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The Impact of Team Building on Communication and Job Satisfaction of Nursing Staff
By: Mary Anne Amos, Jie Hu, Charlotte A. Herrick
Amos, Hu, J. & Herrick (2005). The impact of team building on communication and job satisfaction of a
nursing staff. Journal for Nurses in Staff Development, 21(1), 10-16.
Made available courtesy of Lippincott Williams & Wilkins, Inc:
http://journals.lww.com/jnsdonline/Abstract/2005/01000/The_Impact_of_Team_Building_on_Communication_
and.3.aspx
***Reprinted with permission. No further reproduction is authorized without written permission from
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Abstract:
A series of team-building activities were conducted on a medical-surgical unit and their impact on staff's
communication and job satisfaction was examined. Forty-four unit personnel participated in the interventions.
Staff communication and job satisfaction were measured before and after the intervention. The findings linked
team-building activities with improved staff communication and job satisfaction. Team-building strategies
assisted the nurse leader/manager to build an effective work team by strengthening communication and
interpersonal relationships so that the staff could function as a more cohesive group. Staff development
consultants can help nurse managers become more effective team leaders by identifying the necessary resources
and by helping to plan and coordinate team-building strategies.
Article:
In 2000, The North Carolina Center for Nursing conducted a survey and found that in many North Carolina
hospitals, vacancy rates ranged from 6% to 16 % (Letvak, 2002). Registered Nurse (RN) turnover is currently
a major problem, contributing to the critical shortage of nurses and affecting the economic stability of
hospitals (White & Rice, 2001). In 1998, the median turnover rate for RNs was 15% and the cost to hospitals
to replace a nurse was between US$42,000 and US$64,000 (Advisory Board Company, 2000). A common
factor leading to staff dissatisfaction is the perception that pay is inadequate (Flanagan & Flanagan, 2002;
Joshua-Amadi, 2002; Stamps, 1997; Yaktin, Azoury, & Doumit, 2003). White and Rice (2001) noticed two of
the most common factors in retention of nurses are job satisfaction and a positive work environment, with
good staff relationships. A study conducted by Shader, Broome, Broome, West, and Nash (2001) found a
positive association between higher rates of group cohesion and work satisfaction and a lower anticipated
turnover rate in an acute care setting. This suggests that in order to retain nursing staff in acute care, strategies
should be implemented to create cohesive work teams (Kerfoot, 2000).
STAFF PERCEPTIONS OF WORK ENVIRONMENTS
The perception that the work place is supportive influences both job satisfaction and retention (Sullivan &
Decker, 2001). A study by Garret and McDaniel (2001), which explored interpersonal relationships,
environmental uncertainty, social climate, and burnout, found that social networks and a supportive workplace
were important in preventing job dissatisfaction. Leppa (1996), using the Index of Work Satisfaction (IWS),
found that a cohesive support group might compensate for other frustrations in the work environment (Huber,
2000). Leppa found that interpersonal relationships were an important part of job satisfaction and were also
associated with greater patient safety and higher quality of care.
Hinshaw, Smeltzer, and Atwood (1987) identified the work environment as an important aspect in retaining
nurses and positively affecting the quality of patient care. In their study of over 1,500 nursing staff members
(nurses and nurse assistants), they found that group cohesiveness was positively related to job satisfaction and
staying in the work setting.
Effective teams are characterized by a common purpose, clear goals, competent members, a unified
commitment, complementary skills, a collaborative climate, mutual accountability, standards of excellence,
and principled leadership (Homans, 1995; Tuckman, 1965). Teams with these characteristics develop
enthusiastic work groups, in which members share resources, information, and skills (Tuckman & Jensen,
1977).
TEAM BUILDING AND SUPPORTIVE INTERPERSONAL RELATIONSHIPS
Grohar-Murray and DiCroce (2003) claimed that team building brings a fundamental change in the way that
work in healthcare institutions is structured today, changing the work environment and the way staff perceive
it. They found that the benefits of a well-functioning cohesive team included increased productivity, improved
quality, reduced costs, reduced conflict, and increased adaptability and flexibility of both managers and
workers. Most importantly, they found that staff members were more motivated, which greatly reduced
absenteeism and staff turnover. "A team, by definition, is a motivated group of people who work together,
share resources, are committed to a common objectives through coordinated efforts, and produce a product or
service that is far superior than that of an individual alone" (p.133).
SUGGESTED STRATEGIES TO BUILD COHESIVE TEAMS
The leader/manager has the responsibility to plan, coordinate, and monitor the group's activities and to convey
a vision, inspiring team collaboration (Homans, 1995). It is important for the nurse leader/manager to
understand the principles of group dynamics in order to apply them to team building (Antai-Otong, 1997;
Blegen, 1993). Helping staff develop interpersonal skills is essential to building a cohesive team (Homans,
1995). Open communication and supportive interpersonal relationships have been consistently linked with
positive attitudes toward the work environment, which leads to job satisfaction, improved job performance,
and an increase in retention. Few studies, however, have investigated team building in relation to job
satisfaction. The current study, therefore, examined the impact of team-building strategies on communication
and job satisfaction.
CONCEPTUAL FRAMEWORK
Homans' social system conceptual model served as a framework for the team-building activities (Garrett &
McDaniel; 2001; Pincus, 1986). The model focuses on the relationships among members of small groups and
consists of "activities," defined as the tasks that individuals perform, "interactions," the behaviors that occur
among group members while performing the tasks, and "attitudes," the feelings individuals have toward each
other. A change in any one element produces a change in the others. Homans' model incorporates the stages of
group development identified by Tuckman (1965) and Tuckman and Jensen (1977). Stage 1, forming, is the
initial coming together; group members approach each other cautiously as they begin to understand each other.
Stage 2 includes storming and norming. Storming occurs when there are interpersonal conflicts and members
are competitive, leading to dissatisfaction. Norming occurs when the group overcomes interpersonal conflicts,
becomes cohesive, and develops structure, roles, and relationships. Stage 3, performing, occurs when members
cooperate, communicate, collaborate, and work is accomplished. Stage 4, adjourning or reforming, is the final
phase, when the group may dissolve because of a major change, the goals may have been reached or have
changed, or group members may have left and been replaced by new members, so that the group needs to
recycle to the initial stage of development (Antai-Otong, 1997; Blegen, 1993). This conceptual framework
provided a guide for developing the design of the team-building intervention.
METHODS
Design
A group pretest and posttest design was used to measure staff communication and job satisfaction before and
after receiving a team-building intervention. Pretest or baseline data were obtained using a demographic
questionnaire, a staff communication evaluation tool, and the IWS (Stamps, 1997). The subjects then attended
a team-building intervention program. Three months later, a posttest was given, using the same questionnaires.
In addition, participants completed the hospital employee perceptions survey given to all employees 2 months
after completing the team-building intervention program.
Sample and Setting
The convenience sample consisted of 44 of the 52 nurses, nursing assistants, and nursing secretaries/monitor
technicians working on a medical-surgical unit in a general hospital. Both the university and the hospital
Institutional Review Boards approved the study. An oral and a written introduction with an explanation of the
study's procedure was given to the participants, who signed an informed consent form. The subjects received
educational credit for attending the team-building intervention program. Two sessions were conducted. One
half of the participants attended each session, while the other half covered the unit. Each session was for 8
hours and the sessions were held twice, once in the fall and once in the spring. Thus, participants received a
total of 16 hours of continuing education credit. The costs of the program included staff salaries and the staff
development consultant's fee, the cost of the location, and the cost of food. US$3,200 were budgeted for the
two sessions.
The Intervention Program
The group facilitator, a consultant in private practice, was an expert in staff development. The facilitator acted
as a consultant to the nurse manager. Together they planned the team-building program. The program included
the following topics presented by the facilitator: (a) identification of communication styles, effective
communication, and listening skills; (b) conflict resolution; (c) stress management; (d) a review of different
personality styles and suggestions for working with different personality types; (e) information about the
stages of normal group development and group dynamics. Activities included presentations by the facilitator
and other experts, group discussions, and role play. Role play was used to demonstrate the stages of group
development and to provide opportunities to practice communication skills and strategies for conflict
management. Strategies for stress management were also introduced to assist staff with self-care.
The facilitator presented the phases of group development and used group exercises to illustrate concepts. The
first stage of group development, identified by Tuckman (1965) and Tuckman and Jensen (1977) as the
forming phase, was called by the facilitator the orientation and exploration phase. Staff members practiced
listening skills to illustrate the importance of active listening during group formation. They were divided into
groups of three and instructed to tell a story to each other about an event that had happened to them in the past;
the other members were asked to repeat the story exactly as it was told. The facilitator pointed out that
listening requires energy and stressed the importance of listening intently in order to fully understand the other
person.
The facilitator explained that in the second stage of group formation, called the storming and norming stage,
group members first become defensive and uneasy, fearing loss of control, and this may cause interpersonal
conflicts. The group was reminded that conflict during the storming phase is natural and healthy and must be
openly dealt with for effective resolution. Norming occurs when group members master the ability to resolve
conflicts. The staff was divided into small groups, and each group was given a scenario based on actual
conflicts that had occurred on the nursing unit prior to the intervention. Each group was asked to create a win-
win solution for the assigned situation.
The facilitator presented Stage 3 as the working, or the performing, phase when group members work together
collaboratively, use open communication, take risks, become more trusting, and rely on one another to get the
work done. The staff participated in an activity to learn more about each other's roles as charge nurse, staff
nurse, nurse assistant, or nursing secretary/monitor technician. Each staff group discussed one of the nursing
roles and identified responsibilities and associated stressors and problems of the role. The group was asked to
offer suggestions to make each role easier. Knowledge of all of the roles and their interdependence helped staff
to better understand each team member and the importance of each role to a well-functioning team.
The final stage discussed was the consolidation and termination phase, when members are working well
together until someone leaves the group or new members join it or major changes occur on the unit. In this
stage, labeled by Tuckman (1965) and Tuckman and Jensen (1977) as the adjourning, reforming phase, it is
necessary for the team to recycle to the initial phase of group development.
Following the presentations on group development, strategies for stress management were presented,
relaxation techniques were introduced, and a massage therapist provided recommendations to reduce stress in
the work place.
Instruments
A demographic questionnaire was administered to determine staff characteristics. The Staff Communication
Evaluation Tool and the IWS were used to measure the outcomes of the team-building intervention. The Staff
Communication Evaluation Tool included eight concepts with 25 items in the following categories: open,
honest communication; recognition, respect, and trust in peers and their contributions; problem solving toward
the goals of the agency or the profession; the ability to convey constructive feedback to the peers regarding
their practice; identification of conflict; accountability for one's own role; objectivity and empathy regardless
of personal feelings; sharing of knowledge and skills with others; and support for team, system, and
organizational goals. Participants responded to items using a Likert-type scale ranging from 1 (rarely) to 5
(always). The Staff Communication Evaluation Tool had been used in the Nursing Department at this hospital
with approximately 150 people for 4 years. The tool demonstrated good reliability, with a Cronbach's alpha
coefficient of .96 in this study.
The IWS (Stamps, 1997) was used to measure job satisfaction. The two-part IWS is a 44-item scale that
contains six subcomponents: pay, autonomy, task requirements, organizational policies, interaction, and
professional status. Part A of the IWS asks respondents to rank order the importance of the six components.
Part B asks about levels of satisfaction in these six areas of work. A high level of satisfaction is reflected by
higher scores on each subscale. The reliability and validity of the instrument are well established. Construct
validity was reported for all subscales in the IWS as significantly related to the overall scale (p < .0001)
(Stamps,1997). In this study, the Cronbach's alpha coefficient for the total scale was .91 and for the subscales
were as follows: pay scale, .84; professional status, .77; autonomy, .76; organizational policies, .80; task
requirements, .64; nurse-to-nurse interaction, .70; and nurse-to-physician interaction, .80.
The Continuous Employee Perceptions Survey is used annually by the hospital to assess staff satisfaction of all
hospital employees. It was administered to the subjects 2 months after the completion of the intervention on
team building. The survey includes components such as leadership, compensation and benefits, team
environment, and overall satisfaction, using a Likert-type scale. Satisfaction with the team environment was
considered a valuable outcome of the study. Scores that range from 76.0% to 100% are considered high,
acceptable scores range from 61.0% to 75.9%, negative scores range from 46.0% to 60.9%, and very negative
scores range from 20.0% to 45.9% (The Jackson Group, 2002).
RESULTS
The 44 participants in the study consisted of 24 nurses (55%), 13 nursing technicians (30%), and 7 nursing
secretaries/monitor technicians (15%). The mean age of the sample was 35 years (SD = 11.19) with a range
from 21 to 58 years. The average number of years of employment was 8 (SD = 7.55) with a range from 3
months to 26 years. The average number of years in nursing was 9 (SD = 8.38) with a range from 3 months to
31 years. Table 1 summarizes demographic data.
TABLE 1 Demographics of the Subjects (N = 44)
TABLE 3 Index of Work Satisfaction Component Scores (N = 44)
A paired t test was used to examine the impact of the team-building intervention on communication and job
satisfaction. There were no statistically significant differences between baseline and 3-month posttest scores on
the Staff Communication Evaluation Tool (p > .05).
There were also no significant differences between baseline and 3-month posttest scores on the IWS total job
satisfaction score (p = .96) and the scores on the subscales: pay (p > .05); autonomy (p = .52); task
requirements (p = .27); organizational policies (p = .73); interaction (p = .58); and professional status (p = .66).
Long-term benefits of the program were assessed by the Continuous Employee Perceptions Survey. The
evaluation of the team environment in the department increased over the previous year by 7% from 75.6% to
80.8%. Evaluation of the team environment was the second highest score after customer service.
DISCUSSION
The use of positive and constructive feedback by staff improved 5% after the intervention. Staff reported that
they improved their listening skills and communicated more openly after the team-building intervention. They
were better able to address conflicts directly with people in the work group. Both the staff and the nurse
manager reported improvements in (a) following through on commitments, (b) explaining obstacles, (c)
keeping others updated on progress, (d) accepting constructive feedback in a positive, nondefensive manner,
(e) demonstrating personal accountability, and (f) acquiring and sharing knowledge related to the job.
Although the differences pre- and posttest were not statistically significant, staff reported that esprit de corps
on the unit improved. The staff also discussed their experiences with staff from a similar unit. They believed
that the team-building program was beneficial and recommended that the other unit manager and staff develop
a similar team-building program.
The turnover rate from the year prior to the intervention to the year after the team-building program dropped
from an annual rate of 13.42% to 6.56% (Wesley Long/Moses Cone Health System Turnover Report, 2001,
2002).
Members of the nursing staff were still not satisfied with pay rates, and they thought pay rates were the most
important factor in work satisfaction. Consistent with these findings, in a study using the IWS with 150 nurses
in a Midwestern hospital, Goodell and Coeling (1994) also found that nurses rated pay as the most important
factor in job satisfaction. In that same study, professional status and interactions were ranked most satisfying
by the nursing staff, and pay and task requirements were rated least satisfying. Clearly, policies related to pay
and benefits must be continually evaluated to retain nursing staff. Although staff may remain on the job
because of status and good interpersonal relationships, leaders/managers must still address issues related to pay
in order to retain nurses.
Kovner, Hendrickson, Knickman, and Finkler (1994) also found that good communication was essential to
building a cohesive work unit. Leppa's (1996) study found that job satisfaction improved as a result of being
part of a cohesive work group, and Shader et al. (2001) found that job satisfaction and group cohesion were
important in improving staff retention. Leader/managers may not always have control over policies related to
pay and benefits, but building a cohesive team is something they can do to retain nursing staff.
TABLE 4 Tips for the Staff Development Consultant
The staff development consultant, as an unbiased group facilitator, educator, and strategist, can be extremely
helpful to the unit manager in developing positive relationships among staff members. Team building in today's
healthcare environment is important to improve morale and enhance staff retention. A nursing unit's reputation
as a positive work environment becomes well known among other hospital employees, and this also helps to
recruit motivated and dedicated staff. Table 4 contains helpful hints for the staff development educator.
CONCLUSIONS
Strategies to enhance communication and provide an understanding of group dynamics and the importance of
interdependent roles promoted good working relationships. Building a successful team is essential to create a
positive work environment. Team-building activities must be ongoing; however, the nurse leader/manager
must nurture interpersonal relationships and encourage staff's efforts at effective communication. Skill
building to improve communication should be a managerial goal. With improved interstaff communication,
team members will become more comfortable in addressing issues among themselves, problem solving
together, and resolving conflicts. Promoting activities that increase teamwork will ultimately improve staff
satisfaction. Staff members who are satisfied with their work environment will want to remain on the job,
saving hospitals' money needed for staff recruitment. Retaining a stable work force will enable hospitals to
provide quality care, resulting in positive outcomes for patients and economic viability for healthcare
organizations. The staff development expert can assist the leader/manager to develop strategies for building an
effective team and helping nursing staff develop interpersonal skills and function as a cohesive group.
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