This chapter will explore leadership and its role in the support of teams and team working. Leadership is not a solo activity, and many skills are required for leaders to deal with team development and task completion such as motivation, conflict resolution, clinical decision‐making, innovation and addressing change. Leaders who are successful gain a personal insight and grasp of their own values and beliefs, their personal strengths, and weaknesses and how to marshal their team’s strengths. Indeed, the leaders’ capacity to recognise the strengths and limitations of their team and how to build, develop or maintain effective teams is vital. In modern healthcare environments, ideal teams are rare. The reality is that teams commonly struggle to maintain success (Lencioni 2002; Cantwell 2015). They may appear cohesive but are often made up of people who are unsupportive, uncooperative and in competition, have personal grudges and are in open conflict, and as a result, talented, skilled people, frustrated by the limitations of a poorly performing team with poor leadership, fail to deliver their best work. Team working can be very difficult to get right and although challenging to achieve, team working remains one of the best ways to organise people and tasks (Lencioni 2002; Pedler et al. 2004; Kalisch et al. 2010; Marlow et al. 2016). Falcone et al. (2008), Capella et al. (2010), Siassakos et al. (2011), Deering et al. (2011) and Steinemann et al. (2011), support Borrill et al. (2000, p. 371) who suggests that “good teamwork can make a critical contribution to effectiveness and innovation in health care delivery and contributes to team members’ well‐being’.” The ability to work in teams is highly prized as a valuable organisational asset and team working feels right because this is what we have grown up with in our educational systems, sports clubs and early life experiences. Indeed, team working is a feature of our deep history with teams used in hunting and conflict representing our cultural development for millennia. Effective team working is also identified as a requirement for enhanced clinical outcomes (Leggat 2007; Lyons and Popejoy 2014) and recognising the need for team working skills is particularly important in an organisation where “customer” service is important (Handy 1999). This is because often teams can make the best local decisions and are becoming largely self‐managing (Elloy 2008). Organisations where teams work well have a common purpose, a culture of trust, support, interdependence and collaboration. This chapter considers why team working matters from a nursing perspective, considers the value of support and challenge in helping teams work well and provides an overview of effective and ineffective teams and the role of a leader in managing conflict. The World Health Organization (WHO 1988, p. 6) defined a healthcare team and teamwork in the following way: Health team: A group of people who share a common health goal and common objectives, determined by common needs, to the achievement of which each member of the team contributes, in accordance with his or her competence and skill, and in coordination with the functions of others. The manner and degree of such cooperation will vary and has to be determined by each society according to its own needs and resources. There can be no universally applicable composition of the health team. While dated this definition indicates that there is no clear one way to define a healthcare team, and it alludes to the goal of creating greater inter‐professional interaction within healthcare teams. Stanton and Chapman (2010) add that teams achieve their best through interdependent collaboration, open communication and shared decision‐making, and they add that the notion of working in teams, within healthcare, instinctively feels good and particularly so in relation to a multidisciplinary and patient‐focused context. As ideal as teams may be, it is also clear that getting teamwork right can be difficult or challenging. Frequently team members are not supported, ill‐coordinated and uncooperative, lack open, honest or collegial relationships and fail to work well to build cooperation or complete tasks successfully. Teams are not always needed, as some tasks can be done through good allocation of work to individuals or carried out by a group working more or less cooperatively (Lessard et al. 2008). Teams are not really needed if the task relates to a simple exchange of information, if it involves simply sharing out work, updating each other and/or making simple operational decisions. These interactions relate mainly to reference and consultation groups with low levels of interaction, requiring only clear lines of communication (Lessard et al. 2008). Teams are needed if the work is uncertain, difficult and complex, or where a high degree of collaboration and interdependence is required (Casey 1993; Stanley and Stanley 2018). A group is defined as a number of individuals assembled together or having some unifying relationship (e.g. members of a club). These are groups because all the various members are related in some way to one another because of their involvement in a certain endeavour. A team is described as a number of people associated together in specific work or activity. Parker (1990) indicates that a team is based on a highly interdependent set of people that: Added to this are the ideas that teams work best if they recognise the value of: The attributes of effective teams include the following: It is suggested that organisational culture has come to be seen as an important factor in the adaptability and performance of healthcare institutions (Meterko et al. 2004; Creighton and Smart 2022). Moreover, the degree of emphasis placed on teamwork and collaboration appears to be a pivotal dimension of organisational culture; for example, studies have shown that hospitals with a culture emphasising teamwork were able to further advance in their efforts to implement quality improvement processes (Shortell et al. 1995; Rathert and Fleming 2008; Hood et al. 2014; Stanley and Stanley 2018; Algunmeeyn et al. 2023). In another study of rehabilitation teams, Strasser et al. (2002) demonstrated that work cultures accentuating teamwork were associated with more effective rehabilitative professionals. In another study by Gifford et al. (2002), examining the obstetric units of seven hospitals found that an effective teamwork culture was associated with a lower turnover of nurses. It is also worth noting that teams construct their own internal culture and therefore occupy the position of a subculture within the larger culture of the organisation (Seago 1996). Understanding this and assessing team effectiveness can sometimes facilitate useful insights into the nature of team difficulties. Understanding the connection between organisational cultures, with a focus on the value of teamwork, and improvements in a number of team performance indicators show that a strong relationship between patient satisfaction and a teamwork culture existed over other types of workplace culture (i.e. entrepreneurial, bureaucratic and rational) (Meterko et al. 2004; Creighton and Smart 2022; Indeed.com 2023), supporting the aim of the WHO (1988) to build workplace teams that enhanced patient satisfaction. There are a raft of studies that have focused on the benefits of inter‐professional learning as a tool to facilitate greater attitudes towards teamwork in the clinical environment (Balmer et al. 2010; MacDonald et al. 2010; Newhouse and Spring 2010; Deering et al. 2011; Hood et al. 2014; Al‐Sabei et al. 2022; Algunmeeyn et al. 2023), and it is clear that health professionals who learn together will find better ways to work and communicate with each other. Jelphs and Dickinson (2008) and Markiewicz and West (2011) suggest that for a healthcare team to function effectively, it can only be accomplished with collaboration, interdependent working, effective communication and decision‐making that is shared among the team members (including the clients). To achieve this, it requires several health professionals with complementary skills, common goals and the employment of a dynamic process to assess, plan and evaluate patient care (Creighton and Smart 2022). They add that this approach to healthcare team working should result in better care and add value to organisational and staff‐related outcomes (Jelphs and Dickinson 2008; Andersen et al. 2010; Kalisch and Lee 2010, 2013; Al‐Sabei et al. 2022). Leggat (2007) and Dawson et al. (2010) suggest the majority of healthcare workers work within team‐based structures, but they may not work in effective teams. Healthcare teams could develop into pseudo‐teams that are large, have a weak or non‐existent requirement for interdependent working, fail to meet regularly and have few or no shared goals. Dawson et al. (2010) suggests that while 90% of NHS staff reported working in teams, less than 40% of them reported working in effective teams. If teams are to function well, they need the right mix of people with diverse skills, who communicate effectively, manage conflict well, and know and are all working towards common goals. Established teams usually fall into three or four basic sets. These are: These teams need little more than recognition and resourcing; they have established good working habits and address their own learning and development needs. They have “synergy” and an “all‐hand” culture (Leanne 2010), with the rules for creating synergy related to: Rath and Conchie (2008) support these ideas and suggest that strong teams have these key attributes in common. These include a commitment to areas of their lives beyond the team, healthy debate within the team so that conflict is used positively and not avoided (Dunlap 2010; Leanne 2010), an eye for the big picture or organisational goals, and balancing their work and personal lives successfully. In addition, Rath and Conchie (2008) and Leanne (2010) propose that high‐performance teams embrace diversity and act as magnets for talent, with their success acting as an attraction for other talented people. These suggestions were confirmed in a study by Rathert and Fleming (2008) who found that clinicians who perceived the ethical climate to be benevolent (supportive, encouraging and blame‐free) had significantly greater teamwork in their teams. High‐performance or effective teams also demonstrate effective team cohesion and greater focus on their common goal. Effective teams are also described as self‐directing, having shared authority and decision‐making and appearing leaderless at times. It has also been proposed that high‐performing teams, where a climate of excellence already exists, use their excellence as a liberating force to support further innovation and generate a cycle of team interaction that leads to further excellence (Eisenbeiss et al. 2008). While strong teams are desirable, they can have negative aspects too: becoming exclusive, complacent, competitive and big‐headed, or they may lose sight of the big picture and focus on their own goals. They may build power through loyalty to the team and create barriers and competition with other teams to the detriment of the organisation, holding on to their own staff, stifling adaptability or innovation and rejecting newcomers. Thus, the balance between the potentially positive and the potentially negative issues need to be monitored carefully for success to be sustained. These make up a large number of teams. Some may need no intervention while others need constant intervention to keep them functioning well. They might not work brilliantly, but they work well and have a competent balance. These teams may have tried and tested ways of addressing problems but lack the confidence to try new approaches. They are often based on traditional hierarchical structures with a traditional supervisor/subordinate relationship. They may have formal communication and authority lines, and these teams can be recognised right across the health service. It is suggested that these sorts of teams are good at puzzles. These are made up of people with skills in the teams that know the way to find the answers. However, they may struggle with complex problems, lack confidence or struggle to create new partnerships and motivate each other, and fail to act collectively or collaboratively. Leadership in these teams is commonly shared, but members from a dominant professional group (such as medicine) may feel they have leadership authority (Sangvai et al. 2008; Cherry et al. 2010; Stanton et al. 2010), and some professionals may continue to focus on their own and not the overall team goals. Struggling teams face the biggest challenges and may offer the closest reflection of a pseudo‐team. They may fight turf wars within the team, have individuals that avoid work activities that will make them look bad, avoid disagreement and plain speaking, support “consensus” decisions that nobody wants and have poor‐quality leadership, poor personal relationships and unresolved conflicts. The main issue is often a lack of trust or commitment or as Algunmeeyn et al. (2023) identify there may also be issues with professionals misunderstanding other roles, or a lack of inter‐professional socialisation or team working (Al‐Sabei et al. 2022). Teams not committed to working together will not learn together and will often fail to develop. These teams lack a collective output, with Lencioni (2002) suggesting that there are five key areas evident in struggling teams. These are: Grenny (2010) adds that one reason teams may struggle is if they are “virtual” or if members are located in disparate sites. These sorts of teams are becoming more common in the business world and even in healthcare, with the advent of tele‐health and other electronic media. To combat this Grenny (2010) recommends that even more effort is required to create team identity with a focus on mission, values and operating rules. In addition, communication skills need to be enhanced and supported, with greater social contacts established and fostered, motivation being monitored and rewarded appropriately and team performance being tracked on a daily or weekly basis. If teams are not working well, it may be that the team as a whole is failing to function, or it may be that there are some pernicious individuals within the team that are – through bullying or controlling behaviour – bringing the contribution of the whole team down (Mikaelian and Stanley 2016). Assessing the core problems with struggling teams is vital before taking action, because if the issue is that of destructive individuals, reforming the team without addressing them will only transfer the problem to the newly created team, making its formation a more difficult process. Dubnicki (1991) developed an excellent team assessment questionnaire to facilitate a team’s self‐evaluation of their roles, activities, members’ relationships and the work environment. Used correctly, this tool can be used to support an assessment of the success or otherwise of a team and identify areas where remedial action needs to be applied. These teams are often given a broad set of goals or objectives and then allowed to “get on with” the job of addressing them without the traditional manager or supervisor oversight. These “leaderless” teams are commonly referred to as self‐led or self‐managed teams. Of course, they are not “leaderless” as the leadership responsibilities are simply devolved to the team, so that the team assumes responsibility for its own systems, processes and “management” duties. In many respects, this is fulfilment of “followership” crossing over or amalgamating with leadership roles (Kellerman 2012; Raffo 2013; Malakyan 2014). Hurst et al. (2002) evaluated a set of integrated self‐managed community health teams in the United Kingdom and found that these teams faced a number of barriers, including a loss of “corporateness” (associated with the previous structure) and poor communication processes as information struggled to cascade to the teams from “the top” of the organisation. However, the benefits were that teams enjoyed greater autonomy in decision‐making, felt they had greater cohesion and felt that at a local “team” level the communication was more positive, and they undertook greater inter‐professional sharing of health information and team working strategies (Hurst et al. 2002, p. 478). These benefits were supported by Stoker’s (2007) study of leadership in self‐managed teams, where flexible and supportive leadership styles were found to increase the effectiveness of individual team members and support an increase in team autonomy (Smama’h et al. 2023). Self‐led teams, sometimes referred to as “team leadership” (Jones and Bennett 2018), offer a “flat” structure (unlike the hierarchical structure of “traditional” teams and foster the engagement and participation of followers in the activity of leadership more easily) and the leadership approach required to support a self‐managed team is also different with leaders in self‐led teams needing to focus on trust building, effective communication, giving feedback, goal‐setting activities, encouragement of innovation and decision‐making (Elloy 2008). It should be noted that leaders operating within a team leadership model or in self‐led or self‐managed teams need to ensure trust, stability, compassion and hope to ensure that leaders can answer the question in this context of “why would anyone want to follow me?” Traditional teams required these factors to be addressed too, but in self‐led teams these are the factors that appear to link directly to success and team effectiveness (Jones and Bennett 2018). Self‐directed teams excel at using their team members’ differences and sharing the team resources and assets to their overall advantage.
6
Leadership and Teams
6.1 Introduction
6.2 Healthcare Teams Defined
6.2.1 A Group
6.2.2 A Team
6.3 The Value of Teamwork
6.4 Types of Established Teams
6.4.1 High‐Performance Teams
6.4.2 OK or Functional Teams
6.4.3 Struggling Teams
6.4.4 Self‐Led Teams
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