jan12064(1).pdf

ORIGINAL RESEARCH

The relationships between communication, care and time

are intertwined: a narrative inquiry exploring the impact of time

on registered nurses’ work

Engle Angela Chan, Aled Jones & Kitty Wong

Accepted for publication 10 October 2012

Correspondence to A. Jones:

e-mail: [email protected]

Engle Angela Chan BScN MA PhD

Associate Head (Undergraduate Studies)

School of Nursing, Hong Kong Polytechnic

University, Kowloon, Hong Kong

Aled Jones PhD BN RN

Senior Lecturer

School of Nursing and Midwifery Studies,

Cardiff University, UK

Kitty Wong MSc BN RN

Senior Clinical Associate

School of Nursing, Hong Kong Polytechnic

University, Kowloon, Hong Kong

CHAN E .A . , JONES A . & WONG K . ( 2 0 1 3 ) The relationships between communi-

cation, care and time are intertwined: a narrative inquiry exploring the impact of

time on registered nurses’ work. Journal of Advanced Nursing 69(9), 2020–2029.

doi: 10.1111/jan.12064

AbstractAim. To report a qualitative study which explores registered nurses’ views on the

issue of time in the workplace.

Background. There is a worldwide shortage of healthcare workers, subsequently

time as a healthcare resource is both finite and scarce. As a result, increased

attention is being paid to the restructuring of nursing work. However, the

experience of time passing is a subjective one and there exists little research

which, over a prolonged period of time, describes nurses’ experiences of working

in time-pressurized environments.

Design. A narrative inquiry.

Method. Five registered nurses were individually interviewed a total of three

times over a period of 12 months, amounting to a total of 15 interviews and

30 hours of data. Data were collected and analysed following a narrative enquiry

approach during the period 2008–2010.

Findings. Participants describe how attempts to work more effectively sometimes

resulted in unintended negative consequences for patient care and how time pressure

encourages collegiality amongst nurses. Furthermore, the registered nurses’ account

of how they opportunistically create time for communication with patients compels

us to re-evaluate the nature of communication during procedural nursing care.

Conclusion. Increasingly nursing work is translated into quantitative data or

metrics. This is an inescapable development which seeks to enhance understanding

of nursing work. However, qualitative research may also offer a useful approach

which captures the otherwise hidden, subjective experiences associated with time

and work. Such data can exist alongside nursing metrics, and together these can

build a better and more nuanced consideration of nursing practice.

Keywords: hospital/institutional environment, narrative inquiry, nursing care,

qualitative, routine work, time, workforce issues

2020 © 2013 Blackwell Publishing Ltd

JAN JOURNAL OF ADVANCED NURSING

Introduction

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�3million 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 demon-

strated (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 find-

ings from a qualitative study that explored registered

nurses’ (RNs) views on time and its effects on their every-

day 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 prac-

tice, research, and education and offer an insightful coun-

terbalance to the more abundant studies which measure

nursing work.

Background

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 prac-

tice, theory, and research. Jones (2001) concluded that the

small amount of literature in existence revealed misconcep-

tions 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 pres-

ent, 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 out-

come-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 coun-

tries 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 medi-

cal 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).

The study

Aim

The study explores how time is experienced in nurses’

everyday work in Hong Kong. Specifically, we were inter-

ested in the following questions:

● How do nurses describe their time spent caring for

patients in their particular settings?

● How does their understanding of time affect them and

their work?

Design

A narrative inquiry approach (Clandinin & Connelly 2006)

was adopted to study how nurses make meaning of their

© 2013 Blackwell Publishing Ltd 2021

JAN: ORIGINAL RESEARCH Nursing work and time in Hong Kong

experiences by telling and retelling accounts of how time

influences their work. Experience refers to nurses’ knowl-

edge, including what and how they know and is shaped by

both personal meanings and the contexts where nurses

work. Repeated interviews with a limited number of partic-

ipants are a common strategy in narrative inquiry seeking

to generate depth of understanding of phenomena (McCrac-

ken 1988). This research approach enables nurses to reflect

on their stories of experience, helping them make meaning

of the function of time in patient care but also of their lives

as nurses and their professional identity.

Participants

Following the granting of Research Ethics Committee

approval by the University Research Ethics Committee,

in-depth interviews were carried out with five participants

between mid 2008 to early 2010. Study participants were

assured confidentiality throughout the research process.

Consistent with the rationales of small studies presented by

Crouch and McKenzie (2006), our study was ‘intensive,

rather than…extensive’ (p. 494) and conceptually persua-

sive, rather than quantifiably demonstrative. We recruited

RNs with a minimum of 1 year’s postregistration experi-

ence and at least 6 months experience in their current clini-

cal areas. Our dependence on volunteers meant that we

could not ‘control’ for the clinical areas from which RNs

were recruited. This purposive sample (Patton 2002) there-

fore consisted of RNs who worked on an intensive care

unit, an acute neurosurgical unit, a rehabilitation ward, a

medical ward with primarily respiratory patients, and a

community setting in Hong Kong.

Data collection

We interviewed each of the five participants a total of three

times, making 15 interviews amounting to almost 30 hours

of data. The in-depth interviews with participants were

unstructured and conversational in nature, with occasional

questions from the interviewer to seek clarification. The

interviews occurred in the researchers’ offices and were

planned in accordance with the participants’ schedule,

giving them a sense of control and collaboration in the

process. Interviews lasted between 1�5 and 2�5 hours. The

total number of interviewees allowed for repeated and more

in-depth interviews to be scheduled.

The first interview focused on developing rapport and

making initial forays into the topic. For example, the inter-

view would start with a question asking the participants to

describe their everyday work for a typical and an atypical

day. The second interview aimed to develop the discussion

and allow participants time to explore their experiences in

more depth. Participants would also be asked about what

things were most important to them when delivering patient

care. How do they decide its importance and how do they

get things done if they do not have sufficient time? The

third interview allowed the researcher to clarify and expand

participants’ descriptions and to follow any changes in their

experience. Since the participants’ continuous reflection on

their stories is part of the process of retelling them, this

component was the focus of the last interview.

Data analysis

Data collection and analysis proceeded concurrently (Morse

& Richards 2002), the research team met regularly to share

preliminary understanding of the data. A number of strate-

gies were employed to ensure that the data interpretation

was rigorous and reflected the phenomena under investiga-

tion. These included each of the research team members

reading and rereading their interview transcriptions and

field notes prior to the meetings. Narrative codings were

then produced to identify possible plotlines, how they inter-

connected, the tensions that emerged and the settings/con-

texts of the events (Tappan & Brown 1989).

Diverse events were also examined along a temporal

dimension and the effects of one event on another were

identified (Polkinghorne 1988). In addition, plotline clarifi-

cation with participants occurred from beginning to end as

written materials were revised.

Narrative inquiry proved to be an excellent way to facili-

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-

pared a written summary of the texts, including identified

common meanings and excerpts from the text to support

the themes. The corresponding author read the summaries

to discern patterns and meanings in and across the texts.

Findings

The following sections describe the interconnected narra-

tives 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


E. A. Chan et al.

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 read-

ings 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 condi-

tion’ 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 else-

where 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 work-

place (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 familiar-

ity 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 sutur-

ing 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 corre-

lates 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 conse-

quence 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 tempo-

rally 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 fin-

ishing 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 impor-

tant 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 ideo-

logical 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 sit-

uation 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 val-

ues 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 frag-

mentation of documentation which resulted in less time for

individualized patient care. She said, ‘Because of the enor-

mous 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 litiga-

tion 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 col-

leagues 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 num-

ber of reasons. First, a description is provided of how time/

work pressure resulted in Kathy and her colleagues combin-

ing 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 sug-

gests 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 fur-

ther supports the earlier assertion that routines are intro-

duced 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 dis-

charged, 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 dis-

charged, 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 recount-

ing 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


E. A. Chan et al.

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 expecta-

tions of RNs are beyond the limits of what could be consid-

ered 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 commu-

nicate with patients. For example, when administering pro-

cedural 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 inter-

twined. 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 naso-

gastric 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 dur-

ing 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.

Discussion

It has recently been stated that the current body of knowl-

edge relative to nursing time is insufficient to address many

of the important questions with which nursing as a profes-

sion 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. How-

ever, 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. Further-

more, care in this ‘time-pressured’ context is designed as

routine, leading to unthinking ‘habituated’ ways of work-

ing 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 occu-

pational concerns (Wang et al. 2011). Wang et al. suggest

that a heavy workload and lack of support in the work-

place 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 Founda-

tion 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 com-

pared 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 coordina-

tion 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 colle-

giality 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 work-

loads. Macdonald (2007) similarly found that nurses work-

ing 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 circum-

stances.

When not discussing issues of time pressure, all of the

participants described how spending time talking and get-

ting 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 nuan-

ces in individual treatment responses. Our findings reinforce

Macdonald’s (2007) conclusions that time is the most com-

monly identified factor that contributes to nurses knowing

patients. For example, the RNs utilized every potential

opportunity to get to know patients better, describing how

What is already known about this topic

● Shortage of healthcare workers and registered nurses

mean that time is an increasingly rare healthcare

resource.

● Although nursing work is increasingly being measured

there is little research which subjectively explores the

interface between nursing work and time.

What this paper adds

● Registered nurses capitalize on the briefest task-related

episodes of care-giving by communicating with

patients and families.

● Registered nurses support each other when busy and

rally to and ‘rescue’ individuals with heavy workloads.

● Work priorities are shaped by the expectation that

nurses should ensure that colleagues are not overbur-

dened by unfinished work.

Implications for practice and/or policy

● Routines, habitual ways of working, and the culture of

busyness which often exists in nursing should be chal-

lenged as activities which often lead to wasting rather

than saving time.

● Research is recommended that merges qualitative data

which explores the work/time interface with nursing

metrics or quantification of nursing work.

● More attention should be placed by researchers on

exploring the value and content of short sequences of

interaction between nurses and patients.


E. A. Chan et al.

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 dismiss-

ing 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 measure-

ment of the availability of nursing time is also very impor-

tant. 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.

Limitations

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 partici-

pants allowed us to generate rich, in-depth data.

Conclusion

Nursing work has changed considerably in recent years and

there is a growing understanding of the relationship between

nurses’ work environments, patient/client outcomes, and

organizational and system performance. In light of this,

managers and policy makers should note how RNs in our

study describe the routinization of nursing work in the face

of competing time leads to detrimental levels of patient care

and a sense of guilt in nurses. Our study also suggests that,

alongside metrics-based analysis of nursing work and per-

formance, a more nuanced understanding of the dynamic

relationship between time and nursing work was required.

For example, the potential for rich communication between

nurses and patients during brief, routine nursing tasks chal-

lenges previously held assumptions about the ‘perfunctory’

nature of such episodes of communication.

Acknowledgements

We would like to thank the nurses who participated in the

study and all who made this study possible.

Funding

This research received no specific grant from any funding

agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

All authors meet at least one of the following criteria [recom-

mended by the ICMJE (http://www.icmje.org/ethical_1author.

html)] and have agreed on the final version:

● substantial contributions to conception and design,

acquisition of data, or analysis and interpretation of

data;

● drafting the article or revising it critically for important

intellectual content.

References

Adam G. (1995) Timewatch: The Social Analysis of Time. Political

Press, Cambridge.

Allen D. (2001) The Changing Shape of Nursing Practice. The Role

of Nurses in the Hospital Division of Labour, Routledge, London.

Buchan J. & Calman L. (2005) Skill Mix and Policy Change in the

Health Workforce; Nurses in Advanced Roles. OECD Health

Working Papers No. 17. OECD, France

Canadian Health Services Research Foundation (2006) What’s

Ailing Our Nurses? A Discussion of the Major Issues Affecting

Nursing Human Resources in Canada. Canadian Health Services

Research Foundation, Ottawa, ON.

Chan E.A., Chung J. & Wong T. (2008) Learning from the severe

acute respiratory syndrome (SARS) epidemic. Journal of Clinical

Nursing 17, 1023–1034.

Clandinin J. & Connelly M. (2006) Narrative Inquiry: Experience

and Story in Qualitative Research. Jossey-Bass, San Francisco.

Clarke M. (1978) Getting through the work. In Readings in the

Sociology of Nursing (Dingwall R. & McIntosh J., eds),

Churchill Livingstone, Edinburgh, pp. 67–86.

Crouch M. & McKenzie H. (2006) ‘The logic of small samples in

interview based qualitative research.Social Science Information

45(4), 483–499.

Dalgaard K.M. & Delmar C. (2008) The relevance of time in

palliative care nursing practice. International Journal of

Palliative Nursing 14, 472–476.

Doherty C. (2009) A qualitative study of health service reform on

nurses’ working lives: learning from the UK National Health



Service (NHS). International Journal of Nursing Studies 46, 1134

–1142.

Duffield C., Forbes J., Fallon A., Roche M., Wise W. & Merrick E.

(2005) Nursing skill mix and nursing time: the roles of registered

nurses and clinical nurse specialists. Australian Journal of

Advanced Nursing 23, 14–21.

Duffield C., Gardner G. & Catling-Paull C. (2008) Nursing work

and the use of nursing time. Journal of Clinical Nursing 17,

3269–3274.

Fine G. (1996) The Culture of Restaurant Work. University of

California Press, Berkley.

Gilbert J. & Yan J. (2008). Letter to Author and Other Health

Care Colleagues. World Health Organization, Geneva.

Goodin R.E., Rice J.M., Bittman M. & Saunders P. (2005) The

time pressure illusion: discretionary time vs free time. Social

Indicators Research 73, 43–70.

Gugerty B., Maranda M.J., Beachley M., Navarro V.B., Newbold S.,

Hawk W., Karp J., Loszalka M., Morrison J.D., Poe S. & Wilhel

D. (2007) Challenges and Opportunities in Documentation of

Nursing Care of Patients. Maryland Nursing Workforce

Commission Documentation Work Group, Baltimore, MD.

Hemsley B., Balandin S. & Worrall L. (2012) Nursing the patient

with complex communication needs: time as a barrier and a

facilitator to successful communication in hospital. Journal of

Advanced Nursing 68(1), 116–126.

Hewison A. (1995) Nurses’ power in interactions with patients.

Journal of Advanced Nursing 21, 75–82.

Hobbs J. (2009) A dimensional analysis of patient-centered care.

Nursing Research 58, 52–62.

Jones A. (2001) Time to think: temporal considerations in

nursing practice and research. Journal of Advanced Nursing

33, 150–158.

Jones A. (2007) Admitting hospital patients: a qualitative study of

an everyday nursing task. Nursing Inquiry 14, 212–223.

Jones T. (2010) A holistic framework for nursing time: implication

for theory, practice and research. Nursing Forum 45, 185–196.

Jones A. & Collins S. (2007) Nursing assessments and other tasks:

some constraints on participation in interaction between patients

and nurses. In Patient Participation in Healthcare Consultations

(Collins S., Britten N., Thompson A. & Ruusuvuori J., eds),

Open University Press, Buckingham, pp. 143–163.

Kane R., Shamliyan T., Mueller C., Duval S. & Wilt T. (2007) The

association of registered nurse staffing levels and patient

outcomes. Medical Care 45(12), 1195–1204.

Kerr M., Spence Laschinger H., Severin C., Almost J. & Shamian

J. (2005) New strategies for monitoring the health of Canadian

Nurses: results of collaborations with key stakeholders. Canadian

Journal of Nursing Leadership 18(1), 67–81.

Lundstrom T., Pugliese G., Bartley J., Cos J. & Guither C. (2002)

Organizational and environmental factors that affect worker

health and safety and patient outcomes. American Journal of

Infection Control 30(2), 93–106.

Macdonald M. (2007) Origins of difficulty in the nurse-patient

encounter. Nursing Ethics 14, 510–521.

Manias E. & Street A. (2000) The handover: uncovering the

hidden practices of nurses. Intensive and Critical Care Nursing

16, 373–383.

McCabe C. (2004) Nurse-patient communication: an exploration

of patients’ experiences. Journal of Clinical Nursing 13, 41–49.

McCracken G (1988) The Long Interview. Qualitative Research

Methods Series 13. Sage Publications, Newbury Park, CA.

Morse J. & Richards L. (2002) Readme First for a User’s Guide to

Qualitative Methods. Sage Publication, Thousand Oaks, CA.

O’Brien-Pallas L. & Baumann A. (2000) Toward evidence-based

policy decision: a case study of nursing health human resource in

Ontario. Canada. Nursing Inquiry 7, 248–257.

Patton M.Q. (2002) Qualitative Research & Evaluation Methods,

2nd edn. Sage Publications, London.

Polkinghorne D.E. (1988) Narrative Knowing and the Human

Sciences. State University of New York Press, Albany.

Royal College of Nursing (2009) Nurses’ Employment and Morale.

Royal College of Nursing, London.

Seneviratne C.C., Mather C.M. & Then K.L. (2009) Understanding

nursing on an acute stroke unit: perceptions of space, time and

interprofessional practice. Journal of Advanced Nursing 65,

1872–1881.

Strauss A. & Corbin J. (1998) Basics of Qualitative Research.

Sage, Thousand Oaks, CA.

Tappan M. & Brown L.M. (1989) Stories told and lesson learned:

toward a narrative approach to moral development and moral

education. Harvard Educational Review 59, 182–205.

Thomassen N. (2001) Trouble and Happiness. Gyldenal,

Copehagen.

Thompson D., O’Leary K., Jensen E., Scott-Findlay S., O’Brien-

Pallas L. & Estabrooks C. (2008) The relationship between

busyness and research utilization: it is about time. Journal of

Clinical Nursing 17, 539–548.

Thorne S., Hislop G., Stajduhar K. & Oglov V. (2009) Time-

related communication from the cancer patient perspective.

Psycho-Oncology 18, 500–507.

Tyler D.A., Parker V.A., Engle R.L., Brandeis G.H., Hickey E.C.,

Rosen A.K., Wang F. & Berlowitz D.R. (2006) An exploration of job

design in long-term care facilities and its effect on nursing employee

satisfaction.Health Care Management Review 31, 137–144.

Walent R. (2003) On time, money, and caring. Journal of

Gerontological Nursing 29, 3.

Wang W., Kong A.W.M. & Chair S.Y. (2011) Relationship

between job stress level and coping strategies used by Hong

Kong nurses working in an acute surgical unit. Applied Nursing

Research 24, 238–243.

Waterworth S. (2003) Time management strategies in nursing

practice. Journal of Advanced Nursing 43, 432–440.

Yam B.M.C. & Rossiter J.C. (2000) Caring in nursing: perceptions

of Hong Kong nurses. Journal of Clinical Nursing 9, 293–302.


E. A. Chan et al.

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of

evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance

and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original

research reports and methodological and theoretical papers.

For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan

Reasons to publish your work in JAN:

• High-impact forum: the world’s most cited nursing journal, with an Impact Factor of 1·527 – ranked 14/101 in the 2012 ISI Jour-

nal Citation Reports © (Nursing (Social Science)).

• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries

worldwide (including over 3,500 in developing countries with free or low cost access).

• Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan.

• Positive publishing experience: rapid double-blind peer review with constructive feedback.

• Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication.

• Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley

Online Library, as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).



Documents

jan12064(1).pdf