Effective team leadership: techniques that nurses can use to improve teamworking
Exploring how implementing a three-point strategy in team meetings enables members to reflect on their team’s effectiveness and build on this
Nash, S., Govier, I. (2009) Effective team leadership: techniques that nurses can use to improve teamworking. Nursing Times; 105: 19, early online publication.
This is the second article in a two-part series on leadership. The first examined transformational approaches to effective leadership in healthcare settings. This article describes the strategies that nurses can use to ensure healthcare teams are effective: team reflection; ensuring all members participate; and establishing ground rules.
Key words: Leadership, Team Effectiveness, Action learning team, Reflection
- This article has been double-blind peer-reviewed
Sue Nash, MBA, BSc, RGN,is facilitator of individual, team and service development, Action Learning Teams Consultancy; Ian Govier, MSc, PGCE, BN, DipN, RNT, RGN, is development manager – nursing leadership, National Leadership and Innovation Agency for Healthcare, Llanharan, Wales, and runs CTR Training and Consultancy; both are associates of the RCN Consultancy Service.
- Evidence shows that nurses’ psychological well-being has decreased over recent years.
- Team effectiveness is directly linked to members’ well-being and quality of care.
- Nurses can use a three-point strategy to improve their team’s effectiveness, which involves team reflection, ensuring that all members participate and establishing ground rules.
- Becoming an action learning team will enable nurses to maximise team effectiveness.
Lord Darzi (2008) said: ‘Leadership is not just about individuals, but teams.’
Govier and Nash (2009) discussed the principles that underpin transformational and effective leadership in healthcare settings. This article builds on this by focusing on the importance of team development and offers some practical exercises that leaders and teams can do to consider their effectiveness.
Teams that work well together and have higher levels of participation are more effective in delivering high-quality health care, have better team member well-being and lower stress levels (Borrill et al, 2002).
The Health and Safety Executive (2008) identified that nursing has a high prevalence of self-reported work-related stress. Ball and Pike (2006) reported that nurses’ levels of psychological well-being fell between two RCN surveys in 2000 and 2005.
Team effectiveness and the ability to reflect are two of the least valued qualities when teams have completed a 360-degree feedback team performance inventory (Aston Organisation Development, 2009). Given the evidence that teams that are effective can improve members’ well-being as well as quality of care, it is important to consider how teams can increase their effectiveness.
This article aims to introduce some simple techniques to enable team leaders and members to reflect on their team’s effectiveness and to build on this with some development activities.
This does not negate the fact that, at times, teams may wish to use external help and other resources to support this process.
These techniques can be used both following team-development programmes as a way to embed and revisit development, and to identify development needs.
Given that such programmes may be seen as a luxury, the techniques outlined below can be used in routine team meetings. The act of using the techniques not only focuses the team on the issues but also has a development effect in itself.
The issues and simple techniques described are:
- Team reflection;
- Ensuring all team members participate;
- Establishing ways of working/ground rules.
It is difficult to build time for reflection is into a busy working day, week or meeting. The frequent cry is: ‘Don’t just stand there – do something.’ However, evidence suggests we would do well to cry: ‘Don’t just do something – stand there, reflect and then take action.’
West (1996) argued that team members’ ability to reflect on their task objectives, processes and team culture is the best predictor of their team’s effectiveness. The preference to lean towards action rather than reflection is observed in many groups.
Four facilitated groups taking part in the RCN Nutrition Now campaign were recently asked to reflect on how they were working as a team and the next steps they needed to take with their projects. Each team immediately focused on the action to be taken. When the facilitator asked what their reflections were about teamworking, they either said they had not discussed it or that they were working well. After another prompt from the facilitator about communication there was a pause, then team members suggested there were perhaps issues with communication. This led to further reflections and discussions about their effectiveness and actions on how they would communicate between sessions.
When reflecting, teams need to consider how they rate themselves in terms of their effectiveness. Are members working well together? What is the communication like in the team, especially about the task being carried out, the methods and processes used to get the work/task done? Does the team review its objectives?
A discipline of asking the following questions will help teams to reflect:
- What is working well?
- What is not working well?
- What can we do about it?
This is a simple form of reflection. The model often used in the more formal clinical supervision groups is Gibbs’ (1988) model of reflection (Fig 1). Done well, this provides a framework to explore critical issues, near misses and incidents, working towards an avoidance culture instead of a blame culture.
For the purposes of this article, the three questions above are all that are needed initially for teams to experiment together – the key is in getting started.
We gravitate naturally towards ‘what is not working well’ in discussions. There is a place for this to get it off our chests. However, the difference between this ‘whinge session’ and a structured, reflective session is the learning and action that follows.
This process of challenge, in a supportive environment, is the foundation of action learning. Lord Darzi (2008) said: ‘Throughout my career, in all the clinical teams I have worked in, my colleagues and I have challenged one another to improve the way we provide care for patients.’
Action learning is about reflection and experiential learning. It is a balance of support and challenge. The benefits of this activity are:
- Service improvement by reflecting, questioning and finding better ways of doing things;
- Individual development – growth in personal awareness and interpersonal skills;
- Learning from successes and failures;
- Improving change-management skills;
- An opportunity for reflection, supervision, ensuring momentum in taking action and support in a safe environment.
Action learning is usually done in sets of 6–10 people who meet every six weeks and carry out a form of group coaching/clinical supervision. These principles can be applied to teams so the discipline of action learning becomes the normal way of working – challenging, supporting and coaching to improve the way in which we provide patient care.
In the high-profile cases of poor care that appear in the press, was the challenge element missing in the team responsible? Whether the challenge concerns lack of resources, priorities or poor practice – are we asking the right questions?
The ability to reflect, learn from reflection and take action on what needs changing is an important part of team effectiveness. Another important element is the participation of all members.
Ensuring all members participate
The essentials of a good meeting are:
- Having the right people participating;
- Having clarity of purpose for the meeting;
- That it is evident how the meeting contributes to high-quality service provision (RCN and NHS Institute for Innovation and Improvement, 2007).
This is an art in itself. The next steps are to ensure that all team members participate.
The theory of personality type covers the different ways in which people take in information and make decisions, and where they focus their attention and get energised. These differences can lead to misunderstandings and miscommunication. It is not necessary to know our personality ‘type’ to ensure team meetings are effective, as the theory of personality is taken into account in current guidelines and good practice.
However, having the team do a Myers-Briggs Type Indicator or similar exercise will stimulate discussion around ways to improve teamworking.
How often do meetings appear to be dominated by the few? This may be because those who focus their attention externally and get energised by interacting with others (extraversion) will naturally think out loud while they are discussing something. Those who focus on their internal world of ideas and experiences and energise by reflecting on their thoughts, memories and feelings (introversion) need time to think things through before commenting.
To facilitate this and to help those who think things through while talking, it is necessary to prepare in advance for the meeting. Of course this is good practice, but often meetings are run without agendas, or agenda items appear as a list of subjects with no clarity about the decision that needs to be made.
Nash (2006) argued that effective meetings need the following:
- An agenda and papers sent out in advance so the introverts can think about the information as can the extraverts, whose tendency is to do-think-do;
- Kline (1999) suggested that the agenda items are phrased as a question, so that each team member can think about what is needed from them. For example, how can we ensure patients get adequate nutrition at mealtimes?
- Round robins are also useful as everyone has equal air time, that is, each person has one minute to talk about an agenda item – this ensures that everyone has input and prevents someone dominating the time or others remaining quiet (Nash, 2006).
So, now the team is in place, it has the right people and clarity of purpose, and all members are participating. Do we articulate what we expect of each other?
Establishing ground rules
One element of team effectiveness is about establishing an understanding of the ways of working, in both the processes and behaviours expected as well as team tasks.
It is natural to focus on tasks as they appear more tangible. However, it is the misunderstandings around perceived values and behaviours that can cause team conflict and stress. It is important to try to articulate what each team member means by their own values.
When exploring ways of working or setting ground rules, the discussion usually takes the form of listing various words on a flipchart, such as confidentiality, honesty and respect. Misunderstanding and miscommunication result from our different interpretations of these ground rules. A simple but effective way of discussing these values and behaviours that make up ways of working is the how/why technique. This simple exercise could form part of the team’s reflection time.
Each team member says what is important to them when working together. If they say a value such as respect, other team members are encouraged to ask ‘How?’ until the behaviours are identified. If the person mentions a behaviour such as ‘Listening to me’, then the question ‘Why?’ is asked until the value (in this case respect) is identified. An example is outlined in Table 1.
Table 1. Values and associated behaviours
|Value (the why)||Behaviours (the how)|
‘How can we show respect to you?’
Ground rules and ways of working are meant to be reiterated and reinforced. Establishing these is not meant to be an exercise that is done once at the team’s inception; they should be revisited, not only if there is a problem, when clearly this must be challenged, but also as part of the team’s reflective activity.
Putting it into practice
So what would a team meeting be like if we tried the interventions and techniques set out above? It need only take about 10 minutes, which can be at the start, end or as an agenda item during a meeting.
The following is an example of putting this into practice:
- The team leader or chair of the meeting says that the team will be asked to think about an issue, for example, how the team communicates. This may be listed as an agenda item for people to come prepared;
- The agenda item is written as three questions – for example on communication:
- What is working well in the way we communicate?
- What does not work well in the way we communicate?
- What can we do to improve communication?
- There is then a round robin. Each member is given a specific time to answer the questions – 30 seconds to a minute is long enough. There are no discussions or interruptions at this stage;
- When all members have been able to contribute, the team identifies one action on which they agree that they can try between now and when the team meets again;
- If the action agreed is a specific behaviour, such as not interrupting when others are speaking, by using the how/why technique and asking why, the team will arrive at a value such as respect. The value and behaviour can be added to the ways of working/ground rules.
- At the next meeting there is a discussion about whether the action agreed had been taken, what the learning was and what, if any, the follow-up actions are. In this way the team shows that it takes action and learns together – an action learning team.
Taking time to reflect, ensuring that all team members participate and establishing ways of working does not need to be time-consuming or onerous.
Like anything worth doing, it needs practice – the more it is done the easier it becomes and will start to be second nature. Evidence and research show that taking time to do this improves team effectiveness. Since this has a direct correlation with team member well-being and quality of care, the question is not can we afford to do it but rather can we afford not to do it?
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Aston Organisation Development (2009) The Aston Team Performance Inventory Manual.
Ball, J., Pike, G. (2006) At Breaking Point? A Survey of the Wellbeing and Working Lives of Nurses in 2005. London: RCN.
Borrill, C. et al (2002) Team Working and Effectiveness in Health Care: Findings from the Health Care TeamEffectiveness Project. Birmingham: Aston Centre for Health Service Organisation Research.
Darzi, A. (2008) High Quality Care For All: NHS Next Stage Review Final Report. London: DH.
Gibbs, G. (1988) Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Further Education Unit, Oxford Brookes University.
Govier, I., Nash, S. (2009) Examining transformational approaches to effective leadership in healthcare settings. Nursing Times; 105: 18, 24-27.
Health and Safety Executive (2008) Stress-related and Psychological Disorders. London: HSE.
Kline, N. (1999) Time to Think – Listening to Ignite the Human Mind. London: Cassell Illustrated.
Nash, S. (2006) Knowing yourself – understanding others.Clinical Leadership News. London: RCN.
RCN, NHS Institute for Innovation and Improvement (2007) Guide 5. Effective Team Meetings. In: Developingand Sustaining Effective Teams. London: RCN.
West, M.A. (1996) Reflexivity and work group effectiveness: a conceptual integration. In: West, M.A. (ed) TheHandbook of Work Group Psychology. Chichester: John Wiley.