RESEARCH ARTICLES

 

Graphic team sculpting for Nursing Management : The way Forward

 

 

Me Oosthuizen -Van Tonder^I,*; A Du Preez^II; P Bester^III

^INorth-West University, School of Nursing Science. oosthuizen.m.e@gmail.com
^IINorth-West University, School of Nursing Science. Antionette.DuPreez@nwu.ac.za
^IIINorth-West University, Africa Unit for Transdisciplinary Health Research (AUTHeR). petra.bester@nwu.ac.za

 

 

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ABSTRACT

In a multifaceted, fast-paced healthcare environment, providing staff with opportunities to improve teamwork is fundamental to healthcare providers' job satisfaction, organisational effectiveness and patient outcomes. This article highlights the value of middle management applying a newly developed technique, graphic team sculpting as a strategy to enhance teamwork. The aim was to explore and describe the role of the nursing unit manager to improve nursing teamwork in a mental health care facility. A qualitative, explorative, interpretive descriptive and contextual study was done. The population consists of thirteen unit managers (N=13), selection criteria was used and all qualifying participants voluntarily participated in either the focus group discussion or the graphic team sculpting or both. Data was collected through one focus group discussions (n=8) and graphic team sculpting (n=9). Data was analysed through content analysis. The results indicated that nursing teamwork was influenced by organisational-, unit specific- and unit manager specific factors. Negative organisational culture contributed to absenteeism and resistance to change, which lead to power struggles. As every team is complex; it is recommended that unit managers must embrace uniqueness and diversity in teams. It is vital to recognise the importance of nursing teamwork in improving quality care and promoting positive work environments that will contribute to nurses' job-satisfaction, improve patient safety and quality care. Unit managers should incorporate graphic team sculpting as a team building strategy.

Key phrases: Graphic team sculpting; mental health; nurse manager and teamwork

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1. INTRODUCTION

A successful organisation that has strong teams enables the organisation to reach its goals, create a positive work environment and ensure holistic quality care. To guarantee a successful organisation it is critical to provide staff with opportunities to improve teamwork (Eichorst, Soderstorm, Reid, Brisbin, Simard & Edmonton 2018:49). Teamwork, strong leadership and appropriate resources are the key components for managing emergency situations (Eichorst et al. 2018:49), and the unit on a daily basis.

The positive impacts of a functional team enhance quality holistic care, improve patient safety (McComb, Lenmaster, Henneman & Hinchey 2017:237), lead to higher levels of job satisfaction (Grover, Porter & Morphet 2017:92), increase staff morale and reduce nurses' turn-over rates (Caprari, Porsuis, Olivo, Bloem, Vehmeijerb, Stolkc & Melles 2018:21).

Cole (2018:2682) identified the need for greater collaboration among teams but due to the complex conceptual differences of the various team members efforts to enhance collaboration were unsuccessful. Challenges such as limited resources and insufficient infrastructure, staff shortages, (Cleary, Horsfall, O'hara-Aarons, Jackson & Hunt 2012:473) inadequate training of nurses (Muraraneza, Mtshali & Mukamana 2017:12), overburdened facilities, resistance to change (Steege & Rainbow 2017:20) and a lack of community support pose further challenges to these services, compounded by the ageing population and the burden of chronic diseases (Barrow, Mckimm, Gasquoine & Rowe 2015:119).

Graphic team sculpting provides a means to overcome health care challenges by improving teamwork as it focusses on the team as a unit. It is a therapeutic data gathering technique that provides managers with an overview of their current team situation, comprehending the reality of their team structure and roles. Graphic team sculpting is an adapted version of graphic family sculpting, a known strategy in psychology and social sciences but new to nursing. Graphic family sculpting was originally used in a family setting to assess family dynamics through visual drawings and as a form of psychotherapy. During graphic family sculpting a family member is asked to draw a picture of his/her family of origin, presenting each family member with a circle (Venter 1993:12). Information is gathered, in both techniques by giving step-by-step instructions to the participant on completing the drawing.

The aim of the current study was to explore and describe the role of the nursing unit manager to improve nursing teamwork in one mental health care facility in Gauteng, South Africa. Based on the studies' findings, recommendations were made to improve the quality of mental health care rendered to mental health care users as well as strategies to enable teams to be more efficient. The nurse unit manager is central to the initiation as well as the maintenance of the nursing teams (South Africa 2011:52). The article focusses on how unit managers can improve teamwork by using graphic team sculpting.

 

2. METHODS

2.1 Design

The study was conducted from a qualitative, explorative, interpretive description (Thorne, Kirkham & O' Flynn-Magee 2004:1) and contextual design that aimed to describe and explore nursing teamwork from a unit managers' viewpoint. A qualitative approach was used to understand human dynamics as perceived by the unit manager. The study design was helpful to explore the phenomenon and to gather information about the current status of nursing teamwork and to make recommendations for improved nursing teamwork in a mental health care facility. Exploratory studies are used to increase knowledge of a phenomenon but are not intended for generalisation (Grove & Gray 2018:192). Interpretive description is an "inductive qualitative analytic approach to understand a clinical phenomenon that yields application and implications, whilst acknowledging the constructed and contextual nature of human experience" (Thorne et al. 2004:21).

2.2 Ethical considerations

This initial study formed part of a research program titled "Leadership and governance as mechanisms towards excellence in South African health systems". Ethical clearance was obtained from the North-West University, Potchefstroom Campus (NWU-00050-12-S1). International ethical frameworks were adhered to namely the Helsinki Declaration, Belmont Report, and the Nuremburg Code. In addition to the adherence to international ethical frameworks, the researcher obtained consent from the Acting Chief Executive Officer in the mental health care facility where the research was conducted and the Director of the Westrand District, Region A, from the Department of Health of South-Africa. The principles of ethics in research (respect for persons, beneficence and justice) were ensured throughout data collection and analysis. Anonymity was ensured by using code names while analysing and reporting data. The participants signed confidentiality agreements during the focus group discussion and graphic team sculpting's. There were no hidden cameras, one-way mirrors or hidden microphones during the focus group discussions. The participants had the right to withdraw from the study at any time without discrimination (Walliman 2017:47). Through close observation the participants were protected from discomfort and harm (Walliman 2017:49). During data collection, the comfort of all participants was ensured by selecting a comfortable and accessible venue. Informed voluntary consent was obtained from each participant. While recruiting participants, information was provided in an understandable language (Walliman 2017:47). An information leaflet was given to each potential participant during the recruiting phase. Fairness was ensured by giving each participant an equal chance to take part in the study. No unauthorised persons had access to the information which was stored in a locked cabinet.

2.3 Population and sampling

The population (Walliman 2017:96) of this this study comprised of 13 unit managers in a public mental health care hospital. From these 13 unit managers, nine participated in the focus group discussion and eight in the graphic team sculpting. Selection criteria were used and all qualifying participants voluntarily participated in either the focus group discussion or the graphic team sculpting or both. Non-probability, purposive sampling was used where participants were selected due to their information-rich characteristics because of their expertise concerning the research topic. The following inclusion criteria (Grove & Gray 2018:703) were used for both the focus group and the graphic team sculpting: participants had to be fluent in English; be in active unit manager posts and registered as professional nurses at the South African Nursing Council (SANC); have at least three years' experience in mental health care and be working in the specific public mental health care hospital in Gauteng for a minimum of one year.

2.4 Data collection and analysis

The researchers combined different methods of data collection, namely graphic team sculpting (phase 1), a focus group discussion (phase 2) and the integrated discussion of the research results from both phases (phase 3). Data were collected during 2013. This combination of methods ensured rigour through data triangulation. The proposed research method, with specific reference to the different phases of data collection, is portrayed in Figure 1.

2.4.1 Graphic team sculpting

Graphic team sculpting was used as a data collection method (n=9) by adapting Venters' (1993:12) instructions of the original graphic family sculpting technique to focus on team members. Participants were provided with an A3 sheet of paper and an HB pencil and eraser. The following instructions were given to the participants (Example with analysis illustrated in Figure 2)

1. On the one side of the paper you must draw the nursing team with which you work, presenting each team member as a circle. You can draw the circles as small or as large as you wish. In each circle or next to it, write the name of the relevant team member.

2. Number each circle according to the order in which you have drawn them.

3. On the back of the paper, next to number 1, write down whether you have discovered anything new about the nursing team. If you did, what was it?

4. Next to each circle on your drawing, write whether the person presented is sitting, standing or lying down. You could describe the position more fully, for example standing up straight or sitting and reading.

5. On the back of the paper, next to number 2, write down whether you have discovered anything new about the nursing team. If so, what?

6. Indicate the direction in which each person is looking. Do this by drawing an arrow from the team member in the direction in which he/she is looking. Choose one direction for each member. If you feel strongly that a person must look in more than one direction, secondary arrows can be presented by a dotted line. If you feel that one person is looking at everybody, you can draw one arrow and write everybody next to that arrow. A person can be looking away from the team members or look forward or even look inwards or 'not look' anywhere.

7. On the back of the paper, next to number 3, write down whether you have discovered anything new about the nursing team. If you did, what is it?

8. Allocate a label to each team member as you think the team has labelled that person, for example the quiet one, the cheeky one, the hard worker or the clever one. Next to each label write (L). If you can't decide on a label for a specific team member you can put a question mark with a (L) next to that specific circle. You can give more than one label to a person.

9. On the back of the paper, next to number 4, write down whether you have discovered anything new about the nursing team. If you did, what was it?

10. Allocate a particular emotion or feeling that you think is mostly experienced by each team member. Write the emotion or feeling next to each circle with an (E) after it. If you can't decide on an emotion you can put a question mark with a (E) next to it. If necessary you can allocate more than one emotion to a person.

11. On the back of the paper, next to number 5, write down whether you have discovered anything new about the nursing team. If so, what was it?

12. Finally answer these questions on the back of the paper:

13. Next to number 6, write down whether it was easy for you to draw your team. Yes or No, and why?

14. Next to number 7, write down whether you have learned anything in the process. Yes or No?

15. Next to number 8, write down whether you became emotional during the process. Yes or No?

16. Next to number 9, write down whether you have referred to a specific shift. If you have referred to a specific shift indicate which one it is, for example day or night shift (Adapted from Venter, 1993:13).

Graphic family sculpting was validated by Van Hoek (Venter 1993:12) as a valid multidimensional instrument. Three factors were identified, namely structure, process and intra-philological experiences. The same rationale can be applied to graphic team sculpting. The application rationale of graphic team sculpting presents the advantages of this technique when used as a strategy to enhance teamwork. It is an adaptation of Venters' (1993:12) rationale for Graphic Family Sculpting in order for the reader to understand the use of this method of data collection. A true reflection of the teams' functioning was produced, enabling richer data collection.

The possibility of the unit managers' modifications of their answers was eliminated, as they did the sculpting individually in a private room and handed the data in immediately to the researcher. Graphic team sculpting is a visual spatial metaphor which enables one to redefine complexities and vague issues as simple workable forms. This minimises the possibility of misinterpretations (Venter 1993:12). The unit managers were enabled to confront their emotional experiences concerning team issues, by asking the unit manager to indicate if he/she has learned anything new about the nursing team after each instruction (Venter 1993:12). This technique appeals to the right hemisphere functions of the brain, namely the functions responsible for more holistic, creative and intuitive processes of the brain (Venter 1993:12).

In the application of graphic team sculpting the unit manager is intellectually involved in studying the material that has a high emotional content and acquires new knowledge about the team. The manager can therefore be more objective about issues within the team and assume an "I" position. This promotes individual self-differentiation within the nursing team (Venter 1993:12). Graphic team sculpting has an adhesive effect on teams. The unit manager realises that the members establish a unit within the team and that each member is a crucial part of the team whose behaviour influences team functioning and nursing teamwork. The unit manager identifies positive and negative characteristics within his/her nursing team, and how these characteristics influence professional and personal development (Oosthuizen-van Tonder 2014:64). The information obtained during the application process can enable effective change within the team (Venter 1993:12).

The interpretation technique developed by Venter (1993:12-13) for graphic family sculpting's was modified with the developers' assistance to fit into a team context. The graphic team sculpting's were thus analysed through the following 12 steps; Gestalt, placement, direction, position, label, emotion, order, line quality, space, location, answers at the back of each sculpting/drawing and general statements.

After initial analysis the steps of interpretive analysis by Terre Blanche, Durrheim and Kelly, as described in Botma, Greeff, Mulaudzi and Wright (2010:226) were followed to categorise the data from the graphic team sculpting. The steps in the interpretive analysis comprise familiarisation, development of themes, coding, elaborating and interpreting. See example of graphic team in Figure 2.

Analysis of graphic team sculpting example

Background information: This is a male forensic ward

1. Gestalt: There is clear hierarchy present in a horizontal position; the AM is placed first at the top of the page, followed with the OM and then PNs' etc. This is horizontal hierarchy.

2. Placement: The AM (Assistant manager/Matron) is included. A clear hierarchy is present because the AM is placed at the top of the page, followed by the unit manager (OM). The team members are ranked. At the bottom of the page two general ward assistants are included.

3. Direction: The unit manager is looking at everybody. Team members are looking at each other (mostly in pairs) this could indicate clique formation or a buddy system.

4. Positions: No one is lying down. 9/21 of the team members are standing. 1/21 has no position. 11/21 is sitting. In question 2 the unit manager indicates that the team is doing their tasks while sitting, it could thus be said that every person in this team was contributing towards the team's functions.

5. Labels: 10/21 labels indicate that they were hard workers. 3/21 is regarded as being cheeky. Some are seen as stubborn (2/21). Most team members had positive labels but this seemed to be incongruent with their emotions as some members were hard workers but they were sad/frustrated (Team members C2 and C3). This could be due to a high workload.

6. Emotions: 10/21 was happy and had positive emotions. The rest of the team members were sad/frustrated. The unit manager was frustrated.

7. Order: The AM had a very big circle compared to the rest of the team. The general ward assistants (GWA) had very small circles. This could indicate that the unit manager felt that the AM played a more important role in the team according to his/her position compared to the GWA that played a smaller part in the team functioning.

8. Line quality: No significance

9. Amount of space: No significance

10. Location: No significance

11. Answers at the back: According to the unit manager some members gossiped (this confirms the clique formation of the direction in number 3). The unit manager also stated that there was no cohesion and no job satisfaction. The unit manager felt frustrated as a manager as he/she had no say in who came to his/her ward.

2.4.2 Focus group discussion

One focus group discussion, with eight participants, explored the specific role of the unit manager in improving nursing teamwork. The discussion was conducted in English and lasted approximately 45 minutes. During recruitment, potential participants received information leaflets about the study. Written voluntary consent was obtained prior to the focus group. The session was digitally voice recorded and transcribed verbatim during the data collection and analysis phases. The following questions were posed during the interview: Please describe the status of nursing teamwork present in your unit? What do you think is the role of the unit manager (operational manager) to improve teamwork? What factors hinder nursing teamwork? What practical strategies can be implemented by the unit manager to improve nursing teamwork?

Content analysis was used for data analysis of the transcribed focus group. An independent psychiatric registered nurse was a co-coder. In the focus group the main and sub-themes were categorised, using the principles of qualitative data analysis recommended by Tesch (Creswell 1994:154-155). During the data collection process, field notes were kept by the researcher, including empirical and personal observations.

 

3. RESULTS

The results of the study indicated that various factors have an influence on teamwork. The factors can be classified as organisational-, unit-specific- and unit manager-specific factors. Both the focus group and graphic team sculpting's had hindering and facilitating factors as displayed in Table 1.

3.1 Graphic team sculpting

During graphic team sculpting main and sub-themes were identified. The main themes identified were categorised into facilitating and hindering factors that influenced nursing teamwork. The sub-themes were divided into factors pertaining to team member, the team and the organisational.

3.1.1 Facilitating factors

Team member factors

Diversity within teams was evident by individualism concerning labelling/emotions, depending on the ward structure, type of patients and nursing staff. Most team members' contributed to the team's performance. The gestalt positions of the drawings (horizontal/vertical) are incongruent with ranked individuals' characteristics, thus team members were seen as unique individuals. The label, emotion and position depended on individual circumstances and personality of the member, affirming the appreciation of individualism from the unit managers. Unit managers were seen as the team leaders as in 66.6% of the sculpting, team members looked at the unit managers, indicating the unit manager's central role in the team.

Team factors

General ward assistants an administration clerks formed part of the nursing teams in most drawings as 44.4% included non-nurses in the teams. General ward assistants form part of the team as they contribute to the cleanliness and everyday functioning of the ward and the unit managers saw them as key figures in the team. Only 22.2% of the unit managers included ward administration clerks in the nursing teams. There was no team separation between day and night shifts. The unit managers provided guidance to the team members.

Organisational factors

Clear hierarchical structures were present within nursing teams and unit managers perceived these hierarchical structures as being important by including these in their drawings. Despite clear hierarchical structures, more operational structures within the units were required. Female wards were reportedly more positive work environments with more positive emotions and labels compared to male wards. There was no distinct difference between the acute and forensic wards. The focus group discussion confirmed this finding.

3.1.2 Hindering factors

Team member factors

Of the emotions, 25.7% were negative including frustration/irritation, anger, stress, sadness, disinterest, anxiety, manipulation or annoyance, possibly indicating negative workplace attitudes. Team members were unhappy / dissatisfied which might reveal low job satisfaction levels which could contribute to burnout

Team factors

Group/clique formation between team members (portrayed in 44.4% of the drawings) influenced teamwork negatively and contributed to distrust and poor communication indicated by the direction in which the team members were looking. These directions illustrated that two or three people that would exclude other team members and focus on each other.

Organisational factors

Negative organisational culture and mediocrity existed within the organisation itself. The assistant mangers were not actively involved at ward level. Although 22.2% of the drawings included the assistant manager, top level management did not feature in 88.8% of the drawings - a noticeable absence.

3.2 Focus group

During the focus group interview it became evident that nursing teamwork was influenced by organisational, unit-specific and unit manager-specific factors - both facilitating and hindering factors.

3.2.1 Facilitating factors

Unit-specific factor

Team members tried to co-operate and achieve cohesion. Unit manager (UM) 4 stated: "I am still trying to build the team so that we can have this cohesiveness, working together." UM 2 realised that cohesiveness was important by stating: "We need to achieve as a team."

Unit manager-specific factors

The unit managers could delegate effectively, ensure fairness, and view themselves as leaders and role models. The managers solved problems and conflicts while promoting team cohesion. They viewed every team member as being valuable with unique characteristics. UM 6 said that delegation needs to be fair: "With the delegation we need to be impartial not to take sides, in conflict and all those things." UM 0 used delegation as an empowering tool: "For good practice you give them, you delegate." UM 7 emphasised the importance of a team leader: "You cannot walk without a head, the leader is the head." UM 3 identified consistency as a positive role example "And you as a leader, if you are not consistent and being considerate or flexible, the people will not make a good team." UM 4 noted that appreciation is a powerful tool used within team dynamics: "And you have to value each and every person, they should be aware of their value, to realise that they have value in the team you know."

3.2.2 Hindering factors identified

Unit specific factors

The ward structure and type of ward played a role. Increased workloads and high patient-staff ratios were aggravated by nurses' absenteeism. UM 7 stressed that they felt overworked: "There is too much work because there is an overcrowding of patients. You see having few people with many patients. So at the end there is those things that causes the teamwork to fail". UM 4 felt that the staff patient ratio was too low: "Staffing levels: I would say no they are very low, and it needs to be upped, to be increased, and to be proportionate to the number of patients." Constant supervision/delegation was needed for smooth functioning of the ward. UM 5 confirmed this by saying: "If the operational manager is not there they don't want to do their job always they need a policeman to be there." Nurses were so accustomed to routine work that they resisted change. UM 3 gives a great example of this by saying: "The people that are long in this hospital, they got this thing they are so influential. They have got this pulling down syndrome and they are influential. I don't know if it is a burnout thing, really. They will always say in our times this is what we used to do and you are not going to tell me". Nursing team members displayed negative attitudes, and unclear hierarchical structure below the level of the unit manager created uncertainty. Clique formation caused divisions between team members.

Organisational-specific factors

The organisation's culture impacted negatively on nursing teamwork as the culture was perceived as being laissez-faire and mediocre. UM 7 said: "They just come and go they no longer show interest."

 

4. INTEGRATED DISCUSSION OF RESULTS

Findings, from both the graphic team sculpting and the focus group interview, indicated that both team member, team, organisational, unit-specific, unit manager and specific- factors affected the teams' overall functioning.

The team member factors revealed uncertainty about the hierarchical structures below the unit manager which created power struggles within the nursing team. The uncertainty of hierarchy also influenced responsibility and accountability (Ditlopo, Blaauw, Rispel, Thomas & Bidwell 2013:138). Only some team members contributed towards the team. The general ward assistants and administrative clerks were also seen as part of the team even though they were not directly involved with patient care; they performed important functions within the team.

Pertaining to the team factors, occupational specific dispensation, formation of cliques and power struggles, caused team divisions and low cohesion (Ditlopo et al. 2013:138). Cliques within a team inhibited trust and communication between the team members. The unit manager should improve cohesion by keeping the team goal-directed and enhancing trust between the individuals (Kalisch & Lee 2012:2).

The organisational factors revealed the following themes. A negative organisational culture was portrayed by negative labelling of attitudes and emotions in the sculpting's as well as in the quotes of the focus group participants. Organisational culture could emanate from a group of people who have a history and stability. This occurs once a group has learned to share common assumptions, resulting in automatic perception patterns of perceiving, thinking, feeling, and behaving to provide meaning, stability, and comfort (McComb et al. 2017:237). Negative attitudes contributed to absenteeism. During the focus group discussion it was disclosed that the team members resisted change. The team members had low levels of motivation and did not accept responsibility and accountability for managing the ward in the absence of the unit manager. The individual team members were not empowered to solve their own problems, as they required direction and supervision (Cleary et al. 2012:472). The unit managers reported poor support from top management. The wards were overcrowded increasing nurses' workloads. More male nurses are needed for effective team functioning, according to the unit managers (Grover et al. 2017:92).

Concerning unit specific factors, every team identified different factors influencing the complexity of each team's functioning; every team should thus be seen as a distinct entity. Male forensic wards were viewed as being difficult wards where mental health care users displayed aggression and male nurses were reportedly more effective in handling these difficult situations than female nurses.

The unit manager factors included that the unit manager played a vital role through leadership and guidance. Every ward, individual and team presented with unique elements based on their structure, individual characteristics and type of ward. Such diversity should be embraced by the unit manager to enhance teamwork (Clark 2017:379). Workplace diversity refers to the inclusion of individuals. Diversity in the workplace could be managed by building an organisational environment that is favourable to the development of every team member's potential while fulfilling the organisational objectives (Neiva, Torres & Mendoca 2017:227). The unit manager should appraise differences amongst people, award controversial thinking instead of criticising the differences between team members. The unit manager should focus on each team member's strengths and use his/her best qualities to improve nursing teamwork (South Africa 2011:6). The unit managers could enhance teamwork through collaboration, fair delegation, guidance, acting as role models and leaders, collaborating to solve problems, facilitating effective communication and involving all the team members in decision making. A lack of teamwork could lead to patient-related errors (Kalisch & Lee 2012:1). When nurses work in effective teams they are more productive and less stressed, rendering higher quality patient care with fewer errors (Kalisch & Lee 2012:1). Nurses reported feeling more energetic and motivated when they worked in excellent teams (Cleary et al. 2011:456). Teamwork contributes to high levels of job satisfaction, increases staff morale and reduces staff turn-over rates (Kalisch & Lee 2012:2). Burnout could be prevented through effective team functioning, which reduces frustrations of working in isolation (Maslach & Leiter 2017:160). Work engagement plays a vital role in individual performance. If team members are engaged in their work they have higher energy levels, enthusiasm, inspiration and pride in their work (Neiva et al. 2017:63). Such a highly motivated individual has positive effects on the entire team. The unit manager should thus ensure that members are engaged in their work activities. Nursing unit managers' leadership and management styles play an important role in team cohesion. Toode, Routasalo & Suaminen (2011:246) identified five factors affecting nurses' work drive including workplace characteristics, working conditions, personal characteristics, individual priorities and internal psychological states. Nursing unit managers should create a positive work environment that facilitates teamwork (Registered Nurses' Association of Ontario (RNAO) 2013:Internet). A satisfied nurse has a greater readiness to work collaboratively and deliver high quality care. Staff members are an organisation's most valuable asset; therefore, it is important to enable them through teamwork to become as productive as possible. It is the role of the nursing manager to improve nursing teamwork.

The declining in the standard of health care and lack of professionalism is due to insufficient leaders and role models in practice. From the research findings it is clear that a unit manager has a strong influence as a role model in a team. In the absence of the unit manager the team had power struggles and failed to take responsibility as hierarchy structures were unclear.

A role model shapes not only professional development in less experienced team members but also teamwork, aspirations and competencies (Felstead & Springett 2016:66) provided that a supportive culture (Gray & Brown 2016:216) is formed in practice environments. It may be argued that there is a need for top managers to actively promote team work and support role models by cultivating a practice environment that enables the role of the unit manager to act as a leader. A clear leadership figure is essential for learning and development within a team as poor role models leads to fragmented communication, low morale and a lack of focus on patient care (Felstead & Springett 2016:66).

 

5. LIMITATIONS

The study was conducted in one public mental health care facility in the Gauteng Province of South Africa, thus limiting the findings to the specific setting. As this study is contextual in nature, a dense description has been provided to enhance trustworthiness. The graphic team sculpting technique presented the perception of each unit manager in his/her specific setting and might have been influenced by preconceived conceptions of unit managers toward the team members. Individual interviews about the drawings were not conducted after the graphic team sculpting. The richness of data could have been enhanced based on graphic team sculpting's if each participant had been questioned about his/her sculpting.

 

6. RECOMMENDATIONS

The following are recommendations that can be implemented in hospital or on organisational level to improve teamwork. The studies' findings should be applied in life skills workshops for employees as a team building strategy. Unit managers should use graphic team sculpting's as a practical team building activity in their unit to get a clearer picture of current teamwork and identify the strengths and weaknesses of the team. Graphic team sculpting can enhance trust, and cohesiveness in a team. Appropriate role-models and leaders should be identified by top manager to mentor inexperienced nursing unit managers in leadership and mentoring skills. Positive practice environments should be created by managers to facilitate teamwork despite limited resources and challenges in the hospital. Collaboration and communication between middle level managers and top management should be enhanced through regular meetings and mentorship programmes. Uncertain hierarchy structures should be addressed by top management to create a secure structure in the absence of the unit manager for teams to function in. Top management can show support by being more involved and communicating openly with teams in the ward.

 

7. CONCLUSIONS

The need for effective teamwork is critical for any business and health care facility. The ability to simultaneously perform individually and collectively with team members is the key to attaining growth and success. Teamwork is essential to accomplish the overall objectives and goals of an organisation. Using graphic team sculpting as a team building strategy will contribute to team cohesion, relieve tension, enhance trust and improve quality care. Middle level managers can use graphic team sculpting as a teamwork enhancement strategy as it is cost effective, delivers an instantaneous overview of the current team situation and is an eventful activity for team members.

 

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* corresponding author