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chapter
12
Building Teams
for Productivity
and Efficiency
CAROL SEAVOR, EDD, RN

CHAPTER MOTIVATION

“People make fewer errors when they work in teams. When processes
are planned and standardized, each member knows his or her
responsibilities as well as those of teammates, and members ‘look out’
for one another, noticing errors before they cause an accident. In an
effective interdisciplinary team, members come to trust one another’s
judgments and attend to one another’s safety concerns.”
Institute of Medicine, 2000

CHAPTER MOTIVES

■ Describe the contributions of teams and teamwork to quality

patient care.
■ Discuss the relationship between good communication, healthy
group dynamics, and effective teamwork.
■ Understand the competencies needed for successful team
building and effective team leadership.

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184 Skills for Being an Effective Leader

D elivery of health care is quite complex. Even

though nurses may deliver care as individuals, they
This chapter will review the importance of team-
work in nursing and health-care delivery. Learning
to be an effective team member and/or team leader
are usually part of a caregiving team working in will serve you, your patients, and their loved ones
concert. Even care delivered to patients by an indi- well. Understanding the dynamics that occur within
vidual nurse or other caregiver has probably been teams, the roles that members play, and the patterns
influenced by others, through diagnosing, planning, of communication that develop will help you be
referral, or other types of collaboration. The admit- an effective team member. Learning about these
ting physician provides the initial medical diagno- dynamics will prepare you to ease some of the fric-
sis, the admitting nurse establishes the initial tion, avoid some of the conflict, and learn from both.
nursing care plan, and other health-care disciplines, You will see that partnerships and collaboration are
such as social work, physical therapy, diet therapy, essential for safe, efficient, and effective health care.
and occupational therapy, may influence the plan of Teamwork with other nurses, teamwork with other
care. Treatments, equipment, and medications have disciplines, and multidisciplinary teams will help
been developed over time and studied and tested by you provide the best possible care for your patients.
unknown numbers of professionals (many working Good teamwork is essential for good nursing, and
in teams) to develop the best models of care. Many good teamwork begins with good group work.
nursing interventions are also the result of nurse
researchers working in teams to broaden the reper-
toire of evidence-based practice. The complexity of
both the health-care arena and the nursing profes-
Group Work
sion challenges nurses to become proficient in the
skills of collaboration and team building. Most Nurses usually work in diverse caregiving groups
health-care delivery agencies employ nurses with and are expected to collaborate with others to pro-
varying credentials and levels of education. The duce positive patient care outcomes. The popular
existence of multiple levels of nursing personnel adage “A camel is a horse designed by a committee”
requires that all nurses understand the various roles is a reminder how ineffective group work may have
performed at each level. Doctoral, master, bachelor, unintended and unwanted outcomes. Groups con-
and associate degree nurses work along with sist of people in relationships. As the size of the
licensed practical nurses (LPN) and certified nurs- group grows, group dynamics become more com-
ing assistants (CNA) in large medical centers. In plex, and the opportunities for misunderstanding,
order for patients to receive effective, coordinated friction, and conflict grow. Those who share a
optimal care, smooth teamwork must exist. Table household with their children may recall the sim-
12-1 summarizes the levels of educational oppor- plicity of life prior to parenthood. Similarly, those
tunities in nursing and the roles associated with who are oldest children in the birth order of their
each. family may harbor fond memories of a time when
As multiple roles have evolved within nurs- sharing was not necessary or when negotiating was
ing, so too have the roles within other health-care not a daily event. Students expected to work within
disciplines. For example, respiratory therapists, a study group or required to complete group projects
physician assistants, occupational therapists and have experienced how group work can be fraught
occupational therapy assistants, surgical technol- with pitfalls and frustration. Although groups may
ogists, radiological technicians, and a myriad of differ in their purposes, structure, and processes,
other supportive technicians are likely to be part of most groups do have one characteristic in common:
the health-care team. Never has mutual under- the possibility of conflict. Understanding the phe-
standing, mutual respect, group work, and team- nomena associated with good group functioning
work been more important and more crucial to the facilitates good group work and eases frustration
well-being of patients receiving care within the and conflict. When group members are aligned
health-care system. Table 12-2 provides examples of about their purpose, work within a well-understood
the roles played by some of the health-care disci- structure, and have a strong and healthy group pro-
plines likely to be included in the care of hospital- cess, their group is poised to function as an effective
ized patients. health-care team.
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Building Teams for Productivity and Efficiency 185

TABLE 12-1 Levels of Nursing Education

CAREGIVER ROLE

Nurse’s aide (NA) Assistants who work under the direction of an LPN, registered nurse (RN), or physician provide basic
care for patients. Most states require a minimum number of hours of clinical practice and classroom
instruction in a formal program, usually at a community college, in adult education, or in a hospital
or nursing home. The program usually lasts for several weeks. In most states, an examination must
be passed for certification, and the aide is designated as a CNA.
Licensed practical The LPN or LVN is an entry-level nurse who is responsible for providing basic nursing care, working
nurse (LPN) or under the direction of a physician or RN. Educational programs usually last about 1 year and are
licensed vocational given in community colleges or hospital settings. LPN educational content is similar to that for RNs
nurse (LVN) but the amount of time, the number of hours required, the prerequisite courses, and the responsi-
bilities and decision-making expectations are reduced. A national examination (NCLEX-PN) must be
passed for licensure.
RN Requires completion of a formal education program in nursing at a community college, state
university, or private college. A national licensing examination (NCLEX-RN) must be passed for
licensure as an RN. Graduates of the following nursing programs are allowed to sit for the NCLEX-RN
examination: associate degree, baccalaureate degree, or entry level master’s degree. Associate
degree nurse (ADN) programs typically require 2 years of course work. Bachelor of science nurse
(BSN) programs require 4 years for completion. In some states, hospital-based programs (diploma
programs) offer training required for licensure without an academic degree, usually lasting 3 years.
An entry-level master’s degree is a graduate program that admits students with bachelor or higher
degrees in other fields and prepares graduates with an initial degree at the master’s level in nursing.
Master of Science Usually requires students to have a BSN degree and includes 1 or more years of course and clinical
in Nursing (MSN) work, offered by private and state universities. MSNs are prepared in several specialties, including
nursing education, nursing administration, medical/surgical, family, psychiatric, community, and
pediatrics obstetrics health nursing. They are also prepared for various practice roles such as clinical
nurse specialist (CNS), nurse practitioner (NP), family nurse practitioner (FNP), certified nurse midwife
(CNM), and certified registered nurse anesthetist (CRNA).
Doctoral prepared Usually requires 3 or more years of education at a doctorate granting institution. These nurses have
nurse (for exam- strong research, theory, and practice skill and serve in nursing faculty positions, research positions,
ple, PhD, DNS) direct research-based clinical specialty practice, or administrative positions.

GROUP PURPOSE a contribution to an organization may become a for-

mal group. Groups containing members who are
In caregiving agencies, groups (often in the form of clear about their purpose and are committed to
committees) exist or are created to fulfill an ongoing working toward achieving their purpose have the
function, responsibility, or task within the organiza- best potential for success. Some illustrations of for-
tion. Managers also create short-term groups (often mal and informal groups include:
called ad hoc groups or task forces) to accomplish a Formal:
specific task or outcome. Long- and short-term ■ A group of nurses assigned to the recovery
groups created and supported by the organization room or a surgical floor
are called formal groups. Informal groups may ■ A group of nurses employed by a visiting nurse
also form within caregiving agencies. These groups agency
are not officially designated or supported by the ■ The institutional research board of a commu-
organization but exist because the participants nity hospital
chose to be in a relationship to share a common ■ The curriculum committee of a nursing educa-
interest. Effective informal groups that demonstrate tion program
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TABLE 12-2 Examples of Team Member Roles

TEAM MEMBER EXAMPLES OF PRACTICE ROLES

Patient/consumer/ Participates to extent possible in plan of care and goal setting; identifies cultural needs and
client practices; reports own experience of progress
NURSING
RN, doctorate Conducts clinical research; provides consultation to clinical staff and administrative leadership
within agency; serves as nursing faculty
RN, master’s Within a specialty, provides comprehensive nursing care, health promotion, histories, and physicals
in outpatient and acute/home/long-term care settings; teaches and counsels; if certified as an
advanced practice nurse may order, conduct, and interpret laboratory and diagnostic tests as
allowed by state nurse practice act; provides consultation support for nursing staff; serves as
nursing faculty; provides administrative leadership within agency
RN, bachelor’s Develops and implements comprehensive nursing care in all settings; provides leadership for
health-care teams
RN, associate Develops and implements nursing care usually in settings where patients have stable and
predictable health needs
LPN Delivers basic nursing skills as defined by the facility under the supervision of an RN or physician
CNA or NA Assists with basic nursing skills as defined by the facility under the supervision of an RN; see
Chapter 22 for additional examples of unlicensed assistive personnel (UAP)
MEDICINE
Physician Diagnoses and treats diseases and injuries, provides preventive care, prescribes drugs, and
performs medical or surgical specialty care according to preparation
Psychiatrist Medical doctors who diagnose and treat mental, emotional, and behavioral disease and conditions
ALLIED HEALTH
Dietitian Evaluates the nutritional status of patients; works with family members and medical team to
determine appropriate nutrition goals for patient
Occupational therapist Utilizes therapeutic goal-directed activities to evaluate, prevent, or correct physical, mental, or
emotional dysfunction or to maximize functions for optimal independence
Pharmacist Devises and revises patient’s medication therapy to meet medical and therapeutic needs;
information resource for the patient and medical team
Physical therapist Evaluates, plans, utilizes exercises, rehabilitative procedures, massage, manipulations, and physical
agents such as mechanical devices, heat, cold, air, light, water, electricity, and sound in the aid of
diagnosis or treatment
Physician assistant (PA) Practices medicine under the supervision of licensed physicians; provides a broad range of
diagnostic and therapeutic services
Speech language Assesses and treats speech, language, and swallowing disorders; provides individual or group
pathologist therapy to maximize functional communication and swallowing ability
OTHER PROFESSIONS
Chaplain Provides spiritual support and ministry to patients and families
Psychologist Assesses, treats, and manages mental disorders; provides psychotherapy with individuals, groups,
and families
Social worker Assesses individual and family psychosocial functioning and provides care to help enhance or
restore capacities, including locating services or providing counseling

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Building Teams for Productivity and Efficiency 187

■ The annual dinner ad hoc committee sibilities, meeting schedules, tasks, goals, purpose,
■ A committee assigned to research the factors minutes, and agendas help members understand the
related to an increased incidence of patient expectations of membership. These expectations
falls on a nursing home unit suggest appropriate and productive group and home-
work activities. Groups with a purpose but little or
Informal: no structure are likely to have confused and frus-
■ A lunch group with an interest in starting a trated members. Productivity and achieving goals
local chapter of a nursing specialty group become more difficult.
■ A mutual support group of new employees
■ A group interested in research on empathy in GROUP PROCESS
nursing
A group usually exists to get a job done a job that is
often referred to as the group task. Group process
GROUP STRUCTURE comprises the dynamics that occur between and
among group members as they work to complete
Formal and informal groups may be highly struc- the group task. Group process encompasses pat-
tured or have very little structure or few rules terns of behavior and issues that occur as a group
that guide their collaboration. Formal groups with forms and develops over time. Just as an individual
longevity are apt to have more rules and provide develops from infancy to adulthood and moves with
more guidelines for the expectations of behavior of some predictability through patterns of behavior
group members. The amount of structure in a group and stages of development, so do groups. Having
is reflected by its written guidelines, record keeping, an understanding of what to expect of an individ-
style of leadership, process of decision making, and ual’s development helps parents to guide children
membership. A highly structured group maintains through each stage and successfully negotiate
by-laws or other documents that define expecta- growth and development. Understanding the dy-
tions of the group’s functions. These documents namics of group process and what to expect as
may address, for example: purpose; goals; roles and groups grow and develop will help group members
responsibilities of members; time, place, and order function more effectively and more comfortably.
of meetings; and how minutes will be recorded and
filed. The leadership structure and process will be
defined clearly as will lines of authority and respon- Group Stages of Development
sibility. The process of decision making will be clear
and consistent. Members of structured groups are
usually chosen because of their competence or abil- Decades ago, Homans (1950, 1961) proposed a con-
ity to meet the goals and purposes of the group and cise and easily understood process that described the
are apt to have the same or similar backgrounds and predictable progress and process of groups. His the-
educational levels. sis has stood the test of time and has been reviewed
Groups with little structure take a more laissez- and expanded by others (Tuckman, 1965; Tuckman
faire approach; roles and responsibilities are not & Jensen, 1977; Lacoursier, 1980; Drinka & Clark,
spelled out clearly, and group members decide 2000). Homans’ theory suggests that groups move
among themselves, often through trial and error, through four stages: forming, storming, norming,
how to proceed. The role of leader may rotate among and performing.
members, or a leader may evolve. Decision making
may be by consensus or fiat by a leader or member. STAGE 1: FORMING
Perhaps little decision making will occur or be
needed. Members may not always be the same, and In this initial stage, group members look to the
backgrounds and educational levels may vary. leader for guidance. If there is no designated leader,
The extent of structure within a group has a one may emerge, or several members may take a
significant impact on the group’s productivity and leadership role at various times. Conversation is
effectiveness. For example, groups with clearly com- polite; the goal is to create a safe environment and
municated guidelines for membership, roles, respon- find common interests and areas of acceptance.
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188 Skills for Being an Effective Leader

Box 12-1 as possible and to take responsibility for leading

future meetings. The goal is to enroll at least 75 of
Group Members’ Thoughts the 100 juniors by November 1.
in the Forming Stage Kathryn has assembled the group of eight for the
I wonder what they are thinking about me? first meeting. Most are chatting quietly about the
Will I be accepted or rejected? courses they are taking, the faculty they have, and
their concerns about the seniors telling them how
Will they think my ideas are stupid?
difficult the next 2 years will be. Kathryn tells
Will they pressure me to talk?
everyone what Kerry expects them to do during the
Will I fit in? next 6 weeks. All are quiet; sidelong glances are
Will I say too much? passing through the group as each waits to see who
What if they find out what I am really like? will be the first to speak.
What if I say the wrong thing? Amy thinks, “There’s no way anyone is going to
come up with $20 to join NSA because I ask them
What if they ask me to do something I don’t want to do?
to. I am a total failure at selling anything.” She says
edgily, “Why do we have to get members? Why
don’t the seniors do their own work? They are the
Members are alert to similarities and differences NSA officers.” More time passes quietly, and Greg
that they will note for future reference when form- thinks “I know I won’t fit in here because I’m a guy,
ing subgroups later. The group avoids controversial and they probably don’t even care if guys join or
or serious subjects. Discussion centers around how not.” Lindsey thinks, “I never should have come to
to define the scope of the task, how to approach it. this school; too many spoiled children will see me as
See Box 12-1 for some of the thoughts and private the ‘old lady’ with children of my own and think I
concerns that members are likely to be having at have nothing important to say.” Shanna says, “Can
this stage. anyone tell me where the bookstore is? I haven’t
Characteristics of this stage can include impa- bought my books yet.” Trent says, “Sure, I’ll show
tience, confusion about group purpose, anxiety, you where it is. Where are you from?” Kathryn asks
silence and awkwardness, and off-topic chatter. tentatively, “Well, I know we have a big job to do. Is
General issues of trust are being considered as the anyone willing to help work on a plan for how to
group struggles to find a level of ease. To grow from begin?” Jane thinks, “I knew I shouldn’t have come
this stage to the next, each member must relinquish here. I’m already sure I’m going to fall behind in my
the comfort of nonthreatening topics and risk the schoolwork and part-time job, and here I am being
possibility of conflict. As members take small steps asked to do more work. What’s wrong with me?”
risking sharing their substantive ideas and begin Superficial remarks go on for the course of the
to experience positive reactions, group comfort will meeting as members learn about each other’s
grow, and the group will move to the next stage of towns, mutual friends, dorms, and so on. Eventu-
development. Consider the following example: ally, Greg and Shanna agree to meet with Kathryn
During the first week of fall semester, eight mem- the next day and work on a plan of activities to
bers of a new junior-level class of nursing students move them toward their goal. All agree to meet at
have agreed to join their college chapter of the least once a week until November 1, when their list
Nursing Student Association (NSA). They have of new members and the money must be turned in.
been told by the seniors who are the leaders of the Over the next 2 weeks, there are three meetings of
NSA that they should meet regularly and work the core group and two more where all eight attend.
toward enrolling all of their junior-year classmates By then, when all are gathered, there is more com-
into the NSA. They are expected to be the “front fortable conversation. Some have met for dinner
runners,” who will convince their classmates of the and arrived together; two others have joined an aer-
benefits of joining this organization, and they need obics class together and have arrived energized.
to learn as much as they can about the organization Others are trading notes from their leadership class.
as quickly as possible so they can be effective men- Some are still shy, but most are ready to talk about
tors for others. The president of the NSA, Kerry, the next steps of their plan for approaching new
has asked Kathryn to call the first meeting as soon NSA members.
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Building Teams for Productivity and Efficiency 189

STAGE 2: STORMING “Just because someone happens to be dating a

senior, he thinks he knows what is going on better
As work begins on the job at hand (group task) and than the rest of us.”
the group tries to get organized, competition and “I have lots of people who want to join. Why do
conflict develop among personal relations (group we have to collect the money and be so strict about
process). This conflict occurs because many individ- keeping a record? Why can’t we just take their word
uals attempt to contribute, blend, and mold their for it and put their names on the new member list?”
ideas, feelings, attitudes, and beliefs as they try to “I think the four of us who live in Windsor Hall
find a way to approach the task at hand. As each should be a team and not have to keep meeting with
individual contributes to the group, there may be everyone every week.”
fear of rejection, fear of failure, tentativeness, frus- “If we can’t figure out a better way to work
tration, and a growing desire for structure, clarifica- together, we aren’t going to come anymore.”
tion, and sense of direction. Questions will arise After a couple of such discouraging meetings,
about the rules, who is responsible for what, what Kathryn talks with Greg and Shanna about what to
the goals are, and how goals will be evaluated. These do next. They approach Dr. X, one of the NSA fac-
questions and comments reflect emerging conflicts ulty advisors they trust, and explain the situation
over leadership, purpose, structure, authority, and and ask for help. The advisor explains she thinks
influence. As these areas of difference emerge, there the group behaviors may reflect positive group
will be varying levels of comfort within the group as growth and signify that the group is moving out of
well as wide differences in behaviors. Some mem- the “I”-centered forming stage and beginning to test
bers may become very silent and withdraw; others the tolerance of others. Some are showing their frus-
will attempt to dominate. Cliques and subgroups tration with the group’s lack of productivity by
will develop as agreement and disagreement over angry silences or by angry remarks. Dr. X agrees to
issues become apparent. Trivial matters may be- try and help. At the next meeting, Kathryn explains
come the focus of attention but may be masking they talked with Dr. X and asked her to help the
frustration and an inability to deal openly with group get better organized. She asks if the group is
larger issues. willing to have Dr. X work with them. The response
In order to progress to the next stage, group mem- is lukewarm but, hearing no strong objections, Dr. X
bers must move from a “testing and proving” to a thanks the group, hands out an agenda, and explains
problem-solving mentality. Leadership and the abil- some ground rules for the meeting. The ground
ity of group members to listen to each other are crit- rules ask that all stay focused on the agenda items,
ical for groups to move on to the next stage of agree to speak only when recognized by the leader,
development. An effective group leader will utilize promise to make an effort to listen carefully with an
skills of negotiation and consensus building, to help open mind to the person who is speaking, to make
group members develop greater tolerance for diverse notes for reference if they have something to add
views, and the varying roles and contributions of all when it is not their turn to speak, and to contribute
the members. Think about the NSA group as they with serious, thoughtful, suggestions focused on the
continue developing into the storming stage. problem being discussed. All agree to follow the
The group has been experiencing some rocky ground rules. Dr. X then shares her impressions of
times. The meetings are often fraught with sullen the situation. She acknowledges the group’s frustra-
silences and sarcastic remarks. Frustration and tion. She also notes the commitment of everyone, as
anger seem to be frequent visitors, and members are reflected by consistent attendance. She tells them
sometimes missing with no explanation. Some of that their willingness to voice their frustration is
the remarks heard during the last few meetings very likely related to their being people who do not
include: like to waste time and who are conscientious and
“It would be nice if someone would give us the goal-oriented and want to get the job done well.
right information once in awhile. Are we supposed There are nods of agreement.
to be collecting money from our classmates or not?” She passes out a feedback form, asking everyone
“Looks like someone wants to take all the credit to take a few minutes to write about what they
for herself” (glancing sidelong at Kathryn, who had value about this group, what they wish was differ-
just reported on the number of members joined). ent, what they would like to accomplish, and what
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190 Skills for Being an Effective Leader

suggestions they have to accomplish the goals. They and encourages those who may be having less than
spend the rest of the evening discussing the collec- stellar results. Dr. X attends meetings for a few min-
tive feedback of the group and brainstorm a list of utes each week to offer her help but observes that
goals, a list of short-term objectives, a detailed plan the group has shifted its focus from individual
of tasks, and a list of volunteers to work on each needs to the group job. Many good ideas for ways to
task. Finally, they develop a time line for the com- encourage their classmates to join NSA are gener-
pletion of each task. The next few meetings are ated, and members are often heard complimenting
less chaotic, becoming more focused on the group each other for their successes.
purpose.
STAGE 4: PERFORMING
STAGE 3: NORMING
Not all groups reach the performing stage. If they do,
The next stage is called norming because, as the the capacity of the group members and the depth of
group becomes more cohesive and tolerant of differ- their relationships become truly interdependent; the
ences, the group process becomes calmer. Members group has established a highly functioning team.
have had time to become more familiar with each Group members can work independently, in sub-
other and are better able to predict each other’s reac- groups, or as a total unit with equal facility. Roles,
tions and behaviors. This normalcy lessens anxiety authority, and responsibilities easily adjust to the
and builds trust as group norms begin to develop. changing needs of the group and of individual mem-
Over time and with good group leadership, roles and bers. Members feel secure, and the need for group
responsibilities become clearer, and members begin approval is no longer an issue. Members have
to feel less tension. More productive patterns of become highly task-oriented and people-oriented.
behavior develop. Cliques dissolve, and members lis- Morale and group identity are strong; group loyalty
ten to and value facts, ideas, and opinions brought is intense. The group is productive, engages in gen-
to the group. Problem solving improves. The group uine problem solving, and creates effective solu-
job during this stage entails actively engaging in tions. The transformation from being a group of
problem solving, sharing ideas, doing research, and individuals to being a highly functioning team is
producing facts and information. The group mem- complete.
bers share feelings and ideas, solicit and offer feed- November 1 was celebration day for the group.
back to one another, and explore actions related to Through the weeks, members produced steady
the task. Creativity is high. At this stage, interac- results and rallied around each other to overcome
tions (group process) are characterized by more obstacles. As midterm approached, all were chal-
acceptance, openness, and sharing on both a per- lenged by increased demands on time. Greg admit-
sonal and task level. Consider the NSA group as it ted that he was behind in his research paper for
embarks on group norming. adult nursing; Shanna volunteered to keep records
Over the next couple of weeks, group members for a week so he could catch up. Lindsey’s father
have additional interaction as they compare notes suffered a serious illness that required all her atten-
and communicate between classes and in the eve- tion. The rest of the group took turns baby sitting
nings about how well tasks are being completed. each evening for her and involved her two children
Greg is feeling more comfortable that his classmates in stuffing membership envelopes. Trent took on
appreciate his record-keeping skills, even though he Lindsey’s role of encourager by making a large chart
does not share their interest in the shopping trip showing progress toward the goals for the week.
they are planning. Jamie has experience selling Jamie invited a different senior to come each week
books door-to-door and is teaching the group the art to talk about the fun and professional activities that
of how to convince others of the value of what you membership in the NSA offers. At one point, it
are selling and how to follow through with collect- became clear to the group that several juniors
ing the money. Amy keeps everyone informed by wanted to join NSA but could not afford member-
e-mail of the progress being made. Trent takes re- ship. Kathryn, Jane, and Shanna had an idea that
sponsibility for safeguarding the money collected was quickly embraced by the entire group. Kathryn
and issuing receipts. Lindsey plays the role of being approached the manager of the local music store
the sounding board for the latest gripes, ideas, and where she worked, and he agreed to donate a $50
suggestions. She strives to keep everyone motivated gift certificate to the group. The group organized a
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Building Teams for Productivity and Efficiency 191

raffle. Each member committed to sell at least 12 error. Consider the level of nursing care that might
tickets for $2 each, and they raised $200 from stu- be delivered by a group at an early stage of develop-
dents, friends, family, and faculty. With the help of ment, perhaps at the storming stage, compared with
Dr. X, the money was discreetly distributed to 10 a team at the performing stage. See Table 12-3
qualified students to help them pay membership (adapted from the Web page of Nondestructive
dues. During this process, it was clear that the group Testing, Teamwork in the Classroom [2004]).
members were willing to work together toward
group goals, and each knew he or she could count on
teammates for help with tasks and personal support.
Not all groups develop to the performing stage,
Interdisciplinary Teams
but those that do become highly functioning, highly
effective teams. Many groups form and accomplish As society has experienced a knowledge and tech-
a task without investing the time and energy neces- nology explosion, the number of health-care disci-
sary to become a team. But when work groups do plines has increased, and coordination of care has
become teams, they return the highest level of pro- become more complex. A patient entering the
ductivity to their employers and the highest level of health-care delivery system, even for an overnight
service to their clients. The difference in effective- stay, is likely to be observed, interviewed, examined,
ness of teams versus lower-functioning groups that tested, treated, discharged, and monitored by a
have not negotiated through the group development dozen different caregivers representing several med-
stages can mean the difference between optimal ical, nursing, and allied health disciplines. This
nursing care and care fraught with inefficiency and process offers the patient a breadth and depth of

TABLE 12-3 Group Versus Team Characteristics

STORMING STAGE GROUPS PERFORMING STAGE TEAMS

Members work independently and may not be Members work interdependently and work toward both personal
working toward the same goal. and shared team goals and understand these goals are accom-
plished best by mutual support.
Members focus mostly on themselves and are not Members feel a sense of ownership toward their role in the
involved in the planning of their group’s objectives group because they committed themselves to achieving goals
and goals. they helped create.
Members are assigned tasks or told what their job is, Members collaborate and use their multiple talents and experi-
and suggestions are rarely welcomed. ences to meet the team’s objectives.
Members are cautious about what they say and are Members base their success on trust and encourage all members
afraid to ask questions. They may not fully understand to express their opinions, varying views, and questions.
what is taking place in their group.
Members do not trust each other’s motives, and roles Members make a conscious effort to be honest and respectful
are not clearly understood. and listen to every person’s point of view.
Members may have a lot to contribute but hold back Members are encouraged to offer their skills and knowledge, and
because of superficial relationships with other members. in turn each member is able to contribute to the group’s success.
Members are bothered by differing opinions or dis- Members consider conflict as a part of human nature, and they
agreements because they consider them a threat. react to it by treating it as an opportunity to hear about new
There is no group support to help resolve problems. ideas and opinions. Everybody wants to resolve problems
constructively.
Members may or may not participate in group decision Members participate equally in decision making, and each
making, and conformity is valued more than positive member understands that the leader might need to make the
results. final decision if the team cannot come to a consensus.
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192 Skills for Being an Effective Leader

comprehensive knowledge and expertise and re- The study points out the need for professionals to
quires a high level of communication, collaboration, confront each other about detrimental caregiving
mutual understanding, and respect among the care- behaviors that contribute to hundreds of thousands
givers. Caregivers may include a physician (perhaps of patients being harmed each year. In addition, it
multiple specialists); physician assistant; nurses; re- notes that 1 in 20 hospitalized patients will be given
spiratory, occupational, or physical therapist; social a wrong medication; 3.5 million will get an infec-
worker; nutritionist; and a myriad of administra- tion due to lack of handwashing or good precau-
tors, aides, and technicians. Clerical employees and tions (Wenzel & Edmond, 2001); and 195,000 will
other support persons may be assisting each disci- die because of other mistakes made by caregivers
pline. This plethora of personnel presents a serious (HealthGrades Quality Study, 2004).
challenge to effective communication and efficient
teamwork.
Health-care agencies expect their caregivers to be
competent practitioners and effective team mem- Practice Proof 12-1
bers. To be effective, each team member must under- Article: Silence Kills, The Seven Crucial Conversations for
stand the various roles played by each discipline. Healthcare
Physicians are trained and educated to be the central
Author: Maxfield D., et al. Source: VitalSmarts in Partner-
hub of the health-care team. They are likely to be the ship with the American Association of Critical Nurses,
first point of contact, and they focus on the disease www.silencekills.com
process or condition that has caused the patient to
This study addressed communication patterns among
seek health-care services. Nurses are educated and caregivers in hospitals. Researchers collected data from a
trained to focus on the holistic needs of the patients sample of 1700 nurses, physicians, and other health-care
as they respond to the stresses associated with their personnel in 13 U.S. hospitals during 2004. Data collection
disease or condition. methods included interviews, surveys, and observations.
The critical importance of teamwork and com- They examined how caregivers communicate their
munication in health care has been underscored by concerns to their coworkers when they observe them
several published reports in the last decade. These providing care in ways that contribute to errors, reduced
studies document the association between quality productivity, poor morale, and high turnover. Results
patient care and effective teamwork (Firth-Cozens, suggest that the majority of health-care workers practice
safely and competently. More than half the caregivers
2001; Institute of Medicine Study, 1999; Kaissi,
surveyed, however, reported observing some number
Johnson, & Kirschbaum, 2003; Majzun, 1998;
of workers who exhibit problem behaviors continuing
Sexton, Thomas, & Helmreich, 2000). The findings over long periods who were not held accountable. They
suggest that teamwork enhances efficiency, con- reported witnessing policy infractions, incompetence,
tributes to improved morale and job satisfaction, and mistakes. Yet fewer than one in ten discussed their
lowers stress, and improves patient satisfaction. concerns with the coworker, and most indicated they
Risser et al. (1999) points out that effective team- did not think it was possible to change and felt no
work provides a safety net against patient care responsibility to raise their concerns. Twenty percent of
errors because it allows for coordinated and inte- the physicians said they saw harm come to patients as a
grated clinical activities and gives caregivers more result of these concerns, and 23% of nurses reported
control over their work environment. An earlier considering seeking new positions as a result of these
concerns. About 10% of the respondents reported willing-
study by Williamson et al. (1993) and cited by
ness to raise their concerns with their coworkers and as a
Kaissi reported that 70%–80% of medical errors
result observed better patient outcomes, more satisfac-
are related to interpersonal interaction issues. tion, and commitment to staying in their positions. The
Communication and teamwork issues have been study results suggest that if more health-care workers
often cited as shortcomings in the health-care sys- would communicate their concerns when they see inap-
tem. Caregiver errors contribute to compromised propriate practice behaviors, there would be significantly
patient safety and diminish job satisfaction among fewer errors, higher productivity, and lower turnover.
health-care professionals. A recent report, entitled Most health-care workers want patients to get good care
“Silence Kills,” (2005) published by VitalSmarts in yet they are reluctant to confront their coworkers when
collaboration with the American Association of they see risky behaviors. Why does that happen and can
Critical Care Nurses (AACN), addresses the need you describe some examples of similar situations?
for health team members to communicate better.
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Building Teams for Productivity and Efficiency 193

Another significant published work that calls

attention to the need for teamwork in the context of Practice to Strive For 12-1
patient safety is “To Err is Human: Building a Safer
The team must have clear goals. Team goals should call
Health Care System” prepared by the Institute of for a specific performance objective that is expressed so
Medicine (1999). This report cites many factors concisely that everyone knows when the objective has
related to health-care errors and makes many been met.
recommendations for improvement, including the The team must have a results-driven structure. Teams
need for excellent communication among health need latitude to organize themselves in a way that will let
team members and effective teamwork training. them produce results. Teams needs space, resources, mem-
The report calls for health-care organizations to bers with expertise, self-defined roles, and time.
implement patient safety programs that promote The team must have competent team members. The
team functioning and to train in teams those problems given to the team should be those the members
who are expected to work in teams. Drinka and can solve given their level of knowledge and experience.
Clark (2000) support the “training in teams” con- The team must have unified commitment. This does not
cept. They recommend that students participate in mean that team members must always agree. It means
interdisciplinary courses during college. In their that all individuals must be directing their efforts toward
courses, the goal is to develop an appreciation for the goal. If a member’s efforts are going toward personal
and an understanding of the differences and simi- goals, the team should address this and communicate the
larities among their professions. Students could need for commitment to goals from all.
engage in learning about the theoretical and value The team must be collaborative. Trust produced by hon-
orientations of other professions and develop a est, open, consistent, and respectful behavior and commu-
foundation for continued understanding and col- nication is required. With trust, teams perform well; without
laboration that will transfer to practice. McPherson, it, they fail.
Headrick, and Moss (2001) also support edu- The team must have high standards that are understood
cational strategies that prepare learners to col- by all. Team members must know what is expected of them
laborate and provide a comprehensive review of individually and collectively. All are responsible for clarifying
recent literature that identifies the issues, examples, confusion and giving and asking for guidance when
methods, and conclusions about “interprofessional needed.
education.” The team must receive external support and encourage-
Kaissi, Johnson, and Kirschbaum (2003) con- ment. Encouragement and praise work just as well to
ducted a survey that explored the attitudes of motivate teams as they do individuals.
nurses related to patient safety and teamwork. The The team must have principled leadership. Teams usually
nurse respondents were members of teams practic- need someone to lead the effort. Team members must
ing in high-risk areas, such as operating room, know the team leader is competent and is working for
the good of the team. Team members will not support
emergency room, and intensive care units. These
the leader motivated primarily by the need to achieve
nurses believed that effective teamwork was as personal recognition or other benefits not related to
important as clinical competency with respect to achieving team goals.
patient safety. They also reported the need for
clearer team leadership roles, more team input into
patient care decisions, and better teamwork rela-
tions between nurses in high-risk areas and with Note some best practices based on the work of
anesthesiologists and nurse anesthetists. These Larson and LaFasto (1989).
reports strongly support the need for health care-
givers to be proficient and effective team members
and continually to build skills needed to be success- Effective Communication
ful team leaders. Effective teams need the structure
of clear ground rules that all members know,
Within Teams
understand, and support. Teams with good struc-
ture, good communication, and good leadership will Many of the problems that occur within teams are
far exceed the accomplishments of an individual. the direct result of people failing to communicate
Teams that invest the time and energy to learn and effectively. Effective communication takes place
execute team skills will provide uncommon results. only if the receiver understands the exact informa-
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194 Skills for Being an Effective Leader

tion or idea that the sender intended to transmit. Box 12-2

Most literature about effective communication
agrees that the communication process begins with
Common Nonverbal Behaviors
the sender having information in his or her mind. It Vocal: Tone, pitch, rhythm, timbre, volume, and inflection
may be a thought, a conceptual idea, technical infor- are nonverbal gauges of enthusiasm and interest. A
mation, or a feeling. The sender “sends” this com- monotone sends a signal of boredom, dullness, and
munication, using observable behaviors, to the disinterest.
receiver, and the receiver “gets it” using senses, and Facial expressions: Smiling signals happiness, friendliness,
translates the words or message into information in warmth, and liking to Smiling is likely to create comfort
and willingness to listen.
the receiver’s mind. This could be described as a
“mind to mind” transmission. During the process, Eye contact: Signals interest in others. Initiates flow of the
the receiver will receive a message about both the message and conveys interest, concern, warmth, credibil-
ity, and presence.
content and the context of the message. Content is
the actual spoken or written language that can be Personal space: Dictated by cultural norms to signify
understood by those who speak the same language. a comfortable physical distance for interaction with
others. Signals of discomfort caused by invading one’s
Misunderstandings or confusion may occur when
space include moving away, turning away, rocking, leg
senders and receivers apply different interpretations
swinging, finger tapping, averting eyes.
or usage to the same words. Context, sometimes
Speaking style: A lively speaking style captures the
referred to as paralanguage, includes the additional
listener’s attention, makes the conversation more
messages that may be sensed or perceived through
interesting, and facilitates understanding. Lack of
nonlanguage behaviors. Context may include tone animation while speaking may be perceived as bore-
of voice, the look in the sender’s eyes, body lan- dom, ill ease, and disinterest.
guage, hand gestures, or real or perceived state of
Posture and body orientation: Standing erect and
emotion (anger, fear, uncertainty, confidence, etc.). leaning forward communicate approachability,
These multiple variables of paralanguage can easily receptivity, and friendliness. Interpersonal closeness
cause misinterpretation of or confusion about what is created when sender and receiver face each other.
may appear to be clear content. Individuals believe Turned to side or back, looking at the floor or ceiling
what they see over what they hear and tend to trust communicate disinterest and discomfort.
the accuracy of nonverbal behaviors more than ver-
bal behaviors (Schuster, 2000, p.13). Several non-
verbal contextual behaviors that have a significant
influence on the way messages are received are Active listening is listening with full attention with
described in Box 12-2 (Arnold & Boggs, 1995; the intention of understanding. It requires a con-
Burgoon et al, 1996; Riley, 2000; Schuster, 2000). scious focus of energy and concentration and full
In the process of communication, there are many engagement of the listener. It requires listeners to
opportunities for a message to become distorted or listen as if they will be asked to repeat every word
altered between the sending and receiving. For they have heard. Not only will this level of attention
example, many team leaders think they have com- promote effective communication of the message, it
municated once they have told someone to do some- will also nonverbally communicate full attention
thing (“I don’t know why it did not get done, I told and interest back to the sender. Some signs of active
Jim to do it.”) Perhaps Jim did not hear or under- listening appear in Box 12-3 (Arnold & Boggs,
stand the message. The message has not been com- 1995; Burgoon et al, 1996; Riley, 2000).
municated unless the receiver has received and Feedback is another powerful communication
understood it exactly as the sender intended it to be tool because it helps to verify that the message
understood. Communicators can validate if a mes- received was the one sent. Providing feedback may
sage has been properly received by engaging in two- entail the receiver paraphrasing or restating what
way communication (feedback). Communication was perceived, such as “This is what I understood
is an exchange, not just a one-way give, and both you to say” or “This is what I understand you are
parties must participate in the feedback process feeling. Am I correct?” The feedback process can
to be sure nothing was “lost in translation.” One identify the need for further discussion to prevent
excellent way to ensure effective two-way commu- misunderstanding. Communication “in a hurry”
nication is with active listening and feedback. and without feedback can lead to errors, hurt feel-
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Building Teams for Productivity and Efficiency 195

Box 12-3 techniques be practiced and utilized with genuine-

ness by the communicators. He cautioned that uti-
Signs of Active Listening lizing feedback techniques in a mechanical way or
Spends more time listening than talking. as manipulations would likely be recognized as
Notices own biases. (We all have them. We need to such by the communicators and interfere with clear
recognize them, acknowledge them, and ask ourselves communication and trust building. Effective com-
how they affect what we are hearing.) munication is a cornerstone of effective teamwork,
Does not daydream or become preoccupied with own and it works best when those involved are commit-
thoughts when others talk. ted to utilizing excellent communication skills,
Allows time for other speaker to talk. Does not dominate attempt to suspend personal judgments, and extend
the conversation. respect and positive regard for their teammates.
Creates responses after the other person has finished Good communication is a rare and precious tal-
speaking, not while the person is speaking. ent and requires practice. Nurses working together
Provides feedback but does not interrupt incessantly. must apply best practices of good communication to
Analyzes by looking at all the relevant factors and asking minimize opportunities for errors or omissions in
open-ended questions. Reflects, summarizes, asks for care based on misunderstandings. Communication
more information. skill is foundational to professionals being able
Stays attentive to what the speaker says; does not shift to to share, collaborate, delegate, and integrate their
what interests the listener. knowledge, expertise, and experiential wisdom.
May take brief notes, which requires concentration on Professional expertise that is shared and blended
what is being said. among colleagues optimizes benefits to patients.
Each discipline must understand its own roles as
well as the roles of other team members so that
appropriate referrals can be made and specialized
ings, wasted time, and an inefficient and ineffective expertise applied.
work environment. When providing feedback, it is
important to stay positive and nonjudgmental.
Being nonjudgmental requires conscious effort on
the part of the listener. The listener must attempt
Team Leading
to resist being distracted by inner thoughts and
judgments that arise in reaction to the message Effective team leaders must understand the con-
being heard. Attending to these inner thoughts and cepts and theories that explain how teams function
judgments, instead of giving full attention to the so they can meet the challenges inherent in this
message, distracts the listener and may create mis- complex leadership role. Adjusting to the complexi-
understanding. For example, if the listener experi- ties of caregiving settings, negotiating development
ences anger at what is being said during the first through group stages, facilitating effective commu-
part of the message, it is likely that the feeling nication, and maintaining patient safety is work to
of anger will become the focus of the listener, and be guided by the team leader. In fact, one of the
the rest of the message may be distorted or lost. most important factors in overcoming these chal-
If the listener can make a conscious effort to wait lenges and rising to the opportunities is having a
until the entire message is heard before attending to competent team leader.
any emotions that may be associated with the mes- LaFasto & Larson (2001) note “Your purpose
sage, it will improve the effectiveness of the commu- as a leader is to add value to your team’s effort”
nication. (p. 99). The team leader’s primary job is to stay
Dr. Carl Rogers, a noted psychologist during the focused on the results that the team has been
first half of the 20th century, was an advocate for charged to produce. As tasks are shared, different
nonjudgmental communication. He advocated points of view are expressed during planning, or
using several deliberate techniques to provide feed- conflicting feelings are shared about group events,
back. He recommended paraphrasing, interpreting, and the leader must react appropriately. The chal-
providing supportive statements, probing for more lenge will be to interpret and react while keeping
information, reflecting back the same words and/or the ultimate goal of the team in mind. The best lead-
feelings, and sharing feelings. He advised that the ers will consistently monitor the progress toward
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196 Skills for Being an Effective Leader

the goal and plan actions accordingly. The leader ing will build confidence and create the opportunity
must “keep an eye on the prize” and rally team to experience a “win.” A leader who is fair and
members to do the same. impartial, shows no favoritism, and facilitates inclu-
Some skills to assist the leader to stay focused on siveness will create a team that is willing to take
the goal include: greater and greater risks. Building confidence will
create more motivation for positive action. A good
■ Define the goal often to the team and ask the
leader says “thank you” in as many verbal and non-
team to do the same.
verbal ways as can be imagined.
■ Provide visual reminders of the goal.
Effective leaders are mindful of the need for good
■ Explain how tasks or assignments will con-
technical expertise. Teams need to have the nec-
tribute to accomplishment of the goal, and ask
essary knowledge, experience, and background nec-
members to do the same.
essary to reach the goal. Hard work goes a long way
■ Keep the goal alive by discussing it frequently
toward success, but without the right knowledge in
and in different ways.
the right areas effective problem solving is unlikely.
■ Use frequent examples of how all contribu-
A team leader who recognizes that a team has
tions are moving toward the goal.
knowledge deficits will search for assistance.
■ Share examples of reports/stories/literature of
Possible solutions include adding more knowledge-
how others reached similar goals.
able team members or providing the team with
■ Help all to understand how/why difficult tasks
strong consultation to assist members with building
may be the key to creating the change.
the competence needed.
■ Value team members, and trust them.
While keeping the team’s ultimate goal in mind, a
Team leaders must also invite active participation wise leader will also develop interim steps designed
of all team members and make it clear that all mem- to move toward goal achievement and will assist
bers’ input is valued. Team leaders should be honest members with prioritizing each step. To focus
when providing feedback to members. Ground rules energy and ensure efficiency, leader and members
must call for the expectation of honest communica- must be clear about what work is essential and what
tion delivered in a respectful manner. The leader is not. Effective leaders set priorities by asking,
must set the tone and example for communicating “What are the three most important steps for us to
honestly and respectfully and must calmly and achieve today (or by our next meeting)?” Teams can
respectfully confront others not observing this rule. not reach goals, work collaboratively, build confi-
In most circumstances, the leader should expect, dence, or apply their expertise if they are not clear
acknowledge, and reward collaboration over com- about the priorities or if they have too many priori-
petition (see Chapter 21). Providing guidance in ties. The team leader must consistently communi-
using a methodical and clear problem-solving cate the priorities to be met and help envision how
method is essential. A balance between tending to the step-by-step priorities fit within the big picture
the need for technical knowledge and expertise and of goal attainment.
tending to interpersonal group process needs must Finally, the team leader must apply management
be met. There will be times that team effectiveness skills to facilitate effectiveness and productivity.
is blocked because a deeper level of knowledge is Nonperformers must be managed in a positive
needed or times when progress is impeded because way. The leader must communicate concern to non-
team members are not working well together. The performers and provide clear descriptions of ex-
good team leader will constantly monitor the team’s pected performance. Nonperformers must be made
progress toward its goals and provide the skill and aware of expected time lines and the rewards and
support that are needed to help the team progress. consequences that will be applied for improved or
This may take the form of exposing the team to new continued lack of performance. Lack of response by
information, or it may require mediating a disagree- nonperformers will create deterioration of team
ment between team members who are not working morale and will soon affect team productivity. Non-
well together. Providing effective leadership will performers will likely appreciate guidance toward
require diligent monitoring and holding high expec- better performance or will welcome the opportu-
tations of team members. Encouraging task assign- nity to acknowledge they would prefer not to be
ments that have high expectations but are doable part of the team. Team leaders who guide their team
will stretch the team’s ability. Success with stretch- to stay focused on the goal, stay in a collaborative
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Building Teams for Productivity and Efficiency 197

rather than competitive mode, maintain confidence, for service. They will also be appreciated by their
provide or build the necessary technical knowledge team members and will make a lasting contribution
for goal attainment, set priorities, and manage per- to the safe and effective care of health-care con-
formance will find themselves in constant demand sumers.

chapter star:
Two nurses and a physician have led formal performance poor attendance privately and respectfully with a
improvement teams, created with the approval and member and requested better performance in future.
support of hospital administration, to improve patient After little improvement, member was confronted again
care outcomes. Issues of care addressed by the teams and given the opportunity to withdraw from the team
included length of stay and care of patients at risk for with the promise of joining at a future time when she
or experiencing deep vein thrombosis, cardiac care, would have more time to devote to teamwork. This
pneumonia, and infections. Team membership varied with proved to be an acceptable solution to all and preserved
the condition being addressed and involved a wide variety integrity of team and member.
of levels and disciplines, including physicians of multiple 4. Need for mutual trust. Members expressed concern
specialties, nurses of multiple units and specialties, case that data-gathering protocols were not followed by
managers, pharmacists, compliance officers, education some group members. Leader acknowledged the
consultants, telephone operators, unit secretaries, health concern and evaluated data-gathering process. Leader
information managers, and technology support. Team used the incident as an opportunity to facilitate open
leaders unanimously agreed that their experience with discussion among team members about the need to
leading interdisciplinary teams left them with the beliefs respect, trust, and value the competence and
that good teams create safer and better patient care, contributions of all caregiving disciplines while
improve resource utilization, improve collaboration, acknowledging the responsibility of the team to identify
and contribute to more satisfied caregivers. Informal concerns about inadequate performance.
conversations with these team leaders also revealed 5. Need for effective communication. Leaders believed
eight recurring themes that exemplified the challenges, the need for good communication was imperative. They
opportunities, rewards, and value of effective team noted that willingness to communicate created opportu-
leadership in caregiving settings. These themes are: nity to solve problems effectively within the team. They
1. The need for clear goals. Leaders emphasized that a also noted that when team members became more
condition for success was the identification of clear goals familiar with each other’s roles, communication
and the need for leaders to facilitate the “buy-in” of goals improved as did respect and collaboration.
by all team members. Asking each team member to 6. Need for recognizing progression from norming to
commit to the success of the team one by one was storming. One member consistently monopolized team
noted as a successful strategy within one team. The time to criticize progress. Reactions from other team
importance of leaders having public support of the team members reflected frustration, sarcasm, defensiveness,
goals from highly regarded influential hospital leaders and clique formation. Leader led discussion with
was also noted as crucial. Adopting national quality reminders for respect and focus on issues. Resolved
indicators for patient care issues was also noted as an by giving the criticizer the responsibility for a new task
important element in goal setting. Leaders also noted the that would improve productivity and take advantage
need to revisit goals and articulate the vision loudly and of his talent for attention to detail and doing it his way.
often. 7. Need to facilitate scholarship oriented collaboration:
2. The need for ground rules. Leaders agreed that Improved relationship and respect for others led to shar-
members need to know expectations for structure and ing of professional literature and ideas. Assessment tools
behavior and that leaders must make these clear. Ground and protocols were developed reflecting interdisciplinary
rules that were considered most important included: interests. Team members reported more collaborative
clear expectations for time and place of meetings, atten- care and more satisfaction with their work environment.
dance, communication, collaboration, and mutual 8. Need to communicate across generations: New team
respect among members. Examples of interventions approach seemed to threaten autonomy and “old way
that were applied by leaders to address the need to of doing things” for some practitioners. Team agreed to
follow ground rules included the next five themes. enlist key peers of older generation (who were accept-
3. Need for attendance. A leader discussed pattern of ing of changes) to communicate rationale for changes.