Teams that anticipate difficulties in advance, based on prior experience with particular team members or complex tasks or goals, can engage in preemptive team building. Other occasions for team building include arrival of a new leader, influx of new members, or a major shift in the task or goals of the team.

Elements of a Team Building Program

Some teams with serious difficulties or with ambitious development goals will choose to invest in a systematic program to build the team, as opposed to sporadically identifying issues and then addressing them with team building interventions. To begin a team building program, a team should assess its own functioning. A serious and systematic team building cycle includes stages of problem identification, data collection and analysis, action planning, implementation, and evaluation (Dyer et al, 2007).

Data gathering provides a team with the opportunity to develop a foundational understanding of its own problems. Surveys, interviews, and round robin sharing are all examples of how a team can gather data about its problems. Next, to develop an agenda for its team building program, a team should prioritize the information collected and consider how well the team is functioning, what is related to existing problems, and how the team can change. Finally, using findings from the data collection and analysis phase, a team should generate an action plan, implement it, and evaluate its success. Action planning is often as simple as coming to agreement, defining assignments, and following up to ensure that actions have been completed.

As with any infrastructure investment, systematic team building makes more sense, the more permanent the team is. For teams expected to do concentrated work in a delimited time frame, though, team building can accelerate the movement of the team through stages to the performing stage. (See Chapter 8 for a discussion of the stages of team formation.) Such teams may not have the luxury of time to work out those elements of effective teams in the natural course of events. Only in teams of very short duration is systematic team building not an option due to the lack of time. For template teams, where team composition varies over time, team building activities in the pool of potential team members can help develop the template teams. For example, team building could be conducted for a group of 45 physicians, nurses, and technicians who work together in an emergency room in ever-shifting template teams.

Team Building or Team Training?

Relative to team training, there is some indication that team building is more effective for teams with relatively lower task interdependence, while team training is more effective for teams with higher task interdependence (Shuffler et al, 2011). This may be because specific, isolable problems can be better addressed via particular team building activities, while more complex (highly interdependent) ones benefit from foundational improvement in individual competencies via training. Another occasion for investment in team training, as opposed to team building, is with template teams. Building teamwork competencies in the pool of individuals who can comprise a template team may be a more useful pursuit than running myriad combinations of template team members through team building exercises, when they may not interact with those same people again. For similar reasons, teams with a short lifespan (for example, a 2-month quality improvement project team) may not have time to engage in team building exercises, and prior teamwork training of participants would be valuable for those individuals.

Inside or Outside?

Team building activities can be managed by existing team members, typically the leader, or by external facilitators. Facilitation by the team leader (or another suitable team member) is reasonable under the following conditions (Dyer et al, 2007, p. 80):

1. The leader is comfortable with the activity.

2. The team is experienced in successfully working through difficult issues.

3. The leader is not part of the problem.

4. The activity is easy to understand.

Team leaders may be comfortable with some of the shorter and simpler team building interventions, while more extensive interventions, or delineation of a systematic team building program, may benefit from expert facilitation.

Another possibility is that an outsider could be used to collect data from the team, interviewing each member to identify problems and concerns. The information could then be discussed by the team as a whole, which could then decide if team building events are needed, and whether an outsider should facilitate them. The team members may feel comfortable addressing the problems and concerns without outside help.

TYPES OF TEAM BUILDING INTERVENTIONS

There are several types of team building activities. We categorize team building activities into the following categories: clarifying goals, building interpersonal relationships, establishing team identity, clarifying roles, or improving processes. The categories are listed in Table 15–2, along with examples of each. We also discuss a popular setting for many team building activities, the team retreat. The team retreat can cover many or all of the different types of team building. It is discussed separately due to its popularity.

Clarifying Goals

A basic foundation of team effectiveness is a shared goal or set of goals, understood by all members. New teams need to directly develop this shared understanding, and long-standing teams need to revisit this shared understanding as membership changes or as goals shift. Relevant team building events can be as simple as an agenda item to review the team’s goal (or charter, mission, vision, or values) and going around the room to make sure there is understanding and, ideally, buy-in, on the part of all team members. Such an activity seems indicated for Dr. Richter’s long-term care patient management team in the opening vignette.

To clarify a team’s goal more comprehensively and collectively, a designated team member or the team leader (or team sponsor) can lead a more formal exercise, typically occupying a full meeting. First, someone reads and explains the team goals. A set of questions is then discussed regarding the goals, with each question receiving separate attention. The team then could be divided into sub-groups for discussion purposes, with groups assigned different questions and reporting back to the full team. Questions such as the following allow for probing and understanding of team goals (Scholtes et al, 2003, p. C-28):

1. Is it clear what our sponsor expects of us?

2. Where do we fit in the larger scheme of things? Is our team a priority of the sponsor?

3. Are the boundaries of our work clear? What is outside our jurisdiction?

4. What resources do we need?

5. Does our goal make sense to us based on our knowledge of the area?

6. Do we have the right people on the team to accomplish the goal? What other people who are not on the team will be crucial to our efforts?

7. Who will support us in our efforts? Who will be opposed? Who will be neutral? How should we communicate with them?

Unanswered questions should be assigned out for investigation and follow-up discussion.

Building Interpersonal Relationships

Historically, most team building interventions have focused on building relationships among team members. Building interpersonal relationships typically begins with “ice breakers” for team members who do not know each other. Ice breakers are useful for new teams or teams that need to bond quickly or when members come from quite different backgrounds. Sharing simple information about each other begins the process of establishing a relationship. Dr. Richter’s long-term care patient management team (in the earlier vignette) likely would benefit from members sharing some personal information about each other.

Ice breakers come in endless variety, from members taking turns sharing one little known fact about themselves to members meeting in pairs and then introducing each other to the group. One ice breaker exercise has each member answer 4 questions in writing (Biech, 2008, pp. 419-423). Answer sheets then are collected and read aloud, after which the members record their (silent) guesses on paper as to who gave the answers. Then the correct identifications are announced. The 4 suggested questions are:

1. The one thing that nobody in this room realizes about me is…

2. My favorite leisure activity is…

3. A perfect day for me would be to…

4. The actor or actress who should portray me in the movie of my life is…

Any number of other questions, customized to team members, would fulfill the same purpose.

Other relationship-building activities go beyond the ice breaker stage, involving members in a shared activity where teamwork is needed. An Internet search reveals hundreds of such team building activities, including competitions around cooking, golf, building catapults, game shows, and transporting marbles along pipes, or shared experiences, such as ropes courses and other obstacle courses. Some of these activities will seem very pointless (or unprofessional or inane) to many scientists and healthcare professionals, so it is important that team members participate in the design of the activities and that team leaders know their members and tailor activities to their preferences. At worst, some team building activities can waste time, embarrass team members, and even cause physical injuries (for example, paintball games can do some damage). They can create resentment due to lost time and resources spent on the activity.

Social events are additional examples of team building activities that can strengthen bonds among team members. Again, social activities need to be tailored to the team members’ time constraints and preferences. Team leaders often learn through trial-and-error the preferences of their team members on the timing and type of social activity that adds value. In Chapter 6, a primary care team, Red Family Medicine, is described. This team had a positive social climate. Each summer Red Family Medicine held a picnic which included joke awards that expressed caring and humor. Social events may or not be appropriate for a team, depending on the permanence of the team and the need for strong bonds among members.

More intensive relationship-building activities begin to cross into the arena of team training. Members can complete behavioral profiles and share self-assessments of traits and preferred styles. Ideally, behavioral profiles give members a reliable and objective means to reveal their strengths and weaknesses and supply a common vocabulary for team members to communicate differences and similarities. Usually, profiling questionnaires should be administered, analyzed, and debriefed by a qualified consultant or trainer. Often, sharing of results within the team aids understanding of different interaction and work styles (Amos et al, 2005).

There are many profiling tools, including StrengthsFinder (strength.gallup.com), Insights Discovery (www.insights.com), and DiSC (www.inscapepublishing.com). DiSC places individuals into one of 4 behavior styles–dominance (direct and decisive), influence (optimistic and social), steadiness (cooperative and supportive), and conscientiousness (cautious and concerned). All individuals possess all 4 styles but differ in the strengths of each. Insights Discovery similarly uses 4 major categories of temperament, matched with colors—fiery red is driving and aggressive, cool blue is formal and deliberate, earth green is caring and relaxed, and sunshine yellow is enthusiastic and sociable. StrengthsFinder identifies areas where an individual has the greatest potential for building strengths based on recurring and consistent patterns of thought, feeling, or behavior. Examples of the areas, which are 34 in number, include: learner (having a great desire to learn and wanting to improve continuously), positivity (having an enthusiasm that is contagious), achiever (having a great deal of stamina and working hard; taking great satisfaction from being busy and productive), and competition (measuring progress against the performance of others; striving to win first place or finish first).

The Myers-Briggs Type indicator (MBTI) is a popular choice for behavioral profiling in professional teams (Quenk, 2009). The MBTI has relatively well-established and adequate psychometric properties. The MBTI classifies individuals into one of 16 types based on the 4 dimensions of introversion-extroversion, sensing-intuition, thinking-feeling, and judging-perception. The types are preferences, with no type better or worse than the others. The MBTI or variations of it that focus on team roles can be useful in launching discussions of team members’ preferred styles. For example, extroverts are more likely than introverts to speak up in discussions and to enjoy brainstorming. Perceiving types pay less attention to deadlines than judging types. Since interpersonal conflicts often are related to personality type, knowledge of others’ preferences can decrease the likelihood of interpersonal conflict on the team. As well, members can be better matched with tasks depending on their personality traits. For example, compared to most other MBTI types, the Introvert-Sensing-Thinking-Judging (ISTJ) type likely would enjoy tasks requiring extreme attention to detail.

As discussed in Chapter 6, trust in teammates is an important attribute of team members that often is lacking, particularly during the forming and storming (early) stages of new teams. (The stages of new teams are examined in Chapter 8.) Interpersonal trust can be influenced by team building activities. Generally, team building activities to develop trust involve experiential exercises or sharing of personal vulnerabilities. Experiential exercises to develop trust include ropes courses, which involve climbing a rope then being lowered to the group by a teammate, and similar recreational challenges that require dependence on teammates, such as ascending a tall ladder with a partner (all with appropriate safety equipment, of course). The “trust fall” exercise involves a team member falling backwards from table height into the arms and hands of the other team members. We do not recommend this one, for health reasons among others.

One expert, Patrick Lencioni, argues that sharing of vulnerabilities is essential to the development of trust (Lencioni, 2005). Lencioni recommends that in an off-site location, teams go around the room with each member explaining where they grew up, how many siblings they had, and the most important challenge of their childhood. He argues that such sharing can be handled by most individuals without embarrassment and that it is an efficient way to develop empathy. Many healthcare professionals may be uncomfortable sharing feelings, and some degree of facilitation expertise is required for this type of team building exercise. For example, some members may discuss particularly painful memories. Other questions, such as best job and worst job, or biggest mistake at work, can provide a basis for sharing vulnerabilities. The key is to have people reveal something personal about themselves that is relevant but not embarrassing or silly. Guidelines on time per person, such as 1-2 minutes, are helpful, although they need not be strictly enforced.

Establishing Team Identity

A strong team identity, and related characteristics that contribute to identity, such as common values, processes, and shared goals, are critical to team effectiveness (see Chapter 6). Team identity ideally is established early in the development of a team, but if it is not, or if turnover creates uncertainty about identity, team building activities can help. Earlier in this chapter we addressed activities to build shared goals. Other activities to build identity include honoring team history, telling team stories, celebrating team accomplishments, and designing team symbols.

Honoring Team History

Busy teams rarely take time to document their history. Simple information like founding date, team composition, major events, and changes in membership and leadership can be recorded in an “About” section of a website, or in paper documents. Even for template teams, a history of the team’s accomplishments, which could be publicized to the pool of potential team members, establishes permanence of purpose and respect for members. Recording membership may not be of major import to past members, but it signifies to current members that their contributions and legacy are valued.

Telling Team Stories

Telling stories about the team lends legitimacy to the identity of a team, and it conveys that aspects of the work of the team will be communicated into the future and to new members and perhaps even to outsiders. Team stories might reveal special actions of a leader or sponsor to save the team, for example, or efforts “beyond the call of duty” on the part of a team member to further team goals. Selfless service to the team can be memorialized through team stories.

Celebrating Team Successes

Publicizing team activities and accomplishments (as opposed to individual member activities and accomplishments) promotes pride and team identity. Team sponsors and leaders should take the lead in communicating and praising team accomplishments, but if they are not actively doing so, other team members can assume that function. A specified physical site (like a bulletin board) or website can be used to store team history and accomplishments. Organizations that promote teamwork are careful to recognize team accomplishments in order to build teamwork into organizational culture (see Chapter 18).

Designing Team Symbols

Symbols of the team convey meaning to members that they belong to the same unit. Recalling the Red Family Medicine vignette from Chapter 6, that team went through a stage where several member wore an article of red clothing on “Ruby Tuesdays” to indicate pride of membership on the Red Team. The practice gradually faded away, after having served a team building function. Requiring the practice would have been counterproductive. In addition to the occasional piece of symbolic clothing, of course, Red Family Medicine had its own distinctive name. Red Family Medicine also could have developed a team logo, or a team slogan or motto. Symbols of team identity include names, logos, mottos, or physical objects that have meaning to team members. Symbols generally should be developed or approved by team members rather than imposed. Distributing baseball caps to team members who never wear caps may just invite concern over the wasted investment. Shirts with a team logo or motto are a popular option. Leaders need to involve team members or know their members well enough to select appropriate symbols that will have meaning and will not be viewed as wasteful.

Clarifying Roles

Symptoms of the need to clarify team roles include widespread conflicts around responsibility for particular tasks. Or, members may wonder what other members are contributing to the team and may suspect that the others do not understand their contributions. Occasionally, a crisis will occur when everyone thinks someone else is responsible for handling a task that falls through the cracks. Role clarification issues are more common in new teams, teams with high turnover, and teams that do not meet frequently, causing members to feel isolated (Dyer et al, 2007, pp. 122-123).

Goals of a role clarification exercise are that members emerge with: (1) a clear understanding of their own roles, (2) comfort that other members understand their roles, and (3) an understanding of what others expect of them. A formal means of role clarification is the following exercise (Dyer et al, 2007, pp. 126-129):

1. Going around the room, each member takes turn being the focal member, describing her or his role—what is expected, when it is expected, and how it is expected to be done.

2. Clarifying questions from other members follow, after which other members indicate that they understand the focal member’s role.

3. Finally, the focal member talks directly to each person in the team, specifying what he or she needs from the other member.

Researchers claim that this is one of the easiest and most effective team building exercises (Dyer et al, 2007, p. 127). A similar exercise, labeled role negotiation, has each team member post a list of her or his principal activities (West, 2012, pp. 100-101). Other team members write on the list, indicating whether they think the focal member should do more, do less, or maintain each activity at the present level. Comments are signed. Pairs of team members then discuss the end results.

A less comprehensive exercise, the responsibility matrix, helps teams identify and assign responsibility for tasks to appropriate team members (Scholtes et al, 2003, pp. C-11 to C-12). The activity begins with the identification of tasks that are not clearly assigned to a team member or set of team members. Together, the team creates a list of unclear tasks. The list is posted or circulated, and team members record whom they believe is responsible for each task. Finally, the team collectively discusses each of the tasks and the responses from team members. Team members must reach a consensus on each task assignment.

Improving Teamwork Processes

Chapter 16 covers methods of improving team performance by using formal process improvement methodologies. These could be considered team building activities. In addition, less formalized interventions can help build the team’s capacity to process information, solve problems, and make decisions.

To identify potentially problematic patterns of interaction within the team, individual team members can be assigned to observe team processes during a meeting, watching for specific behaviors, and taking notes. At a designated point in the meeting agenda, the observers then report findings, and the team discusses the observations together. Observers should have clear guidelines about what they are looking for, and the measured behaviors should be explained to the team in advance. Examples of such checklists are available (Scholtes et al, 2003). Observers can record the types of contributions made by members, for example, or record the pattern of interaction during a team meeting.

Confronting Disruptive Behavior

Team processes may be hampered by members holding side conversations, reading during meetings, talking at length, or other potentially disruptive behaviors. Such issues can be addressed by team building activities. In one disruptive group behavior exercise, the team develops a shared understanding for acceptable team behavior through agreement on how to manage group problems, how much disruptive behavior is allowed, and how much a leader can do to deal with a problem (Scholtes et al, 2003, pp. C-16 to C-18). The activity is best used after the second or third meeting of a new team, when team members are more familiar with one another, or when team member’ behaviors begin to disrupt team activities. The exercise should be introduced to team members as a method of creating guidelines for meetings and developing ways to manage disruptive behavior. The exercise begins with brainstorming about behaviors that may disrupt team activities. (See Chapter 10 for a discussion of brainstorming.) Voting reduces the list to a manageable number. The team then discusses possible responses to the behaviors, ranging from prevention, to minimal intervention, to strong intervention. The team reaches consensus on ways to deal with the key disruptions. The activity sensitizes team members to pay attention to the flow of their meetings and other team activities, and encourages them to confront and manage disruptive behaviors.

Managing a Problem Team Member

Sometimes disruption of team processes is due to the continuous actions of one or more problem members. Such team members consistently may miss team activities, take a negative position on team consensus issues, or fail to complete their tasks. A first consideration is to consider the value that challenge can bring to the team, particularly in the form of creativity. A certain degree of task-related disruption through questioning can be healthy for the team. (Chapter 10 on creativity discusses this in more detail.) However, if the disruption is persistent and does not provide value, then some action is often warranted to stop the disruptive behavior. In Chapter 17, various options are discussed. In extreme cases, it may be necessary to remove the member from the team. This often requires support from the team sponsor.

Retreats

For the first time, Russell MacIntyre, MD, a psychiatrist, left a team retreat with a feeling of accomplishment. His adult behavioral health team held annual retreats whether they needed them or not. Under the team’s previous leader, a psychiatrist colleague of Dr. MacIntyre’s, retreats were occasions for promoting pet ideas and surprises that his colleague had run across in his readings or travels. The leader fancied that the team would enjoy and benefit from her pet ideas. Last year, for example, 6 hours of “authentic engagement” exercises were the main activity at the all-day retreat, which was preceded by a long dinner the evening before. The exercises were embraced by a small minority of team members, mostly newer ones, while Dr. MacIntyre and the majority of his fellow teammates looked for excuses to check their voicemail or take a long walk. He felt that he already knew his teammates well, maybe too well.

Recently, psychologist Miriam Adelman, PhD, had assumed the team leader role. Unlike her predecessor, Dr. Adelman solicited team feedback to guide the content of the retreat, well in advance of the retreat. Most of the retreat was spent debating the merits of a relatively new therapy for depression, vagus nerve stimulation, and whether or not to add a team member who had knowledge of that therapy. Social time consisted of a short luncheon.

A follow-up survey and team discussion (another new activity implemented by Dr. Adelman) would confirm whether Dr. MacIntyre’s conclusions were shared by other team members.

Retreats are extended team meetings, typically held away from the work location and lasting anywhere from several hours to several days. At retreats, social activities frequently accompany review of the team’s performance, problems, and opportunities. Retreats often are useful in the start-up stage of team development, because accelerated progress can be made on a variety of foundational issues, in a short time period. Some teams use annual retreats to review performance and plans. Other teams use retreats to examine issues that are “stockpiled” or “put in the parking lot”—issues that deserve intensive examination but cannot be addressed during normal operations.

At worst, retreats can be a major source of dissatisfaction in teams, if members conclude they are a waste of valuable time. Dr. MacIntyre and many of his colleagues in the adult behavioral health team in the vignette held that view of retreats for their team. This is very common but largely preventable. Several guidelines increase the probability of successful retreats (Clevenger, 2007). Table 15–3 outlines the guidelines. First, team members in addition to the leader should plan the retreat, with the help of an outside facilitator if needed. Team members should own the retreat. Second, attendance should be required, particularly of all key players. Scheduling to allow for maximum attendance is critical. If members are reluctant to contribute full days, a one-half day retreat still can be useful. Retreats generally should be held away from the normal workplace, to minimize work distractions and provide a degree of symbolism of the importance of the event. The location needs to be accessible, though.

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