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Building teams for today's nursing home care: a guide to creating interdisciplinary teams.

Long-term care facilities have been gearing up their rehabilitation programs and complex medical care and entering into the fast growing arena of subacute care.

In caring for a more complex type of patient, the interdisciplinary team has moved to the forefront. Most of us strive for an interdisciplinary versus a multidisciplinary team, because we know such a team is more efficient.

In all our efforts to pull such a team together, though, we forget one very important component: the skills of team development. One study[1] found that among members of a multidisciplinary team, there can be a limited understanding of the workings of the interdisciplinary process. Many team members in this study expressed concern over professional boundaries, or in more common terms, their "turf." These difficulties illustrate that the interdisciplinary team, by its very nature, is more complex and time-consuming than the simpler multidisciplinary concept.

According to O'Toole,[3] an effective interdisciplinary team has the ability to reduce health care costs and improve client outcomes. "Effective" means that the team has good communication, and works in an environment promoting openness, creativity and true teamwork. We cannot simply expect employees to learn this through experience. We need to promote a formal training process -- and one that begins with top management. If leadership does not buy into a team concept, but prefers a controlling, top-down approach, attempts at team building will be met only with frustration and failure. Indeed, the manner in which the team is led is the single most important factor in determining its success.[4]

Team building can be accomplished in numerous ways. It can be done by a strictly formal method, where only classroom instruction is given, or by the method that the author prefers: Initiate the team-building with a formal classroom instruction (often two to four hours) including members of all disciplines, but accompany this with informal teaching accomplished through frequent follow-through and coaching. Your aim, in other words, is to "catch people doing things right" and reinforce their behavior.

As for formal courses, these can be approximately four hours in length, but can be divided into two or more sessions. Here's an example of how one might be structured:

Sample Team Building


I. Icebreakers (20 minutes)

This is an activity to help the staff get comfortable. Take a few minutes to allow each team member to say a few personal things about themselves (although let it be known that anyone has the right to refuse). Why is this useful? In a team, acceptance of each member is paramount for success of the entire team. Some suggested questions:

* What is your greatest accomplishment?

* Why did you choose this field?

* What would another choice be?

* What would you do with $1 million?

* What would your dream vacation be like?

II. Phases of Team Development

(30-45 minutes)

These phases remind us that what we are going through as a group is a normal learning process. Knowing that there are phases also reminds us that the more "painful" phases are only temporary and will soon yield to a more peaceful phase. The following phases are typical: 1. Forming:

* Cautiously explore boundaries of acceptable behavior

* Make the transition from individual to team member status

* Test the leader's guidance, both formally and informally

During this and other phases, the developing team's responses can be analyzed by their feelings and behavior. For Phase 1: Feelings:

* Excitement

* Anticipation

* Optimism

* Fear, anxiety about the job ahead Behaviors:

* Difficulty identifying relevant problems

* Complaints about the organization, and barriers to the task 2. Storming:

* The most difficult stage for the team

* Members begin to realize the difficulty of the task Feelings:

* Resistance

* Fluctuations in attitude about the team and any project's chance of success Behaviors:

* Arguing

* Defensiveness

* Questioning the wisdom of others

* Establishing unrealistic goals

* Increased tension, jealousy

* Concern about excessive work

* A perceived pecking order, disunity, increased tension 3. Norming:

* Members reconcile competing loyalties and responsibilities

* They accept the team and ground rules, and their roles

* Competitive relationships become more cooperative Feelings:

* Willingness to express constructive criticism and praise

* Acceptance of other team members

* Relief that it seems things will work out Behaviors:

* Competing relationships become more cooperative

* Obvious attempts to avoid conflict

* More friendliness, confiding in each other

* A discernible sense of team cohesion

* Moves to establish ground rules and boundaries 4. Performing:

* With relationships and expectations set, the team can begin performing, i.e., diagnosing and solving problems Feelings:

* Members confident they have insight into personal and group process

* Satisfaction with the team's progress Behaviors:

* Team members accept each others' strengths and weaknesses

* Attempts at constructive self-change

* Expressions of close attachment to the team

* Demonstrated ability to prevent or work through problems

Each phase should be reviewed and discussed. After all phases have been reviewed, see if the group can agree on what phase they are in. From the author's experience, they usually can.

III. Concepts Relevant to Team

Development (45 minutes)

These generally include: a) Organization: Operational team meetings should be scheduled to foster team development, promote communication, and empower staff for problem-solving. Representatives from the entire team (staff, not just supervisors) are allowed to provide input on any changes that impact patient care. b) Task and Purse: Development of common goals that are client-centered, not centered on individual team members or disciplines. c) Membership: Identify core and "extended' members. d) Leadership: Determine who will "lead" the group. e) Problem Solving: Members mutually identifying problem areas and pursuing alternative solutions. f) Communication: Open system, both verbal (formal and informal get-togethers) and written: g) Role: Each team member has a specific role that assists in helping the team as a whole function efficiently, and perceives that role clearly. Flexible roles are more conducive to team building h) Boundaries: There may be overlapping boundaries among team members, but focus should remain on care needs, goals and outcomes. i) Atmosphere and Conflict: Team members need to acknowledge, validate and positively reinforce each other, attempting to resolve conflict, but balancing this with maintaining a positive atmosphere. j) Evaluation: The team needs to determine whether they are, as a team, enhancing or decreasing the effectiveness of patient care.

IV. Types of Health Care Teams

(15 minutes)

* Multidisciplinary

* Interdisciplinary

* Transdisciplinary Review strengths/weaknesses of each

V. Team Building Activities

(time varies)

By this point, if not before, it is important to engage the team in team-building activities, or "play." There are several possibilities (see "Suggested Team-Building Activities," p. 23).

VI. Forces Enhancing Team

Cohesiveness (10-15 minutes)

1) Client needs 2) Institutional support 3) Work satisfaction 4) Mutual respect and friendship 5) Understanding of teamwork

VII. Factors Reducing Team

Cohesiveness (10-15 minutes)

1) Contradictory institutional policies 2) Professional rivalries 3) Team members' misunderstanding due to "team-splitting" by patient 4) Personal competitiveness 5) Lack of understanding of collaborative problem-solving process

VIII. Methods to Facilitate Team

Collaboration (20-30 minutes)

1) Team goal setting with input and prioritizing encouraged on the part of all team members 2) Encouragement of collaborative treatment 3) Psychological support for clearing with stress-producing clients 4) Acknowledgement of accomplishments and sharing of constructive criticism 5) Orientation focused on the roles of each discipline 6) Focus maintained on patient outcomes 7) Respect among team members 8) Recognition that conflict is normal 9) Understanding "The Vision"

IX. Characteristics of a Successful Team

(20-30 minutes)

1) Has work tasks and goals that are clear and accepted 2) Members carefully listen to one another 3) Disagreements solved creatively 4) Members are comfortable with self-criticism and mutual feedback 5) Members express feelings as well as ideas 6) Leader does not dominate 7) Members have a sense of loyalty to one another 8) Priority given to interest/ commitment/availability to serve 9) Sense of direction and growth

X. Dealing with Conflict (20-30 minutes)

1) Confrontation of problems 2) Open, honest accurate communication 3) Problem-solving emphasized 4) Recognizing that responses to conflict occupy a range:

* Competition: might makes right

* Accommodation: selflessness

* Avoidance: issues sidestepped

* Compromise: mutual acceptance of solution

* Collaboration on a mutually satisfactory solution


In today's nursing home environment, a little time spent promoting team development can go a long way toward increasing the staff's efficiency and effectiveness, reducing costly employee turnover, increasing morale and, most importantly, improving patient satisfaction. Team building does work. When teamwork fails, patients and families will notice it -- and the bottom line will reflect it.


Team-Building Activities

There are several play activities that can help break down the walls hampering interdisciplinary teamwork. One that has been popular has been The Nine Dots. An illustration with nine dots, three rows of three dots, is placed on an overhead or in a handout. Ask staffers to connect all nine dots without lifting their pencils or retracing or crossing a line, and making only four lines. The answer clearly shows that to solve the problem one has to look outside the self-imposed boundaries of the imaginary box formed by the nine dots.

Other activities have included dividing the audience into small interdisciplinary groups. Provide a list of questions that each group must answer, such as: 1. Name the Seven Deadly Sins 2. What were the 13 original colonies? 3. Name the planets, in order of distance from the sun

How the answers are found is up to the group members. The only purpose is to get team members to work together. You'll be surprised how closely the team's performance of these activities correlates with their teamwork on the rehab unit.

Another technique: Institute a communication book. This book is used only to facilitate the positive, No negative comments or complaints can be written in the book; rather, these should be handled between individuals, as the team learns methods of conflict management. The communication book provides a public way of passing along positive comments to an individual or group, including comments from patients and families, and to communicate important team events. Supervisors can use it to comment on the accomplishments of specific employees. This book is often one of the first things turned to when people report on duty. It is, indeed, "magnetic" in pulling a team together.


[1.] Strasser DC, Falconer JA, Martino-Saltzman D. The rehabilitation team: Staff perceptions of the hospital environment, the interdisciplinary team environment, and interpersonal relations. Archives of Physical Medicine and Rehabilitation 1994; 75: 177-181.

[2.] Melvin JL. Status report on interdisciplinary medical rehabilitation. Archives of Physical Medicine and Rehabilitation 1989; 70:273-276.

[3.] O'Toole MT. The interdisciplinary team: Research and education. Holistic Nursing Practice 1992; 6(2):76-83.

[4.] Francis D, Young D. Improving Work Groups: A Practical Manual for Team Building. San Diego, University Press, 1979.

Timothy M. Krzys, RN, MSN, CRRN, is Subacute Program Director of the Health Care and Retirement Corporation, Toledo, OH.
COPYRIGHT 1996 Medquest Communications, LLC
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1996, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

Article Details
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Author:Krzys, Timothy M.
Publication:Nursing Homes
Article Type:Cover Story
Date:Mar 1, 1996
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