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Evaluation of an intensive group-process based model of team leadership development: implications for… Black, Timothy G. 1999

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EVALUATION OF AN INTENSIVE GROUP-PROCESS BASED MODEL OF T E A M LEADERSHIP DEVELOPMENT: IMPLICATIONS FOR C A N A D I A N H E A L T H C A R E E M P L O Y E E S by Timothy G. Black B. A , The University of Western Ontario, London, Canada. A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE D E G R E E OF M A S T E R OF ARTS in THE F A C U L T Y OF G R A D U A T E STUDIES (Department of Counselling Psychology) We accept this thesis as conforming to the required standard The University of British Columbia April, 1999 © Timothy G. Black, 1999. In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver, Canada Date DE-6 (2/88) II ABSTRACT The traditional model of leadership in medicine and health care generally centres around a hierarchical structure of power and influence, resting in the hands of a select few administrators, with limited input from employees. A newly developed Cancer treatment centre in the Province of British Columbia, Canada has attempted to institute a unique, team-based system of shared leadership and decision-making. In order to accomplish this task, the Senior Administrator of the centre hired professional group development experts to facilitate the formation of the newly established Leadership Team. A team of nine individuals participated in a group-process based model of team leadership development, consisting of a series of intensive weekend workshops. This study evaluates the impact of those intensive workshops on the members of the Cancer centre Leadership Team. Qualitative case-study methodology, combined with the use of indepth interviews, illuminated eight categories of shared experience among seven of the nine team members, as a result of having participated in the workshop series. TABLE OF CONTENTS Abstract ii Table of Contents " i Acknowledgements v Chapter 1 - Introduction 1 Background 1 An Innovative Model 2 The Challenge 3 Purpose/Rationale for Study 4 Chapter 2 - Review of the Literature 5 Organizational Development 5 The Uniqueness of Health Care Groups 10 Group Development 13 Group Process 15 Interpersonal Communication: The Central Group Process 20 Chapter 3 - Methodology 25 The Workshop Descriptions - Overview 26 Weekend Workshop Number One 28 Weekend Workshop Number Two 30 Final Weekend Workshop 34 Follow-Up Session One 37 Follow-Up Session Two 38 Research Methodology at a Glance 39 Research Design 40 The Interviews: Format 41 The Interviews: Procedure & Process 41 Data Transcription & Analysis 44 Analysis of Transcripts - Overview 44 Analysis of Transcripts - The Process 45 Chapter 4 - Results 48 Research Outcomes 48 The Eight Categories of Experience 49 (1) Understanding Others as Persons... 49 (2) Formation of Personal Connections 53 i v (3) Sense of Acceptance 56 (4) Sense of Safety and Trust... 58 (5) Sensitivity to Levels of Commitment 62 (6) Appreciation of Facilitated Group Experience 64 (7) Experience of Group Morale 66 (8) Reciprocity and Demonstration of Support 69 The Senior Administrator Interview 73 Humanistic/Holistic Patient Care 74 Interview with an Eight Member of the Team 76 Chapter 5 - Discussion 77 Implications for Theory of Group Development 78 Relating the Results to Group Process Theory 82 Understanding Others... 82 Personal Connections... 83 Sense of Acceptance 84 Sense of Safety... 85 Sensitivity to Commitment. 87 Appreciation of Facilitated Group. 89 Experience of Group Morale... 90 Reciprocity and Demonstration of Support 91 Figure 1.1 - The Interconnectedness of Group Experience 92 Reliability and Validity in a Qualitative Study 95 Limitations of the Study 97 Implications for Practice 98 Multidisciplinary Teams and Organizational Policy 98 Participation of Managers/Employers 98 Task and Maintenance of Group Life 99 Implications for other Health Care Settings 100 Considerations for Management & Administration 100 Directions for Future Research 101 Conclusion 102 References 103 Appendix A - Interview Form 106 Appendix B - Informed Consent Form 107 Appendix C - Johari Window 109 Acknowledgements v I wish to acknowledge several people who have lent themselves tirelessly and selflessly to the completion of this document. I wish to thank all of the members of the Leadership Team for their patience, and for their participation in the workshops and the subsequent evaluation. It literally wouldn't have happened without you!! Thanks to Dr. Larry Cochran for his assistance with the technical work in this study and for his words of encouragement. Thanks to Dr. Patricia Wilensky for her inspiration in helping me finish this document in time to pursue further interests, and for her steadfast support in the trials along the way. I wish to thank the members of my family for their never ending support as I have pursued my endeavours on the other side of the country. To my partner in life...thank you for your love and encouragement as I struggled through this document and through these past four years. It just gets better all the time!! Finally, I wish to express my deepest thanks to Dr. Marv Westwood. There's always more... 1 CHAPTER 1 INTRODUCTION Background In Canadian society, there are certain types of employees who are called upon, in the course of a day's work, to perform duties that most people would never want to perform. Watching a person struggling to hold on to life, removing pieces of peoples' bodies in the hopes of extending life, inundating people with toxic chemicals, and flooding areas of the human body with lethal doses of radiation are a few of the duties that we ask these individuals to perform. In many cases, these individuals are forced to watch helplessly as their efforts to preserve life ultimately end with the death of a child, perhaps a mother, a father, or a sibling. These are the individuals that we ask to take care of us, to cure us, and to save our lives. These are the employees of our nation's Cancer clinics and treatment centres and the question that is rarely asked by the average person is, "What are we doing to take care of these people in their work?" This study is an evaluation of a model employed to help address the interpersonal and professional communication needs of an administrative team of leaders, currently working in one of our country's state-of-the-art Cancer care and treatment facilities. The model being investigated in this study is the result of the vision of the Senior Administrator of the Cancer centre for a creating a unique organizational structure in Cancer care. Since the 1960's Organizational Development (OD) has been a rapidly growing and ever-evolving industry, as practitioners and researchers alike have attempted to discover how organizations work and, more importantly, what factors combine to help make organizations work better. R. Wayne Boss (1989) points out that organizational development has been evolving since the 1960's and that health care organizations in particular are faced with unique challenges and barriers to the productive development efforts made by OD consultants (pp. 6-17). It is also true 2 that the employees working in health care institutions also face special challenges that many people do not face in their work-a-day worlds. Cohen & Lipken (1979) and others have recognized the impact that working with critically ill and dying people has on the professionals who treat and care for them and they state that the staff who care for organically ill patients are extremely vulnerable to the pressures that come with their work (p.235). Given the difficulties involved in the organizational development of health care institutions and the psychological stresses faced by their employees, new strategies for caring for workers have become an organizational imperative in the present day. An Innovative Model One of the most entrenched organizational structures in many areas of the medical profession is the rigid hierarchy of power and influence, characteristic of most hospitals and health care facilities, dominated by one power group (physicians) who are socialized as professionals, assume cosmopolitan roles, and function autonomously and independently from the rest of the organization (Ross, 1989, p. 16). In a Cancer-care facility in the province of British Columbia, Canada, an attempt to alter the state of this hierarchy, and the concomitant negative impacts on the organization and the employees of that organization, has been undertaken. In this study, the case we are interested in, that of the Administrative Leadership Team of the Cancer centre, is unique in that the group represents an attempt to construct a new form of leadership based on cooperation and equality in a health care institution. The Senior Administrator of a newly developed Cancer care and treatment facility decided that in order to improve the organization as a whole, it would be necessary to employ a more democratic, team-oriented leadership structure. This goal was to be accomplished by the formation of a multidisciplinary team comprised of nine individuals, who would form the basis of an administrative team with shared decision-making capacities. The crux of the development of this team would lie in the interpersonal relations of the nine team members, not simply on the knowledge and expertise of a group of professionals in Cancer-care, but as a team of human 3 beings with needs that extend far beyond the professional duties and responsibilities of a team leader. The Cancer-care facility was not yet operational, when the Senior Administrator hired a team of external consultants to work with the nine leaders, in that no patients were to be seen for another six months, while the system was being put in place. The Senior Administrator (SA) recognized the fact that this constituted a unique opportunity to build a new organization from the "ground up" with a team of staff that, despite having years of combined experience in Cancer-care, were all new-comers to the facility. The SA also recognized that the formation of the team would require the involvement of professional "team-builders" in order to create a cohesive, stable unit in time for the opening of the Cancer Centre. A team of group development specialists, consisting of two psychologists and one physician, all professionals in group methods and counselling, was contracted to facilitate the team-building of the Centre's new team of administrative leaders, called the Leadership Team. The Challenge The Leadership Team of nine individuals participated in a series of three intensive two-day team-building workshops over a period of three months, prior to the opening of the Centre for patient-care. The stated goal of the facilitators leading the workshops was: to employ a group-process model of team leadership development to facilitate the formation of the group of individuals into a cohesive unit of administrators, able to operate in a shared system of decision-making. This was to be achieved by: (1) - the facilitation of team members learning how to relate to and communicate with each other on an interpersonal basis (2) - the facilitation of increased levels of trust among group members (3) - the facilitation of increased group solidarity, and (4) - the reduction of misunderstanding and conflict among group members (5) - the facilitation of skills for preventing and resolving intra-group conflict. 4 The study that follows is an evaluation of the impact of an intensive team-building program on the individuals who participated in and who are now working at the fully operational Cancer-care facility. Purpose/Rationale for Study The rationale for the following study is to evaluate the impact that the series of intensive team-building workshops had on the nine individual participants, through an intrinsic case study approach, as outlined by Robert Stake, in Denzin & Lincoln (1994). The model employed was a group-process model, focusing on the interpersonal processes which invariably occur in group settings. The experience of the individual participant in such a group is tantamount to outcome data that one would find in a typical scientific study. The use of a semi-structured interview to illuminate the experience of each of the individuals involved in the workshops would provide valuable information to group facilitators, health care administrators, and potential group participants regarding the use and impacts of such a model. Further, the results of an evaluation of such a model serve to inform the literature, and possible practice approaches, regarding the refinement of such group-based interventions. Those aspects of the workshops which had a negative impact on participants will be re-examined and altered for use in the future. Aspects of the workshops which impacted the group positively will be further refined and perfected, allowing future groups to gain maximum benefit from similar interventions. The results of this particular study will be provided for the Senior Administrator of the Cancer centre, the Group Facilitators, and the members of the administrative Leadership Team, all of whom will glean different usage from the data presented in the following pages. Likewise, the reader is invited to make his/her own extrapolations as to the ultimate utility of the information contained herein. 5 CHAPTER 2 REVIEW OF THE LITERATURE The literature that will be reviewed focuses on five main areas of interest: (1) - group development, (2) - group process or group dynamics theory, (3) - interpersonal communication theory, (4) - team leadership development, and (5) - organizational development in health care being the relevant areas in the literature which inform this evaluation. The workshops of this study were conducted according to the fundamental processes of group building and group dynamics in an organizational setting and, therefore, reviewing the relevant literature in these areas is required. The fact that the participants are all health care professionals in a Cancer-care facility must also be considered when reviewing the literature that will inform this evaluation. ORGANIZATIONAL D E V E L O P M E N T Groups functioning in an organizational setting have special needs and characteristics which distinguish them from the classic therapeutic group. In addition, health care organizations and their employees have their own peculiar nature, which also must be considered. Given that there are qualitative differences in each type of group, several common factors of group experience do exist and these will be reviewed following the review of the literature on Organizational Development. A review of the literature on groups and on individual change in the organization would be incomplete without examining the work of two pioneers of the movement. Schein & Bennis (1965), in their seminal work entitled, Personal and Organizational Change Through Group Methods, describe laboratory training as an educational strategy which influences the development of learning in individuals and induces changes in Organizations (p.3). Learning and changes are accomplished through the participation of individuals in T-groups, theory or information sessions, focused exercises, and various other exercises (p. 14). Schein & Bennis (1965) go on to outline 6 the goals of laboratory training as: (1) - self-insight or some variation of learning related to increased self-knowledge, (2) - understanding the conditions which inhibit or facilitate group functioning, (3) - understanding interpersonal operations in groups, and (4) - developing skills for diagnosing individual, group, and organizational behaviour (p.35). These goals seem to reflect, in principle, the stated goals of the workshops being evaluated in this study which are: (1) - the facilitation of team members learning how to relate to and communicate with each other on an interpersonal basis; (2) - the facilitation of increased levels of trust among group members; (3) -the facilitation of increased group solidarity, and; (4) - the reduction of misunderstanding and conflict among group members; and, (5) - the facilitation of skills for preventing and resolving intra-group conflict. According to Schein & Bennis (1965), the following is an outline of the outcomes expected under each proposed area of change: 1. Increased awareness of own feelings and reactions, and own impact on others. 2. Increased awareness of feelings and reactions of others, and their impact on self. 3. Increased awareness of dynamics of group action. -Self 4. Changed attitudes toward self, others, and groups; ie., more respect for, tolerance for, and faith in self, others, and groups. 5. Increased interpersonal competence; ie., skill in handling interpersonal and group relationships toward more productive and satisfying relationships. 6. Increased awareness of own organizational role, organizational dynamics, dynamics of larger social systems, and dynamics of the change process in self, small groups and organizations. —Role 7. Changed attitudes toward own role, role of others, and organizational relationships; ie., more respect for and willingness to deal with others with whom one is interdependent, greater willingness to achieve collaborative relationships with others based on mutual trust. 8. Increased interpersonal competence in handling organizational role relationships with superiors, peers, and subordinates. 9. Increased awareness of, changed attitudes toward, and increased interpersonal competence about specific organizational problems existing in groups or units which are —Organ- interdependent. ization / 7 10. Organizational improvement through the training of relationships or groups rather than isolated individuals, (p.37) Schein & Bennis (1965) also state that the goals and outcomes of the workshops will largely differ based on the focus of the training in the three categories of self, role, and organization and that the goals are usually a creative compromise reached collaboratively between the representatives of the client population, or organization, and the laboratory planners (p. 59). The workshops being evaluated in this study incorporated many of the features of Bennis & Schein's laboratory training sessions but would not be considered classic or formal laboratory group training, as much of what occurred focused more on the self-development of the group members. The organization as an entity has been studied extensively and, in particular, the behaviour of individuals in organizations has received much attention. However, in order to provide a sense of clarity, the term organization will heretofore be defined as Simon et al. have defined it in Blau (1974) as "a planned system of co-operative effort in which each participant has a recognized role to play and duties to perform. These duties are assigned to achieve the organizational purpose (p. 58)." The Cancer-care facility in this study can, therefore, be defined as an organization in which the planned co-operative effort of Cancer treatment requires each member of the leadership team to play a recognizable role in their performance of the specific duties involved in the care and treatment of individuals with Cancer. In Fincham & Rhodes (1992), Guirdham suggests that there are three norms that are generally present in work environments: (1) - Fairness - In the context of group norms people expect others in the group to behave equitably, lest the group becomes distressed or the offenders are punished; (2) - Reciprocity - This implies that if one helps another, then the other is expected to help or offer something in return; and, (3) - Reasonableness - Most people in business expect each other to behave reasonably, (p. 157). As mentioned above, each group must establish its own norms and it seems as though work groups tend to function most effectively when the above three norms are adhered to and followed by group members. 8 Fincham & Rhodes (1992) go on to outline what they perceive to be the peculiar group processes for work groups such as cohesiveness, synergy, group innovation, groupthink, and group polarization. Cohesiveness is no different in work groups than in others except for the structure or environment in which it is consolidated. Synergy is the notion that a group will, in most conditions, outperform even their best member, while groupthink can be conceived of as the opposing force, defined as a deterioration of mental efficiency, reality testing, and moral judgement that results from in-group pressures. Group polarization is the phenomenon that groups will tend to make decisions that are more extreme than those of the individuals in the group (pp.158-162). One begins to gain an appreciation of the complexity of interactions in work groups, but we also discover that the individual tends to behave differently, or uniquely, in an organization. Adrian Furnham (1997) states that cooperation is one of the major influencing factors on the functioning of any organization. Furnham describes cooperation as a basic form of coordination of activities which occurs when two or more persons or groups work together and help each other, usually in order to achieve some shared goals, which ideally yields positive outcomes for all participants. The interpersonal factors that seem to foster and encourage cooperation include: the reciprocity norm and communicative propinquity, (p.348-349). That is to say, the individual in a group will function best in a cooperative environment in which there is reciprocity between members and in which the individual is afforded the opportunity to have frequent, non-threatening contact with fellow group members. This seems to support the group norms of fairness, reasonableness, and reciprocity, described above by Fincham & Rhodes (1992). Furnham goes on to outline the major problems that a newly formed work group must face and solve. The group that participated in the three workshops at the Cancer centre was newly formed group and, according to Furnham (1997), faced several challenges as a new group, namely solving many of the following problems: 9 (1) - Climate: Should the group be intimate or simply associative? (2) - Participation: How much and what type of participation should occur? (3) - Goal Comprehension: How much of the group goals need to be understood by each commitment member and how crucial is it that all members are committed to them? (4) - Communication: What channels are preferred and how is the group networked? Do they prefer face-to-face versus fax? Are they all regular e-mailers? Do they all have open access to each other? (5) - Conflict Handling: How are conflicts and disagreements handled? What systems and rules have developed for preventing and solving conflict? Indeed, whether conflict is encouraged or discouraged at all? (6) - Decision-making: How are decisions made and by whom? (7) - Performance Evaluation: How are members to be appraised? What are the criteria? Whether it is formal or informal? The regularity of appraisal and who does it? For what purpose is it primarily done? (8) - Division of Labour: How are tasks assigned and subgroups formed? Are members put into subdepartments on the basis of their skills, demography or interests? (9) - Leadership: How are leaders elected and what are their functions? How do team heads get elected and what do they have to do to stay in office? (10) - Process Monitoring: How are internal and task processes monitored and checked, and how is feedback provided? Who takes the soundings regarding to morale? (p.430) The newly formed group of team leaders who have participated in this study would be dealing with these issues before, during, and after the workshops. It can be conceived of as a process, owing to the fact that groups are dynamic entities. Groups are ever-evolving and constantly struggling with new problems and/or addressing different stages of the same problems. Finally, Furnham (1997) provides the reader with an extensive list, composed by Likert (1969) of twenty-four characteristics of an effective workgroup and also a list, composed by MacGregor (1960), of eleven characteristics of an effective workgroup. Furnham emphasizes that there needs to be a fit between task/technology, group size and composition, physical layout and environment, and organizational system in order for a group at work to be effective, and that this fit is necessary, but not sufficient to provide for effective operation of the group (pp.446-451). It might seem at this point that there are far too many conditions and considerations required when 10 dealing with work groups and individuals in organizations for any single intervention to have a lasting impact. The reader can thus appreciate the millions of dollars that are continually poured into organizational development and research in industrial psychology each fiscal year. In the realm of organizations all institutions, agencies, and companies are not created equal and, as such, one must also consider the uniqueness of the health care institution as an organization. The Uniqueness of Health Care Groups R. Wayne Boss (1989) gives a detailed explanation of why health care institutions must be given special attention in the realm of organizational development. He cites multiple pressures acting on the health care institution such as technological pressures, personnel pressures, consumer pressures, financial pressures and management problems. Boss also states that there are specific barriers to change in health care which do not exist in many other organizations. Barriers such as the health professional's expectations of autonomy as a result of being granted special status and high levels of functional independence. This sense of autonomy presents a formidable resistance to imposition of formal methods for assuring quality health care (pp.6-17). This expectation is most often reflected by the stereotypical picture of the demanding, unbending physician in a large hospital. Expectation of autonomy represents but one of the barriers to change in health care. Boss (1989) also describes barriers such as: collective benefits of stability; calculated opposition to change; programmed behaviour; tunnel vision; resource limitations; sunk costs; accumulations of official constraints on behaviour; unofficial and unplanned constraints on behaviour; and inter-organizational agreements. Boss also describes how health care institutions differ qualitatively in nature from industrial firms which underscores the point that a group of Cancer care specialists involved in a team-building process is unique, when compared with other types of work groups (pp. 6-17). A team of leaders will be influenced by many factors in an organization, but what of the teams that are comprised of a range of leadership roles, the so-called multi-disciplinary team? 11 John Stokes (1994) discusses the difficulties that face multi-disciplinary teams such as the one that participated in the aforementioned workshops. Stokes (1994) states that multidisciplinary teams, such as those employed in health care, may be staffed by nurses, doctors, social workers, counsellors, administrators and midwives. He continues to explain that these types of teams often have difficulty developing a coherent and shared common purpose since their members come from different trainings with different values, priorities and preoccupations. Also, the lack of clarity concerning the primary task that often characterizes these teams can actually cause confusion, frustration and bad feeling which interferes with work. In fact, as Stokes explains, these teams may end up behaving more like a collection of individuals agreeing to be a group when it suits them, but disbanding when serious internal conflict occurs (p.24). Given that this is a possibility for such teams, it would be imperative that any multi-disciplinary team remain crystal clear about the purpose for the team's existence and about the nature of the team within the organization. It would be imperative, then, that the team participating in this study ensure that there was a valid and agreed upon reason for the group continuing to meet. Let us now examine the individual concerns for employees in health care. In addition to the organizational constraints and problems associated with health care, there are considerable personal and psychological concerns that health care workers must also cope with individually. Cohen and Lipkin (1979), in their book Therapeutic Group Workfor Health Professionals, outline several of the reasons why employees of health-care institutions face unique challenges in their work that are not included in the job description of many occupations. Cohen & Lipkin (1979) state that health care professionals are faced with not only the patients' psychological reactions to organic illnesses (cancer, AIDS, leukaemia) and the reactions of the patients' families, but also with their own psychological reactions and feelings aroused by working with critically ill patients. Further, such work is often performed in an environment of impersonal rules and regulations imposed by hospital administrators (p.235). The individuals working with patients who are dying are inextricably linked to the awareness of their own mortality and may have a multitude of reactions including denial, emotional splitting-off, and even the experience of 12 existential angst. If employees are experiencing these difficulties, then the relationship to their fellow employees will ultimately suffer, as each individual will be forced into self-focused behaviour limiting their capacity for interpersonal connections (for further discussion regarding this topic see Snow & Willard's book, "I'm Dying to Take Care of You", 1989). Northouse (1992) discusses several of the problems associated with professional relationships in health care. Northouse (1992) outlines three problem areas that have an impact on professional-professional relationships in health-care: (1) - role stress, (2) - lack of interprofessional understanding, and (3) - autonomy struggles. Northouse states that role stress for health care professionals (eg. decision making on matters that affect life and death) is only part of the problem. Another major stress comes from the problems carrying out professional roles, as a result of role conflict and role overload. The lack of interprofessional understanding results from education in virtual isolation from the other care provider roles, and autonomy struggles result from the effect of the dominant professions (eg. physicians) who tend to underestimate the professionalism or competence of other professionals (eg. nurses) leading to conflict and il l-feelings (pp. 86-95). Combine these factors with the employees own personal difficulties mentioned above and one begins to appreciate how a lack of social support and a lack of interdependence might result in certain health care institutions. One may wonder as to what the ultimate usefulness of social support or supportive communication from fellow employees is, in fact. Two studies in particular examined the impact of social support on the well-being of the individual in an organization. Heaney et al. (1995), using an experimental design, assessed an intervention called the Care Giver Support Program (CSP), designed to - (1) teach employees about the helping potential of support systems and to build skills in mobilizing available support from others at work, and - (2) teach employees about participatory problem-solving approaches and to build skills in implementing such approaches in work team meetings, thus creating an organizational context amenable to employees participating in and having influence over decision-making (p. 3 3 5). The assessment of the CSP revealed that, through participation in the six session 13 program, employees were able to increase their coping resources of social support and work team climate. The CSP also reduced the amount of increase in the depressive symptoms and somatization of those employees who were deemed "more likely to leave their job". In other words, those employees who were unhappy at work experienced some relief from their depressive symptoms and somatization during the course of the study (p. 348). In light of the proposed evaluation in this study, the above research provides a precedent for the importance of evaluating interventions like the three weekend workshops. Further research reveals the impact of factors such as support on employee well-being. Kivimaki et al. (1997), in their research study on employee absenteeism due to sickness, found that there was a definite correlation between social support and health outcomes. Prior to adjusting the figures for demographics and health-risk behaviours, it was determined that low social support at work related positively to increased sickness absence. The authors also explained that because social support also highly correlated with socio-economic status a clear correlation between absence due to sickness and social support was impossible. However, the authors were convinced that lack of social support, in and of itself, did account for the increase in sickness absence (pp.858-872). Medical work is challenging and demanding at the best of times and professionals working in this area require personal, emotional and psychological care to prevent the work from damaging their souls. The unique challenges and differences that face the group and the individual in an organization are many and varied. However, within any group there also exist several common conceptualizations of group development and group process described in the literature on group psychology and group theory. GROUP D E V E L O P M E N T The literature abounds with writings on group development and group psychological theory and an exhaustive review is not warranted for this study, but rather an examination of several major and most relevant theorists and practitioners will be presented. Also, it is important to observe that although group development theory can be applied to many different types of 14 groups, the participants in the workshops being evaluated here may be most aptly defined as a T-group, as the reader will recall was an integral part of the laboratory training pioneered by Schein & Bennis (1965). The T-group (Bradford, L.P., Gibb, J.I., & Benne, K.D. , 1964) has been described by Corey & Corey (1987) as a group which emphasizes the human relations skills required for successful functioning in a business organization in which members are taught how to observe their own processes and also how to develop a leadership role so that they can continue the groups on their own. Corey & Corey also state that the focus of T-groups is on the group process rather than on personal growth (p. 12). Given this definition, the group of nine leaders in this particular study can be accurately described as members of a T-group, which incorporates some, but not all, of the features of the classic T-group of Schein & Bennis (1965). It is generally an agreed upon principle of group development that each group will tend to move through several distinct, though not necessarily exclusive or even chronologically ordered stages. Corey and Corey (1987) separate the stages of a group into the Initial stage, Transition stage, Working stage, and Ending or Termination Stage. Vander Kolk (1985) conceptualizes the four stages as Beginning the Group (Phase One), Conflict and Dominance (Phase Two), Cohesiveness and Productivity (Phase Three), and Completing the Group Experience (Phase Four). Others also recognize four stages of group development as well, including Gladding's (1995) Forming Stage, Transition orNorming Stage, Working Stage and Termination. Amundson et al. (1989) recognize the same four stages of group development but include two additional stages which the previous authors do not treat as particular stages in and of themselves. Amundson et al identify a pre-group Planning Stage as the initial stage in group development and a Post-group Stage as the final stage following Termination (p.274). Despite the different names and labels given to the various stages or phases of group development, it is clear that a group comes into being, has a particular life-span, and comes to a definitive end. Each of these stages or phases is characterized by how the individuals in the group interact with each other, the leaders and themselves and are the focus of the Group Dynamics or Group Process. The literature on Group Development seems to reflect a common conceptual 15 framework for the life of a group, despite the different names or labels given to the phases or stages. Group process and dynamics are more likely to be conceptualized according to the various theoretical frameworks and the literature reflects the many and varied ideations of the major researchers and authors. GROUP PROCESS Citing the work of Jacobs, Harvill, and Masson (1994), Gladding (1995) provides us with a basic definition of what group dynamics, or group process, can be defined as, namely: "the forces that are operating in a group" (p28). The way in which the dynamics of a group are viewed is largely dependant on the particular theoretical orientation of the investigator or facilitator. Vander Kolk (1985) outlines six major theoretical schools in the area of group work: (1) -Pyschodynamic, (2) - Transactional Analysis, (3) - Gestalt, (4) - Carl Rogers' Basic Encounter Group, (5) - Rational-Emotive, and (6) - Behavioural Counselling in groups. Each of these schools will differ in how they describe and interpret group processes and even individual therapists within the schools will differ in their interpretations. Given the diversity of theoretical orientation in the area of group work, any attempt to explain the meaning of the dynamics of a particular group would invariably be open to interpretation and debate. As such, the following will include only a description of the various conceptual processes involved in the formation of group dynamics and not the ultimate meaning or theoretical interpretation of their manifestation in a group. Wilfred Bion (1961) writes an in-depth and, at times, complicated description of his view of Group Dynamics in his work entitled, Experiences in Groups (pp. 141-191). These processes or, as Bion has termed them, basic assumptions include different modalities or underlying emotional patterns of group life such as: dependency, fight-flight, and pairing. The concept of basic assumptions refers to the tendency of the group to behave as if a certain assumption is true and valid and as //certain behaviours are vital to the group's survival. The basic assumption of dependency indicates that the group's main purpose is that of attaining security and protection 1 6 from one individual, either a designated leader or a member who assumes that role. When the group is functioning under the fight/flight basic assumption, the group perceives its survival as dependant on either fighting (active aggression, scapegoating, physical attack) or fleeing from the task (withdrawal, passivity, avoidance, ruminating on past history). Pairing phenomenon includes bonding between two individuals who express warmth and affection leading to intimacy and closeness (Furnham, 1997, pp. 474-475). Luft (1969), in Group processes: An introduction to group dynamics., outlines several additional group processes. In addition to the processes described by Bion, Luft (1969) also describes and explains what he believes are several other major processes at work in many groups. These include the concepts of: group mind (ie. - the emotional tone or health of the group); dependence-independence and interdependence of group members with respect to each other and to the leaders of the group; and, the notion of individual versus group productivity (ie. - those situations in which a group proves to be more or less productive than the individual and vice versa) (pp. 17-20). Luft (1969) also includes the concepts of structure (ie. - the internal organizations and procedures of a group with respect to how much structure, and how the group will build its own rules, limits, and procedures appropriate to its own needs), conflict (ie. - not whether it exists but how is it conceptualized and dealt with), role (ie. - the pattern of behaviour which characterizes an individual's place in a group), and role-playing as a method for studying the attitudes and feelings of individuals in simulated situations (pp.21-23). Citing the work of Kurt Lewin (1951), Luft (1969) includes in his discussion the concept of morale described as relying on the notion that a group's goals are sufficiently high to reflect the ideals (or long-range goals) of the group, but at the same time keeping in touch with reality for work on immediate goals. The most common meaning of morale refers to the level of effectiveness of a group and how the members feel about belonging to the group and maybe described as a feeling of we-ness or solidarity feeling, or as esprit de corps (p. 23). Luft (1969) goes on to state that, as with other basic processes such as role, conflict, structure, and leadership, it is impossible to discuss communication without relating it to all phenomena of group life. He 17 also cites the processes of listening, humour-rumour and the unknown in group life, and leadership and power. The process of listening in a group needs no explanation except to say that it can be a powerful influence on the communication of the group. Luft (1969) explains that rumours tend to develop when there is a strong need to know what is going on but, for various reasons, information and communication are limited and they tend to flourish around regions of high potential, that is around persons or subgroups exerting a strong influence (pp.26-28). This last point may be particularly salient to this study due to the highly influential and powerful nature of the Cancer Centre leadership team in relation to the almost two hundred other employees. The unknown is a constant in group life which can feed the rumour mill, while humour can have the impact of relieving tension or expressing hostility (p. 28). Finally, Luft (1969) discusses the process of leadership and power and the importance of how leaders function in a group and with individual group members (pp. 28-29). A pioneer in the area of group dynamics, Irvin D. Yalom also outlines several important concepts in group dynamics. Yalom (1975) states that there are a limited number of ways in which in which individuals can respond to social or interpersonal stress. In his citation of Horney's work he relates that individuals can move toward others (a search for love), against others (a search for mastery), away from others (resignation, a search for freedom), or with others (a co-operative, mature collaboration) (p. 181). This conceptualization of group processes follows Bion's modalities of emotional life of the group, and also encompasses Luft's categories of group processes described above. Amundson et al (1989) outline the group processes in employment group counselling as communication, norm setting, decision making/confronting the problem, and problem solving/confronting controversy (p.274). Brown (1988) also refers to several similar categories in his discussion of interaction process analysis by citing the work of Bales (1950) which include: problems of communication; problems of evaluation; problems of control; problems of decision; problems of tension reduction; and problems of reintegration (p. 36). It becomes apparent that 18 when examining the different dimensions of group process there is considerable overlap in the literature concerning those processes of group life that constitute group dynamics. A greater understanding of the functioning of a group can be gained by further examining the underlying factors which influence group process. One way of understanding the notion of group process is to understand what motivates and influences the members of the group at any given developmental stage in the life of the group. When one comes to appreciate and understand the individual in the group then a greater understanding of the group as a whole results. Yalom helps the reader to understand the individual in the group by relating the individual's experience in one-on-one therapy to the individual's experience in a group setting. Yalom (1975), in The Theory and Practice of Group Psychotherapy draws the analogy between the therapeutic effect of the 'relationship' between therapist and client in individual therapy, and the concept of'group cohesion' in group psychotherapy. Citing Fiedler, Yalom relates that expert clinicians from various theoretical schools all resemble one another in their conception of the ideal therapeutic relation and the nature of the relationship that they establish with their patients. Yalom also states that, "The evidence supportive of the critical role of the relationship in individual therapy outcome is now so considerable that it compels us to ask whether "relationship" plays an equally critical role in group therapy (p.46)." Yalom goes on to suggest that the group therapy analogue of the patient-therapist relationship extends beyond the patient-therapist to include the patient's relationship to the individual group members and the patient's relationship to the group as a whole and has termed these factors "group cohesiveness" (p.46). Regardless of one's theoretical orientation, then, it has been shown that in individual therapy if is the relationship which can be considered the common denominator and in group therapy it is group cohesion which is the primary concern of the therapist. In accordance with the limitations of the therapeutic relationship in individual therapy, Yalom also offers the caveat that what he has termed "group cohesiveness" is a necessary but not sufficient precondition for effective therapy (p.47). It may be postulated that in a group those 19 factors which enhance group cohesiveness serve to strengthen the group and those factors which inhibit or damage group cohesiveness serve to weaken the group. Yalom (1975) summarizes the primary concerns of the group members at each of the various stages of group development examined above and one can recognize the influence that each of these concerns has on group cohesiveness.. Citing Schutz, Yalom relates that in the first phase or forming stage of the group the members' primary concern is one of inclusion versus exclusion. Assuming there is an adequate sense of being included, the members then concern themselves in stage two or the transition stage with the issues of distribution of power and exercise of control. Finally, in the third phase or working stage of the group the primary concern is one of intimacy and disclosure (p. 312). It must be mentioned that the concerns of group members at each particular stage may not necessarily be completely resolved before the group enters another stage. It might be better stated that phases of a group emerge, become dominant, and then recede, only to have the group return again later to deal with the same issues with greater thoroughness (p. 313). Other authors also cite the work of Schutz when discussing concerns of the individual. A model which is also helpful in describing group process is presented by Hedley G. Dimock. Dimock (1987), also basing his work on Schutz, states that groups have three basic developmental needs: inclusion, control, and intimacy or openness. Dimock echoes Yalom's statement about the circular nature of group development and group needs asserting that the nature of group development moves in an ascending spiral addressing the needs of inclusion, control and intimacy as they emerge in the evolution of the group (pp.66-68). Dimock also states that, "Groups that have resolved the usual concerns of members in the areas of inclusion, control and intimacy are solid, cohesive groups with members who know where they stand in relation to one another and to the task of the group (p. 71). According to stage theory, a group forms, develops or evolves, and comes to an end. Group processes, on the other hand, exist and exert their influence on the group at each and every stage of a group's development. One can conceptualize stage or phase theory as an attempt to 20 describe," What the group goes through in its life", and group process theory as an attempt to describe, "How the group goes through its life." Groups of all types seem to pass through recognizable developmental stages and these stages are characterised by the group processes which occur at each moment of the group's evolution. Further, group dynamics are influenced by the cohesiveness of the group at each stage of its development, as members struggle with the "holy trinity" of group life, namely, inclusion, control and intimacy. Understanding groups at this level gives the reader a strong foundation from which to understand, scrutinize and contextualize the findings of this particular study. A complete examination of the relevant literature for such a study, however, necessarily includes the literature relating to the foundation of all group experience: Interpersonal Communication. INTERPERSONAL COMMUNICATION - The Central Group Process The foundation of all group behaviour and experience is interpersonal communication. Verbal, non-verbal, intentional, unintentional, overt or covert, regardless of the title, groups succeed or fail based on the quality and amount of interpersonal communication between individual members. Johnson (1997) goes so far as to say that our identity itself is determined by our relationships with other people and that, "As we interact with others we note their responses to us, we seek feedback as to how they perceive us, and we learn how to view ourselves as they view us. From the reflections of others, we develop a clear and accurate picture of ourselves" (p. 7). The team of facilitators made explicit use of structured and unstructured interpersonal communication exercises in the workshop weekends, recognizing the importance of such an intervention. Ross (1989) addresses the issue of group communications and how they manifest and develop throughout the life of a group. Ross (1989), writing on the development of group communication states that group communication tends to be processual in nature and that it usually is conceptualized in one of two ways. The recurring phase model suggests that certain aspects, themes, issues or parts of the process may become the focus of a group at different times in its development but, that there is 21 not necessarily any order or sequence in which the issues are addressed or tend to arise. According to Ross, the sequential stage model posits that the communication in a group does, indeed, tend to follow a progressive or sequential order depending on the stage of the group (p. 64). It cannot be understatement to assert that the importance of the quality of our interpersonal relationships is paramount and that the quality and type of interpersonal communication we receive and provide is of equal import. The workshops that are being evaluated in this study were meant to not only improve the quality of interpersonal communication, but also to help the team members achieve a new awareness of themselves intrapersonally and an awareness of themselves interpersonally as they relate to their co-workers. The nature of this process based intervention is most closely related to and defined by the concepts contained in the literature on Gestalt Therapy. According to Corey (1996), Gestalt therapy, in the case of the individual, has as its main goal for clients to gain awareness of what they are experiencing or doing through experiential learning in which clients become aware of what and how they are thinking, feeling, and doing as they interact with another person, namely the therapist (p. 224). The reader will find more detailed and thorough explanations of the nature of Gestalt Therapy in Frederick S. "Fritz" Perls' original works such as: The Gestalt Approach &Eye Witness to Therapy (1973), Gestalt Therapy (1977), or Gestalt Therapy Verbatim (1992). The focus of the workshops, in which the leadership team participated, was on interpersonal communication through experiential learning. Members engaged in a series of communication exercises which were designed with the intention of increasing each team member's awareness of themselves, and of how each person interacts with their fellow team members on a daily basis. The exercises focused on the group members' experiences of interpersonal communication during the workshops in vivo, as opposed to merely discussing the type and quality of communication in the group. This result was a workshop environment focused on experiential learning, augmented by limited psychoeducational presentations. 22 Consistent with early innovations in group training, the facilitators of the workshop also helped to increase and focus the awareness of the group members by recording and distributing group process notes to the group members in the weeks separating the three workshops. Lieberman et al (1973) cite the work of Kurt Lewin, who in 1946 conducted workshops in Connecticut with a team of social psychologists to train leaders to deal effectively with interracial tensions. Process notes were kept and fed back to the group participants who agreed that the feedback notes aided the understanding of their own behaviour and its impact on the problems they were addressing in the workshops. Out of Lewin's work came the Sensitivity or T-group in which leaders also employed concepts such as feedback, giving and receiving of interpersonal perceptions, and "participant observation" or the conscious study of the process of a group of which one is a member (p.5). As mentioned previously, the group being studied in this paper invoked many of the principles of T-group or laboratory training. The negative impact of dysfunctional or defensive communication has also been examined in the research on interpersonal relations and communication. Jack Gibb (1961), in his seminal article on Defensive Communication, makes a specific case for the reduction of the degree of defensiveness between individuals in order to improve interpersonal communication and interpersonal relationships. Gibb's basic assumption is that defensiveness in either the listener or the speaker interferes with communication due to a perceived threat or anticipated threat in the group. Defending against a perceived or anticipated threat requires an expenditure of energy and a division of attention, compromising the individual's ability to be fully present in the group and diminishing his/her ability to communicate interpersonally with other members of the group. Gibb's notion of defensive communication is predicated upon a perceived need to defend oneself against members of the group. This relates directly to the literature examined above regarding the needs of group members for inclusion, control and intimacy. A defended person will tend to either remove themselves from the group or exclude others from their personal space in order to effect a feeling of personal control within the group context. Preoccupation with control, 2 3 trust and inclusion severely inhibits the group member from establishing intimacy or openness within the group, thus precluding interpersonal relationships from progressing beyond a superficial level. There are specific interpersonal skills which can be utilized to reduce a group climate of defensiveness. A well developed model for understanding interpersonal communication is provided by John L. Wallen (1972) in his article on the Interpersonal Gap. Simply put, Wallen asserts that interpersonal communication goes through a sequence of transformations from the moment one individual intends to communicate something, to the moment another individual receives that piece of information. Wallen describes these transformations as encoding and decoding operations, and that the interpersonal gap exists when there occurs a discrepancy between the intended meaning of the encoded message and the perceived meaning of the decoded message (pp. 145-46). The larger the interpersonal gap becomes the more strained are interpersonal communications and relationships. The events of the three weekend workshops being evaluated were designed to effectively reduce the interpersonal gap between members of the leadership team. Interpersonal communication in groups occurs instantaneously and continuously from the moment a group convenes and, as such, a group facilitator would find it in his/her best interest to ensure that defensive communication and the interpersonal gap are minimized. This can be accomplished by having the group members participate in structured communication exercises with clear boundaries about what is communicated and how that communication happens between individuals. As Corey & Corey (1987) have clearly stated, "The proper question is not whether a group leader should provide structure but, rather, what degree of structure (p. 130)." Research by several other authors such as Bednar, Melnick, and Kaul (1974), Stockton & Morran (1982) and Dies (1983) cited by Corey & Corey (1987) all indicates that a balance must be reached with the use of structure. Increased structure in the beginning phases helps to reduce member anxiety and as members become more comfortable in the group the required amount of structure decreases appropriately (p. 131). 24 It is clear that all groups share certain common characteristics in their development or evolution and in the processes or dynamics which influence the course of that evolution. Interpersonal communication is inextricably linked to all aspects of group process and development, regardless of whether we are discussing a therapeutic group, a workgroup, or a leadership team in a Cancer-care and treatment facility. 2 5 CHAPTER 3 METHODOLOGY The workshops that are the subject of this study were conducted by two psychologists who both specialize in group therapy, group training and psychoeducational group instruction. The stated purpose of the workshops was to develop a team of nine leaders, each one a supervisor of their respective Cancer-care departments, into a cohesive working group, based on interpersonal relationships and intrapersonal awareness of communication styles. The methodology employed in the evaluation of this intervention is based on Stake's notion of the intrinsic case study, in Denzin & Lincoln (1994). In his description of the intrinsic case study, Stake (1994) asserts that study is undertaken because one wants better understanding of the particular case. It is not undertaken primarily because the case represents other cases or because it illustrates a particular trait or problem, but because, in all its particularity and ordinariness, this case is itself of interest. Stake also describes the instrumental case study as providing insight into an issue or refinement of theory, and the choice of case is made because it is expected to advance our understanding of another interest. He also reminds the reader that there is no line distinguishing the intrinsic case study from the instrumental case study (p. 237). In this study, the case we are interested in, that of the Administrative Leadership Team, is unique in that the group represents an attempt to construct a new form of leadership based on cooperation and equality in a health care institution. The case also provides the facilitators with valuable information as to the effectiveness of this particular intervention and, as such, one would describe this case study as both intrinsic and instrumental. The reader will find, in the lines that follow, a brief outline of each workshop, followed by detailed accounts of what occurred during each session. Detailed accounts of the two follow-up meetings held after the final workshop are also included below. 26 The Workshop Descriptions The team building workshops took place on three separate weekends in December of 1997, and in January and February of 1998 respectively, for a total of 35 combined hours. As mentioned above, the model employed was one of group-process which is ultimately concerned with interpersonal communication and intrapersonal awareness. Each session, therefore, was designed to facilitate group development in those areas. The following is a detailed account of the events which took place during the workshops, including the workshop formats, the exercises performed and the interventions employed. Each workshop began on a Friday night, resumed on the following Saturday morning, and ended on the Saturday evening. Below is an outline of the events of the workshops, followed by a detailed account of the three weekend sessions. December - 1997 - Weekend One: (Note: Time in hours is approximate) Friday Night - (3hrs) Group members introduce themselves: a) - state personal responsibilities at Centre b) - state one thing done to renew oneself Pairs exercise: a) - tell partner what was most frustrating since beginning work b) - tell partner what was most delightful/satisfying since beginning work c) - each person tells rest of the group about their partner's frustration and delight Group Discussion: a) - disclosing fears and hopes for the future b) - tell the group - (i) What are you bringing with you to the centre? (ii) What are you leaving behind? Saturday Morning - (4-1/2 hrs) Group Check-in: - unfinished business from Friday night is discussed Role-Play using doubling technique Amundson Individual Style Survey for Leaders Exercise Saturday Afternoon - (4-l/2hrs) Review of critical incidents from morning Closure and group check-out January - 1998 - Weekend Two: Friday Night - (3hrs) Group Check-in followed by group-process discussion Saturday Morning - (4-1/2 hrs) Group Check-in - unfinished business from previous night Group discussion regarding death and mistakes in health care Group incident regarding professional role of team member occurred Saturday Afternoon - (4-1/2 hrs) Role enactment using technique of doubling to address role clarification issue Group process discussion about role clarification Closure and group check-out February - 1998 - Weekend Three: Friday Night - (2 hrs) Review and Re-establishment of group goals Group Check-in Saturday Morning - (4-1/2 hrs) Group Check-in - unfinished business Johari Window Exercise Interpersonal Communication Exercise: a) - in rotating pairs tell each member of the team three things: (i) You can count on me to... (ii) I might let you down by... (iii) You could help me by... b) - perform the exercise by sitting and facing each other while touching each other's palms, and sitting with knees touching knees. Saturday Afternoon - (4-1/2 hrs) Group process discussion about the communication exercise Re-enactment of a critical team meeting by facilitators Group Check-out Acknowledgement by Leaders - Final Closure The following is a detailed account of the above events, taken from the notes of the researcher, and from the process-notes of one of the facilitators. 2 8 December 1997 - Weekend One Friday Night -The group met at approximately seven o'clock on the Friday evening in an unused conference room at the Cancer Centre. The meeting was attended by three facilitators, the researcher, and eight members of the leadership team, while the ninth member of the leadership team was kept away due to a family crisis. In the initial stages of group development safety is of the utmost importance and this served as the organizing principle behind the design and structure of the first group meeting. The first order of business was to make introductions because, although the members of the leadership team knew each other, the facilitators and the researcher were unknown to most of the team members. Each member of the group (including each of the facilitators and the researcher) was asked to introduce themselves, and was asked to mention what their personal responsibilities were in the Centre and also mention one thing that they do to renew themselves. The renewing of oneself could include anything that a person enjoyed doing or participating in to relieve stress, rejuvenate themselves, or just make themselves feel better when they were feeling tired and overworked. The members introduced themselves and their responsibilities and mentioned that, to relieve stress and renew themselves, they participated in their favourite activities or hobbies such as reading, taking a walk, visiting with family, or hiking, to name a few. The group then participated in an exercise that was performed in pairs. The group members were paired, by the facilitators, with each other and asked to share with their partner two pieces of information: (1) - What they found most frustrating since beginning work at the Cancer Centre and, (2) - What they found most delightful or satisfying since starting work at the Centre. The pairs then returned to the group for the final stage of the exercise in which each person was asked to tell the rest of the group what their partner found most frustrating and most delightful about their experience of working at the Centre. The researcher wrote each frustration and each satisfaction on a white board and the facilitators then processed the activity with the group via a discussion about what had been 29 disclosed. The group, then, spontaneously broke into a discussion about their hopes and fears for the future. The fears and hopes were also written on the board, by the researcher and again the facilitators used basic group skills of linking, clarifying, joining and elaborating to help process the personal disclosures of the individual team members. After all of the team members had disclosed their fears and hopes, the facilitators addressed the implications of the disclosures for the group as a whole. Finally, the group members were asked to comment on two questions: (1) - What are you bringing with you to the Centre? and, (2) - What are you leaving behind? Each member answered the questions and spoke into the group, after which the first night was drawn to a close. Saturday Morning -The morning session began with an "unfinished business" check-in by each member. This exercise allowed issues from the following night to be addressed and, hopefully, resolved before moving on to the day's activities. A critical incident arose and was addressed through a mini-psychodrama or role enactment in which the facilitators used the technique of "doubling" for one of the group members. This doubling was used in order to help clarify a feeling of ambivalence that the group member felt, regarding his role in the group. One of the group facilitators assumed the role of the ambiguous member and then group members were invited to address the "double" with their comments. This allowed the ambiguous group member to receive valuable feedback regarding his role in the group, while maintaining a safe distance in the role of observer. The doubling also served to allow group members to address the double without less reservation than they might have felt addressing the actual group member. The ambivalent group member was able to gain some valuable insights into how his role was conceived by the other group members. The incident was processed and the group then participated in a more structured exercise entitled, "The Amundson Individual Style Survey for Leaders". The Amundson ISS for Leaders helps leaders evaluate themselves and determine their strengths as leaders and also those areas in which they might want to make some improvements. Following the completion of the Amundson ISS, one of 3 0 the facilitators excused himself from the workshop and said goodbye to the group before the group broke for lunch. Saturday Afternoon -Owing to the fact that one of the group members (i.e. a facilitator) had left the workshop, the group process was effectively stopped and so no new material was introduced on the Saturday afternoon. Instead, critical incidents from the morning were reviewed in the afternoon and a contract was made by team members with the facilitators. The contract made was meant to ensure that the one team member, who was not able to attend the workshop due to a family crisis, was briefed on the contents and nature of the workshop. Each group member was then invited to check-out of the group by commenting on their experience of the workshop up until that point. The following workshop was attended by all nine team members and took place in the month of January, 1998. As part of the group process, each member of the team was given summary process notes made by one of the facilitators. These notes, written during the sessions, outlined the facilitator's interpretations of the critical incidents in the group and her observations of the group dynamics. Team members were asked to read the process notes in the time between each workshop weekend. January. 1998 - Weekend Two The stated purpose of the second workshop was to: build on the work done during the December workshop; to clarify the leadership model; and, to begin to concretize different ways for the team members to be with each other as colleagues, and different ways for the team members to be with patients. The group meeting was attended by the nine team members, the three facilitators and the researcher. Friday Night -The night began with a check-in, during which the missing member from the first workshop spoke for the first time. Issues that were raised by the team members included: work concerns, concerns about moving (as many had recently moved to the city in which the Centre was 31 located), family concerns, external agency pressures, and personal stressors from members' lives. The following section is taken from the process notes distributed to each team member by one of the facilitators (Wilensky, 1998). The evening discussion focused on the group's concerns about: the integrity or wholeness of the team; the impact of the governing agency in a nearby urban centre; ways of interacting with one another that are more personal; communicating personal needs to the group; and integrating professional concerns into the group. The discussion concerning the maintenance of the integrity or the wholeness of the team involved team members learning how to listen to each other's personal feelings (e.g. family matters), learning how to support team members in their professional roles (e.g. staffing concerns), and making time for one another as a team (e.g. coffee together). The group also discussed the impact of the governing agency (the Cancer Centre constitutes one branch of a central agency in the province of British Columbia, Canada). The discussion included remembering past mistakes made in other facilities, in an effort to ensure that the same mistakes are not made again in the new Centre. The team discussed the importance of being careful not to polarize the new Centre and the governing agency, as well as the importance of how new staff, coming from the other branches of the governing agency, are integrated into the Centre. The facilitators noted that the areas of focus for the team members must include interpersonal communication, focusing on openness and respect, avoiding disassociation and supporting one another. The issues of integrating personal needs and integrating professional concerns were also raised and discussed. The group facilitators emphasised that when a member of the group communicates personal stressors to the group the group must respond with personal caring. It was stated that the response can never be haphazard, unfeeling or perfunctory and the point is not to fix but only to hear. Finally, the facilitators emphasized that professional concerns must be made known in the group, there must be no shame involved in tabling professional concerns for discussion, and that helpfulness is an ethical necessity (Wilensky, 1998). The remainder of the Friday night session 3 2 involved a discussion of critical challenges that the team would be facing. These critical challenges were written on the white board and processed by the facilitators. On the Friday night there were several deeply personal disclosures made regarding disturbing occurrences in a few members' lives, centred on patient care and patient death. Fears were addressed again and much of the discussion centred around the fact that as Cancer-care specialists there is a tremendous burden of responsibility placed on the group and that the issues of the life, death and injury are ever-present in such a group. The time in the group passed very quickly and the group adjourned at approximately ten o'clock. Saturday Morning -Once again the group reconvened and checked-in with unfinished business from the previous night. One of the members, who had disclosed very personal information, stated that she had a sense of profound trust and safety in the group. One of the facilitators openly acknowledged another team member for also disclosing a tragic personal story. A discussion ensued which focused on the issues of professional mistakes and the death of patients, two very serious concerns in the Cancer-care profession. The comments made about mistakes and death prompted a discussion about the difference between those with direct patient contact and those without direct patient contact. It became evident that everyone who works in the cancer centre is affected by the patients whether their contact occurs as a surgeon, a nurse, a physicist setting up a radiation treatment, or a medical records transcriptionist taking in information about patient's body parts through a set of headphones. It was agreed that the "patient-contact / no patient-contact" dichotomy was a false one in the end. Following the coffee break, a discussion about professional roles of certain team members began. This discussion proved to be a critical incident in the life of the team. The discussion arose because one of the group members wanted to gain some insight regarding how the rest of the team viewed her role. It became clear that there was a considerable amount of ambiguity and/or ignorance on the part of the group members, as to the nature of that 3 3 particular member's role at the Centre and vvithin the group. One of the facilitators commented that this individual's lack of role legitimacy was negatively affecting the whole team and that no more work could be done until the issue was addressed. The group work which characterized the morning effectively stopped due to the clarification issue regarding this particular member's role . The group broke for lunch with an unsettled mood. Saturday Afternoon -The afternoon began with a role play. In this enactment, one facilitator took on the role of the ambiguous team member, while another facilitator took on the role of one of the Co-Manager's of the centre. In these roles, the facilitators engaged in a discussion between themselves regarding how each viewed the other's role, while the rest of the team members observed. This enactment illuminated several issues concerning both the balance of power in the group and the role responsibilities of individual group members. It became clear that some of the team members had much more responsibility in the centre than others and, as such, had more power and influence in the group compared with other team members. This enactment upset the balance of the group. The formation of the group was predicated on a team-based model of leadership in which all group members were supposed to be equal. It became clear that, although the individual members had equal value as people and leaders in the team they did not have equal power or responsibilities in the centre. The result of the afternoon's discussion constituted a group crisis which was not resolved before the group adjourned for the evening. Instead, two major goals were established to be completed by the Co-Managers before the final workshop weekend: 1) to clarify and be specific about people's roles and responsibilities, and 2) to review and reconstitute the centre's organizational chart. The group checked-out and all members agreed that it had been a difficult and challenging day which also served to solidify the commitment of the team to one another and to the centre. In the days following the end of the second workshop, the facilitators re-established the initial goals of the workshops with the Senior Administrator. It was agreed that organizational development was not the purpose of the workshops, but rather team-building and group cohesion were the 3 4 stated goals. The third and final workshop weekend began with a reiteration of the initial goals for the team. February. 1998 - The Final Weekend Friday Night -Continuing with the established group norm, the group met at approximately 7 o'clock p.m. One of the facilitators began the discussion by providing a recap of the events from the previous workshop. The facilitator outlined the newly re-established goals for the final weekend and stated that the weekend would follow a more process-oriented structure, as opposed to the organizational development and role clarification that characterized the second workshop. The personal concerns of several members that had arisen from the previous weekend were addressed, and the facilitators made amends for the fact that the concerns could not be fully addressed previously, due to the importance of the role clarification exercise. Another of the facilitators addressed the group stating that the group must learn to be good to one another, especially in conflict. She also emphasized that no one teaches us, as individuals, how to be good to one another so the group must learn how to do it themselves. The evening meeting continued with the established norm of checking-in. It became readily apparent that many of the team members were tired and feeling the strain of being away from their families for extended periods, due to their responsibilities at work. Several members expressed concern over the increased workload and the approaching deadline for the opening of the Centre. The facilitators and group members agreed that it would be to the benefit of the group to finish early on the Friday night and begin fresh on the Saturday morning. Everyone seemed to be relieved and the group was adjourned. Saturday Morning -The morning began with the standard check-in and unfinished business from the previous night. There was no unfinished business in the group and so the facilitators moved on to the first 3 5 exercise of the morning which was a psychoeducational introduction to the Johari Window (Appendix C), with a focus on how each member related to their colleagues. Each person was invited to conceptualize their own Johari Window, as a means for increasing their self-awareness of their own interpersonal relations with fellow group members. The exercise was psychoeducational in that it did not involve direct group-process but rather an introduction of the concept of the Window for each member to consider. The exercise that followed was particularly process-oriented and focused on intensely intimate, interpersonal communication. The team members engaged in an interpersonal communication exercise, in which each member of the group would be paired with another group member in a rotating cycle such that each person would have the opportunity to speak with every other member of the team. The pairs were given three sentence fragments which they were to asked to complete according to the person to whom they were speaking. The three sentence fragments were: (1) You can count on me to (2) I might let you down by (3) You could help me by The pairs were given approximately fifteen minutes to make the disclosures and then the individuals rotated and were paired with another group member, until each person had met with every member of the group (note: since there were nine team members, one member, on each rotation, would "take a break" in which they could choose to converse with the facilitators or sit quietly by themselves and wait for the next rotation). A significant stipulation of the exercise was that the partners had to sit touching "palm-to-palm and knee-to-knee" as they completed the three sentence stems. Each partner was asked to think about what they wanted to say to each person they spoke to and finish the sentence stems while sitting facing their partner "palm-to-palm and knee-to-knee" (ie. - the pairs laid their palms flat against each other, parallel to the floor, while touching knee cap to knee cap). The group members engaged in this exercise for approximately one-hour, in which several rotations were completed and each person had the opportunity to speak to several other 3 6 group members. The team was then brought back to the large group and a discussion about the exercise, up until that point in the day, ensued. In the discussion, the group struggled with the notion of what were considered acceptable guidelines for human touch with male and female patients, and between male and female professionals. The group returned to finish the exercise, so that every person was given the opportunity to speak with every other member of the team. The researcher noted, at this time, that several individuals did not sit with their partners in the palm-to-palm / knee-to-knee position. The group broke at approximately 1:15p.m. for lunch. The team returned for the remainder of the afternoon session at approximately 2:45 p.m. at which time the group met in a circle and once again checked-in and processed their experiences of the morning's exercises. Each member was encouraged to tell the group how they felt about the exercise, and then the group moved on to the final exercise of the day. The group had agreed that they would like to witness a role-play in which a previously held team meeting, that had been unsuccessful and problematic, would be re-enacted by the facilitators. The members of the team agreed that the meeting had caused a certain amount of conflict and defensiveness in the group members, despite the fact that the meeting agenda centred on the rather "simple" problem of assigning parking space allotments. The re-enactment was designed to serve as an educational model for an effective method of conducting a meeting, in which the Chair of the meeting was able to keep the team on the agenda, while at the same time reducing the amount of interpersonal defensiveness. The Facilitators and the researcher planned and re-enacted the meeting in a way that demonstrated a more effective method of conducting the meeting in which a decision was finally made regarding the relative importance of the decision about the allotments. The re-enactment was designed to educate the team regarding the process of such meetings, rather than an attempt to solve the problem of the parking space allotments. Following the demonstration, the group reconvened for the final time. The three workshops ended with a final check-out by the group members and with a special acknowledgement of the team members by the facilitators. One of the facilitators, on behalf of the other facilitators, acknowledged the personal qualities and characteristics of each 3 7 team member that would be remembered by the facilitators after the closing of the group (eg. "Jessica, we will remember your spontaneity and your sensitivity. Mike, we will remember your talent for metaphors and your humour."). The group members listened to the acknowledgements of the facilitators and the group was adjourned for the final time. The workshops finished at approximately 6:00 p.m. on Saturday, February 7th, after the team had made the commitment to meet, as a group, in March, 1998. The meeting was planned in order to continue building and maintaining the group cohesion that had solidified during the three workshops and was held at the home of one of the team members, facilitated by the researcher. Two such meetings were planned by the group and facilitated by the researcher. The following is an outline of the events of those two meetings. Follow-Up - Session One Friday, March 20,1998. As mentioned above the researcher was given the role of observer during the workshops and so it was necessary for the researcher to comment on the new role that he was assuming in facilitating the follow-up meetings. The researcher addressed this at the beginning of the session. The group met at approximately 7:00 p.m. in the home of one of the group members and began the session with a check-in, in which the team members were asked to say a word or a sentence which reflected how each person was feeling at that time. Team members were also asked to share with the group one thing that each person had done to take care of themselves since the last workshop in February. The group engaged in this exercise for approximately one hour. The final hour of the meeting was spent with the group members disclosing to the group: one frustration or challenge that they were experiencing at that time, and what the individual needed or wanted from the team to help remedy the situation. The group meeting ended with a check-out which consisted of a word or phrase of the individual's choice. During the check-out, the group members mentioned that what they were taking from the session was: a renewed sense of energy from the session; an awareness that there were accomplishments and successes since the 3 8 last workshop; and, an appreciation for the words of acknowledgement from others. One member felt that the group meeting served to renew their empathy for each other by meeting this way, while others appreciated the opportunity to exchange information with fellow team members. A second meeting time was set for April, 1998 and the session was adjourned. It should be noted that the meeting time for the second session was significant in that it occurred after the official opening of the Cancer Centre and after the treatment of the first patients. Follow-Up - Session Two Thursday, April 23, 1998. The group began at approximately 7:30 p.m. with a check-in, following the established group norm from the previous sessions. The team members were once again invited to tell the group how they were feeling, and it became apparent that the tenor of the group was one of diminished energy levels combined with increased work levels. The opening of the centre proved to be an important time for all the members but the feelings about work since the opening were mixed and there was a sense of ambivalence at the beginning of the session. The group was then split into small groups of three in which each person was asked to tell one of the two other members: (a) - One area that they handled competently - something that they can take credit for doing well since the opening, and (b) - One thing that they felt would be an ongoing challenge for them in their work. Each person was asked to report back to the group for another person on what they had heard, similar to the first exercise of the initial weekend workshop described above. The group reconvened after approximately one hour and each person spoke into the group on behalf of their partner. After completing the exercise, each group member checked-out by telling the rest of the team why it was personally important to them to keep the group together. The group adjourned at approximately 10:30 p.m. and this would be the last time the group would come together for a facilitated group meeting in the year of 1998. The interviews were conducted approximately five 3 9 months after the end of the final workshop and approximately two months after the last group follow-up session with all nine team members. The research methodology and construction of the protocol employed are presented below. The reader will, as above, find a brief outline of the research process followed by a detailed explanation of the methods employed by the researcher in constructing the interview protocol, in gathering the interview data, and in analyzing and organizing the data into several categories of experience. Research Methodology at a Glance Step One - Constructing the Interview Format Four main areas of investigation were identified through consultation with research advisor, communication, morale, support, and ability to provide more humanistic/holistic patient care. Step Two - Refining the Interview Format Prior to conducting the actual interviews, a "mock" interview was conducted with researcher's supervisor to refine the technique of interviewing. Step Three - Briefing the Participants Prior to the interview each participant was briefed on the interview format and given a brief verbal summary of the events of the three workshops, by the researcher, to stimulate discussion and stimulate recall of the workshop activities. Step Four - Conducting the Interviews Participants were interviewed by the researcher using the semi-structured interview format found in Appendix A. The interviews were conducted in an empathic, conversational manner allowing for free flowing discussion between researcher and participant. Step Five - Data Transcription and Analysis The audiotaped recordings of the interviews were transcribed by the researcher and subsequently were analyzed to determine commonalties of the participants' experiences in the workshops. 40 Research Design The design of this study is one of a formative, qualitative evaluation examining the impact of a series of three team-building workshops at a major Cancer-care centre in British Columbia, Canada. The researcher set out to investigate the impact of the workshop series on the participating members of the leadership team, through the use of a semi-structured interview. The following pages will outline the steps taken in the construction of the research protocol for the study, including the decisions on salient issues for investigation, the interview design, and the participant selection, as well as the interviews themselves, and the analysis of the data. The workshop facilitator commissioned this study as a means of evaluating the impact of the workshops for future refinement and as a means of providing the group members with critical feedback on those aspects of the workshops which impacted them positively and those aspects which impacted them negatively. Prior to constructing the interview protocol, the most salient issues for investigation were identified through a consultation with one of the facilitators of the workshops. Four main areas of investigation were identified as the focus for the interviews, namely: communication, morale, support, and the ability for members to provide more humanistic/holistic patient care. The areas of communication, morale and support were identified by the researcher, through consultation with his research advisor, as those aspects of the workshops which were most directly related to the process of team-building and the group dynamics using a group-process model. The area denoted as "the ability for members to provide more humanistic/holistic patient care" was included because it represented one of the stated outcome goals of the Senior Administrator for forming a democratic leadership team in a Cancer-care facility, based on interpersonal relationships. The interview protocol was constructed around these four areas of interest. Prior to conducting the interviews with the team members, the researcher engaged in a "mock" interview with a research supervisor to become familiar with the process of interviewing and to refine the interviewing technique. 41 The Interviews: Format The interviews were conducted using a semi-structured format presented in Appendix A. The interview was designed to focus on each participant's experience of the aforementioned topics. The interviewer focused on critical events, identified by the participants, which occurred during the workshops, and the significance that the participants placed on those events. The interviewer also facilitated discussion surrounding the participants' experiences in the workplace, following the end of the workshops. The experiences of the team members at work, following the workshops, was explored in the interview process in order to determine what impact, if any, the workshops may have had on the team leaders in their daily work lives. The team that participated in the workshops consisted of nine administrative team leaders including: the Senior Administrator, the Co-manager of the facility, an executive secretary, a radiation oncologist, a medical oncologist, a systemic therapy supervisor, a patient information manager, a physicist, and a radiation technologist. The team of nine was hired as part of a plan to institute a unique administrative structure into the Cancer Agency, based on the notion of team leadership and team decision-making. Selection of the participants for the interview was done on a volunteer basis and all nine of the team members were invited to participate in a research interview. The Interviews: Procedure & Process The members of the leadership team were not given the option of participating in the three workshops, as it was required that they participate by the Centre's Senior Administrator. However, the participant's who were subsequently interviewed were self-selected, in that each of the nine team members was offered the opportunity to provide the facilitators with feedback about their experience of the workshops, with no obligation to do so. The researcher was a participant-observer in the group and was known to all group members as having the role of researcher and observer. It was made clear to the participants that, although they were under no obligation to provide an interview, the process would provide the facilitators with valuable feedback. The facilitators also stated that an interview with the researcher would help to solidify some of the 42 learning that took place for each team member, as a result of having participated in the workshops. The interview process was described as a type of "debriefing" for the individual participants. Step 1 - The interviewer contacted each individual by telephone and asked them, individually, if they would be willing to participate in a research interview. Interview times were subsequently scheduled. As all of the interviews took place in a city different from the one in which the interviewer was located, all of the interview times were scheduled on the same weekend. Scheduled interviews were conducted at the Cancer Centre, in order to accommodate the work schedules of the individual team members. The interviewer established an interview room in one of the empty office spaces at the centre and notified all scheduled participants of the location. An audio tape recorder was used to record each interview. Step 2 - Prior to conducting the interviews, the researcher explained to each participant that the purpose of the interview was to provide the team members with the opportunity to give feedback to the facilitators and, consequently, to receive a type of debriefing which would help to consolidate the impacts of the workshop on each of them as individuals. It was stated above that during the course of the weekend workshops, each participant received summary process notes, from one of the facilitators, taken during each of the workshops. The researcher asked each participant to re-orient themselves to the workshops by reviewing the notes. This request was made due to the fact that approximately six months had passed since the final weekend workshop. Participants also indicated that they had difficulty recalling much of what had occurred during the workshops. The researcher also re-oriented each participant to the exercises that took place in the workshops by reading aloud a summary of the events and by referring to this outline of events during the course of the interview. When the participant was prepared the interview commenced, following the outline of Appendix A. 4 3 Step 3 - The researcher, being trained at the graduate level in Counselling Psychology conducted the interviews using the basic interviewing techniques of summarizing, paraphrasing, clarifying. The researcher also encouraged each participant to expand on and/or elaborate on their experiences, both during the workshops and in the period of time that had elapsed since the workshops, in order to promote a free-flowing discussion during the interview process. Step 4 - The interview was semi-structured in that the main focus of the interviews centred on the four aforementioned areas, but participants were encouraged to include any information that they felt compelled to share, even if it seemed unrelated to the topics of discussion. Although the interview protocol was constructed in a linear fashion moving from one topic to the next, participants were not restricted to discussing the topics in chronological order. The duration of each interview fell in the range of forty-five minutes to one hour and fifteen minutes and the participants were informed that at any time during the interview they were free to make comments "off the record", at which time the tape recorder would be turned off. This was done to engender a sense of safety during the interview process and to promote a more relaxed and free-flowing interview environment. Step 5 - At the end of each interview, the participants were invited to make any final comments about their experience in the workshops that may not have been discussed in the duration of the interview. A total of seven interviews were conducted, as two of the participants were unable to participate at the time of the scheduled interviews. The recorded interviews were then transcribed and analysed by the interviewer. 44 DATA TRANSCRIPTION & ANALYSTS Transcription The transcription of the interviews included only those aspects of the interview that related to the workshops either directly or indirectly. Comments made by the participants concerning their experience of the workshops, and their experience of how the workshops impacted their work and interactions with fellow team members, were included. Comments that were neither directly nor indirectly related to the participants' experiences of the workshops were omitted from the transcription process. During the transcription process, the researcher dwelled on the topics of communication, morale, support and the ability to provide holistic/humanistic patient care. The relationship of the participants' experiences to the workshops were either explicitly stated or implied by the participants in the process of the interview. The analysis of the data followed the transcription process. Analysis of Transcripts Overview A - Preliminary Constructs -Separation of interview data into four constructs of communication, morale, support, humanistic/holistic patient care, following interview format. B - Initial Stage -Three separate reviews of the transcripts by the researcher to begin to identify commonalties and differences of experience. C - Fourth Review of Transcripts -Similar phrases and quotations extracted and grouped under above preliminary constructs, generating several categories of experience: Communication -Morale -Support -Hum/Hoi. P-C - Determined to be a non-issue for participants. 12 categories of experience 13 categories of experience 15 categories of experience 4 5 D - Collapsing the Categories of Experience Upon re-examination, the preliminary categories were not qualitatively or significantly different enough to warrant the use of so many categories and were thus collapsed according to similarity, once again: E - Eliminating the Constructs It became apparent that the categories of experience, under each construct, were too similar and interconnected to warrant their separation along the lines of communication, morale and support. The constructs were eliminated and the resulting eight categories of common experience emerged: (1) - Understanding others as persons or being understood as a person (2) - Formation of personal connections to others (3) - A sense of belonging/acceptance/inclusion (4) - A sense of safety and trust in communicating (5) - Sensitivity to perceived level of team member commitment (6) - An appreciation of facilitated group experience (7) - An experience of group morale, and (8) - Reciprocity and demonstration of support. Analysis of Transcripts - The Process The initial stage of the data analysis involved three reviews of the transcripts by the researcher, which consisted of reading and re-reading the records, in order to gain a familiarity with the material and in order to begin the preliminary identification of common experiences of and statements made by the participants. The preliminary stages of the analysis included a separation of the data into the four constructs mentioned above and the transcripts were initially examined construct by construct beginning with communication, morale, support and ending with holistic/humanistic patient care. On the fourth review of the transcripts, similar phrases and comments were extracted and grouped into preliminary categories. The transcripts describing experiences relating to communication seemed to include twelve categories of common experiences, while experiences Communication Morale -Support -7 categories 7 categories 6 categories 4 6 that described morale and support seemed to include thirteen and fifteen categories respectively. The final construct entitled the ability to provide humanistic/ holistic patient care was then separated out, due to its lack of relevance as revealed in the interview process. The participants stated that the issue of patient care was not relevant to the discussion of the workshops and their impacts. Upon re-examination of the preliminary categories it became apparent that the number of separate categories was unnecessary due to the similarity of content in many of the categories. The preliminary categories were then collapsed into fewer categories under each construct (Communication - 7, Morale - 7, and Support - 6), based on the similarities and commonalties of content. It then became apparent that the four constructs originally designed to illuminate different experiences were restricting the analysis of the data by placing artificial constraints on the information contained in the transcripts. The constructs of Communication, Morale and Support overlapped to such a degree that the delineations were no longer useful and the constructs were collapsed and the boundaries eliminated. After consultation with the interviewer's research advisor, the categories were further refined and grouped according to their similarities. This refinement produced eight categories of data describing the participants' experiences of the impacts of the workshops . The delineations of Communication, Morale and Support, as stated above, were abandoned. A final analysis of the transcripts was performed following the last revision of the categories, to determine if all of the interviewed participants shared all eight of the categories of experiences. In the end, the data revealed that all but one of the participants had shared in all eight of the categories of experience. Triangulation The process of triangulation is a common method employed in the final analysis of qualitative data. In this particular study, the categories that are being presented emerged from the analysis of the data as descriptions of the participants' experiences. Although one may have chosen different wording for the titles denoting each of the eight categories, the description of the experiences comes straight from the testimony of the participants and has not been interpreted or manipulated by the researcher. As such, the process of triangulation would not serve to improve 47 the reliability or validity of the data in this study. For example, under the category entitled, "Understanding others as persons or being understood as a person" there may be another title that one would choose for such a statement as, "So it gives you a better ability to read the per son...by knowing more about them I think your..you just naturally communicate better because you know more and you understand them more." However, the statement itself is quite self-explanatory, thus negating the need for such a process as triangulation. In addition, each category has been explained in a short paragraph preceding the presentation of quotations. 4 8 CHAPTER 4 RESULTS Research Outcomes The following results represent the experiences of six of the nine team members, as described by each person in an in-depth interview with the researcher. Two members of the team were unable to provide interviews at the time the researcher conducted the interviews, one of which was interviewed by the researcher after the categories of experience had been identified. A short summary of the interview with this participant follows the presentation of the data. In addition, the experience of the Senior Administrator (SA) will be summarized separately, following the results of the six interviewed participants, due to the unique role that the SA played in the life of the group. The SA's role was unique, owing to the fact that he was the employer and supervisor of all eight team members and, thus, occupied a special place in the group. The remaining six group members described their experiences as falling into eight broad categories, which all six participants reported experiencing. The results revealed eight categories of experience. They are. (1) Understanding Others as Persons or Being Understood as a Person (2) Formation of Personal Connections with Others (3) A Sense of Belonging/Acceptance/Inclusion (4) A Sense of Safety and Trust in Communication (5) Sensitivity to Perceived Levels of Team Member Commitment (6) An Appreciation of Facilitated Group Experience (7) An Experience of Group Morale, and (8) Reciprocity and Demonstration of Support. These were the major experiences that the team members reported having either during the workshops, or during working hours after the workshops, as a direct result of having participated 4 9 in the three weekends. Experiences which did not fall into the above eight categories have been outlined in the section entitled, Humanistic/Holistic Patient Care, which was the fourth component to the interviews and warrants a subsection of its own. The SA did not describe the same experiences in the workshops, as mentioned above and, as such, will be treated as having a separate category of experiences in the section entitled The Senior Administrator Interview. The reader will find that the descriptions contained in the categories of experience seem to melt together and overlap at times. It became apparent that the interviewees' descriptions of different experiences were often described with similar or sometimes even identical terms. These shared experiences, during and after the workshops are intimately connected with and interdependent upon one another in that one experience often occurred in conjunction with others. Often an experience was the precursor or the result of another experience. The reader will gain an appreciation for the interconnectedness of the experiences while reading the following testimonials. THE EIGHT CATEGORIES OF EXPERIENCE: (1) - Understanding Others as Persons or Being Understood as a Person The group members reported that, as a result of participating in the three weekend workshops, they experienced a deeper understanding of their colleagues as people, beyond their professional roles. They also reported feeling as though they were understood by fellow group members in the same manner, beyond their professional roles and responsibilities. The members stated that this came as a result of the personal disclosures concerning the individuals' thoughts, emotions and experiences, or by the direct observation of the persons in the group. Team members reported that understanding others as persons or being understood by others as a person had a positive impact on the participants and seemed to serve as the foundation for many of the other interactions and experiences that the group members described. Members also claimed to have achieved a greater appreciation for the experience of the other team members and the 50 meanings that others attach to the events in their own lives. The following quotations represent the participants' experiences of Understanding Others as Persons and Being Understood as Persons: [Note: Interviewer's comments appear as italics in the quotations] D - I think it strengthens each of your understanding of how communications happen, and you start to understand more why people are different and how they communicate differently, because you spend time with them away from the pressures of your work and you hear about their personal lives and you understand what else is happening in their life. D - So it gives you a better ability to read the person...by knowing more about them I think your...you just naturally communicate better because you know more and you understand them more. D - And it also made me aware that you know I have to admit that traditionally I've always viewed work as work and I used to be somewhat intolerant of staff who would call in and say, you know, two calls in the morning...you know you're short staffed already, 'My kid's sick...I can't come to work today.' That would have been a kind of minor annoyance to me previously... I now have a far better appreciation of what that means for that person and that is a small thing but I think that's something that will stick with me forever. D - I probably, in any other work environment would never have the opportunity to express what I did to the leader of our centre. I mean where else would you be able to disclose what you feel you need... Right...Uh, to that sort of a position of a... an individual in that position. C - What I recall from the workshops, from the weekends was uh the sense of the humanity of all the people that were in the group. So I felt that I had an opportunity to know them as people more than I would have had I...had we not...had we not done any of that. C - I liked..um that I was able to have that insight into or be invited in and have that level of disclosure...Right...come from people and appreciated that and thought it was very neat because it allowed me to experience those people who I would normally not get close to because we're different enough or we...you...we circulate in different circles or our lives just don't, outside of work, touch each other. C - Any team building that I've been involved in, in other work settings, hasn't... doesn't go near the disclosure. The personal... the 'Who is this person sitting in front of me?', kind of stuff. It's more, you know, the management issues or specific team building functions that speak to how we work together in... as a professional group, rather than - 'Who is this person sitting there? And what might they be bringing in that's personal for them and unique for them?' 51 C - I think it was unique that we had the opportunity to do that because it means that we know one another differently at a deeper level than a group at another centre for instance might know themselves and the others that are there. C - I'm aware that when we know people less, it has a diff...it resonates differently. That whole issue around respect and when you know someone and you understand that.. that personal element or you have a personal element that you're aware of the respect is...feels different than just the general regard that you have for other people. G - There were a few incidents when people disclosed really personal, urn... emotional parts of themselves and things that disturb them about their jobs... Right... You know...I mean I don't...you know you could see people feeling, well you know, crying. G - Well when X had to leave the room, when she talked about [city name] and what happened there... Yeah... you know and that was really uncomfortable and I felt really badly for X . You know...I just felt so bad that she carried so much with her, that she had such strong feelings and...still about that...that it still made her cry when she thought about it. G - It forces us to..to remember that we are human. That we have feelings and we are dealing with people and it does affect us and I think as a team, you know... I mean people can go in their work and they talk about, you know... different sites of cancer and pieces of people's body like they're...you know something in a butcher shop. You know and always just like this... but to know that even though you have a role where you end up treating people's bodies like...like hunks of meat... it... they are still people and people do still connect that they are humans and that does affect us. A - So one of the first things, with regard to communication, was team...just introducing each other.. .on a team, as it were building. Who are the members of the team? And we, I think were quite effective in that. Um...we got to know each other and very quickly, when I reflect on the notes, we got really quite intimate in terms of sharing our...um feelings. A - ...and also what was interesting there was uh.. .um learning what things were upsetting people that I had no clue would be upsetting them. So that was very helpful... good communication exercise...just checking-in and listening to what was bugging people... A - During the group process, it was very intimate, very feeling oriented, very process oriented and...um it's not the way one normally comes to work and communicates with a colleague. Right. More personal? Yeah, yes and more... what are...how are we communicating? More process... analytical of process as opposed to issues. F - I think the connection really came on the touchy/feely eye-to-eye — knee-to-knee day. And, um...you really got a sense for what people...how people felt they could support you in your role and vice versa. And, um...get an understanding for um... their limitations or their weaknesses in supporting you and vice versa. 52 F - People were talking about their personal situations, their personal beliefs and values. U m . w e didn't talk a lot about work. It was things like urn...you know, 'You need to recognize that when I can't stay at five o'clock it's because of my personal needs.' F - When I interact with them or I communicate with them I understand um... why it is they can't help me when I need help. F - The connection with the leadership team has given us an understanding of um... some of the frustrations and some of the accomplishments of the other members of the leadership team. E - So you tend.. .you can get to know a lot more about people. A lot more about their... their um...worries or...you know...internal or home... E - You get an idea of what...you get a better idea of what the people are like. I think I mentioned before that I noticed Y , for example, was very uncomfortable with that. Um..hmmm, yeah. That uh.uh he actually wouldn't, you know we didn't sit in the regulation position [laughter]. It was kind of, you know, just on the edge of comfort for him. E - As I said, I think the.. .the one exercise that was done was very.. .was very uh.. .took our level of intimacy to a... to another level. C - There's more credence given to it. It's a more credible... Right... request somehow because we have a sense of each other as individuals. C - When we come together only as a professional group, to me something's missing from that and what's missing is my sense of the humanity of the other... Right...and yes we can talk about the professional issues and we can disagree or we can agree or, you know we can be very matter of fact with one another...and I realize sometimes we are that way with other people. Being able to see the humanity of another means more because it adds something also to that discussion that is otherwise not there and it allows that disclosure. It invites that disclosure more. D - And it gave you an opportunity to bear your soul. Which...how often do you get to do that with your work colleagues. You know, really do it in an environment where no one else is knocking at the door or trying to talk to you. G - You know, but...and I don't think if we had just had our roles and I hadn't had, you know...known enough about X or, you know...to even notice, I would just, you know walk by another [professional position] because I never worked for a [professional position] before...Right...and have just ignored his frustrations... G - I guess trust is built over...I find um...a period of becoming more familiar with each other. You know having spent that time and listening, you know in a... in a... in a group situation and in a one-on-one situation listening to that person talk, not about work, but about themselves. So you're building up familiarity with them and getting to know who they are an trust came along with that. 5 3 G - That people understand... like I... I understand who the other members of the leadership team are. They, as individuals have a glimpse of who I am. G - It did become apparent during the workshops...// did? Okay... It became you... you could tell...I could see the...the discomfort even more so, more than...than my own...Right... You know, I thought, 'Oh, I'm really bad at this,' and then I looked around, 'well some people are worse than me.' F - What we did was we brought the person into the team and not just the role and that was, I'm not sure if anybody else felt that way, but I certainly felt that people care about you as a person first and then your role. E - I think it's just getting to know people and getting past these professional barriers and you...getting to know people, um.so that you can talk to them about things that are outside the realm that you would normally talk to them about. E - In particular during the workshops there was a lot of um...uh...you know, I think we were both willing to um...tell a lot about ourselves, [unclear over talking] Well yeah to one another. (2)- Formation of Personal Connections with Others Participants reported the sense that, throughout the course of the three workshops, they formed personal connections with some team members. These personal connections were experienced as a sense of shared personal understanding, a type of attachment or a bond, somewhat emotional in nature, or a personal closeness. They also stated that, since the workshops they had either maintained those connections or felt that those connections had been somewhat damaged, or even lost. The statements are of a subjective nature in that each participant describes the personal connections as a feeling either towards, or shared with, certain team members. Participants also reported that these connections had a positive impact on them as people, and a loss of those connections was experienced as negatively impacting them. The following represents the participants experiences both during the three weekends and after the end of the workshops. D - So had I not known that about him and he not known that about me...um we wouldn't ever have had that connection. So I felt that connected me far differently to X than I would have ever had an opportunity to do otherwise, you know in a normal work setting.. A nd do you think that the workshop helpedfacilitate that? Oh, I know it did. I know it did because I wouldn't 5 4 have...we wouldn't have gotten that far down the path to be able to do that had we not had the work that we did previously. D - I think it was because of the physical, maybe the physical connection um.as opposed to talking. Um..I can remember the um..the conversation I had pretty well with everyone and it was..it...some other parts of the workshop, you know didn't seem as important. Not didn't seem important...that connection for me was that exercise. C - I think that initially there was that sense of closeness um.. .we've been.. .we've been extremely busy since we've opened and we have a huge volume of patients to deal with and um...I noticed that uh...um it would be that I....I have found that as we've gotten busier, people have kind of retreated into whatever their professional model or mode is. C - We've kind of, my feeling is that some people I have lost some touch with of the group.. Right... Some people I'm close to. I've remained close to. C - The one's how I understand from that human... humanistic point of view, I still have that understanding of them but I don't feel the connection in terms of my enacting it in my communication with them...Oh I see...and I...and I think its because we've... we've been busy and I also noticed that when people are busy to the point of being stressed they revert back to old patterns.. A - The effect of the opening, including your meeting in March, so the effect of the opening has been profound. We haven't explored that, on the group. We haven't checked-in with each other so the communication effectively stopped the day the centre opened, in...in a formal way. We have our business communication, our interactions, but the group process really stopped. A - Now the communication is back to the...to what we predicted would happen. The honeymoon's over. We're now into a phase of... of very difficult stressors on the group and I think the group itself has, um...become much more foggy, in terms of its continuity, because I...I'm tending to interact, not as a group, but with individual members of the group and some more than others. A - There are people in the group that I'm losing touch with. For example uh...I don't interact much with Y anymore...um like I did in the group. I have my own [professional position] designation. I interact with Y in a pleasant, social and occasional way, but not with the sort of degree of involvement we had. A - The hallmark of this, in my mind, is we're starting to communicate by e-mail and um.. .apart from the fact that e-mail is grossly misused in the agency as a whole, it's also a defense mechanism 'cause you don't have to interact with the person with eye contact, with body language and I'm as...I'm as guilty as the next person, but that, to me, is a warning that um..we're, you know we're doing business, but we're doing it at a very impersonal level. 55 A - We had the luxury of no patient pressure, no stressors...well we had stressors but we didn't have that sort of immediacy that we knew was going to hit us when the centre opened... and... and with no prospect, I might add, of letting up. Um...now, because of that, I think we're tending to try and communicate in the most efficient way we can. I mean just trying to get us all together for a meeting has been difficult. F - I go back to that day on the clarification of roles and I think about the tension in that day and how I think it actually impeded communication. F - We...people ran away when they heard, or when it was stated what...what the group felt, in terms of...of um...roles and role clarification. F - I guess when I think about what actually the outcome was , in terms of communication, I think, on the Monday when we came back to work um... it was like nothing had happened. It was...it was kind of remarkable that... actually I shouldn't say nothing happened because there was some avoidance for a couple of days, not wanting to talk about it, not wanting to get into it. F - It was more of a... a connection with that individual as a person and not as a co-worker or as a process leader or as a physician. F - Like there's a real connection with this person and it's interesting because it's probably, out of the entire leadership team...I mean there are nine of us, of which I'm one, so there's really only eight...I think I have that connection with probably three people. That...that true, where I really feel connected. That when I..when I interact with them or I communicate with them I understand um...why it is they can't help me when I need help. F - Well, definitely that third day. The, you know, 'I can help you by...and might let you down by...', was an eye-opening experience for me. Up to that point you sort of had a sense that your team was there but you really didn't know um...how they felt. So when...when you made that personal connection and you understood that, you know, they're there to support you it went a long ways for me. F - I probably have a greater connection with the people who were explicit than implicit...[unclear over talking]...they felt comfortable saying it and not just implying it. E - I mean, I find that quite a...quite a.. quite an interesting exercise because you... you.. you um...because it's really quite intimate in the...you know with people. G - I would say just the idea of.. .um.. .talking to each team member and saying... holding hands and saying, you know, 'I can help you by...I might let you down by...and this is what you can do to help me.'...Right...I think that was...was a good reconnecting exercise just to know, you know, to look them in the eye... A - And we were just happy to kind of socialize in a sense. Reconnect on a personal level? Yeah, and that...that was coming back to the group dynamic that we had during the workshop. 56 That kind of sharing...checking-in, which is what you did, I mean we checked-in again and that's the part I found helpful. F - I think the check-in...checking-in with the group to see how they were feeling um...really allowed us to make the personal connection C - I think probably I...I again, I feel like I get that from two people out of the group and I had that before ...Yes... and it strengthened it even more going through the workshop and it has continued ...Okay...and it hasn't abated. I have two people I still feel very connected to. C - ... and the touching, the closeness, the disclosure there.. .Right.. urn.. .1 think all of that just added to the richness of it. It was...just made it that much more obvious that it was a good connection. G - You know... i f we hadn't had these connections before it would have never have come out. E - I remember again in that last workshop the...the one-on-one uh...interaction with her was um...uh...I just remember that being particularly um...interesting. Sort of um... I'm just not quite sure how to express it...uh...like we'd known each other since uh... since...I guess I'd met her when I came up for an interview, since we moved up here and it had always been kind of uh...you know, friendly. And then, just able.. .1 just felt we connected on a slightly deeper level. Right, [unclear over talking] And on a personal level. (3) - Sense of Acceptance/Belonging/Inclusion The team members reported an enhanced, broadened and deepened sense of acceptance, sense of belonging, or sense of inclusion from the team as a whole, which had a positive impact on their feelings toward their colleagues and their experience of work. Whereas personal connections focused on interpersonal interactions with team members, the sense of belonging/ inclusion/ acceptance focused on the individuals' sense of themselves in the group and their sense of the group as a whole. There were two members who felt that at certain moments in the course of the workshops they were not accepted, did not belong, or were not included in the team as much as they would have liked and this was experienced negatively when it occurred. D - Do you know why that was [interviewer's name]? It was because I came into this position with quite a number of holes in my curriculum, in my resume, to actually do this job. And so.up until that point a lot of people didn't know that I didn't have any [particular type of] experience or [particular type of] experience. This position I'm in is a real stretch for me and I wanted...I felt very much better when I could tell people. 57 G - I would say I've never had the opportunity to communicate hand-to-hand/knee-to-knee with the people I work for...Right..and have been included to work with. So that was a big one. F - It was good for me to see that, even though they were experienced in cancer care, that they had respect for where I had come from and that they valued my input and my experience. Right, so it was validation of your role? Absolutely, that was critical for me at that point in time. E - One thing that I...over the weekend and I was thinking about it, I...I um... I realized there's another layer to this that sort of confuses things and I think., which is that um...we all came new to this place and everyone came new at the same time. And I think that's really quite different. E - Not having an established way of doing things and so nobody's an outsider. Everybody comes kind of in... at the same time. E - It.. .it was um.. .the implication was um.. .this was.. .this was an enactment that [facilitator's name] um...[facilitators' names] did, and uh...basically they described a situation where the...the group was not a group. It was an outside group and an inside group, and X and Y was the inside group and that certainly wasn't what I thought we had bought into. Um...and clearly that...clearly [facilitators' names]didn't come up with that out of their heads. C - So we could call the group together quickly because there was a respect for the view of the person who would want to call the meeting. Right. That this was important enough that we needed to come together and deal with it. A - But I do at least have the feeling that if I screamed in frustration I know we could get the group to kind of work on this. Right. I think we all try and avoid that though because we're all so busy getting on with things. F - I think the check-in for me is...is a really important piece. It says I'm concerned about you as a person not just as a process leader or a member of this team. D - For me personally, this is a very personal thing so maybe I shouldn't speak about it, but it sort of perhaps helps to see how I see the group. Um, I have had my mother die since we last met as a group and I have also been quite ill since we last met. So I find that um, the fact that people will approach me...ask me about what happened more openly about a family death which...which a lot of people are fearful about even asking about and not one member of that team didn't come to me and express something and look me in the eye and talk to me. K - I felt, anyway, that they realized that I hadn't been in the first group but that didn't matter. That they knew why, that they understood that um...you know, I would have been there under any other circumstances. So um...that acceptance, I guess of realizing that...um this was an unavoidable event 5 8 D - Uh, my mother was still critically ill but... and so that kind of understanding I think was tremendously supportive for me. I mean, I don't think frankly I could have done the work I had to do to open the Centre, with the emotional difficulties with family an what was happening in my life, had I not had that support from the team. G - I guess, just in general um...being able to cross processes easier. Like most people have their..their roles and their teams and their processes that they fit into and then, having participated in a workshop where you know we didn't sit in the lines of our teams. We sat in a circle to join. I feel that has allowed me to go into the different processes. K - I can make a comparison, um..of a person who has the same role as me in the building but came on board much later and hasn't had as long to build up relationships with these people, but I don't think will ever have the opportunity to build that depth of relationships with the rest of the leadership team. G - Just to know that you're...that you don't...that I don't have to handle these things alone. That I don't have to carry it all on my shoulders. A - I got the sense of just a group of people coming together with a vision of the... of the Centre, with a kind of um...I thought fairly good idea of what we thought we want to do here. A - I really like the people in our group. I mean...there are individuals in the group that I clearly will have more conflict with than others. I mean we identified that to some extent, but overall, you know, I like everybody. F - I think the workshop recognized that we were equals. Equals as people? As people. Right. And um...that your role was critical to the success of the team. E - I think what was happening there was that um... Y was able to speak with knowing that she had the backing of everybody. You know...knowing that we were all there with her, which makes it...probably makes it easier for her to deal with the situation. (4) - Sense of Safety and Trust in Communicating The participants reported the experience of a sense of safety and trust in the group which allowed them to express personal feelings and thoughts to each other, without the fear of being criticized, judged, ridiculed, or negatively evaluated. This sense of safety allowed group members to make self disclosures to the group, which enhanced trust formation among group members. It also allowed the team members to feel safe in communicating with each other after the workshops had terminated. When the group members experienced a decrease in this sense of safety, the effect 59 was to decrease their personal disclosures to the other members of the team and to jeopardize the trust formation between members. D - I remember not knowing any of you [the facilitators and researcher] initially, but seeing and understanding how much of a strength there was in your team, which made me realize that a lot of planning had happened. You had come with very prepared information and that that to me perhaps gave me confidence that I understood that I was safe. D - I think in terms of quality, we have...um...developed a trust and uh..a safe group to exchange and call and talk about a whole variety of issues and you can't have good communication if you don't have that trust. So, to me, that is essential. I would never disclose some of the things I disclose if I didn't feel safe and trust in the group. D - I'm, in this position, I'm fearful of some of the issues I have to deal with, but I have a lot to learn, 'I'm willing to learn, you know, slog though it, but you need to know that I don't have this', and with X it was, 'I just don't have the technical expertise that you might think I do have.' Um...so to disclose that...what you, you know, you have to be pretty safe to feel you can say to somebody, 'You know what?'... These are my shortcomings? ... 'I can't do this.' D - I guess it's the, around the issue of disclosing. If you feel you can be so safe and. and able to speak and...what surprised me about it was the number of people in the room. You know, you normally think of...keep using this expression, "Baring your soul", but that, to me that's, that's often done on a one-on-one in a psychiatrist's office so um. You know having not ever seen a psychiatrist I don't know what that's about but, it..it to me it's probably the closest I've ever come to feeling I could say anything about work, about my home life, about my family. C - It's like the vessel thing that [facilitator's name] talked about. You know, you become this crucible and into it comes all of the issues all of the...it's the safety. It's the place where all of those things can come in. C - The personal quality of knowing that you hold...there's, .there's a high degree of trust involved in giving people...in being disclosing with people and letting them have a look inside you and see what those things are that trouble you or uh...that is unique. C - So there's a vulnerability involved in that as well and if there's not the safety or a sense of togetherness in the group that vulnerability is a liability. You..you don't feel safe and you know you're hung out all over... C - I could bring an issue to you and sit down and know that we had this experience together. So we can sit down here and talk with one another because we had that connection that creates that safety for us. So I could be forthcoming and.and I know that you hear that. 60 G - I guess it was..it was really hard to do at first. I'm not..I'm not a touchy-feely person. So, it was like, 'Oh no!', and the first person I was with, I don't believe is either. So, I was..we..I could just feel both of us going, 'Ohh!', and the other ones who are, they were like, 'Yes!' [laughter], so um..it was uncomfortable but..but it was allowed. We allowed it. G - I found afterwards it was useful. I mean, when I think of an awkward situation when I need to go tell somebody something or communicate something to them, I have that experience with each individual in mind, going, you know, we've built this trust... Right. We've gone beyond that. We can now..you know, I feel free to communicate these things, to me, that they trust me back and we've built up this ability. G - If it's something important that I needed to tell somebody, I would have told them anyways but having the security of knowing that I can look these people in the eye and they will believe me and trust in what I'm saying. That this is something serious that they need to..to be aware of and to act on even if it was not in person that I told them. G - I guess I had one incident with somebody from the leadership team that kind of. he was very upset about the way things were working and it's not somebody what I work directly with and just happened to run into them elsewhere in the building and he just kind of let go of a lot of things and like...I'm like, 'Whoa!! What can I do to help you?', you know? And I..and I think having not gone through that process again....um..I chalked it up to, 'Okay, he trusts me enough to speak that language to me.'.. Right. But still I thought, 'I don't like this.' So, in another...other work settings if someone had come out and dumped that stuff on you or blasted you like that, would you have felt the same way as you did with this person? Would you have been able to say, 'Oh, this isn't about me or..' Probably not...probably not. I think I would have taken it more seriously, gone off and reported it somewhere [laughter]. A - We got really quite intimate in terms of sharing our..um feelings...trusting and sharing our feelings. So that dynamic built over from December through January and February. A - When was the most profound communication for you occurring? Well it was occurring when you were sharing your needs because..um...you were, in a way, um.. vulnerable...the most vulnerable at that point A - To share any sense of um.need or vulnerability has always been difficult for me. If I have that need, I'm more inclined to hide it. But, I felt with the group that I had permission to.to um, make that very clear to people. And what was it...what was it about that group that you felt you had the permission to do that? Well we built a sense of trust, .um mutual trust, I think. It was a non-judgmental environment. I mean we. .we really did, I think uh..um have that capacity. A - Um.the, of course, most difficult exercise was the um.. intense one-on-one holding hands or touching...um contracting exercise. I found that, as most people I suspect did, found that uncomfortable at least. But, we had built up such a level of trust to that point that in fact, I believe that was our third workshop. It was probably the most effective. 61 F - There was a lot of silence in the room, if you recall? Yes. And um..I know for myself, I certainly didn't.I didn't.I don't think I said anything. Just listened and observed and was really cautious to say anything. Don't recall if I had anything to say.. You didn't feel safe? But I didn't necessarily feel safe saying it. F - We need to be cautious in what we say and when we say it. / see. And even though the group has this relationship... and I see it now too [interviewer's name] in some of our leadership meetings is that we have this connection with each other to the point where you won't say what you really think because of the fear or the concern that the connection will be altered. F - Some of the tougher issues that we're trying to deal with is that, because we val.. value the relationship and the exercise you went through um...you're not necessarily open in you communication. F - I guess...the communication is probably more respectful of um.. different opinions and perspectives than it was in the past. Um. .there's certainly more trust. F - And you went to her as a person to say that? Yeah, yeah and I felt comfortable doing that. It just sort of is an example though of. of how I felt the tension coming to work the first two days after that. F - When someone outside of that leadership team comes forward with concerns or comments, .you. .we've established that linkage that allows you to take it back to that leader and say. .you know., understand this is a concern or whatever. So, you've got that relationship of trust and respect that you can go and say that. E - An important factor, and I've thought about this a little bit recently, was uh.that uh..everyone or most of the people opened up quite a bit and told..you know, let down some of the guards that you tend to have um.when you've got.um work relationships. E - I just think that, in general, there's more comfort uh. .in raising issues with, .with people than I've had in similar situations in the past. In particular where you get uh.. either actual or implicit authority relationships. For example, the most common one I.. I would quote would between X and [speaker] which is traditionally uh..the [professional position] uh. .because ultimately they carry the can with the patients. Um..the uh.J've found that there are occasions that that's a difficult, difficult um... interaction because they expect to be the authority. Right and this has been your... Implicitly or explicitly. There's a power differential there. Yeah, yeah and I think..I feel much more comfortable going probably to X than I would with some of my previous colleagues in a similar situation...because...I mean we know each other a little bit better. As people? Yes . [unclear]..you know the...you know the person at a different level and so uh...you're able to...it's more comfortable to go and speak to them. C - Some of the values, or some of the professional values now are starting to become more visible and more obvious between the groups and uh...and uh.so there's a little more distancing I've noticed and some issues become a little more difficult to talk about because they speak to 62 professional values and the roles of. of people in different groups in different professional groups. So it becomes more difficult to have that kind of discussion. (5) - Sensitivity to Perceived Levels of Team Member Commitment Team members reported that they were sensitive to the level of commitment to the group, and the workshops, that they perceived in their fellow team members. The level of perceived commitment was dependant on such factors as: a willingness to communicate and participate in group activities; a willingness to work on relationships in the group; attendance at group meetings; and, perceptions of fellow team members' attitudes towards the group process. A high level of perceived commitment to the group and the workshop activities tended to enhance the members' positive feelings, such as trust and acceptance towards one another, whereas a perceived lower level of commitment to the group, and the group activities, tended to decrease the levels of trust and affiliation towards the offending member. E - I felt that X wasn't willing to be uh..to work..really wasn't willing to uh..be open with the group, as..as the rest of us were [unclear talking over]. She didn't participate an awful lot, I don't think. C - You gotta work at this thing. You can't just expect it's gonna bloom on it's own. You have to make the commitment to come back together again and I think our commitment has waned a little. That we need somebody to say, 'Okay, you know we oughta come back together again and have another meeting.' But it helps us, you know in terms of everything that has happened in those places where we might not have agreed or there's been friction, we can set all that aside and come back together again as a group. C - I think it's like a relationship. If people are not.. .if they can't find a way to remind themselves of why it is they decided they wanted to be together, then pretty soon they're not together anymore. They become strangers. They become indifferent to one another and they go off and live their own lives and, you know pretty soon they're not together anymore. C - It's not a judgement on it, but it..if the willingness or the uh..if the awareness is not such that this is... this is something that we really need to do to preserve that, if we value that and we see we need to preserve it, then we have to act on that. G - We don't have as many meetings as we need to have. I haven't seen the whole leadership team in one room for a very long time...Since that last time at R's house?... Were we all there? Yeah, we were all there, yeah. Um..and even our meetings, like our operational meetings, people 6 3 are usually not there for the entire thing so that's all just business and everybody is so often involved in their own processes, in their own teams that I don't see a lot of communication happening. A - You could start to see the. .the weariness setting in, in the communication and then the commitment that we all undertook in more relaxed times has been terribly strained and, in fact, the committee, apart from meeting in an unofficial capacity, we haven't had a group process. A - I think that's true of the three workshops. You wanted to..to succeed. So, we worked very hard to make it succeed, but in the heat of the aftermath of., of the process there's a tendency to fall back on old habits and say, 'Yeah, I wanted it to work but, you know let's face it, I'm on my agenda first.1 Right. So the selfishness and the sort of.uh games start to creep back in. E - On the last weekend, the exercise with the uh..the holding hands - touching knees exercise. Yes right, yeah we talked about that. But, of course I recognize that that came on the end of a lot of other stuff. So, I mean..obviously we wouldn't have gotten into that in the first day. You know we'd already made a lot of commitments by that point. D - I think too, through the second workshop, and I remember the knee-to-hand exercise and everyone sort of feeling kind of amused but, you know, committing to it and we went late to lunch because we all wanted to finish the rounds. And finish that part off, yeah I remember. And so, to me that spoke a lot about um you know, there could have been other groups where the morale would have just fizzled because people would have said, 'Well I'm not doing that. Forget that.' C - We came together and we handled it. That was good. And how do you think the group's participation in the three weekends contributed to that? Or do you think it did? I think it did because I think what it did was it..it allowed people to accept that this was a priority and it had to be dealt with now. So we could call the group together quickly. A - Well everyone was there, i f I recall and the value was obviously evident to everyone. A - And that would have been the group process but um. .my worry is that if we don't uh. pay attention to it then it'll unravel. E - I mean, when I talked about communication, it's really with most of the members of the group. But, I find it really um...uh..quite hard to deal with Z, especially in some business matters because um...because I don't think she has bought into this...um way of doing business. E - I think she hasn't been willing to buy into the group and maybe that's disclosure urn.! don't think she behaves as a team player. F - I guess the difference on the leadership team [interviewer's name] was the fact that we were all committed to that and when you go... when we went beyond that group of nine and attempted to bring in the bigger group of a hundred... 6 4 (6) - Appreciation of Facilitated Group Experience The team members expressed an appreciation for the need to continue having some type of structured, facilitated group experience. They also reported an appreciation for how the structure of the workshops, and the activities that they participated in, positively influenced their experience in the group, and their experience of their fellow group members. Participants reported the feeling that if some type of structured group time with a professional facilitator was not incorporated into the usual operations of the team, there would be an adverse effect on the team's ability to remain cohesive and intact over the long term. A - We were also..with uh..and this isn't sucky, we were extremely well facilitated. I mean, I know a little bit about facilitation and there's no question we were with real professionals in facilitation. That, um.when one of us would start to monopolize Q or Y or yourself or anybody in the group, X , would...um very effectively direct the work of the group..not always but most of the time. A - The support of the group is now implicit as opposed to explicit and unless we do some work around making the support of the group more explicit, we're going to, I think, lose..lose a lot of the um...a lot of the value of the group process. And [facilitator's name] spoke to that. He said, unless...and you and others..unless we work on this, unless we have lunches together and do things together and intentionally meet, the group will fall apart. A - So that the implicit sort of interaction is, I think the fact that we. we had something there that we haven't lost but is now below the surface, whereas during the workshops it's right in the room. E - But I thought that was really um.. that really pushed things quite a lot further actually. Quite a lot...can you say a little bit more about 'quite a lot further'? Um.. well I don't think..I don't think...you know I think we had to have..we had to be uh...we had to have that exercise suggested to us. I mean that...that sort of made things a lot more um..uh it..it's just going beyond the bounds of what you normally do. Beyond the professional masks that everybody requires in their role? Right, right. Going to more personal issues? Yeah, yeah. D - I'd just like to add that it was a unique experience. That, I think um..we. .well certainly personally I went into with somewhat of a you know, What is this going to be like?'. It is something I'll always remember. I found it very um..what's the word? Not... valuable but...it made me dig deep. It made you dig deep. Which, I don't think I've ever been expected or asked or suggested that I do before. 65 C - The fact that the very first evening was very personally centred um..was big for you? Um hmm [affirmative]. In that functioning of.of starting the group and then containing it as well? Because it..it sets the tone. When we come together with people everything we do, right from the beginning, sets the tone for how things will then go. Right. So it's really important what happens in that initial bit of time. C - Well, I think that we. .we've, .there's a recognition, certainly of.from me, that we did work to come together as a team and we did some things that were unique to create a culture of team and now my feeling is that we might be in jeopardy of losing it i f we're not willing to continue to support it in some way and create a forum in which it can be supported. G - I've seen um.you know B struggling with something and if I hadn't had the experience of the workshop and talking with him, I would have probably not gotten to help him because he's not in my line in my team. A - I think the..the issue around the hand-to-hand/knee-to-knee is..I think you get caught up in the emotion of doing it at the moment and it's not the way I would feel comfortable relating of course, now...unless it was highly structured. A - The sense I have is we both agreed that had we not done this we would be a much poorer group. When we come together there's still that..the skills that we learned of respect. A - I think highly of most people and I feel that's part of what we are as human beings too. It's basically a way of expressing love to one another. I. I've felt that and I think I've done that but what the. .what the workshop did is really um. brought it up as an imperative. A - For me the warning bells are ringing or lights or whatever flashing because um.. as time goes on, with the way things are happening, um you. .you get either lazy or you get forgetful of the needs for that. But um..right now it's only three months after opening. We've maintained our skills from..that we set up. Wouldn't have had that if we didn't have the workshops. C - It's almost like we needed to be able to come together and acknowledge, openly amongst ourselves, the hard work that was going in to any particular area that might have been struggling. We didn't do that. I..I noticed after the workshops that um.. Z, for instance uh .was away a lot. He's been busy. He's been travelling. He hasn't been here. I think that the. what the group needed was to continue having our regular leadership meetings. They were moved and postponed. G - I think the workshops were probably not very high on people's priorities of things to be focusing on but, I think that it was a good thing that they took place anyways to remind us and to keep the container alive and to keep it safe and to know that it's there. A - If I have a particularly hard problem with one of the team members..um I know that i f . i f we checked-in together we could work on it. I don't think necessarily at a leadership group meeting with a huge agenda is the time that that will come up. 66 F - When you do a check-in like that [interviewer's name] it gives you a sense for... if I was to say, '[Interviewer's name] and how are you today? How's life for you today?', and you said, 'Oh it's the pits.' You know...you know how far to go. You tell me, 'I can't cope with whatever you're gonna unload on me today.' If you don't do a check-in... um you go in with blinders on. You don't know what's happening in someone's life. That they're bringing to work today or bringing to the team discussion and um...boy you set yourself up for some huge...huge issues. And that can lead to um...difficulties in relationships and communication. (7) - Experience of Group Morale Participants described their experience of the morale of the team, using varied terms and descriptors. Morale itself proved to be a difficult concept to define except to say that each individual identified, not only their perceptions of the group morale, but also those factors in the work environment, that they felt had the potential to either enhance or damage the morale of the team. Factors such as external agency versus internal agency pressures; accomplishments and successes in their work; workload and anxiety; and, lack of pressures were all cited as influences on team morale. Team members also reported that morale also has its own effects on the group, such as buffering or dampening the effects of conflict. It became clear that the easiest way for the group to define morale was to describe their own personal experience of it. D - So, in terms of morale, I say we have to meet extremely soon for us to maintain morale at the level it is. it was at um.. we're losing momentum. Yes, you need that rejuvenation. And I actually expressed it this way, 'I need my fix!' I need to get back in that environment. D - The first workshop I remember feeling uh..not so much the Friday night, but certainly as the weekend moved on, almost like a high at times. You know, people feeling very energetic and excited. C - Well we've gone through some difficult times since we opened and some of that has been the external influences that we didn't have any control over and then there have also been internal events that have affected..uh..the team...have affected our ability to come and sit together at the table. The external one's bother me less, although they are frustrations, than the internal ones. But I'm thinking, you know it's hard to really separate them our because I recognize that the external events create a..a sense of urgency or uh...a a need to, you know get things done. C - I think the morale was high. Well..and to, in all fairness, no patients were coming in the door yet. So, we weren't having to deal with the application piece. Right. We were still dealing with the preparatory piece and the application piece is when we started to realize there were some holes and gaps. 67 C - I think we had a couple when we had to call like an emergency meeting to deal with an issue that came up and we were able to do that very quickly. Like from the time that the...that the issue arose until the time that we were able to sit down as a group an deal with it..very quick and it was good. It reminded me that we could come together as a group and resolve and issue and...and be successful with a resolution. G - I think that by the time the workshops started the reality started to set in..like, 'Oh, my God. We have so much work to do.' You know, we've got so many days. I mean Y started to count it. G - As the people started getting..coming on..the staff, it started to become more apparent how much more work there needed to be done. So, I think the morale..you., we kept on setting ourselves up with our, from my point of view that things were going to be getting better. But they kept on getting worse. So it was demoralizing. It was bringing the morale down because we kept on thinking, .that it.it..the cloud kept on getting bigger instead of brighter. G - Morale, workload and anxiety? Yeah, I guess they would all be intertwined..um that the morale wouldn't be as high without the satisfaction of completing things. With the increased workload and., and the anxiety for not being able to complete the number of tasks that you needed to complete to..to reach, you know a level of job satisfaction. Not of job satisfaction but of day to day work satisfaction. That you're chipping away at the pile instead of the pile growing and growing. I think that beats on the morale. A - The morale built very quickly in the group. The first week was uh..the first workshop when the only person absent was H and the fact that we were including her so intentionally and carefully, the morale built quite quickly. I thought. It was carried over into the second workshop where the morale dipped. A - Yeah, and I think we all agreed it was kind of a bummer workshop. We all felt kind of a bit down because I think we had thought it would be easier. Um..what..what happened is we suddenly had to do some work and the work was hard. Right. But the morale didn't suffer that much. I had..I thought the group was um..pretty..pretty healthy and at that point despite some negative feelings, but we weren't working in the centre, other than trying to get things moving. A - The third workshop the morale shot back up again because, there was two reasons for that, one - it was a.an intimate and a sharing and a better facilitated workshop, I thought. Was there a part of that, that you think of um.. something that happened or..you said better facilitated. Well we kept on time. We kept moving the subjects along [interviewer says something inaudible] well but also content. We covered more ground I thought the... We did more things? We did more things. We got some more work done. A - The morale was good. We wanted the morale to be good though. I mean, it would have been a real.um I mean, there was an expectation that the morale should be good and so there was a real need for the group to have a high morale on that last workshop because it was the last time we would meet in the sort of full facilitation before the centre opened. 6 8 A - Now when we met with you at J's house um. .the tension was building. The morale was still there but it was being strained and there was a sense of weariness 'cause we were all tired and feeling a sense of being somewhat overwhelmed. Everything was kind of coming in. I mean, I can remember..sense weariness that was in the group. Well, weariness always affects morale. A - I think I was reflecting how I was feeling. I was feeling very weary at that point and urn.my particular issues around manpower and that hadn't been solved. In fact, looked just as bad as they ever looked. There was a sense of inevitability at that point. A - So when we have critical incidents amongst ourselves.um as various team members, between our responsibilities, um...you always get the feeling that there's been a safety net below it. A - In my view the whole thing becomes, .the morale dips when you have a problem with a team member. I mean, if you're getting along with somebody else and you're just sharing your mutual, 'Oh, God let's get on with things.' But if you have an argument, a tension and a need to work through some really hard issues with a team member..um I think we revert to old..kind of tried and true behaviours. F - How do you experience the team morale now? I think the team is tired. I think the team has put in a lot of hours and a lot of months and had a lot of dreams and hopes and they all didn't come to be. F - I don't see morale as low. I see it as plateaued and, if anything, on occasion it's a little higher than that. It's not really high. Right. There's no doubt people were sick. E - I found the first workshop um..very um..comfort building and the second one I was much less comfortable with. E - I felt after the second one that um..we really got into some issues that...there was a lot of differences of opinion about and uh..so we went away from that with a little less satisfaction. So I suspect that's kind of...I suspect that's what I think is..is uh.. are morale issues. E - The opening was..uh..the target that people were working towards and it actually arrived and it actually happened and it was actually quite um.. what's the word..it was uh.want to say it was an epiphany. I not sure if that's quite what I mean. But, I just remember it being very..really wonderful when you get to that stage and it's just like a big release. We'd still a lot of stuff to do but, you know we'd actually made it to that point. Unr.and then afterwards a whole lot of things went wrong, not only in my department luckily but in some of the other departments and so there was a lot of uh..that...that was quite a down time for some people. F - Well I know that I can go to someone and say, you know I need your thoughts and uh. .they'll let you vent and they'll give you their thoughts or sometimes they'll just let me vent and I know that u m . Y has come into my office and says, 'This is just not working', and it's totally out 69 of my field but he sits and we talk and he says thanks for letting me vent and he goes off and that all...to me, that all influences morale and there's the trust that exists. (8) - Reciprocity and Demonstration of Support Group members reported that they were able to provide support for their fellow team members and were able to remain open to receive support from others. Support, for most team members, included such demonstrable actions as listening to others, physical comforting or physical presence, talking with others, and verbal expressions of support, among others. The participants expressed the importance of reciprocity in demonstrations of support from their fellow team members. Team members reported that a sense of reciprocity enhanced their abilities to both provide and receive support from others, and a lack of reciprocity hindered those capacities. Group members also expressed their perception of the positive impact of visible or overt demonstrations of support to one another. D - So you know I realize the strength of our team is not just um..as a team but as individuals who are able to support on a whole range of issues and just the fact that that behaviour is so apparent urn. make such a difference. D - I can think of an evening where I was ready to go home and uh..there'd been a very..it was probably about three weeks before we opened and there was a very critical event going on and we had all been called to the leadership table, .um by Z at very short notice and it was a pretty emotional meeting. It was around [certain] issues. It was a very difficult um..issue we were dealing with an and everyone left after and it was quite late, probably about six o'clock and I went back to my office and got my purse and was about to leave and I saw one of the team going back into their office an and they looked quite distressed. So, I knocked on the door, although the door was closed, and um..found her crying. So, I stayed and we talked for about a couple of hours and um..I had other appointments but I stayed and um..it wasn't so much um..that she was upset about what had happened in the meeting but more that um. there were mixed messages being given...um by [certain individuals] and were.. Confusing? ...confusion issues...and her frustration was just so extreme. So, uh you know I sat and listened. I didn't say much or do much or whatever... How is that different from other work environments that you've been in? I was just going to say that I..I think probably I would have just poked my head in and said, you know...'Would you like me to call you later? Um...ril give you a call at home. I don't want to bother you now. You look upset.' I'd probably just left. So that was unique for you to do that to actually... It was because I think didn't even try and I mean it wasn't the sort of appointment you'd have to notify somebody but I had an arrangement. Let's put it that way and I didn't even attempt to pick 70 up the phone and call. So, I..I kind of realize, now I talk to you about it, I realize that um..it was a different situation [unclear] the way I dealt with it, than I might have previously. And you..you think that that probably had something to do with the team's participation in the workshop and those exercises... the hand-to-hand/knee-to-knee? Oh, absolutely, I really do...I just can't see, you know how else would it have changed for me? I haven't done anything else. C - The support is there and I know...and it's honest. It's not, you know that defiant kind of support like, 'This is my pal.' You know it's not that sort of thing. It's very honest um..back and forth that can happen with those individuals. And you mentioned that was enhanced by the three weekends. Yeah it was. L - Well I'm. .I'm thinking of two of them and um. .I'm thinking.. I'm thinking about X and that first time she came because she was upset and I followed her out and spent a bit of time with her. The... we had that experience in common but I came after. So, I knew of it and I was there for the aftermath of it, but X was there when it all happened. Right. So, just being able to go out and put my arms around her you know because I know what it was like when I came. So, I..I could relate to that experience and just being able to provide that well of support to her. G - Well he was struggling. He was looking for a piece of equipment that we own but he the doesn't know how to use. So, we brought it into this room. I went and got all the equipment for him. Got the manual and said, 'Okay.' He wanted to do a presentation on this [piece of equipment] that we have. So, I'd never used it before either but he., just not focusing...so I...okay let's just figure it out and we set it up in the room. G - There have been, you know events that have happened and things are getting kind of harry an and emotional around the office and things were happening and there has been one in particular member of the leadership team and came and sat at the chair beside my desk and... and has noticed and has known what's been going on and asked if I wanted to go and sit and talk. G - Just to know that it was noticed and it wasn't all just talk. Right. That it was really true and when, .when I did need to have, you know somebody recognized what I was doing, .that it was recognized. G - It's a relief to know that, you know... see...you know, I mean I've seen somebody sitting there and, 'How're you doing?' - 'Well can you come in and shut the door?1... and just listen. You know, I don't have to fix anything, don't have to have an answer but just to listen and to know what's going on. G - Just to know and listen and it's nothing that I can help them with but I can, you know let them say it. Andjust listening and being an ear for them. And other people refuse you know. Like there are people we work with who won't say a word and don't want to hear. In the leadership team or other or outside? In the leadership team. 71 G - The fact that that person came..do you think that was related to the workshop.Jo the fact that you'd gone through that with this person and. Yes. ...done those particular exercises? Yes I do. And is there anything that..that you..that makes you..that would make you think that? Like, did you have an experience with this person in the workshop? Yeah, when we did the hand-to-hand thing. We talked about stuff like that. A - The opportunity for people to listen to me was the most helpful. A - I have so much regard for her as a person, I'm worried that she's not getting enough feedback that it's Okay. You know... [unclear talking]...yeah, I just let her know that, 'Hey! You're doing a good job.' A - I find I can do that more with somebody who I see being um. .where things are.. where their problems are kind of.I..I identify them. I can see them. Um...Q and I work more together and um.and she is a more guarded individual because of her personality. She's a less outgoing person than Z. So, it's easier for me to support Z 'cause she kind of feeds back, you know. A - Each person needs support in a..a different way and some people, I can't support as well as others because we're either in conflict over issues...and when you're in conflict over issues then the support drops. F - I also understand when, because that person shared with me how they can support me and how they might let me down and how I can help or what I can do to help. I know what it is that needs to be carried through. F - It was Friday, when we were talking about risk management and K and had shared with us an experience and B had shared with us his experience. Um..I think that the support that we gave them was a very personal support..understanding one human being to another. It wasn't...we certainly couldn't understand what they went through in terms of process or., or responsibility but we could relate to what they'd gone through as a person. F - One of the leadership team members um..said to me that um..you know, I will support you and so on and so forth and so it's that demonstration of what I see, in terms of support. It's not..it's not a verbalization saying, 'I support you.' Right. You know, a reminder of the day that I support you. It's actually taking those words and putting them into action, [unclear] I now see that that person is truly supporting me as he said he would in that..in that third weekend and that, to me, is the huge success. F - I quite often will take the five minutes and go and sit at W's desk and just chat with her about how her weekend was and how she is. How she is as a person? Exactly. Do you think that's different, very much from..from what you experienced prior to that? Oh, sure. Right. Absolutely. E - On a number of occasions Y has asked me to come and sit in on some meetings she was having which are really peripheral to what I'm doing and uh..you know where I don't necessarily 72 have a big contribution to make but I just uh. .where I have a little bit of. of interest. You know things like um...dealing with [particular issues], she will ask me to come along and I kind of.I know the people and I don't think I'm contributing an awful lot to the actually mechanics of the meeting nor of the solution. Uh..and during the meeting I'm not or after..you know during the meeting and afterwards I'm not sure that I actually did anything but clearly it has helped in some way. [unclear talking over] Just, just being along and putting in my moral support and few words occasionally that uh.J'm not sure exactly what I'm doing on these occasions but I'm just sort of being there. But you're doing something for Y? But I'm doing something that helps the process or.. And how is that different from other experiences you've had at work um..would you have been willing to do that for other people or would other people have even have asked you? I suspect they wouldn't have asked because they would have assumed that since I wasn't doing anything with it then...it's not going to do anything. E - Being able to go to and speak to J about it and getting some very valuable advice. Right. ...on that. That I suspect um..in previous situations I wouldn't have um..I wouldn't have done that. E - And you find her quite supportive, you said? Yeah, and I think I..I support her endeavours um..our..our positions are..it..the relationship that we have...the professional relationship is one of the outcomes of the reorganization in the centre and it's..in the..in the agency...and it's um...it's a relationship uh.that.um is potentially very tense because it really changes the um..how can I describe it? The., it treads on a lot of professional um.. sorry I'm just having trouble finding the words. Uh. in other words uh...what [professional occupation] have traditionally not had any sort of reporting relationship to someone with Z's background and so this is quite a different relationship. In fact, one of my opposite numbers in one of the other centres found this so intolerable that it was one of the factors that caused him to resign from the agency. Oh! So, it's quite charged. It's quite charged. Right. And um..and I don't think it is here. Right. And part of that is uh.is. well, part of that is that we're different people from the other people. But, I certainly think a part of that is that we have done quite a bit together. In particular during the workshops there was a lot of um..uh..you know, I think we were both willing to um...tell a lot about ourselves, [unclear] Well, yeah to one another. E - You know, it's my battle but here I'm raising the issue, but she will go to bat for me and vice versa. E - When she gets information on these matters, even though..even ones that uh.that I find that she shares information with me. You know, so when she gets something she will come along and uh..pass it on to me even though uh.she will pass., she will pass that on, I think, more than, .than I would normally have expected. She's very open about that. E - She's quite uncomfortable about the whole process because it's all new for her. So, when she passes it..so, when she's open..passes the information out to me..and I have some..something that's useful..that could be useful for her, then I will make sure that she gets that information. You know, so she's not struggling in the dark. 7 3 E - Well, I know, because she lets me in to what her problems are, I know that uh..doing this job, she has some discomfort underneath. So, I'm able to um.give her specific information either form my experience that I've picked up in the past or because it's..it has some particular relationship to what I do um..and I will give her information that will help her deal with her problems. A - I mean obviously we'd feel comfortable in our own way being listened to but also in listening. It's a mutual process. So, if people have the energy and time to listen to my problems and support me then I at least owe them, at the very minimum, the same in return. F - You know there are certain people on the leadership team that you can go in and vent and you know that it's not going anywhere. They know you're venting and that's um. .that's critical. I mean the day to day stressors, to be able to go in and talk to someone and have a caring, respectful conversation or even someone just to listen is critical. G - I think that because X felt that he... I mean there are two secretaries sitting outside of his door. Right. But they aren't in his process, so he didn't ask them and I walked by and I'm not in his process either but he did ask and I think I can only attribute that to the relationships that were built up through the workshops. E - Well, I think it..uh..yeah it makes it..it makes it harder to communicate with that person when..when you're not..when it's not an equal communication. F - I personally talked to X on day one or two after that session and said to her, 'You know none of this was directed at you as a person.' and she was relieved to hear that. So, I think she was taking some of that very personally, that maybe she was letting us down and although she wasn't verbalizing that. So you sort of felt that need to go out... I certainly felt that need to go out and say to her, you know, like, 'You know, we're not talking...you know any comments I said, X were not directed at you as X , but at your role.' The Senior Administrator Interview Due to the fact that the Senior Administrator's role in the centre was unique (i.e. - the SA hired all of the members of the leadership team and could potentially terminate their employment), his role in the group was also unique. He was perceived by the team members as having a more supervisory role throughout the workshops and, thus, seemed to have had a slightly different perspective on the experience of participating in the three weekends. During the interview the SA of the Centre was able to offer a more global evaluation of the workshops, with respect to how he 7 4 felt the workshops had accomplished the stated goals of team-building and leadership development. SA - A l l of my personal goals for the workshop series were met. You know, we caught their attention; we got a team building process which was based on personal friendships and personal relationship strengths. Um..we managed to bring together a very eclectic, interdisciplinary group. SA - If we hadn't built the team work in advance, when the "knock-ons" came those were the issues and since they've been really big and very heavy and very loud, the only thing that's allowed us to prevent those issues from becoming personalized has been the interpersonal strengths that were built in advance of the conflict. So, I see this process as a conflict reso..it's..it's a prevention..it's..it's a conflict prevention model. SA - We've had a couple of near calls and on each occasion, what allowed those near calls to deflect without collision was the sense of respect and trust that they had with each other, which they had built in advance. SA - It gave them that respect for their neighbour's process rather than their own operational..rather than focus the vertical focus on their focus on their own process. They were able to look horizontally at uh.at a strategic level across. SA - In my view, we would not have gotten through those, .those hard early three months had it not been for the consolidation o of the relationships between team members, because it was the team members' teams that were "knocking on". SA- People were going off and doing it in their subgroups, which gave me an enormous amount of satisfaction to see each of the leadership members, in their own way, having subgroup meetings and using the techniques that they had seen in the first, earlier workshops with their own teams. Humanistic/Holistic Patient Care The fourth component of the interview was aimed at discovering what, if any, impact the team members' participation in the workshops had on their ability to provide a more humanistic or holistic quality of patient care. Patient contact had been an emotional issue in the Second Workshop and this prompted the above question. The reality of the situation was that some members of the leadership team had no direct patient contact and felt that they could not comment on their ability to provide such patient care. Other team members mentioned that they felt they already possessed a certain sensitivity to the needs of patients and that the workshops did not 75 influence their practice with patients: Several members noted that it was their sensitivity to and awareness of patient needs that had influenced the SA's decision to employ them in the first place. D - I don't think I'm practising any differently as a result of the workshops H - I'm aware that each contact and I think I..I was this way before though, means something. So if I'm going to make the effort to make a contact that I need to be here now when I do that. Right. Because it means something, however brief it might be. It means something. So, I'm probably conscious of that with this patient population but I.. I think I had that before. One team member felt that although he kept the vision of more humanistic patient-care, he felt that the work load and time constraints hindered his ability to focus on a higher-level of quality care: V - I mean we are just keeping our heads above water to provide minimal medical care and in fact we're not meeting the sort of minimum standards that the agency sets in patient care and we are reeling from one patient, in [member's department], we're reeling from one patient to the next. And now, all my attention is on the care of my staff that are here, worrying about them burning out. Finally, one member related a story about how she put a patient's needs ahead of agency protocol: O - A nurse needed the camera to take a picture of a..a post-mastectomy woman with a., who was having some kind of skin reaction and the nurse couldn't figure out the camera. She couldn't get a hold of [one of the co-managers]. X was in a meeting somewhere. So, she asked me if I could come downstairs and show her how to work the camera, which is a big monster camera. So, I thought, 'Okay, fine I've taken a few pictures with it. We'll figure it out.' So I went down to A C U , into the room where the nurse was and said, 'Okay, well just try this.' and was trying to focus and the lady sat there with her gown on. And then she [the nurse] said, 'Well, why don't you just do it?' and I didn't think about processes and roles and abilities. And I was there talking to the lady and I wished..I'd introduced myself to her more so, you know and asked her name and everything and made it more personal, but I didn't. So, the nurse told her to stand up and she took down her gown and we took all of these pictures of her for the chart. When asked about how the workshops might have influenced this person's behaviour, the person stated that listening to her fellow team members talk about patients' needs made her more aware of what this patient might have been feeling: 76 O - Everybody has recognized the importance of the patient's feelings. So, knowing..you know, having that opportunity to talk to the group of nine about their personal feelings about patients gives it a higher priority at my desk. Past-Results Interview with an Eighth Member of the Team It was mentioned in the introductory paragraph to this chapter that an interview was conducted with an eighth member of the leadership team, after the categories of experience had been identified by the researcher. This particular member was not available at the time of the initial interviews but agreed to comment on the eight categories of experience reported by his fellow team members. In a telephone interview, lasting approximately one hour, the researcher asked the eighth member of the leadership team to comment on whether or not his experience during the workshops concurred with the experiences reported by his fellow team members. The researcher described each of the eight reported experiences, after which the eighth member of the team reported having shared the same experiences as his fellow team members. The findings of this post-results interview solidify the results reported in the evaluation of this model. 77 CHAPTER 5 DISCIISSTON The results outlined in Chapter 4 of this study support many of the assertions made in the theoretical literature reviewed in Chapter 2. In the final chapter, the results of the evaluation will be examined in light of the literature on organizational development, group development, group process, and organizational psychology. Implications for practice regarding the implementation of such a model will also be considered, along with recommendations for future use of such a model. Finally, the limitations of this study and its results will be discussed. The results will first be discussed in light of Schein & Bennis' (1965) seminal work, regarding laboratory training groups. The reader will recall from the Review of the Literature that Schein & Bennis (1965) described a total of 10 expected outcomes of participation in a laboratory training group. Although the leadership team cannot be considered a laboratory training group in the classic sense, the workshops included many of the characteristics of laboratory training. It is clear that the outcomes reported by team members are consistent with the expected outcomes in the area of 'Self, described by Schein & Bennis, which include: 1. Increased awareness of own feelings and reactions, and own impact on others. 2. Increased awareness of feelings and reactions of others, and their impact on self. 3. Increased awareness of dynamics of group action. 4. Changed attitudes toward self, others, and groups; ie., more respect for, tolerance for, and faith in self, others, and groups. 5. Increased interpersonal competence; ie., skill in handling interpersonal and group relationships toward more productive and satisfying relationships. Reports of team members also indicate that expected outcomes numbered 6 and 7, in the area of "Role', were also achieved by the members of the leadership team, although this awareness tended to have a negative impact on the team members who were interviewed (recall the conflict 7 8 event in Weekend # 2 centred around the organizational role ambiguity). The results of the evaluation, however, do not indicate whether or not outcome number 8 was achieved. 6. Increased awareness of own organizational role, organizational dynamics, dynamics of larger social systems, and dynamics of the change process in self, small groups and organizations. 7. Changed attitudes toward own role, role of others, and organizational relationships; ie., more respect for and willingness to deal with others with whom one is interdependent, greater willingness to achieve collaborative relationships with others based on mutual trust. 8. Increased interpersonal competence in handling organizational role relationships with superiors, peers, and subordinates. Outcomes numbered 9 and 10, below, are not indicated in the reported experience of the leadership team members. However, this may point the direction for future research to be conducted with this particular group. 9. Increased awareness of, changed attitudes toward, and increased interpersonal competence about specific organizational problems existing in groups or units which are interdependent. 10. Organizational improvement through the training of relationships or groups rather than isolated individuals, (p.37) Despite the fact that this group was not a classical laboratory training group, such as the one's described by Schein & Bennis (1965), many of the expected outcomes were achieved, indicating that the workshops were a success in terms of the expected outcomes for such a training group. Implications for Theory of Group Development A picture of the development of this group emerges, as one examines the results of the study and when one takes into consideration the participants' reported experiences. Upon reviewing the events of the workshops, in light of the participants' reports, it becomes apparent that the Leadership Team passed through several stages, or phases, of group development at a somewhat accelerated rate. The group was formed in the first weekend, and then passed into the transition stage (often characterized by conflict and power issues) in the second weekend (- the reader may recall the group struggling with role clarification and distribution of power and responsibility in the group). The group experienced the beginning of the working stage (- the 79 reader may recall the groups' participation in the hand-to-hand / knee-to-knee exercise) in the final weekend and finally, the group passed through the termination stage, all in the third weekend. The group seemed to pass through four stages, akin to the stages or phases outlined in the review of the literature in Chapter 2, namely: Gladding's (1995) Forming Stage, Transition or Norming Stage, Working Stage and Termination; Corey & Corey's (1987) Initial stage, Transition stage, Working stage, and Ending or Termination Stage, and Vander Kolk's (1985) Beginning the Group (Phase One), Conflict and Dominance (Phase Two), Cohesiveness and Productivity (Phase Three), and Completing the Group Experience (Phase Four). The group passed through these four stages in a chronological, and relatively linear fashion, at an accelerated rate, given the fact that there were only three weekend workshops. This reflects the notion of an "intensive team-building workshop", mentioned previously. Weekend one would necessarily include the forming stage and weekend three would necessarily include the termination stage. The transition stage manifested in the second weekend with the role clarification conflict, but one must guard against delineating the stages with distinct boundaries. The fact that the conflict or critical incident occurred in the middle session supports the notion that group development tends to progress in a linear fashion, after which, the group was then able to move into the working stage and terminate during the final weekend. It should also be mentioned that even though the group passed through the various stages or phases, one must consider the fact that all four stages are undeniably interconnected and were more likely being dealt with, in varying degrees, throughout the workshop dates. For example, to state that the termination stage occurred only in the third weekend would be inaccurate, due to the fact that all group members were aware of the time frame for the sessions. As such, group members would have been subtly aware of the impending termination of the group as early as the first session. The stages or phases are examined as distinct entities as a matter of convenience in the writing, not as a reflection of their separateness in the life of the group's development. 80 It would be reasonable to assume that if the workshops had been extended to five or six weekends, a more distinct working stage may have evolved and the conflict or transition phase may have lasted longer than one weekend. A significant aspect of the group's development is revealed when one considers that the team passed through three stages or phases in a short period of time. Several factors most likely contributed to accelerated development of the Leadership Team. First, the group facilitators were aware of the time constraints, as were the team members and, as such, the formation of the group had to be facilitated in a relatively short span of time. In the literature on group development, there is an assumption that the forming stage begins with the first meeting of the individuals involved. The first weekend workshop was not the first meeting of the members of the Leadership Team. Team members had been working together in the Cancer-centre for several months prior to the first workshop and, as such, a considerable amount of group formation had already occurred prior to the arrival of the facilitators and the researcher. The acceleration of the group's formation, therefore, is explained by prior contact of group members to one another. Team members indicated, to the facilitators, that a significant amount of group formation had occurred, prior to the first session. In fact, during their first few weeks of their employment at the centre, several of the team members were required to share office space in a corner of the building, due to the fact that their own offices were unfinished. It was described as a "cozy little environment" that undoubtedly contributed to the members' feelings of solidarity and oneness. The group was also highly motivated, as they were working together in the process of implementing a model of leadership that had never been attempted in the Agency, of which they were a branch. This motivation would enhance group solidarity and give them a sense of oneness in their purpose which, as Stokes (1994) stated was necessary for the successful functioning of multidisciplinary teams in health care. Pre-group contact and interaction, solidarity, and oneness of purpose all contributed to the rapid formation of the Leadership Team in the workshops. The 81 conflict event which occurred in the second workshop suggests that Transition followed the Forming stage. The Transition stage is usually marked by intragroup conflict, as a result of members feeling safe enough to express discontent or disagreement, following a successful forming stage. The intragroup conflict arose as a result of role confusion and ambiguity, regarding the role of one of the team members. However, there also seemed to be some role conflict or ambiguity, among the members of the Leadership Team, regarding the mandate of the workshop facilitators. The stated purpose for conducting the workshops was team- building and leadership development, but the group conflict emerged due to some confusion surrounding organizational roles and responsibilities, as identified by the group members. The organizational ambiguity of this team member's role became a group-process issue, that was not able to be resolved in a process group focusing on interpersonal communication. The roles and responsibilities of the team members, within the organization, had to be addressed first and needed to be made clear outside of the process group, before the focus could return to the interpersonal communication between group members. The clarification was subsequently accomplished by the Senior Administrator, in the weeks immediately following the second session, prior to the beginning of the third workshop. The facilitators were subsequently able to refocus their attention on the process of group development and team building, prior to the third workshop. The facilitators ensured that the team members were made aware, once again, that the third weekend would be the last official meeting of the team in a workshop setting. The fact that team members were aware of the inevitable end to the workshops may have helped them focus more intently on their interpersonal relations, and motivated them to participate more enthusiastically, especially in the non-verbal portion of the hand-to-hand/knee-to-knee exercise. In fact, some group members stated that the success of the touching exercise may have been due, in part, to the sense of urgency to connect with each other before the end of the sessions. These are hypotheses attempting to provide reader with an explanation for the leadership team's seemingly accelerated development. The results of the study 82 were consistent with, and lend support to, the stage or phase theories of group development contained in the literature on group processes. Relating the Results to Group Process Theory Understanding others or being understood by others: The notion of understanding others or being understood by others supports Schutz's notion of the basic group need for intimacy or openness. Team members reported that being understood by others and understanding others positively impacted their feelings about themselves and others. This finding indicates that the workshops were successful in meeting the group's needs for interpersonal intimacy, resulting from personal disclosures. Yalom (1975) wrote of'group cohesion' and the impact that positive interpersonal relations have on the cohesiveness of the group. He states that each member's relationship to their fellow group members has an impact on the cohesion of the group. The team members' reports of interpersonal understanding indicate that they felt their relations with each other were positive and personally enhancing. It can be concluded, then, that this was a cohesive group, as defined by Yalom (1975). John Wallen's (1972) work on interpersonal communication is also supported by this study's findings. Wallen's (1972) concept of the Interpersonal gap is also supported by the reported experiences of the team members. The fact that group members reported the experience of understanding each other at a personal level supports Wallen's notion of the interpersonal gap, and the positive impact of decreasing the gap between what a person means to say and what the receiver of that message hears or understands the message to be. When one examines the reported experiences of the team members, it becomes evident that the interpersonal gap between team members was decreased, which helped to diminish the strain on their interpersonal communications and relationships. This decrease in strain would have positively impacted the group's development, sense of solidarity and cohesion, and feelings of intimacy towards one another. 8 3 Finally, the positive impact that the experience of understanding others and being understood had on the team members, lends credence to Johnson's (1997) work on self-disclosure. Johnson (1997) states that self-disclosure allows a person to validate their perceptions of reality, helps to manage stress and adversity, fulfils a human need to be known, and increases one's self-awareness and understanding of themselves (pp.35-36). The self-disclosures of team members allowed them to understand others and themselves and, although team members did not state explicitly the benefits that Johnson discusses, the positive impact that this sense of understanding had on members, suggests that group members may have experienced some of these benefits. Further research might investigate what were the positive impacts that members experienced, as a result of understanding others and being understood by others? Formation of personal connections with others: Reports of members feeling connected to others, through an emotional bond or attachment also supports Schutz's concept of the group's need for intimacy and interpersonal connectedness. Citing Maslow (1943), Trotzer (1989) states that we all have a desire for affectionate relations with people and that without these relationships with family, friends, or people in general we experience loneliness and social isolation. Trotzer follows with the assertion that every human being experiences an essential necessity for love and that our need for love is not one-sided, but that giving love is as important as receiving it (p. 71). Reports of personal connections to others, and the concomitant positive affect, indicates that this group may have experienced the giving and receiving of a type of love with their fellow team members. At the very least, they reported experiences of affectionate exchanges with each other, indicating that a very basic human need may have been fulfilled through the team members' participation in the workshops. Again, this was achieved through interpersonal communications between members that included very personal self-disclosures, by many of the individuals in the team. Reports of personal connections to other team members also supports Bion's concept of pairing which, as Furnham (1997) states, includes bonding between two individuals who express 84 warmth and affection leading to intimacy and closeness (Furnham, 1997, pp. 474-475). Based on statements made by team members, the experience of personal connections to others is akin to the pairing experience described above. Given that pairing involves a sharing of warmth and affection, one comes to fully understand the negative feelings reported by team members, resulting from a perceived loss of that connection. Sense of belonging/acceptance/inclusion: The sense of belonging/acceptance/inclusion relates directly to Schutz's work once again, this time supporting the group member's need for inclusion. Owing to the fact that all group members experienced this sense of inclusion or acceptance, one would be safe in asserting that the workshops were also successful in meeting the member's needs of inclusion. The importance of the fulfilment of this need for inclusion is evidenced by the positive feelings associated with acceptance, and the contrasting negative emotions related to a lack of acceptance or exclusion. Individual group members also reported positive experiences of themselves, in relation to the rest of the group, which supports Yalom's (1975) writings on group cohesion. The reader will recall that group members reported positive experiences with individual group members, described in the above sections entitled 'Understanding others or being understood by others' and *Personal connections with others'. The person to person relationships reported by team members constitute only one aspect of Yalom's (1975) notion of group cohesion. The second factor indicated, in the fostering of group cohesion, is the individual group member's relation to the group as a whole. Team members reported that, on the whole, they experienced themselves positively in relation to the entire group, revealed in feelings of acceptance, belonging and inclusion. Given that team members reported positive experiences of both individual relationships and relationships to the group as a whole, one can conclude that there was a significant amount of group cohesion, as defined by Yalom (1975, p.46). Trotzer (1989) goes on to say that when we experience acceptance by others, we experience fulfilment and a sense of belonging, leading to a sense of association with the person or group who accepted us, which 85 contributes to our identity (p. 71). One cannot underestimate, then, the value of team members reports of acceptance, belonging and inclusion. Sense of safety and trust in communicating: Luft (1969), as outlined in the review of the literature, stated that it is impossible to discuss communication without relating it to all phenomena of group life. Given that this true, as sense of safety and trust, when communicating with fellow group members, would have a significant impact on the life of the leadership team. The reported experience of a sense of safety and trust in communicating is related to group members' needs for control. It is my assertion that a sense of control must be established by group members in order for feelings of safety to be enhanced, and that control can be conceived of as a necessary, though not sufficient, precondition for group members' feelings of safety. The team members would have experienced a sense of control over their participation in the group, fostered by their trust in the facilitators and in their colleagues, allowing them to experience a sense of safety in communicating. Lacking this sense of safety in the group, the communication between group members would be stilted and superficial due to the increased defensiveness of group members, which is supported by the work of Gibb (1961) and his writings on the effects of defensive communication. Jack Gibb (1961) states that reducing the degree of defensiveness between individuals significantly improves the interpersonal communication and interpersonal relationships. The reported sense of safety and trust in communicating indicates that, in this particular group, members were communicating non-defensively. As such, team members were not preoccupied with issues of control or trust, which allowed them to establish intimacy with their fellow team members, to make personal connections, to feel accepted or included, and to understand one another. The experiences of the team members are intimately interconnected with one another and, in some cases, even dependant on one another. If this group had not felt safe in communicating with one another, understanding and connection would not have been possible. Trotzer (1989) discusses the human need for safety. 86 Trotzer (1989) outlines the human need for safety referring to Maslow's hierarchy of human needs. Besides the needs of physical and material safety, the human needs for safety are person- oriented and relational in nature, achieved through trust formation. The needs to trust others and to be trusted by others are the foundation of our social relationships and are essential therapeutic elements in the group process and we can only meet these needs through our personal contacts with others (p. 69). Reports of safety in communicating by the team members suggests that there was significant trust formation in the group and also indicates that reported positive emotional experiences may have had a therapeutic effect on various team members. A quote by one of the team members illustrates this point: D - "If you feel you can be so safe and..and able to speak and...what surprised me about it was the number of people in the room. You know, you normally think of... keep using this expression, "Baring your soul", but that, to me that's, .that's often done on a one-on-one in a psychiatrist's office so um. You know having not ever seen a psychiatrist I don't know what that's about but, it..it to me it's probably the closest I've ever come to feeling I could say anything about work, about my home life, about my family. " This statement underscores the possible therapeutic effects of trust formation in groups, outlined by Trotzer (1989). This is significant because, as Amundson et al. (1989) state, "Trust is a precondition for self-disclosure as self-disclosure is a pre-condition for productivity" (p.202). A group that is unproductive, especially in organizations, will be questioned as to the rationale for its continued existence. An unproductive group can cost the organization in terms of member productivity and, at the bottom line, can cost the organization in terms of dollars. The leadership team, having established trust, a feeling of safety, and an environment conducive to self-disclosure, can be considered a productive group. Furnham also refers to the benefits of a sense of safety in communicating. Furnham (1997) discusses the role of proximity in cooperation at work and suggests that when people have the opportunity to have frequent and non-threatening contact with others then cooperation is enhanced and fostered. The reported experience of safety in communicating would indicate that the leadership team has the potential for a high degree of cooperation, as defined by 87 Furnham (1997), to exist and function in the group, given that the group is provided with the opportunity to continue their group meetings on a regularly scheduled basis. In the statements made by group participants the feelings of safety and the sense of trust are often mentioned in the same sentence and are seemingly interchangeable. It seems as though both trust and safety occur simultaneously and can be conceived of as two sides of the same coin. Webster's defines safe as a state of being, "out of danger", defines safety as, "the condition of being safe from risk or danger", and defines trust as, "confidence in a person or thing because of the qualities one perceives or seems to perceive in him or it." The question that can be asked, then, is, "Can a person feel safe without trust in others and can a person feel unsafe despite their trust in others?" According to Maslow, as cited by Trotzer (1989) above, it would seem that so long as person's physical and material needs of safety are met, then all other safety needs can be met through trust formation with others. One could then conclude that when team members reported a sense of safety and a sense of trust in communicating with each other, this means that they feel no danger or risk while communicating with each other. The risk or danger of being judged, condemned, ridiculed or criticized is not present, due to the feelings of trust in their fellow members. It would seem, then, that a person cannot feel safe during interpersonal communications with a person that they do not trust. Sensitivity to perceived levels of team member commitment: Group members' reports, concerning their sensitivity to commitment of fellow team members to the group process, is related to the notion of control and trust in the group. Why is it important to group members that they perceive others to be equally committed to the process? The uncommitted member may pose a threat to the cohesiveness of the group. Group cohesiveness, according to Yalom (1975), is akin to the therapist/client relationship in individual psychotherapy. Cohesion is the foundation upon which the group is built and ultimately survives. As such, any perceived threat to the cohesion of the group may be interpreted as a threat to the 88 survival and integrity of the group itself. The reader can turn to the literature on organizational behaviour to inform the discussion of the individual's commitment within an organization. Charles O'Reilly (1991) defines organizational commitment as an individual's psychological bond to the organization, including a sense of job involvement, loyalty, and a belief in the values of the organization. In the above scenario, we are discussing the commitment to a group, not an organization, but the reader may recall that the team of nine was the organization at the time that the workshops took place. The workshops took place prior to the hiring of other staff and so the nine individuals, functionally represented the entire organization at that time. O'Reilly (1991) outlines three stages of commitment: compliance occurs when the person accepts the influence of others mainly to obtain something from others; identification occurs when the person accepts influence in order to maintain a satisfying, self-defining relationship; and, internalization in which the person finds the values of the organization to be intrinsically rewarding and congruent with personal values (p.299). The level of commitment reached by an individual member would be positively correlated with their sensitivity to the perceived commitment of their fellow team members. A hyperbolic example would include the extreme measures that certain cult members (most of whom have reached the final stage of commitment called internalization) would go to in order to prevent a fellow member from leaving the group. Intimidation, threats and even violence are used to prevent members from leaving the group, as a result of the perception that a member's leaving could threaten the integrity of the group. In regards to the leadership team, the sensitivity to the commitment of other members would more likely reflect a level two stage of commitment to the group, identification with others. This lower level of commitment to the group produces a less severe reaction to the perceived lack of commitment of others, such as an uncomfortableness, perhaps a feeling of vulnerability, or a sense of irritability with that member, as indicated in the experiences reported by the team members. 89 Appreciation of facilitated group experience: The fact that team members reported an appreciation of the structured group activities, for expressing personal emotions and thoughts, is consistent with the statement made by Corey & Corey (1987) that, "The proper question is not whether a group leader should provide structure but, rather, what degree of structure." Luft (1969) also discusses the concept of structure (ie. -the internal organizations and procedures of a group with respect to how much structure, and how the group will build its own rules, limits, and procedures appropriate to its own needs) and its place in the development of group dynamics. The reported experiences of the participants in this evaluation support the literature regarding group structure. Several group members stated, in essence, that they would have never communicated personal emotions and thoughts, had it not been for the particular exercises they participated in during the workshops. Translated, this statement reads, "I felt safe talking about myself and my feelings during the exercise, but I never would have said those things on my own." Structured group activities provided the group members with a sense of control over the environment of the group. Research by several other authors such as Bednar, Melnick, and Kaul (1974), Stockton & Morran (1982) and Dies (1983), cited by Corey & Corey (1987), all indicates that a balance must be reached with the use of structure. Increased structure in the beginning phases helps to reduce member anxiety and as members become more comfortable in the group the required amount of structure decreases appropriately (p. 131). In their discussion of structured learning groups, Amundson et al. (1989), citing the work of Middleman & Goldberg (1972), speak to the relationship between structure and control by stating that, "Another feature of the structured learning situation is the psychological safety factor provided by the boundary of each structured situation" (p. 81). The structured activities that the group members participated in enhanced their feelings of safety and control in the workshops, resulting in the reported appreciation of the structure of the facilitated group sessions. The group members also expressed the desire and a felt need for more and continuing structured group sessions, however, at the time of the interviews, there had not been any further group sessions 90 planned. One can conclude that including continual group sessions, in regular work schedules, would benefit group members. Experience of group morale: In all of the literature reviewed there seems to exist a dearth of research on, or conceptualization of, the term morale, with the exception of Luft (1969) who cites Kurt Lewin's concept of morale. Lewin, in Luft (1969), states that morale relies on the notion that a group's goals are sufficiently high to reflect the ideals (or long-range goals) of the group, but at the same time keeping in touch with reality for work on immediate goals. The most common meaning of morale refers to the level of effectiveness of a group and how the members feel about belonging to the group and maybe described as a feeling of we-ness or solidarity feeling, or as esprit de corps (p. 23). This is consistent with the statements made by group members to the effect that, when members were successful at work and effective in solving problems, morale tended to be higher, whereas increased workload and lack of successes at work tended to damage morale. Webster's defines morale as a "psychological state with regard to dependability, confidence, strength of purpose [and curiously] etceteras." Much time and energy seems to be spent on improving employee morale, preventing it from dipping too low and maintaining morale in the long term. Despite the difficult task of operationalizing the concept of morale, people seem to know intuitively that which is required to influence the morale of a group. Based on the testimony of the group participants, one could attempt to describe the morale of this particular group as: "An indication of the psychological and emotional tenor of group members which fluctuates, can be volatile and is subject to the influence of the intrapersonal, interpersonal, and work-related forces in the lives of team members." This definition will ultimately fall short for every situation in which morale is a factor of group life, but captures the essence of the leadership team's experience of group morale, both during and after the weekend workshops. 91 Reciprocity and demonstration of support: Team members reported the experience of giving and receiving support and they also reported that the perceived reciprocity and observable support of others significantly and positively impacted the group members' experiences of one another. The impact of this experience supports the literature in organizational development on the importance of reciprocity and demonstrations of support at work. The results of this study, described in the section entitled, Reciprocity and demonstration of support, support the notions of Fincham & Rhodes' (1992) work environment norms, namely: (1) - Fairness - In the context of group norms people expect others in the group to behave equitably, lest the group becomes distressed or the offenders are punished; and, (2) - Reciprocity - This implies that if one helps another, then the other is expected to help or offer something in return, cited in (p. 157). Based on the testimony of the group members, one can conclude that the fairness and reciprocity norms are, indeed, important factors in the life of the Leadership Team at the Cancer centre. Furnham (1997) also describes the notion of the "reciprocity norm" in cooperation at work, which, in order to function, must battle against the self-serving attribution bias. The self-serving attribution bias dictates that a person must first judge the effort and motivation of another, and then match it reciprocally. Difficulties arise if one person judges another's cooperative effort as lower than it is and one's own effort as higher, because the judging person will, then, undermatch their effort to coincide with their perceptions of the other's effort. If people are constantly undermatching or over-evaluating cooperation efforts then the results could be disastrous. In such a scenario, a genuinely meant, helpful response is misperceived, and punishment and competition may result (p. 348). The self-serving attribution^ bias and the reciprocity norm would seem to coincide with the group members' expressions of the importance of reciprocity and visible demonstrations of support. When supportive efforts are made explicit, then there is less opportunity for a misperception of the level of cooperative effort to occur, and it is less likely that misattributions will be made by fellow team members. "The cards are all on the table" so to speak, thereby 92 releasing both the giver and the receiver of support from serious misattributions. This, in turn, reinforces the notion that one can trust in and rely upon their fellow team members to "be there for them" when they need them. The above examination of the meaning of the results of this study provides the reader with an appreciation for the experiences of the team members in relation to the literature on group development, group process, and organizational psychology. It also becomes apparent that there exists a great degree of interrelatedness or interconnectedness of the experiences that members in the group shared. Figure 1.1 depicts the interconnectedness of the leadership team's experiences, in relation to Schutz's concepts of inclusion, intimacy, and control. The experiential results of the team members have been grouped under the three headings of intimacy, control and inclusion, accordingly, arranged about Yalom's (1975) concept of group cohesion. The experience of group morale has been included under all three subheadings, as it cannot be separated from any of Schutz's three basic needs of group members. Morale is influenced by and influences all three member needs. The graphic also includes Yalom's (1975) / \ Morale (7) Belonging (3) t INCLUSION INTIMACY Understanding (1 Connection (2) Morale (7) ( C O N T R O L ^ Safety (4) Commitment (5) Structure (6) Reciprocity (8) Morale (7) Figure 1.1 - The Interconnectedness of Group Experiences 9 3 concept of cohesion indicating that all of the experiences reported by group members influence the cohesion of the group, and that cohesion remains the central concern in all group life, just as the client-therapist relationship in individual therapy is the central organizing principle. Dimock (1987) stated that, "Groups that have resolved the usual concerns of members in the areas of inclusion, control and intimacy are solid, cohesive groups with members who know where they stand in relation to one another and to the task of the group (p. 71)." In the case of the leadership team, one can conclude that the group members had, at the very least, experienced feelings of inclusion, control, and intimacy, but it would be premature to suggest that the group had resolved these issues to any degree. Let us now examine the results of this evaluation in light of the stated goals of the workshop. The stated goal of the facilitators leading the workshops was to employ a group-process model of team leadership development, to facilitate the formation of the nine individuals into a cohesive unit of administrators, able to operate in a shared system of decision-making. This was to be achieved by: (1) - the facilitation of team members learning how to relate to and communicate with each other on an interpersonal basis (2) - the facilitation of increased levels of trust among group members (3) - the facilitation of increased group solidarity, and (4) - the reduction of misunderstanding and conflict among group members, and (5) - the facilitation of skills for preventing and resolving intra-group conflict. It seems that, in light of the findings in this evaluation that the goals of the workshop were achieved. However, the facilitators might have included more role rehearsal and behavioural practice in helping team members learn now to relate to and communicate with one another. Through the use of micro-skill teaching, feedback, and practice, group members would have been able to experience successful, and unsuccessful, attempts to communicate with each other in the safety of the group. This type of practice would have been especially helpful in dealing with possible conflicts between team members. The rehearsal of conflictual events and topics, 94 combined with micro-skill feedback and practice, would enable group members to experience successful resolution of conflicts based on interpersonal openness and non-defensive communication. One method, which has been employed at the University of British Columbia in the training and supervision of second-year Psychiatry residents, is that of video feedback. The residents videotape their interviews with patients and receive micro-skill feedback on their behaviours and reactions, combined with in vivo practice of the various skills with a supervisor. This method could have been very effective in the facilitation of the leadership team's learning. Based on the testimony of group members, it would have been useful to address the conflict that emerged in the second weekend. Group members reported strong, negative emotional reactions to the role clarification exercise that took place in the second weekend. Feelings of safety were jeopardized and team members reported that their feelings of inclusion and belonging were negatively impacted, as a result. The facilitators might have benefited from modelling to the team members a successful processing of the negative emotions surrounding the event. Solving the role ambiguity was not attempted, nor was it warranted, but group members also reported that they felt the conflict was not resolved for them emotionally and that they felt somewhat blocked from expressing their emotional reactions to the conflict. It was a difficult situation which emerged unexpectedly and without sufficient time to process group members' reactions. However, in retrospect, future conflicts might include a process debriefing of the team members' emotional reactions to the event, not with the goal of placating or solving the emotions, but of allowing a full expression of each of the team member's reactions. In this case, the time restraints were the main factor in the facilitator's inability to process the event. Future workshops might be extended beyond a Friday night and a Saturday, to include a full weekend for each session. Based on the evaluation conducted in this study, it would seem that the workshops were successful, in the sense that a solid foundation was created, upon which the group can continue to build a stable, cohesive unit. It must be noted, however, that group-building or team-building is the first step in the process. A group is a dynamic entity that is constantly evolving and growing, 95 in accordance with the development of its members. Unlike the individual who is able to leave the client-therapist relationship, a process group cannot exist on its own, devoid of external facilitation. Hence, continued group sessions, facilitated by an experienced psychologist are indicated in the case of the Leadership Team. It may interest the reader to know that, at the time this study was written, a two day workshop was planned for the Administrative Leadership Team, and was conducted in January, 1999. This workshop involved only seven of the original nine group members, as the Senior Administrator and the Co-Manager of the facility did not attend, at the behest of the Facilitators. The change in the team was made in order to re-establish a balance of power and influence in the group. Plans are currently underway, at the Cancer centre to provide regularly scheduled, facilitated group sessions for the members of the Leadership Team. Reliability and Validity in a Qualitative Study The question is often posed, when the results of a qualitative study are discussed, "How reliable are your findings?" and, "Are these results valid?". Reliability and validity are constructs found under the scientific paradigm of classic experimental procedures and have been defined by authors such as Ted Palys (1997). Reliability has been defined as the degree to which repeated observation of a phenomenon — the same phenomenon at different times, or the same instance of the phenomenon by two different observers — yields similar results (p. 424). Validity has been defined by Palys (1997) as a term that refers, in the most general sense, to whether research measures what the researcher thinks is being measured (p.428). The terms reliability and validity are difficult to relate to qualitative research due to fact that the experimental conditions of control groups, objectivity, and contamination by the researcher through involvement with the subjects do not apply. Since the study was performed under the guise of a different paradigm to that of classical scientific studies, namely the paradigm of qualitative research, the issues of reliability and validity do not apply. Although an in-depth discussion of reliability and validity in qualitative research is not warranted here, one can turn to the work of authors such as Guba & Lincoln (1989), in Mertens (1998), and in Krefting (1991). 96 Krefting (1991), citing Guba (1981), states that the major concern of the qualitative paradigm is the notion of Trustworthiness (p.215). The trustworthiness of a qualitative study is enhanced when one considers the degree to which certain criteria have been achieved. The criteria upon which trustworthiness is determined can be found in Mertens (1998), who cites the work of Guba & Lincoln (1989). Mertens (1998) summarizes the parallels between the concepts reliability and validity in quantitative and qualitative research. In qualitative research, the analogue to internal validity is found in the notion of credibility which asks if there is a correspondence between the way the respondents actually perceive social constructs and the way the researcher portrays their viewpoints (p. 181). The analogue cited for external validity is contained in the concept of transferability determined by the reader, based on the author's use of "thick description" of the time, place, context, and culture. Finally, the analogue of reliability in a scientific study is contained in the concept of dependability, determined by examination of the quality and appropriateness of the inquiry process. Mertens (1998) goes on to include other qualitative measures such as confirmability (the parallel of objectivity), which means that the data and their interpretation are not figments of the researcher's imagination, and authenticity, which answers the question, Has the researcher been fair in presenting views? (pp. 183-185). The above concepts all influence and determine the trustworthiness of a qualitative study. Based on the requirements for the trustworthiness of a qualitative study, it can be concluded that the evaluation contained herein meets the basic requirements of credibility, transferability via thick description, dependability, confirmability, and authenticity. The basic requirements for trustworthiness being met aside, there do exist several limitations of the study. 97 Limitations of the Study The first potentially limiting factor in this study is the fact that the researcher was known to the participants and may have been perceived as being aligned with the facilitators, and with the Regional Vice-president of the centre. Given the possibility of this occurring, one might question the influence that this perception might have had on the participants' responses. Team members may have been reluctant to criticize or negatively evaluate the program in their interviews with the researcher, thus skewing the data in the direction of a favourable evaluation of the workshops. Second, the researcher acted as group facilitator in the two follow-up sessions conducted after the workshops were completed. The direct involvement of the researcher as a facilitator for group process might lead one to question the researcher's ability to set aside his biases or expectations of the group members' experiences. However, the data that has been presented has not been altered by the researcher and therefore, assuming that all participants were being truthful in the statements made about their experiences, the personal biases of the researcher would not have affected the data significantly. The fact that the interviews were conducted almost five months after the completion of the workshops represents another limitation. Many of the participants found it difficult to remember what had occurred during the three weekends because so much time had elapsed since the final workshops. Had the interviews been conducted earlier, the participants' recollections may have been clearer, and more representative of their feelings at the time of the workshops. However, conducting the interviews immediately after the workshop may also have resulted in a distorted picture of the positive impact of the workshops. Team members reported extremely high levels of morale, and even elation, after the end of the third weekend, which was subsequently replaced by feelings of anxiety and lowered morale after the opening of the centre, three months later. The timing of the interviews was arranged to allow the participants to experience the impact of working at a fully operational cancer treatment centre, after the workshops were completed. This, it was reasoned, would act as a type of proving ground for the impact of the workshops. 98 Finally, the fact that only seven of the nine participants were interviewed constitutes a limitation on the results of the study. The data revealed by the final two participants, would have given the study a wholeness that is otherwise lacking. Since one of the participants not interviewed was also a Senior Administrator (the Centre is co-managed by two individuals), it would have been interesting and informative to discover if she too had a similar experience to that of her fellow Senior Administrator in the group sessions. These constitute the major limitations of this particular study. Implications for Practice Multidisciplinary Teams and Organizational Policy The results of this study provide the practitioner with valuable information regarding the implementation of such a model, within the context of a multidisciplinary health care leadership team. The results indicate that exercises designed to enhance interpersonal communication and self-disclosure serve to increase group cohesion, as well as increase positive feelings experienced by group members. The facilitator running such a group would also benefit from the knowledge of how issues surrounding organizational policy and agents' roles and responsibilities, are better addressed, prior to the beginning of such a workshop, allowing the focus to remain on interpersonal communication. Team development and team-building must not be confused with organizational policy on employee roles and responsibilities. Participation of Managers/Employers This study has also shown that the participation of team managers or employers is not possible in a group based on highly personal disclosures, as the power imbalance, that would necessarily be felt, negatively effects the development of the group, and of each individual member. Group members can never feel totally safe to communicate personal information in a group, knowing that certain members of the group could potentially terminate their employment. 99 Task and Maintenance of Group Life The group facilitator will also benefit from the outcomes of this study regarding the issues of task and maintenance in group life. This study reveals how important it is for the group facilitator to attend to the maintenance function of the group, in order to enable the task of the group to be completed. When the role clarification incident that surfaced in Weekend # 2 emerged, the facilitators were faced with the choice of either - (1) attempting to push ahead with the task of the group (ie. continuing the interpersonal communication exercises), or - (2) attending to the maintenance of the group (ie. recognizing that the issue was emotionally charged for the team members, and that no further group work could be done until the issue was, at the very least, addressed openly in the group). The facilitators recognized that ignoring this "organizational issue", and pushing ahead with the workshop agenda, would have prevented the group from reaching a deeper state of solidarity and cohesion. Attending to the needs of the group members to address the role clarification issue openly maintained the collective health of the group, despite the fact that no resolution, at an organizational level, was reached by the facilitators. Had the issue not been addressed openly, the group would have been unable to resume with full participation in the workshop. Addressing the issue in an open manner within the group brought the ambiguity of that person's role "into the light", so to speak, preventing it from becoming a hindrance to the workshop agenda. By dealing with the issue within the group context, and not treating it as an issue for management to deal with outside the workshops, the facilitators also modelled how to address such sensitive issues in an open and respectful manner. Further, no attempt was made to solve the problem of role ambiguity, but rather to illuminate the feelings of group members regarding the problem. Attending to the maintenance of the group allowed the remaining and final workshop (ie. further connection and interpersonal understanding of group members) to be the most productive workshop in the series. 100 Implications for other Health Care Settings The utility of this intensive team-building model has application for both health care employees and their employers, in that the nature of the work that they perform has the tendency to cause these people to separate or remove themselves from the group. The stress that is placed on employees working in health care has been demonstrated to have deleterious effects on the individual, both psychologically and physiologically. It has also been shown that these effects can be minimized through social support and interpersonal relationships (see Kivimaki et al., 1997, and Heaney, Price, & Rafferty, 1995). Given the beneficial aspects of interpersonal relationships and social support on the psychological and physiological well-being of employees in health care and, given the success of the model evaluated in this study in creating those interpersonal relationships, group practitioners can recognize the opportunity for joint ventures with the medical and health care communities to occur. Considerations for Management and Administration Finally, the administrator or manager in health care will benefit from the results of this study by learning how a leadership team can be built based on interpersonal communications and self-disclosures of an emotional nature, and how that process is experienced positively by employees. The manager who is considering such an intervention would benefit by establishing regular group-process sessions and incorporating those sessions into the team members' monthly work schedules. A fixed schedule for group process would enhance the feelings of safety, trust and control of the individual group members, and would decrease the negative impact on morale, which may result from unsuccessful attempts to bring all the group members together at the same time. The findings of this study also point the direction for possible future research to be conducted. 101 Directions for Future Research There are many directions which subsequent research could take from the findings of this study, as the results contained herein speak to the effectiveness of group-process team-building workshops, and their subsequent positive impacts on participating team members. Several future directions will be discussed, as well as an examination of an example of a successful team building project that almost destroyed an organization. Ross (1989) offers the prospective manager or facilitator, considering such an intervention, a caveat regarding team-building exercises and their impacts on health care organizations. Ross (1989) cites a curious example of a successful team building endeavour that resulted in a near organizational breakdown. The details of the scenario revealed that, as a result of a highly successful team-building intervention with a group of supervisors in a public health agency, the relationships between supervisors and subordinates degenerated to the point that the subordinates refused even to sit down with their supervisors to discuss their differences. Formal grievances were filed, news media followed the story in local and state newspapers and, within two months, 16 employees had resigned and three more had been terminated. Ross (1989) goes on to state that the team building workshop was designed to help reduce conflict among supervisory team members, allowing for more solid and cohesive group development, and was deemed very successful. Team members spent a substantial amount of time discussing how the supervisors would work with and support one another in the future. As a result, a situation arose which polarized the team of supervisors from their subordinates and almost destroyed the organization (pp. 155-157). Future research might include a follow-up investigation into the effects of the team-building process at the Cancer-centre on subordinates, peers, and other employees. One might ask, "How do the employees, not included in the group, feel about the group? Do they feel left out of the process? Does it matter to them if they never become part of the team?" Other future research might also consider investigating the impact of membership in the group on the team members' physical health. 102 As mentioned in the review of the literature, there is evidence in support of the positive impact of social support on the health and well-being of employees. One might consider a longitudinal study, following and tracking the work attendance of group members, and the incidence of stress leave or related illnesses absences. This would indicate that the group formation may have had a significant impact on the health and well-being of the members of the leadership team. Reduced illness and reduced absence would indicate happier, healthier workers and, ultimately, less of an economic drain on the organization. Conclusion In this evaluation we have examined the impacts of an intensive, group process-based team-building workshop, on a team of nine administrative leaders working in Cancer care. The evaluation has shown that such a model can facilitate the forming of interpersonal relationships based on mutual respect and understanding of team members as individuals, beyond their professional roles and responsibilities. The evaluation has also shown that the net result of forming these types of relationships, with a team of health care professionals, is one of increased positive affect towards one another, and an increase sense of group cohesion, group solidarity, and mutual support. What is, arguably, most important is the demonstrated importance of the inclusion of the personal aspects of professional life, beyond the roles, titles, and responsibilities of the employees. Given that, in Canadian society, the public relies on these employees to care for us, and to heal us when we become afflicted with life-threatening diseases such as Cancer, it is imperative that we take whatever actions necessary to ensure that their health and well-being is preserved and enhanced. It is a debt that we owe, and a service that we can provide, to those who might someday save our lives. 103 REFERENCES Amundson, N.E. , Westwood, M.J. , Borgen, W.A. & Pollard, D E . (1989) Employment groups: The counselling connection. Minister of Supply and Services Canada. Bion, W.R. (1959). Experiences in groups: and other papers. New York: Basic Books, Inc. Blau, P .M. (1974). On the nature of organizations. New York: John Wiley & Sons Boss, R.W. (1989). Organization development in health care. New York: Addison-Wesley Publishing Co. Bradford, L P . , Gibb, J.I., & Benne, K .D. (eds.) (1964). T-group theory and the laboratory method. New York: John Wiley & Sons Inc. Brown, R. (1988). Group processes: Dynamics within and between groups. Oxford: Basil Blackwell Inc. Cohen, R.G. & Lipken, G.B. (1979). Therapeutic group work for health professionals. New York: Springer Publishing Co. Corey, G. (1996). Theory and practice of counseling and psychotherapy (5th ed.). Pacific Grove: Brooks/Cole Publishing Co. Corey, M.S. & Corey, G. (1987). Groups: Process and practice (3rd ed.) Pacific Grove, California: Brooks/Cole Publishing Co. Dimock, H.G. (1987). Groups: Leadership and group development. San Diego, California: University Associates, Inc. Fincham, R. & Rhodes, P S . (1992). The individual, work and organization: Behavioural studies for business and management (2nd ed.). London: Weidenfeld and Nicolson. Furnham, A. (1997). The psychology of behaviour at work: The individual in the organization. Hove East Sussex: Psychology Press, Publishers. Gladding, ST . (1995). Group work: A counseling speciality (2nd ed.). Englewood Cliffs, New Jersey: Prentice Hall. Heaney, C A . , Price, R.H. & Rafferty, J. (1995). Increasing coping resources at work. A field experiment to increase social support, improve work team functioning, and enhance employee mental health. Journal of Organizational Behaviour, 16, pp.335-352. 104 Johnson, D.W. (1997). Reaching out: Interpersonal effectiveness and self-actualization (6th ed). Boston: Allyn & Bacon. Kivimaki et al. (1997). Psychosocial factors predicting employee sickness absence during economic decline. Journal of Applied Psychology. 82, (6). pp. 858-872 Krefting, L . (1991). Rigor in qualitative research: The assessment of trustworthiness. The American Journal of Occupational Therapy. 45, (3), pp. 214-222. Lieberman, M.A . , Yalom, I D . , & Miles, M . B . (1973). Encounter groups: First facts. New York: Basic Books. Luft, J. (1969). Group Processes: An introduction to group dynamics. Palo Alto, California: National Press Books. Merten, D . M . (1998). Research methods in education and psychology: Integrating diversity with quantitative and qualitative approaches. London: Sage Publications. The New Lexicon: Webster's encyclopaedic dictionary of the English language (Canadian ed.) (1985). New York: Lexicon Publications. Northouse, P.G. & Northouse, L . L . (1992). Health communication: Strategies for health professionals (2nd ed.). Norwalk, Connecticut. Appleton & Lange. Palys, T. (1997). Research decisions: Quantitative and qualitative perspectives (2nd ed.). Toronto: Harcourt Brace & Company. Perls, F.S. (1972). The Gestalt approach & eye witness to therapy. Science & Behaviour Books, Inc. Perls, F.S., Hefferline, R.F., & Goodman, P. (1977). Gestalt therapy: Excitement and growth in the human personality. London: Bantam Books. Perls, F.S. (1992). Gestalt therapy verbatim. Highland, New York: The Gestalt Journal (A division of The Centre for Gestalt Development). Ross, R.S. (1989). Small groups in organisational settings. Englewood Cliffs, New Jersey: Prentice Hall. Schein, E .H. & Bennis, W.G. (1965). Personal and organizational change through group methods: The laboratory approach. New York: John Wiley & Sons, Inc. Snow, C. & Willard, D. (1989). I'm dying to take care of you: Nurses and co-dependents, breaking the cycle (1st ed.). Redmond, Washington: Professional Counselor Books Publishing. 105 Stake, R.E. (1994). Case studies In N.Denzin & Y.S.Lincoln (Eds.), Handbook of qualitative research (pp. 236-247). London: Sage Publications. Stokes, J. (1994). The unconscious at work in groups and teams: Contributions from the work of Wilfred Bion. In Obhozet, The Unconscious at Work. Routledge Press. Trotzer, J.P. (1989) The counselor and the group (2nd ed.). Muncie, Indiana: Accelerated Development Inc. O'Reilly, C. (1991). In Straw, B . M . Psychological dimensions of organizational behaviour. New York: Macmillan Publishing Corp. Vander Kolk, C.J. (1990). Introduction to group counseling and psychotherapy. Illinois: Waveland Press, Inc. Wallen, J.L. (1972). The interpersonal gap. Portland, Or: Northwest Regional Educational Lab. Wilensky, P. (1997-98). Unpublished process notes from group workshops conducted on December 12th/13thr 1997 and January 16fh/17fhT 1998 Yalom, I D . (1975). Theory and practice of group psychotherapy (2nd ed.) New York: Basic Books, Inc. 106 Appendix - A The Interview Format (1) - THE IMPACT OF Y O U R EXPERIENCE IN THE WORKSHOP ON: COMMUNICATION - What happened in the workshop that had an impact? Can you describe the experience you had at the time? - How have you experienced yourself or others doing that? Can you describe an example? - How does it feel? How is it different? - Have you noticed the impact? Tell me more about the experience in the workshop. Is there anything else that you would like to add? (2) - THE IMPACT OF Y O U R EXPERIENCE IN THE WORKSHOP ON: MORALE - What happened in the workshop that had an impact on the morale as you experienced it? Can you describe the experience you had at the time? - What was your experience of the morale immediately following the workshop? - How has it changed? How is it different now? Can you describe an experience? - Have you noticed the impact? Tell me more about that experience. Is there anything else that you would like to add? (3) - THE IMPACT OF Y O U R EXPERIENCE IN THE WORKSHOP ON: SUPPORT FOR E A C H OTHER - What happened in the workshop that made a difference or had an impact? Can you describe your experience? - How do you experience yourself being able to support now? How have you experienced receiving support? Can you think of any specific occurrences? - How does it feel? How is that different than before? - Have you noticed the impact? Tell me more about that experience. Is there anything else that you would like to add? (4) - THE IMPACT OF Y O U R EXPERIENCE IN THE WORKSHOP ON: YOUR ABILITY TO PROVIDE HOLISTIC/HUMANISTIC PATIENT CARE - What happened in the group that has made an impact? Can you describe it? - How do you experience yourself doing that now? - How does it feel? How is that different? - Have you noticed the impact? Can you describe that? Tell me more about that experience. Is there anything else that you would like to add? 108 Appendix - B (cont'd) Consent: I understand that my participation in this study is entirely voluntary and that I may refuse to participate or withdraw from this study at any time. I have received a copy of this consent form for my own records. I consent to participate in this study. Subject Signature Date Signature of a Witness Date Appendix - C Johari Window Known to Self Unknown to self Known to others Unknown to others 1. Free to Self 2. Blind to Self 3. Hidden area 4. Unknown Self Adapted from: Johnson (1997. p.40) 

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