JAN

JOURNAL OF ADVANCED NURSING

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: 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

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JAN: ORIGINAL RESEARCH

Nursing work and time in Hong Kong

Nursing work is often characterized by a shortage of time to

deliver patient care. According to the World Health
Organization, there is a shortage of approximately 4
3
million health workers worldwide (Gilbert & Yan 2008),
with the result that time is an increasingly scarce resource in
the workplace. Consequently, health practitioners are
increasingly feeling that more time is needed than is available
(Waterworth 2003). To address this shortage, increased
attention is internationally being paid to the restructuring of
work processes to give a more efficient and productive health
workforce (Duffield et al. 2008).
Existing research on nursing work and time largely
focuses on task analysis studies addressing the nature and
amount of time spent on patient care (OBrien-Pallas &
Baumann 2000, Chan et al. 2008). The relationship
between having more time and being able to deliver better
quality nursing care outcomes has been clearly demonstrated (Hobbs 2009). However, other studies also describe
nurses concern about the impact of time scarcity on the
quality of nursing work and patients (Dalgaard & Delmar
2008, Seneviratne et al. 2009).
During the course of this article we will describe the findings from a qualitative study that explored registered
nurses (RNs) views on time and its effects on their everyday work. Through interviewing RNs over a period of time,
a clear picture emerged of how time shapes the way that
nurses plan and deliver patient care. The findings from this
study will be of interest to those involved in nursing practice, research, and education and offer an insightful counterbalance to the more abundant studies which measure
nursing work.

least two concepts: (1) world time, outside, as measurable by

the clock; and (2) life time, inner, as personal time with present, past, and future. Every person is subject to both concepts
of time and for nurses to work in time, they are challenged to
create space and connections between the two.
However, time is increasingly equated with healthcare
costs and efficiency. This has resulted in an increased global
focus on task-oriented clock time and has led to attempt to
quantify and reduce time available to complete healthcare
tasks (Walent 2003). This is particularly evident in the outcome-oriented nursing culture in Hong Kong, with its focus
on routines and tasks, which has inadvertently directed
attention towards what nurses do rather than to what they
experience (Yam & Rossiter 2000).
Healthcare modernization and subsequent changes to
nursing roles has often been accused of resulting in negative
changes to the availability and use of nursing time. In countries such as the USA, Hong Kong, South Korea and the UK
new nursing roles have been implemented and existing roles
extended to improve efficiency, as a response to medical
staff shortages and to improve services in rural and remote
areas (Buchan & Calman 2005). For example, nurses in the
UK have often been required to compensate for loss of medical capacity as a consequence of the reductions in junior
doctors hours in line with the European Working Time
Directive. Duffield et al. (2005) reported that Australian
advanced nurse practitioners were increasingly spending
time on clerical tasks and activities which significantly
diverted the amount time available for direct patient care.
As nurses struggle to manage the tensions produced by time
pressure, they often exchange patient-centredness for routine
practices that render the patient an object of clinical and
administrative work (Jones & Collins 2007).

Background

The study

Introduction

The issue of time is one of the most important influences on

nursing behaviour, yet temporal issues have traditionally
attracted little attention in the literature about nursing practice, theory, and research. Jones (2001) concluded that the
small amount of literature in existence revealed misconceptions and a lack of value of nursing time, possibly indicative
of the dominance of linear models of time (such as clock and
calendar time) and the historical ascendancy of medicine and
science in health care. Jones proposed that nursing practice
exists in nonlinear, complex, and parallel temporal worlds
rather than merely in clock time, which extends from past to
future measured by seconds, minutes, and hours (Adam
1995). Similarly, Thomassen (2001) asserted that time is an
experiential and existential phenomenon that relates to at
2013 Blackwell Publishing Ltd

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.

experiences by telling and retelling accounts of how time

influences their work. Experience refers to nurses knowledge, 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 participants are a common strategy in narrative inquiry seeking
to generate depth of understanding of phenomena (McCracken 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.

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.

Participants

Data analysis

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 thanextensive (p. 494) and conceptually persuasive, rather than quantifiably demonstrative. We recruited
RNs with a minimum of 1 years postregistration experience and at least 6 months experience in their current clinical 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) therefore 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 and analysis proceeded concurrently (Morse

& Richards 2002), the research team met regularly to share
preliminary understanding of the data. A number of strategies were employed to ensure that the data interpretation
was rigorous and reflected the phenomena under investigation. 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 interconnected, the tensions that emerged and the settings/contexts 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 clarification with participants occurred from beginning to end as
written materials were revised.
Narrative inquiry proved to be an excellent way to facilitate, reflect an expanded understanding of the phenomenon
of time through our attendance to nurses multilayered stories (Clandinin & Connelly 2006). Each researcher later prepared 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.

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 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
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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.

Nursing work and time in Hong Kong

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

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:

work. For instance, I was initially very cautious about patient

transfer because of safety, but at times, when things become too
familiar and routinized, I may make a wrong assumption because
of my lack of sensitivity or alertness. For example, a patient was
admitted to the ward due to an external head injury, but no suturing was required. He was alert and conscious, with a mental score

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)

Kathy describes how, despite having checked 20 blood

pressure readings she would not know the patients condition or think of possible reasons for an unusually low
reading. The undertaking of tasks on patients about whom
the nurses know little or nothing is reminiscent of the taskcentred approach to nursing care, where nurses value the
completion of tasks rather than establishing a more patientcentred 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 patients 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.

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.

The priorities of nurses and nursing

Nursing is seldom, if ever, a solitary occupation; as a consequence nurses must learn how to work with other nurses
and professions. However, working with others can create
tension, especially when one persons workload is temporally dependent on the timely completion of colleagues. As
a result, nurses have long valued colleagues who pull their
weight (Clarke 1978, Allen 2001). The value placed on finishing tasks before colleagues commence the next shift was
a recurring theme in the narratives, for example:

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

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)

Yam describes how her priorities are shaped by the

expectation that nurses should ensure that colleagues are
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E. A. Chan et al.

not overburdened by unfinished work. This results in the

categorization of some areas of nursing work as trivial
(e.g. talking to patients) and others as important (e.g.
tasks). As discussed elsewhere (Allen 2001, Jones 2007),
although nursing as a profession subscribes to an ideology
of individualized patient care, the organization of nursing
work is essentially focused on more pragmatic temporal
issues that are based upon being responsive to contingencies
arising in the workplace rather than adherence to an ideological stance.
Another feature of the narratives was a description of
unintended consequences that resulted from organizational
attempts to help nurses work more efficiently. For example,
participants discussed the increasing number of HealthCare
Assistants (HCAs) and how this has resulted in a lessening
of the amount of care provided by qualified nurses. Yam
describes how RNs have increasingly lost touch with
patients and the value of providing basic patient care, a situation which was exacerbated by the introduction of HCAs:
The introduction of the HCA for basic care was to help nurses
with their work demands. As a result, however, nurses were
removed from the bedside and thus from knowing their patients.
Therefore, I think if nurses could have better insight into their values and change their attitudes towards basic patient care, it would
redirect what is important in nursing and our use of time. (Extract
5, Yam)

In a similar vein, the burden of administration was felt

by Sharon, who was frustrated by the duplication and fragmentation of documentation which resulted in less time for
individualized patient care. She said, Because of the enormous amount of documentation, be it manual or electronic,
we waste time in duplicated writing. Sharons comment is
echoed by other nurses, who often blame their inability to
spend time interacting with patients on paperwork (Tyler
et al. 2006). As is the case globally, increased patient acuity
and complexity, shortened lengths of stay, increased litigation have all significantly increased the amount of record
keeping and report writing (Gugerty et al. 2007) required
by RNs in Hong Kong.

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

Working collegially and opportunistic communication

with patients

came to help. I felt exhausted. (Extract 7, Michelle. SOS nurse is

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:

The above extract shares narrative similarities with

atrocity stories as described by other researchers recounting the experiences of nurses (Allen 2001). Michelles
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

2024

reference to a company which transports patients)

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in the transgression of what she considers to be a legitimate

burden to deal with during one shift. The recounting of
such atrocity tales is often intended (by the speaker) as a
means of reaffirming normative boundaries. For example,
Michelle hopes that by voicing her disapproval of such
extreme working conditions, the audience will empathize
with these concerns whilst reinforcing that these expectations of RNs are beyond the limits of what could be considered as reasonable.
All of the participants commented on how much they
valued spending time talking and getting to know patients
and their relatives as this benefitted the care they gave. Busy
RNs described difficulty finding time to talk to patients and
as a result they would utilize every opportunity to communicate with patients. For example, when administering procedural care to patients such as dispensing medication,
changing dressings, or inserting a nasogastric tube, RNs
would utilize such episodes to get to know and educate
patients:
The relationships between communication, care and time are intertwined. For example, when I was cleaning a wound () the client
was made to understand the importance of self-care. Hence, the
time that we were with the patient had to be well-utilized in getting
to know how we could help them to care for themselves and to
gauge their learning over time. (Extract 8, Sharon)

Phoebe similarly describes how she communicates with

patients when she undertakes procedures with them:
It doesnt take extra time to talk to patients during your procedural
care. So caring for the patient can occur even when there is not
enough time. Now I also realize that I am more observant, for
example a patient once stared at me when I was changing his nasogastric feeding tube, and I figured out that he didnt want me to
touch his nose. I have learnt so much from patients when I paid
attention to them. (Extract 9, Phoebe)

Both Extracts 8 and 9 provide an important insight into

RNs working practices which see them using their time
during care activities to also communicate with patients.
We believe this insight to be particularly important as it
compels us to re-evaluate the nature of communication during procedural or task-centred nursing care. For example,
there is a tendency in some studies to characterize nurses
communication when administering medication or changing
dressings as consisting of exclusively perfunctory talk which
focuses merely on the completion of the task, rather than
on more meaningful or patient-centred interaction with the
patient (Hewison 1995).
However, our data suggest that communication during
tasks exists at a more meaningful level than merely
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Nursing work and time in Hong Kong

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 nonverbal 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 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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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 overburdened 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 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.

Job stress is an increasing concern in Hong Kong, so

much so that more nurses have begun to seek help for occupational concerns (Wang et al. 2011). Wang et al. suggest
that a heavy workload and lack of support in the workplace were frequent stressors experienced by Hong Kongs
surgical nurses. Globally too nurses report feeling pressured
by employers and colleagues into working beyond their
normal shifts (Canadian Health Services Research Foundation 2006) and describing their workplaces as haotic as
they struggle to cope with constant and rapid change (Kerr
et al. 2005).
A recent survey by the UKs 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
2026

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
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they would often engage the patient in conversation during

brief tasks. In a similar vein, Thorne et al. (2009) reported
that patients believed a 3-minute interaction with nurses
was sufficient to convey the sense of presence which
patients often equate with good nursing care.
It may be that the short period of time available for
interaction during procedures has led to researchers dismissing this type of communication. We therefore agree, to a
point, with Joness (2010) view that what happens, and
how it happens in a given period of time is more important
for the nurse-patient relationship than merely measuring the
physical time spent with patients. However, the measurement of the availability of nursing time is also very important. For example, Kane et al. (2007) discuss how every
additional patient per RN per shift is associated with a 7%
increase in relative risk of hospital-acquired pneumonia, a
53% increase in pulmonary failure, and a 45% increase in
unplanned extubation. As illuminative as these statistics are
such associations should not be interpreted as causality,
however, it is clear that understanding more about the
dynamic relationship between nursing work and perceived
time availability is of great importance to the well-being of
patients and staff.

Nursing work and time in Hong Kong

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

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) Whats
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, 10231034.
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. 6786.
Crouch M. & McKenzie H. (2006) The logic of small samples in
interview based qualitative research.Social Science Information
45(4), 483499.
Dalgaard K.M. & Delmar C. (2008) The relevance of time in
palliative care nursing practice. International Journal of
Palliative Nursing 14, 472476.
Doherty C. (2009) A qualitative study of health service reform on
nurses working lives: learning from the UK National Health
2027

E. A. Chan et al.
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, 1421.
Duffield C., Gardner G. & Catling-Paull C. (2008) Nursing work
and the use of nursing time. Journal of Clinical Nursing 17,
32693274.
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, 4370.
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), 116126.
Hewison A. (1995) Nurses power in interactions with patients.
Journal of Advanced Nursing 21, 7582.
Hobbs J. (2009) A dimensional analysis of patient-centered care.
Nursing Research 58, 5262.
Jones A. (2001) Time to think: temporal considerations in
nursing practice and research. Journal of Advanced Nursing
33, 150158.
Jones A. (2007) Admitting hospital patients: a qualitative study of
an everyday nursing task. Nursing Inquiry 14, 212223.
Jones T. (2010) A holistic framework for nursing time: implication
for theory, practice and research. Nursing Forum 45, 185196.
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. 143163.
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), 11951204.
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), 6781.
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), 93106.

2028

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

encounter. Nursing Ethics 14, 510521.
Manias E. & Street A. (2000) The handover: uncovering the
hidden practices of nurses. Intensive and Critical Care Nursing
16, 373383.
McCabe C. (2004) Nurse-patient communication: an exploration
of patients experiences. Journal of Clinical Nursing 13, 4149.
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 Users Guide to
Qualitative Methods. Sage Publication, Thousand Oaks, CA.
OBrien-Pallas L. & Baumann A. (2000) Toward evidence-based
policy decision: a case study of nursing health human resource in
Ontario. Canada. Nursing Inquiry 7, 248257.
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,
18721881.
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, 182205.
Thomassen N. (2001) Trouble and Happiness. Gyldenal,
Copehagen.
Thompson D., OLeary K., Jensen E., Scott-Findlay S., OBrienPallas L. & Estabrooks C. (2008) The relationship between
busyness and research utilization: it is about time. Journal of
Clinical Nursing 17, 539548.
Thorne S., Hislop G., Stajduhar K. & Oglov V. (2009) Timerelated communication from the cancer patient perspective.
Psycho-Oncology 18, 500507.
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, 137144.
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, 238243.
Waterworth S. (2003) Time management strategies in nursing
practice. Journal of Advanced Nursing 43, 432440.
Yam B.M.C. & Rossiter J.C. (2000) Caring in nursing: perceptions
of Hong Kong nurses. Journal of Clinical Nursing 9, 293302.

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