The root terms time
are rich with meaning and should be used to inform our understanding of the concept nursing time
. A holistic approach to the conceptualization of nursing time is therefore advocated and the following conceptual framework () proposed and presented as a work in progress. Nursing time is conceived to exist in three forms – physical, psychological, and sociological. Physical nursing time is measured by the clock and assigned a number. It is exemplified by commonly used staffing metrics such as hours of care and nurse-patient ratios (Kane, Shamaliyan, Mueller, Duval, & Wilt, 2007
). Physical nursing time is public – it belongs to the world outside of the nurse-patient relationship, e.g. to the world of managers, payors, researchers, and administrators. Physical nursing time provides a platform for uniformity – for a shared definition and interpretation. Such uniformity and standardization form the foundation for quantitative comparisons and expectations for regulation of behavior.
Conceptual Model of Nursing Time
The physical time consumed in the completion of individual nursing activities is often summed and averaged to determine how many nurses are needed and how many patients an individual nurse should be able to care for during a shift. Examples of behavioral expectations associated with physical nursing time include establishing nursing unit schedules and assignments based on pre-set boundaries around physical nursing time. Measures such as nurse-patient ratios and hours of care have become benchmarks around which nurse managers set goals and upon which organizations are evaluated. However, these measures are meaningful only to the extent that the rules of computation are clarified and applied consistently. It is important to know, for example, which census was used to determine patient days (e.g. midnight vs noon), and which types of nursing staff (registered, vocational, or unlicensed) were included. Did the computation include only productive clinical time and how was productive time defined?
In the context of human resource management, productive time is synonymous with “worked hours” as defined by the U.S. Department of Labor. Worked hours, according to the Fair Labor Standards Act (FLSA) is time spent on any activity required for employment, including time spent at meetings and educational events (29 USC § 201). The data used to compute physical nursing time typically come from hospital payroll databases designed to comply with the reporting requirements of the FLSA. Consequently, they often lack the capability of isolating direct care providers and direct clinical time. While it may be useful to include work-time of staff not providing patient care for budgeting purposes, its inclusion may pose problems with respect to clinical benchmarking. Apparent differences in hours of care, for example, may actually be due to differences in the length of orientation, number of staff in orientation, or continuing education activities among units. High nurse-patient ratios may actually reflect a higher percentage of nurses in non-clinical roles rather than more direct care providers per patient.
Measures of physical nursing time are typically reported as global rather than particular measures because they reflect an entire shift or day of work rather than specific nursing activities. Consequently they do not retain any of the experiential meaning from particular nurse-patient encounters. Global measures of physical nursing time may tell us that patients on a given nursing unit receive an average of eight hours of nursing care per day, but they tell us nothing about the nature of care for particular patients. What specific activities or events occurred in that time? Were the activities orderly? Were the activities skillfully completed? Were the activities sufficient to achieve intended goals? Though global measures of physical nursing time are associated with patient outcome (Kane et al., 2007
), the specific nursing activities responsible for such outcomes have not been identified. The “what” or the “how” of nursing from global measures of physical nursing time alone cannot be realized.
Psychological nursing time is conceived as that internal to providers and recipients of nursing care. It is subjective, perceptual, and elastic. Psychological nursing time is influenced by the history, experience and expectations of the participants. It is what
participants experience as nursing and how
they experience it. Regardless of the quantity of physical time patients receive from a nurse, if needs and expectations are not met they may perceive the time as insufficient. Temporality and the semiotics of time are integral to the patient perception of feeling cared for (Davis, 2005
; Davis, 2006
; Hayes & Tyler-Ball, 2007
; Henderson et al., 2007
; Jennings, Heiner, Loan, Hemman, & Swanson, 2005
; McCabe, 2004
). For example, Henderson et al (2007)
found that patients express dissatisfaction when nurses are not readily available to respond to specific requests, or when they forget to follow up and complete activities after getting distracted. Presence, described as “being there and being with,” was reported as a pervasive thread in patient exemplars of good nursing care (Davis, 2005
). Patients also report experiencing a feeling of safety when staff is present, i.e. when they are watched over (Schmidt, 2003
). This reflects the elastic nature of psychological nursing time and suggests that what happens and how it happens in a given period of time, are perhaps more important for the nurse-patient relationship than physical time alone.
Nurse perceptions of nursing time provide information relative to the adequacy of time to meet patient needs and other role expectations, and also identify opportunities for improvement. Upenieks, Akhavan, Kotlerman, Esser, & Ngo (2007)
described which activities nurse’s perceive to add value to patient care, and how much time they spend on value-added (60%), necessary (19.7%) and non value-added (20.7%) care. Furthermore, it is estimated that nurses spend 39% of their time on activities that require a registered nurse, 12% of their time on activities that could be done by an unlicensed staff member alone, and 49% of their time on shared tasks (Gran-Moravec & Hughes, 2005
). Such information directs us to look for opportunities to better use the RNs available.
Research suggests that elements of care are being missed as a result of inadequate physical nursing time (Kalisch & Williams, 2009
; Schubert, Glass, Clarke, Schaffert-Witvliet, & DeGeest, 2007
; Schubert et al., 2008
). Interventions across multiple categories of care are missed, and nurse-perceived missed care is more strongly associated with patient outcome than are measures of physical nursing time. Therefore, knowing what
nurses do (or do not do) is as important as knowing how much time they have available. Moreover, measures of physical nursing time are not strongly correlated with nurse-perceived missed care – i.e. care is missed across the continuum of ratios and hours of care. Although staffing is often identified by nurses as a major reason for missed care, it does not seem to be exclusively an issue of an inadequate number of available nurses across an entire shift. For example, Kalisch, Landstrom, & Williams (2009)
determined that staffing problems were identified as frequently resulting from a sudden or unexpected increase in care demands within the shift. This is consistent with what has been described as turbulence in the literature (Jennings, 2008
). Sources of turbulence may include sudden changes in patient volume (admissions), acuity (physical or emotional deterioration of patients), or activity (patient discharges, patient transfers, or bedside procedures).
Nursing time also is experienced within the social context of the healthcare system. As members of organizational communities, nurses participate in shared time structures that become the foundation of practice patterns and routines. Examples of time structures that influence nursing care include established work shifts, standardized medication times, standardized procedure sequences, and hours of operation for ancillary departments. Nurses make decisions and organize their actions during a shift within the social process of time structuring. Patients may be awakened at a certain time based on when food trays are routinely delivered, and preoperative medications are administered around routine operating room sequences (e.g. case order and start times). Calls to physicians may be delayed to coordinate with routine rounding practices. Answering a call light may be delayed in favor of administering the first dose of antibiotics to a patient within the expected time interval of diagnosis.
The sociological form of nursing time is therefore described as that which is experienced by providers and recipients of nursing care through shared temporal structures. It is a shared inter-subjective experience of patterns of behavior. Sociological nursing time is characterized by the sequential ordering of events within the daily routine of a practice setting. Coordination of care, which has become a primary role in nursing, involves participation in numerous time structures within a HCO. The potential for overlap among multiple interdependent time structures is significant and the need for prioritization among nurses is critical (Hendry & Walker, 2004
; Waterworth, 2003
). The result for patients may include missed, delayed, or inappropriately sequenced care and the result for nurses may include a sense of time pressure
(Detrick, Bokovoy, Stern & Panik, 2006
; Roszell, S., Jones. & Lynn, 2009
; Stefancyk, 2009
). The negative effects of time pressure on well-being, performance and decision making have been demonstrated in a variety of settings outside nursing (Calderwood, Klein, & Crandall, 1988
; Dhar & Nowlis, 1999
; Goodin, Rice, Bittman & Daunders, 2005
; Höge, 2008; Lin & Carley, 1997
; Peters, O’Connor, Pooyan, & Quick, 1984
; Pollock & Grimes, 2002
; Roxburgh, 2004
; Sonnentag & Niessen, 2008
; Staudenmayer, Tyre, & Perlow, 2002
; Suri & Monroe, 2003
). Though the experience of time pressure has not been adequately evaluated in nursing, there is some evidence to suggest that similar negative effects are experienced (Thompson et al., 2008
The Ethics of Nursing Time
In her classic work on the science and ethics of a practice discipline, Beckstrand (1978)
affirmed that the goal of a practice discipline is to bring about changes in entities such that a greater degree of defined good (value) is realized. The defined good for a practice discipline is determined in the context of normative and metaethics. Within this context the moral obligation of nurses toward patients is established, as are the standards for evaluating the relative “goodness” or “badness” of people (moral value) and things (nonmoral value). Things, such as nursing time, may be judged to be of value if they are good in and of themselves (intrinsic value), or if they lead to a good outcome (instrumental value).
A compelling logical argument for the intrinsic and instrumental value of time to the practice of medicine was eloquently articulated by Braddock and Snyder (2005)
. They asserted that time has ethical significance within the context of the patient-physician relationship and the inherent duties, such as respect of patient autonomy, promotion of well being, maintenance of fidelity, and preserving justice. The authors distinguished between time as quantity and quality. Perceived quality of time is viewed as fundamental to the patient experience and equivalent to the concept of adequate
time. Adequate time is said to exist when there is sufficient time to meet professional and ethical obligations with patients. The following sequence of logical statements is a general summary of their thesis: 1) time as quantity is necessary for time as quality (adequate time); 2) adequate time is necessary to promote trust and patient-centered communication; 3) trust and patient-centered communication are inherent to strong therapeutic relationships; 4) strong therapeutic relationships lead to good outcomes (patient satisfaction, adherence to treatment regimens, better patient outcomes); and 5) time as quantity and quality has intrinsic and instrumental value.
The parallels between the respective conceptualizations of time and therapeutic relationships within the disciplines of medicine and nursing are strong and intuitively obvious. Getting to know the patient is germane to the nurse-patient relationship (Kirk, 2007
; Macdonald, 2008
), and has been identified as a fundamental form of nursing knowledge for decades (Carper, 1978
). This esthetic knowledge is described as being gained through direct experience with the patient and allows the nurse to understand the meaning of the illness for the patient and recognize nuances in individual treatment responses (Macdonald, 2008
). Time is the most commonly identified factor among nurses and patients that contributes to nurses knowing the patient and when time is lacking, task-oriented care based on the principle of nonmaleficence, rather than beneficence, may result (Macdonald, 2008
). Time, therefore, has significant intrinsic and instrumental value in the practice of nursing.