One main theme emerged from the content: ‘Stolen time’- delivering nursing at the bottom of a hierarchy, capturing three interrelated themes: ‘Under the dominance of stronger paradigms’, ‘The loss of professional identity’, and ‘The power of leadership’. The themes consisted of two to three subthemes (Table 1).
Table 1: Overview of the main theme, themes, and sub-themes
Main theme
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‘Stolen time’- delivering nursing at the bottom of a hierarchy
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Themes
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Under the dominance of stronger paradigms
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The loss of professional identity
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The power of leadership
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Sub-themes
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Detained by the Medical Model
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Filling the left-over time gaps
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The mediator of culture and hierarchy
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Time-thieves
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Knowledge without action
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Stealing back time
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The impact of a professional terminology
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All themes and subthemes present barriers and facilitators influencing RNs’ adherence to EBGs recommendations for NC at the individual, team, and organisational levels. These barriers, facilitators, and their interrelatedness are presented in Figure 1.
‘Stolen time’- delivering nursing at the bottom of a hierarchy.
The content of the main theme ‘Stolen time’–delivering nursing at the bottom of a hierarchy–expressed that RNs lacked time to perform evidence-based NC. They did indeed lack time; however, this was not because of the workload. The observations illuminated that time for NC was lacking because it was stolen. RNs’ time was stolen by other professions, management, colleagues, their organisation of work, and even by the RNs themselves, for example, when they lacked competences to work systematically with a focus on the patients’ fundamental needs. Furthermore, RNs lacked professional identity and terminology as well as power and leadership to inhibit other professions in stealing their time. Therefore, RNs helplessly ended up at the bottom of the hierarchy. Consequently, NC was carried out unplanned and unsystematically in the time gaps between the demands from other professions.
Under the dominance of stronger paradigms
This theme illuminates that the context, a working culture organised around the biomedical model and cooperation with other professions, strongly influenced RNs’ focus, their use of time and prioritisation of NC, placing NC interventions lowest in the hierarchy of tasks in these units, with the acceptance of RNs and nurse managers.
Detained by the Medical Model
The observations revealed that the RNs’ working processes, focus, and planning of their tasks were strongly influenced by the context in which the medical model ruled with its biomedical focus. NC was invisible in interdisciplinary meetings and communication, where the focus of attention was always on the other professions’ tasks and goals. For example, RNs attended compulsory interdisciplinary meetings with high relevance for physicians, mainly focusing on planning patient flow, medical aspects, or diagnostic procedures. At those meetings, every patient’s treatment plan was discussed and revised because of the patient’s health and recovery status. RNs prepared themselves daily for those meetings by extracting biomedical information from the patient records and served physicians and other professionals with information about drug therapy, blood exams, and patient flow instead of focusing on NC:
The RN presents the report focusing on whether samples have been taken or not, what the blood samples showed, and what medication patients get. There is only a focus on medical problems.
(Observation 6, line 115–119)
These meetings directed the RNs’ focus and planning of their day-shift program towards medical, administrative, and physical and biomedical aspects of care, rather than NC and the patient’s fundamental needs. This appeared to be one of the greatest barriers to performing NC in a systematic, person-centred (PCC), and knowledge-based way.
Moreover, RNs’ expressed that carrying out tasks in connection to the patient flow was extremely important, as non-adherence to physicians’ plans for the patient flow caused delayed discharge and increased expenses for the unit. Lack of time was considered the cause of any possible non-adherence. Non-adherence to physicians’ discharge plans upset and frustrated the RNs and physicians, and RNs felt guilty if patients were not discharged according to the plan.
The physician speaks very strictly, and there is no doubt that she is annoyed. You can see that, in her body language and hear it in her voice. In addition, the RN is snarled at and accused of not having contacted the municipality on behalf of one of the patients.
(Observation 6, line 104–114)
Furthermore, observations revealed that RNs used their time to plan the patient-rounds for the physicians, but seldom attended them, as they used the time to catch up with other tasks. In general, RNs expressed that they had to concentrate on administrative and biomedical tasks and check on the physicians’ tasks as they felt responsible for the patient’s condition and stability, and they were to blame if something was overseen or went wrong.
Time thieves
There was consensus among the RNs that they lacked time, and that this was due to a heavy workload. The disproportionate relationship between time and tasks was highlighted as the main barrier for delivering systematic and evidence-based NC. Indeed, the participating RNs were busy, and time seemed scarce; however, the observations revealed that time was there but was stolen by other professions in the form of interruptions and unannounced visits. RNs were available 24 h a day, and they could be interrupted anytime and anywhere. Additionally, their lunchbreaks often lasted five to ten minutes.
Even kitchen staff decided over RNs’ time. The delivery of meals from the hospital kitchen was organised according to the kitchen’s work schedules and had a very tight timeframe that allowed the RNs only a ½ hour to distribute the meals to their patients, before the carriages were taken back to the central kitchen. This left little or no time for patient participation or person-centred care, let alone nutritional information, or to encourage the patient to eat. This was accepted as normality and never questioned at any level in the team.
The lack of overall coordination of the many professional groups’ workflows and work procedures constituted a fundamental condition and a barrier for the delivery of nursing. Consequently, many tasks were organised at the same time. The above-mentioned work schedule of the hospital kitchen is one example, which provided four to six RNs half an hour to serve the meal, administer medicine, and mobilise 15–25 patients to the dining area, while being interrupted by colleagues, patients, nurse managers, or other professionals:
While the RN is distributing the meal: The physician contacts her and asks if a blood test for blood culture has been taken ... The RN begins straight away to investigate this… The RN sets out to find the physician to pass on the message ... While the RN is back to serve the meal to her patients, the physician contacts her again and asks her to order new blood tests (a task that physicians normally would do).
(Observation 1, line 430; 440; 447–448).
The hospital electronic patient record (EPR) was a time-thief in itself, although this seemed to be a consequence of lacking competences at the user level. The RNs felt that they had received insufficient training to use the EPR, and therefore spent a large amount of time reading and extracting information and used the EPR differently. This resulted in insufficient knowledge bases for treatment and care plans as well as duplicated working processes. Home-made pocket sheets were filled in by hand by each RN at the start of every shift, although the same information could be extracted from the EPR. RNs acknowledged that it was a duplicate work but had no other solutions to a more efficient working process.
The loss of professional identity
This theme illuminates that the context and other professionals influenced RNs’ focus and their use of time. In addition, the lack of professional identity and professionalism was a barrier at the individual level influencing RNs’ performance in NC.
Filling the left-over time gaps
Working under time pressure and not being in charge of their own time left RNs to deliver NC in the time gaps that were left over from the demands of other professions. The time gaps were small amounts of time delineated by the prior and next tasks (coordinating or biomedical) or interruptions. When and where these time gaps would occur was uncertain; hence, RNs prioritised at the spur of the moment and NC was delivered unsystematically and haphazardly. NC and time-consuming tasks were also underprioritized or left undone, although RNs were painfully aware of not being able to perform optimal evidence-based NC and the consequences of missing care for patients. However, they seemed powerless and lacked solutions to this problem.
... I don’t have time for it all. I must learn that there isn’t time for me to do everything. I try to choose what I can (prioritize). The problem is that even though I haven't eaten breakfast and stuff like that (she means, skipping her brake times), there’s still not enough time. I want to do it all, but ... what can I do? I can't (she sighs resignedly).
(Interview 11, line 893–902).
In most cases, tasks left undone were handed over to colleagues during shift changes hoping that they had time. In several observations, these tasks were still incomplete the following day.
Furthermore, colleagues or other professionals requested NC interventions from the RNs e.g. given patient fluids, nutrition or respiratory therapy. This indicated unsystematic organisation of care, possibly due to a lack of professional identity or role clarification. In several cases, nurse managers or physicians asked RNs about the fundamental NC interventions during the interdisciplinary meetings or during the patient rounds; they did not have a clear answer. However, RNs were well-informed and well-prepared for questions regarding patient hemodynamics or medication plans. The confusion around role clarification was visible during the actions and communication between RNs and physicians. RNs can guide physicians about tasks that are specific to their profession (e.g. ordination of medication, blood tests, or discharging patients in the IT system), and physicians guided or informed RNs how to conduct fundamental NC tasks (mobilisation, seating, respiratory treatment). In addition, LPNs asked RNs to conduct tasks that were specific to their profession, while helping RNs administer medication.
Knowledge without action
In general, RNs are knowledgeable about nursing interventions such as oral care, respiratory therapy, sputum mobilisation, nutrition, and fluid therapy and mobilisation, which are recommended in EBGs for patients with CAP. However, observations illuminated that RNs often did not apply their knowledge in clinical practice. For example, patients did not receive oral care based on several observations. In the interviews about missing care, several RNs admitted that they were aware of the importance of oral care, but they often forgot about oral care when organising their tasks, or they prioritised other tasks instead:
I think we all underprioritize oral care. I think that's stupid because ... I know how important it is. But I almost never think about it. I just forget. Yes. I just forget it. (RN looks down at the floor and her hands settle into her lap. Her body language signals embarrassment).
(Interview 2, lines 717–744)
RNs delegated most of the fundamental NC to LPNs, while RNs took care of patient rounds, administrative tasks, medicine administration, admission or discharge of patients, and attended compulsory meetings. Only when there was time or when LPNs needed help did RNs take part in fundamental NC. RNs expected LPNs to have the relevant and necessary knowledge and competencies to carry out NC and for them to ask for help if needed. However, the observations revealed that this was not always the case, and a phenomenon ‘action without knowledge’ appeared. In several cases, RNs and LPNs performed interventions without knowledge of the interventions’ rationale, the recommended intensity, frequency, or effect of the interventions. For example, one of the RNs attended an acutely ill patient in need of oxygen therapy. Although she acted immediately by providing her patient oxygen, the level of oxygen was not sufficient according to the EBGs recommendation.
In another example, one LPN motivated and guided the patient to use positive expiratory pressure (PEP) therapy for sputum mobilisation. Communication between the patient and LPN revealed that the LPN was not aware of the correct technique or the intensity of PEP usage. The observation and interview revealed that LPNs did not receive supervision by RNs and had no patient care plan to guide them in providing correct PEP therapy, consequently putting the patient at risk of treatment failure.
When delegating fundamental NC interventions to LPNs, RNs also appear to be responsible. RNs expressed that they seldom had an overview of the care their patients did or did not receive. Observations revealed that no supervision of the LPNs took place and little feedback was delivered from the LPNs to the RNs regarding fundamental care. They sometimes communicated in passing, when meeting in the hallway, about how far they were with their tasks and arranged to help each other during available time gaps.
The impact of a professional terminology
The RNs’ documentation and their communication with colleagues and other professionals revealed a lack of professional and concise terminology. This constituted a potential hazard to patient safety as they had difficulty catching the attention of team members from other professions when arguing for the patient’s case. In several cases, during the observations, this led to a delay in acute treatment, thus depriving the patient of timely intervention. The teamwork and the working climate were influenced by this, and sometimes the RNs felt rejected and treated disrespectfully:
RN: It's been difficult. Today, it has been difficult. Ehhh ... I think...ehhh, ... that the doctors seem a little dismissive. In their communication. It is hard ... to get in touch with them (tears in her eyes). SE: You got rejected? RN: (laughs a little) ... you must have some really strong arguments and that's probably where we're missing ... that it is probably there I ... that it will slip if you do not have your arguments in place. Thenyou may not quite get your message through.
(Interview 1, lines 593–614).
Further, RNs expressed that the lack of professional terminology resulted in seldom reading notes written by RNs when extracting information from patient records or preparing for interdisciplinary meetings. Several RNs found nursing notes irrelevant or lacked sufficient information about the patient’s care and treatment. Nursing notes even had a nickname: ‘cosy notes’. Consequently, nursing documentation was not used for planning and organising NC:
SE: Do you read medical notes only? (I ask because I can see her skipping nursing notes). RN: No not only, but yes mostly…. SE: Do you use patient care plans? RN: Not very much.
(Observation 1, lines 95–98; Interview 4, lines 431–441)
Due to the lack of NC plans, RNs had to read physician notes to create an overview of the patient, patient status, and treatment plan. Prioritisation of physicians’ notes was also explained by the fact that they needed to be prepared for interdisciplinary meetings where they had to answer questions such as medical treatment, patient’s medical status, and so forth. This seemingly blocked the view for fundamental NC, as RNs’ focus turned to the physical and biomedical aspects of patient treatment. However, RNs who used professional terminology and who used evidence-based knowledge as arguments received the physicians’ attention and were treated respectfully.
Interdisciplinary whiteboard meeting: The RN presents her patients by name, diagnosis, age, and the NC plan. She knows her patients and answers all questions from the physician and the nurse manager. She is professionally well- articulated. I (SE) get the feeling that she is respected and approached in a completely different way than her colleagues.
(Observation 1, line 236–247)
The power of leadership
This theme illuminates that nurse managers appear to have the power to mediate the working culture in the units and to support or eliminate the confining structures of the organisational hierarchy.
The mediator of culture and hierarchy
In the units where the nurse manager was absent or focused on biomedical tasks rather than NC, nursing practice was task-oriented and focused on biomedical tasks. In these units, the hierarchy was most apparent, as in other professions’ schedules, organisation of work, and needs overruled RNs’ working process and obligation to deliver NC. Seemingly, NC was invisible and not integrated into the organisation of teamwork, as was also the case for the time needed to perform it. Moreover, none of the RNs or nurse managers openly delineated the boundaries for NC, thus claiming time and manpower for it.
Nurse managers can even contribute to the theft of time from NC. This was the case when the nurse managers had difficulties organising the RNs during the shift or were less resolute about their decisions. In those cases, RNs overruled the managers’ decisions of work organisation and spent time (in some cases, a whole shift) to reorganise the plans laid out by the manager. In one observation, RNs had difficulties in arriving at an agreement about how to organise the shift and tasks among each other, and this resulted in a conflict. These situations could also occur if the nurse manager was absent during the morning shift change, where the decisions about work organisation were usually led by nurse managers. Consequently, RNs fell behind their working schedules and lost time on NC.
While the RN from the night shift gives her report, the staff begins to discuss who has cared for which patients and which patients they should care for... The discussion continues, but no agreement was found... The RNs find their computer, but the discussion comes up again and one of the RNs notes the distribution on the whiteboard. There is no management present, her office is dark, and the door is closed.
(Observation 1, lines 28–30, 32–33, 37–39).
Stealing back time
In contrast, one nurse manager had a consistent focus on NC, and the power to put NC on the agenda in interdisciplinary cooperation, thus making nursing visible. She demanded RNs to be in charge and actively participated in the patients’ care planning process, with a focus on NC. She attended all interdisciplinary meetings and continually demanded a status for NC plans for every patient in her unit. In this way, she indicated the importance of NC and positioned it as an equal part of the overall patient treatment and care plan.
The nurse manager evidently knows all the patients in the unit. Their status needs and their plan. She contributes with information when physicians ask questions the RNs cannot answer. At the same time, she asks RNs about the NC tasks that need to be done or tasks that have not been carried out. If RNs are in doubt, she makes suggestions on what to do or how to take action. She also asks the physicians about interventions such as nutrition, mobilisation, etc.
(Observation 5, lines 118–124).
In addition, RNs who focused on biomedical tasks were asked to turn their focus back to NC. This nurse manager had a strong ally in the clinical nurse specialist, who was a skilled facilitator for improving NC by stimulating RNs to think and work based on evidence. The nurse manager and the clinical nurse specialist had daily meetings with RNs and LPNs where the evidence for NC interventions, relevant for the unit specialty, was presented and reflected upon. RNs participated actively in those meetings, either by presenting evidence or by discussing the implementation of evidence in their own clinical practice. Hence, the professional management of nursing in this unit had the power to steal back time to NC by mediating RNs with their professional identity and possibly facilitating their ascent from the bottom of the hierarchy.