Journal of Advanced Nursing 1979, 4 , 57-67
A sociological approach to the analysis of nursing work, Kath IV^'elia B.Nurs. S.R.N. H.V.Cert. N.D.N. Cert. Research Associate, Nursing Research Unit, University of Edinburgh Accepted for publication 7 June
MELLA K . M . (1979) Journal of Advanced Nursing 4, 57-67
A sociological approach to the analysis of nursing work This paper describes, from a sociological perspective, the work of hospital ward nurses. An analogy is drawn between the work organization of miners at the coal-face and that of nurses in hospital wards. Work roles are considered in order to provide a framework for the analysis of the work of nurses. Multi-skilled and single skilled work roles are described and the concept of a hierarchy of nursing tasks is considered. Problems of observing and analyzing the work of nurses are highlighted with particular reference to the type of environment in which hospital nursing takes place.
INTRODUCTION This paper has its origins in a study of the different patterns of hospital ward organization. In order to determine the deployment pattern of the nurses, an observational study was carried out in each of 50 hospital wards (Moult et al. 1978). The data from the observational study are analyzed here using a sociological framework. Use is also made of data appertaining to the ward sister of each of those 50 wards, these data were collected as thesis material (Pembrey 1978). The analogy drawn between the work organization in the coal-mining industry and the work of hospital ward nurses was developed from the work of Pembrey and for further discussion in this area the reader is referred to Pembrey (1978).
THE SYSTEMS A P P R O A C H The difficulties encountered in attempting to describe the organization of hospital ward nursing stem from the nature of the work. 'Any attempt to analyze this type of work (nursing) inevitably results in a cold, calculated list of duties and fails to convey the atmosphere in which the duties are performed.' O3O9-24O2/79/oioo-oo59$O2.oo
©1979 Blackwell Scientific Publications
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This statement was made by Goddard (1953) when he set out to determine 'what is the proper task of the nurse?' He used a job analysis approach and discovered that there are some aspects of nursing work which are impossible to observe or analyze. Nursing is a complex activity which is difficult to describe or define. This paper attempts to organize the data and analyze the work of hospital ward nurses using a systems approach. The systems approach has the advantages of embracing the different aspects of the work organization whilst recognizing their separate properties and of seeking to understand the relationships between them. A system is a set of interrelated parts each of which is related to every other part. 'Open' systems regulate themselves, differentiate and grow by means of exchange processes with their environments. The Tavistock Institute of Human Relations was concerned with the interaction of technological and social factors in industrial production systems. The studies undertaken in the British coal-mining industry in the 1950s which were pubhshed in 1963 (Trist et al) provide a helpful introduction to this analysis of the work of nurses. The approach adopted by the researchers at the Tavistock Institute was that of considering each production unit as a socio-technical system. The concept of a socio-technical system was developed from the studies on the coal-mining industry, in order to draw attention to the interdependence of the social and technological systems in production enterprises. The notion of a socio-technical system arises from the consideration that any production system requires both a technological organization (equipment process layout) and a work organization, relating those who carry out the necessary tasks to each other. 'A work organization has social and psychological properties of its own that are independent of the technology involved' (Rice 1958). The socio-technical concept can be considered in relation to nursing where nursing skills and knowledge are operationalized for the dehvery of patient care through a work organization. The open socio-technical system conceptuahzed by Emery & Trist (1965) as a result of studies in coal-mining techniques is 'open' because it is a system concerned with obtaining inputs from the environment and exporting back to its environment. The notion of environment and the interaction between the environment and the production enterprise is crucial to systems theory, thus there is a relationship between the work group system and the environment. The production enterprise in the case of nursing is the care of patients, and the environment is the ward in which the nursing takes place. Emery and Trist (1965) looked more particularly at environments and classified them according to their degree of complexity basing their ideas on economic concepts of competition. Their classification ranged from the placid, randomized environment to that of a 'turbulent field'. The 'turbulent' environment is an unstable one which is hable to disorganization and so demands a particular form of work organization for the production to continue. Trist et al. (1963) stated that
Sociological approach to nursing work there are two distinct tasks at the coal-face. These are the specific production cycle task of the worker and the task of coping with the environment. They maintained that 'the ability to contend with this second or background task comprises the common fund of underground skill shared alike by all experienced face workers. This common skill is of a higher order than that required simply to carry out, as such, any of the operations belonging to the production cycle' (Emery & Trist 1965). The production tasks take a relatively short time to learn whereas the skill of contending with the underground situation is developed over a number of years of working at the coal-face. The coal-face environment is a 'turbulent', unstable one which can be compared with the work environment of a hospital ward. Given that this 'turbulent' environment exists, it is, according to Trist et al. (1963) inappropriate to study the work organization in such an environment along conventional work study factory system lines. The factory environment is stable, controlled and predictable, whereas the coal face and the hospital ward are exactly the opposite in that they are unstable, uncontrolled and unpredictable. In Emery and Trist's (1965) systems parlance the ward environment is 'a disturbed reactive environment from which dynamic field processes have emerged as an unintended result of the interactions of the constituent systems'. The situatuion at the coal-face was described by Trist et al. (1963) in terms of the work being carried out and the work roles which the miners occupied. Some attention is given to a description of the work organization at the coalface in order to show the analogous situation in nursing work. The work that has to be performed is referred to by Trist et al. (1963) as the 'primary task'. The 'primary task' is the concept which integrates the technological, economic and psychological aspects of a production system. In the coal-mining industry the 'primary task' is the daily completion of the production cycle, in nursing it is the daily carrying out of patient care. This 'primary task' integrates the 'technical' and 'basic' skills with the psycho-social aspects of ward work. The miners worked in task groups and occupied different work roles within these groups. The task groups made up single social and economic units which' received a common pay note; that is to say the miners in each task group were paid as a group for the work that they carried out collectively. In nursing there is no such concept as a task group in this sense and so for the purposes of the analogy the task group in the hospital ward setting would be the group of nurses responsible for patient care on a particular ward for a particular day. Trist et al. (1963) examined the work roles within the task groups and described these roles in terms of the jobs which people do every day and become identified with. Thus a work role is what a man does, where, when and with whom; this role is largely determined by the formal division of labour or allocation of tasks which constitute the cycle. In nursing the work roles are the recognized places nurses have in the hospital hierarchy: sister, third year student nurse, etc. In the study of the coal-mining industry Trist et al. (1963) identified three types of task groups. They describe the identical role group where all the members do
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the same task, working more or less independently of each other. Reciprocal role groups were identified where the component activity parts of the main task are shared out between members of the group. Lastly the situation was described where the task group consisted of one isolated role worker who carries out a main task alone. The types of task groups identified at the coal-face can be transposed to the ward setting. The identical role group, where every member performs the same amount of the same task, can be compared with the nursing work pattern according to the ward routine: for example, all the nurses would make beds then take recordings of vital signs, serve morning coffee etc. The reciprocal role groups, where the component activity parts of the main task are shared out between the members of the group, is comparable with the task system in nursing. Lastly the isolated role, where a single man has a multi-task role and thus carries out a main task alone, compares with the multi-skilled role of a nurse in a patient allocation setting where she carries out all the care for one or more patients. Three types of work organization at the coal-face were studied by Trist et al. (1963): traditional single place working, conventional longwall and the composite longwall systems. The single place worker is a multi-skilled self supervising worker, a role which has already been compared to the nurse in a patient allocation system of work organization. The conventional longwall system is based on the principle of one man, one job, whereas with the composite method there is no such rigid division of labour. The composite work system derives from the single place tradition and removes the overspeciahzation or work roles giving rise to multiskilled roles, where all members of the team share equally a direct interest in the completion of the cycle. The patterns of work organization on the longwalls can be compared with those in the hospital ward setting. The conventional longwall system can be compared with the task system in nursing. The composite system corresponds with the system of team nursing, where there is a shared responsibihty for patient care, with the team allocating nurses to tasks in order to complete the 'primary task' of patient care. The theoretical framework of the Trist et al. (1963) study in the coal-mining industry has been used only as a guide in the analysis of the nurse-patient interaction data. In the following analysis and discussion no attempt has been made to draw parallels between the work organization at the coal-face and that in hospital wards, neither has any claim to similarity between the two study methods been made. It simply provided a standpoint from which to look at the data and a useful basis for discussion. ANALYSIS A N D F I N D I N G S The data were collected by means of an observational study in the aforementioned work (Moult et al. 1978). In the study 50 wards were observed, each for one day: this observation yielded data concerning the activities of the 262 nurses and nursing auxiliaries working on the 50 wards. The observation was patient centred and
Sociological approach to nursing work Moult et al. (1978) recorded every activity that the nurses engaged in. Thus each observation recorded consisted of a code for the nurse, the patient and the activity. At the end of the observation period it was possible to determine what nursing activities each nurse had performed, and which patients she had interacted with. In sociological parlance the nurse's role can be defined in terms of the nursing activities she performs. This is in accordance with Trist's thesis that a work role can be described in terms of what a person does, when and with whom. These data were analyzed initially merely in order to identify the type of role that each nurse occupied on each of the 50 wards. Further analysis was concerned with the ward design and the areas of the wards in which the nurses worked. For this further analysis some of the 50 wards were excluded because there were only three or less nurses on duty apart from the sister. Nurses starting work 2 hours or more later than the start of the shift were excluded, as the pattern of work was well established by that time. Goddard's (1953) term 'basic' and 'technical' nursing are used in this analysis. He coined the term 'basic nursing' in order to describe 'those nursing duties having their origin in the physical needs of the patient. The essential characteristic of basic nursing is that it is universal. . . irrespective of the disease from which he (the patient) is suffering.' In other words 'basic nursing' is the general maintenance level of nursing which provides the patient with all that he needs in terms of physical comfort, which he would provide for himself if he were fit to do so. The fact that these needs vary from patient to patient and that the skill required by the nurse to fulfil these needs will vary with the patient's condition does not alter the fact that the nursing care is of a basic nature witliin this definition. 'Basic nursing', if it is to be related to level of skill, must be examined in conjunction with patient data. In this study there were no data to describe the condition of the patients observed and, therefore, a value judgement, concerning the level of skill required to meet a particular patient's basic nursing needs, was not made. Goddard used the term 'technical nursing' to describe the care given as a result of the disease from which the patient is suffering. The character of 'technical nursing' was therefore determined by the disease condition of the patient. Goddard's concepts of'basic' and 'technical' nursing were used here in the way originally intended, that is as a description of the work of nurses for quantitative purposes. In order to obtain a shghtly more precise picture of the nurse's role an adaptation of Goddard's categories of nursing care was used. Thus his 'technical nursing' category was subdivided into observation and recording activities; technical procedures including such activities as dressings, injections, catheterizations and the oral administration of drugs. The code hst used in the observational study was an adaptation of the Department of Health and Social Security nursing activity code list. The four groups of nursing activities used in the analysis were: 1 basic nursing 3 technical nursing 2 observation and recording 4 drug administration.
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'Basic nursing' as a term has fallen into disrepute because it can be seen to imply lack of skill or importance. With the increase of intensive care and speciahst units the term 'technical nursing' has gained momentum and prestige in recent years. There has been a tendency within the nursing profession to confuse the concept of a hierarchy of nursing skills with the notion of basic and technical nursing. McFarlane (1976) said that 'a great disservice has been done, by the profession taking over words originally used by Goddard (1953) as categories of quantitative measurement of the work of nurses . . . and investing them with a qualitative meaning'. McFarlane went on to describe her idea of'primary' nursing by which she meant 'acts of helping and assisting individuals in activities they normally perform unaided that are related to health'. Primary she used 'to describe the primacy of the caring role in nursing'. When looking at nursing care in the context of this analysis it matters httle whether the areas of care, related to assisting the patient to perform his activities of daily living, are described as basic or primary. The term 'basic' was chosen because this study was concerned only with the type of nursing activity the nurse carried out and not with the quality or primacy of her action.
ANALYSIS OF THE W O R K ROLES The four groups of nursing skills, basic, observation/recording, technical and drug administration, provided a starting point from which to determine the nature of the roles occupied by the nurses in this study. A nurse who undertook activities from one of the four groups only can be described as having a single skill role; a nurse who vmdertook nursing activities from two or more groups has a multiskilled role. The 'technical' nursing group was more commonly found on the surgical wards. It was expected that the nursing auxiharies included in the study would have single skill roles, but this was not always the case. The majority of the nurses were found to be multi-skilled. The nurses had identical multi-skilled roles, all undertaking a variety of tasks to achieve the 'primary task', that of the daily delivery of care to patients. In Trist's (1963) sociological terminology, the nurses worked in 'identical role task groups', each nurse having a multi-skilled role, undertaking the same activities and working more or less independently of each other. Of the 262 nurses and nursing auxiharies on the 50 wards in the study only six nurses had single-skill roles, these were 'basic nursing' skilled roles. Five of these six nurses were first year learners and the sixth was a staff nurse. In the latter case the state enrolled nurses and first year student and pupil nurses carried out 'basic' and 'technical' nursing care, whereas the staff nurse undertook only 'basic' nursing care. In the five instances of first year student and pupil nurses undertaking only 'basic' nursing, it was found that other first year learners on the same wards on the day of observation undertook activites from the 'basic', 'recording' and 'technical' groups of nursing skills in four of the cases. In the fifth case another first year
Sociological approach to nursing work student nurse carried out 'recording' activities and a tliird year student nurse undertook 'technical' nursing. There are several occasions on which first and second year nurses administered drugs; this was always under the supervision of a senior nurse.
H I E R A R C H Y OF N U R S I N G SKILLS McFarlane (1976) states that the nursing profession imphes that ' "basic" is easy, "technical" is difficult. "Basic" is for junior learners, "technical" for senior learners and trained staff.' Thus the existence of a hierarchy of nursing skills is implied. The analysis presented here would seem to indicate that a hierarchy of nursing skills does not exist in the organization of nursing work. The five instances of the first year student nurses performing single-skilled 'basic' nursing roles can be explained rather by chance than an exphcit desire on the part of the ward sister to allocate 'technical' nursing to more senior learners. It is of course merely possible to speculate about the intentions of the ward sister in the allocation of work, as only the end result could be observed: that is how and where the nurses actually worked. It is, however, worthy of note that on three of the 50 wards the sisters claimed to allocate nursing tasks on a hierarchical baisis. On the days that these wards were observed the first year learners were seen to carry out 'technical' nursing skills on one ward but not on the other two. If, as McFarlane (1976) suggested, the profession has adopted the terms 'basic' and 'technical' and given them quahtative overtones, then a potential hierarchy of skills can be seen in the four categories used in this analysis. Any true hierarchy of skills can only be found when the care is related directly to a particular patient. In other words a hierarchy of patients rather than a hierarchy of skills would yield more information about the operational level of the learners.
W A R D DESIGN Ward design is an important variable in the organization of the work of nurses. If a ward is structurally divided into several bed areas, the consequent division of the patients into small groups can be seen as a presage of patient centred nursing. The five hospitals included in the observational study contained a variety of wards in terms of design. There were, traditional 'long Nightingale' wards, 'L shaped' wards and 'short Nightingale' wards which were divided longitudinally down the centre by a wall, both sides interconnected by archways or in one case a column of rooms with doors opening to both sides of the ward. Two wards in the category 'Other' (Table i) were of modem design with a nurses' station surrounded by several bed areas and a number of single rooms. It should be noted that one was a purpose built medical ward, the other a purpose built maternity unit being used as a gynaecological ward. The remainder of the wards have been grouped together and described as 'physically divided' wards. Among these were
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64 TABLE I
Kath M. Melia Summary of geographical work organization Long Nightingale
Short Nightingale
Physically divided
'L' shaped
Other
Total
Nurses working in particular areas of the ward
I
2
4
2
2
ii
Nurses working all over the ward
21
2
—
1
—
24
Some nurses working in particular areas; others all over the ward
3
Not classified: too few nurses on duty
2
I
6
27
5
50
Total
wards comprising a number of rooms of five to eight beds; wards with a large rectangular room of 13 beds with one or two smaller rooms at the other side of a passage, and Nightingale wards which had been partitioned off into two or three distinct bed areas. These wards have been described in terms of design in order to relate the design to the working patterns of the nurses. Again it was not possible to say that nurses were allocated to certain patients or areas of the ward as it is only the end result that was observed. The data were analysed by noting with which patients each nurse interacted according to the four nursing care caegories. In this instance the number of times she interacted with any one patient was irrelevant. The aim was to obtain a simple geographical pattern of her movements. It was found that on most wards the working patterns of all the nurses were similar. That is to say if one nurse was working with a certain number of patients only, then the other nurses tended to be working to a similar pattern. There were however a small number of wards where one or two nurses were working within a 'particular area of the ward' and the others were working in all areas of the ward (Table i). From the patient's viewpoint these two work patterns, within particular areas and all over the ward, had some significance. In situations where the nurses worked 'all over the ward' each patient was more likely to receive elements of his care from many of the nurses whereas, by definition, if the nurses were confined to specific areas of the ward the number of nurses interacting with an individual patient would be reduced. As previously stated, six wards were omitted from this attempted classification because there were too few staff on duty. The remaining 44 wards fall into three groups. Those in which the nurses worked in 'particular areas of the ward', those in which the nurses worked 'all over the ward' and those in which some nurses worked in 'particular areas of the ward' whilst others worked 'all over the ward' (Table i).
Sociological approach to nursing work A closer look should be taken at the wards in which the nurses worked in 'particular areas of the ward'. The first point of note is that this pattern of nurses working in 'particular areas of the ward' occurred only once in an open Nightingale ward. In the 10 other wards with this same work pattern there was some physical design factor which could have affected the way in which nurses worked. Out of the 19 wards with some architectural means of dividing the patients into groups, there were 10 wards where the nurses worked in 'particular areas of the wards' and six where this system was partially in operation, with some nurses working in 'particular areas of the ward' and others working 'all over the ward'. In 21 of the 25 Nightingale wards the nurses worked 'all over the ward'. In the other three, some nurses worked in 'particular areas of the ward' and some 'all over the ward'. These fmdings would appear to indicate that the physical design of the ward does have some influence on the work pattern of the nurses. In only one ward were the areas in which the nurses worked absolutely rigidly adhered to. This was one of the purpose built wards. In the others the nurses to greater and lesser degrees crossed from one area to another. In this sub group, where the nurses worked in particular ward areas, the nurses had multi-skilled roles and worked together in small groups to complete the primary task' of caring for the patients. The shared responsibilities for the care of the patients and the multi-skilled roles that the nurses adopted to complete this task bore some resemblance to the composite work system at the coal-face. This was particularly true of two wards where the areas in which the nurses worked were fairly clearly adhered to and the nurses adopted multi-skilled roles. In these wards the nurses were held accountable for their work and reported on their patients to the ward sister before the end of the shift. CONCLUSIONS AND DISCUSSION This analysis, sociological in nature, was based on the work role of the nurse. In the hospital ward setting the organization of the work must be flexible in order to cope with any sudden crisis or alteration in patient's needs. The nature of the work is, therefore, such that it is not always possible to observe all nursing activity. As Goddard (1953) pointed out 'it is clear that an essential part of the duties of the nursing staff is to exercise constant vigilance towards the patient's condition, but this function cannot be measured in the same way as, for instance, their responsibihties for providing food or toilet facihties.' Rather than simply to quantify the work of the nurse, the approach presented in this paper attempted to describe her role, where she worked and what kind of nursing skills she undertook in her day's work. This type of role analysis can be made in a hmited way only from the observational study data. The analysis of the nurses' work in terms of roles rather than tasks gives this work a sociological perspective which is pertinent to the work of nurses. A work role carries with it an expected mode of behaviour, certain obhgations and several
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necessary skills, it is these very attributes that make role analysis crucial in the study of nursing. Trist et al. (1963) discussed the importance of the task of coping with the environment at the coal-face, a skill only developed over several years of working at the coal face. The same problem of coping exists in nursing, and an examination of the role of the nurse rather than the tasks she undertakes, is an essential distinction to be made if the work of nurses is to be studied in a meaningful way. This approach could usefully be taken further in the direction of the studies in the coal-mining industry where: 'The pattern of work organization, the way in which those who carry out the necessary tasks are related to each other, was analyzed in terms of the quality of work roles, the kinds of task groups, the prevailing work culture, the nature of inter-group relations and the character of the managing system' (Trist et al. 1963). On the basis of role description an attempt to explain the patterns of work has been made. The design of the ward might have influenced the way in which the nurses carried out their work. The ward sister could be influenced by the physical design of the ward or, even if she gives no directives, it may be that the nurses themselves chose to work in a particular fashion according to the design of the ward. In order to gain a full picture of the nurse's work role at each grade it might be of interest to undertake continuous observation of one particular nurse at a time. In this way some of the complexities of the role may be identified and a little more insight obtained into the 'turbulent' environment in which the nurse works. The two main points which emerge from this analysis are that nurses on the whole occupy multi-skilled roles and that the work pattern of the nurses is possibly influenced by the architectural design of the ward. It may be that the argument of Trist et al. (1963) 'that the fragmented task approach of the conventional mining method is a temporary form of organization in the evolution of the composite organization from the traditional organic form' has a parallel in nursing. Originally nursing was undertaken by the patient's relatives at home on a multi-skilled single place work basis. When patient care became more organized and hospital admissions commonplace, the way of coping with patient care shifted to the task based hospital system as a step along the way to a composite organization of nursing care in the form of team nursing.
Acknowledgements This paper is based on data which were collected during the course of a study supported by a grant from the Leverhulme Trust which is gratefully acknowledged. Thanks are due to Anne Moult who collected these data. Sue Pembrey was of great assistance in the development of the sociological framework, thanks are due to her. Special thanks are due to Lisbeth Hockey who provided encouragement and guidance throughout. Lastly, thanks go to Kathryn Higgs, who typed this paper.
Sociological approach to nursing work
6j
Bibliography D.H.S.S. Unpublished report of the Ministry of Health Central O. & M. Unit—an assessment of nursing staff requirements in wards. ELDRIDGE J.E.T. & CROIVIBIE A . D . (1974) A Sociology of Organizations. George Allen and Unwin Limited, London. EMERY F.E. & TRIST E.L. (1965) The causal texture of organizational environments. Human Relations 18, i, 21-31. GODDARD H.A. (1953) The Work of Nurses in Hospital Wards. Nuffield Provincial Hospital Trust, London. HENDERSON V. (1966) The Nature of Nursing. Collier MacMillan, London. MCFARLANE J.K. (1976) A charter for caring. JoMrna/ of Advanced Nursing I, 187-196. MOULT A., HOCKEY L. & MELIA K . M . (1978) Unpublished Report for the Leverhulme Trustees. PEMBREY S. (1978) The Role of the Ward Sister in the Management of Nursing: A Study of the organization ofnursing on an individual patient basis. Unpublished Ph.D. Thesis, University of Edinburgh. RICE A . K . (1958) Productivity and Social Organization: The Ahmedabad Experiment. Tavistock Publications, London. TRIST E.L. & BAMFORTH K . W . (195 I) Some social and psychological consequences of the longwall method of coal cutting. Human Relations, 4. TRIST E.L., HIGGIN G.W., MURRAY H . & POLLOCK A . B . (1963) Organizational Choice. Tavistock
Publications, London.
A sociological approach to the analysis of nursing work, Kath IV^'elia B.Nurs. S.R.N. H.V.Cert. N.D.N. Cert. Research Associate, Nursing Research Unit, University of Edinburgh Accepted for publication 7 June
MELLA K . M . (1979) Journal of Advanced Nursing 4, 57-67
A sociological approach to the analysis of nursing work This paper describes, from a sociological perspective, the work of hospital ward nurses. An analogy is drawn between the work organization of miners at the coal-face and that of nurses in hospital wards. Work roles are considered in order to provide a framework for the analysis of the work of nurses. Multi-skilled and single skilled work roles are described and the concept of a hierarchy of nursing tasks is considered. Problems of observing and analyzing the work of nurses are highlighted with particular reference to the type of environment in which hospital nursing takes place.
INTRODUCTION This paper has its origins in a study of the different patterns of hospital ward organization. In order to determine the deployment pattern of the nurses, an observational study was carried out in each of 50 hospital wards (Moult et al. 1978). The data from the observational study are analyzed here using a sociological framework. Use is also made of data appertaining to the ward sister of each of those 50 wards, these data were collected as thesis material (Pembrey 1978). The analogy drawn between the work organization in the coal-mining industry and the work of hospital ward nurses was developed from the work of Pembrey and for further discussion in this area the reader is referred to Pembrey (1978).
THE SYSTEMS A P P R O A C H The difficulties encountered in attempting to describe the organization of hospital ward nursing stem from the nature of the work. 'Any attempt to analyze this type of work (nursing) inevitably results in a cold, calculated list of duties and fails to convey the atmosphere in which the duties are performed.' O3O9-24O2/79/oioo-oo59$O2.oo
©1979 Blackwell Scientific Publications
57
58
Kath M. Melia
This statement was made by Goddard (1953) when he set out to determine 'what is the proper task of the nurse?' He used a job analysis approach and discovered that there are some aspects of nursing work which are impossible to observe or analyze. Nursing is a complex activity which is difficult to describe or define. This paper attempts to organize the data and analyze the work of hospital ward nurses using a systems approach. The systems approach has the advantages of embracing the different aspects of the work organization whilst recognizing their separate properties and of seeking to understand the relationships between them. A system is a set of interrelated parts each of which is related to every other part. 'Open' systems regulate themselves, differentiate and grow by means of exchange processes with their environments. The Tavistock Institute of Human Relations was concerned with the interaction of technological and social factors in industrial production systems. The studies undertaken in the British coal-mining industry in the 1950s which were pubhshed in 1963 (Trist et al) provide a helpful introduction to this analysis of the work of nurses. The approach adopted by the researchers at the Tavistock Institute was that of considering each production unit as a socio-technical system. The concept of a socio-technical system was developed from the studies on the coal-mining industry, in order to draw attention to the interdependence of the social and technological systems in production enterprises. The notion of a socio-technical system arises from the consideration that any production system requires both a technological organization (equipment process layout) and a work organization, relating those who carry out the necessary tasks to each other. 'A work organization has social and psychological properties of its own that are independent of the technology involved' (Rice 1958). The socio-technical concept can be considered in relation to nursing where nursing skills and knowledge are operationalized for the dehvery of patient care through a work organization. The open socio-technical system conceptuahzed by Emery & Trist (1965) as a result of studies in coal-mining techniques is 'open' because it is a system concerned with obtaining inputs from the environment and exporting back to its environment. The notion of environment and the interaction between the environment and the production enterprise is crucial to systems theory, thus there is a relationship between the work group system and the environment. The production enterprise in the case of nursing is the care of patients, and the environment is the ward in which the nursing takes place. Emery and Trist (1965) looked more particularly at environments and classified them according to their degree of complexity basing their ideas on economic concepts of competition. Their classification ranged from the placid, randomized environment to that of a 'turbulent field'. The 'turbulent' environment is an unstable one which is hable to disorganization and so demands a particular form of work organization for the production to continue. Trist et al. (1963) stated that
Sociological approach to nursing work there are two distinct tasks at the coal-face. These are the specific production cycle task of the worker and the task of coping with the environment. They maintained that 'the ability to contend with this second or background task comprises the common fund of underground skill shared alike by all experienced face workers. This common skill is of a higher order than that required simply to carry out, as such, any of the operations belonging to the production cycle' (Emery & Trist 1965). The production tasks take a relatively short time to learn whereas the skill of contending with the underground situation is developed over a number of years of working at the coal-face. The coal-face environment is a 'turbulent', unstable one which can be compared with the work environment of a hospital ward. Given that this 'turbulent' environment exists, it is, according to Trist et al. (1963) inappropriate to study the work organization in such an environment along conventional work study factory system lines. The factory environment is stable, controlled and predictable, whereas the coal face and the hospital ward are exactly the opposite in that they are unstable, uncontrolled and unpredictable. In Emery and Trist's (1965) systems parlance the ward environment is 'a disturbed reactive environment from which dynamic field processes have emerged as an unintended result of the interactions of the constituent systems'. The situatuion at the coal-face was described by Trist et al. (1963) in terms of the work being carried out and the work roles which the miners occupied. Some attention is given to a description of the work organization at the coalface in order to show the analogous situation in nursing work. The work that has to be performed is referred to by Trist et al. (1963) as the 'primary task'. The 'primary task' is the concept which integrates the technological, economic and psychological aspects of a production system. In the coal-mining industry the 'primary task' is the daily completion of the production cycle, in nursing it is the daily carrying out of patient care. This 'primary task' integrates the 'technical' and 'basic' skills with the psycho-social aspects of ward work. The miners worked in task groups and occupied different work roles within these groups. The task groups made up single social and economic units which' received a common pay note; that is to say the miners in each task group were paid as a group for the work that they carried out collectively. In nursing there is no such concept as a task group in this sense and so for the purposes of the analogy the task group in the hospital ward setting would be the group of nurses responsible for patient care on a particular ward for a particular day. Trist et al. (1963) examined the work roles within the task groups and described these roles in terms of the jobs which people do every day and become identified with. Thus a work role is what a man does, where, when and with whom; this role is largely determined by the formal division of labour or allocation of tasks which constitute the cycle. In nursing the work roles are the recognized places nurses have in the hospital hierarchy: sister, third year student nurse, etc. In the study of the coal-mining industry Trist et al. (1963) identified three types of task groups. They describe the identical role group where all the members do
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the same task, working more or less independently of each other. Reciprocal role groups were identified where the component activity parts of the main task are shared out between members of the group. Lastly the situation was described where the task group consisted of one isolated role worker who carries out a main task alone. The types of task groups identified at the coal-face can be transposed to the ward setting. The identical role group, where every member performs the same amount of the same task, can be compared with the nursing work pattern according to the ward routine: for example, all the nurses would make beds then take recordings of vital signs, serve morning coffee etc. The reciprocal role groups, where the component activity parts of the main task are shared out between the members of the group, is comparable with the task system in nursing. Lastly the isolated role, where a single man has a multi-task role and thus carries out a main task alone, compares with the multi-skilled role of a nurse in a patient allocation setting where she carries out all the care for one or more patients. Three types of work organization at the coal-face were studied by Trist et al. (1963): traditional single place working, conventional longwall and the composite longwall systems. The single place worker is a multi-skilled self supervising worker, a role which has already been compared to the nurse in a patient allocation system of work organization. The conventional longwall system is based on the principle of one man, one job, whereas with the composite method there is no such rigid division of labour. The composite work system derives from the single place tradition and removes the overspeciahzation or work roles giving rise to multiskilled roles, where all members of the team share equally a direct interest in the completion of the cycle. The patterns of work organization on the longwalls can be compared with those in the hospital ward setting. The conventional longwall system can be compared with the task system in nursing. The composite system corresponds with the system of team nursing, where there is a shared responsibihty for patient care, with the team allocating nurses to tasks in order to complete the 'primary task' of patient care. The theoretical framework of the Trist et al. (1963) study in the coal-mining industry has been used only as a guide in the analysis of the nurse-patient interaction data. In the following analysis and discussion no attempt has been made to draw parallels between the work organization at the coal-face and that in hospital wards, neither has any claim to similarity between the two study methods been made. It simply provided a standpoint from which to look at the data and a useful basis for discussion. ANALYSIS A N D F I N D I N G S The data were collected by means of an observational study in the aforementioned work (Moult et al. 1978). In the study 50 wards were observed, each for one day: this observation yielded data concerning the activities of the 262 nurses and nursing auxiliaries working on the 50 wards. The observation was patient centred and
Sociological approach to nursing work Moult et al. (1978) recorded every activity that the nurses engaged in. Thus each observation recorded consisted of a code for the nurse, the patient and the activity. At the end of the observation period it was possible to determine what nursing activities each nurse had performed, and which patients she had interacted with. In sociological parlance the nurse's role can be defined in terms of the nursing activities she performs. This is in accordance with Trist's thesis that a work role can be described in terms of what a person does, when and with whom. These data were analyzed initially merely in order to identify the type of role that each nurse occupied on each of the 50 wards. Further analysis was concerned with the ward design and the areas of the wards in which the nurses worked. For this further analysis some of the 50 wards were excluded because there were only three or less nurses on duty apart from the sister. Nurses starting work 2 hours or more later than the start of the shift were excluded, as the pattern of work was well established by that time. Goddard's (1953) term 'basic' and 'technical' nursing are used in this analysis. He coined the term 'basic nursing' in order to describe 'those nursing duties having their origin in the physical needs of the patient. The essential characteristic of basic nursing is that it is universal. . . irrespective of the disease from which he (the patient) is suffering.' In other words 'basic nursing' is the general maintenance level of nursing which provides the patient with all that he needs in terms of physical comfort, which he would provide for himself if he were fit to do so. The fact that these needs vary from patient to patient and that the skill required by the nurse to fulfil these needs will vary with the patient's condition does not alter the fact that the nursing care is of a basic nature witliin this definition. 'Basic nursing', if it is to be related to level of skill, must be examined in conjunction with patient data. In this study there were no data to describe the condition of the patients observed and, therefore, a value judgement, concerning the level of skill required to meet a particular patient's basic nursing needs, was not made. Goddard used the term 'technical nursing' to describe the care given as a result of the disease from which the patient is suffering. The character of 'technical nursing' was therefore determined by the disease condition of the patient. Goddard's concepts of'basic' and 'technical' nursing were used here in the way originally intended, that is as a description of the work of nurses for quantitative purposes. In order to obtain a shghtly more precise picture of the nurse's role an adaptation of Goddard's categories of nursing care was used. Thus his 'technical nursing' category was subdivided into observation and recording activities; technical procedures including such activities as dressings, injections, catheterizations and the oral administration of drugs. The code hst used in the observational study was an adaptation of the Department of Health and Social Security nursing activity code list. The four groups of nursing activities used in the analysis were: 1 basic nursing 3 technical nursing 2 observation and recording 4 drug administration.
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'Basic nursing' as a term has fallen into disrepute because it can be seen to imply lack of skill or importance. With the increase of intensive care and speciahst units the term 'technical nursing' has gained momentum and prestige in recent years. There has been a tendency within the nursing profession to confuse the concept of a hierarchy of nursing skills with the notion of basic and technical nursing. McFarlane (1976) said that 'a great disservice has been done, by the profession taking over words originally used by Goddard (1953) as categories of quantitative measurement of the work of nurses . . . and investing them with a qualitative meaning'. McFarlane went on to describe her idea of'primary' nursing by which she meant 'acts of helping and assisting individuals in activities they normally perform unaided that are related to health'. Primary she used 'to describe the primacy of the caring role in nursing'. When looking at nursing care in the context of this analysis it matters httle whether the areas of care, related to assisting the patient to perform his activities of daily living, are described as basic or primary. The term 'basic' was chosen because this study was concerned only with the type of nursing activity the nurse carried out and not with the quality or primacy of her action.
ANALYSIS OF THE W O R K ROLES The four groups of nursing skills, basic, observation/recording, technical and drug administration, provided a starting point from which to determine the nature of the roles occupied by the nurses in this study. A nurse who undertook activities from one of the four groups only can be described as having a single skill role; a nurse who vmdertook nursing activities from two or more groups has a multiskilled role. The 'technical' nursing group was more commonly found on the surgical wards. It was expected that the nursing auxiharies included in the study would have single skill roles, but this was not always the case. The majority of the nurses were found to be multi-skilled. The nurses had identical multi-skilled roles, all undertaking a variety of tasks to achieve the 'primary task', that of the daily delivery of care to patients. In Trist's (1963) sociological terminology, the nurses worked in 'identical role task groups', each nurse having a multi-skilled role, undertaking the same activities and working more or less independently of each other. Of the 262 nurses and nursing auxiharies on the 50 wards in the study only six nurses had single-skill roles, these were 'basic nursing' skilled roles. Five of these six nurses were first year learners and the sixth was a staff nurse. In the latter case the state enrolled nurses and first year student and pupil nurses carried out 'basic' and 'technical' nursing care, whereas the staff nurse undertook only 'basic' nursing care. In the five instances of first year student and pupil nurses undertaking only 'basic' nursing, it was found that other first year learners on the same wards on the day of observation undertook activites from the 'basic', 'recording' and 'technical' groups of nursing skills in four of the cases. In the fifth case another first year
Sociological approach to nursing work student nurse carried out 'recording' activities and a tliird year student nurse undertook 'technical' nursing. There are several occasions on which first and second year nurses administered drugs; this was always under the supervision of a senior nurse.
H I E R A R C H Y OF N U R S I N G SKILLS McFarlane (1976) states that the nursing profession imphes that ' "basic" is easy, "technical" is difficult. "Basic" is for junior learners, "technical" for senior learners and trained staff.' Thus the existence of a hierarchy of nursing skills is implied. The analysis presented here would seem to indicate that a hierarchy of nursing skills does not exist in the organization of nursing work. The five instances of the first year student nurses performing single-skilled 'basic' nursing roles can be explained rather by chance than an exphcit desire on the part of the ward sister to allocate 'technical' nursing to more senior learners. It is of course merely possible to speculate about the intentions of the ward sister in the allocation of work, as only the end result could be observed: that is how and where the nurses actually worked. It is, however, worthy of note that on three of the 50 wards the sisters claimed to allocate nursing tasks on a hierarchical baisis. On the days that these wards were observed the first year learners were seen to carry out 'technical' nursing skills on one ward but not on the other two. If, as McFarlane (1976) suggested, the profession has adopted the terms 'basic' and 'technical' and given them quahtative overtones, then a potential hierarchy of skills can be seen in the four categories used in this analysis. Any true hierarchy of skills can only be found when the care is related directly to a particular patient. In other words a hierarchy of patients rather than a hierarchy of skills would yield more information about the operational level of the learners.
W A R D DESIGN Ward design is an important variable in the organization of the work of nurses. If a ward is structurally divided into several bed areas, the consequent division of the patients into small groups can be seen as a presage of patient centred nursing. The five hospitals included in the observational study contained a variety of wards in terms of design. There were, traditional 'long Nightingale' wards, 'L shaped' wards and 'short Nightingale' wards which were divided longitudinally down the centre by a wall, both sides interconnected by archways or in one case a column of rooms with doors opening to both sides of the ward. Two wards in the category 'Other' (Table i) were of modem design with a nurses' station surrounded by several bed areas and a number of single rooms. It should be noted that one was a purpose built medical ward, the other a purpose built maternity unit being used as a gynaecological ward. The remainder of the wards have been grouped together and described as 'physically divided' wards. Among these were
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64 TABLE I
Kath M. Melia Summary of geographical work organization Long Nightingale
Short Nightingale
Physically divided
'L' shaped
Other
Total
Nurses working in particular areas of the ward
I
2
4
2
2
ii
Nurses working all over the ward
21
2
—
1
—
24
Some nurses working in particular areas; others all over the ward
3
Not classified: too few nurses on duty
2
I
6
27
5
50
Total
wards comprising a number of rooms of five to eight beds; wards with a large rectangular room of 13 beds with one or two smaller rooms at the other side of a passage, and Nightingale wards which had been partitioned off into two or three distinct bed areas. These wards have been described in terms of design in order to relate the design to the working patterns of the nurses. Again it was not possible to say that nurses were allocated to certain patients or areas of the ward as it is only the end result that was observed. The data were analysed by noting with which patients each nurse interacted according to the four nursing care caegories. In this instance the number of times she interacted with any one patient was irrelevant. The aim was to obtain a simple geographical pattern of her movements. It was found that on most wards the working patterns of all the nurses were similar. That is to say if one nurse was working with a certain number of patients only, then the other nurses tended to be working to a similar pattern. There were however a small number of wards where one or two nurses were working within a 'particular area of the ward' and the others were working in all areas of the ward (Table i). From the patient's viewpoint these two work patterns, within particular areas and all over the ward, had some significance. In situations where the nurses worked 'all over the ward' each patient was more likely to receive elements of his care from many of the nurses whereas, by definition, if the nurses were confined to specific areas of the ward the number of nurses interacting with an individual patient would be reduced. As previously stated, six wards were omitted from this attempted classification because there were too few staff on duty. The remaining 44 wards fall into three groups. Those in which the nurses worked in 'particular areas of the ward', those in which the nurses worked 'all over the ward' and those in which some nurses worked in 'particular areas of the ward' whilst others worked 'all over the ward' (Table i).
Sociological approach to nursing work A closer look should be taken at the wards in which the nurses worked in 'particular areas of the ward'. The first point of note is that this pattern of nurses working in 'particular areas of the ward' occurred only once in an open Nightingale ward. In the 10 other wards with this same work pattern there was some physical design factor which could have affected the way in which nurses worked. Out of the 19 wards with some architectural means of dividing the patients into groups, there were 10 wards where the nurses worked in 'particular areas of the wards' and six where this system was partially in operation, with some nurses working in 'particular areas of the ward' and others working 'all over the ward'. In 21 of the 25 Nightingale wards the nurses worked 'all over the ward'. In the other three, some nurses worked in 'particular areas of the ward' and some 'all over the ward'. These fmdings would appear to indicate that the physical design of the ward does have some influence on the work pattern of the nurses. In only one ward were the areas in which the nurses worked absolutely rigidly adhered to. This was one of the purpose built wards. In the others the nurses to greater and lesser degrees crossed from one area to another. In this sub group, where the nurses worked in particular ward areas, the nurses had multi-skilled roles and worked together in small groups to complete the primary task' of caring for the patients. The shared responsibilities for the care of the patients and the multi-skilled roles that the nurses adopted to complete this task bore some resemblance to the composite work system at the coal-face. This was particularly true of two wards where the areas in which the nurses worked were fairly clearly adhered to and the nurses adopted multi-skilled roles. In these wards the nurses were held accountable for their work and reported on their patients to the ward sister before the end of the shift. CONCLUSIONS AND DISCUSSION This analysis, sociological in nature, was based on the work role of the nurse. In the hospital ward setting the organization of the work must be flexible in order to cope with any sudden crisis or alteration in patient's needs. The nature of the work is, therefore, such that it is not always possible to observe all nursing activity. As Goddard (1953) pointed out 'it is clear that an essential part of the duties of the nursing staff is to exercise constant vigilance towards the patient's condition, but this function cannot be measured in the same way as, for instance, their responsibihties for providing food or toilet facihties.' Rather than simply to quantify the work of the nurse, the approach presented in this paper attempted to describe her role, where she worked and what kind of nursing skills she undertook in her day's work. This type of role analysis can be made in a hmited way only from the observational study data. The analysis of the nurses' work in terms of roles rather than tasks gives this work a sociological perspective which is pertinent to the work of nurses. A work role carries with it an expected mode of behaviour, certain obhgations and several
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necessary skills, it is these very attributes that make role analysis crucial in the study of nursing. Trist et al. (1963) discussed the importance of the task of coping with the environment at the coal-face, a skill only developed over several years of working at the coal face. The same problem of coping exists in nursing, and an examination of the role of the nurse rather than the tasks she undertakes, is an essential distinction to be made if the work of nurses is to be studied in a meaningful way. This approach could usefully be taken further in the direction of the studies in the coal-mining industry where: 'The pattern of work organization, the way in which those who carry out the necessary tasks are related to each other, was analyzed in terms of the quality of work roles, the kinds of task groups, the prevailing work culture, the nature of inter-group relations and the character of the managing system' (Trist et al. 1963). On the basis of role description an attempt to explain the patterns of work has been made. The design of the ward might have influenced the way in which the nurses carried out their work. The ward sister could be influenced by the physical design of the ward or, even if she gives no directives, it may be that the nurses themselves chose to work in a particular fashion according to the design of the ward. In order to gain a full picture of the nurse's work role at each grade it might be of interest to undertake continuous observation of one particular nurse at a time. In this way some of the complexities of the role may be identified and a little more insight obtained into the 'turbulent' environment in which the nurse works. The two main points which emerge from this analysis are that nurses on the whole occupy multi-skilled roles and that the work pattern of the nurses is possibly influenced by the architectural design of the ward. It may be that the argument of Trist et al. (1963) 'that the fragmented task approach of the conventional mining method is a temporary form of organization in the evolution of the composite organization from the traditional organic form' has a parallel in nursing. Originally nursing was undertaken by the patient's relatives at home on a multi-skilled single place work basis. When patient care became more organized and hospital admissions commonplace, the way of coping with patient care shifted to the task based hospital system as a step along the way to a composite organization of nursing care in the form of team nursing.
Acknowledgements This paper is based on data which were collected during the course of a study supported by a grant from the Leverhulme Trust which is gratefully acknowledged. Thanks are due to Anne Moult who collected these data. Sue Pembrey was of great assistance in the development of the sociological framework, thanks are due to her. Special thanks are due to Lisbeth Hockey who provided encouragement and guidance throughout. Lastly, thanks go to Kathryn Higgs, who typed this paper.
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