The Invisible Work of Nurses

Hospitals, Organisation and Healthcare

Davina Allen

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317934783
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Nursing is typically understood, and understands itself, as a care-giving occupation. It is through its relationships with patients – whether these are absent, present, good, bad or indifferent – that modern day nursing is defined. Yet nursing work extends far beyond direct patient care activities. 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 worse 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.

Drawing on extensive observational research of the everyday work in a UK hospital, and insights from practice-based approaches and actor network theory, the aim of this book is to lay the empirical and theoretical foundations for a reappraisal of the nursing contribution to society by shining a light on this invisible aspect of nurses' work. Nurses, it is argued, can be understood as focal actors in health systems and through myriad processes of 'translational mobilisation' sustain the networks through which care is organised. Not only is this work an essential driver of action, it also operates as a powerful countervailing force to the centrifugal tendencies inherent in healthcare organisations which, for all their gloss of order and rationality, are in reality very loose arrangements.

The Invisible Work of Nurses will be interest to academics and students across a number of fields, including nursing, medical sociology, organisational studies, health management, science and technology studies, and improvement science.

1 A figure-ground reversal

Virginia Henderson famously claimed that:

The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge.

(Henderson 1966: 15)

Almost 40 years later, after an extensive consultation exercise, the UK Royal College of Nursing (RCN) offered the following definition of the work of the profession:

The use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death.

(Royal College of Nursing 2003: 3)

These quotations illustrate a wider trend spanning the last 40 years, in which nursing’s claim to expertise has been expressed exclusively in terms of its care-giving function (Armstrong 1983; May 1992; Allen 2001a). It is through its relationships with patients – whether these are absent, present, good, bad or indifferent – that modern day nursing is defined. The near-universal drive for cost-containment across the international arena has progressively pulled nurses away from this professed metier, but when society becomes concerned about the care of its citizens, it is nurses that are held to account. Yet nurses contribute to service quality in numerous ways which reach far beyond their direct clinical contact with patients. Consider the following:

It is 11.30 and Maureen has paused at the Nurses’ Station to review progress. The ward is the calmest it’s been all day. Only a few individuals have yet to be washed and everyone scheduled for theatre this afternoon is prepared. Sunlight has started to flood into the corridor from the ward areas as one by one the curtains that have enfolded the bed spaces since shortly after breakfast are drawn back. 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. Several issues now have been attended to: the junior doctor has prescribed medication for the patients going home tomorrow; the discharge letters for the community nursing service are prepared and the receptionist has been instructed to arrange out-patient appointments. Maureen ticks off these items on her sheet and glances at the clock. 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. Maureen picks up the telephone but quickly returns it to the receiver when she notices that the colorectal nurse specialist has arrived on the unit. She knows she will want an update on Mrs Banner. As they are talking, Maureen takes the opportunity to ask about another patient whose stoma management is interfering with their wound care. The colorectal nurse agrees to change the appliance. Maureen makes a note to this effect on her list. She is now running late for the meeting, so she quickly surveys the bed board and heads off down the corridor. En route she encounters a rather lost-looking junior doctor who inquires, ‘Where do you keep purple blood bottles?’ ‘In there’ Maureen replies, pointing to a cupboard on her right and, without breaking her stride, she disappears out of the ward.¹

This brief episode depicts a typical moment in the day of a nurse responsible for ward coordination and in many ways is wholly unremarkable. Yet it captures many elements of the nursing role that are of interest here: their work in bringing patients into the organisation and mobilising action; their work in maintaining an overview of the current status of individuals’ care and communicating this to relevant actors; their work in ensuring all essential activities are carried out and do not interfere with each other; their work in assembling the materials and resources that are required to support conduct; their work in overseeing bed utilisation and their work in facilitating patient transfers. I have called this ‘organising work’.

Organising work is that element of the nursing role often referred to as the ‘glue’ in healthcare systems. Vital as this is for service quality, however, it is largely taken-for-granted, or at least, that is, until things go wrong. Some estimate that this activity counts for more than 70 per cent of the work nurses do (Furaker 2009), yet it rarely features in the profession’s public jurisdictional claims and has only ever been studied as a distraction from patient care rather than as a practice in its own right. For example, the RCN develops further the definition quoted above with a description of nursing’s six singular characteristics. All centre on the clinical function and, save for a single sentence which acknowledges that ‘[i]n addition to direct patient care, nursing practice includes management, teaching, and policy and knowledge development’ (Royal College of Nursing 2003: 3), nurses’ wider contribution to healthcare remains hidden from view. This neglect is mirrored in academia. James (1992) developed the formula ‘care = organisation + physical labour + emotional labour’ to identify the component parts of care work and to systematically assess how their character and interrelationships varied across different contexts. In recent years, there has been considerable interest in emotional labour as a constituent of nursing work (James 1989; Smith 1992; Bolton 2000, 2001; Smith and Gray 2001; Theodosius 2008) and there is a smaller but emerging field focused on physical labour, including studies of ‘body work’ (Lawler 1991; Quested and Rudge 2002; Rudge 2009; Cohen 2011) and nurses’ technical skills (Sandelowski 2000; Nelson and Gordon 2006; Messman 2008, Pols 2010a, b, 2012; Pols and Willems 2011). Yet ‘organisation’, understood as the practices through which care is organised, has received relatively little attention. Indeed, while intending for ‘organisation’ to be read as both a noun and a verb in her formula, James (1992) concentrates her analysis on the former. To draw an analogy with the Gestalt psychology of perception, in nurse education, policy and practice, nurses’ organising work is always perceived as the ‘ground’ to the ‘figure’ of direct patient care. The famous image depicting both a vase and two profiles of a human face (the Rubin vase) is often used to illustrate the concept of figure-ground. Depending on whether the white or black colour is seen as the figure (forefront) or the ground (background) the brain will interpret the picture as two different images and, according to Gestalt psychological theory, it is impossible to perceive both simultaneously. The figure is what you notice and the ground is everything else. Crucially, the concept of figure-ground depends on the observer and not on the item itself. In the same way that a figure-ground reversal can be used as an intentional visual design technique to create new images, the aim of this book is to place direct patient care in the shadows in order to shine a light on nurses’ organising work.

Invisible work

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). 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 (Suchman 1995; Hampson and Junor 2005, 2010). Work can be rendered invisible in a number of ways. Some work gets done in invisible places, such as the behind the scenes work of librarians (Nardi and Engeström 1999), the behind the screens work of nurses (Lawler 1991) or the backstage work of food maids (Paterson 1981). Work may be defined as routine when it actually requires skilled problem-solving expertise (Hampson and Junor 2005, 2010). Work can also be done by invisible people. Star and Strauss (1999) reveal how gender, race and class intersect to render domestic workers invisible. They illustrate their argument with the example of an ethnographic study in which the author, an African-American sociologist, passed as a maid and experienced first-hand the processes through which she became progressively ‘unseeable’ by her employers (Rollins 1985). Hart (1991) makes similar observations in her study of hospital domestics. In the reverse of this scenario, the worker can be visible, but the work can be relegated to the background. ‘If one looked, one could literally see the work being done – but the taken for granted status means that it is functionally invisible’ (Star and Strauss 1999: 20 original emphasis).

The premise that we have special authority in relation to our own knowledge and expertise suggests that we should have the ability to shape not only how we work, but also how that work is perceived (Suchman 1995). Yet workers themselves are not always aware of their contribution to an overall activity (Nardi and Engeström 1999), may not have a language with which to describe certain tacit skills or the confidence with which to assert their claims. Moreover, studies have shown that some types of work are more likely to be invisible than others. Feminist scholars have drawn attention to the invisible work of women who are often employed in service sector posts, poorly remunerated because their role is believed to rest on natural attributes rather than workplace skills. It is also the case that the better the work is done the less visible it is to those who benefit from it (Suchman 1995). In their public jurisdictional claims occupations elect to foreground certain activities over others. Some work may remain invisible therefore because it creates strains with an occupational identity (Hughes 1984).

Visibility and invisibility are not inherently good or bad. In 1968 200 female sewing machinists famously stopped production at the Ford Motor Company in Dagenham when they went on strike following a re-grading exercise in which their work was classified as ‘unskilled’ whereas comparable work done by men was classified as ‘semi-skilled’. The strike is widely regarded as prompting the passing of the UK Equal Pay Act in 1970. Greater visibility can also result in increased control and surveillance, however. Bowker et al. (2001) analyse an attempt by nurses from the University of Iowa to categorise nursing practice and trace the delicate balancing act this entailed whereby nurses struggled to gain formal recognition for their work while simultaneously maintaining areas of discretion. Beyond the direct consequences for workers, the visibility–invisibility of work has implications for organisations. A number of studies have shown that technology implementation and/or workplace restructuring advanced on the basis of only work that is visible can run into difficulties. For example, Westerberg (1999) studied home care in Sweden and describes how workers operated with a formal visible vertical organisational structure and informal horizontal social networks. Both were critical to the management of the work and served important functions that ensured citizens received high quality home care. Despite its potential to augment the informal networks, however, a new computer system was designed to support only the formal structure. In the Danish public sector, Stroebaek (2013) highlights the importance of coffee breaks in sustaining communities of coping that enabled workers to deal with emotionally demanding jobs, through sharing cases and exchanging professional opinions as well as expressing personal frustrations. Stroebaek argues that coffee breaks should not be considered as the ‘waste fabric’ of productivity, but an important part of the work. Similarly, in the inexorable drive for efficiency, organisations increasingly find it necessary to slim down and this may involve judgements about the necessity of the work being done, the numbers of staff required or the mix of skills involved. If such decisions are based on a flawed understanding of the work, the consequences can be serious.

Nursing work has many features that make visi...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Fieldnote conventions
• Foreword
• Preface
• Abbreviations
• 1 A figure-ground reversal
• 2 Creating working knowledge
• 3 Articulating trajectories of care
• 4 Match-making
• 5 Passing the baton, parsing the patient
• 6 Rethinking hospital organisation, rethinking nursing
• Index