Introduction The skills related to team building pertain to the second domain of the three domain model of leadership described in previous article.(1) The skills related to managing self, such as emotional competencies, time management and active listening are foundational for managing and leading teams.(2) In the hierarchy of leadership a competent and highly skilled individual is at the first level of leadership, in the second level of leadership s/he also becomes an effective team player while updating technical expertise and at the third level s/he becomes an effective team leader while retaining the skills of the first two levels.(3) The skills of team building play a pivotal role in achieving the goals of the organization. These skills are even more important in health sector both in clinical and public health settings. The most distinguishing characteristic of a team is collective vision towards the accomplishment of goals. The team is a symbiotic relationship complementing and supporting each other's skills, communicating openly and clearly with one another and holding themselves mutually accountable.(4) Its members respect and trust each other and strongly believe that every member brings unique skills and strengths to the team and the right competitive spirit to bring the best contribution. However, the structure of team differs depending upon its purpose, its task, its setting, the mix of professions and the formal relationship between health professionals in it.(5 6 7) The team based practice is well understood only when the distinction between team, team work, collaboration and collaborative practices is known. In developed countries the teamwork and collaboration in healthcare delivery has been discussed in government reports as a key strategy in health care renewal.(8 9 10 11) Team Building in Health Care Systems Team work has shown improvement in performance in many aspects of healthcare in primary health care and public health systems. The evidence suggests that quality of care, patient safety, shortage of manpower, and stress among health care professionals is managed better through an effective team work.(12 13) In the ‘Team Method’ in nursing care of indoor patients, all the staff members under the leadership of a professional nurse, are assigned to a group of patients, who assigns the tasks, supervises, instructs, guides and coaches them- the team. It is an excellent and most desirable method but requires good team building and supervision. It is generally preferred over ‘Case Method’ where a nurse is assigned to the complete nursing care of a number of patients, or the ‘Functional Method’ where nurses are assigned specific functions for all the patients in the ward. The teamwork can significantly reduce workloads, increase job satisfaction and retention, improve patient satisfaction and reduce morbidity. The review of health care effectiveness literature suggests that decision making largely accounts for improvement in patient care and organizational effectiveness and the diversity of clinical expertise involved in a team. Collaboration, conflict resolution, participation, and cohesion are most likely to influence staff satisfaction and perceived team effectiveness.(14 15) In recent days organizing primary care services for acute, chronic and preventive care is a major challenge.(16) To handle such situations successful teams and team work always matters to accomplish the task with collaborative efforts. Many studies have identified teamwork as an essential tool for high quality work and safe patient care.(17 18) The teams that work together are more effective and innovative. High quality health care is achieved if team motives are clearer. The participation level of the team members has greater emphasis on quality and support for innovation. Hospital research also shows working in team lowers level of stress.(15) The health care has changed enormously in past 20 years. This rapidity of change continues to accelerate and both clinicians and patients need to integrate new technologies into management of wellness and illness.(19) Thus the leaders in health sector need to look beyond health sector to address health determinants in other sectors to improve health. Teams are Dynamic Building effective team is necessary for creating an appropriate organizational environment.(20 21) Bruce Tuckman has described four main stages of team development: Forming, Storming, Norming, and Performing. Later a fifth stage of Adjourning/Transforming was added.(22) The forming is the initial phase of team building, members are uncertain about their roles, rules, norms, and expectations from them. The next step is, storming where members tend to get into competitiveness, defensiveness, jealousy, and conflict over roles and personalities; members may become critical of the leader and of each other. In norming members get to know each other, agree on the norms, working styles and systems to follow. In performing the teams works with positive and creative attitude to achieve the goals. Finally in adjourning, after completion of the team tasks, members bring a sense of closure and bonding between members. Most experts in team development agree that teams go through five different stages mentioned above but how fast a team moves through each stage will depend on the team members, their individual skills, the work they are expected to do, and the type of leadership available to the team. Allan Drexler and David Sibbet's(23)"Team Performance Model"illustrates team development as seven stages, four to create the team and three to describe increasing levels of sustained performance which are summarized below: Creating stages Orientation: Why I am here? Trust Building: Who are you? Goal and role definition: What are we doing? Commitment: How will we do it? Sustaining stages Planning: Who does what, where? Implementation: High performance stage Reassessment & renewal: Do we continue? Yes, why & how? The Creating stages of Drexler A and Sibbet E correspond to Forming, Storming and Norming stages of Tuckman B Model and Sustaining stage corresponds to Performing and Adjourning stages. A good team leader understands the dynamics of a team and takes it to performing stage(s) as soon as possible by actively engaging with the team members to ensure smooth transition through creating, forming, storming and norming stages. The proper transition through creating stages is important and has strong implications for team performance. The teams do not necessarily pass through the above mentioned stages and stay in the stage reached but keep moving back and forth. The various factors, such as, new member(s) join and current members leave, new tasks are assigned, the leadership changes etc keep the teams moving back and forth among various stages. The leader has to remember that storming stage is a necessary evil and s/he has to anticipate and closely observe the issues which may hinder progress towards achieving the goal and proactively address the issues fast before it assumes self defeating proportions. Behaviors that Promote and Hinder Teams Work Lencioni has described five dysfunctions of team, discussing why teams, even the best ones, often struggle.(24) The first dysfunction he describes is “absence of trust”. Without trust neither the team can be formed nor can they achieve results. The fear of conflict, lack of commitment, avoidance of accountability and inattention to the results were the other dysfunctions. In fear of conflict, the team members ignore controversial issues that may be critical to team success, waste time and energy in interpersonal risk management to keep harmony in the team. Lack of commitment and avoidance of accountability, creates ambiguity in the team about direction and priorities. The team misses deadlines and deliverables, places an undue burden on the team leader as the sole source of discipline. Inattention to results occurs when members of the team seek individual recognition and goals at the expense of the collective goals and often work towards ‘saving own skin’ and pass on the blame. Ego and status can lead to team members focusing on their individual accomplishments instead of the common purpose. Table 1 below summarizes the qualities and obstacles of effective team work. Table 1 Facilitative and obstructive behaviors for team work Motivating Team Members Motivation is accomplishing things through the efforts of others. It is important for the team leader to keep his team motivated to achieve the desired results. Job performance = ability × motivation × organizational support. Only motivated team members can produce quality work. What motivates people may include money, power, attractive position, enhanced self respect on accomplishing a task etc. A motivated team member is able to do more and adds quality to whatever he does. Motivating employees is not a one time or a periodic but is an ongoing activity both during bad and good time an individual, team or an organization passes through. It requires more attention when an individual, team or an organization is passing through a turbulent phase. According to Maslow a person works to satisfy his needs which he described as a hierarchy. The first need, Physiological Needs, was the basic need essential for survival like salary, working conditions etc. Once the first need was met one worked for the next need i.e. Safety/ Security like job security, insurance or son preference in India followed by Social Needs like connecting with people and being accepted. Once these lower order needs were achieved one worked for higher order needs like Self Esteem, wherein one looked for self -respect, appreciation etc. The last stage, Self-Actualization, was achieved when one was self -driven and worked for growth and self-fulfillment. Thinkers came up with other theories which were similar but looked at motivating people from different angles. Herzberg gave a slightly different perspective in his Two Factor Theory. Not disagreeing with Maslow, he differed with the traditional view that, while working, the opposite of Satisfaction was Dissatisfaction. So there was either Dissatisfaction or No Dissatisfaction in work. Similarly the employees found Satisfaction or No Satisfaction in their work. Job Dissatisfaction could be reduced by Hygiene Factors like salary, facilities like housing, health insurance, working conditions in office. Poor hygiene factors would make the person unhappy and irritated but their absence would not make him enthusiastic to work, which would be determined by the work itself. Determinants of Job Satisfaction were Motivators: The work itself, responsibility, advancement, recognition etc. If they were absent there would be no satisfaction in the job, while he may not be dissatisfied if the hygiene factors were present. Motivators would increase job satisfaction while the hygiene factors would reduce job dissatisfaction. Money as a reward would be a motivator otherwise a hygiene factor. The leader of team should focus on Job enrichment (the work itself) as a job satisfaction strategy when money and hygiene factors cannot be increased or no longer motivate a staff member. Job Enrichment In most situations it is not possible to promote or financially reward good work for motivating team members. In such situations job enrichment is a good practice to keep a staff member motivated and acquire new skills. The job must be designed to provide opportunities for achievement, recognition, responsibility, advancement growth. Designing jobs that include a greater variety of work content requires: A higher level of knowledge and skill. Give employees more autonomy and responsibility in terms of planning, directing, and controlling their own performance. Provide an opportunity for personal growth and meaningful ful work experience. Get due credit for the success achieved. Five core dimensions that enrich jobs Benefits for job enrichment for health care organisations Job enrichment benefits both the team members and the organisation. It benefits a team member by giving more job satisfaction, greater responsibility and authority, the opportunity to experience more growth and development, a greater sense of achievement, more job autonomy and a greater diversity of job experiences and more practice at taking decisions. It benefits the organization by higher level of job performance, imoroved quality of patient care and services, improvement in quality of decisions, increased employee's loyalty and commitment to organisation, lesser absenteeism and lower turn over rate. Mentoring and Coaching Mentoring and coaching skills are a must for leaders and managers. In formal education of health care professionals, mentoring is considered as a fundamental tool for helping people achieve required competencies. Formal and informal mentoring has been increasingly encouraged as a way of supporting people's continuing professional development.(25) Mentoring is primarily the identification and nurturing of potential for the whole person. It can be a long-term relationship, where the goals may change but are always set by the learner. The learner owns both the goals and the process. Feedback comes from the mentees – the mentor helps them develop insight and understanding through reflections, that is, becoming more aware of their own experiences and areas of improvement.(26) However, coaching relates to performance improvement (often short-term) in a specific skills area. The goals are typically set with or at the suggestion of the coach. While the learner has primary ownership of the goal, the coach has primary ownership of the process. In most cases, coaching involves direct extrinsic feedback (i.e. the coach reports to the coachee what he or she has observed).(27) The mentor or coach may be a supervisor or a leader. Leaders prioritize time for the ongoing coaching that is an important element of team success.(21) 70% of the leading employers use coaching and mentoring in their workplace to create higher organizational performance. It increases creativity (69%), learning and knowledge management (63%) and motivates people (57%).The study conducted by the Chartered Institute of Personnel and Development indicates that 93% of all the respondents believed coaching and mentoring is a key mechanism for transferring training skills into the workplace.(28) Figure 1 below gives the stages in the coaching and mentoring relationship. Figure 1 Stages in the coach-mentoring relationship(25) Conflict Resolution It is important for team leader to encourage team members to bring in different opinions to enrich the work of the team. This needs to be accepted by team members without bringing their ego into play. The team members should look at these as differences on issues rather with other team members. The role of the leader is to ensure that these differences are dealt with in a healthy manner and do not lead to conflict. Conflicts are disagreements that lead to tension within, and between people. Often people are confused between conflict and disagreement. Conflict is a more serious form of disagreement. When two people are having disagreement their relation is intact and in conflict, the relation often turns sour and dialogue ends.(29) Many factors in health care system can contribute to the escalation of conflict. It starts from the disagreement and once the conflict escalates the focus shifts from the issues to the person's faults leading to expansion of problem with breakdown of dialogue. The escalation of conflict is enemy images, resulting in violence, dehumanization process leading to open hostility and polarization where co-existence is no longer possible. A conflict brings down the productivity of the team and vitiates the work environment preventing members to put in their best.(29) An important skill for team leader to have and impart to team members is negotiation skill. This will be dealt with in a subsequent article. At an organizational level, the process of conflict resolution is an opportunity for growth and change in a work environment. Conflict resolution is important for the bottom line on an organizational level as well as for personal achievement to see change in overall success.(30) Proper conflict management contributes to higher effectiveness, trust, and openness and results in successful conflict resolution.(31) In organizations where conflict is not viewed positively or as an opportunity for improvement, see conflict as unproductive, unpleasant, and a waste of time and energy. If conflict is not controlled early, it can have damaging effects in the workplace, stifling the growth of departments and deflating employee morale.(32) Conclusion Skills of team building are essential for every manager and leader. The teams are dynamic and are created for a purpose. Only a good team player can become a good team leader. It is important for the team leader to take them through team creation stages and move to productive stage. In the productive stage team members complement each other's skills and efforts to achieve common goals. In the process they trust and respect each other's opinion, even when the views differ. Team leader and members acknowledge each other's contribution and inputs. The team leader steps in early to resolve conflict when it arises. S/he keeps them motivated through recognition and coaches and mentors them when required. Job enrichment is one important way of acquiring new skills and keeping team members motivated.