Table 2. Summary of findings
Outcomes for staff
The most frequently researched outcome for staff (five studies) was burnout, measured as emotional exhaustion; the predictors of work satisfaction were explored in one study.
Outcomes for patients
Patient outcomes were predominantly indicators of quality of care (four studies); hospital use and all-cause mortality (indicators of the clinical effectiveness in primary health care) were used in two studies.
Team composition
Mix of skills and staff characteristics (for example, team size, disciplinary mix, and provider age and sex)
One study found emotional exhaustion or burnout was lower when physicians account for a higher proportion of the total team FTE. This study recorded higher burnout than other studies (85%) and no difference between rates for physicians and other clinicians (nurse practitioners and physician assistants).19 Other studies reported lower rates of burnout (30%–60%) with physicians (especially residents) at higher risk than other clinical and support staff.21,22,26
Two studies reported higher burnout among female physicians19,20 and non-physician clinicians.19
One study reported no association between team size and structure (family physician plus one or two or three other roles) and emotional exhaustion or burnout.20
Patients in practices with a predominance of female physicians reported better continuity, comprehensiveness, and responsiveness of care, and more counselling and screening, although these associations were confounded by the younger average age of female doctors. In adjusted analysis, the only significant difference from male predominant practices was worse access in female predominant practices, which was explained in terms of higher part-time working by female physicians.28
Hospital readmission rates were found to be lower in the panels of female clinicians, although that finding did not extend to index hospital admissions or ED visits. Panels of physicians had the lowest ED visits (versus nurse practitioners and physician assistants). The strongest predictors of higher hospital use were panel complexity and less time in clinical practice (attributed to less clinical acumen and lower risk tolerance).18 This study also found that hospital use was not associated with the proportion of care FTE that was physicians.
Team climate
The ‘relational process of teamworking’,11 variously measured (for example, work environment, staff stability, delegation, leadership, team effectiveness, team functioning, team dynamics, and workload)
There is consistent evidence that a range of factors synonymous with good working environments and team dynamics reduce the risks of emotional exhaustion and burnout, including: team stability, staff feeling and acting like a team, having control over workload, participating in decision making, and working at the top of their competencies.2022,26
Staff and skill shortages were identified as catalysts to burnout.2022
One study concluded that ‘culture trumps structure’; a poor team culture (as measured by the Team Climate Inventory) could override the effects of a stable team environment and have a negative effect on emotional exhaustion.26
Clinician satisfaction was associated positively with team dynamics, but through the mediation of patient care coordination: clinicians were found to derive satisfaction from better patient care coordination, which the researchers associated with good team dynamics.25 In another study, more than one-third of physicians reporting burnout were also satisfied.20
Higher workload and staff insufficiency were significantly associated with more complaints, less clinician time with patients, and lower patient-reported quality of care, with diminishing benefits observed from adding extra staff above VHA-recommended levels because of coordination problems and ‘social loafing’.23,24
Better team functioning was associated with reduced hospital admissions (vulnerable patients) and lower all-cause mortality (all patients, not vulnerable). Greater emotional exhaustion was associated with lower ambulatory care sensitive admissions; staff sufficiency was associated with higher all-cause admissions.27
Better relational climate and cohesion of the work group was associated with improved quality of care.23,24
Team climate was found to mitigate the adverse effects of high workload on patient outcomes. While workload negatively affected quality of care if the relational climate was poor, a strong relational climate can protect against poor quality of care if the workload is high.24
Team dynamics were found to be strongly positively associated with physician-rated patient care coordination, which, as noted above, in turn mediated a strong positive association between team dynamics and clinical work satisfaction.25
  • ED = emergency department. FTE = full-time equivalent. VHA = Veterans Health Administration