to also produce related outcomes and how the practice is empirically distinct from executive coaching itself.

Hackman & Wageman (2005) argue coaching is a practice that is pervasive throughout the lifespan, such as a father teaching a son how to ride a bike, and up to that point in time, a practice that had mostly focused on individual skill acquisition (Fournies, 1978; Hackman & Wageman, 2005). Given the lack of a strategy that focused on the collective as a whole, Hackman and Wageman developed what would be the basis for future team coaching work, a theory of team coaching (2005). They define team coaching as a “direct interaction with a team intended to help members in the coordinated and task-appropriate use of their collective resources in accomplishing the team’s work” (Hackman & Wageman, 2005, p. 269). It can be understood as the practice of using coaching principles to “inhibit process losses and foster process gains” for team performance processes (Hackman & Wageman, 2005, p. 273). According to the framework, team effectiveness is a function of the level of effort expended by group members, the appropriateness of strategies being used by the team to carry out the task, and lastly, the amount of knowledge and skills team members have to be able to complete the designated task (Hackman & Wageman, 2005). Unlike executive coaching, team coaching is a separate practice because it focuses on the team as a unit, and its purpose is not to improve individual performance but to facilitate and improve team performance (Hackman & Wageman, 2005). Additionally, team coaching focuses on the team’s learning and reflection, and it uses distinct methods from individual coaching (Jones et al., 2019).

Hackman and Wageman (2005)’s framework laid the foundation for team coaching research and is well-regarded as its earliest conceptualization (Graves, 2021). Yet, eighteen years later, the team coaching literature (like many others in psychology) suffers from a lack of consensus in definitions, specifically in defining what team coaching actually is and who should implement it (Jones et al., 2019). Moreover, given the lack of consensus in defining team coaching, it is well-regarded that “there is insufficient empirical evidence on the discipline of team coaching [...] and inconsiderable evidence linking the impact of team coaching to team effectiveness” (Murphy & Sayers, 2019, p. 76). Perhaps these issues explain the strategy’s near absence from healthcare. This aside, given the strategy’s explicit focus on performance improvement directly related to the team task (Clutterbuck et al., 2019), team coaching has the potential to benefit healthcare organizations and the problems the field is currently facing.

However, it is important to acknowledge that the healthcare context has certain unmovable stipulations (i.e., medical hierarchies, strict procedures, etc.), and we argue interventions need to work with these instead of against them. In order to review the team coaching literature, we first quickly revisit the debate between the use of internal and external team coaches. Then, we review some of the most commonly cited team coaching frameworks (see Murphy & Sayer, 2019), such as Hackman & Wageman’s (2005) original framework, Systemic Team Coaching by Hawkins (2017), Clutterbuck’s (2013) work, and Thornton’s psychodynamic approach (2016). We also review recent work on the team coaching operating system (TCOS) framework, conducted by Hauser (2014). We discuss advantages and disadvantages of each model.

Internal team coaches

Unlike executive coaching, the team coaching literature has taken a different path. While the ICF continues to reiterate the importance of professionally trained coaches, the team coaching literature sways back and forth between the benefits of external team coaching and internal team leader coaching. In 2013, Peters and Carr remarked on this issue, but seven years later, a systematic review revealed that 80% of team coaching studies have conceptualized team coaching with a leader-behavioral approach, which in other words, involves an internal team leader completing the coaching (Traylor et al., 2020). While external team coaches have been tied to positive outcomes (see O’Connor et al., 2017), and have certain benefits over internal coaches, such as bringing in new perspectives (Godfrey et al., 2014), internal coaches continue to outweigh them (in healthcare contexts) for two reasons. Firstly, they are more likely to be acquainted with local context, meaning the inner-workings of the team and other specific healthcare knowledge (as acknowledged by Godfrey et al., 2014). Secondly, there is simply more literature behind this type of intervention (as Traylor et al., 2020 demonstrate). Notwithstanding, there is a way to reconcile both points. Maynard et al. (2021) offer up the only highly controlled empirical study that tests team coaching in a healthcare context. In this study, they had a retired surgeon (certified in crew resources management training) coach current surgeons, who later coached their teams. This “middle-of-the-ground” approach takes fruit from both trees, and leaves behind a team leader that has the necessary skills to coach a team throughout its lifespan. This is ideal for multiple reasons: the intervention supports leadership development and the trained leaders gain the ability to take these skills and continuously use them in future teams. Therefore, team coaching serves as a holistic intervention that allows for team performance improvements in the process of the task completion, avoiding the need for separate team trainings and making use of what hospitals currently have (i.e., internal hires and networks). Furthermore, this type of approach (i.e., leader-behavioral) is supported by Wageman and other authors in the team coaching literature, such as Hawkins (Peters and Carr, 2013).

A review of existing team coaching models

The original team coaching framework (i.e., Hackman and Wageman, 2005) posits that team coaching is a strategy that can improve team effectiveness because of its ability to do three main things: target a team’s level of effort, target a team’s specific performance strategies, and potentially increase the amount of knowledge and skill utilized by team’s members; using the leader-behavioral approach (Traylor et al., 2020). This framework posits four necessary success factors for team coaching to be effective, including that the team needs to be relatively unconstrained by task and organizational requirements (constraint factor); the team needs to have a supportive environment (supportive environment factor); the focus of the intervention needs to be the team (focus on team factor); and the coaching intervention needs to be done at the correct time (timing factor). Moreover, Hackman and Wageman’s model was built on the assumption that teams require three different types of coaching depending on the stage the team is at (2005). For example, teams require motivational coaching at the beginning of the team lifecycle, consultative coaching in the middle, and educational coaching at the end. However, one major critique of this model is that the timing factor has not been empirically supported, and moreover, the assumption that different types of coaching correspond to different timepoints in a team’s lifespan has thus far been unsupported by existing empirical literature (see Liu et al., 2009). When cross-referenced with other literature, the extant three success factors have support (Hackman and Wageman, 2005; Hastings & Pennington, 2019; Liu et al., 2009; Van Wyk et al., 2019).

One last pivotal piece of this model is that it is task-focused. Hackman and Wageman (2005) advise against a focus on the interpersonal, instead taking a “structural view” where conflict arises due to higher order process issues, such as an unclear team goal, rather than interpersonal differences (Peters and Carr, 2013). This aspect of the model has been critiqued by the literature, and other models (such as Thorton, 2010) have pivoted in placing emphasis on these interpersonal relationships (Murphy & Sayer, 2019).

Following the publication of “A theory of team coaching” a series of developments followed (i.e., models including but not limited to Clutterbuck, 2007; Thornton 2010, Hawkins, 2021). Systemic team coaching was one of them, proposing that an external coach needs to take into consideration factors that exist outside of the team, such as hospital administrators or other patient demands. Hawkins and colleagues developed the Systemic Team Coaching model that seeks to encompass systems teams face, and for this reason, proposed the Five Disciplines Model (2021). This model proposes that in order to be an effective team, a team has to have the following five disciplines: commission, clarifying, co-creating, connecting, and core learning. Commission encompasses understanding stakeholder requirements, clarifying means understanding the team’s mission, co-creating means being able to be generative, connecting means being able to engage with one’s team and external stakeholders, and lastly, core learning refers to how a team develops as a whole and learns from said development (Hawkins et al., 2021). Overall, Systemic Team Coaching was an innovative development in the team coaching literature for its emphasis on the team and its wider systemic context “[as the] new center of focus” (Hawkins 2019, p. 40)

Given that the healthcare industry is complex, as there are teams, multiteam systems, multidisciplinary collaborations, and profession upon profession, all whilst handling patient lives; Systemic Team Coaching has the undeniable strength that it looks at the system in its entirety. This systematic view has been picked up with other authors, who have begun to emphasize factors external to the team (Widdowson et al., 2020). However, as Lawrence (2021) points out, a systemic view might not always be helpful in understanding smaller groups. Lawrence (2021) makes the argument that a systemic view assumes clear boundaries and established membership (now conceptualized as role stability, see Wageman et al., 2012), which might not always be the case with modern teams. Moreover, another critique of Systemic Team Coaching is its underlying assumption that a team has considerable power of its goals and external relationships, most likely stemming from the fact that it was designed for senior leadership teams (Clutterbuck, 2019). While senior leadership teams might benefit from such competencies (e.g., commission), teams that do not have the ability to actively engage with stakeholders and make their own mission might benefit from other approaches that focus on the dynamics of the team itself (what is deemed as a first order approach, see Lawrence, 2021). For example,

[Systemic Team Coaching] requires a committed partnership between the coach and the whole team over an extended period of time, involving the coach working with the team [... and taking in consideration] how the team engages all their stakeholders [...] and their customers, investors, partner organizations, local organizations, and their natural environment (Hawkins, 2019, p. 39).

While such a focus might be beneficial for the directors of a healthcare organization, smaller teams that are currently suffering from burnout, lack of psychological safety, and communication mistakes tied to patient safety do not regularly engage with stakeholders such as investors (e.g., generally, a surgical team does not regularly engage with financial investors). Moreover, the model assumes a horizontal view of leadership instead of a hierarchical one (Hawkins, 2019, p. 48), going against the reality of the healthcare industry as of right now (Krishnakumar et al., 2021). Hence, while it may be possible for teams to take from Systemic Team Coaching, an approach that focuses on task dynamics might be more appropriate for the healthcare context.

Another view of team coaching is provided by Clutterbuck (2012, 2013, 2019) who approaches team coaching as a learning intervention that uses reflection and dialogue for change; with task, behavior, and learning as the three key components of effective teams. Clutterbuck approaches a team coach’s tasks as everything from helping the team be more honest with themselves, defining the team’s mission, understanding the environment and team processes, identifying barriers to performance, building the capacity to manage conflict, and more (Clutterbuck, 2013). Clutterbuck’s focus on task and learning is invaluable in the healthcare context, where a team’s ability to focus on the task at hand and learn from prior mistakes can result in improved future performance. However, the case with behavior is less clear.

Clutterbuck focuses on interpersonal issues and conflict, putting forth strategies that team coaches should surface and aid in the resolution of conflict. Examples include using via a “conflict matrix” where individual team members talk about how they perceive conflict in the team, later combining them into one composite in order to be able to analyze conflict situations (Clutterbuck, 2012). While these strategies are undeniably helpful for teams that have a common goal, a less stringent hierarchy, and a more lenient timeline; in the healthcare context, they work against the system in place. Healthcare is an environment with high power distance given its hierarchical nature (Krishnakumar et al., 2021). While psychological safety remains important (as is discussed below) strategies that focus on the task and not intragroup relationships are bound to be more successful. Moreover, Clutterbuck’s recommendations (such as the conflict matrix) rests on the assumption that a team coach is an objective observer, and while that might be the case for an external coach, that is not the case for an internal team leader.

Thornton (2016) offers a similar view of team coaching. This model views team coaching as helping the team “achieve a common goal, paying attention to both individual performance and group collaboration and performance” (Clutterbuck et al., 2019, p. 6). However, Thornton takes on a psychodynamic approach, where a focus on interpersonal relations is the priority (Hastings & Pennington, 2019), with a guiding pillar that “expressing feelings enables greater freedom and creativity in the team” (Thorton, 2019, p. 215). Thorton describes five guiding questions for this approach. An example of one is, “What is undiscussable” – asking team coaches to work with teams on points such as unwritten rules, what a visiting alien might make of the team’s rules, and so forth (Thorton, 2019, p. 217). Once again, while this focus might be appropriate for other contexts – such as the innovation sphere – it is not adept to healthcare needs or its organizational constraints. While we do not negate the power of a psychodynamic approach for other fields, medical hierarchies would work best with a task-focused approach. Extant literature supports this, such as recent meta-analytic evidence that found that task-focused cohesion was more predictive of team performance than social cohesion – across multiple fields, not just healthcare (Grossman et al., 2021).

Lastly, Hauser (2014) presents the team coaching operating system (TCOS) framework, which is based on the work of external team coaches. Important findings from this work include the shape-shifter model, which proposes that a coach can transition into different roles depending on the focus that is needed (i.e., coordination, learning, transition, and cohesion). A coach may also be more or less directive or more or less dialogic depending on the focus and timeline of the team. Though this model presents the benefit of adaptability, there is limited research to support the use of distinct interventions at different times during a team’s life span with internal coaches (such as Liu et al., 2009, who found limited evidence for this idea).

The last eighteen years have seen a proliferation in coaching research. Advancements continue to follow with internal and external coaching work. Notwithstanding, the field’s inability to concur with defining team coaching has limited its empirical power. The majority of team coaching research tends to take the concept of team coaching and extract their own conclusions on the outcomes it can give without reference on how to implement (or replicate) the findings (Van Wyk et al., 2019). Most research lies with the behavioral model, and more recent research (with a systemic focus) does not encapsulate the specific healthcare context of smaller working teams, such as surgical teams, nursing teams, and so forth. Therefore, while debated many times, Hackman and Wageman’s model (2005) is the best fit and allows for the best starting point for incorporation of team coaching into the healthcare context as the foundational model of team coaching.

We argue this model is the most adept to healthcare needs for three main reasons: 1) it uses the dominant internal team leader approach that works with healthcare needs, 2) it has the most empirical research behind it (“the academic authority” of team coaching, see Murphy and Sayer, 2019, p. 76) and 3) it is task-focused. The power of Hackman and Wageman’s model lies in its ability to blend into healthcare needs, beginning with the model’s behavioral approach. Additionally, healthcare teams have one primary task to complete, at all times, which is patient safety. Therefore, a task-focused model, which focuses on what the team needs to accomplish rather than personal relationships or creativity, is preferable under healthcare contexts (Lawrence, 2019). It is important to remark that Hackman and Wageman’s (2005) view is not that interpersonal relationships are unimportant: it is that interpersonal issues arise because of the way the team is functioning and set-up, and can therefore be resolved by going back to structure and context. In this case, the model’s structural view is also a strength, compatible with current healthcare structures, where people lower on the chain of command are sometimes unable to speak up due to high power distance (Leonard & Frankel, 2011). We posit that a model that focuses on task and does not focus on breaking these chains but instead bettering them via an improvement in goal-setting and direction works with the healthcare context and its reality. Lastly, in this context – a first order view, as explained by Lawrence (2021) is appropriate. For the most part, healthcare teams have explicit boundaries and while there is dynamic membership, there is usually stability in roles.

By putting Hackman and Wageman’s (2005) model forward, we do not argue for its infallibility, but more so its roots, and move forward with the necessary dissection to corroborate what aspects are empirically supported and which ones are not, pulling from a variety of literature. Furthermore, we also integrate research from more recent literature into our recommendations for how to move forward with this intervention.

The Hackman and Wageman (2005) Framework

The main takeaway from the publication of Hackman and Wageman (2005)’s framework is that team coaching is a tool that can help improve team performance and effectiveness under certain conditions. Once again, the authors state team coaching can target a team’s level of effort, target a team’s specific performance strategies, and potentially increase the amount of knowledge and skill utilized by team’s members; but how it can yield these improvements requires review. Notwithstanding, a review of the literature from other fields can help explain what the original framework did not: how team coaching leads to these positive results. Using empirical evidence, we aim to dissect what has been known as the team coaching black box (Liu et al., 2009) – and review the three outcomes that team coaching has been known to yield – improvements in group effort, interpersonal processes, and increases in team knowledge and learning, corresponding to Hackman and Wageman’s (2005) original propositions.

Evidence from other fields

Group Effort

In order for a team to be effective, it must be able to sustain performance over time, be resilient, and exhibit vitality (Tannenbaum and Salas, 2021). In healthcare, a profession replete with burnout, which is associated with negative job performance outcomes (Salyers et al., 2017) – solutions that target a team’s effort reserves are desperately needed. Research in oncology has demonstrated that burnout can be mitigated by team-based interaction and group meetings that focus on communication, engagement, and information sharing (Alabi et al., 2021); all concepts that are related to a team’s effort levels or goal-commitment. Though effort is loosely defined (if at all) in the coaching literature, conceptualizing it as a commitment to providing quality patient care can help reframe the goal for those who implement the strategy (see Chassin and Loeb, 2013; who find that leadership commitment to achieving zero patient harm can help organizations progress towards high-reliability).

Furthermore, research has shown team coaching to be capable of yielding better group effort outcomes. In the field of technology, an empirical research study that looked at 133 research and development teams found team coaching directly affects team member effort (Liu et al., 2009). Another study found that team coaching is positively related to team members’ commitment to goals (Rousseau et al., 2013). Though neither of these studies measured active interventions of team coaching (they measured already existing team leader coaching behaviors), analyzing the team coaching behaviors the leaders implemented and the researchers measured can help explain why team coaching led to positive outcomes in effort and goal commitment. Leaders who implemented feedback on performance for their teams, who mentioned positive aspects about team members, who kept the team in the loop of changes, and most interestingly, worked with team members to develop an optimal approach to their work, were the teams that exhibited these positive outcomes (Liu et al., 2009; Rousseau et al., 2013), supporting Hackman and Wageman (2005)’s claim of the strategy’s ability to improve team effort. Not only did the strategy lead to this improvement in team dynamics, but it also led to the organizational impact of facilitating innovation in both of the studies described. Innovation can also be an important organizational outcome for healthcare, and the fact that team coaching has led to overall organizational outcomes (rather than simply team-level outcomes) in other fields speaks to the power of the intervention if done correctly.

We know that improvements in healthcare professionals’ effort are needed. As stated above, there is a consistent negative link between burnout and perceived quality of care, quality indicators, and perceptions of safety (Salyers et al., 2017). Research has demonstrated that in order to truly alleviate burnout, interventions need to be deliberate, and incorporate honest efforts for a supportive environment along realistic work expectations (Brindley et al., 2019). Though alleviating burnout is an organizational-level effort (not simply a team-level effort), internal team leader coaches can help in the process by doing what is within their power, such as communicating what is needed, communicating what needs to be done, and how to do it (i.e., performance expectations; see Brindley et al., 2019). By using such strategies, team leaders can help their teams become more effective. Effective teams are led by many drivers, but one of them is adequate conditions (Tannenbaum and Salas, 2021; known by Hackman and Wageman as the supportive environment factor). By creating an environment where people feel empowered and understood (i.e., by being clear, by modeling commitment to the goal in sight), people are more likely to be willing to coordinate with one another (Tannenbaum and Salas, 2021), which will lead to better team performance.

Bettering interpersonal processes

Psychological safety can be conceptualized as the ability to voice questions, ideas, or problems in the workplace without the fear that one will be negatively reprimanded for doing so (Edmondson, 1999). Psychological safety has been repeatedly demonstrated to be directly related to all three aspects of team effectiveness, and a lack thereof can obstruct teamwork and other organizational outcomes (Tannenbaum and Salas, 2021). The second claim Hackman and Wageman (2005) make in their framework is that team coaching can lead teams to use more appropriate performance strategies given the task at hand. The literature has found that if appropriate performance strategies, a loosely defined category, is defined as improvements in interpersonal processes (such as psychological safety within a group), team coaching can yield better performance outcomes. Though Hackman and Wageman (2005) did not push for a focus on interpersonal relationships, a focus on setting the stage for a team that supports healthy exchanges (i.e., via system and context) was encouraged. Findings from the literature include that training leaders is positively associated with team psychological safety (Edmondson, 1999); more recently supported by (Graen et al., 2020) - who reported on Google’s ^® findings that team coaching can enhance psychological safety and drive organizational effectiveness. With Hackman and Wageman’s (2005) understanding of performance strategies, this might mean internal team leaders might push for the creation of norms to encourage positive team behavior. Other ideas include modeling respectful and clear communication behaviors for the team to follow, to ensure everyone feels as though they are in a safe environment.

Psychological safety enables effective teams (see Aranzamendez, et al., 2014; Kessel et al., 2012; O’Donovan and McAuliffe, 2020). In addition, research has shown that team leaders play a big role in fostering this factor (Aranzamendez et al., 2014). Psychological safety continues to be reiterated by researchers because of its ability to help people be more open with each other, be more honest, and be more engaged. In the context of healthcare, this could mean someone speaking up before a mistake is made, allowing team members to raise concerns if possible, and be more engaged as they feel part of a collective and collaborative environment (Tannenbaum and Salas, 2021).

Team knowledge and learning

The last claim Hackman and Wageman (2005) make is that team coaching can increase team knowledge and learning. The literature has empirically supported this claim via the mechanism of improving interpersonal processes. A study conducted in Israel with over 300 employees across teams (including finance, education, and hospital teams) found that team leader coaching can improve interpersonal processes (via contentious communication) within a team, which can then lead to more team learning (Schaubroeck et al., 2016). The authors define contentious communication as a communication pendulum where consensus is hard to reach given the stance individuals take in the conversation (Schaubroeck et al., 2016). This may be particularly relevant to healthcare teams, where healthy debate and disagreement is part of the everyday life of healthcare workers. Furthermore, Edmondson (1999)’s model also posited that team leader coaching leads to team safety and subsequently to team learning behaviors. Additionally, a variety of fields, from education (Miller and Stewart, 2013) to the tourism industry (Azanza et al., 2022) - have also supported the claim that team coaching can lead to increasing job-specific skills, a form of team knowledge and learning. Therefore, team coaching has support in its claim to improve team knowledge and learning.

Improvements in team knowledge and learning are extremely important to healthcare teams because they allow them to learn from past failures. One potential way for team leaders to foster knowledge and learning is via debriefs. In general, debriefs have been known to yield individual and team performance improvements by up to 25% (Tannenbaum et al., 2012). If internal team leaders allow for time after a work event to debrief, teams may begin to see improvements in team performance. Furthermore, debriefs have been shown to help with creating a supportive culture where team members feel safer speaking up in operating rooms (see Leonard et al., 2022). In addition to this, they help individuals understand the task at hand is of collective responsibility (Leonard et al., 2022). However, more empirical research is needed to draw a definitive connection between debriefs, team coaching, and team performance.

To summarize, team coaching has been empirically supported by various industries to do three specific things: increase group effort, better interpersonal processes via improvements in psychological safety, and increase team learning and knowledge. Improving these three facets of a team is vital, because together, they all lead to improvements in teamwork processes. Improvements in teamwork processes have been established as having a positive relationship with team performance and team member satisfaction (LePine et al., 2008). For this reason, alongside healthcare’s triple threat, team coaching seems to be an especially targeted intervention for this field’s immediate needs. Yet, it has not been incorporated into the TDI literature. We incorporate it into the TDI literature based on Lacerenza et al. (2018)’s model, as displayed in Figure 1 below. As one can observe from Figure 1, team coaching fits seamlessly into the TDI literature. It is a process intervention and it is capable of attacking two team aspects at once: interpersonal processes and team processes.

Figure 1.

Incorporating team coaching into the TDI interventions literature. Based on Lacerenza et al. (2018), p. 520.

Important to note from Figure 1 is that team coaching encapsulates both a training and a process intervention depending on how it is evaluated. On one hand, if a team leader decides to use coaching strategies without training, it is simply a process intervention. That aside, advancements such as Maynard et al.’s (2021) study have made it clear that it can involve leadership training (a training intervention), and following this, then a process intervention. By incorporating team coaching into this framework, we seek to solidify team coaching’s ability to produce results with improvements in both interpersonal and team processes and pointing out its characteristics as a holistic teamwork strategy. Oftentimes, organizations are unsure of what strategies to implement, and by incorporating team coaching into the TDI literature, team science can move forward into a better understanding of the tools we have, where the gaps lie, and what to use when problems arise.

Until now, team coaching has not been widely used in the healthcare industry; but there are some studies that show significant promise for its future as a TDI. One study looking at neonatal intensive care units found that team coaching led to improvements in supervisor-supervisee relationships (psychological safety), led to increased motivation, and led to more constructive feedback (Cochrane et al., 2007). Farh and Chen (2018) found that coaching leader behavior promoted voice, an aspect of psychological safety, in phases of team performance within surgical teams. Maynard et al. (2021) found that surgeons who underwent team coaching training by retired surgeon had better surgical outcomes, via the mechanism of improvements in team transitions and interpersonal processes. Notwithstanding, the majority of the research described is not using pure experimental manipulation, making it harder to draw definitive conclusions on the efficacy of team coaching. It is clear team coaching can yield the improvements healthcare needs, however, we believe that empirical research will strengthen team coaching’s place in the TDI literature and help research move forward with a more integrative view of the strategy.

Application to Healthcare

Before incorporating any TDI tool, an organizational needs-analysis can help reveal if teamwork challenges are being caused by a lack of teamwork skills. If this is the case, a TDI is appropriate. If healthcare organizations wish to incorporate a TDI that simultaneously targets the triple threat all at once, team coaching is the path to take. Moreover, training a singular individual - in this case the leader - to implement specific teamwork strategies would be a timely investment, given that this training is likely to be much less costly and time-consuming than training multiple teams on multiple timelines.

As conceptualized by the majority of the literature, team coaching is a strategy that begins with the leader (Traylor et al., 2020). For this reason, organizations wishing to incorporate it must train their leaders first. However, this can go one of two ways: by taking Maynard et al. (2021)’s approach, using a subject matter expert (SME) that coaches the team leader, or coaching the internal leader with an external coach that specializes in teamwork strategies, a cited benefit of external coaching (Graen et al., 2020). Regardless of the path taken, the end-result must be a team leader that is trained in team coaching, as having stand-in internal coaches can help adequately identify a team’s developmental needs over time (Traylor et al., 2020).

Maynard et al.’s (2021) approach of having a retired surgeon coach the leading surgeon might be beneficial when healthcare organizations need specific technical skills refined. In this study, the retired surgeon coach was trained on crew resources management training (CRM) - but we believe an individual who has the technical healthcare knowledge and the addressed leadership competencies (and is part of the team in question) would be more than sufficient. However, healthcare organizations should determine specific team coaching needs by administering tools like the Team Diagnostic Survey (TDS) prior to intervention in order to understand how a team functions and where its faults lie (Wageman et al., 2005).

In the process of training the leader, organizations should make sure leaders learn to observe their teams and note where they are falling short. Though we encourage the use of team coaching (the revised version examined here) as understood by Hackman and Wageman (2005), other team coaching researchers have developed important strategies that help in the training of such leaders; that, if adapted to this model, could help in the development of internal coaches. For example, Clutterbuck (2012) offers up questions to help an external coach understand a team’s relationship with its leader. One of these questions is, “Does everyone have the same understanding about the task priorities?” (Clutterbuck, 2012, p. 229). If adapted to internal leaders, task-focused questions can help them guide their team through the day, and set norms for how the team is going to work and how things will be accomplished.

In this training process, the leader should learn different strategies to implement so they may better group effort, psychological safety, and improve team learning for their team. If taking an approach like Maynard et al.’s (2021), where internal team leaders were trained prior to coaching, this could mean informing a current surgeon they need to speak more gently when they ask the anesthesiologist to do a particular task, in order to improve psychological safety in the group. Another example could be informing the nursing supervisor to, every once in a while, highlight nurses’ efforts to improve group effort. Whatever the case might be, these learning sessions should not be a one-size-fits-all, and most importantly, the stand-in internal team leader needs to learn to adapt coaching strategies to the specific threat the team is experiencing. Here, some of the questions developed by Hawkins and colleagues (2021) could be utilized. If psychological safety can be fostered through the creation of norms, then asking questions such as, “[What are] our collective goals and roles? How do we not only run our functions, but contribute to the whole?” can help internal team leader coaches aid their team in understanding what everyone’s place is and how they can contribute (Hawkins et al., 2021, p. 4). What we mean to emphasize is that there is much power in the existing coaching literature: but what we need is to focus on what is empirically corroborated, and from there, adapt what we can from other team coaching strategies to start moving towards a holistic view based on the original model. This holistic view should be adaptable and falsifiable. We advocate for Hackman and Wageman (2005) as a starting point but that does not exclude new innovations or the inclusion of recent ones.

Once trained, leaders can coach their teams to improve these three areas by modeling desired behaviors and being consistent in communication (Tannenbaum and Salas, 2021). This aids in the creation of a safe psychological climate, where team members feel safe to come together, ask questions, and speak up if there are issues to be addressed. Moreover, all three areas can be aided through the creation of norms, which has shown to improve a team’s wisdom- defined as their ability to manage the intrinsic tensions of teamwork (Nielsen et al., 2006). This could mean hosting a team meeting every Wednesday morning in order to create a space where team members can voice tactical concerns. Such a strategy goes hand in hand with the structural view, which understands interpersonal conflict but takes a context-like approach to resolving issues. Overall, team coaching is an evidence-based strategy that can yield powerful results in a cost-effective and efficient way.

How to move forward

We believe that in order to advance this tool, more empirical research should take place. Team coaching works through three main processes: by improving group effort, bettering interpersonal processes, and increasing team knowledge and learning. The black box has become gray. Yet, given the state of the literature, we believe that authors that undertake studying coaching should make deliberate attempts to describe their approach and how they choose to implement it: as this will yield better and more replicable results. This includes describing how leaders are being trained to coach and by whom. This includes describing team processes before and after intervention to note change. More documentation and clarity in research processes will aid in highlighting team coaching’s ability to produce results. Through discussion of other team coaching models, we hope to incentivize research to solidify Hackman and Wageman’s (2005) model but also seeks to incorporate more recent advancements mentioned here, moving towards an updated, integrative team coaching view. Furthermore, the majority of research has focused on the task-focused, behavioral view. By discussing models like Thorton’s (2011) psychodynamic view and Hawkins (2021) Five Disciplines Model, we invite ways in which we can grow the original framework to encompass valuable characteristics, such as the systematic view, which to this day, remains vastly unexplored in empirical studies.

In the meantime, we believe that hospitals looking for a way to better teamwork can take the approach described here, based on Maynard et al. (2021)’s findings. Team coaching brings people together: and if it takes down healthcare’s triple threat, it seems like the perfect remedy.