Teamwork: a Qualitative Study

International Journal of Mental Health Nursing (2011) 20, 454–459

doi: 10.1111/j.1447-0349.2011.00752.x

Feature Article

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Valuing teamwork: Insights from newly-registered nurses working in specialist mental health services
Michelle Cleary,1 Jan Horsfall,1 Judy Mannix,1 Maureen O’Hara-Aarons1 and Debra Jackson2
1

Family and Community Health Research Group, School of Nursing and Midwifery, University of Western Sydney, and 2Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, New South Wales, Australia

ABSTRACT: In this qualitative study, the experiences of a small cohort of registered nurses (RN) during the first 2 years of mental health employment were documented. A total of 13 semistructured interviews were completed from within a specialist mental health setting. Eleven issues were identified: (i) teamwork; (ii) experiential learning; (iii) self-development; (iv) confidence; (v) listening; (vi) rapport; (vii) keen observation; (viii) patience; (ix) empathy; (x) learning from colleagues; and (xi) maintaining a positive approach towards patients. The nurses focused on the here-and-now circumstances, rather than on future plans, or past preparation, and were able to elucidate the qualities and skills that they brought to their clinical work. Participants were most proud of achievements that bridged the personal and professional, such as self-development, working closely with patients to develop rapport, experiential learning, and teamwork. Findings highlight the importance of teamwork to newly-graduated RN entering the mental health environment. It is known that teamwork can convey a sense of belonging and help create an environment in which applied experiential clinical learning can occur. Therefore, it is important that efforts are made to facilitate team building and opportunities for teamwork when new graduates are transitioning into the mental health clinical practice environment. KEY WORDS: experiential learning, interpersonal, mental health nursing, teamwork, transition programme.

INTRODUCTION
The transition from student to registered nurse (RN) is a crucial period in the career trajectory of nurses. Student nurses’ expectations of the impending transition to RN, while encased within feelings of apprehension, are generally positive (Kelly & Ahern 2008), particularly in relation to working relationships with colleagues (Heslop et al.

Correspondence: Michelle Cleary, Family and Community Health Research Group, School of Nursing and Midwifery, University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW 1797, Australia. Email: [e-mail] Michelle Cleary, RN, PhD. Jan Horsfall, PhD. Judy Mannix, RN, BEd (Nsg), MN (Hons). Maureen O’Hara-Aarons, RN, MN. Debra Jackson, RN, PhD. Accepted April 2011.

2001). Adequate support and assistance for new graduate nurses during the transition period optimize their experiences (Cleary et al. 2009a,b; Mannix et al. 2009), and the effectiveness of the transition has been linked to workforce sustainability (Cleary & Happell 2005). There is an emerging body of research into the experiences and perceptions of new graduates during their first year of mental health nursing (Cleary & Happell 2005; Cleary et al. 2009a,b; Hayman-White et al. 2007; Patterson et al. 2008; Prebble & McDonald 1997). The literature reveals that programmes to aid the transition to the psychiatric/mental health environment are considered significant in mental health nursing, but there is a paucity of published research to determine their effectiveness (Cleary et al. 2009a,b). The present project documents some experiences of a small cohort of RN during the first 2 years of mental health

© 2011 The Authors International Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc.

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employment, and explores their views about their challenges and achievements. Exploring some of these clinical experiences might have implications for transition programmes, structured supportive clinical learning opportunities, and nurse retention in mental health services.

METHOD
The study was approved by the relevant university human research ethics committee, and permission to circulate flyers was given by the Area Health Service Ethics Review Committee. Participants in the study were recruited from a specialist inpatient mental health facility via general invitation and through snowball sampling. They were required to have 3–24 months’ post-registration experience and to be undertaking (or have undertaken) their graduate year in mental health nursing. Individual interviews were conducted face to face by an experienced mental health nurse researcher (December 2010, January 2011). Interviewees were assured of confidentiality. There were eight semistructured questions that the interviewer asked each respondent, and these covered the following issues: reasons for undertaking a graduate year in mental health nursing, their experience of mental health during their undergraduate course, and the skills and qualities they consider necessary to work effectively in inpatient mental health units. The interviewer then asked informants to outline two situations from their recent clinical practice – one with what participants considered a positive outcome, and the other with a less desirable result – and to identify what has enabled them to feel proud to be a mental health nurse. Finally, they were asked about their career plans and to provide advice to RN considering working in mental health. Responses were transcribed and checked against the digital recording to ensure accuracy. Interview transcripts were read, coded, reviewed and categorized by the researchers to identify recurring ideas and themes that emerged in response to the semistructured questions. The researchers developed a qualitative overall picture of the interviewees’ experiences, challenges, and intentions, as well as more focused information associated with specific questions and clusters of elicited key issues.

RESULTS
A total of 13 interviews were completed. The qualitative analysis revealed 11 key issues. In order of prevalence, these were: (i) teamwork; (ii) experiential learning; (iii) self-development; (iv) confidence; (v) listening; (vi) rapport; (vii) keen observation; (viii) patience; (ix)

empathy; (x) learning from colleagues; and (xi) maintaining a positive approach towards patients. Overall, the issue that recurred most frequently was teamwork. It was discussed mostly in response to a memorable clinical situation with a positive outcome, but also in relation to advice, skills brought to the setting, and pride in their work, and arising from their undergraduate mental health clinical placement experiences and their attraction to mental health nursing in the first place. Participants were most forthcoming about the skills and qualities they felt they brought to mental health nursing. In order, these included the ability to convey empathy, listening well, having and gaining more confidence, being an astute observer, having a positive attitude (hopefulness), displaying patience, developing rapport, and fitting in with the team. Likewise, advice to new graduates contemplating mental health work was plentiful. In this category, both self-knowledge and development and clinical learning from colleagues were equally emphasized (by different respondents). In this vein, one respondent said: ‘You get to know yourself . . . and it’s really interesting and it (mental health nursing) is something you can go further with’ (RN 8). Confidence and patience were reiterated, as were listening, observing, teamwork, and maintaining a positive attitude. Responses to other questions were less diverse and numerous. Teamwork predominated when describing a scenario with successful results, along with the power of rapport development and listening, close observation of patient changes and activities, and paradoxically, gaining confidence from practise after a previous experience that did not work out well (such as giving an injection to a disturbed, distressed, and moving recipient). Overall, participants were most proud of achievements that bridged the personal and professional, such as self-development, working closely with patients to develop rapport, and experiential learning, along with teamwork. One respondent summarized her position by saying: ‘You can’t do anything without some rapport’ (RN 7). Generally, the interviewees focused on their here-andnow circumstances, rather than on future plans or past preparation. When asked specifically about career plans, the clearest and most frequent responses centred on experiential learning and building skills through clinical experience. One interviewee simply stated: ‘I just want to be a good nurse’ (RN 10). A small number said that they might consider postgraduate studies once they gained more clinical expertise. Seven of the respondents commented on aspects of their clinical placements during their undergraduate course as having opened their minds to positive aspects of

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working in mental health. For six interviewees, undergraduate mental health learning related primarily to clinical placements, with only two commenting on relevant classroom teaching. Ten of the unsatisfactory clinical incidents involved some form of aggression or violence; in one example, with tragic results. The others involved an inappropriate nurse–nurse directive; disappointment at patients who are deemed well at discharge, but are quickly re-admitted; and one participant expressed frustration regarding patients’ ongoing smoking and drug use. Five topics evoked more enthusiastic and richer responses, and these were, in order of number and diversity of responses: elucidating the skills brought to their clinical work, advice they could give to nurses considering a career in mental health, outlining a clinical situation that turned out well, naming an aspect of mental health nursing that allowed them to experience pride, and to a lesser extent, their future professional intentions. Three topics covered in the interview did not elicit lengthy responses. These focused on the reasons for entering mental health, their recollection of undergraduate mental health learning experiences, and a description of a clinical situation that did not turn out as well as they would have liked.

sional, and clinical learning support; intimate involvement with role models in complex situations, including boundary management; opportunities to practise communication when tension is high; and an interpersonal safety net for neophytes, patients, and the unit as a whole (Cleary et al. 2009a,b; De Bellis et al. 2001; Eraut 2004; McKenna & Newton 2008).

Further developing communication skills
When the 10 remaining issues are considered, the following coherent clusters are formed: enhancing communication skills, clinical learning, and personal qualities. Communication issues that the participants identified included rapport development, listening carefully, empathy, and observing closely. These skills are crucial to effective mental health nursing practice, and as they might not be fully developed in the majority of new graduates, they have to be recognized, practised, and refined to suit specific patients and professionals and a broad range of workplace events, occasions, and incidents. Cleary et al. (2011), in reviewing skills revealed by inpatient mental health nurses, recognize ‘ordinary communication’, which includes being with the patient, getting to know the patient, and recognizing subtle improvements, as well as ‘sophisticated communication’. The latter often emerges from tuned-in listening, and is evident as empathy under duress (Hem & Heggen 2003). The present participants appeared to be aiming to further develop the former, and building on experience, insight, and confidence to head towards the more complex therapeutic communication.

DISCUSSION Teamwork
The emphasis on teamwork can be interpreted in a range of ways; team focus had different meanings among the respondents. Some new graduates’ team commitment might be tantamount to taking shelter (Newton & McKenna 2007) from individual responsibility. For others, it could symbolize the cultural reality (Cleary et al. 2011), especially regarding how complex interpersonal challenges have to be addressed when the going gets tough. In response to being asked to give advice to a new graduate contemplating mental health, one interviewee put it like this: ‘I have a very good experience where excellent teamwork happens, and (I) feel energetic and motivated’ (RN 10). This nurse appreciated the synergy of the team as a whole and its capacity to achieve outcomes that individuals could not manage alone. As McKenna and Newton (2008) comment, teamwork might offer a ‘sense of belonging (that) would seem to be a critical aspect of workplace socialisation (which) in particular enables workplace learning to occur’ (p. 12). Thus, teamwork, as new graduates experience it, can be multifunctional and constitutes a foundation that provides personal, profes-

Clinical learning
This cluster includes experiential learning, selfdevelopment, and learning from colleagues. Clearly, these overlap to some extent; they include the potential for learning complex communication skills, and the first and third issues might devolve on teamwork. Experiential learning constituted the most prevalent idea when interviewees discussed their future plans. A succinct statement by RN 7 – ‘My career plans (are) to get more experience and be a better mental health nurse’ – is a representative response. These interviewees acknowledge that doing– reflecting–improving clinical skills takes time and cannot be squeezed into a predetermined timeframe. It is therefore crucial that senior nurses and managers also understand the complex reality and centrality of experiential clinical learning to new nurses entering the mental health environment (Valdez 2008).

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Duchscher’s (2008) decade of nurse transition research allowed her to develop an explanatory conceptual framework, with the first phase described as ‘doing’ (talking about the first year of professional acute care practice), followed by ‘being’, and culminating in expert independent clinical knowledge. ‘Their discovery that all was not as they had expected it to be sent these newly graduated nurses into a flurry of learning and subsequent performing’ (Duchscher 2008, p. 444) is emblematic of the ‘doing’ phase. In mental health nursing settings, it could seem that this ‘flurry of learning’ extends well beyond the first year, perhaps because the clinical work devolves on emotional self-awareness and a range of subtle abilities to articulate complex personal and interpersonal concerns with a clarity of language that resonate with clients’ needs. Clinical learning, especially in mental health nursing, is inextricably intertwined with self-development, an issue almost as common as experiential learning among these participants, and sprinkled across a broader range of questions. It came up most often when the RN were considering advice to new graduates: ‘You have to be able to challenge yourself on how to deal with difficult patients and (work out) how to overcome the difficulties’ (RN 6). This is a blunt acknowledgement that working in mental health challenges the nurse to interact with patients with multifaceted difficulties and understand these to allow them to be addressed in ways that improve patient wellbeing, while enabling the nurse to be safe (Waite 2006). Ultimately, this work challenges the person of the nurse to look inside themselves and develop awareness and skills that might not be knowingly used in their ordinary lives. Learning from colleagues is the third aspect of this interconnected learning cluster, and reveals the importance these neophyte nurses placed on the generosity of colleagues who showed willingness to contribute to their socialization, learning, and development. Professional generosity has been identified as an important and underacknowledged aspect of professional life in nursing (Jackson 2008). Learning from colleagues also emerged from being asked to give advice to newcomers to mental health nursing. One interviewee (RN 4) replied: ‘Be prepared to learn, and don’t be scared, because everything is a learning curve, and you can learn a lot from your colleagues, and everyone’s supportive’. This finding resonates with literature focusing on the clinical learning experiences of undergraduate nurses (Jackson & Mannix 2001), and encapsulates the anxiety and personal challenges, the opportunity to learn an array of skills, and the presence of supportive staff to facilitate clinical learning and development.

Personal attributes
After teamwork, experiential learning and confidence were the most frequently discussed issues. As many respondents mentioned confidence in response to qualities that they brought with them to the field as those who included it in the advice to new graduates. This indicates that for these interviewees at least, confidence is a personal quality and a virtual prerequisite for mental health work. One participant, however, provided the following tempering advice: ‘Don’t be too confident. In the university we learn lots . . . but . . . only having the knowledge is not enough. You need the skill. You need the experience’ (RN 2). As with advice, patience arose in response to questions about personal skills and in the advice section. RN 12 advised that new graduates ‘need to be full of patience and good listening skills; that’s the basic thing you need in mental health nursing’. The importance of a positive attitude was most evident in the responses to the skills RN bring with them to the workplace. One interviewee succinctly advised: ‘Confidence. Positive thinking and study in your spare time’ (RN 1). Having a positive attitude also can be an equivocal matter, a quality to strive for in the face of adversity, as well as an attribute to arrive with.

Strengths and limitations of this project
Finally, as with all research, there are strengths and limitations. The strengths of this study include the ability to document some experiences of a small cohort of RN during their first 2 years in the inpatient mental health environment, and ascertain views about their challenges and achievements, with the ultimate aim of improving new graduate nurses’ transition to mental health nursing practice. Notwithstanding this, the generalizability of the findings is limited, as only nurses from a large specialist mental health setting were interviewed. Other limitations include not being able to explore the views of nurses in more depth, the inpatient focus, and that the study itself was relatively small scale in nature.

RELEVANCE TO CLINICAL PRACTICE
Teamwork was identified as a crucial issue to these newlygraduated RN entering the acute mental health environment. The importance of becoming part of the team for these participants was revealed in several ways, notably in response to clinical situations resulting in positive outcomes, and the desire to become mental health nurses. It is known that teamwork can assist in professional

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M. CLEARY ET AL. and practical considerations. International Journal of Mental Health Nursing, 18, 265–273. Cleary, M., Matheson, S. & Happell, B. (2009b). Evaluation of a transition to practice programme for mental health nursing. Journal of Advanced Nursing, 65 (4), 844–850. Cleary, M., Hunt, G. E., Horsfall, J. & Deacon, M. (2011). Ethnographic research into nursing in acute adult mental health units: A review. Issues in Mental Health Nursing (in press). DOI: 10.3109/01612840.2011.563339. De Bellis, A., Longson, D., Glover, P. & Hutton, A. (2001). The enculturation of our nursing graduates. Contemporary Nurse, 11 (1), 84–94. Duchscher, J. B. (2008). A process of becoming: The stages of new nursing graduate professional role transition. The Journal of Continuing Education in Nursing, 39 (10), 441– 450. Eraut, M. (2004). Informal learning in the workplace. Studies in Continuing Education, 26 (2), 247–273. Hayman-White, K., Happell, B., Charleston, R. & Ryan, R. (2007). Transition to mental health nursing through specialist graduate nurse programs in mental health: A review of the literature. Issues in Mental Health Nursing, 28 (2), 185– 200. Hem, M. H. & Heggen, K. (2003). Being professional and being human: One nurse’s relationship with a psychiatric patient. Journal of Advanced Nursing, 43, 101–108. Heslop, L., McIntyre, M. & Ives, G. (2001). Undergraduate student nurses’ expectations and their self-reported preparedness for the graduate year role. Journal of Advanced Nursing, 36 (5), 626–634. Jackson, D. (2008). Random acts of guidance: Personal reflections on professional generosity. Journal of Clinical Nursing, 17 (20), 2669–2670. Jackson, D. & Mannix, J. (2001). Clinical nurses as teachers: Insights from students of nursing in their first semester of study. Journal of Clinical Nursing, 10, 270–277. Kelly, J. & Ahern, K. (2008). Preparing nurses for practice: A phenomenological study of the new graduate in Australia. Journal of Clinical Nursing, 18, 910–918. Mannix, J., Wilkes, L. & Luck, L. (2009). Key stakeholders in clinical learning and teaching in Bachelor of Nursing programs: A discussion paper. Advances in Contemporary Nursing, 32 (1/2), 59–68. McKenna, L. & Newton, J. M. (2008). After the graduate year: A phenomenological exploration of how new nurses develop their knowledge and skill over the first 18 months following graduation. Australian Journal of Advanced Nursing, 25 (4), 9–15. Newton, J. M. & McKenna, L. (2007). The transitional journey through the graduate year: A focus group study. International Journal of Nursing Studies, 44, 1231– 1237.

socialization, convey a sense of belonging, and contribute to an environment in which applied experiential clinical learning can take place (McKenna & Newton 2008). Furthermore, teamwork can create an environment in which modelling of desired professional nursing demeanour and conduct can occur. Research into undergraduate student clinical learning reveals the importance of clinical nurses to student learning (Jackson & Mannix 2001), and it is likely that this continues throughout the transition experience. In view of the centrality and importance of teamwork, it is therefore critical that efforts are made to facilitate team building for new graduates, and ensure the provision of opportunities for teamwork, particularly when neophytes are transitioning into the mental health clinical practice environment.

CONCLUSION
The findings from this study highlight the importance of the new graduate experience in shaping the early career development of nurses and contributing to the development of their professional demeanour and values. Eleven issues were discerned from interviews with new graduate nurses: (i) teamwork; (ii) experiential learning; (iii) selfdevelopment; (iv) confidence; (v) listening; (vi) rapport; (vii) keen observation; (viii) patience; (ix) empathy; (x) learning from colleagues; and (xi) maintaining a positive approach towards patients. For our participants, the focus was on the here and now, rather than on past educational preparation or plans for the future. They valued the contribution of colleagues to their learning, and placed high importance on feeling they were part of a team. As team members, all mental health nurses have an important role to play in ensuring optimal transition experiences for neophytes entering acute mental health services.

ACKNOWLEDGEMENTS
The project was partially funded by the School of Nursing and Midwifery, University of Western Sydney.

REFERENCES
Cleary, M. & Happell, B. (2005). Promoting a sustainable mental health nursing workforce: An evaluation of a transition mental health nursing programme. International Journal of Mental Health Nursing, 14, 109–119. Cleary, M., Horsfall, J. & Happell, B. (2009a). Transition to psychiatric/mental health nursing programs: Expectations

© 2011 The Authors International Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc.

INSIGHTS FROM NEWLY-REGISTERED NURSES Patterson, C., Curtis, J. & Reid, A. (2008). Skills, knowledge, and attitudes expected of a newly-graduated mental health nurse in an inpatient setting. International Journal of Mental Health Nursing, 17 (6), 410–418. Prebble, K. & McDonald, B. (1997). Adaptation to the mental health setting: The lived experience of comprehensive nurse graduates. Australian and New Zealand Journal of Mental Health Nursing, 6, 30–36.

459 Valdez, A. M. (2008). Transitioning from novice to competent: What can we learn from the literature about graduate nurses in the emergency setting? Journal of Emergency Nursing, 34 (5), 435–440. Waite, R. (2006). The psychiatric educational experiences of advance beginners RNs. Nurse Education Today, 26, 131– 138.

© 2011 The Authors International Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc.

Copyright of International Journal of Mental Health Nursing is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder 's express written permission. However, users may print, download, or email articles for individual use.

References: Cleary, M. & Happell, B. (2005). Promoting a sustainable mental health nursing workforce: An evaluation of a transition mental health nursing programme. International Journal of Mental Health Nursing, 14, 109–119. Cleary, M., Horsfall, J. & Happell, B. (2009a). Transition to psychiatric/mental health nursing programs: Expectations © 2011 The Authors International Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc. INSIGHTS FROM NEWLY-REGISTERED NURSES Patterson, C., Curtis, J. & Reid, A. (2008). Skills, knowledge, and attitudes expected of a newly-graduated mental health nurse in an inpatient setting. International Journal of Mental Health Nursing, 17 (6), 410–418. Prebble, K. & McDonald, B. (1997). Adaptation to the mental health setting: The lived experience of comprehensive nurse graduates. Australian and New Zealand Journal of Mental Health Nursing, 6, 30–36. 459 Valdez, A. M. (2008). Transitioning from novice to competent: What can we learn from the literature about graduate nurses in the emergency setting? Journal of Emergency Nursing, 34 (5), 435–440. Waite, R. (2006). The psychiatric educational experiences of advance beginners RNs. Nurse Education Today, 26, 131– 138. © 2011 The Authors International Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc. Copyright of International Journal of Mental Health Nursing is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder 's express written permission. However, users may print, download, or email articles for individual use.