Daily, numerous efforts are made to manage nurse staffing levels, with significant time spent mitigating shortfalls to support the safest staffing position possible shift by shift. In a document on workforce development, NHS Improvement (2018) cited steps to support organisations to use best practice for effective staff deployment and workforce planning:
- Trusts must ensure three components are used in their safe staffing processes: evidence-based tools, professional judgement and outcomes
- An assessment, or resetting of the nursing/midwifery establishment and skill mix (based on acuity and dependency data using an evidence-based toolkit), must be reported to the board by ward or service twice a year. This must be linked to professional judgement and outcomes
- There must be no local manipulation of the identified nursing/midwifery resource from the figures embedded in the evidence-based tool used, as this may adversely affect the recommended establishment figures derived from use of the tool
- Any redesign or introduction of new roles, including but not limited to nursing associates and advanced nurse practitioners, would be considered a service change, and must have a full quality impact analysis.
NHS England/NHS Improvement will check delivery of this annually; I am just reviewing my trust's annual process. Having reflected and written about ‘missed care’ and, like many nurse leaders, considered how we could further reduce harm from pressure damage, falls and other incidents, we know skill mix is a factor, but the issue of nursing workload is less prominent than it should be.
Reviewing 121 articles, Jackson et al (2021) identified that, while there is ample evidence nurses are under strain, the creation of a modern model of nursing may assist in developing workable solutions to professional issues and foster cohesion among teams. The work cited by Jackson et al (2021) included that reported by Benner in 1981, Corbin in 2008, Hockey and Allen-Collinson in 2009 and Allen in 2014.
Corbin reflected that a reductionist nursing narrative had prevailed, suggesting that nursing work is simple, easy and can be undertaken by anyone. However, Jackson et al's (2021) article revealed four narratives, with several subsets of nursing, where work is conceptualised as labour.
Physical labour
Refers to work nurses do with their bodies. First, this is the impact of physical labour on nurses, but also the impact on time to undertake activities. This is area is not fully understood when setting staffing establishments. For example, advances in ambulatory care mean I am observing that acuity and dependency has risen in wards, with more patients at risk of harm and requiring preventive nursing care such as repositioning. In a subtheme, Jackson et al (2021) cited work by Hockey and Allen-Collinson recognising the efforts required in sensory work, such as observational skills, listening for alarms or noting smells, stating that nurses regulate their responses to sensory information, such as keeping their faces neutral when smelling something unpleasant.
Emotional labour
Hochschild, as Jackson et al (2021) reported, defined emotional labour as the commodification of managed emotions. The labour occurs when nurses induce or suppress their feelings to produce a desired display, invoking a feeling in the patient. Also discussed is the concept of the emotional labour of nursing: this describes nurses as managing their own emotions to create therapeutic environments for patients. The ‘labour’ is required when nurses need to project something different from what they felt.
Cognitive labour
Jackson et al (2021) discussed that learning while working (infamously coined by Benner) refers to developing expertise in clinical practice, rather than the process of nursing education. Also discussed is critical thinking, decision-making and reasoning as part of nurses' work. An interesting subtheme identified was ‘stacking’, which refers to the cognitive load on nurses' working memories due to the long list of tasks and changing priorities nurses must remember.
Organisational labour
The concept of organisational labour was created when Allen recognised organisational labour as a legitimate part of nursing work (Jackson et al, 2021). Allen defined it as arranging essential activities for a patient, their family and the organisation, ensuring patient flow through the system. Organisational labour is said to generally be unrecognised, even by nurses, but is defined largely as paperwork, or a bureaucratic exercise that removes nurses from doing their ‘real jobs’, that ensures safe management of a patient's trajectory through the health system.
As nurses, we know that nursing work is complex, with numerous unrecognised aspects that are difficult to specify. This review has chimed with me following numerous conversations with colleagues when reviewing harm events and considering workload as a factor for missed care. The authors have developed a useful model for representing nursing work when considering the professional judgement elements of safe staffing reviews.