The purpose of this observational study was to examine how nurses working at inpatient psychiatric wards distribute their time across different activities during a working day. The 129 h of data registered showed that nurses at the clinic under study spent most of their time performing medication-related tasks. Talking about and planning the care of the patients was the second largest category and direct care came in as the third largest category.
A noteworthy result was that time spent on direct care (15.3%) was much lower in this study compared to other studies where figures ranging from 18 to 40.3% have been reported [20,21,22, 24, 31,32,33]. In a previous study, Furåker [25] showed that nurses at a psychiatric clinic in Sweden spent on average 3 h 15 min per day performing different direct care tasks. The results in the present study show a considerably lower figure at an average of 1 h 13 min per working day. The average direct care task lasted only about eight minutes which casts into doubt whether it is possible to create trusting and therapeutic relationships with the patients in such a short time. Qualitative research shows that in general, patients desire more time spent together with nurses [34] and invested in relationship building [17]. Instead, at a time when person-centred care is emphasized, this study indicates that the care provided by psychiatric nurses is moving in the opposite direction.
The observed nurses spent slightly more time performing indirect care tasks than tasks where the patient was present. These indirect care activities often consisted of planning the care of the patient without the patient present. The direct care category however did not include many planning tasks. It is therefore possible to draw the conclusion that most of the planning of the patient’s care was carried out without the patient’s direct involvement. This is in violation of the ideal of person-centred care [13] and also contravenes with what patients consider to be of importance in good quality care [2, 5, 8]. A review of papers using person-centred care in relation to in-patient psychiatry showed the significance of patient involvement, a therapeutic milieu and relationships that are characterised by closeness, engagement and trust [14]. In order to promote a more person-centred approach to psychiatric caring, patients should be given the opportunity to be more involved in planning their care. However, this calls into question whether the work conditions of psychiatric nurses in Sweden really allows a development towards person-centred care or if in reality administrative tasks are given precedence.
Not unexpected, medication tasks constituted the largest of the observed categories and nurses spent on average 17.5% of their work day performing medication tasks. Interruptions during medication tasks are common [22, 35, 36] and this study was no exception. Interruptions during medication tasks is believed to be one of the main factors associated with medicine administration errors [37, 38] which should be a reason for management to reduce the occurrence of interruptions.
The result from this study show a tendency within the organization of focusing more on doing than being. An orientation towards doing is more focused on tasks and working hard towards a result than taking time to reflect and focus on the here and now [39]. This is evident in the relatively high percentages of time spent on ward-related activities in comparison with the very low percentage spent on training. Without the time to reflect and access and read research, professional development and implementation of new techniques and procedures will prove difficult The distribution of time spent on ward-related tasks, in this study reported at 11.3%, was higher than in previous studies with figures ranging from 4 to 8% [20,21,22, 31, 33]. There may be a reason for nurses to ask themselves the question “How do we use the time?”
The nurses included in this study had relatively short experience working at their respective wards, with 3 years being the longest any nurse had been working at the same ward. Benner’s historically important work on nurses’ levels of expertise [40] highlights the correlation between the nurse’s experience and her skill level as well as what method of work characterises these different levels. Comparing the experience and skill levels put forth in Benner’s work with the demographic information in this study, the average level of experience could be classified as “Advanced beginner” (0–2 years of experience working at the present ward). Advanced beginners lack confidence in prioritizing and seeing the “big picture” and tend to focus on tasks that are characterised by strict guidelines and clear routines. In this study, several of those tasks can be found in the “Medication” and “Ward-related” categories. Although being able to follow guidelines or protocols does not equate expertise, experience alone is not equal to expertise either. Christensen and Hewitt-Taylor [41] argue that expertise is an amalgamation of knowledge and skills, intuition and experience. There is also evidence that the context in which nurses act affect clinical nursing expertise [42]. The higher the proportion of nurses with academic training the better the odds of nurses reporting a more advanced level of expertise [42]. Against this background, the observed nurses’ level of expertise could provide a possible explanation for why these categories were more pronounced in this study compared to other studies. This also highlights the importance of the manner in which beginner nurses are introduced to their profession by more experienced nurses.
The imbalance between direct care and other tasks might be a reflection of various trends in mental health care, including for example denuding of staffing levels. Research shows that inadequate staffing levels are seen as antithetical to the therapeutic alliance and might lead to an over-reliance on pharmacology [44].
This study was designed as a time-motion study with structured observations. This method gives valuable insight into how nurses distribute their time. Studies comparing observations with self-reporting suggest that there are greater margins of error with self-reporting and that staff more readily accepted observations compared to self-reporting [31, 43]. An advantage in this study was that the observers themselves were registered nurses with psychiatric care experience and hence familiar with the tasks carried out, making it easier to quickly identify the observed tasks and thus increase reliability.
Observing a whole work shift has several advantages over work sampling. One advantage is that the risk of missing certain tasks that the nurse may be postponing to the end of the shift, such as documenting, is eliminated entirely. Other tasks are carried out at certain hours of the day and are also at risk of being excluded if work sampling is utilized. Another advantage of longer observations is that the participant may habituate to the presence of the observer which reduces the risk of a Hawthorne effect, that is, the risk that participants change their behaviour due to knowing that they are being studied. There is an increased risk of observer fatigue and several time-motion studies have limited the observations to 60 or 90 min at a time, but there is little evidence to support the notion that 90 min is an upper limit [19]. Nevertheless, this risk cannot be entirely disregarded.
There were several occasions where the nurse performed multiple tasks at once. In this case, the observers only registered the first task. A second simultaneous task was only registered if the first task was interrupted. This approach has been used in previous studies [24]. Using the application on a tablet computer was advantageous compared to a regular stop-watch and note-taking procedure. It is considerably faster as there is no need to note the observed time and there is also less risk of the observer mistyping. A disadvantage was in regard to phone calls. Since the observer could not know in advance whether the nurse talked to for example a patient, a relative or another caregiver, it was impossible to track this information with the application and a separate category for phone calls was implemented. With a traditional stop-watch this would not have been an issue. Despite this, the advantages of the application outweighed the possible advantages of using a stop-watch.
Limitations
The foremost limitation is that the observations took place at wards with different specialisations. Two of the wards focused on care for patients suffering from psychosis-related disorders, one ward focused on substance abuse disorders, one on eating disorders and two on general psychiatry. There were variations regarding how tasks were carried out at the different wards and how time spent on these tasks was distributed. Since the results of this study are presented as averages, it is possible to generalize the results to some extent, despite variation of care context.
Another limitation is the fact that two tasks carried out simultaneously could not be recorded. It is probable that for instance some medication tasks also presented opportunities for the nurses to interact with the patients and would have constituted as direct care tasks as well.
Although direct, continuous observations are a useful approach to gathering data, in this case the observation scenarios were complex and inter-observer reliability is a concern [27]. To help deal with this, pilot observations were conducted. In addition, the fact that the observers had relevant clinical backgrounds should help improve reliability [45].
There are also limitations to this study concerning participant reactivity. Direct observation may incur what is sometimes dubbed the Hawthorne effect, where participants change their behaviour due to knowing that they are being studied. To offset the occurrence of a Hawthorne effect, all participants were informed that the observations were not centred on their quality of work and that the study was not initiated by their employer. Although it is difficult to rule out the Hawthorne effect completely, recent studies seem to indicate that it may not be as prevalent as previously believed [31, 46].