Nurses are increasingly being expected to understand group process and to function competently in groups. Some undergraduate programs now require a course dealing with group and organizational behavior for all students. It is a wellaccepted fact that nurses spend a great deal of their professional life in groups, as either leaders or participants: staff groups, committees, patient groups, etc.* At the same time, the recognition that nurses are particularly susceptible to the symptoms of burnout is growing.
Various articles discuss burnout, how to recognize it and some hints for dealing with it. Schubin discusses the stages (developed by Christina Maslach) of "burnout" as the progressive process of fatigue and depletion of resources; energy is reduced. The three stages are characterized as 1. physical fatigue, or feeling drained; 2. psychological fatigue which, includes the physical symptoms as well as a sense of alienation from patients and the work which is to be done; and 3. spiritual fatigue, which involves doubting one's effectiveness, values and even the morality of one's efforts. At this point the person has trouble investing in others and starts thinking, consciously or not, of escape.1
In seeking to discover more about this phenomenon, Maslach and Pines studied 200 mental health workers (including nurses, psychiatrists, psychologists, social workers, attendants and volunteers) and found that when work group relationships were good, staff reported many "good days" and few "bad days"; in addition, those with good work relationships felt more positively toward their clients/patients than did those with poor work relationships.2 Work was perceived as less stressful if the workload was shared in the work group. Pines and Maslach suggest that staff meetings, in addition to being the place to discuss patient/client issues in a detached, intellectualized way, should also become a place where individual staff members receive emotional and social support and have a chance to confer openly with other staff about themselves and about their patients/clients. They also suggest taking precautions as individuals: setting realistic goals, acknowledging vulnerabilities and being willing to meet one's own needs as well as those of their clients/patients, in other words, knowing and taking care of oneself. They also encourage the professional educational programs which train students to deal with future stresses.2
This study highlights two key abilities which are needed to deal with the stresses in human service organizations: 1. the ability to develop mutually supportive relationships with colleagues at a relatively personal level, and 2. the ability to be in touch with one's own needs, feelings, etc. so as to be able to know and, consequently, to take care of oneself. The following process will aid in developing these abilities as well as help in learning group process skills.
The Group Experience
Individuals are placed randomly in groups of five to seven members. Participants are told that the group will have a task to carry out; at the same time the group will function as a vehicle for each member to learn about themselves, their needs in groups, and how they relate interpersonally. Each group is given a structured assignment of developing a presentation dealing with some aspect of group process or organizational behavior which they are to present to the other groups. (Any number of groups greater than two can be used.) The presentation is to have practical relevance as well as cover some conceptual material.
One hour per week in class or during work time for eight weeks is set aside to work on the assignment. Another one to two hours during each of those weeks are used for giving the large group (all participants) conceptual and practical information about working in groups. Each group member meets once in the eight weeks for a half-hour consultation with the instructor/trainer. These meetings are held after every second session; group members alternate so that each meeting is made up of one member from each group.
There are two deadlines the group as a whole must meet. One, to develop an outline of their presentation by the third or fourth week and secondly, to have a presentation ready at the end of the eight weeks. In addition, each individual is responsible for producing a two-part written analysis of their group's process and their own role in that process; one part is due at the end of the first four weeks, the other due after the group presentations. This analysis is to follow a very structured format requiring participants to carefully analyze and give examples illustrating: 1. process factors in their group, such as goals, norms, leadership, role expectations, decision-making and conflict resolution methods; 2. the balance between task and maintenance behaviors in the group and their own behavior's effect on that balance; 3. the stages of their group's development over time. In addition, they are to complete a force field analysis on some aspect of their group's functioning that they would like to see changed. Finally, they are to do a selfappraisal of their own group skills, analyzing and giving examples of their assets and liabilities to the group as well as their personal development during the life of the group. Each of these areas is covered in at least one of the large group sessions which all participants attend and which is described in the next section.
The Group Sessions
For the first two or three sessions the groups receive minimal help from the instructor. During the third or fourth session each group is observed by the other groups (in a "fishbowl" arrangement) as they hold a regular group session. These observation sessions follow the introduction of readings and lectures covering conceptual material about group process; e.g., Rubin and Beckhard's process factors in health teams. Bales' task and socioemotional behaviors in groups, Schutz's as well as Tuckman's stages of group development.3"6 Each observer is assigned to watch for various concepts illustrated in the process of the group being observed. For example, three or four people may attempt to determine at what stage the group is in in its development. Three or four others may look for the decisionmaking processes utilized in the group.
Although these observations are carried out for the expressed purpose of sensitizing participants to aspects of group process, the observations also serve to give groups, and the individuals within them, feedback about their own processes. In turn, this provides a starting point for the group analysis paper required of each individual.
In the first large group session following the process observations, the process of giving and getting feedback is discussed. Information about the "Johari window" (a model demonstrating openness in individuals and groups) is presented together with a self-test which allows each participant to plot his or her own Johari window, i.e., his or her degree of interpersonal openness. Each group then discusses what they think their group's Johari window would look like. According to Joe Luft and Harry Ingram's formulation (from whom the Johari window is derived), openness in individual interpersonal style as well as openness in a group is positively associated with productivity in relationships and task accomplishment. Openness is a function of two dimensions: 1. how willing each person is to expose or be open about his or her thoughts, feelings and beliefs; and 2. how willing each person is to solicit and accept feedback from others.7 Following this introduction on the importance of openness and feedback, the fifth or sixth session is devoted to an exercise which requires each member to give feedback and request feedback from other members in the group.
The next large group session focuses on "force field analysis," an assessment tool based on systems or field theory. In order to assess the feasibility of change and to select appropriate intervention points, one lists forces in the environment, organization, group, and those individuals involved which favor the desired change and those forces which are resistant to that change.8'9 As described above in the second group analysis assignment, each individual selects an aspect of their group's process which they would like to see changed and assesses the feasibility of the change utilizing "force field analysis."
Group presentations (which are 45 minutes to one hour in length) are evaluated by both the instructor and the other groups for pertinence of information as well as for evidence that the group has worked effectively together. (Frequent subjects for presentation are "combatting 'reality shock/" "preventing 'burnout,'" "dealing with conflict in groups," "assertiveness in organizations," etc.)
This format, with minor modifications, has been used with approximately 400 undergraduate students over the past three years. Approximately half of these were juniors in a baccalaureate program and the others were registered nurses returning to school to obtain their B. S. N. degree. The response to this format has been quite positive, although initially many students are not in favor of working in groups, and are reticent to become personally involved in the groups. Feedback from students has shown this to be a useful process, both for increasing self-awareness and for learning about group process. Returning R, N. students have been espedally appreciative of the overall experience.
The Group Experience and Self-Awareness
This group experience gives nurses and nursing students an opportunity to approximate a situation they have faced or will face many times in their work, i.e., working with a group of peers on tasks which necessitate their working together. In the experience just described, however, two aspects are different; first, they are not working with people they will have to work with on an ongoing basis and secondly, there is a dual focus in this work group: the task and self-learning.
A great deal of encouragement is given to participants in the large group session and in the consultation meetings to be aware of their own feelings, to let others in their group know what they are feeling, and to ask others for feedback when they are unsure what others are thinking about them. They are encouraged to deal openly with conflict, with the view that conflict is not inherently good or bad, but an expression of differences among people. Different methods of conflict resolution are discussed. The discussion efforce field analysis" emphasizes awareness of the difficulties of change, and the importance of taking into account one's own energy supply from which change efforts must come. As part of the group analysis paper, participants are to make a judgment as to whether or not the problem to which they have applied "force field analysis" would be a feasible change for them to attempt at the present time. The emphasis throughout is on being in touch with oneself and taking care of one's "self" as well as finding ways to work more satisfyingly with co-workers.10'11,1
For work situations and for life generally, the way we develop awareness of our own feelings is in our interaction with others. Our psychic energy to deal with repeated stresses and failures comes from inside ourselves, from our feelings of selfworth. There is a dilemma here. When the self is well formed and continues to be strong, experimentation and innovation become possible; when the self is fragile, then it takes on simple, ritualistic and perhaps compulsive behavior. This limiting of competence can lead to alienation and depression and the continued struggles to innovate, draw out and exhaust the skills of the self and its selfworth. The only clearly explored ways of rebuilding ego-strength are to develop valid, sharing, trusting, collaborative, nondependent relationships.12 And yet it takes a high level of ego strength to build these collaborative, trusting relationships.
The Group Experience and Developing Collaborative Relationships
Developing such relationships in organizations is not easy because of the difficulties cited above and because collaboration is not supported by the norms of most organizations nor of our society. This is true even though organizations depend on people working together and even though the need for collaborative relationships for organizations to be effective seems to be increasing. Nurses as well as other professional workers are part of large-scale organizations in increasing numbers, tasks are becoming more complex and interdependent, and diverse specialists often come together for relatively short periods of time to solve problems. In the work situation, there is little support for a person to gain the ability to develop "valid, sharing, trusting, collaborative, nondependent relationships. "Although Americans and Western culture in general pay great lip service to all forms of cooperation and teamwork, this is not translated into behavior. Individualism, even if it is hollow. is a strong competing ethic. This diluting of both ethics has been called "antagonistic cooperation"; we feign harmony and act autonomously.13
To approach this problem, the development of collaborative, authentic relationships and the development of self-understanding and self-fulfillment are crucial. Their development seems to occur in a dialectical process. Interpersonal skills are needed to improve self-understanding and self-understanding is needed to improve interpersonal skills. There must be growing levels of interpersonal trust and openness of relationships that affirm that trust. Collaboration does not exist prior to the development of an affective and interdependent relationship. These affective and interdependent relationships cannot be ordered; they involve closeness and trust and mutual confidence. As change becomes more and more commonplace, interpersonal skills of quickly establishing trust, openness and support for the help with feelings and ideas in new or changing group affiliations will become more necessary. Thus, it is important that experiences like the one described above be provided nurses so that they have the opportunity to develop the interpersonal skills which will allow them to feel more comfortable being open and thereby more comfortable getting support from their colleagues.
The Group Experience and Learning About Group Process
To learn about group process and the possibilities of meaningful experiences in groups, one must be intimately aware of and familiar with one's own feelings, reactions, biases, values to know where the boundary is between those feelings, biases, etc. that are one's own and those that belong to others in the group. In this group experience, at the same time participants are becoming more tuned in to their feelings and developing peer relationship skills, they are learning about group process. This group approach translates the rather abstract concepts of group process into a concrete experience of what those concepts "feel like," e.g., the concepts of norms, internal role expectations of group members, socio-emotional and task leadership; methods of resolving conflict; and stages of group development.
Certainly, this one group experience will not serve to immunize nurses against burnout, nor will it insure sophisticated knowledge of group process or problemfree group participation. However, it can serve to introduce nurses to two important professional concerns, both of which have broad ramifications for the satisfactory and effectiveness of individual nurses and for the well-being and growth of the profession.
- 1. Shubin S: Burnout: The professional hazard you face in nursing. Nurs '78 87):22-27, 1978.
- 2. Pines A, Maslach C: Characteristics of staff burnout in mental health settings. Hasp Community Psychiatry 29(4):233-237, 1978.
- 3. Rubin I, Beckhard R: Factors influencing the effectiveness of health teams. Milhank Memorial Fumi Quarterly. June 1972, pp 317-335.
- 4. Bales RF: Interaction Process Analysis. Cambridge, Massachusetts, Addison-Wesley, 1950.
- 5. Schutz WC:Fítt>: A Three-Dimensional Theory of Interpersonal Behavior. New York, Holt, Rinehart and Winston, 1958.
- 6. Tuckman B: Developmental sequence in small groups, in Hinton B, Reitz H (eds): Group and Organizations. Belmont, California, Wadsworth, Publishers, 1971.
- 7. Luft J: The Johari window: A graphic model of awareness in interpersonal relationships, in Luft J: Group Processes, ed 2. Palo Alto, California, Mayfield, 1970, pp 11-20.
- 8. Benne K, Birnbaum R: Principles of changing, in Bennis W, Benne K, Chin R (eds): The Planning of Change, ed 2. New York, Holt, Rinehart and Winston, 1969.
- 9. Watson G: Resistance to change, in Bennis W, Benne K, Chin R (eds): The Planning of Change, ed 2. New York, Holt, Rinehart and Winston, 1964.
- 10. Grimm L, Crawford J: Assertiveness training for nurses. / Nurs Adm, Spring 1978, pp 59-63.
- 11. Numerof RE: Assertiveness training for nurses in a general hospital. Health Sor Wort 3(l):79-102, 1978.
- 12. Hainer R: Rationalism, pragmatism and existentialism: Perceived but undiscovered multicultural problems, in Glatt E, Shelley MW (eds): TAf Research Society. New York, Gordon and Breach, 1968.
- 13. Bennis W: Changing Organizations. New York, McG reinforced to be aware of others' feelings and to take care of others, so being out of touch with onself is a hazard of the female sex-role. Assertiveness training for nurses has been advocated to deal with this problem; this paper suggests a related approach.