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Building Blocks of Teamwork

Effective strategies can reduce turnover rates, improve group cohesion and nurse satisfaction

For a printer-friendly version of the test you can print out, complete and mail in to ADVANCE, click here

This offering expires in 2 years: February 18, 2010

The goal of this continuing education offering is to provide nurses with current information on teamwork in the workplace. After reading this article, you will be able to:

1. Define team-building, give examples of team-building activities and explain why team-building is important.

2. Identify the five stages of group development.

3. Discuss why team-building is necessary in nursing.

You can earn 1 contact hour of continuing education credit in three ways: 1) For im-mediate results and certificate, go to Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 008-0-07), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).


Why is team-building necessary in nursing? Solid teamwork is fundamental to achieving outcomes and increasing effectiveness. But to create high-functioning teams, healthcare leaders must focus on several areas. The most important of these are nurse recruitment and retention. The ability of leaders in healthcare institutions to reduce turnover and continue to attract qualified nurses rests on their capacity to promote, develop and retain a cohesive nursing workforce. Targeted, unit-based team-building strategies can reduce turnover rates, as well as improve group cohesion and nurse satisfaction.

Team-building also improves nurse satisfaction and thus increased commitment to the organizations served. Team members are empowered to speak to one another more freely because they have come to better know and respect one another. They also are empowered to behave in new ways and can modify their approach to work for the benefit of fellow team members, not just themselves.

Rebuilding Structures

There is a clear link between team-building activities, staff communication and job satisfaction. Team-building encourages the most eager staff members to retain their passion, while offering less enthusiastic staff opportunities to change their approach to work - or move on. Team-building can fundamentally change the structures of working practices and environments in healthcare institutions, as well as how staff members perceive them.1

Teamwork also impacts patient care and safety. There is a large variation in the way physicians and nurses interact in the clinical setting, approach education, treat colleagues and work together as a team. Safety is all about relationships between the team members and their common goals: to reduce errors and provide quality patient care. The most effective way to learn teamwork - how to respect colleagues and collaborate with them - is by "just doing it" and overcoming the barriers as a group.2

Defining a Team

A team can be defined as a group of people with complementary knowledge and skills who are committed to a common purpose, performance goals and approach for which they hold themselves mutually accountable.

A team also can be described as a group of people who work together to deliver care by an organized division of labor. Like high-functioning families (as compared to dysfunctional families), teams accomplish more when they pull together than when each member is focused on one's own individual agenda.3 Team performance requires both individual accountability as well as mutual accountability.4

Approaches to team-building vary from organization to organization. To be successful, organizations must support team-building. In healthcare organizations, team-building can be accomplished through a variety of options, such as meetings and retreats. The overriding purpose is to improve communication.1

Good teamwork is fundamental to achieving positive results. Teamwork begins with overcoming assumptions one may have about another's roles. Communication is essential to ensuring successful outcomes. A framework of positive approaches is core to the management of people with challenging behaviors, and this approach also can be effectively used for managing staff. Equity and fairness are crucial in how staff are treated so everyone's view is heard and no one group dominates.5

Research studies have noted teamwork increases effectiveness. That is, teams are likely to achieve more than individuals. This is not simply because of a greater number of people; the achievement develops from the pooling of knowledge, skills and the energy created by the team.3

How Groups Form

The five stages of group development are:

  • forming: initial coming together of group members, during which they approach each other cautiously as they begin to understand each other;
  • storming: phase of interpersonal conflict, during which group members become competitive and are, therefore, dissatisfied;
  • norming: group members overcome their interpersonal conflicts and develop roles and relationships as the group becomes cohesive and develops a structure;
  • performing: members start to cooperate, communicate and collaborate, and work is accomplished; and
  • reforming: group dissolves as a result of reaching or changing its goals.

    The average timeline for each of these stages varies from team to team. The process then returns to the forming stage. Each of these stages must be achieved for a group to become a team.1

    Essential Components

    A strong foundation is required to build a successful team. This foundation consists of leadership, adequate time and resources, clear goals and objectives, and trust.

    A team leader must be identified. It is the responsibility of the team leader to guide the team to learn how to self-regulate. This can be accomplished by providing a balanceof action and patience. A team leader should empower the team by creating and communicating vision, providing resources, coaching and helping team members overcome adversity. Effective team leaders are distinguished by their ositive and motivating attitudes - and their keen listening skills, allowing all team members to be heard.

    A team leader must be given adequate time and resources to ensure a successful outcome. Resources can be in the form of an adequate budget, dedicated space and sufficient time. The most important part of team-building is for the organization to buy into the process and be committed to investing the appropriate time and resources.

    A team must have clear goals, and objectives should be clearly defined. Performance objectives serve as a measurement of success.

    Quantifiable goals help keep the team on the task at hand. Without these goals, it can be difficult to measure the success of the team, support the team's efforts and provide adequate resources.

    Make sure the mission and vision are clear. Unless the vision of the healthcare institution is clear to those attempting to implement change, teams will not succeed. It is essential to review team progress with the mission.

    Teams are built on trust. The best way to build trust is to work together to achieve results.4 Effective teams function through collaboration among patients, families, team members and other teams throughout the healthcare system.

    Collaboration occurs through relationships and rapport. Trust is the foundation for facilitating effective relationships. Without trust, team collaboration, along with patient safety, is compromised.6 One way to establish trust within a team is to set ground rules (e.g., no one will be negatively criticized for their ideas or questions). This is most effective when communicated at the beginning of a meeting or event. In addition, allowing the team members to add to pre-established rules will allow for increased ownership.

    Strong Teams

    Team-building interventions can result in greater problem-solving, increased morale and improved coordination of work. These interventions create a culture of openness and team learning that has been related to organizational effectiveness.7 Examples include highlighting and celebrating the group's accomplishments. When the group feels appreciation for a job well-done, productivity and energy within the group are amplified. In addition, bonuses or other financial compensation, and time off, are all good motivators.

    Another approach to keeping the team strong is to have the team members plan a retreat.8

    The retreat approach to team-building has been successful in many primary healthcare settings. After a retreat, community staff team members are more able to approach one another. Hierarchies are flattened.1

    Retreats are a great opportunity to celebrate accomplishments and set future goals. The major outcomes of retreats include professional development, increased cooperation among team members and staff satisfaction, opportunities for rewards and recognition, and nurturing of positive morale. Retreats can be difficult to implement, however, because not all staff can be away from work at the same time.9 If this is the case, having another type of activity, such as an in-house luncheon, is a viable alternative.

    Barriers to Team-Building

    To build a strong team, barriers or obstacles must be discussed at the outset. One barrier to be addressed is how gender differences in the workplace affect how group members behave toward one another.1

    Generational differences also come into play. In today's healthcare environment, four different generations work closely together. As a result, there can be frequent misunderstandings and misconceptions throughout all levels of the healthcare hierarchy. Therefore, it is important to recognize and value the variation in generational perspective.

    Working collegially with team members from various generations offers the opportunity to explore new ways of thinking in an ever-changing environment while recognizing the importance of wisdom. By accomplishing this, intergenerational teamwork and the care provided to patients can be strengthened.10 For example, younger nurses may be more willing and able to initiate technological advances to patient care, and this can be shared with the older nurses. In contrast, older nurses are generally able to prioritize patient care better than younger nurses, and can share that knowledge with the younger nurses.

    Collegial Relationships

    To be a participating member of any team requires the individual to have ample resources to share with the team. Networking with colleagues (nurses as well as other healthcare professionals) is a good way to cultivate resources.

    Networking is a process of forming interlacing tracks, channels or lines, or an interconnected system. Networking helps establish and maintain relationships, form links between people who share common interests, and preserve associations and relationships over time. To be most effective, the networking relationship must benefit all parties involved. It is important for nurses to understand how networks are formed and how to enhance new and existing relationships.

    Where Networking Happens

    Formal networking takes place in a conventional setting or forum created to enhance networking, such as professional organizations, conferences, alumni associations and business events. Attending important nursing conferences, whether local, state or national, enhances a nurse's ability to develop and maintain networking relationships within these organizations and their members.

    Opportunities for informal networking abound and include interactions on a more personal level. Informal networking takes place in settings such as sporting or social events, or over a casual meal. Informal networking also takes place in impromptu settings, such as a chance encounter in a hallway or wherever nurses discuss patient care issues.

    Networking also can take place within institutions. Getting to know and forming relationships with others in different units or departments is a means of establishing an informal network within a facility.

    Sharing Knowledge

    All nurses should learn the value of personal and professional networking and enhance their networking abilities. Nurses often begin building relationships in nursing school. Newly hired nurses begin forming a network of relationships as they are being oriented and socialized into the routines of their roles. As new nurses begin work within the organizational setting, they should learn the networking they engage in is a unique collaboration that can benefit themselves and their patients.

    One of the simplest means of professional networking is joining a professional organization.

    Professional organizations allow for networking on many different levels, whether locally by professional specialty or at the national level. Involvement with organization can be as simple as attending local meetings or as diverse as taking on leadership roles across the span of the organization at the local, state or national level.

    Another mode of networking is by way of the Internet. Electronic networking settings provide nurses with contacts that go beyond their local environment. Nurses from across the country and around the world can converse on issues of shared interest, forming global networks. Nurses from anywhere in the world can go onto the Internet and type "nurse" in any search engine, and countless Web sites are found that allow nurses to connect with one another.

    Counting the Benefits

    Organizations gain other benefits from the networking of their members or employees. One benefit is an increase in the supply of information shared across the network. This sharing of information often generates solutions to common problems.

    Another organizational benefit is that networking breaks down barriers and builds trust and respect between organizations. Organizational growth can take place as a result of individual networking within the system.11

    Dual Outcomes

    Good teamwork is fundamental to achieving positive outcomes and increasing effectiveness. To promote, develop and retain a cohesive nursing workforce, healthcare leaders must address issues of recruitment and retention, as well as present nursing conditions. Therefore, it is essential to implement team-building strategies that can help improve employees' satisfaction with, and commitment to, their organizations.

    Team-building can result in greater problem-solving, increased morale and improved coordination of work. In addition, networking helps establish and maintain relationships in the workplace, form links between people, and preserve associations and relationships.


    1. Toofany, S. (2007). Team building and leadership: The key to recruitment and retention. Nursing Management, 14(1), 24-27.

    2. Buerhaus, P. (2007). Is hospital patient care becoming safer? A conversation with Lucian Leape. Health Affairs 26(6), 687-696.

    3. Newson, P. (2006). Participate effectively as a team member. Nursing and Residential Care, 8(12), 541-544.

    4. Weinreb, J. (2004). Building a team for change in an academic radiology department. Radiology, 232(2), 327-330.

    5. Blyth, A. (2006). Team building: A daily task. Pediatric Nursing, 18(7), 44.

    6. Reina, M., Reina, D., & Rushton, C. (2007). Trust: The foundation for team collaboration and healthy work environments. AACN Advanced Critical Care, 18(2), 103-108.

    7. Horak, B., et al. (2006). Create cultural change and team building. Nursing Management, 37(12), 12-14.

    8. Levin, R. (2005). Leadership and team building. Journal of American Dental Association, 136(5), 666-667.

    9. Clevenger, K. (2007). Team building retreats. Nursing Management, 38(4), 22-24.

    10. Weston, M. (2007). Integrating generational perspectives in nursing. The Online Journal of Issues in Nursing, 11(2), 2-10.

    11. Waller-Wise, R. (2006). Growing collegial relationships. AWHONN Lifelines, 10(1), 34-38.

    Christine M. Gonzalez is a nurse clinician III at the Weinberg Intensive Care Unit and Stacey Rotman is heart care coordinator, both at The Johns Hopkins Hospital, Baltimore.

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