Ontario’s Community Family Health Teams

Équipes de santé familialecommunitaire de l’Ontario

Ontario’s Aboriginal Health Access Centres

Centres Autochtones d’accèsaux soins de santé de l’Ontario

Ontario’s Community Health Centres

Les centres de santécommunautaire en Ontario

Supporting New Leaders in Developing Collaborative

Teams: A Toolkit

Updated January 2009

1

Table of Contents Acknowledgments

Pg. 3

Executive Summary

Pg. 4

Introduction

Pg. 5

Module 1: Leadership

A. Background Pg. 7

B. Leadership Concepts Pg. 7

C. Leadership Styles Pg. 7

D. Leadership Qualities Pg. 8

E. Challenges in Leading Teams Pg. 13

F. Power in Teams and Organizations Pg. 17

G. Leading Change Pg. 19

H. Best Practices in Leadership Development

Pg. 21

I. Resources Pg. 21

J. References

Pg. 22

Module 2: Recruitment, Selection and Hiring Practices that Support Interprofessional Teams

A. Background Pg. 23

B. Hiring Professionals with the Essential Knowledge, Skills and Attributes

Pg. 24

C. Resources Pg. 31

D. References

Pg. 31

Module 3: Team Roles and Responsibilities

A. Background Pg. 32

B. Team Definition Pg. 32

C. Dimensions of Team Roles Pg. 35

D. References

Pg. 41

Module 4: Interpersonal Communications

A. Background Pg. 42

B. Communication Styles Pg. 43

C. Active Listening Skills Pg. 45

D. Communication and Conflict Pg. 47

E. Gender and Communication Pg. 47

F. Culture and Communication Pg. 48

G. Giving and Receiving Feedback Pg. 48

H. Resources Pg. 50

I. References Pg. 51

2

Module 5: Meetings

A. Background Pg. 52

B. To Meet or Not to Meet Pg. 52

C. Resources Pg. 59

D. References Pg. 60

The information contained in this document is confidential and proprietary to the Association of Ontario Health Centres (AOHC). Unauthorized distribution or use of this document or the information contained herein is strictly prohibited. Requests for permission should be addressed to: Association of Ontario Health Centres 970 Lawrence Ave. West, Suite 500 Toronto, Ontario M6A 3B6 Tel: (416)236-2539 Fax: (416)236-0431 Email: mail@aohc.org

3

Acknowledgments

The development of the training toolkit on the New Leaders in Developing Collaborative Teams involved many committed and passionate individuals whose support and contribution were vital to the production of this document. These include members of Davies/Ring Consulting, the Reference Group and of AOHC Education and Development Team who brought invaluable expertise to the project. Project Charter Group

AOHC Education and Development Team

Michael Barkley Interim Executive Director Flemingdon Community Health Centre Liben Gebremikael Executive Director TAIBU Community Health Centre Deborah Kanate Manager Dilico Family Health Team Lynne Poff Executive Director North Hastings Family Health Team Simone Thibault Executive Director Centretown Community Health Centre

Project Director: Roohullah Shabon Director, Education and Development Project Manager: Carolyn Poplak Training Manager Team Members: Sophie Bart Centre Development Team Lead Brian Sankarsingh Clinical Management Systems Lead Sandra Wong Administrative Assistant

Davies/Ring Consulting

Lynda Davies Laurienne Ring In addition, we would like to thank all AOHC staff for their support and the representatives who shared their lived examples, experiences, opportunities and challenges that helped bring these training tools to life.

4

Executive Summary This toolkit is a resource for new leaders (administrative leads, executive directors) and for newly emerging or emerged community-based healthcare organizations that are still in the process of hiring leaders and staff, as well as satellite organizations and teams going through high employee and management turnover. The focus of the toolkit is to provide information and guidance on how to build and maintain an interprofessional primary healthcare team from the start with a united focus on collaboration and team work. This document is divided into five modules identified by the Reference Group as fundamental topics to support new leaders in the building of collaborative teams. These modules include: Leadership; Recruitment, Selection and Hiring Practices; Team Roles and Responsibilities; Communications I: Interpersonal Communications; and Communication II: Meetings. Each module addresses pivotal questions and provides useful and tangible activities that can be utilized by new leaders forming interprofessional teams. The modules and activities can be used individually or as a cohesive whole and each provides a background and a list of references and resources for further research and elaboration. For comments on this document and for workshops on team building and collaborative practice, please contact: The Education and Development Team The Association of Ontario Health Centres 416-236-2539 ext. 230 education-development@aohc.org

5

Introduction The Association of Ontario Health Centres (AOHC) is the policy and advocacy organization for non-profit, community-governed, interprofessional primary healthcare services. AOHC is the public voice of Community Health Centres (CHCs), Aboriginal Health Access Centres (AHACs) and Community Family Health Teams (CFHTs). It believes that effective primary health care should address the social determinants of health, including social inclusion, access to shelter, education, income and employment, security, food and stable eco-systems. The Association engages in research, develops policy and advocates in support of this community-centred primary healthcare model. AOHC’s member centres are located throughout Ontario and AOHC works directly with communities that want community-centred primary health care. An initial comprehensive study on interprofessional care in the CHC sector was funded in August 2004 by the Primary Care Health Transition Fund (PCHTF). The study was developed based on the CHC experience and used both quantitative and qualitative approaches to collect and analyze information that would contribute to improving the effectiveness of primary health care teams. In 2007, AOHC published the research document Building Better Teams: Learning from Ontario’s Community Health Centres: A Report of Research Findings based on its innovative research done in the CHC sector. In addition, a toolkit was developed in order to put the research findings into practice. Effective workshops to support and strengthen teamwork among CHCs based on the research findings and subsequent toolkit have since been successfully implemented across the sector. The research and workshops provided on teamwork and collaboration prompted discussion by new AOHC member organizations wishing to form collaborative teams. Some of the new leaders and steering committees of over 21 CHCs, 28 satellites, and many emerging CFHTs requested support on how to start an organization from scratch with strong interprofessional teams made up of members willing to commit and advocate for collaboration. While Building Better Teams provides excellent resources and tools on how to work with already established teams; emerging organizations were looking for support on how to lay the groundwork to develop an interprofessional primary healthcare team practicing within a collaborative framework. Leaders were also requesting guidance on how to implement this framework even before the team (and often before the executive director) is hired. Questions raised by new leaders included: What leadership concepts are relevant to leading collaborative or interprofessional teams? What are the essential knowledge skills and attributes required for a person to work effectively within an interprofessional team? How do I recruit team players? What are the roles and responsibilities of team members? How do we communicate efficiently and effectively from the beginning? A Reference Group made of both new and seasoned leaders representing AOHC members was developed to guide AOHC’s Education and Development Team in addressing the issues and concerns faced by new leaders in the building of collaborative teams. We acknowledge that CHCs, CFHTs, and AHACs have similar functioning in terms of team work and team development. And so, this toolkit was developed to support all AOHC member organizations in developing strong teams from the start. Davies/Ring Consulting, part of the collaborative effort behind the Building Better Teams toolkit, co-authored the five modules presented in this toolkit. This toolkit is a starting point for new leaders. A Note on the Terminology: We are seeing a transition in the literature on collaborative care from the use of the term interdisciplinary to interprofessional. Building Better Teams acknowledged the distinct use of the two terms in 2007,1 Interdisciplinary implies a deeper degree of collaboration between team members. It implies an integration of the knowledge and expertise of several disciplines to develop solutions to complex 1Davies Lynda, Ring Laurienne. Building Better Teams: A Toolkit for Strengthening Teamwork in Community Health Centres: Resources, Tips, and Activities you can Use to Enhance Collaboration, June 2007. Toronto: Association of Ontario Health Centres. Pg. 2

6

problems in a flexible and open-minded way. This type of team shares ownership of common goals and has a shared decision-making process. Members of interdisciplinary teams must open territorial boundaries to provide more flexibility in the sharing of professional responsibilities in order to meet client needs. Interprofessional is the term used more recently and is seen as best reflecting a practice that promotes the active participation of several healthcare disciplines and professions who work collaboratively with patient-centred care as a focal point. When all members coalesce around the client, professional paternalism and traditional methods of intervention can be minimized. It includes healthcare providers learning to work together, sharing in problem solving and decision making to the benefit of patients. The term interprofessional has entered the primary health care field and is now being utilized by organizations to define teams of mixed health-care professionals working collaboratively under a unified vision to help improve the delivery of care and health outcomes. We acknowledge that interprofessional refers to all team players from the management, clinical, administrative, and health promotion fields. According to the Health Force Ontario website,2 interprofessional care is defined as:

The provision of comprehensive health services to patients by multiple health-care professionals who work collaboratively to deliver the best quality of care in every health care setting. Interprofessional care encompasses partnership, collaboration and a multi-disciplinary approach to enhancing care outcomes.

The term interprofessional has been used throughout this document.

2 http://www.healthforceontario.ca/WhatIsHFO/AboutInterprofessionalCare.aspx

7

MODULE 1

Leadership

A. Background Leadership in organizations is “the ability to influence, motivate, and enable others to contribute toward the effectiveness and success of the organizations of which they are members.”3 In community-based primary health care, staff members may be leaders in developing programs that are responsive to community and client needs, lead the implementation of changes that are expected to improve client access or health outcomes. They may provide leadership in group processes such as developing stronger interprofessional teams. This module provides you with ideas for developing your leadership and those in your teams. The questions addressed here include:

What leadership concepts are relevant to leading collaborative or interprofessional teams?

What qualities or styles are important for leaders?

What skills do team leaders need?

What are the particular challenges in leading interprofessional teams?

B. Leadership Concepts Over the last decade, there has been a deepening understanding of leadership concepts applicable to leadership in general and to leading in team and collaborative settings. Leadership is now viewed as actions that integrate personal style factors such as our strengths and self awareness with factors related to the situation or environment we find ourselves in. Whether you have formal or informal leadership responsibilities, you will find leadership concepts that can help you to consider the kind of leader you are—or want to become. Past models of leadership often reinforced leadership as a stereotypical set of charismatic, assertive qualities that were innate. We know now that people from a wide variety of backgrounds, disciplines, organizational positions and possessing a variety of personal qualities can learn to be effective leaders. Learning has emerged as an important quality that effective leaders share. Leaders are able to learn their way through new situations.

C. Leadership Styles Leadership style has popularly been viewed as a combination of personal qualities such as charisma combined with a management style such as those classified according to the degree of control or autonomy a manager might display along a continuum of authoritarian, democratic or laissez-faire leadership behaviour.4 Early ideas about leadership examined the transaction between the leader and followers. Three newer approaches to leadership styles incorporate broader, more inclusive ideas about leadership. Those highlighted here are known as transformational, constructivist and situational leadership. i. Transformational leadership Transformational leadership refers to a leadership style that honours human relationships while achieving organizational goals. This style contrasts with transactional leadership, where the human relationship between leader and followers was an instrumental one, important in so far as a relationship

3 McShane, S. (2004) Canadian Organizational Behaviour, p.400 4 Shulman, L. (1993) Interactional Supervision. Washington: National Association of Social Workers Press

8

helped the leader to motivate organizational members to achieve organizational goals. Many successful leaders have rejected the manipulative tendency within this style and favour a more authentic approach in their interactions. Transformational leadership views the relationship as an important end in itself and acknowledges that “leadership is a relationship.”5 Transformational leaders intend to facilitate each individual’s growth and development and believe that when individuals are working towards worthwhile personal goals in concert with shared team or organizational goals, the congruency unleashes powerful energy that is available to teams and organizations. The transformational leader seeks to inspire others to work towards shared goals using shared values. Values such as respect, personal integrity, credibility and trust are viewed as essential qualities in this style, where “the ultimate in disrespect of individuals is to attempt to impose one’s will on them without regard for what they want or need and without consulting them. To behave paternalistically toward followers—even for their own good—is to deny them the basic right of individual dignity.”6 Transformational leadership with it’s respect for people and emphasis on values such as trust, authenticity, and credibility often resonates with people in the helping professions due to the congruency with the aims and values of community health initiatives. ii. Constructivist leadership Constructivist leadership emerged from the education sector based on learning theories that acknowledge that everyone - whether student or teacher - learns in context. Learning, including learning as a member of a workplace community, is affected by social factors such as culture, race and economic status. Constructivist leadership views colleagues and practitioners as members of a collective effort, where learning is facilitated by reflecting together and results in shared knowledge. As in transformational leadership, relationship plays a central role in leadership. Leadership is viewed as facilitating transformation through “reciprocal, purposeful learning in community.”7 The learning community becomes the site for change and growth by creating the connections that “form the basis for reflecting on and making sense of who we are and how we work. Relationships may well be the most important factor…”8 The constructivist leader builds opportunities for the developing shared meaning. iii. Situational Leadership Situational leadership acknowledges that no one personal style is the right style for all situations or contingencies. Situational leadership suggests that rather than rely on personal preference, leaders need to consider situational factors such as the stage of group and team development, experience of the people involved, and novelty of the situation and adjust their personal style to provide the kind of leadership best suited to these contingencies. Leaders are effective when they “seek to understand demands and constraints, and they adapt their behaviour accordingly.”9 This style is also congruent with team development and the need to draw on the leadership abilities of all team members over time or in different situations. As teams become more experienced they can become more fluid in their leadership roles, selecting the person most suited to the situation to lead on a particular initiative. Opportunities for shared leadership can be personally enriching and a source of developmental opportunities that help to meet members’ needs for growth and experience.

D. Leadership Qualities Authors Kouzes and Posner have researched leadership behaviour for over twenty-five years and have published their results in one of the leading guides to leadership development, The Leadership Challenge. Their research and recommendations have resonated with many people in the caring professions.

5 Kouzes, J. and Posner, B. (2007) The Leadership Challenge (4th ed.) p. 27. 6 O’Toole, J. (1996) Leading Change: the Argument of Values-Based Leadership. New York: Ballantine Books. p. 12. 7 Lambert, L.; Walker, D.; Zimmerman, D.; Cooper, J, Dale Lambert, M., Gardner, M., Szabo, M. (2002). The Constructivist Leader (2nd ed.) Teacher’s College Press, Columbia University. New York, New York. 8 Lambert, Lambert, L.; Walker, D.; Zimmerman, D.; Cooper, J, Dale Lambert, M., Gardner, M., Szabo, M. (2002). The Constructivist Leader (2nd Ed.) Teacher’s College Press, Columbia University. New York, New York. p. xvii. 9 Yukl, G. (2002) Leadership in Organizations Custom Edition for LT 516. Victoria: Royal Roads University (p. 216)

9

Their results indicate that the qualities most admired in leaders have remained stable across their years of researching leadership and are validated by the data they have gathered in Canada. i. Characteristics of Admired Leaders10

Using these qualities they have generated five practices of exemplary leadership along with commitments that accompany each practice. 1. Model the Way

This practice is supported by modeling the behaviour you expect to see in others. This includes the practices of clarifying and articulating your own and the organization’s values. 2. Inspire a Shared Vision

This practice is supported by developing a positive and compelling vision of the future and inspiring others to work with you towards this vision. 3. Challenge the Process

This practice is supported by facing challenges and leaving the status quo by trying something new, facilitating innovation taking the risk toward growth. 4. Enable Others to Act

This practice is supported by the skills of collaboration and building trusting working relationships with others. 5. Encourage the Heart

This practice is supported by recognizing the difficulties along the way and offering genuine caring and appreciation. An assessment tool adapted to health professionals from the practices they recommend can be accessed from http://www.hsc.mb.ca/leadership/?mode=view&id=141 For an assessment from a different perspective, consider the questions in this tool as an example of how you can introduce a constructivist approach to inquiry, shared reflection, knowledge generation and meaning making in building a leadership community.

10 Kouzes, J. and Posner, B. (2007) The Leadership Challenge (4th ed). Jossey- Bass (p. 30)

Honest

Forward looking

Inspiring

Competent

Intelligent

Cooperative

Courageous

Determined

Caring

Imaginative

Fair-minded

Straightforward

Broad-minded

Supportive

Dependable

Mature

Ambitious

Loyal

Self-controlled

Independent

10

ii. Assessment Questions11 1. Do you have opportunities to participate in leadership in this centre (or team)?

2. How skillful do you feel you are in your collaborative work with colleagues? What are your areas of strength? Areas for growth?

3. Do we work together collaboratively? If so, please offer examples.

4. Are the purpose and core values of our centre (team) clear? How would you personally describe them?

5. How do we use data to improve client and community outcomes?

6. How do you think we are doing with regard to client or health outcomes? What added value do we bring to our clients’ lives?

7. Can you think of an occasion when we have posed our own questions and sought our own answers about practice and effectiveness?

8. Are there other opportunities for reflective practice (such as coaching, writing, and dialogue) that we might look into?

9. What management actions have encouraged and supported the above work? In what ways has the Health centre (team) supported our efforts to build leadership capacity?

10. As you reflect upon these questions, are there other comments that you would like to add? Leadership roles and actions are synthesized from a wide variety of historical and theoretical perspectives in the list below. The following functions “can be performed by any member of the organization, but they are especially relevant for the designated leader.”12 iii. The Essence of Effective Leadership

1. Help Interpret the Meaning of Events

Helping people to find meaning in complex events is important, especially when the pace of change is accelerating and touches every part of our lives. Effective leaders help people to interpret events, understand why they are relevant, and identify emerging threats and opportunities. 2. Create Alignment on Objectives and Strategies

Effective performance of a collective task requires considerable agreement about what to do and how to do it. Helping to build consensus about these choices is especially important in newly formed groups and in organizations that have lost their way. Effective leaders help to create agreement about objectives, priorities and strategies. 3. Build Task Commitment and Optimism.

The performance of a difficult, stressful task requires commitment and persistence in the face of obstacles and setbacks. Effective leaders increase enthusiasm for the work, commitment to task objectives, and confidence that the effort will be successful. 4. Build Mutual Trust and Cooperation

Effective performance of a collective task requires cooperation and mutual trust, which are more likely when people understand each other, appreciate diversity, and are able to confront and resolve differences in a constructive way. Effective leaders foster mutual respect, trust, and cooperation.

11 Adapted from: Lambert, L. (2003). Leadership Capacity for Lasting School Improvement. Association for Supervision and Curriculum Development. Alexandria, Virginia. 12 Yukl, G. (2002) Leadership in Organizations Custom Edition for LT 516 Victoria: Royal Roads University. p. 231-232.

11

5. Strengthen Collective Identity

The effectiveness of a group or organization requires at least a moderate degree of collective identification. In this era of fluid teams, virtual organizations, and joint ventures, boundaries are often unclear and loyalties divided. Effective leaders help to create a unique identity for a group or organization, and they resolve issues of membership in a way that is consistent with this identity. 6. Organize and Coordinate Activities

Successful performance of a complex task requires the capacity to coordinate many different but interrelated activities in a way that makes efficient use of people and resources. Effective leaders help people get organized to perform collective activities efficiently, and they help to coordinate these activities as they occur. 7. Encourage and Facilitate Collective Learning

In a highly competitive and turbulent environment, continuous learning and innovation are essential for the survival and prosperity of an organization. Members must collectively learn better ways to work together toward common objectives. Effective leaders encourage and facilitate collective learning and innovation. 8. Obtain Necessary Resources and Support

For most groups and organizations, survival and prosperity require favourable exchanges with external parties. Resources, approvals, assistance, and political support must be obtained from superiors and people outside of the unit. Effective leaders promote and defend unit interests and help to obtain necessary resources and support. 9. Develop and Empower People

To be successful, a group or organization usually needs active involvement by members in solving problems, making decisions, and implementing changes. Appropriate skills must be developed to prepare people for leadership roles, new responsibilities, and major change. Effective leaders help people develop essential skills and empower people to become change agents and leaders themselves. 10. Promote Social Justice and Morality

Member satisfaction and commitment are increased by a climate of fairness, compassion, and social responsibility. To maintain such a climate requires active efforts to protect individual rights, encourage social responsibility, and oppose unethical practices. Effective leaders set an example of moral behaviour, and they take necessary actions to promote social justice. With the emphasis on relationships in leadership, there has been attention to the competencies associated with emotional intelligence as important for effective leadership. The following tool was designed to assess the emotional dimensions of leadership.

12

iv. Leadership Skills: Rate Yourself13

The best leaders have strengths in at least a half-dozen key emotional –intelligence competencies out of 20 or so. To see how you rate on some of these abilities, asses how the statements below apply to you. Although getting a precise profile of your strengths and weaknesses requires a more rigorous assessment, this quiz can give you a rough rating, Most important, we hope it will get you thinking about how well you use leadership skills—and how you might get better at it. Answer (put a check) “Seldom” to those statement with which you Seldom Agree “Occasionally “ with which you Occasionally Agree, “Often” with which you Often Agree and “Frequently” with which you Frequently Agree.

Statement Seldom Occasionally Often Frequently 1. I am aware of what I am feeling

2. I know my own strengths and weaknesses.

3. I deal calmly with stress. 4. I believe the future will be better than the past.

5. I deal with changes easily. 6. I set measurable goals when I have a project.

7. Others say I understand and am sensitive to them.

8. Others say I resolve conflicts. 9. Others say I build and maintain relationships.

10. Others say I inspire them. 11. Others say I am a team player.

12. Others say I helped to develop their abilities.

Total the number of checks in each column:

Multiply that number by X1 X2 X3 X4 Total the score for each column: Add the 4 column scores to get your TOTAL Score:

Scoring: 36+ Suggests you are using key leadership skills well—but ask a co-worker or partner for their opinions to be more certain.

30-35 Suggests some strengths and also some underused leadership abilities.

29 or less Suggests unused leadership abilities and room for improvement.

13 From Goleman, D, (2002) cited in Grossman, S. & Valiga, T. (2005) The New Leadership Challenge: Creating the Future of Nursing, (2nd ed) Philadelphia, PA: F.A. Davis.

13

E. Challenges in Leading Teams This section reviews some of the most frequently mentioned challenges found in interprofessional primary health care practice. These include maintaining a focus on both the task and interpersonal aspects of team work. Another ongoing challenge for leadership within primary health care teams include frictions associated with various aspects of power along with the need for frequent change and adaptation. The module concludes with recommended practices for leadership development. As teams develop trust and confidence, leadership within teams often becomes more shared, with less reliance on the formal leader. This can provide great opportunities for enrichment for all team members and can set the tone for collaborative leadership that utilizes the skills of all members. There are also challenges for team leadership. Recent research in Ontario community health centres identified five leadership challenges to primary heath care team work. These were “unfair treatment of certain staff or projects; closed or unapproachable leadership style; inappropriate workload assignment; lack of understanding of the CHC philosophy; and ineffective conflict management.”14 Power imbalances and role confusion often emerge in interprofessional teams. In the module on team work, it was noted that role confusion occurs within teams due to factors such as the overlapping roles of the professions and the sometimes contradictory messages embedded in policy positions. While it is promoted as a best practice to develop leaders from within through the use of learning opportunities and developmental assignments, a potential pitfall is a further contribution role confusion or perceptions of lack of fairness in employment relations. This was expressed in recent research in the community health sector where an example was provided where “a Nurse Practitioner in a peer leader capacity may need to give direction to a Family Physician one hour and consult with the physician the next hour about a patient.”15 In order to lead teams, effective team leaders are aware of the task, human relations needs and the situational setting for the team. The following checklist incorporates the leadership dimensions of task focus, awareness of interpersonal factors and situational elements for the leader to consider.

14 Bickford, J., Belle Brown, J., Moss, K., and Gillis, L. Challenges to Team Work in CHCs in Building Better Teams: Learning from Ontario Community Health Centres: A Report of Research Findings, June 2007. Toronto: Association of Ontario Health Centres. p. 109. 15 Davidson, B. Leadership and Interdisciplinary Teams: Ontario Community Health Centres in Transition, in Building Better Teams: Learning from Ontario Community Health Centres A Report of Research Findings, June 2007.(p. 206)

14

i. Effective Leader Checklist16 Please read the statements below. Circle the number that most accurately describes your response to the statement. Use the following key to respond to each statement.

1. Disagree strongly 2. Disagree to some extent 3. Agree to some extent 4. Agree strongly

1. I avoid taking leadership assignments for which I do not have sufficient task-related knowledge. 1 2 3 4 2. I avoid taking leadership assignments for which I do not have the appropriate leadership style. 1 2 3 4 3. I am motivated to act as the leader for this team. 1 2 3 4 4. I am able to adjust my leadership style to meet the developmental needs of the team at a particular point in time. 1 2 3 4 5. With a team in the early stages of development, I am a directive and confident leader. 1 2 3 4 6. I come to early team meetings with a clear, written agenda. 1 2 3 4 7. At early meetings, I am able to state the team’s goals clearly. 1 2 3 4 8. Especially at the beginning, I run meetings efficiently. 1 2 3 4 9. Early on, I am comfortable assigning tasks to individuals as necessary. 1 2 3 4 10. Early on, I am comfortable making decisions as needed. 1 2 3 4 11. In early meetings, I work to reduce member anxiety, fears of rejection, and concerns about safety. 1 2 3 4 12. I treat members sensitively and fairly. 1 2 3 4 13. I address members by name and make sure members know each others’ names from the beginning. 1 2 3 4 14. I try not to put individuals on the spot, especially in early meetings. 1 2 3 4 15. I encourage members to participate, but I don’t demand participation. 1 2 3 4

16 Whelan, S. (1999) Creating Effective Teams A Guide for Members and Leaders. Thousand Oaks: Sage Publications. p. 89-92.

15

16. I give lots of positive feedback to the team and to individuals. 1 2 3 4 17. I facilitate open discussion of team goals, values and tasks. 1 2 3 4 18. I encourage the expression of different opinions. 1 2 3 4 19. When members are having difficulty expressing different opinions, I use methods to elicit opinions anonymously. 1 2 3 4 20. I facilitate member feelings of competence by providing supervision, training, and education in task-related activities when necessary. 1 2 3 4 21. I facilitate member feelings of competence by providing supervision, training, and education in group participation skills when necessary. 1 2 3 4 22. I set high performance standards from the beginning. 1 2 3 4 23. I review quality expectations early and often. 1 2 3 4 24. I review standards for member and leader participation as well. 1 2 3 4 25. Initially, I negotiate with other groups and external individuals for needed resources. 1 2 3 4 26. Initially, I buffer the team from excessive external demands. 1 2 3 4 27. Initially, I scan the rest of the organization to collect information that might be useful to the team. 1 2 3 4 28. Initially, I report team progress to others to ensure that the rest of the organization has a positive image of the team. 1 2 3 4 29. When members begin to demand more participation in running the team, I slowly begin to empower them to take it. 1 2 3 4 30. I expect challenges to my authority and see them as a sign of team progress. 1 2 3 4 31. I try not to take attacks and challenges personally. 1 2 3 4 32. I facilitate open discussion and resolution of conflicts that emerge. 1 2 3 4

16

33. I encourage the use of effective conflict resolution strategies. 1 2 3 4 34. As the team matures, I increasingly involve members in the leadership function of the team. 1 2 3 4 35. I encourage and support member efforts to share in the leadership function of the team. 1 2 3 4 36. I encourage the team to make any necessary changes in the team’s structure that will facilitate team productivity. 1 2 3 4 37. When a team is fully functional, I act more as an expert member than as a leader. 1 2 3 4 38. I continue to monitor team processes, especially for signs of regression. 1 2 3 4 39. I ask for organizational support reviews on a regular basis. 1 2 3 4 40. Regardless of the stage of the team, I follow guidelines for effective team membership as well as the guidelines for effective leadership. 1 2 3 4 Minimum Score: 40

Maximum Score: 160

My Score: ______

17

F. Power in Teams and Organizations From an organizational perspective, power is “the capacity of a person, team or organization to influence others.”17 Power in teams is composed of several factors that include the degree to which the team members are dependent on one another to complete their work, how important the person or team is to completing needed tasks and the sources of power available to the team. In health-care teams we often see the manifestation of power in the professional roles of team members, where team members perceive “that in practice, their profession had less power and therefore a weaker voice in the organization.”18 Organizational literature considers five sources of power. Some power derives from the organizational position of the person or team. Examples of this type of power are classified as legitimate, reward and coercive power. The power from these sources flows from the role or position, regardless of who is the role. Legitimate power flows in an organization from the roles people fulfill- that according to documents such as job descriptions, the person is perceived through mutual agreement to have power to request actions from other members of the team. Reward power derives from ability to allocate rewards within the organization. This includes obvious rewards such as pay as well as promotion, development opportunities, assignments and time off. Coercive power is the ability to be punitive in the organizational setting through such actions as the ability to reprimand, discipline or terminate the employment of someone. It is also possible for teams to apply coercive power, for example by using peer pressure to enforce conformity. In addition to the power inherent in these organizational or professional roles, people or teams can acquire power through personal expertise or qualities. Expert power is found when a person or team builds up valuable knowledge and is then in a position to influence others. Referent power comes from the high regard held by the person or team which others can then identify with. Referent power could flow from having well developed interpersonal skills or being viewed as trustworthy. Power in organizations is also influenced by factors known as the contingencies of power. Power may accrue to those roles or people where they cannot be substituted, are central to accomplishing the tasks, have a high level of discretion about what actions to take or are highly visible. Tensions regarding power in health care may stem from contingencies of power that flow from the high regard health services providers are held in by the community as well as the centrality and non-substitutability of professions roles. There is also a strong historical context to these tensions, where “gender and social class issues have been factors in the friction and conflict that has existed between professions until present day.”19 This activity provides an opportunity for you to examine your relationship to power. As a team, you can reflect on your past experiences with power.

17 McShane. p. 344 18 Bickford, J., Belle Brown, J., Moss, K., and Gillis, L. Challenges to Team Work in CHCs in Building Better Teams: Learning from Ontario Community Health Centres A Report of Research Findings, June 2007.(p. 109) 19 Hall, P. Interprofessional teamwork: Professional Cultures as Barriers in Journal of Interprofessional Care (May 2005) Supplement 1: p. 188-196.

18

i. Past Experiences with Power20 Objectives: 1. To revisit experiences with power 2. To distinguish elements that contribute to positive or negative feelings about power 3. To create an initial foundation for further discussions of the concept of power Materials needed:

Chart paper Felt pens

Individually write down one example of a time when you observed or experienced power being used in a positive or productive manner. You may have observed this in person, on television, from afar, or actually used your power in this way. After you note this experience, write down what it was about this experience that caused you to remember it as productive and positive? Then, write down one example of a time when you observed or experienced power being used in a negative, disrespectful or destructive way. Again, this may have been power observed or experienced in person, on television or from afar. Note what caused you to remember this experience as negative. In your [small] group, share the details and reactions to both of these experiences. On one piece of chart paper, collate the elements that comprised positive experiences. On another piece of chart paper, collate the elements that comprised negative experiences. Each group will share its thoughts and listings with the whole group and post. As a whole group, discuss whether the positive or negative experiences have influenced your current views of power and why that might be.

20 McKinley, L. and Ross, H. (2008) You and Others Reflective Practice for Group Effectiveness in Human Services. Toronto: Pearson Education.

19

G. Leading Change Leading change is frequently a challenge for leaders. If you are the leader of a new initiative, health centre or family health team you are likely leading a change of some kind. The need to respond to community needs and a rapidly changing policy environment as well as the tremendous challenges to the health-care system means that change may be occurring at many levels within an organization, often simultaneously. To help you think about the kind of change you are leading and the supports that could be used by team members, you can consider whether the change is developmental, transitional or transformational.21 Developmental change aims to change an existing situation or process through enhancement. This type of change may seek to improve communication, team work or implement an improvement such as a new process or technique. In developmental change the goal or desired outcome of the change is clear. The leader supports developmental change by providing information that shares the rationale for the needed change and by assisting with the setting of new goals that stretch team members while also ensuring that the resources and support for meeting the new goal are in place. Transitional change is characterized by the need to “replace what is with something entirely different.”22 This order of change requires leaders to recognize that something completely different is required in order to respond to an opportunity or challenge. Examples of transitional change include the introduction of new programs or implementing new technologies that are similar to existing ones. Transitional change may not require high levels of change from the people involved or within the workplace culture. The leader uses clear communication, participation of the affected people and their control over the implementation to achieve the desired new state. The leader supports transitional change by identifying the differences between the existing and desired outcomes. The leader can facilitate the identification of anything that can be brought forward to serve the new situation, what will have to be left behind or is no longer needed, and what new components will be created to complete the new state. This type of change is often implemented with a parallel structure: one to keep existing operations going and another to manage the stages of planning and implementing the required changes. The third type of change is transformational change. This type of change is marked by high levels of uncertainty and complexity that will require attitude, behaviour and cultural changes from all involved. The final result or outcome may not be known and the “scope of this change [is] so significant that it requires the organization’s culture and people’s behaviour and mindsets to shift fundamentally in order to implement the changes successfully and succeed in the new state.”23 In transformational change, the result emerges from a chaotic or unstable state. The leader’s role in transformational change is to monitor all sources of feedback to continually assess the process and direction of the change and adjust the course to continue in the desired direction. The leader becomes an adept learner to interpret and act on the feedback and facilitates learning in others.

21 Anderson, D and Ackerman Anderson, L. (2001) Beyond Change Management: Advanced Strategies for Today’s Transformational Leaders. Jossey/Bass – Pfeiffer. 22 Anderson and Ackerman Anderson, p. 35. 23 Anderson and Ackerman Anderson, p. 39.

20

i. Determining the type of change required24 (Adapted from Anderson and Ackerman Anderson)

Instructions: determine the primary type of change you are leading by answering the “litmus test” questions listed below. If you answer “yes” to two or more questions for one type of change, then that is the primary type of change you are facing. Remember to think of the overall change that is occurring, not the pieces within it. In most cases, all three types of change are occurring, but only one is primary. Developmental Change Questions

1. Does your change effort primarily require an improvement of your existing way of operating, rather than a radical change to it?

2. Will skill or knowledge training, performance improvement strategies, and communications suffice to carry out this change?

3. Does your current culture and mindset support the needs of this change? Transitional Change Questions

1. Does your change effort require you to dismantle your existing way of operating and replace it with something known but different?

2. At the beginning of your change effort, were you able to design a definitive picture of the new state?

3. Is it realistic to expect this change to occur over a pre-determined timetable? Transformational Change Questions

1. Does your organization need to begin its change process before the destination is fully known and defined?

2. Is the scope of the change so significant that it requires the organizations culture and people’s behaviour and mindsets to shift fundamentally in order to implement the changes successfully and achieve the new state?

3. Does the change require the organization’s structure, operations, products, services or technology to change radically to meet the needs of clients, the community and policy environment? Conclusions

1. Which of the three types of change is the primary type required?

2. Which of the other two types of change will also be needed to support this primary type? In what ways?

3. What leadership skills and strategies will you need to draw upon to lead this change?

24 Anderson, D and Ackerman Anderson, L. (2001) Beyond Change Management: Advanced Strategies for Today’s Transformational Leaders. Jossey/Bass – Pfeiffer. p. 48 & 49.

21

H. Best Practices in Leadership Development25 As a leader, you will also be interested in supporting the leadership development of others. You may have responsibilities for contributing to a succession plan or may want to foster the ongoing development of team members. Ideally, developing leaders within your centre will use a variety of processes. The practices noted here will help you to plan leadership development for one person or to create a leadership development program. A comprehensive approach to leadership development would include:

Technical knowledge of the field of practice

Development of: o Interpersonal judgement o Self awareness o Learning ability, to engage in problem solving

Developmental experiences

A strong program acknowledges that much learning of leadership and management skill occurs through experience. Developmental experiences should play a central role in your program. These experiences would be supported by including elements of assessment, challenge and support. Feedback, training and specific job assignments can also be incorporated. Coaching and mentoring relationships also play an important role in supporting leadership development.

I. Resources

Kouzes and Posner have recently published the 4th edition of The Leadership Challenge. More information about their work, research methodology and companion publications can be found through their website. A great place to start is with their Recommended Reading page at:

http://www.leadershipchallenge.com/WileyCDA/Section/id-131341.html The online assessment tool for nurses (suitable for other healthcare professionals) based on their practices of exemplary leadership is available at:

http://www.hsc.mb.ca/leadership/?mode=view&id=141 Other resources of interest include:

Nursing Leadership Network of Ontario: http://www.nln.on.ca/

Leadership development for physicians: http://www.hpme.utoronto.ca/about/conted/plp.htm

Collaborative leadership in public health: http://www.collaborativeleadership.org/ http://www.collaborativeleadership.org/pages/tools.html For an excellent summary of leadership theories and contemporary developments, see Chapter One in Carroll, P. (2006) Nursing Leadership and Management: A Practical Guide. New York: Thomson Delma Learning.

25 Groysberg, B. and Cowen, A. (2006) Developing Leaders. 9-407-015. Boston: Harvard Business School Publishing.

22

J. References Anderson, D. and Ackerman Anderson, L. (2001) Beyond Change Management: Advanced Strategies for

Today’s Transformational Leaders. Jossey-Bass – Pfeiffer. Bickford, J., Belle Brown, J., Moss, K., and Gillis, L. Challenges to Team Work in CHCs in Building Better

Teams: Learning from Ontario Community Health Centres: A Report of Research Findings, June 2007. Toronto: Association of Ontario Health Centres.

Davidson, B. Leadership and Interdisciplinary Teams: Ontario Community Health Centres in Transition,

p. 206 in Building Better Teams: Learning from Ontario Community Health Centres: A Report of Research Findings, June 2007. Toronto: Association of Ontario Health Centres.

Goleman, D, (2002) cited in Grossman, S. & Valiga, T. (2005) The New Leadership Challenge: Creating

the Future of Nursing, (2nd ed) Philadelphia, PA: F.A. Davis. Groysberg, B. and Cowen, A. (2006) Developing Leaders. 9-407-015. Boston: Harvard Business School

Publishing. Hall, P. Interprofessional Teamwork: Professional Cultures as Barriers in Journal of Interprofessional

Care (May 2005) Supplement 1: p. 188-196. Kouzes, J. and Posner, B. (2007) The Leadership Challenge (4th ed). Jossey-Bass p. 30. Lambert, L.; Walker, D.; Zimmerman, D.; Cooper, J, Dale Lambert, M., Gardner, M., Szabo, M. (2002).

The Constructivist Leader (2nd ed.) Teacher’s College Press, Columbia University. New York, New York.

Lambert, L. (2003). Leadership Capacity for Lasting School Improvement. Association for Supervision

and Curriculum Development. Alexandria, Virginia. p. 30. McKinley, L. and Ross, H. (2008) You and Others Reflective Practice for Group Effectiveness in Human

Services. Toronto: Pearson Education. p. 118. McShane, S. (2004) Canadian Organizational Behaviour (5th ed). McGraw-Hill Ryerson. p. 400. O’Toole, J. (1996) Leading Change: The Argument for Values-Based Leadership. New York: Ballantine

Books. p. 12. Shulman, L. (1993) Interactional Supervision. Washington: National Association of Social Workers

Press. p.228-229. Whelan, S. (1999) Creating Effective Teams A Guide for Members and Leaders. Thousand Oaks: Sage

Publications. p. 89-92. Yukl, G. (2002) Leadership in Organizations Custom Edition for LT 516. Victoria: Royal Roads

University. p. 216; p. 231-232.

23

MODULE 2

Recruitment, Selection and Hiring Practices

A. Background

One of the foundations of Primary Health Care Reform in Canada has been a focus on teams of professionals as the basis of care provision. A recent federal policy paper has suggested that,

A healthcare system that supports effective teamwork can improve the quality of patient care, enhance patient safety and reduce workload issues that cause burnout among healthcare professions. (CHSRF, 2006)

There is mounting evidence (Health Force Ontario, 2007) in Canada that an interprofessional care environment may offer multiple benefits including:

increased access to health care

improved outcome for people with chronic diseases

less tension and conflict among caregivers

better use of clinical resources

easier recruitment of care givers

lower rates of staff turnover

Given the move toward interprofessional teams across the health-care system, education initiatives regarding interprofessional care are being undertaken within Canadian Colleges and Universities that provide education for healthcare professionals.(D’Armour, &. Oandasan, 2005). Future health-care professionals will be required to acquire the knowledge, skills and attributes needed for interprofessional care. It has been recommended that a set of competencies be developed to guide the education of health-care professionals. It is hoped that the development of a common competency framework will provide guidance regarding the knowledge, skills, competencies and attributes required to practice interprofessional care. (Health Force Ontario, 2007) In the mean time, new primary health-care teams are forming and health-care professionals are being hired to work within them. This module is intended to be of assistance to those leaders of primary health care organizations and/or teams who have the responsibility for recruiting, selecting and hiring staff members who will contribute actively to the development of effective primary health care teams. The research on interprofessional teams conducted by the Association of Ontario Health Centres found that ‘hiring for fit’ was a good practice within community health centres: “the findings emphasized the importance of making hiring decisions based on the philosophy of the CHC in order to insure a fit with its values” (Laiken et al, 2007. p. 127) The questions that will be addressed in this module:

What are the essential knowledge skills and attributes required for a person to work effective within an interprofessional team?

How might a position/job advertisement be written to attract a pool of candidates with the knowledge skills and attributes required?

What questions might be asked in an interview that would assist the interview panel to assess the candidate’s knowledge skills and attributes?

What questions would assist a candidate with the necessary knowledge, skills and attributes to demonstrate those?

24

What types of people might the hiring committee ask the candidate’s permission to speak to as references? What questions might the references be asked?

What language in an employment letter might reinforce the importance of interprofessional care?

The module is not intended to be an extensive resource on general standards of practice for hiring personnel nor the legal and regulatory aspects of hiring. Those who are seeking general hiring information are directed, as a starting place to the resource section of this module.

B. Hiring Professionals with The Essential Knowledge, Skills and Attributes

There is a growing amount of evidence that there are several essential qualities required for people to participate effectively in interprofessional teams. A recent review of empirical studies (San Martin Rodriguez et al, 2005) concludes, that in order for a healthcare professional to work effectively as member of an interprofessional team she/he would need to:

Be willing to commit to a collaborative process

Be able to establish relationships built on trust

Demonstrate skills in interpersonal communication

Have developed respect and recognition for the contributions of other professions to the team

While a set of competencies has yet to be developed at the policy and post secondary education levels, there has been a fair amount of work completed, much of it in Canada, to identify and articulate the essential competencies. The next section outlines one set of suggestions that have been made regarding the competencies necessary for collaboration. i. Collaborative competencies26

Describe one’s role and responsibilities clearly to other professions. Recognize and observe the constraints of one’s role, responsibilities, competence, yet perceive needs in a wider framework. Recognize and respect the roles, responsibilities and competences of other professions in relation to one’s own. Work with other professions to effect change and resolve conflict in the provision of care and treatment. Work with others to assess plan, provide and review care for individual clients. Tolerate differences, misunderstandings and short comings in other professions. Facilitate interprofessional case conferences and team meetings. Enter into interdependent relationships with other professions. Given the importance now placed on interprofessional care and the necessary knowledge, skills and attributes, an emphasis on these issues during the hiring process is well warranted. Even before the interviews, some attention to the position/job advertisement can assist your organization in attracting the most appropriate pool of candidates. An example of an advertisement that contains references to interprofessional care is in the next section.27

26 Oandasan, Ivy & Reeves, Scott. (2005) 27 This position advertisement was developed following a review of several position advertisements for primary health care teams posted www.charityvillage. in July /Aug 2008.

25

ii. Job Posting: Registered Nurse The your organization is an interprofessional CFHT,CHC,AHAC providing access to primary health care to a diverse group of clients in an urban area that has been chronically under served. We have an opening for a Registered Nurse (1.0 FTE – 12 month contract). The Registered Nurse (RN) reports to the Executive Director. Responsibilities:

Delivering comprehensive nursing care in a primary care family practice setting as established by the standards of nursing practice of the College of Nurses of Ontario.

Provides safe and competent care through the application of nursing knowledge, the technical aspects of professional practice and the demonstration of compassion, professionalism and critical thinking.

Responsible to provide a variety of modalities of client care (telephone assessment, home visits, group education sessions, well baby clinics, geriatric assessments, diabetic teaching, pregnancy planning and contraception, immunization, counseling and program development)

Responsible for assessment, nursing diagnosis, integrated care plan development, implementation and evaluation of nursing care.

Responsible for the provision of primary health care services through effective collaboration with the other members of the health care team.

Qualifications:

Registered with the College of Nurses of Ontario.

Bachelors Degree in Nursing required.

Current Basic Cardiac Life Support (BCLS) and Cardio-Pulmonary Resuscitation (CPR) certificate required. Advanced Cardiac Life Support (ACLS) Certification will be considered an asset.

Experience working in a family practice or primary health care setting required.

Minimum five (5) years experience in utilizing the nursing process in planning, implementing and evaluating patient care.

Experience in oral/point of care anticoagulation, chronic disease management, telephone triage and clinical nursing skills required.

Competencies:

Good attendance and work record.

Knowledge and proficiency in current, evidenced-based methods and practices of primary care delivery, with an emphasis on health promotion and risk reduction.

Superior leadership, organization, research, evaluation, time management and interpersonal skills.

Willingness to commit to a collaborative model for the provision of primary health care services that recognizes and values the contributions of all members of the interprofessional team.

Proficiency in the use of the computer hardware and software, particularly in Microsoft Word, Excel and Outlook, knowledge of electronic medical record Excellent verbal and written communication skills.

Experience in the development of effective linkages with other health, social service and education agencies as appropriate.

Experience in working with a diverse population.

26

Excellent client assessment skills.

Ability to function in a multi-tasking fast paced environment.

Able to work independently and as an effective member of an interprofessional team

Once the applications have been received and a short listing process undertaken, the interviews will take place. Asking questions of candidates that allow the candidate to present their skills and knowledge and the interview panel to assess the candidate’s knowledge and skills and ‘fit’ is as much an art as a science. The questions provided here are meant to be examples that could be used. The questions can be modified, edited, made simpler or more complex based on your particular context and needs. It is an effective method to have the hiring committee, which ideally will be made up of a variety of health professionals (Laiken et al, 2007), spend some time discussing these questions and deciding together what questions to ask in the interview. You will be able to ask only one or perhaps two questions regarding the person’s skill in collaboration, so the questions need to be the best ones for your setting and context. This type of discussion and group decision making models the collaborative approach to decision making that is most appropriate to fostering effective team work.

27

iii. Suggestions for Interview Questions28 Questions What to look for Can you tell us about a time when you were able to gain commitment from others and motivate them to work together to achieve goals

Look for experience working with groups or teams and an awareness of the contribution of everyone to the team’s work. Look for awareness that people need to be involved in decisions and processes that will affect them.

How have you helped/participated in building rapport in teams?

Look for insight and/or understanding from the person as to how she or he has personally contributed to effective team work. (perhaps through practices such interpersonal communication, valuing the contribution of others, helping to resolve conflicts)

As the (insert job title) you will need to take a lead role in (insert key job expectation). How would you see yourself working and relating to other professions, disciplines, teams and managers within the organization? What strategies would you use to move forward to meet these expectations?

Look for ability to see both task/activities and processes that would need to take place. Look for awareness of interdependence of people in the organization, communication, trust building, involving all those affected in decision making.

Two staff people have indicated to you that they believe there are some positions within the team that are not as respected or valued as others. What strategies might you use to address these concerns?

Look for understanding of the importance of valuing the diversity of knowledge, skills and experience in an interprofessional team Look for problem solving and the importance of involving the whole team in resolving the concerns.

What has been your experience working as a member of a team? Based on these experiences, what do you think are the key elements of successful teamwork? What are the challenges to effective teamwork?

Look for awareness and/or experience in developing trusting relationships, establishing good interpersonal communication skills, and a willingness to address conflict. Look for knowledge that effective teams need a shared vision, a common purpose, open communication, conflict resolution mechanisms and individual as well as team accountability.

Can you give an example of how you worked to resolve a dispute with another provider regarding the care of a client?

Look for collaborative communication and conflict styles, rather than a competitive/win lose style; look for an

28 Thanks to Ms. Lynne Raskin of South Riverdale Community Health Centre Health Centre and Dr. James Read of the Sherbourne Family Health Team for providing examples of the questions they have used in hiring processes. Their questions formed a starting point for this guide.

28

appreciation of the other’s role and accountabilities, look for democratic rather than hierarchical problem solving attitudes and skills.

All organizations have a unique culture. What strategies have you used in the past as a newcomer to an organization to work through building trust, developing relationships and to work effectively within a team?

Look for an appreciation that trusting relationships take time and require mutual respect of each profession’s role. Good communication skills and demonstrating competence in ones’ own profession also enhance trust.

Have the candidate review the vision statement for you centre and ask them how they would work within the team the centre to make the vision a reality

Look for the individual alignment with organization vision and for the knowledge that it takes a team working together to achieve a vision with all member’s contributions valued

iv. Checking References After the interview you may have 2 or more candidates that you are seriously interested in for the position. You will want to speak to people who have worked with the candidate. A now common place method is to speak to a person who has supervised the work on the candidate, a second person who has worked as a peer/colleague and a third person who has reported to the candidate. This strategy provides you with information about the candidate from a variety of perspectives. Questions regarding the candidate’s suitability for working within an interprofessional teams are offered in Figure 4. These are suggestions only and can be adapted according to your particular needs. Questions for References

What were the person’s strengths in working with others? Please give examples if possible.

What was the person’s contribution to effective working relationships among his/her peers and colleagues? Please provide an example

What challenges did the person experience in working with others? Please give examples if possible.

Was the person able to learn from the experience and improve their relationships?

How did this person go about promoting collaborative working relationships with others? v. Letter of employment Inserting language regarding the importance of collaborative practice into a letter of employment will convey the high value placed on collaboration at your Centre. This wording is an example that could be used or adapted.29

In addition to the duties and responsibilities outlined in the job description, it is understood that a further job duty is the need for you to work effectively within the strong team context that exists at (insert centre name). The expectation that you will work professionally, collaboratively and respectfully with all of your colleagues in the Centre is as important as your other duties and responsibilities.

vi. Job Descriptions 29 Thanks to Ms. Lynne Raskin of South Riverdale CHC for providing this wording

29

Embedding the concepts of interprofessional care within your organizational culture can be further assisted by ensuring that job descriptions of all members of your team contain references to the aspects of the person’s job that relate to collaborative care. There are now over 20 regulated health professions in Ontario. There are also a variety of unregulated workers such as community mental health workers, grief counselors, unregulated social workers, peer counselors, health promoters, community developers, traditional healers and elders that provide needed and often culturally relevant services in their communities (Purden, 2005). And in all primary health care settings, administrative, information technology and secretarial staff are key to well functioning teams. Whatever the positions within your team, which may change over time depending on the populations you are serving and the needs you identify, every job description can contain references to interprofessional care. This is a strategy that can remind each team member that she/he is responsible to participate in establishing and maintaining collaborative relationships with others. AOHC is not advocating or suggesting a particular type or model for job descriptions. The following suggestions could be easily added to the job descriptions you are currently using. Position Responsibilities As a member of the interprofessional team:

Communicates effectively with other members of the team

Collaborates with others through providing appropriate support and consultation to other primary care staff and participates in chart reviews and collaborative case conferences

Recognizes and respects the value of each member of the team.

Qualifications

Knowledge, skills and aptitudes necessary to establish and maintain collaborative relationships with other members of the interprofessional team

vii. Summary Checklist on Hiring The following exercise provides a checklist that captures the ideas presented in this module. The checklist can provide a method for ensuring each of the steps we have suggested has been incorporated into your processes.

Hiring Checklist

Topic Yes No Have we included references to experience with interprofessional collaboration in our recruitment material?

Have we incorporated questions about interprofessional collaboration in our interview questions?

Have we included questions about interprofessional competencies in our reference checks??

Have we included competences associated with interprofessional care in our position/job descriptions?

Have we mentioned the responsibility to function effectively as a team member in our contract letter?

viii. Thinking ahead to Performance Appraisals

30

Each person hired to work within a primary health care interprofessional team will eventually have regular performance appraisals. New employees usually have a probationary period of employment as part of their employment contracts. When team members are aware that one aspect of their performance appraisal will be a focus on their contribution to establishing and maintaining effective collaboration within their team, the overall effect will be to increase the knowledge, skills and aptitudes within the entire team. It is beyond the scope of the module to suggest a particular method and forms for performance appraisals. The intention behind the example30 provided is to assist leaders and teams to consider the ways in which the knowledge, skills and aptitudes for interprofessional care discussed throughout the module might be incorporated into your performance appraisals. The suggestions provided can be modified and edited to fit your particular context.

Performance Appraisal

Instructions: Each person who is contributing to the performance appraisal will rate the employee on the following dimensions using the rating guide provided at the end. Interprofessional Team Skills

1. Communicates knowledge and information to other team members

2. Participates in establishing effective team meetings, case conferences

3. Demonstrates accountability to the team by contributing to the team meeting its objectives and by supporting team decisions

4. Participates in individual work planning as well as team work planning

5. Assists other team members with their growth and development, answers questions and pitches in to complete the team’s work.

6. Works with team members to resolve conflicts

7. Demonstrates respect for the diverse contributions of team members and their roles

8. Accepts constructive feedback and acts on suggestions for improvement

9. Arrives for work and meetings on time

10. Reinforces and acknowledges positive behaviour, performance and successes of other team members

RATING SCALE

Excellent: “Role model” or leader in demonstrating this behaviour/action

Good: Behaviour/action demonstrated consistently and effectively

Fair: Developmental Opportunity. Behaviour/action demonstrated with room for improvement. Specific actions to help employee improve their performance will be developed.

Poor Development is Critical. Behaviour/action is rarely/never/poorly demonstrated; significantly impacts performance. Specific actions to help the employees improve their performance will be developed

N/A not applicable

Don’t Know I don’t have enough knowledge to indicate whether behaviour/action is demonstrated

C. Resources

30 Thanks to Ms. Simone Thibault, Executive Director of Centretown Community Health Centre for providing their performance appraisal tools which were adapted for this module.

31

Community Health Inc. or COHI This organization owns and administers the quality improvement and accreditation program called Building Healthier Organizations. (BHO) The website www.cohi-soci.ca has a section entitled BHO Resource Library that contains many resources on hiring and related topics. Under the heading 1.6 Creating a Healthy Workplace, there are resources on Anti-discrimination in hiring, reference checking, checking of professional registrations, advertising, recruitment, interviewing, selection, examples of performance appraisal tools and a variety of other HR tools and examples. Charity Village This website, www.charityvillage.com, which is used by many non profit groups to advertise positions also contains a Resource and Library section. In the Resource and Library section there is a section entitled Management Resources that contains several resources specific to hiring such as establishing selection criteria, selecting interview questions, candidate evaluation and human rights legislation in Canada. Other sections of the site contain links to nonprofit management resources and are worth a browse. Ontario Ministry of Labour This website www.labour.gov.on.ca/english/es contains detailed information on the Employment Standards Act (2000) which enforces the minimum standards that employers and employee must follow.

D. References Canadian Health Services Research Foundation (2006) Team Work in Health Care: Promoting effective

team work in health care in Canada: Policy Syntheses and Recommendations. http:/ www.chsrf.ca Retrieved June 23, 2006

D’Armour, D. Oandasan, I. (2005) Interprofessionality as the field of interprofessional practice and

interprofessional education: An emerging concept. Journal of Interprofessional Care Supplement 1 May: p 8-20

Health Force Ontario (2007) Interprofessional Care: A Blueprint for Action in Ontario. http/:www

healthforceontario.ca/IPCproject. Retrieved May 25, 2008 Laiken, M. E., Chatalalsingh, C., Brown, J.B., Bickford, J., Moss, K. & Gillis, L. (2006). Organizational

Support for Interprofessional Teams in Primary Health Care in Building Better Teams: Learning from Community Health Centres.(2007) Association of Ontario Health Centres. Etobicoke.

Oandasan, Ivy & Reeves, Scott. (2005) Key elements for Interprofessional education. Part 1 The

learner, the educator and the learning context. Journal of Interprofessional Care, Supplement 1. May: p 21-35

San Martin-Rodriguez, L.S., Beaulieu, M. D., D’Amour, D., & Ferrada-Videla, M. (2005) The

determinants of successful collaboration: A review of theoretical and empirical studies. Journal of Interprofessional Care Supplement 1 May, p132-147

32

MODULE 3

Team Roles and Responsibilities

A. Background Members of primary health-care teams are continuing to develop their expertise in team work and various applications of interprofessional collaboration. Initiatives in health sciences education and health-care policy now emphasize the need for team work to address the needs of clients and communities; initiatives that link interprofessional care, collaboration and the ability to work as an effective team member are well underway. This interest in team work builds on the history of working in interdisciplinary and multi-disciplinary teams and addresses some of the current challenges to providing primary health care. The advantages associated with effective team work in heath care include improvements in patient care, enhanced patient safety, and a way to reduce some of the challenges in workload that lead to burnout.31 In community-based primary care, benefits have included “coordinated and comprehensive client care; appropriate internal client referrals; the sharing and application of professional skills and knowledge; and staff being aware of, contributing to and directing their client to the various CHC programs available in the community.”32 As teams come together and attempt to deepen their levels of collaboration, they often begin by defining personal and team roles and responsibilities. This module asks:

What are the types of roles within primary health-care teams?

How can understanding team roles and responsibilities be facilitated?

What are the challenges for primary health care teams in defining team roles?

B. Team Definition What is a team? One of the most widely used definitions of teams emphasizes the interdependence of team members which distinguishes teams from other work groups: A team is a small number of people with complementary skills who are committed to a common purpose, performance goals and approach for which they hold themselves mutually accountable.33

Health-care teams will have members with specific functions, such as dietitians, health promoters, physicians, nurse-practitioners and nurses. Each team will also become established as a team. They will need to work through team development tasks that help them to operationalize the benefits of working as a team. During this forming stage, team members need to articulate their common understanding of what it means to be a team. A number of tools have been developed to help teams to articulate their common purpose and state their shared approaches through activities such as developing a team Vision and Values. In the forming stage, a foundation is set for building trust and confidence in each other so they can become comfortable with their mutual accountabilities. (For a full discussion of the team development stages and the tasks of forming, as well as examples of how you can assist your team to name elements of team practice, please see the AOHC publication, Building Better Teams: A Toolkit for Strengthening Teamwork in Community Health Centres.)

31 Canadian Health Services Research Foundation(2006) Teamwork in Healthcare: Promoting Effective Teamwork in Healthcare in Canada p. iii 32 Davies, L., & Ring, L., ( 2007) Building Better Team: Learning from Ontario Community Health Centres AOHC (p.7) 33 Katzenbach, J. and Smith, D. (2003)The Wisdom of Teams Creating the High Performance Organization. p. 45.

33

In order to assess the areas of forming, including roles and responsibilities, that would be beneficial to your team, you can use the survey below to identify areas that require attention. Compiled results can be shared and discussed as a team. Team Formation Survey34 In order to determine if your team needs to hold discussions aimed at establishing a clear framework to guide its operations, would you please respond to the following questions. Remember that this survey is anonymous. 1. Familiarity: How well do you know the other members of this team? Have you been properly introduced to them? Do you know their personal goals, likes, dislikes, talents and interests? 1 2 3 4 5 Don’t know Know some things Know others quite well the others about a few people 2. Goal clarity: How clear are you about the goal of the team? 1 2 3 4 5 Unsure of our goal Somewhat unsure Clear about our goal about our goal 3. Member profile: How clear are you about other member’s individual skills? To what extent do you know who is an expert in specific areas? 1 2 3 4 5 Don’t know Know the skills Clear about skills members skills of some members of all members 4. Rules: Does the team have a set of team rules or norms that members use to govern relations and meeting management? Does the team use and update its rules from time to time? 1 2 3 4 5 We have We have rules We post our no rules but don’t use them rules and use them 5. Decision-making options: Has the team explored the different decision-making options and does the team consciously select the method best suited to each situation? 1 2 3 4 5 We are not Sometimes consider We are always aware of how we will make conscious about decision options a decision how we make decisions 6. Clients and services: Has the team created a profile of who the clients are and what services we provide? 1 2 3 4 5 No profile We are somewhat clear We have a exists about the profile profile 7. Work objectives and results measures: Does the team have detailed objectives that include specific results indicators that describe how the team plans to achieve its goal?

34 Bens, I. (2000) p. 43 & 44.

34

1 2 3 4 5 We don’t have We have some objectives We have either and/or some measures both 8. Empowerment plan: Does the team have a clear picture of which decisions it can make and which require management approval? 1 2 3 4 5 There is no We are clear about We are clear about how empowerment some items empowered we are plan 9. Roles and responsibilities: Are you clear about what’s expected of you and how your role relates to the roles of other team members? 1 2 3 4 5 I’m unclear I’m somewhat clear I’m totally clear 10. Communication plan: Does the team have a plan that describes who it should communicate with, when, and how? 1 2 3 4 5 No plans Somewhat planned We have a plan Comments: Return the completed survey to: [Insert contact information] Team members seek opportunities to define roles and responsibilities during the team formation stage. Team members “may be unclear about their expectations of each other, and group leader’s expectations of them; and are probably unsure about the roles each of them will play in the work of the group.”35 Team members will want to discuss their roles and responsibilities, often with a heavy emphasis on their tasks. Some people respond to the uncertainty of the forming stage by “want[ing] every task defined and allocated to someone and their own job, responsibilities and powers clearly defined.”36 Payne cautions that this is a polarity: there may not be a right answer, rather, the team needs to find a balance between too much uncertainty or too much constraint leading to unnecessary bureaucracy. He suggests five categories for considering team priorities, specialization and workload allocation and notes that in practice these categories are often combined with factors such as geographic location and team member skills and interests to create a complex system for defining roles and responsibilities:

legal requirements

types of work (for example, group work, cognitive-behavioural therapy)

service user categories (for example, client problems)

levels of risk, difficulty or complexity

organizational or political policies (for example, performance indicators)

C. Dimensions of Team Roles 35 Laiken, M. 1994) 36 Payne, M. (2000) p. 86.

35

Within any system of devising work roles and responsibilities, there are two dimensions that scholars of teams have observed. Both task roles and maintenance roles contribute to well functioning teams. i. Task roles Task roles, sometimes also called functional roles, are the specific descriptions of each team member’s function on the team. In order to carry out the goal of the team, the team “must develop the right mix of skills… the complementary skills necessary to do the team’s job”.37 Payne has noted that task differentiation in health and social services is generally outlined in competency documents, such as scope of practice statements, legislation or policy documents.38 Position (job) descriptions for each team member also provide a reference point for discussing task roles within the team. Examples of typical functional roles in health-care teams are physicians, dietitians, pharmacists, nurses, nurse practitioners, heath educators or promoters, and social workers or counsellors. Teams may meet as a functional team, such as a program team, administrative team, clinical team and/or as interprofessional teams that include a range of disciplines. Teams that are forming and learning their roles and responsibilities are supported by having some structure. Structure and somewhat more directive leadership take the place of the trust and confidence that has not yet been built. The team will need the leader to provide the structure that will allow them to explore roles and responsibilities while they are learning about each other and the strengths and skills they bring to the team. Examples of structure that can support teams at this stage include:

Regular team meetings.

Discussion at team meetings that helps team member to get to know each other and their complementary skills.

Collecting documentation of roles and responsibilities such as position descriptions and scope of practice statements.

A team discussion on roles and responsibilities can be stimulated by using an activity such as the one below.

What I Give, What I Need39 The goal of this discussion is to assist you to understand what each team member’s role is in support of your team’s vision and goals. First, think of your role and describe what it is that you give to this team- the complementary skills you bring and what you are willing to contribute. Then, think about what you need from the team to be effective and achieve the responsibilities associated with your role. Complete these lines at least 3 times: I provide this team with… What I need from the team is… Facilitate a round where each person provides their replies. Encourage questions and discussion so that each team member agrees and understands the role(s) of every other team member. You may want to arrange for the replies to be consolidated into a chart that is circulated to everyone as reference and can be updated as roles and membership evolve. What I give to this team What I need from this team

37 Katzenbach & Smith (2003) p. 47. 38 Payne, M. (2000) p. 85. 39 Adapted from Jude-York, D., Davis, L., and Wise, S. (2000) Virtual Teaming: Breaking the Boundaries of Time and Place (p. 31 and 32.)

36

Name: Role: Name: Role: Name: Role: Name: Role: Team challenges You may become aware that something more than clarifying roles and responsibilities through “just enough” structure and information is required when a team is grappling with some of the challenges to teamwork that are particular to primary health care teams. Two specific challenges identified in literature on primary health care teams are role confusion and power conflicts.40 Role confusion Role confusion occurs when there is ambiguity, lack of clarity and lack of predictability regarding the outcomes of one’s behaviour and is heightened in new situations where team members are uncertain of task and social expectations.41 This effect can be pronounced in interprofessional teams where professional skills overlap.42 A challenge for interprofessional teams is to come to terms with the multitude of skills now at their disposal. The difficulty lies in making the best use of team members’ skills and reducing the unnecessary duplication. With the current emphasis on interprofessional education, inclusion and appreciation of diverse skills and the pressing external need for more health-care practitioners, it is the areas of overlap that often provide the friction in teams. By holding team discussions with the goal of clarifying roles, the team can:

Reduce confusion and resulting conflict.

Reduce unrealistic expectations.

Make clear overburdened or underworked team members.

Help to avoid one person being left with all the unpleasant jobs. You can manage role confusion by:43,44

Expecting some blurring of roles in the early stages of team development.

Using role clarification to learn about your team and manage areas of work.

Anticipating the need to review and adapt roles- conventional views may not always apply

Finding opportunities for team members to work on collaborative projects where they can interact

Convening retreats with role clarification as a focus Power

40 Payne, M. (2000); Davies & Ring (2007) 41 McShane, S. (2004) Canadian Organizational Behaviour (p. 205) 42 Payne, M. (2000) Teamwork in Multiprofessional Care (p. 89) 43 Payne, M.(2000) p. 88- 91 44 Davies, L., % Ring, L., (2007) Building Better Teams: Learning from Ontario Community Health Centres AOHC p. 130.

37

A second challenging factor that influences teams’ roles and responsibilities is power dynamics. Research in community-based primary health care teams in Ontario found that power dynamics were an internal factor that could create challenges and conflict for teams.45 It has been observed that in primary care settings, “diffferences in culture, technology, training, identity and attitude to service users underpinned by differences in the structure of the professions made for difficult relations.”46 Interprofessional teams bring “together people with clearly defined professional boundaries with long traditions and authoritative and powerful professional interests.”47 Team norms and forums for decision-making and conflict management channel different understanding of roles, responsibilities, accountability and professional practice into open discussion. ii. Maintenance roles The second dimension of teamwork is often described as maintenance and includes turning attention to the process of working together as a team. Effective team work balances the achievement of task with inclusion and support to all team members. Maintenance roles are “behaviours that help the group maintain harmonious working relationships.”48 The AOHC research found that teams that supported professional development activities, participated in either planned or ad hoc social events and had opportunities for sharing important life events also helped to achieve this goal.49 Behaviours associated with maintenance include:

Encouraging: indicates by words and body language unconditional acceptance of others, agrees with contributions of other group members; is warm, friendly and responsive to other group members.

Harmonizing: attempts to reconcile disagreements; helps members reduce conflict and explore differences in a constructive manner.

Compromising: admits mistakes, offers a concession when appropriate; modifies position in the interest of group cohesion.

Gate keeping: helps keep communication channels open; points out commonalities in remarks; suggests approaches that permit greater sharing.

Setting standards: calls for the group to reassess or confirm implicit and explicit group norms when appropriate.50

Teams can assess their attention to both tasks by asking two team members to observe the team during a discussion, and noting the presence of task and maintenance behaviours using the activity below. Observing Task and Maintenance Functions During a team discussion of approximately 30 minutes, two observers use the following prompts to note team attention to task and maintenance functions. Task Functions you observed:

1. Initiating

2. Information seeking

45Belle Brown, J., Bickford, J., Moss, K. and Gollis, L. in Building Better Teams: Learning from Ontario Community Health Centres (2007) p. 109 46 Payne, M. (2000) p.182 47 Payne, M. (2000) p. 89 48 Arnold, E., and Underman Boggs, K. (2003) p. 270 49 Davies & Ring (2007) p. 105 50 Arnold, E., and Underman Boggs, K. (2003) p. 270

38

3. Clarifying

4. Consensus

5. Testing

6. Summarizing Maintenance Functions you observed:

1. Encouraging

2. Expressing

3. Group feeling

4. Harmonizing

5. Compromising

6. Gate keeping

7. Setting standards

Following the observation period, observers provide feedback and the team discusses:

Was there an adequate balance between task and maintenance activity?

What roles did different members assume?

Were the two observers in agreement as to members’ assumptions of task versus maintenance functions?

If there were discrepancies, what do you think contributed to their occurrence?

What did you learn from this exercise? You can initiate a discussion on how your team is using team meetings by utilizing a team meeting evaluation from time to time that reminds you to assess both task and maintenance dimensions. A Team Meeting Evaluation

1. How well did we do today in accomplishing our task?

1 2 3 4 5 poor fair satisfactory good excellent

2. How well did we do today in working as a group and building our relationships? 1 2 3 4 5 poor fair satisfactory good excellent

3. What were the strengths of the meeting?

4. What areas could have been improved?

5. What should be done next time?

39

Effective member checklist51

Please read the statements below. Circle the number that most accurately describes your response to the statement. Use the following key to respond to each statement:

1. Disagree strongly

2. Disagree to some extent

3. Agree to some extent

4. Agree strongly

1. I avoid blaming other for team problems. 1 2 3 4 2. I assume that every team member is trying to do a good job. 1 2 3 4 3. I encourage the process of goal, role and task clarification. 1 2 3 4 4. I work to ensure that the input and feedback of every member is heard. 1 2 3 4 5. I work to ensure that we all have the chance to demonstrate our competence and skills in the team. 1 2 3 4 6. I act, and encourage others to act, in the best interests of the team. 1 2 3 4 7. When members stray off task, I diplomatically try to bring the discussion back to that task. 1 2 3 4 8. When members contribute good ideas, I express my appreciation. 1 2 3 4 9. I encourage the use of effective problem-solving and decision-making procedures. 1 2 3 4 10. I encourage the team to outline, in advance, the strategies that will be used to solve problems and make decisions. 1 2 3 4 11. I work to ensure that decisions and solutions are implemented and evaluated. 1 2 3 4 12. I encourage norms that support productivity, innovation and freedom of expression. 1 2 3 4 13. I treat people as individuals and don’t make assumptions about them based on my pre-conceived notions. 1 2 3 4

51 Wheelan, S. (1999) Creating Effective Teams: A Guide for Members and Leaders

40

14. I discourage any team tendency to adopt excessive or unnecessary team norms. 1 2 3 4 15. I go along with norms that promote team effectiveness and productivity. 1 2 3 4 16. I encourage high performance standards. 1 2 3 4 17. I expect the group to be successful and productive. 1 2 3 4 18. I encourage innovative ideas. 1 2 3 4 19. I am, and encourage others to be, cooperative. 1 2 3 4 20. I encourage the use of effective conflict management strategies. 1 2 3 4 21. In conflict situations, I communicate my views clearly and explicitly. 1 2 3 4 22. I respond cooperatively to others to who are behaving competitively. 1 2 3 4 23. I encourage and work to achieve mutually agreeable solutions to conflict. 1 2 3 4 24. I have negotiated, or would be willing to negotiate, with other teams and individuals to help my team obtain needed resources. 1 2 3 4 25. I share information and impressions I have about other parts of the organization with the group. 1 2 3 4 26. I encourage the team not to overwhelm itself with too much external information or demands. 1 2 3 4 27. I talk positively about my team with outsiders. 1 2 3 4 28. I keep other members of the organization informed about what my team is doing. 1 2 3 4 29. I support division of labour necessary to accomplish team goals. 1 2 3 4 30. I use what I have learned about team development and productivity to help my team become effective. 1 2 3 4

41

31. I encourage the team to assess and alter its functioning frequently, if necessary. 1 2 3 4 32. I do not get bogged down in interpersonal issues or personality conflicts. 1 2 3 4 33. I support the leader’s efforts to coordinate and facilitate team goal achievement. 1 2 3 4 34. I volunteer to perform tasks that need to be done. 1 2 3 4 35. I offer advice to the leader when I think the advice will be helpful. 1 2 3 4 Minimum Score: 35

Maximum Score: 140

My Score: __________

D. References

Arnold, E. and Underman Boggs, K. (2003) Interpersonal Relationships: Professional Communication Skills for Nurses W.B. Saunders.

Association of Ontario Health Centres ( 2007) Building Better Teams: Learning form Ontario Community

Health Centres. Bens, I. (2000) Advanced Team Facilitation. Goal QPC. Canadian Health Services Research Foundation (2006) Teamwork in Healthcare: Promoting Effective Teamwork in Healthcare in Canada Jude-York, D., Davis, L., and Wise, S. (2000) Virtual Teaming: Breaking the Boundaries of Time and

Place. Crisp Publications Katzenbach, J. and Smith, D. (2003) The Wisdom of Teams: Creating the High Performance

Organization Laiken, M. (1994) The Anatomy of High Performing Teams A Leader’s Handbook Ontario Institute for

Studies in Education. McShane, S. (2004) Canadian Organizational Behaviour (5th ed). McGraw-Hill Ryerson. Payne, M. (2000) Teamwork in Multiprofessional Care. Lyceum. Wheelan, S. (1999) Creating Effective Teams: A Guide for Members and Leaders Sage Publications.

42

MODULE 4

Interpersonal Communications

A. Background There are two areas of communication that are of particular importance in primary health care teams (Guide to Collaborative Team Practice, 2005). The first is the more formal type of communication that occurs through meetings, whether team meetings, all staff meetings, team retreats or case conferences/consultations. These types of communications will be addressed in another module entitled Communication II: Meetings. The focus of this module is the second area identified, interpersonal communication, which has been defined as “a process undertaken by two or more individuals in which messages are exchanged and understood” (Chesla, 2000) The module will provide a review of interpersonal communication and suggest some activities and tools that could assist new teams in developing effective interpersonal communication from the beginning. The module is not intended to be seen as the whole story on interpersonal communication. Those interested in further training may want to explore communication workshops for their team and may find the print and web resources at the end of the module helpful. Effective interpersonal communication skills on the part of health professionals have been identified as playing a critical role in the development of collaborative relationships. Three main reasons have been suggested to explain why communication is a key determinant of successful collaboration. (San Martin Rodriguez, Beaulieu, D’Amour & Ferrada-Videla, 2005). These reasons are:

Collaborative practice demands that professionals understand how their work contributes to client outcomes and team objectives and know how to communicate this to other professionals.

Efficient communication is essential as it allows constructive negotiations with other professionals.

Communication is a vehicle for the other determinants of successful collaboration (mutual respect, sharing and trust).

The findings of the research conducted by AOHC validate the findings outlined in the literature. Open lines of communication are recognized as necessary to effective teamwork and effective communication contributes in several ways to interprofessional teamwork. (Brown, Bickford, Moss and Gillis, 2007; Bickford, Brown. Moss and Gillis, 2007). In CHCs, effective communication was identified as important for the following reasons:

The ability to communicate and discuss concerns both formally and informally was identified as important to reducing the stress of the work in CHCs.

Casual face to face encounters provide support and assistance to team members in their roles.

Poor communication was identified as a barrier to resolving conflict. The awareness and respect for each others’ strengths that is necessary for effective collaboration requires communication both within each team, and across all programs and services. The Ontario Ministry of Health has recognized the importance of communication in primary health-care team and has suggested that effective communication is one of the attributes that characterizes a well functioning team,

Team members need to be willing and able to listen to each other, express their ideas and respond to what they hear. This is easier if team members feel comfortable sharing information with fellow team members and in addressing issues as they arise in a style that is clear and direct. (Guide to Collaborative Team Practice, 2005)

43

B. Communication Styles People have particular styles of communication with which they are most comfortable and use most often. These styles evolve from inherited traits, teachings and life experiences. (Robbins & Hunsaker, 2008). Being aware of your communication style and the styles of others can be a benefit in working within an interprofessional team. The following section outlines eight commonly found communication styles and a self assessment tool is provided to help individuals reflect critically on their own style. The tool can be used for both individual self reflection and/or as a group exercise within a team to help the team learn about the diversity of styles within its membership. I. Eight Common Communication Styles52

Avoidance

This is a communication style adopted by many people because they are afraid, for a variety of reasons, to displease or anger a receiver. Often their avoidance sets the stage for conflict. Even though many problems will go away or disappear if ignored, others – because they tend to engender strong emotions – may escalate, even to the point of violence. Accommodation

This communication style takes into consideration the wants and needs of others (receivers) at the expense of the wants and needs of the communicator. There are times when accommodation is useful and there are times when a less accommodating style is necessary, depending on the importance of the issue. Compromise

This style is often used when reducing tension is desired. It can lead to a middle ground and can be useful when decisions need to be made quickly or do not have serious consequences. People who compromise give away something of themselves to receivers. This can be useful when seeking peace but may create future tensions that will need to be resolved. Some people who compromise wind up unhappy, thinking that they have not attended to their own needs or have not been true to themselves. For this reason, the act of compromising has been perceived as negative, although it is not always so. Aggression

A person who has an aggressive communication style may give the receiver the impression that maintaining his or her position is more important than maintaining good human relations or reaching a mutually agreeable resolution. An aggressive communication style often puts the receiver into a defence mode. This may move a dispute into an impasse or to an accommodating style on the one hand or escalate to an aggressive style on the other. The highest escalation of this style is personal violence or warfare. Long-term solutions generally are not products of this style. Assertion

An assertive communication style generally is received well because it combines firmness of purpose with a willingness to listen and work through situations. An assertive person clarifies his or her wants and needs as well as those of the other person. Assertiveness is a neutral style that does not include threats. A person with an assertive communication style may or may not collaborate but has the ability to stand firm on his or her principles without aggression. Collaborative

52 Figures 1 is adapted from Kestner & Ray. (2002) The Conflict Resolution Training Program. Participant’s Workbook. Jossey Bass. San Francisco. p 35-38

44

A collaborative style holds possibilities for problem solving because it encourages trust. It indicates a willingness to cooperate and encourages receivers to be flexible and creative. Collaborators generally seek common ground. Flexible

This communication style is a combination of all of the styles listed above. There may be times when it is best to use a variety of styles in order to communicate most effectively. For example, this may include being passive, accommodating, assertive, and collaborative. Worksheet: Personal Communication Style53

Describe the communication style that you usually use at work. Describe the communication style that you usually use at home. Describe the communication style that you usually use with friends. Describe the predominant characteristics of the communication style you use most often. Describe a communication style that tends to irritate you. Describe a communication style that you respect in other people

53 Kestner & Ray. (2002) The Conflict Resolution Training Program. Participant’s Workbook. Jossey Bass. San Francisco. p 35-38

45

C. Active Listening Skills Listening “tops the list” of communication skills (Robbins & Hunsaker, 2008, p 88). The same authors suggest that we confuse hearing with listening. Hearing is merely picking up sound vibration while listening is making sense out of what we hear. Communication problems can be reduced when effective listening skills are used regularly by all team members. The following provides a self assessment tool and scoring information for team members to assess their own listening skills. Self assessment: My Listening Habits54 For each of the following questions, select the answer that best describes your listening habits:

Scoring and Interpretation For questions 1, 3, 5, 6, 7, and 8, give yourself 3 points for Usually; 2 points for Sometimes; and 1 point for Seldom. For questions 2, 4, 9, and 10, give yourself 3 points for Seldom; 2 points for Sometimes; and 1 point for Usually. Sum up your total points. Score of 27 or higher means you’re a good listener. A score of 22-26 suggests that you have some listening deficiencies. A score below 22 indicates that you have developed a number of bad listening habits. After completion of the assessment and if your team is interested and willing, each team member could set their own learning goals in this area, practice the skill and then ask for feedback from the other team members. Giving and receiving effective feedback are in themselves communication skills and there are some guidelines regarding feedback later in the module. Active listening skills are often

54 Robbins & Hunsaker, (2008), p88

Usually Sometime Seldom

1. I maintain eye contact with the speaker. ______ ______ ______

2. I determine whether or not speakers’ ideas are worthwhile solely by their appearance and delivery. ______ ______ ______

3. I try to understand the message from the

speaker’s point of view. ______ ______ ______

4. I listen for specific facts rather than for the big picture. ______ ______ ______

5. I listen for factual content and the emotion

behind the literal words. ______ ______ ______

6. I ask questions for clarification and understanding. ______ ______ ______

7. I withhold judgment of what speakers are

saying until they are finished. ______ ______ ______

8. I make a conscious effort to evaluate the logic and consistency of what is being said. ______ ______ ______

9. While listening, I think about what I’m going

to say as soon as I have my chance. ______ ______ ______

10. I try to have the last word. ______ ______ ______

46

taught to health-care professionals in the context of client interviews and counselling but the same skills are just as basic to interprofessional communication. The following outlines the basic skills of active listening.

i. Basic Skills of Active Listening55

Communication Skill Examples Open ended questions invite the speaker to say more about a given topic without limiting the kind of information.

Can you tell me more about that? What happened next? How did the client react?

Encouraging statements convey interest in what the person is saying and encourages them to keep talking.

I would like to hear more from you about the incident/the patient/the situation? I am interested in knowing if you were concerned about the interaction with the patient

Clarifying Questions are useful to gain more information and to help the speaker be specific.

Can you give me an example? Can you help me picture the situation? What would you like to see happen?

Summarizing is help to show you are listening and understand what is being said and to check your interpretation of what you heard.

You saw the patient as anxious, upset and angry. You were hoping the client would accept the diagnosis more readily than she did.

Reflecting feelings (also called echoing or mirroring) shows that you understand how the speaker feels/felt and helps the speaker clarify his/her own feelings after hearing them named by a third party. Reflecting feelings is helpful to reducing emotional intensity.

You are upset that the client was unable to hear you the first time. You felt hurt that your co-worker would treat you this way.

Using silence, sometimes waiting for the person to speak can get you more information than asking more questions, silence helps a person recall what went on.

Validating is used to acknowledge another person and show appreciation for their actions

I appreciate you being flexible to meet the needs of the team on such short notice. I appreciate your willingness to discuss these matters with me.

Focused questions narrow the range of information and so are used when specific information is needed and can help a person recall more details and specifics.

What actually transpired between you and the client? What did he say to you?

D. Communication and Conflict 55 Adapted from Ivey, A., & Ivey, M. (2003) Intentional Interviewing

47

Effective communication can assist in resolving conflict in teams; some types of communication can cause conflict or exacerbate it. (Robbins & Hunsaker, 2008). When you are having conflict within the team, whether in the storming stage of group development56 or at other times, the types of communication that can contribute to further conflict and/or entrenched conflict are contained in the following section.57 If you are finding that your team uses these types of communications regularly, it may be helpful to ensure an effective feedback process and/or undertake team training in interpersonal communications.

Dichotomization. This is the process of narrowly viewing only two options, viewpoints or solutions – the “either/or” phenomenon.

Comparison. Some comparisons about situations and things are helpful. Others are detrimental or unnecessary. For example, an irritating and useless comparison is when an employee compares a present supervisor to a former supervisor.

Polarities and extremes. It often is not helpful to deal with extremes. Answers are more often found in the middle ground.

“Yes, but.” People frequently respond to ideas or advice by starting a sentence with “Yes, but ... “Yes, but” has been called a verbal erasure of what has previously been stated. It seems to indicate a rejection of the advice or an unwillingness to try out the suggestion.

“The answer.” Frequently, during problem-solving situations, people fixate on one answer rather than being creative and generating several possible answers.

E. Gender and Communication Communicating with other professionals within an interprofessional team means communicating across gender. Taking gender into account and understanding the differences in the way men and women communicate will lead to more effective communication and therefore the mutual trust and respect needed for effective team work. While stereotyping itself can be a barrier to communication, some gender differences in communication have been identified in the research. The following chart presents a summary of that research as outlined in Robbins and Hunsacker, (2008 p.124-125). One suggestion for a team activity would be to discuss the information in the chart and consider your team and any differences and/or similarities you see. Are these gender differences evident in your team? Are there others you experience that are not listed here?

Women Men

Focus on relationships Focus on facts Seek connection with others Seek solutions

Use intense adverbs Use words that are more descriptive and defining

Use more qualifying terms Use less qualifying terms Can seem unsure of self Can appear more self assured

Task orientation Process/people orientated Talk and interrupt less Talk and interrupt more

F. Culture and Communication

56 Please see Davies & Ring (2007) Building Better Teams for information regarding stages of team development. 57 Kestner & Ray, (2008) p77

48

Cultural competence has yet to be made integral to the education of health professionals or essential to standards of practice (Purden, 2005). This means that many of the health-care professionals working in primary health-care teams may not have had any exposure to the concepts of cultural competency and cross cultural communication skills. Assisting leaders and team members to become culturally competent is well beyond the scope of this module. Becoming fully culturally competent requires training, mentoring, critical self evaluation, experience and time. The tools that are provided here are intended to be a starting point only. The following provides a definition of cross cultural communication: “Cross cultural communication competence is the ability to communicate effectively in cross cultural situations and to relate appropriately in a variety of cultural contexts.”58

Effective Cross-Cultural Communication59 To communicate effectively across cultures I try to be...

1. Sensitive to my own cultural reality.

2. Aware of my own values and biases and how they may affect other people.

3. Open to learn about each person’s background, without making assumptions.

4. Comfortable with differences between myself and others,

5. Aware of factors that influence communication, and able to generate and receive a wide variety

of verbal and non-verbal messages.

6. Informed about the way the socio-political system operates in Canada with respect to minorities,

and about the impact of racism and systemic discrimination.

7. Aware of my own limitations, and able to make appropriate referrals.

8. Committed to principles of equality and fairness for all.

9. Able to recognize and learn from my own mistakes, and start again.

G. Giving and Receiving Feedback Teaching and learning communication skills is best achieved in small groups using experiential methods. (Priest, Sawyer, Roberts & Rhodes, 2005). As a small group, your primary health care team can be a site for learning new skills. The team members are well placed to contribute to each other’s development. A key ingredient in learning a new skill is receiving feedback. As people develop new or improved skills, they need feedback as to how they are doing, what progress has been made and what still needs improvement. The following provides some guidelines for giving feedback. i. Characteristics of Helpful Feedback60 1. Helpful feedback is descriptive, not judgemental.

To be told that ‘You are an arrogant bully’ is less helpful than to be informed that: ‘Whenever you and I discuss this kind of issue I am left with the feeling that you don’t listen to my views and that you attempt to get your way by threatening me.’ The first example is evaluative: the giver of the feedback is making a judgement about the other’s behaviour. The second example is more descriptive. It describes the effect the behaviour had.

58 Bennet & Bennet (2004) Developing Intercultural Sensitivity: An Integrated Approach. p 149 59 Teach Me to Thunder (1997) 60 Hayes, J. (2002) Interpersonal Skills at Work.

49

2. Helpful feedback is specific, not general.

To be told: ‘You never seem to be able to communicate effectively in groups’ offers the other person few clues about what they might to differently to improve matters. On the other hand, to be told that: ‘When you were presenting your case to the group last Thursday you spoke so quickly that I couldn’t grasp all the points you were trying to make’ provides the other person with information that is sufficiently specific for them to determine how they may change their behaviour if they want to obtain a different outcome at the next meeting. 3. Helpful feedback is relevant to the needs of the receiver of feedback.

We need to be aware of whose needs we are trying to satisfy when we offer feedback. Sometimes feedback does more for the giver than the receiver. For example, an angry outburst may help relieve our frustrations but do little for the other person. 4. Helpful feedback is solicited rather than imposed.

People seek feedback in many circumstances. However, while they may ‘want to know’ they may be fearful of finding out. We need to be sensitive to those cues which signal when they have received as much as they can cope with for the time being. Pushing too hard, and continuing to give feedback to people who have already been given as much as they can cope with, can trigger a defensive reaction. It can lead to the person dismissing or ignoring further feedback. People tend to be much less receptive to feedback which they feel is imposed than to that which they have sought out for themselves. 5. Helpful feedback is timely and in context.

Feedback is best given as soon after the behaviour as possible to avoid confusion. The introduction of formalised appraisal systems sometimes encourages helpers to store up feedback for the appraisal interview when it would have been much more effective if it had been offered at the time the problem was observed by the helper. However, accurate behavioural records such as audio- or videotape-recordings can extend considerably the period over which the feedback is timely; these methods also preserve much of the context and therefore are particularly valuable in training situations. 6. Helpful feedback is usable and concerned with behaviour over which the receiver is able to exercise control.

Feedback can improve a person’s knowledge of how they typically behave and the effects their behaviour has on others. However, feedback can only help others secure desired outcomes if it focuses on behaviour they can do something about. To tell a person who has a severe stutter that they are making you impatient, and that they should be quick and say what they have to say or shut up, is unlikely to afford much help. 7. Feedback can only be helpful when it has been heard and understood.

If in doubt, we need to check with the other person to ensure that the feedback has been received and understood.

H. Resources

50

Practice Guideline: Culturally Sensitive Care (2008) College of Nurses of Ontario: Available from the College of Nurses Website. www.cno.org/docs/prac/41040_CulturallySens.pdf

A new resource that provides principles and practices for culturally sensitive care. Although focusing on

client care, the resource is very relevant to interprofessional collaboration. Gallois, C. & Callan, V. (1997). Communication and Culture: A Guide for Practice. New York: John Wiley

& Sons. A practical hands-on resource that looks at how culture influences values, social rules, self expression,

relationships and social identity. A resource for anyone who wants to become more culturally competent

Robbins, S. & Hunsaker, P.L. (2008). Training in Interpersonal Skills: Tips for Managing People at Work

(3rd ed). Prentice Hall. New Jersey. An accessible resource with many exercise and self-assessment checklists about interpersonal

communication. The title implies the resource is for managers, but it would be helpful for anyone wanting to work on their communication skills.

51

I. References Bennet & Bennet (2004) Developing Intercultural Sensitivity: An Integrated Approach to Global and

Domestic Diversity in D Landis, J.M. Bennett & M.J. Bennet (Eds.) Handbook of Intercultural Training 3rd edition pp 147-165 Sage. California

Brown, J.B., Bickford, J., Moss, K., & Gillis, L. (2007) What Makes a Team Work in a Community Health

Centre? in D. McMurchy, L. Gillis, & K. Moss (Eds.), Building Better Teams: Learning from Community Health Centres. Association of Ontario Health Centres. Toronto.

Bickford, J., Brown, J.B., Moss, K., & Gillis, L. (2007). Challenges to Teamwork in CHCs in D. McMurchy,

L. Gillis, & K. Moss (Eds.), Building Better Teams: Learning from Community Health Centres. Association of Ontario Health Centres. Toronto.

Chesla, Erik. (2000) Successful Teamwork: How to become a Team Player. Learning Express, New York Davies, L., & Ring, L., (2007) Building Better Teams: A Toolkit for Strengthening Team Work in

Community Health Centres. Association of Ontario Health Centres.Toronto Guide to Collaborative team practice (2005) Family Health Teams: Advancing Primary Health Care.

Ministry of Health and Long Term Care. Toronto Retrieved September 19, 2008 from www.health.gov.on.ca/transformation/fht/guides/fht_collab_team Hayes, J. (2002). Interpersonal Skills at work. Routledge... London Kestner, P.B. & Ray, L (2002), The Conflict Resolution Training Program: Participants Workbook. Jossey

Bass. San Francisco. Purden, M., (2005) Cultural Considerations in Interprofessional Education and Practice. Journal of

Interprofessional Care. May. Supplement.1 224-234. Priest, H., Sawyer, A., Roberts, P. & Rhodes, S. (2005) A survey of interprofessional education in

communication skills in health care organizations in the UK. Journal of Interprofessional Care 19 (3) 236-250

Robbins, S. & Hunsaker, P.L. (2008). Training in Interpersonal Skills: Tips for Managing People at Work

(5th rd ed). New Jersey: Prentice Hall. San Martin-Rodriguez, L.S., Beaulieu, M. D., D’Amour, D., & Ferrada-Videla, M. (2005). The

Determinants of Successful Collaboration: A Review of Theoretical and Empirical Studies in Journal of Interprofessional Care. May Supplement 1 p. 132-147.

Teach me to Thunder: A Training Manual for Anti-racism Trainers (1997). Canadian Labour Congress,

Ottawa.

52

MODULE 5

Meetings A. Background The AOHC research found that meetings need to be valued as a legitimate and critical part of effective team work. While it is widely recognized that the demand for client care and community involvement continues to grow and competes with meeting time, not having the time to meet can undermine the effectiveness of collaboration. (Laiken, 2007) The literature on interprofessional care confirms the importance of meetings as a method for the team to share information, develop interpersonal relationships and address team issues. (San Martin Rodriguez et al, 2007). In many CHCs, meetings are the only way that teams learn about each others day to day work and understand each others perspective and roles, and share new ideas, strategies and information. (Gierman, 2007) The AOHC research suggests that meetings need to be reframed as key to establishing high performing teams in CHCs. Encouraging meetings during work hours, providing the needed support and resources, booking blocks of time well ahead to allow part time staff and others to schedule their attendance and defining the task in meetings so that staff see them as contributing to their work with clients all can go a long way to valuing the time spent in meetings. (Laiken, 2007) There is a consensus in the AOHC research and the interprofessional care literature that meeting together as professionals supports effective collaboration. At the same time, many people anecdotally note that there seems to be ‘too many meetings that do not seem to accomplish a great deal. This module is intended to assist new teams in establishing effective meetings that contribute to effective collaboration. The questions that will be addressed are:

When is a meeting the most appropriate means of communication?

What are the types of meetings we would expect to have in primary health care?

What makes a meeting effective?

What contributes to ineffective meetings?

How might ineffective meetings be improved?

How do we evaluate our meetings?

B. To Meet or Not to Meet There are many methods available to communicate information and community health centres in Ontario use a variety of methods for communication such as written memos, web based communications such as intranets, email communication, newsletters and face to face meetings. (Davies & Ring, 2007). Meetings may not always be the most appropriate and effective means of communication. Choosing the appropriate method of communication can reduce the number of unnecessary meetings and the frustration that comes with them. Organizational communication research suggests that face to face meetings are the preferred method of communication when interaction, responsiveness, immediacy and sensitivity are needed in communications (Gillis, 2006). A great deal of communication in primary health care requires these elements which explains why meetings are frequently chosen as the medium for communication.

i. Types of Meetings in Primary Health Care Case Consultation

These are meetings that are often planned for a regular time and can also occur spontaneously in the day to day work of providing client are. Case consultations among professionals help to establish the

53

best care for the client but also build trust between team members as each learns about the other’s functional role. Senior professionals often provide mentoring to younger colleagues and students through case consultation. Team meetings (Ongoing)

Regular team meetings provide opportunities for the whole team to discuss issues such as quality client care, program development and team work planning. Team decisions are frequently made through discussions at team meetings and the meetings provide an opportunity to include everyone in decisions that affect them. Conflict resolution can also occur at team meetings. All staff meetings

All staff meetings are often used for leaders to communicate sensitive information that is relevant to the whole group. All staff meetings, frequently held monthly, can also develop relationships across programs and reduce the silos that can occur between clinical teams and health promotion and community teams. (Bickford, Brown, Moss & Gillis, 2007). The awareness and respect for each others strengths that is important to collaboration requires communication within each team and across all programs and services. (Brown, Bickford, Moss and Gillis, 2007). All staff meetings are an opportunity for these processes to occur. Project Team Meetings

These types of meetings are usually time limited for the course of a specific project. They have a beginning, middle and ending phases and usually a designated team leader. There may be only internal staff or may include people external to the organization if a partnering relationship on the project has been established. ii. The 5 Key Ingredients for Effective Meetings Meetings can accomplish many of the team’s goals. In order for that to happen, there are key ingredients to making your meetings both satisfying and productive. The 5 key ingredients will be reviewed in the order they are presented here:

1. Meetings need a stated and agreed upon purpose.

2. Meetings need to have an agenda.

3. Key roles of facilitator, note taker and time keeper need to be in place.

4. Ground rules (often called norms) need to be developed and maintained.

5. All team members need to take responsibility for the success of meetings.

6. Meetings need to be regularly evaluated and improvements made when necessary. 1. Every Meeting Needs a Purpose

When people come to the same meeting with different ideas and assumptions about the purpose, it can lead to difficulties. Most good meetings start in advance with good preparation and good preparation starts with identifying the purpose or purposes of the meeting. Identifying the purpose would include asking questions such as, What do we want to accomplish? What are our goals? What needs to be resolved? Discussed? Decisions made? If there is more than one purpose for each meeting this should be made explicit and everyone in the meeting needs to know all of the intended purposes. The Purpose Defines the Agenda 2. Meetings Need to Have an Agenda

Once the purpose is clear an agenda needs to be created that will accomplish those purposes. Ideally, the participants would receive the agenda ahead of time to allow then to come prepared for discussion of the agenda items. The agenda should include the purpose of the meeting, the topics to be discussed with a sentence or two that defines each item, the lead person for each topic and the estimate of time

54

it will take to address that item. If it is not possible to have the agenda available ahead of time, the first few minutes of the meeting should be devoted to developing the agenda. A sample agenda is as follows: Sample Meeting Agenda61 Team_____________________________________________ Purpose of meeting__________________________________ Date, Time, Place___________________________________ Time Agenda Topics Person Providing Information Review agenda Meeting facilitator Topic One Topic Two Topic Three Topic Four Decision Summary Note taker Action Summary Note taker Identify Items for next

meeting All

Evaluate the meeting All

3. Determining Important Meeting Roles

A stated purpose, a well planned agenda will help with obtaining effective meetings, but it is the people in the meeting that make it work or not work. The first step is to establish three key roles; meeting facilitator, timekeeper and note taker. (Scholtes, Joiner & Streibel, 2003 & Bens, 1997). The role of the meeting facilitator is to:

Open the meeting

Review the agenda

Make sure the roles of note taker and timekeeper have been decided

Move through the agenda one item at a time

Keep the participants focused

Establish an appropriate pace

Facilitate discussions

Manage participation

Help the group use appropriate decision making methods

Help the group evaluate the meeting

Gather ideas for the next meeting

Close the meeting

The roles of the timekeeper are to:

Move the meeting along by keeping track of time during the meeting

Alert the group when the allotted time or an item is almost up so the team can decide whether to continue, or postpone the discussion

The note takers responsibilities are to:

61 (Scholtes, Joiner & Streibel, 2003).

55

Serve as the record keeper/historian by recording key points raised during discussions, decisions made, action items, and items to be discussed in subsequent meetings

to distribute/post the minutes as soon as possible after the meeting

As the meeting participants become more skilled, meeting roles can be combined or modified to fit the circumstances. Within a meeting, skilled members can fluidly take turns acting as timekeeper, note taker and facilitator (Scholtes, Joiner & Streibel, 2003). 4. Establishing Ground Rules

Agreeing on the purpose of the meeting, having an agenda a head of time and deciding on the important roles will ensure that you are well on your way to establishing effective meetings. The next important ingredient is establishing the norms for how the team members will relate to each other and ensure effective discussions. Establishing norms or ground rules for meetings can in itself be a team building activity. Questions such as ‘what do people expect of each other and of the leader? and ‘what types of behaviours are acceptable and not acceptable?’ are important questions to be answered during the forming stage of team development. The process of discussing the ground rules can assist in the development of trust which is so critical to interprofessional collaboration. Each team will have differing norms depending on the outcome of the discussions, but there are common areas that norms need to be developed for. The following gives examples of the types of norms that need to be developed. Setting Ground Rules62 Attendance

Teams should place a high priority on attending meetings. Identify legitimate reasons for missing a meeting and establish a procedure for informing the Team Leader if a member is unable to attend. Decide how to bring absent members up to speed.

Promptness

Team meetings should start and end on time. This makes is easier on everyone’s schedule and avoids wasting time. How strongly does your team want to enforce this rule? What can you do to encourage promptness? What does “on time” mean to your team?

Disagreements when handling conflict

Focus on ideas, not people. Agree to look at pros and cons of all ideas and to value and respect different perspectives. Resolve differences of opinion with data wherever possible.

Participation

Everyone’s viewpoint is valuable. Therefore, emphasize the importance of both speaking freely and listening attentively.

Interruptions

Decide when interruptions (e.g., phone calls) will be tolerated and when they won’t. Turn off beepers and cell phones, or set them to “vibrate.”

Basic conversational courtesies

Agree to listen attentively and respectfully to others; don’t interrupt; and don’t hold more than one conversation at a time.

62 (Scholtes,, Joiner & Streibel, 2003).

56

Confidentiality

Decide what information should not be discussed outside of the meetings.

Assignments

Much of a team’s work is done between meetings. When members are assigned responsibilities, it is important they complete their tasks on time.

Breaks

Decide whether to take breaks, and how long breaks will be.

Rotation of responsibilities

Decide who will be responsible for facilitating the meeting, taking notes, acting as a timekeeper, writing minutes, setting up the meeting room, etc., and how to rotate these duties among members.

Meeting place and time

Specify a regular meeting time and place, and establish a procedure for notifying members.

5. All team Members are Responsible for the success of meetings

Everyone on a team has an investment in ensuring the team meets its goals. Each member brings different skills to being effective in meetings and some members are more skilful than others. Meeting skills, like most skills can improve with practice. Each team member can begin by reflecting on the skills they do have and the areas for improvement. The meeting skills checklist presented in Figure 3 can be filled in individually or as a team exercise. If the team has developed enough trust in each other, team members may want to consider asking for feedback as they practice with the intention of developing new skills

Figure 3: Meeting Skills Checklist

Behaviour Never Occasionally Often 1. I suggest procedures for the group to follow or

methods for organizing the task.

2. I suggest new ideas, activities, problems, or courses of action.

3. I attempt to bring the group back to work when joking, personal stories, or irrelevant talk goes on too long.

4. I suggest, when there is some confusion, that the team make an outline or otherwise organize a plan for completing the task.

5. I initiate attempts to redefine goals, problems, or outcomes when things become hazy or confusing.

6. I elaborate ideas with concise examples, illustrations. 7. I suggest resource people to contact and bring in

materials.

8. I present the reasons behind my opinions. 9. I ask others for information and/or opinions. 10. I ask for the significance and/or implications of facts

and opinions.

11. I see and point out relationships between facts and opinions.

12. I ask speakers to explain the reasoning that led them to particular conclusions.

13. I relate my comments to previous contributions.

57

14. I pull together and summarize various ideas presented.

15. I test to see if everyone agrees with, or understands, the issue being discussed or the decision being made.

16. I summarize the progress the group has made. 17. I encourage other members to participate and try to

unobtrusively involve quiet members.

18. I actively support others when I think their point of view is important.

19. I try to find areas of agreement in conflicting points of view (e.g., “How could we change our solution so that you could support it?” or “It sounds to me that we all agree to X, Y, and Z.”.

20. I use appropriate humour to reduce tension in the group.

21. I listen attentively to others’ ideas and contributions. 6. Evaluate your Meetings Like every other aspect of your work, it is important to evaluate. Meetings are processes and can be studied and improved upon like any other process. Some authors suggest evaluating every meeting (Scholtes, Joiner & Streibel, 2003 & Bens, 1997). After a series of evaluations, improvements and re evaluations, team members develop a common understanding of what ‘a good meeting is’. There are several short methods for evaluating each meeting.63 1. Round robin comments: Let each member of the team share her or his comments about the meeting in turn.

2. Open discussions: Anyone speaks in any order

3. Thumbs up, thumbs down thumbs sideways. Everyone signals their overall evaluation of the meeting (good, neutral, negative). Then each person in turn explains why.

4. Flip Charting: This involves putting three questions up on a flip chart.

What were the strengths of the meeting? What were the weaknesses? What should we do to correct the weaknesses?

Each participant in the meeting adds their comments, and the results are discussed at the next meeting

5. Exit Survey: A short survey can be filled in by each person and the results shared at the next meeting.

Our meeting today was:

Rambling 1 2 3 4 Focussed The pace was:

Too fast 1 2 3 4 Just right

63 Adapted from (Scholtes, Joiner & Streibel, 2003 & Bens, 1997).

58

Everyone got a chance to participate

No 1 2 3 4 Yes Our purpose was

Confused 1 2 3 4 Clear We followed our ground rules

No 1 2 3 4 Yes Intervening When Meetings become Ineffective Despite your best intentions, sometimes meetings do not go well and people are reluctant to come. The following chart suggests interventions based on a presenting symptom.

SYMPTOMS INTERVENTION As each person finishes speaking, the next person starts a new topic. There is no building on ideas, thus no continuity of discussion. This results in a half-dozen topics in the air.

Have each person acknowledge the comments of the last speaker. Make it a rule to finish a point before moving forward.

People argue their side, trying to convince others that they’re right rather than understanding either the issue or anyone else’s input. There is no listening.

Train members to paraphrase what is said in response to their point. Use the flip chart to record all sides of an issue. Get everyone to understand these differing views. Only then, try for a decision.

As soon as a problem is mentioned, someone announces that they understand the problem. A solution is very quickly proposed and the discussion moves to another topic.

Use cause and effect diagrams or systematic problem-solving to bring structure to meetings. Become thorough in solving problems. Avoid jumping to obvious solutions.

Whenever someone disagrees with a group decision, the dissenting view is ignored.

Develop an ear for dissenting views and make sure they get heard. Have someone else paraphrase the dissenting opinion.

The group uses brainstorming and voting to reach all decisions.

Pre-plan meeting processes so other tools are on-hand, and then use them.

Conversations often go nowhere for twenty to thirty minutes. In frustration the group goes on to another topic.

Set a time limit on each discussion and halfway through evaluate how it’s going. Use periodic summaries and push for closure.

People often speak in an emotional tone of voice. Sometimes they even say things to others that are quite personal.

Have people stop and rephrase their comments so there are no distracting personal innuendoes.

Group members hold frequent side meetings to discuss what they’re thinking. No one says any of this out loud of course.

Encourage honesty by valuing all input. Draw side chatterers back to the general conversation.

Group members don’t notice they’ve become sidetracked on an issue until they’ve been off-topic for quite awhile.

Call “sidetrack” or have some other signal to flag it. Decide if you want to digress or park the particular issue.

59

Only the real extroverts, or those with “power,” do most of the talking. Some team members say little at most meetings.

Use round-robins to get input. Call on members by name. Use idea slips to get written comments from everyone.

No one pays attention to body language or notices that some people have tuned out or even seem agitated.

Make perception checks and ask people to express their feelings.

There is no closure to most topics. Little action takes place between meetings.

Stress closure. Reach a clear decision and record it. Have an action planning form handy. Bring actions forward at the next meeting.

There is little achieved week after week. Do a meeting evaluation, and discuss the outcome before the next meeting. Post any new rules or improvement.

Effective meetings do not just happen; they require planning facilitation. Effective meetings can enhance collaboration which in turn enhances client care. Building the foundations for effective meetings early in the team’s development is worth the time and energy.

C. Resources

1. An informative website is www.effectivemeetings.com. This website is also referenced as part of the Collaboration Toolkit at the federally funded Enhancing Interdisciplinary Collaboration in Primary Health Care www.eicp_acis.ca The website contains a over a hundred tips and tools such as:

10 Commandments of meetings

Spend less time in meetings

Leading a Meeting

Dealing with Meeting Notes

Six tips for Effective Meetings

How to Create an Agenda, Step by Step

10 tips for Starting and Finishing your Meetings on Time

Fun in the Meeting Room

Test your meeting IQ 2. Scholtes, P. R., Joiner, B. L. & Streiber, B. J. (2003). The Team Handbook (3rd ed.) Madison, WI,

Oriel Incorporated. This resource has several practical and accessible sections on meetings and how to make the best use of meeting time. Section headings include:

Guidelines for Good Meetings

Guidelines for Effective Record Keeping

Guidelines for Effective Discussions.

Guidelines for Initial Team Meetings

Guidelines for Regular Team Meetings

Guidelines for closing a project

60

D. References

Bens, I. (1997). Facilitating With Ease Toronto, Ontario: Participative Dynamics Brown, J.B., Bickford, J., Moss, K., & Gillis, L. (2007) What Makes a Team Work in a Community Health

Centre? in D. McMurchy, L. Gillis, & K. Moss (Eds.), Building Better Teams: Learning from Community Health Centres. Association of Ontario Health Centres. Toronto.

Bickford, J., Brown, J.B., Moss, K., & Gillis, L. (2007). Challenges to Teamwork in CHCs in D. McMurchy,

L. Gillis, & K. Moss (Eds.), Building Better Teams: Learning from Community Health Centres. Association of Ontario Health Centres. Toronto.

Davies, L., & Ring, L., (2007) Building Better Teams: A Toolkit for Strengthening Team Work in

Community Health Centres. Association of Ontario Health Centres.Toronto Gierman, N., Jackson, S., Bickford, J., Brown, J.B., Gillis, L. & Moss, K. (2006).Health Promotion in

Community Health Centres (CHCs): Silos or Teams in D. McMurchy, L. Gillis, & K. Moss (Eds.), Building Better Teams: Learning from Community Health Centres. Association

of Ontario Health Centres. Toronto. Final Report. Gillis, Tamar (2006) Internal Communication Media in Gillis, T (ed.) The IABC Handbook of

Organizational Communication: A guide to Internal Communication, Public relations, marketing and leadership. Jossey-Bass.San Fransisco

Laiken, M. E., Chatalalsingh, C., Brown, J.B., Bickford, J., Moss, K. & Gillis, L. (2006). Organizational

Support for Interprofessional Teams in Primary Health Care in Building Better Teams: Learning from Community Health Centres. Association of Ontario Health Centres. Toronto.

San Martin-Rodriguez, L.S., Beaulieu, M. D., D’Amour, D., & Ferrada-Videla, M. (2005) The

Determinants of Successful Collaboration: A Review of Theoretical and Empirical Studies in Journal of Interprofessional Care Supplement 1 May, p132-147

Sholtes, Peter R., Brian L. Joiner and Barbara J. Streibel. The Team Handbook. Third Edition. Oriel

Incorporated, 2003. Gierman, N., Jackson, S., Bickford, J., Brown, J.B., Gillis, L. & Moss, K. (2006).Health Promotion in

Community Health Centres (CHCs): Silos or Teams in D. McMurchy, L. Gillis, & K. Moss (Eds.), Building Better Teams: Learning from Community Health Centres. Association

of Ontario Health Centres. Toronto. Final Report.