Group Dynamics in Healthcare Settings

Abstract

Group dynamics have broad and necessary applications. And there is arguably no more of a need for such than in a healthcare setting as a result of the fast-paced, high pressure, and seemingly always shifting focus from patient need within policy framework. Nonetheless, the abilities for clinicians' to successfully interact within a multidisciplinary team is essential for patient care outcomes and effective and efficient use of system resources. This paper will review, discuss, and propose a strategic framework for team work development and improvement within a healthcare setting. Suggestions for future studies are also provided.

Source: Adam J. McTighe and Samantha Donovan, http://pubs.sciepub.com/rpbs/5/1/5/index.html
This work is licensed under a Creative Commons Attribution 4.0 License.

Introduction

Overview

Development of a sound strategy to identify the unique challenges, barriers, and obstacles is critical. You have been explicitly directed from upper management that this team will be under your direction, which may help ease (or intensify) some worry. Nonetheless, being able to accurately identify and espouse the roles and subsequent responsibilities of each member may help reduce feeling overwhelmed. (Take away: Identify roles and expectations!)

The preeminent work of Tuckman regarding group dynamics will provide a sound theoretical basis for your team's development: Forming, storming, norming, performing and adjourning. However, there are particular aspects of group dynamics that transcend the specific stages proposed by Tuckman. As such, the process of evolving communication, purpose, competency, advocacy, and adaptation are critical to provide cohesive multidisciplinary work in a healthcare setting.

Communication

As your group forms, establishing open communication is crucial to lay the foundation for trust and respect for one and other. Being able to clearly identify the "who and the what" prevents vagueness and ambivalence of responsibility. Your treatment team will likely consist of, but is not limited to, a psychologist, social worker, nurse, patient experience coordinator/patient advocate, and a physician (and one or more students); one of which will be the team leader. Generally (and certainly, historically), the physician has always been viewed as the team leader. As the psychologist/mental health clinician, we do not and (in most cases without jeopardizing the scope of competency) cannot question this. (When was the last time a psychologist prescribed an MAOI inhibitor?) However, you and your team have been called on for a consultation for a reason! (Please remember this). Perhaps it is an issue with treatment adherence, diagnostic clarification (mental health rule in or rule out), or something related to a cultural diversity issue, but remaining calm through conflict helps cohesion and the ultimate goal of patient care and treatment. (Take away: Remain communicative and calm!)

Selfless

The adage, "Stay in your lane" permeates professional healthcare at all levels. As noted above, following this 'sign' has distinct advantages and practical applications. (This also references the concept of silos). However, the functionality of a multidisciplinary team providing brief consultation within the hospital setting requires flexibility, both within the core team unit but also with the referring physician/unit. Therefore, the next main point to address team cohesion is to utilize the concept of "one down approach". Using this ideology, you and your team (either through its part or the gestalt) are no better or know no more than anyone else in the room, will help reduce any possible tension. While your team may have a specific expertise, taking away this edge will reduce a possible barrier that commonly occurs in the storming stage of Tuckman's theory. (Take away: Remove the EGO!)

Another essential piece of a successful multidisciplinary team is having a humble and selfless leader. Ideally the leader is obsessed with the success of the team and is unbelievably ambitious. These Level 5 Leaders generally can be described in the following words; humble, servant, modest, shy, understated, and mild-mannered. In accordance with the need to remain humble, effective leaders are able to admit mistakes and limitations and attribute praise where necessary. Humble leaders are able to improve the leader-follower relationship which results in the followers' greater commitment to contributing to the team unit. This relationship fosters the development of a shared group identity.

As the group becomes more stabilized, explicit and careful attention must be made to the cultural issues, both within your group as well as with the groups' interaction with others. Effecting the one down approach should help to avoid power struggles with the physician (or another authority/expert figure), which is very important not only for the patient but also for future consults. Remember, some physicians may regard mental health consults as a necessary and seemingly underutilized asset within the hospital domicile; however, some do not. Further, some may not even be aware such services exist! As the research suggests, utilization of mental health consultation in the hospital has evidenced 94.8% of individuals to experience an improvement in overall patient care and treatment. Not to mention a higher rating in patient satisfaction! So, while these findings may bolster you and your team's self-worth, keeping in mind the appreciation may not be universal is helpful (e.g., If the physician is the expert, then why would an outside team be necessary?).

Advocacy and Competence

For those situations when the referring physician (or another healthcare unit) are unsure about the scope of clinical and/or health psychology, providing a cohesive introduction and utility of your services may be necessary. (It is, however, likely that the hospital may already have a brochure created, if so, skip this section). Working with your newly developed team to create an informative packet would be a nice way to further establish rapport and trust, not just among your professional aims and skills, but it also provides an opportunity for a personal connection with each other. After all, the more time invested helps to develop the shared identity as well as increase the value added proposition to the overall business model (your admins will love this). There is always a bottom line to services rendered, and as healthcare policies continue to change, providers and systems must adapt in real time. Having each member create a small biography with a picture would be a nice personalized touch. (Take away: Promote your team!)

Cultural Competency and Diversity

Cross-cultural diversity is inevitable in the workplace that demands the need for cultural competency and diversity training. As such, observing your team members' interactions with each other is crucial in order to address potential issues within the group. The concept of microaggressions is especially relevant to this need as they have the potential to damage the wellbeing of minorities by making one feel isolated, underappreciated, targeted, and inferior. Being able to understand the differences in age, gender, and ethnicity will help tremendously with group cohesion, trust, and rapport. This helps to create a culturally equitable workplace, which is dependent on adopting policies and procedures to meet the needs of the diverse individuals in the workplace.

Research on fostering cultural competency suggests there are many challenges to establishing competency and understanding. They include, but are not limited to: language barriers, negative perceptions towards certain cultures, microaggressions, lack of mentoring, adverse climates, and tokenism. In order to avoid these, the organization (and system at-large) must ensure that the mission commits to cultural competency. Of equal importance is understanding the dimensions of the cultural diversity within the team and then seeking commitment from individuals to nurture such differences. Consultation should always be used to provide support to those group members who are lacking in this area. Baker also found that in doing so, the group will not only benefit from greater cohesion, but the individual member(s) will gain from added insight that will ideally also increase patient satisfaction and treatment.

Another example of possible barriers to group cohesion is age. Research suggests younger and older team members' health can be affected by age diversity. Liebermann found that younger team members' health is affected when working in age diverse teams, if they hold negative stereotypical views of their older colleagues. These negative stereotypes include associating these members with a lower level of ability, motivation, and productivity. Such members may also be associated with the inability to adapt to new situations and to have less potential for personal development. Addressing the negative age stereotypes is essential to foster mutual acceptance and trust. Lieberman argues that exposure to members that disconfirm the age stereotypes can reduce these categorizations. Moreover, having a large age discrepancy in the organization can negatively affect the health of employees if steps to reduce any existing age stereotypes are not met.

Research also suggests that developing culturally relevant curricula and training opportunities, providing positive mentoring opportunities and support to minorities, and creating a diversity-friendly environment are essential to managing diversity. Providing culturally relevant curricula includes emphasizing cultural sensitivity in order to allow members of the team to become more competent in communicating with individuals from different cultures. Increasing mentoring opportunities also provides members the chance to demonstrate personal satisfaction in helping others, increase enthusiasm about their work, and help minority members develop a sense of belongingness; increasing the presence of minorities promotes diversity and professional development. These initiatives involve educating individuals and managing diversity in pursuance of optimizing the performance of all individuals in the multidisciplinary team. (Take Away: Cultural competency is a must!)

Adaptation

Telehealth is the use of modern information and communication technologies for distance-related health activities. Telehealth allows for ease of communication between health professionals and between health professionals and their patients. These services can reduce healthcare costs, reduce travel burden, and improve health outcomes if used properly. Alternatively, the use of telehealth services can also create conflict and exacerbate communication if members of the team reside in different geographic locations where similar resources are not available. Factors such as different communication standards, cultural norms, and teamwork structure can also impede on collaboration. Therefore, although telehealth services can improve clinical outcomes and teamwork outcomes, opportunities can be missed due to misunderstandings and a lack of perceived usefulness and knowledge, or both.

Having proper electronic health record software is essential to communicate and maximize services. Medical professionals can access patients' health record protected accounts during remote appointments. Physicians are able to communicate through these secured networks rather than sending confidential medical information though an unsecured network that is susceptible to data theft and potential HIPPA violation fines. These regulations may affect group dynamics and impede on the fluidity of communication. Adherence to such procedures must be uniformly followed by all members of the multidisciplinary team. In addition, if members of the group are not as adept at computer usage as others, this may affect the efficiency of group communication. If used properly, telehealth services can dramatically change healthcare services for the better. (Take away: Encourage adaptation!)

Conflict and Problem Solving

Conflict will arise, it is unavoidable. Yet being able to deftly address and adapt is key to promoting a positive work environment. Although conflict can undoubtedly cause discomfort and uncertainty, conflict can also improve communication and allow issues to be espoused and resolved. Positive conflict management can foster growth, encourage mutual respect between colleagues, and enhance quality and standards of care. However, conflict resolution strategies must be met with open communication practices and a clear understanding. Asymmetry in the perception of conflicts can be extremely detrimental to the functioning of the multidisciplinary team. The actual and perceptual distribution of power between members of the team can also play a crucial role in conflict resolution effectiveness. A clear power hierarchy is paramount to effectively discussing and implementing conflict resolution.

According to the Dual Concern Theory, conflict resolution is a function of high or low concern for self along with high or low concern for others. The resulting four way taxonomy includes two passive and two active conflict management strategies. A high concern for others and oneself results in preference for problem solving, which is viewed as the most constructive management strategy. This framework includes the initial identification of the problem, lists potential solutions, considers the impending risks, and executes a plan for the solution that minimizes risk. Although this solution contains elementary framework, it can be applied in the sophisticated area of a multidisciplinary healthcare team. Strategies as such may be used to alleviate the pressure and strain between colleagues, open lines of communication, and improve relationships. (Take away: Embrace conflict!)

Assessment

Assessment tools have been developed to objectively test collaboration progress. This is especially important in a multidisciplinary team because care is dependent on the ability of the professionals to work together in a coordinated manner. Although a health professional may think their team works collaboratively, these validated tools can provide comparable data.

One assessment tool with strong validity is the Assessment of Interprofessional Team Collaboration Scale (AITCS). This tool focuses on three elements that are essential in the collaborative practice: partnership/shared decision making, cooperation, and coordination. The instrument consists of 37 statements stemming from these themes and is rated on a 5-point Likert scale. The strengths of the AITCS are the unique capacity and versatility to evaluate collaboration among teams in various settings and its incorporation of patient involvement as part of team practice.

Another assessment tool is the Primary Care Team Dynamics Survey. This model defines effective team dynamics using three criteria: team performance, member satisfaction, and team adaptation. This conceptual model focuses on three enabling conditions: a stable team, clearly described responsibilities and predetermined norms, and supportive rewards and incentives. According to the model, when the enabling conditions are present, team members report that the care they deliver is more effective for patients and professionals. Similar to the AITCS, the Primary Care Team Dynamics Survey uses a 5-point Likert scale but is a 29-item survey. Research supports this tool as an effective measure of the effectiveness of intervention strategies to improve collaboration among the team.

The last model used to measure team collaboration is the Team Survey. This measurement tool consists of the Team Questionnaire, Psychological Contract Scale (PCS), and additional questions that address communication, perspectives, and valuing others. The Team Questionnaire contains items to measure team interaction, team identification, team potency, and team metacognition. The PCS predicts whether members of the team are motivated to perform either monetarily or emotionally. Research suggests that the Team Survey is a robust and suitable instrument for measuring healthcare team performance. This tool is widely applicable, valid, reliable, and not solely reliant on self-report data.

The three assessment tools mentioned above are all easily administered, taking about 10 to 15 minutes to complete. Any of the aforementioned tools can be used to examine the cohesiveness and collaboration efforts of the team. (Take Away: Evaluate team performance!)

Wellness

Wellness is a balanced state of health in both mind and body. This concept is especially important for both individual employees but as well with the group members at large. Companies have wellness initiatives that promote physical exercise and proper nutrition to improve employees' physical, emotional, and psychological health. Such programs are proactive approaches using preventative measures to help employees with lifestyle changes as according to the Center for Disease Control and Prevention, more than 66% of Americans are overweight or obese and nearly half reported to have at least one chronic medical condition. These impairments have indirect costs to the economy, both in terms of financial loss and personal burnout and/or turnover. In order to slow the rising healthcare costs and maintain a productive workforce, wellness plans have been developed to prevent these national health problems.

Research has found three essential components to developing and implementing an effective wellness program. An efficient program must have support from the top level of management, employees at all levels must "buy into" the program to some degree, and the program must be accessible and applicable to all employees. It is also important to be aware of the possible implications of stigma, as some employees may not share the same desire to participate.

Involvement in such programs has the ability to benefit at the individual and group level. Research suggests that employees with an unhealthy diet are 66% more likely to report having experienced a loss in productivity than those that consume a healthy diet. Envick also found that individuals involved in wellness programs were less likely to report work-related incidents and the incidents that were reported were less severe and took less time-off. According to the latest Principal Financial Well-Being index, 74% of workers surveyed agreed that wellness benefits encouraged them to work harder and perform better, while 48% said wellness offerings encouraged them to stay in their current position. There is also support that a positive relationship exists between psychological well-being and productivity. Included within the context of psychological wellbeing is emotional fitness, which can be explained as the capability of the mind to stay away from negative thoughts and focus on constructive tasks. Wright also found that ridding the mind of negative emotions such as anger, anxiety, sadness, and distress can contribute to increased productivity in everyday tasks. At the group level, wellness programs can increase productivity in the workforce, decrease absenteeism, and save money by lowering insurance premium costs. These programs also encourage a culture of health that allows more people to become aware of the importance of personal health choices and establish initiative in the employees. An additional benefit of wellness programs among organizations is increased employee morale, pride, trust, and commitment. Promoting competition within a wellness program can also increase participation, accountability, and effectiveness. For example, several companies engaged in a "wireless step competition" to see which organization could walk the most steps in a given time period. Many individuals within these groups were inspired to exceed their current fitness goals. Collaborative initiatives as such encourage employees to participate, which ultimately leads to productivity and greater team and group cohesion.

Workplace wellness programs are categorized into two subgroups, individual-level interventions and public health strategies. Individual-level strategies identify specific health risks of individual workers through a screening process and treat independently based on need. Public health strategies target the entire workforce collectively and attempt to promote healthy behaviors and develop a culture of wellness. These programs are designed to work with employees on non-work related issues that have the potential to interfere with productivity on the job. Many strategies and techniques have been developed to promote an ease of access to employees. One initiative uses wireless technology to track employees' activities, which then get transmitted to the password-protected activity log specific to the company's wellness program. The ease and convenience of this technology increases employee participation and health plan monitoring.

Another support is the use of telephone-based health coaching. These plans are individually tailored for each participant, developed to focus on "triggers" that prevent the individuals from reaching fitness goals, and increase accountability by having contact with a personal trainer, health educator, or registered dietitian on a scheduled, regular basis. In order to maximize member participation and success in health improvement, wellness programs create an environment that consistently highlights and reinforces healthy behaviors. Other suggested channels to encourage participation include: poster and brochure promotion, email reminders, meetings, and intranet notices.

Wellness incentives and programs are generally funded considering the return on investment and reduction of health insurance premiums as research on the effects of increased employee fitness has shown a possible 300 percent return on investment per employee. Moreover, according to research from the Texas Coalition of Worksite Wellness, for every dollar invested in corporate health promotion a savings of between $3.50 and $6.00 is achieved through reduced absenteeism, higher productivity, and fewer health care related costs. Regardless of the potential return on investment, wellness programs are well worth the time and financial investment for both the employer and employees.

Promoting wellness in the workplace is vital to the livelihood of the employees. In fact, the value of achieving optimal wellness is to subdue stress, reduce the risk of illness, and live a more productive life. Furthermore, exercising increases the production and release of the hormone serotonin, which regulates mood, the sleep/wake cycle, and appetite; and in low levels, it is linked to depression. Another benefit to wellness is the promotion of self-care. Self-care may involve the practice of mindfulness exercises that are especially relevant to sustaining focus and increasing the gray matter in the prefrontal cortex. Increasing the gray matter in this area of the brain promotes greater executive functioning. Therefore, wellness is important for the employer beyond simply the return on investment.

Conclusion

Becoming an effective leader to a diversified group of individuals is a challenging undertaking. Moreover, developing a cohesive multidisciplinary team is critical in any healthcare setting in order to meet high standards and quality of care. Foremost, establishing an open line of communication is crucial for the foundation of the multidisciplinary team in order to build trust and respect. Also, and essential to the rapport development and maintenance, is being a humble and selfless leader. Meeting the standards of a Level 5 Leader can be the determining factor of on-going and sustained success, and is vital to improving leader-follower relationships. However, when conflict inevitably arises, positive conflict management strategies must be employed in order to foster growth, encourage mutual respect between colleagues and enhance quality and standards of care.

Essential to the efficiency of the team is adaptation of services to ease communication lines. Research has shown that the use of telehealth services can reduce costs while improving health outcomes. Adoption of these services can bolster collaboration efforts and create better teamwork and clinical outcomes. The continuing success of a healthcare team requires the use of assessment tools to evaluate performance. These assessment tools can be used in different dimensions and areas of focus but are designed to target deficiencies and improve quality of care. The last area of focus discussed is the implementation of wellness initiatives. Research indicates that wellness programs in the workplace can increase productivity, decrease absenteeism, and save money by lowering insurance premium costs. Wellness programs also create a culture of health that allows the team to become more aware of the importance of personal health choices.

Using the aforementioned principles can provide guidance towards fostering positive group dynamics that are both effective and efficient. Each must be used in collaboration with support from all members to satisfy its intended benefit.