Social Science & Medicine 119 (2014) 131e138

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Re-conceptualising holism in the contemporary nursing mandate:

From individual to organisational relationships
Davina Allen
Cardiff School of Healthcare Sciences, 4th Floor East Gate House, 35-43 Newport Road, Cardiff CF24 0AB, United Kingdom

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 20 March 2014
Received in revised form
26 August 2014
Accepted 27 August 2014
Available online 28 August 2014

Over the last forty years, nursing's claim to professional expertise has been expressed in terms of its caregiving function. Informed by a distinctive holistic approach, models of nursing identify therapeutic
relationships as the cornerstone of practice. While knowing the patient has been central to clinicians'
occupational identity, research reveals that nurses not only experience signicant material constraints in
realising these ideals, their contribution to healthcare extends far beyond direct work with patients.
Amidst growing concern about healthcare quality, a body of critical commentary has emerged proposing
that the contemporary nursing mandate, with its exclusive focus on care-giving, is no longer serving the
interests of the profession or the public. Drawing on an ethnographic study of UK hospital nurses'
organising work and insights from practice-based approaches and actor network theory, this paper lays
the foundations for a re-conceptualisation of holism within the nursing mandate centred on organisational rather than therapeutic relationships. Nurses can be understood as obligatory passage points in
health systems and through myriad processes of translational mobilisation sustain the networks
through which care is organised.
2014 Elsevier Ltd. All rights reserved.

Keywords:
Nursing
Healthcare organisation
Holism
Professional mandate
Ethnography
Practice theories
Actor network theory

1. Background
Over the last forty years, nursing's claim to expertise has been
underpinned by a bio-psycho-social model which underlines the
importance of close engagement with the patient as a whole person (Armstrong, 1983; May, 1992). While the more phenomenological aspects of this version of nursing practice have not been
received uncritically, the ideals of holism and knowing the patient
have become central to nurses' professional identities.
The evolution of modern healthcare systems is having a profound effect on the context, content and pace of nursing practice.
Hospital nurses are expected to process faster more acutely ill patients and simultaneously contain service costs. Community nurses
must respond to the challenge of a growing number of frail older
people. Changes in skill-mix and increased numbers of support
workers have made it necessary to devise alternative models of
care delivery, whilst policies for the preparation of junior doctors
and the evolution of medical technologies have provided the
impetus for the delegation of new tasks.
Against this backdrop, research regularly reveals contemporary
nursing practice to bear only a eeting resemblance to the

E-mail address: allenda@Cardiff.ac.uk.

http://dx.doi.org/10.1016/j.socscimed.2014.08.036
0277-9536/ 2014 Elsevier Ltd. All rights reserved.

profession's holistic ideals. Nurses are not only increasingly distant

from direct care (Cavendish, 2013), they undertake a wide range of
activities not captured by the prevailing professional image (Allen,
2004; Nelson and Gordon, 2006). Buttressed by growing societal
unease about fundamental care standards (Institute of Medicine,
1999; House of Commons, 2010), a body of critical policy commentary has emerged questioning the tness of the traditional
nursing mandate for contemporary healthcare systems (Dingwall
and Allen, 2001; Maben and Grifths, 2008). As leaders across
the world reect on how to ensure service quality in a context of
unprecedented nancial constraint, the need for such a reformulation is increasingly apparent, but not without its challenges.
Professional identity can be extremely resilient, which, while an
asset in certain contexts, means it can be difcult to change
(Goodrick and Reay, 2010). The concrete substance of nurses' work
is also poorly understood and nurses lack a language to describe
their practice (Nelson and Gordon, 2006).
This paper aims to contribute to this agenda. It draws on
ethnographic research undertaken to better understand the nonclinical elements of frontline nurses' practice, referred to here as
organising work, and builds on a substantial body of scholarship
(Allen, 1997, 2001; 2004; Dingwall and Allen, 2001) through which
I have become committed to moving beyond essentialist conceptions of the nursing role to make visible the work nurses actually

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D. Allen / Social Science & Medicine 119 (2014) 131e138

do. Some have estimated that organising work accounts for more
than 70% of nursing activity (Furaker, 2009), yet it has only ever
been studied as a distraction from patient care rather than as a
practice in its own right (for example, Davies, 1995). It is the dirty
work (Hughes, 1984) of the profession and much ink has been spilt
on the question of how practice can be brought back into alignment
with nursing's patient-centred ideals. In the context of growing
concerns about deteriorating standards of basic care, arguments
about the negative effects of non-clinical activities on the real
work of nurses undoubtedly have credence. Yet as Hughes (1984)
has argued, an occupation is not some particular set of technical
functions, 'it is the part of an individual in any on-going system of
activities' (p.286). Accordingly, this study aimed to examine the
organising work of nurses and the system features that make it
necessary. Only then is it possible to reach informed decisions
about the future nursing role.
2. Theoretical orientation
Data generation was informed by a practice approach and insights from actor network theory (ANT). Practice theories share a
number of conceptual similarities (Nicolini, 2012) with origins
traceable through praxeology (Bourdieu, 1977), ethnomethodology
(Garnkel, 1967), structuration (Giddens, 1984), and activity theory
m, 2000). All conceive of social phenomena as created by
(Engestro
human agency with practices understood as emerging from dynamic interactions with the material and social world as people
nd solutions to their problems. Thus in trying to understand
nurses' organising work, I focused on what nurses did, the tools
they used and what these practices revealed about what they know.
Practice theories are inherently relational and regard the world
as an assemblage of actors: people, knowledge, technologies, and
artefacts. ANT affords an analytic sensitivity to these relationships
and directs attention to both humans and nonhumans comprising a
eld of practice. Translation is the broad term used for understanding such associations, and refers to the movement of an entity
in space and time, as well as its transformation from one context to
another. In analysing actor networks it is useful to focus on a single
actor and consider translational processes from its vantage point.
Accordingly, in this study nurses and their organising practices
were the focus of concern, and healthcare delivery processes
examined from this perspective.
3. Methods
Forty UK hospital nurses in frontline adult care roles were
shadowed. The primary sources of data were observations and
ethnographic interviews, with an average of eight hours spent with
each participant. I accompanied nurses as they carried out their
activities, drawing on my nursing background to ensure my presence was minimally disruptive of participants' work and respectful
of patients' privacy. Data were recorded contemporaneously in a
spiral-bound jotter and word-processed at the earliest opportunity.
As far as possible interactions were recorded verbatim and observations were low-inference, capturing what was actually said and
done without interpretation. Ethics approval was granted by the
University. To ensure maximum variability, participants were purposively sampled, with selection guided by a typology of practice
environments developed in consultation with an expert reference
group. Senior nurses in the study site assisted in populating these
abstract categories with concrete examples. Exhaustive coverage of
all elds or the full nursing function was not intended; the purpose
was to identify roles most perspicacious given the research aims.
Twelve roles were identied initially, with others added in light of
the concurrent analysis. The nal sample comprised nurses

working in rotating (undertaken by different team members periodically) and permanent roles (Table 1).
Nurses were recruited through line-managers but assured
participation was voluntary. Signed consent was obtained and individuals told they could withdraw from the study at any time,
although none did. Although formal demographic data were not
collected; most participants (36) were experienced nurses who had
worked for several years in the organisation; only two were male.
Data generation and analysis proceeded concurrently.
Throughout the study, I periodically reviewed the totality of materials, drawing out similarities across, and differences between roles,
in order to identify broad themes. Interpretations were regularly
shared with participants and senior nurses to check face validity.
Once eldwork ended, data were entered into computer-assisted
qualitative data analysis software (Atlas/ti). An initial descriptive
coding frame was devised to support data retrieval and then rened
alongside the emerging analysis. Organising practices were the
focus of concern. The aim was to describe these as explicitly as
possible along with the artefacts that supported them, tease out the
knowledge and skills that underpinned them and explicate the
system features which made them necessary. The analysis progressed through reading and re-reading all materials, identifying
patterns and relations, and attending to how the data related to the
theoretical framing. Inductively generated ideas were considered in
the light of relevant literatures and sensitising concepts.
4. Findings
4.1. Overview: healthcare organisation and nursing's niche
As health service provision becomes ever-more complex, quality
care depends not on individual brilliance but on ensuring that the

Table 1
Study sample.
Typology
category

Role

Process-based
roles

Discharge liaison

Service-based
roles

Patient access
Scheduled surgery
coordinators

Number of
participants
Medicine
Neurologicalrehabilitation

Colorectal
Respiratory
Vascular
Unscheduled care
Emergency unit
coordinators
Medical admissions
Trauma and
orthopaedics
Medical
assessment
Surgical
assessment
Rehabilitation
Specialist unit
Short-stay surgery
coordinators
ITU e general
ITU - cardiac
Triage
Surgical
assessment
Emergency unit
Post-anaesthetic recovery
Nurse specialists Pain
Anaesthetic assessment
Colorectal
Stroke
Rehabilitation
Cardiology
Out-of-hours site manager
TroubleHospital-at-night practitioner
Shooting
Roles

2
1
1
3
1
1
2
1
2
1
1
2
1
3
2
1
1
2
1
2
1
1
1
1
3
1

D. Allen / Social Science & Medicine 119 (2014) 131e138

appropriate conguration of actors e actions, technology, expertise, materials e is in place to address patient need. This is reected
in the recent explosion of technologies intended to rationalise
service processes. Yet healthcare routinely dees standardisation
and control. A profoundly distributed activity, to a considerable
extent it is progressed through individual rather than collaborative
activity (Ellingsen and Monteiro, 2003). Each actor operates with a
different version of the patient, reecting their singular purposes
and the artefacts with which they work (Mol, 2002). Rarely, if ever,
do all participants come together to share information and organise
their work activities. Even where alignment with a formal plan is
possible, the care of individuals takes place in organisations
responsible for clinical populations, and as such, patients are in
competition with each other for access to services, facilities and
staff's attention. Sometimes this can be managed through formal
systems of triage and scheduling, but often not; healthcare organisations are less able to control their inputs than other industries.
Furthermore, theirs is ineluctably people work; patients and their
families not only have a view of the production process, they are
co-producers too.
Frontline nurses work in the sites of care and at critical service
interfaces, where they navigate the interstices of healthcare systems to assemble and align the constellation of actors through
which services are delivered. In the hospital context, this organising work is comprised of four interconnected domains of practice:
creating a working knowledge to support activity, articulating patient trajectories, matching people with beds, and managing
transfers of care. In the next part of this paper, I will summarise
these four domains of organising work before moving on to
consider the implications of their collective effects for our understanding of both nursing and healthcare organisation.
4.2. Organising work
4.2.1. Creating working knowledge
The rst domain of organising practices relates to the work
nurses do to create the working knowledge that supports everyday
service delivery. The medical record is widely regarded as the
central source of patient information and the importance of recordkeeping is underlined in pre-registration healthcare provider education. Nevertheless, as trust in professionals is replaced by trust
in auditable systems (Power, 1997), the structure, content and form
of the medical record increasingly has been driven by its archival
functions, undermining its value in supporting ongoing work
organisation (Allen, 2013). Far from serving as a straightforward
presentation of clinical data, the medical record embodies multiple,
fragmented representations of the patient (Berg and Bowker, 1997;
Mol, 2002). Synthesising information from this complex assemblage is demanding, and in the study site it was nurses and not the
patient record that functioned as the principal information source
for the purposes of organising on-going service delivery.
Well we're the link [] everyone tell(s) us and then we communicate it to everyone else.

133

associated resources and activity. The following extract is a typical

example.
Night Staff Nurse: Bed 3 [] a new lady, 84, came in with a fall and
broken arm. She has a POP ((plaster cast)) in situ. She's on 12
hourly obs ((observations)) and is to be seen in Fracture Clinic in a
week. She's for a 24-hour ((ECG)) tape to see whether her fall was
due to arrhythmias. She's mobile over short distances but has some
shortness of breath. She's been using a commode over night. I don't
know what she's like during the day.
Coordinator: I didn't have chance to assess her with all that was
going on yesterday.
Night Staff Nurse: She is a smoker and we need the doctor to assess
whether she wants a nicotine patch or anything. She lives alone but
I am not sure how well she copes.
Coordinator: Her daughter spoke to me yesterday and said that she
is no longer coping at home so we need to make a social worker
referral.
Nurses created a written record of trajectory narratives during
handover. At rst I thought these were simply lists of jobs to do
(referrals to make, documentation to be completed, medications
to be prescribed). I realised, however, that their notes included
details of concluded actions and not just those for which nurses
were responsible, but the work of others too. In the extracts
below, which are reproduced from a coordinator's handover
notes, a number of ticked boxes indicate completed activities:
unied assessment (UA) forms 3e11 (important in managing
discharge from hospital); a social worker (SW) referral, and a
hoist ordered. In the rst extract there is a query about whether a
patient is eligible for continuing health care (CHC) funding, in the
second, the nurse documents that a case conference (c/conf) will
be required and in the third, it is noted that the patient needs
blister packs (b/packs), a medication management technology, to
support discharge.
Drain, UA 3-11 ? CHC, SW
C/conf lives alone, SW
Home mon 10am, b/packs, hoist
Whether inscribed on scraps of paper, pre-printed handover
sheets, or the unit coordinator's book designated for this purpose,
the handover record was a highly portable plot summary of the
status of individual trajectories. It comprised a synthesis and
translation of information aggregated from diverse sources, plus
additional intelligence necessary for managing the work. It functioned as a pragmatic condensation of the current trajectory status
that was unavailable elsewhere and was an important aide
memoire.
Coordinator: Have you seen my handover sheet? I've lost it.
Deputy Sister: It's like losing your memory!

Trajectory narratives were central to this work. Narratives of

encapsulation (Knorr-Cetina, 1999), trajectory narratives, were
created by nurses when patients entered the service, set into circulation through the nursing handover, and modied in the course
of everyday practice. They functioned as a working record of individual's overall care, incorporating the clinical, social and
organisational information necessary for the coordination of action.
Within the nursing body, the construction of trajectory narratives
was a collaborative endeavour. Nurses worked together during
handover to assemble a picture of the patient, their care, and the

Plot summaries could be readily updated through scrutiny of

the medical record, attendance at ward rounds and meetings, and
dialogue with network actors. This entailed more than simply
accumulating information; it involved sensemaking (Weick, 1995).
Decisions had to be made about what to take note of and what to
ignore and the relationship between different knowledge sources
had to be adjudicated. Not to be confused with interpretation,
sensemaking entails authorship and it was through these practices that nurses created the working knowledge that sustained

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D. Allen / Social Science & Medicine 119 (2014) 131e138

everyday service delivery. Nurses were not simply functioning as

a distributed memory system (Bowker et al., 2001) moreover;
they brought about translations, adjusting trajectory narrative
content to the needs of different audiences. From out of each
interaction new translations emerged, with questions in one
context transformed into answers in another, in an almost
continuous ow.
Coordinator: Mr [] in the cubicle was admitted yesterday but he
doesn't have a drug chart. He's taking his own meds at the moment,
but he's a bit constipated and I'd like to get that sorted out before
theatre.
Junior Doctor 1: When's he going?
Coordinator: Possibly Tuesday and he's possibly for a cardiac angio
today.
Both junior doctors look surprised: Oh!
Coordinator: Mr [] happened to mention it when he popped in
Saturday!
This work was barely perceptible, embedded as it was in the
daily interactions with the multitude of actors who moved in and
out of the care setting, but it was vital in creating the knowledge on
which local work organisation depended.

4.2.2. Articulation work

Closely related to working knowledge creation is articulation
work (Strauss et al., 1985), that is, the work nurses do to support
trajectories of care by connecting network actors together. This
entailed temporal articulation practices directed at ensuring actions contributing to an activity took place at the appropriate time
and in the right sequence (Bardram, 2000). Nurses drew on their
oversight of trajectory progress and organisational knowledge to
anticipate how care would unfold so arrangements could be made
to expedite timely action. They utilised their clinical knowledge to
act as the eyes and ears of the organisation in response to patients'
evolving needs and notied the responsible actor taking into account the urgency of the task and the temporal constraints of the
system.
Nurses run the place. [] That requires anticipating people's needs
and constantly being two steps ahead.
Beyond identifying, lining up, prioritising, and assigning tasks,
trajectory mobilisation also depended on the availability of materials to support the work. I have termed this material articulation.
Practices are always mediated by artefacts and thus material
articulation is a necessary counterpart to temporal articulation.
With their work located in the sites of care, nurses took responsibility for ensuring the availability of resources and materials,
both through their routine work in maintaining a functioning
clinical environment, and in the work they did to assemble materials to support specic actions. This was necessary in circumstances where providers were operating under pressures of work,
when action was time-critical, and where actors were unfamiliar
with the location of resources and equipment. For example, the
stroke coordinator was responsible for preparing the eld to support thrombolysis, an intervention to be administered within three
hours of the onset of a stroke.
I go to see everything is ready and I draw up the medicines loads
and stay with the patient until they are transferred to the Stroke
Unit.

In addition to the work done to facilitate action, trajectory

mobilisation also required attention to the coherence of different
elements. I have called this integrative articulation. Because
healthcare providers interacted infrequently, it was necessary for
nurses to mediate these relationships. Operating with an overview
of patient trajectories, nurses understood the relationships between constituent elements. Actions that appeared reasonable in
isolation might be questionable from a trajectory perspective.
Nurses had an important role in supporting joined-up decisionmaking, resolving anomalies or contradictory elements in individual's care and anticipating potential problems before they
arose.
Staff Nurse makes a call to another doctor to clarify earlier advice
about a dextrose infusion and 2 hourly BMs ((blood glucose
monitoring)) in the light of a decision taken by another team that
the patient can eat and drink for now but will be nil by mouth from
midnight.
Trajectory integration extended to the socio-material congurations to support patient needs. In the next example, the nurse
negotiates with the doctor over a drug dosage. She is concerned
because the medications do not come in tablet form in the dosage
prescribed and the patient, who is about to be discharged home, is
unable to break them in half in order to administer the correct dose.
Staff Nurse: [] has gone down to 90 is there any chance you could
go to 100 as they don't have 90 tablets and he's got to give them
himself.
Junior Doctor: When I increase it, it increases his epistaxis so it's
likely to have to come down further.
Staff Nurse: 80 e they do 80 tabs. OK so I can have a word with the
registrar.
This is a nely-wrought judgement in which the nurse draws on
her knowledge of the patient and the dose formats of this medication to identify the potential risks involved in discharging the
patient home on his current prescription.

4.2.3. Bed management

The third domain of organising practices relates to nurses' work
in matching patients with beds and expediting patient ows
through the organisation. Hospitals face a daily challenge of
balancing the demands of an unknown and variable volume of
patients and ensuring a sufcient but not excessive number of beds
is available for individuals with differing needs (Comptroller and
Auditor General, 2000). Maintaining throughput and assigning
people to the right bed with all the accompanying resources this
confers has important implications for healthcare quality. Nurses
throughout the organisation, from ward to board, were engaged in
allocating beds and overseeing the movement of patients through
the system (Allen, forthcoming).
Beds are a complex currency. Even if we limit discussion to the
material artefact, we discover a wide variety: hospital beds, paediatric beds, bariatric beds, low-rise beds. Trolleys may be used as
beds, but only for certain kinds of patient and for a limited period.
Beds are also associated with expertise, specialist equipment and
staff, and even within the same department, certain beds are in
spaces which make them more-or-less suitable for particular
patients.
Throughout the organisation nurses drew on a ne-grained
understanding of the local economies in which they functioned

D. Allen / Social Science & Medicine 119 (2014) 131e138

and coupled this with clinical knowledge to match individual patients with beds and expedite patient ows.
Standing in the middle of the High Dependency Unit ofce Coordinator says, I need a medical patient who can go to Medical
Assessment Unit. One of the doctors says that he might have one,
Tachycardia, no precipitating factors.
Coordinator: So it will need monitoring.
In this extract, when the doctor volunteers a patient, the
Coordinator translates the clinical information provided into the
type of bed that will be required (so it will need monitoring)
which limits the bed they can occupy in the unit to those with
cardiac monitors.
The pressure on beds in the study site was intense and in such
circumstances, bed management required skilled judgement to
bring about the accommodations necessary to balance individual's
quality of care with the organisation's responsibility for whole
populations. This entailed an iterative process of moving from one
possible coupling to another and the negotiation of adjustments to
the bed through for example, the deployment of additional staff,
equipment and/or a reassessment of patient need.
One nursing home has refused to accept the patient even though
they have a room. The room is small and cannot accommodate a
hoist. However, Discharge Liaison Nurse argues that the patient
will not use a hoist as he does not get out of bed. [] She will
contact the home and see if she can charm them and get him
accepted into this room until a more suitable one becomes
available.

4.2.4. Transfers of care

As healthcare becomes ever-more specialised and bed pressures
increase, patients typically traverse multiple services during an inpatient episode and these boundary crossings are highly consequential for the care received. In the study site all health providers
contributed to interface management, but given their location in
the sites of care and everyday contribution to the organisation of
service delivery, nurses had overall responsibility for this function.
Within the professional and policy literature, boundary crossing is
conceptualised as a process in which patient care is transferred
from one service to another, and success is believed to hinge on role
clarity and accurate information exchange. Yet navigating a safe
passage involves more than a clear division of labour and robust
systems of knowledge management; it requires patients to be
translated from the work object of one service into the work object
of another, referred to here as parsing patients.
For the transferring department, a transfer of care is an occasion
of closure in which the trajectory and its history must be crystallised. This is always a retrospective construction: the sense and
meaning of a trajectory is accomplished once elapsed actions are
available for review (see: Berg, 1992). But this transformation has
another dimension: transfers of care also require patients to be
reassembled into the work object of the new service and identities
(re)congured accordingly. Thus boundary crossings involve a
double translation and have a retrospective-prospective orientation, requiring staff to look back to gure patient identities in terms
of the course that has been travelled and forward to translate this
into a form that will facilitate their onward journey. Documents
were signicant actors in mediating these processes and were a
primary source of the paperwork about which nurses habitually
complained. The following example is taken from my observations
in the Post Anaesthetic Recovery Unit.

135

Staff Nurse is recovering a patient in the space directly opposite

the Nurses' Station. She is completing paperwork and as I
approach she says that she is getting up to date with the
observation charts before she takes the patient back to the ward.
She is lling in an arterial observations chart, completing the
information on a host of clinical indictors for a series of 15
minutely observations which she has not yet recorded hard copy.
After she has completed this documentation she moves on to the
observations ((BP, temperature, pulse)) chart. Here again she
goes through the same process of completing the form but this
time using information from the monitor to update the information. [] When she has done this she ticks all the boxes in
the recovery discharge criteria check list, which includes inter
alia: maintenance of airway, oxygen saturation, respiratory rate,
cardiovascular observations, temperature, surgical drains, wound
site, pain, urine output, neurological status, nausea and
vomiting.

In this example, the nurse brings about a retrospective crystallisation and prospective translation of the patient's identity
formally mediated by a handover check-list and the associated
observational charts. This paperwork brings together the numerous
physiological observations through which the nurse has reached a
decision about the patient's suitability for transfer, enables her to
account for her action by documenting the recovery trajectory and
to demonstrate, through the satisfactory completion of the
discharge criteria, the patient's readiness to leave the unit. Through
this process the individual is transformed from a patient recovering
from anaesthesia to a patient suitable for transfer. Then, having
assembled this information and completed the handover check-list,
the nurse accompanies the patient back to the ward, where the
documented information is supplemented by a face-to-face
handover.
Transfers of care are highly variable, and the source of this
variability is both clinical and organisational. Factors that are
consequential for this work included the complexity and predictability of patient trajectories, the range of trajectory types
traversing an interface, the scope of care responsibility to be
handed over, the proximity and familiarity of collaborating departments/professions, the amenability of the transfer process to
rationalisation and technical mediation, the potential for boundary
crossing to be supported by social interaction, the degree of interpretative work demanded of practitioners in fabricating identities
for the work purposes of others, the ease with which pertinent
information can be accessed and the politics of transfer. Thus
transfers between proximal units within the organisation were
easier to effect than transfers that entailed connecting more distant
departments which interacted infrequently. The management of
internal transfers of care which could be supported by human
mediation were generally less demanding than those involving
external agencies where opportunities for face-to-face interaction
were more limited. And transfers where relevant patient identities
could be rationalised and pre-specied were more amenable to
technical mediation than those in which the required information
was difcult to determine prospectively and involved sensemaking
and interpretative work on the part of health professionals. There is
a growing appreciation of the importance of interface management
for the quality of patient care and yet less recognition of the nature
and demands of this work and the time it entails. Nurses were
required to full this function in the turbulence of the clinical
environment which was subject to constant interruptions and for a
whole range of reasons interface management in certain parts of
the organisation was considerably more burdensome and risky
than it needed to be.

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D. Allen / Social Science & Medicine 119 (2014) 131e138

4.3. Synthesis: rethinking nursing, rethinking healthcare

Although not typically regarded as the primary actors in
healthcare systems, through their organising work, nurses are the
means for bringing together and keeping apart the various heterogeneous entities to accomplish everyday service delivery. They
make the connections across occupational, departmental and
organisational boundaries and mediate the needs of individuals
with the needs of populations. Not only is this work an essential
driver of action, it 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 study of everyday practices reveals what social structures
look like from within (Anderson and Sharrock, 1993) and viewed
from the vantage point of nurses, the image of health service provision that emerges is that of a stochastic, contingent, and distributed process in which patient identities are gured and
recongured according to the purposes at hand and the organisation is shaped and reshaped by the demands of the populations
served. Far from being a managed linear pathway through the
service, for much of the time an individual's healthcare is an
amorphous network of heterogeneous elements and the patient, as
work object, is widely distributed.
In practice-based approaches to work, boundary object theory
(Star and Griesemer, 1989) has been applied widely to understand
cooperation between different social worlds. In the absence of
consensus, boundary objects are able to bridge divisions between
groups because they satisfy a range of needs. In recent years a body
of literature has emerged exploring how artefacts function as
boundary objects to support inter-professional working in healthcare. There is, however, a more radical application of boundary
object theory that is useful in enlightening understanding of hospital organisation. In their research on technical projects, Garrety
and Badham (2000) distinguish between primary and secondary
boundary objects; the former referring to the project itself - the
object around which activity is organised - and the latter referring
to the physical or abstract entities that enable communication
across project collaborators. Applying this framework to healthcare,
it is the patient that is the primary boundary object around which
work is organised (see also, Bloomeld and Vurdubakis, 1997;
Middleton and Brown, 2005). Rather than the orderly management process portrayed in the rationalising myths beloved by
policy makers, it is the object of the patient in all its interpretative
exibility that enrols the work of actors into recognisable patterns
of action e what service managers call pathways of care e and it is
nurses who are central in bringing about the translations through
which this is accomplished. It is less a case of services being
organised around the needs of the patient, and more a case of the
patient, by dint of the work nurses do, holding services together,
however fragmented and fragile these arrangements might be. As
Finger et al. (1993) have underlined, human mediators are often
necessary in making boundary objects act as such and it is clear
why nursing is so often referred to as organisational glue or oil.
From an ANT perspective, nurses are the obligatory passage
points in healthcare systems. Barely anything happens that does
not pass through the hands of a nurse. Described by some (Dear and
Flusty, 2002) as the network's panopticon, an obligatory passage
point is a privileged location which can see and act at a distance and
have control over all transactions between the local and global
networks (Law and Callon, 1994: 31). Through their organising
work, nurses are the network builders, system enablers and principal mediators through which the diverse elements that comprise
trajectories of care are ordered. These are relatively invisible
practices which take place under the radar of formal organisational

structures, but they are vital to the quality and efciency of

healthcare provision. As insights from new institutionalism have
shown us, this disconnection between the formal hospital plan and
the reality of everyday practice reects the importance of certain
widely accepted cultural models in conferring legitimacy within
the eld in which organisations function (Meyer and Rowan, 1977).
While historically healthcare organisations gained legitimacy from
professional logics, more recently they have been penetrated by
market and managerial logics and these have had a profound effect
on their formal structures. One of the challenges for nursing, then,
is for its own practices to be treated as legitimate both internally by
the profession and externally within the healthcare eld. In the rst
instance this requires a language with which to articulate nursing's
distinctive organising logic and a better understanding of the
knowledge and skills that underpin it.
Taken as a whole, nurses' organising practices can be understood as effecting translational mobilisation. In ANT, translation
has a dual meaning and both apply here. The semiotic sense of the
word encapsulates the work nurses do at service interfaces to
transform people and their problems into patients with organisationally recognisable identities, their work in clinical locales in
converting trajectory narratives into formats that align with the
information needs of providers, their work in matching patterns of
clinical signs with the appropriate organisational response, their
work in integrating trajectory elements so that these do not interfere with each other, and their work in reconciling the needs of
patients with available resources. Translation also refers to the
movement of an entity in space and time, and so alludes to the role
of nurses in managing patient ows through their bed management practices and transfers of care, ensuring temporal articulation, and aligning the socio-material congurations that support
action. I have combined translation with the notion of mobilisation
in preference to that of coordination because organising work extends far beyond aligning and integrating activity. Nurses initiated
and ensured actions happened in the rst place, resolved anomalies
and contradictions, and devised strategies to overcome obstacles to
progress. Coordination also has connotations of formal processes
designed to align conduct according to a predened plan, whereas
much of the work that nurses do is in reaction to unexpected
contingencies, whether these are clinical or organisational in
origin. Mobilisation is also intended to convey something of the
energy entailed by organising work and its involved and continuous character.
Of course it might be argued that these are just fancy words for
what nurses already know, as was suggested by a conference delegate when I rst presented these ideas. Yet while they may
acknowledge their work when it is reected back to them, nurses
nd it extraordinarily difcult to describe this element of their role,
either to themselves or wider society. Moreover, because the profession's self-understanding is so tightly bound up with patient
relationships, nurses are deeply ambivalent about the value of
organising work which discourages professionally-led efforts to
better understand and augment what is a signicant dimension of
nursing practice. A corollary of this is that nurses often nd themselves having to accommodate technologies that hinder rather than
support their activities and they are unable to justify their endeavours when these are called into question. Nevertheless, nursing
has a strong record of accommodating changes in scope and practice
through stretching old labels to accommodate new functions
(Goodrick and Reay, 2010) and here I propose that the concept of
holism be extended to incorporate nurses' organising work.
In studying practices ethnographically, one does not search for
knowledge in participants' minds, it is located in activities, events
and procedures (Mol, 2002); and it is evident that translation
mobilisation depends for its success on a blended understanding of

D. Allen / Social Science & Medicine 119 (2014) 131e138

patient and organisational factors. That nurses operate with a

clinical gaze (Foucault, 1973) is well understood (May, 1992), but
my data also highlight the importance of organisational awareness,
and it is the synthesis of these two knowledge types that characterises nurses' professional vision (Goodwin, 1995). This is clearly a
holistic approach to healthcare, and a unique orientation not
shared by members of other professions, but quite different from
the bio-psycho-social model that has dominated nursing's jurisdictional claims in recent history and underpinned by a subtly
different knowledge-base and skill-set.
In addition to their clinical knowledge, translational mobilisation is founded on nurses' detailed understanding of the relevant activity systems in the local ecologies in which they worked.
The basic unit of analysis in activity theory, an activity system refers
to the practices and artefacts oriented towards a shared object, in
this case, the patient. An activity system is always heterogeneous
and multi-voiced and different subjects, because of their relative
positions in the division of labour, construct the object in different
ways. In addition to their direct clinical care of patients, however,
nurses operated with a global view and drew on this knowledge to
mobilise everyday healthcare delivery. Thus, the creation of working knowledge and managing transfers of care depended on the
ability to appreciate others' work purposes and distinctive ways of
understanding the same situation so that the relevant information
was prioritised and expressed in their language. Articulation work
required knowledge of the relationship between activity system
elements, what some have called coordinative awareness (Cabitza
et al., 2005), so that network actors can be aligned and the potential
for interferences identied. Bed management depended on familiarity with the local bed economies in which nurses operated and
the categories of patient suitable for placement. Indeed, in a more
general sense, activity system artefacts, such as patient typications and organisational routines, were important resources for
accomplishing translational mobilisation. Specic patients were
matched with particular types of beds, different categories of patient prompted particular courses of action, certain decisions were
associated with lines of work and different clinical presentations
were coupled with discrete interventions. Patterns and routines did
not determine patient care in a straightforward way, however; they
were adapted in a given case or situation, sometimes by nurses,
sometimes by others. But by deploying the routines and the categories with which they were familiar, nurses were able to assemble
the network actors necessary for action. Through the synthesis of
clinical and organisational knowledge, nurses maintained an activity awareness of the trajectories of care for which they were
responsible. Research on collaborative work has identied that
different kinds of awareness are necessary to support practice.
Whereas action awareness relates to information about short-term
tasks (Hindmarsh and Pilnick, 2007), activity awareness (Paul and
Reddy, 2010) refers to knowledge of an evolving activity over
time. As far as the ongoing management of care was concerned
nurses had a trajectory awareness that was unavailable to others
and which had an important role in supporting care delivery.
5. Discussion
The analysis presented here offers empirical foundations for a
more inclusive conceptualisation of holism within the nursing
mandate founded on organisational as well as individual patient
relationships. Professional mandates are important in making work
publically visible, transmitting occupational culture and dening
group membership (Whittaker and Olesen, 1964). They also
encourage members to strive for their principles when these are
challenged in the work setting (James, 1992). If the gap between
professional ideals and reality becomes too wide, however,

137

mandates can become dysfunctional (Becker,1970). This can result in

alienation from work, in a classic Marxist sense, leading to burn-out,
withdrawal from employment or diminished commitment reected
in indifferent standards of care (Dingwall and Allen, 2001; Maben
et al., 2006). Such misalignment not only distorts expectations for
practice, it does not reect what nurses actually do in practice, and
thus prevents the profession from realising its potential. The reformulation of holism to incorporate nurses' organising work provides
an opportunity to rethink the nursing contribution to healthcare
based on the work that they actually do, whilst also maintaining
some continuity with the profession's self-understanding.
Beyond the challenges of winning the hearts and minds of the
profession and its publics, these ndings raise important questions
about the organisation of nurse education and professional development. Most of the nurses shadowed were experienced and had
developed their knowledge and skills over many years working
within the organisation. These are not plug and play capacities, but
built up over time and integrated with the surroundings. Even very
experienced nurses became deskilled in activity systems with
which they were unfamiliar. Moreover, when it was necessary for
nurses to practice beyond the boundaries of their local context,
such as when transfers of care had to be accomplished with more
distant services, translational mobilisation became more challenging. This helps to explain why nurses are often reluctant to be
redeployed outside their normal practice areas and why outliers,
that is patients that belong to another clinical service, are unpopular with staff and experience service discontinuities. The challenge
for the profession is to consider how the knowledge and skills that
underpin translational mobilisation can be taught, what might be
done to accelerate the learning process and how the understanding
and organisational knowledge on which it rests might be made
more widely available.
6. Conclusion
Since it was developed in the 19th century, nursing has always
included an organisational component (Dingwall et al., 1988). Thus
to reinstate organisation into the professional mandate is not a
departure from modern day nursing's foundations nor is it a
derogation of nursing knowledge and skills. Indeed, given the
complexity of contemporary healthcare systems, to reformulate the
nursing mandate around the organisation of healthcare actually
strengthens the case for graduate-level nurses because of the sophisticated technical, organisational and social skills necessary to
undertake this work. It does, however, raise challenging questions
about what occupational category will be the bedside carer in
modern healthcare systems and models of practice necessary to
ensure high quality care.
Acknowledgements
The eldwork on which this research is based was carried out
during a sabbatical period supported by Cardiff School of Nursing
and Midwifery Studies and the data analysis was undertaken as
part of an Improvement Science Fellowship (2011e2014) funded by
The Health Foundation. I am immensely grateful for such investment, enthusiasm and support. Thanks are due to the senior nurses
in the study site who championed the research and the individuals
who willingly allowed me to peer over their shoulder while they
went about their everyday activities. I am also appreciative of those
who assisted with the development of the sampling frame: Sarah
Morley, Amanda Monsell, Gillian Knight, Stephen Grifths, Ann
Jones, Alison Evans, Rhian Barnes, Judith Carrier and Elaine Beer.
Robert Dingwall made a number of insightful observations which
strengthened the original analysis.

138

D. Allen / Social Science & Medicine 119 (2014) 131e138

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