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Are real teams healthy teams?

EXECUTIVE SUMMARY

This study examines the impact of real-team--as opposed to a team in name only--characteristics (i.e., team boundaries, stability of membership, and task interdependence) on team processes (i.e., team learning and emotional support) and team effectiveness in the long-term care sector. We employed a longitudinal survey in which the real-team characteristics and team processes were rated by team members, and team effectiveness was rated one year later by team members and managers. Our results show that team learning and emotional support are predictors of team effectiveness as rated by team members and managers. They also show that there is no such thing as a real team in the long-term care sector because each real-team characteristic has a different impact on team processes and effectiveness. Whereas one set of real-team characteristics (i.e., stability of membership) is beneficial for healthy team processes and team effectiveness, another set (i.e., team boundaries) has only an indirect effect on team effectiveness via team processes or is even detrimental (i.e., task interdependence). We conclude that more intensive teamwork in the long-term care sector will lead to better outcomes if this teamwork involves increased stability of membership and clarified team boundaries but not if it involves added task interdependency among team members.

INTRODUCTION

Teams are an integral feature of health services delivery in the long-term care (LTC) sector. LTC teams provide supportive services (e.g., health, social, housing, transportation) to clients with intellectual, physical, or cognitive disorders that compromise their ability to live independently (Bodenheimer, 1999). By providing such services, the teams help their clients maintain the best possible quality of life with the greatest possible degree of autonomy, participation, personal fulfillment, and human dignity. Providing LTC is a collective effort; one caregiver cannot provide all of the care needed by a client, and teamwork is believed to improve the quality of care via the exchange of feedback among colleagues. Effective teamwork is becoming even more important because of the increasing demand for LTC services; the growing complexity of care; and the influence of recent labor trends, such as staff turnover and personnel shortages (Harrington, Cassel, Estes, Woolhandler, & Himmelstein, 1991; Sloane and Zimmermann, 2005; WHO, 2000, 2002).

According to Wageman, Hackman, and Lehman (2005), the presence of real-team characteristics increases the likelihood that a team will perform well. Real teams have boundaries that clearly distinguish members from nonmembers, have at least a moderate degree of stability of membership, and include members who function interdependently when working to achieve a common purpose. If team membership is stable and clearly delineated, members work together over a long period of time; they come to trust and know each other well and have the time and opportunity to learn how to collaborate, exchange information, and provide emotional support. Furthermore, if team members work interdependently to achieve a common purpose, they are more likely to see the added value of teamwork than if they approached tasks independently and, therefore, to invest in team processes, including team learning and emotional support (Wageman et al., 2005).

Team stability depends on the amount of turnover in a team and varies among LTC teams. The variation in task interdependency and team delineation depends in part on clients' characteristics (i.e., the severity and complexity of their disorders). However, because LTC teams are highly autonomous and self-managing, they make most care-related decisions on their own and therefore are able to influence their own level of task interdependency. Whereas some teams prefer individual caregivers to deliver everyday care for one designated client (apart from the handoffs between different shifts), making them less task interdependent, other teams prefer to work closely together and share the care delivery for one patient. In addition, depending on the labor market, teams can determine their boundaries by choosing to include several part-time, flexible-shift caregivers or to include a few full-time staff. The variation in team characteristics is not so much caused by the type of care provided (i.e., intramural, extramural, semimural) as it is by the client population, which varies within and between these types of care, and by team preferences on how to design the team they are working in.

Although it seems likely that real teams are more effective than are teams in name only, this assumption has never been investigated. For this reason, we explore the extent to which real-team characteristics lead to more team learning and emotional support, which in turn lead to superior team performance in the LTC sector.

Team learning--the activities through which a team obtains, processes, and uses information--has proved to be a powerful predictor of team performance in various sectors (De Dreu, 2007; Edmondson, 1999; Van der Vegt & Bunderson, 2005; Van Offenbeek, 2001; Van Woerkom & Croon, 2009; Van Woerkom & Van Engen, 2009; Zellmer-Bruhn & Gibson, 2006), including the acute care hospital sector (Morey et al., 2002). In particular, we expect LTC teams, which attend to clients over an extended period, to benefit from team learning activities because they have many opportunities to implement the knowledge they have obtained.

Emotional support is especially important in the LTC sector because the workload is high and the clients and their families are highly demanding and sometimes aggressive (Denton, Zeytinoglu, Davies, & Lian, 2002; Gray-Toft & Anderson, 1981; Schaefer and Moos, 1993). The emotional burden can be high in the LTC environment because clients and caregivers may interact for years in a simulated daily life situation in which pleasant social interactions are valued (Moyle, Skinner, Rowe, & Gork, 2003; Stone & Wiener, 2001). Therefore, emotional support from team members who listen sympathetically, provide empathy, demonstrate care, and inspire trust when a coworker faces difficulties (Nijman & Gelissen, 2011; Sarason, Levine, Basham, & Sarason, 1983) may reduce or prevent stress, leading to a higher level of team performance.

This study aims to shed light on the predictors of effective teamwork in the LTC sector by examining the impact of real-team characteristics--clear team boundaries, stability of membership, and task interdependence--on team effectiveness via team learning and emotional support.

HYPOTHESES

Figure 1 illustrates the conceptual model of this study.

Relationship Between Team Characteristics and Team Processes

Following earlier studies (De Dreu, 2007; Edmondson, 1999; Van Offen-beek, 2001 ; Van der Vegt & Bunderson, 2005; Van Woerkom & Croon, 2009), we define team learning as the learning activities carried out by team members through which a team acquires, processes, stores, and uses information. Real teams are likely to invest more time and effort in team learning activities than are nominal teams. If team members are negligibly interdependent, the team's membership is unstable, and the team's participants are not easily identified, little interaction likely takes place between team members.

Although fluidity of boundaries may lead to increased access to diverse knowledge and experience (Huckman, Staats, & Upton, 2009), we expect that this potentially positive effect on learning will be counterbalanced by a lack of opportunity to engage in shared team learning activities and lack of motivation to invest in these activities because the potential improvements will be difficult to sustain (Van Woerkom & Croon, 2009; Wageman et al., 2005). Hence, we anticipate a positive relationship between real-team characteristics and team learning.

Hypothesis la Real-team characteristics are positively related to team learning.

Another beneficial team process in the LTC sector is emotional support. Emotional support refers to the mechanisms by which interpersonal relationships buffer a stressful environment (Cohen & McKay, 1984). Emotional support may reduce strain (e.g., frustration, anxiety, depression) directly or through alleviating stressors, or it may prevent stressors from occurring (Beehr, Jex, Stacy, & Murray, 2000; Muhonen & Torkelson, 2003; Van Daalen, 2007; Viswesvaran, Sanchez, & Fisher, 1999).

Members of loosely knit teams work in an unstable social environment, where they are not likely to develop the social relationships necessary for providing emotional support to each other (Gladstein, 1984; Guzzo & Dickson, 1996; Mickan & Rodger 2000; Wageman et al., 2005). Emotional support is more likely to emerge when team members know who is part of the team (team boundaries), work with each other over a long period of time (team member stability), and need to interact due to task interdependence (Wageman et al., 2005). Therefore, we also expect a positive relationship between real-team characteristics and emotional support.

Hypothesis 1b Real-team characteristics are positively related to emotional support.

Team Effectiveness

When beneficial team processes, such as team learning and emotional support, are in place, the chance of acquiring good team outcomes increases (Heinemann & Zeiss, 2002). Following Van Woerkom and Croon (2009), we define team effectiveness as the absolute level of attainment of goals and expectations that depends on the degree to which work processes are free of errors and the extent to which clients are satisfied with the value of services provided by the team. Team effectiveness is often seen as an objective measure. However, in the LTC setting, as in other healthcare settings, objective outcome measures on the team level are often absent (Poulton & West, 1994). Therefore, in line with other studies (Campion, Medsker, & Higgs, 1993; De Dreu, 2007; Van der Vegt, Bunderson, & Oosterhof, 2006; Van Woerkom & Croon, 2009), we include ratings of team effectiveness by team managers and team members separately as performance indicators.

Relationship Between Team Processes and Team Performance

Several studies have shown that team learning is positively related to team effectiveness (De Dreu, 2007; Edmondson, 1999; Van Offenbeek, 2001; Van der Vegt & Bunderson, 2005; Van Woerkom & Van Engen, 2009; Van Woerkom & Croon, 2009; Zellmer-Bruhn and Gibson, 2006). Sharing, interpreting, and storing information may help teams adapt to changing circumstances and continually refine their processes and practices (Bunderson & Sutcliffe, 2003; Van Woerkom & Croon, 2009). Although this evidence is not derived from research in the LTC sector, we expect that here, too, team learning is positively related to team effectiveness.

Hypothesis 2 Team learning is positively related to team effectiveness.

Team members who offer emotional support may prevent or reduce the negative effects of strain and stress on other members by helping them to divert attention from potential stressors and reinterpret and modify stressful situations (Cohen & McKay, 1984; Heaney, Price, & Rafferty, 1995; Schaefer and Moos, 1993; Van Daalen, 2007). This stress reduction allows team members more time and energy for task-related activities (Baruch-Feldman, Brondolo, Ben-Dayan, & Schwartz, 2002). For this reason, we expect to find a positive relationship between emotional support and team effectiveness.

Hypothesis 3 Emotional support is positively related to team effectiveness.

The Relationship Between Real-Team Characteristics and Team Effectiveness

The question of whether team design influences team performance directly or by means of team processes is difficult to answer (Campion et al., 1993; Campion, Papper, & Medsker, 1996; Gladstein, 1984; Stewart & Barrick, 2000; Wageman et al., 2005). In line with sociotechnical systems theory and the classic input-process-output model, in which input leads to processes that in turn lead to outcomes (llgen, Hollenbeck, Johnson, & Jundt, 2005; Stewart & Barrick, 2000), we expect that real-team characteristics by themselves may lead to team effectiveness but are more likely to lead to better outcomes by engendering beneficial team processes. Therefore, we propose the following:

Hypothesis 4 The relationship between real-team characteristics and team effectiveness is mediated by (a) team learning and (b) emotional support.

METHODS

Study Design

We conducted a longitudinal survey in two large LTC organizations in the Netherlands. Data were collected at two points in time: October 2009 (TO) and October 2010 (Tl). LTC organizations provide a broad range of services that address the variety of demands and needs of clients with physical or intellectual disorders. LTC teams help to provide living accommodations in residential areas, organize day-care activities for clients, offer home visits or consultations to clients who live independently, or provide a mix of these services. Teams are generally homogenous, with only their team characteristics differentiating them from one another. They also tend to be monodisciplinary and self-managing, and the team members have similar educational backgrounds. Moreover, all LTC teams operate in a similar organizational environment in terms of management, structure, rewards, and other administrative features.

The teams in our sample consisted of the staff who provided direct care to their clients. In both organizations, for purposes of the study, the employees who had a facilitative role (e.g., secretaries, domestic workers) and the team manager were not viewed as team members. Members of the teams were asked to complete a survey on the three real-team characteristics and team learning, emotional support, and team effectiveness. The team managers were asked to complete a survey on team effectiveness only. The surveys were sent to participants by mail with a letter from the researchers and the employing organization.

To gain insight into the developments that might have taken place between T0 and T1 and the changes at the organizational level that might have affected our results, we conducted in total seven interviews with managers and staff members in October 2010 (Bogner, 2003). The results indicated that no significant organizational changes had occurred between TO and T1 that could act as an underlying cause of our findings.

Sample

At T0, 246 teams (2,731 team members) and 67 team managers received a questionnaire. In total, 1,219 members from 229 teams returned the questionnaire (response rate of 45 percent). A sample of 183 teams (1,096 respondents; mean = 5.98 respondents per team) met our required minimum response rate of 30 percent (Van Mierlo, Vermunt, & Rutte, 2009). We matched this aggregated sample with the surveys of the team members at T1 and produced a sample that consisted of 171 teams. After matching this sample with the team managers' ratings at T1, we produced a final sample that consisted of 142 teams.

Most respondents in our final sample were female (84 percent). This figure is representative of the overall LTC setting in the Netherlands, in which 85 percent of the workers are female (RVZ, 2006). The average age was 40.49 years (SD = 6.75), similar to that in the overall LTC setting in the Netherlands (RVZ, 2006). The respondents on average had worked almost 12 years in the current organization (SD = 6.17) and had been members of their current team for 5.21 years (SD = 3.70). Of the final sample respondents, 50.4 percent had completed secondary vocational education and 28 percent held a bachelor's or another university degree, whereas in the overall LTC setting, no more than 6 percent of the care providers hold a bachelor's or another university degree (RVZ, 2006). This difference can be explained by the fact that the two participating organizations provided care to clients with severe disorders.

Instruments

The survey consisted of items presented with a 5-point Likert-type response scale ranging from totally disagree (1) to totally agree (5). The scales used for each characteristic measured were taken from the literature. The following list shows the scale and its source; each scale includes one or more sample survey items.

* Team boundaries and stability in membership--measured using scales developed by Wageman et al. (2005)

Examples

--Team membership is quite clear; everybody knows exactly who is and is not on this team, (team boundaries)

--This team is quite stable, with few changes in membership. (membership stability)

* Task interdependence--measured using a scale developed by Langfred (2005)

Example

--My work cannot be done unless other people do their work.

* Team learning--measured using the scale developed by Van Offenbeek (2001)

Example

--In my team we use each other's comments to evaluate our team functioning.

* Emotional support--measured using the scale developed by Sarason et al. (1983) and adapted to the LTC setting for this study

Example

--In my team, team members can count on each other in crisis situations, even when it is hectic.

* Effectiveness--measured using a scale developed by van Woerkom and Croon (2009) and slightly adapted

Example

--Our team achieves its goals.

We tested all the scales in a focus group that consisted of directors, staff members, team managers, and team members. Principal component analyses confirmed the one-dimensional character of all scales and verified that the real-team characteristics are three separate constructs. Cronbach's alpha varied from .71 to .91 with the exception of team boundaries, which showed a moderate alpha of .60 (see Table 1).

Analysis of variance showed no significant differences (p < .05) between the participating organizations on the focal variables. We aggregated our data to the team level by calculating the mean value of the team members' scores, as our theoretical concepts were all conceived on the team level. To check whether aggregation to the team level was justified, we calculated the intraclass correlation coefficients (ICC1 and ICC2) and the within-group agreement ([r.sub.wg] index) (Bliese, 2000; James, Demaree, & Wolf, 1984). ICC1 at T0 and T1 ranged from 0.16 to 0.45, implying that 16 to 45 percent of the variance could be attributed to the team level. These values lie within the range of ICC1 encountered in applied field research (Van Mierlo et al., 2009). The ICC2 at T0 and T1 (referring to the reliability of the group-level constructs) all exceeded the minimum value of 0.50 (Van Mierlo et al., 2009). The [r.sub.wg] indexes were all above .70, suggesting sufficient within-team agreement to further justify aggregation to the team level.

RESULTS

Correlation Analysis

Table 1 provides the descriptive statistics and the correlations between all variables included in this study. In line with our expectations, team boundaries and stability in membership at T0 were positively related to team learning and emotional support at T0 (ranging from r = .23 to r = .41). Surprisingly, task interdependence at TO was negatively related to team learning (r = -.29, p < .01) and emotional support (r = -.25, p < .01) at T0. Team learning at T0 was positively related to team effectiveness at T1 (team members' rating r = .50, p < .01, and team managers' rating r = .45, p < .01). Emotional support at T0 was also positively related to team effectiveness at T1 (team members' rating r = .43, p < .01, and team managers' rating r = .34, p < .01). The team boundary measure at T0 was positively related to team effectiveness as rated by team managers at T1 (r = .25, p < .01). Stability of membership at TO was positively related to team effectiveness at T1 (team members' rating r = .46, p < .01, and team managers' rating r = .31, p < .01). Notable is the negative relationship between task interdependence at T0 and team members' ratings of team effectiveness at T1 (r = -.29, p < .01).

Regression Analysis

The hypotheses were tested using multiple linear regression analysis (see Tables 2 and 3). Tests for multicollinearity (variance inflation factors) showed no multicollinearity problems in any of the regression analyses.

Team boundaries and stability in membership at TO were positively related to team learning ([beta] = .22, p < .01, and [beta] = .21, p < .01, respectively) and emotional support ([beta] = .25, p < .01, and [beta] = .27, p < .01, respectively) at T0. However, task interdependence at T0 was negatively related to team learning ([beta] = -.29, p < .01) and emotional support ([beta] = -.26, p < .01) at T0. Therefore, Hypotheses la and lb can be only partially confirmed.

Hypothesis 2 can be confirmed because team learning at TO was positively related to team effectiveness at T1 (team members' rating [beta] = .39, p < .01, and team managers' rating [beta] = .39, p < .01). Hypothesis 3 can also be confirmed because emotional support at T0 was positively related to team effectiveness at T1 (team members' rating [beta] = .29, p < .01, and team managers' rating [beta] = .23, p < .05).

We tested Hypotheses 4a and 4b using the procedure recommended by MacKinnon, Fairchild, & Fritz (2007). This procedure, when applied to our study, confirmed that (1) a mediating effect exists when the independent variables at T0 have a significant impact on the mediating variables at T0 and (2) the mediators have a significant impact on the dependent variables at T1 in a regression analysis, which also includes the independent variables. We speak of partial mediation when the independent variable has a significant but reduced effect on the dependent variable, in addition to the impact of the mediating variable. We speak of pure mediation when only the mediating variable has a significant effect on the dependent variable (MacKinnon et al., 2007).

Table 3 shows that team learning has a pure mediating effect in the relationship between team boundaries and task interdependence on the one hand and team effectiveness (rated by team members and managers) on the other hand. Team learning also has a pure mediating effect in the relationship between stability of membership and team effectiveness as rated by team managers, but it has a partial mediating effect when team effectiveness is rated by team members. Emotional support has a pure mediating effect in the relationship between team boundaries and task interdependence on the one hand and effectiveness as rated by team members on the other hand. Emotional support has a partial mediating effect in the relationship between stability of membership and task interdependence on the one hand and team effectiveness as rated by team members on the other hand. Emotional support has a pure mediating effect in the relationship between team boundaries, stability of membership, and task interdependence on the one hand and team effectiveness as rated by team managers on the other hand.

In addition, we tested the mediating effect of team learning and emotional support by bootstrapping (Preacher and Hayes, 2004), which is a nonparametric method for assessing indirect effects. Using 10,000 iterations, we generated the 95 percent confidence interval (CI) for the indirect effects. Results from bootstrapping showed a significant indirect effect of team boundaries, stability, and interdependence on team effectiveness (team member rating) through team learning (CI .03 to .19, CI .03 to .10, CI -.26 to -.06, respectively) and on emotional support (CI .06 to .19, CI .02 to .09, CI -.19 to -.03, respectively). Looking at managers' ratings, we also see a significant indirect effect of team boundaries, stability, and interdependence on team effectiveness through team learning (CI .11 to .37, CI .06 to .19, CI -.44 to -.08, respectively) and emotional support (CI .06 to .29, CI .04 to .16, CI -.41 to -.09, respectively). The overall findings support Hypotheses 4a and 4b.

DISCUSSION AND CONCLUSION

Following the theory of real teams, we had expected each real-team characteristic to lead to healthier team processes and, consequently, to have a positive impact on team learning and emotional support in LTC. Although this assumption proved to be true for team boundaries and stability of membership, task interdependence was shown to have a negative effect on team learning and emotional support. Therefore, we conclude that a real team as defined by Wageman et al. (2005) is not a unitary construct for LTC teams. We concluded that the study would be best served by analyzing the three real-team characteristics separately rather than addressing real teams in the context of LTC.

An explanation for the negative effect of task interdependence may be found in the nature of care provision in the LTC sector. Care provision for disabled people is mostly monodisciplinary, and other disciplines (e.g., medicine, nursing, occupational therapy, physiotherapy, speech therapy) may be accessed when needed but are not involved in the everyday practices of LTC teams and are not part of the team. Thus, all the everyday care of a specific patient could be delivered by a single caregiver, and this approach may even be seen as the optimum form of care because this caregiver would be fully knowledgeable about the client and capable of creating a high-quality relationship with this person. For practical reasons (e.g., a single caregiver is not available 24 hours a day, 7 days a week) and for reasons related to quality and control (e.g., teamwork offers opportunities to provide feedback and reflect on each other's work), teamwork is necessary. However, teamwork also increases the necessity of handoffs, which increase the probability of (tacit) knowledge loss about the client, errors, and inaccuracies and results in a lower-quality relationship between the caregiver and the client. Hence, task interdependence might be an unavoidable influence on monodisciplinary teams in LTC.

A pervasive assumption in the literature is that more teamwork is always better (Erhardt, 2011). Task interdependence is considered one of the most important variables in defining a real team (Barrick, Bradley, Kristof-Brown, & Colbert, 2007; Campion et al., 1993; Kozlowski and Bell, 2003; Stewart 2006). However, our study showed that a high level of task interdependence does not generate outcomes that are superior to those of teams that demonstrate less task interdependence (Firth-Cozens, 1998; Katzenbach & Smith, 1993). We may need to reevaluate the concept of interdependence. We focused only on task interdependence, which refers to the degree to which team members need to interact with one another and coordinate their efforts to complete tasks (Guzzo & Shea, 1992). However, the overall concept of team interdependence may be referring to interdependency on structural elements, such as tasks or technological requirements, but also on sociopsychological elements, such as social demand to work together and need for emotional support to perform well (Barrick et al., 2007). Our study shows that an increase in interdependence that refers to interdependency on structural elements (e.g., tasks) does not enhance team learning, emotional support, or team effectiveness. Although we did not examine whether interdependence that refers to the interdependent sociopsychological needs of team members facilitates team processes and effectiveness, our results do show the importance of emotional support within teams. The team members in the LTC sector may have a greater need than those who assist in accomplishing tasks to work with colleagues who listen, show compassion,

and give feedback. Because the same might be true for other sectors, future research should develop a broader understanding of the concept of interdependence in teams.

Limitations

One limitation of our study is that we used subjective measures for team performance, as objective indicators are rarely documented at the team level in the healthcare sector. However, subjective ratings of performance are often found to be related to objective performance (Ancona & Caldwell, 1992). Also, because real-team characteristics and team processes relate significantly to both team members' and team managers' ratings of team effectiveness, common method bias is not likely to occur (Conway & Lance, 2010).

Although we conducted this study in LTC organizations that provide care for clients with physical and intellectual disorders, we believe that our findings are generalizable to other LTC settings, such as elder care and mental healthcare, that rely on autonomous, monodisciplinary teams for the provision of care.

Implications for Management

Even considering that most organizations in the LTC sector are team based, we cast doubts on the general premise that teams composed of highly task-interdependent team members generate outcomes superior to those of work groups consisting of professionals who work more often on an individual basis (Firth-Cozens, 1998; Katzenbach & Smith, 1993). Teams whose members are strongly interdependent need to be stimulated by their team managers to use their time together not only to manage individual clients but also to evaluate performance, provide feedback and support, and use information from both inside and outside the team to discuss ways to improve performance. However, less task interdependence most likely also decreases flexibility and transparency. If individual care workers provide all of the necessary care for one client, it becomes harder to replace workers in the case of illness or absence on holidays and to have control over the quality of care. As a result, the work may generate undesirable outcomes (e.g., losses in efficiency, declines in quality, strong attachments to clients) (Allen & Hecht, 2004). The appropriate level of task interdependence might be a tradeoff between the importance of flexibility and quality control and the effectiveness of teams. Therefore, LTC teams that wish to enhance their effectiveness should determine the proper level of task interdependence by performing job and task analyses at the team level. Finally, our findings suggest that LTC organizations should try to keep their care teams as stable and bounded as possible to ensure that the teams are healthy and effective. Reducing staff turnover, and thereby establishing greater team stability, may be an important way to increase teams' effectiveness.

PRACTITIONER APPLICATION

Meera Ananthaswamy, PhD, RN, FACHE, director, Center for Advancing Professional Practice, Texas Health Presbyterian Hospital, Dallas, Texas

Acute care hospitals are accountable for more than internal organization-wide outcomes. Successful outcomes, such as compliance with core measures, are a result of team performance. As we move forward in the new climate of value-based reimbursement, we may be rewarding team performance rather than individual performance.

Thus, the findings on teams from this long-term care study translate well to the acute care setting, as delivery of high-quality, safe patient care in this setting is contingent on effective team functions. Establishing and maintaining team boundaries by defining roles and tasks ensures that team members are aware of their responsibilities and expectations, making this area a predictor of team effectiveness. Code teams and rapid response teams, for example, are highly effective because they have established boundaries and delineated roles. In addition, by participating in team learning exercises, such as mock codes and post-event debriefings, these teams build relationships among team members. But such efficiencies should not be limited to code teams; they need to be replicated in day-to-day, routine operations.

Team stability, characterized by a workforce with low turnover, is also discussed as a predictor of team effectiveness. In my experience, employees stay at or leave organizations on the basis of their relationships with their supervisor and other team members. Team building requires the development of authentic relationships. Two strategies that I consistently implement are rounding and employee recognition. I have found that rounding with direct reports is time well spent. Conversations take just a few minutes but represent an important investment in relationships with staff. Employees also appreciate being recognized. They value this recognition even more when it is given in a timely way in the presence of their team members, rather than waiting to be acknowledged at an organizational event.

Our main function as leaders is to build effective teams by role-modeling team behaviors and creating a culture that promotes teamwork. Leaders can use organization-wide presentations as opportunities to reiterate the mission, vision, and values; create connectivity; and build consensus. The goal is to have all members of the interprofessional team identify themselves as being part of the same team.

Nurses in acute care settings must function effectively in teams. In the past, nursing students attended classes, completed clinical rotations, and graduated together as a group. They developed relationships and learned to function as a team. Nursing students today follow individual degree plans and do not gain the same team experience. In addition, much of the healthcare curriculum is delivered to discipline-specific groups. My anatomy and physiology class in nursing school was also attended by medical and physiotherapy students. Coming from different disciplines, we trained together, and as a result, we found working in teams to be natural when we entered the workplace. My nursing curriculum also emphasized group processes and helped us develop skills as facilitators. These core skills are essential in building effective teams in the acute care setting or the community.

The study concludes that team learning and emotional support are predictors of team effectiveness. We cannot continue to train or work in siloed, discipline-specific groups. As leaders, if we want to build effective teams, we need to offer combined training and education for interprofessional groups, develop processes and structures that promote teamwork, and focus on building relationships.

ACKNOWLEDGMENTS

We thank Professor Jaap Paauwe, PhD, for his contribution to the study design. We also thank the two Dutch long-term care organizations for participating in this study.

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Martina Buljac, PhD, Institute of Health Policy and Management, Erasmus University Rotterdam, Netherlands; Marianne Van Woerkom, PhD, Department of Human Resources, Tilburg University, Netherlands; and Jeroen D. H. Van Wijngaarden, PhD, Institute of Health Policy and Management, Erasmus University Rotterdam

For more information about the concepts in this article, contact Ms. Buljac at buljac@bmg.eur.nl.

TABLE 1
Descriptive Statistics and Correlations Between Variables

                               N    [alpha]     Mean     SD        1

1     Boundaries T0            3      .60       4.12     .49
2     Stability T0             3      .85       3.31     .81    .37 **
3     Interdependency T0       7      .71       3.54     .29    .22 **
4     Team learning T0        17      .87       3.57     .28     .23 *
5     Emotional support T0     4      .86       3.84     .48    .30 **
6     Effectiveness T1         8      .89       3.61     .38      .11
        (team members'
        rating)
7     Effectiveness T1         8      .89       3.70     .61    .25 **
      (team managers'
        rating)

Control variables T0

8     Gender ratio                              1.84     .21     -.07
      (1 = male,
        2 = female)
9     Average age                              40.49    6.75      .03
10    Average education                         4.98     .75     -.03
11    Average years in                         11.82    6.17      .04
        current
        organization
12    Average years on                          5.21    3.70     -.05
        current team

                                 2         3          4         5

1     Boundaries T0
2     Stability T0
3     Interdependency T0      -.18 *
4     Team learning T0        .35 **    -.29 **
5     Emotional support T0    .41 **    -.25 **    .71 **
6     Effectiveness T1        .46 **    -.29 **    .50 **    .43 **
        (team members'
        rating)
7     Effectiveness T1        .31 **      -.07     .45 **    .34 **
      (team managers'
        rating)

Control variables T0

8     Gender ratio             -.09       -.09       .14       .03
      (1 = male,
        2 = female)
9     Average age             .24 **      .03        .09       .03
10    Average education        -.10       -.01      -.10       .00
11    Average years in        .36 **      -.06      .18 *    .20 **
        current
        organization
12    Average years on        .30 **      -.07       .13       .07
        current team

                                 6        7        8         9

1     Boundaries T0
2     Stability T0
3     Interdependency T0
4     Team learning T0
5     Emotional support T0
6     Effectiveness T1
        (team members'
        rating)
7     Effectiveness T1        .42 **
      (team managers'
        rating)

Control variables T0

8     Gender ratio              .01      .04
      (1 = male,
        2 = female)
9     Average age             .21 **    -.03     -.15
10    Average education        -.01     -.05    -.15 *     -.10
11    Average years in        .26 **     .03    -.15 *    .65 **
        current
        organization
12    Average years on         .16 *     .08    -.16 *    .45 **
        current team

                               10       11

1     Boundaries T0
2     Stability T0
3     Interdependency T0
4     Team learning T0
5     Emotional support T0
6     Effectiveness T1
        (team members'
        rating)
7     Effectiveness T1
      (team managers'
        rating)

Control variables T0

8     Gender ratio
      (1 = male,
        2 = female)
9     Average age
10    Average education
11    Average years in        -.10
        current
        organization
12    Average years on         .08    .48 **
        current team

* Correlation is significant at the .05 level (2-tailed analysis).

** Correlation is significant at the .01 level (2-tailed analysis).

TABLE 2
Results of Regression Analyses Predicting Team Learning
and Emotional Support

Real-team             Team Learning    Emotional Support
characteristics        T0 ([beta])        T0 ([beta])

Boundaries T0             .22 **             .25 **
Stability T0              .21 **             .27 **
Interdependence T0       -.29 **            -.26 **
[R.sup.2]                  .21                .25
Adjusted [R.sup.2]         .20                .23
F test                   15.76 **           19.58 **

* [beta] is significant at the .05 level (2-tailed analysis).

** [beta] is significant at the .01 level (2-tailed analysis).

TABLE 3
Results of Regression Analyses Predicting Team Effectiveness T1

                                    Effectiveness at T1:
                                    Team Members' Rating

                         Model 1     Model 2     Model 3     Model 4
                         [beta]      [beta]      [beta]      [beta]
Real-team
 characteristics
Boundedness T0            -.02        -.12        -.10        -.12
Stability T0             .43 **      .36 **      .36 **      .35 **
Interdependence T0       -.21 *       -.10        -.15        -.10
Team processes
Team learning T0                     .39 **                  .35 **
Emotional support T0                             .29 **        .07
[R.sup.2]                  .26         .37         .32         .38
[DELTA] [R.sup.2]           -        .12 **      .06 **      .12 **
Adjusted [R.sup.2]         .24         .36         .30         .36
F test                  19.15 **    24.77 **    19.37 **    19.86 **

                                   Effectiveness at T1:
                                   Team Managers' Rating

                        Model 1    Model 2    Model 3     Model
                         [beta]     [beta]     [beta]     [beta]
Real-team
 characteristics
Boundedness T0            .16        .02        .10        .02
Stability T0             .24 *       .17        .16        .18
Interdependence T0        -.05       .06        .01        .05
Team processes
Team learning T0                    .39 **                .42 **
Emotional support T0                           .23 *       -.05
[R.sup.2]                 .12        .23        .16        .23
[DELTA] [R.sup.2]          -        .11 **     .04 *      .11 **
Adjusted [R.sup.2]        .10        .20        .13        .20
F test                  6.17 **    9.95 **    6.28 **    7.95 **

* [beta] is significant at the .05 level (2-tailed analysis).

** [beta] is significant at the .01 level (2-tailed analysis).
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Author:Buljac, Martina; Van Woerkom, Marianne; Van Wijngaarden, Jeroen D.H.
Publication:Journal of Healthcare Management
Article Type:Survey
Date:Mar 1, 2013
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