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ORIGINAL RESEARCH
Correspondence to A. Jones:
e-mail: jonesa97@cardiff.ac.uk
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
C H A N E . A . , J O N E S A . & W O N G K . ( 2 0 1 3 ) The relationships between communication, care and time are intertwined: a narrative inquiry exploring the impact of
time on registered nurses work. Journal of Advanced Nursing 69(9), 20202029.
doi: 10.1111/jan.12064
Abstract
Aim. 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 20082010.
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
Background
The study
Introduction
Aim
The study explores how time is experienced in nurses
everyday work in Hong Kong. Specifically, we were interested 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
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E. A. Chan et al.
Participants
Data analysis
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 15 and 25 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 interview would start with a question asking the participants to
describe their everyday work for a typical and an atypical
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Findings
The following sections describe the interconnected narratives of the ways five participants, Kathy, Michelle, Sharon,
Phoebe and Yam, recounted their meanings of time and
how these understandings affected their work. The findings
are presented as three major themes on pages 9, 11, and
13. Although participants worked in different clinical areas
and had variable length of service we were struck by the
commonality of temporal experiences, regardless of context.
Furthermore, following the first stages of analysis our
2013 Blackwell Publishing Ltd
work. Routines often bring a sense of order to the workplace (Waterworth 2003), but consist of habitual ways of
responding to occurrences in everyday life and are often
taken for granted until they are disrupted in any way
(Strauss & Corbin 1998).
In the next data extract, Michelle describes how familiarity with repetitive tasks leads to a habitual way of doing:
Sometimes I might be desensitized to a habitual way of doing,
given the repetitive everyday activities and the similar nature of
ings were below the baseline tasks. Most often, I wouldnt know
(Extract 1, Kathy)
Routines and habituated practice appear here as correlates of time, apparent when Michelle recounts how initial
caution about safe transfer of patients was eroded over time
by familiarity with a task. Although routines can reduce the
time pressures that nurses experience, Michelles narrative
relates how routine practice led to the individual needs of
the patient being temporarily overlooked.
daily and stayed outside the ward during the non-visiting hours.
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
Michelles feelings of guilt reinforce the point made elsewhere that competing temporal demands in the workplace
produce emotion in the workforce (Fine 1996). Competing
temporal demands may also lead to the routinization of
2013 Blackwell Publishing Ltd
because you have spent time on a triviality and missed the important tasks that they now have to pick up for you. (Extract 4, Yam)
E. A. Chan et al.
I had a terrible night once, with four new admissions. My colleagues and I were working frantically on the admissions, one of
which was a trauma case, throughout the night. There was a lot to
do: three of us would be helping with the admissions, the other
three attending to other patients. We were run off our feet but
other colleagues helped whenever they could. In general, we helped
each other. (Extract 6, Kathy)
Kathys terrible night narrative is interesting for a number of reasons. First, a description is provided of how time/
work pressure resulted in Kathy and her colleagues combining their labour; an overall sense of teamwork and of
nurses helping each other emerges out of the data. For
example, the phrase my colleagues and I and repeated use
of the pronoun we indicates collective action in response
to there being a lot to do. Kathys description also suggests that in response to the situation, nurses took a taskoriented approach to care, with three nurses doing the
admissions and three attending to other patients. This further supports the earlier assertion that routines are introduced as a mode of working in response to excess demands
on the time available (Waterworth 2003).
Michelles extract below similarly describes a busy shift
and how colleagues had come to her rescue:
My assignment was for eight patients as usual, of whom two
needed to have operations in the morning, five were to be discharged, and one had a psychiatric problem. Of the patients who
required surgery, one of them had a ventilator, so I had to escort
him to the operating room. Of the patients who needed to be discharged, one was to return to an old age home in mainland
China.
This created extra work for me, as I needed to give a report to the
SOS nurse. When I was preparing for the pre-operative checks and
discharges, a doctor suddenly indicated that the psychiatric patient
needed to be transferred. The telephone rang, and I was needed to
escort the patient with the ventilator back to the ward. I screamed
that I was very busy. A colleague came to calm me down. She told
me not to rush, and to proceed with one thing at a time.
I needed to transfer the orthopaedic patient, who was an overflow
case from the orthopaedic ward. I screamed again and a colleague
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Discussion
It has recently been stated that the current body of knowledge relative to nursing time is insufficient to address many
of the important questions with which nursing as a profession has to deal (Jones 2010). Nursing is a profession that
often describes itself as lacking in time and throughout the
course of this study nurses clearly articulate how time is a
fundamental factor in how their work is organized and
understood. The breadth of clinical areas from which the
RNs were recruited may be considered a limitation. However, the question of how nurses makes sense of, and use
time, is one which all RNs can contribute to, regardless of
the clinical areas in which they work.
For example, RNs described how competing temporal
demands lead to a form of task-centred nursing where
patient care is delivered in an impersonal manner. Furthermore, care in this time-pressured context is designed as
routine, leading to unthinking habituated ways of working with damaging effects on the quality of care and
patient safety. The experiences of the RNs resonated with
participants in Thompson et al. (2008) and Hemsley et al.
(2012) who similarly report the negative effects of time
pressure on decision-making and communication with
patients.
In Hong Kong, as elsewhere, the RN workforce has
undergone restructuring and downsizing, developments
which internationally seem to impact on the health and
well-being of nurses and on patient safety (Canadian Health
Services Research Foundation 2006). Our findings are also
comparable to Lundstrom et al.s (2002) study undertaken
in the USA, who noted that nurses stress affects patient
outcomes and frequency of patient incidents (p.97), a
points which resonates with Michelles experiences in
Extract 3.
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E. A. Chan et al.
busyness which often exists in nursing should be challenged 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.
most or every shift. The study also raised the issue of how
nurses who have adult caring responsibilities at home were
more likely to feel under too much pressure at work compared with nurses who do not have these responsibilities
(62% compared to 53%). The impact of work on the
home-life of nurses is an area of research that deserves
more attention.
We also found that the way nurses normatively organize
their activities had an effect on their time management. For
example, ensuring that nursing work is completed in a
timely way required an effort of cooperation and coordination across the nursing team. Participants described how
cooperation is underpinned by a collective agreement about
normative nursing behaviours and routines. For example,
one normative expectation that emerged was that nurses
prioritized their work so not to burden colleagues on the
subsequent shift with unfinished tasks. However, the strong
expectation that tasks be completed by the end of the shift
resulted in some of the nurses not talking to patients as
they feared this would obstruct their work. Others have
noted that the inability to complete desired activities may
be experienced by workers as time pressure (Goodin et al.
2005) and may contribute to a nursing culture based on a
tyranny of busyness (Manias & Street 2000, p,.378) rather
than on patient need. The effects of busyness includes
compromised safety, emotional and physical strain, sacrifice
of personal time, incomplete nursing care, and the inability
to find or use resources (Thompson et al. 2008). In this
way, nursing work can be seen as something that both
shapes and is shaped by the perception of time pressure.
On the other hand, time pressure often encourages collegiality amongst nurses, both in the sense of supporting each
other to complete their tasks but also in such things as
instructing HCAs towards more effective care. Nurses were
seen to rally to and rescue individuals with heavy workloads. Macdonald (2007) similarly found that nurses working closely together when confronted with time pressure
enabled tasks to be completed and a sense of satisfaction
that they had done as much as they could under the circumstances.
When not discussing issues of time pressure, all of the
participants described how spending time talking and getting to know patients and their relatives benefitted caregiving and saved time in the long run. Time spent talking
to patients and relatives enabled nurses to recognize nuances in individual treatment responses. Our findings reinforce
Macdonalds (2007) conclusions that time is the most commonly identified factor that contributes to nurses knowing
patients. For example, the RNs utilized every potential
opportunity to get to know patients better, describing how
2013 Blackwell Publishing Ltd
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 [recommended 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.
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 participants 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 performance, 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 challenges previously held assumptions about the perfunctory
nature of such episodes of communication.
2013 Blackwell Publishing Ltd
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