The integration of a new member into a multi-professional team is a two-way learning process. The newcomer has a great deal to learn about the roles and expectations of the team, while existing team members have to find out about the newcomer.
This article describes a case study of a diabetes ward team, which was undertaken to investigate the process by which new members are integrated into the team.
The study ward was situated within a general hospital and offered outpatient facilities, inpatient facilities (11 beds), community-based services for GPs and their patients, organised from the ward, and a 24-hour telephone advice service. It was staffed by nine registered nurses and normally two student nurses. The ward also had the services of pharmacists attached to four consultant firms, dietitians, physiotherapists, occupational therapists (OTs), and a podiatrist and social worker.
Non-participant observation (86 hours) and semi-structured interviews (17) with the ward diabetes team members were used to gather data about the multi-professional team over a one-year period.
During this period, six new members of staff (one newly qualified nurse, grade D; one E grade nurse; one nurse specialist; one physiotherapist; one junior house officer; and one senior house officer) and two students joined the ward, and their integration into the team was observed.
Every team has its own way of working and expectations about how much each of the different professions contribute. Under-standing team roles and what they mean in practice is no easy task. As one team member (a pharmacist) in the case study put it:
‘The biggest thing I’ve found, no-one really knows what everyone else does. Everyone knows what doctors do, but not secondary groups like OTs and physios … people think that pharmacists sit and count tablets, some people do not realise what we can contribute to the team.’
Gill and Ling (1995) distinguish between the different types of knowledge needed in teamwork, i.e knowledge about the work, roles and responsibilities of others, about the skills and strategies for collaboration, and about the interactive experience of learning with others.
Although a great deal has been written about teamwork, there is a lack of relevant literature about how people learn to become part of a multi-professional team; this can be as difficult for an experienced professional as for a student. Previous experience is helpful to a certain extent, but can be a hindrance if the expectations of the newcomer do not match those of the team.
Stages of becoming a team member
The evidence from the case study suggested the following stages for the integration of newcomers into the diabetes ward team:
- New arrival
- Background participant
- Recognised by others
- Competent and confident
- Supporter of others.
These stages are illustrated in Figure 1. The duration of each stage is not fixed, but varies with each individual situation.
1. New arrival
In the early stages, the concern of new arrivals was with orientation in their own professional role — ‘What am I expected to do?’ and ‘What is the normal routine here?’ — before beginning to learn about how the multi-professional team operated.
It was also a period of checking out by the existing team and the newcomer that they had each made the right choice and were prepared to invest time and energy in integrating and getting integrated, respectively, into the team.
Junior house officers and student nurses may have been allocated to the team rather than choosing it. For them, ‘new arrival’ may be the only stage reached because, as they are ‘passing through’, a significant investment may not be perceived as worthwhile (by either party). Statements from a number of ward team members supported the student nurse’s contention that, in order to get involved:
‘You have to show you are interested, otherwise you fade into the background, especially with consultants. Show you are interested and want to learn from them; be positive and ask lots of questions.’ (Student nurse)
2. Background participant
Once potential team members had demonstrated some commitment, they entered the second stage. The initial phase of this stage was usually mono-professional: the new arrivals were developing their own skills and expertise in this new context and checking out the role and responsibilities of their own profession.
Many of the expectations held by the team about the way in which a member would work remained unspoken. They might not be made explicit to the newcomer until he or she fails to fulfil them.
Expectations in the new role were clarified, normally in conjunction with a mentor or preceptor from the newcomer’s own professional group. For example:
‘With her [manager], … she can bounce things back without making you feel stupid or criticising. Virtually everything has been challenged about my diabetic knowledge, I have had to pick up the work and structure it in some way.’ (Nurse specialist)
The ward had a clear philosophy and objectives for patient care, which were displayed for all to see. However, it was the exchange of ideas through this process of positive challenge which enabled newcomers to move from knowing the philosophy to taking it on board and enabled achievable goals to be agreed.
Despite the planned programme for induction and preceptorship, there were occasions when newcomers had to fend for themselves. When this happened, feedback seemed particularly important:
‘When I got here, staffing levels were so dire I was just thrown in at the deep end to cope and some days that is just what I did. They have all told me I am doing OK, doing what every other staff nurse does, so I am coping … I feel as though I am part of a team, it is slowly building up, I feel of more worth … On the whole, everyone is supportive, but it is no use standing back and expecting it to come to you, you have to ask.’ (Experienced nurse)
During this stage, newcomers became familiar with the philosophy of the team and met other team members, both formally, as part of an orientation programme, and informally, in the course of the work and sharing the environment.
Newcomers absorbed a background understanding of the context and demands on the team and individual interests and expertise. This tacit knowledge was not available in books or policy guidance and was often not referred to by practitioners, being recognised only by its absence. They asked questions they would not have risked earlier because of what others might think of their lack of knowledge:
‘The consultant was much better with me today when I did the ward round. My knowledge of the patients was much better and I was asking more questions … the first two weeks I was quite nervous so you have to let it build up gradually … I have sort of orientated myself … I ask a lot of questions.’ (Nurse)
The learning was not only about the roles per se, but also about how best to engage and work with those individuals; it could be seen as ‘getting your voice heard’.
3. Recognition by others
The stage of background participant merges with the next stage, where there is recognition of the newcomer’s membership by those outside the mono-professional group and increasing participation by the individual in all aspects of both the work and the life of the team. The individual may be invited to team meetings, and to work-related and social events.
‘I’ve only been to one team meeting so far. As a student, I didn’t go to ward meetings as I felt an outsider. I can contribute now … I didn’t go because I was never asked.’ (Newly qualified nurse)
‘Being invited’ signifies to the individual that he/she is recognised as having something to contribute, as having earned some respect and being worthy of investment. Both students and new practitioners argue that they have to demonstrate that they are interested and willing to learn before the existing team members are willing to support them, explain how things work and offer opportunities to reflect and assist in problem solving.
4. Confidence and competence
By this stage, newcomers are confident of their competence to function within the team, including having the confidence to say ‘I don’t know’. This stage was characterised by the establishment of trust between team members, cohesion as a group, an understanding of the language of the team and the codes in which team members spoke. The following comment from a physiotherapist highlights some of these issues:
‘Most of them know me by name and don’t just call me the physio. They are very friendly and have got quite good respect; they listen to what I have to say. I always go to them [the nurses] to get report and I report back verbally and sometimes write in the medical notes. I primarily link through the nursing team.’
The physiotherapist also displayed considerable knowledge of how the nursing team was organised to provide care for patients, and hence whom she could gain information from, report to and work with.
The use of language may be the same in many settings, but its precise meaning, and the actions that necessarily follow in its wake are probably unique to each setting (Mackinnon, 1984; Wolf, 1989).
For example, a request to ‘educate the patient’ about his/her diabetes did not simply mean ‘provide the patient with information and knowledge’: it set in train a whole process of consultations, referrals and enrolment in a formal patient education and assessment system, which was taken for granted by the consultant and the team. It took the senior staff nurse at least half an hour with the new staff nurse on the team to describe and list the actions that needed to be undertaken when such a request was made.
For the newly appointed nurse specialist, there was a similar amount of learning to do with regard to ‘referral’:
‘You have to suss out what a referral means. There is no set referral form, letters, bits of paper, phone calls or fully typed letters. You often don’t know what is expected of you’.
There was a need to learn the code and in this case each person making a referral seemed to have a different set of expectations about the outcome of their communication. ‘Observe’, ‘admit’ and ‘discharge’ were other examples.
The speed of progression to this stage varied, depending on seniority and role in the team. A new consultant would be expecting to go straight to this stage. In the case study, an E grade nurse was quickly accepted to this stage, while a D grade nurse who had been around for a year was still building up competence in the team.
5. Supporter of others
Finally, competent practitioners became mentors to others, supporting members of their own and other professions in the team by enabling and facilitating them to make their contributions.
This was either on their behalf when they were absent or by making an opportunity for their voice to be heard. They offered advice and support as a guide to making sense of the meanings and requirements of each situation, helped reflection on practice and in unpacking the language and codes.&
The key elements of supporting strategies are shown in Table 1. This could be formally embodied in a recognised preceptor role or might be an informal occurrence which developed out of the culture and philosophy of the ward team.
Becoming a member of a team is a developmental process in which people will be concentrating on different aspects of the team and doing different things at different stages. Existing team members can help and speed up the process by giving appropriate support at each stage.