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\begin{document}

\title{The impact of Huddles on a multidisciplinary healthcare teams' work
engagement, teamwork, and job satisfaction: a systematic review}



\author[1]{Brendan Rowan}%
\author[2]{Sabrina Anjara}%
\author[2]{Aoife De Brún}%
\author[3]{Steve MacDonald}%
\author[1]{Emma Kearns}%
\author[4]{Michael Marnane}%
\author[2]{Eilish McAuliffe}%
\affil[1]{Mater Misericordiae University Hospital}%
\affil[2]{UCD}%
\affil[3]{University of Limerick}%
\affil[4]{The Mater Misericordiae University Hospital Department of Neurology}%


\vspace{-1em}



  
  \date{May 24, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Job satisfaction and retention of healthcare staff remains an ongoing
issue in many health systems. Huddles have been endorsed as a mechanism
to improve patient safety by improving teamwork, collaboration, and
communication in teams. This study synthesizes the literature to
investigate the impact of huddles on job satisfaction, teamwork, and
work engagement in multidisciplinary healthcare teams. Five academic
databases were searched to conduct a systematic review of peer-reviewed
literature published from January 2000 -- January 2020. Articles were
included if they (1) featured a daily huddle, were conducted in a
healthcare setting, and involved a multidisciplinary team and (2)
measured variables including job satisfaction, work engagement, or
teamwork. Results were reported in accordance with the Systematic
Synthesis Without Meta-analysis (SWiM) and Preferred Reporting Items for
Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We identified
445 articles of which 12 met the eligibility criteria and are included
in this review. All 12 studies found a predominantly positive impact on
teamwork and job satisfaction. None of the studies discussed or reported
evidence of the impact of huddles on work engagement. This review
highlights the value of a daily multidisciplinary healthcare team huddle
in improving job satisfaction and teamwork for the healthcare staff
involved. However, there is a dearth of high-quality, peer-reviewed
evidence regarding the direct impact of huddles on job satisfaction,
teamwork and in particular on work engagement. Further research --
particularly controlled studies on adoption, implementation, and
outcomes for healthcare team culture -- is needed to further assess this
intervention.%
\end{abstract}%



\sloppy


\textbf{Title:}

The impact of Huddles on a multidisciplinary healthcare teams' work
engagement, teamwork and job satisfaction: a systematic review

\textbf{Short Running Title:}

Huddles: Do they lead to a happier workplace?

\textbf{Author Details:}

Brendan L Rowan\textsuperscript{1,2}

Sabrina Anjara\textsuperscript{1}

Aoife De Br\selectlanguage{ngerman}ún\textsuperscript{1}

Steve MacDonald\textsuperscript{3}

Emma C Kearns\textsuperscript{1,4}

Michael Marnane\textsuperscript{2}

Eilish McAuliffe\textsuperscript{1}

\emph{Corresponding Author:}

\begin{itemize}
\tightlist
\item
  Dr Brendan L. Rowan
\item
  brendan.rowan@gmail.com
\item
  Department of Medicine, Royal Perth Hospital, Victoria Square, Perth,
  WA 6000
\item
  +64411263484
\end{itemize}

\textsuperscript{1}UCD Centre for Interdisciplinary Research, Education,
and Innovation in Health Systems (UCD IRIS), School of Nursing,
Midwifery \& Health Systems, Health Sciences Centre, University College
Dublin, Dublin, Ireland

\textsuperscript{2}Mater Misericordiae University Hospital, Dublin 7,
Ireland

\textsuperscript{3}School of Medicine, University of Limerick, Limerick,
Ireland

\textsuperscript{4}St Vincent's University Hospital, Dublin 4, Ireland

\emph{Footnote:}

Dr Brendan L. Rowan current address and affiliation:

Department of Medicine, Royal Perth Hospital, Victoria Square, Perth, WA
6000

\textbf{Abstract \& Keywords:}

\emph{Abstract:}

Job satisfaction and retention of healthcare staff remains an ongoing
issue in many health systems. Huddles have been endorsed as a mechanism
to improve patient safety by improving teamwork, collaboration, and
communication in teams. This study synthesizes the literature to
investigate the impact of huddles on job satisfaction, teamwork, and
work engagement in multidisciplinary healthcare teams.

Five academic databases were searched to conduct a systematic review of
peer-reviewed literature published from January 2000 -- January 2020.
Articles were included if they (1) featured a daily huddle, were
conducted in a healthcare setting, and involved a multidisciplinary team
and (2) measured variables including job satisfaction, work engagement,
or teamwork. Results were reported in accordance with the Systematic
Synthesis Without Meta-analysis (SWiM) and Preferred Reporting Items for
Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

We identified 445 articles of which 12 met the eligibility criteria and
are included in this review. All 12 studies found a predominantly
positive impact on teamwork and job satisfaction. None of the studies
discussed or reported evidence of the impact of huddles on work
engagement.

This review highlights the value of a daily multidisciplinary healthcare
team huddle in improving job satisfaction and teamwork for the
healthcare staff involved. However, there is a dearth of high-quality,
peer-reviewed evidence regarding the direct impact of huddles on job
satisfaction, teamwork and in particular on work engagement. Further
research -- particularly controlled studies on adoption, implementation,
and outcomes for healthcare team culture -- is needed to further assess
this intervention.

\emph{Keywords:}

\begin{itemize}
\tightlist
\item
  Huddle
\item
  Work engagement
\item
  Teamwork
\item
  Job satisfaction
\item
  Collective leadership
\item
  Health management
\end{itemize}

\textbf{Main Text:}

\textbf{INTRODUCTION:}

A huddle can be defined as a structured, brief (5-15 minutes), routine
(daily or multiple times a day), face-to-face communication of a team's
membership.\textsuperscript{1} Daily healthcare huddles have been
consistently shown to improve patient safety by enhancing teamwork,
creating standardised communication processes, and providing a feeling
of shared responsibility.\textsuperscript{2-6} A recent systematic
review on the impact of multidisciplinary team huddles on patient safety
published in the BMJ concluded that ``the present body of research
related to such huddles demonstrates a generally positive impact on
safety''.\textsuperscript{7} Despite the evidence on the impact of
huddles on patient outcomes and patient
satisfaction,\textsuperscript{8-11} there is a dearth of literature on
the impact of huddles on individual healthcare staff, particularly in
relation to job satisfaction and work engagement.

The WHO Global Code of Practice on the International Recruitment of
Health Personnel states that each country must `educate, retain, and
sustain' an appropriate health workforce.\textsuperscript{12} However,
in the context of increased pressures on services, organisations can
struggle to attract and retain skilled staff. One of the primary reasons
for this type of `brain drain' is the lack of job satisfaction within
the health care system, which has been attributed to poor working
cultures in organisations and the strong hierarchical nature of
healthcare systems.\textsuperscript{13} Research has indicated that the
feeling of not having a voice or influencing decisions decreases
engagement, motivation, and wellbeing among medical
staff\textsuperscript{14} and such environments can result in greater
reported intention to leave. A strong body of evidence has demonstrated
that turnover intention is a reliable indicator of job
dissatisfaction.\textsuperscript{15,16}

Job satisfaction among healthcare professionals is also important
because if their own needs are not met, they often have difficulties in
meeting the needs of their patients.\textsuperscript{17,18} Job
satisfaction in healthcare workers has been reported to be related to a
number of factors: having autonomy in decision-making, effective
communication among staff and supervisors, and having the ability to
express one's opinion freely,\textsuperscript{19} all of which are
potentially facilitated by the implementation of a daily team
huddle.\textsuperscript{20} Huddle implementation in a healthcare team
has been perceived by staff to increase accountability, create a culture
of collaboration, foster a heightened sense of community, and increase
empowerment, by giving all team members a dedicated time and platform to
discuss concerns.\textsuperscript{20}

Improved communication between team members has been shown to be a
specific intervention that improves interdisciplinary
teamwork.\textsuperscript{21} Programs such as TeamSTEPPS (Team
Strategies and Tools to Enhance Performance and Patient Safety), the
Aston Team Facilitation Programme, and ISBAR (identify, situation,
background, assessment, recommendation) are widely used in multiple
healthcare systems to improve team
communication.\textsuperscript{22}Thus, it is hypothesised that the
implementation of a huddle would therefore promote teamwork by improving
communication between team members.

We conducted a systematic review on the impact of daily,
multi-disciplinary huddles on healthcare staff. The primary outcomes of
interest were staff satisfaction, teamwork, and work engagement in a
healthcare setting. We are not aware of any other reviews conducted on
these potential outcomes of the huddle in a healthcare setting.

\textbf{METHODOLOGY:}

A systematic review was conducted to synthesise the available literature
with the aim of informing clinical practice.\textsuperscript{23,24} This
review followed the Cochrane Collaboration
guidelines\textsuperscript{25} and results are reported in line with the
Preferred Reporting Items for Systematic Reviews and Meta-Analysis
(PRISMA) and the Synthesis Without Meta-analysis (SWiM)
guidelines.\textsuperscript{26-28} The protocol was published in the
PROSPERO database in June 2020 (registration number CRD42020180283).

Search Strategy and Data Sources:

Following the development of the review focus, keywords were selected
that were determined pertinent to the topic. Five electronic databases
(PubMed, Cumulative Index of Nursing and Allied Health Literature
(CINAHL), PsycINFO, EMBASE, and Cochrane) were used as sources of
relevant literature. These searches were conducted for articles
published from January 6, 2000, to January 6, 2020 (searches were
carried out on 6-8\textsuperscript{th} January 2020).

Keywords and terms used in searching included `huddle', `team brief',
`preoperative brief', `brief', `multidisciplinary healthcare team',
`MDT', `team', `work engagement', `job satisfaction', `turnover
intention', `satisfaction', and `teamwork'. Previous publications on
team-based interventions helped to inform the search
strategy.\textsuperscript{7,29,30} Groups of keywords relevant to a
specific category (e.g. Huddle) type were combined using the `OR'
Boolean term (e.g. `huddle' OR `brief' OR `preoperative brief') and
categories of keywords were combined using the `AND' Boolean operand.
Researchers also scanned the reference lists of included papers and of
previously published systematic reviews. Copies of all database search
strings can be obtained by contacting the corresponding author.

Eligibility Criteria:

We searched for peer-reviewed studies published in English over the last
20 years to capture the evolution in the use of huddles over time.
Studies were included if they featured a daily huddle, were conducted in
a healthcare setting, and involved a multidisciplinary team
(\textgreater{}1 profession). No restrictions were placed on country of
study origin.

Studies were excluded if they did not meet the inclusion criteria or
were duplicates. Preoperative briefs/huddles that were based on the
surgical safety checklist were also excluded as they did not meet our
definition of a huddle. Non-empirical article types such as reviews,
comments, or letters to the editor were not included.

Study Selection:

Searches of the databases were carried out by the primary researcher
(BR). Titles and abstracts of retrieved records were screened for
relevance independently by two researchers (BR and SA) and any
disagreements were discussed and resolved between the two researchers.

Data Extraction:

Data from all included studies was extracted independently by two
researchers (BR and SM) into a datasheet compiled for this review.
Extracted data included information related to the setting, study sample
size, the type of huddle specified, methods of evaluation, the
intervention content and duration, main findings or emergent themes,
general conclusions, and limitations of the studies. Reviewers also
collected information such as first author, publication year, and study
design. All reviewer conflicts were resolved by a third researcher (SA).

Risk of Bias and Quality Appraisal:

Two researchers (BR, SA) used the Cochrane Systematic Review Handbook to
assess the risk of bias and the quality of the studies. Following this,
the Mixed Method Appraisal Tool (MMAT)\textsuperscript{31} was used to
evaluate the quality of included studies. This provided a validated,
systematic approach to assessing the methodological quality and the risk
of bias in the included studies. The results of the MMAT quality
appraisal can be found in Table 1. Disagreements between reviewers'
judgements were resolved by consulting a third reviewer (SM). No studies
were excluded following the quality appraisal.

Table 1: Mixed Methods Appraisal Tool

Data Synthesis:

Meta-analysis could not be performed due to lack of comparable data,
heterogeneity of studies, and the different outcome measures across
studies. Due to the inclusion of mixed methodology papers, a narrative
synthesis approach was adopted to summarise and synthesise findings. The
SWiM reporting guidelines were used in conjunction with the PRISMA
guidelines.\textsuperscript{26-28}

\textbf{RESULTS:}

Study Selection:

The database searches yielded a total of 436 articles. Authors (BR, SA)
screened the abstracts and titles, and 411 articles were removed as they
did not meet the inclusion criteria, despite containing keywords in
their title or abstract. The reference lists of the remaining 25
articles were then scanned and nine additional records were identified
through these sources. 14 duplicates were then removed, leaving 20
full-text articles to be assessed for eligibility. Following the
independent full-text review by the researchers (BR, SA), 12 articles
were included and analysed.\textsuperscript{1,20,32-41} Two articles
were removed following full-text review as the huddle was not daily, two
were removed from this review as they did not involve a
multidisciplinary team, and four were removed for not according to the
PRISMA guidelines regarding methodology.\textsuperscript{26,27} Figure 1
depicts the PRISMA flow diagram of selection of eligible studies.

Description of Studies:

Table 2 summarises the details of the articles included in the review.
Study characteristics extracted include the year published, study
design, setting, study sample size, methods of evaluation, and
intervention. There were six quantitative
studies,\textsuperscript{32,35,36,38,39,41} three
qualitative,\textsuperscript{20,37,40} and three mixed method
studies\textsuperscript{1,33,34} included in the final review. All of
the studies took place in the USA and UK, with three taking place in
community-based care,\textsuperscript{1,37,41} and nine taking place in
university hospital-based inpatient
care.\textsuperscript{20,32-36,38-40} The results are discussed in terms
of the three outcomes of interest: teamwork, job satisfaction, and work
engagement.

Table 2: Summary of Findings

Intervention Methods:

Six of the studies included looked primarily at the implementation of
daily huddles.\textsuperscript{1,20,34,36,38,40} The other six studies
looked at the effect of multiple interventions, one component of which
was a huddle-- the details of these interventions are included in Table
3. The qualitative or mixed methods approach of these studies were
therefore useful in gathering results on the specific components (i.e.,
daily huddle) of each intervention that was introduced.

Table 3: Intervention Characteristics

Teamwork:

Six included studies looked at the impact of huddles and quality
improvement interventions on
teamwork.\textsuperscript{33,35,36,38,39,41}

Of 12 studies, only two were controlled
trials.\textsuperscript{35,38}Monash \emph{et al} measured attending and
trainee physicians' perception of nursing involvement during morning
rounds. The new structure of rounding introduced in the intervention arm
incorporated a pre-round huddle. Level of agreement for a statement
(e.g., I am satisfied with morning rounds) was measured on a continuous
scale; 0 (far too little) to 100 (far too much), with 50 being `about
right'. This was carried out using an electronic survey adapted from
previously published work,\textsuperscript{42} however this is not a
standardised, validated survey. They measured the standard mean of
attending and trainee responses and found both groups in the
intervention arm perceived a significantly higher level of nursing
involvement during morning rounds than the control arm; (44.6 v 35.7
adjusted mean, p=0.032) and (45.2 v 37.7, p=0.006) respectively. It is
likely that this extra involvement bolstered team dynamics and enhanced
workflow and engagement, improving the teamwork of healthcare staff
involved.\textsuperscript{43}

Pannick \emph{et al} measured the effect of introducing daily briefings
with teams over a six-month period and found improvements in both
teamwork attitudes and patient safety outcomes.\textsuperscript{38} With
sustained implementation, the estimated marginal mean `teamwork score'
significantly improved (81.7 v 70.0, p=0.004). The teamwork score
measures the perceived quality of collaboration between personnel.

Communication between members of a healthcare team has previously been
shown to be one of the most important factors to improve teamwork and
work engagement.\textsuperscript{44} Stapley \emph{et al} conducted 76
semi-structured interviews with staff members on four wards four months
after the intervention.\textsuperscript{40} Thematic analysis showed
that the huddle helped to \emph{`increase their awareness of important
issues \ldots{} communication, teamwork, and encourage a culture of
increased efficiency'.} One nurse described that the daily huddle helped
the team work better on the ward:

\emph{``I think it helps that boundary between medical staff and nursing
staff, it sort of links them a little bit more.''}

Rodriguez \emph{et al} reported that huddles were described as an
important mechanism to ensure member awareness of what each team
member's role is and improved communication between
members.\textsuperscript{1} When one registered nurse was asked what she
felt was the most important change implemented she said:

\emph{``To be honest, the huddle, because you're communicating with each
other, you know? And that's key to everything. To have success for any
relationship whether it's with - for the patients' benefits, when we're
getting it across and trying to solve problems, looking at it and
tackling it.''}

Scotten \emph{et al} also showed that the daily brief helped to improve
teamwork across the hospital by looking at the results of the TeamSTEPPS
Teamwork Perceptions Questionnaire.\textsuperscript{39} This looked at
the individuals' perception of teamwork with a five-point Likert scale.
The mean for teamwork rating improved by 14.1\% post-intervention, p
\textless{}0.05.

Goldenhar \emph{et al} conducted semi-structured interviews and focus
groups to obtain a deeper understanding of the huddle system and its
outcomes as implemented in a large academic tertiary care children's
hospital.\textsuperscript{20} One of their five key themes was `sense of
community'. Participants reported that they had a `deeper understanding
of what their colleagues across the hospital deal with on a daily basis'
and that this makes them `feel more connected to their peers'. Another
key theme reported was a `culture of collaboration/collegiality'. Since
introduction of the huddle system, one participant commented that:

\emph{``Anti-competition, consideration, compassion -don't assume that
the unit is saying no because they don't want to help, all have a better
idea of what's going on on other units and know that everyone is
busy!''}

The Canadian Interprofessional Health Collaborative National
Interprofessional competency Framework\textsuperscript{45} was used by
Hastings \emph{et al} to develop staff
surveys.\emph{\textsuperscript{33}} They introduced a number of new
processes including regular care-hub huddles. Perceptions were measured
with a Likert scale and completed at baseline and post-intervention.
Similar to the previous studies mentioned, responses increased
significantly for `collaboration and communication' post-introduction of
a huddle (4.4 v 3.4; p \textless{}0.001).

Job Satisfaction:

Monash \emph{et al's} randomised controlled trial measured attending and
trainees job satisfaction as a secondary
outcome.\textsuperscript{35}This was carried out using an electronic
survey adapted from previously published work,\textsuperscript{42}
however this is not a standardised, validated survey. The efficiency of
the new style of rounds incorporating a huddle was assessed against
normal rounding practices and it found that trainees found the rounding
less efficient (60.5 v 72.3, intervention v control; p=0.008). Trainees
reported that it increased workload for the rest of the day and gave
them less autonomy. The opposite was reported for attending physicians.
Jain \emph{et al}reported that the `day's flow' improved dramatically
after huddle implementation in a surgical environment (median rating
increased from 5 to 9, with 10 being the best).\textsuperscript{34} The
average number of unexpected delays also decreased post-implementation
(15 v 4). This was a much smaller study however, with only three
surgeons surveyed.

Dingley \emph{et al} analysed 495 discrete communication events pre and
post-huddle implementation.\textsuperscript{32} Trained data collectors
were used to record communication processes within the health system by
using a standard form and asking nurses their perception of
communication events. Comparison of pre- and post-intervention positive
resolution of communication/issue (nursing staff's perception of
resolution of the patient's issue following an interaction/communication
with medical staff) and satisfaction scores revealed a significant
increase in positive resolution scores (\emph{p} =0.04), and a
difference in satisfaction scores approaching significance (\emph{p}
=0.08) in the Medical Intensive Care Unit and nonsignificant increases
in resolution and satisfaction scores (\emph{p} =0.13, \emph{p} =0.53,
respectively) in the Acute Care Unit. Positive responses to both the
resolution and satisfaction questions in the post-intervention period
increased.

Turnover intention has been shown to be a reliable indicator of job
satisfaction.\textsuperscript{15,16} Hastings \emph{et al} examined
intent to leave within the next twelve months. This was conducted using
staff interviews (n=15) and staff surveys (n=25) and showed those that
implemented team huddles were significantly less likely to plan to leave
after implementation than they were before the new model was introduced
(20\% at final evaluation vs. 48\% at baseline).\textsuperscript{33}This
included nursing staff, allied health professionals, managers, and
physicians. Of note, there were multiple changes to the organisation
including comfort rounds, bedside shift reports, patient whiteboards,
rapid rounds, and team huddles.

Newman \emph{et al} similarly found improved job satisfaction across all
provider groups (cardiologist, resident, nursing
staff).\textsuperscript{36} Job satisfaction was measured using an
electronic survey that was piloted to twelve senior staff members to
establish validity. Pre-post intervention surveys asking if staff had a
positive overall experience working in the unit resulted in (20 v 25
residents agree/strongly agree (n=26 pre) (n=25 post); p=0.001), (8 v 16
cardiologists agree/strongly agree (n=14 pre) (n=17 post); p=0.005), (3
v 13 nursing staff agree/strongly agree (n=14 pre) (n=15 post); p
\textless{} 0.001).

The job satisfaction ratings post-huddle implementation were also higher
in Rodriguez \emph{et al's} study. They measured differences in
`huddlers' and `non-huddlers' by using a survey that included the
experiences of teamwork and practice climate.\textsuperscript{1} Those
who implemented daily huddles in their practice were found to have
higher satisfaction with their teams (83.1\% v 51.7\% satisfied; p
\textless{}0.001), higher psychological safety (61.7\% v 46.0\%; p
\textless{}0.001), and better experiences of practice communication
(60.9\% v 48.1\%; p \textless{}0.01). However, 42\% (n=174) of those
surveyed indicated they found huddles `not very helpful' when asked.
Psychological safety in the workplace has been strongly linked to
improved job satisfaction in the literature.\textsuperscript{46}

As previously mentioned communication between team members has been
shown to be a specific intervention that improves interdisciplinary
teamwork\textsuperscript{21} O'Malley \emph{et al} similarly reported
that huddles played a role in improved communication among healthcare
professionals and that this improved communication resulted in higher
job satisfaction.\textsuperscript{37} 23 out 27 practices mentioned that
huddles were `\emph{key to maintaining structured communication within
teams'} . Participants who adopted new forms of delegations such as
huddles reported improved provider satisfaction and productivity.

However, it was also found that not all teams found the huddle was
required to improve work engagement, teamwork, or job satisfaction.
Rodriguez \emph{et al} reported that some teams that did not choose to
partake in daily huddles ``have positive experiences of teamwork and
indicated daily huddling was not necessary once team norms were firmly
established and roles and responsibilities were very
clear''.\textsuperscript{1} It is noted however that a greater
proportion of non-huddlers interviewed described ``challenging
interpersonal dynamics among team members''.

Work Engagement:

There was an apparent lack of published research on the impact of
multidisciplinary healthcare huddles on work engagement. Although themes
linked to work engagement, such as collegiality, organizational
commitment, and staffing perceptions were measured in some of the papers
included, no paper explicitly mentioned the impact of the huddle on the
work engagement of healthcare staff involved.

\textbf{DISCUSSION:}

This systematic review explored the impact that a daily huddle can have
on staff job satisfaction, teamwork, and work engagement in healthcare
settings. Most of the studies found that the huddle improved
communication between team members and in turn increased overall job
satisfaction and teamwork. Effective, respectful communication has
impacts on both collegiality, collaboration, and on patient safety
outcomes and is a key pillar of effective teamworking and collective
leadership across a healthcare system.\textsuperscript{47} Despite a
large amount of data on the association between patient safety outcomes
and huddles, we noted the limited number of studies published on the
sole impact of huddle implementation and its outcomes on the healthcare
team. A wide variety of intervention design and evaluation methods were
used in previous studies in this area.\textsuperscript{7} As a result,
it is difficult to compare findings across studies. Some key emergent
themes from the studies identified included `sense of community',
`trust', and `hierarchy'.

Sense of Community:

Healthcare teams experience frequent staffing changes due to the ongoing
training and rotation of staff in different hospitals, particularly
among doctors in training\textsuperscript{48}. One important finding of
our review is that the implementation of a daily huddle improved
teamwork by facilitating team members to communicate with each other
in-person on a daily basis. This has been shown in the literature to be
a specific intervention that improves multidisciplinary
teamwork\textsuperscript{21}. The huddle allows multidisciplinary teams
to raise safety incidents, to address staffing gaps, and to outline the
goals of care for each patient effectively and collaboratively.

Frequently used terms in the conclusions of the studies included in our
review included `practice climate', `working environments', and
`teamwork attitudes'. The huddle brought the team together on a daily
basis to remind them of their overall team goal -- to improve the health
and wellbeing of their patients collectively. This heightened sense of
community has a positive impact on the overall satisfaction of employees
and empowered them to work more productively and efficiently as a
team.\textsuperscript{20}

Trust:

Previous systematic reviews have highlighted the importance of trust
relationships on staff members intention to leave and work
engagement.\textsuperscript{49} Those reviews also examined the
influence of trust, communication, and job satisfaction on healthcare
workers' performance. Our review suggests that the implementation of
huddles is one such intervention that improves trust in a workplace.
Increased levels of trust were particularly noted in three higher
quality studies included in our review.\textsuperscript{35,36,38} This
increased level of trust resulted in higher safety incident reporting
and improved interprofessional dynamics, leading to higher satisfaction
among care providers.

Hierarchical Differences:

Historically, interactions between healthcare teams have been dominated
by doctors,\textsuperscript{50} and staff often classify their `team' as
the other staff members of the same profession (e.g. medical team,
nursing team etc.). This contrasts to high reliability organisations
such as military aviation and nuclear power who work more
collaboratively, and also have low accident and failure
rates.\textsuperscript{51} Seven studies in our
review\textsuperscript{1,32,34-37,40} reported that huddles improved
communication between various professional groups, primarily between
doctors and nurses. Having a structured interdisciplinary gathering
bridges the communication barrier and allows the multidisciplinary team
to work more cohesively and collaborate collectively on a daily basis.
However, one study reported lower levels of job satisfaction with
resident doctors taking part in the huddle.\textsuperscript{35} This was
due to a feeling of decreased autonomy and that it added to their
often-overstretched workload.\textsuperscript{52} This review highlights
the importance that all team members take part in the huddle, regardless
of seniority, to ensure it is an ongoing process and to benefit from the
collaboration and collegiality it can facilitate. This collaboration and
collegiality is a key component of improving teamwork among healthcare
providers.

Strengths and limitations:

An important strength of this review is that it has systematically
collated evidence on the impact huddles can have on a healthcare team's
job satisfaction and teamwork. The lack of published data on the impact
of the huddle on work engagement highlights the need for future research
in this area. The review adopted broad inclusion criteria and
interrogated five major research databases to identify as many relevant
studies as possible. This review used two different appraisal tools to
minimise bias and appraise the quality of included studies. Due to the
fact surveys used in the studies identified tended to report more
positive outcomes, the mixed methods approach of many of the studies
included allowed us to see both sides more clearly, while simultaneously
allowing the data specifically to the huddle to be extracted and
reviewed.

The variability in intervention models and in the measurement tools used
in the studies we reviewed reflects the lack of a standardised framework
for huddle implementation and appraisal. Intervention models varied from
entire new care processes that incorporated a
huddle\textsuperscript{33}to a night-shift interprofessional
huddle.\textsuperscript{36} Within these, the comparable interventions
were variously reported as `briefs', `huddles', or `pre-rounds'. This
lack of common language makes synthesising data and comparing studies
challenging. This has previously been documented in reviews related to
huddles and patient handoffs.\textsuperscript{7,53} We would support the
proposed taxonomy and standardisation of reporting measures for future
huddle-related studies as proposed by \emph{Franklin et
al,\textsuperscript{7}} however we would also suggest that staff
satisfaction is measured by a validated survey, such as the Satisfaction
of Employees in Health Care survey (SEHC)\textsuperscript{54} or the
Hospital Survey on Patient Safety Culture (HSOPSC)\textsuperscript{55}
as part of the safety culture measures to support future comparability
of studies.

However, a limitation of this review is that many studies implemented
whole new care processes, rather than just introducing the huddle
concept. This makes it challenging to isolate the impact of the huddle
when part of a complex intervention. Additionally, the use of a
validated common survey to evaluate outcomes was rare. Publication bias
may result in successful huddle programme implementations being
over-represented in the literature we identified. Finally, almost all
the studies in our review were uncontrolled, pre-post studies, conducted
in a single hospital/ward, in one country, with relatively small sample
sizes, and a lack of rigorous study designs. All the studies included
took place in the UK or the USA. We therefore cannot generalise the
findings to other health service contexts, or to low and middle-income
countries.

\textbf{CONCLUSION:}

The findings of this systematic review highlight the potential value of
a daily multidisciplinary healthcare team huddle in terms of improved
job satisfaction and teamwork for the healthcare staff involved. It
contributes an up-to-date synthesis of literature to the current body of
work on healthcare staff retention, communication in healthcare teams,
and the importance of collegiality for both staff and patient outcomes.
Our review suggests that through strengthening workplace trust
relationships, increasing the sense of community and collaboration on
healthcare teams, and applying collective leadership models to reduce
hierarchical frameworks that currently exist in healthcare settings, it
may be possible to decrease turnover intention and improve the overall
engagement of staff. With the aforementioned high turnover rates of
medical staff in the UK and Ireland, it is important for the healthcare
services to implement changes sooner rather than later.

Although much has been written about the value of huddles in healthcare
settings, there is an apparent lack of high-quality, peer-reviewed
evidence regarding the direct impact of huddles on job satisfaction,
teamwork and particularly on work engagement. Further research --
particularly controlled studies on adoption, implementation, and
outcomes for healthcare team culture -- is needed for this important
intervention that can strengthen health systems from community level to
acute care.

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\textbf{Acknowledgements:}

The authors wish to thank all cited authors for their contribution to
published scientific articles.

This research is being funded by the Health Research Board
(RL-2015-1588) and is supported by the Health Service Executive.

\textbf{Conflict of Interest Statements:}

None declared

\emph{Table 1: Mixed Methods Appraisal Tool}\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
\emph{MIXED METHODS:} & \textbf{Are there clear research questions?} &
\textbf{Do the collected data allow to address the research questions?}
& \textbf{Is there an adequate rationale for using a mixed methods
design to address the research question?} & \textbf{Are the different
components of the study effectively integrated to answer the research
question?} & \textbf{Are the outputs of the integration of qualitative
and quantitative components adequately interpreted?} & \textbf{Are
divergences and inconsistencies between quantitative and qualitative
results adequately addressed?} & \textbf{Do the different components of
the study adhere to the quality criteria of each tradition of the
methods involved?}\tabularnewline
\midrule
\endhead
\textbf{Hastings} & Yes & Yes & Yes & Yes & Yes & Yes & Can't
tell\tabularnewline
\textbf{Jain} & Yes & Can't tell & Yes & Yes & Can't tell & Can't tell &
Can't tell\tabularnewline
\textbf{Rodriguez} & Yes & Yes & Yes & Yes & Yes & Yes &
Yes\tabularnewline
\emph{RCT:} & & & \textbf{Is randomization appropriately performed?} &
\textbf{Are the groups comparable at baseline?} & \textbf{Are there
complete outcome data?} & \textbf{Are outcome assessors blinded to the
intervention provided?} & \textbf{Did the participants adhere to the
assigned intervention?}\tabularnewline
\textbf{Monash} & Yes & Yes & Yes & Yes & Yes & Yes & Yes\tabularnewline
\emph{QUANTITATIVE} & & & \textbf{Is the sampling strategy relevant to
address the research question?} & \textbf{Is the sample representative
of the target population?} & \textbf{Are the measurements appropriate?}
& \textbf{Is the risk of nonresponse bias low?} & \textbf{Is the
statistical analysis appropriate to answer the research
question?}\tabularnewline
\textbf{Newman} & Yes & Yes & Yes & Yes & Yes & Yes & Yes\tabularnewline
\textbf{Pannick} & Yes & Yes & Yes & Yes & Yes & Yes &
Yes\tabularnewline
\textbf{Scotten} & Yes & Yes & Yes & Can't tell & Yes & Can't tell &
Yes\tabularnewline
\textbf{Thomas} & Yes & Yes & Yes & Can't tell & Yes & Yes &
Yes\tabularnewline
\textbf{Dingley} & Yes & Yes & Yes & Yes & Yes & Yes &
Yes\tabularnewline
\emph{QUALITATIVE:} & & & \textbf{Is the qualitative approach
appropriate to answer the research question?} & \textbf{Are the
qualitative data collection methods adequate to address the research
question?} & \textbf{Are the findings adequately derived from the data?}
& \textbf{Is the interpretation of results sufficiently substantiated by
data?} & \textbf{Is there coherence between qualitative data sources,
collection, analysis and interpretation?}\tabularnewline
\textbf{Goldenhar} & Yes & Yes & Yes & Yes & Yes & Yes &
Yes\tabularnewline
\textbf{O'Malley} & Yes & Yes & Yes & Yes & Yes & Yes &
Yes\tabularnewline
\textbf{Stapley} & Yes & Yes & Yes & Yes & Yes & Yes &
Yes\tabularnewline
\bottomrule
\end{longtable}

\emph{Table 2: Summary of Findings:}\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Reference}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Study Design}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Setting}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Study Sample Size}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Methods of Evaluation}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Intervention}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Dingley \emph{et al}, 2008\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Uncontrolled pre-post study\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
University-based hospital (USA)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2 hospital units (495 communication events)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Analysis of 495 communication events\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Structured communication tool including huddle during each shift\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Goldenhar \emph{et al}, 2013\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Qualitative study using semi-structured interviews and focus
groups\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
University-based hospital (USA)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10 key informants, 21 focus group participants\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Analysis of interview and focus group data\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3-level huddle system operating at different levels of the staff
structure. Group training to implement huddling\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Hastings \emph{et al}, 2016\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Mixed methods using interviews and uncontrolled pre-post surveys of
staff and patients, plus administrative records\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
University-based hospital (USA)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
15 interviews with staff post, 25 staff surveys pre- and post-, 26
patient surveys pre-, 37 patient surveys post-intervention\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Qualitative analysis of interview data, qualitative analysis of staff
and patient surveys, quantitative analysis of key indicators from
administrative data.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
New model on delivering care including regular huddles during the
day\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Jain \emph{et al}, 2015\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Pilot study\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
University-based hospital (USA)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3 surgeons, plus surgical teams (totalling 65 operations)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Baseline and timepoint measurement of surgical outcomes, interruptions,
and questions from a worksheet completed by surgeons for each day's
cases.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Daily pre-operative huddle using template with entire surgical
team\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Monash \emph{et al}, 2017\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Cluster RCT\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
University-based hospital (USA)\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Intervention arm: 19 attendings + 60 trainees; 595 patients. Control
arm: 17 attendings + 61 trainees; 605 patients.\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Audit of adherence to practice recommendations; patient satisfaction
questionnaires using Likert-type scales; staff questionnaires based on
previously-published work\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Workshop to train teams on daily pre-round huddle as part of a package
of 5 Attending Round practices\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Newman \emph{et al}, 2016\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Retrospective cohort study\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
University-based hospital (USA)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Resident (n= 26 Pre and 25 Post), Cardiologist (n= 14 pre and 17 post)
and Nursing (n= 14 pre and 15 post)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Retrospective chart review + retrospective pre-post survey on
satisfaction with the intervention and impact of the intervention on
team-based communication\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Intervention arm teams were trained in 5 Attending Round practices: 1)
pre-rounds huddle; 2) bedside rounds; 3) nurse integration; 4) real-time
order entry; 5) whiteboard updates. The control arm continued normal
practices..\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
O'Malley \emph{et al}, 2015\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Qualitative study using in-depth interviews\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Community-based facilities (USA)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
63 respondents ranging from physicians to front-desk staff.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
In-depth interviews using standardised protocol followed by qualitative
analysis.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Team huddles to support communications (exact type not specified as this
paper accessed a large number of organisations/teams)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Pannick \emph{et al}, 2017\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Prospective stepped-wedge non-randomised cluster controlled trial\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
University-based hospital (UK)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
85 staff members from 7 interdisciplinary medical ward teams\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Anonymised patient and ward level outcomes extracted from routinely
collected data sets. Anonymous staff surveys were administered at
baseline and 6 month timepoint.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Prospective Clinical Team Surveillance (PCTS) - Intervention program
comprised structured team briefing, facilitation, and feedback\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Rodriguez \emph{et al}, 2015\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Mixed methods study using interviews and surveys of staff\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Community-based facilities (USA)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
79 teamlet member interviews + 418 clinician and staff PCMH survey
responses (total number of individuals unclear)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Analysis of interview and survey data followed by qualitative and
quantitative analysis.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Patient Aligned Care Teams (PACT) initiative including structural
reorganisation of teams\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Scotten \emph{et al}, 2015\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Uncontrolled pre-post study\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
University-based hospital (USA)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
65 faculties --number of participants unclear\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Analysis of questionnaire data completed at baseline and timepoints,
with providers using T-TAQ\textsuperscript{+}, T-TPQ\textsuperscript{++},
ITPS\selectlanguage{ngerman}\textsuperscript{§}, AITCS\textsuperscript{¶}, and patients using
EHCPS\textsuperscript{\#}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
TeamSTEPPS introduced with in situ simulations and development of an
interprofessional transitional care model intervention which included
telehealth approaches for patient / provider communication\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Stapley \emph{et al}, 2018\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Qualitative study using semi-structured interviews\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
University-based hospital (UK)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
76 staff\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Qualitative analysis of interview data.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
`SAFE' (Situation Awareness for Everyone) programme which incorporates
huddling\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Thomas \emph{et al}, 2013\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Quality improvement report\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Community-based facilities (USA)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Whole system (1300 staff)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Adoption of TeamSTEPPS competencies was assessed using direct
observation and anecdotes. Effects of the training was evaluated, using
Hospital Survey on Patient Safety Culture and targeted variables.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
TeamSTEPPS training was implemented across the system after
piloting.\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

+T-TAQ = TeamSTEPPS Teamwork Attitude questionnaire

++ T-TPQ = TeamSTEPPS Teamwork Perception questionnaire

\selectlanguage{ngerman}§ ITPS = Interprofessional Team Performance Scale

¶ AITCS = Assessment of Interprofessional Team Collaboration Scale

\# EHCPS = Engagement with Healthcare Provider Scale

\emph{Table 3: Intervention Characteristics}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{Reference}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{Length}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{Content}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{Delivery}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Dingley \emph{et al}, 2008\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
24 months\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Provider/Team communication toolkit: ISBAR\textsuperscript{+} Team
Huddles Multidisciplinary rounds using daily goal sheets\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Lectures and interactive group activities on an organisational and
departmental level with follow-up education over months, information
notebooks, concept posters, visual reminders, PowerPoint presentation,
`champion' roles.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Goldenhar \emph{et al}, 2013\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
5 years\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Inter-related tiered huddle system: Unit huddle Inpatient huddle Daily
operations brief\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Employed safety officers, trained senior staff on implementation,
gradually introduced the concept following a pilot, expanded number and
participants of huddles over time\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Hastings \emph{et al}, 2016\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
14 months\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
New care processes: Name Occupation Duty More timely initial patient
assessment Comfort rounding by HCAs Bedside shift report by RNs Patient
whiteboards Rapid rounds Care hub huddles regularly\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Collaborative practice lead available to help guide staff and provide
feedback, reorganisation of teams to help implementation\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Jain \emph{et al}, 2015\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1 month for baseline, 6 weeks for data collection\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Daily pre-operative huddle with entire surgical team completed prior to
first case of the day\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Surgeons given a template to follow for the huddle, instructed by author
on how to perform huddle\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Monash \emph{et al}, 2017\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Unclear\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Attending Rounds introduced: Pre-round huddle Bedside rounds Integrating
bedside nurses Completing real-time order entry using bedside computers
Updating patient's whiteboard with care plan\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Study investigators led a 1.5hr workshop to train teams allocated to the
intervention arm, informational handouts distributed, control arm not
informed of study aims\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Newman \emph{et al}, 2016\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
24 months\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Night-shift interprofessional huddle: Rounding process with overnight
residents and bedside nurses followed by conference call among
residents, charge nurse, and at-home cardiologist Potential concerns
discussed with resident, charge nurse, and cardiologist\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Not detailed.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
O'Malley \emph{et al}, 2015\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
N/A\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Generally a morning or afternoon huddle that lasted 5-10 minutes with
physician, assistants, nurses, and sometimes front-desk staff.\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
N/A\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Pannick \emph{et al}, 2017\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
6 months\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Hospital Event Analysis Describing Significant Unanticipated Problems
(HEADS-UP) briefing: Daily briefings with teams Briefings could be led
by any member of the ward team\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Visual format delivered to teams with options of making minor changes,
facilitator to raise concerns of frontline teams about issues raised in
the HEADS-UP briefings to bring about tangible unit and
organisational-level changes\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Rodriguez \emph{et al}, 2015\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3 years at last data collection\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Huddle adoption and use as part of Patient Aligned Care Teams
Initiative\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
N/A\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Scotten \emph{et al}, 2015\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
12 months\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
TeamSTEPPS: ISBAR\textsuperscript{+} format Daily briefs
CUS\textsuperscript{++} communication tool to identify safety
concerns\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Train-the-trainer methodology, 2 hour sessions for team members on the
project.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Stapley \emph{et al}, 2018\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
16 months total, data collected at 4 months\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Situation Awareness For Everyone (SAFE): Huddling
ISBAR\textsuperscript{+} PEWS\selectlanguage{ngerman}\textsuperscript{§}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Not specified.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Thomas \emph{et al}, 2013\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
3 years\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
TeamSTEPPS\selectlanguage{ngerman}\textsuperscript{¶}: Briefs, huddles, debriefs
Cross-monitoring, feedback, advocacy, two-challenge rule
CUS\selectlanguage{english}\textsuperscript{++}, DESC\textsuperscript{\#} script, Collaboration,
ISBAR\selectlanguage{english}\textsuperscript{+} Call-out, check-back, handoff\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
2.5 day master trainer course, 4hr fundamental course for all staff
providing direct patient care, essentials course for all non-clinical
staff\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

+ ISBAR; Identify, Situation, Background, Assessment, Recommendation

++ CUS; I am Concerned, I am Uncomfortable, This is a Safety issue

\selectlanguage{ngerman}§PEWS; Paediatric Early Warning Systems

¶ TeamSTEPPS; Team Strategies and Tools to Enhance Performance and
Patient Safety

\# DESC; D, Describe the specific situation; E, Express your concerns
about the action; S, Suggest other alternatives; C, Consequences should
be stated

\textbf{Figure Legends:}

Figure 1: PRISMA flow diagram of selection of eligible studies\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1-Huddle-JECP/Figure-1-Huddle-JECP}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

