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[Audio] © Shutterstock / Olha Kostiuk PART I Team and Group Development “When sufficient numbers of organization members become more self-aware, more concerned about the needs of others and more effective as group members and group leaders—they cannot help but eventually have a positive influence on the total function and structure of any system.” Shaffer and Galinsky, 1989, p. 192 Chapter 1: Groups-Teams-Systems Chapter 2: Group Development Chapter 3: Team Building Blocks: Norms, Goals, Roles, Communication, Leaders, and Members Part I Activities © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

[Audio] © Shutterstock / Olha Kostiuk © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

[Audio] © Shutterstock / Olha Kostiuk learning objectives 1. Understand groups as complex, open systems. 2. Apply the concept of open systems to healthcare teams. 3. Differentiate groups and teams. 4. Describe levels of systems and how they relate to healthcare teams. 5. Recognize how the diversity inherent to interprofessional healthcare teams contributes to their adaptability and sustainability. Why Groups? Humans are wired to be interdependent. We bond together in families, friendship groups, neighborhoods, work groups, and recently in electronic social networks like Facebook and Twitter. The world has become more complex, and the exponential growth of information that is required to solve problems is not the purview of a single person or a single profession. By recognizing our need to join with others to meet challenges, we have the opportunity for collective wisdom to emerge and facilitate the creation of new connections and innovative strategies to ensure the health and stability of the world that we share (Briskin, Erickson, Ott, & Callanan, 2009). Groups and teams have been and will Groups-Teams-Systems 3 CHAPTER 1 © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

[Audio] continue to be an essential part of our daily lives. Nowhere is the need for teamwork more relevant than in the healthcare arena. Diagnosis and intervention require the efforts of a cadre of physician specialists, nurses, therapists, pharmacists, social services personnel, laboratory personnel, information managers, dietitians, transportation workers, home health aides, family caregivers, and patients. Quality health care that is accessible and cost effective requires that the boundaries between these stakeholders are made permeable through consistent collaboration (Grant & Finocchio, 1995). Skills in team building, team membership, and the understanding of group dynamics are foundational and indispensable for the next generation of healthcare leaders. Well-functioning healthcare teams are linked to good morale, reduced staff turnover, and positive patient outcomes (Gittell, 2009; Lawrence, 2002; Torrens, 2010; Woltmann et al., 2008). What Distinguishes a Group from a Random collection of People? There is a unique designation for each of the myriad groupings in the animal kingdom such as school (fish), troop (baboons), murder (crows), gam (whales), and group (humans). No matter what the species, the critical element that is common to all the groupings is that the individual members are interdependent. In the case of humans, “members cASe SToRY: The Importance of Interprofessional Teams At our organization, everything is a committee decision. You can have input from multiple perspectives such as nursing, social work, occupational therapy, physical therapy, and dietary. Elder problems are highly complicated. Getting other perspectives is helpful. For example, let’s say you can’t transport Mrs. X into the center because she keeps hitting people and is not putting her seatbelt on. What do you do? You need to get different perspectives in order to make a decision. It is like that example of the blind men and the elephant. No single perspective will describe the elephant and there probably is not one single resolution. This requires that team members are confident in what they know, amenable to listen to someone else’s ideas, and willing to offer their own ideas. — Karen J. Nichols, MD, Chief Medical Officer for VIP Plans at AmeriHealth Caritas 4 | Chapter 1 Groups-Teams-Systems © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

[Audio] are linked together in a web of interpersonal relationships. Thus, a group is defined as two or more individuals who are connected to one another by social relationships” (Forsyth, 2006, pp. 2–3). Alderfer (1977) expanded the definition of human groups to include how they are distinguished from and perceived by nonmembers and how they relate to other groups. For the purposes of this text, in order for a group to be distinguished from a random collection of people, its members must have common interests and goals and regular patterns of interaction, exert influence among the members, and work interdependently to achieve goals (Cartright & Zander, 1968; Lewin, 1948; Smith, 2008). What Is the Difference Between a Team and a Group? The terms team and group are often used interchangeably. However, making the distinction between these two terms can offer valuable insight into how groups work and can facilitate leadership and full participation in productive teams. The term group comes from the French word groupe and the Italian gruppo, which were borrowed originally from the prehistoric Germanic kruppaz and is translated into a “round mass, lump” (Online Etymology Dictionary, 2011). The term group is defined by Merriam Webster (Definition of Group, 2011) as “a number of individuals assembled together or having some unifying relationship.” Team is defined as a group that engages in more focused intentional action. The word is derived from the Middle English term teme and the Old English tēon, which is to draw or pull (Definition of Team, 2011). Katzenbach and Smith (1993) describe a team as “a small number of people with complementary skills who are committed to a common purpose, set of performance goals, and approach for which they hold themselves mutually accountable” (p. 112). The difference between a group and a team can be described on a continuum (Figure 1-1). At one end of the spectrum, group refers to people with something in common and at the other end, team refers Figure 1-1 Group-team continuum. Students in a Classroom Advisory Committee ER Team Group = A collection of people who have something in common. Team = A group of people who must work together to reach common goals or outcomes. What Is the Difference Between a Team and a Group? | 5 © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

[Audio] to people who must work together to get to a common agreed-upon goal or outcome. In this text, the term group will be used in discussions regarding the dynamics, processes, and patterns found in human collectives. Health professionals who are working together to achieve positive patient outcomes will be designated as teams. A Systems Approach to Groups Systems theory conceptualizes all physical and social systems as integrated wholes as opposed to agglomerations of disparate pieces. The 18th-century German philosopher Hegel introduced systems theory by suggesting that the whole is more than the sum of its parts: the whole determines the nature of the parts and the parts are dynamically interrelated and cannot be understood in isolation from the whole. The biologist Ludwig von Bertanffly proposed that all biological systems are open to each other and each identifiable component is related to other parts (Banathy & Jenlink, 2004). From a systems theory perspective, an individual member of a team cannot fully be understood in isolation from the team, and a team cannot be fully understood without understanding the organizational context within which it exists. Katz and Kahn (1978) explored the systems theory further when they proposed a method to analyze open (living) social systems. They ReflecTIon: Identification of Groups Rank in order the descriptions below with 1 being the most grouplike and 10 the least grouplike. Give reasons for your rankings. ______ The spectators at a college football game ______ Two strangers exchanging meaningful looks across a crowded bar ______ A secretary conversing with the boss by telephone ______ Five students at a university working together on a classroom assignment ______ A mob of rioters burning stores in the inner city ______ Thirteen inmates talking and lifting weights in a jail’s exercise yard ______ A committee deciding the best way to handle a production problem ______ Six employees working on an assembly line ______ An aggregate of individuals waiting in silence for a bus ______ The Smith family of Richmond, Virginia (Mr. Smith, Mrs. Smith, and their daughter Jane Smith) 6 | Chapter 1 Groups-Teams-Systems © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

[Audio] posited that the interactive paradigm of analyzing living systems like organizations is based on continual cycles of input, throughput (processing), and outputs. All living organisms, like healthcare organizations and the groups that comprise them, are fully open systems. There are some key characteristics of open systems that resonate in the healthcare arena. Information provided by hospital staff, care recipients, suppliers, and funding sources is an example of input. Intervention from health professionals is an example of throughput, while patient outcomes, patient satisfaction rates, and quality improvement outcomes are examples of system outputs (Meyer & O’Brien-Pallas, 2010). Health care organizations can be described as complex, adaptive systems because of the non-linear and often unpredictable nature of the interactions between the many microsystems that comprise the larger system (Sturmberg & Martin, 2013). Suchman, Sluyter, and Williamson (2011) provide an apt metaphor for healthcare organizations that is consistent with the description of complex, open systems as non-linear, open to the environment, self-organizing, and evolving (Sturmberg & Martin, 2013). We can perceive a healthcare organization as a gigantic complicated conversation involving its staff, patients (and their families), payers, regulators, neighbors, competitors, and anyone else who interacts with or is affected by it. Within this gigantic conversation, there are . . . myriad [simultaneous] sub-conversations . . . board meetings. . . . chance conversations at the water cooler . . . faceto-face or in virtual space . . . in the language of spoken or written words or of symbolic gestures . . . between individuals or in the private space of each person’s thinking. . . . Thinking of an organization as a conversation rather than a machine . . . [we] understand that we can influence but not control what goes on, and that we do so more by the way in which we participate than by the plans we make (p. 15–16). Each participant in a team takes in the ideas and opinions of others (input), processes this input and compares and integrates it with their most current thoughts (throughput), and together with the group, creates a new, collective perspective (output) (Figure 1-2). The organizational conversations reflect the organization’s values, mission, culture, knowledge base, and interactive patterns among the microsystems/ groups that comprise the larger organization. Organizations that attempt to impose a mechanistic, linear orientation upon an inherently open system such as a group, organization, or community discount the value A Systems Approach to Groups | 7 © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

[Audio] and challenges of randomness. These tightly coupled systems find themselves too rigid to respond to internal or external signals for the need to change. For example, in a hierarchical healthcare system, team members are less likely to question designated leaders and are often unwilling or unable to be professionally assertive. As a result, the repertoire of solutions to problems may be limited and the team may be ill equipped to respond to change. Change in open systems is inevitable, and adapting to these environmental changes is a continuous process. The manner in which groups and their parent organizations respond to change determines the possibilities for or limits to creativity, productivity, and outcomes (Sturmberg & Martin, 2013; Vickers, 1983; Weick, 1976). Systems, subsystems, and the environment, are complex, interactive, and interdependent. The dynamic relationship between structure and function of all aspects of the system and its environment render the boundaries permeable and changes at any level of a system affect all other levels of the system. For instance, organizational culture is as much a product of individual behaviors as it is a facilitator of individual behaviors (Studer, 2003). The mood of an individual leader can impact the Figure 1-2 Conversations allow us to inquire, exchange and process information, expand thinking, and negotiate and transform that information into a common perspective that is different than the sum of its parts. © Michael D Brown/Shutterstock 8 | Chapter 1 Groups-Teams-Systems © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

[Audio] mood of the team and be impacted by the tone of the team, or a team’s effectiveness or ineffectiveness can impact and be impacted by the success of an organization. Nembhard & Edmondson (2006) found that inclusive behavior on the part of physician leaders yielded higher perceptions of psychological safety, increased engagement in all members of the healthcare team, and concomitant positive quality improvement efforts. Healthcare organizations that have been able to institutionalize relationship building as a means for integrating myriad systems consistently report higher staff retention rates and better clinical outcomes (Gittell, 2009; Singh, 2000; Woltmann et al., 2008). Within all living systems, the balance between energy consumption (entropy) and energy infusion (negentropy) is necessary for the maintenance of a steady state for optimal systems functioning (homeostasis). An example of this in healthcare practice is the effect of caretaker rest (energy infusion) on patient care (indicates status of system’s functioning). The relationship between decreased caretaker rest and decreased cognitive and clinical performance on the part of the caretaker and concomitant medical errors has been well documented (Reed, Fletcher, & Arora, 2010). The evolutionary capacity of a system depends on flexible and adaptable patterns of organization that facilitate its ability to deal with environmental challenges and opportunities. The most agile, adaptable, and successful healthcare teams are those that are able to routinely evaluate who needs to be present and who has the most cogent information or expertise. Diverse perspectives and a broad range of information is essential for sound clinical decision-making (Briskin et al., 2009; Wheatley, 2005). Inclusionary practices such as incorporating caregivers and support personnel into the healthcare team and giving equal attention to each team member’s contribution broaden the perspective of the team. In addition, psychological safety and willingness of members to share information facilitates the generation of innovative solutions for improved patient care (Meyer & O’Brien-Pallas, 2010; Nembhard & Edmondson, 2006). Applying Systems Theory When attempting to study, understand, and effect change in a complex social system, it is helpful to distinguish between the individual, interpersonal, group, organizational, and community levels of the system. Individual: One person. Interpersonal: Two individuals interacting. Applying Systems Theory | 9 © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

[Audio] Group: Three or more individuals working toward a common goal or purpose. Organization: A social structure, often made up of groups, that pursues a collective goal to deliver some product or service. Community: Anything beyond the organizational level. This includes other organizations, governments, or global social networks. Systematic analysis and intervention in complex organizations takes the entire system into account (Rojas-Smith, Ashok, & Morss-Dy, 2014). Each interprofessional care team, department, or group can be considered a microsystem and can be examined with regard to its purpose, patients, professionals, processes, and patterns that distinguish it from and link it within the larger system. High-performing microsystems are characterized by inclusive leaders, strong organizational support, ongoing staff development, cohesive teams, patient/community focus, evidence-based practice, process improvement, and technologyenhanced communication through a variety of formal and informal channels (Barach & Johnson, 2006). Successful change agents, whether they are leaders or members of groups, learn to differentiate between systems levels, shift attention from one level to another, and make an informed decision about the best level at which to intervene based on a realistic appraisal of the change agent’s sphere of influence (Gillette & McCollom, 1990; Wells, 1995). Sturmber and Martin (2013) contend that intervention in complex systems is most effective when problem solvers consider the system from a variety of perspectives, frequently test hypotheses, engage in structured problem solving, practice self-reflection, and consider goals in light of their effects on the whole system. While the primary focus of this text is the group level of system, individual and interpersonal levels will also be explored. Table 1-1 shows examples of intervention methods that are commonly used at various system levels. Our current healthcare system is one that is complex and changing rapidly. It can been described as volatile, uncertain, complex, and ambiguous or VUCA. VUCA is a concept that was originally developed by the military and has since been applied to the rapidly evolving healthcare environment. Using a systems perspective helps to address the challenges of a VUCA world by engaging all stakeholders in conversations that will leverage their expertise and resources, broaden and strengthen relationships among stakeholders, engender creative problem solving, and inspire the diffusion of new ideas and practices (Sturmberg & Martin, 2013; Lindberg, Hatch, Mohl, Arce, & Ciemins, 2013). 10 | Chapter 1 Groups-Teams-Systems © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

[Audio] Table 1-1 Intervention at Each Level of System level Focus goal Methods Individual Individual’s behavior, perceptions, and emotions. Increase selfawareness and self-management. Coaching, training, mentoring, and feedback. Interpersonal The relationship and communication between two people. Clarify the nature of the relationship and goals and strengthen foundations for clear communication. Conflict management, mediation, communication, and conflict resolution training. Group Group goals, tasks, roles. Clarify the nature of individual contributions, the group’s purpose, and group behaviors that will foster accomplishment of goals. Education and feedback on the stages of group development, team building, leadership, and coaching behaviors that contribute to team effectiveness and productivity. Organization Culture, leadership development, and organizational strategy and structure. Increase awareness of the people in the organization that the whole is different from the sum of its parts. Identify what attributes, behaviors, and strategies are necessary in order to reach the organizational goals. Analysis of organizational state including culture, training in culture change, top team development, and executive coaching. Identify organizational strengths in order to leverage culture change, appreciative inquiry, and dynamic inquiry. Community Finding common ground so that the community can be served. Building partnerships and collaborations across communities to deliver services. Strategic planning, community development, and futuring. Applying Systems Theory | 11 © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

[Audio] cASe STUDY: SYSTeM leVel InTeRVenTIon The chair of the pediatrics department in a large health system, Dr. Clarice Barna, was struggling with a problem. Three of the 75 residents asked for a meeting with her. During the meeting the residents complained that they were getting inconsistent instruction from the faculty and not getting the feedback and one-on-one attention from the faculty they felt they deserved. They also felt that the nurses often gave them different instructions than the ones they got from the faculty about patient care. Although three residents were in the meeting, almost all of the talking was done by one resident, Jason. Dr. Barna set up a meeting with the faculty and shared Jason’s feedback on behalf of the residents. The faculty discussed ways to improve instruction and thought that it would be good to get additional feedback from the nurses. The faculty expressed frustration that the residents, although great students, seemed to get confused when trying to grasp that there can be more than one way to do a procedure. Each of the faculty had unique perspectives and practices they wanted to offer the residents and felt the residents needed to understand and accept multiple methods for procedures. Dr. Barna then discussed the situation with the nursing team that worked most often with the residents. The nurses said they really enjoyed working with the residents and that they were really a top-notch group. The head nurse, Eileen Fenway, upon hearing that Jason was the student who brought this up, reminded the chair that Jason completed his internship at University Children’s Hospital where the interns were each assigned a specific mentor, coach, and technical instructor in addition to faculty. She suggested that Jason’s perception and expectations needed to be addressed. QUESTIONS: 1. Look at the row labeled “Individual” in Table 1-1 . Assume that Jason is the individual. Describe how Dr. Barna could improve things by talking only to Jason. 2. Look at the row labeled “Group” in Table 1-1 . Describe how Dr. Barna could engage the group of faculty and nurses to help achieve the goals of improving resident education based on the feedback given by the residents. 12 | Chapter 1 Groups-Teams-Systems © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

[Audio] References Alderfer, C. P. (1977). Organization development. Annual Review of Psychology, 28, 197–223. Banathy, B. H., & Jenlink, P. M. (2004). Systems inquiry and its application in education. In D. H. Jonassen (Ed.) Handbook of Research on Educational Communications and Technology (pp. 37–57). Mahwah, NJ: Lawrence Erlbaum Associates. Barach, P., & Johnson, J. (2006). Understanding the complexity of redesigning care around the clinical microsystem. Quality & Safety in Healthcare, 15(Suppl I): i10–i16. Briskin, A., Erickson, S., Ott, J., & Callanan, T. (2009). The power of collective wisdom and the trap of collective folly. San Francisco, CA: Berrett-Koehler. Cartright, D., & Zander, A. (1968). Group dynamics: Research and theory. New York, NY: Harper & Row Publishers. Definition of Group. (2011). Merriam-webster.com. Retrieved 3 August 2016, from http://www.merriam-webster.com/dictionary/group Definition of Team. (2016). Merriam-webster.com. Retrieved 3 August 2016, from http://www.merriam-webster.com/dictionary/team Forsyth, D. R. (2006). Group dynamics (4th ed. [International student edition.]). Belmont, CA: Thomson Wadsworth Publishing. Gillette, J., & McCollom, M. (1990). Groups in context: A new perspective on group dynamics. Lanham, MD: University Press. Gittell, J. (2009). High performance healthcare: Using the power of relationships to achieve quality, efficiency and resilience. New York, NY: McGraw-Hill. Grant, R. W., & Finocchio, L. J.; California Primary Care Consortium Subcommittee on Interdisciplinary Collaboration. (1995). Interdisciplinary collaborative teams in primary care: A model curriculum and resource guide. San Francisco, CA: Pew Health Professions Commission. Katz, D., & Kahn, R. (1978). The social psychology of organizations. Hoboken, NJ: Wiley. Katzenbach, J. R., & Smith, D. K. (1993). The wisdom of teams: Creating the highperformance organization. Boston, MA: Harvard Business School. Lawrence, D. (2002). From chaos to care: The promise of team based medicine. Cambridge, MA: Perseus Publishing. Lewin, K., Lewin, G. W. (Ed.). (1948). Resolving social conflicts: Selected papers on group dynamics. New York, NY: Harper & Row. Lindberg, C., Hatch, M., Mohl, V., Arce, C., & Ciemins, E. (2013). Embracing uncertainty: complexity-inspired innovations at Billings Clinic. In J. Sturmberg & C. Martin (Eds.), Handbook of systems and complexity in health (pp. 697–713). New York, NY: Springer Science+Business Media. Online Etymology Dictionary. (2016). Etymonline.com. Retrieved 3 August 2016, from http://www.etymonline.com/index.php?allowed_in_frame =0&search=group Meyer, R. M., & O’Brien-Pallas, L. L. (2010). Nursing services delivery theory: An open system approach. Journal of Advanced Nursing, 66(12), 2828–2838. Nembhard, I., & Edmondson, A. (2006). Making it safe: The effects of leader inclusiveness and professional status on psychological safety and References | 13 © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.

[Audio] improvement efforts in health care teams. Journal of Organizational Behavior, 27, 941–966. Reed, D., Fletcher, K., & Arora, V. (2010). Systemic review: Association of shift length, protected sleep time and night float with patient care, residents’ health and education. Annals of Internal Medicine, 53, 829–842. Rojas-Smith, L., Ashok, M., & Morss-Dy, S. (2014). Contextual frameworks for research on the implementation of complex system interventions (Internet). Rockville, MD: Agency for Healthcare Research and Quality. Shaffer, J., & Galinsky, M. (1989). Models of group therapy (2nd ed.). Englewood Cliffs, NJ: Prentice Hall. Singh, S. (2000). Running an effective community mental health team. Advances in Psychiatric Treatment, 6, 414–422. Smith, M. (2008). Experience in groups and other papers. New York, NY: Tavistock Publications Limited. Studer, Q. (2003). Hardwiring excellence: Purpose, worthwhile work, making a difference. Gulf Breeze, FL: Fire Starter Publishing. Sturmberg, J., & Martin, C. (Eds.). (2013). Complexity in health: An introduction. In J. Sturmberg & C. Martin (Eds.), Handbook of systems and complexity in health (pp. 1–17). New York, NY: Springer Science+Business Media. Suchman, A., Sluyter, D., & Williamson, P. (2011). Leading change in healthcare: Transforming organizations using complexity, positive psychology and relationship-centered care. London, England: Radcliffe Publishing. Torrens, P. (2010). The health care team members: Who are they and what do they do? In B. Freshman, L. Rubino, & Y. Chassiakos (Eds.), Collaboration across the disciplines in health care (pp. 1–19). Sudbury, MA: Jones and Bartlett Publishers. Vickers, G. (1983). Human systems are different. London, England: Harper and Row. Weick, K. (1976). Educational organizations as loosely coupled systems. Administrative Science Quarterly, 21(1), 1–19. Wells, L. (1995). The group as a whole: A systemic socio-analytic perspective on interpersonal and group relations. In G. Gillette, & M. McCollum (Eds.), Groups in context (pp. 50–85) Lanham, MD: University Press of America. Wheatley, M. (2005). Finding our way: Leadership for an uncertain time. San Francisco, CA: Berret-Koehler Publishers, Inc. Woltmann, E. M., Whitley, R., McHugo G. J., Brunette, M., Torrey, W. Coots, L., & Drake, R. (2008). The role of staff turnover in the implementation of evidence-based practices in mental health care. Psychiatric Services, 59(7), 732–737. 14 | Chapter 1 Groups-Teams-Systems © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION.