In one page watch the above videos and compare and contrast the teams from the videos by answering the following questions:
Identify any clear team roles in either team example from the videos, compare and contrast. (provide rationale)
Using Table 19.1 in the Yoder-Wise text (p. 338), identify effective and ineffective team attributes you see in both teams. Compare and contrast your findings
identify some of the behaviors you see in each video that contribute to positive and negative team experiences.
“Building Effective Teams
Karren Kowalski
Learning Outcomes
• Evaluate the differences between a
group
and a
team
.• Value four key concepts of teams.• Describe the process of
debriefing
team functioning.• Apply the guidelines for
acknowledgment
to a situation in your clinical setting.• Compare a setting that uses agreements with your current clinical setting.• Develop an example of a team that functions synergistically, including the results such a team would produce.• Discuss the importance of a team to patient safety and quality.
Key Terms
acknowledgment
active listening
commitment
dualism
debriefing
group
interprofessional teams
synergy
team
The Challenge
Diane Gallagher
, RN, MS Director, Women’s and Children’s Services, Rush-Presbyterian–St. Luke’s Medical Center, Chicago, Illinois
An extensive “team” of people works together to care for a neonate in a neonatal intensive care unit (NICU). The team includes registered nurses, physicians, respiratory therapists, physical therapists, social workers, neonatal nurse practitioners, and ancillary staff. Occasionally, specialists are consulted for specific cardiac, neurologic, or gastrointestinal problems. These are intermittent “team” members who play a crucial role in the baby’s care.
Recently a new group of specialists joined our team. They were identified as a top-notch group who would, by virtue of their expertise and reputation, increase the census and revenues for the hospital. Our team was excited to have this opportunity to grow in an area in which we had infrequent experience. However, integration of these new team members did not go smoothly. Clinical disagreements, communication breakdowns, and interpersonal conflicts occurred. The experience evolved into mutual distrust and control issues.
As disagreements, insults, and complaints escalated on both sides, the situation came to a defining moment when the director of the specialty group said, “I’m never bringing any of our patients here. I’m sending them to the PICU [pediatric intensive care unit].” The response from the NICU team was, “Fine with us; we don’t need you, your patients, or the hassle.” It seemed reasonable to not work together because, in fact, functionally we were already not working together. This response was in direct conflict with our belief that we could provide a valuable service and make a difference for both the patients and their families. This posed a dilemma for the staff, but everyone felt the situation was hopeless.
No one believed we could function as a team, and therefore further efforts to work together were futile. We had tried and failed. “Let’s just cut our losses and move on.” How does one create a team when no one believes it is possible and some believe it is not even necessary?
What would you do if you were this nurse?
Introduction
As we experience changes such as cost-cutting and quality and safety issues in health care, teamwork becomes critical. The adage “If we do not all hang together we will all hang separately” was never more true than now as we move through an era in which nursing is accountable for quality patient outcomes that affect reimbursement for care and the institutional financial bottom line. To create finely tuned teams, communication skills (see Chapter 8) must improve. Each team member must focus on improving his or her own skills, as well as supporting other team members, to grow in effective communication. These skills will be increasingly important as teams negotiate an evolving healthcare system that includes rapid change in state and federal payment systems and regulations.
In our society, because of the emphasis placed on the individual and individual achievement, teamwork is the quintessential contradiction. In other words, with all the focus on individuals, we still need individuals to work together in groups to accomplish goals and keep patients safe. In today’s world, a nursing unit or team might have representatives from five different generations: The Silent Generation, Baby Boomers, Generation X, Millennials, and Generation Z or iGen (Hampton & Key, 2016). The differences in these generations can be staggering, which is challenging for functioning as a team.
Groups and teams
One definition of group is a number of individuals assembled together or having some unifying relationship. In groups, performance and outcomes are a result of the work of individual group members. Groups could be all the parents in an elementary school, all the members of a specific church, or all the students in a school of nursing, because the members of these various groups are related in some way to one another by definition of their involvement in a certain endeavor. A team, on the other hand, is a number of individuals collaborating in specific work or activity that focuses on a specific goal or outcome. Not every group is a team, and not every team is effective.
A group of people does not constitute a team. From Lencioni’s perspective (2016), a team is a group of people with a high degree of interdependence geared toward the achievement of a goal or a task. Often, we can recognize intuitively when the so-called team is not functioning effectively. We say things such as, “We need to be more like a team” or “I’d like to see more team players around here.” Consequently, in the process of defining team, effective versus ineffective teams should be considered. Teams are a collective of people who have defined objectives, ongoing positive relationships, effective respectful communication, and a supportive environment. In health care, teams are focused on accomplishing specific tasks and are essential in providing cost-effective, high-quality health care. As resources are expended more prudently, patient care teams must develop clearly defined goals, use creative problem solving, and demonstrate mutual respect and support. Facilities with ineffective teams may not survive the current changes in health care.
Exercise 19.1
Think of the last team or group in which you participated. Think about what went on in that team or group. Specifically think about what worked for you and what did not work. Use the “Team Assessment Exercise” in
Box 19.1
to assess specific aspects of your team. Address each of the identified areas and discover how well your team or group functioned. Think about roles, activities, relationships, and general environment. Consider examples of shared decision making, shared leadership, shared accountability, and shared problem solving. These are the concepts that can be used to evaluate the functioning of almost any team of which you are a member.
Box 19.1
Team Assessment Exercise: Are We a Team?
Directions:
Select a team with which you work. Place a checkmark beside each item that is true of your team. If the statement is not true, place no mark beside the item.1. The language we use focuses on “we” rather than “you” or “I.”2. When one of us is busy, others try to help.3. I know I can ask for help from others.4. Most of us on the team could say what we are trying to accomplish.5. What we are trying to accomplish on any given work day relates to the mission and vision of nursing and the organization.6. We treat each other fairly, not necessarily the same.7. We capitalize on people’s strengths to meet the goals of our work.8. The process for changing policies, procedures, equipment is clear.9. Meetings are focused on the goals we are trying to achieve.10. Our outcomes reflect our attention to goals and efforts.11. Acknowledgment is individual and goal-oriented.12. Innovation is supported by the team and management.13. The group makes commitments to each other to ensure goal attainment.14. Promises are kept.15. Kindness in communication is evident, especially when bad news is delivered.16. Individuals can describe their role in the overall work of the group.17. Other members of the team are seen as trustworthy and valued.18. The group is cost-effective and time-effective in attaining goals.19. No member is excluded from the process of decision making.20. Individuals can speak highly of their team members.
Tally the number of checkmarks and multiply that number by 5. The resultant number is an assessment of how well your team is functioning. The higher the score, the better the functioning.
In a smoothly functioning team, each nurse is responsible for care provided to the patient and for the care provided by the whole team. In thinking about the whole team in a hospital setting, consider such activities as bedside shift handoffs when the teams from both shifts are present and collaborating with one another. Think also of interprofessional rounding when nurses, physicians, pharmacists, physical therapists, case managers, and social workers, to name a few, are present to assess and plan with the patient for the care that is needed. Think about how each of these professional groups communicate respectfully with one another. Huddles also allow nursing staff to focus on how they may best collaborate to provide care for the patient. This interactivity of the team promotes the best possible care for the patient and family while demonstrating the value of nursing (Pappas, 2017).
When a team functions effectively, a significant difference is evident in the entire work atmosphere, the way in which discussions progress, the level of understanding of the team-specific goals and tasks, the willingness of members to listen, the manner in which disagreements are handled, the use of consensus, and the way in which feedback is given and received. The classic work done by McGregor (1960) and the more recent work by England (2013) shed light on some of these significant differences, which are summarized in Table 19.1.
Table 19.1Attributes of Effective and Ineffective TeamsAttributeEffective TeamIneffective TeamGoalsTask or objective is understood and supported by team members.Team interaction fails to clarify the task or objective of group.ContributionsAll team members participate in discussion and comments are pertinent.A few members dominate the discussion and minimize others’ contributions.EnvironmentInformal, comfortable, relaxed.Indifferent, bored, tense.LeadershipShared and shifts according to expertise.Autocratic and remains with the chairperson.AssignmentsClearly stated, assigned, and accepted.Unclear and lacks clarity regarding who is doing specific tasks.ListeningListen attentively to each member; every idea is heard.Members do not listen; ideas are ignored, judged, and overridden.ConflictMembers are comfortable with disagreement with no conflict avoidance.Disagreements are ignored or suppressed; voting results and minority is disconnected.Decision makingGeneral agreement reached by consensus.Actions or voting occurs before examination or resolution of real issues.Self-evaluationConscious of its own process; ongoing evaluation; assesses interferences with team function.Group avoids any discussion of effectiveness or operation.
Adapted from England, P. Effective vs ineffective teams. www.eventus.co.uk/effective-vs-ineffective-teams/.
On the other hand, ineffective teams are often dominated by a few members, leaving others bored, resentful, or uninvolved. Leadership tends to be autocratic and rigid, and the team’s communication style may be overly stiff and formal. Members tend to be uncomfortable with conflict or disagreement, avoiding and suppressing it rather than using it as a catalyst for change. When criticism is offered, it may be destructive, personal, and hurtful rather than constructive and problem-centered. Team members may begin to hide their feelings of resentment or disagreement, sensing that they are “dangerous.” This creates the potential for later eruptions and discord. Similarly, the team avoids examining its own inner workings, or members may wait until after meetings to voice their thoughts and feelings about what went wrong and why.
In contrast, the effective team is characterized by its clarity of purpose, informality and congeniality, commitment, and a high level of participation. The members’ ability to listen respectfully to each other and communicate openly helps them handle disagreements in a civilized manner and work through them rather than suppress them. Through ample discussion of issues, they reach decisions by consensus. Roles and work assignments are clear, and members share the leadership role, recognizing that each person brings his or her own unique strengths to the group effort. This diversity of styles helps the team adapt to changes and challenges, as does the team’s ability and willingness to assess its own strengths and weaknesses and respond to them appropriately. Because of the importance of effective teams, we have seen the movement from the Triple Aim to the Quadruple Aim that incorporates the climate in which care is delivered.
The challenges encountered in today’s healthcare systems are prodigious. Patient safety issues are at the forefront. Ongoing rounds of downsizing, budget cuts, declining patient days, reduced payments, and staff layoffs abound. Effective teams participate in effective problem solving, increased creativity, and improved health care. The effects of smoothly functioning teams on patient safety and the creation of a just culture are critically important.
Creating effective teams
When thinking about teams, consider the power of teamwork and what can be accomplished by a group of people working synergistically. It is helpful to have people who are able to work together in a complementary way. In the classic work of LaFasto and Larson (2001), in which they studied 600 teams and 6000 team members, the two key factors that emerged in the effectiveness of team functioning were great relationships between team members and excellent communication skills. Both of these concepts are complex and worth exploring in more detail. For example, building relationships has two major aspects: behaviors, or what people do with each other; and characteristics, or who they are as human beings.
Building Relationships
Being in relationship is about being connected or related and having mutual dealings, connections, or feelings between two parties. Specific learned behaviors, demonstrated by team members, can accelerate building extraordinary relationships among team members. Occasionally, a team member can shoulder the responsibility for criticism or for what did not work on behalf of the team. Taking the criticism, especially if he or she is not emotionally attached and can remain objective, demonstrates a willingness to go out of the way to support a team member. Thus another team member can have the space to de-escalate and gain control of their emotions. Such support can go a long way toward developing relationships. Another aspect of building relationships is the ability to “step in” to help without being asked. A subtle difference exists between someone who volunteers help before being asked and someone who agrees to help only after being asked. A true builder of relationships pays close attention to the well-being of others. This is also a demonstration of caring and serendipitously builds stronger relationships.
In building relationships, anticipate the “question under the question.” Often team members will ask a more superficial question than the one they really want to ask. A person might ask about an issue that was raised in the last meeting and what is really desired is a deeper understanding and appreciation of his or her contribution to the team.
Be willing to demonstrate thoughtfulness of others by giving unexpected praise or acknowledgment. Take time each day to do something nice for a teammate just because you can. This approach can be coupled with a desire to help, not because you need something from someone, but because you can support or help someone else. Approach relationship building from the perspective of the other person, not about yourself or your needs. In other words, give more than you receive.
The authors describe research on assigning teams from several organizations, including Google. The authors’ own work suggests that effective teams have a mix of skills and personalities, so it is important to consider the two roles every person plays in a working group: a functional role, based on formal position and technical skill, and a psychological role, based on the type of person one is. For best outcomes, teams should include members with different skills.Results-oriented: Team members who naturally organize work and take charge tend to be socially self-confident, competitive, and energetic.Relationship-focused: Team members who naturally focus on relationships, are attuned to others’ feelings, and are good at building cohesion tend to be warm, diplomatic, and approachable.Process and rule followers: Team members who pay attention to details, processes, and rules tend to be reliable, organized, and conscientious.Innovative and disruptive thinkers: Team members who naturally focus on innovation, anticipate problems, and recognize when the team needs to change tend to be imaginative, curious, and open to new experiences.Pragmatic: Team members who are practical, hard-headed challengers of ideas and theories tend to be prudent, emotionally stable, and level-headed.
Implications for Practice
As you assign working groups or become part of a group, consider the balance of member characteristics needed to support effective team development.
Valuing every member of the team can have major positive outcomes. Find something positive about each one and his or her contribution. Every human being is important, as is each job.
Behaviors of Great Team Members
Teams function with varying levels of effectiveness. The interesting part of this is that effectiveness can be created systematically. Truly effective teams are ones in which people work together to produce extraordinary results that could not have been achieved by any one individual. This phenomenon is described as synergy. In the physical sciences, synergy is found in metal alloys. Bronze, the first alloy, was a combination of copper and tin and was found to be much harder and stronger than either copper or tin separately. Because the tensile strength of bronze cannot be predicted by merely adding the tensile strength of tin and of copper, it is far greater than simple addition. Working cooperatively, an effective team produces extraordinary results that no one team member could have achieved alone. To create synergy consistently, certain basic rules must be followed: establish a clear purpose, use active listening, tell the truth, be compassionate, be flexible, commit to resolution, and capitalize on what individuals bring to the team. See the Research Perspective.
Establish a Clear Purpose
Creating a smoothly functioning team requires a clear purpose. Each member of the team must understand the reason the team is together, determine what he or she wishes to accomplish (as delineated by defined goals and objectives), and express his or her belief in both the value and feasibility of the goals and tasks. Teams function best when the members can not only tell others about their purpose but also define and operationalize succinctly the meaning and value of this purpose. Being aware of what each can contribute and expects allows all other members to capitalize on individual talent and support each other in goal attainment.
Use Active Listening
Active listening means that you are completely focused on the individual who is speaking. It means listening without judgment. It means listening to the essence of the conversation so that you can actually repeat to the speaker most of the speaker’s intended meaning. It means being 100% present in the communication. This requires the skill of active listening. Examples of how to validate such listening appear in Table 19.2.
Table 19.2Active ListeningUse of Active ListeningExamplesTo convey interest in what the other person is sayingI see! I get it. I hear what you’re saying.To encourage the individual to expand further on his or her thinkingYes, go on. Tell us more.To help the individual clarify the problem in his or her own thinkingThen the problem as you see it is …To get the individual to hear what he or she has said in the way it sounded to othersThis is your decision, then, and the reasons are … If I understand you correctly, you are saying that we should …To pull out the key ideas from a long statement or discussionYour major point is … You believe that we should …To respond to a person’s feelings more than to his or her wordsYou feel strongly that … You do not believe that …To summarize specific points of agreement and disagreement as a basis for further discussionWe seem to be agreed on the following points … But we seem to need further clarification on these points …To express a consensus of group feelingAs a result of this discussion, we as a group seem to feel that …
Developing a defensive response or argument in your head while the other person is still speaking is not active listening. To listen actively, a person must be absorbing words, posture, tone of voice, and all the queues accompanying the message so that the intent of the communication can be received.
Tell the Truth
To tell the truth means to speak clearly to personal points and perspectives while acknowledging that they are, merely, personal perspectives. If an observation is made about the tone or behavior of a speaker that affects the ability of others to hear the message, feedback can be provided in a way that does not make the speaker wrong. This is accomplished in an objective rather than subjective manner using neither a cynical nor a critical tone of voice or by asking a question for clarification. To be effective, one must own, or be responsible for, personal opinions and attitudes.
Be Compassionate
To be compassionate means to have a sympathetic consciousness of another’s distress and a desire to alleviate the distress. Consequently, focusing time and energy on making the other person wrong, especially when your perspective differs from his or hers, is inappropriate. Listening from a caring perspective—one that is focused on understanding the viewpoint of the other person rather than insisting on the “rightness” of one’s own point of view—is the goal.
Be Flexible
Flexibility and openness to another person’s viewpoint are critical for a team to work well together. No single person has all the right answers. Therefore acknowledging that each person has something to contribute and must be heard is important. Flexibility reflects a willingness to hear another team member’s point of view rather than being committed to the “rightness” of a personal point of view.
Commit to Resolution
To commit to resolution means that one can agree to disagree with someone even when that perspective is different. Rather than assuming the person is wrong, this is a commitment to hear his or her perspective, listen to the real message, identify differences, and creatively seek solutions to resolve the areas of differences so a common understanding and shared commitment to the issue can be reached. Both parties need to then agree that they feel heard and agree to the resolution. This differs greatly from compromise and majority vote seen in the democratic process. When compromise exists, acquiescence or relinquishing of a significant portion of what was desired likely occurred. This generally leaves both parties feeling negative about themselves or the agreement. Consequently, most compromises must be reworked at some future date. Working on conflict and its resolution (
Box 19.2
) is time-consuming but essential to effectively functioning teams (Lencioni, 2016).
Commitment
to resolution is integral to the needs of the team. One team member may disagree with another team member, but the successful work of the team is at stake in this conflict. Without commitment to resolution for the sake of the team, individuals often have less impetus to seek a common ground or to agree to disagree.
Box 19.2
Aspects of Conflict
Destructive• Diverts energy from more important activities and issues• Destroys the morale of people or reinforces poor self-concepts• Polarizes groups so they increase internal cohesiveness and reduce intergroup cooperation• Deepens differences in values• Produces irresponsible and regrettable behavior such as name-calling and fighting
Constructive• Opens up issues of importance, resulting in their clarification• Results in the solution of problems• Increases the involvement of individuals in issues of importance to them• Causes authentic communication to occur• Serves as a release for pent-up emotion, anxiety, and stress• Helps build cohesiveness among people sharing the conflict, celebrating in its settlement, and learning more about each other• Helps individuals grow personally and apply what they learn to future situations
The team is not successful when one team member becomes a self-proclaimed expert who has the “right” answer. Nor is it successful when people fail to speak. Each team member has good ideas, and these need to be shared. They may not be shared, however, when someone feels uncomfortable in the team. It is difficult to speak up and appear wrong or inadequate. The challenge each person faces is to push through discomfort and become a full participant in problem identification and resolution for the overall benefit of the team.
Acknowledge
Part of focusing on people’s strengths is being willing to acknowledge peers, faculty, and the other significant people in one’s life (Ke Yu, Harter, & Agrawal, 2013). In contrast, many role models focus on correction. Consequently, many of us spend a large portion of our time correcting others rather than appreciating them for all the wonderful things they are. Focusing on strengths rather than on weaknesses is far more productive and leads to excellence. According to the classic work of Gallup about people’s strengths as reported by Rath (2007), weaknesses will never be improved to more than average or mediocre. If the focus is on improving our strengths, it is much easier to excel and then to be acknowledged for what we do well. Unfortunately, focusing on weaknesses tends to decrease the appreciation and thus the acknowledgments. Furthermore, we seem to believe that a finite number of acknowledgments exist. This attitude of scarcity of acknowledgments leads to stinginess in acknowledging people. Of course this approach is a bit ridiculous. Acknowledgments are infinite. The more we sincerely give to others and to ourselves, the smoother the team functions. On the other hand, we do not always give acknowledgments in a way they can be received and valued.
Box 19.3
can serve as a guide for giving acknowledgments.
Box 19.3
Guidelines for Acknowledgment1. Acknowledgments must be specific. The specific behavior or action that is appreciated must be identified in the acknowledgment; for example, “Thank you for taking notes for me when I had to go to the dentist. You identified three key points that needed to be reported.”2. Acknowledgments must be “eye to eye,” or personal. Look the person in the eye when you thank him or her. Do not run down the hall and say “Thanks” over your shoulder. Written appreciation also qualifies as “eye to eye.”3. Acknowledgments must be sincere, that is, from the heart. Each of us recognizes insincerity. If you do not truly appreciate a behavior or action, do not say anything. Insincerity often makes people angry or upset, thus defeating the goal. Further, it discredits the person who is insincere.4. Acknowledgments are more powerful when they are given in public. Most people receive pleasure from public acknowledgment and remember these occasions for a long time. For people who are shy and may prefer no public acknowledgment, this is an opportunity to work on a personal growth issue with them. Public acknowledgment is an opportunity to communicate what is valued.5. Acknowledgments need to be timely. The less time that elapses between the event and the acknowledgment, the more powerful and effective it is and the more the acknowledgment is appreciated by the recipient.
Exercise 19.2
Within the next 3 days, find three opportunities to acknowledge a peer or acquaintance using the five guidelines for acknowledgment shown in Box 19.3. Use these same guidelines to acknowledge yourself for something you have done well.
Communicating Effectively
Communication in the work environment is not only important to creating a healthy work environment that retains nurses, but is essential to reduction of medical errors (American Association of Critical Care Nurses [AACN], 2016). These skills are crucial to smoothly functioning teams. Further discussion of communication skills can be found in Chapter 8. An example of a commonly used tool for effective communication is the Situation, Background, Assessment, Recommendation (SBAR) format in
Box 19.4
.
Box 19.4
SBAR Communication
Miscommunication is the most commonly occurring cause of sentinel events and “near misses” in patient care. One of the most popular structured communication systems, created by professionals in the California Kaiser Permanente system, focuses on a method to provide information that honors the system in which practitioners and medical providers learn to glean information and apply it to decision-making trees. SBAR is the system that honors the structured transfer of information.Situation. The nurse identifies the patient, the physician, the diagnosis, and the location of the patient. The nurse describes the patient situation that has instituted this SBAR communication.Background. Next the nurse provides background information, which could include information relevant to the current situation, mental status, current vital signs (all of them), chief complaint, pain level, and physical assessment of the patient.Assessment. The nurse offers an assessment of the chief problem and describes the seriousness of the situation. Any specific changes in the patient’s condition should be described.Recommendation. The nurse can make a request of the physician or suggest specific action such as a medication, laboratory work, or an x-ray examination. The nurse could also request that the physician come and evaluate the patient.
Data from Institute for Healthcare Improvement. (2018). SBAR tool: Situation-background-assessment-recommendation. http://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx.
For purposes of establishing effective teams, consider some aspects of communication. These skills are essential to clinical practice, to building teams, and to leadership. Because communication consists of both verbal and nonverbal signals, humans are continuously communicating thoughts, ideas, opinions, feelings, and emotions. Once the message is sent, the first impression of the communication usually is lasting. However, it is often an unconscious response or reaction. To become more aware of communication in teams, consider the following model.
Positive Communication Model
Whenever human beings are in distress, unengaged, or disengaged or have an emotional reaction to a situation or the actions of another, a conditioned response is to move into one or all of the following: blame, judgment, or demand. These are depicted in the awareness model found in Fig. 19.1. With effort and practice, it is possible to create a communication interaction that produces a significantly improved outcome.
Fig. 19.1 Awareness model: differentiating between unconscious and conscious responses.
When an individual is reacting at the feeling level, he or she tends to move unconsciously to blame. By taking accountability for these feelings, one can move out of blame and own one’s feelings by stating, “I feel …”
Likewise, when an individual is trapped in distress or reaction at the thinking level, he or she most often turns to judgment. By thinking compassionately, one can dismantle the judgment and state what one thinks in a compassionate way: “I think …”
Finally, when in distress, we make demands that are often unreasonable. By calming yourself, you can find respect for the other human being and make a request for what you want for yourself in a given situation: “I want an effective professional relationship.” Wanting the other person to change is pointless because it is unlikely to happen and you don’t control the other person.
Most broken relationships are stuck in blame, judgment, and demand. Being accountable, compassionate, and respectful helps clarify what goes on inside each of us.
Everyone needs to feel as though his or her skills, tools, and contributions are needed and valued and that he or she is respected for what personal contributions are offered to the workplace, team, or group. Everyone has weaknesses, and emphasizing these or spending time in ongoing correction is not productive. Rather, focus should be placed on people’s strengths, specifically acknowledging and emphasizing what people do well.
Exercise 19.3
Think of an example or a recent incident when you were very upset or felt stuck in blame, judgment, and/or demand. You might even write down what you were feeling in that moment, what it was about for you, and what you wanted for yourself. Share the issue or problem situation with someone and practice talking using I feel, I think, and I want instead of blame, judgment and/or demand.
Debriefing
The general definition of debriefing is to carefully review upon completion or to question someone about a completed undertaking. The most common use of debriefing in nursing is with the use of simulation. The International Nursing Association for Clinical Simulation and Learning (INACSL, 2016) describes debriefing as a reflection or a conscious consideration of the meaning and implication of an action, which includes the assimilation and understanding of knowledge, skills, and attitudes. Reflection can lead to new interpretations or understanding by participants who can reframe the situation or scenario cognitively as an essential part of learning. The skills of the debriefer are important to ensure the best possible learning outcomes. Debriefing is one example of the process of reflection. Likewise, the exercises in this chapter are an opportunity to practice debriefing and to determine what was learned in the exercise.
Key concepts of teams
In rare instances, a team may produce teamwork spontaneously, like kids in a schoolyard at recess. However, most management teams learn about teamwork because they need and want to work together. This kind of working together requires that they observe how they are together in a group and that they unlearn ingrained self-limiting assumptions about the glory of individual effort and authority that are contrary to cooperation and teamwork. Keys to the concept of team include the following:• Conflict resolution• Singleness of mission• Willingness to cooperate• Commitment
Conflict Resolution
Realizing that conflict is fundamental to the human experience can be helpful. Conflict is an integral part of all human interaction. Therefore the challenge is to recognize the breakdown in the communication process and to deal appropriately with it (Porter-O’Grady & Malloch, 2017). Conflicts are usually based on attempts to protect a person’s self-esteem or to alter perceived inequities in power, because most human beings believe that other people have greater power, and thus these human beings are unlikely to achieve their objectives. For example, when a nurse recognizes upset and reaction between two nursing assistants with whom he or she is working, the following steps can be helpful:• Identify the triggering event.• Discover the historical context for each person.• Assess how interdependent they are on each other.• Identify the issues, goals, and resources involved in the situation.• Uncover any previously considered solution.
Assessing the level of working relationship between the conflicted parties is essential, particularly if they work together on a regular basis.
The word team is usually reserved for a special type of working together. This working together requires communication in which the members understand how to conduct interpersonal relationships with their peers in thoughtful, supportive, and meaningful ways. Working together requires that team members are able to resolve conflicts among themselves and to do so in ways that enhance rather than inhibit their working together. In addition, team members must be able to trust that they will receive what they need while being able to count on one another to complete tasks related to team functioning and outcomes. To communicate effectively, people must be willing to confront issues and to express openly their ideas and feelings—to use interactive skills to accomplish tasks. In nursing, constructive confrontation has not been a well-used skill. Consequently, if communication patterns are to improve, the onus is on each of us as individuals to change communication patterns. In essence, for things to change, each of us must change.
Singleness of Mission
Every team must have a purpose—that is, a plan, aim, or intention. However, the most successful teams have a mission—some special work or service to which the team is 100% committed. The sense of mission and purpose must be clearly understood and agreed to by all (Lencioni, 2016). The more powerful and visionary the mission is, the more energizing it will be to the team. The more energy and excitement are engendered, the more motivated all members will be to do the necessary work.
Willingness to Cooperate
Just because a group of people has a regular reporting relationship within an organizational chart does not mean the members are a team. Boxes and arrows are not in any way related to the technical and interpersonal coordination or the emotional investment required of a true team. In effective teams, members are required to work together in a respectful, civil manner. Most of us have been involved in organizations in which some people could accomplish assigned tasks but were not successful in their interpersonal relationships. In essence, these employees received a salary for not getting along with a certain person or persons. Some of these employees have not worked cooperatively for years! Organizations can no longer afford to pay people to not work together. Personal friendship or socialization is not required, but cooperation is a necessity. Traditionally, these interpersonal skills were considered “soft” skills and were difficult in coaching people or in holding them accountable. In most organizations, employees can now be terminated for a lack of willingness to work cooperatively with team members.
Commitment
Commitment is a state of being emotionally impelled and is demonstrated when a sense of passion and dedication to a project or event—a mission— exists. Often, this passion looks a little outrageous as people go the extra mile because of their commitment. They do whatever it takes to accomplish the goals or see the project through to completion. Charles Garfield provides an example of commitment when he talks about the team that created the lunar landing module for the first man to walk on the moon. People on the team did all kinds of things that looked odd, including working extended hours and shifts, calling in to see how the project was progressing, and sleeping over at their work stations so as not to be separated from the project—all because each member knew that he or she was a part of something that was much bigger than himself or herself. They were a part of sending a man to the moon, something that human beings had been dreaming about for thousands of years. It was a historic moment, and people were intensely committed to making it happen.
Many people go through their entire lives hating every single day of work. Needless to say, most people who hate their work are not committed. Because we spend an extensive amount of time in the work setting, we must enjoy what we do for both physical and mental well-being. If this is not the case for you, then try to find a different job or profession—one you might love. Life is too short to do something that you hate doing every day. While you are moving into whatever you decide you love doing, commit to yourself to do your best at whatever you are now doing. Be 100% present wherever you are. Do the best work you are capable of doing. This honors you as a human being, and it honors your co-workers and patients.
Exercise 19.4
Review the eight questions about exploring commitment in
Box 19.5
. Spend at least 20 minutes in a quiet place thinking about and writing answers to these eight questions. Pay particular attention to question 7.
Box 19.5
Exploring Commitment
The key to finding your compelling mission or passion that will lead you to success and peak performance is to ask yourself the right questions. Your answers to these questions will help you understand what you need to know about yourself. Read each question, then think carefully for a few minutes, and answer each question honestly. Do not censor or edit out anything, even if it seems impossible or unrealistic—allow yourself to be surprised. Let your imagination soar.1. Am I deriving any satisfaction out of the work I am now doing?2. If they did not reward (praise or pay) me to do what I now do, would I still do it?3. What is it that I really love to do?4. What do I want to pursue with my time and energy that is worthwhile?5. What motivates me to reach out and do my best to excel?6. What is it that only I can say to the world? What needs to be done that can best be done only by me?7. If I won $40 million in the lottery tomorrow, how would I live? What would I do each day and for the rest of my life?8. If I were to write my own obituary right now, what would be my most significant accomplishment? Is that enough?
Repeating this exercise often will give you additional insights and information about what you really want and love to do. If taken seriously, the exercise should help you have an understanding of why you selected this profession and whether you have the stamina to do whatever it takes to make a contribution and to make a difference in the practice of nursing.
Issues that affect team functioning
When individuals come together purposefully to form a team, they spend considerable time in group process or social dynamics, which allows them to advance toward becoming a team and completing a goal. Each person within the emerging team struggles with key issues about cooperation, power, appreciation, agreements, emotions, trust, differences, and feedback that must continually be reevaluated and renegotiated.
“In” Groups and “Out” Groups
Most of us want to be valued and recognized by others as a part of the group, one who “knows” or understands. Most people want to be at the core of decision making, power, and influence. In other words, they want to be part of the “in” group, and researchers have demonstrated that those who feel “in” cooperate more, work harder and more effectively, and bring enthusiasm to the group. The more we feel we are not a part of the key group, the more “out” we feel and the more we withdraw, work alone, daydream, and engage in self-defeating behaviors. Often, intergroup conflict results when individuals who feel they are “out” and want to be “in” create a schism or a division that prohibits the team from accomplishing its goals.
Dualism
Our society tends to be dualistic in nature. Dualism means that most situations are viewed as right or wrong, black or white. Answers to questions are often reduced to “yes” or “no.” As a result, we sometimes forget a broad spectrum of possibilities actually exists. Exercising creativity and exploring numerous possibilities are important. This allows the team to operate at its optimal level.
An extension of this idea of dualism is a person who is a self-proclaimed expert, to whom it is critically important that he or she be right and acknowledged as right and who becomes judgmental of others whose perspectives and opinions differ. Consequently, being able to tell the truth to a team member and to encourage team members to stretch and look at different ways of functioning is vital. This requires strong skills in good negotiation and conflict resolution, something for which few of us have been trained. If self-proclaimed experts think we are judging them, they will not hear the questions, the observations, or the “truth,” because the message seems to be making them wrong. Going beyond dualism is critical to the team.
Power and Control
Everybody wants at least some power, and everybody wants to feel he or she is in control. When faced with changes that we cannot influence, we feel impotent and experience a loss of self-esteem. Consequently, we want to feel that we are in control of our immediate environment and that we have enough power and influence to get our needs met. When a situation or an event arises that we cannot handle, we attempt to compensate for it in some way; most of these ways are not productive to smoothly functioning teams. You may have been “right,” but the sense of a loss of control or power is very uncomfortable, sometimes resulting in stress and fear. Mature behavior is required to maintain a positive, problem-solving approach.
Exercise 19.5
Think about a time when you and a small group wanted to change something, such as a scheduled time (a class or meeting), an assignment, or an outcome measure (grading curve of a test or a performance evaluation criterion), and the person “in charge” adamantly refused. How did you feel? What was the response? Did you engage in gossip to make others appear wrong?
Use, Develop, and Be Appreciated for My Skills and Resources
Each member of the team has unique skills and resources to bring to the goals and tasks to be accomplished by the team. The Gallup (2017) research is quite clear in its evaluation of the work environment that one of the most powerful indicators of a successful, supportive work environment can be predicted by the scores from the following question: “At work, do you have the opportunity to do what you do best every day?” When the score is low in this area, team members clearly do not believe their skills are recognized, well used, or appreciated. To accomplish the goal of having each team member believe that his or her skills are recognized, encouraged, and used and his or her growth is encouraged requires a strong, knowledgeable team leader. Fewer than 20% of employees feel their strengths are used every day (Wagner & Harter, 2006). When nurses do not believe their skills are used, they are more prone to be in the “out group.” This leads to being unengaged and even disengaged in the workplace. This is not supportive of a positive, creative work environment or in developing effective teams.
Group Agreements
One of the most helpful tools available is to have the team members come to an agreement about their relationships with one another. This can take place in various ways. Multiple types of guidelines can even be used to set the context for how people relate. Many hospitals and facilities have service agreements that new employees accept when they are first hired. These are often in the employee handbook and are used to hold people accountable for behaviors. One example of a set of agreements comes from the Colorado Center for Nursing Excellence, the nursing workforce center for the state (
Box 19.6
). These are called the “
Commitment to My Team Members
.” They have gone through multiple transitions and redesigns, but the basic tenets are essentially the same. People must agree on the goals and mission with which they are involved. They have to reach some understanding of how they will exist together. Tenets or agreements such as “I will respectfully speak promptly with any team member with whom I have a problem” go a long way to avoid gossiping, backbiting, bickering, and misinterpreting others. These team agreements are reviewed regularly (e.g., monthly or quarterly), because this process helps members of the team be accountable for upholding the agreements and receive/give feedback when the agreements have been violated or need to be changed. Without agreement, people have implicit permission to behave in any manner they choose toward one another, including angry, hostile, hurtful, and acting-out behavior.
Box 19.6
Commitment to My Team Members
The staff at the Colorado Center for Nursing Excellence developed these agreements in 2010. The staff included both professional and support personnel. These agreements are reviewed at each monthly “all staff meeting.” This review serves as a reminder of our agreements, and each person considers these agreements integral to the smooth functioning of the team.• I accept responsibility for establishing and maintaining healthy interpersonal relationships with every member of this team. I recognize that the words, actions, and attitudes of each of us individually reflect on the whole of the Colorado Center for Nursing Excellence.• I will respectfully speak promptly with any team member with whom I am having a problem. The only time I will discuss it with another person is when I need assistance in reaching a satisfactory resolution. The goal of a conversation with a trusted colleague is not to complain or triangulate but to gain insight into resolution. I will always remember to “take the mail to the correct address.”• I will establish and maintain a relationship of trust with every member of this team. My relationships with each of you will be equally respectful, regardless of job title, level of educational preparation, or any other differences that may exist.• I will accept each team member as they are today, forgiving past problems and asking each person to do the same with me.• I will remember that no one is perfect and that our errors will be accepted as opportunities for forgiveness, growth, and learning.• Because all members of our team are leaders and followers, we are committed to finding solutions to problems and embracing accountability for the success of the whole organization.
Different projects have different team members as the leader, and the remainder are followers. Sometimes the leader of a specific project is a support person and the followers, both professional staff and support staff, take direction from that person.• My words, actions, and attitudes make my team members feel appreciated, included, and valued. I will have fun and keep a sense of humor at work.• As leaders we practice what The Center teaches.
The Center delivers educational offerings on leadership, teaching, quality, and safe patient care and presentations. The common threads exemplified in the above agreements are taught, and each member of the team is expected to demonstrate the behaviors we teach to participants.• I expect and accept if at any time I do not comply with the above statements my team members will have a confidential conversation with me directly in order to raise awareness and accountability to the above commitments.
From Colorado Center for Nursing Excellence. (n.d.). Commitment to my team members. http://www.coloradonursinfcenter.org/center-staff.
Exercise 19.6
Think about a group meeting you attended that did not go well. Identify three examples of group agreements that might have improved the tone and outcomes of the meeting.
Managing Emotions
Probably one of the greatest fears in team-building is that people will become emotional, that they will lose control of themselves or the environment, or that they will appear weakened or vulnerable. Management and leadership are usually more willing to deal with the “thinking” side than the “feeling” side of individuals within the team. The use of a communication tool (Fig. 19.2) can support team members in managing emotions.
Fig. 19.2 Potential communication rhythms.
Trust
Trust is the basis by which leaders and managers facilitate the activities and the progress of the team. Warrell (2015) believes that trust is not only the core of relationships but also the currency of influence in both the specific workplace and the entire organization. She describes what she believes to be the three core domains of trust: competence, reliability, and sincerity. Competence refers to a specific skill set. For example, you might trust me to teach you about leadership and administration, but you would not want me to attempt to take care of you in the critical care unit if that is not my area of expertise (and you shouldn’t). From another perspective, when the best clinical nurse is promoted to nurse manager without formal training or preparation for the new role, it would be best to manage expectations until she or he has the skills and resources for that new role.
Reliability relates to counting on a person to manage and honor commitments. A team member may be trusted as competent at a specific task but may have a track record of tardiness or sloppy work, and this prevents you from complete trust. It comes down to: Can your word be trusted?
Sincerity is related to the assessment of someone’s integrity, to the fundamental nature of their character. It is the most pivotal in the decision to trust someone and it is the most important aspect of leadership. It is why allegations of impropriety or infidelity in leaders is so devastating. For example, in a marriage, infidelity has a devastating effect, whereas forgetting an anniversary is much less damaging. Likewise, when colleagues talk about you behind your back, it is much more significant than if they are chronically late to meetings. Sincerity also relates to how much someone cares about what you care about, such as a sick or dying relative. Do your colleagues even acknowledge they know about the situation and do they check on you? If the answer is no, trust is eroded. We are supposed to care about those who are part of our workplace “family.” When trust erodes, influence, intimacy, and relationships also erode. If this continues in a downward spiral, organizations fail from lack of collaboration, understanding, and effective problem solving, those things which are most closely related to success.
Trust is also a major issue among newly formed teams and their members, and one of the first questions to come up is who can you trust or not trust. Team members model trust through behaviors such as facilitating the establishment of ground rules and agreements by which the team will function and hold team members accountable. Trust is probably the most delicate aspect within relationships and is influenced far more by actions than by words. Therefore what people do is more powerful than what they say. Trust is a fragile thread that can be severed by one act. Once destroyed, trust is more difficult to reestablish than it was to initially create.
Accepting and Celebrating Differences
Every human being is different, with different backgrounds, different skill sets, different strengths, and different approaches. Yet it is not unusual for us to assume that team members are like us. Other team members must understand us and can even see or appreciate our “point of view.” If we go into the situation with the awareness that not everyone is like us, we can reach out to other team members. We can always build from one connection to other connections. Appreciating differences may help us capitalize on talents we don’t possess or value a behavior or situation from a different perspective. Celebrate the fact that you may complement each other.
Giving and Receiving Feedback
Feedback is like plant fertilizer; it allows human beings to learn and to grow. Feedback may not always feel great, but it can be very good for you. Stone and Heen (2014) have excellent suggestions about how to receive feedback and ask clarifying questions. Many of us are more anxious about receiving feedback than about giving feedback. It is very helpful to attempt to listen to feedback with an openness and to clarify anything that might be unclear. Assume the best of intentions. Work not to be defensive but to search for the pearl—the grain of truth that can support your learning and growing. Any information received can be accepted and incorporated or rejected. It just might be information about a “blind spot” that you may have never seen.
When giving feedback, focus on how you would like to receive it. Remember to ask questions and to focus on growth. Tonality and “how” something is said is of premier importance.
Exercise 19.7
Think about the last team project in which you participated. What worked about the team? What did not work about the team? Was there a member who did not carry his or her share of the work? Was there a team member who was a “know it all”? How did you handle the situation? Was there a person on the team who took the lead? How many of the qualities of a good team player do you possess? Be honest. What are areas in which you could improve? What are your strengths; that is, where do you shine?
Interprofessional teams
Interprofessional teams are essential to quality patient care. Nurses, physicians, dietitians, social workers, case managers, pharmacists, and physical therapists, to name a few, must work together to achieve cost-effective care while achieving the highest quality of care in the healthcare setting. This means efforts must be expended to understand the various roles and backgrounds of each profession. At the same time, nurses are frequently leading teams comprising licensed practical/vocational nurses and technicians or assistants of various kinds. Here again, it is critical to understand everyone’s role and job description as well as his or her background and identity as an individual. In addition, the collaboration needed in interprofessional teams cannot be created without mutual trust and respect among the members (Maxfield, Grenny, Lavandero, & Groah, 2013).
Core competencies for interprofessional collaborative practice were developed in 2016 by an expert panel of the Interprofessional Education Collaborative consisting of the following groups: American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, American Dental Education Association, Association of American Medical Colleges, and the Association of Schools of Public Health.
The identified competency domains include the following: Values/Ethics for Interprofessional Practice, Roles/Responsibilities, Interprofessional Communication, and Teams and Teamwork (Interprofessional Education Collaborative [IPEC], 2016). These competencies were applied to requests for funding proposals to the Health Resources and Services Administration (HRSA), a division of the Department of Health and Human Services of the US federal government, beginning in 2012. These government grants emphasized the importance of interprofessional practice in healthcare.
The Teams and Teamwork competency includes the following aspects of team functioning (IPEC, 2016): • Describe the process of team development and the roles and practices of effective teams.• Engage other health professionals—appropriate to the specific care situation—in shared patient-centered problem-solving.• Integrate the knowledge and experience of other professions to inform care decisions.• Apply leadership practices that support collaborative practice and team effectiveness.• Engage self and others to constructively manage disagreements about values, roles, goals, and actions among healthcare professionals and with patients and families.• Share accountability with other professions, patients, and communities for outcomes.• Reflect on individual and team performance for individual as well as team performance improvement.• Use process improvement strategies to increase the effectiveness of interprofessional teamwork and team-based care.• Use available evidence to inform effective teamwork and team-based practices.
This work begins with education and transitions to practice and is the wave of the future, even though some practitioners are resistant to adapting traditional roles and responsibilities.
Several additional aspects of interprofessional work are crucial to creating and maintaining these teams. Coyne (2005) emphasized the importance of understanding each situation, which includes clarifying misperceptions and inaccurate information about others within the team, including any assumptions that one professional group is favored over another. Noticing professional expectations and unwritten processes and cultures of the various professions within the team is also critical to working together seamlessly. It is helpful for nurses to note how other groups talk and behave and to note the special language they use. Encourage the different disciplines to learn from each other. For example, in comparing the different codes of ethics, the many similarities, as opposed to the differences, can create commonalities. Most are focused on the patient.
The team leader must set a positive tone. If the leadership expects interprofessional teamwork and verbalizes and models positive and upbeat attitudes, the various disciplines will work together smoothly.
Frequency of interaction of the team members can create ongoing interactions and familiarity with one another. Team members who are in a professional relationship with one another are more apt to work together smoothly. As an example, a weekly patient care meeting in which patients with significant needs or problems are reviewed allows each profession to address issues from a specific area of expertise. Keep communication open includes telling the truth in a way that it can be heard and understood. If an aspect of care is governed by regulations, it is helpful when a knowledgeable member of the team speaks to the issue or regulation, always remembering to phrase the information in a way that facilitates hearing and understanding. At all times the interprofessional team must focus on the patient. When the deliberations are focused on the delivery of best patient care for the specific patient, mutual respect can be developed, and open sharing of ideas and problem solving occurs.
Exercise 19.8
Interprofessional Teams
Identify a problem that you have heard discussed in a healthcare setting—for example, awkward timing of admissions and discharges, running out of supplies, or conflicts in scheduling procedures. Make a list of all of the different professions and support staff who might be involved with that issue in some way and who would need a voice during efforts to improve that situation.
The value of team-building
When things are not going well in an organization and problems need to be resolved, the first intervention people think of is “team-building.” Naturally, for teams (a collection of people relying on each other) to be effective, they must function smoothly and communicate effectively to create the best possible work environment. The difficulty is that when organizations are facing difficulties, they generally do not have teams whose members function well together. Team-building and consultants can help; however, to sustain smoothly functioning teams, the leadership is critical.
Regardless of the problem, appropriate assessment of the team is essential (see Exercise 19.1). The success of the team depends on its members and its leadership. Providing feedback in a manner in which it can be heard and growing the team creates value in the team.
A resurgence in team building has occurred. Corporations are once again focused on the importance of teams. Vogt (2017) believes team-building activities are particularly vital to the success of small businesses, and most nursing units or clinics are essentially a small business. Vogt demonstrates that team-building exercises can build trust, ease conflicts, increase collaboration, and increase the effectiveness of communication. She further believes that increasing mutual trust through team-building activities can increase the codependence on one another in the team, thus increasing the efficiency and the productivity. Team building can ease conflicts by supporting team members to know each other better on a personal level, to bond with one another, and to become more comfortable with each other’s personalities. Team-building activities can increase collaboration among the team members and increase their awareness of interdependency.
Lencioni (2016) builds a strong case for dealing constructively with building an underlying foundation for teams. He believes that three major components of smoothly functioning teams must be created:• Mutual trust among the members• A strong sense of team identity (that the team is unique and worthwhile)• A sense of team efficacy (that the team performs well and its members are synergistic in their manner of working together)
At the heart of these components are the emotions we often work so hard to keep out of the workplace. However, as human beings, we function the same way in both our work and personal lives. Mutual trust can be developed only when each team member tells the truth about feelings, thoughts, and wants and listens and supports other members of the team to do likewise. Every person yearns to be a part of something bigger than himself or herself—to do something important that makes a difference. Well-functioning teams allow this to happen (Fig. 19.3). Developing such teams can increase nursing job satisfaction and group cohesiveness, decrease nurse turnover rates, and promote patient safety and quality outcomes.
Fig. 19.3 Teams can form strong relationships external to the work environment.
Understandable anxiety exists concerning the safety of being vulnerable and exposed if personal issues are revealed. That is why it is helpful for a team-building facilitator to make a thorough assessment of major issues and the willingness on the part of members to work on issues. One approach is to interview members of the team individually to discover the critical issues. The types of questions that might be asked, found in
Box 19.7
, provide some sense of the major issues within the team so that the facilitator has a better understanding of how to work with the team.
Box 19.7
Interview Questions for Team Building1. What do you see as the problems currently facing your team?2. What are the current strengths of your institution or work group? What are you currently doing well?3. Does your boss do anything that prevents you from being as effective as you would like to be?4. Does anybody else in this group do anything that prevents you from being as effective as you would like to be?5. What would you like to accomplish at your upcoming team-building session? What changes would you be willing to make that would facilitate a smoother-functioning team and accomplishment of the team goals?
Because people spend such a large percentage of their time in the work setting, it would be unrealistic to believe that they continually appear in an unemotional and controlled state. Human beings simply do not function that way. What is observed are people’s aspirations, their achievements, their hopes, and their social consciousness; they are observed falling in love; falling in hate and anger; winning and losing; and being excited, sad, fearful, anxious, and jealous. Consequently, these “feelings” are important components of organizational life and can undermine work effectiveness. Most of us know of situations in which, because of an emotional disagreement, two individuals have avoided each other for years. Because of the power of emotions and the inevitability of their presence, their effect on interpersonal relationships, and their influence on productivity, the quality of work, and the safety of patients, emotions should be a high priority when examining the functioning of the team. Fortunately, research addresses the importance of emphasizing the “emotional intelligence” of individuals when working in teams in the classic work by Goleman (2011). Those teams that address these issues are much more successful and create a more positive work environment than those that do not.
Suppressing emotions at work is neither healthy nor constructive for team members. When emotions are handled appropriately within the team, several positive outcomes are possible for the work setting. One creates a sense of internal comfort with the workings of the team and the organization. When stress is lowered and kept at lower levels on average, problems are much more easily resolved. This phenomenon is similar to releasing steam slowly with a steam valve rather than having the gasket blow. Interpersonal relationships on the team are more stable, and people have a sense of closer ties and collegiality when emotions are addressed. Fewer negative relationships or interactions develop, which results in more effective and pleasant working relationships all around.
Work group effectiveness improves when the team is functioning smoothly and emotions and “feelings” are being addressed on a routine basis rather than waiting for a volcanic eruption. The daily routines of frustration and boredom and retreat from the group are likely to undo a team. People who are engaged and have leaders who help them achieve goals are more effective. The skills and tools previously discussed (e.g., speaking supportively) are the basic tools one needs to handle the emotional aspects of the team. Choosing to cope with emotional upset must be a conscious choice, one that requires practice to improve the skill.
Literature Perspective
Resource: Kouzes, J. M., & Posner, B. Z. (2016). Learning leadership: The five fundamentals of becoming an exemplary leader. San Francisco: Jossey-Bass, John Wiley & Sons.
The original model focuses on how leaders in all walks of life and all aspects of the workplace mobilize people to get extraordinary things done. Ordinary people such as novice nurses can guide others along pioneering journeys to phenomenal accomplishments. The research and work that Kouzes and Posner have done establish relationships as the core of leading any change or initiative. Five key aspects of establishing and maintaining relationships constitute the heart of this leadership model:• Model the Way: Credibility is the foundation of leadership. It is established by consistently doing what you say you will do or by setting the example for the other team members.• Inspire a Shared Vision: Imagine exciting and ennobling possibilities, and enlist others in these dreams through positive attitude, excitement, and hard work.• Challenge the Process: Seek innovative ways to change, grow, and improve—experiment and take risks.• Enable Others to Act: Foster collaboration by promoting cooperation and building trust. Create a sense of reciprocity or give and take. Establish a sense of “We’re all in this together.”• Encourage the Heart: Novice leaders encourage their constituents to carry on. They keep hope and determination alive, recognize contributions, and celebrate victories.
Implications for Practice
When nurses use this model to approach leadership, they can strengthen their skills. Each of these examples provides a way for new, emerging, and established leaders to remain committed to the team with which they work. This model also emphasizes that each of us learn to be leaders and this is a lifelong learning process.
The role of leadership
Teams usually have a leader. In addition, teams function within large organizations that have leaders. Team-building, which can be a costly endeavor in terms of consultation fees as well as work time and team resources, is difficult to undertake and of questionable effectiveness without the approval and the support of the leader. Although very strong teams may be able to educate themselves regarding some of the issues, such as establishing goals and priorities or clarifying their own team process, addressing any kind of relationship issue among team members without a more objective outside party or skilled leader facilitating the process is exceedingly difficult. The Literature Perspective presents the essence of a model for leadership—one that could form the basis for how teams can be built.
Because leadership is such a pivotal part of smoothly functioning teams, it is illuminating to examine leaders more carefully. Truly progressive leaders understand that leadership and followership are not necessarily a set of skills or “putting on a role”; rather, these are qualities of character. Leadership and followership is as much about character and development as it is about education. Leaders realize their capacity for influence, risk taking, and decision making more fully. Team-building is a natural outgrowth. This type of leader understands that the best in a person is tied intimately to the individual’s deepest sense of himself or herself—to one’s spirit. The efforts of leaders must touch the spiritual aspect in themselves and others. The same could be said for skillful followers. Warren Bennis (2009) once said that leaders simply care about more people. Consequently, this caring manifests itself in doing whatever it takes to improve team functioning. This may imply involving oneself in team building with the team. The risk in such an endeavor is that the team leader is open to being vulnerable, to being judged by others, and to being wrong. However, if the leader has been a role model for the team agreement and has held people accountable to these statements, the team-building exercise will not degenerate into judging and placing blame.
If true leadership is about character development as much as anything, then character development is also beneficial for followers—that is, members of the team. The areas of character development often addressed include communication, particularly those aspects of speaking supportively that enhance understanding the other person’s message while avoiding placing blame and justifying.
Box 19.8
highlights an example of character development from personal experience, the concept of self-confidence.
Box 19.8
The “Can Do” Brigade: An Army Nurse’s Study in Character Development
As life events are reviewed, important or pivotal learning can be identified. One life event that significantly affected me was the year I spent as an Army Nurse Corps officer in South Vietnam. This was the first time I remember an awareness and understanding of confidence in the face of incredible obstacles. I had spent the first 10 months of my nursing career in labor and delivery at Indiana University before volunteering for a guaranteed assignment to Vietnam. I went to Fort Sam Houston for 6 weeks of basic training, where they taught me really important things like how to salute, how to march, and how many men are in a battalion. No one ever asked me if I could start an IV or draw a tube of blood. This was important because Indiana University had the largest medical school class in the United States at that time and nurses did nothing that interfered with medical education. Therefore I had never started an IV or drawn blood. When I arrived in Saigon, they put me in a sedan with another nurse and sent me up to the Third Surgical Hospital, one not unlike the one in M*A*S*H. We even had a Major Burns—that was not his name but it was his function. Surgical hospitals receive only battle casualties; their purpose is to stabilize and to transport.
The Third Surgical Hospital was located in the middle of the 173rd Airborne Brigade, whose job it was to defend the Bien Hoa Air Base, where all the sorties in the south were flown during the war. We were stopped at the gate by an MP who stepped up and saluted very snappily. He knew that a staff car must contain either a very-high-ranking officer or, if it was his lucky day, females.
When I was in Vietnam, 500 American women and 500,000 American men were there. The MP looked in the window, saluted snappily, and said “Afternoon, ma’am!” He wanted to know where we were going; he talked to us for a few minutes and assured us that if there was anything he could do for us, we should just give him a call. He saluted us and said, “can do.” I didn’t understand because I did not know that there are units with very high esprit de corps who attach snappy little sayings at the end of things like salutes, phone conversations, memos, and so forth. The 173rd was the “can do” brigade.
When we got to the hospital and met the chief nurse, she took us down to the mess hall and introduced us to all the doctors and nurses. We were sitting and having coffee when the field phone rang in the kitchen and the mess sergeant yelled out, “Incoming wounded.” Everybody got up and started to leave for the preop area. I just sat there until the chief nurse said, “Come on.” I said, “You don’t understand, I deliver babies.” She was not impressed! She took me by the arm and led me to preop.
When we got there, we discovered there were not just a few incoming wounded, there were more than 30, and some were very seriously injured. She immediately told the sergeant to call headquarters battalion of the 173rd Airborne and tell them that the Third Surg needed blood. She turned to me and said, “Lieutenant, you are responsible for drawing 50 units of fresh whole blood.” I was shocked! I had never drawn a tube of blood, but I found in the back section of preop a Specialist 4th class who was already setting up “saw horses” and stretchers, putting up IV poles, and hanging plastic blood sets. I started to help, and soon I heard trucks out back. I opened the door and looked outside. There were two huge Army trucks, and kids—17, 18, 19, and 20 years old—were jumping out. They were covered with red mud from the bottom of their boots to the tops of their helmets. I looked at them, and I looked at the clean cement floor, and in an instant, my mother came to me. I put my hand on my hip and said, “Where have you boys been?” One PFC stepped forward and saluted me very snappily and said, “Ma’am, we just came in this afternoon from 30 days in the field, we have been out in the rice paddies chasing the Viet Cong, we have not had a hot meal, and we’ve not had a shower, but Sergeant Major said the Third Surg needs blood!” He saluted smartly and said, “can do!” They were very clear. After 30 days of chasing and being chased by the Viet Cong, giving a unit of blood was easy. “Can do!” They were confident. They were kids who had looked into the face of death. At that moment, I knew if they can do, I Can Do! Life requires confidence. With confidence, you can make your dreams come true!
Confidence, which loosely translates as faith or belief that one will act in a correct and effective way, is a key aspect of character. Thus it follows that confidence in oneself can be closely tied to self-esteem, which is satisfaction with oneself. The greatest deterrent to self-esteem and self-confidence is fear. Fear is described by some as “false evidence appearing real.” Working on self-confidence requires an attitude of belief, of confidence, of I “can do” whatever is required.
Leading the team is clearly not the easiest thing to do, but neither is being an active, fully participating member of the team. Both require taking risks, including being in a relationship. Being in a team-building experience and hearing those things that have not worked for people in their interactions with peers and the leader can be scary but worthwhile. It requires a focus on personal and professional growth. It requires building character.
Conclusion
Whether a nurse is a leader, a manager, or a member of the team, effective performance requires commitment to the group. Forging new relationships and strengthening old ones are typically facilitated by deliberate actions ranging from creating clarity of purpose through holding each other accountable.
The Solution
Diane Gallagher
The first question that needed to be asked was, “Were we committed to providing the most optimal care for the neonate?” In other words, why would teamwork be important in this situation? What’s the vision or mission? After achieving agreement among the neonatal intensive care unit (NICU) team, we strategized on how to create a “team” with the specialists. Making our intent clear was very important. A meeting with the director of the specialty team, the NICU medical director, and nursing leadership was arranged. We discovered that we shared a common goal: to provide the best care possible for the baby. Keeping that goal as the focus, we then identified areas of mutual respect. From there, both sides were willing to listen to each other’s concerns. Care guidelines could be identified, as well as areas of responsibility. Ideas on how to improve the communication process were also discussed. A plan based on patient needs, complete with agreements, was implemented.
Were we a team yet? The answer is “no.” There was still a little skepticism and reserve. Everyone seemed to have a “wait-and-see” attitude. The first big chance was identified when the specialty group insisted that a patient of theirs be admitted to the NICU because they believed it was the best place for the baby to be. Another measurable outcome was having the agreements honored. This reinforced to everyone that his or her concerns had been heard and respected. Mutual trust was building, and a collegial relationship began. A year later, it is hard to imagine that this situation ever occurred. There is enthusiasm for this specialty’s physicians and their patients. It is certainly a change in attitude.
There are many components to team-building, but the most important component is to be clear about your mission and intentions and to be clear in communication when working with potential team members. The intention to provide the best care possible assisted each one of us to be more open, creative, and trusting. These are all necessary components of team-building. Remember, teams are made up of individuals. Ask yourself if you are willing to accept responsibility for your response and actions. Be the change that you want to see.
Would this be a suitable approach for you? Why?
Reflections
Consider the following questions, then write a one-paragraph summary. When could you have been more effective as a team member or group leader recently? What personal behavior could you improve in your next group or team experience?
The evidence
TeamSTEPPS is a well-documented, integrated program created through the auspices of the U.S. Department of Health & Human Services Agency for Healthcare Research and Quality (AHRQ) and the U.S. Department of Defense (DOD) Healthcare Team Coordination Program; it stresses teamwork and communication among physicians, nurses, and other healthcare personnel to increase patient safety (Castner, Foltz-Ramos, Schwartz, & Ceravolo, 2012). Multiple projects and evidence have been accrued regarding the use and implementation of TeamSTEPPS, as well as the outcomes produced from this program. The goal is to produce highly effective interdisciplinary teams that achieve the best outcomes for patients. The tools and strategies used include leadership that coordinates the team and initiates planning, problem solving, and process improvement. Also, situation monitoring is used. This tool focuses on the ability of the nurse to actively scan behaviors and actions of co-workers; it also fosters mutual respect and team accountability, which creates a safety net for the team and patient. Specific skills are taught that increase the ability of each team member to support other team members by accurately assessing their workload and helping them. These skills protect the team from work overload that might reduce effectiveness and increase risk to patients. The last skill set focuses on communication that highlights clear, accurate information exchange among team members, including SBAR, Call-out, and Handoff. The TeamSTEPPS teaching manual, including PowerPoint presentations and teaching videos, is available from the DOD Patient Safety Program for minimal cost.
Tips for team building• Commit to the purpose of the team.• Develop team relationships of mutual respect.• Communicate effectively, and actively listen.• Create and adhere to team agreements concerning function and process.• Build trust.
References
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Coyne C. Strength in numbers: How team building is improving care in a variety of settings. PT Magazine of Physical Therapy. 2005;13(6):40–51.
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