From research to point of care
The original study was unapologetically sociological and deeply theoretical. This was necessary in order to make the familiar strange and see nursing with fresh eyes. Artists deploy similar kinds of tricks to help them really see in order to draw realistically. But while sociological concepts help the researcher to train their eye, they are less useful for healthcare practitioners.
The Care Trajectory Management framework builds on and extends this work to provide a point of care framework applicable to clinical practice.
"Translational Mobilisation Theory (Allen and May 2017) 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."
Care Trajectory Management Framework
"Knowing exactly what’s going on everywhere"
Trajectory awareness refers to the work of maintaining oversight of trajectories of care as they evolve in time and space.
Allen, D (2018) Care Trajectory Management:
A Conceptual Framework for Formalising Emergent Organisation in Nursing Practice, Journal of Nursing Management
#2 Trajectory Working
"We’re the link; they tell us and then we tell everyone else!"
'Working knowledge' refers to the translational work that creates the information flows necessary for the on-going organisation of trajectories.
"Nurses run the place. […] That requires anticipating people’s needs and constantly being two steps ahead"
Trajectory articulation refers to the practices through which trajectory elements are aligned in time and space.
"Care Trajectory Management is a conceptual framework for formalising emergent organisation in healthcare and nursing practice."
Is Care Trajectory Management new work?
Since its emergence as a formally recognised occupation in the mid nineteenth century, nursing has always entailed an organisational component.
For Nightingale, ‘nursing’ entailed being responsible for creating the environments that foster healing and health. Her healthcare improvements had as much to do with increasing the productivity of staff and enhancing sanitary conditions as with directly attending to the comfort of patients.
While nursing may always have had an organisational component, its content, form and function in contemporary healthcare systems has singular features arising from a specific historical context which have greatly increased the demands of this work. Patients admitted to hospital are more acutely ill than they once were and many are frail, elderly and have co-morbidities, magnifying the challenges of care coordination.
While some areas of healthcare work are becoming increasingly rationalised, there are great swathes of activity where increased complexity and intensity of coordination threatens service quality and safety.
Specialisation, coupled with accelerated patient throughput, has increased the work involved in transfers of care and bed management creating continuous ‘churn’ (Duffield, et al 2017) with which nurses must contend. Pressure on resources has made it progressively more difficult to secure discharge from hospital and because patients move through the system more quickly, activity that in the past could be extended over several days are compressed into ever-decreasing time-frames (Duffield, et al 2017).
All of this has taken place against the backdrop of wider changes to the workforce which has seen an overall reduction in qualified nurses (Ball, et al 2013), a concomitant growth in healthcare assistants and a rebalancing of specialist and generalist nursing skill mix and spiralling demands on frontline staff for paperwork and data entry (Royal College of Nursing, 2013; Cavendish, 2013; NHS Confederation 2013).
In her 'Notes on Nursing' Nightingale argued that:
"Bad sanitary, bad architectural, and bad administrative arrangements often make it impossible to nurse. But the art of nursing ought to include such arrangements as alone make what I understand by nursing, possible."
Nightingale, 1860/1969: 8
Why is recognising organising work important for healthcare?
We tend to treat healthcare as if it could be controlled by rational processes and yet there are great swathes of activity where successful coordination depends on people responding to processes as they unfold.
Recognising emergent organisation and the work involved in care trajectory management has important implications for healthcare. We know that coordination failures undermine the quality and efficiency of patient care and are some of the primary causes for safety incidents.
Care trajectory management is poorly serviced by existing management systems and information technologies; the work of nurses was certainly more burdensome than it needed to be and nurses had often developed their own personalised systems for supporting their practice.
While nurses’ care trajectory management makes an important contribution to the quality and safety of patient care, nurses have uncertain authority in performing this aspect of their role. Formalisation of this work would go someway to overcoming the organisational hierarchies and power imbalances that make this work more challenging and would confer upon others, the obligation to orient their own practices to such arrangements.
Care trajectory management is not an exclusively nursing activity. Increasingly this responsibility falls on family carers. So the more we understand how professions undertake this work then we are better placed to support family carers in fulfilling this function.
Health quality & safety
"The most common gap in care was: 'goals of care not discussed or the discussion was inadequate (n=25 (25.8%)) and 'delay of failure to achieve a timely diagnosis' (n-8 (8.3%)
(Kobewka et al 2016)
Research on patient safety in healthcare has repeatedly identified that the unavailability of equipment and/or medications as factors that have contributed to catastrophic outcomes in critical incidents.
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
"Creating an organisational space and infrastructure for models of organisation and management founded on flexibility, negotiations and contingency in the face of dominant neoliberal management logics in health and social care will not be easy, but it is essential if the quality and safety of health and social care is to be assured. This is an urgent and essential leadership role for nurse managers. Paradoxically as health and social care is increasingly organised through management models that emphasise standardisation and rationalisation, a growing number of service users present with non-standard and uncertain needs."
Are there risks in making the invisible 'visible'?
Making this work more visible and providing a language with which to describe it is an important contribution to refreshing our understanding of the nursing role in the face of the challenges of contemporary healthcare systems.
Visibility and invisibility are not inherently good or bad. Some have cautioned about making the invisible visible because of the dangers that this will bring efforts to control it. This is a very real risk in a system which in its efforts to ensure the quality of care has placed its faith in processes and procedures rather than in the judgement and expertise of professionals.
But as Lucy Suchman has observed, visible work tends to be equated with formal work that is authorised and documented and thus invisible work is at the heart of politics about what will count as work. Greater visibility of nurses’ organising work can enable us to build this more explicitly into education and preparation for practice and can inform debates about the systems that are necessary to support this activity. It is also the case that nurses themselves are not always aware of the contribution of this aspect of the role; this explains in part is status as the dirty work of the profession.
Beyond nursing, the other side of the argument is the impact of such a move on the public. Being honest about the emergent and uncertain qualities of much healthcare work organisation has to be handled carefully, making it clear that emergent organisation is inherent in the nature of the work, and not a reflection of broken systems.