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Letter to the Editor on "Classifying Nursing Work"

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March 17, 2004
in response by Hugh McKenna to Classifying Nursing Work 
with reply by authors

Dear Editor:

I write in response to the article, "Classifying Nursing Work," by Bowker, Star, and Spasser.

Galileo urged that people should measure what is measurable, count what is countable, and what is not countable – make countable. This obsession with measuring has been the basis for science for many centuries. With quantification comes power, a lesson learned from the medical profession’s propensity to classify and categorise. Therefore, for the development of nursing as a profession and as a discipline, the attraction of being able to count and quantify is understandable. After all, if you cannot identify it, it cannot be measured, it cannot be costed and it cannot be rewarded. However, the problem with all-nursing classification systems, workload measurement systems, and audit systems is that much of what nurses do cannot be measured. How do you quantify compassion? How do you calibrate a presence and how do you count empathy? I offer two examples to illustrate the issue further.

A manager observes a nurse sitting by a bedside talking to a patient. To the untrained eye the nurse is merely conversing and others who are not highly paid practitioners can do that! However, the nurse may be educating the patient about his medication or she may be counseling the patient who is distressed. The nurse could be using an expansive and complex repertoire of knowledge and skills from the fields of nursing, medicine, psychology, sociology, and ethics. How is this intervention quantified? Would counting the amount of time she spent with the patient provide details of effectiveness?

Similarly, picture a nurse recording a patient’s pulse. To the untrained eye she is counting, and once again, other less expensive employees can do that. However, the nurse may be doing more than just counting. She could be observing the patient’s skin, reassuring the patient, and checking for abnormalities in cardiac rate and rhythm. This gestalt of processes occurs simultaneously and does not lend itself well to measurement.

In contrast, many of the technical tasks that nurses do can be measured. With new technological advances these are increasing in number and many nurses are metamorphosing into technicians. Nonetheless, the recipients of care, while they value the nurses’ technological expertise, also place high value on the non-technological aspects of care. Research by McCance, McKenna and Boore (2000) showed that patients appreciated the subtle nuances of care, the nurse’s ability to be humorous, to be there, to support, and to care. Perhaps there are psychologists who would assert that they could measure such a nebulous phenomenon as being with a patient. Does that mean that touching a patient ten times is twice as effective as touching them five times? Caring and nursing are not that simple.

As alluded to above, medicine values measurement. After all, this is the way that most physicians are educated. However, the best doctors also have the human touch. I note with interest that journals such as the British Medical Journal and the New England Journal of Medicine have recently begun to accept articles that use qualitative research methodologies. Similarly, research funding bodies have recognised that qualitative research can also be rigorous, systematic and worthy of grant support. If scientists have accepted that there are researchable phenomena that cannot be quantified, why can it not be accepted that there are interventions that defy quantification, nursing classification and workload measurement?

In the history of the world, the desire to measure and quantify has had a relatively short life span. This predilection can be traced to empiricism, a philosophy of science that believes that knowledge is derived entirely from sensory experience. In other words if something cannot be observed, it does not exist. The origin of empiricism can be traced to the English philosophers of the 17th, 18th, and 19th centuries. Of these John Locke (1632-1704) was the first to put forward empiricist principles, although his fellow countryman, Francis Bacon (1561-1626), had anticipated some of its characteristic conclusions.

The 20th century positivists of the Vienna Circle further developed these early views. In essence, the doctrine involved the following logic: our minds interpret the world through our senses; and because the world is subject to the laws of science, events outside the mind can be observed, described, explained, and predicted. Therefore, to make sense of the outside world all we have to do is study it empirically and undertake experiments to test hypotheses that are formulated from observing this natural world. Proponents of positivism believe that knowledge and objective truth exist and the goal of science is to go out and discover it.

However, in the 1960s large cracks formed in the quantitative paradigm; and it is not inconceivable that a Kuhnian paradigm shift (Kuhn, 1970) is occurring where quality will gain more respect that quantity. Should nurses and nursing race to embrace a quantitative paradigm and attempt to measure all that we do when we have the opportunity to have a rich knowledge base composed of quantitative and qualitative science?

As Bowker, Star, and Spasser (2001) suggested, the crucially important invisible aspects of the nurses’ role will have secondary status if nursing rushes headlong into the pursuit of "representing nursing work in the form of atomic, indivisible units." Furthermore, imperceptibly the more invisible aspects of the nurse’s role will not be valued and will be no longer seen as nursing work. This will open the door to an increase in the number of unqualified assistants undertaking direct patient care activities. Re-engineering of nurses’ work will follow and greater value would be placed on what can be counted and measured. Nurses will be farther away from the patients’ bedside and become the technological architects of care rather than the doers. This is a recipe for Darwinian professional cleansing. Nurses should be trying to re-humanise nursing by getting closer to the patient, not farther away.

If a person wanted to seek professional help from a lawyer or an engineer, they would expect to see the most qualified person in that office. They would not expect to be helped by the most unqualified person in the firm. In contrast, when ill people are admitted to hospital it is often the most unqualified person they see; and it is they who provide the most ‘hands on’ care.

Physicians have learned that staying close to the patient is where power lies. This lesson does not appear to have been inculcated into nursing, the so-called caring profession. At their best, senior physicians have four roles: they treat patients, they teach students, they research, and they have a managerial role. In contrast, nursing has mostly compartmentalised these roles across different jobs. Many of those who wish to care for patients stay in the clinical area, those who wish to teach leave the wards and go to work in colleges of nursing, those who wish to research work in universities or research institutes, and those who wish to manage often leave the clinical setting and enter administration positions. Such division leads to weakness not strength.

For decades nurses throughout the western world have been using the nursing process and models of nursing. In many countries the resulting care plans have to be complete for quality auditing purposes by the Joint Commission for Hospital Accreditation and a condition for participation in Medicare (Bowker et al., 2001). However, many nurses dislike this paperwork believing that it takes them away from more important work. Bowker et al reminded us that 28% to 34% of nurses' time is spent on this task. They rightly cite McCloskey (1981), who maintained that few plans are written.

Increasingly, care plans have been computerised or pre-written as core or standardised care plans. Rather than writing more informative qualitative plans, this has had the effect of nurses merely ticking boxes and selecting shorthand options that may only partly explain what care took place. Because of shortages of staff, busy wards, and the lack of value nurses place on care plans, such care plans are readily accepted (McKenna & Deeny 1994). Unlike textual commentary about care, computer careplans lend themselves well to audit and workload classification. However, will such shorthand bites of information provide a true picture of the patients’ needs and the care delivered?

Bowker et al. (2001) quote an assertion by Huffman (1990, p. 319), that "nurses' notes are primarily a means of communication between the physicians and nurses." The evidence for this is not convincing. While nurses often read medical notes, physicians seldom read nursing notes. It could be argued that nursing notes are there to safeguard the hospital or the physicians when, at some future date, aggrieved patients or families seek claims for negligence. Bowker et al. (2001) agreed with this, stating that the nurse’s duty is to remember for others by acting as a distributed memory system for doctors and hospital administrators. However, if care plans are merely a collection of tick boxes and shorthand statements, then even this perceived value may wane.

Nursing has often tried to mimic medicine. This has led to nurses expanding their role into areas previous the domain of physicians. They complain about the jargon used by nursing theorists but readily devour medical terminology and the medical model. The pursuit of credibility through embracing medical technology and medical research approaches are the latest attempts in this pursuit of greater professional standing. However, by doing this nurses may be trying to fit into a world that does not fit with the real substance of nursing – the analogy of a square peg in a round hole is appropriate.

Nursing theories have not helped in dealing with their complicated and conflicting attempts to define nursing. McKenna (1997) identified over fifty grand theories in nursing and a similar but growing number of mid range theories. Rather than clarify nursing, these have often lead to confusion. Many have been abandoned and seen as a late 20th century phase that the discipline of nursing had to go through, part of its initiation towards professionalism. Rightly, other disciplines are often amused at the plethora of nursing theories and the nursing process.

According to Bowker et al. (2001) the Nursing Intervention Classification (NIC) deals richly with the central tension between the desire for and the dangers of visibility. They stated that the original NIC system consisted of a list of some 336 interventions; each comprised of a label, a definition, a set of activities, and a short list of background readings. Each of those interventions was in turn classified within a taxonomy of six domains and 26 classes. This description alone conjures up the importance of visibility and the measurable, rather than the invisible and the unmeasurable.

In conclusion, nursing is a young profession still struggling to find its way in the health care world. This is natural and fitting for a discipline in what Kuhn (1970) called a pre-paradigmatic stage of development. The essence of nursing is care and by definition care means ‘hands on’ working with patients, their families and communities. Our education and research programmes should reflect this focus. If we accept that nursing’s underpinning philosophy is one of care, then we have to accept that the phenomena that will occupy our thought and actions will mostly be nebulous and qualitative in nature. If our attempts at classifying nursing, measuring workload, and auditing nursing systems lead us towards some quantitative mirage of professionalisation, we may be denigrating what is core to our existence as a discipline and becoming mini administrations, mini doctors and mini technologists. While nurses are on the hilltop horizon scanning, unqualified assistants are in the swampy lowlands working with real patients with real problems in real situations. Which group do the patients need most?

Hugh McKenna, D. Phil, RN
Professor & Head, School of Nursing
University of Ulster
Northern Ireland


Bowker, G.C., Star, S., & Spasser, M. (2001). Classifying nursing work. Online Journal of Issues in Nursing. Retrieved February 12, 2003, from

Huffman, E. (1990). Medical record management. Berwyn, IL: Physicians’ Record Company.

Kuhn, T.S. (1970). The structure of scientific revolutions (2nd ed.). Chicago: University of Chicago Press.

McCance, T., McKenna, H.P., & Boore, J.R.P. (2000). An exploration of caring: A comparison of patients’ and nurses’ perceptions. Journal of Advanced Nursing, 31(4), 543-551.

McCloskey, J.C. (1981). Nursing care plans and problem-oriented health records. In H. H. Werley & M.R. Grier (Eds.), Nursing information systems. New York: Springer.

McKenna, H.P. (1997). Nursing theories and models. London: Routledge.

McKenna, H.P., & Deeny, P. (1994). Care plan sham. Nursing Standard, 8(41), 42-43.