From initial spark to programme of research
I first became interested in the organising work of nurses during my PhD. In this study, recognising that nursing work included a substantial organisational component helped to explain the readiness of nurses to take on doctors' work in response to new policies in the early 1990s, despite considerable professional resistance to these changes.
In a second study I reviewed all the observational research on nursing work undertaken between 1994-2004 in order to address the question: What do nurses do? Although none of the studies were designed to specifically examine organising work, all highlighted its centrality to the nursing role. The primary insight from the review was how nurses acted as intermediaries in healthcare systems and managed a whole set of complex relationships through which patient care was delivered.
Then fast forward to 2011 and I had the opportunity to undertake the first ever study designed to examine the organisational elements of nursing work in its own right.
Allen, D. (1997b) The nursing-medical boundary: a negotiated order? Sociology of Health and Illness 19 (4): 498-520 –https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1467-9566.1997.tb00415.x
Allen, D. Re-reading nursing and re-writing practice: towards an empirically-based reformulation of the nursing mandate (2004a) Nursing Inquiry 11 (4): 271-283 –https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1440-1800.2004.00234.x
"I realised that nurses did an awful lot of organising work including organising the work of doctors and actually the truth was that it was easier for nurses to do some of the doctors' jobs themselves than it was for them to try and locate the doctor who could be working somewhere else in the hospital."
Studying organising work
I shadowed forty nurses working in adult care settings with the aim of directly studying their practice in real life contexts in order to better understand organising work.
My interest was in what nurses did, the tools they used to support their work, what these work practices revealed about what nurses know and the circumstances that make organising work necessary.
The aim of this research was intended to bring about a figure ground reversal in the way in which we see nursing, placing patient care in the background and bringing nurses' organising work into the spotlight.
"All too often prescriptions for nursing have arisen from armchair theorising about what nurses should do rather than research into what they actually do and an understanding of how this role function is shaped by the contexts in which they work."
What does organising work look like?
When you shine a light on organising work it looks very ordinary. It tends to be interleaved with other aspects of nursing work and is performed on the fly.
It involves information seeking, making sense of complexity, communication and the use of information technologies and the better this is done the less visible it is to those who benefit from it.
"No work is intrinsically visible or invisible. Work is made visible through a number of indicators and these change according to the context and the perspectives through which it is viewed."
Muller, 1999: Star and Strauss, 1999
What were the findings of the research?
High quality healthcare in contemporary healthcare systems requires that all the elements necessary to meet patient needs are in the right place at the right time.
Rational planning methods are the dominant approach to achieving the coordination of services. Yet a significant proportion of healthcare organisation cannot be planned for, rather it is emergent and depends on on-going and flexible management in response to changing patient needs and organisational capacity. Nurses’ organising work arises from the need to manage emergent trajectories of care in conditions of organisational turbulence.
The research identified four broad domains of organising work, bound together by a common set of mechanisms and underpinned by clinical and organisational knowledge.
The four domains of organising work
Practices that support information sharing to allow care to progress.
Practices that align in time and space all the elements (people, knowledge, materials) through which care is delivered
Practices that ensure patient needs are matched with available 'beds' and bed utilisation is maximised.
Practices that bring about convergent understanding of an individual trajectory of care to enable handover to the new team.
Translational mobilisation theory was developed from this work to describe, identify and explain the mechanisms of emergent organisation in complex organisational contexts and subsequently applied to the organisational components of the nursing role
Translational Mobilisation in Nursing Practice
"There is very little that moves in healthcare without passing through the hands of a nurse."
The knowledge and skills underpinning organising work
Translational mobilisation depends on a synthesis of clinical and organisational knowledge which gives nurses a distinct professional vision – that is a particular way of seeing healthcare services – in order to inform their work.
That nurses have clinical knowledge is well recognised, but the importance of organisational knowledge is less well understood. Nurses had a detailed understanding of the processes and procedures in their areas. This enabled them to reflexively monitor and make sense of patient trajectories and as they evolved and to have the foresight to anticipate contingencies and plan ahead.
Translational mobilisation also depends on the skills of perspective taking so that information and action can be conveyed to patients, families and different members of the healthcare team in terms that are understandable and take account of their purposes. Translational mobilisation also requires the ability to operate in a turbulent work environment and the resilience to cope with fluctuating and unpredictable patterns of demand.
Allen, D., & May (2017) Organising Practice and Practising Organisation: Towards an outline of Translational Mobilisation Theory, Sage Open, April-June 2017 1-14, DOI: 10.1177/2158244017707993
Allen, D. (2016) The importance, challenges and prospects of taking work practices into account for healthcare quality improvement: Nursing work and patient status at a glance white boards, Journal of Healthcare Management and Organisation, 30(4): 672-689
Allen, D (2015) Inside ‘bed management’: Ethnographic insights from the vantage point of UK hospital nurses, Sociology of Health and Illness 37 (3): 370-384
Allen, D. (2015) The Invisible Work of Nurses: Hospitals, Organisation and Healthcare, London: Routledge
Allen, D. (2014) Reconceptualising holism within the contemporary nursing mandate: from individual to organisational relationships, Social Science and Medicine 119: 131-138
Allen, D. (2018) Translational Mobilization Theory: A new paradigm from understanding the organisational components of nursing work, International Journal of Nursing Studies, 79 (February 2018): 36-42