Vol. 30, No. 3, pp. 211–220 Constructing a Team...

Nurs Admin QVol. 30, No. 3, pp. 211–220c© 2006 Lippincott Williams & Wilkins, Inc.

Constructing a Team ModelCreating a Foundation forEvidence-based Teams

Tim Porter-O’Grady, EdD, APRN, FAAN;Daniel R. Alexander, MS; Jo Blaylock, MS;Nazem Minkara, MS; Dominique Surel, MBA

Teams are the fundamental element of work in the contemporary clinical setting. As interdisci-plinary teams become an essential component of the evidence-based framework for clinical prac-tice, their formalization, integration, and synthesis within the practice framework will becomeincreasingly mandatory. Outlined here is a contextual model for team action that is formalizedas the organizational leadership continuously addresses the structural and process componentsof team dynamics in a continuous and cybernetic frame that assures all of the elements of effec-tive teamwork. The theoretical foundations for team modeling are explicated, the elements of thesystems approach to team process are outlined, and a necessary synthesis of team processes isdescribed and established as a foundation for evidence-based clinical practice. Key words: cy-bernectic, evidence-based teams, interdisciplinary, systems models, team dynamics, teams

TEAMS are increasingly becoming the for-mat for ways of doing work as the nature

of clinical work is being dramatically trans-formed. Creating models that conceptualizeand contextualize team processes are impor-tant to clinical leaders in order to provide anevidence-based context to the work of leader-ship and to delineate the elements, relation-ships, and flow of teams. Outlined here is aninnovative Dynamic Cybernetic Team (DCT)model reflecting the state-of-the-art thinkingand research on concepts and application ofan evidence-building team model. Incorpo-rated into the DCT model are the elementsthat give the direction, organizational strategy,contextual influences, organizational mission,and purpose and the action stages that relateto implementation and application of the el-ements of the team model in achieving team

From the Tim Porter-O’Grady Associates, Inc, Otto,NC.

Corresponding author: Tim Porter-O’Grady, EdD, APRN,FAAN, Tim Porter-O’Grady Associates Inc, 529 Crys-tal Creek, Otto, NC 28763 (e-mail: [email protected]).

outcomes and sustaining success. In addition,emphasis includes knowledge generation andgrowth and development, both incorporatedas a part of the model’s application. All ofthese components assure the establishment ofan evidence-based framework for team perfor-mance and systematizing the achievement ofoutcomes, team performance evaluation, andteam sustainability.

THEORETICAL AND CONCEPTUAL

FOUNDATIONS FOR THE TEAM MODEL

While encapsulated in a whole range ofnames and processes, teams have a long his-tory in the human experience. In his classicwork Histories, Herodotus, the famous Greekhistorian, identified the tremendous sense ofthe Spartan teams and their team organiza-tion and how this focus on team action in-formed the leadership thinking and successof the greatest Persian ruler, Cyrus (580–529BCE). While many generations have passedsince that time, the basic concepts and el-ements of team have remained unchangedfrom Herodotus’ description of Spartan teams,

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even though our understanding of teams andthe external and internal forces that influencetheir effectiveness has deepened and growndramatically, especially in the past 30 years.

The flow of work and the effectiveness ofteams relate specifically to the synthesis of anumber of internal and external dynamics thatoperate consistently to affect the function andprocess of teams.1 The question of the inter-face of external and internal elements affect-ing team process has generated out of a broadrange of research, indicating a need to com-prehend and apply group dynamics principlesto assure team effectiveness.2–4

The ability of the team to be able to gen-erate competence from individuals and con-solidate it into group effort is a critical coreelement of a good team.5 This issue of com-petence as a core element can also be ex-tended to knowledge creation, management,and generation as a part of what the teamdoes to advance its own competence, im-pact its work, and improve its outcomes. Thisknowledge-driven process is a cybernetic dy-namic that continuously impacts team compe-tence, work process/quality, and outcomes,6

and forms a framework for the DCT model.No team process can operate indepen-

dently of the context within which it func-tions.7 All teams respond to the environmen-tal, social, technological, and managementinfluences that create the specific contextand format within which team action takesform, and to which team process must demon-strate responsiveness.8 These forces createthe conditions and circumstances withinwhich teams perform and have a direct influ-ence on the elements of process in the team’sexercise of its work. In addition to these ex-ternal forces, there are internal processes thatgenerate from team member behaviors, in-teractions, and relationships. All of these in-ternal forces converge in the DCT model tocreate conditions that both affect and directthe team processes in a way that can be bothfacilitating and impeding.2

The clinical team processes (process fac-tors) form the active framework that both de-scribe and define the team’s processes. Each

of these steps in the DCT model processesdoes not act independent of each other, butrather, reflect a continuum of intersectionsand stages acknowledging the complex of ac-tivities that make up the team flow.9 Each ofthe steps and stages in the DCT model reflectsthe fundamental core (mission, purpose, ob-jectives, principles, relationships, and moti-vators), and all are indicators of the team’sprogress toward actualizing them and focus-ing them on the work of the team.10 Noneof them operate independent of each other,and all intersect with each other in the dy-namic interface that reflects their interdepen-dencies and the influence one has on theother. From phase 1 through phase 5 in theDCT model, the elements necessary to act andperform in a way that achieves expectationsand outcomes are specifically delineated.11 Inmoving through the stages, the expectationsfor performance reflect team member’s rolesand connect them in the mosaic of activitiesthat ultimately leads team members in con-cert to the achievement of desired results.12

The results get defined through the fulfillmentof specific expectations or outcomes that re-flect the desired level of performance, quality,and user satisfaction. Because this is a cyber-netic process, it continually revolves aroundits stages (process factors) in a multidimen-sional dance of flow and intersection, advanc-ing and improving team structure, relation-ships, performance, and outcomes.13,14

Effective clinical teams operate at severallevels of synthesis.15 Each of these elementsof referencing and flow operates interdepen-dently, requiring a solid goodness of fit withand between each of them in order to assurethat they facilitate the action of teams ratherthan act as barriers to effective team per-formance. This application of complexity isimportant to a deeper understanding of thedynamic nature and fluid circumstances, pos-itively influencing teamwork.16 This complexinterface of structure, process, relationship,and action in the DCT model is continu-ously woven into a network of convergingand intersecting forces and factors that bothindividually and collectively affect the team

Constructing a Team Model 213

dynamics and impact its work.17 The appli-cation of complexity design and multidimen-sional modeling helps create a more compre-hensive view of each and all of the elementsmaking or breaking the delicate and fluid dy-namic that is a team.

INFLUENCES AFFECTING A WORKING

TEAM MODEL

The team’s knowledge creation process asdepicted in Figure 1 is the dynamic synthe-sis of its social structures, participants, goals,technology, and environments; each elementinteracts and influences the other elementsthat comprise the organization. In his germi-nal work on organizational structures, Leavittexplicates the analytical framework found inFigure 2.8(p1145) To understand how the teamfunctions in creating knowledge, its primarypurpose, one must understand how each el-ement of the framework interacts with theother elements in an interdependent dance.Leavitt’s framework has stood the test of timeand it prescribes the backbone of the DCTmodel.

The Leavitt framework, along with its 6factors, consists of the essential environmen-tal and organizational influences, the externaland internal forces, and pushing and pullingat the seams of the team as it operates un-der its open system paradigm. All 6 factorscontribute process depth to achieve an ef-fectively balanced team that shares data andknowledge both ways across its transparentboundaries. The team’s social structure con-sists of its “normative, cultural-cognitive, andbehavioral structures of a social group.”18(p19)

The participants are the members within theteam organization who seek to achieve thegoals of the organization because of eitherinternal or external inducements to achievelearning by creating knowledge. The goals ofthe team are concepts for achieving its vi-sionary end state (knowledge creation); goalsguide the progress assessments for the team.Technology includes the empowering, en-abling tools hardware, software applications,

and knowledge skills that facilitate the trans-formation of resources into products. Theteam collectively and symbiotically adapts toits “physical, technological, cultural, and so-cial environment.”19(p23)

The team core structure

The team core structure is based on themodel of Nonaka and Nishiguchi6(p130) com-prising the following elements: Socialization,Externalization, Internalization, and Combina-tion. Together, these categories provide a pro-cess for “knowledge transformation.”7(p131)

This process is the dynamic structure thathosts the other elements of the DCT model.

Socialization and combination are di-rected more toward the team and customer in-teractions, whereby “. . . customers (patients)get and maintain their agreement on the re-quest they make to the performers.”7(p130)

These possible interactions are keys in ensur-ing that customer (patient) needs are beingmet.

This process of the DCT model can be seenas the fulcrum between customer (patient)relationship and the dynamics of the learn-ing and knowledge-generating concept. TheDCT model incorporates this process into itscooperative learning concept in terms of theteam individuals, not merely exchanging in-formation but transforming the informationinto knowledge and sharing it among them-selves and, when applicable, with customers(patients).

Team core elements

The DCT model’s philosophy is to de-liver beyond patient expectations while gen-erating knowledge in a cooperative setting(Fig 3). Barnard first introduced the conceptof a cooperative system with “. . . his notion ofincluding both internal equilibrium and exter-nal adjustment.”19(p266) He had the vision that“Cooperation within formal organizations af-forded possibilities for expanding the pow-ers of the group beyond what the individ-ual could accomplish alone.”19(p267) Barnardalso introduced the concept of considering


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Figure 2. Leavitt’s diamond: A model of organization.8

teams as a group of individuals who have dif-ferentiated needs and aspirations. He believedthat “. . . efficiency was the result of individualefficiencies . . . efficiency was the degree towhich individual motives were satisfied, andonly the individual could determine whetheror not this condition was being met.”19(p267)

The DCT model endeavors to maximize itsteam potential by focusing on individual teammembers and creating a cooperative environ-ment.

The elements in the team core can be seenas the bonding material that holds it all to-gether. The purpose of the team and the mis-sion needs to be clearly defined and contextu-alized so that the individuals understand not

Figure 3. Team core elements.

only their task but also how it fits into the bigpicture. This further establishes the eviden-tiary relationship between clinical work andthe purposes identified as driving it.

Purpose and mission

The purpose and mission of the team arecritical as they set the stage for the other sup-porting core elements. The purpose and mis-sion create the vision that needs to be pre-cise and relevant to the clinical strategy andaligned with the patients’ needs. Hamel andPrahalad guard against undifferentiated mis-sion statements, “A strategic intent should of-fer clinical workers the enticing spectacle of anew destination, or at least new routes to well-known destinations.”20(p145) Therefore, a clearroadmap of the purpose and mission shouldbe presented while highlighting the unique-ness or specificity of the path chosen and itsapplicability to practice.

Meaning and motivation

Meaning and motivation are derived froman understanding on the part of the team ofits mission, and the vision, with clearly de-fined expectations. Senge states, “Visions areexhilarating. They create the spark, the ex-citement that lifts an organization out of themundane.”21(p208) In the clinical environment,


motivation finds its source in meaning andin care. An understanding of what motivatesteam members is required on the part of theleader. In the DCT model, it is assumed thatMaslow’s first 2 basic hierarchical needs, phys-iological and safety, are met and that the teammembers are striving for the higher needs thatinclude esteem and self-actualization.19(p281)

Hamel and Prahalad state: “Employees are un-likely to rise to a particular challenge if theydon’t believe they will benefit proportion-ately from the organization’s success. For chal-lenges to take root, an atmosphere of ‘sharedpain, shared gain’ must prevail.”20(p157) Conse-quently, motivational factors need to be clari-fied and responsibility must be shared both atthe team and organizational levels.

Commitment and competence

Commitment is not something that canbe commanded into play. It is elicited andearned. Finding the source of what can elicitcommitment from individuals is the respon-sibility of the leader. As Senge points out,“Shared visions compel courage so naturallythat people don’t even realize the extent oftheir courage. Courage is simply doing what-ever is needed in pursuit of the vision.”21(p208)

Consequently, by rallying individuals around acommon belief and goal, motivation and com-mitment become natural byproducts. Inamorigoes further when addressing the subject ofcommitment by describing “. . . the will of aperson committed to a larger purpose as a‘cry from the soul which has been shaken andawakened.’ ”21(p172) Perhaps, not all team vi-sions can be made that compelling, but thepoint is that commitment, and motivation, issourced through the essence of individualsand the leader needs to reach his or her teamas individuals. In clinical practice, it is easyto lose this connection to personal motiva-tion. The leader works to keep caregivers con-nected to their personal vision and purposeand to be motivated by applying those valuesto patient care.

It is assumed that members selected for theteams have been screened and demonstrate

appropriate professional competence. How-ever, should problems arise, the fluidity andcooperative structure of the DCT model willenable team members to support those expe-riencing difficulty.

Team learning

The work and completion of the task, as de-scribed in this team core, leads to a learningexperience. Senge states, “People with a highlevel of personal mastery live in a continuallearning mode. They never ‘arrive.’ ”21(p142)

This describes the spirit of the DCT model—to support the growth of team members bygiving them the tools and direction. This cre-ates a learning experience. The next step con-sists in harvesting the generated knowledge,assimilating it, and reinvesting it back into theteam and the company in general.

Team performance and outcomes

Team performance is an outcome of the 5process factors and the team core dynamics.It includes an evaluation process that will beexplored in the next assignment. The qualityof the outcomes, or deliverable, is dependentupon the team performance. The outcomesmust meet the predefined customer/patientneeds. The deliverable must not only be ontarget in meeting the goals but also be timelyand represent excellence in order to go be-yond the patient’s expectations (Fig 4). Evi-dence requires a strong interface and valid re-lationship between the process elements thatboth achieve and sustain clinical outcomes.

PROCESS FACTORS

Process factor 1: Goals

This process factor refers to the early un-derstanding of team members to the team’sgoals and the extent to which these goalsdirect the behavior of different team mem-bers in order to achieve the desired results.Militello et al22 identified 3 essential aspectsto envisioning goals: (1) the ability of theteam to identify its goals; (2) the ability ofthe team to ensure that all its members share


Figure 4. Performance-outcome elements.

the same goals; and (3) the degree to whichthese shared understanding of goals containsa workable temporal element.

Process factor 2: Competence

Competence depends on the skills of teammembers in acquiring and interpreting in-formation; making choices concerning towhom acquired information is to be commu-nicated, as well as communicating accuratelyand completely; making decisions concern-ing ways to cope with unusual or unantic-ipated situations; and executing actions de-riving from such decisions—all performed athigh levels of proficiency and coordination.22

Margerison23 in her study of the skills neededfor teams identified 9 team competencies thatare necessary to produce high level of per-formance. These competencies are (1) Advis-ing, which relates mainly to gathering andreporting information and the levels of teammembers giving advice to each other and thepeople outside their teams; (2) Innovating,which relates with the level of creating andexperimenting with new ideas; (3) Promot-ing, which deals mainly with exploring andpresenting opportunities and influencing oth-ers; (4) Developing, which assesses and testsnew approaches and ensures that systems andproducts are well developed; (5) Organiz-ing, through which the team arranges howthings work using a systematic approach; (6)Producing, through which the team makesand delivers output by internal and externalteam linking; (7) Inspecting, through which

the team controls and audits the working sys-tem ensuring high quality and effective pro-cess; (8) Maintaining, in which the teamupholds and safeguards the standards and pro-cesses; and (9) Linking, through which theteam coordinates and integrates with others.Each team, in order to succeed, requires itsmembers to collectively cover all areas.

Process factor 3: Resources

This process factor deals with the extent towhich team members conceive of their teamas an independent unit and operate as suchwhile engaged in the different tasks. Militelloet al22 identified 4 dimensions for achievingthis independence: (1) Defining Roles, Func-tions, Resources, where each team memberunderstands the task responsibility and rolesof every member and the resources requiredby the team for performing its functions; (2)Engaging All Members, in which team mem-bers get actively involved in the team’s activ-ity, take responsibility, and encourage othermembers to get involved; (3) Compensatingand Coaching, which deals with the shift ofteam resources to cover for areas outside theirteam roles or responsibilities by stepping out-side their functions to help the team reachits goals (compensating) or when the experi-enced team members offer direction to lessexperienced to bring them to greater levelof individual proficiency (coaching); and (4)Interpersonal Aspects, which refers to theconflicting or harmonious styles of the teammembers.


Figure 5. Team process factors.

Process factors 4 and 5: Work demands

and results

These process factors refer to a team’s abil-ity to observe its performance processes toreach the highest performance levels of pro-ductivity. The assignment of specific tasksto team members according to their areasof competency and preferences create confi-dence and stability within the team.24 Doore-waard et al25 mentioned 4 dimensions to teamself-management to achieve the best results:(1) Monitoring, where the team continuouslyobserve its performance and look for signs ofeffective behavior for building on it and in-effective behavior to adjust accordingly; (2)Adjusting, which is the ability of the teamto adjust its strategies to cope with the dif-ferent internal and external changes affectingits work; (3) Detecting Gaps and Inconsisten-cies, which refers to the ability of the team todiscover and fill gaps in the team’s informa-tion base and assumptions, and to recognizeand handle inconsistencies or contradictionsthat might be present; and (4) Time Manage-ment, where the team is conscious of meet-ing the goals before deadlines by sequencingtasks and subtasks in such a way that out-put from one task acts as an input of another(Fig 5).

TEAM ORGANIZATIONAL AND

PARTICIPANT INFLUENCES

As the DCT model is utilized, the dynam-ics of its use are influenced by organizationaland participant influences. The view the or-ganization has of teams, the value placed onteams, the structural support for teams, andthe organizational culture has a great impacton how teams function, and ultimately theteam’s success. According to Thompson etal, “When teams are properly used in orga-nizations and when the organization’s inter-nal climate is one that is consistent with ateam approach, the results have been largelypositive.”26(p255)

Likewise, participants also influence thedynamics of the model and the success ofteams. Historically, the American culture isbased on the values of individualism. Withclinical integration, evidence-based practice,pay for performance, and clinical restructur-ing, interdisciplinary and multifocal clinicalteams are becoming more of the norm inhealthcare and are seen as one way of lever-aging organizational strengths to offset thesenew service challenges.24 Participants influ-ence the team dynamic as a result of howthey feel as a part of the team. The processfactors of the DCT model greatly reflect the


participant’s influence. As participants be-come more confident in their abilities, pur-pose, and support for teaming, their influenceon the process increasingly becomes positive.

CONCLUSION

In the spirit of Vaill’s white waterperception27 influencing the clinical en-vironment, one of continuous disruption,the DCT model presents a process-groundedsystem that is open and flexible in order toanticipate and meet the challenges of tomor-row’s ever-changing clinical environment.Influenced by Vaill’s philosophy of “learningas a way of being,”27(p53) the DCT modelenables the generation of knowledge thatflows through feedback loops, creating acontinuous cybernetic energy that keeps thepractice environment dynamic and fostersa proactive attitude to continuous clinicaltransformation in team members. The soulof the model endeavors to support the well-being and growth of evidence–driven clinicalpractice.

This team model will need a special typeof clinical leadership. Drucker in addressingthe necessary qualities for tomorrow’s suc-

cessful leaders, compares such individuals toopera conductors: “You have your stars andyou can’t give them orders; you have the sup-porting cast and the orchestra; you have thepeople who work behind the scenes; and youhave your audience.”28(p90) Each section hasdifferent needs and processes. What holds theorchestra together, says Drucker, is that ev-eryone has the same score. Increasingly, inassuring evidence-based teams, the leader as-sures they are composed of individuals whomake different yet identifiable contributionswith clearly defined practice roles while in-terfacing with external forces and other teamscontributing to the achievement of evidence–based clinical goals. In using the DCT model,the clinical leader affirms the use of a spe-cific systematic framework that consistentlyleads to achieving valid clinical outcomeswhile keeping the focus on the score, or thevision. Evidence-based practice will requirethe leader to use more integrated, synthesis-based approaches like the DCT model pre-sented here as a way of fully addressing therequisite purpose-driven, relational, process-linked, performance-based format for buildingand using evidence-based approaches for sus-taining excellence in patient care.

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Vol. 30, No. 3, pp. 211–220 Constructing a Team...

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