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P R O F E SS I O N A L I SS U E S

The significance of routines in nursing practice


Patrik Rytterstrom, Mitra Unosson and Maria Arman

Aim. The aim of this study was to illuminate the significance of routines in nursing practice.
Background. Clinical nursing is performed under the guidance of routines to varying degrees. In the nursing literature, routine is
described as having both negative and positive aspects, but use of the term is inconsistent, and empirical evidence is sparse. In
the research on organisational routines, a distinction is made between routine as a rule and routine as action.
Design. A qualitative design using a phenomenological-hermeneutic approach.
Method. Data collection from three focus groups focused on nurses experience of routines. Seventeen individual interviews
from a previous study focusing on caring culture were also analysed in a secondary qualitative analysis. All participants were
employed as qualified nursing pool nurses.
Result. Routines are experienced as pragmatic, obstructive and meaningful. The aim of the pragmatic routine was to ensure that
daily working life works; this routine is practised more on the basis of rational arguments and obvious intentions. The
obstructive routine had negative consequences for nursing practice and was described as nursing losing its humanity and
violating the patients integrity. The meaningful routine involved becoming one with the routine and for the nurses, it felt right
and meaningful to adapt to it.
Conclusions. Routines become meaningful when the individual action is in harmony with the cultural pattern on which the
nursing work is based. Instead of letting contemporary practice passively become routine, routines can be assessed and
developed using research and theoretical underpinnings as a starting point for nursing practice.
Relevance to clinical practice. Leaders have a special responsibility to develop and support meaningful routines. One approach
could be to let wards examine their routines from a patient perspective on the basis of the themes of pragmatic, meaningful and
obstructive routine.
Key words: culture, lifeworld, nursing practice, phenomenological-hermeneutic method, routine, ward
Accepted for publication: 17 January 2010

Introduction
The routine appears to be a central part of human life,
involving everything from a childs bedtime routines to
routines for preventing mistakes in health care. There is
ambivalence towards routines as a phenomenon; people seem
Authors: Patrik Rytterstrom, PhD Student, Department of Social and
Welfare Studies, Faculty of Health Sciences, Linkoping University;
Mitra Unosson, RN, PhD, Professor, Department of Social and
Welfare Studies, Faculty of Health Sciences, Linkoping University,
Norrkoping; Maria Arman, PhD, Associate Professor, Department of
Neurobiology, Care Sciences and Society, Division of Nursing,
Karolinska Institute, Stockholm, Sweden

to search for routines to offer predictability and comfort,


while at the same time, routines can be experienced as
monotonous, repetitive and even counterproductive. In a
health care organisation that is constantly transitioning
between change and stability, flexibility and adaptation,
the routine can function as a way of understanding the
Correspondence: Patrik Rytterstrom, PhD Student, ISV, Health
University, Linkoping University, Norrkoping, 601 74 Sweden.
Telephone: +46 11 363551.
E-mail: patrik.rytterstrom@isv.liu.se

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 35133522


doi: 10.1111/j.1365-2702.2010.03522.x

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prerequisites of care and how care is created. For nurses,


routine work is what they perform in their everyday
activities, but the significance of this as experienced by
nurses is by no means clear. Therefore, this study attempts to
illuminate the importance of routines, as an expression of the
care culture, to nursing practice. Our basic interest is in
grasping the essential parts of a care culture that supports
caring in nursing.

also see ritual as the opposite of professional activity. This


mechanical view of ritual misses its symbolic meaning and
ignores the meaning and purpose of nursing actions (Philpin
2002). Instead, ritual may be used as a kind of protection
from anxiety (Menzies 1977) and to maintain social order
and meaning (Chapman 1983). In the defence of nursing
rituals, Biley (1997) argues for an exploration of their
meaning and latent function.

Background

Organisational routines

To varying degrees, clinical nursing is performed under the


guidance of something we know as routines (Wikstrom &
Satterlund Larsson 2003, Willard & Luker 2006, Jones 2007).
Routine practice has a dual nature of comfort and constraint
(Highmore 2004), and this ambiguous meaning of the term is
also found in the nursing literature. Sometimes, routines are
partly described as something desirable and worth striving for.
Routine may, for example, improve well-being in older adults
(Ludwig 1998) or give higher functional status in patients with
Alzheimers disease (Baum 1995), and health routines may
also explain and predict family health behaviours (Denham
2003). On the other hand, routines are also described as
obstacles to good care (Willard & Luker 2006), possibly
impeding recovery (Procter 1989) and causing nurses to lose
the flexibility that is necessary in responding to patients
(Bowers et al. 2001), and have been shown to structure nurses
work instead of patient-centred care (Pearcey 2007).
Thus, routines occur frequently in the nursing literature,
but the term is used inconsistently, and empirical evidence is
scarce (Zisberg et al. 2007). In most cases where routines are
emphasised, the topic is not intentional but more like an
emergent concept. Based on a concept analysis, Zisberg et al.
(2007) suggest a working definition: Routine is a concept
pertaining to strategically designed behavioural patterns
(conscious and subconscious) used to organise and coordinate activities along the axes of time, duration, social and
physical contexts, sequence and order (p. 446).
The concept of routine is also frequently used interchangeably with that of ritual. According to Fiese et al. (2002) and
Fiese (2007), routines are instrumental: the commitment is
more perfunctory, momentary and repeated over time. Rituals
have a more symbolic meaning: the commitment is permanent
and affective. The meaning of a ritual is interpreted by insiders.
These insiders are described (Humphrey & Laidlaw 1994) as
actors that take on a ritual commitment, a special attitude
towards their own actions. Rituals create nothing in themselves, but instead create meanings (Rappaport 1999).
According to Walsh and Ford (2001), care can be harmful
when it is carried out in an unthinking, ritualistic way. They

A more theoretical description of the concept of routines is


evident in research on organisational routines and efficiency.
Routines account for much of what happens in an organisation (Becker & Zirpoli 2008) and can have different effects
on it. Routines enable coordination in the organisation,
facilitate simultaneity and give regularity to and instructions
for the form of programmes. Another effect is that routine
tasks can be performed subconsciously, thus using fewer
cognitive resources. Routines can also provide some degree of
stability of behaviour and solidify knowledge (Becker 2004).
Routines are described as having two related parts: the
ostensive and the performative aspects (Feldman & Pentland
2003, Pentland & Feldman 2005). The routine viewed as a
rule is the ostensive aspect and describes the routine in
principle, the ideal routine. It is routine as a generalised
pattern that guides individual performance. The routine as a
behaviour pattern is the performative aspect, the routine in
action. The routine is translated to specific people, places and
times.
Organisational routines are often described as stable and
inert, but Feldman (2000) demonstrates that routines have
the potential for continuous change. Participants in routines
can change them when the expected outcome does not occur
or when the outcome opens up new possibilities. This
illuminates the variation and openness that characterise
routine behaviour.

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Routine as an expression of culture


One way to conceptualise the routine as a phenomenon is to
view it as a cultural activity (Gallimore & Lopez 2002)
influenced by cultural norms and values (Essen 2008). The
world we live in, our lifeworld, is a world we take for
granted. This means that the lifeworld is not just natural, but
also cultural (Stroker 1997). Alfred Schultz and Brodersen
(1964) describe how the lifeworld of the individual contains
traces of a collective, shared experience. This lifeworld is
composed of a ready-made, standardised scheme of cultural
patterns. These culture patterns rely on unquestioned recipes

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Professional issues

that have to be followed, although they are not always


understood. To understand the world, the cultural group uses
types or mental constructs to predict the lifeworld and to
give the natural world meaning. This unreflective attitude
entails that actions in the lifeworld become routinised.
Routines have been identified as an important part of the
care culture (Rytterstrom et al. 2009). The nursing practice is
guided by the care culture, interpreted and given meaning by
the personnel as well as the organisation. In the care culture,
caring becomes comprehensible and meaningful.
This study is part of a larger study (Rytterstrom et al.
2009) focusing on care culture, where nurses working in a
qualified nursing pool were interviewed about their experience of different care environments. Routines were identified as an important part of the care culture and as something
the nursing pool nurses adapted to at the different wards. The
participants gave various descriptions of routines as lived
experience, and their descriptions gave rise to many questions
about routine as a phenomenon that were not fully explored.
With this as our starting point, we decided to supplement the
data using focus group interviews.

Study aim
The aim was to illuminate the significance of routines in
nursing practice.

Method
This study is based on empirical research conducted from a
lifeworld perspective. According to Dahlberg et al. (2008),
individuals can never fully be understood if they are not
looked at as living wholes. The picture of the individual must
take into account his/her own experience and understanding
of the self and the meaning of the lived experience.
A phenomenological-hermeneutic approach, inspired by
the philosophy of Ricoeur (1976), was chosen for this study.
The purpose of using this method is to explain and understand the meanings of a given phenomenon (Ericson-Lidman
et al. 2007), in this case, routines as described by practising
nursing staff. The interpretation of the text constitutes a
movement from understanding to explanation and from
explanation to comprehension. This is a dynamic movement
between the whole and the parts of the text, and thus between
understanding and explanation.

Context
The study took place between November 2007February
2008 at three hospitals in Sweden. All the hospitals have

The significance of routines in nursing practice

something they call qualified nursing pools: Nurses working


as part of a pool have permanent jobs, but are not
permanently employed at a single ward. This means that an
individual can serve 417 wards, depending on the person
and the hospital. Working as a qualified pool nurse requires
extensive competence and experience in different medical
disciplines. The reason for choosing qualified pool nurses as
participants in this study was that they are able to participate
in everyday life on the wards, but still have an outsider
perspective.

Data collection
Seventeen pool nurses between 2664 years of age had
previously been interviewed individually, as described earlier
(Rytterstrom et al. 2009). The interview evolved around the
following opening question: There are people who talk about
the care culture. What do you think about when you hear the
term care culture? The interview then focused on each nurses
experience of the care culture. To deepen the routine dimension
in this study, three focus groups were conducted, one for each
hospital. A total of 30 nurses were eligible, 24 of whom
volunteered to participate. Eleven of them were registered
nurses, and 13 were assistant nurses (here called nurses).
Fifteen of the 24 participants had participated in both the
previous individual interviews and the focus group interview,
and nine had taken part only in the focus group. The
participants were all women between 2664 years of age and
were employed as a qualified nursing pool nurses.
A focus group session with seven to nine participants
lasted between one hour and two hours and evolved around
the following opening question: It seems that an important
part of your work is to adapt to different routines at the
different wards you work on. Have I understood this
correctly and could you give me an example of how you
experience routines? All interviews were conducted by the
first author (RP), who functioned as a moderator for the
focus group interviews, which had a less structured approach
(Morgan 1996). The moderators role was more to help the
group stay on topic and to support the group effect. All
interviews were digitally recorded and later transcribed
verbatim.

Data analysis
The data from the individual interviews were handled in line
with what Thorne (1998) describes as analytic expansion and
retrospective interpretation. Thus, two types qualitative data
were used in the present study to answer new questions about
routines and to develop themes that emerged but were not

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fully analysed in the first study. However, the data from the
focus groups and the individual interviews were analysed at
the same time.
Data analysis was conducted using the phenomenologicalhermeneutic method developed by Lindseth and Norberg
(2004) and practised by Talseth et al. (2003), Srlie et al.
(2006), Nygren et al. (2007) and Edvardsson and Nordvall
(2008). The dialectic movement started with a nave reading
of the text to grasp the text as a whole. From the nave
reading, questions emerged that guided the next phase:

structural analysis, trying to identify themes of meaning. The


entire interview text was divided into meaning units and
condensed into everyday language. This condensation was
compared and abstracted to create subthemes and themes
(Table 1). The themes were mirrored against the nave
understanding to validate it. The last phase involved a
comprehensive understanding, which was a critical in-depth
interpretation based on the nave understanding, the structural analyses, the researchers preunderstanding and a
lifeworld perspective.

Table 1 Example of structural analysis. Theme: The meaningful routine


Meaning unit

Condensation

Subthemes

Theme

Focus group 2
Nurse 4. Everyone opens a window
Nurse 2. I think most wards do that
Nurse 6. Especially on wards where they are used to seeing
patients pass away
Interviewee. Why do you open a window?
Nurse 6. I dont really know
Nurse 2. Maybe its to release the soul of the deceased
Nurse 1. I dont really believe in that, but it feels natural to
open a window. Its like closure that a patient has died and
we can start the things that must be done after a death
Interview 8: Ive never thought about it, but most people
open a window. They just do It just feels good to do it
and theres nothing strange about it
Focus group 1
Nurse 1. The best wards are the ones where you feel at
home. You can be yourself in a different way. You can
take off your professional persona and just be who you
are. Everything somehow just feels natural. I think you
care better when you can be yourself
Nurse 7. Just take a simple task like showering a patient.
There are tons of routines for it and its different from
ward to ward. For example, I like Ward 5. I am at ease
with the routines so I feel at home
Nurse 3. Thats how it is for me on Ward 4. Everything is
easier. More freedom. I feel comfortable just walking into
the unit and its easy to adapt to their routines. Somehow,
it just feels natural
Interview 13: Routines become self-explanatory. Almost as
if you have worked in the unit for an extended period
Interview 5: In most units, there is almost always one or
several people that make you at ease just by the way they
act. You can overlook the procedures and sometimes just
sit with a patient and just talk. Somehow, it feels OK to do
it. Theres room to do the things we really should do all
the time
Focus group 1
Nurse 2: Its important that there are people like that
Nurse 5: It feels as if you can do things that actually matter.
It becomes a routine
Nurse 2: But there have to be people who somehow show
that it is OK to do it

Most nurses open a window in


connection with a death. The
reasons vary and are
sometimes unclear, but it
feels right

The ritual

The meaningful
routine

The best wards are described


by the nurses as making them
feel at home and allowing
them to be themselves. The
routines are described as a
feeling of being one with the
routine

Being one with


the routine

Colleagues can create a good


environment with their
personalities and it is possible
to deviate from the routines

Deviating from
the routine

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Professional issues

Research ethics
Permission to conduct and record the focus groups was
obtained from the hospitals and each participant. Participants
were assured that all information would be treated in
confidence and according to the principles of research ethics.
All participants were aware of their right to withdraw from
the focus groups at any time. The focus group meeting began
with a verbal contract stating that what came up in the focus
group discussion was not to be spread outside the focus
group. According to Swedish law (SFS 2003:460), the
approval of an official research ethics committee is not
required for this kind of research.

The significance of routines in nursing practice

routine to be experienced as good or bad for the nursing


practice? The structural analysis resulted in three themes: the
pragmatic routine, the meaningful routine and the obstructive
routine.
Theme: the pragmatic routine
Knowing your work. Adapting to a wards invisible routines
makes it is easier to be accepted by staff on the ward.
Adaptation leads to fewer incidents of conflict and questioning. A feeling of knowing your work was based on adaptation
to the wards routines:
You do what they want on the ward. I cant do what I think is right
all the time. You have to adapt. If you do as they do, the notion is
that you know your work. Thats normally how youre evaluated.

Findings
Naive understanding
The experience of working at different wards entails adapting
to the wards different working practices. This mainly
involves adapting to what the nurses described as the wards
invisible rules and working practices. In describing the
routines, the participants differentiated between formal,
written rules and informal, invisible routines. It was of
primary importance that they try to adapt to the informal
routines. Working on the basis of unwritten rules was
expressed as fitting in on the ward and having a feeling of
knowing your work.
The unwritten rules often differ across wards. Many of the
routines were experienced as having nothing to do with direct
patient care. How the cream pitcher is placed on the coffee
table and which patient room is visited first for morning work
duties were two examples of routines that had no direct
connection to care provision, but that the nurses nevertheless
tried to adapt to.
Some routines were entirely inadequate and were sometimes offensive to the patients. Examples of negative routines
were when morning duties, such as washing and dressing
patients, resulted in poor treatment of patients or when the
care work took place without reflection. At the same time,
some routines were experienced as meaningful. The meaningful routines were harder to describe, but could be
characterised as routines that feel good to follow.

Adaptation can entail everything from knowing the morning


care routines to knowing how the coffee table should be laid.
Pragmatic routines are characterised as having no actual
significance for the direct patient care. They differ from ward
to ward, but the difference is not valued as good or bad.
Learning these routines is a way of showing ones adaptation
to everyday routines, and the routines serve as a guide for
how the nursing work on the wards should be performed.
Getting daily working life to work. Routines mean that
adaptation is closely tied to the daily duties. The routines
vary across the wards:
Sure, each ward is different, but many tasks are just things that have
to be done clean, food orders, etc. Its to make the daily tasks easier.
I mean, it doesnt matter to me if I order the food before breakfast, as
they do on Ward 3A, or after the breakfast, as they do on Ward 6.

Routines have a practical function in that they can facilitate


care work. They can concern how the ward handles cleaning,
laboratory routines or food orders. Routines can be elaborated differently across wards, and it is ones duty to learn the
different wards routines. The general aim is to make sure
that daily working life works.
Fair and equitable care. Regarding adaptation, a picture
emerged where routines serve as a guarantee for fair and
equitable care:
It is nice to have routines for certain tasks. In the long run, its fairer
for everyone. You dont have to make a decision about what room a

Structural analysis
Based on the nave reading, three questions emerged that
guided the structural analysis: How do the routines affect the
nursing practice? How is it possible to give individual care
and at the same time follow the routine? What causes a

patient should have or when to release a patient. Obviously, you can


make exceptions, but it is nice to have something to guide you in the
right direction.

Routines mean that care acts do not always need to be


explained and justified. Underlying the routines is the notion

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of what is right, and by following the routines, one promotes


the idea of equal care for all. Naturally, routines can be
adjusted to circumstances, but as a basic idea for acts of
caring, they serve as a guarantee for fair and equitable care.
Theme: the meaningful routine
The ritual. Some routines can be described as rituals. The
meaning is not obvious, but there is a sense that there is more
behind the behaviour than what is actually articulated. One
example of this is opening a window in the room when a patient
has passed away. It feels natural to participate in and adapt to
this ritual action, even if the meaning is somewhat unclear:
Interviewer: Why do you open a window?

and sometimes just sit with a patient and just talk. Somehow, it feels
OK to do it. Theres room to do the things we really should do all the
time.

Adapting to a colleagues working practices results in a new


routine. The routine becomes a deviation from the expected
practice and instead involves doing what is right at the
moment.
Theme: the obstructive routine
The unreflected action. Emerging from the interviews were
certain misgivings about uncritically adapting to the wards
working practices:
Sometimes it frightens you. An entire day goes by and you do a bunch

Nurse 6: I dont really know.

of work, when you suddenly realise, what have I really accom-

Nurse 2: Maybe its to release the soul of the deceased.

plished? When caring goes on routine without thinking, thats when

Nurse 1: I dont really believe in that, but it feels natural to open a


window. Its like closure that a patient has died and we can start the
things that must be done after a death.

Some wards have their own rituals to adapt to. It is difficult


to understand the aim of such rituals, but it feels right and
meaningful to adapt to them.
Being one with the routine. Some wards are considered
more preferable than others. These wards are described in
terms such as home and family. At these wards, the adaptation to routines feels entirely natural. These routines allow
you to be yourself, and there is no need to play a role:
Nurse 1: The best wards are the ones where you feel at home. You
can be yourself in a different way. You can take off your professional
persona and just be who you are. Everything somehow just feels
natural. I think you care better when you can be yourself.

you are in trouble.

It is possible to adopt the wards routines without reflecting


on the nursing work. The unreflected action is viewed as a
potential danger, because it shows that care provision has lost
its humanity.
Routine as a protection. One kind of adaptation to the
wards routines was described as protection from difficult
situations. Such routines can function as protection from
suffering that is difficult to deal with. At the same time, there
is an awareness that this protection can have negative
consequences for care provision:
Sometimes and its really horrible, but sometimes it feels great to be
busy. I dont have to take the time to stop and see what the patient
really wants. Strange, but true. Sometimes, it just becomes too much
to absorb. When you see an ill patient and not just ill because of
their illness it can be loneliness or just that theyre scared then, it

Nurse 3: Thats how it is for me on Ward 4. Everything is easier.

is easy to blame it on routines that must be done. And sure, they

More freedom. I feel comfortable just walking into the unit and its

have to be done, but the question is if they have to be done in that

easy to adapt to their routines. Somehow, it just feels natural.

instant.

Being yourself implies that the care was more genuine and
spontaneous. Adaptation to the routines happens automatically and feels natural. This could concern routines that allow
you to sit down with a patient, to deviate from daily duties
routines that create a sense of freedom in the care work.
There is a feeling of becoming one with the routine.

Routines that function as protection are often characterised


by an aspect of time. Not remaining at a patients side is
excused with lack of time, because routines must be followed.

Deviating from the routine. There are nurses on some wards


who, based on their experience and serenity, radiate a feeling
of security. These people provide good examples to adapt to:
In most units, there is almost always one or several people who put
you at ease just by the way they act. You can overlook the procedures

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When the routine is wrong. There are also routines that are
clearly wrong. Nurses may find themselves in a dilemma:
Should they adapt to the care routines or be true to
themselves? This doubtfulness was described as a matter of
conscience. It is primarily the routines that in one way or
another violate the patients integrity that are experienced as
wrong. Routines that were inadequate and totally lack
purpose are also difficult to adapt to.

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Professional issues

Comprehensive understanding
The three questions that emerged from the nave understanding and that guided the structural analyses were interpreted
based on the researchers preunderstandings and the lifeworld
perspective in the comprehensive understanding. The questions were developed into three assumptions that structured
the comprehensive understanding.
Adaptation to routines viewed as meaningful, obstructive and
pragmatic
Based on the structural analysis, it seems impossible to
unequivocally answer the question of how routines affect the
actual nursing practice for the patient. Common to the three
themes emerging from the structural analysis was the clear
importance of adapting to routines. This could be interpreted
as the adaptation to a standardised recipe and a typical way
of behaving on the ward, where routines play an important
part in the cultural pattern (Schultz & Brodersen 1964). On
the ward, there seemed to be an expectation that all caregivers had the same orientation scheme and that all would act
in a certain way based on the current cultural pattern.
A meaningful routine was experienced when nurses recognised a cultural pattern that was in harmony with their own
interpretation scheme. They described the meaningful routine
in family terms, such as we are like a family, which
emphasises the common cultural pattern. The meaningful
routine was easy and natural to adapt to and was experienced
as a feeling of comfort.
The theme the pragmatic routine did not contain the same
search for meaning. Pragmatic adaptation was evaluated
more on the basis of rationale argument and obvious
intentions. The pragmatic routine was rarely questioned,
but it was not in its nature to be questioned. Routines in the
form of laboratory tests, documentation and food ordering
must exist if nursing care is to be accomplished. The fact that
the routines took on different shapes on the different wards
made the nurses work difficult, but the routines as such were
never questioned.
In the the obstructive routine, there was an inner
conflict between individual values and the wards attitude
towards the routines. For the regular ward personnel, these
obstructive routines were often unconscious. The antagonism between the individual and the general creates a
conflict between doing the right thing and ignoring the
suffering patient, under the protection of the routine. The
ward personnels and the pool nurses cultural patterns
were not in harmony. This demonstrates the dilemma of
providing individual care and simultaneously following the
routines.

The significance of routines in nursing practice

Interplay between the individual and the general dimension


in routine practice
Routines seem to be comprehensive and something that
caregivers must adapt to, consciously or unconsciously. At
the same time, routine behaviour must be applied to the
individual situation of the patient. Here, the general
requirements of following the wards routines were set
against the individual action when the nurse encountered the
patient. This seems to involve interplay between the individual and the general dimension, which could in part be
interpreted to mean that routines are both action and representation (Becker 2005).
The individual dimension concerns routine as an individual
act. The routine is interpreted from individual to individual.
In the interview text, the nurses described this dimension as
I do it like this. The general dimension concerns routine as
a rule. It is the common culture and shapes how the
individual views and acts according to the routine. In the
interview text, this dimension is described as we do it like
this.
The meaningful routine could be understood as an interplay between the general and the individual, between I do it
like this and we do it like this. On the other hand, in the
obstructive routine, the interplay between I do it like this
and we do it like this has ceased.
The routine as common sense and as a mirror of the sensus
communis
A meaningful and good routine seems to originate from an
interplay between the individual and the general. This
interplay can be understood in the light of Gadamer (1997)
and his ideas about the communal sense the sensus
communis that is, the sense of what is true and the sense
that establishes community. In the present study, the sensus
communis is interpreted as how each ward develops a
common sense that they ascribe to themselves. The routines
could thus be viewed as a mirror of the sensus communis.
Thus, when the nurses evaluate a routine as good or bad,
they are also evaluating the underlying culture and their
own reasons for thinking the routine is good or bad. This
means that, to understand the nursing practice, it is not
enough to make people aware of routines and rituals.
According to Gadamer, our understanding is connected to a
history of effects. When nurses experience how the routines
differ across the wards, they are experiencing the different
traditions reflected in the routines. Thus, when the nurses
open a window after a patient has died, they adopt a special attitude, a ritual undertaking (Humphrey & Laidlaw
1994).

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Discussion
Method discussion
Focus groups are frequently used as a complement to
individual interviews (Morgan 1996). One limitation of
the present study is that the routines described were classified
as routines only on the basis of the nurses own definitions.
This means that there is variation in the descriptions of
routines and no single definition. Nurses commonly described
routines as recurrent actions (Becker & Zirpoli 2008) that are
followed by the majority of the staff. This means that there is
also some confusion about whether they are talking about
routines at a collective level or about habits, which occur at
the individual level (Dosi et al. 2000, Knudsen 2007). In
theory, the distinction between routine and habit is clear, but
in a practical setting, making this distinction is more
problematic.

Result discussion
It is important to study routines, as nursing practice is guided
largely by routines that are often not reflected on and
unquestioned. In the health-related literature, the concept of
routine is not sufficiently defined, but has the potential to
advance our understanding of many health-related phenomena and their relation to patients and nurses. One aspect of
routine is its relation to care culture, whereby culture could
define what an ideal routine is.
Viewing the routine in terms of the ostensive and
performative aspects is partly in line with the present
studys assumption that there is an interplay between the
general and the individual dimensions. A gap between these
dimensions means a risk that routines will be experienced
as obstructive to the care work. Organisational routines are
not developed from a caring perspective. Instead, they
often focus on tasks that have to be accomplished. In
nursing practice, care for patients is not a mere task. At its
core, nursing care comprises an invitation to a caring
communion in a spirit of love and charity (Eriksson 2001,
Lindstrom et al. 2006). Therefore, the interplay between
the individual and the general dimensions must be understood from a caring perspective. And even if there is an
interplay and the routine is experienced as meaningful, this
feeling of meaningfulness presupposes the sensus communis, the communal sense.
Perhaps the caring act is so taken for granted that no one
reflects on whether the communal sense actually leads to

3520

good patient care. In this view, it is possible to have noncaring routines that the ward staff feel are totally adequate.
Instead of letting contemporary practice passively become
routine, one way of judging and developing routines is to use
research and theoretical underpinnings as a starting point for
nursing practice. Theoretical nursing science is aiming at
providing the tools for creating visions and guidelines for
nursing/caring routines. Further research is needed to view
how nurses who work only on a particular ward experience
routines and should also include the patient perspective and
examine how patients experience obstructive and meaningful
routines.

Conclusions
Routines become meaningful only when there is interplay
between the general and the individual. The individual
represents the caregivers personal cultural patterns and,
in time, the caregivers individual patient care. The general
describes the routine and its expression of underlying
assumptions and values. The interplay between the general and the individual is therefore an interplay between
values. The routine guides the nursing practice, but the
nursing practice also guides the routine. Routines become
meaningful when the individual action is in harmony with the
cultural pattern on which the nursing practice is based.

Relevance to clinical practice


Wards could examine their routines on the basis of
the themes the pragmatic, the meaningful and the
obstructive routine and relate these themes to their routines
from a patient perspective. Possible questions for revealing
routines are as follows: Why do we have this routine?
What is its purpose? Can we do this another way?
Good nursing practice must be supported by meaningful
routines; therefore, leaders have a special responsibility to
develop and support meaningful routines.
It is important to pay attention to the gap between the
individual and the general dimensions of routines. Acting
according to routines that are not in accordance with ones
own values may lead to negative stress.

Acknowledgements
The authors wish to thank the Department of Social and
Welfare Studies, Faculty of Health Sciences, Linkoping
University and all the participants in the study.

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 35133522

Professional issues

The significance of routines in nursing practice

Contributions

Conflict of interest

Study design: PR, MA; data collection and analysis: PR, MA


and manuscript preparation: PR, MU, MA.

No stated of conflicts of interest.

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