Group Process in Health Care Quality PDF

Group process in health care quality Dr. Ganna POLA Introduction Nurse leaders in today’s health care organizations must be skilled group facilitators with an exquisite ability to manage and lead the collective work of people. A significant percentage of work completed in organizations today is done...

Group process in health care quality Dr. Ganna POLA Introduction Nurse leaders in today’s health care organizations must be skilled group facilitators with an exquisite ability to manage and lead the collective work of people. A significant percentage of work completed in organizations today is done through collective efforts, either in work groups, committees, or teams. Understanding the characteristics of each of these entities and basic principles for attaining successful outcomes increases the leader’s effectiveness. Introduction In the 1990s, many health care organizations attempted to convert their traditional hierarchical, bureaucratic structures to a team-based structure, with varying degrees of success. Teamwork is the new imperative for various reasons. Changing reimbursement, managed care organizations, increasing complexity, technology advances, rapid information dissemination at the worker level, and the shift to a knowledge worker–based service society are some of the social and economic forces operative in health care. These forces converged to create great change in health care delivery. Introduction A major trend in the late 1990s, creating successful teams was thought to provide the strength and structure to deal with work complexities and changes. When the redesign, integration, merger, and partnering strategies settle, a decentralized and organic structure called the knowledge organization emerges with a growing emphasis on the role of teams. Although interdisciplinary teams have always played an important role in home care, hospice, and other community settings, hospitals and large health care organizations are placing more emphasis on teams as a part of their core structure. Introduction Developing effective teams of professionals from different disciplines has proven to be difficult. However, effective knowledge work teams can create a form of synergism in which the outcome is greater than the sum of individual efforts. Such synergism confers a competitive edge and boosts productivity under conditions of constrained resources. Developing a teambased structure is one way to enlist employee participation. Team building is a strategy for designing, implementing, developing, and nurturing work teams in organizations. Introduction Nurses do not work in isolation. In many nursing care delivery settings, nurses function in a work group environment or as a part of a team. Group work is a major managerial accomplishing work through others. strategy for Introduction In some occupations, people work in relative isolation from others, but that is not the reality of the work of nursing. As health care restructures and becomes more complex, a greater value is being placed on high-performing and cohesive work groups. This is because complexity and cost-control factors in the health care environment have dictated the use of interdisciplinary and crossfunctional work teams. Therefore nurses need to learn how to function constructively in group situations and continually build their skill set in team collaboration. Introduction In nursing, group process theory relates to both how to be therapeutic with clients and how to work as an employee within an organization that is often large and complex. Nursing has at its core both a caring and a coordinative function. The nurse’s coordinative role is at the hub of all client care information. (For example, nurses collect, process, and integrate the initial assessment and laboratory data; handle the tracking of all therapeutic interventions for the client; are at the bedside in hospitals for surveillance of minute-byminute changes; and are the major point of contact for clinical care delivery in many settings and sites.) (For example, if analgesics are given in a hospital, nurses track whether that intervention has worked, whether alternative pain strategies might be needed, and what psychological reaction the client might have.) Nurses predominate in actual client care in home health, long-term care, hospice, and many other settings. Introduction Nurses have to work collaboratively, not only with other nurses and their nurse manager but also with people who do not share the same Professional background, such as those in the administrative structure of the organization, other providers, the supply department, or the legal staff. These interpersonal and collaborative activities shape the essence of nursing practice. Group interactions A basic understanding of groups helps nurses function more effectively. These principles apply to any group, whether an actual team, a committee, or an informal group effort. Group interactions are composed of the following elements The process that the group undergoes to reach outcomes: This relates to the unique way the group interrelates and begins to work together. The leader can assess group process through observation. What is the process that occurs while accomplishing its task? The standards that regulate the group’s behavior: This relates to the specific values and norms that are chosen for group processing. Which ones are chosen; which are discarded? The process of problem solving or decision making that the group adopts: Does the group solve problems? How are decisions made? Are they group decisions made by consensus, or are they individual decisions made with group input (as occurs when the group participates but the decision is made by a leader or manager)? Group interactions are composed of the following elements The communication that occurs among group members: What are the internal patterns and styles of communication used by group members? To whom does the group communicate? Do they report as a subcommittee to a full committee? If a team, does the team have frequent communication with external team leaders? What are the internal and external modes of communication for group input and output? The roles played by each member: Members will adopt a variety of group roles within the group, but roles are fluid. Members may take on different roles in different situations. For self-awareness, knowing what part one played in his or her family helps an individual recognize roles that he or she might gravitate toward in groups. It is important to remember when assessing group interactions that roles in the group are not always clearly established by the leader or the group. In this situation, each group member moves in and out of group roles that best suit him or her. Clarity in the more formal roles such as team leader, facilitator, recorder, and time-keeper is Groups tend to go through a series of stages in their work and development Farley and Stoner identified these as : 1. 2. 3. 4. Orientation Adaptation Emergence Working Stages in the work and development The first stage, orientation, occurs when the group first forms and the members begin to relate to one another and the task. The group needs to develop trust and define boundaries in order to establish involvement and identification. The second stage, adaptation, occurs as the group begins to develop a collective identity and differentiate roles. The group needs a facilitative structure and climate to maximize its processing and to work through the establishment of roles, rules, norms, and a common language. Stages in the work and development The third stage, emergence, occurs as control issues arise. Disputes, disagreements, confrontations, alliances, and power struggles mark this stage of determining control over the group in order to emerge with a more consolidated identity. The final stage, working, occurs when conflict and dissension dissipate and the group achieves greater cohesion through negotiation. The group is now focused primarily on decision making and productivity. The stages may overlap and are not necessarily sequential. The group leader pays attention to the stage of the group as a way of monitoring the group’s development and progress. WHY PEOPLE JOIN GROUPS? WHY PEOPLE JOIN GROUPS? In nursing, the formation of groups occurs primarily for one of two reasons: 1. To provide a personal or professional socialization and Exchange forum 2. To provide a mechanism for interdependent work accomplishment. Groups can be social, professional, or organizational in purpose. WHY PEOPLE JOIN GROUPS? The following are some reasons why groups would be established in organizations: Group activities can create a sense of status and esteem. Groups allow an individual to test and establish reality. Groups function as a mechanism for getting a job done. The work to be accomplished requires the complexity of knowledge and skill possible only in a group configuration. WHY PEOPLE JOIN GROUPS? The work group provides an institutional and professional identity for an individual nurse, and work groups become a focus for interpersonal relationships, support, and social integration. Interpersonal relationship elements such as work group cohesion, communication, and social integration remain consistent moderate-level predictors of nursing job satisfaction. Being part of a healthy group or team is also related to the level of organizational commitment by the employee. Individuals with an emotional connection to their work group have lower levels of turnover WHY PEOPLE JOIN GROUPS? Work groups can be disrupted by factors such as downsizing, reorganization, absenteeism, and turnover. Work group disruption has been shown to be linked to negative outcomes. There was a relationship between work group disruption and interpersonal relations. Work group relationships can reinforce behaviors and reinforce rationalization, thus leading to deviant behaviors becoming passively or actively accepted ADVANTAGES OF GROUPS Veninga identified the following five majör advantages of group problem solving over individual problem solving: ADVANTAGES OF GROUPS 1. Greater knowledge and information: Obtaining a broader and wider range of knowledge and experiences creates a higher-quality input into group problem solving. The insights of one member can stimulate the thinking of others. With the increased specialization of health care workers today, this is especially true. 2. Increased acceptance of solutions: If there is a decision to be made in an organization, people can get together in a group to talk about it so that the people themselves are more committed to the decision. When individuals who are going to be affected by a decision are part of the decision-making process, they do not have to be convinced of the rightness of the decision and are more likely to be committed to implementing it. ADVANTAGES OF GROUPS 3. More approaches to a problem: Complex problems typically are more manageable when a number of perspectives are mixed together to address the problem. The advantages include blending and complementing individual learning and problemsolving styles to capitalize on strength through diversity. 4. Individual expression: Groups allow for individual expression, and in organizations specifically, there may be few mechanisms for expression of individual perspectives. Sharing information and getting input are done best in groups. Sometimes groups allow people to Express themselves—for example, if they are anxious about a change or if morale is low. ADVANTAGES OF GROUPS 5. Lower costs: If the group is functioning in a positive and constructive manner, the use of a group can be less expensive than the use of individual effort to accomplish a task. Group decision making is cost-effective if it saves time. For example, when a group meets for one session as opposed to the leader meeting multiple times with multiple individuals, the leader and possibly the group members save time. Furthermore, costeffectiveness may result through the division of labor ADVANTAGES OF GROUPS Sometimes when the work output of a group of nurses is analyzed, meetings appear to be very costly endeavors. For example, when the number of hours spent by all committee members is multiplied by their individual hourly salary and fringe benefit cost and added together to compute a committee total, the sum of costs for the group may be astounding. This is another reason for paying attention to how well the group is functioning. ADVANTAGES OF GROUPS A well-tuned and functioning group is positive for an organization. Often such a group is less expensive and time-consuming in terms of solving complex problems. Participation and involvement in a group decision typically results in individuals being more committed to a decision, even if there is disagreement. DISADVANTAGES OF GROUPS Group decision making can be derailed at a number of points in the process. The three disadvantages commonly noted about group decision making are the potential for premature decisions, individual domination, and disruptive conflicts DISADVANTAGES OF GROUPS Premature Decisions The disadvantages of group work include the fact that decisions can result from pressure. Once a majority vote is taken, the minority experience an element of pressure because of psychological dynamics related to subtle pressure for group acceptance and conformity. This is often referred to as “groupthink.” It may be difficult to be a “devil’s advocate” or to adopt the role of bringing alternative critique points to the group for consideration because of a concern about not being personally socially accepted. For example, derision and humiliation can occur if members react with strong negative opinions. This response stifles further input. DISADVANTAGES OF GROUPS Individual Domination Some of the disadvantages of groups relate to the possible emergence of dominating or argumentative members who obstruct the group process. These members make it an unpleasant experience for all involved. In a sense, they sabotage the work of the group. An example occurs when the group is not functioning well or the members are not adhering to the task of the group because of a chronically negative individual or other distractions (e.g., socializing, avoiding the task, not preparing themselves). It becomes costly and time-consuming for the group to divert its energy and productivity to working out interpersonal dynamics rather than moving forward on the group’s task. DISADVANTAGES OF GROUPS Disruptive Conflicts If people perceive an adverse effect on a group member or members or if they feel threatened, conflicts usually emerge. Conflicts can accelerate in a competitive environment when members vest in their own position. Conflicts may also occur over personality differences, differences of opinion, or clashes of values. Although it may seem contradictory, conflicts can serve as a control mechanism in a group and may actually result in far superior outcomes. When group members are comfortable respectfully disagreeing with each other, a premature acceptance of decisions can be avoided because opposing viewpoints are considered. However, group members and leaders need to become skilled and comfortable in handling interpersonal dynamics. DISADVANTAGES OF GROUPS A group or committee has certain powers, tasks, and functions, as well as certain parameters or latitude in terms of how far to go in making a decision. Decision power is a matter of degree, with four distinct points on the continuum of authority for decision making: autocratic, consultative, joint, and delegated. Range of decision powers DISADVANTAGES OF GROUPS On one end of the continuum is an autocratic decision procedure in which the leader makes all of the decisions. In this process there is input, perhaps, but not necessarily a vote. For example, in certain legislative committees the chairperson may or may not be able to put forth legislation or block a bill. It may be the case that an autocratic leader controls the power and the committee exists mainly for the sake of appearance. This type of committee is set up for reasons other than making participative decisions. It is hoped that very few of these structures are found in human service organizations because they can generate increased cynicism. DISADVANTAGES OF GROUPS A consultative decision procedure occurs when decisions involve employee participation but the leader still makes the final decision alone. Group members may make certain recommendations, but these must then go to the leader, chairperson, or head of the group, who makes the final decision. There is more participation with this type of procedure, but the ultimate decision is not under the control of the group members. DISADVANTAGES OF GROUPS Some decision procedures result in joint decision making. In this approach, the entire group decides, whether by a two-thirds vote, simple majority, consensus, or some other process. In a joint decision procedure, the employees have as much influence as the leader. The leader has one voice, one vote. The leader can use persuasion, but when it comes to the final vote, the leader’s vote is equivalent to that of any other member of the group. This is fundamentally different from the leader making the decision with group input. DISADVANTAGES OF GROUPS Finally, at the other end of the decision continuum is the delegated decision procedure. This occurs when the committee chair or leader allows participants to make the final decision. For example, in true self-scheduling, the leader may set up the basic parameters but the staff members (usually through the work of a smaller, designated team) actually decide what schedule they work. The true test of a delegation decision procedure is whether the leader overrides the followers’ decision. Technically, the leader would not have the authority to veto or override. If it is truly a delegation situation, the leader would go forward with the approach that the decision is the choice of the group. DISADVANTAGES OF GROUPS It is advisable for the followers in any group to determine who has the authority to make decisions. Knowledge about what type of group it is and what delegation or decision procedures can be anticipated is critical to participation. A leadership or conflict moment may occur when a group assumes that the decision procedure rule in effect is delegation and the decision is its to make but the leader has a different idea. Clarity before beginning work on an issue avoids unnecessary conflict and augments productivity. Group process in health care quality Part II Dr. Ganna POLA GROUP DECISION MAKING Group work can be, and typically is, a slow process. It takes more time for a group to arrive at a decision than for one person to make the decision. GROUP DECISION MAKING A group or committee has certain powers, tasks, and functions, as well as certain parameters or latitude in terms of how far to go in making a decision. Decision power is a matter of degree, with four distinct points on the continuum of authority for decision making: autocratic, consultative, joint, and delegated. Range of decision powers GROUP DECISION MAKING On one end of the continuum is an autocratic decision procedure in which the leader makes all of the decisions. In this process there is input, perhaps, but not necessarily a vote. A consultative decision procedure occurs when decisions involve employee participation but the leader still makes the final decision alone. Group members may make certain recommendations, but these must then go to the leader, chairperson, or head of the group, who makes the final decision. There is more participation with this type of procedure, but the ultimate decision is not under the control of the group members. GROUP DECISION MAKING Some decision procedures result in joint decision making. In this approach, the entire group decides, whether by a two-thirds vote, simple majority, consensus, or some other process. In a joint decision procedure, the employees have as much influence as the leader. The leader has one voice, one vote. The leader can use persuasion, but when it comes to the final vote, the leader’s vote is equivalent to that of any other member of the group. This is fundamentally different from the leader making the decision with group input. GROUP DECISION MAKING Finally, at the other end of the decision continuum is the delegated decision procedure. This occurs when the committee chair or leader allows participants to make the final decision. For example, in true self-scheduling, the leader may set up the basic parameters but the staff members actually decide what schedule they work. The true test of a delegation decision procedure is whether the leader overrides the followers’ decision. Technically, the leader would not have the authority to veto or override. The leader would go forward with the approach that the decision is the choice of the group. GROUP DECISION MAKING It is advisable for the followers in any group to determine who has the authority to make decisions. Knowledge about what type of group it is and what delegation or decision procedures can be anticipated is critical to participation. A leadership or conflict moment may occur when a group assumes that the decision procedure rule in effect is delegation and the decision is its to make but the leader has a different idea. Clarity before beginning work on an issue avoids unnecessary conflict and augments productivity. WORK TEAMS In health care, interdisciplinary care teams are a matter of survival. High-performance teams are essential to an organization’s efficiency and effectiveness because collaboration and teamwork are essential to achieving high-quality work outcomes and cost control. WORK TEAMS Three types of teams found in health care are: primary work teams leadership teams ad hoc teams WORK TEAMS Primary work teams include all forms of client care teams such as an emergency department trauma team. In the operating room, teams are often based on the specialty (e.g., a cardiovascular or an orthopedic team). The senior executive team is an example of an executive or management leadership team. At the hospital department level there may be a leadership team that is composed of the nurse manager, the charge nurses, and perhaps an educator. Continuous quality improvement teams, project teams, and problemsolving teams are examples of ad hoc teams found across settings and sites. Specific problem-solving teams in departments are other examples of ad hoc teams. WORK TEAMS Among all types of teams, any team may become a self-directed work team. This is a group that accepts increasingly higher levels of authority for its area of responsibility. A self-directed work team is fully responsible for delivering a welldefined segment of a finished product or service. It has the requisite capacity and authority for the work undertaken. WORK TEAMS Designing, building, and implementing effective work teams requires a specific methodology and process. A primary work team fails if it behaves like a collection of individuals operating from narrowly defined jobs; if it is composed of the wrong mix of members, size, structure, responsibility, or expertise; or if it cannot fluidly shift activities and adapt to changes. WORK TEAMS The following four steps are key to designing a highly effective health care team: 1. Define the total pool of work for the team. 2. Differentiate responsibilities within the pool. 3. Narrow the design options to attractive alternatives. 4. Identify the single best design to implement WORK TEAMS These principles apply regardless of the type of team being formed. After the team has been carefully designed for the work it is to accomplish, the next step is to build the team by incorporating the essential elements needed to function. These elements are meaningful purpose, consistent membership, specific performance goals, commitment to a common approach, complementary and overlapping skills, and mutual accountability for outcomes. WORK TEAMS Managing this development process is a key leadership function. This means that the leader guides the team in the development of its purpose. The team members are more likely to coalesce into a strong team if they have been given the time and opportunity to carefully reflect on their purpose and agree on what they do and for whom they do it. The team becomes a true team by doing its work. Specific performance goals give it direction and also provide evaluative criteria by which the team’s success can be measured. WORK TEAMS it is simplistic to say that the team has common working approaches, unnecessary conflict occurs in this area if the leader and team members have not established these key processes. Agreement is needed about how things are going to be done and by whom. This ranges from the establishment of team behavioral norms to agreement on procedural issues. This step usually requires a significant amount of time and will continue to be addressed throughout the lifetime of the team. By laying a foundation carefully, effective teams can emerge. WORK TEAMS The dynamics of interdisciplinary teams create some unique issues. Regrouping people into multidisciplinary groups can create anxiety and fear. A lack of common vocabulary and understanding about other disciplines’ practices may become apparent. It has been said that professionals simply do not know how to work together in teams. Other perils and pitfalls occur when teams are assigned, not designed. WORK TEAMS Additional errors may include the following: Confusion occurs about the team’s work. The team lacks real authority. Structural team building is not done. Dysfunctional behavior occurs. Team-based outcome measures and coaching are lacking. WORK TEAMS Trust and communication are critical elements of building effective work teams. It is not enough to simply structure the team. Team members need to work collaboratively and interdependently first before striving to work synergistically. Key to moving away from independent action and toward synergistic work teams is to change the use of power among team members toward finding synergistic solutions that address divergent needs WORK TEAMS Team performance and effectiveness are important managerial concerns. Dysfunctional team behaviors can occur. Lencioni (2002) identified five key dysfunctions of a team as absence of trust, fear of conflict, lack of commitment, avoidance of accountability, and inattention to results. WORK TEAMS Team norms are best established when the team initially forms. They are continually revisited, modified, and expanded throughout the life span of the team. The process for developing norms is usually leader-initiated and begins with a conversation within the team about how members expect each other to behave and contribute. The norms are usually developed during a group meeting in which ideas are shared, refined, and finally negotiated with all team members. WORK TEAMS Appropriate topics for behavioral norms include, but are not limited to, expectations around the following: Communication, both at the individual and group levels How team members treat each other How support is to be demonstrated Decision-making process How conflict is to be handled WORK TEAMS Often these norms are referred to as the team operating agreement, the code of conduct, or articulated expectations. In many teams, once they are identified, team members sign on to them, indicating agreement, and they often are posted in sight in the workplace. These norms are more than just a paper exercise. They signify that the team member agrees to live by the expectations and address other team members who do not. WORK TEAMS Katzenbach and Smith (1993) looked at the spectrum of teams and plotted the following five discrete points along a team performance curve: 1. A working group in which there is no incentive to form a team 2. A pseudoteam that has no common purpose or set of goals 3. A potential team in which significant incremental performance is needed 4. A real team that fits their definition 5. A high-performance team that outperforms other teams and has members deeply committed to one another’s growth and success Performance in teams is linked to productivity, but the direct applicability to the delivery of nursing care remains a complex challenge WORK TEAMS Nurse leaders need to learn how to manage in a team-centered environment; staff nurses must learn how to be effective team players. Interactive leadership is needed to create a group identity. Participatory management; sharing power and information; and generating trust, mutual respect, and enhanced self-worth are seen as key elements in successful performance teams. Teamwork begins with members who are well prepared and personally competent. Teamwork then includes shared ownership and decision making. Nurses often begin with experiences on client care teams and ad hoc problemsolving teams or continuous quality improvement teams, moving later to senior leadership and interdisciplinary or cross-functional teams. WORK TEAMS Group process is a framework by which to understand team development. Sovie identified four essential components of highperforming teams: roles, activities, relationships, and the environment. This means that highly effective teams establish positive roles among the members, who are able to focus their activities toward productivity. To become highly effective, the relationships of the team members need to become cohesive. The team requires a facilitative and supportive environment in which to work through the task and relationship elements. Management of team building and team performance includes skill in the process of conflict management. Diverse backgrounds and varying views result in the potential for differences, conflicts, turf battles, and office politics. COMMITTEES An essential part of any nurse’s role is to be involved in committee and group work. Work is accomplished through people, and the coordination of care is furthered through committee actions. It also is important to nurses’ job satisfaction and autonomy to have an avenue of involvement and participation in which to actively solve problems and retain autonomy over nursing care. Shared governance models incorporate staff nurse participation in groups and committees as a core element of how work gets accomplished. COMMITTEES Some people react negatively to committees because they dislike the time involved and because they are frustrated with the psychodynamics of group process and decision making. However, committees are a mainstay of organizations and can be an important way to make changes in clinical practice. COMMITTEES Committee structures are preferable in the following two kinds of situations: 1. Situations in which each member’s input is needed to attain a certain goal. For example, a committee may be set up to implement self-scheduling or to start a new program to benefit clients. If the work cannot be done alone or if there is a need to have everyone’s agreement, then a committee is probably appropriate. COMMITTEES Situations in which diverse representation facilitates implementation of proposed activities. To have a diverse group of people provide input in order to get the job done, a committee should be created. For example, a multidisciplinary products committee could be established to develop a process in which products would be reviewed before a large amount was purchased. This approach avoids the nurses at the care delivery site using products that are potentially unsafe or unusable, and thus costly. COMMITTEES Some groups or committees are structured to gather together members based on organizational position or job position. For example, all the nurse managers may belong to a group of nurse managers or staff nurses may belong to a staff nurse council. By holding the position of nurse manager, the person belongs to that committee. This provides an opportunity for peer interaction, support, and problem solving. COMMITTEES There are multidisciplinary interdivisional committees. A multidisciplinary committee includes participants from several divisions or specialties. The participants may all be from within the institution or from both inside and outside the organization. These committees often are used to coordinate and eliminate boundary conflicts. COMMITTEES Within organizations, committees perform a central role in the implementation of the strategic plan. A committee is a group that can assume accountability for planning, implementing, and evaluating the outcomes of a strategic goal translated to the operational level. Committees accomplish some departmental activities and provide a mechanism for increasing staff participation in decision making. In an environment characterized by complex work, committees become a majör vehicle for resolving issues related to the organization’s mission. EFFECTIVE MEETINGS EFFECTIVE MEETINGS Meetings are common occurrences in health care organizations. Whether a meeting involves a group, a committee, or a team, the leader’s role is to maximize the benefits of the meeting. Structuring a meeting for effectiveness requires preparation and effort. To manage effective meetings, the leader should consider the purpose for which they are organized. EFFECTIVE MEETINGS There are several purposes for meetings. The first type of meeting is held for information dissemination. For example, the designated leadership person calls the group together to let the members know that direction has come down to cut the budget by 10% because of fiscal retrenchment. A meeting is called to disseminate information about what is happening and to provide time for questions and answers. Perhaps there has been an organizational change, such as the decision that one unit is going to be consolidating with another unit or that a new building, department relocation, or merger is being planned. EFFECTIVE MEETINGS Second, there are meetings held for the purpose of opinion seeking. The goal of these meetings is open dialogue to solicit group opinions and ideas on specific topics or issues. This purpose does not imply that decision making is the prerogative of the group. Seeking opinions is an input strategy and may be used only for gathering data or testing group reactions. For example, an opinion-seeking meeting may be called to invite input on equipment purchases for budget requests. EFFECTIVE MEETINGS The third type of meeting is held for the purpose of problem solving. The meeting is structured to solicit help in clarifying, analyzing, and solving a specific problem. This type of meeting is more action-oriented. Group participation in decision making is encouraged. For example, group problem solving or unit meetings may be called to dis- cuss ways to solve problems related to disruptive or manipulative clients or family members. Meetings for the purpose of problem solving must follow a methodical structure; otherwise, they are likely either to deteriorate into a complaint session or to result in ineffective or unacceptable recommendations. Effectively leading these groups requires strong facilitation skills and knowledge in problem solving techniques. EFFECTIVE MEETINGS A meeting is a forum for updating shared knowledge among a team. A meeting rein- forces the collective goals and objectives of the team. Furthermore, a meeting can create a sense of commitment to group decisions. It can be an opportunity for a manager to be perceived as a leader. A true team uses the meeting time to accomplish a collective work product as compared with a committee or work group who uses meeting time to discuss issues and then delegate the work out- side of the actual meeting time. However, a meeting is a waste of time for all concerned unless they clearly understand what the meeting is intended to achieve. EFFECTIVE MEETINGS As nursing department meetings became unmanageable, one organization developed a questionnaire to survey the group and evaluate the meetings. Aspects such as the cost/benefit ratio of attending meetings, group process, decision making, and relevancy of agenda items were examined for individual members’ feelings about effective- ness. The group then discussed ideas for restructuring the meetings. Active participation was seen as being the essence of effective meetings. EFFECTIVE MEETINGS The leader of the group can facilitate meeting effectiveness by preparing and dealing with both the task and the people involved. The leader needs to listen carefully, process the interactions, control the flow, and keep the meeting directed toward accomplishing the objectives. The ideal size of a group is 4 to 7 people, with 12 being the upper limit. Members should be care- fully selected for best input and potential contribution to the work. The leader needs to start on time and be alert to seating positions. The leader can facilitate effectiveness by controlling the compulsive talkers, drawing out the silent members, protecting the junior members, encouraging the clash of ideas, discouraging the clash of personalities, avoiding the squashing of creative ideas, and closing on a note of achievement. The leader also needs to attend to careful meeting wrap- up. Summarizing after the meeting the group’s accomplishments and verifying task assignments going forward are important leader responsibilities. CONSTRUCTIVE GROUP MEMBERS CONSTRUCTIVE GROUP MEMBERS People in groups assume a variety of roles. Lancaster identified both group building roles and group maintenance roles as being a part of group interactions. Group building roles include initiator, encourager, opinion giver, clarifier, listener, and summarizer. Group maintenance roles include tension reliever, compromiser, gate- keeper, and harmonizer. The group building roles concentrate more on relationship functions than on task functions; the group maintenance roles focus more on task functions than on relationship functions. CONSTRUCTIVE GROUP MEMBERS One positive way to handle meetings is to identify a facilitator. Often this is the formal group leader or individual in a position of authority, but it does not have to be. If this is a true team, the role of facilitator may rotate among team members. In a committee, the facilitator is probably the committee chairperson. A facilitator conducts the meeting, ensuring that everyone has the opportunity to speak, maintains the focus of the meeting, and ensures that group dynamics remain positive. CONSTRUCTIVE GROUP MEMBERS Also needed is a group recorder. The task of taking minutes or summarizing discussion and decisions may need to be delegated to a clerical support person (if possible) if group members are averse to taking on the task of recording outcomes. However, a recorder who is a group member technically can do far more than just take minutes. This person should be in tune with the group processing and with the inputs and roles of group members and help keep the group on time. The recorder can provide feedback to the facilitator in terms of how to improve the process. One key tip is to construct a standardized meeting record (or minutes) form to facilitate the process and flow documentation. CONSTRUCTIVE GROUP MEMBERS Finally, group members are needed. In this instance, group members means active participants, each with equal status in the meeting. The three components of facilitator, recorder, and group members contribute to the design of a positive working group. DISRUPTIVE GROUP MEMBERS Another role that the group leader assumes is that of process facilitator. The leader must observe group member actions and be prepared to control or redirect disruptive behaviors. Following are common types of disruptive group members that are encountered, with strategies for the leader to use in managing dysfunctional members. DISRUPTIVE GROUP MEMBERS Compulsive Talkers The leader needs to identify individuals who are compulsive talkers and consider how their behavior can be modified. One suggestion is to thank them for their input and then ask to hear from others on that same topic before they are given permission to speak again, as a way of guiding and opening up the meeting to be more effective. If this behavior continues to impact the group negatively and the individual is not receptive to this subtle feedback, meeting with the person after the group work and giving direct, constructive feedback about the negative impact of his or her behavior may be necessary. DISRUPTIVE GROUP MEMBERS Nontalkers The nontalkers are the quiet ones. The leader can ask them to write down and submit their ideas or ask to hear their thoughts on the matter at hand. The leader can specifically ask them questions to draw them out and thereby open up a broader range of group input. Preparing members in advance by posting the agenda or letting them know where their input will be crucial is also a way to include the nontalkers. Sometimes these people need time to think through their thoughts before they engage in a conversation, unlike their more spontaneous and verbal peers. DISRUPTIVE GROUP MEMBERS Interrupters The leader has to control the interrupter because this person is demonstrating a lack of self-control. The interrupter can be a problem in groups because the person who is interrupted feels violated and wonders why he or she is not given the courtesy of finishing a thought and having his or her full input considered. The leader needs to halt the interruption and control and redirect the interrupter. This can easily be accomplished by saying “Let’s let Joan finish what she was saying.” DISRUPTIVE GROUP MEMBERS Squashers Squashers try to squash an idea before it is even developed. Suggestions about processes or procedures that have not been proven or even tried are much easier to criticize than are facts or opinions. Persons who are averse to change may have a litany of reasons why a potential solution would never work or why this proposed project simply cannot or should not happen. Often these are people who do not want to take a personal risk or undergo the personal effort of making a change, so it is easier to squash everything and maintain the status quo. Especially during brain- storming sessions, the leader must be alert to and have a method for containing the squasher. An easy way to influence this is to set the expectation at the beginning of the session by saying, for example, “For this exercise, please do not engage in analyzing or saying anything negative about the ideas thrown out until we have them all identified.” DISRUPTIVE GROUP MEMBERS Busybodies Busybodies really are not committed to the group’s work. They frequently arrive late, leave early, take personal messages or cell phone calls during the meeting, never read the agenda, are passiveaggressive, and simply want to show up for a few minutes for the purpose of appearances but do not con- tribute any effort. They are meeting their needs by showing up, but they are not contributing to the ongoing group work or the task at hand; nor are they invested in the group’s goals. The leader needs to find creative mechanisms to engage the busy- bodies, perhaps by giving them a concrete assignment with accountability. If this does not work, they may need to be released from the group or placed in an advisory role.