- Top of page
- The study
- Conflict of interest
- Author contributions
Nursing work is often characterized by a shortage of time to deliver patient care. According to the World Health Organization, there is a shortage of approximately 4·3 million health workers worldwide (Gilbert & Yan 2008), with the result that time is an increasingly scarce resource in the workplace. Consequently, health practitioners are increasingly feeling that more time is needed than is available (Waterworth 2003). To address this shortage, increased attention is internationally being paid to the restructuring of work processes to give a more efficient and productive health workforce (Duffield et al. 2008).
Existing research on nursing work and time largely focuses on task analysis studies addressing the nature and amount of time spent on patient care (O'Brien-Pallas & Baumann 2000, Chan et al. 2008). The relationship between having more time and being able to deliver better quality nursing care outcomes has been clearly demonstrated (Hobbs 2009). However, other studies also describe nurses' concern about the impact of time scarcity on the quality of nursing work and patients (Dalgaard & Delmar 2008, Seneviratne et al. 2009).
During the course of this article we will describe the findings from a qualitative study that explored registered nurses' (RNs) views on time and its effects on their everyday work. Through interviewing RNs over a period of time, a clear picture emerged of how time shapes the way that nurses plan and deliver patient care. The findings from this study will be of interest to those involved in nursing practice, research, and education and offer an insightful counterbalance to the more abundant studies which measure nursing work.
The issue of time is one of the most important influences on nursing behaviour, yet temporal issues have traditionally attracted little attention in the literature about nursing practice, theory, and research. Jones (2001) concluded that the small amount of literature in existence revealed misconceptions and a lack of value of nursing time, possibly indicative of the dominance of linear models of time (such as clock and calendar time) and the historical ascendancy of medicine and science in health care. Jones proposed that nursing practice exists in nonlinear, complex, and parallel temporal worlds rather than merely in clock time, which extends from past to future measured by seconds, minutes, and hours (Adam 1995). Similarly, Thomassen (2001) asserted that time is an experiential and existential phenomenon that relates to at least two concepts: (1) world time, outside, as measurable by the clock; and (2) life time, inner, as personal time with present, past, and future. Every person is subject to both concepts of time and for nurses to work in time, they are challenged to create space and connections between the two.
However, time is increasingly equated with healthcare costs and efficiency. This has resulted in an increased global focus on task-oriented clock time and has led to attempt to quantify and reduce time available to complete healthcare tasks (Walent 2003). This is particularly evident in the outcome-oriented nursing culture in Hong Kong, with its focus on routines and tasks, which has inadvertently directed attention towards what nurses do rather than to what they experience (Yam & Rossiter 2000).
Healthcare modernization and subsequent changes to nursing roles has often been accused of resulting in negative changes to the availability and use of nursing time. In countries such as the USA, Hong Kong, South Korea and the UK new nursing roles have been implemented and existing roles extended to improve efficiency, as a response to medical staff shortages and to improve services in rural and remote areas (Buchan & Calman 2005). For example, nurses in the UK have often been required to compensate for loss of medical capacity as a consequence of the reductions in junior doctors' hours in line with the European Working Time Directive. Duffield et al. (2005) reported that Australian advanced nurse practitioners were increasingly spending time on clerical tasks and activities which significantly diverted the amount time available for direct patient care. As nurses struggle to manage the tensions produced by time pressure, they often exchange patient-centredness for routine practices that render the patient an object of clinical and administrative work (Jones & Collins 2007).
- Top of page
- The study
- Conflict of interest
- Author contributions
The following sections describe the interconnected narratives of the ways five participants, Kathy, Michelle, Sharon, Phoebe and Yam, recounted their meanings of time and how these understandings affected their work. The findings are presented as three major themes on pages 9, 11, and 13. Although participants worked in different clinical areas and had variable length of service we were struck by the commonality of temporal experiences, regardless of context. Furthermore, following the first stages of analysis our reading of the literature revealed that a commonality of experience extended beyond our study to other countries and areas of nursing practice (Buchan & Calman 2005, Doherty 2009). The first section of the findings draws extensively from data to discuss how nurses sometimes struggle with time scarcity to deliver an optimum level of care. Data extracts are chosen for inclusion on the strength of their ability to communicate each narrative theme.
Time and nursing work: lack of time gets in the way of getting to know patients and families
This first narrative extract shows Kathy reflecting on how a lack of time and pressure of work restricted the amount of time available to get to know patients and their families:
I recall the time when I had to check 20 patients’ blood pressure readings in a surgical ward: I would recheck them only if the readings were below the baseline tasks. Most often, I wouldn't know the patient's condition and I wouldn't think of possible reasons for the blood pressure or wonder about possible internal bleeding. (Extract 1, Kathy)
Kathy describes how, despite having checked 20 blood pressure readings she ‘would not know the patient's condition' or ‘think of possible reasons’ for an unusually low reading. The undertaking of tasks on patients about whom the nurses know little or nothing is reminiscent of the task-centred approach to nursing care, where nurses value the completion of tasks rather than establishing a more patient-centred relationship (McCabe 2004).
In the following extract, Michelle describes looking after a patient who required barrier nursing, which resulted in ‘extra work’ for the nurses. The extract also demonstrates how spending time talking to the patient's husband results in the nurse seeing the patient as a ‘person’ rather than the ‘time-consuming’ object of care as first described:
Like many others, as it is time-consuming to put on and take off the protective gown and face shield, I was also reluctant to care for this patient.
However, I was moved by the patient's husband, who visited her daily and stayed outside the ward during the non-visiting hours. After talking with him, the patient became a person: someone's beloved wife. I felt guilty about our neglect of her because of the extra work. (Extract 2, Michelle)
Michelle's feelings of guilt reinforce the point made elsewhere that competing temporal demands in the workplace produce emotion in the workforce (Fine 1996). Competing temporal demands may also lead to the routinization of work. Routines often bring a sense of order to the workplace (Waterworth 2003), but consist of habitual ways of responding to occurrences in everyday life and are often taken for granted until they are disrupted in any way (Strauss & Corbin 1998).
In the next data extract, Michelle describes how familiarity with repetitive tasks leads to a ‘habitual way of doing’:
Sometimes I might be desensitized to a habitual way of doing, given the repetitive everyday activities and the similar nature of work. For instance, I was initially very cautious about patient transfer because of safety, but at times, when things become too familiar and routinized, I may make a wrong assumption because of my lack of sensitivity or alertness. For example, a patient was admitted to the ward due to an external head injury, but no suturing was required. He was alert and conscious, with a mental score of 15, and the doctor also prescribed activities as tolerated. He needed to have a CT scan. After the patient was transferred into the wheelchair, he had a generalized seizure and fell to the ground. As this patient was fully conscious, his need to be escorted to the CT department had not been considered. (Extract 3, Michelle)
Routines and habituated practice appear here as correlates of time, apparent when Michelle recounts how initial caution about safe transfer of patients was eroded over time by familiarity with a task. Although routines can reduce the time pressures that nurses’ experience, Michelle's narrative relates how routine practice led to the individual needs of the patient being temporarily overlooked.
The priorities of nurses and nursing
Nursing is seldom, if ever, a solitary occupation; as a consequence nurses must learn how to work with other nurses and professions. However, working with others can create tension, especially when one person's workload is temporally dependent on the timely completion of colleague's. As a result, nurses have long valued colleagues who ‘pull their weight’ (Clarke 1978, Allen 2001). The value placed on finishing tasks before colleagues commence the next shift was a recurring theme in the narratives, for example:
It is good to talk to patients. But if you haven't completed your expected routines and treatments, you have increased the workload for your peers. And that should not happen. Hence, if someone has to do your work because you were talking to patients, which your colleague would perceive as unimportant, they will be upset because you have spent time on a triviality and missed the important tasks that they now have to pick up for you. (Extract 4, Yam)
Yam describes how her priorities are shaped by the expectation that nurses should ensure that colleagues are not overburdened by unfinished work. This results in the categorization of some areas of nursing work as ‘trivial’ (e.g. talking to patients) and others as ‘important’ (e.g. tasks). As discussed elsewhere (Allen 2001, Jones 2007), although nursing as a profession subscribes to an ideology of individualized patient care, the organization of nursing work is essentially focused on more pragmatic temporal issues that are based upon being responsive to contingencies arising in the workplace rather than adherence to an ideological stance.
Another feature of the narratives was a description of unintended consequences that resulted from organizational attempts to help nurses work more efficiently. For example, participants discussed the increasing number of HealthCare Assistants (HCAs) and how this has resulted in a lessening of the amount of care provided by qualified nurses. Yam describes how RNs have increasingly lost touch with patients and the value of providing ‘basic patient care’, a situation which was exacerbated by the introduction of HCAs:
The introduction of the HCA for basic care was to help nurses with their work demands. As a result, however, nurses were removed from the bedside and thus from knowing their patients. Therefore, I think if nurses could have better insight into their values and change their attitudes towards basic patient care, it would redirect what is important in nursing and our use of time. (Extract 5, Yam)
In a similar vein, the burden of administration was felt by Sharon, who was frustrated by the duplication and fragmentation of documentation which resulted in less time for individualized patient care. She said, ‘Because of the enormous amount of documentation, be it manual or electronic, we waste time in duplicated writing’. Sharon's comment is echoed by other nurses, who often ‘blame’ their inability to spend time interacting with patients on paperwork (Tyler et al. 2006). As is the case globally, increased patient acuity and complexity, shortened lengths of stay, increased litigation have all significantly increased the amount of record keeping and report writing (Gugerty et al. 2007) required by RNs in Hong Kong.
Working collegially and ‘opportunistic communication’ with patients
The following section considers participants’ discussions of the effect that extremely busy shifts had on the way they worked with other nurses. In particular, when time was scarce, nurses described a situation where they helped each other out. Although we would expect this to be so, there is little research that actually documents this to be the case:
I had a terrible night once, with four new admissions. My colleagues and I were working frantically on the admissions, one of which was a trauma case, throughout the night. There was a lot to do: three of us would be helping with the admissions, the other three attending to other patients. We were run off our feet but other colleagues helped whenever they could. In general, we helped each other. (Extract 6, Kathy)
Kathy's ‘terrible night’ narrative is interesting for a number of reasons. First, a description is provided of how time/work pressure resulted in Kathy and her colleagues combining their labour; an overall sense of ‘teamwork’ and of nurses helping each other emerges out of the data. For example, the phrase ‘my colleagues and I’ and repeated use of the pronoun ‘we’ indicates collective action in response to there being a ‘lot to do’. Kathy's description also suggests that in response to the situation, nurses took a ‘task-oriented’ approach to care, with three nurses doing the admissions and three attending to ‘other patients’. This further supports the earlier assertion that routines are introduced as a mode of working in response to excess demands on the time available (Waterworth 2003).
Michelle's extract below similarly describes a busy shift and how colleagues had ‘come to her rescue’:
My assignment was for eight patients as usual, of whom two needed to have operations in the morning, five were to be discharged, and one had a psychiatric problem. Of the patients who required surgery, one of them had a ventilator, so I had to escort him to the operating room. Of the patients who needed to be discharged, one was to return to an old age home in mainland China….
This created extra work for me, as I needed to give a report to the SOS nurse. When I was preparing for the pre-operative checks and discharges, a doctor suddenly indicated that the psychiatric patient needed to be transferred. The telephone rang, and I was needed to escort the patient with the ventilator back to the ward. I screamed that I was very busy. A colleague came to calm me down. She told me not to rush, and to proceed with one thing at a time….
I needed to transfer the orthopaedic patient, who was an overflow case from the orthopaedic ward. I screamed again and a colleague came to help. I felt exhausted. (Extract 7, Michelle. ‘SOS nurse’ is reference to a company which transports patients)
The above extract shares narrative similarities with ‘atrocity stories’ as described by other researchers recounting the experiences of nurses (Allen 2001). Michelle's extract shows how she considers the ‘extra work’ during this particular shift results in excessive demands on her time. The nature of the demand on her time clearly results in the transgression of what she considers to be a legitimate burden to deal with during one shift. The recounting of such ‘atrocity tales’ is often intended (by the speaker) as a means of reaffirming normative boundaries. For example, Michelle hopes that by voicing her disapproval of such extreme working conditions, the audience will empathize with these concerns whilst reinforcing that these expectations of RNs are beyond the limits of what could be considered as reasonable.
All of the participants commented on how much they valued spending time talking and getting to know patients and their relatives as this benefitted the care they gave. Busy RNs described difficulty finding time to talk to patients and as a result they would utilize every opportunity to communicate with patients. For example, when administering procedural care to patients such as dispensing medication, changing dressings, or inserting a nasogastric tube, RNs would utilize such episodes to get to know and educate patients:
The relationships between communication, care and time are intertwined. For example, when I was cleaning a wound (…) the client was made to understand the importance of self-care. Hence, the time that we were with the patient had to be well-utilized in getting to know how we could help them to care for themselves and to gauge their learning over time. (Extract 8, Sharon)
Phoebe similarly describes how she communicates with patients when she undertakes ‘procedures’ with them:
It doesn't take extra time to talk to patients during your procedural care. So caring for the patient can occur even when there is not enough time. Now I also realize that I am more observant, for example a patient once stared at me when I was changing his nasogastric feeding tube, and I figured out that he didn't want me to touch his nose. I have learnt so much from patients when I paid attention to them. (Extract 9, Phoebe)
Both Extracts 8 and 9 provide an important insight into RNs working practices which see them using their time during care activities to also communicate with patients. We believe this insight to be particularly important as it compels us to re-evaluate the nature of communication during procedural or task-centred nursing care. For example, there is a tendency in some studies to characterize nurses’ communication when administering medication or changing dressings as consisting of exclusively perfunctory talk which focuses merely on the completion of the task, rather than on more meaningful or patient-centred interaction with the patient (Hewison 1995).
However, our data suggest that communication during tasks exists at a more ‘meaningful’ level than merely expediting task completion. Sharon demonstrates how she utilized time during a dressing change to also inform and educate the patient about the procedure, thus encouraging self-care. Similarly, Phoebe describes how she now uses eye-contact as a form of non-verbal communication with patients during procedures, a process which helps her ‘pay attention’ to the patient and, in turn, be more receptive to patients’ own use of non-verbal communication. This ‘opportunistic’ type of communication, especially non-verbal communication, is easily overlooked by researchers and observers as merely being ‘procedural’ or task-related talk. However, both participants here describe how brief and task-related interactions can be both rich in meaning and patient-centred.
- Top of page
- The study
- Conflict of interest
- Author contributions
It has recently been stated that the current body of knowledge relative to nursing time is insufficient to address many of the important questions with which nursing as a profession has to deal (Jones 2010). Nursing is a profession that often describes itself as lacking in time and throughout the course of this study nurses clearly articulate how time is a fundamental factor in how their work is organized and understood. The breadth of clinical areas from which the RNs were recruited may be considered a limitation. However, the question of how nurses makes sense of, and use time, is one which all RNs can contribute to, regardless of the clinical areas in which they work.
For example, RNs described how competing temporal demands lead to a form of task-centred nursing where patient care is delivered in an impersonal manner. Furthermore, care in this ‘time-pressured’ context is designed as routine, leading to unthinking ‘habituated’ ways of working with damaging effects on the quality of care and patient safety. The experiences of the RNs resonated with participants in Thompson et al. (2008) and Hemsley et al. (2012) who similarly report the negative effects of time pressure on decision-making and communication with patients.
In Hong Kong, as elsewhere, the RN workforce has undergone restructuring and downsizing, developments which internationally seem to impact on the health and well-being of nurses and on patient safety (Canadian Health Services Research Foundation 2006). Our findings are also comparable to Lundstrom et al.'s (2002) study undertaken in the USA, who noted that nurses' ‘stress affects patient outcomes and frequency of patient incidents’ (p.97), a points which resonates with Michelle's experiences in Extract 3.
Job stress is an increasing concern in Hong Kong, so much so that more nurses have begun to seek help for occupational concerns (Wang et al. 2011). Wang et al. suggest that a heavy workload and lack of support in the workplace were frequent stressors experienced by Hong Kong's surgical nurses. Globally too nurses report feeling pressured by employers and colleagues into working beyond their normal shifts (Canadian Health Services Research Foundation 2006) and describing their workplaces as ‘haotic’ as they struggle to cope with constant and rapid change (Kerr et al. 2005).
A recent survey by the UK's Royal College of Nursing (2009) reported that 49% of respondents agreed that the nursing establishment where they work is insufficient to meet patient needs. Respondents (42%) reported that this leads to patient care being compromised at least once or twice per week, with a quarter saying that care is compromised on most or every shift. The study also raised the issue of how nurses who have adult caring responsibilities at home were more likely to feel under too much pressure at work compared with nurses who do not have these responsibilities (62% compared to 53%). The impact of work on the home-life of nurses is an area of research that deserves more attention.
We also found that the way nurses normatively organize their activities had an effect on their time management. For example, ensuring that nursing work is completed in a timely way required an effort of cooperation and coordination across the nursing team. Participants described how cooperation is underpinned by a collective agreement about normative nursing behaviours and routines. For example, one normative expectation that emerged was that nurses prioritized their work so not to burden colleagues on the subsequent shift with unfinished tasks. However, the strong expectation that tasks be completed by the end of the shift resulted in some of the nurses not talking to patients as they feared this would obstruct their work. Others have noted that the inability to complete desired activities may be experienced by workers as time pressure (Goodin et al. 2005) and may contribute to a nursing culture based on a ‘tyranny of busyness’ (Manias & Street 2000, p,.378) rather than on patient need. The effects of ‘busyness’ includes compromised safety, emotional and physical strain, sacrifice of personal time, incomplete nursing care, and the inability to find or use resources (Thompson et al. 2008). In this way, nursing work can be seen as something that both shapes and is shaped by the perception of time pressure.
On the other hand, time pressure often encourages collegiality amongst nurses, both in the sense of supporting each other to complete their tasks but also in such things as instructing HCAs towards more effective care. Nurses were seen to rally to and ‘rescue’ individuals with heavy workloads. Macdonald (2007) similarly found that nurses working closely together when confronted with time pressure enabled tasks to be completed and a sense of satisfaction that they had done as much as they could under the circumstances.
When not discussing issues of time pressure, all of the participants described how spending time talking and getting to know patients and their relatives benefitted care-giving and saved time in the long run. Time spent talking to patients and relatives enabled nurses to recognize nuances in individual treatment responses. Our findings reinforce Macdonald's (2007) conclusions that time is the most commonly identified factor that contributes to nurses knowing patients. For example, the RNs utilized every potential opportunity to get to know patients better, describing how they would often engage the patient in conversation during brief tasks. In a similar vein, Thorne et al. (2009) reported that patients believed a 3-minute interaction with nurses was sufficient to convey the sense of ‘presence’ which patients often equate with good nursing care.
It may be that the short period of time available for interaction during procedures has led to researchers dismissing this type of communication. We therefore agree, to a point, with Jones's (2010) view that what happens, and how it happens in a given period of time is more important for the nurse-patient relationship than merely measuring the physical time spent with patients. However, the measurement of the availability of nursing time is also very important. For example, Kane et al. (2007) discuss how every additional patient per RN per shift is associated with a 7% increase in relative risk of hospital-acquired pneumonia, a 53% increase in pulmonary failure, and a 45% increase in unplanned extubation. As illuminative as these statistics are such associations should not be interpreted as causality, however, it is clear that understanding more about the dynamic relationship between nursing work and perceived time availability is of great importance to the well-being of patients and staff.
It is important to note that the study was limited by the collection of data from only two locations and in common with other qualitative studies no claims are made about generalizability. The sample size is also small, however, repeated interviews with the same small number of participants allowed us to generate rich, in-depth data.