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Chapter 4: Working in a CAT from the staff perspective
The study examined staff perspectives of working in a CAT covering three areas:
1. Role identity
2. Team relationships
3. The effects of co-location
Role Identity
Theme Context:CAT staff were asked to consider how nursing and social care roles were distinguishable within their CAT and how their role had changed by being part of an integrated team. Stakeholders were asked to consider how important the issue of awareness of the professional identity of CAT staff was to their departments, such as when communicating with either a nurse or social care worker.
Analysis summary
- The most substantial role changes during the first year occurred at Team Leader level. Managing an integrated team posed situation specific challenges for Team Leaders. Managerial competencies that had seemed useful for managing within a single organisation were not always transferable to an integrated team situation.
- As role identities shifted and levels of understandings about roles and responsibilities became more confused for CAT staff, team relationships deteriorated in the process. Gaining agreement on where roles overlap and become generic or what is regarded as ' specialist' became the main bone of contention between nursing and social care staff.
- The value both nurses and social care workers attached to their group roles was not about 'expert' or 'specialist' competencies, but instead was measured by the levels of working activity that they had undertaken i.e. ' the value of my role is determined by how busy I am'.
- The practice of Care Management was inextricably linked to why team relationships were deteriorating. Social care workers complained that " nurses don't Care Manage…we do all the work."
- Alcohol nurses continued to have less experience of working in partnership with Children & Families in comparison to their [drug] nursing colleagues. Similarly, social care stakeholders in Children & Families were less aware of how the alcohol service component of CATs functioned.
- If social care workers and nurses were not engaged in shadowing exercises, it was more likely they would make assumptions about what other staff or stakeholders do. This could potentially exacerbate negative attitudes, based on confusion, curiosity and suspicion.
- The integration of skills did not happen during the first year as anticipated, and in turn, reinforced the continuation of traditional pre- CAT roles.
- Lines of accountability were more likely to be blurred for nursing staff whose Team Leader was from a social care background, whilst social care workers with a Team Leader from a health background were equally confused as to whom they were most accountable to. Lines of accountability, however, were found to be influenced by whether Team Leaders shared the same professional background to those who reported to them and if they held 'credibility' in the eyes of their junior colleagues.
- Nurses did not believe that being part of an integrated team changed their adherence to the NMC Code of Practice. It did change their behaviour as they found they had become increasingly hyper-vigilant regarding recording information after communication with their social care colleagues.
Implications for policy and practice
- A different set of competencies might need to be developed for CAMs to enable them to manage across organisational boundaries.
- The importance of role identity in an integrated team issues needs to be recognised, and attention paid to addressing the issues around roles and responsibilities within CATs. This would help to develop and maintain healthy team relationships.
- An opportunity for discussion and exchange of views, possibly provided by an Organisational Development event, could help nurses and social care workers develop and maintain a greater understanding of each others' roles and responsibilities. This process should be arranged prior to any role conflict developing during team discussions, allocation meetings or during crisis management.
- Although defining traditional roles and responsibilities is comparatively easy, teams need to reach agreement on where roles overlap and become generic or regarded as 'specialist'. This is more difficult and could possibly prove contentious.
- With levels of activity increasingly defining roles, care should be taken not to compromise the quality of care and performance.
- CATs need to consider how they embark on developing a shared understanding of Care Management so that joint working in practice can be fully developed.
- There is scope for developing partnership arrangements between CAT alcohol services and Children & Families.
- Shadowing link workers across organisational boundaries is an effective way of producing a greater understanding about alcohol management. CAT staff that do not shadow or develop awareness and knowledge of other stakeholder agencies are arguably disadvantaged and their clients might receive a less effective quality of service. CAMs should consider categorising shadowing exercises as a form of 'protected learning' to help teams gain a better understanding of each other's roles. Shadowing exercises might be included as part of nurses and social care workers' Professional Development Plans ( PDPs).
- Shadowing exercises should precede any process of skills integration as it is comparatively less complex, less time-consuming and enables group learning during the formative stages of team development.
- To prevent the development of separate lines of accountability, CAT staff need to be given specific direction or information about where, to whom and when they are accountable within a new integrated team.
- The element of choice should not determine the lines of accountability for CAT staff. Senior managers should make sure that statutory or clinical governance requirements are adhered to. Accountability should not depend on a member of staff's subjective opinion of the senior person's credibility or depth of knowledge about the issues involved.
- The improvement of team relationships and building up of trust need to be encouraged to lessen the hyper-vigilance reported by nurses working in the pilot CATs during the first year.
- AllCAT members need to be made aware that they are accountable for their professional conduct.
Team Relationships
Theme context:CAT staff were initially asked to describe their expectations of working together with their new nursing or social care colleagues. At 6 and 12 months, they were asked to describe what was having both a positive and negative impact on team relationships with their respective teams.
Analysis summary
- The main positive factor on team relationships was where the integrated approach produced benefits for service users and where both nursing and social care staff jointly produced a positive outcome for the same client.
- Confusion over roles and responsibilities and the perceived uneven distribution of the workload persisted in being the two main issues that had the most detrimental effect on team relationships in East and North East CATs.
Implications for policy and practice
- Formally sharing successful experiences within the team on a bigger scale via case presentations at weekly meetings could help to improve motivation and remind staff what joint working achieves for service users.
- A starting point for developing trust between nurses and social workers through understanding each others' roles should be to identify where there are role similarities. Focusing on a common purpose is more conducive to establishing mutual agreement and recognition of shared values. Trust is a gradual process but can be achieved sooner if nurses and social care workers can identify quickly where they have common aims.
- New ideas about how CATs can develop should be actively encouraged and managed via a formal, constructive and open approach to service development.
Effects of Co-Location
Theme Context: Nursing and social care staff were asked to describe their experiences of working in the same building together compared to previous experience where they were located in separate buildings, whilst stakeholders were asked their views on CATs being located within GCC Social Work buildings.
Analysis summary
- The overwhelming benefit of working in the same building focused on the timesaving factor when seeking or sharing information with staff from other disciplines. All staff reported, " things get done so much quicker" by means of informal verbal communication.
- Initial concerns from CAT nurses, health and voluntary stakeholders about CATs being located within a Social Work Services building were not borne out in practice. Nursing staff and stakeholders did not find that service users objected to attending the CAT within a social work building.
Implications for policy and practice
- Co-location is able to achieve benefits that would be otherwise impossible when nurses and social care workers remain physically separated in different working bases.
- Co-location benefits include better communication between nurses and social care workers and strengthening links with Children & Families and Criminal Justice agencies.
- Being able to monitor the progress of a referral means that CAT staff are more likely to cross-refer clients.
- Co-location helps to overcome partnership working problems.
- Locating CATs within a social work location does not present a barrier to service user engagement.
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