Welcome to this edition of Journal of Nursing Management which explores interagency collaboration and teamwork. The articles featured capture and critique professional and interprofessional activity from a range of viewpoints, although all have leadership as a unifying strand. As individuals with experience of the interagency practice context, albeit in different roles, professions and agencies, we have valued this opportunity to present some of the current research concerns of practitioners. Much of our experience has been in the field of learning disability and this is reflected in some of our commentary. However, the papers published in this edition also embrace the broader field of practice and we hope that the issues presented by our contributors offer new insights into both the familiar and less common dynamics of exchange in the interagency arena.
Having first encountered some of the challenges of interagency and interprofessional working in a different decade, it is interesting to note both some recurring themes and a shift in focus of the researcher practitioners writing here. In our editorial role, it is tempting to ignore the recurring themes, taking them as givens and go directly for the innovative in order to please our readers, and embrace the spirit of change and modernization. However, it remains the case that those omnipresent issues remain constant themes as the contexts and tensions of professional and interprofessional practice shift.
One such constant theme is that of leadership. All too often in interprofessional practice, it has been the action of a few individuals with vision that have created real change in service delivery in relation to peoples lives and opportunities. These individuals have managed to work and lead effectively despite the maze of separate service budgets, distinct disciplines and different values. Antoinette McCallin's paper considers these political, socio-economic and ideological strands in relation to models of leadership in health care in the 21st century. As she suggests, leaders of today need to take account of very different interprofessional or interdisciplinary practice, a world away from traditional forms of leadership based on rigid disciplinary separation, individual professional expertise, and competition for resources. Instead McCallin endorses a shared model of team leadership, where each person accepts responsibility as a member-leader, and where individuals step in and out of the primary leadership role, guiding colleagues and making decisions. However, as she states, developing individuals to take on these roles requires investment and further research, and the concept of interdisciplinary team leader remains a relatively new one. Crucially McCallin concludes that interdisciplinary leadership may be a critical role for the nurse. This may be highly significant when we consider the impact of the All Means All agenda (DoH 2002) which in health terms means that specialist learning disability nurses will share their knowledge and skills with other disciplines and professionals to help mainstream health services meet need. The paper by Sharon Outhwaite describes, from an individual learning disability nurse practitioner perspective, the processes involved in leading change towards an integrated team context. Again there are constantly recurring themes, notably frustration around resource constraints at organizational level across agencies as well as the problem of different organizational values. However, the insightful exploration of leadership styles and skills from Outhwaite suggest some tools for change, underpinned by a recognition of the need to ensure that individual reflexivity is not lost as the context of practice changes and the number of partner agencies increases. This is critical if the successful implementation of Valuing People is to take place and the need to work in partnership grows. Increasingly, partner organizations in learning disability services are likely to move beyond the health and social care service sectors and engage with others, i.e. employment services, Connexions and Learning and Skills Councils, all which have a different primary focus and language.
Further, the position of individuals who use services and their families must remain central and underpin all partnerships. Recent research from Joseph Rowntree Foundation (2003) indicates that service users look at their lives as a whole whilst services take a more fragmented approach. Service boundaries, professional roles and the tensions of family empowerment are raised by Fiona Gallagher and Melanie Jasper in their research into health visitors' experiences of family group conferences (FGCs). In exploring the health visitors' experiences of FGCs, the authors note the gaps between the health visitors' theoretical perceptions of the process as an empowering one for families, and their actual experience gained through attendance. The authors suggest that for the practitioners in this study, further training along with stronger interagency and interprofessional links may be required, with specific recommendations on FGCs in local child protection guidelines. Whilst the authors do not attempt to generalize their findings, there are issues here for all professionals faced with very different and changing contexts for practice, and different expectations from service users. We have valued the chance to make public some of the more complex and emerging concerns of professionals.
Janet McCray's paper explores interprofessional practice and changing leadership roles, from the individual practitioner perspective, in the long term support of people with learning disability. Through bringing together practitioner knowledge and thoughts on good practice, a tool for use in practice has been designed. One of its purposes is to facilitate the identification of training needs of professionals, significant for professionals and their managers at this time when ideas around effective interprofessional leadership roles are changing, and there are new skill-mix demands on the workforce.
Responding to modernization, and attending to the needs of practitioners in extended or changing roles, is the challenge that leaders face in research by Trish Reay, Karen Golden-Biddle and Kathy Germann. Their work in Canada explores the introduction of a new nurse practitioner role and offers some useful insights into the anticipated and actual interprofessional team challenges to their role development. Leadership strategies to facilitate and guide the process are given which offer a refreshing shift in focus in both identifying, and responding to, that all too constant inertia labelled the interpersonal issue!
Another challenge, again a constant theme in many agencies, is that of determining the competence of its workforce. As we mentioned earlier, new skill-mixes, differing service user expectations, and changing networks and partnerships all demand new knowledge and skills, and increasingly sophisticated training and education strategies from workforce planning confederations. The paper here from Riita Meretoja and Helena Leino–Kilpi compares nurse managers and their practising nurses' assessments of their competence. In common with other studies, there was a higher level of competence accorded by nurse mangers on their nursing staff, than in the practising nurses' own competence assessments. However when it comes to frequency of use of competency there was a higher level of agreement across both groups. What is interesting here is the point raised by Meretoja and Leino-Kilpi in relation to what leaders and managers actually do with research data, and how it can be used to inform decision-making and improve quality of care.
In the different context of the nursing home sector, Julie Baldwin and colleagues review the role of the support worker. The literature suggests some evidence of difference regarding the views on the support worker role, from the support workers themselves and registered nurses. Furthermore Julie and colleagues document a lack of preparation for the support worker role, amidst a considerable blurring of boundaries in relation to the nursing and support worker tasks. The issue of level of support and a need for greater understanding of the support worker role from other professionals was noted.
For us it returns us to another common theme, which is that managers for the best possible reasons, may think staff are competent to take on new roles and are able to work in new contexts, when this may not yet be the case. Increasingly in healthcare, all members of interprofessional teams will have to work with vulnerable groups such as those with learning disability, as interagency working shifts and broadens.
Some of the papers published here have shown that not all staff are fully prepared for this shift, and that they may still be unsure of the value of some emerging professional, interprofessional roles, and care strategies. On the other hand, a number of innovative tools and potential leadership strategies have been offered in response to this situation. The future of interagency working looks positive and it has been good to lay aside some of the earlier concerns of interprofessional working, notably traditional hierarchies in healthcare and the immoveable interpersonal conflict. However there remain considerable challenges for leaders, with regard to facilitating a truly interprofessional healthcare workforce. For despite faith in and positive views of their teams, unless they take on board many of the questions and issues raised by these contributors, in terms of planning and providing focused training and education, the quality and fragmentation of services will be unchanged.