hallin2007

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International Journal of Nursing Studies 44 (2007) 1221–1230
www.elsevier.com/locate/ijnurstu
Registered nurses’ experiences of daily work, a balance
between strain and stimulation: A qualitative study
Karin Hallina,, Ella Danielsonb
a
Department of Health Sciences, Mid Sweden University, Östersund, SE-831 25, Sweden
b
Institute of Nursing, The Sahlgrenska Academy at Göteborg University, Sweden
Received 12 December 2005; received in revised form 3 May 2006; accepted 21 May 2006
Abstract
Background: The challenges in the health care have given rise to a highly stressful work situation and a more
complicated role for registered nurses (RNs). Qualitative studies about daily work as a whole is limited. It is therefore
vital for future development of nursing knowledge and nursing education to recurrently investigate RNs’ experiences of
their ability to grasp and manage their daily work situation and to promote a high quality of care.
Aim: The aim of this study was to describe RNs’ experiences of their daily work.
Methods and participants: This follow up study was carried out involving 15 Swedish RNs 6 years after their
graduation. Interviews, conducted with conversational strategy, were chosen for the data collection and content
analysis was used to handle the interview texts.
Results: The analysis resulted in a main theme ‘to balance strain and stimulation’, two themes and seven sub-themes. The
first theme ‘a stressful work situation’ consisted of the sub-themes: ‘to meet all demands’, ‘to be insufficient’, ‘to be unsure of
oneself’, and ‘too little contact with patient’. The second theme ‘a stimulating work situation’ consisted of the sub-themes: ‘to
encounter patients and health care staff is enriching’, ‘to have the situation under control’, and ‘to have the skills necessary to
be independent’. A pattern emerged throughout the themes, which showed that due to the increasing number of patients RNs’
capacity for management, prioritising and planning out of team work, and performing exacting documentation diminished.
Conclusion: The RNs’ daily work has been illustrated as a scale of balance that oscillated between strain and
stimulation; an oscillation towards strain could lead to a vicious circle. The RNs need support from the start through
nursing education and continuously in profession. This is a crucial issue for nursing education and health care sector.
r 2006 Elsevier Ltd. All rights reserved.
Keywords: Content analysis; Daily work; Experience; Registered nurses; Stimulation; Strain
What is already known about the topic?
Over the last decades nursing education and health
care sector have gone through great challenges.
Increasing number of seriously ill patients per nurse
is associated with the risks of patients receiving a
poorer quality of care and the nurses feeling constant
dissatisfaction.
Qualitative studies concerning solely skilled RNs’
experiences of their daily work as a whole are limited.
What this paper adds
Corresponding author. Tel.: +46 63 165652;
fax: +46 63 165626.
E-mail addresses: [email protected] (K. Hallin),
[email protected] (E. Danielson).
RNs
0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2006.05.011
with six years experience oscillated between
strain and stimulation.
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K. Hallin, E. Danielson / International Journal of Nursing Studies 44 (2007) 1221–1230
The
unbalance diminished the RNs ability for
management, and performing exacting documentation.
The unbalance was like a vicious circle in which the
RNs attempted to acquire control and accomplish
quality of care but were unsuccessful in their methods
of working.
1. Introduction
This study has focus on RNs’ experiences of daily
work. Daily work means situations and activities that
RNs are involved in every day and in various care
contexts as a part of their normal work life in health
care.
The role of graduated nurses has become more
complicated due to the fact that the health care is
rapidly developing with high care technology, shortened
lengths of stay in hospitals, cost effectiveness and
downsizing of staff. These challenges have given rise to
a highly stressful work situation for nurses (Aiken et al.,
2001) and subsequently undesirable consequences for
people in need of care (Aiken et al., 2002a). Several
studies all over the world show how nurses experience
frustration in their work and how many of them leave
the health care (Aiken et al., 2002a; Buerhaus et al.,
2005; Sheward et al., 2005) or experience stress and
burnout (Severinsson, 2003; Billeter-Koponen and
Freden, 2005). Qualitative studies concerning solely
skilled RNs’ experiences of their daily work are however
limited.
Also nursing education has undergone several
changes; from being a process of primarily practical
and vocational training to having become an university
education (Kapborg and Fischbein, 1998; Wheeler et al.,
2000). It will be vital for the future development of
nursing and nurse competence to recurrently investigate
nurses’ experiences of daily work (SOSFS, 2005). Follow
up studies, in Sweden as well as in other countries, have
focused on graduated nurses’ experiences, primarily on
transition during their first years in the profession
(Kapborg and Fischbein, 1998; Maben and Clark, 1998;
Ramritu and Barnard, 2001) or heterogeneous nursegroups for delimited issues such as work satisfaction
(McNeese-Smith, 1999; Makinen et al., 2003; Sheward
et al., 2005), identity (Fagermoen, 1997; Fagerberg and
Kihlgren, 2001), autonomy (Atencio et al., 2003;
Rafferty et al., 2001; Mrayyan, 2004), quality of care
(Aiken et al., 2002a, b; Furåker et al., 2004), documentation (Bjorvell et al., 2003; Florin et al., 2005a, b) and
reflection (Gustafsson and Fagerberg, 2004) and clinical
supervision (Begat et al., 2005). Few studies in
Scandinavia have focused on RNs with bachelor degrees
and more than 2 years of professional experience
(Fagerberg, 2004; Hedberg and Larsson, 2004).
In 1993, a new programme for nursing education was
introduced in Sweden. This programme involves a 3year study plan, 120 points, and ought to be scientifically
based at a bachelor’s degree, in order to provide
opportunities for continued studies in specialist education, master’s and doctoral studies.
As in many other countries, Swedish RNs are required
to be autonomous and to have a high command of the
nursing profession. In accordance with scientific knowledge, current laws and ordinances they have to perform
and develop their profession. Demands are made on
RNs to obtain a holistic view and good quality of care
for each patient (SFS, 1982:763). With self-awareness,
empathy and an ethical approach the RNs have to meet
and teach patients, relatives and team workers (SOSFS,
2005). RNs’ work includes documentation of quality
assurance concerning the nursing process (SFS,
1985:562; SOSFS, 1993:20).
Acquiring professional nursing skills is a long process,
which is not completed at graduation. A lot of research
has focused on graduated nurses in specific areas and
work conditions, but research about daily work as whole
is limited. Therefore, it will be particularly interesting to
investigate how one of the first groups in the new 3 years
Swedish programme for RNs, experience their daily
work 6 years after graduation.
2. Aim
The aim of the study was to describe registered nurses’
experiences of their daily work.
3. Method
3.1. Study design
A descriptive qualitative research design was used to
describe experienced RNs with 6 years post-qualification
experiences of daily work. Sandelowski (2000) means
that qualitative descriptions are a suitable design of
research for description of a phenomenon or a situation;
these researchers also keep closer to the data than
researchers conducting other qualitative methods with
further interpretation. To be able to grasp the whole
context of a phenomenon it is essential to understand
how the various contexts are experienced by people in a
specific environment (Polit and Beck, 2004).
Conducting interviews was the method chosen for the
data collection and content analysis was used to analyse
the texts. The interviews were based on the idea of
providing a framework for the questions, in order to
enable participants to become actively involved as soon
as possible and express their experiences in their own
words (Patton, 2004). Content analysis does not require
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K. Hallin, E. Danielson / International Journal of Nursing Studies 44 (2007) 1221–1230
an underlying theory (Sandelowski, 2000). It is, however, possible to carry out a certain amount of
interpretation and theoretically discuss the results.
3.2. Participants
In 1996, 20 student nurses were randomized from two
classes, a total of 77 students, at two university colleges
in the central Sweden. These student nurses were one of
the first groups in Sweden studying the new 3-year
bachelor programme in nursing education. Twenty of
them participated in an earlier interview study before
graduation. Fifteen RNs from the same group, 13
women and two men, agreed in 2003 to participate in
this study. Five RNs were excluded because two refused
participation, one became registered later, another did
not work as a RN and one had died.
Six of the fifteen RNs had specialist education in areas
of medical/surgical care, anesthesia, operation, midwifery and primary health care. Twelve had post-qualification work experiences from Sweden and six had
experiences from other countries as Norway, Denmark
and England. Eight of the RNs had experiences from
more than two (3–6) workplaces. At the time of the
interviews 12 participants lived in different parts of
Sweden and three lived in Norway. Six worked in the
area of medical/surgical care, five in emergency care, two
in home or long-term care and two in private care. Their
age ranged from 26 to 55 years (median 32 years, mean
34 years).
3.3. Data collection
3.3.1. Interviews
The interviews were carried out using one broad open
question: ‘‘What are your experiences of the daily
work?’’ In order to conduct the interview more on a
conversational line several other follow up questions
were asked, such as ‘‘What do you mean?’’ or ‘‘Can you
develop on that, please?’’ Furthermore additional
questions, such as ‘‘Please tell me more about the
environment’’ or ‘‘How did you experience the demands?’’ were asked in order to explicate the answers.
Both the open question and the additional questions
were written down in an interview guide, and the
researcher remained free to establish a conversational
style.
3.3.2. Procedure
The first researcher tested the mode of interview
before data collection. After some technical adjustments
of the tape-recorder the researcher continued and
performed all data collection in a setting suitable for
the participants. Nine interviews took place face to face
at the participants’ workplace or in their home. In the
case of participants living more than 300 km from the
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researcher six interviews were conducted by telephone.
Each interview lasted 60–90 min and was conducted in a
conversational manner in a tranquil environment (Polit
and Beck, 2004). The tape-recorded interviews were
transcribed verbatim for analysis.
Interviews by telephone could be a possible weakness
of this study because postures, gestures and eye contact
were missing, so consequently some underlying meaning
may have been missed (Patton, 2004). Weighing against
this is the fact that the participants were not disturbed or
distracted by the tape-recorder and the researcher could
be a good listener without influencing postures (Polit
and Beck, 2004). Compared with in-person interviews,
telephone interviews is a reliable method of obtaining
detailed exposure information (Cook et al., 2003). Cook
et al. showed an excellent level of agreement when they
used the same questionnaire and memory aids in
comparing a telephone interview with an in-person
interview four weeks later.
3.3.3. Data analysis
Content analysis was principally made by the first
author. This type of analysis can focus on communication with relevance for research in several fields as
education and nursing. According to Baxter (1991),
Krippendorff (2004) and Patton (2004) content analysis
is appropriate to analyse texts from interviews. In this
study content analysis, describing experiences of work-aday life, contains interpretation of the underlying
meaning of the text that advocates searching inductively
for recurrent codes and themes (Baxter, 1991; Patton,
2004).
The interviews were read through several times in
order to get an overall pictures of the contexts and
subjects and the essential features that could be
comprehended (Sandelowski, 1995). The actual text
was condensed thereafter into meaning units. From
these units various codes were labelled and organised in
similar areas from which seven sub-themes emerged, as
well as two other themes. The two authors discussed in
an open and critical diallog all themes and all steps in
the analysis process until consensus was achieved
(Lincoln and Guba, 1985; Sandelowski, 2000). However,
the analysis was not completed because the content of
the two themes contained something more; that interlaced into a main theme.
3.3.4. Ethical considerations
The study is approved by the Ethic Committee at the
university. All information was given both in written
and verbally forms before the RNs gave their informed
consent. Confidentiality was guaranteed and secured by
coding all data. Names and codes were kept separated.
There was no relationship of dependency between the
interviewer and the participants.
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when newly qualified nurses had to take responsibility
meant for experienced RNs, for example:
4. Results
The results are presented with the main theme ‘to
balance strain and stimulation’ and the two themes; ‘a
stressful work situation’ and ‘a stimulating work
situation’. According to Fig. 1 the first theme shows
with the four sub-themes; to meet all demands; to be
insufficient; to be unsure of oneself; too little contact
with patients. The second theme shows with the three
sub-themes; to encounter patients and qualified health
care staff is enriching; to have the situation under
control; to have the skills to be independent.
4.1. To balance strain and stimulation
‘To balance strain and stimulation’ means that
descriptions of their experiences of their daily
oscillated between strain and stimulation. The
work was, however, described as containing
stressful than stimulating work situations.
RNs’
work
daily
more
4.1.1. A stressful work situation
4.1.1.1. To meet all demands. ‘To meet all demands’
means the RNs’ experience of the work day makes
demands on them personally, from patients and
colleagues to perform safe quality of care in prerequisites. The RNs described an ever increasing number of
patients; staff and skills were not always sufficient or
adequate to manage the care of the seriously ill, which
consequently led to feelings of frustration:
There are currently so many seriously ill patients on
hospital wards but you don’t have the resources to
increase the number of staff (No. 6).
Daily work, which entailed management of a substantial flow of patients, many of whom were transferred
between different units in the health care, was described
by the RNs as a process leading to arduous paper work
and time-costly reports. Situations could become chaotic
That you don’t correctly understand what kind of
work situation you adjudge RNs today inasmuch we
in fact have to strain from being enrolled nurse to
being doctor (No. 11).
The RNs had high demands on themselves, e.g. they
endeavored to complete as many medical and nursing
tasks as possible in the time allotted, allow time space
for acute situations and tried to avoid having to leave
uncompleted tasks for the relieving RN. They stated
that it was especially frustrating to be continually
interrupted, which forced them to deal with other
priorities. One RN who tried to take things easy was
unsuccessful in achieving this:
As well trying to be more efficient and work more
effectively I also tried to take thing a little easier. But
it didn’t work. If I try to take things easy and do just
one task at time, then tasks will just pile up during
the day. You are constantly aware of the fact that
something unplanned can happen at any time during
the day (No. 15).
Demands of adaptability, high working capacity, the
strength and patience to handle all sorts of RNs’
assignments, was repeatedly mentioned in the narratives.
Organisational changes, an accelerating work pace and
sometimes insufficient leadership influenced the daily
work situation. The RNs’ frustration and anger was
directed towards politicians and decision-makers.
The RNs experienced responsibility for documentation as being exacting and the more care the patients
needed the more the demands on documentation
increased. It appeared that documentation was made
when RNs had the amount of time available which was
often during brakes or after working shifts with what
they had in mind:
You must carry out so much documentation nowadays and even if I don’t really think this is wrong I do
TO BALANCE STRAIN AND STIMULATION
A stressful work situation
To meet all demands
To be insufficient
To be unsure of oneself
Too little contact with patients
A stimulating work
To encounter patients and qualified health care
staff is enriching
To have the situation under control
To have the skills to be independent
Fig. 1. RNs’ experience of daily work oscillated between strain and stimulation.
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K. Hallin, E. Danielson / International Journal of Nursing Studies 44 (2007) 1221–1230
think that it takes too much time from the patients
(No. 4).
The quality and content of the documentation
appeared to vary among the RNs so consequently and
seemingly unnecessarily shortcomings in this field
caused extra work.
4.1.1.2. To be insufficient. ‘To be insufficient’ means
feeling anxious about being inadequate; having missed
something at the end of the working day. There was a
feeling of coercion in fulfilling the tasks of both the RNs
and enrolled nurses (ENs). Some of the RNs received
scant understanding for their work situation from the
ENs:
I almost have to prioritise not carrying out the work
of a RN, in order to catch up on basic nursing care,
which is surely wrong (No.15).
Difficulties in delegating tasks to ENs were something
that currently appeared to cause prevailing conflicts, due
unwillingness to help or lack of knowledge since their
education no longer aims to assist RNs.
The RNs explained if they constantly had interruptions and met with delays, caused by and a heavy
workload, they took ‘‘shortcuts’’. This led to the nurses
did not pay active attention to what the patients were
trying to tell them or they avoided answering the
patients’ questions. Consequences of this could be
especially troublesome in situations in which RNs
lacked experience and did not have the time to acquire
the relevant knowledge:
Have no time to think things through clearly.
Problems can arise that you have no idea how to
resolve and you just do not have the time to look for
the relevant information or try to find out (No. 13).
Despite delays the RN managed to complete assignments by taking no pauses, having a cup of coffee
instead of eating lunch or staying on after the relieving
staff came on duty. Another solution was to start the
shift earlier in order to get the work done in time. The
charges carried out on spare time were mainly completing the documentation or the doctors0 prescriptions and
being prepared to help out in urgent situations. The RNs
described feelings of having time only for the most
important tasks.
4.1.1.3. To be unsure of oneself. ‘To be unsure of one
self’ means wanting to be able to influence development
work but the ability to achieve changes varied. The
descriptions show that earlier fruitless discussions, lack
of time and resistance from colleagues and managements
inhibited creativity and rendered the RNs passive, which
meant that they adopted a wait-and-see policy.
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Obligation to take part in research and development
work was revealed as a desire either to participate in it or
dissociate from it. None of the RNs was involved in any
research or development project of their own. They
could, however engage in reports related to evaluations
and changes of organizations, as well as become updated
in certain fields of nursing, e.g. caring for wounds,
documentation and drug store issues. The RNs elucidated that they fell short in one respect, i.e. when they
compared their ambitions in development and research
with those of the doctors:
You see, I feel that our County Council has low
priority on nursing research (No. 5). It is more
difficult because we have no tradition in nursing
research yI haven’t noticed anything else than
answering questionnaires sent from colleagues who
are doing this as part of their education (No. 7).
Supervision of nurse-students was as well as research
and development described as important but arduous
and time-expensive despite the degree of interest.
4.1.1.4. Too little contact with patients. ‘Too little
contact with patients’ means impossibility to create
sufficient chances for achieving a general picture and
confirmation that the patients are receiving optimal care
and have a feeling of security. When the contact was
unsatisfactory RNs experienced a poorer quality of care.
Reasons for the lack of time the RN has to spend with
each patient were a continuous substantial flow of
patients and demands for documentation:
Everything must be written down—it must all be
documented yThen I wonder so to say, how much
time will be left over to see to the patient? (No.13).
Time together with patient was described by the RNs
as a reward. The RNs on anesthetic wards and in the
operating theatre wanted to establish shared commitments with a medical or surgery ward, because they
missed the contact with patients and were not satisfied
with this.
4.1.2. A stimulating work situation
4.1.2.1. To encounter patients and qualified health care
staff is enriching. ‘To encounter patients and qualified
health care staff is enriching’ means good relationship. It
was the encounters with patients that enriched the RNs’
working day most of all. A sense of wellbeing as well as
professional and personal growth emerged when there
was time to talk to and support the patient. The support
was described as a close relationship in both joy and
deep sorrow. Exacting relationships with patients were
also experienced as enlightening if they provided an
opportunity for follow-up talks. Some of the RNs
participated sporadically in professional clinical super-
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K. Hallin, E. Danielson / International Journal of Nursing Studies 44 (2007) 1221–1230
vision while others were of the opinion that such
supervision was unnecessary because there were a
sufficient number of staffs in the working team that
could supply back up:
Some patients are troublesome and I think you
should be allowed to say this. Because I mean you are
no superman. If you can talk about this then at least
you have a chance to do something about it. And I
think that we nursing staff on the whole are too bad
at telling what we really feely The more trouble and
complaints you experience the more you need to talk
about it (No. 6).
At workplaces with sufficient qualified staff and staffmembers standing up for each, the RNs felt pleasure and
experienced security; their daily work situation was
enriched. In such environments the RNs took their time
to supervise and instruct ENs and when ENs worked
more autonomously the RNs obtained load-relieving.
4.1.2.2. To have the situation under control. ‘To have
the situation under control’ means it is like receiving a
‘‘vitamin injection’’, when everything is going well and it
is possible to manage a chaotic situation. If RNs
experienced lack of control they were regarded as
vulnerable and unable to go on with any further
workload. In order to carry out various work situations
adequately the RNs related that it was necessary to
acquire routines as soon as possible, not to undertake
too many assignments and to think about teamwork.
The RNs, who planned together with ENs and took time
to train them and delegate tasks to them, explained that
in the long run they found that they obtained both relief
in their workload and an increased ability to control
their daily work.
The RNs’ descriptions show that planning with an
additional timetable contributed to a more tolerable
work situation. Those who managed to keep the
timetable, to finish their duties and to facilitate the
hand-over to the relieving colleague, described a feeling
of accomplishment; this way proved RNs’ capacity as
‘‘highly skilled’’ and subsequently received feedback on
performed efforts. RNs, who had few interruptions and
were responsible for few patients, with ample time for
care, described this as a privilege. The time that other
RNs spent on admissions and discharges could in their
case be spent on ‘‘their’’ patients. They were afraid that
this would deteriorate if hospital managers became
aware of their pleasant work environment:
But you don’t talk out loud about this, because you
are sure that the hospital managers will put a stop to
this way of working. It is as if you mustn’t have
things too good (No. 10).
4.1.2.3. To have the skills necessary to be independent. ‘To have the skills necessary to be independent’
was expressed to not standing nonplussed without
knowing what to do, to be capable of making prompt
decisions and to be able to act from a general picture of
any given situation. Confirmation of having done the
right thing provided satisfaction:
Sometimes it takes a long time before you can get
hold of a doctor. I do not just stand around
nonplussed—I am really capable and ready to act.
Yes, it’s good to know you can handle the situation
(No. 11).
The number of workmates and RNs’ ability for
instruction and organisation influenced the sensation of
autonomy. Challenges, assignments of various contents,
elements of acute situations in moderate quantities were
all considered as being an added stimulation in the
working day.
When acute circumstances arise and the patient
survives you really feel that you are doing something
worthwhile (No. 14).
At the time one’s head feels ready to explode, but these
are short intervals and perhaps this is what makes
nursing a terrifically exciting profession (No. 3).
RNs sometimes choose to work nights or change their
place of work in order to acquire stimulation in the form
of new challenges, more independent work and to feel
more in control of their work situation.
5. Discussion
5.1. Result discussion
This qualitative study has provided insight in regarding the daily work of RNs’ with more than 6 years
experience of the profession. The main result shows a
scale of balance that oscillated between strain and
stimulation; an oscillation between two poles, an ideal
day full of stimulation or a day filled with strain. On the
whole oscillation seemed to be related to the various
experiences RNs had of their work; i.e. of the time that
available for each patient, their ability to promote the
quality of care and their independence. However, a
pattern also emerged throughout the results, which
showed that due to the increasing number of patients
and the skills of the staffs, RNs’ ability for management,
prioritising and planning out of team work diminished.
The RNs seemed to be unstructured for their work
regarding documentation. The patient contact appeared
to be RNs’ greatest source of rewards and personal
development, but if they met with delays, they took
unsafe ‘‘shortcuts’’.
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RNs, who experienced a stimulating work situation,
possessed the skills necessary for working independently
and for making prompt decisions from a general concept
of a limited number of patients. Experiences of
autonomy and team work with doctors and qualified
health care staff were important and strong predictors of
stimulation. RNs in these cases compared chaotic
situations to a ‘vitamin injection’. If they also had
managed to complete their duties at the end of the day,
they praised themselves as being ‘highly skilled’.
Nurses feel satisfied when they are able to provide
good care and complete the given work tasks (McNeeseSmith, 1999) without too many interruptions (Hedberg
and Larsson, 2004). However, since the different parts of
the result in our study, in reality were woven into
circumstances of different situations, the balance of
RNs’ scales tipped more towards strain than stimulation. The price of such negative balance can lead to
serious consequences for the patients and the RNs
themselves (Aiken et al., 2002a, b). Nurses are more than
other staff members ‘‘at hand’’ for all kind of interactions and task-solutions that can lead to fragmentary
work. Interpersonal and technological interruptions can
be features which could jeopardize the decision-making
outcome (Hedberg and Larsson, 2004). As it will be
discussed further, when RNs’ were frequently interrupted and when assignments were too large compared
to available time, the risk for miscalculating and taking
perilous short cuts increased. RNs, who experienced a
stressful work situation, expressed all variations of strain
in accordance with RNs in transition (Gerrish, 2000;
Wheeler et al., 2000; Ramritu and Barnard, 2001).
The RNs were conscious of the need to meet with all
the demands in order to provide care that was both
holistic and of good quality for each patient but they felt
powerless to set limits for their workload. That is worth
considering when an increasing number of seriously ill
patients per nurse is clearly associated with the risks of
patients receiving a poorer quality of care and the nurses
feeling constant dissatisfaction (Aiken et al., 2001,
2002a; Sheward et al., 2005). Feelings of insufficiency
were described by RNs’ as being worried and anxious
about being inadequate and having missed something at
the end of the working day. Delays could lead to serious
consequences when RNs chose to take ‘‘shortcuts’’ and
avoided answering questions or avoided supervising
patients and students. Such behavior became especially
troublesome and unsafe for patients in situations in
which RNs lacked experience and did not take the time
to acquire the relevant knowledge. Such circumstances
are directly contrary to laws and ordinances that apply
to professional nursing (SFS, 1982:763; SOSFS, 2005).
The leading question is what kind of support is available
for a RN, when increasing demands lead to serious
situation where something goes drastically wrong
(Ahern and McDonald, 2002). According to Stacciarini
1227
and Troccoli (2004) critical thinking is significantly
related to occupational stress and physical and psychological ill-health. No doubt, high care complexity
induces attention for the patient, but the knowledge is
limited here about how much RNs ought to fulfill in
their daily duties.
Some of the RNs had difficulties to delegate tasks to
ENs and tried to accomplish the tasks for both, which
resulted in work duplication. Reasons given why RNs
did not delegate tasks to their team colleagues were that
this was due to ENs’ unwillingness and inadequate
knowledge. In such situations these RNs need further
encouragement to take on a leading position with the
power to solve conflicts, to delegate, and to pinpoint and
prioritise timesaving strategies. Even Adams and Bond
(2000) confirm this with their results that show how
workload and work organisation influence both nurses’
and patients’ wellbeing. Furthermore, unsuccessful
planning and failure to set priorities can lead to both
confusion, disorganization and poor care for patients
(Fagerberg, 2004) but unfortunately little empirical
research has been carried out of regarding nurses’ skills
in prioritising (Hendry and Walker, 2004). RNs in our
study, who had trained ENs and also took time to plan
the work together with them, stated that in the long run
they achieved both relief a lightening of their workload
and an increased ability to control their daily work.
To be unsure of oneself dealt with the RNs’ ability to
influence development and changes in their workplaces.
These RNs strove to provide nursing care independently
and with personal responsibility but adopted a wait-and
see policy regarded participating development work.
They were aware of the need of a research-based
practice, but in spite of this felt unsure about the time
available to conduct research. In line with earlier
findings nursing research was seldom prioritised (Kajermo et al., 2001; Kuuppelomaki and Tuomi, 2005).
The RNs experienced that they had too little contact
with patients, which resulted in two described effects:
lack of rewards and impossibility for achieving a general
picture of each patient. These results are similar with the
study by Fagerberg (2004), who found that RNs, 5 years
after graduation, worked hard at bonding with their
patients and tried to organize the daily work situation
according to patients’ needs and safety. It is interesting
and in accordance with results by Sheward et al. (2005)
that the patient contact appeared to be RNs’ greatest
source of rewards and personal development.
The RNs seemed to be unstructured for their work
regarding documentation. This circumstance was like a
vicious circle; RNs, in their attempt to acquire control and
accomplish a high quality of care, were unsuccessful in
their methods of working. Documentation was repeatedly
mentioned as being troublesome, time-costly and was
experienced as stealing time from the patients. The
documentation was often carried out during breaks with
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a considerable amount of unreliable notes; texts that were
linguistically unclear, which were created from memory.
They experienced that defective documents led to more
work. Why do RNs not document bedside and continuously while they observe and talk with patients? Such
procedures would provide RNs with more time with the
patient, more reliable documentation and would automatically involve the patients with the plans and priorities
for their health care. RNs are autonomously responsible
for documenting the nursing process by a legally enforced
quality assurance of RNs’ work (Ehnfors and ThorellEkstrand, 1992; SFS, 1985:562), but evaluations indicate
that nurses with different experiences rarely document
nursing diagnosis, nursing goals and nursing outcomes
(Tornvall et al., 2004). In the initial phase, 48 h, RNs have
considerable difficulty in identifying the needs of their
patients, particularly problems with nutrition, sleep, pain,
and emotions/spirituality (Florin et al., 2005a). To obtain
better congruence between nurses’ and patients’ descriptions structured recording following chronological order
can be used (Ehrenberg and Ehnfors, 2001). Furthermore,
education followed by constant discussions and facilitating
forms for recording seem to be necessary (Bjorvell et al.,
2003; Florin et al., 2005b; Tornvall et al., 2004).
RNs appeared to balance their experience of stressful
and stimulating work as a modest and reserved position
on the scale. Various frustrations from the daily work
situation were reported but no one talked about
solutions. The RNs chose to consult colleagues for
support but their descriptions of receiving back-up
depicted more a tête-à-tête than conversation using
reflection as a tool (Gustafsson and Fagerberg, 2004).
This can undoubtedly have helped for the moment, but
in the long run personal development and work changes
should be promoted by structured professional discussions. Reflections with colleagues, in combination with
sessions of clinical supervisions, can eliminate the risk of
proceeding with routines based on tradition. Significant
positive correlations are presented between clinical
supervision, work demands, collaboration and good
communication (Begat et al., 2005). Unfortunately, most
of the RNs in our study declined structured clinical
supervision, but due to this, such supervision could then
prove to be an excellent tool for helping nurses to handle
work demands and achieve control of the daily work
situation (Begat et al., 2005). It would also be a good
help for handling factors that diminished nurses’
autonomy; like autocratic management, increased workload and poor collaboration with doctors (Mrayyan,
2004; Rafferty et al., 2001).
5.2. Methodological considerations
The trustworthiness has been assured through using
Lincoln and Guba’s (1985) criteria for dependability,
credibility and transferability. As factors of instability are
changeable over time the trustworthiness of this study has
been valued on the grounds that the participants narrated
experiences from their actual daily work situation with the
same questions (Sandelowski, 1993). One strength of the
study was the fact that sampled participants with similar
education and various experiences increase the chances to
shed light on the research from a variety of aspects
(Patton, 2004). Another strength was that the researchers,
both RN and educator, were familiar with both concepts
and contexts (Sandelowski, 2000). In contrast, there is a
slight risk that the researchers may have missed certain
information both in the interviews and the analysis, due to
their comprehension of nursing education and the
conditions of the nursing profession (Patton, 2004). Our
study’s results have a rich content that ought to be
transferred both to nursing education and health care
organisation.
6. Conclusion
This study has described RNs’ with six years
experiences of their daily work situation. The strength
of this study has been to show this work situation as a
whole. Other studies have reported parts of this work
with heterogeneous participants. The main results
regarding this work situation has been illustrated as a
scale of balance that oscillated between strain and
stimulation; an oscillation between two poles, an ideal
day full of stimulation or a day filled with strain. The
oscillation seemed to be related to the various experiences RNs had of their work; i.e. of the time that
available for each patient, their ability to promote the
quality of care, skills for team work and to be
independent. A clearly pattern emerged throughout the
results, which showed that due to the increasing number
of patients and the skills of the staffs, RNs’ capacity for
management, prioritising and planning out of team
work, diminished. The RNs seemed to be unstructured
for their work regarding documentation. These circumstances were like a vicious circle; RNs, in their attempt
to acquire control and accomplish quality of care, were
unsuccessful in their methods of working. As experienced RNs can have difficult to hold the balance
between strain and stimulation, how difficult is it for
newly qualified? Our study shows that is a need for RNs
to find a more successful and personal way to perform
their daily work in an ever increasing downsizings and
reorganization of the health care sector; it is necessary to
receive support from the start through the nursing
education and continuously in the profession. This is a
crucial issue for nursing education on different levels
and health care sector. Furthermore our study points to
the need for further research regarding skilled RNs’
experiences, in order to focus on the trends and
difficulties that are found in daily works situations.
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K. Hallin, E. Danielson / International Journal of Nursing Studies 44 (2007) 1221–1230
Acknowledgements
We would like to acknowledge the contribution of the
nurses involved in this study and would like to thank
them for allowing us to share their unique experiences.
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