Developmental Stages in Public Health Partnerships: A Practical Perspective

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Developmental Stages in Public Health Partnerships: A Practical Perspective Laura E. McMorris, PhD Nell H. Gottlieb, PhD Gail G. Sneden, MA Health education practitioners often form and provide support to partnerships directed toward public health goals. The authors viewed the start-up of a state health department/multiuniversity partnership for the evaluation of the state’s tobacco settlement pilot project using the lens of the Tuckman four-stage model of group development. The four stages—forming, storming, norming, and performing—occurred in sequence but with pronounced overlap. Two types of performing— institutional and group performing—were observed. An awareness of group developmental stages can allow leaders and members to improve the ways their partnership works together. Applying Tuckman’s model also can allow expectations about the group’s progress and members’ interactions to be managed so that tasks are aligned with the appropriate stage of development. Finally, for partnerships that have a long life span, understanding that the stages may occur several times throughout the group’s existence can acclimate members to shifting responsibilities and relationships over time. Keywords: health education practice; small group development; partnership

> INTRODUCTION

A better understanding of how collaborative groups function can assist health educators in providing support for, and encouraging participation in, the teams, task forces, and coalitions that are an integral part of today’s work environment. Such partnerships are complex entities that previously have garnered research interest in elements that explain how groups develop and change over time (cf. Butterfoss, Goodman, & Wandersman, 1993; Florin, Mitchell, & Stevenson, 1993; Kreuter, Lezin, & Young, 2000; Mizrahi & Health Promotion Practice April 2005 Vol. 6, No. 2, 219-226 DOI: 10.1177/1524839903260647 ©2005 Society for Public Health Education

Rosenthal, 2001). One of the originators of the discussion about developmental stages in small groups was Tuckman (1965), whose model includes the stages of forming, storming, norming, and performing. The issues that encompass the four stages were delineated by group structure (interpersonal relationships and behaviors) and task activity. Over the years, researchers and practitioners have noted the relevance, influence, and endurance of Tuckman’s (1965) widely referenced work (Elwyn, Greenhalgh, & Macfarlane, 2001; HendersonLoney, 1996; Johnson & Johnson, 2000; McGrew, Bilotta, & Deeney, 1999; Worchel, 1994). The model is not without its detractors, however (e.g., Beck & Yeager, 1996; Worchel, Coutant-Sassic, & Grossman, 1992). One of the main criticisms is that the model is seen as “idealized” due to the seemingly straightforward movement from Stage 1 to 2 to 3 to 4 (Rickards & Moger, 2000, p. 276). Researchers in this area consider groups to be complex entities that experience progression, regression, growth, and stasis, although usually not in any specific, sequential order (Henderson-Loney, 1996; Jessup, 1992; Shaw, 1981). In general, Tuckman’s (1965) model is viewed as valid on its surface but lacking in a complete explanation of how groups change over time (Rickards & Moger, 2000). Tuckman (1965) himself wrote that “the suggested stages of group development are highly visible in the literature reviewed. The fit is not perfect, however” (p. 397). Even in the presence of its imperfections, though, “the model retains its value as a simple means of discussing and exploring team dynamics” (Rickards & Moger, 2000, p. 277). One of the strengths of the Tuckman (1965) model is its ease of use at the practitioner level. This model approaches development and change across the life span of coalitions and partnerships from a practical perspective that emphasizes more of a commonsense approach to a group’s natural progression. In this article, we used the Tuckman (1965) model as a framework for observing the stages of small group development and as a lens to view the start-up of a public health partnership. Funded with tobacco settlement dollars, this partnership involved researchers from eight academic institutions and practitioners from a public health de219

partment. The group worked together to gather baseline data, assist with program implementation, and evaluate a tobacco pilot initiative, which was the public health department’s response to a government mandate. The partnership met regularly throughout 2000 to design and conduct the data collection and evaluation, with each university carrying out different aspects of the pilot project under its contract with the public health department. However, it was not until we were well into the growing pains of this team effort that we began viewing our work from Tuckman’s (1965) perspective.

> BACKGROUND

Over the years, Tuckman’s (1965) four-stage model has achieved a prominent position in the practice literature of group and coalition development in public health (Bantuveris & Robbins, 1993; Habana-Hafner, Reed, & Associates, 1989; Texas Department of Health, 1996). This literature base includes training manuals, handbooks, and so forth, that assist team members in finding effective techniques to develop and manage their collaborative efforts. Interpretations of the model allow participants to acknowledge and understand group processes in ways that emphasize growth and change, as well as to accept the inevitable difficulties and challenges of group work (Habana-Hafner et al., 1989; Henderson-Loney, 1996; Manor, 1996). Members of partnerships can thus acquire more realistic goals within the context of the developmental stages, even though Tuckman’s (1965) descriptions of the four stages represent the ideal developmental process (Rickards & Moger, 2000). A brief summary of the four stages of group process (Tuckman, 1965) offers a better understanding of the context within which members of partnerships are believed to operate. In the initial stage of forming, the most pressing concern of the individuals involved is a general orientation to the partnership, other members, and tasks. The outlook is often optimistic, although some uncertainty may be present. There is a need to find one’s place, identify the boundaries of expected and acceptable behavior, get to know the other members of the group, seek out a leader, understand the group’s purpose, and begin to obtain resources that will support the group’s goals. Tentative relationships and networks start to be established among some individuals, whereas others are still making determinations about whether or how much to commit to the partnership. In the next stage, known as storming, tension and conflict begin to form. Factions arise and take hold, clashing with other factions and with the leader; issues of control and of competition threaten the fragile stability of the group. Interactions are mostly unproductive, whereas resistance to the requirements of the task is commonplace. In spite of their desires to maintain membership in the partnership, individuals also may feel their independence and their identity are at 220

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The Authors Laura E. McMorris, PhD, does consulting and grantwriting for non-profit and for-profit organizations and is an adjunct faculty member in the School of Management and Business at St. Edward’s University in Austin, Texas. Nell H. Gottlieb, PhD, is professor and coordinator of health education programs at the University of Texas at Austin. Gail G. Sneden, MA, is Project Director for Applied Research on Tobacco Control at the University of Texas at Austin.

risk if they continue to adhere to the partnership’s structure. During the third stage of norming, the difficulties have been overcome and members are now ready to develop norms that will guide the group’s work together, reinforce interdependence among individuals, and take steps to ensure cohesion and harmony. Efforts are made to avoid destructive conflict and to encourage interactions that promote openness as well as the exchange of information and opinions. Consensus is sought and commitment is strengthened. Working relationships among members become more cooperative and more directed toward achieving the partnership’s goals. Once performing, the model’s fourth and final stage, is reached, the forecast for the partnership looks positive. The group has attained a level of maturity that it did not have previously, so problem-solving activities and constructive measures that lead to collective performance finally occupy the partnership’s efforts. Individuals are able to accept flexible roles and invest their energy in accomplishing the group’s tasks. Relationships are integrated into group processes; past experiences, no matter how difficult or divisive, have allowed the partnership to grow into its responsibilities and become a well-tuned machine that functions efficiently and effectively. A better understanding of group development can help coalitions and collaborative efforts in public health work more effectively. Tuckman’s (1965) model represents a relevant starting point for such an understanding.

> METHOD

This study examined a tobacco prevention and control partnership involving eight universities and a public health department. Three researchers from one of the universities analyzed the data, drawn from the academic/practice partnership’s activities for the period of January 2000 through December 2000. The data originated from meeting agendas and minutes, pro-

TABLE 1 Definitions for Use in Coding Partnership Documents Stage

Group Structure Issues

Task Orientation Issues

Forming

Testing and dependence Testing: Determining what behaviors are acceptable Dependence: Looking to leader, powerful group member, or existing norms for guidance Orientation

Orientation to the task Identification of task as per relevant parameters How will the group experience be used to accomplish the task? What type of info will be needed for the task? What are the ground rules? Orientation

Storming

Intragroup conflict Uneven interaction Infighting Lack of unity Polarization over key issues Conflict Emotionality in response to a discrepancy between the individual’s personal orientation and that demanded by the task

Emotional response to task demands Resistance to task demands and group influence Emotionality in response to a discrepancy between the individual’s personal orientation and that demanded by the task

Norming

Development of group cohesion Establishment of new norms related to group’s continued existence Desire to maintain/perpetuate group Harmony, avoidance of conflict Development of ingroup feeling and cohesiveness Openness to other group members

Open exchange of relevant interpretations Exchange of opinions Information is acted on and alternative interpretations are considered Openness to other group members

Performing

Functional role-relatedness Group becomes a problem-solving instrument Roles become flexible and functional Roles are adopted that enhance task activities Emphasis is on constructive action Congruence between structure/task realms

Emergence of solutions Constructive attempts at successful task completion Emphasis is on constructive action Congruence between structure/task realms

SOURCE: Adapted from Tuckman (1965).

cess notes, project records (timelines, matrices, etc.), and transcripts of personal interviews with 22 of the 25 original participants. Interviews took place between March and July 2000. We analyzed all documents using Tuckman’s (1965) definitions for each stage of the model. Table 1 contains the definitions for the group structure and task orientation issues for each stage. It should be noted that the interview guide was openended and was not intended to capture any structural or task activities related to Tuckman’s model of group development stages. The analysis process consisted of the researchers reading a document and coding pieces of data according to the applicable stage component. At least one specific example of a component within a particular month had

to be present for us to label a component as to one of Tuckman’s (1965) four stages. We considered tracking the number of times a component occurred per month but rejected that possibility due to the discrepancies between quality and quantity of information. In other words, we did not view frequency of components as indicative of the strength or value of that component. So, in the relevant table (Table 3), instead of placing an “X” for each instance of a component’s occurrence within a given month, we used a single “X” to show that component’s presence. Another reason we did not distinguish between quantity and quality of the data is because it was not possible to weight the information on any type of scale that would determine the quality, importance, or rele-

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vance of that information. Thus, as long as a piece of information adhered to Tuckman’s (1965) definitions for one of the developmental stages, we coded the data for that particular stage. Finally, we compiled the coded pieces of data, separated by stage, and placed them in a table (Table 2).

> RESULTS

Table 2 offers examples of activities, separated by month, that corresponded to each of Tuckman’s (1965) developmental stages. Forming activities included the distribution of a contact list, the development of survey instruments, a discussion of funding and program strategies, a request for an activity timeline, and plans for future meetings. Such endeavors would be expected in the initial stages of a partnership’s life; setting ground rules as well as understanding how the partnership will work to accomplish its tasks also are part of the early processes. Storming events for the partnership involved several interpersonal conflicts and power struggles among representatives of institutions; infighting between individuals and a lack of unity as to the group’s tasks appeared. Health department staff expressed concerns that the academic researchers were micromanaging the health department’s program planning and implementation activities. During meetings, some members’ rigid, closed body language and their uneven participation reflected the tension being felt. Another example of storming occurred when it came to light that a researcher from one institution had been working independently of the group to develop program objectives with health department staff members. This approach clashed with the “team spirit” intended to prevail across the partnership. Also, managers at the health department made several program decisions that did not involve input from the group at large, even though partnership members would be affected by those decisions. Where norming occurred, examples of group cohesion were present, and members were willing to take risks in offering their concerns and presenting issues to the group. For example, several institutions collaborated on submissions to a conference, and subgroup meetings took place so that specific problems could be openly discussed and various solutions could be offered in response. A listserv was created for the sharing of information and concerns among all members of the partnership. This sharing represented a new norm that leaders hoped to promote. Finally, examples of performing suggested that there were actually two types of performing activities occurring: performance by individual institutions and performance by partnership members acting as a cohesive unit. Institutional activities centered on data collection and distribution of results (i.e., the carrying out of contractual obligations). Meanwhile, activities by the part222

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nership as a whole focused on the reports to be submitted to the legislature. These latter tasks involved developing an initial outline, assigning sections of the report, and writing/editing the report. Table 3 represents the occurrence of examples of the four components of Tuckman’s (1965) model as instances of these components transpired over time. As is obvious upon viewing the table, the stages of development for this particular partnership do not indicate the neat, orderly process one might expect from Tuckman’s delineations of the stages. Instead, the stages may be better considered as representing different layers of task and interpersonal elements that unfolded as the project and its activities progressed. For instance, in February 2000, forming, storming, and institutional performing were all taking place at the same time. In March, April, and May 2000, storming, norming, and institutional performing were taking place simultaneously.

> DISCUSSION

Overall, Tuckman’s (1965) model proved useful in analyzing the development of our public health partnership. For example, upon feedback of findings to the group, the acknowledgment of a storming phase alleviated some concerns that participants had about the conflicts that had occurred between and among partnership members. Recognizing that storming can—and most likely will—take place under such circumstances can provide participants with an understanding of group dynamics they might have otherwise overlooked. Especially when participants have dissimilar educational and cultural backgrounds, as well as different motivations for their participation, differences and conflicts are bound to happen. Some researchers have suggested that not only is a storming stage valuable but it may even be necessary for progress to occur and for problem solving to take place (Henderson-Loney, 1996; Manor, 1996). Awareness of a storming phase may therefore better prepare partnership members for discord and uneven interactions. In fact, some research has even suggested that once negative feelings and disharmony have been expressed (i.e., storming), the path becomes more accessible to positive interactions among group members and progress for the group as a whole (Scheidlinger, 1952, cited in Shambaugh, 1978). In addition, we discovered that examples of storming mostly emerged in the interview transcripts and process notes. This made sense because documents such as meeting minutes and other project records contained information that was most likely to be free of opinions, value judgments, and the like. Due to the conflict-laden nature of storming, the inclusion of “emotional” data was necessary to the analysis process; this inclusion also prevented an incomplete picture of the developmental process from emerging. Consideration of the partnership’s activities from a visual perspective highlighted another significant

TABLE 2 Partnership Activities Within Tuckman’s (1965) Stages of Small Group Development Stage of Development Forming

Date of Occurrence January 2000

February 2000

Storming

February 2000

March 2000

April 2000

May 2000 Norming

March 2000 April 2000

May 2000 Performing (Institution)

February 2000 March 2000

Activity MM: Researchers discuss development of various survey instruments. MM: Monthly planning meetings are scheduled for the first Monday of every month. Items placed on agenda for the next meeting. MM, PR: Report given on school and media Requests for Proposals; funding and program strategies discussed. PR: Contact list distributed at meeting. MM: Cessation and prevention logic models are distributed and reviewed by the group. MM, PR: Drafts of survey instruments are shared with group. MM: Request for timeline of evaluation activities being scheduled. PN: Responsibility for law enforcement survey removed from one institution and given to another. PN: Health department staff member expresses concerns about the researchers’ micromanagement of program components. The perception is that the researchers are telling health department staff how to run their programs. PN: A researcher from one institution has been working with health department staff to determine objectives for program implementation; these activities are a surprise to researchers from other institutions. PN: Health department chairperson initially fails to attend a group planning meeting, eventually arrives 20 min after the scheduled start time. PN, PR: One university’s researchers are prevented from contacting a key legislator’s office. PN: Several researchers discover that the health department has been developing school-related program guidelines that are inconsistent with the agreed-upon evaluation design. IT: “I can think of a few meetings where tension was high, people were removing themselves from the room or were sitting really far away from the others or weren’t adding to the meetings or had scowls on their faces. . . . Definitely there’s dissension there.” (#76977, 196-202) PN: Uncomfortable meeting, palpable tension. Interactions are strained and decisions are made with difficulty. IT: But I also think it might be too individualized right now. People are their own little islands and there’s not enough, an adequate amount of interaction between the islands per se, and so that might be detrimental to the whole group.” (#76977; 35-38) IT: One institution had surveys and interviews scheduled with participants in the field but the activities could not take place. Although the work plan was approved in March, funding still had not been received. (#51958, 42-52) PN: During meeting with local contractors, topic of group discussion is consistently overtaken by one researcher. PR: A LISTSERV is established to facilitate communication among group members. MM: Abstracts are solicited for World Conference on Tobacco or Health; crossinstitutional submissions are encouraged. MM, PR: Smaller group meetings are taking place among members involved in the same program/evaluation areas (e.g., law enforcement, media, etc.). MM: Request made for institutions to submit monthly progress reports to the health department. MM: Youth Tobacco Survey distributed to schools. MM: Media research is underway. MM: Results of one-on-one interviews with smokers are distributed. (continued) McMorris et al. / PUBLIC HEALTH PARTNERSHIPS

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TABLE 2 (continued) Stage of Development

Date of Occurrence April 2000

May 2000 June 2000 July 2000

Performing (Group)

August 2000 September 2000 October 2000 November 2000

Activity MM: Principal and Lead Health Educator surveys are distributed to pilot sites, responses still in progress. MM: Updates provided on media evaluation, cessation intervention and evaluation, and school/community interventions and evaluation. MM: Sentinel school preliminary data are available. MM: Presentation of T1 Principal and Lead Health Educator surveys. MM: Presentation of research design for community level key-informant survey. PR: One university sponsors an annual statewide tobacco prevention and education conference. MM: Presentation of initial results from Youth Tobacco Survey. MM: Principal Investigator meeting held to discuss issues relevant to legislative report. MM: Partnership meeting held to discuss issues relevant to legislative report. MM: Guidelines for legislative reports are distributed. Work groups meet to write assigned sections of legislative reports.

NOTE: IT = interview transcripts, MM = meeting minutes, PN = process notes, PR = project records.

aspect of the findings: the overlap among stages. Arrow, McGrath, and Berdahl (2000) propose that such overlap is not unusual during the group development process, especially in the early period of a group’s existence; sometimes groups must engage in forming and performing concurrently. In contrast, Tuckman (1965) refers to the movement from one stage to another as a “sequence” (p. 396), whereas the model itself implies the completion of one stage before the commencement of the next stage. However, Tuckman does note that some groups may experience the stage components in a different order than that put forth by the model. This point also was shown by our research, because the punctuated quality of the partnership’s development is apparent for forming, storming, norming, and institutional performing. Next, we found there were two types of performing that were occurring: performing by individual institutions and performing by the group as a whole. Tuckman (1965) did not account for multiple subgroups working both independently and collaboratively in a larger group setting. In our case, contractual obligations necessitated the performance and completion of numerous time-specific activities by individual institutions. Therefore, we observed that institutional performing began taking place at the start of the partnership. Meanwhile, group work on the legislative report that served as a cross-institution task did not occur until the 9th month of the partnership’s existence, at a point when performing would likely be expected to ensue.

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It is not uncommon for groups to begin assigning tasks and developing products before they have the benefit of becoming acquainted, working out differences, and establishing a rhythm of working together (Arrow et al., 2000). Although this lack of a “honeymoon period” affects group dynamics, we were unable to measure any variables related to this characteristic of the partnership’s initiation. It should be noted that this study has several other limitations. First, there were activities and experiences associated with the public health partnership’s project that did not fit under any of Tuckman’s (1965) definitions for group development. For example, health department efforts to conduct tobacco inspections under the Synar amendment became null and void due to a ruling by the Supreme Court in March 2000 (Kelder, n.d.). Although this information was reported at a meeting, the event itself—the ruling—occurred outside the boundaries of the group and could not be analyzed with Tuckman’s (1965) stages. The impact of the ruling on the group did not coincide with Tuckman’s stages, either. Another example of activities that did not correspond to any of Tuckman’s (1965) stages of group development concerned the reporting of details that, once again, fell outside the scope of the group. For instance, the public health department reported on subcontractors it had hired and announced the procurement of an advertising/marketing firm for addressing the mediarelated needs of the project. In addition, in several inter-

TABLE 3 Tracking of Tuckman’s (1965) Stages of Small Group Development in the Partnership Across Time 2000 Forming Storming Norming Performing (Institutional) Performing (Group)

Jan

Feb

X

X X X

Mar

Apr

May

X X

X X

X X

X

X

X

Jun

Jul

Aug

X

X

X

Sept

Oct

Nov

Dec

X

X

X

X

NOTE: X = one or more activities relevant to Tuckman’s developmental stages took place.

view transcripts, the participants noted that their contracts had not been finalized and, therefore, certain activities were at risk of not being started or completed. There were no examples within Tuckman’s descriptions of the stages that addressed external obstacles, such as bureaucracy, that affected the group. These illustrations indicate that there are factors that remain unaccounted for or that we could not measure due to the coding definitions we used. How these unmeasured aspects would affect our findings is not known. Second, our interview schedule and project documents were not constructed or intended to uncover themes specific to the Tuckman (1965) model, so direct analysis of project activities and participants’ experiences within Tuckman’s framework was not possible. Nonetheless, we still were able to explore the data from the open-ended interview questions and the project documents by using Tuckman’s descriptions of each developmental stage and then applying those descriptions to relevant project interactions, activities, and events. Last, the findings from this study may not be generalizable to other groups. Although there is reason to believe that the methods could be applied to a range of group settings, our results were limited by the unique set of circumstances under which this group operated. In particular, the individually contracted relationships between each university and the public health department were not typical of a collaborative partnership. This likely contributed to the finding of institutional performing, separate from group performing. Nevertheless, there are practical lessons to be learned from our results.

> CONCLUSIONS

Public health practitioners may find the following implications useful when working with partnerships. An awareness of group developmental stages would allow leaders and members to improve the ways that their partnership works together. This is especially relevant for the almost-inevitable storming stage. Acknowledging the existence of conflict and tension can alleviate their power over the group’s efforts; bringing issues

into the forefront can prevent them from derailing members and the important work of the partnership. Sampson and Marthas (1990) have noted that “conflict . . . is not inevitably destructive, nor a symptom of a faulty group; in fact, it is something to deal with and to build upon” (p. 84). Applying Tuckman’s (1965) model also can allow expectations about the partnership’s progress and members’ interactions to be managed so that tasks are aligned with the appropriate stage of development. When members of a group seek to undertake tasks that are beyond their level of development—when they “bite off more than they can chew” (Wheelan, 1994, p. 54)— their efforts may be wasted because they have chosen goals that are beyond their ability at the present or they simply have not established a functional foundation from which to operate. Finally, for partnerships and coalitions that have a long life span, understanding that the stages may occur several times throughout the group’s existence can acclimate members to shifting responsibilities and relationships over time (McGrew et al., 1999; Shaw, 1981). The repetition of stages is particularly likely to result as some members drop out of the group and new members join. Viewing such movement between developmental stages as part of the terrain may alleviate concerns of group members. Although the inevitable bumps in the road require attention, they need not distract from the group’s growth and progress. More and more often, partnerships in public health involve stakeholders with a wide range of knowledge and experience. From statewide advisory boards to local community coalitions, these partnerships must find ways to function as collaborative teams and not simply as groups of individuals. Because of the complexity of the partnership phenomenon, we are unable to recommend one best formula for ensuring the success of coalitions and other collaborative endeavors. However, reflection on the findings from this study and those previously cited will enable the health education practitioner to make informed decisions for action. Our findings suggest that the Tuckman (1965) stage model provides an effective lens that is useful for viewing practice settings across the spectrum of public health.

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