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The Effectiveness of Teamwork Training on Teamwork Behaviors and Team Performance : A Systematic Review… McEwan, Desmond; Ruissen, Geralyn R.; Eys, Mark A.; Zumbo, Bruno D.; Beauchamp, Mark R. (Mark Robert), 1972- Jan 13, 2017

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RESEARCH ARTICLEThe Effectiveness of Teamwork Training onTeamwork Behaviors and Team Performance:A Systematic Review and Meta-Analysis ofControlled InterventionsDesmond McEwan1*, Geralyn R. Ruissen1, Mark A. Eys2, Bruno D. Zumbo3, MarkR. Beauchamp11 School of Kinesiology, The University of British Columbia, Vancouver, British Columbia, Canada,2 Departments of Kinesiology/Physical Education and Psychology, Wilfrid Laurier University, Waterloo,Ontario, Canada, 3 Department of Educational and Counseling Psychology, Faculty of Education, Universityof British Columbia, Vancouver, British Columbia, Canada* desi.mcewan@ubc.caAbstractThe objective of this study was to conduct a systematic review and meta-analysis of team-work interventions that were carried out with the purpose of improving teamwork and teamperformance, using controlled experimental designs. A literature search returned 16,849unique articles. The meta-analysis was ultimately conducted on 51 articles, comprising 72(k) unique interventions, 194 effect sizes, and 8439 participants, using a random effectsmodel. Positive and significant medium-sized effects were found for teamwork interventionson both teamwork and team performance. Moderator analyses were also conducted, whichgenerally revealed positive and significant effects with respect to several sample, interven-tion, and measurement characteristics. Implications for effective teamwork interventions aswell as considerations for future research are discussed.IntroductionFrom road construction crews and professional soccer squads to political parties and specialoperations corps, teams have become a ubiquitous part of today’s world. Bringing a group ofhighly-skilled individuals together is not sufficient for teams to be effective. Rather, teammembers need to be able to work well together in order for the team to successfully achieve itspurposes [1, 2]. As a result, there has been a proliferation of research assessing whether, andhow, teams can be improved through teamwork training. A wide range of studies have shownpositive effects of teamwork interventions for improving team effectiveness across several con-texts such as health care (e.g., [3]), military (e.g., [4]), aviation (e.g., [5]), and academic (e.g.,[6]) settings. Similarly, improvements in teamwork have been observed as a result of trainingwith a variety of team types including new teams (e.g., [7]), intact teams (e.g., [8]), and thosecreated for laboratory-based experiments (e.g., [9]). In sum, the extant empirical evidence todate appears to suggest that teams can be improved via teamwork training.PLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 1 / 23a1111111111a1111111111a1111111111a1111111111a1111111111OPENACCESSCitation: McEwan D, Ruissen GR, Eys MA, ZumboBD, Beauchamp MR (2017) The Effectiveness ofTeamwork Training on Teamwork Behaviors andTeam Performance: A Systematic Review andMeta-Analysis of Controlled Interventions. PLoSONE 12(1): e0169604. doi:10.1371/journal.pone.0169604Editor: Nico W. Van Yperen, RijksuniversiteitGroningen, NETHERLANDSReceived: September 15, 2016Accepted: December 19, 2016Published: January 13, 2017Copyright: © 2017 McEwan et al. This is an openaccess article distributed under the terms of theCreative Commons Attribution License, whichpermits unrestricted use, distribution, andreproduction in any medium, provided the originalauthor and source are credited.Data Availability Statement: All relevant data arewithin the paper and its Supporting Informationfiles. Raw data (taken from the studies in our meta-analysis) are available upon request from thecorresponding author.Funding: The authors received no specific fundingfor this work.Competing Interests: The authors have declaredthat no competing interests exist.What is Teamwork?Within teams, members’ behaviors can be categorized in terms of both taskwork and teamworkprocesses [2]. Marks et al. [10] differentiated between the two by suggesting that “taskworkrepresents what it is that teams are doing, whereas teamwork describes how they are doing itwith each other” (p. 357). Specifically, while taskwork involves the execution of core technicalcompetencies within a given domain, teamwork refers to the range of interactive and interde-pendent behavioral processes among team members that convert team inputs (e.g., membercharacteristics, organizational funding, team member composition) into outcomes (e.g., teamperformance, team member satisfaction) [2, 10]. Some examples of teamwork (and respectivecomparisons to taskwork) include: the seamless communication between a surgeon, nurse,and anaesthesiologist, rather than the technical competencies of these practitioners; the syn-ergy between a quarterback and receiver to complete a passing play, rather than their respec-tive skill sets related to throwing or catching a football; the collaborative adjustments a flightcrew makes in response to adverse weather or system problems, rather than each individual’saviation skills; and so forth. Research from an assortment of studies indicates that teamwork—the focus of the current paper—is positively related to important team effectiveness variables,including team performance, group cohesion, collective efficacy, and member satisfaction [1].Teamwork has been conceptualized within several theoretical models. For example, in theirreview, Rousseau et al. [2] reported that 29 frameworks related to teamwork have been pub-lished. Although there is much overlap across these models, there are also some notable differ-ences. These relate to the number of dimensions of teamwork being conceptualized as well asthe specific labelling of these dimensions. One thing that is generally agreed upon, however, isthat teamwork is comprised of multiple observable and measurable behaviors. For instance,two highly cited frameworks by Marks et al. [10] and Rousseau et al. [2] consist of 10 and 14dimensions of teamwork, respectively. In general, teamwork models focus on behaviors thatfunction to (a) regulate a team’s performance and/or (b) keep the team together. These twocomponents coincide with the two respective processes that Kurt Lewin, the widely recognizedfather of group dynamics, originally proposed all groups to be involved in: locomotion andmaintenance [11].With regard to regulating team performance (i.e., locomotion), teamwork behaviorsinclude those that occur (a) before/in preparation for team task performance, (b) during theexecution of team performance, and (c) after completing the team task [2]. First, with regardto teamwork behaviors that occur before/in preparation for team task performance, theseinclude the active process of defining the team’s overall purpose/mission, setting team goals,and formulating action plans/strategies for how goals and broader purposes will be achieved.These behaviors help ensure that all team members are clear in terms of what is required ofthem in order for the team to function effectively. Second, teamwork behaviors that occur dur-ing the execution of team tasks include actions that correspond to members’ communication,coordination, and cooperation with each other. At this stage, team members translate whatthey have previously planned (during the preparation phase) into action. Third, in terms ofteamwork behaviors that occur after completing the team task (i.e., reflection), these includemonitoring important situations and conducting post-task appraisals of the team’s perfor-mance and system variables (e.g., internal team resources, broader environmental conditions),solving problems that are precluding team goal attainment, making innovative adjustments tothe team’s strategy, and providing/receiving verbal and behavioral assistance to/from team-mates. Hence, team members determine whether their actions have moved them closertowards accomplishing the team goals and objectives, and whether any modifications arerequired in order to facilitate future success. In addition to these three dimensions concernedA Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 2 / 23with the regulation of team performance, a fourth dimension of teamwork involves behaviorsthat function to keep the team together (i.e., maintenance). These behaviors focus on theteam’s interpersonal dynamics, and include the management of interpersonal conflict betweenmembers and the provision of social support for members experiencing personal difficulties.Managing interpersonal dynamics is critical as it is theorized that teams cannot operate effec-tively when these issues are present [2].How Can Teamwork Be Trained?Teamwork interventions have utilized a number of training methods in order to target the reg-ulation of team performance (i.e., preparation, execution, reflection) and management of teammaintenance (i.e., interpersonal dynamics) dimensions. These intervention strategies generallyfall under one of four categories. First, the most basic approach to training and developingteamwork involves providing didactic education to team members in a classroom-type setting,such as lecturing about the importance of providing social support within the team or promot-ing ways to manage interpersonal conflict among teammates. This type of training has beenfound to be useful for enhancing team effectiveness (e.g., [12]). A second category of teamtraining involves utilizing a more interactive workshop-style format, wherein team memberstake part in various group activities, such as having discussions about the team’s purposes andgoals (e.g., [13]) or working through case studies together (e.g. [14]). The third broad categoryof team training involves simulation training, wherein teams experientially enact various team-work skills, such as interpersonal communication and coordination, in an environment thatmimics upcoming team tasks (e.g., airline simulators or medical patient manikins). Althoughoften used as a means of fostering taskwork competencies (e.g., teaching new surgeons how toperform the technical skills of a medical operation), simulation training has been found to bean efficacious approach to teamwork intervention (e.g., [15]). In addition to these three train-ing approaches that occur outside of the team task environment (i.e., training within class-room and simulation settings), teamwork can also be fostered by incorporating team reviewsin-situ (i.e., where the team actually performs its tasks), which allows teams to monitor/reviewtheir quality of teamwork on an ongoing basis. These team reviews involve some form of teambriefs before (e.g., creating action plans), during (e.g., monitoring team members’ actions),and/or after (e.g., assessing the team’s performance) team task execution, and have also beenshown to be efficacious in previous studies (e.g., [16]).The effectiveness of teamwork interventions can be determined with an assortment of crite-ria, including team- and individually-based behaviors, cognitions, and affective states. Hack-man and Katz 2010 [17] posit that team effectiveness can be determined by examining theextent to which the team has achieved its a priori objectives. Since the broad purpose of form-ing a team is to produce something of value, it is perhaps unsurprising that the most widelytested criterion of team effectiveness has been team performance [18–20]. Thus, althoughteams come from an array of settings and are idiosyncratic in their own ways, one questionthat essentially all teams address at some point during their tenure is whether they are per-forming well. For example, is that road construction crew fixing potholes adequately? Does thelocal soccer squad have a respectable winning percentage? Has an elected political party suc-cessfully completed the tasks for which they campaigned? Did a special operations corpsachieve the mission it set out to accomplish? When taken in concert, questions related to teamperformance are often of central interest when characterizing a team’s effectiveness.In addition to assessing the outcome variable of team performance, researchers have alsobeen interested in whether teamwork training actually improves teamwork itself. The efficacyof these interventions can be determined with a number of objective (e.g., products producedA Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 3 / 23by an industry team), self-report (e.g., questionnaires regarding perceived social supportamongst team members), and third-party assessments (e.g., expert ratings of team behaviors).Both general/omnibus measures of teamwork (e.g., [21]) as well as those assessing specificdimensions of teamwork (e.g., communication [22]) have been operationalized to examine theeffectiveness of these interventions. For example, do team goal setting activities actually resultin members creating and pursuing effective team goals? Does simulation training improve therequisite coordination processes among aviation cockpit crews? Has a didactic lecture contrib-uted to improved conflict management among team members? Answering these types of ques-tions is important for determining whether an intervention is actually efficacious in changingthe variable that is targeted for improvement (i.e., teamwork behaviors).The Current ReviewPrior to outlining the purposes of this systematic review, it is important to recognize that pre-vious quantitative reviews have been conducted that addressed—to some degree—teamworktraining. In preparation for this systematic review, we conducted a scoping review whichrevealed that eight previous meta-analyses have assessed teamwork intervention studies insome way. However, these reviews were delimited based on various sample and/or interven-tion characteristics. For example, some reviews included studies that were only conductedwith certain team types (e.g., intact teams [23]) or within a particular context (e.g., sports [24];medical teams [25]). Others were delimited to specific training programs/strategies that wererestricted to a narrow range of teamwork strategies (e.g., [23, 25–29]). Finally, studies thatused a combination of teamwork and taskwork intervention components have been systemati-cally reviewed [30]; however, these types of interventions result in a limited ability to deter-mine the extent to which the resulting effects were due to teamwork training versus taskworktraining.It should also be noted that all but one [23] of these previous reviews pooled together stud-ies that included a control condition (i.e., wherein teams do not receive any type of teamworktraining) and those that did not (as mentioned above, that study only analyzed the effects ofcertain teamwork strategies). This is an important consideration, as it has been suggested thatcontrolled and uncontrolled studies should not be combined into the same meta-analysis dueto differences in study quality (which is a major source of heterogeneity) and since strongerconclusions can be derived from controlled interventions compared to uncontrolled interven-tions (e.g., [31]). Therefore, while previous systematic reviews have provided valuable contri-butions to the teamwork literature, a systematic review that assesses the effects of controlledteamwork interventions across a range of contexts, team types, and involving those that tar-geted diverse dimensions of teamwork appears warranted. In doing so, a more comprehensiveassessment of the efficacy of these teamwork interventions is provided, while also having thecapacity to look at the potential moderating effects of various sample, intervention, and mea-surement characteristics. Moreover, by including only controlled studies, one is able to makestronger conclusions regarding the observed effects.The overall purpose of this study was to better understand the utility of teamwork trainingfor enhancing team effectiveness. Specifically, a meta-analysis was conducted on controlledstudies (i.e., comparing teams who have received teamwork training with those who have not)that have examined the effects of teamwork interventions on teamwork processes and/or teamperformance. To better disentangle the effectiveness of these studies, we also sought to assesspotential moderators of these main effects; that is, to determine whether there are certain con-ditions under which the independent variable of teamwork training more strongly (or weakly)causally influences the dependent variables of teamwork behaviors or team performance [32].A Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 4 / 23The specific moderators that we assessed included: (a) the team context/field of study, (b) thetype of teams that were trained, (c) the primary type of intervention method employed, (d)the dimensions of teamwork that were targeted in the intervention, (e) the number of dimen-sions targeted, (f) the types of measures used to quantify the training effects, and (g) in studieswhere teamwork was assessed as an outcome variable, the dimensions of teamwork that weremeasured. It was hypothesized that teamwork training would have a positive and significanteffect on both teamwork and team performance and that these effects would be evidentacross a range of the aforementioned sample, intervention, and measurement characteristics/conditions.MethodsLiterature SearchSearches for potential articles were conducted in the following databases: PsycInfo, Medline,Cochrane Central Register of Controlled Trials, SportDiscus, and ProQuest Dissertations andTheses. Hand searches were also conducted across thirteen journals that typically publish arti-cles on group dynamics (e.g., Group Dynamics: Theory, Research, and Practice; Small GroupResearch, Journal of Applied Psychology; Personnel Psychology, Human Factors; Academy ofManagement Journal, Journal of Sport & Exercise Psychology). In each database and journalsearch, the following combination of search terms were used: (team OR interprofessional ORinterdisciplinary) AND (intervention OR training OR building OR simulation) AND (teamworkOR mission analysis OR goal specification OR goal setting OR planning OR strategy OR coordi-nation OR cooperation OR communication OR information exchange OR information sharingOR monitoring OR problem solving OR backing up OR coaching OR innovation OR adaptabilityOR feedback OR support OR conflict management OR situation awareness OR confidence build-ing OR affect management). These terms were based on various models of teamwork that existwithin the literature (see Rousseau et al. [2] for an overview of these models). An additionalsearch was conducted within these databases and journals using the search terms (Team-STEPPS OR Crew Resource Management OR SBAR [Situation-Background-Assessment-Rec-ommendation]), as several articles in the initial search used these specific training programs.We also searched the reference sections of the articles from past teamwork training reviewpapers as well as from articles that initially met inclusion criteria to determine if any additionalarticles could be retrieved. The searches were conducted in September 2015 and no time limitswere placed on the search strategy. Each article was first subjected to title elimination, thenabstract elimination, and finally full-text elimination.Eligibility CriteriaTo be included in the meta-analysis, a study needed to examine the effects of teamwork train-ing by comparing teams in an experimental condition (i.e., those who received teamworktraining) with those in a control condition (i.e., where teams did not receive teamwork train-ing). Cross-sectional/non-experimental studies were excluded, as were intervention studiesthat did not include a control condition. As this review was only concerned with teamworkinterventions, studies that focused on training taskwork—whether independent of, or in addi-tion to, a teamwork intervention—were excluded. For example, as previously mentioned, sim-ulation-based training (SBT) has been used as a means of training individuals to performtechnical skills and also to enhance teamwork. In order for a SBT intervention to be includedin this meta-analysis, it had to be clear that only teamwork (not technical skills) was being tar-geted during training. In order to address our primary research question, the study had to pro-vide data on at least one teamwork dimension and/or team performance. The study alsoA Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 5 / 23needed to provide sufficient statistics to compute an effect size. In cases of insufficient data,corresponding authors were contacted for this information. The articles were delimited tothose published in the English language.Data AnalysisArticles that met the aforementioned eligibility criteria were extracted for effect sizes andcoded independently with respect to seven moderators by two of the authors (DM and GR).Interrater reliability for the coding of these moderators was over 90%, kappa (SE) = 0.80(0.01). The moderators examined were based on a scoping review (the purpose of whichincluded identifying pertinent characteristics that were commonly reported in previous team-work intervention research), which was conducted in preparation for this systematic review.The moderators that were examined in this review included (1) the context within which anintervention was conducted (health care, aviation, military, academia, industry, or laboratoryexperiment), (2) the type of team targeted (intact or new), (3) the primary training methodapplied to conduct the intervention (didactic education, workshop, simulation, or team reviews),(4) the dimension(s) of teamwork (preparation, execution, reflection, and/or interpersonaldynamics) targeted in the intervention as well as (5) the number of dimensions targeted(between one and four), (6) the type of measure used to derive effect sizes (self-report, thirdparty, or objective measures), and—when teamwork was assessed as the criterion variable—(7)the specific dimension(s) of teamwork that were measured (general, preparation, execution,reflection, and interpersonal dynamics).Once coded, data were entered into the software Comprehensive Meta-Analysis, Version 2[33] and analyzed as a random-effects model (DerSimonian and Laird approach). This type ofmodel assumes that there is heterogeneity in the effect sizes across the included studies and isthe appropriate model to use in social science research, as opposed to a fixed-effects model(which assumes that effect sizes do not vary from study to study) [34, 35]. Where possible,effect sizes for each study were derived from means, standard deviations, and sample sizes atbaseline and post-intervention [34, 36]. If these statistics were not fully provided, they weresupplemented with F-statistics, t scores, correlations, and p-values to compute the effect size.Each study was given a relative weight based on its precision, which is determined by thestudy’s sample size, standard error, and confidence interval (i.e., the more precise the data, thelarger the relative study weight) [34].In instances where a study provided data to calculate multiple effect sizes (such as when sev-eral measures of the criterion variable—teamwork or team performance—were examined),these effects were combined into one overall effect size statistic (i.e., a weighted average) forthat study. This was done to ensure that those studies that had multiple measures of teamworkor team performance were not given greater weight compared to studies that only providedone effect size (i.e., only had one measure of performance or teamwork), which could poten-tially skew the overall results [34]. The exception to this was when articles reported the effectsof more than one intervention (i.e., had multiple experimental conditions), each of which hada unique teamwork training protocol. In these cases, an effect size from each intervention wascomputed. Thus, these articles would contribute multiple effect sizes to the total number ofcomparisons within the meta-analysis. To correct for potential unit-of-analysis errors in theseparticular articles, the sample size of the control condition was divided by the number ofwithin-study comparisons [31]. For example, if three different types of teamwork interventionswere compared to one control condition (e.g., which had a sample size of 30 participants), then of the control condition was divided by 3 (i.e., 30/3 = 10) when calculating the effect sizes ofthose interventions. Cohen’s d was used as the effect size metric to represent the standardizedA Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 6 / 23effect (i.e., the average magnitude of effectiveness) of teamwork interventions on teamworkand team performance [37]. Standard errors and 95% confidence intervals were computed totest for the accuracy of the standardized effects obtained.To reduce heterogeneity and improve the interpretability of the results, we pooled studiesinto those that measured teamwork as its criterion variable and those that measured team per-formance. Pooling studies in this manner not only reduces heterogeneity but also allowed usto identify the extent to which teamwork interventions impact team performance and, sepa-rately, the extent to which they affect teamwork processes. Heterogeneity within the meta-analysis was also assessed by computing a Q value—which estimates the variability in theobserved effect sizes across studies—and an I2 statistic—which estimates the ratio of the trueheterogeneity to the total observed variation across studies. High Q and I2 statistics can beproblematic for interpreting the results of a meta-analysis and can also indicate that the meta-analysis includes outlier studies. We also planned to identify and exclude outliers from subse-quent moderator analyses in two ways. First, sensitivity analyses were carried out by removinga single intervention from the meta-analysis and noting the resulting effect size—this estimatesthe impact that each individual intervention has on the overall effect size of teamwork or teamperformance. If the resulting effect size with an intervention removed (i.e., K– 1) is substan-tially different than the effect size with that intervention present, this may suggest that it is anoutlier and needs to be removed [34]. Second, we noted any studies that had abnormally higheffect sizes and standardized residuals (above 3.0), especially when these values were accompa-nied by narrow confidence intervals. If heterogeneity (Q and I2) is substantially reduced uponremoval of a study, this further confirms that the study is an outlier and should be omittedfrom subsequent subgroup/moderator analyses.Once the two pools of studies were produced, bias within each pool was assessed. First, pub-lication bias was examined by calculating a fail-safe N statistic, which estimates the number ofunpublished studies with null findings that would have to exist to reduce the obtained effectsize to zero [38]. If this number is sufficiently large—Rosenberg [39] recommends a criticalvalue of 5N+10—then the probability of such a number of studies existing is considered to below. For example, if 20 studies were included in a meta-analysis, then the resulting fail-safe Nshould be larger than 110 (i.e., 520 + 10); if this value was not larger than 110, then publica-tion bias is likely within this pool of studies. We also obtained two funnel plots (one for studieswhere teamwork was the outcome variable and one for team performance as the outcome) toprovide a visual depiction of potential publication bias. We then conducted an Egger’s test as ameasure of symmetry for these two funnel plots. If this test statistic is significant (p< 0.05),this denotes that the distribution around the effect size is asymmetric and publication bias islikely present [34].ResultsLiterature SearchThe literature search from the five databases returned 22,066 articles, while the hand searchesof the 13 journals returned 3797 articles, vetting of studies from previous team training reviewsreturned 191 articles, and the ancestry search of reference lists returned 471 articles (see Fig 1).After removing duplicates, 16,849 articles were subject to title and abstract screening, wherethey were dichotomously coded as ‘potentially relevant’ or ‘clearly not relevant’. 1517 poten-tially relevant articles were then full-text reviewed and coded as meeting eligibility criteria oras ineligible for the following reasons: (1) not a teamwork intervention; (2) teamwork-plus-taskwork intervention; (3) insufficient statistics to compute an effect size; (4) not including ameasure of teamwork or team performance; or (5) not including a control group. As a result ofA Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 7 / 23this eligibility coding, 51 articles were included in the meta-analysis. 13 of these studiesreported results on two or more interventions, bringing the total number of comparisons (k)to 72 with 8439 participants (4966 experimental, 3473 control). See S1 Table for descriptionsof each study with regard to study context, type of team and participants, targeted teamworkdimensions of the intervention, number of effect sizes, the criteria measured, and an overviewof the intervention.Summary StatisticsResults of the overall effect of teamwork interventions on teamwork processes along with sum-mary statistics and sensitivity analyses (i.e., the final column marked ‘ES with study removed’)for this pool of studies are presented in Table 1. This pool included a total of 39 interventionsfrom 33 studies. The results revealed that teamwork interventions had a significant, medium-Fig 1. Results of Literature Search (PRISMA Flow Diagram).doi:10.1371/journal.pone.0169604.g001A Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 8 / 23to-large effect on teamwork, d (SE) = 0.683 (0.13), 95% CI = 0.43–0.94, Z = 5.23, p< 0.001; Q(df) = 660.7 (38), I2 = 94.2. The funnel plot for this pool of studies is shown in Fig 2. The fail-safe N was 3598, which is sufficiently large, as it exceeds the critical value of 205 (539+10).Table 1. Summary Results of Interventions Assessing the Effects of Teamwork Training on Teamwork.Study Relative Weight Effect Size (SE) 95% CI (lower, upper) Z-value p-value ES with intervetion removedAaron 2014 [13] a 2.43 1.432 (.35) .74, 2.13 4.04 < .001 0.67b 2.48 .869 (.33) .22, 1.52 2.61 .009 0.68Becker 2005 [40] 2.75 .635 (.21) .22, 1.05 3.02 .003 0.69Beck-Jones 2004 [41] a 2.70 -.030 (.24) -.50, .44 -0.13 .898 0.70b 2.69 -.003 (.24) -.47, .47 -0.01 .990 0.70Beranek 2005 [42] 2.67 .649 (.25) .16, 1.13 2.62 .009 0.68Bjornberg 2014 [9] 2.83 .080 (.16) -.23, .39 0.50 .615 0.69Brannick 2005 [5] 2.72 1.229 (.23) .79, 1.67 5.47 < .001 0.69Bushe 1995 [43] a 2.53 .405 (.31) -.20, 1.01 1.31 .192 0.69b 2.53 .534 (.31) -.08, 1.14 1.71 .086 0.69Cheater 2005 [12] 2.82 .336 (.17) .00, .67 1.97 .049 0.69Clay-Willaims 2013 [44] a 2.04 .531 (.51) -.46, 1.53 1.05 .296 0.69b 2.06 -.213 (.50) -1.20, .77 -0.43 .671 0.70c 2.12 0.000 (.48) -.94, .94 0.00 1.00 0.70Dalenberg 2009 [45] 2.82 1.001 (.17) .68, 1.33 6.02 < .001 0.67Deneckere 2013 [46] 2.92 .129 (.09) -.04, .29 1.52 .129 0.70Dibble 2010 [47] 2.92 -.242 (.09) -.42, -.07 -2.72 .007 0.71Eden 1986 [48] 2.92 .427 (.09) .07, .42 2.73 .006 0.70Ellis 2005 [14] 2.88 .792 (.13) .54, 1.05 6.14 < .001 0.68Emmert 2011 [49] 2.54 .763 (.31) .16, 1.36 2.48 .013 0.68Entin 1999 [50] 2.32 .771 (.40) -.01, 1.55 1.93 .054 0.68Friedlander 1967 [51] 2.72 .495 (.22) .06, .94 2.21 .027 0.69Green 1994 [52] a 1.91 .665 (.56) -.44, 1.76 1.19 .236 0.68b 1.87 1.058 (.58) -.08, 2.20 1.82 .069 0.68Jankouskas 2010 [7] 2.22 .778 (.44) -.08, 1.64 1.77 .077 0.68Kim 2014 [53] 2.65 .062 (.26) -.45, .57 0.24 .813 0.70Marshall 2009 [22]* 2.70 3.277 (.33) 2.65, 3.95 9.90 < .001 0.61Martinez-Moreno 2015 [54] 2.86 .503 (.14) .23, .78 3.63 < .001 0.69Morey 2002 [3]* 2.93 1.896 (.08) 1.75, 2.05 24.83 < .001 0.64O’Leary 2011 [21] 2.82 .426 (.17) .10, .76 2.54 .011 0.69Padmo Putri 2012 [6] 2.82 -.097 (.17) -.42, .23 -0.58 .561 0.71Prichard 2007 [55] 2.40 1.981 (.37) 1.26, 2.70 5.381 < .001 0.65Rapp 2007 [56] 2.61 .535 (.28) -.01, 1.08 1.93 .053 0.69Shapiro 2004 [57] 2.03 .689 (.52) -.32, 1.70 1.34 .181 0.68Smith-Jentsch 2008 [4] 2.63 1.103 (.27) .58, 1.63 4.13 < .001 0.67Thomas 2007 [58] 2.39 .891 (.37) .16, 1.62 2.40 .016 0.68Volpe 1996 [59] 2.71 .450 (.23) .00, .90 1.97 .049 0.69Weaver 2010 [60] 2.41 .580 (.36) -.13, 1.29 1.61 .109 0.69Weller 2014 [61] 2.64 1.563 (.26) 1.05, 2.08 5.92 < .001 0.66OVERALL 100 .683 (0.13) 0.43, 0.94 5.23 <0.001Note. a, b, c = intervention groups within study; SE = standard error; CI = confidence interval; ES = effect size.* = Study identified as an outlier and removed from subsequent moderator analyses.The final column marked ‘ES with study removed’ indicates the results of the sensitivity analysis for each respective intervention.doi:10.1371/journal.pone.0169604.t001A Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 9 / 23The funnel plot for this pool of studies is presented in Fig 2. Egger’s value for this funnel plotwas not significant (B = 0.364, SE = 1.30, 95% CI = -2.26–2.99, t = 0.28, p = 0.78), which alsosuggests that bias was not present. Two studies were identified as outliers within this pool ofstudies: Morey et al. [3] and Marshall et al. [22]. The resulting effect size when these studieswere excluded was d (SE) = 0.550 (0.08), 95% CI = 0.39–0.71, Z = 6.73, p< 0.001; Q (df) =187.53 (36), I2 = 80.8. Subsequent moderator analyses were conducted with these two outlierstudies being omitted.Results of the overall effect of teamwork interventions on team performance as well as sum-mary statistics and sensitivity analyses (i.e., the final column marked ‘ES with interventionremoved’) for this pool of studies are presented in Table 2. This pool of studies included a totalof 50 interventions from 32 studies. It was shown that teamwork interventions had a signifi-cant, large effect on team performance—d (SE) = 0.919 (0.14), 95% CI = 0.65–1.19, Z = 6.72,p< 0.001; Q (df) = 851.3 (49), I2 = 94.2. The funnel plot for this pool of studies is shown in Fig3. The fail-safe N was 6692, which is sufficiently large, as it exceeds the critical value of 260(550+10). The funnel plot for this pool of studies is presented in Fig 3. Egger’s value for thisfunnel plot was not significant (B = 0.131, SE = 1.19, 95% CI = -2.26–2.54, t = 0.11, p = 0.91),which also implies that bias was not present. There were five outlier interventions (from fourstudies) in this pool of studies that assessed team performance: Morey et al. [3], Smith-Jentschet al. [4], one of the interventions from Buller and Bell [63]; teambuilding condition), and bothinterventions from Bushe and Coetzer [43]. When these outliers were removed, the resultingeffect size was d (SE) = 0.582 (0.06), 95% CI = 0.47–0.69, Z = 10.30, p< 0.001; Q (df) = 101.1(44), I2 = 56.5. Subsequent moderator analyses were conducted with these five interventionsomitted.Fig 2. Funnel Plot for Studies Assessing Teamwork. Circles filled with black indicate outlier studies.doi:10.1371/journal.pone.0169604.g002A Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 10 / 23Table 2. Summary Results of Interventions Assessing the Effects of Teamwork Training on Team Performance.Study Relative Weight Effect Size (SE) 95% CI (lower, upper) Z-value p-value ES with intervention removedBeck-Jones 2004 [41] a 2.16 .502 (.18) .35, 1.04 3.91 < .001 0.93b 2.15 .902 (.18) .33, 1.30 3.83 < .001 0.92Bjornberg 2014 [9] 2.24 .466 (.16) .15, .78 2.91 .004 0.93Brannick 2005 [5] 2.20 .237 (.21) -.17, .64 1.15 .249 0.94Brown 2003 [62] 2.25 .267 (.15) -.02, .56 1.80 .072 0.94Buller 1986 [63] a 1.33 1.435 (.77) -0.08, 2.95 1.86 .063 0.91b* 1.11 3.72 (.94) 1.88, 5.56 3.96 < .001 0.89C 1.46 1.58 (.69) .23, 2.94 2.30 .022 0.91Bushe 1995 [43] a* 1.67 4.57 (.56) 3.47, 5.66 8.19 < .001 0.86b* 1.47 5.96 (.68) 4.63, 7.29 8.75 < .001 0.84Cannon-Bowers 1998 [64] 2.22 .46 (.19) .09, .82 2.45 .014 0.93Chang 2008 [65] 2.04 1.344 (.33) .70, 1.99 4.09 < .001 0.91Dalenberg 2009 [45] 2.24 .653 (.16) .34, .97 4.06 < .001 0.93Dibble 2010 [47] 2.29 .181 (.09) .01, .36 2.04 .042 0.94Entin 1999 [50] 1.92 .927 (.41) .13, 1.72 2.88 .022 0.92Fandt 1990 [66] 2.25 .095 (.15) -.19, .38 0.65 .518 0.94Green 1994 [52] a 1.67 .655 (.56) -.44, 1.75 1.17 .243 0.92b 1.62 1.212 (.59) .05, 2.37 2.05 .040 0.91Haslam 2009–1 [67] a 2.08 .223 (.30) -.37, .82 0.73 .464 0.93b 2.06 .690 (.31) .07, 1.31 2.20 .028 0.92Haslam 2009–2 [67] a 2.02 .941 (.34) .27, 1.61 2.76 .006 0.92b 2.04 .610 (.33) -.03, 1.25 1.87 .062 0.93c 2.02 .957 (.35) .28, 1.63 2.78 .005 0.92d 2.03 .963 (.34) .31, 1.62 2.87 .004 0.92Ikomi 1999 [68] 2.06 1.008 (.32) .39, 1.63 3.18 .001 0.92Jankouskas 2010 [7] 1.86 -.173 (.44) -1.04, .70 -0.39 .696 0.94Jarrett 2012 [69] a 2.22 .243 (.19) -.12, .61 1.31 .191 0.94b 2.21 .834 (.19) .46, 1.21 4.34 < .001 0.92c 2.22 .358 (.19) -.01, .72 1.92 .055 0.93d 2.21 .940 (.19) .56, 1.32 4.84 < .001 0.92Kring 2005 [70] a 2.00 .062 (.36) -.64, .76 0.17 .862 0.94b 2.00 -.092 (.36) -.79, .61 -0.26 .795 0.94Longenecker 1994 [71] 2.03 1.89 (.33) 1.24, 2.54 5.66 < .001 0.90Morey 2002 [3]* 2.29 2.781 (.09) 2.61, 2.95 31.51 < .001 0.80Padmo Putri 2012 [6] 2.23 .542 (.17) .21, .87 3.21 .001 0.93Rapp 2007 [56] 2.12 .254 (.27) -.28, .79 0.93 .353 0.93Schurig 2013 [72] a 2.26 .513 (.27) -.02, 1.05 1.88 .061 0.93b 2.26 .688 (.28) .15, 1.23 2.49 .013 0.93Siegel 1973 [73] 1.99 .594 (.36) -.11, 1.30 1.64 .100 0.93Sikorski 2012 [74] 2.26 .272 (.14) -.01, .56 1.89 .059 0.94Smith-Jentsch 2008 [4]* 1.91 3.729 (.41) 2.92, 4.54 9.07 < .001 0.86Smith-Jentsch 1996 [75] a 1.74 .206 (.52) -.81, 1.22 0.40 .690 0.93b 1.74 .025 (.52) -.99, 1.04 0.05 .961 0.94c 1.71 .901 (.54) -.15, 1.95 1.68 .092 0.92Stout 1997 [76] 2.04 .984 (.33) .34, 1.63 3.00 .003 0.92Villado 2013 [16] 2.19 .834 (.22) .41, 1.36 3.88 < .001 0.92Volpe 1996 [59] 2.16 .877 (.24) .28, 1.12 3.70 < .001 0.92(Continued )A Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 11 / 23Moderator AnalysesThe results of the moderator analyses are shown in Table 3 (for teamwork behaviors) andTable 4 (for team performance). With respect to sample characteristics, significant positiveeffects of teamwork interventions were found for enhancing teamwork across all contexts(ds = 0.46–1.23) except for the single effect size from an industry setting (d = 0.50). In terms ofteam performance, significant effects were evident across all settings (ds = 0.40–1.76). In addi-tion, interventions were effective for enhancing teamwork with intact teams (d = 0.33) andnewly-formed teams (d = 0.67), with the effect size for new teams being significantly larger(Q = 4.04, p = 0.004) than that for existing teams. Teamwork training was also effective at fos-tering team performance for both team types; however, in contrast to the findings on team-work, the effect size for intact teams (d = 0.99) was significantly larger (Q = 6.04, p = 0.02) thanthat for new teams (d = 0.54).Table 2. (Continued)Study Relative Weight Effect Size (SE) 95% CI (lower, upper) Z-value p-value ES with intervention removedWegge 2005 [77] a 1.91 1.004 (.41) .19, 1.81 2.44 .015 0.92b 1.90 .682 (.42) -.14, 1.50 1.64 .102 0.92c 1.95 .487 (.39) -.28, 1.25 1.25 .212 0.93OVERALL 100 .919 (.14) .65, 1.19 6.72 <0.001Note. a, b, c, d = intervention groups within study; SE = standard error; CI = confidence interval; ES = effect size.* = Study identified as an outlier and removed from subsequent moderator analyses.The final column marked ‘ES with study removed’ indicates the results of the sensitivity analysis for each respective intervention.doi:10.1371/journal.pone.0169604.t002Fig 3. Funnel plot for studies assessing team performance. Circles filled with black indicate outlier studies.doi:10.1371/journal.pone.0169604.g003A Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 12 / 23Three intervention characteristics were analyzed as potential moderators. First, with regardto the intervention method utilized, significant effects on teamwork were found for workshopTable 3. Moderator results for interventions assessing teamwork as the outcome variable.Moderator K Effect size (SE) 95% CI Z-value p value Q value (df), p-valueSample CharacteristicsContext 3.272(5), p = 0.658Health care 13 0.51 (0.15) 0.20, 0.81 3.30 0.001Academia 10 0.46 (0.17) 0.14, 0.78 2.78 0.005Laboratory experiment 6 0.51 (0.20) 0.12, 0.89 2.55 0.011Military 6 0.77 (0.23) 0.33, 1.22 3.42 0.001Aviation 1 1.23 (0.47) 0.25, 2.21 2.46 0.014Industry 1 0.50 (0.50) -0.48, 1.47 0.99 0.321Team type 4.04(1), p = 0.004Intact 13 0.33 (0.14) 0.05, 0.60 2.35 0.019New 24 0.67 (0.10) 0.47, 0.87 6.58 <0.001Intervention CharacteristicsMethod of intervention 6.17(3), p = 0.10Didactic education 4 0.19 (0.19) -0.20, 0.57 0.95 0.341Workshop 18 0.50 (0.10) 0.31, 0.70 4.96 <0.001Simulation 11 0.78 (0.16) 0.48, 1.09 5.05 <0.001Team Reviews 4 0.64 (0.19) 0.26, 1.01 3.34 0.001Teamwork dimensions targeted aPreparation 20 0.75 (0.11) 0.54, 0.95 7.09 <0.001Execution 21 0.64 (0.11) 0.42, 0.86 5.70 <0.001Reflection 22 0.65 (0.11) 0.43, 0.86 5.80 <0.001Interpersonal dynamics 11 0.69 (0.16) 0.38, 1.00 4.33 <0.001Number of dimensions targeted b 19.73(4), p = 0.001One 6 0.05 (0.16) -0.26, 0.35 0.29 0.775Two 11 0.65 (0.12) 0.42, 0.89 5.39 <0.001Three 6 0.98 (0.16) 0.66, 1.30 6.04 <0.001Four 7 0.57 (0.15) 0.27, 0.87 3.70 <0.001Measurement CharacteristicsType of teamwork measure c 16.86(1), p<0.001Third party 45 0.80 (0.07) 0.66, 0.94 10.92 <0.001Self-report 46 0.38 (0.07) 0.25, 0.52 5.47 <0.001Teamwork dimension measured c 2.98(1), p = 0.56General 27 0.71 (0.11) 0.49, 0.93 6.36 <0.001Preparation 8 0.53 (0.19) 0.16, 0.89 2.80 0.005Execution 31 0.55 (0.10) 0.35, 0.74 5.57 <0.001Reflection 12 0.70 (0.16) 0.40, 1.01 4.50 <0.001Interpersonal dynamics 13 0.45 (0.14) 0.17, 0.73 3.12 0.002Note. The df of the Q-value represents the total number of combinations of the targeted dimensions minus 1.a: The total k of this moderator is greater than 37 as many interventions targeted more than one dimension of teamwork. Because of this, each categorywithin this moderator was analyzed independently (i.e., whether each teamwork dimension was targeted or not targeted in the intervention); as a result, itwas not possible to calculate a Q value for this moderator.b: The total k of this moderator is less than 37 as seven interventions were unclear in terms of the exact teamwork dimensions targeted.c: The total k of this moderator is greater than 37 as many studies used more than one type of criterion measure of teamwork. Because of this, eachcategory within this moderator was analyzed independently.doi:10.1371/journal.pone.0169604.t003A Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 13 / 23training (d = 0.50), simulation-based teamwork training (d = 0.78), and team reviews (d =0.64) but not for didactic education (d = 0.19). All training methods were effective for enhanc-ing team performance (ds = 0.41–0.69). Second, significant effects of training on teamworkwere evident when two or more dimensions of teamwork were targeted (ds = 0.65–0.98) butnot when only one dimension was targeted (d = 0.05). Team performance, however, improvedsignificantly as a result of teamwork training regardless of the number of teamwork dimen-sions that were targeted (ds = 0.46–0.67). Third, significant effects were shown regardless ofTable 4. Moderator results for interventions assessing team performance as the outcome variable.Moderator k Effect size (SE) 95% CI Z value p value Q value (df), p-valueSample CharacteristicsContext 16.94(5), p = 0.01Health care 2 0.76 (0.31) 0.15, 1.36 2.46 0.014Laboratory experiment 25 0.54 (0.07) 0.41, 0.67 8.08 <0.001Aviation 4 0.64 (0.18) 0.28, 0.99 3.51 <0.001Military 5 0.66 (0.17) 0.34, 0.99 3.99 <0.001Industry 3 1.76 (.32) 1.13, 2.38 5.52 <0.001Academia 6 0.40 (0.12) 0.17, 0.63 3.35 0.001Team type 6.04(1), p = 0.02Intact 6 0.99 (0.18) 0.64, 1.33 5.63 <0.001New 39 0.54 (0.06) 0.42, 0.65 9.32 <0.001Intervention CharacteristicsMethod of intervention 2.44(3), p = 0.49Didactic education 4 0.41 (0.16) 0.09, 0.74 2.52 0.012Workshop 24 0.55 (0.08) 0.39, 0.71 6.87 <0.001Simulation 7 0.57 (0.17) 0.23, 0.90 3.30 0.001Team Reviews 10 0.69 (0.10) 0.50, 0.89 6.88 <0.001Teamwork dimensions targeted aPreparation 15 0.60 (0.07) 0.46, 0.73 8.69 <0.001Execution 26 0.52 (0.08) 0.37, 0.66 6.87 <0.001Reflection 22 0.55 (0.08) 0.40, 0.70 7.17 <0.001Interpersonal dynamics 6 0.57 (0.18) 0.18, 0.95 2.88 0.004Number of dimensions targeted b 3.98(4), p = 0.67One 20 0.61 (0.09) 0.44, 0.79 6.85 <0.001Two 12 0.63 (0.12) 0.40, 0.86 5.31 <0.001Three 9 0.46 (0.11) 0.24, 0.67 4.08 <0.001Four 3 0.67 (0.25) 0.19, 1.15 2.74 0.006Measurement CharacteristicsType of team performance measure c 2.03(1), p = 0.15Third party 31 0.56 (0.08) 0.40, 0.72 6.79 <0.001Objective 62 0.61 (0.06) 0.48, 0.73 9.70 <0.001Note. The df of the Q-value represents the total number of combinations of the targeted dimensions minus 1.a: The total k of this moderator is greater than 45 as many interventions targeted more than one dimension of teamwork. Because of this, each categorywithin this moderator was analyzed independently (i.e., whether each teamwork dimension was targeted or not targeted in the intervention); as a result, itwas not possible to calculate a Q value for this moderator.b: The total k of this moderator is less than 45 as one intervention was unclear in terms of the exact teamwork dimensions targeted.c: The total k of this moderator is greater than 45 as many studies used more than one type of criterion measure of team performance. Because of this, eachcategory within this moderator was analyzed independently.doi:10.1371/journal.pone.0169604.t004A Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 14 / 23which dimension (i.e., preparation, execution, reflection, interpersonal dynamics) was targetedfor both teamwork (ds = 0.64–0.75) and team performance (ds = 0.52–0.60).With regard to measurement characteristics, significant improvements on teamworkemerged when either third-party (d = 0.80) or self-report (d = 0.38) measures of teamworkwere utilized; the effect size for third-party measures was significantly larger (Q = 6.02,p = 0.014) than the effect size for self-report measures. For team performance outcomes, signif-icant effects were shown for both objective (d = 0.61) and third-party measures (d = 0.56).Finally, significant effects on teamwork were found when general/omnibus measures of team-work were taken (d = 0.71), as well as when a specific dimension of teamwork was measured(ds = 0.45–0.70).DiscussionThe purpose of this systematic review and meta-analysis was to quantify the effects of theextant controlled experimental research of teamwork training interventions on teamwork andteam performance. We found positive and significant medium-to-large sized effects for theseinterventions on teamwork and large effects on team performance. When outlier studies wereremoved, medium-sized effects were found for both criteria. Additional subgroup/moderatoranalyses also revealed several notable findings, each of which will be discussed in turn. Thepaper concludes with a discussion of the limitations associated with this meta-analysis as wellas considerations for future teamwork training research.Who Can Benefit From Teamwork Training?With regard to sample characteristics, teamwork interventions were shown to be effective atenhancing both teamwork and team performance across a variety of team contexts, includinglaboratory settings as well as real-world contexts of health care, aviation, military, and academia.This highlights the efficacy of teamwork training as a means of improving teams; this is animportant finding as effective teams (i.e., those that work well together and perform at a highlevel) are vital in many of the aforementioned contexts. For example, it has been estimated thatapproximately 70% of adverse events in medical settings are not due to individuals’ technicalerrors but, rather, as a result of breakdowns in teamwork [78]. Thus, there is a critical need toensure that teams are effective across these settings, as these teams greatly impact (among otherthings) the welfare of others. The results of this meta-analysis suggest that teamwork trainingcan indeed be a useful way of enhancing team effectiveness within these contexts.We also examined whether there were differential effects of teamwork training for newteams compared to intact teams. It was shown that these interventions were effective for bothteam types. The effects of teamwork training on teamwork outcomes were significantly largerfor new teams (who showed a medium-to-large effect size) compared to existing teams (whohad a small-to-medium effect size). Interestingly, when we examined team performance as thecriterion variable, the training effects were significantly larger for intact teams (who showed alarge effect size) compared to newly-formed teams (who again showed a medium-to-largeeffect size). It should be noted that there were many more studies conducted with new teamscompared to intact teams—thus, caution should be exercised in directly comparing these find-ings. Nonetheless, at this point, the existing research seems to suggest that teamwork interven-tions work particularly well at enhancing teamwork processes for newly established teams—and also work with existing teams—but not the same extent. It is possible that teamwork pro-cesses might be more malleable and display greater potential for improvement with new teamscompared to more established teams whose teamwork processes may be more entrenched. Onthe other hand, it is notable that the effects of teamwork training on team performance wereA Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 15 / 23stronger for established teams. In line with this, it is plausible that, while intact teams mayshow less pronounced changes in teamwork, they might be better able to translate their team-work training into improved team performance outcomes.What Type of Training Works?Three moderator variables were assessed with regard to intervention characteristics. First, withregard to the training method utilized, it was shown that all four training methods were effec-tive for enhancing team performance. These included the provision of didactic lectures/pre-sentations, workshops, simulation training, and review-type activities conducted in situ.Although significant effects were shown for the latter three training methods for teamworkoutcomes, those interventions that targeted didactic instruction did not result in significantimprovements in teamwork itself. This suggests that simply providing educational lectureswherein team members passively learn about teamwork is not an effective way of improvingteamwork. When taken together these findings suggest that teamwork training should incor-porate experiential activities that provide participants with more active ways of learning andpractising teamwork. These may include various workshop-style exercises that involve all teammembers, such as working through case studies of how teams can improve teamwork, watch-ing and critiquing video vignettes of teams displaying optimal versus suboptimal teamwork,discussing and setting teamwork-related goals and action plans, or other activities that helpstimulate critical thinking and active learning of effective teamwork. Teams may also find ituseful to conduct simulations of specific team tasks that the group is likely to encounter in-situ, such as aviation teams using an airplane simulator, surgical teams conducting mock-sur-geries on medical manikins, military teams practising various field missions, and so on. Team-work can be also fostered by having team members participate in team reviews/briefingsbefore, during, and/or after the execution of team tasks that occur in-situ. In summary, simplylecturing about the importance of teamwork is not sufficient to create meaningful improve-ments in teamwork; rather, substantive positive effects can be derived by having team mem-bers engage in activities that require them to actively learn about and practise teamwork.We also sought to assess how comprehensive an intervention should be—specifically, thenumber of teamwork dimensions that need to be targeted—in order to be effective. Withregard to improving team performance, there were significant effects when one or moredimensions were targeted. However, in terms of improving teamwork behaviors, significanteffects only emerged when two or more dimensions were targeted. From an applied perspec-tive, individuals concerned with intervention (e.g., team consultants, coaches, managers, teamleaders) can utilize these findings by targeting more than one dimension of teamwork withintheir training protocol. For instance, if the purpose of an intervention is to improve a healthcare team’s communication, greater effects may be derived by not merely targeting communi-cation during the execution phase alone (e.g., with a structured communication tool), but byalso incorporating strategies that target other dimensions of teamwork, such as setting goalsand action plans for how communication will be improved (i.e., the preparation dimension ofteamwork) as well as monitoring progress towards those goals, resolving any communication-related problems that arise, and making adjustments to action plans as necessary (i.e., thereflection dimension).Relatedly, we sought to address whether there were differential effects of teamwork inter-ventions on teamwork and team performance based on the dimensions of teamwork that weretargeted. It was found that interventions had a significant effect on both teamwork behaviorsand team performance when any dimension of teamwork was targeted. This is important as itmeans that if those concerned with intervention target any one of the four dimensions ofA Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 16 / 23teamwork, this will likely result in improvements in team functioning. While the preparation(i.e., behaviors occurring before team task performance such as setting goals and action plans),execution (i.e., intra-task behaviors such as communication and coordination), and reflection(i.e., behaviors occurring following task performance such as performance monitoring andproblem solving) dimensions have each been theorized to be implicated in fostering team per-formance [2, 79], is particularly noteworthy that interventions targeting the interpersonaldynamics of a team (i.e., managing interpersonal conflict and the provision of social supportbetween members) also displayed significant effects in relation to team performance. Specifi-cally, efforts to enhance interpersonal processes have generally been theorized to be related tosupporting team maintenance more so than supporting team performance [2, 79]. However,the results from the current review provide evidence that training teams with regard to socialsupport and interpersonal conflict management processes may actually be a useful way toenhance team performance. While the exact reason for this effect is not immediately clearfrom this review, it may be that improving interpersonal dynamics has an indirect relationshipwith team performance. That is, teamwork training focused on improving social support andconflict management may improve the functioning of a team, which, in turn, improves theteam’s performance. As Marks et al. [10] contend, these interpersonal processes “lay the foun-dation for the effectiveness of other processes” (p. 368). Relatedly, Rousseau et al. [2] suggestthat problems related to social support and conflict management “may prevent team membersfrom fully contributing to task accomplishment or from effectively regulating team perfor-mance” (p. 557). Further research examining this potential relationship is required as thiswould have implications in both research and applied teamwork settings.Does It Matter How Criterion Variables Are Measured?Two measurement characteristics were examined as moderators within this meta-analysis. First,significant, large- and small-to-medium sized effects were found for third party and self-reportmeasures of teamwork, respectively. Significant medium effects were also evident for third partyand objective measures of team performance. It is worth noting that significantly larger effectsizes emerged for third party assessments of teamwork compared to self-report measures. Takentogether, these findings suggest that the positive effects that were found for teamwork interven-tions are not merely perceptive and/or due to individuals’ self-report biases (i.e., social desirabil-ity). Rather, these results indicate that the effects of these interventions on both teamwork andteam performance are clearly observable with measures beyond self-report indices.Finally, we sought to assess whether the effects of teamwork training varied based on whichteamwork dimension(s) were measured. Medium-to-large effects emerged when general/omnibus measures of teamwork—that is, those that provided an overall score of teamwork asopposed to examining individual dimensions of teamwork—were taken. Measures that tappedinto the specific dimensions of teamwork (e.g., those that provided individual scores on prepa-ration, execution, reflection, and interpersonal dynamics) also yielded comparable effect sizes.Hence, teamwork interventions appear to have a somewhat similar effect on each of the com-ponents of teamwork. In summary, the results of the above two moderators (i.e., type of mea-sure and dimension of teamwork examined) suggest that teamwork training has a positiveimpact on teamwork and team performance regardless of the way in which these variables areassessed.LimitationsDespite the contributions of this meta-analytic review, it is not without limitations. First, therewere additional variables that we had planned to analyze as moderators a priori including teamA Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 17 / 23size and length of/contact time within the intervention. However, there was an insufficientamount of reliable data across the studies on these variables to conduct these subgroup analy-ses appropriately. For instance, although many studies noted the total number of participantswithin an organization (e.g., a hospital) that took part in an intervention, information on thesize of the teams within the organization (e.g., various units within the hospital) was oftenmissing. Team composition variables such as this have been noted as important factors to takeinto account when examining teams (e.g., [30, 80]). Similarly, although some studies wereexplicit about the total length of the intervention and the contact time between interventionistsand participating teams, this information was not provided consistently. This too would havebeen a valuable feature to analyze in order to provide more specific recommendations abouthow teamwork training programs should be designed—that is, how long an interventionshould last? Unfortunately, due to the paucity of information available in the included manu-scripts, we were unable to determine whether these variables moderated the observed effects ofteamwork training on teamwork and team performance in the current meta-analysis.Furthermore, there was a considerable amount of variability within some of the moderatorcategories that were coded. For instance, with regard to intervention methods, ‘workshops’consisted of many different types of activities including team charter sessions, strategy plan-ning meetings, case study activities, and so on. Combining these activities into one categorywas done for the sake of being adequately powered to conduct moderator analyses (i.e., includea sufficient number of studies within each of the resulting categories). However, while theabove examples are indeed activities that teams do together, they are of course each differentin their own ways. Hence, although it is evident that workshop-type activities are effectiveoverall, it is unclear if specific workshop activities are more effective than others. This exampleunderscores the difficulty that can occur when trying to balance statistical power with accuracyfor each moderator category when conducting subgroup analyses in a meta-analysis.Relatedly, effect sizes were only computed with the statistics that were provided from base-line and post-intervention, even if studies provided additional data on teamwork and/or per-formance at some other point in between or at a follow-up point in time (although it is worthnoting that relatively few studies actually did this). This was done in order to minimize hetero-geneity within the meta-analysis and improve the interpretability of the results (i.e., determin-ing the effects of teamwork training from pre- to post-intervention). However, by not takingthese measurement time-points into consideration, two questions in particular are raised.First, do certain dimensions of teamwork and team performance evolve differently over timeand, if so, how? For instance, do improvements in teamwork occur immediately in response totraining and then plateau; or do they improve in a slower, more linear fashion from the onsetof training? Second, what are the long-term implications of teamwork training? That is, doesteamwork training result in sustained improvements in teamwork and team performancebeyond the intervention period or do these effects eventually wane? Answers to these typesof research questions would certainly be of interest to teamwork researchers and appliedpractitioners.Future DirectionsIn addition to summarizing the previous research on teamwork interventions for improvingteamwork and team performance, the findings from this systematic review also highlightseveral potential avenues of future research. First, with regard to sample characteristics, themajority of studies that examined the effects of teamwork interventions on team performancewere conducted within laboratory settings, with relatively fewer controlled studies having beenconducted in real-world settings. Thus, although significant effects on team performance (andA Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 18 / 23teamwork) were found in health care, aviation, military, and academic settings, the extant liter-ature would be strengthened by conducting further controlled intervention research withinthese contexts. It was also shown that teamwork training was less effective for improving team-work for intact teams compared to new teams. Since many teams seeking teamwork trainingare likely to be intact, it is important that future research continue to test various training strat-egies that can be utilized with these types of teams. In addition, there are other contexts inwhich controlled interventions have not yet been conducted such as with police squads, fire-fighting crews, sports teams, political parties, and so on. Research in these areas is clearly ripefor future inquiry.Further research on the ideal combination of teamwork dimensions (i.e., preparation and/or execution and/or reflection and/or interpersonal dynamics) targeted in an interventionwould also enhance our current knowledge in terms of how to train teamwork most effectivelyand efficiently. We had originally planned to further assess this moderator by conducting amethod co-occurrence analysis [81]. Specifically, since there would likely be a variety of combi-nations of dimensions that were targeted in the teamwork interventions (e.g., preparation only;preparation and execution; preparation, execution, reflection, and interpersonal dynamics; etc),we had hoped to examine if there would be differential effects of these combinations with regardto intervention effectiveness. Unfortunately, since there were such a large number of combina-tions of dimensions targeted in the included studies, there was an insufficient number of inter-ventions that fell into each category. We were, therefore, unable to pursue this method co-occurrence analysis [81] of the various combinations of dimensions. Thus, although our find-ings suggest that interventions are more effective when two or more dimensions are targeted,further research that examines the effects of the ideal combinations of these dimensions wouldcertainly enhance our current knowledge of teamwork training. For example, if the objective ofteamwork training is to improve the coordination and cooperation of the team, should thetraining also target (in addition to targeting these execution behaviors) both the preparationand reflection dimensions of training (or simply one or the other)? Answering such complexquestions will help to advance our understanding of what makes for an effective teamworktraining program.ConclusionBalanced against the contributions and insights provided by the various moderator analysesconducted in this study, the overall take-home message is that teamwork training is an effec-tive way to foster teamwork and team performance. These effects appear to be evident across arange of samples, utilizing numerous intervention methods, and when considering variousmeasurement characteristics. Interventions appear to be particularly effective when they targetmultiple dimensions of teamwork and include experiential activities for team members toactively learn about, practise, and continually develop teamwork.Supporting InformationS1 Table. Summaries of Interventions. Summaries of each study and intervention includedin the meta-analysis is provided in the S1 Table.(DOCX)S1 File. PRISMA Checklist. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist [82] for this review is presented in the S1 File.(DOC)A Meta-Analysis of Teamwork TrainingPLOS ONE | DOI:10.1371/journal.pone.0169604 January 13, 2017 19 / 23Author ContributionsConceptualization: DM ME BZ MB.Data curation: DM.Formal analysis: DM.Investigation: DM GR.Methodology: DM MB.Project administration: DM MB.Resources: DM MB.Supervision: MB.Validation: DM GR MB.Visualization: DM GR ME BZ MB.Writing – original draft: DM MB.Writing – review & editing: DM GR ME BZ MB.References1. 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