Chapter 4

Perspectives on Leadership

Learning Objectives

1.  Analyze various theories of leadership.

2.  Understand the relationship of personality and leadership styles.

3.  Analyze how leadership is affected by the context and situation in which it is exercised.

4.  Understand the relationship of emotional intelligence and leadership.

5.  Analyze competencies required for health professions leadership.

6.  Identify personal leadership characteristics.

Leadership emerges as a compilation of mysteries that have been investigated for centuries. Researchers have attempted to answer questions such as: Are leaders born? Can leaders be developed? Does the environment create the leader? Is leadership emergence synonymous with leader effectiveness? What role does social dynamics have in the leadership equation? Can leadership be shared (Avolio, 2007; Zaccaro, 2007)? How and why should members assume a leadership stance? The latter questions resonate when contemplating the development and sustainability of effective interdisciplinary healthcare teams. An examination of the broader phenomenon of leadership provides a context for that inquiry.

Perspectives on Leadership

Leadership connotes position as well as action. Positional leadership refers to responsibility given to an individual or group of individuals to guide, direct, or control. The act of leadership or ability to lead refers to the effective use of influence and a complex dynamic that has inspired much of the research on leadership. Leadership can be simply defined as the exercise of power and influence with others. Some theorists have posited that leaders are born while others focus on the role that social, cultural, political, and environmental factors have on the emergence of leaders.

Many perspectives regarding leadership offer intriguing views of the leadership concept, but no definitive conceptualization exists. A comprehensive review of these views is beyond the scope of this book. For the purposes of our discussion, we will focus on three broad theoretical approaches that are supported by modern-day research and are most applicable to healthcare leadership development. These include personality/trait, contingency/situational, and relational theories. We will provide a summary of each of these theoretical approaches, highlight the most relevant theoretical concepts, and provide opportunities for the practical application of these concepts.

Personality and Trait Theories

Early conceptualizations of leadership focused on the “great man” theory, which hypothesized that leaders were born with certain characteristics that predisposed them to take command and lead others (Carlyle, 1841). The Zeitgeist theory credited the convergence of social, political and individual factors with the emergence of a leader—the right person for the right time in history (Tolstoy, 1869). Subsequent trait theorists, informed by the big five theory of personality (discussed later in this chapter), described a constellation of traits that were indicative of a leadership personality.

MYERS-BRIGGS TYPE INDICATOR

One of the first and most widely used models to identify traits was developed by Katharine Cook Briggs and Isabel Briggs Myers based on the Carl Jung’s psychological type theory. Jung’s theory is based on a hypothesis that people are born with innate personality traits (Jung, 1991; Myers, McCaulley, Quenk & Hammer, 1998).

The Myers-Briggs type indicator (MBTI) is a self-report survey instrument that helps to determine personality and preferred behavioral style across the following four dichotomies: extroversion/introversion, sensing/intuition, thinking/feeling, and judging/perceiving. The MBTI is designed to determine preferences for finding energy, gathering information, making decisions, and orienting to the environment. While it does not identify talents, quantify intelligence, or predict leadership success, it facilitates self-awareness, which does correlate with leadership success (Goleman & Boyatzis, 2008).

MYERS-BRIGGS TYPE DICHOTOMIES

This diagram summarizes the four types of dichotomies and their related preferences based on Myers and Briggs’s conceptualization.

Data from: Myers, Isabel Briggs; McCaulley Mary H., Quenk, Naomi L., Hammer, Allen L. (1998). MBTI Manual (A guide to the development and use of the Myers Briggs type indicator). Consulting Psychologists Press; 3rd ed.

REFLECTION: MBTI Detailed Descriptions

Read the following descriptions to determine your personality and preferred behavioral style on each of the four MBTI dichotomies.

Modified and reproduced by special permission of the Publisher, CPP, Inc., Mountain View, CA 94043 from MBTI® Manual: A Guide to the Development and Use of the Myers-Briggs Type Indicator Instrument®, Third Edition by Isabel Briggs Myers, Mary H. McCaulley, Naomi L. Quenk, and Allen L. Hammer. Copyright 1998 by Peter B. Myers and Katharine D. Myers. All rights reserved. Further reproduction is prohibited without the Publisher’s written consent.

REFLECTION: MBTI 16 Types at a Glance

Read the following descriptions and match your MBTI findings to interpret your personality and preferred behavioral style on each of the four MBTI dichotomies.

The 16 MBTI Types

Modified and reproduced by special permission of the Publisher, CPP, Inc., Mountain View, CA 94043 from Introduction to Type, Sixth Edition by Isabel Briggs Myers. Copyright 1998 by Peter B. Myers and Katharine D. Myers. All rights reserved. Further reproduction is prohibited without the Publisher’s written consent.

BIG FIVE THEORY OF PERSONALITY

The big five theory of personality suggests that there are five universal personality traits: extroversion (positive attitude, sociable), agreeableness (accommodating, adaptable), conscientiousness (goal oriented), neuroticism (need for stability, pessimistic), and openness (imaginative, creative, open minded). Each of these traits is represented as a continuum that ranges between two extremes (e.g., extroversion and introversion) (McCrae & Costa, 1987). It is accepted that personality is a complex phenomenon with wide variation among individuals. However, according to this theory, the “ideal leader” is resilient (low on the neuroticism factor), energetic and outgoing (high on the extroversion factor), visionary (high on the openness factor), competitive (low on the agreeableness factor), and dedicated to a goal (high on the conscientiousness factor).

Contingency and Situational Theories and Leadership Styles

Contingency and situational theories postulate that effective leaders use a combination of behaviors or styles that are contingent upon the particular situation, the personalities involved, the task, and the organizational culture (Fiedler, 1967; Hersey, 1985). Contingency and situational theorists such as Fiedler (1978) and Hersey and Blanchard (1976, 1982) refrained from describing an ideal leadership style based solely on traits or personality and emphasized that successful leaders are able to understand their motivations and preferred style and are able to adapt their style to the situation and the needs of the group. Fiedler’s (1978) basic premise was that leadership was a function of the leader’s motivational style and the control requirements of the situation. According to the contingency theory, there are two primary motivations for leaders: relationship building and task completion. In addition, the control requirements of situations are dependent upon leader–member relations, task structure, and positional power. Leader–member relations pertain to the way followers feel about the leader. Tasks can be clearly structured or ambiguous and unstructured. Disinfecting equipment in the physical therapy clinic after a patient treatment session is an example of a highly structured task, while creating a process that will improve patient care in a particular unit from intake to exit would be considered an unstructured task.

Position power is related to the assigned power the leader has over the group. A leader has more positional power if everyone formally reports to that leader. The attending physician has strong positional power over a group of medical residents while a case manager has less positional power over the nurses and therapists who are part of a treatment team since each of the members report to different units in the organization.

Stress and anxiety increases when the leader’s style does not match a situation, and poor decision making is often the result. The most successful outcomes occur when the leader’s preferred style matches the situational requirements and they are able to expand their behavioral repertoire through formal training. Relationship-oriented leaders are able to incorporate task-oriented behaviors while task-oriented leaders demonstrate increased relationship-building behaviors (Fiedler, 1978; Northouse, 2010).

Hersey and Blanchard’s situational theory (1976, 1982) posits that the best leaders are able shift their focus over time from task to relationships based on the developmental needs of the group. Newly formed or immature groups that have yet to build commitment and expertise may do best with a directive, task-oriented leader, while moderately mature and mature groups are most successful when guided by a supportive, relationship-oriented leader. Ultimately, the level of engagement, participation, autonomy, and maturity that is achieved by the group depends, in part, on the degree to which decision-making authority is shared between the leader and the group members (Blanchard, Zigarmi & Zigarmi, 1985).

Blake and Mouton (1978, 1980, 1982) proposed that leadership style is informed by the degree to which the individual is concerned with task completion or relationship building. Their leadership grid provided a graphic representation of the variations in leadership styles ranging from (1,1) apathetic and not concerned with people or outcomes to (9,9) a leader who demonstrates his/her dual concern for relationship and goal attainment by fostering teamwork. Blake and Mouton identified the latter as the ideal leadership style.

REFLECTION

The following grid is based on the work of Blake and Mouton (1978, 1980, 1982) and depicts managerial style based on the level of caring about people (concern for people) and caring about getting the job done (concern for production).

1.  In the culture of your organization, which style is the most common?

2.  Is this style effective? Why or why not?

FIGURE 4-1 The leadership grid.

Reproduced from: Blake, R. Moulton, J. (1964). The Managerial Grid: The Key to Leadership Excellence. Houston, TX: Gulf Publishing Company.

Relational Theories

Later theories recognized leadership as a reciprocal interaction between leaders and followers with the hallmark of good leadership being transformation of the followers who are committed to the leader’s vision (Bass & Avolio, 1994). The application of neuropsychological and neurocognitive research to the field of leadership has supplemented the wealth of information from the sociopsychological fields. Most recently, leadership is conceptualized as a set of learnable attitudes, behaviors, and skills geared toward relationship building. The effect on others is an awakening of self-efficacy, confidence, and capability, which enables proactive, engaged collective action toward a common goal (Goleman et al, 2002).

Emotional Intelligence

Decades of neuropsychological research have established that emotions can dictate our thinking, motivate us, and mobilize us into action. It is generally accepted that thoughts can induce emotions, and emotions also generate thoughts. For instance, when an individual is upset about something (emotion), he or she may engage in self-talk or internal dialogue (thoughts), which may fuel a spiral of intense emotions and upsetting thoughts.

The thoughts and emotions that shape human behavior originate from separate centers of the brain and are interactive determinants of one another. The amygdala or the feeling mind is a primitive part of the brain that triggers a fight-or-flight response, which is tempered by the prefrontal cortex or thinking mind. When stress, drugs, or alcohol compromises the nervous system, the tempering function of the prefrontal cortex may fail to block the instructions from the amygdala, and behavior that is not rational or adaptive to the situation may result.

Effective leaders are not as susceptible to this “amygdala highjack” as other leaders are. They are tuned in to their emotional skills and are able to use them in an appropriate way and in the proper context (Goleman et al, 2002). Daniel Goleman found that outstanding leaders were judged by their superiors as performing significantly better on a constellation of personal skills and social skills that fell into the following four broad categories: self-awareness, self-management, social awareness, and relationship management. This constellation of behaviors has been termed emotional intelligence (see Table 4-1 ) and is a prerequisite for relationship building that is the bedrock of sustainable leadership practices (Goleman, 1995). Developing competency in relationship management is contingent upon competency in self-awareness, self-management, and social awareness and essential for success in life and/or workplace.

In most healthcare organizations, leaders and managers are often appointed based on expertise and years of experience. However, as supervisory responsibility increases, so does the need for people-handling skills. Research indicates that some leaders and managers who are appointed primarily because of technical skill may lack the necessary emotional and relational competencies that enable them to lead and/or manage effectively (Goleman et al., 2002). They also need personal and social skills, which are the bases for emotional intelligence and are essential for effective leadership. In a team environment, skills such as effective listening, adaptability, empathy, collaboration, and the ability to give and use feedback are requisite for not only the designated leader, but for all members of the team. When members of a team are emotionally intelligent, they can create a collaborative atmosphere that leverages the inherent skills and power of the whole group (Goleman et al, 2002).

TABLE 4-1 Emotional Intelligence Domains

Adapted from: Goleman, D., Boyatzis, R. and McKee, A. (2002). Primal Leadership: Realizing the Power of Emotional Intelligence. Boston, MA: Harvard Business School Press.

REFLECTION: Emotional Intelligence Checklist

Rate yourself on each of the components of the emotional intelligence checklist to determine your characteristics in each of the domains.

Data from: Goleman, D., Boyatzis, R. and McKee, A. (2002). Primal Leadership: Realizing the Power of Emotional Intelligence. Boston, MA: Harvard Business School Press.

Resonance

The perceived attitude and emotional status of the leader is instrumental in the creation of a positive or negative emotional climate (Nembhard & Edmondson, 2006; Pescosolido, 2000). When a leader is impatient, frustrated, or fearful of failure, the group members react with defensive and self-protective behaviors—often setting off a reciprocal volley of destructive emotions and creating a dissonant and unproductive climate that is focused on self-preservation rather than cocreation. Conversely, leaders who project enthusiasm, realistic optimism, and care for the group engender these same feelings within the group. The group members are engaged, in sync, or are resonant with the leader and each other and have more energy to engage in the work of the group and face challenges more creatively (Pescosolido, 2000).

According to Boyatzis & McKee (2005), resonant leaders are mindful, compassionate, and hopeful and are skilled in eliciting affiliative and affirmative emotions in others. They are mindful in that they are fully aware of themselves, others, and the environment and are committed to their values while being open to other perspectives. The manifestation of hopefulness is confidence in their own and the group’s ability to reify dreams. Compassion is reflected in their acceptance that they, in concert with their fellow humans, have strengths and vulnerabilities and are not omniscient. They face challenges and opportunities with equanimity and respect the contributions and value of the people they lead and those they serve.

FIGURE 4-2 The resonant leader.

Data from: Boyatzis, R. & McKee, A. (2005). Resonant Leadership. Boston, MA: Harvard Business School Press.

There seems to be agreement that the best leaders are self-aware, self-regulating, and attuned to the diverse perspectives, needs, and abilities of their followers and the requirements of the situation. Good leaders have high levels of social and emotional intelligence, an ability to develop and maintain reciprocal relationships, and a willingness to empower others, and they are able to employ a balance of task-related and relation-building behaviors. Put simply, good leaders can get the job done well while maintaining a supportive emotional atmosphere (Goleman, 1998; Kouzes & Posner, 2007; Maxwell, 2005; Whitney et al, 2010).

Chapter 3

Team Building Blocks: Norms, Goals, Roles, Communication, Leaders, and Members

Learning Objectives

1.  Analyze how personal values and other motivating forces influence group process and development.

2.  Differentiate personal and group needs.

3.  Analyze the relationship between role assumption, group needs, and goal attainment.

4.  Understand the relationship between communication and learning styles.

5.  Match communication style to the needs of the listener.

6.  Give and receive feedback.

Norms

Group norms are agreed-upon standards of behavior. Norms are the shared explicit or implicit rules that a group uses to identify standards of performance and distinguish appropriate from inappropriate behavior. When group norms are explicit or made explicit, they are commonly referred to as ground rules, agreements, group charters, conditions, or guidelines. However, not all norms are explicit, and the perceptions and concomitant behavior of individuals in groups is profoundly—and often unconsciously—affected by social influence (Sherif, 1936).

FIGURE 3-1

In many progressive organizations, errors are routinely considered teaching moments that can provide opportunities for open discussion, team-based problem solving and continuous organizational improvement. While similar normative responses to errors would elicit the same type of team and organization improvements in health care, the dire consequences of medical mistakes tend to discourage the very discussions that are necessary to prevent their occurrence (O’Daniel & Rosenstein, 2008). This tendency, in combination with differing professional identities, cultures, skills, domains of concern, differences in power, capacity, resources, goals, and accountability actually requires that more attention be paid to constructing organization-wide standards that encourage and reward interaction. In groups where intraprofessional and interprofessional conflict avoidance is the normative behavior, the ensuing misunderstandings and related mistrust tend to limit collaborative or cooperative behavior. Sustainable collaborative environments for interprofessional healthcare teams require a collectively constructed core of prescriptive (do’s) and proscriptive (don’ts) norms or ground rules that inform interaction at intrapersonal, interpersonal, and systems levels (Nash, 2008). Using normative structures that highlight the commonality of patient-centered care while acknowledging the existence of divergent organizational and personal priorities will help team members to understand that personal goals and wishes will often be subordinate to the goals of the group. The acceptance of professional differences and the proactive examination of errors help to create opportunities for increased communication, understanding, and trust and pave the way for collaborative endeavors between disciplines (Doucet, Larouche, & Melchin, 2001).

REFLECTION: Explicit and Implicit Norms in a Group

Identify the norms or rules of your work group.

Interview members of your group and ask them to identify the rules of your group.

How does your response differ from your coworkers? How is it the same?

How does the similarity/difference of perception affect the group’s functioning?

As team members come to expect and deliver full participation, and experience consistent adherence to norms associated with role assumption, communication, and authority, accountability is shared. Trust in each other’s expertise engenders a parity of participation and shared ownership of team outcomes (Ratcheva, 2009).

Goals

Group goals, like norms, are both explicit and implicit. Implicit goals address the developmental processes inherent to group maturation. Focusing on, defining, and committing to the explicit work-related goals of a group is a major key to success. Commonly held goals and the collective efficacy that the achievements of these goals engender are key contributors to group performance (Silver & Bufanio, 1996). Not surprisingly, the ease of goal attainment is related to the level of goal complexity.

In the current healthcare climate, team goals for professionals are complex and require problem solving using multiple types of data and a convergence of multiple areas of expertise and skill sets. To add to that complexity, interdisciplinary team members bring diverse professional values, individual personal goals, and goals influenced by multiple reporting relationships. It is essential that goals are not only clear but constantly revisited.

Groups that continually communicate and become more explicit with regard to the teams goals are more successful in performance. Regardless of the complexities of the team tasks and team membership, if group members are committed to the group goals, the team can succeed. If the commitment to the goals is low then there is little chance of success (Locke, Latham, & Erez, 1988).

Roles

The inherent diversity of teams makes team members’ interaction and relationships key factors in team effectiveness. Researchers have studied groups of people who have a variety of styles in order to ascertain whether a particular complement of individual member styles has any impact on group effectiveness, outcomes, and development. Lewin (1943) observed that behavior is a function of the person and the environment or B = ƒ (P, E). Role assumption in groups is a function of an individual’s preferred style or personality in the context of the complex system of group dynamics that comprises team behavior and effectiveness. Subsequent research examined functional roles in groups. These roles are not necessarily attached to any individual but affect the group’s developmental progress and productivity.

Wheelan (2005) identifies three primary roles that group members assume regardless of their personality types. Task roles are needed to facilitate a project from inception to completion. Socioemotional or maintenance roles contribute to positive atmosphere of the group and foster cohesion. Organizational roles like the leader, recorder or project manager keep the group organized. According to Benne & Sheats (1948), individual roles tend to disrupt group progress and weaken cohesion. Table 3-1 provides examples of each role.

TABLE 3-1 Benne & Sheats’s Group Member Roles

Data from: Benne, K. & Sheats, P. (1948). Functional roles of group members. Journal of Social Issues, 4(2), 41–49.

Belbin (2010) studied teamwork and observed that people in teams tend to assume various team roles, which alternate in their dominance depending upon the developmental stage of the group’s activities. The nine roles where categorized into the following three groups: Action oriented, people oriented, and thought oriented. The action-oriented group includes shaper (SH), implementer (IMP), and completer-finisher (CF) roles. The people-oriented group includes coordinator (CO), team worker (TW), and resource investigator (RI) roles. The thought-oriented group includes plant (PL), monitor-evaluator (ME), and specialist (SP) roles. Each team role is associated with typical behavioral and interpersonal strengths. Belbin also defined characteristic weaknesses that tend to accompany each team role. He called these the allowable weaknesses—areas to be aware of and potentially improve upon (see Table 3-2 ).

A group that is composed of members who assume only those roles related to job completion while ignoring the roles that engage and facilitate member participation runs the risk of diminished cohesion, unmanaged conflict, and apathy. All of these negatively affect the sustainability of good performance and successful outcomes. However, groups that are stymied in a quagmire of conflicting emotions or that are burdened with members who are myopically focused on their personal agenda will never get any work done. These scenarios can negatively impact healthcare teams who routinely deal with issues related to complex medical decision-making and the resultant interventions that will impact a patient’s lifestyle and quality of life. Throughout the life of every group of health professionals, leaders and members must be alert enough to recognize what roles need to be assumed and be flexible enough to assume the roles that will sustain optimum group functioning and consistently positive patient outcomes.

TABLE 3-2 Belbin’s Team Roles

Reproduced with permission from: of Belbin Associates, www.belbin.com.

The attempt to carry out functional group roles, as described, is further complicated by the many other personal and professional roles that are held by members of healthcare teams. While a primary challenge for all team members is to separate personal needs and roles from the team needs and roles, healthcare professionals must also juggle team and discipline-related roles that often conflict at the intraprofessional and interprofessional levels. Perceived roles and responsibilities may diverge based on variations in professional socialization, experience, and organizational expectations. Some professionals—often from the same discipline—may see themselves as primarily responsible for the physiology of care while others believe they need to incorporate the contextual aspects of the illness experience in their treatment planning (Doucet et al., 2001). When faced with budget restrictions in a rehabilitation department, does the physical therapist on the team focus her energy on advocating for the physical therapy equipment budget or facilitating a group discussion regarding prioritizing the needs of the department? The answer depends on how group, member, and contextual issues are negotiated. Each member of the healthcare team is faced with similar decisions about role choices. These choices will affect the culture, development, and performance of the team and ultimately determine the nature of patient outcomes (Freshman, Rubino, & Chassiakos, 2010).

Communication Patterns

In spite of the role differentiation that exists among the disciplines, holistic approaches to health care can engender role overlap, ambiguity, and boundary management challenges (Gray, 2008; Klein, 2010; Nash, 2008). Teams that leverage common ground as well as disciplinary differences through well-constructed and maintained communication strategies are likely to demonstrate sustained high performance and achieve positive patient outcomes (Drinka & Clark, 2000; Gittel, 2009).

The first step in productive communication is to get the attention of the person with whom one is trying to communicate. Team members who understand that communication styles often reflect learning styles and professional orientation will be most successful if they take the time to adjust their communication style to complement the styles of the people with whom they are communicating. People who are action oriented are interested and tend to talk about objectives, results, performance, and productivity. Strategies, organization, and facts tend to pique the attention of those who are process oriented. People who are idea oriented are interested in concept development and innovation, while those with a people orientation focus their communication on values, beliefs, and relationship building (Youker, 1996).

While the previous examples give an indication of how communication is carried out and received, the following model provides some insight into what is communicated. Conscious attention to how and what is communicated allows for more mindful, strategic, and effective communication in teams.

CASE STUDY: Communication Style Match

Members of the interprofessional team on a geriatric unit (physician, nurse, physical therapist, occupational therapist, and social worker) are meeting to discuss patient safety on the unit. During the previous quarter, falls increased by 10%. Analysis of the incident reports indicates that an examination of the fall prevention program that is offered jointly by nursing, physical therapy, and occupational therapy is indicated. The team is meeting with the goal of designing a revised fall prevention program for the unit. The proposed program will need to be based in the most current evidence, ensure the safety of the patients, and be cost effective. All four styles of communication noted previously in this chapter—action oriented (physician and physical therapist), process oriented (occupational therapist), people oriented (social worker), and idea oriented (nurse)—are represented. The leader (in this case, it is the physical therapist) is an identified action-oriented communicator. In preparation for the first meeting, she reviews strategies for adjusting her communication style to the team members and prepares her opening remarks. Her remarks might vary depending on how she perceives the other members of the group. She lists pointers for addressing the others based on their communication styles, along with alternate statements for each type.

COMMUNICATING WITH AN ACTION-ORIENTED PERSON:

  Focus on the results first.

  State your best recommendation.

  Emphasize the practicality of your idea.

At the first meeting, if the other members are action oriented, the physical therapist might say, “The purpose of this group is to address the increased number of falls on the unit this last quarter. We need to revise the fall prevention program that is currently offered. I recommend that we construct a program around the three components that have been identified in the literature. Developing a fall prevention program that includes exercise, fall prevention, and environmental components is the most effective focus.”

COMMUNICATING WITH A PROCESS-ORIENTED PERSON:

  State the facts.

  Present your thoughts in a logical manner.

  Include options with pros and cons.

  Do not rush the person.

If the other members are process oriented, the physical therapist might say, “The purpose of this group is to address the increased number of falls on the unit this last quarter. We need to revise the fall prevention program that is currently offered. One option that we may choose to pursue is to do a literature review on the efficacy of fall prevention and develop a custom program for our unit. We may also explore the option of purchasing existing modules. What are your thoughts?”

COMMUNICATING WITH A PEOPLE-ORIENTED PERSON:

  Allow for small talk at the beginning of a session.

  Stress the relationship between the proposal and the people concerned.

  Show how the idea worked well in the past.

  Show respect for people.

The physical therapist might say to such a group, “The purpose of this group is to address the increased number of falls on the unit this last quarter. Each of you has been chosen for this team because of your demonstrated commitment to patient safety. You are the experts in the day-to-day care of our patients. One area that we may need to consider is a revision of the fall prevention program that we currently offer. Institutions that are similar to ours have reported great success in reducing patient falls using a combination of exercise, addressing fear of falling, and modifying the environment.”

COMMUNICATING WITH AN IDEA-ORIENTED PERSON:

  Allow enough time for discussion.

  Do not get impatient when they go off on tangents.

  Be broad and conceptual in your opening.

The physical therapist could address this type of group by saying, “As key staff members on this geriatric unit, you have demonstrated your commitment to patient safety. I have asked each of you to be a member of this team because we have yet another safety concern. The purpose of this group is to address the increased number of falls on the unit this last quarter. We need to revise the fall prevention program that is currently offered. Yes, the plan for tornado drills has been effective. Is there anything that we learned during the development and implementation of the tornado drill policy that we can bring to the creation of a fall prevention program?”

By acknowledging the presence of a variety of communication styles and adjusting her approach, this leader has demonstrated respect for team members and hopefully avoided potential problems in team communication at the beginning of this important project.

The Johari window (Luft & Ingham, 1950) is a classic model for identifying and improving an individual’s relationship with a group and/or a group’s relationships with other groups. While the discussion that follows addresses the model from an individual perspective, the concepts are applicable to groups as individual entities within organizations, where others refers to other groups.

The model is represented as a square that is divided into four window panes or perspectives as shown in Figure 3-2 and is arranged as follows:

FIGURE 3-2 The Johari window.

Adapted from: Luft, J., Ingham, H. (1950). The Johari window, a graphic model of interpersonal awareness. Proceedings of the western training laboratory in group development (Los Angeles: UCLA).

Quadrant 1: Open/free area—what is known by the individual person and also known by others.

Quadrant 2: Blind area—what is known by others but unknown to the individual.

Quadrant 3: Hidden area—what is known by the individual and consciously hidden from others.

Quadrant 4: Unknown area—what is unknown to both the individual and others.

The panes/areas expand and contract to reflect the proportion of individual or group knowledge about an area. In newly formed groups, for instance, the open area is small since newly assembled groups of people know relatively little about one another. As groups mature, the open area increases as more information is shared and more cooperation and collaboration ensue. If open areas remain diminished, the group may be vulnerable to misunderstanding, mistrust, and confusion and delay progress toward maturity. The ultimate goal for team members is to increase the size of the open area and decrease the size of the other areas through positive communication (see Figure 3-2). The blind area is also known as the “bad breath area” because an individual is unaware of something that is known by everyone else. In the case of an individual, this could be a habit such as constantly glancing at a cell phone during a meeting—unaware that the other members of the group perceive this as disrespectful. Asking for and providing constructive feedback reduce this area.

While it is appropriate to use discretion when disclosing personal or private information, feelings and information related to work proves only be helpful if they are allowed into the open area. The process of disclosure—exposing relevant information and feelings—reduces the hidden area and further expands the open area. So a group member might disclose that he/she feels disrespected when someone is checking a cell phone during a meeting or conversation. The unknown area contains information such as unconscious needs, motivations, or inherent abilities that are unrecognized by the individual or the group. By examining the unknown area, individuals begin to understand that perceptions of present situations may be rooted in our past and the insecurity or anger that may have been experienced during a difficult childhood may be a hot button that is easily triggered by a difficult interaction in the present.

With the realization that our perceptions of present situations are formed through the lens of our own life experiences, we begin to seek information from others in order to construct a more complete picture. The ability to separate our perceptions from actuality allows us to become emotionally independent, no longer bound by automatic negative responses to triggers or hot buttons and better able to make strategic choices regarding our actions and reactions.

If the unknown area is not reduced, the group runs the risk of not being able to leverage all of an individual’s talents. In addition, the individual runs the risk of not realizing his/her true potential—bound by old ways of knowing and reacting and reducing the chances of self-actualization and motivation to become engaged in the group’s work. This type of awareness can be sparked through self-discovery, observations by others, and methods of inquiry that encourage mutual discovery. Leaders and members who use positive communication to facilitate self-discovery, solicit and provide constructive feedback, and foster the free flow of information create a psychologically safe environment that engenders creativity, productivity, and sustained high performance.

FIGURE 3-3 Detail of the steps involved in a working Johari window.

Data from: Luft, J., Ingham, H. (1950). The Johari window, a graphic model of interpersonal awareness. Proceedings of the western training laboratory in group development (Los Angeles: UCLA).

Leavitt (1951) described graphic configurations of the most common communication networks in small groups such as the wheel and circle. An important aspect of communication networks is how information is processed and distributed. Simple tasks that require the processing of limited amounts of information are most efficiently carried out in centralized networks like the wheel where one person serves as the hub for information exchange, while more complex tasks, which require the processing of large amounts of complex information, are most efficiently handled by decentralized networks of communication such as the circle, where there is a free flowing information exchange among all participants.

COMMUNICATION NETWORKS

Simple tasks, like stocking supply closets in the therapy gyms, requires the processing of limited amounts of information and can be most efficiently carried out in a centralized network like the wheel. A supervisor (hub of the wheel) might send out a directive to the therapy aides. More complex tasks, like developing a comprehensive patient discharge plan, requires the processing of large amounts of complex information and might be most efficiently handled by decentralized networks of communication between the physician, nurse, therapists, and social worker.

FIGURE 3-4A

FIGURE 3-4B

Systematic observation of communication and attraction patterns provides insight into morale and levels of satisfaction flow of information, power and influence, cohesiveness, and effectiveness within teams. Communication patterns tend to parallel role, status, and attraction patterns with higher interaction rates being associated with higher status individuals. Lower status individuals are less likely to express their thoughts and feelings in groups with people of higher status. According to the Institutes of Medicine (2003), hierarchical communication patterns are partially responsible for many medical errors. Additional challenges to communication may exist along gender and generational lines (Spector, 2010). However, in teams that continually employ collaborative processes characterized by directness, mutual understanding, and parity of participation, a climate of psychological safety is created along with an effective and efficient exchange of information among all members of the team (Meads & Ashcroft, 2005; Nembhard & Edmondson, 2006.

Healthcare organizations are composed of a diverse network of health professionals, patients, and caregivers who must leverage each other’s expertise by coordinating the exchange and flow of highly complex data. High-quality feedback among interdependent team members yields high levels of cohesion, satisfaction, and performance in teams (Garman, 2010; Gittell, 2009; Goleman, Boyatzis & McKee, 2002). To this end, conscious effort must be applied to developing information exchange strategies that distribute leadership and facilitate accountability and engagement of every member of the team (Gray, 2008; Hammick, Freeth, Copperman, & Goodsman, 2009). Attention to the analysis of social networks and information exchange is crucial to understanding the interpersonal aspects of collaboration around a task, goal, or function (Gray, 2008). Social and interpersonal processes, including team members’ collaborative styles, communication networks, and conflict management and negotiation strategies that emphasize excellence and convey clear goals and expectations are hallmarks of high-functioning teams (Stokols, Hall, Tylor, & Moser, 2008).

The fast-paced healthcare environment places time at a premium. Managers and practitioners find it difficult to justify taking time away from direct patient care in order to attend meetings. However, recent healthcare reforms have linked reimbursement to patient outcomes such as length of stay, readmission rates, and patient satisfaction rather than the number of procedures and services provided. High-functioning healthcare teams have been associated with positive patient outcomes and high retention rates for health professionals. While one could argue that the time spent in meetings is not reimbursable, it would be hard to deny that the improvements in team communication and performance positively affect team sustainability and patient outcomes. Institutions that invest in the development of relationships through formal structures that support frequent and consistent time allocation for team interaction—face-to-face and electronic—will find that gains in patient outcomes will mirror gains in social capital (Drinka & Clark, 2000; Ghaye, 2005; Gittell, 2009; IOM, 2003; Lawrence, 2002; Ratcheva, 2009).

CASE STORY: Check Your Ego at the Door

Any complicated problem lends itself to an interprofessional approach. When we have to do any project we have groups where there are 12 people in different areas on the team (eg: graphics, engineering, administration, nursing) and they talk about the project. Then we break the team into smaller groups of 3 and they all have to come back with their proposed designs and talk about the process of coming to that conclusion. The group, as a whole, reviews all the alternative proposals and pulls them together for their final decision. No one person has the final say—it is not hierarchical. This fosters the idea that everyone has something to contribute. Everyone understands that you have to check your ego at the door. It is not about you. The final decision reflects the goals of the program, not individual goals.

This approach is neither intuitive or the individualistic “American way.” There should be some kind of training so that people learn how to separate their work performance from their own personal needs and work as a team.

—Karen J. Nichols, Chief Medical Officer, University of Pennsylvania LIFE (Living Independently for Elders) Program

REFLECTION: Recognizing and Respecting Diversity

How do you demonstrate respect of diversity in the healthcare team?

How might you use conflict as a path to creative problem solving in the healthcare team?

How do you find shared ground?

How do you influence others on your team?

How do they influence you?

Collaborative, participative environments engender increased knowledge and respect of the health team members for each other. Increased awareness of the expertise available to the team will facilitate the team’s ability to distribute leadership based on the nature of the challenge, or problem and disciplinary boundaries can become points of connection and innovation rather than points of contention (Drinka & Clark, 2000; Gray, 2008; Meads & Ashcroft, 2005; Wheatley, 2006). Leaders, who are willing to trust in the diverse wisdom and singular intent of the collective, actively encourage, and seek participation from all members of the team. Consequently, communication disparities are mitigated and psychologically safe team environments are created. All members are encouraged to contribute, exercise leadership, and be personally engaged and accountable for the team outcomes. (Nembhard & Edmondson, 2006; Wheatley, 2006).

Chapter 2

Group Development

Learning Objectives

Each of the columns in Table 2-1 represents a level of system in the group life—the group as a unit, the individual members within the group, and the context or the environment within which the group exists. Under each component are aspects that contribute to the social–psychological landscape of every group at any point in time. The study of group dynamics attempts to analyze and interpret group life by examining these aspects in a systematic fashion.

TABLE 2-1

What You See Is Not What You Get: The Unconscious Life of a Group

Wilfred Bion, a psychoanalyst, was one of the first researchers to identify patterns in groups. Bion maintained that groups have a conscious and an unconscious life. He named the conscious group the work group and the unconscious group the basic assumption group. The conscious work group focuses on rationally accomplishing overt tasks and activities. The basic assumption group describes the unconscious aspects of a group. Leaders and members often mistakenly perceive these unconscious aspects as interfering with the real work of the group. In fact, this is the way that the collective membership and leadership of the group deal with the anxiety and polarities of individual identity and collective identity. Bion specifically identified the following three basic assumptions: dependency, fight-flight, and pairing (see Table 2-2 ). Leaders and members who learn to identify these group processes as a natural part of a group’s development are better prepared to be positive catalysts in the group. Rather than being caught up in the anxiety of the group, this knowledge can allow a person to be more objective, emotionally independent, and prepared to act in a constructive manner (Bennis & Shepherd, 1956, p. 417–418).

Stages of Group Development

While there are multiple factors that influence group functioning, each group—like each human being—should be considered a unique organism that passes through predictable phases of development. Characteristic member, leader, and group behaviors, as they relate to the acquisition of roles, the assumption of and response to authority, norm development, and communication patterns—like human developmental milestones—serve as indicators of developmental changes in the group over time. Awareness of the interacting determinants of group behavior and the unconscious assumptions of the group will facilitate an understanding of group behavior and facilitate effective group leadership and participation.

Groups display behavioral patterns that are common to all groups and are not dependent on the individuals in the group. A number of theorists have used various terms to describe the key issues that groups address over their life span. While these issues are ever present, some issues gain primacy depending upon the developmental level of the group. In summary, the group, as a whole, struggles to find the right balance between the unconscious desire to have a group identity and retain individual identities. Over time, a group is also challenged with dealing with the paradox of being safely protected by an omnipotent leader and taking control of its own destiny. A mature group learns to deal effectively with these issues. Its members work cooperatively as separate and discrete members who willingly choose to belong to the group because they identify with interests of the group. This group tests its conclusions, seeks knowledge, learns from its experience, and is in agreement with regard to the group’s purpose and tasks (Bales, 1950; Bion, 1974; Rioch, 1983; Schutz, 1958; Tuckman, 1965; Wheelan, 2005; Yalom, 1995).

TABLE 2-2 Wilfred Bion Summary

Data from: Bion, W (1974) Experiences in Groups: And other papers. Paolo Alto, CA: Science and Behavior Books, Inc.

Tuckman (1965) conducted an extensive review of the group development literature and concluded that therapy groups, work groups, and human relations training groups (t-groups)1 had strong developmental similarities despite differences in group composition, task, goal, and the duration of group life. He noted a few critical common themes about groups:

1.  There is a distinction between groups as a social entity and a task entity.

2.  In all groups, the task and the social emotional functions occur simultaneously.

3.  All groups go through four stages of group development. The task and social emotional functions are different for each stage.

4.  The group moves from one stage to the next by successfully accomplishing the task and social emotional/group structure function at each stage.

Tuckman named these stages of group development forming, storming, norming, and performing ( Table 2-3 ). He later added a fifth stage called adjourning, which describes the characteristics of groups as they terminate.

TABLE 2-3 Tuckman’s Description of the Stages of Group Development Based on Literature Review of Therapy and T-Groups

Data from: Tuckman, B. (1965). “Developmental Sequence in Small Groups.” Psychological Bulletin, 63(6), 384–394.

An Integrated Model of Group Development

Susan Wheelan (2005) used empirical research to build on Tuck-man’s model. She proposed and validated an integrated model of group development using the Group Development Questionnaire (GDQ) (Wheelan, 1990; Wheelan & Hochberger, 1996). Using observational and survey data, this integrated model is consistent with previous models in that it describes group stages developing naturally and in a chronological fashion over time. In addition, Wheelan and her team of researchers found that:

  There are specific characteristics that emerge in each stage of a group’s development. Early stages of group development are associated with specific issues and patterns of speech such as those related to dependency, counter dependency, and trust, which precede the actual work conducted during the more mature stages of a group’s life.

  Groups navigate through the stages by accomplishing process-oriented goals like achieving a certain degree of member safety, expressing and tolerating different opinions, and devising agreed-upon methods of decision making.

  There is a normative time frame that most groups need in order to traverse each stage.

  Organizational culture influences group norms and can influence group development.

  Member and leader behaviors are equally important in the development of a group and the dynamic between them must be addressed as the group develops.

Identifying the Stages of Group Development: Characteristics and Goals

While stages of group development are identified by the issues that predominate, there is always a percentage of group energy that is expended on dependency, conflict, trust and work regardless of the stage. For example, work gets done at every stage of development. In earlier stages, most of the work is done under the leader’s direction. In succeeding stages members take increasingly more responsibility. By Stages 3 and 4, responsibility for work is evenly distributed among the members and the leader is used as a resource. The key challenge for group members and leaders is finding the balance between task and social-emotional issues and managing the conflict that these issues engender over the life span of the group. Wheelan and Williams (2003) found that the communication content of groups over their life span mirror key developmental issues. In other words, the amount of time spent talking about task related concerns increases over the life of the group while the amount of time talking about social-emotional concerns decreases as the group matures. Figures 2-3A, B, and C provide an example of how the proportion of attention on key issues might shift based on the developmental level of the group. As with people, no one size fits all and each group ultimately demonstrates unique developmental patterns.

FIGURE 2-2 Key developmental issues of group life.

Data from: Wheelan, S. (2005). Group Processes: A developmental perspective. Boston: Allyn and Bacon.

Stage I (Dependency/Inclusion) is characterized by significant member dependency on the designated leader, concerns about safety, and inclusion issues. In this stage, members rely on the leader and powerful group members to provide direction. This is manifested by the percentage of statements that address dependency and pairing (when two people couple or pair by giving mutual compliments to each other) (8% and 16%, respectively). Statements regarding conflict are few (about 6%). About 17% of the time, team members engage in safe, non controversial discussions filled with flight statements by exchanging stories about outside activities or other topics that are not relevant to group goals while approximately 50% of the time is spent on work related issues. The goals at Stage I are to: create a sense of belonging and the beginnings of predictable patterns of interaction, develop member loyalty to the group, and create an environment in which members feel safe enough to contribute ideas and suggestions.

FIGURE 2-3A

Data from: Wheelan, S. (2005). Group Processes: A developmental perspective. Boston: Allyn and Bacon.

Stage II (Counterdependency/Fight) is characterized by member disagreement about group goals and procedures and conflict is an inevitable. Flight statements decrease to about 7% and work statements remain at 49%. Dependency statements fall to 2% and those regarding conflict rise to 28%. Expressing disagreements and working them out is a necessary part of this process and allows members to communicate and begin to establish a trusting climate in which members feel free to disagree with each other and collaborate. The goals for Stage 2 are to: develop a unified set of goals, values, and operational procedures, and to strike a balance between respect for the individual contributions and mediating individual needs with the group needs.

FIGURE 2-3B

Data from: Wheelan, S. (2005). Group Processes: A developmental perspective. Boston: Allyn and Bacon.

FIGURE 2-3C

Data from: Wheelan, S. (2005). Group Processes: A developmental perspective. Boston: Allyn and Bacon.

Stage III (Trust/Structure) is characterized by more mature negotiations about roles, organization, and procedures. The primary goal for Stage III is to solidify positive relationships that benefit the productivity of the group.

Stage IV (Work/Productivity) is characterized by a time of intense team productivity and effectiveness. Having resolved many of the issues of the previous stages, the group can focus most of its energy on goal achievement and task accomplishment. Roughly 62% of statements are related to work and 20% of the time is spent on sorting out differences of opinion on how the work should get done. At this point the group is resilient enough to remain cohesive while encouraging task-related conflicts.

TABLE 2-4 Wheelan: An Integrated Model of Group Development

Data from: Wheelan, S. (2005). Group Processes: A developmental perspective. Boston: Allyn and Bacon.

REFLECTION: Identify the Stage of a Group

Which stage does the behavior indicate?

  Members are listening and seeking to understand one another.

  Members attempt to figure out their roles and functions.

  Divisive feelings and subgroups within the group increase.

  Group members follow a self-appointed or designated leader’s suggestions without enthusiasm.

  Disagreements become more civilized and less angry and emotional.

  Members argue with one another, even when they agree on the basic issues.

Termination: When groups face their own ending point, some may address separation issues and members’ appreciation of each other and the group experience. In other groups the impending end may cause disruption and conflict.

How Does the Stage of the Group Impact Team Productivity?

Wheelan (2005) found that aspects such as group size and group age affect development and productivity. It usually takes at least six months for a group to achieve the Stage IV developmental level. Newly formed groups are characterized by a higher percentage of dependency counterdependency/flight statements (“I don’t know what to do.” “The leader is incompetent.” “Did you see the game last night?”), while more established groups make more work statements (“Let’s focus on the task at hand.”). These findings are corroborated by Nembhard & Edmondson (2006), who found that long-standing membership in healthcare teams was correlated with the willingness of all members, irrespective of status, to share information and provide innovative solutions—behaviors that are indicative of more mature groups.

In a study involving 17 intensive care units, Wheelan, Davidson, and Tilin (2003) found a link between perceived group maturity and patients’ outcomes in intensive care units. Staff members of units with mortality rates that were lower than predicted perceived their teams as functioning at higher stages of group development. They perceived their team members as less dependent and more trusting than did staff members of units with mortality rates that were higher than predicted. Staff members of high-performing units also perceived their teams as more structured and organized than did staff members of lower performing units.

Group Size: Less Is More

It is not uncommon to hear members of groups complain that some members of the group are doing more work than others. This perceptual phenomenon can happen in any sized group but studies show that the larger the group, the less energy any individual exerts. In the late nineteenth century, Maximillian Ringelman performed one of the first experiments with group size by having groups of people pulling on a rope. He discovered that the more people pulled on a rope, the less each individual contributed. Ringelman called this phenomenon “social loafing.” In addition, larger groups tend to have a more difficult time coalescing around a single identity and distributing work in an equitable fashion. Studies indicate that cohesion and intimacy decrease as team size increases (Bogart & Lundgren, 1974; Fisher, 1953; Seashore, 1954). Members of larger groups perceive their groups to be more competitive, less cohesive, more argumentative and less satisfying (Steiner, 1972). Wheelan (2009) found that small groups tended to be more productive than large groups and small groups reached mature levels of group development more rapidly than large groups.

FIGURE 2-4 Correlation of group size and productivity. According to Wheelan, groups of three to eight were more productive and more mature at six months than groups with nine or more members.

Data from: Wheelan, S.A. (2009). Group size, group development, and productivity. Small Group Research, 40(2), 247–262

The literature seems to indicate that groups are most productive when they are composed of five to eight members. Theoretically, this is because the larger the group, the longer and more difficult it is for the group to develop a common identity.

CASE STORY: How Many People are Needed to Make this Decision?

Our team needs to make decisions regarding who should be enrolled in the program. There are applications that could potentially be denied for various reasons. When I first got here, there were 40 people in the morning meeting where these decisions were made. Everyone read the report at that meeting and, after the coffee kicked in, people were talking amongst themselves, others were listening, and others were on cell phones. People were just getting confused and the decision process was taking around two hours. I worked with the marketing people and changed this system. We now have a separate smaller group of 8 people in a meeting that includes social work, nursing, a physician, transportation and four marketing people who give input but don’t get a vote. We invite additional guests from other departments such as behavioral medicine as needed.

At first, there was a lot of stress associated with the transition because change is stressful. But after six months the length of time from intake to decision was cut dramatically. The morning meeting can be done in 15 minutes!

—Karen J. Nichols, MD, Chief Medical Officer, University of Pennsylvania Life Program

How Long Does It Take for a Group to Develop Through Each Stage?

The most common question team leaders ask us is, “How can I get my team to develop faster?” If teams could develop faster, work productivity would go up, problems would be solved faster, and disagreements would easily be resolved. Research supports that it takes time for groups to mature (Wheelan, Davidson & Tilin, 2003). Under the right circumstances, groups can reach full maturity in six to eight months. Attempting to rush the process would be like expecting a 5-year-old child to behave like a 25-year-old adult. It would not yield good results and would only serve to frustrate everyone involved.

Figure 2-5 is meant to be a guide to the average amount of time researchers have ascribed to the stages of development based on the integrated model of group development. Every group is a bit different, and some may actually get stuck at a certain level of development and take longer to move on to the next stage. Issues such as culture, diversity, group management, organizational dynamics, and complexity of tasks, as well as group commitment and identity impact group dynamics and the way groups develop.

FIGURE 2-5 Time it takes for groups to mature.

Adapted from: Wheelan, S. Davidson, B., & Tilin, F. (2003). Group Development Across Time: Reality or Illusion? Small Group Research, 34(2), 223–245.

Chapter 1. Introduction: The Study of Politics

Learning Objectives

· 1Discuss the value of studying politics.

· 2Identify the three basic elements of politics, as well as the dynamics of each.

· 3Analyze the methods, models, and approaches for studying politics.

· 4Evaluate whether politics brings out the best or the worst in human nature—or both.

Politics is not for the faint-hearted. There is virtually never a day without a crisis at home or abroad. Whenever we catch the news on our radio, TV, or computer, we are reminded that we live in a dangerous world.

In 2008, the spectacle of the world’s only superpower paralyzed by extreme partisanship and teetering on the brink of a “fiscal cliff” loomed like a gathering storm. No sooner had that danger receded than a new threat arose in the Middle East in the form of the so-called Islamic State of Iraq and Syria (ISIS). There were even rumors of a coming end-of-the-world apocalypse—December 21, 2012, to be exact, the final day of the old Mayan calendar.

The politically charged atmosphere and the pervasive sense of an impending crisis was nothing new, but two events dominated the news in 2008. First, a financial meltdown and plummeting stock market wiped out fortunes and rocked the global economy to its very foundations. Second, Barack Obama became the first African American elected to the nation’s highest office.

Political culture plays a big role in shaping public policy, and optimism is part of America’s political DNA. Despite a deepening recession, there was a new sense of hope—perhaps it was the beginning of the end of two costly wars and the dawn of a new era in America. But by 2012 hope had given way to anger and disappointment.

What happened? In 2009, President Obama had moved to revive the U.S. economy, which had fallen into the deepest recession since the Great Depression of the 1930s. But the economic stimulus package he pushed through Congress, where the Democrats enjoyed a solid majority in both the House and Senate, was widely viewed as a Wall Street “bailout”—a massive multibillion dollar gift to the very financial institutions that had caused the problem. It was also criticized as a “jobless recovery”; unemployment rose to nearly 10% and youth unemployment (16- to 19-year-olds) rose about 25% in 2010. Nearly half of young people aged 16 to 24 did not have jobs, the highest number since World War II.

The conservative media (most notably FOX News) and the amorphous Tea Party movement eagerly exploited growing public discontent, handing the Democrats a crushing defeat in the 2010 midterm elections. Republicans regained control of the House and cut deeply into the Democrats’ majority in the Senate (see especially Chapters 11 and 13).

Obama also spearheaded a controversial health care reform that satisfied few, confused everyone, and angered many voters on both sides of the acrimonious debate. His decision to order a “surge” in Afghanistan, committing 30,000 more U.S. troops to an unpopular and unwinnable war, did not placate Congress or greatly improve his standing in the opinion polls, nor did his decision to withdraw the last U.S. combat troops from Iraq in December 2011.

Despite a constant chorus of criticism and a vicious media campaign of attack ads from the right, Obama was elected to a second term in 2012. He defeated Republican Mitt Romney by a margin of 5 million votes (51% to 47% of the popular vote) while taking 61% of the electoral votes. The embattled president’s troubles in dealing with a recalcitrant Republican majority in Congress