When teams are in difficulty they need effective support to turn the situation around, but building resilience can help to prevent teams developing serious difficulties
The first two articles in this three-part series focused on how to build healthy teams and increase team engagement using established leadership research and ideas. This final article considers how to recognise the warning signs of a team in difficulty and ensure it gets the support it needs. Using experience from work helping struggling teams at South Tees Hospitals Foundation Trust, it suggests actions and interventions that support teams through periods of difficulty. The article also discusses the importance of building individual and team resilience to prevent teams falling into difficulty.
Citation: Craig M (2015) Team building 3: Providing support to teams in difficulty. Nursing Times; 111: 16, 21-23.
Authors: Maxine Craig is head of organisation development; Andrew Moore is organisation development lead; both at South Tees Hospitals NHS Foundation Trust.
A team does not fall into difficulty over night; it is a pattern that develops over a period of months or even years, and the fact that a team is struggling is never a secret. Staff know and talk about it behind closed doors or in back rooms with their peers. These conversations are uncomfortable, but what is done with the information determines how long the team waits to receive support.
When team dynamics become challenging, members tend to start behaving badly, forming cliques, and scapegoating and feeling angry with each other, their managers and their organisation. All these things happen long before evidence of any quality failures. A sense of professionalism means that even when their team is struggling, managers and staff generally work hard to maintain patient safety and the quality of care, usually at a cost to themselves. It is therefore vital to pay attention to the stories being told in the team, as these can alert leaders to the fact that a team is in difficulty. Staff must be heard and listened to.
A change in culture
Over 12 years ago, South Tees Hospitals Trust experienced some of the worst bullying and demoralisation of staff the trust had ever known. At the time, we applied accepted best practice using traditional and robust human resources processes to address the situation, but these did not help the team in question to recover.
Staff felt disillusioned with the management response; some expressed hurt and sadness, some were angry and some left the organisation. None of these after-effects were intended and none were helpful. We learned that simply investigating team incidents did not lead to the culture change needed and decided to try a different approach (Box 1), based on the following principles:
- Understand the issue from the position of each and every core team member;
- Use the personal narratives and stories of staff as valid qualitative data, collecting them into a team narrative of “what is it like to be in this team at this time”;
- Focus on how the team treats itself, and how the organisation responds to the team, developing honest conservations at all levels;
- Use both quantitative and qualitative data;
- Provide board-level leadership in a well-defined process of support and accountability;
- Seek to make things better, not find out who is to blame.
Hearing the narrative and stories of staff is central to the South Tees approach. We use organisation development practitioners skilled in this work, and over the years our managers and nurse leaders have learned how to support teams in difficulty.
In order to effectively support struggling teams, nurse leaders must know where in their organisation they can find and access the right support.
Box 1. Responding to teams in difficulty
- Use informal intelligence to build up a pattern or picture
- Support local honest conversations
- Convene the key leaders and accountable officers
- Fully understand the issue from all perspectives
- Hold the boundaries and develop an effective approach to communication
- Support the team to self-assess, discover and understand all the issues
- Co-design the required interventions
- Make the plan a reality: implement the change
- Support the transition to healthy functioning again
- Evaluate, learn and review
Source: Conner and Stabler, 2009
Asking for help when you need it
In our experience, struggling clinical teams often try to signal that they are in difficulty, but feel they are not taken seriously or listened to; one reason for this may be that many clinical leaders, doctors and nurses signal badly and ineffectively when they need help. Poor signalling makes it difficult for managers outside the team to understand what is happening. Often the situation becomes so harmful to team members that grievances increase and sickness levels rise: we have worked with a team whose sickness levels peaked at 30%. Local nurse leaders try to hold things together, but at some point the staff begin to turn against them too. To those outside the team it may look like a staffing issue or personality clash, but the situation is rarely that simple.
If your team is struggling, go and talk calmly about it to your line manager as early as you can; do not try to deal within it alone. Talking about it does not mean you are weak; this is an organisational issue and you need support. Document the meeting in which you tried to explain the difficulty. If you are not heard, do this formally, taking it up to the next level, if necessary to the chief executive; many nurses find it extremely difficult to escalate their concerns - particularly in writing, but it is necessary. As Sir Robert Francis QC (2015) has said: “Each time someone is deterred from speaking up, an opportunity to improve patient safety is missed.” Sometimes it is necessary to escalate the problem to get help and support and keep patients safe.
Coming back from a difficult team dynamic is not easy, but is perfectly possible. The reasons teams fall into difficulty are always complex - there is never a single cause; rather a web of causality, including poor behaviour by people in the team towards each other. This cannot be ignored.
Poor team behaviour and treating colleagues inappropriately and badly has no place in healthcare; South Tees Hospitals has a clear code of conduct, which includes having safe, direct and honest conversations about effective and kind team behaviour (Table 1, attached). We support staff to understand why their behaviour towards their colleagues might be inappropriate, we provide coaching, mentoring, supervision and counselling, and ensure that help and support to change is available. At the same time, we do not tolerate ongoing poor behaviour anywhere in the clinical environment. Staff who are vulnerable, tired, angry or sad have to undertake what we call “inner work”: the development work of looking in the mirror and acknowledging their own role in difficult team situations.
Leading a team out of difficulty is difficult and challenging. As part of this work, during a reflective digital storytelling workshop in 2013, one of our wards audio-recorded the personal accounts of team members coming out of difficult team dynamics (Patient Voices, 2013).
Keeping individuals and teams strong and healthy and able to cope with the challenges they face requires resilience; team leaders need to understand what resilience is, why we need it and how to build it, and to take a proactive approach in supporting individuals and teams.
The pace of technological and scientific advancement, demographic change and economic turmoil means change is a constant in healthcare and is happening on an unprecedented scale. Working in healthcare is becoming increasingly challenging due to financial pressures, restructuring, the complexity of health and disease profiles and uncertainty over changing employment status; staff also have to cope with pressures from their personal lives, and any pressures they put on themselves. It is therefore vital that health professionals develop resilience to help them to live well.
Resilience is the ability to successfully adapt, maintain competent functioning and “bounce-back” from adversity and major life stressors (Edmonstone, 2013; Herman and Jane-Llopis, 2012; Kotze and Lamb, 2012). Jackson et al (2007) suggest it is about adjusting to adversity, maintaining equilibrium, retaining some sense of control over our environment and continuing to move on in a positive manner. In order to be resilient we have to take personal control; no one can do it for us. Just as five portions a day of fruit and vegetables is widely accepted as being good for our physical health, the New Economics Foundation suggests five things we can do on a daily basis that research shows can improve our wellbeing and resilience (Box 2).
Box 2. Five daily habits to increase wellbeing and resilience
Connect: take time to connect with family, friends, colleagues and neighbours, at home, work and in your local community. Think of these connections as the cornerstones of your life and invest time in developing them. They will support and enrich you every day.
Be active: go for a walk or run, step outside, cycle, play a game, garden, dance or exercise. It will make you feel good. Discover a physical activity you enjoy and that suits your level of mobility and fitness.
Take notice: be curious. Catch sight of the beautiful, remark on the unusual, notice the changing of the seasons, savour the moment, whether you are walking to work, eating lunch or talking to friends. Be aware of the world around you and what you are feeling. Reflecting on your experiences helps you appreciate what matters to you.
Keep learning: try something new, rediscover an old interest, sign up for that course, take on a different responsibility at work, learn to play an instrument or how to cook your favourite food. Set a challenge you will enjoy. Learning new things can makes you more confident as well as being fun.
Give: do something nice for a friend or a stranger. Thank someone, smile, volunteer your time, join a community group. Look out, as well as in. Seeing yourself and your happiness linked to the wider community can be incredibly rewarding and creates connections with people around you.
Source: New Economics Foundation (2008)
Our work building healthy teams at South Tees Hospitals has demonstrated that personal and group resilience is critical in helping prevent teams from falling into difficulty. We have introduced a programme of personal resilience learning, which includes helping staff to understand more about resilience, and providing resilience master classes and one-to-one support. We also run a programme in mindfulness, a meditative practice shown to improve wellbeing. To help inform this work we undertook a trust-wide personal resilience survey, with responses from more than 800 staff; this response rate itself demonstrates the level of interest in this area of work. Findings included that on average our staff identified themselves as having moderate levels of resilience and needed to build and strengthening their capability. We also found that respondents’ resilience score increases with age.
Our work suggests organisations must begin by giving staff permission and the incentive to build their resilience. Before we started the programme, staff expressed the view that they would be seen as weak if they began this work. Our colleagues are kind and ready to care for others, but not always so good at looking after themselves; this view is supported by the survey where an average of moderate resilience within the workforce was reported. However, self-care is a prerequisite for good patient care, which is why health professionals need to make personal resilience a priority.
This series on team building has drawn on established leadership research and ideas on team effectiveness to look at how to develop and maintain healthy teams. It has described how South Tees Hospitals Foundation Trust has applied this work in everyday practice to help build teams that are vibrant, focused and healthy and serve the public well, and has discussed how to use this work to help support teams in difficulty.
The importance of effective teamwork is further highlighted in the Nursing and Midwifery Council’s new professional code, which underpins a new system of revalidation to be introduced at the end of this year (NMC 2015). In section 8 on working cooperatively, the code states that nurses must:
- Maintain effective communication with colleagues;
- Work with colleagues to evaluate the quality of their work and that of the team;
- Work with colleagues to preserve the safety of those receiving care;
- Be supportive of colleagues encountering health or performance problems, but never at the expense of patient or public safety.
As part of this focus on revalidation, nurses could reflect on section 8 of the code and the work presented in this series to consider how they are supporting their teams to stay effective and healthy and provide the best possible patient care.
- Staff know when a team is in difficulty long before there is evidence demonstrating this
- Heeding staff warnings and listening to their story when a team is struggling is crucial to ensure patient safety
- If your team is in difficulty tell your manager what is happening without trying to diagnose the problem, making it clear that you need help
- However much a team is struggling, poor behaviour towards colleagues and team members is never acceptable and must be confronted
- The practice of learning about and building resilience is critical to maintaining a healthy team
Conner M, Stabler A (2009) Sharing our Learning: Dealing with the Hidden Side of Organisational Life, Supporting Teams and Clinicians in Difficulty. (South Tees Hospitals NHS Foundation Trust board discussion paper written by the author under her former name.) For copies, email firstname.lastname@example.org
Edmonstone J (2013) Personal Resilience for Healthcare Staff: When the Going Gets Tough. London: Radcliffe Publishing.
Herman H, Jane-Llopis E (2012) The Status of Mental Health Promotion.
Jackson D et al (2007) Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review. Journal of Advanced Nursing; 60: 1, 1-9.
New Economics Foundation (2008) Five Ways to Wellbeing.
Nursing and Midwifery Council (2015) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives.
Patient Voices (2013) Healthy Teams.