[Audio] © Shutterstock / Olha Kostiuk PART I Team and Group Development “When sufficient numbers of organization members become more self-aware, more concerned about the needs of others and more effective as group members and group leaders—they cannot help but eventually have a positive influence on the total function and structure of any system.” Shaffer and Galinsky, 1989, p. 192 Chapter 1: Groups-Teams-Systems Chapter 2: Group Development Chapter 3: Team Building Blocks: Norms, Goals, Roles, Communication, Leaders, and Members Part I Activities © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 

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© Shutterstock / Olha Kostiuk
 PART I 
 Team and Group 
Development 
 “When sufficient numbers of organization members 
become more self-aware, more concerned about the 
needs of others and more effective as group members and 
group leaders—they cannot help but eventually have a 
positive influence on the total function and structure of 
any system.” 
 Shaffer and Galinsky, 1989, p. 192 
 Chapter 1: Groups-Teams-Systems 
 Chapter 2: Group Development 
 Chapter 3:  Team Building Blocks: Norms, Goals, Roles, 
Communication, Leaders, and Members 
 Part I Activities 
© Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION

[Audio] © Shutterstock / Olha Kostiuk © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 

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[Audio] © Shutterstock / Olha Kostiuk learning objectives 1. Understand groups as complex, open systems. 2. Apply the concept of open systems to healthcare teams. 3. Differentiate groups and teams. 4. Describe levels of systems and how they relate to healthcare teams. 5. Recognize how the diversity inherent to interprofessional healthcare teams contributes to their adaptability and sustainability. Why Groups? Humans are wired to be interdependent. We bond together in families, friendship groups, neighborhoods, work groups, and recently in electronic social networks like Facebook and Twitter. The world has become more complex, and the exponential growth of information that is required to solve problems is not the purview of a single person or a single profession. By recognizing our need to join with others to meet challenges, we have the opportunity for collective wisdom to emerge and facilitate the creation of new connections and innovative strategies to ensure the health and stability of the world that we share (Briskin, Erickson, Ott, & Callanan, 2009). Groups and teams have been and will Groups-Teams-Systems 3 CHAPTER 1 © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 

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© Shutterstock / Olha Kostiuk
 learning objectives 
1.  Understand groups as complex, open systems. 
2.  Apply the concept of open systems to healthcare teams. 
3.  Differentiate groups and teams. 
4.  Describe levels of systems and how they relate to healthcare teams. 
5.  Recognize how the diversity inherent to interprofessional healthcare 
teams contributes to their adaptability and sustainability. 
 Why Groups? 
 Humans are wired to be interdependent. We bond together in fami-
lies, friendship groups, neighborhoods, work groups, and recently in 
electronic social networks like Facebook and Twitter. The world has 
become more complex, and the exponential growth of information that 
is required to solve problems is not the purview of a single person or a 
single profession. By recognizing our need to join with others to meet 
challenges, we have the opportunity for collective wisdom to emerge 
and facilitate the creation of new connections and innovative strategies 
to ensure the health and stability of the world that we share (Briskin, 
Erickson, Ott, & Callanan, 2009). Groups and teams have been and will 
 Groups-Teams-Systems  
3
 CHAPTER 1 
© Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION

[Audio] continue to be an essential part of our daily lives. Nowhere is the need for teamwork more relevant than in the healthcare arena. Diagnosis and intervention require the efforts of a cadre of physician specialists, nurses, therapists, pharmacists, social services personnel, laboratory personnel, information managers, dietitians, transportation workers, home health aides, family caregivers, and patients. Quality health care that is accessible and cost effective requires that the boundaries between these stakeholders are made permeable through consistent collaboration (Grant & Finocchio, 1995). Skills in team building, team membership, and the understanding of group dynamics are foundational and indispensable for the next generation of healthcare leaders. Well-functioning healthcare teams are linked to good morale, reduced staff turnover, and positive patient outcomes (Gittell, 2009; Lawrence, 2002; Torrens, 2010; Woltmann et al., 2008). What Distinguishes a Group from a Random collection of People? There is a unique designation for each of the myriad groupings in the animal kingdom such as school (fish), troop (baboons), murder (crows), gam (whales), and group (humans). No matter what the species, the critical element that is common to all the groupings is that the individual members are interdependent. In the case of humans, “members cASe SToRY: The Importance of Interprofessional Teams At our organization, everything is a committee decision. You can have input from multiple perspectives such as nursing, social work, occupational therapy, physical therapy, and dietary. Elder problems are highly complicated. Getting other perspectives is helpful. For example, let’s say you can’t transport Mrs. X into the center because she keeps hitting people and is not putting her seatbelt on. What do you do? You need to get different perspectives in order to make a decision. It is like that example of the blind men and the elephant. No single perspective will describe the elephant and there probably is not one single resolution. This requires that team members are confident in what they know, amenable to listen to someone else’s ideas, and willing to offer their own ideas. — Karen J. Nichols, MD, Chief Medical Officer for VIP Plans at AmeriHealth Caritas 4 | Chapter 1 Groups-Teams-Systems © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 

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continue to be an essential part of our daily lives. Nowhere is the need 
for teamwork more relevant than in the healthcare arena. 
 Diagnosis and intervention require the efforts of a cadre of physician 
specialists, nurses, therapists, pharmacists, social services personnel, 
laboratory personnel, information managers, dietitians, transportation 
workers, home health aides, family caregivers, and patients. Quality 
health care that is accessible and cost effective requires that the bound-
aries between these stakeholders are made permeable through consis-
tent collaboration (Grant & Finocchio, 1995). Skills in team building, 
team membership, and the understanding of group dynamics are foun-
dational and indispensable for the next generation of healthcare leaders. 
Well-functioning healthcare teams are linked to good morale, reduced 
staff turnover, and positive patient outcomes (Gittell, 2009; Lawrence, 
2002; Torrens, 2010; Woltmann et al., 2008). 
 What Distinguishes a Group from a 
Random collection of People? 
 There is a unique designation for each of the myriad groupings in the 
animal kingdom such as school (fish), troop (baboons), murder (crows), 
gam (whales), and group (humans). No matter what the species, the 
critical element that is common to all the groupings is that the indi-
vidual members are interdependent. In the case of humans, “members 
 cASe SToRY: The Importance of Interprofessional Teams 
 At our organization, everything is a committee decision. You can have input 
from multiple perspectives such as nursing, social work, occupational ther-
apy, physical therapy, and dietary. Elder problems are highly complicated. 
Getting other perspectives is helpful. For example, let’s say you can’t trans-
port Mrs. X into the center because she keeps hitting people and is not put-
ting her seatbelt on. What do you do? You need to get different perspectives 
in order to make a decision. It is like that example of the blind men and the 
elephant. No single perspective will describe the elephant and there probably 
is not one single resolution. This requires that team members are confident 
in what they know, amenable to listen to someone else’s ideas, and willing 
to offer their own ideas. 
 — Karen J. Nichols, MD, Chief Medical Officer for VIP Plans at 
AmeriHealth Caritas 
4 
| 
Chapter 1 
Groups-Teams-Systems
© Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION

[Audio] are linked together in a web of interpersonal relationships. Thus, a group is defined as two or more individuals who are connected to one another by social relationships” (Forsyth, 2006, pp. 2–3). Alderfer (1977) expanded the definition of human groups to include how they are distinguished from and perceived by nonmembers and how they relate to other groups. For the purposes of this text, in order for a group to be distinguished from a random collection of people, its members must have common interests and goals and regular patterns of interaction, exert influence among the members, and work interdependently to achieve goals (Cartright & Zander, 1968; Lewin, 1948; Smith, 2008).
What Is the Difference Between a Team and a Group?
The terms team and group are often used interchangeably. However, making the distinction between these two terms can offer valuable insight into how groups work and can facilitate leadership and full participation in productive teams. The term group comes from the French word groupe and the Italian gruppo, which were borrowed originally from the prehistoric Germanic kruppaz and is translated into a “round mass, lump” (Online Etymology Dictionary, 2011). The term group is defined by Merriam Webster (Definition of Group, 2011) as “a number of individuals assembled together or having some unifying relationship.” Team is defined as a group that engages in more focused intentional action. The word is derived from the Middle English term teme and the Old English tēon, which is to draw or pull (Definition of Team, 2011). Katzenbach and Smith (1993) describe a team as “a small number of people with complementary skills who are committed to a common purpose, set of performance goals, and approach for which they hold themselves mutually accountable” (p. 112).
The difference between a group and a team can be described on a continuum (Figure 1-1). At one end of the spectrum, group refers to people with something in common and at the other end, team refers Figure 1-1 Group-team continuum.
Students in a Classroom Advisory Committee ER Team Group =
A collection of people who have something in common. Team = A group of people who must work together to reach common goals or outcomes.
What Is the Difference Between a Team and a Group? | 5
© Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 

Scene 5

are linked together in a web of interpersonal relationships. Thus, a 
group is defined as two or more individuals who are connected to one 
another by social relationships” (Forsyth, 2006, pp. 2–3). Alderfer (1977) 
expanded the definition of human groups to include how they are dis-
tinguished from and perceived by nonmembers and how they relate to 
other groups. For the purposes of this text, in order for a group to be dis-
tinguished from a random collection of people, its members must have 
common interests and goals and regular patterns of interaction, exert 
influence among the members, and work interdependently to achieve 
goals (Cartright & Zander, 1968; Lewin, 1948; Smith, 2008).
What Is the Difference Between a Team and a Group?
The terms team and group are often used interchangeably. However, 
making the distinction between these two terms can offer valuable 
insight into how groups work and can facilitate leadership and full par-
ticipation in productive teams. The term group comes from the French 
word groupe and the Italian gruppo, which were borrowed originally 
from the prehistoric Germanic kruppaz and is translated into a “round 
mass, lump” (Online Etymology Dictionary, 2011). The term group is 
defined by Merriam Webster (Definition of Group, 2011) as “a number 
of individuals assembled together or having some unifying relation-
ship.” Team is defined as a group that engages in more focused inten-
tional action. The word is derived from the Middle English term teme 
and the Old English tēon, which is to draw or pull (Definition of Team, 
2011). Katzenbach and Smith (1993) describe a team as “a small number 
of people with complementary skills who are committed to a common 
purpose, set of performance goals, and approach for which they hold 
themselves mutually accountable” (p. 112).
The difference between a group and a team can be described on a 
continuum (Figure 1-1). At one end of the spectrum, group refers to 
people with something in common and at the other end, team refers 
Figure 1-1 Group-team continuum.
Students in
a Classroom  
Advisory
Committee
ER Team
Group =
A collection of people
who have something
in common. 
Team = 
A group of people who
must work together to reach
common goals or outcomes.
What Is the Difference Between a Team and a Group? 
| 5
© Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION

[Audio] to people who must work together to get to a common agreed-upon goal or outcome. In this text, the term group will be used in discussions regarding the dynamics, processes, and patterns found in human collectives. Health professionals who are working together to achieve positive patient outcomes will be designated as teams.
A Systems Approach to Groups Systems theory conceptualizes all physical and social systems as integrated wholes as opposed to agglomerations of disparate pieces. The 18th-century German philosopher Hegel introduced systems theory by suggesting that the whole is more than the sum of its parts: the whole determines the nature of the parts and the parts are dynamically interrelated and cannot be understood in isolation from the whole. The biologist Ludwig von Bertanffly proposed that all biological systems are open to each other and each identifiable component is related to other parts (Banathy & Jenlink, 2004). From a systems theory perspective, an individual member of a team cannot fully be understood in isolation from the team, and a team cannot be fully understood without understanding the organizational context within which it exists.
Katz and Kahn (1978) explored the systems theory further when they proposed a method to analyze open (living) social systems. They ReflecTIon: Identification of Groups Rank in order the descriptions below with 1 being the most grouplike and 10 the least grouplike. Give reasons for your rankings.
______ The spectators at a college football game ______ Two strangers exchanging meaningful looks across a crowded bar ______ A secretary conversing with the boss by telephone ______ Five students at a university working together on a classroom assignment ______ A mob of rioters burning stores in the inner city ______ Thirteen inmates talking and lifting weights in a jail’s exercise yard ______ A committee deciding the best way to handle a production problem ______ Six employees working on an assembly line ______ An aggregate of individuals waiting in silence for a bus ______ The Smith family of Richmond, Virginia (Mr. Smith, Mrs. Smith, and their daughter Jane Smith)
6 | Chapter 1 Groups-Teams-Systems © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 

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to people who must work together to get to a common agreed-upon 
goal or outcome. In this text, the term group will be used in discussions 
regarding the dynamics, processes, and patterns found in human collec-
tives. Health professionals who are working together to achieve positive 
patient outcomes will be designated as teams.
A Systems Approach to Groups
Systems theory conceptualizes all physical and social systems as inte-
grated wholes as opposed to agglomerations of disparate pieces. The 
18th-century German philosopher Hegel introduced systems theory by 
suggesting that the whole is more than the sum of its parts: the whole 
determines the nature of the parts and the parts are dynamically interre-
lated and cannot be understood in isolation from the whole. The biolo-
gist Ludwig von Bertanffly proposed that all biological systems are open 
to each other and each identifiable component is related to other parts 
(Banathy & Jenlink, 2004). From a systems theory perspective, an indi-
vidual member of a team cannot fully be understood in isolation from 
the team, and a team cannot be fully understood without understanding 
the organizational context within which it exists.
Katz and Kahn (1978) explored the systems theory further when 
they proposed a method to analyze open (living) social systems. They 
ReflecTIon: Identification of Groups
Rank in order the descriptions below with 1 being the most grouplike and 
10 the least grouplike. Give reasons for your rankings.
______ The spectators at a college football game
______ Two strangers exchanging meaningful looks across a crowded bar
______ A secretary conversing with the boss by telephone
______  Five students at a university working together on a classroom 
assignment
______ A mob of rioters burning stores in the inner city
______ Thirteen inmates talking and lifting weights in a jail’s exercise yard
______  A committee deciding the best way to handle a production 
problem
______ Six employees working on an assembly line
______ An aggregate of individuals waiting in silence for a bus
______  The Smith family of Richmond, Virginia (Mr. Smith, Mrs. Smith, 
and their daughter Jane Smith)
6 
| 
Chapter 1 
Groups-Teams-Systems
© Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION

[Audio] posited that the interactive paradigm of analyzing living systems like organizations is based on continual cycles of input, throughput (processing), and outputs. All living organisms, like healthcare organizations and the groups that comprise them, are fully open systems. There are some key characteristics of open systems that resonate in the healthcare arena. Information provided by hospital staff, care recipients, suppliers, and funding sources is an example of input. Intervention from health professionals is an example of throughput, while patient outcomes, patient satisfaction rates, and quality improvement outcomes are examples of system outputs (Meyer & O’Brien-Pallas, 2010).
Health care organizations can be described as complex, adaptive systems because of the non-linear and often unpredictable nature of the interactions between the many microsystems that comprise the larger system (Sturmberg & Martin, 2013). Suchman, Sluyter, and Williamson (2011) provide an apt metaphor for healthcare organizations that is consistent with the description of complex, open systems as non-linear, open to the environment, self-organizing, and evolving (Sturmberg & Martin, 2013).
We can perceive a healthcare organization as a gigantic complicated conversation involving its staff, patients (and their families), payers, regulators, neighbors, competitors, and anyone else who interacts with or is affected by it. Within this gigantic conversation, there are . . . myriad [simultaneous] sub-conversations . . . board meetings. . . . chance conversations at the water cooler . . . faceto-face or in virtual space . . . in the language of spoken or written words or of symbolic gestures . . . between individuals or in the private space of each person’s thinking. . . . Thinking of an organization as a conversation rather than a machine . . . [we] understand that we can influence but not control what goes on, and that we do so more by the way in which we participate than by the plans we make (p. 15–16).
Each participant in a team takes in the ideas and opinions of others (input), processes this input and compares and integrates it with their most current thoughts (throughput), and together with the group, creates a new, collective perspective (output) (Figure 1-2). The organizational conversations reflect the organization’s values, mission, culture, knowledge base, and interactive patterns among the microsystems/ groups that comprise the larger organization. Organizations that attempt to impose a mechanistic, linear orientation upon an inherently open system such as a group, organization, or community discount the value A Systems Approach to Groups | 7
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posited that the interactive paradigm of analyzing living systems like 
organizations is based on continual cycles of input, throughput (process-
ing), and outputs. All living organisms, like healthcare organizations and 
the groups that comprise them, are fully open systems. There are some 
key characteristics of open systems that resonate in the healthcare arena. 
Information provided by hospital staff, care recipients, suppliers, and 
funding sources is an example of input. Intervention from health pro-
fessionals is an example of throughput, while patient outcomes, patient 
satisfaction rates, and quality improvement outcomes are examples of 
system outputs (Meyer & O’Brien-Pallas, 2010).
Health care organizations can be described as complex, adaptive 
systems because of the non-linear and often unpredictable nature of the 
interactions between the many microsystems that comprise the larger 
system (Sturmberg & Martin, 2013). Suchman, Sluyter, and Williamson 
(2011) provide an apt metaphor for healthcare organizations that is con-
sistent with the description of complex, open systems as non-linear, 
open to the environment, self-organizing, and evolving (Sturmberg & 
Martin, 2013).
We can perceive a healthcare organization as a gigantic compli-
cated conversation involving its staff, patients (and their families), 
payers, regulators, neighbors, competitors, and anyone else who 
interacts with or is affected by it. Within this gigantic conversation, 
there are . . . myriad [simultaneous] sub-conversations . . . board 
meetings. . . . chance conversations at the water cooler . . . face-
to-face or in virtual space . . . in the language of spoken or written 
words or of symbolic gestures . . . between individuals or in the 
private space of each person’s thinking. . . . Thinking of an organi-
zation as a conversation rather than a machine . . . [we] understand 
that we can influence but not control what goes on, and that we 
do so more by the way in which we participate than by the plans 
we make (p. 15–16).
Each participant in a team takes in the ideas and opinions of oth-
ers (input), processes this input and compares and integrates it with 
their most current thoughts (throughput), and together with the group, 
creates a new, collective perspective (output) (Figure 1-2). The orga-
nizational conversations reflect the organization’s values, mission, cul-
ture, knowledge base, and interactive patterns among the microsystems/
groups that comprise the larger organization. Organizations that attempt 
to impose a mechanistic, linear orientation upon an inherently open 
system such as a group, organization, or community discount the value 
A Systems Approach to Groups 
| 7
© Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION

[Audio] and challenges of randomness. These tightly coupled systems find themselves too rigid to respond to internal or external signals for the need to change. For example, in a hierarchical healthcare system, team members are less likely to question designated leaders and are often unwilling or unable to be professionally assertive. As a result, the repertoire of solutions to problems may be limited and the team may be ill equipped to respond to change. Change in open systems is inevitable, and adapting to these environmental changes is a continuous process. The manner in which groups and their parent organizations respond to change determines the possibilities for or limits to creativity, productivity, and outcomes (Sturmberg & Martin, 2013; Vickers, 1983; Weick, 1976).
Systems, subsystems, and the environment, are complex, interactive, and interdependent. The dynamic relationship between structure and function of all aspects of the system and its environment render the boundaries permeable and changes at any level of a system affect all other levels of the system. For instance, organizational culture is as much a product of individual behaviors as it is a facilitator of individual behaviors (Studer, 2003). The mood of an individual leader can impact the Figure 1-2 Conversations allow us to inquire, exchange and process information, expand thinking, and negotiate and transform that information into a common perspective that is different than the sum of its parts.
© Michael D Brown/Shutterstock 8 | Chapter 1 Groups-Teams-Systems © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 

Scene 8

and challenges of randomness. These tightly coupled systems find them-
selves too rigid to respond to internal or external signals for the need to 
change. For example, in a hierarchical healthcare system, team members 
are less likely to question designated leaders and are often unwilling or 
unable to be professionally assertive. As a result, the repertoire of solu-
tions to problems may be limited and the team may be ill equipped to 
respond to change. Change in open systems is inevitable, and adapting 
to these environmental changes is a continuous process. The manner in 
which groups and their parent organizations respond to change deter-
mines the possibilities for or limits to creativity, productivity, and out-
comes (Sturmberg & Martin, 2013; Vickers, 1983; Weick, 1976).
Systems, subsystems, and the environment, are complex, interac-
tive, and interdependent. The dynamic relationship between structure 
and function of all aspects of the system and its environment render 
the boundaries permeable and changes at any level of a system affect all 
other levels of the system. For instance, organizational culture is as much 
a product of individual behaviors as it is a facilitator of individual behav-
iors (Studer, 2003). The mood of an individual leader can impact the 
Figure 1-2 Conversations allow us to inquire, exchange and 
process information, expand thinking, and negotiate and transform 
that information into a common perspective that is different than the 
sum of its parts.
© Michael D Brown/Shutterstock
8 
| 
Chapter 1 
Groups-Teams-Systems
© Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION

[Audio] mood of the team and be impacted by the tone of the team, or a team’s effectiveness or ineffectiveness can impact and be impacted by the success of an organization. Nembhard & Edmondson (2006) found that inclusive behavior on the part of physician leaders yielded higher perceptions of psychological safety, increased engagement in all members of the healthcare team, and concomitant positive quality improvement efforts. Healthcare organizations that have been able to institutionalize relationship building as a means for integrating myriad systems consistently report higher staff retention rates and better clinical outcomes (Gittell, 2009; Singh, 2000; Woltmann et al., 2008).
Within all living systems, the balance between energy consumption (entropy) and energy infusion (negentropy) is necessary for the maintenance of a steady state for optimal systems functioning (homeostasis). An example of this in healthcare practice is the effect of caretaker rest (energy infusion) on patient care (indicates status of system’s functioning). The relationship between decreased caretaker rest and decreased cognitive and clinical performance on the part of the caretaker and concomitant medical errors has been well documented (Reed, Fletcher, & Arora, 2010).
The evolutionary capacity of a system depends on flexible and adaptable patterns of organization that facilitate its ability to deal with environmental challenges and opportunities. The most agile, adaptable, and successful healthcare teams are those that are able to routinely evaluate who needs to be present and who has the most cogent information or expertise. Diverse perspectives and a broad range of information is essential for sound clinical decision-making (Briskin et al., 2009; Wheatley, 2005). Inclusionary practices such as incorporating caregivers and support personnel into the healthcare team and giving equal attention to each team member’s contribution broaden the perspective of the team. In addition, psychological safety and willingness of members to share information facilitates the generation of innovative solutions for improved patient care (Meyer & O’Brien-Pallas, 2010; Nembhard & Edmondson, 2006).
Applying Systems Theory When attempting to study, understand, and effect change in a complex social system, it is helpful to distinguish between the individual, interpersonal, group, organizational, and community levels of the system.
Individual: One person.
Interpersonal: Two individuals interacting.
Applying Systems Theory | 9
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Scene 9

mood of the team and be impacted by the tone of the team, or a team’s 
effectiveness or ineffectiveness can impact and be impacted by the suc-
cess of an organization. Nembhard & Edmondson (2006) found that 
inclusive behavior on the part of physician leaders yielded higher per-
ceptions of psychological safety, increased engagement in all members 
of the healthcare team, and concomitant positive quality improvement 
efforts. Healthcare organizations that have been able to institutionalize 
relationship building as a means for integrating myriad systems consis-
tently report higher staff retention rates and better clinical outcomes 
(Gittell, 2009; Singh, 2000; Woltmann et al., 2008).
Within all living systems, the balance between energy consumption 
(entropy) and energy infusion (negentropy) is necessary for the mainte-
nance of a steady state for optimal systems functioning (homeostasis). An 
example of this in healthcare practice is the effect of caretaker rest (energy 
infusion) on patient care (indicates status of system’s functioning). The 
relationship between decreased caretaker rest and decreased cognitive 
and clinical performance on the part of the caretaker and concomitant 
medical errors has been well documented (Reed, Fletcher, & Arora, 2010).
The evolutionary capacity of a system depends on flexible and 
adaptable patterns of organization that facilitate its ability to deal with 
environmental challenges and opportunities. The most agile, adapt-
able, and successful healthcare teams are those that are able to routinely 
evaluate who needs to be present and who has the most cogent infor-
mation or expertise. Diverse perspectives and a broad range of informa-
tion is essential for sound clinical decision-making (Briskin et al., 2009; 
Wheatley, 2005). Inclusionary practices such as incorporating caregivers 
and support personnel into the healthcare team and giving equal atten-
tion to each team member’s contribution broaden the perspective of 
the team. In addition, psychological safety and willingness of members 
to share information facilitates the generation of innovative solutions 
for improved patient care (Meyer & O’Brien-Pallas, 2010; Nembhard & 
Edmondson, 2006).
Applying Systems Theory
When attempting to study, understand, and effect change in a complex 
social system, it is helpful to distinguish between the individual, inter-
personal, group, organizational, and community levels of the system.
Individual: One person.
Interpersonal: Two individuals interacting.
Applying Systems Theory 
| 9
© Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION

[Audio] Group: Three or more individuals working toward a common goal or purpose.
Organization: A social structure, often made up of groups, that pursues a collective goal to deliver some product or service.
Community: Anything beyond the organizational level. This includes other organizations, governments, or global social networks.
Systematic analysis and intervention in complex organizations takes the entire system into account (Rojas-Smith, Ashok, & Morss-Dy, 2014). Each interprofessional care team, department, or group can be considered a microsystem and can be examined with regard to its purpose, patients, professionals, processes, and patterns that distinguish it from and link it within the larger system. High-performing microsystems are characterized by inclusive leaders, strong organizational support, ongoing staff development, cohesive teams, patient/community focus, evidence-based practice, process improvement, and technologyenhanced communication through a variety of formal and informal channels (Barach & Johnson, 2006).
Successful change agents, whether they are leaders or members of groups, learn to differentiate between systems levels, shift attention from one level to another, and make an informed decision about the best level at which to intervene based on a realistic appraisal of the change agent’s sphere of influence (Gillette & McCollom, 1990; Wells, 1995). Sturmber and Martin (2013) contend that intervention in complex systems is most effective when problem solvers consider the system from a variety of perspectives, frequently test hypotheses, engage in structured problem solving, practice self-reflection, and consider goals in light of their effects on the whole system. While the primary focus of this text is the group level of system, individual and interpersonal levels will also be explored. Table 1-1 shows examples of intervention methods that are commonly used at various system levels.
Our current healthcare system is one that is complex and changing rapidly. It can been described as volatile, uncertain, complex, and ambiguous or VUCA. VUCA is a concept that was originally developed by the military and has since been applied to the rapidly evolving healthcare environment. Using a systems perspective helps to address the challenges of a VUCA world by engaging all stakeholders in conversations that will leverage their expertise and resources, broaden and strengthen relationships among stakeholders, engender creative problem solving, and inspire the diffusion of new ideas and practices (Sturmberg & Martin, 2013; Lindberg, Hatch, Mohl, Arce, & Ciemins, 2013).
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Group: Three or more individuals working toward a common goal or 
purpose.
Organization: A social structure, often made up of groups, that 
pursues a collective goal to deliver some product or service.
Community: Anything beyond the organizational level. This includes 
other organizations, governments, or global social networks.
Systematic analysis and intervention in complex organizations takes 
the entire system into account (Rojas-Smith, Ashok, & Morss-Dy, 2014). 
Each interprofessional care team, department, or group can be con-
sidered a microsystem and can be examined with regard to its pur-
pose, patients, professionals, processes, and patterns that distinguish it 
from and link it within the larger system. High-performing microsys-
tems are characterized by inclusive leaders, strong organizational sup-
port, ongoing staff development, cohesive teams, patient/community 
focus, evidence-based practice, process improvement, and technology-
enhanced communication through a variety of formal and informal 
channels (Barach & Johnson, 2006).
Successful change agents, whether they are leaders or members 
of groups, learn to differentiate between systems levels, shift attention 
from one level to another, and make an informed decision about the best 
level at which to intervene based on a realistic appraisal of the change 
agent’s sphere of influence (Gillette & McCollom, 1990; Wells, 1995). 
Sturmber and Martin (2013) contend that intervention in complex sys-
tems is most effective when problem solvers consider the system from a 
variety of perspectives, frequently test hypotheses, engage in structured 
problem solving, practice self-reflection, and consider goals in light of 
their effects on the whole system. While the primary focus of this text 
is the group level of system, individual and interpersonal levels will also 
be explored. Table 1-1 shows examples of intervention methods that 
are commonly used at various system levels.
Our current healthcare system is one that is complex and chang-
ing rapidly. It can been described as volatile, uncertain, complex, and 
ambiguous or VUCA. VUCA is a concept that was originally developed 
by the military and has since been applied to the rapidly evolving health-
care environment. Using a systems perspective helps to address the chal-
lenges of a VUCA world by engaging all stakeholders in conversations 
that will leverage their expertise and resources, broaden and strengthen 
relationships among stakeholders, engender creative problem solv-
ing, and inspire the diffusion of new ideas and practices (Sturmberg & 
Martin, 2013; Lindberg, Hatch, Mohl, Arce, & Ciemins, 2013).
10 
| 
Chapter 1 
Groups-Teams-Systems
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[Audio] Table 1-1 Intervention at Each Level of System level Focus goal Methods Individual Individual’s behavior, perceptions, and emotions.
Increase selfawareness and self-management.
Coaching, training, mentoring, and feedback.
Interpersonal The relationship and communication between two people.
Clarify the nature of the relationship and goals and strengthen foundations for clear communication.
Conflict management, mediation, communication, and conflict resolution training.
Group Group goals, tasks, roles.
Clarify the nature of individual contributions, the group’s purpose, and group behaviors that will foster accomplishment of goals.
Education and feedback on the stages of group development, team building, leadership, and coaching behaviors that contribute to team effectiveness and productivity.
Organization Culture, leadership development, and organizational strategy and structure.
Increase awareness of the people in the organization that the whole is different from the sum of its parts. Identify what attributes, behaviors, and strategies are necessary in order to reach the organizational goals.
Analysis of organizational state including culture, training in culture change, top team development, and executive coaching. Identify organizational strengths in order to leverage culture change, appreciative inquiry, and dynamic inquiry.
Community Finding common ground so that the community can be served.
Building partnerships and collaborations across communities to deliver services.
Strategic planning, community development, and futuring.
Applying Systems Theory | 11
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Scene 11

Table 1-1 Intervention at Each Level of System
level
Focus
goal
Methods
Individual
Individual’s 
behavior, 
perceptions, and 
emotions.
Increase self-
awareness and 
self-management.
Coaching, training, 
mentoring, and 
feedback.
Interpersonal
The 
relationship and 
communication 
between two 
people.
Clarify the nature 
of the relationship 
and goals and 
strengthen 
foundations 
for clear 
communication.
Conflict management, 
mediation, 
communication, and 
conflict resolution 
training.
Group
Group goals, 
tasks, roles.
Clarify the nature 
of individual 
contributions, 
the group’s 
purpose, and 
group behaviors 
that will foster 
accomplishment of 
goals.
Education and 
feedback on the stages 
of group development, 
team building, 
leadership, and 
coaching behaviors 
that contribute to 
team effectiveness and 
productivity.
Organization
Culture, 
leadership 
development, and 
organizational 
strategy and 
structure.
Increase awareness 
of the people in 
the organization 
that the whole 
is different from 
the sum of its 
parts. Identify 
what attributes, 
behaviors, and 
strategies are 
necessary in 
order to reach the 
organizational 
goals.
Analysis of 
organizational state 
including culture, 
training in culture 
change, top team 
development, and 
executive coaching. 
Identify organizational 
strengths in order 
to leverage culture 
change, appreciative 
inquiry, and dynamic 
inquiry.
Community
Finding common 
ground so that the 
community can 
be served.
Building 
partnerships and 
collaborations 
across communities 
to deliver services.
Strategic planning, 
community 
development, and 
futuring.
Applying Systems Theory 
| 11
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[Audio] cASe STUDY: SYSTeM leVel InTeRVenTIon The chair of the pediatrics department in a large health system, Dr. Clarice Barna, was struggling with a problem. Three of the 75 residents asked for a meeting with her. During the meeting the residents complained that they were getting inconsistent instruction from the faculty and not getting the feedback and one-on-one attention from the faculty they felt they deserved. They also felt that the nurses often gave them different instructions than the ones they got from the faculty about patient care. Although three residents were in the meeting, almost all of the talking was done by one resident, Jason. Dr. Barna set up a meeting with the faculty and shared Jason’s feedback on behalf of the residents. The faculty discussed ways to improve instruction and thought that it would be good to get additional feedback from the nurses. The faculty expressed frustration that the residents, although great students, seemed to get confused when trying to grasp that there can be more than one way to do a procedure. Each of the faculty had unique perspectives and practices they wanted to offer the residents and felt the residents needed to understand and accept multiple methods for procedures. Dr. Barna then discussed the situation with the nursing team that worked most often with the residents. The nurses said they really enjoyed working with the residents and that they were really a top-notch group. The head nurse, Eileen Fenway, upon hearing that Jason was the student who brought this up, reminded the chair that Jason completed his internship at University Children’s Hospital where the interns were each assigned a specific mentor, coach, and technical instructor in addition to faculty. She suggested that Jason’s perception and expectations needed to be addressed. QUESTIONS: 1. Look at the row labeled “Individual” in Table 1-1 . Assume that Jason is the individual. Describe how Dr. Barna could improve things by talking only to Jason. 2. Look at the row labeled “Group” in Table 1-1 . Describe how Dr. Barna could engage the group of faculty and nurses to help achieve the goals of improving resident education based on the feedback given by the residents. 12 | Chapter 1 Groups-Teams-Systems © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 

Scene 12

cASe STUDY: SYSTeM leVel InTeRVenTIon 
 The chair of the pediatrics department in a large health system, Dr. Clarice 
Barna, was struggling with a problem. Three of the 75 residents asked for 
a meeting with her. During the meeting the residents complained that 
they were getting inconsistent instruction from the faculty and not get-
ting the feedback and one-on-one attention from the faculty they felt they 
deserved. They also felt that the nurses often gave them different instruc-
tions than the ones they got from the faculty about patient care. Although 
three residents were in the meeting, almost all of the talking was done by 
one resident, Jason. 
 Dr. Barna set up a meeting with the faculty and shared Jason’s feedback 
on behalf of the residents. The faculty discussed ways to improve instruc-
tion and thought that it would be good to get additional feedback from the 
nurses. The faculty expressed frustration that the residents, although great 
students, seemed to get confused when trying to grasp that there can be 
more than one way to do a procedure. Each of the faculty had unique per-
spectives and practices they wanted to offer the residents and felt the resi-
dents needed to understand and accept multiple methods for procedures. 
 Dr. Barna then discussed the situation with the nursing team that 
worked most often with the residents. The nurses said they really enjoyed 
working with the residents and that they were really a top-notch group. The 
head nurse, Eileen Fenway, upon hearing that Jason was the student who 
brought this up, reminded the chair that Jason completed his internship 
at University Children’s Hospital where the interns were each assigned a 
specific mentor, coach, and technical instructor in addition to faculty. She 
suggested that Jason’s perception and expectations needed to be addressed. 
 QUESTIONS: 
1.  Look at the row labeled “Individual” in  Table 1-1 . Assume that Jason is 
the individual. Describe how Dr. Barna could improve things by talk-
ing only to Jason. 
2.  Look at the row labeled “Group” in  Table 1-1 . Describe how Dr. Barna 
could engage the group of faculty and nurses to help achieve the goals 
of improving resident education based on the feedback given by the 
residents. 
12 
| 
Chapter 1 
Groups-Teams-Systems
© Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION

[Audio] References Alderfer, C. P. (1977). Organization development. Annual Review of Psychology, 28, 197–223.
Banathy, B. H., & Jenlink, P. M. (2004). Systems inquiry and its application in education. In D. H. Jonassen (Ed.) Handbook of Research on Educational Communications and Technology (pp. 37–57). Mahwah, NJ: Lawrence Erlbaum Associates.
Barach, P., & Johnson, J. (2006). Understanding the complexity of redesigning care around the clinical microsystem. Quality & Safety in Healthcare, 15(Suppl I): i10–i16.
Briskin, A., Erickson, S., Ott, J., & Callanan, T. (2009). The power of collective wisdom and the trap of collective folly. San Francisco, CA: Berrett-Koehler.
Cartright, D., & Zander, A. (1968). Group dynamics: Research and theory. New York, NY: Harper & Row Publishers.
Definition of Group. (2011). Merriam-webster.com. Retrieved 3 August 2016, from http://www.merriam-webster.com/dictionary/group Definition of Team. (2016). Merriam-webster.com. Retrieved 3 August 2016, from http://www.merriam-webster.com/dictionary/team Forsyth, D. R. (2006). Group dynamics (4th ed. [International student edition.]). Belmont, CA: Thomson Wadsworth Publishing.
Gillette, J., & McCollom, M. (1990). Groups in context: A new perspective on group dynamics. Lanham, MD: University Press.
Gittell, J. (2009). High performance healthcare: Using the power of relationships to achieve quality, efficiency and resilience. New York, NY: McGraw-Hill.
Grant, R. W., & Finocchio, L. J.; California Primary Care Consortium Subcommittee on Interdisciplinary Collaboration. (1995). Interdisciplinary collaborative teams in primary care: A model curriculum and resource guide. San Francisco, CA: Pew Health Professions Commission.
Katz, D., & Kahn, R. (1978). The social psychology of organizations. Hoboken, NJ: Wiley.
Katzenbach, J. R., & Smith, D. K. (1993). The wisdom of teams: Creating the highperformance organization. Boston, MA: Harvard Business School.
Lawrence, D. (2002). From chaos to care: The promise of team based medicine. Cambridge, MA: Perseus Publishing.
Lewin, K., Lewin, G. W. (Ed.). (1948). Resolving social conflicts: Selected papers on group dynamics. New York, NY: Harper & Row.
Lindberg, C., Hatch, M., Mohl, V., Arce, C., & Ciemins, E. (2013). Embracing uncertainty: complexity-inspired innovations at Billings Clinic. In J. Sturmberg & C. Martin (Eds.), Handbook of systems and complexity in health (pp. 697–713). New York, NY: Springer Science+Business Media.
Online Etymology Dictionary. (2016). Etymonline.com. Retrieved 3 August 2016, from http://www.etymonline.com/index.php?allowed_in_frame =0&search=group Meyer, R. M., & O’Brien-Pallas, L. L. (2010). Nursing services delivery theory: An open system approach. Journal of Advanced Nursing, 66(12), 2828–2838.
Nembhard, I., & Edmondson, A. (2006). Making it safe: The effects of leader inclusiveness and professional status on psychological safety and References | 13
© Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 

Scene 13

References
Alderfer, C. P. (1977). Organization development. Annual Review of Psychol-
ogy, 28, 197–223.
Banathy, B. H., & Jenlink, P. M. (2004). Systems inquiry and its application in 
education. In D. H. Jonassen (Ed.) Handbook of Research on Educational 
Communications and Technology (pp. 37–57). Mahwah, NJ: Lawrence 
Erlbaum Associates.
Barach, P., & Johnson, J. (2006). Understanding the complexity of redesign-
ing care around the clinical microsystem. Quality & Safety in Healthcare, 
15(Suppl I): i10–i16.
Briskin, A., Erickson, S., Ott, J., & Callanan, T. (2009). The power of collective 
wisdom and the trap of collective folly. San Francisco, CA: Berrett-Koehler.
Cartright, D., & Zander, A. (1968). Group dynamics: Research and theory. New 
York, NY: Harper & Row Publishers.
Definition of Group. (2011). Merriam-webster.com. Retrieved 3 August 2016, 
from http://www.merriam-webster.com/dictionary/group 
Definition of Team. (2016). Merriam-webster.com. Retrieved 3 August 2016, from 
http://www.merriam-webster.com/dictionary/team
Forsyth, D. R. (2006). Group dynamics (4th ed. [International student edition.]). 
Belmont, CA: Thomson Wadsworth Publishing.
Gillette, J., & McCollom, M. (1990). Groups in context: A new perspective on 
group dynamics. Lanham, MD: University Press.
Gittell, J. (2009). High performance healthcare: Using the power of relationships 
to achieve quality, efficiency and resilience. New York, NY: McGraw-Hill.
Grant, R. W., & Finocchio, L. J.; California Primary Care Consortium Subcom-
mittee on Interdisciplinary Collaboration. (1995). Interdisciplinary collab-
orative teams in primary care: A model curriculum and resource guide. San 
Francisco, CA: Pew Health Professions Commission.
Katz, D., & Kahn, R. (1978). The social psychology of organizations. Hoboken, 
NJ: Wiley.
Katzenbach, J. R., & Smith, D. K. (1993). The wisdom of teams: Creating the high-
performance organization. Boston, MA: Harvard Business School.
Lawrence, D. (2002). From chaos to care: The promise of team based medicine. 
Cambridge, MA: Perseus Publishing.
Lewin, K., Lewin, G. W. (Ed.). (1948). Resolving social conflicts: Selected papers 
on group dynamics. New York, NY: Harper & Row.
Lindberg, C., Hatch, M., Mohl, V., Arce, C., & Ciemins, E. (2013). Embrac-
ing uncertainty: complexity-inspired innovations at Billings Clinic. In  
J. Sturmberg & C. Martin (Eds.), Handbook of systems and complexity in 
health (pp. 697–713). New York, NY: Springer Science+Business Media.
Online Etymology Dictionary. (2016). Etymonline.com. Retrieved 3 August 
2016, from http://www.etymonline.com/index.php?allowed_in_frame 
=0&search=group
Meyer, R. M., & O’Brien-Pallas, L. L. (2010). Nursing services delivery theory: An 
open system approach. Journal of Advanced Nursing, 66(12), 2828–2838.
Nembhard, I., & Edmondson, A. (2006). Making it safe: The effects of 
leader inclusiveness and professional status on psychological safety and 
References 
| 13
© Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION

[Audio] improvement efforts in health care teams. Journal of Organizational Behavior, 27, 941–966.
Reed, D., Fletcher, K., & Arora, V. (2010). Systemic review: Association of shift length, protected sleep time and night float with patient care, residents’ health and education. Annals of Internal Medicine, 53, 829–842.
Rojas-Smith, L., Ashok, M., & Morss-Dy, S. (2014). Contextual frameworks for research on the implementation of complex system interventions (Internet). Rockville, MD: Agency for Healthcare Research and Quality.
Shaffer, J., & Galinsky, M. (1989). Models of group therapy (2nd ed.). Englewood Cliffs, NJ: Prentice Hall.
Singh, S. (2000). Running an effective community mental health team. Advances in Psychiatric Treatment, 6, 414–422.
Smith, M. (2008). Experience in groups and other papers. New York, NY: Tavistock Publications Limited.
Studer, Q. (2003). Hardwiring excellence: Purpose, worthwhile work, making a difference. Gulf Breeze, FL: Fire Starter Publishing.
Sturmberg, J., & Martin, C. (Eds.). (2013). Complexity in health: An introduction. In J. Sturmberg & C. Martin (Eds.), Handbook of systems and complexity in health (pp. 1–17). New York, NY: Springer Science+Business Media.
Suchman, A., Sluyter, D., & Williamson, P. (2011). Leading change in healthcare: Transforming organizations using complexity, positive psychology and relationship-centered care. London, England: Radcliffe Publishing.
Torrens, P. (2010). The health care team members: Who are they and what do they do? In B. Freshman, L. Rubino, & Y. Chassiakos (Eds.), Collaboration across the disciplines in health care (pp. 1–19). Sudbury, MA: Jones and Bartlett Publishers.
Vickers, G. (1983). Human systems are different. London, England: Harper and Row.
Weick, K. (1976). Educational organizations as loosely coupled systems. Administrative Science Quarterly, 21(1), 1–19.
Wells, L. (1995). The group as a whole: A systemic socio-analytic perspective on interpersonal and group relations. In G. Gillette, & M. McCollum (Eds.), Groups in context (pp. 50–85) Lanham, MD: University Press of America.
Wheatley, M. (2005). Finding our way: Leadership for an uncertain time. San Francisco, CA: Berret-Koehler Publishers, Inc.
Woltmann, E. M., Whitley, R., McHugo G. J., Brunette, M., Torrey, W. Coots, L., & Drake, R. (2008). The role of staff turnover in the implementation of evidence-based practices in mental health care. Psychiatric Services, 59(7), 732–737.
14 | Chapter 1 Groups-Teams-Systems © Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 

Scene 14

improvement efforts in health care teams. Journal of Organizational Behav-
ior, 27, 941–966.
Reed, D., Fletcher, K., & Arora, V. (2010). Systemic review: Association of shift 
length, protected sleep time and night float with patient care, residents’ 
health and education. Annals of Internal Medicine, 53, 829–842.
Rojas-Smith, L., Ashok, M., & Morss-Dy, S. (2014). Contextual frameworks for 
research on the implementation of complex system interventions (Internet). 
Rockville, MD: Agency for Healthcare Research and Quality.
Shaffer, J., & Galinsky, M. (1989). Models of group therapy (2nd ed.). Englewood 
Cliffs, NJ: Prentice Hall.
Singh, S. (2000). Running an effective community mental health team. Advances 
in Psychiatric Treatment, 6, 414–422.
Smith, M. (2008). Experience in groups and other papers. New York, NY: 
Tavistock Publications Limited.
Studer, Q. (2003). Hardwiring excellence: Purpose, worthwhile work, making a 
difference. Gulf Breeze, FL: Fire Starter Publishing.
Sturmberg, J., & Martin, C. (Eds.). (2013). Complexity in health: An introduc-
tion. In J. Sturmberg & C. Martin (Eds.), Handbook of systems and complex-
ity in health (pp. 1–17). New York, NY: Springer Science+Business Media.
Suchman, A., Sluyter, D., & Williamson, P. (2011). Leading change in healthcare: 
Transforming organizations using complexity, positive psychology and rela-
tionship-centered care. London, England: Radcliffe Publishing.
Torrens, P. (2010). The health care team members: Who are they and what do 
they do? In B. Freshman, L. Rubino, & Y. Chassiakos (Eds.), Collaboration 
across the disciplines in health care (pp. 1–19). Sudbury, MA: Jones and 
Bartlett Publishers.
Vickers, G. (1983). Human systems are different. London, England: Harper and 
Row.
Weick, K. (1976). Educational organizations as loosely coupled systems. Admin-
istrative Science Quarterly, 21(1), 1–19.
Wells, L. (1995). The group as a whole: A systemic socio-analytic perspective on 
interpersonal and group relations. In G. Gillette, & M. McCollum (Eds.), 
Groups in context (pp. 50–85) Lanham, MD: University Press of America.
Wheatley, M. (2005). Finding our way: Leadership for an uncertain time. San 
Francisco, CA: Berret-Koehler Publishers, Inc.
Woltmann, E. M., Whitley, R., McHugo G. J., Brunette, M., Torrey, W. Coots, 
L., & Drake, R. (2008). The role of staff turnover in the implementation of 
evidence-based practices in mental health care. Psychiatric Services, 59(7), 
732–737.
14 
| 
Chapter 1 
Groups-Teams-Systems
© Jones & Bartlett Learning, LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION

9781284112009_CH01_PASS03.indd

Scene 0

© Shutterstock / Olha Kostiuk PART I  Team and Group  Development  “When sufficient numbers of organization members  become more self-aware, more concerned about the  needs of others and more effective as group members and  group leaders—they cannot help but eventually have a  positive influence on the total function and structure of  any system.”  Shaffer and Galinsky, 1989, p 192  Chapter 1

Norms, Goals, Roles,  Communication, Leaders, and Members  Part I Activities  © Jones & Bartlett Learning, LLC, an Ascend Learning Company

avatar

Understand groups as complex, open systems

Apply the concept of open systems to healthcare teams

Describe levels of systems and how they relate to healthcare teams

Recognize how the diversity inherent to interprofessional healthcare  teams contributes to their adaptability and sustainability

We bond together in families, friendship groups, neighborhoods, work groups, and recently in  electronic social networks like Facebook and Twitter

The world has  become more complex, and the exponential growth of information that  is required to solve problems is not the purview of a single person or a  single profession

By recognizing our need to join with others to meet  challenges, we have the opportunity for collective wisdom to emerge  and facilitate the creation of new connections and innovative strategies  to ensure the health and stability of the world that we share (Briskin,  Erickson, Ott, & Callanan, 2009)

Groups and teams have been and will  Groups-Teams-Systems   3 CHAPTER 1  © Jones & Bartlett Learning, LLC, an Ascend Learning Company

continue to be an essential part of our daily lives

Nowhere is the need  for teamwork more relevant than in the healthcare arena

Diagnosis and intervention require the efforts of a cadre of physician  specialists, nurses, therapists, pharmacists, social services personnel,  laboratory personnel, information managers, dietitians, transportation  workers, home health aides, family caregivers, and patients

Quality  health care that is accessible and cost effective requires that the boundaries between these stakeholders are made permeable through consistent collaboration (Grant & Finocchio, 1995)

Skills in team building,  team membership, and the understanding of group dynamics are foundational and indispensable for the next generation of healthcare leaders

Well-functioning healthcare teams are linked to good morale, reduced  staff turnover, and positive patient outcomes (Gittell, 2009

What Distinguishes a Group from a  Random collection of People

There is a unique designation for each of the myriad groupings in the  animal kingdom such as school (fish), troop (baboons), murder (crows),  gam (whales), and group (humans)

No matter what the species, the  critical element that is common to all the groupings is that the individual members are interdependent

In the case of humans, “members  cASe SToRY

The Importance of Interprofessional Teams  At our organization, everything is a committee decision

You can have input  from multiple perspectives such as nursing, social work, occupational therapy, physical therapy, and dietary

For example, let’s say you can’t transport Mrs  X into the center because she keeps hitting people and is not putting her seatbelt on

You need to get different perspectives  in order to make a decision

It is like that example of the blind men and the  elephant

No single perspective will describe the elephant and there probably  is not one single resolution

This requires that team members are confident  in what they know, amenable to listen to someone else’s ideas, and willing  to offer their own ideas

— Karen J Nichols, MD, Chief Medical Officer for VIP Plans at  AmeriHealth Caritas  4  |  Chapter 1  Groups-Teams-Systems © Jones & Bartlett Learning, LLC, an Ascend Learning Company

are linked together in a web of interpersonal relationships

Thus, a  group is defined as two or more individuals who are connected to one  another by social relationships” (Forsyth, 2006, pp

Alderfer (1977)  expanded the definition of human groups to include how they are distinguished from and perceived by nonmembers and how they relate to  other groups

For the purposes of this text, in order for a group to be distinguished from a random collection of people, its members must have  common interests and goals and regular patterns of interaction, exert  influence among the members, and work interdependently to achieve  goals (Cartright & Zander, 1968

What Is the Difference Between a Team and a Group?

The terms team and group are often used interchangeably

However,  making the distinction between these two terms can offer valuable  insight into how groups work and can facilitate leadership and full participation in productive teams

The term group comes from the French  word groupe and the Italian gruppo, which were borrowed originally  from the prehistoric Germanic kruppaz and is translated into a “round  mass, lump” (Online Etymology Dictionary, 2011)

The term group is  defined by Merriam Webster (Definition of Group, 2011) as “a number  of individuals assembled together or having some unifying relationship.” Team is defined as a group that engages in more focused intentional action

The word is derived from the Middle English term teme  and the Old English tēon, which is to draw or pull (Definition of Team,  2011)

Katzenbach and Smith (1993) describe a team as “a small number  of people with complementary skills who are committed to a common  purpose, set of performance goals, and approach for which they hold  themselves mutually accountable” (p

The difference between a group and a team can be described on a  continuum (Figure 1-1)

At one end of the spectrum, group refers to  people with something in common and at the other end, team refers  Figure 1-1 Group-team continuum.

Students in a Classroom   Advisory Committee ER Team Group =

A collection of people who have something in common

Team =  A group of people who must work together to reach common goals or outcomes.

What Is the Difference Between a Team and a Group

to people who must work together to get to a common agreed-upon  goal or outcome

In this text, the term group will be used in discussions  regarding the dynamics, processes, and patterns found in human collectives

Health professionals who are working together to achieve positive  patient outcomes will be designated as teams.

A Systems Approach to Groups Systems theory conceptualizes all physical and social systems as integrated wholes as opposed to agglomerations of disparate pieces

The  18th-century German philosopher Hegel introduced systems theory by  suggesting that the whole is more than the sum of its parts

the whole  determines the nature of the parts and the parts are dynamically interrelated and cannot be understood in isolation from the whole

The biologist Ludwig von Bertanffly proposed that all biological systems are open  to each other and each identifiable component is related to other parts  (Banathy & Jenlink, 2004)

From a systems theory perspective, an individual member of a team cannot fully be understood in isolation from  the team, and a team cannot be fully understood without understanding  the organizational context within which it exists.

Katz and Kahn (1978) explored the systems theory further when  they proposed a method to analyze open (living) social systems

Identification of Groups Rank in order the descriptions below with 1 being the most grouplike and  10 the least grouplike

______ The spectators at a college football game ______ Two strangers exchanging meaningful looks across a crowded bar ______ A secretary conversing with the boss by telephone ______  Five students at a university working together on a classroom  assignment ______ A mob of rioters burning stores in the inner city ______ Thirteen inmates talking and lifting weights in a jail’s exercise yard ______  A committee deciding the best way to handle a production  problem ______ Six employees working on an assembly line ______ An aggregate of individuals waiting in silence for a bus ______  The Smith family of Richmond, Virginia (Mr  Smith, Mrs  Smith,  and their daughter Jane Smith)

6  |  Chapter 1  Groups-Teams-Systems © Jones & Bartlett Learning, LLC, an Ascend Learning Company

posited that the interactive paradigm of analyzing living systems like  organizations is based on continual cycles of input, throughput (processing), and outputs

All living organisms, like healthcare organizations and  the groups that comprise them, are fully open systems

There are some  key characteristics of open systems that resonate in the healthcare arena

Information provided by hospital staff, care recipients, suppliers, and  funding sources is an example of input

Intervention from health professionals is an example of throughput, while patient outcomes, patient  satisfaction rates, and quality improvement outcomes are examples of  system outputs (Meyer & O’Brien-Pallas, 2010).

Health care organizations can be described as complex, adaptive  systems because of the non-linear and often unpredictable nature of the  interactions between the many microsystems that comprise the larger  system (Sturmberg & Martin, 2013)

Suchman, Sluyter, and Williamson  (2011) provide an apt metaphor for healthcare organizations that is consistent with the description of complex, open systems as non-linear,  open to the environment, self-organizing, and evolving (Sturmberg &  Martin, 2013).

We can perceive a healthcare organization as a gigantic complicated conversation involving its staff, patients (and their families),  payers, regulators, neighbors, competitors, and anyone else who  interacts with or is affected by it

Within this gigantic conversation,  there are . . . myriad [simultaneous] sub-conversations . . . board  meetings. . . . chance conversations at the water cooler . . . faceto-face or in virtual space . . . in the language of spoken or written  words or of symbolic gestures . . . between individuals or in the  private space of each person’s thinking. . . . Thinking of an organization as a conversation rather than a machine . . . [we] understand  that we can influence but not control what goes on, and that we  do so more by the way in which we participate than by the plans  we make (p

Each participant in a team takes in the ideas and opinions of others (input), processes this input and compares and integrates it with  their most current thoughts (throughput), and together with the group,  creates a new, collective perspective (output) (Figure 1-2)

The organizational conversations reflect the organization’s values, mission, culture, knowledge base, and interactive patterns among the microsystems/ groups that comprise the larger organization

Organizations that attempt  to impose a mechanistic, linear orientation upon an inherently open  system such as a group, organization, or community discount the value  A Systems Approach to Groups  | 7

These tightly coupled systems find themselves too rigid to respond to internal or external signals for the need to  change

For example, in a hierarchical healthcare system, team members  are less likely to question designated leaders and are often unwilling or  unable to be professionally assertive

As a result, the repertoire of solutions to problems may be limited and the team may be ill equipped to  respond to change

Change in open systems is inevitable, and adapting  to these environmental changes is a continuous process

The manner in  which groups and their parent organizations respond to change determines the possibilities for or limits to creativity, productivity, and outcomes (Sturmberg & Martin, 2013

Systems, subsystems, and the environment, are complex, interactive, and interdependent

The dynamic relationship between structure  and function of all aspects of the system and its environment render  the boundaries permeable and changes at any level of a system affect all  other levels of the system

For instance, organizational culture is as much  a product of individual behaviors as it is a facilitator of individual behaviors (Studer, 2003)

The mood of an individual leader can impact the  Figure 1-2 Conversations allow us to inquire, exchange and  process information, expand thinking, and negotiate and transform  that information into a common perspective that is different than the  sum of its parts.

mood of the team and be impacted by the tone of the team, or a team’s  effectiveness or ineffectiveness can impact and be impacted by the success of an organization

Nembhard & Edmondson (2006) found that  inclusive behavior on the part of physician leaders yielded higher perceptions of psychological safety, increased engagement in all members  of the healthcare team, and concomitant positive quality improvement  efforts

Healthcare organizations that have been able to institutionalize  relationship building as a means for integrating myriad systems consistently report higher staff retention rates and better clinical outcomes  (Gittell, 2009

Within all living systems, the balance between energy consumption  (entropy) and energy infusion (negentropy) is necessary for the maintenance of a steady state for optimal systems functioning (homeostasis)

An  example of this in healthcare practice is the effect of caretaker rest (energy  infusion) on patient care (indicates status of system’s functioning)

The  relationship between decreased caretaker rest and decreased cognitive  and clinical performance on the part of the caretaker and concomitant  medical errors has been well documented (Reed, Fletcher, & Arora, 2010).

The evolutionary capacity of a system depends on flexible and  adaptable patterns of organization that facilitate its ability to deal with  environmental challenges and opportunities

The most agile, adaptable, and successful healthcare teams are those that are able to routinely  evaluate who needs to be present and who has the most cogent information or expertise

Diverse perspectives and a broad range of information is essential for sound clinical decision-making (Briskin and others, 2009

Inclusionary practices such as incorporating caregivers  and support personnel into the healthcare team and giving equal attention to each team member’s contribution broaden the perspective of  the team

In addition, psychological safety and willingness of members  to share information facilitates the generation of innovative solutions  for improved patient care (Meyer & O’Brien-Pallas, 2010

Applying Systems Theory When attempting to study, understand, and effect change in a complex  social system, it is helpful to distinguish between the individual, interpersonal, group, organizational, and community levels of the system.

Three or more individuals working toward a common goal or  purpose.

A social structure, often made up of groups, that  pursues a collective goal to deliver some product or service.

This includes  other organizations, governments, or global social networks.

Systematic analysis and intervention in complex organizations takes  the entire system into account (Rojas-Smith, Ashok, & Morss-Dy, 2014)

Each interprofessional care team, department, or group can be considered a microsystem and can be examined with regard to its purpose, patients, professionals, processes, and patterns that distinguish it  from and link it within the larger system

High-performing microsystems are characterized by inclusive leaders, strong organizational support, ongoing staff development, cohesive teams, patient/community  focus, evidence-based practice, process improvement, and technologyenhanced communication through a variety of formal and informal  channels (Barach & Johnson, 2006).

Successful change agents, whether they are leaders or members  of groups, learn to differentiate between systems levels, shift attention  from one level to another, and make an informed decision about the best  level at which to intervene based on a realistic appraisal of the change  agent’s sphere of influence (Gillette & McCollom, 1990

Sturmber and Martin (2013) contend that intervention in complex systems is most effective when problem solvers consider the system from a  variety of perspectives, frequently test hypotheses, engage in structured  problem solving, practice self-reflection, and consider goals in light of  their effects on the whole system

While the primary focus of this text  is the group level of system, individual and interpersonal levels will also  be explored

Table 1-1 shows examples of intervention methods that  are commonly used at various system levels.

Our current healthcare system is one that is complex and changing rapidly

It can been described as volatile, uncertain, complex, and  ambiguous or VUCA

VUCA is a concept that was originally developed  by the military and has since been applied to the rapidly evolving healthcare environment

Using a systems perspective helps to address the challenges of a VUCA world by engaging all stakeholders in conversations  that will leverage their expertise and resources, broaden and strengthen  relationships among stakeholders, engender creative problem solving, and inspire the diffusion of new ideas and practices (Sturmberg &  Martin, 2013

Lindberg, Hatch, Mohl, Arce, & Ciemins, 2013).

Table 1-1 Intervention at Each Level of System level Focus goal Methods Individual Individual’s  behavior,  perceptions, and  emotions.

Increase selfawareness and  self-management.

Coaching, training,  mentoring, and  feedback.

Interpersonal The  relationship and  communication  between two  people.

Clarify the nature  of the relationship  and goals and  strengthen  foundations  for clear  communication.

Conflict management,  mediation,  communication, and  conflict resolution  training.

Clarify the nature  of individual  contributions,  the group’s  purpose, and  group behaviors  that will foster  accomplishment of  goals.

Education and  feedback on the stages  of group development,  team building,  leadership, and  coaching behaviors  that contribute to  team effectiveness and  productivity.

Organization Culture,  leadership  development, and  organizational  strategy and  structure.

Increase awareness  of the people in  the organization  that the whole  is different from  the sum of its  parts

Identify  what attributes,  behaviors, and  strategies are  necessary in  order to reach the  organizational  goals.

Analysis of  organizational state  including culture,  training in culture  change, top team  development, and  executive coaching

Identify organizational  strengths in order  to leverage culture  change, appreciative  inquiry, and dynamic  inquiry.

Community Finding common  ground so that the  community can  be served.

Building  partnerships and  collaborations  across communities  to deliver services.

Strategic planning,  community  development, and  futuring.

SYSTeM leVel InTeRVenTIon  The chair of the pediatrics department in a large health system, Dr  Clarice  Barna, was struggling with a problem

Three of the 75 residents asked for  a meeting with her

During the meeting the residents complained that  they were getting inconsistent instruction from the faculty and not getting the feedback and one-on-one attention from the faculty they felt they  deserved

They also felt that the nurses often gave them different instructions than the ones they got from the faculty about patient care

Although  three residents were in the meeting, almost all of the talking was done by  one resident, Jason

Dr  Barna set up a meeting with the faculty and shared Jason’s feedback  on behalf of the residents

The faculty discussed ways to improve instruction and thought that it would be good to get additional feedback from the  nurses

The faculty expressed frustration that the residents, although great  students, seemed to get confused when trying to grasp that there can be  more than one way to do a procedure

Each of the faculty had unique perspectives and practices they wanted to offer the residents and felt the residents needed to understand and accept multiple methods for procedures

Dr  Barna then discussed the situation with the nursing team that  worked most often with the residents

The nurses said they really enjoyed  working with the residents and that they were really a top-notch group

The  head nurse, Eileen Fenway, upon hearing that Jason was the student who  brought this up, reminded the chair that Jason completed his internship  at University Children’s Hospital where the interns were each assigned a  specific mentor, coach, and technical instructor in addition to faculty

She  suggested that Jason’s perception and expectations needed to be addressed

Look at the row labeled “Individual” in  Table 1-1

Describe how Dr  Barna could improve things by talking only to Jason

Look at the row labeled “Group” in  Table 1-1

Describe how Dr  Barna  could engage the group of faculty and nurses to help achieve the goals  of improving resident education based on the feedback given by the  residents

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