It's time to take a second look at nursing
Nursing tends to be seen in terms of its care giving and clinical functions. This is how the profession presents itself and how the work of nurses is widely understood.
What is less well known is that nurses undertake a large volume of organising work. This is a relatively invisible element of the nursing role but is absolutely vital to ensure that patients receive the right care, in the right place and at the right time.
Research carried out by Davina Allen, a Professor at Cardiff University, has put the organisational components of nursing work in the spotlight for the first time.
The research is changing the way we see nursing and changing the way we see the organisation of healthcare.
Putting organising work in the spotlight
...Maureen has just completed processing a newly admitted patient and inserts the various assessment tools, care plans and record forms into the patient's file. She places the medication chart prominently on the Nurses' Station and affixes to it a note requesting that the doctor prescribe night sedation which, she has established, the patient usually takes to help her sleep...
...Maureen removes a sheet of paper from her pocket, unfolds it and scrutinises the content. It is a list of all patients on the unit; for each a complex set of symbols denotes the current status of their care. Some of these inscriptions are in blue, some in red. The latter is information Maureen has added having attended the ward round earlier. It is her practice to colour code her entries so she can identify readily new developments to be passed on to the person responsible...
...there is just enough time to telephone the social worker to check the progress of Mr White's home care arrangements before she must leave for the morning meeting to discuss the bed state. All today's discharges are going ahead, but she knows the elective admissions are likely to remain on hold as there are patients in the Emergency Unit who require beds. She hopes she will not have to take patients for whom another service is responsible as the work of organising care for 'outliers' is more difficult, but accepts this is sometimes necessary...
What is organising work?
Organising work refers to those everyday elements of nursing practice concerned with the coordination and organisation of patient care. It is related to but distinct from direct patient care and nursing management. Whereas the former is patient-focused and the latter is primarily unit-focused, organising work is ‘care trajectory’-focused.
A ‘care trajectory’ refers to ‘the unfolding of patients’ health and social care needs, and the total organisation of work associated with meeting those needs, plus the impact on those involved with that work and its organisation.'
Nurses have a central role in managing these relationships.
"Organising work refers to those everyday elements of nursing practice concerned with the coordination and organisation of
patient care trajectories."
Allen, D
What makes organising work necessary?
Healthcare is one of the most complex systems of work in existence and the challenges of coordination are well known.
#1
Healthcare is a work of ‘many hands’ (Aveling et al., 2016).
#2
Healthcare systems are inherently turbulent.
#3
Healthcare is ‘people work’.
These features of healthcare work pose very real challenges for care coordination, which, according to Strauss et al., mirror those of Mark Twain's celebrated Mississippi River pilot:
"The river was tricky, changed its course slightly from day-to-day, so even an experienced, but inattentive pilot could run into grave difficulties; worse yet, sometimes the river drastically shifted in its bed for some miles into a new course. […] Some of the various contingencies may be anticipated, but only a portion of them may be relatively controllable, […] stemming as they do, not only from the illnesses themselves but from organizational sources."
Strauss et al. 1988
Care coordination in healthcare systems
There are a number of formal management approaches that can be applied to address these coordination challenges.
These are useful when processes are predictable and controllable.
But in healthcare there are also large areas of activity which cannot be organised by formal rational planning processes and depend instead on “emergent organisation”, that is, on-going and flexible management in response to changing patient needs and organisational capacity.
It is nurses that are largely responsible for managing emergent organisation and this work has important implications for the quality and safety of patient care. But while anecdotally nurses are often referred to as the glue in healthcare systems we know little about the work that is involved.
The invisibility of organising work
There are a number of reasons for the invisibility of nurses’ organising work.
Nursing is extraordinarily diverse and there are very real challenges in developing a professional identity that captures the range of activities that nurses do. In recent history, as part of a wider professionalising strategy, nursing has foregrounded its care-giving role. This has influenced nursing research and knowledge, how nurses are educated and prepared for practice, and the wider public perception of nursing work.
At the same time, nursing models of organisation have been replaced by those of general management which emphasise audit, rational planning and standardisation as the means for achieving organisational objectives. Nurses have led the implementation of these new technologies and have achieved some notable improvements in healthcare quality and safety. However, the attendant preoccupation with ‘measure and manage’ heralded by such approaches has rendered invisible emergent organisation and the work of nurses in managing trajectories of care.
"Across the spectrum of locales in which they are employed, nurses, in numerous ways, support and sustain the delivery and organisation of health services. In recent history, however, this wider work has generally been regarded as, at best, an adjunct to the core nursing function, and, at worst, responsible for taking nurses away from their ‘real work’ with patients. Beyond its identity as the ‘other’ to care-giving, little is known about this element of nursing practice."
Allen, D
