new nurses' experience of their role within interprofessional health care teams in mental...

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New Nurses' Experience of Their RoleWithin Interprofessional Health Care

Teams in Mental Health
Lindsay Schwartz, David Wright,and Mélanie Lavoie-Tremblay
hives of Psyc

This qualitative study explored new nurses’ experience of their role withininterprofessional health care teams in a mental health organization in Cana-da. Semistructured interviews were conducted with 10 nurses. Content ana-lysis revealed two main themes, namely, adopting a passive role to learn howto fit in and engaging in an active role to impact on patient care. Establishingcredibility and building trust were central to the new nurses’ transition from apassive to a more active role. Interpersonal and organizational factors con-tributed to the transition. Recommendations for creating healthy work envir-onments that promote interprofessional collaboration and facilitate newnurses’ transition into interprofessional health care teams are presented.© 2011 Elsevier Inc. All rights reserved.

From the Segal Cancer Centre, Sir Mortimer B. Davis-Jewish General Hospital, Montréal, Québec, Canada;McGill University School of Nursing in Montreal, Quebec,Canada; University of Ottawa School of Nursing inOttawa, Ontario, Canada; and Research Center FernandSeguin at the Louis-H Lafontaine Hospital in Montreal,Quebec, Canada.

Corresponding Author: Lindsay Schwartz, N., MSc(A)(c), Nurse Clinician, Segal Cancer Centre, Sir Mortimer B.Davis-Jewish General Hospital, Pav. E, 8th Floor, 3755,Cote-Sainte Catherine Road, Montréal Québec, CanadaH3T 1E2.

E-mail address: [email protected]© 2011 Elsevier Inc. All rights reserved.0883-9417/1801-0005$34.00/0doi:10.1016/j.apnu.2010.08.001

H EALTH CARE INSTITUTIONS worldwideare confronted with the challenge of provid-

ing high-quality care to patients and their familieswhile experiencing the current and projectednursing shortages (Tschannen, 2004). In Canada,the health care system is expected to reach ashortage of 78,000 nurses by 2011 (CanadianNurses Association, 2002); compounding thisproblem is the high turnover rate of 30% amongnew nurses within their first year of practice,escalating to 57% by their second year (Bowles &Candela, 2005). The shortage is magnified withinthe specialty field of psychiatric–mental healthnursing, as most of the new nurses lack interest inthis field (Cleary & Happell, 2005; Happell, 1999;Valente & Wright, 2007). One strategy aimed atimproving the retention of nurses is interprofes-sional collaboration (Rafferty, Ball, & Aiken, 2001;Robinson, Murrells, & Smith, 2005; Schmalenberget al., 2005; Tschannen, 2004). However, there is apaucity of studies that explore new nurses'experiences within interprofessional health careteams (IHTs), and even less work exists within amental health context.

hiatric Nursing, Vol. 25, No. 3 (June), 2011:

LITERATURE REVIEW

New Nurses' Role Within the IHT

According to Hoffman, Rosenfield, Gilbert, andOandasan (2008, p. 655), interprofessional collab-oration is “a patient-centered, team-based approachto health care delivery that synergistically max-imizes the strengths and skills of each contributinghealth professional to optimize the quality of patientcare.” Interprofessional collaboration has been

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http://dx.doi.org/10.1016/j.apnu.2010.08.001

154 SCHWARTZ, WRIGHT, AND LAVOIE-TREMBLAY

associated with positive patient, nurse, and organi-zational outcomes (Baggs et al., 1999; Tschannen,2004; Vahey, Aiken, Sloane, Clarke, & Vargas,2004). Patient outcomes include decreased mortal-ity, reduced costs, and decreased length ofhospitalization (Schmalenberg et al., 2005). Nurseoutcomes include higher job satisfaction, increasedautonomy and decision making, improved reten-tion, and decreased burnout (Rafferty et al., 2001;Schmalenberg et al., 2005; Vahey et al., 2004).Robinson et al. (2005) conducted a longitudinalnational study consisting of 444 new nurses inmental health that examined the link betweennurses' sources of job satisfaction and intention toremain in the profession; positive working relation-ships received high satisfaction scores and werereported as an important factor for remaining in afirst nursing job. In sum, organizations that promoteteamwork and collaboration seem to benefit byhaving more committed and satisfied employees(Tschannen, 2004).

Identifying oneself as a member of the IHT isimportant for new nurses (Halfer, 2007), as formingrelationships with team members fosters a sense ofbelonging to the nursing profession and theorganization (Santucci, 2004). According to Altierand Krsek (2006), new nurses who believe theybring strength to the IHT are more likely to besatisfied and remain in their work environment.Lingard, Reznick, De Vito, and Espin (2002) foundthat new nurses develop a cultural understanding ofprofessional roles and relationships as they interactwith members of the IHT. Furthermore, throughthese interactions, they begin to make sense of theirown professional roles in relation to their teammembers' roles. Understanding their own profes-sional roles and responsibilities in addition todeveloping a better understanding of other profes-sions' roles and scopes of practice is a prerequisiteto effective interprofessional practice (RegisteredNurses' Association of Ontario [RNAO], 2006).

Because of the relative lack of interprofessionaleducation in undergraduate curricula, new nursesand other professionals often start their careers withan unclear understanding of each other's profes-sional vocabulary, culture, values, strengths, roles,and approaches to clinical reasoning and problemsolving (Hall, 2005; Lingard et al., 2002). Thisissue is exacerbated in psychiatric–mental healthnursing, whereby student nurses receive limitedtime in psychiatric clinical placement areas, which

may impact on the clinical readiness, competence,and confidence in their role as new nurses in mentalhealth (Cleary, Horsfall, & Happell, 2009) and ascontributing members to the IHT (Cleary et al.,2009). Research with new nurses suggests thatlearning to work as an interprofessional teammember requires a lot of effort and energy.Schoessler and Waldo (2006) conducted an inter-pretive phenomenological study that examined thetransition of new graduate nurses (NGNs) through-out their first 18 months of practice and found thatduring the first 3 months, NGNs were likely to taketeam members' responses to their questions verypersonally. During 4 to 9 months, NGNs identifytheir role as patient advocate; however, they lackthe skills and confidence with physicians to fulfillthis role. Only after 10–18 months do NGNs beginto see value in fostering interprofessional relation-ships and better understand the nature and out-comes of interprofessional collaboration. Casey,Fink, Krugman, and Propst (2004) conducted aquantitative, descriptive, comparative design of 270NGNs working in six acute care hospitals andfound that NGNs with less than 6 months ofpractice lacked confidence in communicating withthe medical staff, and only after 6 months did theyfeel comfortable in bringing forth suggestions forchanges in patients' plans of care.

Although many studies have examined interpro-fessional collaboration and the link to positive nurseoutcomes, most of these studies have consisted ofexperienced nurses and have not been specific to themental health context. The purpose of this study wasto explore how new nurses at the beginning of theircareer experience their role within IHTs in a mentalhealth organization.

METHODOLOGY

Method

A qualitative, descriptive design was used todescribe new nurses' experience of their role withinan IHT. Qualitative description is the preferredresearch method when a straight description of anevent or phenomenon is desired, as it facilitates theidentification of the “who,” “what,” and “where” ofevents or experiences (Sandelowski, 2000). Indeed,a qualitative research design allows for answers toquestions of relevance to healthcare professionals(HCPs) (Sandelowski, 2000; Thorne, Kirkham, &Mac Donald-Emes, 1997).

Table 1. Demographics

N %

Gender Female 6 60.0Male 4 40.0

Age (years) 21–30 4 40.031–40 3 30.041–50 2 20.051–60 1 10.0

Education College degree 8 80.0Bachelor degree 2 20.0

Work status Full-time 8 80.0Part-time 2 20.0

Title Registered nurse 7 70.0Registered nurse candidate 3 30.0

Experience sincegraduation(months)

5–9 3 30.010–14 2 20.015–18 5 50.0

155NEW NURSES WITHIN INTERPROFESSIONAL TEAMS

Sample

Ten participants were recruited by conveniencesampling from a mental health university teachinghospital in Canada. In the context of this study, newnurses included registered nurse candidates whohad graduated from nursing school but had not yetreceived their nursing license and registered nurses.The roles and functions of registered nurses andregistered nurse candidates within the teams studiedare sufficiently similar to justify their inclusiontogether in one sample. Inclusion criteria were thefollowing: new nurses working at the mental healthhospital, with a minimum of 3 months and amaximum of 18 months of clinical nursingexperience since graduation; working full-time,part-time, or availability; and working any shift.A minimum of 3 months of clinical experience wasused to allow sufficient time for new nurses tobecome oriented to the clinical unit and beacquainted with members of the IHT. Eighteenmonths or less of clinical experience is believed tocapture the experiences of new nurses in accor-dance with Benner's (1984) novice to expertframework of nursing skill acquisition. The studysample included six females (60%) and four males(40%) between the ages of 21 and 55 years (x ̄ = 36.4years) and ranged in clinical nursing experiencefrom 5 to 18 months (x ̄ = 12 months). Eight nurses(80%) had a college degree, one of whom wasenrolled in his bachelors in nursing at the time ofthis study, and two (20%) were bachelor prepared.Eight nurses (80%) worked full-time, and two(20%) part-time. Participants were recruited fromsix different units including the intensive care unit,emergency department, and geriatric psychiatry;four (40%) nurses were recruited from the floatteam. Float nurses are generally not assigned to anyparticular unit but rather trained to work on variousunits throughout the organization on an “as-needed” basis (see Table 1).

Data Collection

Scientific and ethical approval was obtainedfrom institutional review boards at both theresearchers' home university and at the participat-ing site. Data collection occurred between Septem-ber and November 2009. A nurse representativefrom the human resource department of the hospitalapproached eligible new nurses and briefly intro-duced the study. The principal investigator met with

interested new nurses individually on their unit toprovide a detailed description of the study andarranged a time for the interview. Each nurseparticipated in one semistructured individual inter-view during work hours of approximately 45–60minutes with the principal investigator. New nurseswere asked questions that explored their role withinIHTs, including “Can you tell me what yourexperience has been like working as a new nursewith the health care team on this unit?” “Whichhealth care professionals make up the team on thisunit?” “What is your role in relation to othermembers' roles?” and “How do you think otherhealth care team members see your role?” Otherquestions asked about any positive or negativeexperiences of working with fellow team memberson their unit, probed for facilitators and barriers tocollaborating with members of the health care team,and inquired as to whether efforts by the new nurseto develop their role were supported or notsupported by the health care team.

Data Analysis

Interviews were audio taped and transcribedverbatim for analysis. Data were analyzed induc-tively and occurred simultaneously with datacollection (Polit & Beck, 2008). The principalinvestigator immersed herself in the data throughrepeated readings of the transcripts and field notesto achieve a sense of the content as a whole(Loiselle, Lambert, & Cooke, 2006; Tesch, 1990).Data were reduced by generating codes, categories,and data matrices (Miles & Huberman, 1994). Opencoding occurred as the principal investigator

Fig 1. New nurses' transition from a passive to a more activerole within IHTs in mental health.


reviewed transcripts and field notes line by line,highlighting and extracting sections that touched onthe new nurses' experience of their roles within IHT(Glaser & Strauss, 1967; Strauss & Corbin, 1998).Categories were then formed by clustering codesthat referred to similar concepts. Within and acrosscase data comparison was performed to verifywhether the constructed categories were represen-tative of the entire data set (Glaser & Strauss, 1967;Young, Purden, Sauve, Dufour, & Common, 2008).Themes were then generated from the identifiedcategories to represent the essence of the newnurses' experience of their role within IHT. Dataanalysis was performed by the primary investigator(L.S.). To enhance the confirmability and trustwor-thiness of interpretation, a subset of the data wasalso coded and analyzed by two other researcherswith expertise in qualitative analysis (D.W. and M.L.T.); consensus around the emerging interpreta-tions was reached among all researchers throughdiscussion (Polit & Beck, 2008).

FINDINGS

Analysis of the interview data resulted in theemergence of two main themes that captured thenew nurses' experience of their role within the IHTin a mental health context: (a) adopting a passiverole to learn how to “fit in” and (b) engaging in an

Table 2. Examples of New Nurses' Transition From a Passiv

Passive role Establishing credibility an

Familiarize Proving oneselfListening and watching to learn Having good judgmentLack of confidence Communicating pertine

active role to impact on patient care. Establishingcredibility and building trust were central to newnurses' transition from a passive to a more activerole. In addition, several interpersonal and organi-zational factors were found to contribute to thetransition process. Refer to Figure 1 for a visualrepresentation of the transition process as describedby the new nurses in this study and to Table 2 forexamples that illustrate each area.

Adopting a Passive Role to Learn How toFit in

Most of the new nurses in the study describedtheir initial experiences of their role within the IHTas passive. This passive role provided new nurseswith an opportunity to develop a better understand-ing of their work environment including the patientpopulation and the IHT. Nurses in the studyexplained that before they can “get the role of anew part of the team…and play the role that'sexpected,” they first needed to familiarize them-selves with the patients and the IHT on the unit andsee how they could fit in. One nurse explained how“…6 months could have been great…before doingthe interdisciplinary…to learn about the patients, toknow their habits…their level of capabilities…thestaff…to get to know about their way of working…how people react…and the ruling of the unit.”Inherent to learning how to fit in was the need tolisten and watch to learn from members of the IHT;these actions occurred simultaneously.

At the outset, many new nurses expressed a lackof confidence in disseminating patient informationand voicing their opinions to the IHT, particularlyduring team meetings. One nurse stated, “I didn'tfeel I was as competent as them”; another nurse feltuncertain which information was necessary toreport. Many participants expressed that “it's hardto have a voice in the system when you'rebeginning.” One nurse summarized this sentimentas follows: “I think they're [IHT] listening to you,but with just one ear … because you're maybe notspecific enough or you're too green so you'refocusing on things that don't need to be focused

e to a More Active Role Within IHTs in Mental Health

d building trust Active role

Responsibility and accountabilityCollaborating for safety

nt information


on.” To develop his place within the team, thisnurse listened carefully to team interactions, “…youdon't say much at the beginning, you're listeningwith your two ears.” Similarly, new nursesexplained that by watching the IHT in action,they were able to observe the functions anddynamics of the team and identify implicit teamnorms including the roles of each member withinthe team. One nurse commented:

I think for me it was really observing people and observingthe interaction, to know how to approach certain people ifyou need something and who you could count on or not incertain situations…it facilitates the adaptation because thenyou are able to see the strengths and weaknesses of thepeople within the team and work with it.

“Listening and Watching”

New nurses applied the principles of listeningand watching to advance their nursing knowledgeand skills. As new nurses working in mental health,there was much to learn; participants described asteep learning curve acquiring knowledge aboutgovernmental and community services available topatients, diagnostic procedures, patient assessmentskills, technical skills, and crisis intervention.Several participants spoke about learning fromnurse mentors who were senior nurses that sharedtheir experiences on how they managed specificpatient scenarios in the past. One nurse expressedthat his nurse mentor helped him learn ways to betterinteract and communicate with patients and the IHT.Many of the participants took initiative in learningfrom members of the IHT by asking questions andreading team members' notes in patients' charts.One participant explained learning from the IHTduring his first 3 months of practice as follows: “…because less experience…I look a lot at what othersdo because I think that's the way to learn more. Theless you talk and the more you listen.”

Establishing Credibility and Building Trust

New nurses transcended their passive statusgradually as they established credibility and builttrust within the IHT. Most of the participants believedthat they needed to take the time to prove themselves.One nurse expressed this sentiment as follows: “…people watch you when you work and if people seethat you do a good job, it's easier for you then to takean active role and come with suggestions…they [IHT]will be more open to listening to you…that's just the

key, trust.” Participants described the followingmechanisms by which credibility and trust werefostered, such as having “good judgment”; being “upto date, on top of my clients”; going “out of myway tohelp others”; “by the way you manage your ownpatients…work with other professionals and…expressyourself during the meetings”; and by communicatingpertinent patient information to the IHT. One nursestated, “don't take things for granted, you have to telleven little things.”Developing trust was described as asynergistic process whereby trust in individualmembers and trust in the team as a whole were closelyinterrelated, as described by the following participant:

…he [doctor] knows that if you ask something it's not [just]your decision, it's a team decision…he knows the team, heknows he can trust us, and I think he thinks I'm part of theteam …if the others [nurses] have trust in you, the doctor isgoing to have trust in you, because he has trust in the team.

Nurses expressed that trust among members ofthe IHT was important for interprofessional collab-oration. Furthermore, trust was key to ensuring asafe environment. One nurse expressed: “…here it'sthe main thing, trust. You have to trust the other…the other have to trust you because…we're a team,we work as a team, if we don't it could bedangerous here, anything can happen.”

Engaging in an Active Role to Impact onPatient Care

As new nurses transitioned into a more activerole within the IHT, they expressed having greaterresponsibility and accountability over patient care.In the context of mental health, nurses' active roleincluded collaborating to ensure a safe environmentfor patients, for the IHT, and for themselves.Moreover, in the active role, most participantsdescribed having a voice on the IHT and felt thatthey were directly impacting on patient care.

Collaborating to Ensure a Safe Environment

Most new nurses came to recognize that safetywas a central concern for the IHT. A concern forsafety was characterized by a shared concern for thewelfare of the patients as well as the welfare offellow team members. Nurses noted that “a violentsituation can always come up at any moment” and“anything could happen.” Through observation andexperience with intervening in crisis situations, thenurses learned that you need to “watch out for eachother,” count on one another, and “trust that your


colleagues will be there when you need them.” Onenurse expressed: “my security depends on the otherand the others' security depends on me…”; anothernurse added “we're all interrelated…if we're a teamwe're in security, if we're not, we're in danger.”The nurses' role in ensuring a safe environmentincluded evaluating the patient and assessing forany factors that could endanger the patients or staffand to intervene “before it's too late.” Oneparticipant attributed ensuring a safe environmentto being a “good nurse.” Another new nurseexplained it as follows:

When you have a patient who's not in our world, who ishearing voices…he's going to fight for his life…you haveto evaluate the patient, the situation and the environment…If somebody doesn't do that, he put himself in trouble andthe other members of the staff in trouble…everything hereis safety.

Having a Voice on the IHT

In the active role, new nurses recognized thattheir input was very important and valued whendeciding on patients' plan of care. For example,psychiatrists would often ask new nurses for theirevaluations on how their patients were respondingto medications and for their input on patients'readiness for discharge. All of the participantsexpressed a belief that nurses spend the most timewith patients and as such really “know” them best.Therefore, as they adopted a more active role,participants felt confident in their abilities to providecurrent and pertinent information to the IHT. Mostparticipants developed an affinity for voicing theiropinions and offering suggestions to the IHT, whichthey perceived as advocating for patients. Thisability evolved over time as nurses gained a betterunderstanding of their patients' condition andlearned what was most important and significantto report. When asked “how does it make you feelwhen other members listen to you?” one participantreplied: “...my opinions or expertise seem toactuallymatter…it makes for a muchmore satisfyingwork environment…that I'm part of the team andthat I do make some difference in terms of care forthe patients.”Another nurse described an instance ofimpacting patient care as follows: “after 6 months…Iwas able to say ‘hey doctor, send her to ICU becausethere's no way she could rest here’…when you pushhard enough they listen…it gives you more respon-sibility…it's like you just became a nurse.”

Interpersonal and Organizational Factors

Many of the participants described both inter-personal and organizational factors that contributedto the transition (Figure 1).

Feeling Supported and Valued

All of the nurses experienced feeling supportedand valued when asked for their opinion by othermembers of the IHT. Feeling valued appeared toplay a role in job satisfaction, confidence, andfeeling “part of the team.” All of the participantsexpressed that working with interprofessional teammembers who are open, available, and nonjudg-mental to their questions as well as “willing to givea hand” and “share information” facilitated theirprogression and integration into the IHT. One nursedescribed it as follows: “…the doctors here havenever made me feel that I'm not knowledgeable,they always embrace the fact that I have questions,they're always ready to teach me…they're alwaysvery open, and I appreciate that.”

“Stability” on the Same Unit

More than half of the participants spoke about theimportance of stability on the same unit when theyfirst started, which allowed them to get to know thepatients, the IHT, and the unit's culture. Stability onthe same unit positively impacted on new nurses'involvement in patient care plans and promotedcollaborative relationships with IHT members. Thiswas expressed by one nurse as follows:

…even though I'm not the primary nurse, I know a little bitabout almost everybody. So if the social worker is here…Ican still help. They don't have to say oh, we'll wait for theprimary nurse to come back…I can still answer questions, Ican still do what needs to be done for the client, it makes adifference…

Several nurses on the float team expresseddifficulties in rotating from unit to unit, such asfeeling like an “outsider,” being in a “perpetualstate of catch up,” and having a sense that they arethere to “plug in a hole.” One float nurse expressed:“you're kind of on your own…so that's a bit of adrawback in terms of feeling part of a team…youshow up for a shift… you don't know whereanything is…how the team works…at times it feelslike you're not really making much of a differenceor you're not really being listened to.”


DISCUSSION

Findings from this study highlight the transitionthat occurs as new nurses' move from adopting apassive role to learn how to fit in to engaging inan active role to impact on patient care. Central tothe transition was establishing credibility andbuilding trust. Although some findings are con-sistent with existing literature on new nurses'transition and socialization into practice andinterprofessional collaboration in general, thisstudy is unique in that it highlights the importanceof building trust, which enabled new nurses toengage in a more active role within the IHT in amental health organization.

In the passive role, listening to and watchingmembers of the IHT during team interactions was akey strategy for new nurses to learn how to fit in andplay the role as a new team member; nursecolleagues were included in the new nurses'description of members within the IHT. Lingard etal. (2002) report similar findings and suggest that byobserving the social relations inherent to interpro-fessional collaborative practice, novice nurses form“constructions” of the roles of members within theIHT and learn about their own professional roles inrelationship to others, all of which promote theirsense of professional belonging and support theirdesire for team membership.

By listening and watching, nurse participantslearned the social processes inherent to workingwithin the IHT, such as how to approach andcommunicate with physicians, and the appropriateverbal and nonverbal methods of providing teammembers with pertinent patient information. Inter-estingly, these processes contributing to the newnurses' socialization into IHTs are consistent withseveral other studies that explored the new nurses'socialization and transition into nursing practiceand found that learning the implicit rules govern-ing which IHT member to contact and how to mostefficiently and effectively provide team memberswith information are important learning needs fornew nurses (Casey et al., 2004; Delaney, 2003;Duchscher, 2001; Santucci, 2004; Schoessler &Waldo, 2006). Major, Kozlowski, Chao, andGardner (1995) suggest that learning and sensemaking occur as newcomers interact with organi-zational insiders such as coworkers and super-visors, who shape newcomers' assimilation intotheir professional roles and impact on their role

development. Moreover, through socialization,newcomers learn how to work as members ofIHT (Duchscher 2001, 2008; Santucci, 2004;Schoessler & Waldo, 2006), which facilitatestheir integration into a teamwork environment(Cantrell, Browne, & Lupinacci, 2005; Santucci,2004). All of this speaks to the importance ofeffective role modeling among IHT membersduring interprofessional collaborative practice.

Inherent to the new nurses' active role withinthe IHT was collaborating to ensure a safeenvironment, for patients, for the IHT, and forthemselves. Safety within the mental healthenvironment was a main issue expressed bymost of the new nurses in this study. Similarly,safety within the unpredictable and sometimesvolatile nature of mental health environments,associated with violent situations and risks fordanger (Cowman, Farrelly, & Gilheany, 2001;Gilburt, Rose, & Slade, 2008; Owen, Tarantello,Jones, & Tennant, 1998; Trenoweth, 2003), hasbeen noted to be a central concern for bothpsychiatric patients and mental health careproviders (Quirk, Lelliott, & Seale, 2004).Interprofessional collaboration is necessary inmental health to create safe environments thatprotect patients' safety to self and safety of others(Brunt & Hansson, 2002; Shives, 2005).

New nurses in this study assumed bothindependent and interdependent role functionsin ensuring a safe environment, which includedassessing the mental and physical status ofpatients; providing pertinent information toother members of the IHT; communicatingpatient responses to pharmacological interven-tions and the need for any changes in themedication regimen; and accompanying otherHCPs during patient interventions when safetywas a concern. Such functions are reflected inthe literature, where, for example, Cowman et al.(2001) report that psychiatric nurses' roles inpromoting safety may include monitoringpatients frequently, assessing for any factorsthat may precipitate a violent episode, commu-nicating and analyzing pertinent information withother members of the IHT, and planning andevaluating strategies aimed at promoting a safework environment.

New nurses in this study expressed that trustamong members of the IHT is essential forinterprofessional collaboration and allows them


to depend on each other for safety. Similarly,other studies have identified trust as a determinantfor successful interprofessional collaboration,which creates a sense of interdependency amongteam members and impacts on members' per-ceived safety (D'Amour, Ferrada-Videla, Martin-Rodriguez, & Beaulieu, 2005; Henneman, Lee, &Cohen, 1995; Orchard, Curran, & Kabene, 2005;Quirk et al., 2004; Sherwood, Thomas, Bennett,& Lewis, 2002). Interdependency within collab-orative relationships flourishes when team mem-bers trust each other's knowledge, expertise, anddecision-making capabilities (Orchard et al.,2005). Consequently, a lack of trust amongteam members negatively impacts on groupcohesion, communication, and accountability(Firth-Cozens, 2004; Sherwood et al., 2002). Fornew nurses in this study, trust was built overtimethrough demonstrating that they have done a“good job” with their patients and by disseminat-ing critical patient information to team membersin a timely manner. These findings are consistentwith other studies, which suggest that buildingtrust takes time, requires past successes andconfidence in one's role (Henneman et al.,1995), and is fostered through open communica-tion, sharing pertinent information, voicing one'sopinion, and participating in decision making(Sherwood et al., 2002). Moreland and Levine(2002) note that knowledge and ability displayedby new team members impact on the amount oftrust given to them by full members.

Interestingly, establishing credibility and build-ing trust were difficult for float nurses in thisstudy, who lacked the stability of being assignedto work on one unit. Nurses' lack of stability ona given unit negatively impacts on teamfunctioning, such as group cohesion and collab-oration, hindering effective work relationships(Adams & Bond, 2003). Nurses in this studywho floated expressed that at times they did notfeel listened to and were not able to answerquestions asked of them by members of the IHTregarding their patients.

Implications for Practice

Findings from this study have implications fornurse managers, administrators, and educators.Nurse managers and administrators can play acentral role in creating healthy work environmentsthat promote interprofessional collaborative prac-

tice (D'Amour & Oandasan, 2005; RNAO, 2006)and facilitate new nurses' transition into IHT. Somestrategies may include the following:

• Ensuring that effective collaboration is mod-eled to learners (D'Amour & Oandasan, 2005),such as new nurses entering practice.

• Encouraging collaboration between new nursesand members of the IHT (Bowles, & Candela,2005) while supporting their attendance andparticipation in team meetings and rounds.

• Providing new nurses with consistent patientassignments.

• Increasing the presence of new nurses sched-uled on day shifts to promote and support theirinteraction with the IHT.

• Developing a time-limited focus group opportu-nity for new nurses to discuss and explore theirsocialization into the IHT and their experienceswith interprofessional collaboration.

• Providing new nurses with in-services that focuson safety within a mental health setting to supporttheir contributions to creating a safe environment.

• Providing all members of the IHT withprofessional development educational initia-tives that focus on collaborative practice(Creating an Interprofessional Workforce,2007; D'Amour & Oandasan, 2005) and ondeveloping communication skills, which areessential for effective interprofessional collab-oration (RNAO, 2006).

Nurse managers and administrators can play adirect role in improving new nurses' experienceson the float team and foster their socialization intothe IHT by providing them with a sufficientorientation on one unit prior to floating. A timeframe of 3 months has been suggested in theliterature so as to allow new nurses to becomecomfortable in their skills, to be familiar with theorganization's rules and protocols, and for consis-tent support from IHT members (Almada, Carafoli,Flattery, French, & McNamara, 2004; Boswell etal., 2008). Moreover, nurse managers and admin-istrators can try to develop more part-time or full-time positions for new nurses to reduce theirpresence in a float team and promote their stabilityon a single unit.

Nurse educators at the faculty level can promoteinterprofessional education to ensure that new nursesenter practice with appropriate knowledge and skills


needed to work as effective members of the IHT(Health Canada, 2004; RNAO, 2006). Positive out-comes of implementing interprofessional educationmay include the following: Health care students fromvarious disciplines will be socialized in workingtogether toward joint problem solving and shareddecision making and students will develop a mutualunderstanding of each disciplines' contributions tocare and will acquire the competencies required forinterprofessional collaborative practice (HealthCanada, 2004). Nurse educators can also selectclinical practicum settings that promote interprofes-sional collaboration (D'Amour & Oandasan, 2005;RNAO, 2006) and encourage student nurse involve-ment in collaborative practice.

Limitations

The findings reported here are specific to newnurses in one mental health organization. The smallsample of new nurses in this study did not permitfor comparisons to be drawn between differenttypes of participants. For example, it may beinteresting to explore in future studies the potentialdifferences in experience between new registerednurses and nurses who have graduated but have notyet become registered nurses (i.e., registered nursecandidates). Knowledge gained from this studydoes provide an initial understanding of newnurses' experiences of their roles within the IHTin a mental health context and highlights thesignificance of building trust within the IHT.

CONCLUSION

Findings from this study highlight a transitionthat occurs as new nurses' move from adopting apassive role to learn how to fit in to engaging inan active role to impact on patient care.Establishing credibility and building trust withinthe IHT were central to the transition. Trust wasfound to be a key determinant for interprofes-sional collaborative practice; both trust andinterprofessional collaboration are fundamental toensuring a safe work environment within a mentalhealth organization.

ACKNOWLEDGMENT

The primary researcher was funded by fellow-ships from the Training and Expertise in NursingAdministration Research Centre (FERASI). The

authors thank Dr. Margaret Purden, School ofNursing, McGill University.

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