Professional Documents
Culture Documents
Jan 12064
Jan 12064
ORIGINAL RESEARCH
experiences by telling and retelling accounts of how time day. The second interview aimed to develop the discussion
influences their work. Experience refers to nurses knowl- and allow participants time to explore their experiences in
edge, including what and how they know and is shaped by more depth. Participants would also be asked about what
both personal meanings and the contexts where nurses things were most important to them when delivering patient
work. Repeated interviews with a limited number of partic- care. How do they decide its importance and how do they
ipants are a common strategy in narrative inquiry seeking get things done if they do not have sufficient time? The
to generate depth of understanding of phenomena (McCrac- third interview allowed the researcher to clarify and expand
ken 1988). This research approach enables nurses to reflect participants descriptions and to follow any changes in their
on their stories of experience, helping them make meaning experience. Since the participants continuous reflection on
of the function of time in patient care but also of their lives their stories is part of the process of retelling them, this
as nurses and their professional identity. component was the focus of the last interview.
Following the granting of Research Ethics Committee Data collection and analysis proceeded concurrently (Morse
approval by the University Research Ethics Committee, & Richards 2002), the research team met regularly to share
in-depth interviews were carried out with five participants preliminary understanding of the data. A number of strate-
between mid 2008 to early 2010. Study participants were gies were employed to ensure that the data interpretation
assured confidentiality throughout the research process. was rigorous and reflected the phenomena under investiga-
Consistent with the rationales of small studies presented by tion. These included each of the research team members
Crouch and McKenzie (2006), our study was intensive, reading and rereading their interview transcriptions and
rather thanextensive (p. 494) and conceptually persua- field notes prior to the meetings. Narrative codings were
sive, rather than quantifiably demonstrative. We recruited then produced to identify possible plotlines, how they inter-
RNs with a minimum of 1 years postregistration experi- connected, the tensions that emerged and the settings/con-
ence and at least 6 months experience in their current clini- texts of the events (Tappan & Brown 1989).
cal areas. Our dependence on volunteers meant that we Diverse events were also examined along a temporal
could not control for the clinical areas from which RNs dimension and the effects of one event on another were
were recruited. This purposive sample (Patton 2002) there- identified (Polkinghorne 1988). In addition, plotline clarifi-
fore consisted of RNs who worked on an intensive care cation with participants occurred from beginning to end as
unit, an acute neurosurgical unit, a rehabilitation ward, a written materials were revised.
medical ward with primarily respiratory patients, and a Narrative inquiry proved to be an excellent way to facili-
community setting in Hong Kong. tate, reflect an expanded understanding of the phenomenon
of time through our attendance to nurses multilayered sto-
ries (Clandinin & Connelly 2006). Each researcher later pre-
Data collection
pared a written summary of the texts, including identified
We interviewed each of the five participants a total of three common meanings and excerpts from the text to support
times, making 15 interviews amounting to almost 30 hours the themes. The corresponding author read the summaries
of data. The in-depth interviews with participants were to discern patterns and meanings in and across the texts.
unstructured and conversational in nature, with occasional
questions from the interviewer to seek clarification. The
Findings
interviews occurred in the researchers offices and were
planned in accordance with the participants schedule, The following sections describe the interconnected narra-
giving them a sense of control and collaboration in the tives of the ways five participants, Kathy, Michelle, Sharon,
process. Interviews lasted between 15 and 25 hours. The Phoebe and Yam, recounted their meanings of time and
total number of interviewees allowed for repeated and more how these understandings affected their work. The findings
in-depth interviews to be scheduled. are presented as three major themes on pages 9, 11, and
The first interview focused on developing rapport and 13. Although participants worked in different clinical areas
making initial forays into the topic. For example, the inter- and had variable length of service we were struck by the
view would start with a question asking the participants to commonality of temporal experiences, regardless of context.
describe their everyday work for a typical and an atypical Furthermore, following the first stages of analysis our
reading of the literature revealed that a commonality of work. Routines often bring a sense of order to the work-
experience extended beyond our study to other countries place (Waterworth 2003), but consist of habitual ways of
and areas of nursing practice (Buchan & Calman 2005, responding to occurrences in everyday life and are often
Doherty 2009). The first section of the findings draws taken for granted until they are disrupted in any way
extensively from data to discuss how nurses sometimes (Strauss & Corbin 1998).
struggle with time scarcity to deliver an optimum level of In the next data extract, Michelle describes how familiar-
care. Data extracts are chosen for inclusion on the strength ity with repetitive tasks leads to a habitual way of doing:
of their ability to communicate each narrative theme.
Sometimes I might be desensitized to a habitual way of doing,
given the repetitive everyday activities and the similar nature of
Time and nursing work: lack of time gets in the way of work. For instance, I was initially very cautious about patient
getting to know patients and families transfer because of safety, but at times, when things become too
familiar and routinized, I may make a wrong assumption because
This first narrative extract shows Kathy reflecting on how a
of my lack of sensitivity or alertness. For example, a patient was
lack of time and pressure of work restricted the amount of
admitted to the ward due to an external head injury, but no sutur-
time available to get to know patients and their families:
ing was required. He was alert and conscious, with a mental score
I recall the time when I had to check 20 patients blood pressure of 15, and the doctor also prescribed activities as tolerated. He
readings in a surgical ward: I would recheck them only if the read- needed to have a CT scan. After the patient was transferred into
ings were below the baseline tasks. Most often, I wouldnt know the wheelchair, he had a generalized seizure and fell to the ground.
the patients condition and I wouldnt think of possible reasons for As this patient was fully conscious, his need to be escorted to the
the blood pressure or wonder about possible internal bleeding. CT department had not been considered. (Extract 3, Michelle)
(Extract 1, Kathy)
Routines and habituated practice appear here as corre-
Kathy describes how, despite having checked 20 blood lates of time, apparent when Michelle recounts how initial
pressure readings she would not know the patients condi- caution about safe transfer of patients was eroded over time
tion or think of possible reasons for an unusually low by familiarity with a task. Although routines can reduce the
reading. The undertaking of tasks on patients about whom time pressures that nurses experience, Michelles narrative
the nurses know little or nothing is reminiscent of the task- relates how routine practice led to the individual needs of
centred approach to nursing care, where nurses value the the patient being temporarily overlooked.
completion of tasks rather than establishing a more patient-
centred relationship (McCabe 2004).
The priorities of nurses and nursing
In the following extract, Michelle describes looking after
a patient who required barrier nursing, which resulted in Nursing is seldom, if ever, a solitary occupation; as a conse-
extra work for the nurses. The extract also demonstrates quence nurses must learn how to work with other nurses
how spending time talking to the patients husband results and professions. However, working with others can create
in the nurse seeing the patient as a person rather than the tension, especially when one persons workload is tempo-
time-consuming object of care as first described: rally dependent on the timely completion of colleagues. As
a result, nurses have long valued colleagues who pull their
Like many others, as it is time-consuming to put on and take off
weight (Clarke 1978, Allen 2001). The value placed on fin-
the protective gown and face shield, I was also reluctant to care for
ishing tasks before colleagues commence the next shift was
this patient.
a recurring theme in the narratives, for example:
However, I was moved by the patients husband, who visited her It is good to talk to patients. But if you havent completed your
daily and stayed outside the ward during the non-visiting hours. expected routines and treatments, you have increased the workload
After talking with him, the patient became a person: someones for your peers. And that should not happen. Hence, if someone has
beloved wife. I felt guilty about our neglect of her because of the to do your work because you were talking to patients, which your
extra work. (Extract 2, Michelle) colleague would perceive as unimportant, they will be upset
because you have spent time on a triviality and missed the impor-
Michelles feelings of guilt reinforce the point made else-
tant tasks that they now have to pick up for you. (Extract 4, Yam)
where that competing temporal demands in the workplace
produce emotion in the workforce (Fine 1996). Competing Yam describes how her priorities are shaped by the
temporal demands may also lead to the routinization of expectation that nurses should ensure that colleagues are
not overburdened by unfinished work. This results in the I had a terrible night once, with four new admissions. My col-
categorization of some areas of nursing work as trivial leagues and I were working frantically on the admissions, one of
(e.g. talking to patients) and others as important (e.g. which was a trauma case, throughout the night. There was a lot to
tasks). As discussed elsewhere (Allen 2001, Jones 2007), do: three of us would be helping with the admissions, the other
although nursing as a profession subscribes to an ideology three attending to other patients. We were run off our feet but
of individualized patient care, the organization of nursing other colleagues helped whenever they could. In general, we helped
work is essentially focused on more pragmatic temporal each other. (Extract 6, Kathy)
issues that are based upon being responsive to contingencies
Kathys terrible night narrative is interesting for a num-
arising in the workplace rather than adherence to an ideo-
ber of reasons. First, a description is provided of how time/
logical stance.
work pressure resulted in Kathy and her colleagues combin-
Another feature of the narratives was a description of
ing their labour; an overall sense of teamwork and of
unintended consequences that resulted from organizational
nurses helping each other emerges out of the data. For
attempts to help nurses work more efficiently. For example,
example, the phrase my colleagues and I and repeated use
participants discussed the increasing number of HealthCare
of the pronoun we indicates collective action in response
Assistants (HCAs) and how this has resulted in a lessening
to there being a lot to do. Kathys description also sug-
of the amount of care provided by qualified nurses. Yam
gests that in response to the situation, nurses took a task-
describes how RNs have increasingly lost touch with
oriented approach to care, with three nurses doing the
patients and the value of providing basic patient care, a sit-
admissions and three attending to other patients. This fur-
uation which was exacerbated by the introduction of HCAs:
ther supports the earlier assertion that routines are intro-
The introduction of the HCA for basic care was to help nurses duced as a mode of working in response to excess demands
with their work demands. As a result, however, nurses were on the time available (Waterworth 2003).
removed from the bedside and thus from knowing their patients. Michelles extract below similarly describes a busy shift
Therefore, I think if nurses could have better insight into their val- and how colleagues had come to her rescue:
ues and change their attitudes towards basic patient care, it would
My assignment was for eight patients as usual, of whom two
redirect what is important in nursing and our use of time. (Extract
needed to have operations in the morning, five were to be dis-
5, Yam)
charged, and one had a psychiatric problem. Of the patients who
In a similar vein, the burden of administration was felt required surgery, one of them had a ventilator, so I had to escort
by Sharon, who was frustrated by the duplication and frag- him to the operating room. Of the patients who needed to be dis-
mentation of documentation which resulted in less time for charged, one was to return to an old age home in mainland
individualized patient care. She said, Because of the enor- China.
mous amount of documentation, be it manual or electronic,
we waste time in duplicated writing. Sharons comment is This created extra work for me, as I needed to give a report to the
echoed by other nurses, who often blame their inability to SOS nurse. When I was preparing for the pre-operative checks and
spend time interacting with patients on paperwork (Tyler discharges, a doctor suddenly indicated that the psychiatric patient
et al. 2006). As is the case globally, increased patient acuity needed to be transferred. The telephone rang, and I was needed to
and complexity, shortened lengths of stay, increased litiga- escort the patient with the ventilator back to the ward. I screamed
tion have all significantly increased the amount of record that I was very busy. A colleague came to calm me down. She told
keeping and report writing (Gugerty et al. 2007) required me not to rush, and to proceed with one thing at a time.
The following section considers participants discussions of The above extract shares narrative similarities with
the effect that extremely busy shifts had on the way they atrocity stories as described by other researchers recount-
worked with other nurses. In particular, when time was ing the experiences of nurses (Allen 2001). Michelles
scarce, nurses described a situation where they helped each extract shows how she considers the extra work during
other out. Although we would expect this to be so, there is this particular shift results in excessive demands on her
little research that actually documents this to be the case: time. The nature of the demand on her time clearly results
in the transgression of what she considers to be a legitimate expediting task completion. Sharon demonstrates how she
burden to deal with during one shift. The recounting of utilized time during a dressing change to also inform and
such atrocity tales is often intended (by the speaker) as a educate the patient about the procedure, thus encouraging
means of reaffirming normative boundaries. For example, self-care. Similarly, Phoebe describes how she now uses
Michelle hopes that by voicing her disapproval of such eye-contact as a form of non-verbal communication with
extreme working conditions, the audience will empathize patients during procedures, a process which helps her pay
with these concerns whilst reinforcing that these expecta- attention to the patient and, in turn, be more receptive to
tions of RNs are beyond the limits of what could be consid- patients own use of non-verbal communication. This
ered as reasonable. opportunistic type of communication, especially non-
All of the participants commented on how much they verbal communication, is easily overlooked by researchers
valued spending time talking and getting to know patients and observers as merely being procedural or task-related
and their relatives as this benefitted the care they gave. Busy talk. However, both participants here describe how brief
RNs described difficulty finding time to talk to patients and and task-related interactions can be both rich in meaning
as a result they would utilize every opportunity to commu- and patient-centred.
nicate with patients. For example, when administering pro-
cedural care to patients such as dispensing medication,
Discussion
changing dressings, or inserting a nasogastric tube, RNs
would utilize such episodes to get to know and educate It has recently been stated that the current body of knowl-
patients: edge relative to nursing time is insufficient to address many
of the important questions with which nursing as a profes-
The relationships between communication, care and time are inter-
sion has to deal (Jones 2010). Nursing is a profession that
twined. For example, when I was cleaning a wound () the client
often describes itself as lacking in time and throughout the
was made to understand the importance of self-care. Hence, the
course of this study nurses clearly articulate how time is a
time that we were with the patient had to be well-utilized in getting
fundamental factor in how their work is organized and
to know how we could help them to care for themselves and to
understood. The breadth of clinical areas from which the
gauge their learning over time. (Extract 8, Sharon)
RNs were recruited may be considered a limitation. How-
Phoebe similarly describes how she communicates with ever, the question of how nurses makes sense of, and use
patients when she undertakes procedures with them: time, is one which all RNs can contribute to, regardless of
the clinical areas in which they work.
It doesnt take extra time to talk to patients during your procedural
For example, RNs described how competing temporal
care. So caring for the patient can occur even when there is not
demands lead to a form of task-centred nursing where
enough time. Now I also realize that I am more observant, for
patient care is delivered in an impersonal manner. Further-
example a patient once stared at me when I was changing his naso-
more, care in this time-pressured context is designed as
gastric feeding tube, and I figured out that he didnt want me to
routine, leading to unthinking habituated ways of work-
touch his nose. I have learnt so much from patients when I paid
ing with damaging effects on the quality of care and
attention to them. (Extract 9, Phoebe)
patient safety. The experiences of the RNs resonated with
Both Extracts 8 and 9 provide an important insight into participants in Thompson et al. (2008) and Hemsley et al.
RNs working practices which see them using their time (2012) who similarly report the negative effects of time
during care activities to also communicate with patients. pressure on decision-making and communication with
We believe this insight to be particularly important as it patients.
compels us to re-evaluate the nature of communication dur- In Hong Kong, as elsewhere, the RN workforce has
ing procedural or task-centred nursing care. For example, undergone restructuring and downsizing, developments
there is a tendency in some studies to characterize nurses which internationally seem to impact on the health and
communication when administering medication or changing well-being of nurses and on patient safety (Canadian Health
dressings as consisting of exclusively perfunctory talk which Services Research Foundation 2006). Our findings are also
focuses merely on the completion of the task, rather than comparable to Lundstrom et al.s (2002) study undertaken
on more meaningful or patient-centred interaction with the in the USA, who noted that nurses stress affects patient
patient (Hewison 1995). outcomes and frequency of patient incidents (p.97), a
However, our data suggest that communication during points which resonates with Michelles experiences in
tasks exists at a more meaningful level than merely Extract 3.
most or every shift. The study also raised the issue of how
What is already known about this topic nurses who have adult caring responsibilities at home were
Shortage of healthcare workers and registered nurses
more likely to feel under too much pressure at work com-
mean that time is an increasingly rare healthcare pared with nurses who do not have these responsibilities
resource. (62% compared to 53%). The impact of work on the
Although nursing work is increasingly being measured
home-life of nurses is an area of research that deserves
there is little research which subjectively explores the more attention.
interface between nursing work and time. We also found that the way nurses normatively organize
their activities had an effect on their time management. For
What this paper adds example, ensuring that nursing work is completed in a
timely way required an effort of cooperation and coordina-
Registered nurses capitalize on the briefest task-related tion across the nursing team. Participants described how
episodes of care-giving by communicating with cooperation is underpinned by a collective agreement about
patients and families. normative nursing behaviours and routines. For example,
Registered nurses support each other when busy and one normative expectation that emerged was that nurses
rally to and rescue individuals with heavy workloads. prioritized their work so not to burden colleagues on the
Work priorities are shaped by the expectation that subsequent shift with unfinished tasks. However, the strong
nurses should ensure that colleagues are not overbur- expectation that tasks be completed by the end of the shift
dened by unfinished work. resulted in some of the nurses not talking to patients as
they feared this would obstruct their work. Others have
Implications for practice and/or policy noted that the inability to complete desired activities may
Routines, habitual ways of working, and the culture of
be experienced by workers as time pressure (Goodin et al.
busyness which often exists in nursing should be chal- 2005) and may contribute to a nursing culture based on a
lenged as activities which often lead to wasting rather tyranny of busyness (Manias & Street 2000, p,.378) rather
than saving time. than on patient need. The effects of busyness includes
Research is recommended that merges qualitative data
compromised safety, emotional and physical strain, sacrifice
which explores the work/time interface with nursing of personal time, incomplete nursing care, and the inability
metrics or quantification of nursing work. to find or use resources (Thompson et al. 2008). In this
More attention should be placed by researchers on
way, nursing work can be seen as something that both
exploring the value and content of short sequences of shapes and is shaped by the perception of time pressure.
interaction between nurses and patients. On the other hand, time pressure often encourages colle-
giality amongst nurses, both in the sense of supporting each
other to complete their tasks but also in such things as
Job stress is an increasing concern in Hong Kong, so instructing HCAs towards more effective care. Nurses were
much so that more nurses have begun to seek help for occu- seen to rally to and rescue individuals with heavy work-
pational concerns (Wang et al. 2011). Wang et al. suggest loads. Macdonald (2007) similarly found that nurses work-
that a heavy workload and lack of support in the work- ing closely together when confronted with time pressure
place were frequent stressors experienced by Hong Kongs enabled tasks to be completed and a sense of satisfaction
surgical nurses. Globally too nurses report feeling pressured that they had done as much as they could under the circum-
by employers and colleagues into working beyond their stances.
normal shifts (Canadian Health Services Research Founda- When not discussing issues of time pressure, all of the
tion 2006) and describing their workplaces as haotic as participants described how spending time talking and get-
they struggle to cope with constant and rapid change (Kerr ting to know patients and their relatives benefitted care-
et al. 2005). giving and saved time in the long run. Time spent talking
A recent survey by the UKs Royal College of Nursing to patients and relatives enabled nurses to recognize nuan-
(2009) reported that 49% of respondents agreed that the ces in individual treatment responses. Our findings reinforce
nursing establishment where they work is insufficient to Macdonalds (2007) conclusions that time is the most com-
meet patient needs. Respondents (42%) reported that this monly identified factor that contributes to nurses knowing
leads to patient care being compromised at least once or twice patients. For example, the RNs utilized every potential
per week, with a quarter saying that care is compromised on opportunity to get to know patients better, describing how
Limitations
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