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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
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Background
Organisational routines
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Professional issues
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
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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P Rytterstrom et al.
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:
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
The ritual
The meaningful
routine
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.
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.
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
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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.
More freedom. I feel comfortable just walking into the unit and its
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.
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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.
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.
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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
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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.
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.
Professional issues
Contributions
Conflict of interest
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