Team Building and Working with Effective Groups

http://evolve.elsevier.com/Huber/leadership/

Nurse leaders in today’s health care organizations must be skilled group facilitators with an exquisite ability to manage and lead the collective work of people. A significant percentage of work completed in organizations today is done through collective efforts, either in work groups, committees, or teams. Understanding the characteristics of each of these entities and basic principles for attaining successful outcomes increases the leader’s effectiveness.

In years past, many health care organizations attempted to convert their traditional hierarchical, bureaucratic structures to a team-based structure, with varying degrees of success. Many of these efforts were less than successful at the broad organizational level; yet the factors driving these changes still exist. There is vastly increased complexity of both today’s workplace and the work of patient care. Teamwork has become the imperative for leaders today because the level of knowledge required to meet the demands of both patients and systems of care requires collective pooling of thinking styles, diversity of professional backgrounds, and the collaboration of many. Rapidly changing structures of care delivery and reimbursement protocols, increasing governmental regulations, increasing complexity, technology advances, rapid information dissemination at the worker level, and the shift to a knowledge worker–based service society are some of the social and economic forces operative in health care. These forces converge to create tumultuous change in health care delivery.

Employees who work in a collaborative manner with others and who are able to work effectively within a team context can provide the strength, structure, and resiliency to deal with work complexities and changes. Today’s health care organizations are considered knowledge organizations, and there is a renewed emphasis on the role of teams. Although interdisciplinary teams have always played an important role in home care, hospice, and other community settings, hospitals and large health care organizations are placing more emphasis on teams as a part of their core structure and the general way of doing business.

“Knowledge has become so complex and specialized that virtually no single individual can be effective alone” is still true today (Sorrells-Jones & Weaver, 1999, p. 15). Because knowledge workers are specialists, the only way for them to be adequately productive is to work in groups or teams. Thus as the focus shifts to building knowledge work teams, today’s leaders must be able to help these teams be more effective and productive.

Developing effective teams of professionals from different disciplines is challenging. However, effective knowledge work teams can create a form of synergism in which the outcome is greater than the sum of individual efforts. Such synergism confers a competitive edge and boosts productivity under conditions of constrained resources. Teams are a way to enlist employee participation and capitalize on possibilities for improved patient safety, increased productivity, better decisions, and process innovation. Team building is a strategy for designing, implementing, developing, and nurturing work teams in organizations. These work teams are a specialized subset of the many types of groups that form or are formed in organizations.

In nursing, group process theory relates to both how to be therapeutic with clients and how to work as an employee within an organization that is often large and complex. Nursing has at its core both a caring and a coordinative function. The nurse’s coordinative role is at the hub of all client care information. For example, nurses collect, process, and integrate the initial assessment and laboratory data; handle the tracking of all therapeutic interventions for the client; are at the bedside in hospitals for surveillance of minute-by-minute changes; and are the major point of contact for clinical care delivery in many settings and sites. For example, if narcotics are given in a hospital, nurses track whether that intervention has worked, whether alternative pain strategies might be needed, and what psychological reaction the client might have. Even hospitalists who may see a patient multiple times in a day may not recognize the fine distinctions of change in a client’s condition. Nurses predominate in actual client care in home health, long-term care, hospice, and many other settings. The nurse is involved more intimately and more proximately than any of the other health care providers in managing the total health care of the client. Therefore understanding and developing skill in group process and group dynamics is essential within the context of leadership and management in nursing because of the group functioning and coordinative aspects of nursing practice. Nurses need strong group process and interaction skills to communicate clearly and collaborate effectively with a variety of colleagues.

DEFINITIONS

A group is defined as any collection of interconnected individuals working together for some purpose. Groups are important in organizations not only because of informal network dynamics but also because of the multitude of formal committees and teams in the contemporary organization.

A committee is a relatively stable and formally composed group. Committees are a specific type of group in that they are stable, meet periodically, and have an identified purpose that is part of the organizational structure. There is a mechanism for maintaining and selecting members. Typically, committees have official status and sanction within an organization. For example, there is a policy and procedure committee or a patient safety committee.

Team building is defined as the process of deliberately creating and unifying a group into a functioning team.

A team was defined by Katzenbach and Smith (1993) as “a small number of people with complementary skills who are committed to a common purpose, performance goals, and approach for which they hold themselves mutually accountable” (p. 45). Manion and colleagues (1996) modified this definition slightly for health care by noting that the members need to be consistent. This was in reaction to confusion in terminology for many people in health care who had prior knowledge of team nursing, in which whoever was present on a given shift was on the team. In this type of team nursing model, members could vary from shift to shift and from day to day, reducing the overall performance outcomes of the team. Team nursing was an assignment pattern and work allocation methodology rather than a true team model as seen in business and industry.

The distinction between a work group and a true team is crucial. Health care leaders may mistakenly assume that simply calling a group a team actually makes it a team. As Katzenbach and Smith (1993) emphasized, the group becomes a true team only by doing its collective work. The team goes through a developmental process that takes time and the investment of energy to materialize. Many collective entities in today’s organizations are called a team yet clearly function more as a work group than a true team.

A work group is a collection of individuals who are led by a strong, clearly focused leader. They come together to share information and ideas, and they may even mutually make some decisions. However, the members of the work group have individual work products for which they are responsible, and these consume their major focus and effort. For example, in a patient care unit, the unit secretary has certain responsibilities as does the charge nurse, patient care nurse, and nurse manager. The boundaries remain fairly clearly separated when the collective entity is a work group. Each person may feel individual accountability, but there is little to no collective accountability.

This is in contrast with a true team, which is a collective entity in which the leadership rotates and is shared by various members of the team, depending on appropriateness and fit of skills and abilities. In a true team, there are collective work products—for example, the provision of quality patient care to all of the patients housed in the department. There is group as well as individual accountability. If one member of the team is having a problem, it is not just that person’s problem but, rather, is the problem of and for the whole team to resolve. An example of team thinking is “No one sits down until we can all sit down” or “No one goes home until we all go home.” If quality outcomes are difficult for one team member, all team members are affected by this and become engaged in helping the affected team member meet expectations. In the management book The Goal (Goldratt & Cox, 2004), the author tells a parable about taking a Boy Scout troop on a hike. When it was discovered that Scout Herbie was slowing the whole group down, the weight in his backpack was redistributed and the troop sped up. This is how a high-performing team works.

Another collective entity apparent in many organizations is a pseudoteam. This is a group of people who believe they are already a team, although clearly they fall short of the definition of a true team. Characteristics of a pseudoteam include confusion over their purpose, unhealthy or toxic interpersonal issues and communication patterns, members who put individual needs and ambition above the needs of the team, the presence of hierarchical rituals that preclude full participation of all members, unclear goals, and a lack of evaluation criteria. The true danger of pseudoteams is that members think they are already a team and thus see no need for improvement. As a result, they do not grow and develop but, rather, just become more and more dysfunctional with the passage of time.

BACKGROUND

Group interactions are a pervasive element of the health care environment in which nurses work. A basic understanding of groups helps nurses function more effectively. These principles apply to any group, whether an actual team, a committee, or an informal group effort. Group interactions are composed of the following elements (Book & Galvin, 1975) (Figure 8-1):

FIGURE 8-1 Group process elements. (Data from Book, C., & Galvin, K. [1975]. *Instruction in and about small group discussion*. Falls Church, VA: Speech Communication Association.)

• The process that the group undergoes to reach outcomes: This relates to the unique way the group interrelates and begins to work together. The leader can assess group process through observation. What is the process that occurs while accomplishing its task?

• The standards that regulate the group’s behavior: This relates to the specific values and norms that are chosen for group processing. Which ones are chosen and which are discarded?

• The process of problem solving or decision making that the group adopts: Does the group solve problems? How are decisions made? Are they group decisions made by consensus, or are they individual decisions made with group input (as occurs when the group participates but the decision is made by a leader or manager)?

• The communication that occurs among group members: What are the internal patterns and styles of communication used by group members? To whom does the group communicate? Do they report as a subcommittee to a full committee? If a team, does the team have frequent communication with external team leaders? What are the internal and external modes of communication for group input and output?

• The roles played by each member: Members will adopt a variety of group roles within the group, but roles are fluid. Members may take on different roles in different situations. It is important to remember when assessing group interactions that roles in the group may be formal roles, clearly established by the leader or the group. However, there are additionally roles that each group member moves in and out of that best suit him or her (such as clarifier, harmonizer, devil’s advocate, etc.). Clarity in the more formal roles such as team leader, facilitator, recorder, and timekeeper is important to avoid confusion and unnecessary conflict.

Groups tend to go through a series of stages in their work and development. Farley and Stoner (1989) originally identified these as (1) orientation, (2) adaptation, (3) emergence, and (4) working. The first stage, orientation, occurs when the group first forms and the members begin to relate to one another and the task. The group needs to develop trust and define boundaries in order to establish involvement and identification. The second stage, adaptation, occurs as the group begins to develop a collective identity and differentiate roles. The group needs a facilitative structure and climate to maximize its processing and to work through the establishment of roles, rules, norms, and a common language. The third stage, emergence, occurs as control issues arise. Disputes, disagreements, confrontations, alliances, and power struggles mark this stage of determining control over the group in order to emerge with a more consolidated identity. The final stage, working, occurs when conflict and dissension dissipate and the group achieves greater cohesion through negotiation. The group is now focused primarily on decision making and productivity. The stages may overlap and are not necessarily sequential. The group leader pays attention to the stage of the group as a way of monitoring the group’s development and progress. For example, in the orientation stage, the leader may need to be more alert to the need to intervene personally than would be the case in the working stage when the group has achieved a higher level of maturity.

WHY GROUPS ARE FORMED

In nursing, the formation of groups occurs primarily for one of two reasons: (1) to provide a personal or professional socialization and exchange forum, or (2) to provide a mechanism for interdependent work accomplishment. Groups can be social, professional, or organizational in purpose. The following are some reasons why groups would be established in organizations:

• Group activities can create a sense of status and esteem.

• Groups allow an individual to test and establish reality.

• Groups function as a mechanism for getting a job done.

• The work to be accomplished requires the complexity of knowledge and skill possible only in a group configuration.

“The ebb and flow of work done by groups is a major part of the working environment of hospital nurses” (Leppa, 1996, p. 23). The work group provides an institutional and professional identity for an individual nurse, and work groups become a focus for interpersonal relationships, support, and social integration. Interpersonal relationship elements such as work group cohesion, communication, and social integration remain consistent moderate-level predictors of nursing job satisfaction (DiMeglio et al., 2005). In addition, being part of a healthy group or team is also related to the level of organizational commitment by the employee. Individuals with an emotional connection to their work group have lower levels of turnover and higher levels of engagement (DiMeglio et al., 2005; Manion, 2004, 2009).

Work groups can be disrupted by factors such as downsizing, reorganization, absenteeism, and turnover. Work group disruption has been shown to be linked to negative outcomes (Leppa, 1996; Kalisch & Begeny, 2005; Kalisch et al., 2008; Kalisch & Lee, 2010). In a study of four hospitals, interpersonal relations were found to be an important part of nurses’ job satisfaction. There was a relationship between work group disruption and interpersonal relations (Leppa, 1996). Things get done because of relationships among people; nurses need to build successful collaborative relationships among multiple levels of colleagues, key people, organizations, and clients (Laramee, 1999). The level of nursing teamwork has been found to be directly linked to missed nursing care (Kalisch & Lee, 2010).

Furthermore, informal work group norms exert a strong influence on nurses’ behavior and can contribute to forms of nursing deviance. Work group relationships can reinforce behaviors and rationalization, thus leading to deviant behaviors becoming passively or actively accepted. For example, in one study of nurses in practice, nurses used work group norms to neutralize opposition to drug theft and use (Dabney, 1995). Clearly, there is a strong relationship between work groups, interpersonal relationships, and outcomes such as nurses’ behaviors and perceptions. Work group relationships are a powerful mechanism influencing both good and bad outcomes in nursing practice.

ADVANTAGES OF GROUPS

There are advantages to group work. For example, groups are one vehicle for solving problems. Veninga (1982) identified the following five major advantages of group problem solving over individual problem solving:

1. Greater knowledge and information: Obtaining a broader and wider range of knowledge and experiences creates a higher-quality input into group problem solving. The insights of one member can stimulate the thinking of other group members. With today’s highly specialized health care workers, this is especially true.

2. Increased acceptance of solutions: If there is a decision to be made in an organization, people can get together in a group to talk about it so that the people themselves are more committed to the decision. When individuals who are going to be affected by a decision are part of the decision-making process, they do not have to be convinced of the rightness of the decision and are more likely to be committed to implementing it.

3. More approaches to a problem: Complex problems typically are more manageable when a number of perspectives are mixed together to address the problem. The advantages include blending and complementing individual learning and problem-solving styles to capitalize on strength through diversity.

4. Individual expression: Groups allow for individual expression, and in organizations specifically, there may be few mechanisms for expression of individual perspectives. Sharing information and getting input are done best in groups (Veninga, 1982). Sometimes groups allow people to express themselves—for example, if they are anxious about a change or if morale is low.

5. Lower costs: If the group is functioning in a positive and constructive manner, the use of a group can be less expensive than the use of individual effort to accomplish a task. Group decision making is cost-effective if it saves time. For example, when a group meets for one session as opposed to the leader meeting multiple times with multiple individuals, the leader and possibly the group members save time.

It is imperative that the purpose of the group be established, especially when the group is part of a larger organization. Ideally this is an early conversation for the group and is determined with the input of all members. The stated purpose should be evaluated periodically. Is it a functional? Is it accomplishing the task to which it was assigned or committed? If not, should the group be disbanded? When the work output of any group is analyzed, meetings can be financially costly endeavors. For example, when the number of hours spent by all committee members is multiplied by their individual hourly salary and fringe benefit cost and added together to compute a committee total, the sum of costs for the group may be astounding. This is one reason for paying attention to how well the group is functioning. Just as important is the increased cynicism found in organizations where groups are ineffective, when people cease to be interested in participating because nothing really changes as a result of their efforts.

A well-tuned and functioning group is positive for an organization. Often such a group is less expensive and time-consuming in terms of solving complex problems. Participation and involvement in a group decision typically results in individuals being more committed to a decision, even if there is disagreement.

DISADVANTAGES OF GROUPS

Group decision making can be derailed at a number of points in the process. The three disadvantages commonly noted about group decision making are the potential for premature decisions, individual domination, and disruptive conflicts (Veninga, 1982).

GROUP DECISION MAKING

Group work can be, and typically is, a slow process. It takes more time for a group to arrive at a decision than for one person to make the decision.

In addition, a continuum of decision-making power may be vested in a group (Figure 8-2). A group or committee has certain powers, tasks, and functions, as well as certain parameters or latitude in terms of how far to go in making a decision. Decision power is a matter of degree, with four distinct points on the continuum of authority for decision making: autocratic, consultative, joint, and delegated.

On one end of the continuum is an autocratic decision procedure in which the leader makes all of the decisions. In this process there is input, perhaps, but not necessarily a vote. For example, in certain legislative committees the chairperson may or may not be able to put forth legislation or block a bill. It may be the case that an autocratic leader controls the power and the committee exists mainly for the sake of appearance. This type of committee is set up for reasons other than making participative decisions. It is hoped that very few of these structures are found in human service organizations because they can generate increased cynicism and employee disengagement.

A consultative decision procedure occurs when decisions involve employee participation but the leader still makes the final decision alone. Group members may make certain recommendations, but these must then go to the leader, chairperson, or head of the group, who makes the final decision. There is more participation with this type of procedure, but the ultimate decision is not under the control of the group members.

Some decision procedures result in joint decision making. In this approach, the entire group decides, whether by a two-thirds vote, simple majority, consensus, or some other process. In a joint decision procedure, the employees have as much influence as the leader. The leader has one voice, one vote. The leader can use persuasion, but when it comes to the final vote, the leader’s vote is equivalent to that of any other member of the group. This is fundamentally different from the leader making the decision with group input. This is the type of decision making used in a multidisciplinary team. Every voice is heard and valued equally.

Finally, at the other end of the decision continuum is the delegated decision procedure. This occurs when the committee chair or leader allows participants to make the final decision. For example, in true self-scheduling, the leader may set up the basic parameters, but the staff members (usually through the work of a smaller, designated team) actually decide what schedule they work. The true test of a delegation decision procedure is whether the leader overrides the followers’ decision. Technically, the leader would not have the authority to veto or override. If it is truly a delegation situation, the leader would go forward with the approach that the decision is the choice of the group. The group then becomes accountable for the outcome and is responsible for fixing any resulting issues. Hersey and colleagues (2008) labeled these same four procedures as authoritative, consultative, facilitative, and delegative decision-making styles.

It is advisable for the followers in any group to determine who has the authority to make decisions. Knowledge about what type of group it is and what delegation or decision procedures can be anticipated is critical to participation. A leadership or conflict moment may occur when a group assumes that the decision procedure rule in effect is delegation and the decision is its to make but the leader has a different idea. Clarity before beginning work on an issue prevents unnecessary conflict and augments productivity.

WORKING WITH TEAMS

In health care, interdisciplinary care teams are necessary for survival. High-performance teams are essential to an organization’s efficiency and effectiveness because high-quality work outcomes and cost control are impossible without collaboration and teamwork.

Nurse leaders need to learn how to create, lead, and manage teams; all nurses must know how to be effective team players. The formation of a well-functioning group or team is never the work of just the leader. Members give input, participate in decision making, share responsibility, and hold themselves accountable for the outcomes of the group. A highly skilled and effective professional is not necessarily a highly skilled and effective group member. There are distinct skill sets involved, and all are needed by nurses today. Leaders and staff members alike must be able to function both independently and interdependently with others. And they must have the judgment to know when which form of functioning is more appropriate.

Types of Teams

Three types of teams found in health care are (1) primary work teams, (2) leadership teams, and (3) ad hoc teams (Manion, 2011). Primary work teams include all forms of client care teams such as an emergency department trauma team. In the operating room, teams are often based on the specialty (e.g., a cardiovascular or an orthopedic team). The senior executive team is an example of an executive or management leadership team. At the hospital department level there may be a leadership team that is composed of the nurse manager, charge nurses, and perhaps an educator. Continuous quality improvement teams, project teams, and problem-solving teams are examples of ad hoc teams found across settings and sites. Specific problem-solving teams in departments are other examples of ad hoc teams. The chief characteristic of these teams is that they are created to perform a very specific piece of work. When that work is completed, the team dissolves. Designing, building, and implementing effective work teams requires a specific methodology and process. A primary work team fails if it behaves like a collection of individuals operating from narrowly defined jobs; if it is composed of the wrong mix of members, size, structure, responsibility, or expertise; or if it cannot fluidly shift activities and adapt to changes. Teams should be designed based on the work responsibilities of the team. After the team design is determined, the next step is to build the team by incorporating the essential elements needed to function. These include a common purpose; agreed-on performance goals or results-driven structure; competent members; a common approach for the work; complementary skills; a collaborative relationships; mutual accountability; standards of excellence; external support; and principled leadership (Manion et al., 1996).

The complementary skills that are needed, in the right mix, to do the team’s task fall into at least three categories: technical or functional expertise, problem-solving and decision-making skills, and interpersonal skills (Box 8-1).

BOX 8-1

Team Performance Checklist