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Letter to the Editor

Reply by Bowker, Spasser to McKenna on "Classifying Nursing Work"

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March 17, 2004
Reply by authors in response to letter by Hugh McKenna on Classifying Nursing Work (March, 2001)

Visibility is Not About Counting

While McKenna seems to have a basic understanding of the point of the article — ambivalent tensions that making the invisible visible entails — he fails to make a couple of critical distinctions.

He makes much of the qualitative-quantitative divide, but visibility, etc., has no necessary implications for whether something is measured, let alone measured quantitatively. Basically, contra the author, visibility does not equal (or entail) measurability, and certainly not quantification. Visibility as we discussed it is about recognition and acknowledgment: "Only work that is visible can truly be identified as valuable." For example, the author asks the questions (rhetorically?): "Would counting the amount of time she [a nurse] spent with the patient provide details of effectiveness?" or "Does that mean that touching a patient ten times is twice as effective as touching them five times?" In terms of the former, making the amount of time a nurse spends with a patient 'visible' simply does not entail the arithmetic simplicity suggested. The point is that nurses' work should be recognized and somehow valued by constituencies other than nurses, especially by patients, physicians, and hospital administrators, among other powerbrokers.

Using the NIC taxonomy to make nursing work visible is perfectly compatible with and does no necessary violence to the process-oriented nature of nursing work. Quantification might. As we wrote: "They [the Iowa Intervention Team] have recognized in discussions and publications that nursing work is not easily quantifiable and divisible; and they have developed a classification system which retains a judicious level of ambiguity; they do not try to overspecify the parts …."

Is the nurses' touch to be lumped in with a TV and air conditioning in a hospital room, as part of some omnibus room charge considered by the hospital to be overhead (i.e., to be externally erased)? Maybe, maybe not, but that's really a different argument. The argument here is that by "… ensuring that all nursing acts are potentially remembered by any medical organization, the NIC team will have gone a long way to ensuring the future of nursing: (Bowker & Star, 1999, p. 275).

All of which leads to this fallacy about taxonomies to which the author seems to fall prey: that taxonomic applications (what the user sees/does) must conform to the same rules as the underlying taxonomy structure (how the taxonomists construe the phenomena under consideration). This is emphasized in Star’s work on racial systems of categorization (e.g., Bowker & Star, 1999, especially chapter 6). Systems of classification can be structurally flawed and put to flawed/counterproductive uses, but so can sound taxonomic structures. Conversely, sound taxonomies (NIC, for example) can most certainly be used destructively or oppressively (to atomize and deskill praxis, for example). In other words, perhaps the most that can be said is that McKenna shares our concern that we should try to ensure that even theoretically and practically sound taxonomies, clearing mechanisms that make visible the heretofore invisible and transparent, are put to consciously constructive use.

Mark Spasser, PhD, AHIP
Geoffrey Bowker, PhD

References

Bowker, G.C. & Star, S.L. (1999). Sorting Things Out: Classification and its Consequences. Cambridge, MA: MIT Press.

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