Journal of Nursing Education

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The Teamwork Project: A Collaborative Approach to Learning to Nurse Families

Marguerite Warner, RN, PhD; Marilyn Ford-Gilboe, RN, MScN; Yvette Laforet-Fliesaer, RN, MScN; Joanne Olson, RN, MS, PhD; Catherine Ward-Griffin, RN, MScN

Abstract

ABSTRACT

The purpose of this exploratory study was to gain insight into students' perceptions of learning to nurse families using a team approach. A sample of 112 thirdyear baccalaureate nursing students provided data from clinical journals and responses to a teacher-developed questionnaire regarding number of home visits made with a partner, the extent to which partners shared responsibility for the nursing care of two families, perceived benefits and disadvantages of teamwork, roles assumed by team members, perceived outcomes of the team approach, and suggestions for revision of the approach. The degree to which students shared responsibility was moderate and positive perceptions of teamwork were significantly correlated with the degree of sharing of nursing activities. Using Spradle/s qualitative method of domain analysis, interpretation of data from students' clinical journals revealed subjective aspects of the experience that appeared to influence teamwork practices and attitudes. Results suggest that the shared assignment approach offers students a unique opportunity to learn about the realities of collaborative nursing practice.

Abstract

ABSTRACT

The purpose of this exploratory study was to gain insight into students' perceptions of learning to nurse families using a team approach. A sample of 112 thirdyear baccalaureate nursing students provided data from clinical journals and responses to a teacher-developed questionnaire regarding number of home visits made with a partner, the extent to which partners shared responsibility for the nursing care of two families, perceived benefits and disadvantages of teamwork, roles assumed by team members, perceived outcomes of the team approach, and suggestions for revision of the approach. The degree to which students shared responsibility was moderate and positive perceptions of teamwork were significantly correlated with the degree of sharing of nursing activities. Using Spradle/s qualitative method of domain analysis, interpretation of data from students' clinical journals revealed subjective aspects of the experience that appeared to influence teamwork practices and attitudes. Results suggest that the shared assignment approach offers students a unique opportunity to learn about the realities of collaborative nursing practice.

Introduction

Virtually all nurses have had experiences with teamwork and most are aware of the critical role that teams play in their daily work lives. Teamwork is more likely to succeed if members are able to collaborate effectively with one another (Larson & Lafasto, 1989). In this sense, then, there is practical significance associated with helping nursing students to develop the skills and attitudes of collaboration and effective teamwork.

It is also clear that the discovery of valid responses to the health problems of today's society demands the effective collaboration of many individuals. When nurses share responsibility for a group of clients, their common experiences provide a powerful resource for accumulating knowledge about health-promoting interactions. Thus, inquiry-based practice that integrates multiple points of view has become fundamental in assuring the continuing relevance of nursing to the needs of the people we serve. Shared clinical assignment is one method of assisting students to explore teamwork, not solely as a method of getting the work done, but as a way of studying the practice situations in which they are involved and deciding how to make use of their collaborative expertise.

Background

Literature Review

Unfortunately, there is little research to help us understand the process through which nursing curricula and methods of clinical assignment influence students' experiences and perceptions of teamwork. A few descriptions of student responses to team assignment are available, however, and these experiences have generally been positive. Delorey (1972) used the term "multiple assignment" to describe an instructional method where a group of students is referred to one patient. This arrangement usually involves three students: one student provides the nursing care, the second gathers and supplies information pertinent to the patient's situation, and the third functions as an observer of interactions and patient responses. Through informal observation and student feedback, Delorey noted that his students initially resisted the team approach, especially the observer role, but appeared to "slowly come to value the experience of learning with their classmates* (p. 295). New graduates who had been involved in the multiple-assignment method as students said that they had learned to view nursing as an intellectual activity, "not just doing," and that they now felt free to "share with* and "question" their coworkers.

Saxon (1975) observed similar responses among sophomore nursing students, in particular, "their spirit of cooperation for learning" and appreciation for "how much they had learned from each other" (p. 2184). More recently, Olson and Hare (1985) explored the use of team assignment as an instructional method while working with a small group of post-diploma baccalaureate students in a community health nursing course. These authors also suggested several advantages of the team structure, including increased collaboration among peers, and closer faculty supervision due to the smaller number of clients.

Edwards, Eyer, and Kahn (1985), who implemented the practice of shared home visits to increase students' safety during their public health nursing experience, conducted a formal, questionnaire-based survey of student opinions about the benefits of shared home visiting. Overall, students' responses to statements concerning support, collaboration, and safety were positive; of these, support was perceived to be the most important benefit. None of the items addressed inquiry, or what Delorey (1972) referred to as the "intellectual" dimension of nursing practice. Nevertheless, when taken together, the literature on shared assignment suggests that if the psychological climate of student team relationships is positive, the pursuit of common objectives, not merely individual agendas, can occur.

The Family Nursing Course

A new undergraduate course in family nursing was implemented by our faculty in 1988. The course is based on Allen's model of nursing for health (Allen, 1977, 1983, 1986; Kravitz & Frey, 1989) and includes a practice component in which clinical teams of 10 to 12 students work with families in the community, primarily in the home setting. Initially, we sought two family referrals for each student. Although they visited their families independently, students examined nursing situations together in the weekly team conference.

Early in their discussions, students became aware of not only the difficulties that today's society poses to families, but also the diverse patterns of behavior that constitute modern family life. These discoveries jarred loose many of their assumptions about the attributes of healthy families. As a result, they began to question the accuracy of their interpretations of family data and seek assurances that they were "on the right track." Without direct knowledge of each other's families, however, students could not actually test the validity of their perceptions in the group or, alternatively, offer suggestions that were especially relevant to a particular family's situation. Faculty covisits provided the "experienced eye" that students were looking for, but these visits required a large investment of faculty time and, clearly, increasing their frequency was not the best way to orient students to one another as professional nursing colleagues. Over the summer of 1988, we reviewed our observations of student teamwork and revised the practice component of the course to better support collaborative learning and contain faculty workload.

The Teamwork Project

One strategy used to deal with these issues involved the implementation of "the teamwork project." This sharedassignment approach to learning to nurse families requires each student to select a partner from within the clinical team. Each pair of students is then referred to two families to provide nursing care over a three-month period. We introduced the primary-associate concept of team structure to assist students to organize their work together. Within such an arrangement, each student functions as the primary nurse for one family, and as an associate nurse for the other. Students were also advised, however, to let their roles develop in interaction with the families.

The Research Project

Because we wanted to ground our understanding of student teamwork in the experiences and perceptions of students, we also conducted a research study of the shared-assignment approach, utilizing both qualitative and quantitative methods of inquiry. The purpose of the study was to gain insight into the teamwork project from the student's point of view. More specifically, we sought to answer the following research questions:

1. To what extent do student partners actually work together and share responsibility for nursing two families?

2. How do students perceive the teamwork experience at the end of the clinical rotation?

3. What factors appear to influence students' teamwork practices and attitudes?

Method

An exploratory design was employed to examine students' experiences of teamwork. The population consisted of 147 students completing their clinical rotation in family nursing during the 1989-1990 academic year and the fall semester of 1990. Of these, 112 students (76.2%) agreed to participate in the study by signing a consent form permitting us to use data from their clinical journals and their responses to a questionnaire completed at the end of each rotation.

Three methods of data collection were employed:

1. A teacher-developed questionnaire. The questionnaire provided information regarding number of home visits made with a partner, the extent to which partners shared responsibility for the nursing care of two families, perceived benefits and disadvantages of teamwork, roles assumed by team members, perceived outcomes of the team approach, and suggestions for revision of the approach. Data were also collected on student age, program (generic or post-RN), and previous experience with teamwork.

Table

TABLE 1Degree of Sharing of Specific Nursing Activities

TABLE 1

Degree of Sharing of Specific Nursing Activities

2. Students' clinical journals. These journals were examined page by page and all entries pertaining to the shared assignment were transcribed into typed protocols. The data included students' descriptions of their activities, the relationship with their partner, the nurse-family relationship, and their feelings about events over the course of the experience.

3. Participant observation by members of the family nursing faculty. Field notes documenting faculty members' observations of interactions between student partners during clinical conferences, home visits, and meetings with student teams were kept. (Due to limitations of time, however, faculty field notes were not included in the formal analysis.)

All identifying information was removed from the journal transcripts and questionnaires prior to analysis. The questionnaire included numerically coded items that yielded quantitative data, and open-ended questions (e.g., "What are the benefits and risks of this type of team assignment?") that elicited word data. Content analysis of the latter was conducted to transform these data to simple tallies of like responses for the purpose of categorization. Descriptive statistics were then used to analyze the questionnaire data.

Spradley's (1980) qualitative method of domain analysis was employed to organize and interpret student journal data. All transcripts were read line by line and coded into substantive categories. Categories (domains) were then reviewed, category definitions refined, and miscoded data receded. A process of continually comparing each category to all others further refined the categories relevant to the study. These domains were then organized into larger categories. For example, in their initial entries students described a variety of thoughts and feelings, most of which fell into one of three domains: perceived opportunities, concerns about their competence, and concerns about being judged by their partner. After further analysis these domains were organized into a larger category we called "Perceptions of the New Clinical Assignment."

Results

In this section, we describe how students carried out the clinical assignment and their evaluative perceptions of the teamwork experience. We draw upon the journal data to describe those aspects of the experience that appeared to influence students' teamwork practices and attitudes.

Students' Teamwork Practices

Because most student teams adopted the primaryassociate structure, we employed this concept in the first section of the questionnaire. We asked students to (a) state the total number of visits to their "primary" family and how many of these were made with their partner, (b) rate the degree to which they and their partner shared responsibility for each of the nursing activities listed in Table 1, and (c) describe the roles they played when acting as an "associate" nurse during the home visits.

The amount of joint home visiting by partners ranged from 0% to 100%. On average, students were accompanied by their partner on 30% of the home visits. To further investigate the extent to which students shared responsibility for nursing their assigned families, we provided a list of seven common activities. Students were asked to rate the degree to which each activity was shared, using a five-point Likert scale (1 = not at all, 5 = completely). Mean scores were computed for each activity and then rank ordered (Table 1). Items were also summed to represent the total degree of sharing. All items were significantly intercorrelated and the internal consistency of the scale was .82.

The greatest degree of sharing occurred when students discussed the families at clinical conferences and during interactions with family members in the home. Lesser degrees of sharing were noted relative to planning nursing care, seeking out resources, discussions with the health care team, and intervening with the family. Documentation in the family record was the least shared activity. From the students' perspectives, then, the overall degree to which they shared responsibility for nursing was moderate (X= 18.19).

When asked, "Which of the following - observer, participant observer, active participant - best describes the role you took as associate nurse during home visits?" approximately % of the students classified themselves as participant observers, 1A as active participants, and the remainder as observers. Thus, even though students made few home visits together, when they did, the associate nurse was likely to view herself as a participant. Furthermore, in response to an open-ended question concerning "other roles" played as an associate, most students provided a detailed and varied list of behaviors. These subtle features of student teamwork fell into one of three domains:

Figure 1. Distribution of evaluative perception scores by year.

Figure 1. Distribution of evaluative perception scores by year.

* Moral support: listen to, encourage, reassure, commiserate with partner.

* Problem-solving: observe, share ideas, analyze, clarify, interpret, pose questions, identify gaps in data, validate, offer suggestions to partner.

* Interaction with family members: play with child to facilitate partner-parent conversation, make suggestions, teach, pose questions, offer information about resources, validate partner's and family's ideas.

Attitudes About the Teamwork Experience

We investigated students' evaluative perceptions of their teamwork experiences by providing nine outcome statements and a Likert scale for each that ranged from "strongly agree" to "strongly disagree." The statements read as follows.

This teamwork experience:

1. Reduced my anxiety about a new situation.

2. Has not affected my knowledge about teamwork.

3. Has improved my ability to be an effective team member.

4. Increased my confidence in my ability to work with a family.

5. Improved the quality of my nursing care.

6. Increased the competitiveness that I feel toward my peers.

7. Has not affected my knowledge about group decision making.

8. Provided opportunities to validate my perceptions.

9. Enhanced my learning experience.

Before administering the questionnaire to students in the second year of the study, we expanded the Likert scale from 4 points to 5 points to accommodate an "unsure" response. Thus, the perception scores for this group and for the first year's group were examined separately. A score representing general attitude was calculated for each student by summing the individual item scores. Lower scores indicated more positive perceptions of the outcomes of the teamwork experience. Internal consistency of the general attitude score was high in both year's groups (r = .87, r = .79, respectively). Further, in comparing the shapes of the two distribution curves, it was clear that, regardless of the differences in measurement, the bulk of the perception scores of both groups fell toward the positive end of the distribution (Figure 1). In addition, for both groups of students, positive perceptions were significantly correlated with the degree of sharing of nursing activities (r=-.42, p = .0001 and r=-.56, p = .0003, respectively).

Students also identified the risks and benefits of teamwork and described what they would do differently or would recommend to other students by responding to open-ended questions on these items. Content analysis of their responses produced a small set of categories for each item (Figure 2). It is interesting to note that most recommendations refer to increased interaction between partners. The strength of this theme suggests that students had gained a better understanding of the dynamics through which team relationships develop. As we will show in the next section, many of the perceptions of benefit and of risk that students made explicit on the questionnaire were discernible in the journal data as well.

Students' Subjective Experiences of Teamwork

In order to minimize researcher bias, the ethnographer analyzing the journal entries completed her work before the responses to the questionnaire were revealed to her. From the analysis emerged a remarkably consistent picture of the subjective aspects of the team nursing experience that affected how students carried out the assignment. These aspects include students' initial perceptions of the new clinical assignment, their initial experiences of their partner, their beliefs about the nurse-client relationship, and the compatibility of their time schedules.

Perceptions of the new clinical assignment. Many students wrote that they were "looking forward to" the family nursing experience, especially the opportunity to work closely with a classmate. The following excerpts capture the optimism and excitement that students expressed at the beginning of the experience.

I am looking forward to working in a team situation. So often in the hospital, you don't have the opportunity to really work together. By doing the clinical this way, you are able to communicate and share ideas with someone else.

I feel teamwork is especially important within this area of nursing. One may become self-absorbed ... if there is no one else to relate to.

A few students also described their anxieties and the relief they felt in knowing that they would make their first home visits with another student:

My greatest fear was trying to find my family's home because I am just terrible with directions, but I was relieved when T. and I decided to make our first visits together.

During our discussion, we disclosed our anxieties of the visit, which I thought reduced some tension. Finally, we went over the objectives of the initial visit and how we would approach our families. In many instances, we felt the same way (anxious), but we knew that we would both be there to support each other during the visit.

Table

FIGURE 2Perceived Benefits and Risks, and Recommendations

FIGURE 2

Perceived Benefits and Risks, and Recommendations

Other students, however, were worried about how the partner would evaluate their work:

I am uncomfortable enough working with a peer, especially one that I don't know well. I know it could be a lot of support, but on the other hand, I don't think 111 be relaxed during shared visits.

I'm afraid my partner will be evaluating me, so I don't really want to have a shared visit yet. This is a new situation and I don't know what to expect. It makes me nervous to have someone else there.

Another student, reflecting on her first home visit, described these worries in greater detail:

My first home visit went fairly well. I was really worried about having my associate nurse along. I felt very conscious of a lot of things I was saying. I guess I was mainly worried whether she would feel they were appropriate or if I was leaving out things I should have said or asked.

Initial experiences of the partner. When they received their family referrals, student partners met with each other to examine the information together, prepare for their first telephone calls or home visits, and in some cases, discuss how they would continue to work as a team. Meetings that went well left students feeling comfortable about working together:

Later that afternoon we went to the center and were briefed on our clients. We both asked questions about each other's family, to be sure we didn't forget anything. The idea of working with a partner is great. What she forgets to ask, I do, and what I forget to ask, she does.

I felt a mutual sense of excitement and enthusiasm as we discussed our families and what we hoped to do with them. I am really enjoying working with my partner and I can see a good relationship developing between us, full of support, confidence in one another, and trust.

On the other hand, partners who did not enjoy their initial meeting found it difficult to work together. As one student suggested, part of the problem may have been that they had not taken the time to know each other as persons:

We have been getting along better the last couple of weeks, and I am going to talk to her about how I felt at the beginning. I just didn't like being told what to do because she had already done home visits before. I wanted to learn for myself I think another factor is that we had never met before. This was our first interaction, and we needed to learn about each other first.

The first joint home visits also appeared to play an important role in teamwork practices. In the following excerpts, students describe the benefits they derived from their partner's presence:

I made my first visit today and I felt it went fairly well. The 5-year-old was quite active and wanted all of her mother's attention. This made it difficult for us to talk. D. suggested playing with her and she loved this idea. This made it much easier for us to talk. I feel that I will need D. there to help out with the 5-year-old and keep her preoccupied so that I can talk to the mom.

I offered her support and we decided that through close collaboration with each other we would sort through this situation. As a team, L. and I are able to share openly our frustrations, dilemmas, etc., that we are facing with our families, which I find very helpful and confidence-building. Following the visit, we discussed our feelings and both of us felt that the visit was quite unproductive. We talked about why and how we could have made it better.

However, when students perceived too great a discrepancy between their own competence and that of their partner, they worried about being a burden to or being overshadowed by the more "competent" peer: It was not that I didn't know about the information, but I felt a little inferior observing L. teach them about activity. I'm not sure if my teaching would have been as effective. I felt a little useless because after L. intervened and asked the family about what they had learned in the hospital about activity, all the questions following were directed at her.

I really learned a lot from what J. was doing. She has some different methods of communication, interviewing, and collecting data. In reality, J. intimidated me to begin with ... I thought maybe I wouldn't be of much help to her, kind of like an extra weight. I don't know what she thinks or feels.

Beliefs about the nurse-client relationship. Students saw themselves as responsible for developing a positive "trusting" relationship with the family. Their beliefs about the nature and conditions of such a relationship played an important role in decisions regarding joint home visiting. For example, many of those who chose to work alone did so because they thought that private, "one-on-one* interactions with family members were more conducive to trust and confidence than shared interactions. These beliefs are reflected in the following comments:

What is interesting is, once I explained to M. (family member) that I was her primary nurse and E. was her associate nurse, M. maintained eye contact with me only. E. and I thought it would help establish a trusting relationship if I visited alone. I'm wondering if M. might reveal more to one person. Ill see how it goes by myself next week. I personally find it easier to work by myself I think it can be difficult to establish a relationship with a family with another nurse present.

Other students who decided to work alone appeared to view the role of "primary nurse" as a personal assignment. Because they saw the responsibilities as their own, they thought it desirable to adopt the "one nurse-one family" arrangement so that family members would relate to them as "their" nurse. Note the ownership metaphor that these students used to explain their decisions:

I feel that as the primary nurse I'm responsible for the family. Therefore, I should be doing most of the work.

What really ticked me off was the way H. kept talking to Mrs. P about the good old days in nursing. Mrs. P used to be a nurse so I think she was really enjoying it, but H. didn't seem to want to help me meet my objectives for the visit. And I could hardly get a word in. We agreed that this would be my family, so I should have had most of the responsibility for establishing rapport, etc. I'm going to make some visits on my own so the P.'s will know that Fm their primary nurse.

An analysis of the social milieu in which students learn to nurse is essential to an understanding of how role expectations develop in nursing students. Although such an analysis was beyond the scope of our study, one group of students attributed their preference for doing things on their own to a competitive attitude fostered in the school environment:

Yes, people in our class are very competitive. Everyone is out for themselves. I think it is because we have had to fight for marks throughout our schooling in order to get into the best university programs.

Compatibility of time schedules. Limitations of time due to family responsibilities and part-time jobs made it difficult for some partners to conduct home visits together. Similarly, when teammates had very different class schedules or were referred to busy, dual-career families, they often found it easier to work on their own.

We are on different schedules and just find it easier to work on our own. Besides, S.'s family is really busy and would like us to visit when they are both home, about 6:30 PM. That's really hard for me because I have a class at 7 pm. We do consult each other occasionally, especially after the clinical conferences, but arranging shared visits has been too difficult.

Despite the difficulties they experienced, students who found satisfaction in working together appeared to make a concerted effort to use their drives to and from home visits, or moments between classes, to discuss their nursing situations:

A. and I have similar work styles. We are both goaloriented and want to "get the work done" first. Then we discuss our own lives. So although our schedules are quite different, we are able to give helpful input into each other's situations.

Discussion

In general, students made few home visits together, and the degree to which they shared responsibility for nursing their assigned families was lower than we had expected. It is possible, however, that the moderate to low sharing scores indicate a different definition of teamwork than "shared responsibility." Regardless, it is significant that those who made a greater number of joint home visits also reported a higher degree of sharing and perceived the teamwork experience more positively with respect to their learning and the quality of their nursing care.

It is also important to note that students reported considerably more sharing of responsibility whenever both partners were present in a setting and responding to the same events - discussing their nursing situations at clinical conferences, or interacting with family members in the home. In previous reports of shared-assignment methods of clinical instruction, two or more students were assigned to one patient or family (Delorey, 1972; Edwards, Eyer, & Kahn, 1985; Saxon, 1978). Under these circumstances, students may experience more sharing as a result of interactions required by the common assignment.

When left on their own to fashion an approach to the assignment to two families, most teams in the present study divided rather than shared the responsibility. Each partner identified his or her "primary" family and assumed relatively autonomous responsibility for nursing that family. Students referred to this family as "my family" and to themselves as a helper or resource person for the partner. No doubt, this practice was influenced by the students' interpretations of the primary-associate concept that we had introduced at the beginning of the term. Even when they were advised to explore the two roles informally and interchangeably, however, almost all teams used the idea as a way to formally organize their work around separate responsibilities. Thus, students appeared to view teamwork as helping one another carry out separate responsibilities, not sharing responsibility for nursing both families.

Students derived great satisfaction from helping one another when they knew that their actions made a difference. Rawls (1971) argued that a positive sense of professional self-respect is achieved when we value what we do, when our abilities are recognized and appreciated by others, and when we clearly understand how our efforts contribute to the activity in which we are involved. The students who worked closely together had more opportunities to see evidence of their helpfulness than those who did not, which may explain, in part, why their perceptions of the teamwork experience were more positive.

Not all students, however, were bothered by the lack of teamwork in their experience. Approximately 7% stated that they would prefer to "work alone" over "work with one teammate" or "work with rotating partners." As one student, who gently resisted all of her partner's invitations to "come meet my interesting family" said, "I don't feel the need to do that. I'm basically a loner. I prefer to work alone." Nor did she invite her partner to meet the family she was visiting, explaining that it would "disrupt the dynamics of the relationship." This student's undisguised rejection of a shared experience was not typical. It is instructive, however, because it brings into sharp relief the control issues that teams often face and, in her partner's response, the tendency to defer to individual agendas in order to avoid conflict.

Implications for Education and Future Research

The results of this study suggest that a shared clinical assignment that occurs over time offers students a rich opportunity to learn about the realities of teamwork. By assuming responsibility for organizing their work together, and by enjoying or suffering the consequences of their decisions, students can begin to clarify for themselves the abilities they bring to a health care team, and the difficulties that collaborative practice poses to them.

As we discovered in our analysis of the journals, however, the experience of teamwork is as complex as the process of learning to nurse families. The events that students described resemble the problematic situations of professional practice depicted by Schon (1983). Tb deal more appropriately with such situations, Schon recommended a model of practice he calls "reflection-inaction." Through reflection, the practitioner analyzes problems to discover new meanings. Each situation is treated as unique, and inquiry "is triggered by features of the practice, undertaken on the spot, and immediately linked to action" (p. 308).

According to Schon's (1983) model, the nurse educator would help students to develop their problem-solving capabilities, not by telling them what to do, but rather by providing opportunities for individual and group reflection. For example, when student teams receive their assignments, clinical conferences could be designed to engage partners in discussion of the first home visits. Students might be given a set of probing questions, such as: What is the purpose of the visits we are planning today? What might we talk about with family members? How shall we introduce ourselves? What strengths do each of us bring to this assignment and what abilities do we want to develop? Posing such questions may help partners begin to create a structure that integrates and focuses, rather than diffuses, their activities. As they explore other questions in subsequent conferences, a trust may develop that, in turn, will facilitate the growth of collaborative expertise. Students could also be advised to discuss their work styles and look at their weekly schedules together, so that they can identify mutually convenient times for joint home visiting and for working together throughout the semester.

When partners are having difficulty maintaining a positive relationship with one another, the teacher may offer to work independently with them for a few sessions. A "project" could be designed with these students to help them develop human relation skills that are especially relevant to their problems. In the process, they may begin to experience the partnership as a resource, not only for assisting families but for helping themselves to grow as well. Similarly, those who question the efficacy of joint interactions with family members could be invited to test their assumptions by comparing the effects of private visits and shared visits on the family's participation and learning.

Nurse educators might also open up reflective discussions with students by using classroom role playing to demonstrate the cooperative processes of getting to know one another's définitions of the situation. The process of coming to a mutual understanding of shared practice was difficult for many students in this study. Rx)Ie playing might also be employed to contrast these interactions with those where partners negotiate, perhaps unwittingly, independent rather than shared assignments.

Further, the teacher could help students to develop their knowledge about effective teamwork by assigning readings from the research literature. These may include experiments with cooperative learning in the school setting, studies of the characteristics of effectively functioning teams, and theoretical analyses of the concept of collaboration. Reports of qualitative studies that are grounded in the experiences and perceptions of team members would be especially relevant to the needs of students who are trying to come to terms with their own situation.

Finally, rather than introduce the primary-associate structure, student teams could simply be assigned to two families and be encouraged to develop their roles as they go along. Over the past academic year, this change was made and, while many other factors may have influenced students' experiences of teamwork, the current group of students have worked together to a much greater degree than students in the previous study groups. A preliminary analysis of our current data suggests that almost all home visits were shared with the partner and the degree of total sharing for this group is high when compared to that of the study groups.

Future research studies could focus on the effects of implementing the recommendations detailed in the preceding section. For example, a comparative investigation could be conducted of one setting in which all recommendations for improvement were implemented and another setting in which none of the recommendations was implemented. More focused studies could address one aspect of the recommended improvements, such as intervening directly with partners who are not getting along well. Other useful investigations could focus on varying the kinds of clinical setting in which the method of shared practice is implemented. Finally, the findings of follow-up studies of graduates as they assume their full professional role in the health care team could be used to design learning activities that help nursing students begin to extend their collaborative expertise into relations with other practitioners.

Conclusion

Effective teamwork requires collaboration, and most authors agree that collaboration involves sharing goals and responsibilities (Appley & Winder, 1977; Huntington & Shores, 1983; Keenan, 1982; Larson & Lafasto, 1989). Therefore, team members must be able to set aside individual agendas so that a common understanding of the situation can occur. As the students in this study discovered, however, the process of collaboration is not always easy, and certainly is not automatic. In our view, this kind of insight is an important first step in the development of students' understanding of the qualities of effective teamwork. Clearly, the shared assignment method of clinical instruction is a promising educational strategy. But it must be carefully constructed and monitored if the purpose is to assist students to learn how to examine complex situations together and work effectively with one another to discover valid responses to the health problems that today's families bring to nursing.

References

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  • Spradley, J. (1980). Participant observation. New York: Holt, Rinehart, & Winston.

TABLE 1

Degree of Sharing of Specific Nursing Activities

FIGURE 2

Perceived Benefits and Risks, and Recommendations

10.3928/0148-4834-19940101-04

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