understanding partnership practice in child and family nursing through the concept of practice...

F e a t u r e

Understanding partnership practicein child and family nursing through

the concept of practice architectures

Nick Hopwooda, Cathrine Fowlera, Alison Leea, Chris Rossitera and Marg Bigsbyb

aUniversity of Technology, Sydney, NSW, Australia, bRoyal New Zealand Plunket Society, Christchurch, New Zealand

Accepted for publication 29 October 2012

DOI: 10.1111/nin.12019

HOPWOOD N, FOWLER C, LEE A, ROSSITER C and BIGSBY M. Nursing Inquiry 2013; 20: 199–210

Understanding partnership practice in child and family nursing through the concept of practice architectures

A significant international development agenda in the practice of nurses supporting families with young children focuses on

establishing partnerships between professionals and service users. Qualitative data were generated through interviews and focus

groups with 22 nurses from three child and family health service organisations, two in Australia and one in New Zealand. The

aim was to explore what is needed in order to sustain partnership in practice, and to investigate how the concept of practice

architectures can help understand attempts to enhance partnerships between nurses and families. Implementation of the

Family Partnership Model (FPM) is taken as a specific point of reference. Analysis highlights a number of tensions between the

goals of FPM and practice architectures relating to opportunities for ongoing learning; the role of individual nurses in shaping

the practice; relationships with peers and managers; organisational features; and extra-organisational factors. The concept of

practice architectures shows how changing practice requires more than developing individual knowledge and skills, and avoids

treating individuals and context separately. The value of this framework for understanding change with reference to context

rather than just individual’s knowledge and skills is demonstrated, particularly with respect to approaches to practice develop-

ment focused on providing additional training to nurses.

Key words: child and family nursing, community health, family care, nurse-patient relationship, nursing practice, parenting,

partnership, practice architectures, sustaining change.

Nurses internationally play a significant role in supporting

families in relation to parenting young children. This branch

of the profession, referred to as family nursing, or child and

family nursing, includes practices such as home visiting,

clinic-based work (focused on child development assess-

ments, management of behaviour issues, parentcraft), resi-

dential services, parent education and facilitating parenting

groups (Nursing and Midwifery Office 2011). This work

focuses on providing support, education, early identification

and intervention for child health and development issues

and parenting problems. Professionals may be referred to as

child and family health (CFH) nurses, parentcraft nurses,

health visitors, community or public health nurses. Across

such services in many countries, there is now an increasing

emphasis on working in partnership with families. This arti-

cle explores issues of wide relevance concerning how part-

nership practices can be sustained in such services. It does so

by exploring and demonstrating the value of a specific con-

ceptual framework (that of practice architectures), drawing

on perspectives of experienced nurses working in three

organisations that provide a wide range of services as

described above.

Many complex problems, particularly where CFH are

concerned, can only be addressed by treating families as

partners rather than as passive recipients of care (Scott

2010). Partnership differs from traditional models of care in

which the professional is regarded as the (only) expert,

leading decision-making and solving problems for families.

Partnership-focused reform agendas have considerable

momentum internationally (Elkan, Blair and Robinson

2000; Fowler and Lee 2007; Dunston et al. 2009). WithinCorrespondence: Nick Hopwood, Centre for Research in Learning & Change,

PO Box 123, Broadway, NSW 2007, Australia. E-mail: <[email protected]>

� 2012 John Wiley & Sons Ltd

Nursing Inquiry 2013; 20(3): 199–210

child and family nursing, there are several partnership-

related models, including Family Systems Nursing (Wright

and Leahey 2009), the McGill Model of Nursing (Feeley and

Gottlieb 2000), Nurse-Family Partnership1 (Olds 2006) and

the Family Partnership Model or FPM (Davis, Day and Bid-

mead 2002; Davis and Day 20102).

Partnership models and practices are starting to trou-

ble more traditional embedded approaches to clinical

practice (Fowler et al. 2012a). Yet additional research and

conceptual work are necessary to facilitate the introduc-

tion of partnership practices in nursing, enabling nurses

to move from the rhetoric of partnership to embedding

within nursing practice (Fowler et al. 2012b). Like many

attempts to change the relational basis of nursing prac-

tice, FPM is based on an educational approach focused

on developing relevant skills and qualities in nurses.

While means to assess outcomes of in-service training and

education exist, they do not fully connect with what actu-

ally happens in practice. A plethora of contextual features

shapes the ways in which newly developed skills can be

put into practice. Models of change must account for this

if we are to understand what it takes to sustain change

and deliver on the potential offered by practitioner edu-

cation. This article explores how the concept of practice

architectures can meet precisely these needs.

This study focuses on the FPM as a particular conceptu-

alisation of partnership linked to a training-based approach

to service development. FPM was chosen as the context for

several reasons. First, it has been formally adopted in all

states and territories in Australia, and in New Zealand, as the

preferred approach to CFH services. While this constitutes

national relevance within the Australasian region, there is

wider international significance given the growing uptake of

FPM in the UK and Europe (see Davis and Meltzer 2007).

Furthermore, the service organisations participating in this

study identified partnership as a key area of clinical and

organisational concern, having supported staff in complet-

ing FPM training.

The empirical research question framing the study was

‘What do nurses who have completed FPM training perceive

is needed in order to sustain partnership in their practice’?

This was accompanied by a theoretical question: ‘What are

the practice architectures that influence how partnership

practices can be sustained’? Practice architectures (Kemmis

2009) can be defined in simple terms as the conditions that

shape practices. This incorporates what is commonly under-

stood as organisational context, but provides an alternative

framing that avoids separating individuals and context.

Through further explanation of this concept and its use in

interpreting nurses’ comments, its usefulness in highlighting

a range of features that support and enable partnership prac-

tices will be shown. Using a novel conceptual framework to

analyse empirical data, the analysis aimed to offer useful and

relevant tools for thinking about sustaining partnership prac-

tices to a wider audience interested and invested in establish-

ing new ways of working with families.

Background: the Family Partnership Model

The FPM is an approach to understanding the skills and pro-

cess involved in establishing partnership between profession-

als and families and uses this as a basis for professional

education and training. It is not a clinical intervention in

itself and does not specify the content of interactions

(in contrast to the nurse–family partnerships) and does not

include specific clinical tools (unlike family systems nursing).

Instead, it is framed around ideas of relationships, a staged

helping process, and professional skills and qualities. The

FPM has become the basis for work with families of children

at risk or with wide-ranging problems, including chronic ill-

ness and emotional and behavioural difficulties (Davis, Day

and Bidmead 2002). The FPM is linked to a specific, manua-

lised, five-day training programme, focused on helping pro-

fessionals develop skills needed to work in partnership.

While skills development through training is essential, the

concept of practice architectures will be used to show how

this is not sufficient to create sustained change. Tensions

may exist between FPM and the wider conditions that shape

practices.

The model responds to poor uptake and variable out-

comes when professional support is delivered as advice-giv-

ing (Davis and Fallowfield 1991). It reframes help as

enabling parents to use their own resources to find ways of

managing problems in the longer term and engaging

parents in a relationship that is potentially supportive (Davis

and Day 2010). This underlies a focus on communication

1 The Nurse-Family Partnerships (NFP) was developed by David Olds and

adopted primarily in the United States (Olds 2006). It is the most prescriptive

and specific of the models listed, focusing on public health nurses working with

first time young mothers and detailing the content of each visit. Despite the simi-

larity in nomenclature, the NFP is fundamentally a very different kind of model –

a specified clinical intervention in a narrowly defined area of practice. Family Part-

nership Model is a generalised model describing an approach to work across a

wide range of areas.

2 Davis, Day and Bidmead (2002) articulate the model that formed the basis of

the FPM training undertaken by participants in this study. A revised version was

introduced in training and published in Davis and Day (2010). The updated

model is represented in fig. 1, but the key points identified also apply to the origi-

nal version.

200 � 2012 John Wiley & Sons Ltd

N Hopwood et al.

skills needed by professionals. Figure 1 illustrates different

components of the model.

The stages of the helping process begin with exploring a

problem from the parents’ perspective. The professional

may then assist parents in constructing a clear model of the

problem as a basis for negotiating goals. Actions are then

planned, implemented and reviewed. Partnership is estab-

lished by infusing these stages with key characteristics: work-

ing together, power sharing in decision-making, agreeing

aims, complementary expertise, mutual respect, openness,

clear communication and negotiation. Associated training

helps professionals further develop qualities including

respect, genuineness, humility, empathy, quiet enthusiasm

and personal integrity. Such qualities align with nursing cul-

ture and are often already strong. FPM training seeks to

enhance them and integrate them within the staged helping

process, moving from an expert led to a more negotiated

way of working. The model builds on ideas from psychother-

apy, counselling and child development and parenting (Rog-

ers 1959; Bowlby 1988; Kelly 1955). Outcomes are conceived

in terms of helping families identify and build on strengths,

manage problems, foster resilience, facilitate social support

and community development and enhance the development

and well-being of children.

Research on FPM training suggests that it improves

professionals’ helping ability and listening skills, as judged by

professionals and families working with them (Bidmead,

Davis and Day 2002). Similar results were reported in the

European Early Prevention Project (EEPP) (Layou-Lignos

et al. 2005; Papadopoulou et al. 2005). Keatinge, Fowler and

Brigg’s (2008) interview study of seven nurses 18 months

after they completed FPM training showed that the nurses felt

it had built on existing skills and helped them become more

reflective about their role as facilitators and enablers rather

than as solving problems for others.

A UK-based randomised controlled trial compared stan-

dard help with 18 months of weekly visits by FPM-trained

home visitors (Barlow et al. 2007). Outcome measures of

maternal sensitivity and infant co-operativeness favoured the

intervention group. The EEPP, spanning five countries,

included FPM in a nonrandomised intervention. Evidence

of differences favouring the intervention group was apparent

at 24 months (Davis et al. 2005). Research reviews have

found that FPM can enhance outcomes for families

(cf. Davis and Meltzer 2007).

Considerable unexplained variance in outcome mea-

sures suggests the full potential of partnership remains

untapped. Experimental studies are limited in their capacity

to document conditions that shape practices and lack sensi-

tivity to situational responses to practice innovation (Elkan,

Blair and Robinson 2000). Emerging research suggests that

social and organisational contexts may not always help to sus-

tain new initiatives (Crawford and Brown 2009; Rossiter et al.

2011; Fowler et al. 2012a,b). Bidmead and Cowley (2005)

noted this in their evaluation of FPM practice, identifying

time pressures and lack of clinical supervision as barriers to

partnership. Such barriers and other contextual factors influ-

encing how partnership is implemented in practice are

poorly understood. The concept of practice architectures

elucidates precisely these wider conditions. By exploring this

concept in depth, this article presents a framework that may

be of use for understanding the complex array of factors that

have a bearing upon how training- or education-focused

approaches to change may be sustained in nursing practice.

Conceptual framework

The concept of ‘practice architectures’ (Kemmis and Groo-

tenboer 2008) provided the framework within which our

research question was explored analytically. Kemmis (2009)

argues that if practice change is to be sustained, changing

the conditions that shape practices is as much necessary as

changing practitioners’ professional practice knowledge.

This has a direct bearing on change processes that are

Service and community

Helper qualities Helper skills Outcomes

Partnership

Helping process

Parent characteristics

Construction process

Figure 1 Overall framework of the Family Partnership Model (adapted from Davis and Meltzer 2007).

� 2012 John Wiley & Sons Ltd 201

Understanding partnership practice

focused on professional training or education (as with

FPM), begging questions of what relevant features of those

conditions are, and how they might align or conflict with

desired change.

Practice architectures are ‘cultural–discursive, material–

economic and social–political orders and arrangements that

prefigure and shape the content and conduct of a practice’

(Kemmis et al. 2012, 35). Cultural–discursive architectures

comprise what are often established ways of doing things

within institutions or professions, such as an ethos of care.

They also include forms of language, ways of communicating

in practice and factors that shape opportunities for commu-

nication and discussion. The material–economic dimension

refers to fiscal matters (amounts of funding, rules for allocat-

ing money), as well as linked issues of resourcing (including

staff levels and physical ⁄ technological resources that support

practice). Social–political architectures take the form of rela-

tionships between people in practice (contact with col-

leagues, management, supervision, inter-professional

collaboration, hierarchies etc.) and include policy frame-

works, professional codes of conduct, scope of practice speci-

fications and so on.

At first glance, this may evoke notions of organisational

or cultural context. However, the concept emerges from a

body of work that seeks to treat the relation between individ-

ual and context differently. Rather than construing context

as a container for practice, these approaches conceive more

complex relations that defy a clear separation between the

two (Saltmarsh 2009). The theoretical foundation for the

concept comes from Schatzki’s practice theory (1996, 2002,

2003), which proposes a ‘site ontology’. This means that

practices are understood as interwoven or enmeshed with

bundles of material arrangements, and organised by rules,

motivational and affective drives and forms of understanding

such as professional knowledge.

Conceived this way, context changes from being a setting

for practice or set of background features that limit it in

some way. Instead, a range of features are understood to

shape or prefigure practice. These are not separate from

practice, but intimately connected to it, for example, shap-

ing values and conventions (cultural–discursive), fiscal

resources, physical infrastructure and record-keeping (mate-

rial–economic), and rules, policy and professional communi-

ties (social–political). These forms of architectures will be

highlighted in relation to sustaining FPM in the results sec-

tion. The way an individual approaches or carries out a prac-

tice also contributes to its shaping. Practices derive

properties from these relationships, which make practice

possible and constrain it (Kemmis et al. 2012). The concept

of practice architectures thus speaks to what is convention-

ally regarded as organisational or cultural context, but it

encompasses other features through the three-part frame-

work, and it holds these shaping features in a closer relation-

ship with lived practice that would be the case in context as

container or background.

AIMS, DESIGN AND METHODS

The aim was to identify what nurses feel is needed to enable

them to sustain partnership practices, and then to explore

how the concept of practice architectures can be used to

understand these shaping conditions. The research was

exploratory and theoretical in nature, involving qualitative

interviews and focus groups with professionals from three or-

ganisations. The Family Partnership Model is taken as a spe-

cific exemplar of approaches to partnership. Interviews and

focus groups were held with 22 nurses in Australia and New

Zealand, in a two-stage design in which focus groups were

used to validate and explore preliminary findings. For the pur-

poses of the findings reported here, the organisations were

not treated as separate units of analysis, and there were no

explicit cross-case comparisons made, reflecting the relatively

small sample. The focus was not on organisations or services

per se, but rather on what is needed to sustain partnership in

child and family nursing services, using practice architectures

as a conceptual framework. The spread across two countries

was not to enable cross-national comparisons, but rather to

extend the potential for diverse findings and thus to expand

the conceptual richness of the analysis. The qualitative

approach was adopted to generate rich data that attended to

the complexities of local contexts. The theoretical dimension

of the study was designed to connect findings from the spe-

cific study sites to wider issues in contemporary nursing.

The study was conducted in three organisations,3 two in

New South Wales, Australia (Tresillian Family Care Centres

and Kaleidoscope Hunter Children’s Health Network), and

one in New Zealand (Royal New Zealand Plunket Society).

All are government-funded, providing a range of well child

(0–6 years) services, and are predominantly staffed by regis-

tered nurses with qualifications in CFH nursing. All three or-

ganisations have supported a significant proportion of their

workforce to undertake FPM training.

Researchers contacted site managers who circulated

information about the project and organised briefings for

staff who had completed FPM training and worked as a clini-

cian, manager, supervisor or FPM training facilitator. Staff

3 Further information is available online: Kaleidoscope: http://www.kaleido-

scope.org.au; Royal New Zealand Plunket Society: http://www.plunket.org.nz;

Tresillian Family Care Centres: http://www.tresillian.net.


N Hopwood et al.

elected to attend these meetings and a total of 22 nurses

agreed to participate, 10 from Tresillian, eight from Kaleido-

scope and four from Plunket. Of the 22 nurse participants,

10 were practising clinicians, and the remaining 12 included

an even spread of managers, clinical supervisors and FPM

training facilitators. Fieldwork took place between Septem-

ber 2009 and August 2010.

All participants were female and aged between 40 and

65. The clinical nurses were registered nurses with additional

qualifications in CFH nursing. All had at least 10 years’ post-

registration experience, some up to 35 years. The length of

time between completing FPM training and the interviews

ranged from five months to seven years.

The project received approval from relevant university

and health service ethics committees. All participants gave

informed consent. All publications have been de-identified,

so neither individuals nor the organisation of which they

were part are named alongside quoted data.

Data collection and analysis

The first stage of data collection involved semi-structured

one-to-one interviews, approximately one hour in length,

based on a common protocol informed by FPM literature,

prior research (Keatinge, Fowler and Briggs 2008) and guid-

ance from health service ethics committees. The protocol

identified three areas for discussion following a brief explo-

ration of each participant’s background: experience of FPM

training, personal approach to partnership practice, percep-

tions of organisational support for partnership. The discus-

sion of FPM training helped participants recall salient

features of partnership as a focus for discussion. The discus-

sion of personal approach and perceptions of organisational

support were designed to elicit details of practice and a

range of shaping conditions (practice architectures). The

language of ‘organisational support’ served as a useful start-

ing point, but did not limit nurses to discussions of organisa-

tional context (as will be shown below). All interviews

concluded by asking participants whether there was anything

else they wished to discuss, guarding against any constraint

that may have been imposed by the approach to questioning.

Interviews were conducted by three authors and three other

researchers.

Following Srivastava and Hopwood (2009), the analysis

of interviews combined grounded and concept-led

approaches. The concept-led approach drew on Kemmis

(2009) and began with themes that related to individual

practice as it connects to wider conditions, organisational

characteristics and other features. The inclusion of an indi-

vidual theme aligned with the framework, which does not

remove individuals from the range of conditions shaping

practice. The remaining two themes provided ample oppor-

tunity for a wide range of issues to be coded. Kemmis’ tripar-

tite of cultural–discursive, material–economic and social-

organisational features were treated as second-order con-

cepts that could cut across the categories. This retained a

grounded quality and avoided overdetermining the outcome

from a theoretical outset. The first author used constant

comparative methods (Glaser 1965) to expand on these and

identify additional themes, resulting in six themes. Another

team member conducted an independent, wholly grounded

(i.e. not taking theoretical concepts as an a priori structure

for coding) analysis. This resulted in themes very similar to

the original six. A third team member assisted in refining

coding criteria for the final set of themes. Outcomes of the

parallel analytic processes were merged, as the resulting

themes were most inclusive (in terms of data accounted for)

and conceptually rich. Inter-coder reliability was not quanti-

tatively calculated, given the conceptual nature of the analy-

sis. The outcomes are referred to as themes, as they straddle

the three conceptual categories associated with practice

architectures, and brought together a number of more pre-

cise, smaller units of analysis.

Focus groups were conducted after initial analysis of

interview data, two in each Australian setting and one in

New Zealand. All but one of the interviewees returned for

the focus groups, which comprised between three and six

participants. They were led by a subset of the researchers

who conducted the interviews, and lasted around one hour.

Participants were asked to reflect on preliminary findings

presented to them orally and in writing. Participants were

asked to reflect on the themes, to provide further detail or

concrete examples or to explicitly discuss contrasting views

and opinions within groups. Data from focus groups were

incorporated into the existing analytical structure (no new

themes were needed), providing additional detail, and cap-

turing the diversity of views in relation to particular themes.

RESULTS

Analysis resulted in six themes that elucidate practice archi-

tectures in relation to partnership: the importance of ongo-

ing learning, the role of individual nurses in shaping the

practice, relationships with peers and managers, organisa-

tional features, extra-organisational factors and clinical

supervision. The latter is not discussed here because it is

already well documented as a key factor in supporting

nurses’ partnership work and is highlighted as such in existing

FPM literature and training materials. The focus instead is

on the five themes that offer a novel contribution.



Ongoing learning

The FPM framework reiterates that training not be seen as

an end point in learning and developing partnership prac-

tice (Davis, Day and Bidmead 2002). Participants from all

organisations and roles mentioned the importance of

ongoing learning opportunities, with most clinicians talking

at length about this issue. In the overwhelming majority of

cases, this was noted for its absence: ‘They do the course,

and they go back to work. Then there’s nothing’ (2S).4

This gives a sense of the lack of developmental structures

for maintaining a focus on partnership within these nurses’

work environments. This could be interpreted as both cul-

tural–discursive (a lack of ongoing discussion of FPM) and

social–political (a lack of provision of such venues at an

organisational level). This was reinforced by another nurse,

who said: ‘Calling attention to it every now and then will

respark it in people, because it can die very easily and

nurses particularly can easily go back to just the advice-

giving mode’ (1C). The ‘advice-giving mode’ can be under-

stood as a cultural–discursive practice architecture: a

widespread (former) way of working that can continue to

shape current practices if other architectures are not

in place to counter it. The following quote points to the

higher value placed on immunisation in contrast to part-

nership:

It’s not seen as something as important as say immunisationwhere you have an immunisation update. You have an im-munisation update every single year, well why can’t you havea Family Partnership update. Why isn’t it that impor-tant?(1C)

The annual immunisation update constitutes a cultural–

discursive practice architecture that ensures opportunities

for ongoing learning and up to date practice. This nurse

imagined a similar partnership update architecture.

What does this mean for sustaining partnership? Accord-

ing to nurses participating in this study, there are existing

examples of architectures that foster ongoing learning, but

other mandated topics for in-service development take prior-

ity in time-pressured and resource-stretched CFH environ-

ments. Sustainability requires change at the social-political

level so that regular venues for ongoing learning can be

established. These can then facilitate the emergence of new

cultural–discursive architectures in which partnership

becomes a regular focus of discussion and development.

The role of individual nurses in shaping

partnership practice

The concept of practice architectures rejects separation of

individuals from context and, instead, includes how individu-

als approach practice as one of the features that shape it.

Many clinical nurses saw themselves as carriers of FPM,

describing how they sustained a partnership approach in var-

ious ways: writing reflective journals, going back to the

framework in their own time, reading course materials or

new references and resisting the temptation to revert to

expert models. ‘It takes a while. You can’t just go into the

training and then walk out and do family partnership. You’ve

got to actually live it’ (3S). This gives us a sense of sustainabil-

ity as having lived, emergent qualities, rather than something

that can be guaranteed by training and a fixed set of external

conditions, just as Kemmis’ concept suggests.

‘We learn, we get more experienced as the years go on

and you see more things, so it’s actually reflecting on that

and being able to not just let it happen … So it’s actually

your experiences’ (2M). Here, we see the interplay between

practices and shaping conditions that the concept of practice

architectures seeks to capture. For this nurse experience

over time presents an increasingly diverse range of encoun-

ters in practice, and through reflection, these build her

expertise and thus change the way she shapes her own part-

nership practice. This reflection can be understood as a cul-

tural–discursive architecture that both responds to past

events and prefigures future practices.

Relationships with peers

This theme was discussed most extensively of the five themes

presented, across all organisations and professional roles.

Relationships with peers were deemed highly significant in

sustaining partnership. Often these were positive and infor-

mal, sharing experiences day-to-day, debriefing informally,

bouncing ideas of each other and defusing stressful situa-

tions. ‘I also seek [support] informally with the person that I

work with – on a daily basis and she with me as well. So we

use each other very much to discuss what’s happened in our

consultation’ (2C). Here, there is a cultural–discursive archi-

tecture in the form of habitual, casual discussions within the

day-to-day routines of practice. Another nurse noted similar

aid to sustaining partnership, but this time the architecture

linked her to colleagues outside nursing: ‘Our social worker

does three days a week with us, so she’s actually excellent to

bounce off’ (2C). However, some nurses worked alone in

rural areas or had regular contact with colleagues who had

not completed training:

4 To protect participant anonymity, the numeral denotes one of the three organi-

sations randomly assigned a number 1, 2 or 3; the letter stands for the partici-

pant role (C = clinician, S = supervisor, M = manager, F = FPM facilitator).

Thus, 1C refers to a clinician from organisation 1.


N Hopwood et al.

It feels like there needs to be more than one person [prac-tising FPM]. The need to be [with] people who can talk toeach other about what comes up and who can be analyticaltogether about the way that they’re working in light of whatthey’ve learned.(3F)

Others experienced a disconnect when working alongside

people who were opposed to the model: ‘Allied health,

who are very dominant, haven’t done family partnership,

and work from a therapist model … actually often you hear

that they think nurses are stupid’ (3S). Here, the estab-

lished architecture of a different health profession is

framed as a sociopolitical architecture (domination) and a

cultural–

discursive one (discourses of stupidity). Isolation can thus

be experienced through either material–economic architec-

tures where work is conducted alone or in remote areas or

social–political ones where partnership is not a shared

value across professions or where FPM training is not

widespread across a workplace. Such architectures are in

tension with sustaining partnership because the conditions

for establishing the productive architectures discussed by

other nurses are not met. The investment by organisations

in training across their workforce can be seen as an invest-

ment in a peer support architecture that would not be

there if only a few isolated individuals completed FPM

training.

Organisational features

All participating nurses said the organisations they work for

have a significant influence on their partnership work. The

following paragraphs will show how organisations form the

location for practice architectures of various kinds that may

be in tension with or facilitate partnership.

Participants reported tensions between partnership prac-

tice and organisational demands for paperwork or pressures

to reach targets regarding client numbers or reduced waiting

times. Although a minority of participants considered that

working in FPM actually takes less time, the more common

view was that a partnership approach requires more time

with clients or that benefit to families is significantly greater

given more time. ‘I think the admissions also are very

involved. You’re allowing three or four hours, virtually, to do

one admission. If you’re doing too many admissions too

quickly you cannot do family partnership how it should be

done, that’s what we’ve found’ (1M). The pressure for

shorter interactions with families was reported as reflecting

budget constraints. Financial limitations thus create a

material–economic practice architecture that speeds up

practice and, from the perspective of many participants, con-

flicts with partnership. Several nurses also explained how

such constraints reduce staff numbers or make it harder to

release staff for training and clinical supervision:

I think it involves commitment from the organisation that,yes, we perceive that this is really important that we do needto train people and we need to have a regular program andit needs to be resourced properly. Rather than just havingpeople run off and do it and not – yeah. So I think it doesneed – I don’t know – some enthusiasm behind it and somecommitment as well, to help it work.(1F)

Conceived in terms of practice architectures way, budgets

are not context in the sense of background or setting for

practice. Rather they form architectures that infuse daily

practices, shaping them in ways that can make it harder to

sustain partnership.

The material basis of sustaining partnership was raised

through references to documentation: ‘That’s very contra-

dictory with family partnership in the sense that well, proba-

bly a lot of that paperwork is for us and is superfluous for

the family and they just want a few things. But what do you

do’? (1C). This represents the other part of Kemmis’ mate-

rial–economic form of architecture. Paperwork is not a con-

tainer that provides a context for practice. It is part of it, but

yet plays a key role in shaping practices and thus has implica-

tions for sustaining partnership. Another nurse, in a man-

agement role, noted how demands for paperwork can

deflect from relationship-building, a key tenet of partner-

ship:

The amount of paperwork required for each individual fam-ily is growing and the [nurses] … have only got a limitedamount of time to not only do the paperwork but form arelationship with the family and provide some input withand discuss what issues are the problem and what they cando to help.(1M)

However, several participants gave examples where docu-

mentation was refashioned as an architecture that supports

partnership, such as changing client records to include a

maternal file. This material shift can in turn cultivate differ-

ent cultural–discursive architectures that shape written prac-

tices and align with partnership: ‘Once upon a time we

would write ‘‘mother’s not compliant,’’ and ‘‘mother’s not

following through,’’ but now we’d be writing ‘‘mum needs a

lot more support when she’s settling her baby,’’ it’s just so

different’ (3C).

The introduction of care pathways in one organisation

was described as a crucial shift that made sustaining partner-

ship practice much more likely. It moved from a total focus

on the child to working with child and parent and from

expert- or nurse-centred models to approaches more

strongly shaped by families’ perceptions and needs. This

can be interpreted as signalling that the cultural–discursive



architecture of the organisation had changed through the

adoption of care pathways. Participants from other organisa-

tions felt their managers regarded FPM positively, but that a

pervasive attitude of ‘let’s really work on this [FPM] and

maintain it’ (1S) was lacking. Here, while FPM has received

support from managers, the architecture of values and con-

ventions has not changed in the way that would secure its

sustainability more strongly.

Participants also discussed autonomy offered by their or-

ganisations as vital in enabling them to pursue and develop

partnership practice. This could involve having control over

scheduling meetings with families or just a feeling of free-

dom in their work. ‘I felt very comfortable to make changes

and gave myself permission that this was OK’ (1C). Here, it

is clear how social–political architectures within organisa-

tions can shape practices. They allow nurses to build

personal, responsive approaches to practice, which our par-

ticipants felt was key to sustaining partnership.

Extra-organisational factors

Data relating to this theme were spread across all three or-

ganisations and emerged strongly from interviews with clini-

cians. Nurses feel their capacity to work in partnership is

influenced by factors beyond their organisation. Some of

these take the form of sociopolitical architectures, such as the

Families First policy. This policy aims to connect with families

prior to or when a baby is born to ensure early identification

and prevention of potential problems that may compromise

the health and well-being of the baby and their family (NSW

Health 2009). An important part of this initiative is the provi-

sion of universal home visiting: ‘Families First … it’s com-

mendable but it’s also laughable because the women don’t

have an opportunity to form an ongoing relationship with

that nurse’ (3C). The policy was interpreted as well-inten-

tioned, but hampering sustained partnerships because of the

short-lived relationships between nurses and families.

Extra-organisational material–economic architectures

such as funding child and family services according to num-

bers of infants rather than families have knock-on effects

within organisational practices that can be in tension with

partnership:

The baby is the client. We’re funded for the baby but theywant us to change our practice to a family-centred approachbut we’re really restricted administratively and medicalrecords wise about the service provision that we canprovide.(1C)

However, the quote below illustrates how external architec-

tures may align with local partnership practices:

Even just … the personal health record book … that’s fromState down. It’s a lot of emphasis on the parents’ evaluationfrom the six-month checks onwards, so that fits in with part-nership training, that it’s what the parents are perceiving …There was a recommendation of get your baby seen weeklyfor the first month, fortnightly for the second month. Nowthe recommendation is of the minimum and then inbetween as needed. That’s more parent led.(2C)

In this case, the state-wide adoption of a personal health

record book has established both material–economic and

cultural–discursive architectures. The content of the book (a

material record) prompts more negotiated agenda in which

parents can play a stronger role. This was seen as supporting

partnership practices.

DISCUSSION

Limitations

This study explores only one of several partnership-focused

models of care in nursing and is limited in its relation to

child and family nursing. Practice architectures affecting

partnership may be very different in hospital settings. With a

sample of 22, the aim was not to generalise, but to explore

nurses’ experiences in detail. It was expected that partici-

pants might self-select based on interest in or commitment

to FPM, and this was borne out. The study data lack perspec-

tives of younger nurses and those who completed training

but were sceptical about the model or resistant to change.

However, this does not compromise the validity of the data

for understanding how those committed to working in part-

nership perceive factors that influence their practice.

The nurses in this study who were aged from 40 to

65 years were not a representative group of CFH nurses.

These nurses were a more experienced group of nurses, as

the Australian CFH nurse workforce’s average age is

46.4 years (Productivity Commission 2011).

Practice architectures

The results present a number of themes that reflect what

nurses felt affects their ongoing ability to work in partner-

ship once they have completed FPM training. They identify

a number of important issues that must be considered if

the benefits of investing in FPM training or similar profes-

sional education and development initiatives are to be fully

realised. A surface reading of the themes – opportunities

for ongoing learning, individual lived practices, peer rela-

tions and organisational and extra-organisational features –

immediately supports Kemmis (2009) argument that if one

seeks to secure lasting practice change, changing the


N Hopwood et al.

knowledge and skill bases of individual practitioners is not

enough.

Through the lens of practice architectures, it has been

possible to develop a better understanding of the features

and conditions that shape partnership practices. In each

theme nurses’ comments suggested multiple forms of archi-

tectures influencing their work: cultural–discursive, mate-

rial–economic and social–political. These ideas add a new

layer to the analysis and show that it is not simply a question

of scale (individual, group, organisational, state etc.), but

also one of the qualitative nature of conditions under which

practice unfolds. The concept of practice architectures is

also useful in showing how architectures may be linked to

each other.

Having completed FPM training, nurses return to a com-

plex environment comprising continuing formal and infor-

mal learning opportunities (or lack thereof), peer relations,

workplace hierarchies, organisational cultures, protocols,

external policy regulations and bureaucratic requirements.

In time- and resource-limited services, FPM jostles for atten-

tion and priority among other equally valuable agendas.

These tensions reflect personal, organisational, professional

values and ways of working (cultural–discursive), infrastruc-

ture, record-keeping and resource allocation (material–eco-

nomic), forms of professional community (or isolation) and

wider policy developments (social–political). If organisations

invest in FPM training with ambitions to reshape features of

practice across the board, then the need to attend to other

potentially competing architectures is crucial.

Nurses as navigators and shapers

A further value of the practice architectures’ lens that is of

relevance beyond the particular institutions studied is that

does not separate context from individuals carrying out prac-

tices. Through our data, it was found that nurses are not au-

tomatons carrying a fixed model into practice, powerless in

the face of organisational constraints. FPM practices are sus-

tained at least in part through the ways in which nurses come

to understand, adapt and implement the model in personal

ways, shaped by their own professional judgements. These

nurses navigate complex architectures and actively shape

them too – supporting each other as peers, exercising their

professional autonomy and navigating paperwork and proto-

cols in ways they felt were sensitive to families’ needs. As

Braun, Davis and Mansfield (2006) suggest, our data demon-

strate the emergent and responsive qualities of partnership

as it is implemented in practice. The practice trajectories

nurses described were nonlinear and based on complex pro-

fessional judgements. This challenges linear and technico-

rational models of change (Bate, Mendel and Robert 2008)

and opens up further questions as to the relationship

between models of care, training interventions, organisa-

tions, policy and practice.

To sustain this shift in nursing practice, going beyond

providing education requires support at an individual and

organisational level. Working in partnership acknowledges

that both participants during an interaction bring different

knowledge, skills and potentially complementary expertise

(Davis, Day and Bidmead 2002). It can be argued that a par-

allel process is required that creates an environment where

nursing leaders model the tenants of partnership creating

an environment of do unto others as I do unto others (Fow-

ler et al. 2012a,b). Unless this occurs, a continuing tension

between the rhetoric of partnership and the implementation

into nursing and organisational practice will continue. A

resulting undermining of the best efforts of nurses to work

in partnership with families occurs. The data from this study

clearly demonstrated that changing and sustaining new prac-

tices is not easy when they challenge existing practices and

power structures.

CONCLUSION

Value of the conceptual framework

Partnership forms a significant dimension of international

health practice reform agendas. Within the broad move

towards different kinds of relationship between health pro-

fessionals and service users (patients, clients), branches of

nursing that engage primarily with families and their young

children have seen a particular focus on implementing

change aimed at fostering or enhancing partnership. This

study took the FPM as an internationally adopted exemplar

of approaches to this kind of change. It shares many qualities

with other models (discussed above), including a focus on

developing nurses’ skills through provision of targeted edu-

cation or training. This study of three Australasian child and

family services has identified much of relevance to a wider

international audience and demonstrates the value of a con-

ceptual approach that explicitly accounts for a range of fac-

tors and features that influence the sustainability of this kind

of change.

These factors and features have been described as prac-

tice architectures, taking what nurses described about work

in specific contexts and linking their perspectives to a wider

framework that explores cultural–discursive, material–eco-

nomic and social–political dimensions of change. Had the

study been framed with conventional concepts of context as

a container for practice, constraining or enabling but still



separate from it, the outcomes would have been different.

Practice architectures help us address the two-way relation-

ships between individuals and the conditions that shape

their work and to retain a key role for nurses in understand-

ing how partnership is sustained.

What does this analysis offer that applies beyond the con-

texts studied? Practice architectures enable us to cut across

analytic themes to highlight the different forms that shaping

conditions can take. This is important in terms of under-

standing that the change process requires much more than

investment in training: cultural–discursive, material–eco-

nomic and social–political features at a range of scales must

also be addressed. Such an analysis points to important limi-

tations in approaches to change that focus on professional

knowledge and skills without also addressing the architec-

tures that shape the work of those professionals.

This approach adds to rather than competes with exist-

ing models for understanding change in health practice. For

example, the diffusion of innovation literature (Greenhalgh

et al. 2004) assumes a static innovation that spreads, and

identifies conditions that facilitate or hamper this. This study

explored practice architectures with regard to sustaining

change rather than spreading innovation. By focussing on

spread, diffusion models tend to underplay local complexi-

ties and to rest on assumptions that once implemented,

change remains. By looking instead at how new partnership

practices play out after the initial impetus to change (in this

case, FPM training), this article adds new dimensions to

understanding how partnership agendas may be realised in

the longer term. The theoretical lens of conceptual architec-

tures lifts localised findings into a framework that connects

with globally spread trends in family nursing reform.

There are implications for FPM training internationally

and other partnership-focused models based on a similar ini-

tial training intervention. One might be to develop a series

of follow-up interventions that are conceived as part of a sin-

gle training package, rather than as add-ons. These might

not require cohorts to regroup in person, but could be based

online or through materials explored through practitioner

groups within organisations. Furthermore, findings mark

clearly the need for better understandings of organisations

in relation to partnership practice.

One organisation (Plunket) has attempted to implement

training within a broader multi-agency context through prin-

ciples reflecting partnership: recognising the importance of

organisational engagement, utilising an invitational

approach to recruit participants and promoting a collabora-

tive approach, by encouraging diversity within the partici-

pant group. This strategy has sought to capitalise on the

relationships formed between FPM course participants in

order to enhance inter- as well as intra-agency connections.

However, multiple challenges exist with implementing this

approach, including access to funding and the need for

wider-scale promotion of support for the training (Royal

New Zealand Plunket Society 2010).

Health and education organisations, who oversee train-

ing, could develop organisation-level interfaces, in which cer-

tain organisational commitments might be negotiated

alongside training of frontline staff. This might address

issues relating to wider practice architectures that permeated

the nurses’ comments. Supporting and sustaining change

requires more than pedagogical work. The future of partner-

ship in nursing practice depends in part upon how they fea-

ture among the many agendas competing for policy

attention and resources. Training alone is unlikely to bring

partnership agendas up alongside those that have infused

and become embedded across nursing organisations over

time.

Despite the growing policy shift and interest in family

partnership practice, there is limited understanding of the

support needed to implement and sustain it. This has signifi-

cant economic and practice implications if professional

development is provided but then not translated into nurs-

ing practice. The framework of practice architectures offers

a valuable set of conceptual tools for investigating precisely

this difficulty. While the specific challenges and conditions

identified by nurses in this study may not be more widely

generalisable, the message conveyed through description of

complex connections between partnership, education or

training, and cultural–discursive, material–economic and

social–political architectures does apply more widely.

ACKNOWLEDGEMENTS

It is great sadness that we note the passing of Alison Lee in

September 2012. Her contribution to our work and to inter-

national scholarship was immense, and her death represents

a great loss to the intellectual community. We also wish to

acknowledge the University of Technology, Sydney, for fund-

ing this project through the Partnership Grant Scheme,

alongside the contributions and support provided by Tresil-

lian Family Care Centres, Kaleidoscope and the Royal New

Zealand Plunket Society. We also wish to thank Roger Dun-

ston for his contribution to the broader study of which this

paper is part.

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