Descripción de los resultados de las encuestas aplicadas a los habitantes

When team members are willing to accept opportunities and challenges to do things differently, to pioneer new s.tructures in the interdisciplinary

team, the breaking of stereotypical images follows. The nature of

restructuring is such that, more often than not, organisational order appears disordered. Tsoukas ( 1 994) suggests that "events, processes and experiences in organisations are rarely transparent, self-evident or

completely fixed, but are intrinsically ambiguous and, therefore, open­

ended in the interpretations that can be attached to them" (p. 10). When uncertainty increases and work organisation becomes more complex, people seek greater control in a world that appears to be moving out of control. Rational action seldom helps. Rapid reaction and resorting to the

well-tried rituals often makes things worse. This is pioneering country where the practitioner does not know, indeed cannot know what will come next and how best to respond. The indicators of pioneering new structures are opportunities, enthusiasm, and new positions.

In this study, pioneering new structures is a means for re-examining professional work and the usual ways of doing things. Pioneering is allied with entrepreneurship. White and Begun ( 1 998) believe that the entrepreneur "perceives an opportunity and assumes the risk of planning

and creating a means to pursue it" (p. 44) . An entrepreneurial stance

facilitates adaptation within a turbulent workplace. Similarly, Parker ( 1 998) claims that pioneers are recognisable for their knowledge, imagination, mental toughness, energy, and courage to cany ideas to fruition. While that may be so, in this study talented practitioners needed the support of the team leader who was influential in the organisation:

The opportunity presented for us to do something differently . . . . That manager is a live wire! She has a nursing background. She is very entrepreneurial, very keen, very motivated. She's a person you would never constrict. You give her a free reign to run her area as she can and she'll come up with the innovations and change that you want .

. . . And we couldn't just have anyone in those jobs. We were looking for very high calibre, knowledgeable people who could do the job and pioneer a new structure. We wanted something new and this was where there was conflict. It's about enhancement. We wanted the best! We didn't want second best and some of the nurses were defmitely second best. Why would you want them if you were pioneering a new structure? They didn't have the experience or the

knowledge. You need something that will work. (Lilly, Int. 4, p. 56)

Pioneering new structures requires people that are prepared to think outside of the professional box, to give up the old "we have to do it this way" thinking (Kerfoot, 1996, p. 1 23) . This is difficult, as so many semi­ professionals have been trained to think in a linear fashion, to take a fragmented approach to client care. But, when clinicians were given an opportunity to think differently' many responded to that positively:

When we interview for jobs we look for the potential to take tremendous initiative and work independently and want to do things better all the time. We look for people who basically have those

qualities. So when you put them in the right environment, then this happens . . . . We need someone who is prepared to have a got Some of the people we have taken on have had no experience of this . . . We need to be satisfied that they are actually wanting to have a go, that they have something inside them that says, "I'd really like to do this even though I'm scared about it . . . . There's a sort of keenness about them. . . . it's an enthusiasm.... an enthusiasm for all aspects of the job . . . . It's someone who is brave enough to face the challenges . . . . Someone who is prepared to look into the uncharted waters and would quite like that challenge - as long as you can guide them through it. (Alice, Int. 20, p. 290)

Usually, pioneers are enthusiastic people. Pioneers welcome the rare opportunity to practise differently in spite of the hospital bureaucracy. Any freedom to break away from the commonly accepted ways of acting and interacting was highly prized:

I was offered an opportunity to get it right for the patient, to follow them through. However I did it, was up to me. I chose to follow them,

to see that they do get the service they should be getting, and if not,

why not; and then to initiate changes if they need to be made, and to

assist people along the way to understand why the patient didn't get

that service. Well! You would kill for that sort of thing! Especially if

you've worked in this system! (Marilyn, Int. 7, p. 89)

Explorers of unknown territory displayed a readiness to engage in the

deconstructive thinking underpinning pluralistic dialogue. A willingness

to examine both the known and the unknown demonstrated flexible thinking that is invaluable when pioneering new structures. Eagerness to break the symbolic rules and take on new challenges suggests that many

pioneers are dialogical thinkers, keen to· explore alternatives to the status

quo. Bohm ( 1994, 1 996) suggests that they are not bound by roles that carry pre-set assumptions and opinions about the way things should be. When people do not accept what exists unconsciously, the self is free for further inquiry. Individuals though, had to be willing to turn thinking upside down:

It's the sort of thing ''You can't do that because you are a nurse. You can't do that because you are a technician" rather than saying ''You are this. What do you think you can do?" There are obviously certain things like prescribing drugs [the person can't do] but a person who is a nurse would never ask to prescribe a drug. That's not part of the things that she is legally allowed to do. . . . there are no bounds to

what they can take over . . . . like with the nurse practitioner role . . . where they're resuscitating babies and doing the same things as the paediatric registrar - there are no bounds as long as the person is

adequately prepared and trained for the task. (Alice, Int. 20, p. 426)

Organisational structures often constrain practice. When new structures are created, while clinicians depend on organisational patronage to facilitate new roles, they must be well qualified and able to create new positions as well:

The setting influences things quite a lot. I've noticed a change in nurses' expectations of themselves as practitioners . . . they recognise the need for knowledge development and actively seek it out and take themselves further and expand their professional roles as they go . . . . There is quite a move to take back some control and have a clear mind as to how nursing can fit with other disciplines. It's almost as if they're saying, "Look! We do have the knowledge!" They're overt about it now. They're really claiming a place. Unfortunately, they're doing it in a climate where I'm not sure health managers are necessarily supporting that . . . Nurses are moving further into post-graduate study and that's where we are seeing the changes. That is not happening as a result of the organisations. In the current structure there hasn't been a great deal of support for encouraging that development. If you just take a global view on that, the organisational structure that nurses work in very often limits their capacity to realise their potential. . . . The health care providers need to develop opportunities for nurse practitioners. (Diane, Int. 1 1 , p. 1 38)

Although opportunities to pioneer new structures are rare, Larson and

LaFasto ( 1 989) report that "a key factor differentiating high- and low­

success teams is the structure of the team itself' (p. 39) . In this study the

teams that had an opportunity to create f:l new structure had little problem

at all in breaking stereotypical images, envisaging different ways of

practising. Pioneering new structures is so much easier if old roles do not

have to be adapted and there is freedom to forge new structures from the beginning:

I think it is quite hard to sort out a system that is egalitarian and also have a structure, organisation, and a formal process of responsibility and handover for that . . . . We've had an enormous

amount of leeway really to do what we think is appropriate, or, not

to do things. To a certain extent we've been able to dictate our own

. . . We can be quite creative because we do not have to adapt ways that previously existed. A lot of what we do is new. There was some resource constraint . . . but it is much easier to put something in place where there wasn't anything before. Generally, when people are quite grateful that we are · here at all, they are less likely to

grumble about how we do it! We've reached a point now where we need to develop some more formal structures just to keep in touch with the clinical issues for everyone. (Emily, Int, 96, p. 1 5 12)

Pioneering new structures is defmitely simpler in a small team. It was obvious that disciplinary approaches were discussed informally as team members worked together. Once the ground rules were changed, functional expertise was fused to benefit the patient:

This job is new. There weren't any ground rules. It's about contacts really. It's much easier for non-medical people to have good contacts into other areas of the hospital - particularly the physios, the OTs and the nursing side. It's a lot easier for non-doctors to have pull in those areas. It doesn't have to be a nurse in that position. Doctors have not been involved much in patient care. You use everyone else to help you get your patient better but you are not necessarily involved with it. (Richard, Int. 13, p. 1 72)

Pioneering new structures challenges even the most experienced person. The practical reality makes it impossible to be explicit about precise responsibilities in complex situations, which demand ongoing exploration of possibilities. Lumby ( 1 996) believes that current discontinuity offers opportunities to rethink the old ways of working as individuals and as teams of individuals. Rigid thinking though, had the potential to block team action and interaction:

It depends on the individual. . . . There is opportunity for

communication and discussion but I think at times, individuals

won't take that. Sometimes individuals can get quite pedantic about things in bureaucratic systems. They say things like, "My department says I do it this way so that is what I am going to do, even though it doesn't fit in with you! . . . It could be due to insecurity. . .. It is a way for people to use their professional

responsibilities as some sort of a shield for · their own lack of

confidence, or insecurity, or whatever. You can use a pedantic sort of system to say '1'his is the way it's done and you can't make me do it any other way!" That doesn't really work in the long run. (Sophia, Int. 82, p. 1056)

Pluralistic dialogue therefore helped allay apprehension that was especially noticeable among newer practitioners who were fearful of losing their professional connections in direct service attachment. In contrast, well-experienced clinicians were quite philosophical, realising that survival might depend on individual attitude change. Although either-or attitudes maintain a sense of control in the practice domain, practical life is seldom black and white. Rather, it is grey with uncertainty:

When people are practising in particular areas and are experts - when someone new comes into the team who may not be doing what the team have done before - that sometimes causes problems. But the nature of the teams is such that the team gets used to it . . . . People who are very good stand out! And by the time you get to work in those teams you've worked with other professions in other places in the health system so you are used to it really. But, the nurse practitioner role is new. Some of the doctors don't know what we do, and some of the charge nurses have difficulty with what we do, and some think we do nothing at alii I was accepted because I was associated with a team that was well respected. But I still had to prove myself. The others have a standard. (Alec, Int, 37, p. 485) Proactive attitudes helped professionals rethink their responsibilities for the future. Rethinking is about developing new attitudes, new values, and changing mind-sets (Culbert, 1 996) . Rethinking involves moving across boundaries, in a period of history in which Newtonian thinking no longer works, and where paradigms of thought are changing subtly but inevitably. As organisations become more flexible and open, as boundaries blur, and new role responsibilities are created, competence is crucial.