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Nurses' Use of Time in a Medical-Surgical Ward

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Article in Journal of Nursing Management February 2001

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 Journal of Nursing Management, 2001, 9, 1320

Nurses' use of time in a medicalsurgical ward with all-RN stafng

1 2
S. LUNDGREN, RN, D ipl . N urs E d , MS c .and K. SEGESTEN, RN, D ipl . N urs E d , MS c N, P h D .
1
Lecturer and Doctoral student, Department of Nursing and Institute of Health Care Pedagogics, Goteborg University,
Goteborg, Sweden and 2Professor, Department of Health Science, Boras University, and Institute of Health Care
Pedagogics, Goteborg, Sweden

Correspondence LUNDGREN S. & SEGESTEN K . (2001) Journal of Nursing Management 9, 1320

S. Lundgren Nurses' use of time in a medicalsurgical ward with all-RN stafng
Department of Nursing
Goteborg University Aims To investigate allocation of nursing time, organisation of nursing activities and
Billerudsgatan 1 whether or not allocation and organisation have changed over time.
416 75 Goteborg Background In a ward that changed to all-RN stafng, the nurses were encouraged
Sweden to implement a patient-focused philosophy. The nurses perceived that they had
difculty in using the time available efciently.
Methods Non-participant observations were conducted with 2-year intervals. Ten
consecutive weekdays were covered on two occasions. The study was carried out at
a university hospital in Sweden.
Findings Between observations, a signicant change in the organization of the direct
care had occurred, and the same tendency was found in patient administration and
general management. The organization of work changed from a partly fragmented
to a more coherent one. The time used for direct care and administrative activities
increased between the two observations, while indirect care, personal and service
activities decreased.
Conclusion It can be suggested that the nurses used their time efciently and, over
time, they developed a more coherent way of organizing nursing activities.

Accepted for publication: 7 June 2000

Introduction
Nurses' use of their working hours has been subject to
discussion and criticism over the past years both in
Sweden and internationally. Nurses are at times accused of
spending limited time with their patients and too much
time at their desk. The delivery of nursing services has
been described as fragmented and episodic. Nurses are
subject to recurrent interruptions in their work with the
consequence that they have to go back and forth between
activities and spend short periods of time on each activity
(Degerhammar & Wade 1991., Prescott et al. 1991., May
1990.). Patients have also commented on fragmentation in
the care they receive, including different nurses attending
to them, with the result that the communication between
patient and nurse suffers and that caregivers with less skill
perform most of the direct care (Prescott et al. 1991.).
There are also indications that patients wish to have more
time with the nurse (Boman et al. 1997.). The ward focused
upon in this project has undergone a major change in
stafng from previously having had a mixed composition
of registered nurses (RNs) and practical nurses to 100%
RNs. The main reason for this change was budget cuts,
but an additional aim was to enhance the quality of care
and to reinforce practice on the basis of a `patient-in-
focus' philosophy (Nyman et al. 1993.). The new staff
pattern created the possibility to work according to this
philosophy. As a result, the RNs also had to incorporate
the tasks earlier performed by the practical nurses in their

f 2001 Blackwell Science Ltd 13

S. Lundgren
own workload. From a previous study, also a part of this
research project, Segesten et al. (1998.) found that nurses
had difculty in using the time available for activities of
high priority. According to their intuitive feelings, far too
many hours were used on non-nursing activities, such as
cleaning the kitchen, checking the inventory and running
errands tasks that had earlier been the responsibility of
the practical nurses.
Literature review
A review of the nursing literature shows that various
methods for registering how time is spent on different
activities have been used. In some of the studies, data were
collected through individual personal reports (Brillhart &
Sills 1994., Ekman et al. 1991.) while observations were used
in others (Reid et al. 1993., Gardner 1991.). Work sampling
instruments were used in some cases (Bostrom &
Zimmerman 1993., Minyard et al. 1986.) while, in other
cases, chronological notes were made of the activities
performed (Ekman et al. 1991.).
The authors gathered information for various purposes.
The use of time for RNs and practical nurses (LPNs) was
compared (Ekman et al. 1991., Harper 1986., Minyard et al.
1986.) as well as the time used by nurses across the
following areas: orthopaedics, medicine, surgery, neurol-
ogy, obstetrics/gynaecology and paediatrics (Hendricksen
et al. 1990.). Nursing systems have also been evaluated by
measuring time in direct nursing care (Adams et al. 1998.,
Gardner 1991., Fagin 1990., Harper 1986., Minyard et al.
1986.). It is believed that the different systems of nursing
practice provide different opportunities for more effective,
high quality nursing care. In particular, primary nursing
has been in focus for investigations (Melchior et al. 1999.,
Segesten 1997., Nissen et al. 1997., Reed 1988., Giovannetti
1986.).
It is hard to draw any general conclusion from the
reviewed studies, as the methods for time sampling and
analysis are different. The time covered ranged from a
work sample of a few hours, a day shift, to days. The work
samples were recorded during 10 or 15 min at a sequential
or in randomly selected time intervals. In all studies, the
activities observed and/or documented were categorized.
The systems of categories differed greatly between the
studies. To illustrate, Bostrom & Zimmerman (1993.) used
19 different categories, including talking with patients,
patient hygiene, assisting MDs or others, and clerical
work. Harper (1986.) listed six categories: direct care,
indirect care, associated care, housekeeping, off ward and
personal activities. The authors, who used a large number
of categories, also often presented a few core categories to
14
clarify the conclusion reached (Brillhart & Sills 1994.,
Minyard et al. 1986.).
There are studies showing that caregivers with shorter
training spend the longest time on direct patient care
(Ekman et al. 1991., Harper 1986.). Other studies show that
the time spent is not related to the years in education. Other
studies (Quist 1992., Harper 1986., Minyard et al. 1986.) have
found that the lower the skill level, the higher the percentage
of non-occupied time. There are studies showing that the
time nurses spend on indirect patient care varies from 14%
to about 45% and, in direct care, from 21 to 60% (Reid et al.
1993., Quist 1992., Martin 1992., Ekman et al. 1991.,
Degerhammar & Wade 1991., Gardner 1991., Hendrickson
et al. 1990., Minyard et al. 1986., Harper 1986.). Thomas
(1994.) studied the amount of time used in verbal interaction
in nine hospital wards for elderly care and found such
interactions to a signicantly higher degree in wards based
on primary nursing than in wards with functional or team
nursing. Gardner (1991.) demonstrated that the quality was
better and the cost lower in primary nursing compared with
team nursing, even if the time in direct care was almost the
same. In contrast, Degerhammar & Wade (1991.) showed
that the time in direct care was more than doubled when
primary nursing was introduced on wards. The percentage
of time spent on direct nursing care also differs according to
number of hours per shift. Reid et al. (1993.) showed that the
direct care provided by RNs decreased in 12-h shifts
compared to 8-h shifts.
Aim of the study
The aim of this study was to investigate the allocation of
nursing time to various activities, how nurses organized
their time in an all-RN ward and whether or not the
allocation of time and organization of work changed over
time.
Method
The study was carried out at a 22-bed medical-surgical
ward in a large university hospital in Sweden. The ward
mainly houses patients with gastrointestinal diseases, the
majority of whom were severely ill and highly dependent
on nursing care. About 10 months prior to the rst data
collection, the ward reorganized its staff from having
mixed nursing staff to registered nurses only. At the time
of the present studies, 22 nurses, including the head nurse
and assistant head nurse, were assigned to the ward. The
chief physician, the head nurse and the nurse supervisor
gave their consent to the study. The studies were
introduced to all nurses through a letter, which outlined
the course of action.
f 2001 Blackwell Science Ltd, Journal of Nursing Management, 9, 1320

On two occasions, with a 2-year interval, non-
participant observations were carried out at the ward.
Ten nurses were observed on each occasion. On both
occasions, all nurses participating in the research started
to work at 6.45 am with shift reports from the night nurse.
The observation took place from 7 a.m. to 3 or 4 p.m. On
each occasion, one nurse per day, during a period of 10
days, volunteered to be observed during the day shift. All
weekdays Monday to Friday were covered twice in both
studies. All nurses who volunteered to be observed were
females. The observer followed the nurse like a shadow,
continuously making notes. Each time the nurse started on
a new activity, the time was noted and the activity
described. The working hour schedule was determined by
the RNs for 5-week periods. They also had an internal
system to compensate for overtime, which allowed them
to leave early if ward activities allowed. For that reason,
the working hours varied from nurse to nurse during the
time of observation. Nurses being observed informed their
patients about the study, stressing that the nurse, not the
patient, was the focus of interest. When more intimate
nursing procedures were carried out or conversations were
held, the observer discreetly stayed at the other end of the
room. Five nursing teachers, RNs well known on the
ward, carried out the observations. They had no problem
interpreting what was going on and giving the activities
adequate labels. The activities recorded were then
categorized by the rst author.
Data analysis
The main purpose of the activity analysis was to record
the type and nature of nursing activities, the amount of
time used on each activity and how the work was
organized. The activities were coded under two types of
categorization systems. The reason for using two different
categorization systems was to meet the aim of this
particular study and to be able to compare the ndings
with studies of time allocation that have been categorized
according to a frequently used system (Minyard et al.
1986.). The system developed for this study categorized the
activities into seven specied activities (Table 1.). The
other system has four categories according to Minyard
et al. ks (1986) denitions of nursing activities (Table 2.).
Non-parametric statistical tests were used to analyse the
data. The level of signicance was set at <0.05.
Findings
At the rst observation, the nurses worked an average of
8 h and 32 min, breaks and personal time included. The
working hours ranged from 7 h and 45 min to 9 h and
f 2001 Blackwell Science Ltd, Journal of Nursing Management, 9, 1320
Nurses' use of time
Table 1
Denition of nursing activity categories developed for this study
Direct patient care: Occurs in the presence of a patient. Basic nursing
care, treatments and procedures. Communication with patient, medica-
tion, hygiene, nutrition and elimination, routine checks, specimen-
gathering, vital signs, answering intercom.
Indirect care: Activities that occur away from the patient. Preparing for
nursing interventions, medications and therapies.
Round: Rounds with the MD, conferences regarding patients.
Service: Routine maintenance of the environment. Cleaning a dis-
charged patient unit, housekeeping tasks, supply check, errands off unit.
Shift reports: Shift reports, work schedules, general staff meetings.
Patient administration and general management: Report writing,
nursing care plan, paperwork, phone, communications with visitors.
Personal Activities: Activities not directed towards patient care or unit
management. Mealtimes, brakes, non-productive time.
5 min. At the second observation, the nurses worked an
average of 8 h, breaks and personal time included. The
hours ranged from 5 h and 10 min to 9 h.
The nurses were responsible for an average of four
patients on the day shift on the rst observation occasion,
the number varying between two and ve. The average
number of patients per nurse at the second observation
was 3.7, with the same variation as in the rst observation.
The analysis according to the category system devel-
oped for this study showed that the nurses at the rst
observation spent an average of 33% of their time on
direct patient care, which increased at the second
observation to 37%. Indirect care, on the other hand,
decreased between the two observations from 8% to 5%.
Direct and indirect patient care together amounted to a
mean of 41 and 42% of the working hours (Table 3.,
Fig. 1.). According to Minyard et al.'s (1986.) less specied
activity categories, the same tendency between the two
observations can be observed. Here, the two activities
together add up to 60% and 63%, respectively, of the
working hours. (Table 4., Fig. 2.).
None of the nurses were available for rounds with the
physicians, as they had been earlier, due to the new
nursing delivery system. The time for the physicians'
round had to be adjusted to some extent to the patients'
need for care. As the physician usually had several patients
to attend to at the ward, this adjustment could be made.
The average percentages of time spent on round activity,
5%, and verbal shift reports, 10%, were the same on both
observation occasions.
One of the advantages of the observation method was
that not only the amount of time spent on each activity
could be observed but also how nurses organized their use
of time. When looking more closely at the time spent on
the different caring activities and how this time was
distributed over the day, an interesting picture emerged.
The total time of direct care consisted of 128 sequences
15
S. Lundgren

Direct care: Nursing activities that are patient-centred and that take place in the presence of the Table 2
patient and/or family. Denition of nursing activity categories according
to Minyard et al. (1986).
Indirect care: Activities that are away from the patient but in preparation for or in completion of
direct nursing care. Round, shift reports and team conferences regarding a specic patient.
Unit-Related Activities: Activities and tasks necessary for the general management, co-ordination,
and organization of a nursing unit. Functions related to the wellbeing of the patient population on the
unit but not specic to a patient.
Personal Activities: Activities not direct towards patient care or unit management. Mealtimes,
brakes, nonproductive time.

without interruption during the rst observation period,
the majority of which lasted 5 min or less (48 sequences),
followed by 28 sequences lasting from 6 to 10 min. The
remaining sequences followed a sliding scale down to one
sequence with a duration of 70 min. This means that the
nurse was occupied with the same patient for 70 min. The
second observation gave a different picture. The total time
in direct care had increased by 4%, and the sequences of
direct care had decreased in number but increased in
duration. Now 45 sequences were 10 min or less compared
to 76 on the rst observation (Fig. 3.). The duration of the
following sequences had two peaks: one after 25 min and
one after 40 min. The result showed a signicant
difference in length of time and number of sequences of
direct care between the two observations (P<0.05). A
similar picture can be seen in the activities of patient
administration/general management but the difference
was not signicant. The number of sequences decreased
from 111 to 88 and those that were 5 min or less decreased
from 52 to 36. The overall result of the two observations
shows that nurses had changed their mode of organizing
work in the two major nursing activities, direct care and
patient administration/general management, from many
but short sequences to fewer sequences of longer duration.
Discussion
One consequence for the work organization, when
changing the stafng pattern, is that the vertical hierarchy
is also bound to change, either by developing further levels
vertically or attening out the hierarchy horizontally. In
the medical ward concerned, where the stafng pattern
was changed from mixed stafng to all professional
nurses, the vertical hierarchy was attened, as there was
now one less category of personnel. A consequence of this
was that no nursing time was spent on supervision, co-
ordination, scheduling and managing other personnel.
Continuity in care, the seriousness of the patient's
condition and the estimated workload for the nurse
were taken into account when the nurses distributed the
workload between them. The nurses had chosen a nursing
delivery model, where each nurse had the total respon-
sibility for the care of her patients, which meant that all
patients' personal, environmental and service needs were
the responsibility of the nurse.
Our study of nurses' use of their working hours and
organization of work indicates that it takes time to change
from a task allocation system to a patient focus system.
After 10 months in the new organization, nurses were still
working partly according to a task allocation way of
thinking and organizing work, which resulted in many and
short sequences of care. On the other hand, the patient
received care from the same nurse throughout the shift,
which gave some continuity. Two years later, the work
was signicantly differently organized as well as more
patient orientated with longer sequences of direct care. It
can be suggested that the change to patient focus had given
each nurse the opportunity to create her own temporal
design of work. This gave her the freedom to decide in
which order and how to care for the patients based on
patient preferences and needs as well as her own
professional knowledge and experience. The delivery
model gave the nurses rst-hand information about the
patients' condition and health status. The longer

Table 3
Observation I Minimum Maximum Observation II Minimum Maximum
Percentage of time spent on nursing activities
Activity (%) (%) (%) (%) (%) (%) according to categories developed for this study..
Direct Care 33 19 40 37 23 50
Indirect Care 8 2 14 5 0 10
Round 5 2 10 5 0 16
Service 7 1 15 5 2 7
Shift report 10 7 15 10 6 13
Patient adm, unit activities 23 14 35 25 12 42
Personal Activities 14 9 22 13 3 23

16 f 2001 Blackwell Science Ltd, Journal of Nursing Management, 9, 1320

 Nurses' use of time

40 Obs 1 45 Obs 1
35 Obs 2 40
Percentage

30 Obs 2
25 35
20

Percentage
15 30
10 25
5
0 20
Direct Indirect Round Service Shift Patient Personal
care care report admin- activities 15
istration 10
5
Figure 1 0
Percentage of time spent on nursing activities, according to categories Direct Indirect Unit-related Personal
developed for this study... care care activities activities

Figure 2
sequences gave the patients the opportunity to discuss Percentage of time on nursing activities, according to Minyard et al. (1986.).

thoughts, problems and worries and to ask questions

about future treatments. The nurse could inform about
needs and problems that she could foresee. The suggestion
is that the longer sequences of direct care gave the nurses a
feeling of security that the patients' needs had been
captured, and even if she spent more coherent time with
patients, she could still have control and manage the
overall situation. Adams et al. (1998.) and Thomas (1992.)
found that a nursing model of care close to the denitions
of primary nursing has effects on professional nursing
practice, contributes to less hierarchical practice, provides
opportunities for innovative practice and facilitates
improved working relationships between nurses, man-
agers and physicians. Melchior et al. (1999) reported that
the primary nurse found more autonomy in her work and
experienced it as less complex as well as working more
according to patient-orientated care. According to the
studies of Gardner (1991.) and Reed (1988.), primary
nursing results in higher quality of nursing care compared
to team nursing. On the other hand, Nissen et al. (1997.)
arrived at the conclusion that primary nursing is less
effective than commonly thought and may not signi-
cantly improve the quality of care compared to functional
or team nursing.
The time a nurse is available to the patient may be
labelled `nurse professional time' (Narvanen 1994.).
Professional time, i.e. the daily working time, can be
dened either by a patient's condition and needs or by a
formal schedule. The more the daily working time is
organized according to the patient's need of care, the
longer the professional time. This study shows that nurses'
working time was, to some extent, based on patients'
needs and conditions. The nurses adjusted their own
mealtime to periods of low activity and left their work
when the ward activities allowed whatever the time.
The question is how nurses best can organize their work
so that their professional time may increase. One
suggestion is that non-clinical service staff could reduce
the amount of time used on service activities. The nurses
would then be relieved of some of their least satisfying
duties as well as being given more time for nursing
activities. On the other hand, Hendricksen et al. (1990.)
found that, even though the stafng was mixed, RNs used
3% of their time on service activities.
The time the nurses spent on personal activities was in
line with the time which had been scheduled. This result
can be compared with studies of a mixed stafng and
nursing system. Minyard et al. (1986.) found that the
percentage of personal activities was different depending
on the skill level. They found that the RNs spent an
average of 11.4% on personal activities, LPNs 17.4% and
nurse's aids 24.3%. In their report, they refer to industrial
engineers, suggesting that a reasonable gure for personal
activities is 16%. Depending on the nursing system, in
units with modied primary nursing approximately the
same amount of time was spent on personal activities
(Hendricksen et al. 1990.). However, a slightly higher
percentage was found in a study with team nursing
(Harper 1986.) (Table 5.).
The time used for shift reports seemed to be important.
In addition, reporting on patient status, nurses had the
chance to communicate face-to-face with each other,
exchange knowledge and give and receive advice from

Table 4
Observation I Minimum Maximum Observation II Minimum Maximum
Percentage of time spent on nursing activities
according to Minyard et al. (1986.) Activity (%) (%) (%) (%) (%) (%)

Direct Care 34 21 41 39 30 52
Indirect Care 26 11 47 24 18 37
Unit-Related Activities 26 19 40 24 15 31
Personal Activities 14 9 21 13 3 19

f 2001 Blackwell Science Ltd, Journal of Nursing Management, 9, 1320 17

S. Lundgren

60 Obs 1 administrative work. Even small changes in how nurses

50 Obs 2 spend their time could add up to time for professional
care.
Frequencies

40
30
20
10
0
5 10 15 20 25 30 35
Minutes
more
Figure 3
Sequences of direct patient care, frequencies and duration.
peers. However, it can be questioned if the amount of time
is efciently used. The verbal exchange of information
about patients' status could, to some extent, be replaced
by information given in patients' charts. A face-to-face
interaction could follow, where details and nuances could
be explained, and time gained could, instead, be used for
discussions of other nursing issues or for direct care.
Patient administration/general management is the
activity that could be reduced in favour of more
professional time. It can be suggested that more of the
paper work could be handed over to support personnel,
that the chartering routines could be examined and the use
of computers for transfer of information could facilitate
The benet of having all-RNs on the ward is that no
time is spent on supervision of others. In wards with
mixed staff, the RNs spend a great deal of time on
supervision, co-ordination, scheduling and managing
40 others, who do most of the care delivery, and they
or
consequently have less time to practise nursing themselves.
Ekman et al. (1991.) found that time devoted to personnel
administration amounted to over 10% of the working
time. This means that nurses are drawn away from direct
care delivery into spending more time on unit manage-
ment. Several studies indicate that the result will be a
fragmented, episodic delivery of nursing service (Prescott
et al. 1991., Gibbs et al. 1991., Harper 1986.). Ekman et al.
(1991.) also found that, in geriatric wards with mixed staff,
RNs spent, on average, 35% of their working hours with
the patients, enrolled nurses 48% and nursing aids 55%.
This means that the caregivers with the shortest training
spent the longest time on direct patient care (Table 5.).
After a review of the literature, the main point is clear,
namely that professional nurses should be at the bedside of
the patient, not supervising others and leaving less time for
direct contact with the patient (Harper 1986., Prescott et al.
1991, McKenna 1995, Blegan et al. 1998.).

Table 5
Unit related Personal
Studies investigating nurses use of time
Study Direct care Indirect care activities activities

Lundgren & Segesten Observation I 34% 26% 26% 14%

RN
Lundgren & Segesten Observation II 39% 24% 24% 13%
RN
Ekman, Norberg, Viitanen & Winblad (1991). 35%
RN 48%
Enrolled 55%
Aids
Degerhammar & Wade (1991). 60% 1014%
RN
Reid, Robinson & Todd (1993). 40.2%
RN
Quist (1992). 47.2% 29.1% 12.4% 11.5%
RN 44.3% 24.1% 10% 10.8%
LPN 33.0% 22.2% 12.8% 23.5%
Aids
Gardner (1991). 2831%
RN
Hendricksen et al. (1990).. 31% 45% 10% 13%
RN
Harper (1986). 41% 30% 15%
RN 53% 18% 14%
SEN
Minyard, Wall & Turner (1986). 32.8% 26.9% 20.3% 11%
RN 20%
Overall

18 f 2001 Blackwell Science Ltd, Journal of Nursing Management, 9, 1320


It is valuable to compare different studies to be able to
generalize and to see similarities as well as differences.
Two different systems were used to categorize the data,
one more specic and one more general, to enable
comparison with a larger range of research studies.
However, the comparison has to be made on a rather
general level due to methodological and categorization
differences as well as a lack of studies based on all-RN
stafng. A variety of sampling plans has been used in the
different studies and not all are clearly described. The
studies are also carried out at different times, hospitals and
in different countries. Our study differed from some other
studies in that the entire day shifts were observed while
other studies used time sampling at randomly selected
intervals, at different times of day made by observers or
through self-reports. Despite the difculty in comparing
across studies, it can be concluded that the result of this
study indicates that nurses' use of time in nursing activities
is fairly similar to previous studies (Table 5.). However, to
meet the specic aims of this study, the method chosen
made it possible to register type, duration, frequency and
the time of each nursing activity, as close to the natural
setting and with as little interference as possible in the
daily work on the ward.
Comparing studies of primary nursing involves meth-
odological problems. In most studies the wards are
`hybrids' in organizational terms. Few wards exhibit all
required characteristics of primary nursing. Conclusions
about the effectiveness of different nursing systems can
therefore not be drawn at a general level (Adams et al.
1998., Segesten 1997., Giovannetti 1986.).
Conclusion
This study shows that, after working almost three years
with the chosen care delivery model, nurses spent the main
part of their time, 3739%, depending on the categoriza-
tion system used, on direct care of the patient. If indirect
care is included, the percentage of time amounts to 42%
and 60%, respectively, of the working hours. The time
which nurses spent on direct care was well in line with the
ndings of previous studies. The nurses had a feeling of
spending too much time on non-nursing activities of a
service type. This observation study found no objective
basis justifying this feeling considering the actual time
observed performing such activities. The time spent on
activities belonging to the service category only accounted
for a very small part of the working day.
Even if the philosophy of having the patient in focus had
been adopted, patterns of organization carried on from the
mixed staff system were still in effect 10 months after the
f 2001 Blackwell Science Ltd, Journal of Nursing Management, 9, 1320
Nurses' use of time
change. What is most important to note is that the results
from the observation two years later clearly showed a
change in the pattern of nursing care from a partly
fragmented task allocation to a more coherent organiza-
tion of unit-related activities and a signicantly more
coherent organization of patient care. The care delivery
model, used on the ward, promoted a less fragmented and
a more coherent way of organizing work. This indicates
that nurses used the opportunity to organize their daily
work, based on patients' preferences and needs as well as
the nurse's own experience and professional knowledge.
The patients needing more time received more coherent
time for information and support. However, patients'
reactions to the care given were not studied.
Further research is necessary to nd an appropriate
balance between different nursing activities. This balance
may differ depending on the specic conditions existing in
different wards with different types of patients, nursing
care delivery models or stafng pattern.
Acknowledgement
We would like to thank all the nurses who gave us the
opportunity to follow them in their work. We also thank Evy
Agelii, Monica Elmcrona and Irma Lindstrom for conducting
some of the observations. The Swedish Work Environment Fund
supported the study (grant no. 980042).
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