Editorial: Organising care delivery: facilitator or impediment to

supportive working relationships in nursing

There is little doubt that, internation-ally, many nurses face many seeminglyintractable challenges and difficultieswithin their workplaces. The nature,causes and possible solutions to someof these difficulties are theorised exten-sively, and are reflected in the scholarly,professional and industrial discoursesaround nursing. There is a considerablebody of literature attesting to the seri-ousness, the widespread nature and thesequelae of some of these problems, andnurses from across the world have beensufficiently concerned by elements ofworkplace difficulty to have conductedcountless research projects to explorethem closely.

According to the literature, there aremany difficulties facing nurses, includingissues around staffing and resourcing,stress, burnout, emotional exhaustion,bullying and mobbing (Gillespie &Melby 2003, Wolf & Greenhouse2007, Yildirim & Yildirim 2007). Orga-nisational issues such as restructures andresource shortages have been identifiedas causing havoc in the relationshipsnurses have with one another and arecontributory to workplace violationsand to creating cultures in which bully-ing and abuse can occur (Hutchinsonet al. 2006). In seeking to understand thenature of some workplace problems,aspects of the collegial relationshipsbetween nurses have also been exam-ined. However, relatively little effort hasbeen spent on scrutinising some aspectsof the workplace that can either facilitateor impede the development of soundcollegial working relationships betweennurses.

Organisation of care delivery hasbeen largely overlooked in the dis-courses around relationships betweennurses in the workplace. In the

mid-1970s when I began my nursingcareer; team nursing was still beingused as a framework for delivering careat my training hospital. This meant thatthe ward was divided into sections, andteams of nurses were collectivelyresponsible for the care of patients ineach section of the ward. Each teamgenerally reflected a mix of skill leveland had a leader who was responsiblefor ensuring care delivery, that the areawas adequately covered while teammembers took breaks and that workwithin the team was divided so thateach team member performed withintheir level of expertise. Since that time,I have had first-hand experience ofseveral other care delivery models,including various permutations of pa-tient allocation: primary nursing, totalpatient care and case management.

The various approaches to care deliv-ery have their own set of ideologicalunderpinnings, aims, assumptions,strengths and weaknesses. Models ofcare are often adopted (and rejected)based on expected outcomes from apatient care or service viewpoint. How-ever, the potential effects on the work-place and workplace relationships arealso crucial points for consideration.This is especially important in periodsof workforce shortages, as is the cur-rent situation. Some models of caredelivery have the potential to facilitatedevelopment of supportive collegialconnections through fostering teamprocesses and collaborative relation-ships. Other models (perhaps un-wittingly) have fostered a climate inwhich nurses work in relative isolation(Manias et al. 2003) and, consequently,can effectively fracture and isolatemembers of the nursing team. Thus,the ways in which care is organised can

contribute to a culture of individualismwithin the workplace.

The climate of individualism evidentin contemporary society has (not sur-prisingly) also pervaded the nursingworkplace. In the wider community,the effects of individualism can resultin feelings of isolation, marginalisationand alienation (Deveson 2003) and thisis also the case in the workplace. In awork environment characterised byindividualism, people can feel isolated,disconnected and devalued (Jackson2007). A climate of individualism alsopromulgates environments of blame inwhich individuals are liable to censureand reprimand, even when systems fail-ures (rather than individuals) are atfault.

It is accepted that positive humanrelationships in the workplace areimportant (Duddle & Boughton 2007).They have the potential to enhancefeelings of human connectedness andso can ameliorate the sense of isolationthat can be a feature of the workplace(Jackson 2007). Literature that explic-itly explores nurse relationships andworkplace quality in relation to organi-sation of care delivery is relatively scant.However, there is some research evi-dence that does highlight issues fornurses when using various care models.In 1997 a study of primary nursingwithin a team framework noted theimportance of team processes in build-ing a sense of belonging and connected-ness to colleagues, and meeting thelearning needs of junior and inexperi-enced staff members (Manley et al.1997). More recently, primary nursinghas been criticised because nurses canexperience it as isolating, an impedi-ment to the development of team pro-cesses (Manias et al. 2003), logistically

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problematic and stressful (Fitzgeraldet al. 2003).

The various major models of care arewell defined in the literature. However,they are not necessarily applied in theirpure forms. Several papers describe theuse of hybrid and adapted models.Recently Chan et al. (2006) comparedand evaluated various nursing caredelivery models for meeting the needsof people with severe acute respiratorysyndrome (SARS). They noted the use ofa mix of ‘cubicle and named nursenursing’ (p. 661), with cubicle nursingdescribed as being reflective of ‘modifiedteam and functional nursing’, andnamed nurse nursing of a ‘modifiedprimary nursing approach in a team’(Chan et al. 2006, p. 661). In their veryinformative paper, Chan et al. (2006,p. 663) also discussed the usefulness of‘modular nursing’: which they describedas a ‘convergence of team and primarynursing’ within a particular unit. Thismodel seems to capture the best ele-ments of both team and primary nursingin that it attempts to provide somecontinuity of care and reduce opportu-nities for cross infection, whilst alsoattempting to provide nursing staff witha supportive and collegial team contextin which to work. The authors high-lighted the emotional stress and burdenfelt by nurses during the SARS crisis,and particularly noted the importance ofproviding a care delivery frameworkthat supports nurses in their work (Chanet al. 2006).

It is both encouraging and reassuringto read reports of nurses exploring theuse of creative and innovative models ofcare to meet current needs. Indeed, thereis an urgent need to examine approachesto organising and delivering care so thatit is effective for patients but alsosupportive and non-isolating for nurses.Given the amount of literature thathighlights the difficulties endemic inthe nursing workplace, it is timely toreflect on the ways that models of care

delivery can facilitate or impede colle-gial relationships between nurses andcontribute to a working environmentthat nurses can experience as support-ive, rather than isolating. To be effec-tive, a model has to be able to meet theneeds of patients and clients whileabsorbing the challenges of a variedskill mix and the vagaries of a relativelyunstable workforce. Wolf and Green-house (2007) have highlighted theimportance of learning from our history,and remind us of the need to ‘considerstrengths, weaknesses and forces behindthe establishment of care delivery mod-els that have served us in the past,determining what to take with us as wemove into the future’ (p.383).

If we are to engage seriously withsome of the issues that make the nursingworkplace challenging and reduceworkplace violations such as bullying,we need to ensure that processes tofoster a sense of camaraderie, collabo-ration and teamwork are embeddedwithin models of care delivery. Thiscould go part way to diminishing theculture of individualism that can dam-age the workplace. Although the prac-tice and profession of nursing is underpressure in many areas, care of ourworkforce must be the priority. Withouta viable workforce, we are unable toprovide adequate and sustainable nurs-ing services. Therefore, in developingand adopting models of care delivery,we need to ensure that they can con-tribute to nurses feeling supported at thebedside rather than isolated, marginal-ised and beleaguered.

Debra JacksonEditor, JCNE-mail: debra.jackson@uws.edu.au

References

Chan EA, Chung JWY, Wong TKS & YangJCS (2006) An evaluation of nursing prac-

tice models in the context of the severe

acute respiratory syndrome epidemic in

Hong Kong: a preliminary study. Journalof Clinical Nursing 15, 661–670.

Deveson A. (2003) Resilience. Allen & Un-

win, Sydney.

Duddle M & Boughton M (2007) Intrapro-fessional relations in nursing. Journal ofAdvanced Nursing 59, 29–37.

Fitzgerald M, Pearson A, Walsh K, Long L &

Heinrich N (2003) Patterns of nursing: areview of nursing in a large metropolitan

hospital. Journal of Clinical Nursing 12,

326–332.Gillespie M & Melby V (2003) Burnout

among nursing staff in accident and emer-

gency and acute medicine: a comparative

study. Journal of Clinical Nursing 12, 842–851.

Hutchinson M, Vickers M, Jackson D &

Wilkes L (2006) Workplace bullying in

nursing: towards a more critical organisa-tional perspective. Nursing Inquiry 13, 18–

126.

Jackson D (2007) Servant leadership: aframework for developing sustainable

research capacity in nursing, Collegian doi:

10.1016/j.colegn.2007.10.001.

Manias E, Aitken R, Peerson A, Parker J &Wong K (2003) Agency nursing work in

acute care settings: perceptions of hospital

nursing managers and agency nurse pro-

viders. Journal of Clinical Nursing 12,457–466.

Manley K, Hamill J-M & Hanlon M (1997)

Nursing staff’s perceptions and experiences

of primary nursing practice in intensivecare 4 years on. Journal of Clinical Nurs-ing 6, 277–287.

Wolf G & Greenhouse P (2007) Blueprint fordesign: creating models that direct change.

Journal of Nursing Administration 37,

381–387.

Yildirim A & Yildirim D (2007) Mobbing inthe workplace by peers and managers:

mobbing experienced by nurses working in

healthcare facilities in Turkey and its

effects on nurses. Journal of ClinicalNursing 16, 1444–1453.

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Editorial