tate coordination and synthesis activities, however. Feiger and Schmitt also examined the relationship between degree of hierarchy and patient outcomes in four teams in a long-term care setting. They found that better outcomes were perfectly rank-correlated with less hierarchy in the interaction patterns of team members.

In focusing on other group processes that can undermine the effectiveness of team performance, Heinemann and colleagues (1994a) summarize several sociological theories relevant to group decision making and apply them to geriatric interdisciplinary health care teams. Groupthink (Janis, 1972, 1982)—a process theorized to affect highly cohesive teams in which efforts are made to control the input of information that challenges the team’s thinking—is more likely to occur in situations of high stress where there is pressure to act. The theory was first used to examine the dynamics of what went wrong in political fiascoes, such as the Bay of Pigs invasion of Cuba under the leadership of President Kennedy and the Challenger disaster. In tests of the theory, directive leadership was found to increase the likelihood of groupthink processes.

Theories of framing and group polarization have been used to refine ideas developed in groupthink theory. Framing theory focuses on the interpersonal context of decision making, while group polarization theory emphasizes how group discussion exaggerates initial preferences of team members for risk taking or caution. Discussions also have focused on the linkages between the stage of development of group/team cohesiveness and the potential for groupthink behavior (Longley and Pruitt, 1980). In addition, Farrell and colleagues have examined how conditions in geriatric teams may approximate conditions required for groupthink processes and illustrate these processes in a case study description (Farrell et al., 1986, 1988, 2001). They offer the following guidelines for minimizing poor decision making related to these team processes: (1) emphasizing open, honest, and direct communication; (2) facilitating team development, which includes writing a mission statement, formulating goals and procedures for operating, clarifying roles, and orienting new team members; and (3) helping teams identify team processes that predispose to poor decision making, such as overreliance on directive leaders and team isolation. They emphasize the importance of retreats, administrative or process meetings, and acknowledgment of effective work.

Group development theory has provided the theoretical context for a number of studies of health care teams (Farrell et al., 1986, 1988, 2001). This theory posits that teams pass through a series of developmental stages prior to reaching their maximum work effectiveness. Few efforts have been made to measure team development and examine factors that influence team development. Consequently, the usefulness of this theory for understanding team safety behavior is uncertain. One study of researcher-designed and/or



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