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Team building: a continuous challenge for today's nurse leaders.

It is difficult to pick up a health-care or nursing journal today without seeing an article chastising healthcare teams for their lack of teamwork. There are many teambuilding models available addressing teambuilding principles and competencies. This article concisely presents an overview of two prominent models, the PUCK model (Blanchard, 2001) and Lencioni's Functional Team model (Lencioni, 2002). Both of these models are presented as fables in short, informative and enjoyable books. The PUCK model is summarized first followed by Lencioni's model.

Ken Blanchard and colleagues' (2001) write about a man who, after being fired from his job for not being a team player, learns the skills of team building and team participation by coaching his son's hockey team. The acronym PUCK is used to illustrate how repeated reward and recognition focused on aligned behavior is the key to forming successful teams. The PUCK model, discussed below, stands for providing, unleashing, creating and keeping.

P = Providing: Clear Purpose and Values--A Compelling Reason for Being

* Create a challenge, a reason for being, and a "holy grail" that commits and motivates people to work together.

* Set clear and compelling goals and strategies, both for the individual and the team.

* Be clear about your values.

* Create a team charter that formalizes commitments to each other and clearly states what the team wants to accomplish, why it is important, and how the team will work together to achieve results.

U = Unleashing: Developing Skills--Developing Your Bench Strength

* Start with the basics: Build individual skills that will bolster team skills.

* Provide feedback to build skills, confidence, and accountability.

* Learn each other's roles.

* Build a sense of personal and collective power by using individual and collective skills to achieve extraordinary results.

C = Creating: Team Power--None of us is as smart as all of us: Synergistic harmony.

* Build a game plan for the team and stick to it.

* Share leadership.

* Reward team work.

* Rotate positions to build flexibility, introduce change, and build mental and physical skills.

* Turn individual skills into team skills.

K = Keeping: The account on the Positive--Repeated Reward and Recognition

* Look for behaviors that reflect the team's purpose and values and reward, reward, reward!

* Catch people doing things right or approximately right.

* Redirect toward the goal; do not punish.

* Link all recognition and reward back to the purpose and goals (Blanchard, 2001, p. 189-190).

This model can be used by the nurse leader in staff interactions. The "P," clear purpose and value, means that nurse leaders must set clear and achievable goals for self and staff. The "U" represents the skill sets nurse leaders must utilize to create healthy teams. Strong skills will create confidence and strengthen the patient care team. Team power, "C" is acquired by creating a clear, purpose-driven patient-care team. The "K" keeping a positive account represents the responsibility to reward behaviors that reflect the team's purpose and value. Such rewards aim at achieving positive patient outcomes and effective team work. As this example shows, the PUCK model can be easily applied in nursing. As a Nurse Leader utilizes this model, the results will be effective teambuilding and better patient care.

Lencioni's (2002) "Five Dysfunctions of a Team" is a leadership fable about a technology company struggling to attract and keep customers. The new CEO recognized the company's innovative products and great talent was negated because the executives were not a team: They were struggling but unable to agree on an appropriate solution to their problems. The team eroded into naming, blaming and shaming. No one was accepting responsibility nor making important decisions, deadlines were being missed, morale was declining, and the company was losing the battle for market share.

Lencioni (2002) illustrates team dynamics and team work by showing what teamwork is not, termed the five dysfunctions of a team. Then he provides a clear picture of how a healthy team interacts and what it feels like to be part of a successful team. To achieve this goal requires that leaders address the team's dysfunctions head on: Ambiguity is the enemy of results. The five dysfunctions are discussed below accompanied by strategies to move dysfunctional teams to healthy teams (Lencioni, 2002).

1.) Absence of Trust--Team members must:

* Open up to each other.

* Operate without fear of reprisal.

* Overcome the need for invulnerability.

2.) Fear of Conflict--Failure to productively address conflict:

* Leads to preservation of a sense of artificial harmony.

* Results in the ability to accept some conflict, acknowledging that no one gets use to conflict.

3). Lack of Commitment--Arises from failure to hear all the teams concerns before making a decision:

* Is evidenced by ambiguity.

* Thus, if people don't feel like they've been listened to, they won't really get on board (committed).

4). Avoidance of Accountability--All team members are not on the same page results in:

* Organizational leaders won't hold each other accountable because they want to avoid interpersonal discomfort.

* Lowered standards.

Lencioni (2002) points out that some employees are hard to hold accountable. They may appear to be helpful or become very defensive and intimidating. These team members must be 'pushed respectfully' for the team to become a functional team. When team members are not held accountable to the team's interests and goals, the tendency is to look out for their own interests. This is the ultimate dysfunction: The tendency of team members is to seek out individual recognition and attention at expense of team results.

5). Inattention to Results--To focus team members on building a functional team, it is essential that:

* Leaders and team members make the collective ego greater than individual egos.

* Leaders don't leave any room for interpretation when it comes to defining results.

* Expected results must be stated simply and specific enough to be actionable.

* Team performance must be measured regularly so the team can react more quickly on needed changes.

* The focus must be on creating the best team possible, not shepherding careers of individual athletes.

* Goals are reviewed regularly and addressed quickly when unmet.

* Resources are re-directed as indicated to achieve results.

Lencioni (2002) asserts that addressing these five dysfunctions results in cohesive teams that trust one another; address conflict; commit to decisions and plans; hold one another accountable; and focus on the achievement of collective goals.

In nursing, the dysfunctions identified by Lencioni can adversely affect a nursing team. The absence of trust occurs when nurses do not address concerns with physician or co-workers. Lack of commitment may occur when a lack of direction and commitment to patient care results in nurses' lack joy in their work. The fourth dysfunction, avoidance of accountability, is seen when the nurse leader does not give staff clear sets of expectations. In these cases, staff may choose silence rather than confront behaviors not conducive to teambuilding. The fifth dysfunction, inattention to results, is known in nursing as "eating their young." They put their own personal needs and egos ahead of their colleagues; ultimately the team and patient care suffers. Nurse leaders must quickly address these dysfunctions and redirect team member behaviors to achieve positive actions and outcomes.

Research has shown that positive teamwork results in collaboration, improved problem-solving and communication, increased morale, and, ultimately, improved patient care outcomes. The key to teambuilding is creating a framework with clear expectations and open communication. As nurse leaders, we must develop and encourage others to apply team-building strategies that can improve teamwork and patient care.


Blanchard, K., Bowles, S., Carew, D., & Parisi-Carew, E. (2001). High five! The magic of working together. New York: Harper Collins.

Lencioni, P. (2002). The five dysfunctions of a team: A leadership fable. San Francisco: Jossey-Bass.

Susan is an OUHSC Graduate Student in the Nursing Administration Pathway.

Susan Dellegar, BS, RN, Clinical Manager

St. John Hospital-Tulsa
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Author:Dellegar, Susan
Publication:Oklahoma Nurse
Geographic Code:1USA
Date:Jun 1, 2010
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