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This paper focus on nursing and time in endoscopy facilities for short-term stay aiming to explore aspects of time in this setting and how expectations from the healthcare organisation, patients and nurses are expressed and met when managing nursing time.
Former research primarily focuses on the subject of time in the understanding of duration where having more time is closely associated with the ability to deliver better quality nursing care. The main concern is the nurses’ increased number of tasks and the decreased length of time at their disposal. However, few studies describe nursing when time is sparse, and the possibility of providing individualised nursing within a very short span of time.
Inspired by practical ethnographic principles, a fieldwork study was performed in high technology endoscopy clinics during 2008-2010.
Data triangulation included participant observation, participant reports and patients and nurses semi-structured interviews.
The issue of time was an interwoven part of life in the productive endoscopy units. The understanding of time related to the main category: ‘Time - making the best of it’, and the sub categories “Responsibility of time”, “Information and preparation”, and “Time wasters”.
The study underlines the possibility of combining the health care systems, patients and the nurses’ perspectives on and expectations of how to spend nursing time in endoscopy settings. In successful patient pathways nursing maximize patient outcome, support the goals of the healthcare organisations, is reliable, assure, tangible, empathic and responsive, and is individually tailored to the patient’s needs. The study contributes by underlining the importance of discussing not how to get more time in clinical practice but instead how to spend the time in the best way possible.
This paper is a descriptive study of nursing and time in facilities for short-term stay. The aim is to explore aspects of time in an endoscopy setting and how expectations from the healthcare organisation, patients and nurses are expressed and met with focus on managing nursing time.
Time is a major subject of interest in healthcare today. The emphasis on standardisation, efficiency and quality is manifested through an increased production i.e. numbers of patient being treated and a decreased length of stay. The challenge for health care professionals is to make optimal use of the time they have. They have to accept the influence, demands and structure of the health care system and at the same time manage expectations of an individual care from their patients and themselves as a profession. The primary aim must always be to spend the time well - not just pass it.
Facilities for short-term stay cover a large variety of outpatient clinics and treatment and emergency units at hospitals. These units are often technologically advanced and characterised by a very high turnover and limited time for patient and nurse encounters. Time in facilities for short-term stay is short ranging from minutes to a few hours. This applies to time spent on treatment, nursing, interaction with patients and families, tasks and documentation [1-4].
Jones and Yoder  describe that nursing time is relevant to those who produce it, those who receive it and those who must pay for it. When focusing on the subject of time in facilities for short-term stay this focus must embrace expectations on how to spend nursing time from the perspective of the healthcare organisation, patients and the nurses.
Healthcare organisations expect nurses to work efficiently and with quality allocating time to establish and maintain therapeutic relationships with the patients to maximize patient outcome. While they at the same time support the goal of positive profit margin for the organisation .
From a patient perspective time is expected to be spent on nursing that embrace dimensions of reliability, assurance, tangibility, empathy and responsiveness. Reliability refers to the patients’ perception of reliable, accountable and accurate nursing care. Assurance involves professional knowledge and courtesy that instils patient confidence. Tangibility embraces appealing physical facilities, equipment, and nurses. Empathy refers to the nurses’ ability to provide individualised care and finally responsiveness indicates nurses’ willingness to provide a timely service .
From a nurse perspective it is fundamental to exercise relational, compassionate and caring nursing [6-8]. Establishing a strong relationship with the patient is considered to be central to fulfilling this purpose and considered a highly valued aspect of care. A good nurse patient relationship is based on mutual understanding, respect, trust, honesty, co-operation and humour. Nurses wish for time and space to get to know the patient, and find this indispensable to the effort of tailoring nursing to meet the individual patient’s needs [9-12]. However, limited time in today’s healthcare system militates against knowing the patient, because the majority of time is spent on technical and instrumental aspects in nursing, and less time is spent on relational and caring aspects. Thus, nurses find themselves in a constant strive to maintain the balance between the increasing number of tasks to perform and the decreasing amount of time [12-14].
Current research describes how time pressure and a perceived lack of time are common barriers for nurses’ ability to establish a successful communication and interaction with patients to ensure individualised care. In a Swedish emergency care unit, nursing was shaped and adapted to the unit’s efficiency, economy and constant time pressure . Nurses were focused upon facts, principles and medical tasks while no attempts were made to improve the understanding of the patients’ actual caring needs. In an oncological day hospital the constant time pressure and high stress level was experienced as an obstacle to providing adequate holistic nursing . Time was targeted to side effects and physical aspects of chemotherapy while nurses found themselves spending too little time on the social, psychological and spiritual aspects of nursing. In a study from Hong Kong, lack of time and heavy workload were in the way of getting to know the patient . The negative consequence was that nursing turned into a routine practice where individual needs of patients were temporarily being overlooked. Thorne et al.  described how time is a precious commodity in the rapid pace of modern health care delivery. In their study health care professionals managed to buffer, manipulate and manufacture time for communication with cancer patients. However, patients’ experienced this communication as marked by time miss-management and of being rushed.
The literature apparently agrees that time pressure and what is experienced as lack of time are responsible for the deterioration of individualised nursing care [1, 8, 14]. The focus has predominantly been on the nurses’ increased number of tasks and the decreased length of time at their disposal. However, few studies focus on describing indivi-dualised nursing when time is sparse.
This paper sets out to explore aspects of time in endoscopy facilities for short-term stay, and how expectations from the healthcare organisation, patients and nurses are expressed and met when managing nursing time. Moreover, to discuss if it is possible to combine the expectations in order to maximize patient outcome, support the financial goal of the healthcare organisation and offer nursing that meets the individual patient’s needs.
Inspired by practical ethnographic principles, a fieldwork study with participant observations, participant reports and semi-structured interviews was performed . Fieldwork has been shown to be a suitable method in nursing research  to shed light on nursing in facilities for short-term stay . The approach has been phenomenological hermeneutic and aims at producing rich textual descriptions of the experience of a selected phenomenon in the lifeworld of individuals and seeks a deeper understanding of the meaning of that experience .
The fieldwork was carried out in three endoscopy clinics from 2008 to 2010. Participants were patients undergoing endoscopy procedures and nurses working in the clinic during the days of fieldwork.
Field observations were performed during 12 weeks approximately four hours each day. During observation periods the first author stayed in the clinics, trailed a nurse, talked to patients in the resting and waiting area and talked to nurses, doctors and others. The observations employed in this study were scientific. On the surface, scientific observation is deceptively simple: Phenomena happen, phenomena are observed, and phenomena are recorded. However to observe scientifically requires much more than using one’s senses. Sensing is only one aspect, and true scientific observations require coordination of disciplinary knowledge, theory, practice, and habits of attention. The trained observer will know what features to observe and what to look for. Thus, without this specialized knowledge and practice, observers may be unable to make scientifically meaningful observations . Hand written field notes were produced. Field notes were recorded continuously during the participant observations and immediately after finishing the interviews and participant reports. The notes reported described aspects like time, sounds, statements and smells and thereby enabled the researcher to reproduce various characteristics about a given situations. Furthermore, the notes specify who said and did what, and use exactly the words which were used without summing. The result was a detailed and factual account of the social processes that were observed and the context in which these were made.
Both out patients and hospitalised patients were treated at the clinics and they spent approximately between 20 minutes and 2 hours in the clinics. Eight patients were interviewed using a semi-structured interview guide created on the basis of previous fieldwork. Patient interviews were carried out in primacy prior to gastroscopy. Patients undergoing gastroscopy at scheduled appointments on randomly selected days were asked whether they would participate in an interview. Random selection of informants is frequent when you do not know in advance which informants are the most informative . Interviewees were both male and female, over the age of 18 and fluent in Danish; age ranged between 25 and 91 years. This was considered strength because young and elderly patients may have different expectations. Both patients undergoing gastroscopy for the first time and patients undergoing a re-gastroscopy participated based on the assumption that they could have different expectations to how time in the clinic should be allocated [20, 21].
Four nurse interviews were performed after trailing the individual nurse for one day in the clinic. This was a key informant selection where the nurse due to her experience was expected to provide special insight and understanding of the phenomenon under study . Nursing seniority ranged between four and 21 years.
Patient pathway and participant report are in the following referred to as ‘Report’ followed by a number. Interviews are referred to as ‘Patient’ or ‘Nurse’ followed by a number.
According to Danish law no formal ethical approval was needed as the study did not include biomedical material. However the study was conducted in conformity with the ethical guidelines for nursing research in the Nordic countries . Written informed consent was obtained before each interview and confidentiality was assured. Verbal consent was obtained from all participating patients, nurses, doctors and others before each situation of participant observation including the right to withdraw at any time. Choosing to carry out an interview immediately before a gastroscopy may cause undue distress to patients and add to their anxiety. Special attention was therefore paid to proper behaviour and attitudes.
Analysis was performed according to guidelines by Hammersley and Atkinson . The analysis included a thorough reading of the text, identification of patterns, main and sub categories and processing of categories central to analysis. The analysis was an interactive and back and forth process within these steps of analysis. It was an integral part of research and started when identifying the area of research and questions for the study . Construction of empirics and the process of analysis are both extremely time consuming; in this study, participant observations and interviews were carried out prior to the actual processing of categories central to analysis.
The triangulation method of data generation in the form of participant observations, participant reports and interviews provided an opportunity to study the field of the selected phenomenon from several angles. There was constant commute between observations, interviews and participant reports; this resulted in new questions and new areas of observation. The recurring question is whether the number of interviews and days spent in the field were sufficient or whether more could have brought additional nuances to the surface . The duration of participant observations and the number of interviews were not decided in advance, but continued until data saturation, that is, to reach a point when what was heard, seen and experienced seemed to repeat itself in recognizable patterns .
Endoscopy clinics are productive units in the hospital setting . The clinics all had pre-made day schedules indicating the patient’s name, civil registration number, time of arrival, type of examination etc. Patients were booked in 30-45 minute intervals. Hospitalized patients often had no pre scheduled appointment but were called in when a gap in the schedule appeared. In addition, patients could be in need of an acute examination, such appointments were made by delaying pre scheduled patients.
The doctor performing the examination in cooperation with a nurse was in control of the time-schedule for each examination room. The nurse and doctor decided when patients were brought in from wards and the nurse brought in patients from the waiting area to the examination room. However, various factors affected the management of time: The doctor was otherwise engaged, the nurse was needed in another examination room, prolonged examination due to difficulties connected to gastroscopy or patients being late for their appointment.
In the endoscopy setting the issue time was verbalised by and shown through signals by patients, nurses and doctors. Nurses suggested alternative solutions when doctors encountered difficulties while examining patients, asked transportation to wait for patients, rushed the doctors, repeatedly looked at the clock and time schedule, sighing, apologised for delays, rushed through cleaning to get ready for the next patient and skipped breaks and lunch. Patients excused being late, excused being so difficult after complicated examinations, and some reacted with anger when delays occurred. Finally, doctors rushed the nurses, brought in patients themselves, and excused being inexperienced and therefore taking longer to perform gastroscopy.
The sub-categories “Responsibility of time”, “Informat-ion and preparation”, and “Time wasters” appeared when identifying and testing patterns in the empirics and through further processing the main category: ‘Time - making the best of it’ emerged as illustrated in Table 11.
The interaction between nurses and doctors considerably influenced the organisation of time. Their professional attitude towards each other contributed to the quality and flow of the teamwork and their cooperation.
“I actually prefer the doctor to mind his own business and not interfere before it’s his turn - before I have finished what I have to do - depending on the doctor the information can be delivered in cooperation - like a ping - pong game.” (Nurse 1)
Teamwork marked with the respect for the different professions positively affected the patients’ perception of their pathway.
“I’ve tried the examination before and it’s different each time. You clearly get the feeling of security when they work together. Today was such a day. (Report 6)
The terms for teamwork between nurses and doctors were agreed on at the beginning of the day or as the day developed. When no agreements were made nurses and doctors were observed working in disciplinary parallels. The provided care could be impeccable, but without interdisciplinary teamwork the patients’ perceived that something was missing.
The power to organise and control time was observed to be closely connected to how experienced the healthcare professional was and their beliefs in own worth. And power over time was either taken or given.
“It depends on the doctor and how much time they give you” (Nurse 2)
However, the profession played an important role. The hierarchical structure in the hospital was prevailing and often doctors acted superior to nurses.
When entering the examination room with the patient, the nurse sees the doctor sitting in the chair she normally uses. She places herself a bit to the left and asks the patient if he has had a gastroscopy before. The patient answers: Yes, it's probably a re ... The physician interrupts and asks ... The nurse takes a step back (Report 9)
Nurses clearly felt responsible for time. They constantly balanced delays in the pre-made schedule and demands from doctors and colleagues with expectations from patients and families. At the same time nurses struggled to fulfil their own requirements for nursing and what they felt they should be able to manage in the time available. Sometimes this left nurses with feelings of being unable to offer the nursing they actually wished to deliver stressed by the fact that the next patient was waiting.
However, the responsibility of planning the day in their appointed examination room was not only experienced as negative. Most nurses seemed to thrive with the bustle and perceived it as a challenge. Nurses took pride in completing a difficult examination to the satisfaction of the patient and within the planned time, when managing to keep the patient flow even when having to take in acute patients and when receiving appraisals from patients for their care.
“I’m not generally faced with a bad taste in the mouth because I haven’t got enough time, I’m really not- it’s a balance but mostly we succeed” (Nurse 3)
Patients also felt responsible for time. Sitting in the waiting room patients often sensed the bustle of the endoscopy clinic even before entering the examination room. The result was a feeling of having to rush through their examination and as a consequence they were left with unanswered questions and unmet needs.
“You know they are busy and it’s important not to waste their time. They know what’s important - often I get annoyed at myself because I didn’t ask about that …that’s a problem” (Patient 3)
However, patients also appreciated the nurses’ ability to focus on the examination they were facing and highly valued the time allocated to information, advice and support in order to help them manage this.
Awareness among nurses that informing and preparing patients for gastroscopy requires a certain length of time was constantly present. This meant that well prepared patients would most likely have an easier and less time demanding pathway in the clinic than a less prepared patient. Different strategies were used to create and find time for information and preparation.
Some strategies were connected to relieving patient anxiety as anxiety was seen as a feeling that militated against the patient being able to listen and receive necessary information and advice.
“… because those who have been awake all night and are all tied up in knots they often take longer and it’s very hard on them. If you can relieve them of some of the anxiety before you get started, then you win time.” (Nurse 1)
Other strategies of relieving patient anxiety were connected to building a nurse patient relationship based on trust and safety, and a relationship that gave the patient a feeling of being taken care of.
“On the 15-meter walk from the waiting area to the examination room I start talking to the patient, not about private stuff, but to create a little trust, my time is so limited, but it helps to make them feel welcome.” (Nurse 2)
Prolonged waiting time and not knowing the reason why sometimes resulted in patients expressing their feelings through irritability and anger. Strategies to address this were initiated, based on basic knowledge of common human reactions to waiting.
“I try to go to the waiting area and inform patients about expected waiting time when we’re far behind, so they don’t get upset and angry. Often they understand and accept. (Nurse 3)
The benefit of for example a quick visit to the waiting room was that when patients entered the examination room they were informed about the reason for waiting and the available time could be spent on information and preparation.
Patients expressed understanding for the bustle and tried with great tenacity to adjust and fit in. They felt responsible for being prepared and for passing on necessary information to health care professionals to be helped through the examination in the best and safest way possible. However, patients did not always know which information health care professional considered important.
“If you’re prepared and know what’s important for them to know and what’s not, you may create time. (Patient 5)
Patients’ experience of health care professionals’ ability to be present, alert and ready for the needed interpersonal relation was not entirely positive. The serious consequence was that patients restrained themselves and withheld important information.
I always see how things are before I start telling about myself. I quickly detect if they are ready to listen or not. (Patient 4)
Instrumental aspects of nursing and requirements for documentation were defined as definite time wasters and left nurses with feelings of not being able to do the best for the patient.
“Preparation for the examination take up too much time compared to what you can offer the patient” (Nurse 3)
At the same time nurses seemed to be aware not to be overpowered by these time wasters. This became evident through their intentional and instinctive use of communication, eye contact, skills at listening and through the use of physical contact while performing instrumental tasks like for example establishing intravenous access.
“Every patient must feel that they are in good and caring hands but also in skilled hands of cause - this doesn’t necessarily take long.” (Nurse 1)
Patients also experienced how nursing documentation and instrumental tasks could occupy and demand the nurses’ attention. The consequence was that patients experienced that staff were not present.
A patient was brought in to the examination room by the doctor. The nurse was busy preparing medication and documentation and did not immediately welcome the patient. After a few minutes the patient asked:
“Am I in the right place?”(Report 43)
Delays and interruptions from colleagues and telephones during the interaction with the patient were experienced to steal time away from the patient. Not all interruptions can of cause be avoided; however the feeling of being interrupted was familiar among the nurses.
“Often we have delays and I’m interrupted all the time and they ask; are you ready? Because the patients ask when it’s their turn - well I know I’m behind but equipment and documentation must be in order and the intravenous access does not place itself. (Nurse 2)
Time was found to be an interwoven part of life in the productive endoscopy units. Every patient and nurse encounter was short in terms of duration as there were only 5-10 minutes from the initial contact until gastroscopy started. In the endoscopy setting the physical time frame for nursing was clearly set by the health care organisation through the pre-made day schedules. Patients were booked in 30-45-minute intervals; this was the external frame for nursing and the way nurses controlled time. The hospital policy of a 30-minute maximum wait was another factor contributing to structure time in the endoscopy setting . This policy challenged nurses’ ethical awareness of how to treat patients and deliver good quality nursing. The nurses’ possibility to actually win time during the day was by pacing and compromising on their own breaks. However, there was not always a gap in the schedule, possibility for pacing or a break to skip when delays occurred and patients were waiting. The result was a constant challenge to make time within the externally fixed timeframe.
The nurses obviously felt responsible for managing time in the endoscopy setting. Rosa  describes how social acceleration has an affect on all domains of life and thereby transforms our understanding of time and space. As a result each individual healthcare professional experiences a constant pressure to live up to the requirements found and not fall behind.
Adapting to the productivity and bustle in the setting was challenging but not entirely negative. A professional pride was detected when patients were examined within the given time frame and to the satisfaction of patients and nurses themselves. Even pathways that were not entirely successful seemed to be used as learning examples looking forward to improve the next patient pathway. This may be interpreted as another way of thinking and understanding the aspect of time. Constantly seeking what is actually possible to manage in the time given instead of focusing on duration. Former research has shown that “not having enough time” is the main reason for failing to maintain care quality . That time pressure reduces nurses’ ability to detect patient needs in acute care , an association between having more time and being able to deliver better quality nursing care  and that lack of time gets in the way of getting to know patients and relatives and thus the ability to individualise care . Similar characteristics for these studies show that having “enough time” makes everything possible and a lack of discussions of what “enough time” actually is.
In the current study, nurses and doctors worked closely together during patient pathways. It was evident that successful pathways highly depended on this teamwork. When nurses and doctors worked interdisciplinary respecting each other’s professionalism and understood the valuable contribution they each brought to the situation it improved quality and fluency of the teamwork, which positively affected the patients’ experience and limited the time spent. When no distinctions were made between work of the doctor and nurse respectively, the interdisciplinary cooperation worked optimally. As described by Lauvås and Lauvås  and Zeitler  there was a constant commute of sharing knowledge, learning and building consensus. Doctors and nurses contributed with their own mono professional approach. They worked together to help patients through gastroscopy and shared the goal of reassuring a successful patient pathway. However, doctors and nurses sometimes worked in parallels concerning the different patient related tasks. In these situations it developed into a fight between the professions for time, space and the patient’s attention and hence for a positive pathway experience. Multi disciplinary organisation of the work is predominant seen in a hierarchical hospital setting where the doctor prescribes, and other professionals like nurses perform the doctor’s prescription. This fosters a discussion on the importance of teamwork and a search for ways to push forward and prioritise interdisciplinary above multi disciplinarily collaboration. Interdisciplinary teamwork is considered a key element for improving patient outcomes [32, 33], hence few studies involve aspects of training health care professionals to work as a team in the outpatient care setting . However, in recent years various types of interdisciplinary cooperation concerning patient care between students in nursing, physiotherapy and occupational therapy has appeared in University Colleges in Denmark and in the Nordic countries . This demonstrates awareness of the importance of interdisciplinary collaboration and that it may be something that can be learned.
In the endoscopy setting, information to patients before gastroscopy was highly prioritised as well prepared patients clearly had a less time demanding pathway in the endoscopy clinic. This corroborates research findings showing how preoperative information means considerable time and cost benefits to health care. It has been shown to increase postoperative recovery, reduce complications, reduce patient anxiety, assist patients to anticipate future events, prepare and improve patients’ informed decisions making and increase patient satisfaction . When patients in this study felt how nurses’ constantly tried to make time for the essential information they experienced nursing as reliable, assure, tangible, empathic and responsive . The small talk on the way to the examination room, the building of a relationship, the appreciation that waiting is nerve wrecking and the nurses ability to be ready and present are all examples of how good nursing was exercised in a very short time span in the endoscopy setting. As described by Hill , when the nurse offers “snap-shot” information on waiting, the patient is really being told, “we care”; this reduces patient anxiety and stress and supports the patient to feel more valued and in control.
In the endoscopy setting time wasters were perceived to be instrumental aspects of nursing, documentation and interruptions. However, the nurses seemed to be aware that they worked in a productive setting with constraints on time. The awareness manifested itself through the use of physical touch, the attentive observant eye and the ability to pay attention both to verbal and the non-verbal communication. The use of communication and sensing was intentional but also highly based on instinct. Either way a successful use could change a patient’s bad experience of for example an instrumental task to the better. Hence it may not be a matter on how much time the nurse spends on the instrumental task or documentation, but much more on how the task is performed and perceived by the patient. This finding is supported by the research of Bjørk and Kirkevold  on practical skill performance; they claim that skill performance is characterised by complexity at many levels. They pose that every practical skill must embrace aspects of substance and sequence, accuracy, fluency, integration and a caring conduct to be perceived as well performed by the patient. Research findings confirm that carers who listen, have a loving touch and warm voices come across as present carers . Patients wish to receive nursing from nurses who are present, aware and ready to take care of them whenever necessary [1, 8, 14]. This underscores how former research perceives the concept of time in health care in terms of the nurses needing more time to be able to be present, aware and alert. The present study contributes by underlining the importance of discussing not how to get more time but instead how to spend the time in the best way possible.
As a researcher and former endoscopy nurse, the first author’s pre understanding may have limited what was regarded relevant and important . However, the researcher has continuously worked at bracketing own precon-ceptions by relating to and reflecting on own position in the field and the interpretations made (16:238). Discussions with supervisors and triangulation of data generation - participant observations, participant reports and interviews - challenged preconceptions and contributed to validating interpretations.
Pre existing knowledge of the endoscopy specialty was considered a strength as procedure related aspects did not cause distraction and it was possible to keep focus on aspects relevant to research such as the nurse patient interaction.
The ‘generalizability’ of the findings to other facilities for short-term stay may be debatable, as the nature of treatment and care in these settings are very different . In this study, ‘generalizability’ is understood as recognisability to other facilities for short term stay and findings must be accepted within the setting where they are to be used .
This study contributes to the understanding that "having enough time" for nursing does not exclusively relate to the duration of time; it is equally important to consider how available time is organised and used.
The study underlines the possibility of combining different perspectives on and expectations to how to spend nursing time in the endoscopy stetting. It is evident that the healthcare system controls the external time frame; but the internal control of time is equally important. This was demonstrated by showing how patients and nurses took responsibility for time. The doctors and nurses strive to work interdisciplinary; the nurses’ try to prioritise time for information and not allowing themselves to be overwhelmed by time wasters.
The healthcare organisation, the patients and the nurses perceived patient pathways as successful if nursing maximised patient outcome and supported the goals of the healthcare organisation, was reliable, assure, tangible, empathic and responsive, and was individual and tailored to the patient’s needs.
The present study contributes by underlining the importance of discussing not how to get more time in clinical practice but instead how to spend the time in the best way possible.
Moreover it highlights the importance of doctors and nurses working interdisciplinary as improved quality of care, positive patients’ experiences and limited time spent builds on mutual respecting and understanding.
The authors confirm that this article content has no conflict of interest.