Seven Practices of Highly Resonant Teams

Abstract

This chapter evaluates how substantial improvement in quality and outcomes can be achieved by attention to intra- and interpersonal factors that create teamwork. Together, these factors influence learning, growth, and innovation, as well as safety for team members and the patients they care for. It is difficult to quantify the improvement in outcome in terms of lives saved, errors prevented, and morbidity reduced, but the literature on this topic as well as the experience of numerous providers suggest that it will be real and substantial. Medical knowledge, skills, and judgment are not enough to reach high standards of quality and safety, and high performance requires much more than clinical skill. This chapter provides a framed construction for how good teams work and incorporate those important principles into Seven Practices of Highly Resonant Teams.

The way a team plays as a whole determines its success. You may have the greatest bunch of individual stars in the world, but if they don’t play together, the club won’t be worth a dime.

Babe Ruth

Appendix 1

We can define three kinds of interpersonal interactions, all of which we include under the general term integration, which is meant to be inclusive of:

• Congruent [22, 80] – which defines the decision-making process between yourself, others, and the current context in a way that integrates all the competing needs in a manner that honors them and has them contribute to the choices that are made.

• Concordant – which defines the relationship between two or more members of the team such that they are completely “in sync.” This can also be called attunement or resonance.

• Coherent – which defines the communication process between yourself, others, and the current context. It requires simultaneous states of differentiation and linkage to self, others, and contexts. In coherent communication, an individual has a knowing and stable core from which he or she feels available to be influenced and receptive to the opinions of others without disintegrating into chaos or needing to operate/communicate from a rigid status quo. Coherent communication is based on personal insight and interpersonal empathy, and it allows for flexible, adaptive, and creative outcomes.

High-performing (resonant) teams require congruent, concordant, and coherent communication. Without attunement, this kind of communication is not likely to occur. Attunement-driven integration entails the following ten functions that must be practiced and mastered [10, 12, 31, 40, 56, 76, 88, 100]. For experts, these functions can be performed in less than a second. The following is a definition of each and a concrete example of an experience you can incorporate in support of each function:

• 1. Interoception. This is your ability to be aware of the sensation the current situation creates in you in a way that you can sense that it just doesn’t feel right [60]. Sensation is created in our nervous system from implicit and explicit memories. It is important that you be able to observe with all of your senses in the operating room, cath lab, or clinic, not just your eyes, ears, and hands but also with your important sixth sense.

  • (a) What happens inside of you when something unexpected occurs? Do your hands shake, does your heart race, does your breathing become shallow, or do you feel weak and shaky? Try to recognize and tune into these feelings. They will be your clues that you need to get off automatic pilot and tap into a greater wisdom for response.

  • (b) Take a deep breath(s) and connect to your internal sensations. Check-in with yourself. What images or experiences from the past are creating or contributing to this present physiological experience? Do I have someone else’s “hat” on a person in the room? Does this situation remind me of a specific time (explicit memory) or a feeling that I can’t quite explain (implicit memory) that I had an unpleasant experience? Remind yourself that you don’t have to continue to be shaped by the past.

  • (c) Learn to take a deep breath(s) and be aware that something inside you says “danger.”

  • (d) Understand that this is happening inside you and not necessarily out there for others to be aware of, before you formulate your verbal commentary.

• 2. Emotional Balance. This state is controlled by the prefrontal cortex and enables you to use both your brakes and your accelerator. If you lack this internal emotional balance, you will either find yourself panicking or not reacting appropriately to the current circumstance. In order to communicate coherently with team members, you first need to find your emotional balance. You can’t allow the circumstance to knock you off your feet or bounce you off the walls.

  • (a) Practice reflection/relaxation. Take a deep breath(s).

  • (b) Moderate energy and ask yourself: Do I need more energy? Do I need to slow my energy down? Is my nervous system sending both messages simultaneously so that I need to practice self-soothing? Should I provide more energy? Can I sense the energy of my teammates?

  • (c) Check with team to gauge their energy levels.

  • (d) Step back from the surgical table (metaphorically), take a deep breath(s), and connect to your internal sensations. Check-in with team.

• 3. Attunement. As you are assessing your own response, you are aware that something is also happening with others. When we are attuned to ourselves, we experience nonjudgmental compassion for ourselves [66, 67] and others feel felt by us in much the same way. When you are attuned to others, you can resonate with them. This is an essential component for high-performing teams and is required for coherent communication.

  • (a) Practice compassion and genuine caring for yourself and others.

  • (b) Spend time and energy learning more about the other members on your team. The more you can learn about them, the easier it will be to attune to them and value (congruence) what might be happening for them.

• 4. Response Flexibility. This is a leadership trait that is developed by resonant leaders [22] who have learned to break away from patterned reactions and create responses that are flexible and adapt to the current situation. (We will describe this further in our fifth practice of highly resonant teams.) Response flexibility provides you with an openness to be able to consider a variety of options for communicating, including some you rarely use.

  • (a) When you encounter a problem, try to think of three more options. Then ask members of your team what they might do. See if they think of options that you hadn’t considered.

  • (b) Spend time learning about your typical response patterns. There are numerous tools for this kind of learning, including the Thomas-Kilmann Conflict Resolution Index (TKI), the Myers-Briggs Temperament Indicator (MBTI), and the Strength Deployment Index (SDI). Then consider how you would respond if you adopted other patterns.

  • (c) Practice COAL – curiosity, openness, acceptance with love (nonjudgment) [88].

• 5. Focused Energy. Integration requires attentiveness to the present moment. The present moment becomes your consciousness. Imagine having this dialog with yourself:

  •  “Where are you?”

  •    Here

  •  “What time is it?”

  •    Now

  •  “What matters?”

  •    The moment

  Your mind becomes clear and you have an experience of consciousness about consciousness. You have an awareness of the possibility to choose where to direct your focus. This experience was described beautifully by Captain Sullenberger as he prepared to try and land his powerless plane in the Hudson River [97]:

  • (a) Practice mindfulness, reflection, and relaxation.

  • (b) Stop and notice where you are focusing. Does the focus make it more or less intense? Can you observe yourself observing? Observe yourself and what you are choosing to think and feel. Have curiosity and experiment with focusing on a variety of experiences.

• 6. Self-Regulation and Self-Soothing. You find a way to control your impulses and to modulate your fear. You acknowledge your “fear” but you don’t allow yourself to be overcome by it. You know how to bring your heart rate and your fear back under control. This is taught by heart math [11, 12] and can be learned as a tool for stress management. You won’t be able to communicate with others if you can’t control and communicate with yourself:

  • (a) Practice reflection/relaxation.

  • (b) Take calming breaths. Notice the fear without trying to control it. Speak gently to yourself.

  • (c) If a colleague is fearful, angry, upset, don’t respond in kind. Take a deep breath(s) to suppress a reaction and to maintain your stability. From this position, you can communicate with a sense of compassion and empathy.

• 7. Insight. This is where you perform mental time travel to tap into your wisdom of the current situation and link past with present and future. This is termed self-knowing awareness. You have awareness of your choices. You have awareness of what you have learned and how the future can be influenced by the past.

  • (a) Internally articulate your understanding of the present experience to yourself as well as what you want to do with your understanding. Try it on with yourself and then share it with your team, not as a fact, but rather as a speculation. Ask for feedback from others. Do they share your insight? Allow influence.

• 8. Empathy. The cognitive ability to put yourself in the shoes of another and understand the world through their eyes. In order to do this, you need to learn how to practice “self-empathy.” What is the part of you that is reacting or feeling? Does it tap into a past experience (an explicit memory) or are you unable to pinpoint the experience? You only know that the event that is happening has created somehow in your forgotten past a response of anxiety (implicit memory – olfactory memory is an example of the power of implicit memory, when a certain smell can conjure up a very strong emotional association from our past; or perhaps when you hear a certain song, it arouse intense feelings in you related to a past event). Try to identify the part of you that is reacting and have empathy for that part of you – perhaps a part that you have outgrown, like your fear that you might be thought of as not capable, even though you have proven yourself capable many times over many years. It requires the cognitive capacity to move from the concrete to the abstract. Use your knowledge of your colleague to try and understand how they may be having an internal experience based on their memories and tune into what they might be experiencing. Using what you have learned about them, can you understand the experience from their perspective?

  • (a) Think of what you know about another team member. What are their hopes, beliefs, values, and goals? Has your team taken time to learn this about the team members? If you were in their shoes as if you were he or she, ask yourself, “What would I be experiencing?”

  • (b) When appropriate, check out your experience of another to discover if you are accurate. Revise your picture of them to include new information.

• 9. Morality. As you consider the current situation, you also tap into your moral code of what is important to you and you hold the intent to function with the greater good for the whole in mind. As you choose your response, you want to ensure that it is consistent with who you are and who you want to be, as well as being a choice that considers the impact on others:

  • (a) Get clear on your personal values and goals as well as the goals and values of others. Try to write down your values as words or sentences and then ask yourself, “how important is this value to me?” “Would I rather leave this job than sacrifice on this value?” Take your own welfare into account as well as the welfare of others.

  • (b) As a team, articulate and define your values, goals, and mission. Create a vision statement for your team, but in order to do this, you must first be clear on your own values.

• 10. Intuition. Your anterior cingulate cortex has spent years gathering information for you about experiences [60]: If this, then that. The dopamine receptors in your brain have been trained to teach you because they have been responding to patterns your entire life. You have wisdom collected from years of experience and your intuition is more than a random guess. Learn to be aware of what your intuition has learned:

  • (a) Check out hunches with others and tap into the collective wisdom of your team.

  • (b) Keep a record of times you had an intuition. What was the outcome? Were you right? How would you modify your intuition for the next time something similar happens?

As you master these foundation functions, you will develop the ability to attune (to yourself, to others, and to situations) and to communicate from a place of mindful integration. You will exhibit personal insight and the ability to have empathy for others. This is a dynamic, evolving, and expanding process that feeds off energy and information available within yourself and from the members of your team. Mindful integration (as defined by the steps listed above) is the first, and essential, practice for teams to function with the kind of attunement that leads to high performance. It is mandatory for leaders of teams to understand the complexity of integration and to model it for the team.