Editorial: Organising care delivery: facilitator or impediment to supportive working relationships in nursing
Version of Record online: 11 FEB 2008
© 2008 The Author
Journal of Clinical Nursing
Volume 17, Issue 6, pages 701–702, March 2008
How to Cite
Jackson, D. (2008), Editorial: Organising care delivery: facilitator or impediment to supportive working relationships in nursing. Journal of Clinical Nursing, 17: 701–702. doi: 10.1111/j.1365-2702.2007.02246.x
- Issue online: 11 FEB 2008
- Version of Record online: 11 FEB 2008
There is little doubt that, internationally, many nurses face many seemingly intractable challenges and difficulties within their workplaces. The nature, causes and possible solutions to some of these difficulties are theorised extensively, and are reflected in the scholarly, professional and industrial discourses around nursing. There is a considerable body of literature attesting to the seriousness, the widespread nature and the sequelae of some of these problems, and nurses from across the world have been sufficiently concerned by elements of workplace difficulty to have conducted countless research projects to explore them closely.
According to the literature, there are many difficulties facing nurses, including issues around staffing and resourcing, stress, burnout, emotional exhaustion, bullying and mobbing (Gillespie & Melby 2003, Wolf & Greenhouse 2007, Yildirim & Yildirim 2007). Organisational issues such as restructures and resource shortages have been identified as causing havoc in the relationships nurses have with one another and are contributory to workplace violations and to creating cultures in which bullying and abuse can occur (Hutchinson et al. 2006). In seeking to understand the nature of some workplace problems, aspects of the collegial relationships between nurses have also been examined. However, relatively little effort has been spent on scrutinising some aspects of the workplace that can either facilitate or impede the development of sound collegial working relationships between nurses.
Organisation of care delivery has been largely overlooked in the discourses around relationships between nurses in the workplace. In the mid-1970s when I began my nursing career; team nursing was still being used as a framework for delivering care at my training hospital. This meant that the ward was divided into sections, and teams of nurses were collectively responsible for the care of patients in each section of the ward. Each team generally reflected a mix of skill level and had a leader who was responsible for ensuring care delivery, that the area was adequately covered while team members took breaks and that work within the team was divided so that each team member performed within their level of expertise. Since that time, I have had first-hand experience of several other care delivery models, including various permutations of patient allocation: primary nursing, total patient care and case management.
The various approaches to care delivery have their own set of ideological underpinnings, aims, assumptions, strengths and weaknesses. Models of care are often adopted (and rejected) based on expected outcomes from a patient care or service viewpoint. However, the potential effects on the workplace and workplace relationships are also crucial points for consideration. This is especially important in periods of workforce shortages, as is the current situation. Some models of care delivery have the potential to facilitate development of supportive collegial connections through fostering team processes and collaborative relationships. Other models (perhaps unwittingly) have fostered a climate in which nurses work in relative isolation (Manias et al. 2003) and, consequently, can effectively fracture and isolate members of the nursing team. Thus, the ways in which care is organised can contribute to a culture of individualism within the workplace.
The climate of individualism evident in contemporary society has (not surprisingly) also pervaded the nursing workplace. In the wider community, the effects of individualism can result in feelings of isolation, marginalisation and alienation (Deveson 2003) and this is also the case in the workplace. In a work environment characterised by individualism, people can feel isolated, disconnected and devalued (Jackson 2007). A climate of individualism also promulgates environments of blame in which individuals are liable to censure and reprimand, even when systems failures (rather than individuals) are at fault.
It is accepted that positive human relationships in the workplace are important (Duddle & Boughton 2007). They have the potential to enhance feelings of human connectedness and so can ameliorate the sense of isolation that can be a feature of the workplace (Jackson 2007). Literature that explicitly explores nurse relationships and workplace quality in relation to organisation of care delivery is relatively scant. However, there is some research evidence that does highlight issues for nurses when using various care models. In 1997 a study of primary nursing within a team framework noted the importance of team processes in building a sense of belonging and connectedness to colleagues, and meeting the learning needs of junior and inexperienced staff members (Manley et al. 1997). More recently, primary nursing has been criticised because nurses can experience it as isolating, an impediment to the development of team processes (Manias et al. 2003), logistically problematic and stressful (Fitzgerald et al. 2003).
The various major models of care are well defined in the literature. However, they are not necessarily applied in their pure forms. Several papers describe the use of hybrid and adapted models. Recently Chan et al. (2006) compared and evaluated various nursing care delivery models for meeting the needs of people with severe acute respiratory syndrome (SARS). They noted the use of a mix of ‘cubicle and named nurse nursing’ (p. 661), with cubicle nursing described as being reflective of ‘modified team and functional nursing’, and named nurse nursing of a ‘modified primary nursing approach in a team’ (Chan et al. 2006, p. 661). In their very informative paper, Chan et al. (2006, p. 663) also discussed the usefulness of ‘modular nursing’: which they described as a ‘convergence of team and primary nursing’ within a particular unit. This model seems to capture the best elements of both team and primary nursing in that it attempts to provide some continuity of care and reduce opportunities for cross infection, whilst also attempting to provide nursing staff with a supportive and collegial team context in which to work. The authors highlighted the emotional stress and burden felt by nurses during the SARS crisis, and particularly noted the importance of providing a care delivery framework that supports nurses in their work (Chan et al. 2006).
It is both encouraging and reassuring to read reports of nurses exploring the use of creative and innovative models of care to meet current needs. Indeed, there is an urgent need to examine approaches to organising and delivering care so that it is effective for patients but also supportive and non-isolating for nurses. Given the amount of literature that highlights the difficulties endemic in the nursing workplace, it is timely to reflect on the ways that models of care delivery can facilitate or impede collegial relationships between nurses and contribute to a working environment that nurses can experience as supportive, rather than isolating. To be effective, a model has to be able to meet the needs of patients and clients while absorbing the challenges of a varied skill mix and the vagaries of a relatively unstable workforce. Wolf and Greenhouse (2007) have highlighted the importance of learning from our history, and remind us of the need to ‘consider strengths, weaknesses and forces behind the establishment of care delivery models that have served us in the past, determining what to take with us as we move into the future’ (p.383).
If we are to engage seriously with some of the issues that make the nursing workplace challenging and reduce workplace violations such as bullying, we need to ensure that processes to foster a sense of camaraderie, collaboration and teamwork are embedded within models of care delivery. This could go part way to diminishing the culture of individualism that can damage the workplace. Although the practice and profession of nursing is under pressure in many areas, care of our workforce must be the priority. Without a viable workforce, we are unable to provide adequate and sustainable nursing services. Therefore, in developing and adopting models of care delivery, we need to ensure that they can contribute to nurses feeling supported at the bedside rather than isolated, marginalised and beleaguered.
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