Nurses' experiences of busyness in their daily work

Nurses' experience of busyness and stress has been a central issue in studies of working conditions. Stress and workload are words that are repeatedly used when nurses describe their work situation (Norman & Sjetne, 2017; Thompson et al., 2008). Key values in nursing, such as patients' dignity and respect, contrast with the profitability and productivity that are often emphasized in health care services. Being busy and short of time causes experiences of stress and physical exhaustion. Extreme busyness has a number of negative consequences for nurses and for patients and their relatives (Aiken & Sermeus, 2012; Nagington, Luker, & Walshe, 2013). The purpose of this article is to describe nurses' experiences of busyness in their daily work. This article is based on a recent study in which four nurses were interviewed about their experiences with busy working days (Govasli, 2017). The research problem is: How do nurses experience busyness in nursing practice?


| INTRODUC TI ON
Nurses' experience of busyness and stress has been a central issue in studies of working conditions. Stress and workload are words that are repeatedly used when nurses describe their work situation (Norman & Sjetne, 2017;Thompson et al., 2008). Key values in nursing, such as patients' dignity and respect, contrast with the profitability and productivity that are often emphasized in health care services. Being busy and short of time causes experiences of stress and physical exhaustion. Extreme busyness has a number of negative consequences for nurses and for patients and their relatives (Aiken & Sermeus, 2012;Nagington, Luker, & Walshe, 2013).
The purpose of this article is to describe nurses' experiences of busyness in their daily work. This article is based on a recent study in which four nurses were interviewed about their experiences with busy working days (Govasli, 2017). The research problem is: How do nurses experience busyness in nursing practice?

| BACKG ROU N D
Busyness is defined as a person's perception of internalized pressure when he or she is in a situation in which there is a shortage of time in which to accomplish valued work (Thompson et al., 2008, p. 542).
Busyness tends to reduce energy levels and is objectively characterized by substantial action or motion (Thompson et al., 2008). The daily work of nurses is often characterized by a hectic pace in the execution of tasks in the workplace (Aiken & Sermeus, 2012;Kerfoot, 2007). Various conditions contribute to accelerating the rush in the health care services. Society's need for nursing care is constantly increasing (Bing-Jonsson, Foss, & Bjørk, 2016). Advanced medical technologies provide even more treatment possibilities (Bontemps-Hommen, Baart, & Vosman, 2019). There is also an increasing need for documentation. Additionally, patients and their relatives are increasingly aware of their right to medical assistance and tend to have higher expectations for treatment and care (Mastaneh & Mouseli, 2013).
Busyness is not necessarily effective. Being in a hurry has many negative consequences (Aiken & Sermeus, 2012;Nagington et al., 2013;Shirey & Hites, 2015). Frantic and rapid actions easily become ineffective and inefficient. The work becomes fragmented by distracting details and unfocused actions. Richards (2015) notes that busyness drives actors into anxiety, worries and even bad conscience and may result in an underlying feeling of not doing things 'well enough' (Richards, 2015). A European study conducted in 12 countries reports nurses' experience of omitting important nursing tasks due to lack of time. Medications and necessary treatment were rarely omitted. The form of care that includes comfort and trusting conversations, however, could be skipped, which in turn weakens patient satisfaction (Aiken & Sermeus, 2012). Time constraints reduce the nurses' ability to provide quality nursing care. By rationalizing the care, the results for the patients are affected.
The stress experienced by nurses and the care that patients receive are negatively interrelated (McIntosh & Sheppy, 2013). Moral stress is higher if nurses experience too little time for the patients.
At first glance, it may seem paradoxical that those who work more than 30-40 hr a week experience less moral distress than those who work less (De Veer, Francke, Struijs, & Willems, 2013). However, it is not the time consumed by work that represents the stress factors; rather, the lack of 'enough time' to perform required work tasks is the cause of accelerating stress.
Being busy is described as an attitude, a habit and a value that 'settles' within the practitioners: 'we are all in a hurry' and 'life is hectic at our ward' (Kerfoot, 2007;Richards, 2015). Being busy thus may be linked to the work culture of a ward. The stress creates tensions that even have physical effects. The internal stress level of one individual, when encountered by colleagues, tends to increase the group's experiences of busyness. Busy health care professionals convey stress and hurry. This situation creates a turbulent environment that can be felt and experienced by others.
In a discursive perspective, Nagington et al. (2013) find that busyness turns into a form of discourse, as patients and relatives excuse the nursing staff. The patients and relatives see that the home nurses are busy; thus, the rush becomes something that shapes their expectations of care. 'They are so busy; we can't expect more'. Thus, bustle can become a justification for inadequate care (Nagington et al., 2013). Juthberg, Eriksson, Norberg, and Sundin (2008) studied nursing staff's lived experience of busyness in what they call the 'stress of conscience'. Experiences of inadequacy and powerlessness create feelings of guilt. The lived experience of guilt is associated with a sense of powerlessness and of falling short. When others' norms for the work do not match their own, nursing staff may perceive themselves as inadequate employees and caregivers. Interestingly, bad conscience may be used differently among health care personnel. While some acknowledged that they failed to meet the expectations of residents and relatives, others used their conscience as an emotional tool and a guide in their work (Juthberg et al., 2008).
Previous research shows that various dimensions of busyness can potentially lead to a reduction in the quality of nursing. Therefore, the topic needs to be further elucidated. The purpose of this study is to explore busyness as it is experienced by nurses.

| DE S I G N AND ME THOD
This study has a qualitative design. We have drawn on the method developed by Lindseth and Norberg (2004), which is a phenomenological hermeneutical method for interpreting personal experiences.
This article is based on a recent research in which four nurses were interviewed in depth about their experiences with busy working days (Govasli, 2017). Their experiences are gathered and condensed into one story, the story of Else. By analysing the experiences from a phenomenological hermeneutic perspective, we will illuminate the phenomenon of busyness.

| Recruitment and sampling
Qualitative research is intended to illuminate variations in human meaning and understanding (Åkerlind, 2012). To achieve the desired variation, the participants in this study were recruited from four working environments, namely medical, surgical and intensive care departments and one nursing home. The first author (LG) recruited participants with clinical experiences varying from 10 to 40 years.
All the participants had professional capacity building training relevant to the departments they were working in. Two of the interviews were performed at the participants' workplace, within a setting that secured no disruptions. Two participants preferred to be interviewed at home.

| Ethical considerations
The research was conducted in accordance with ethical guidelines for research. Thus, the requirements for anonymity and consent were met and the plan for the study approved by the institutes of Norwegian Centre for Research Data (Norsk senter for forskningsdata).

| Creating the story of Else
The story of Else was created by drawing on in-depth interviews with four nurses about their experiences of being busy. Statements and anecdotes that relate to the overall question in this study have been extracted and collected to create a fictive story. First, the entire material was carefully read through by one of the researchers, to grasp the meaning as a whole. Next, the content corresponding to the research question was highlighted and the meaning units were transformed into a fictive story, the story of Else. Similarities as well as differences in the nurses' experiences were included. Finally, this process was critically reviewed by the second researcher.

| Analysing the story of Else
The systematic investigation of experiences in a phenomenological hermeneutical approach involves three overall steps (Lindseth & Norberg, 2004). In the first step, the story of Else was carefully read through and a brief summary written. Next, the content corresponding to the research question was highlighted, which then revealed meaning units to the phenomenon being investigated.
The story was analysed through an analytical back-and-forth movement with questions and answers to the text. The point of departure for the analysis was the overall question: How do nurses experience busyness in their work practice? However, the story itself raised questions that in turn found their answers through rereading the story. This dialectical movement between the researcher and the text arose by asking the overall questions: What is the meaning of this text? How do nurses experience busyness in their practice? Finally, there was a dialectical movement between the understanding of the findings and appropriate literature. This step elaborated on the phenomenon and findings were discussed in the light of relevant previous research. The constant dialectical movement between questioning and answering was conducted until a new understanding was achieved. The analysis process was critically reviewed by both researchers.

| Limitations
Fictive narratives, like the one presented in this article, have limitations. One such limitation is that the reader gets only the perspective of the subject of the narrative. Else's story and her perspective establish the focus of this article. We can only sense various aspects of her perspective without fully being able to elaborate on them.
Reflecting upon the narrative may, nevertheless, provide a deeper understanding of what busyness in the work situation entails for nurses. Another limitation is that the recruitment of participants was done from a small geographical area. In addition, the first author and the participants were acquaintances, which may have caused participant bias (Shah, 2019). In order to reduce this, the interview guide was given to the participants in advance, to give them the opportunity to be prepared. In addition, the first author kept strictly to the use of open-ended questions and thus avoided leading questions and encouraged the participants to speak freely. The interviewer also made an effort to provide a pleasant atmosphere during the interviews (Govasli, 2017). To avoid researcher bias (Shah, 2019), the authors critically reviewed the process of creating the story of Else.
Furthermore, to reduce subjectivity, both researchers discussed and re-evaluated the impressions and responses from the text, to ensure that pre-existing assumptions were kept at bay. However, the reader will determine whether this article creates a sense of recognition that may be helpful in the facilitation of a working environment that actively addresses the nurses' experiences of busyness in their clinical practice.

| The story
The participants in this study work in various medical contexts. Most wards have some routines and programmes for the day that have common characteristics. The patients' care needs are the starting point for nursing. Patients may be seriously ill, or they may only be in need of some assistance. For instance, they require assistance getting out of bed, taking their morning baths and engaging whatever is on their agenda for the day. In all departments, the common focus is that patients require assistance from nurses to meet their basic needs.
Else has long experience in nursing. She mainly thrives in an active unit and thinks it is 'nice to find out things'. She often takes on new challenges and manages these challenges at arm's length. Else finds it interesting to master new technology, for instance when new journaling routines were adopted and the system was implemented in the unit. However, there have been changes in recent years that make daily life busier. The basic staffing has been reduced, and there has been a greater focus on efficiency, profitability and economy.
Maintaining budgets has become increasingly important. 'Now it is like hurry, hurry, hurry from the time we come until we go home', she says.

| Analysis
The narrative reveals a frustrated and despairing nurse whose experiences reveal that she is not able to do what she believes must be done.
Her inner struggle and outer chaos are prominent: irritation, anger and a bad conscience. She tries to reprove herself: 'Pull yourself together!' She tries to endure but has no energy left. She staunchly declares, 'I must follow my heart'. The reflections below describe the busyness as it is experienced, with specific characteristics and consequences.

| Busyness, disparity between tasks and time available
Busyness is about 'things being done' within a timeframe.
Expressions such as 'I'm in a terrible rush' are used to indicate that there are many tasks to be done within the time available, usually within the frame of a shift. The goal is to have 'everything done' at the end of the shift. Having the opportunity 'to take the time the job requires' emphasizes that different tasks require different amounts of time and that each task must take the time that is required. Busyness involves having a lot to do, but still the experience is okay if one can get 'everything done' within a reasonable time, as the story reveals. The rush becomes uncomfortable if a relatively large amount of work remains at the end of the shift. Busyness is thus proportional to the amount of work that must be done and the timeframe that is available. Harmful busyness is a mismatch between tasks that one perceives must be done and the time available to accomplish these tasks.

| Outer and inner dimensions of busyness and the interaction between them
It is clear from the story that busyness has an outer dimension that is related to the tasks to be solved within the time available. Busyness also creates inner chaos, stress and despair, and these feelings constitute an inner dimension that becomes particularly intrusive in Else's story. The external events affect the inner processes. The idea that two new patients are arriving in an already full ward is more than Else can deal with. Reactions such as stress and irritation prevent her from taking care of her patients and their relatives in a proper manner. She is aware of this fact and is embarrassed and ashamed. Her failure to handle the situation causes reactions in patients and relatives. The patients and relatives encounter a cold and dismissive nurse, which they comment on, only to cause the nurse to become even more irritated and increasingly ashamed. It becomes a vicious cycle of external events and inner processes that mutually reinforce each other. Unbearable bustle occurs when the vicious cycle cannot be broken. From time to time, speed, stress and lack of time directly result in malpractice. This situation is particularly risky in the case of tasks that require great concentration, such as medication management. Thus, busyness has an outer dimension of events and a dimension of internal processes. The dimensions of busyness, the external events and inner processes, interact and mutually reinforce each other.

| Acceptable busyness
Busyness can be acceptable if you find that 'things are being done'.
To be 'extremely rushed' is okay as long as one has 'done everything'. It is the experience of 'being able to take the time the job requires' that makes the bustle tolerable. Even when work has not been accomplished, it feels okay, because one knows that personnel on the next shift will be able to complete the tasks. This description reveals a co-operation among the colleagues in which tasks are performed jointly. If work is not done on one shift, the next team will finish it. Despite having been in an 'awful rush', the day nevertheless left the practitioners with the experience of having 'enough time' to observe the patients. This reveals experiences of having control and overview. Additionally, the close patient contact was perceived to be maintained: 'I spent a lot of time to talk with the patients'. Thus, busyness in the sense of having a lot to do can be tolerated.

| Intolerable busyness
Non-endurable busyness is the type of busyness that creates inner chaos and bad conscience because nurses feel they do not manage 'to do everything'. Busyness fluctuates from day to day, but as the years pass, the experience of bustle seems to increase. This busyness feels unbearable. Some tasks remain undone, and it worries and bothers Else. Food cards are not being updated, and the nurses' documentations are not recorded. The first omission constitutes neglect, and the second is an offence because 'documentation is required by law'. Omissions also include 'the good conversation' that nurses lack time to engage in. It is the tasks that are undone that bother the nurses. Tasks that are perceived as important and remain undone make the bustle intolerable.

| Interruptions reinforce the experience of busyness
The experience of busyness is enhanced by disturbances and interruptions. Else can barely enter the corridor because 'there is always someone who grabs you'. The constant interruptions prevent the practitioner from carrying out an action from beginning to end in a smooth and coherent manner. These interruptions interfere with concentration and delay work. The combination of bustle and work interruptions becomes demanding. Busyness is perceived as enhanced by interruptions in the work.

| A busy satisfaction
Busyness, in the sense of having a lot to do, that still gives a feeling of having 'done everything' is experienced as satisfaction. Sometimes Or, what is done that suggests having 'done enough' for the patient?
Obviously, something is taken for granted. Expectations such as 'doing enough' for the patients are limitless and well-suited to creating feelings of defeat. It seems that the nurse takes for granted that these tasks are part of her responsibility. As a result of the rush and of feelings of 'not having been enough at the patients', the nurse fails to satisfactorily observe the patients. She accuses herself afterwards: 'Why didn't I see this when I was with the patient?' It is when the bustle becomes intolerable that the consequences also seem destabilizing.

| Busyness that destabilizes
When busyness becomes persistent and is no longer tolerable, it becomes harmful. Haste and rush steal energy, deprive the nurse of job satisfaction and acidify the mood, and probably also the atmosphere of the ward. Else has good contact with her own feelings and expresses what bustle does to her. She becomes 'unfocused, a little sad and pert'.
Busyness awakens irritable and angry feelings. The story becomes almost dramatic when she conveys the experiences of the two 'terrible shifts'. She finds herself, on a busy afternoon, angry and annoyed at the patients, and she feels like a 'fury' and 'a black thunderstorm inside her'. She senses her own feelings, but she is unable to hide them from patients and relatives. She neglects the persons she is supposed to help, but cannot do otherwise. Else acknowledges that this is wrong, and she regrets it, at least retrospectively. In addition, she develops a bad conscience. Busyness has bodily consequences as well. Else feels 'pain in chest and stomach'. Her strength is weakened, and she is on the verge of tears. Her sleep is inadequate. The intolerable busyness raises negative emotions, steals energy and weakens health.

| Privatized experience of busyness
The nurse's story provides strong and discouraging information on how busyness can be experienced; coping with busyness seems to be a personal and individual struggle, even though health service enterprises are a collective matter. However, the personal toil has a strong collective impact. The stress of one colleague affects the others. The story reveals little about how her colleagues reflect and react. Admittedly, Else says 'it's been reported to the management', indicating that the nurses have tried to approach the management but have not been heard. Here is a nurse in a collective service who has an insurmountable personal problem. She carries the problem alone and experiences little or no support from those responsible for the service.
In summary, the story of Else leads to an understanding of the meaning of being busy. Busyness is proportional to the number of tasks and the time available. In describing the characteristics of the busyness, the relationship between the inner and outer dimensions is an analytical distinction. In practical everyday life, there is a close interaction in which the external events strongly influence the inner processes. Busyness can be understood as a continuum ranging from tolerable to completely intolerable. Furthermore, it is clear from the story that the busyness affects practitioner. Surprisingly, not only are there negative consequences but also, in this respect, the experiences range from busy satisfaction to emotional and bodily instability.

| D ISCUSS I ON
This study illustrates how busyness is experienced when the number of tasks to be completed is not in reasonable proportion to the time available. Furthermore, the study shows that busyness is an ambiguous phenomenon. When events and tasks occupy more time than is available, inner stress, frustration and bad conscience occur. At the same time, busyness is not necessarily experienced as unequivocally negative. It feels quite 'okay to be in a rush' if important tasks are still completed. Thus, busyness can result in the experience of doing an important job. Richards (2015) refers to busyness as a message. Busyness communicates messages. Statements such as 'I am crazy busy' convey to others messages such as 'I am busy and have a hectic everyday life'. This situation makes people feel important and sought after and may even create a kind of enjoyment (Richards, 2015). On the other hand, busyness can be exhausting. In a British survey involving 3,000 nurses, 76% stated that they did not have enough time to talk to or comfort patients, 40% answered that they did not have time for necessary tasks, such as taking temperatures and ensuring that the patients have had sufficient fluid and nutrition, and 24% did not have time to determine whether patients were developing pressure sores (Borland, 2011). Thus, the busyness becomes doubly problematic as time constraints additionally result in malpractice and neglect of patients. If busyness conveys ambiguous messages, it will be important for nurses to be aware of the message in their bustle. Extreme bustle contributes to poor health of the staff over time (McIntosh & Sheppy, 2013;Richards, 2015).
Bad conscience, as this study shows, can be a sign of intolerable busyness and thus should be perceived as a warning signal (Juthberg, Eriksson, Norberg, & Sundin, 2010). Some actors might be bothered by their failure to meet the expectations of residents and relatives due to their powerlessness. These individuals may feel cowardice and incompetence and suffer from a guilty conscience.
Others may use their conscience as a guide to their work (Juthberg et al., 2008). The warning function of conscience can be an asset and a driving force leading one to follow one's conscience. It is important that the actors be conscious. In addition, it is possible to learn solutions. Reflection allows one to review knowledge about the actors' own situations and to develop a knowledge base through which nurses can decide on meaningful and feasible actions to be undertaken (Ericson-Lidman & Åhlin, 2017). Reflection may be a way to address busyness constructively.
The American ethicist Vicki Lachman (2016) argues for developing personal skills related to enduring high speed and high stress. Her concept of 'moral resilience' refers to the ability and the willingness to speak and take right and good action in the face of an adversity that is moral in nature. Resilience involves maintaining a set of attitudes that allow an individual to cope with a different culture without denying his or her own identity (Lachman, 2016). In periods of physical and mental strength, resilience can be an important factor that helps nurses maintain control, even during extreme bustle. At the same time, resilience can be problematic. Over time, busyness and stressful work break down people's health (McIntosh & Sheppy, 2013;Richards, 2015).
Eventually, busyness and stressful work also weaken their resilience. Extreme bustle over time weakens practitioners' health and results in sick leave. When profitability is to be preserved and no additional personnel are hired, the whole business enters a vicious cycle in which talking about resilience can be perceived as further angering the group.
This study reveals busyness as an individual experience. It is the individual who experiences the busyness and is eventually traumatized over time. The experience is privatized. The individual pattern is also evident in Thompson et al.'s definition, in which busyness is described as 'an individual perception of internalized pressure created by a situation where there is a shortage of time to accomplish valued work' (Thompson et al., 2008, p. 542). It is interesting that a complex enterprise that involves a collaborating collegium results in busyness as an individual experience. This phenomenon occurs despite the fact that nursing is performed within a collective college in the health service. Busyness becomes a burden that is carried by the individual. The coping strategies described above are also individual in character. These can be helpful in everyday life, but do they contribute to an unwanted privatization of the problem? An individual approach to the complexity of problems may result in additional personal burdens for nurses. In addition to the despair that the busyness engenders, nurses find that they are also required to train themselves to withstand stress, develop resilience and cope with challenging situations. Busyness in a ward has serious consequences for the entire health care service, including neglect of patients and health problems that affect the nurses. It seems that busyness becomes an individual trauma of collective omissions.
Who is to be responsible for the busyness in a ward? It is a serious societal problem when patients' needs are not satisfied and nurses are troubled by a guilty conscience and suffer damage to their health when at work. To put an end to the harmful bustle, it is important to understand busyness as something more than an individual experience. The imagination of busyness as an individual characteristic is a barrier to addressing it appropriately. Eliminating busyness may not be possible, but taking action must be a priority of the management lest the entire institution collapse due to their burden. The responsibility of ensuring that the business is doing well and that the staff are working under conditions of tolerable busyness must be assumed by the management.
The solution to the busyness problem is not only the nurses' personal ability to endure busyness and to become aware of their own coping mechanisms. It may be as simple as asking the question: Are there enough people on duty? Insufficient numbers of nurses are one reason for busyness (Thompson et al., 2008). A solution to the busyness problem can therefore be careful examination of the timetable. Better basic staffing will reduce the workload and, in the long run, the amount of sick leave that is taken.
Hiring of extra staff will be avoided, and this will also have a positive impact on finances.
Nurses may feel that managers show little understanding of their busy situation (Thompson et al., 2008). Management's efforts to reduce workloads were not always perceived as beneficial to nurses. Some of the work nurses are required to do is perceived as unnecessary. In Thompson's study, it was noted that leaders quickly commented on nurses with 'idle time', that is nurses who were not providing direct patient care (Thompson et al., 2008). Nurses who find that the leaders do not fully understand their situation will probably not develop trusting, co-operative relationships. Nurses who consistently describe their environments as 'hurried' and 'rushed' should be a warning signal to leaders. Hectic activity in a culture can be destructive and may be counterproductive. One way to maintain the energy in the culture and stop an escalating situation is to critically assess activities and eliminate tasks that need not be done (Shirey & Hites, 2015). Social support on a daily basis appears to be an important factor of health care personnel (Ericson-Lidman & Åhlin, 2017). Leaders need to focus on more than task completion alone. To achieve optimum outcomes, leaders need to pay attention to the complex culture (Kotter, 2013).
This article deals mainly with the individual perspective of nurses' personal experience of busyness in nursing practice, as has also been the focus of previous research on the same topic. Further research is needed to also study and illuminate individual's experience of busyness, their reactions and behaviour in the interaction with other members of the team (leaders and colleagues) in the context of the working situation in a ward.

| RELE VAN CE TO CLINI C AL PR AC TI CE
The results in this study add to our knowledge that busyness conveys ambiguous messages. Being aware of possible messages that busyness conveys can make a difference to how nurses deal with challenging busyness in practice.
The solution to the busyness problem is not only the individual nurse's personal ability to endure busyness. The responsibility of ensuring that the staff are working under conditions of tolerable busyness must be assumed by the management.

| CON CLUS ION
Nurses entering current practice must be prepared to meet a continually increasing demand for rushed practice within turbulent environments. When time is short, the power of health care workers may be reduced as well. The ambiguous message of busyness challenges practitioners to make it clear, both to themselves and to their colleagues, what their culture of busyness conveys. The individual image of being busy in an enterprise that is typically collective is interesting. Ultimately, facilitating good working conditions in health care services is a question of good leadership. A better understanding of how nurses experience being busy in practice can prepare nurses and their leaders to meet increasing demand for rushed practice within turbulent environments.