RESEARCH ARTICLE Open AccessExperiences of reduced work ho.docx

RESEARCH ARTICLE Open Access
Experiences of reduced work hours for
nurses and assistant nurses at a surgical
department: a qualitative study
Kristina Gyllensten1* , Gunnar Andersson2 and Helena Muller2
Abstract
Background: There is a shortage of registered nurses in the
European Union (EU), and job dissatisfaction and perceived
high work–family conflict have been identified as causes of
nursing staff turnover. Reducing work hours is an organisational
intervention that could have a positive effect on nurses’ and
assistant nurses’ job satisfaction, work–life balance, and
willingness to stay in the job. An orthopaedic surgery
department at a large hospital in Sweden introduced reduced
work hours for nurses and assistant nurses in order to improve
the working situation. The aim of the study was to investigate
the experiences of reduced work hours and no lunch breaks
among nurses and assistant nurses at an orthopaedic surgery
department at a hospital in Sweden, with a particular focus on
recovery and psychosocial working environment.
Methods: A qualitative design was used in the study. Eleven
nurses and assistant nurses working at the particular
orthopaedic
department took part in the study, and semi-structured
interviews were used to collect data. The interviews were
analysed by
interpretative phenomenological analysis.

Results: Four main themes were developed in the analysis of the
data: A more sustainable working situation, Improved
work–life balance, Consequences of being part of a project, and
Improved quality of care. Each theme consisted of
subthemes.
Conclusions: Overall, reduced work hours appeared to have
many, mainly positive, effects for the participants in both
work and home life.
Keywords: Reduced work hours, Nurses, Assistant nurses,
Qualitative research, Psychosocial working environment,
Work-life balance
Background
There is a shortage of registered nurses in EU countries,
and this shortage is expected to worsen. Job dissatisfaction
and ill health are two important factors responsible for the
loss of practising nurses [1]. Perceived high work–family
conflict has also been identified as a cause of nursing staff
turnover, and not surprisingly, long working hours and
shift work have been found to be related to work–family
conflict among nurses [2, 3]. A large-scale study on work
shifts for European nurses found that long work hours
had a negative impact on fatigue, health and patient safety
[4]. Introduction of reduced work hours is an organisa-
tional intervention that could have a positive effect on
nurses’ and assistant nurses’ job satisfaction, work–life bal-
ance, and willingness to stay in the job.
The six-hour working day and reduced work hours are
hot topics that have received increasing attention in the
Swedish debate, with supporting arguments focusing on
decreasing unemployment and benefits for dual-earner
families and non-supporting arguments focusing on

reduction of competitiveness of companies and costs for
implementation [5]. Despite the considerable interest,
there are few studies that have investigated the effects of
reduced work hours. A Swedish longitudinal, quasi-
experimental study investigated the effects of reduced
working hours in a group of social workers [6]. It was
found that reduced working hours had a positive effect
on several health measures, including restorative sleep,
sleep quality (on weekends), stress, memory difficulties,
* Correspondence: [email protected]
1Department of Occupational and Environmental Medicine,
University of
Gotenburg and Sahlgrenska University Hospital, Gothenburg,
Sweden
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article
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the data made available in this article, unless otherwise stated.
Gyllensten et al. BMC Nursing (2017) 16:16
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negative emotions, sleepiness, and fatigue and exhaus-
tion (on both workdays and weekends). Moreover, work
demands, instrumental managerial support, and work
intrusion on private life were also affected positively.
Bildt, Åkerstedt and Falkenberg [7] reported the findings
from a large-scale study where approximately 400 em-
ployees within the public sector in Sweden had reduced
work hours (30 h a week). The control group, with
approximately 400 individuals, worked 38–39 h a week.
Results showed that having reduced work hours was
greatly appreciated by the participants, who experienced
improved subjective health and quality of sleep and
reduced stress and tiredness. However, the study did not
find any changes in sick leave or in the biological health
markers. A smaller Swedish study investigated a nine-
hour reduction of the working week (to a six-hour day)
with a comparison group that continued working normal
working hours. The participants were mainly female
health care and day care nursery personnel. It was found
that the group with shortened work hours had improved
scores on social factors (time for family, friends, and so-
cial activities), sleep quality, mental fatigue, heart/re-
spiratory complaints, and attitude to work hours,
whereas the control group did not show changes during
the period of the study [8]. A more recent study investi-
gated shortened work hours and exercise during work
hours and the effect on productivity for dental staff in
Sweden [9]. One group received 2.5 h’ work reduction a
week, and the other group received 2.5 h’ work reduc-
tion with mandatory physical exercise during the re-
duced time. Both groups were compared to a control

group that did not receive any reduction in work hours
or physical exercise. It was found that all three groups
increased their productivity, with the largest increase in
the group with shortened work hours. Moreover, the
group with mandatory physical activity reported the
highest self-rated activity. Gothenburg municipality is
currently testing a six-hour workday for the staff at a
nursing home for the elderly. Another nursing home is
included as a comparison group. In the first interim
report the preliminary results from the first six months
are presented. It was found that the assistant nurses re-
ported more energy and less stress and were more active
than before. In addition, the assistant nurses experienced
that they were providing better care. A negative aspect
was that working many late shifts had a negative effect
on sleep [10]. A report that summarised the research on
reduced work hours concluded that there is no clear evi-
dence that reduced work hours have any effect on
objective health. Subjective health and job satisfaction
do, however, appear to be improved [11].
Reducing work hours concurrently with removing
breaks could mean a more intense work situation. A well-
conducted field study investigated the psychophysiological
effects of intensifying work by increasing workload and
reducing breaks for driving instructors [12]. The number
of examinations during a workday increased from 9 to 11.
Having 11 examinations during the day meant a more in-
tense workday and no breaks between the examinations.
The physiological activation was measured by adrenaline,
and it was found that under the regime of 11 exams a day
rates were high after work and stayed so until sleeping
time. This was significantly different compared to the situ-
ation of 9 exams a day. A conclusion from the study was
that the effects of intense work remain after the end of the

working day.
A lack of recovery from work plays an important role
in stress-related ill health [13]. Recovery can be defined
as the time needed to return to normal following the ter-
mination of a stressor. Several factors can influence the
need for recovery, such as coping factors, health status,
private situation, working conditions, and period of time
available to recover from work. If there is not enough
recovery between work shifts, there may be an accumu-
lation of work-induced fatigue, which increases the risk
of ill health [14]. Aronsson, Astvik, and Gustafsson [15]
examined the relationship between working conditions,
stress, lack of recovery, and health among personnel in
the welfare sector. It was found that the individuals in
the group ‘not recovered from work’ reported a number
of risk factors at work relating to difficult working
conditions and reported significantly worse ill health
compared to the recovered group. In a literature review
on recovery it was found that daily recovery appeared to
have a larger effect on health compared to the effects of
vacation, where the effects soon disappear. Sleep was
suggested to be the most important form of recovery,
although it was concluded that more research was
needed [16].
Despite the media interest in the topic, there appears
to be a lack of research investigating the effects of redu-
cing work hours and eliminating lunch breaks. Indeed,
we failed to find any qualitative studies investigating the
experiences of having shortened work hours and no
lunch breaks for nurses or assistant nurses. Therefore, the
aim of this study was to investigate the experiences of
reduced work hours and no lunch breaks among a group
of nurses and assistant nurses, with a particular focus on
recovery and psychosocial working environment.

Method
Background
The study took place at an orthopaedic surgery depart-
ment at a large hospital in Sweden. For a number of
years, the department had experienced problems with
high turnover and difficulty recruiting nurses and assist-
ant nurses. The staff suggested reducing work hours as a
solution to these problems, and the measure was first
Gyllensten et al. BMC Nursing (2017) 16:16 Page 2 of 12
introduced for a small group in November 2014 and for
all staff in February 2015. All nurses (orthopaedic and
anaesthetic) and assistant nurses reduced their work
hours from eight hours a day to six hours a day, except
for one day a week when they still worked eight hours,
where the two extra hours were intended for administra-
tive work tasks. Salaries were maintained at the same
level as for full-time work. The work schedule was chan-
ged from two shifts – a morning shift (7:00–16:00) and
afternoon/evening shift (12:30–21:30) – to three shifts –
morning (7:00–13:00), afternoon (12:30–18:30), and
evening shift (15:30–21:30). In addition, the lunch break
was eliminated, which meant that time-consuming
respite periods during ongoing operations could be
avoided. Extra staff were recruited, and more operating
theatres opened, and these could be opened during a
longer period of the day compared to previously. As a
consequence, more operations were performed, and the
idea was that these actions would balance the increased
cost of personnel.
Participants

All assistant nurses and nurses (117) at the particular
orthopaedic surgery department were invited via a letter
to participate in the study via a letter from the re-
searchers. If the answer was affirmative, the individual
was invited to participate in an interview about their ex-
perience of reduced working hours. Twelve presumptive
participants agreed to take part in the study, which
meant a response rate of 10%, and eleven subsequently
participated in the interviews. Ten participants were
women and one was male, three were working as assist-
ant nurses, and eight were working as registered nurses
(specialising in orthopedics or anaesthesia). The ages
ranged between 28 and 61 years, and the mean age was
45 years.
Procedure
Semi-structured interviews were used to collect the data,
and the interviews took place at the workplace during
working hours in November and December 2015. Two
of the authors conducted the interviews (HM and GA),
which took between 25 and 55 min. The interview
schedule was used as a guide and contained open ques-
tions on psychosocial work characteristics, recovery
from work, work–family conflict, health, economics, and
laws and regulations. The questions in the interview
schedule were based on previous literature on psycho-
social working conditions and work related health issues
for nurses and assistant nurses. The interviews were tape
recorded and transcribed verbatim. To keep the inter-
views anonymous, each participant was assigned a letter
as means of identification. The lines of the transcript
were numbered, so that each quote presented in this
article is referenced with a letter (participant) and a line
number from the transcript.

Data analysis
The interviews were transcribed verbatim and analysed
using interpretative phenomenological analysis (IPA) in
accordance with the guidelines presented by Smith, Jara-
man and Osborn [17]. IPA aims to explore in detail how
participants make sense of the world. It is a phenomeno-
logical approach that aims to capture the participants’
experiences of the phenomenon that is being studied.
Therefore, it was suitable for the current study, because
the aim was to explore the participants’ experiences of
shortened working hours. The approach is interpretative,
as the researcher is trying to understand the experience
of the participant through a process of interpretative
activity.
In a first step the interview data were coded using pen
and paper, line by line in the left margin of the tran-
script. From this first set of codes more abstract patterns
or preliminary themes were condensed for each inter-
view. Then a list of themes from all interviews was cre-
ated, and themes were grouped together, revised, or
deleted. At this stage it was important to check that the
analysis was in accordance with the data. After this
process a final list of themes and subthemes was devel-
oped (see Table 1).
Results
The aim of the study was to investigate the experiences
of shortened work hours and no lunch breaks in a group
of nurses and assistant nurses, with a particular focus on
recovery and psychosocial working environment. In the
analysis of the data four main themes were developed: A
more sustainable working situation, Improved work–life
balance, Consequences of being part of a project, and
Improved quality of care. Each theme had a number of
subthemes (see Table 1).

A more sustainable working situation
All the participants experienced that the reduced work
hours contributed to create a more sustainable working
situation. Several participants were now able to work
full-time, as they had sufficient energy to cope with this.
They also expressed that they were better able to recover
from work and that the work climate had improved.
However, there were some negative effects of having no
lunch breaks.
Energy for work
The reduced work hours gave the staff the opportunity
to work full-time while retaining their salary and pen-
sion benefits, which was experienced as very positive.
Several of the participants talked about how they were
able to work full-time, something which had not
previously been possible because of difficulty coping
with the physical work demands.
So it [the work] is tiresome and it was… well… yes,
one of the reasons why they introduced this, because
there were many that couldn’t cope with working
full-time. And then you pay for it yourself, both
with salary and future pensions. So it is a big trap
for women in health care. (registered nurse,
E: 110–115)
One participant explained how they had previously
had to work part-time, because the work was too
physically demanding for full-time hours.

Yes, I almost feel better now. My husband can
sometimes say, ‘I think you go to work every day’. Yes,
now I do, do that. Now I am not off one day a week,
I do actually go to work every day. But I can cope with
it, I don’t feel, ‘No I can’t cope’… So after almost a year
I still feel that I can cope. So hopefully I can work like
this until I am 65 years old, because my body can cope
with it. (registered nurse, D: 638–650)
Another aspect of coping with work was experiencing
that one’s energy lasted the whole working day. Several
participants experienced that, compared to previously,
they now had the energy to work in a different way
during the whole shift, which meant that they felt that
they were doing a better job.
I think that we deal with the things that need to be
done in a better way. I think so… All the materials
that arrive from the sterile section should be put away
in the shelves. We deal with that in a better way
than… We didn’t really have the energy before,
perhaps you had forty-five minutes left on your shift
and, ‘No, I don’t have the energy to do it, because I am
totally exhausted!’ But now I do it… because I have
the energy to do it. (registered nurse, D:208–212)
One participant described feeling that it was impos-
sible to be focused during the full six hours, but that it
still worked better than previously.
You don’t have the energy to keep focus for so long,
six hours in one go. Regardless… when I worked
eight hours then I had a dip around two, three in
the afternoon if I finished at four, then there was a

dip when I started looking at my watch. And that
dip comes now as well, although it comes at twelve
and I finish at one o’clock. (registered nurse,
C: 419–423)
Other participants experienced that it was easier to
keep going the last hours, since they knew that the shift
would end soon.
The ordinary evening shifts are half past twelve until
half past six, and if I work one of those tough shifts, if I
stand in one operation for the whole shift, and start at
seven the next day, of course, I will not feel well rested
in the morning. But just the thought of knowing that
when it is one o’clock I have SO much time to recover,
so it is cool. It becomes such a mental thing – you
manage to do it because it is such a short shift, even if
you are not well rested, because it is such a short
period of time until you get to rest. (assistant nurse,
J:249–259)
Improved recovery
Many expressed that they felt more recovered from work
compared to previously. This was a consequence of both
shorter workdays and a different work schedule that
allowed for more time between shifts. Before the re-
duced work hours were introduced, it was common to
work a morning shift after an evening shift. Several par-
ticipants described that they now, because of more avail-
able afternoon shifts, could work an afternoon shift after
having worked the evening shift. This change was seen
as a big improvement, because it was now possible to
have sufficient time for recovery between shifts, even
when working evening shifts.
It feels like there is more time for recovery, absolutely.

(assistant nurse, F: 257)
Like it always has been, all these years, by some
tradition in health care, that the one that has worked
the evening shift shall start early the next day in order
to have some kind of continuity. And it does not have
to be this way. We have the right to get a reasonable
Table 1 Main themes and subthemes
Main themes Subtheme
A more sustainable working situation Energy for work
Improved recovery
Improved work climate
Effects of having no lunch breaks
Improved work–life balance Energy for life outside work
Living life, not just surviving
Consequences of being part of a project Uncertainty over the
future Privilege
Personnel and recruitment
Improved quality of care Improved work performance
Effective use of available resources

rest between the shifts… Then, if you need to work at
7:00 once in a while because of some personal reason,
no one will forbid you, but the possibility is there, to
arrange for a long rest between the shifts. (registered
nurse, E: 156–166)
One person who used to work part-time, described
how she worked more days a week compared to previ-
ously, but because the days were shorter the daily recov-
ery was better, and there was less need for long
weekends to rest.
If you compare the schedule, now I work here almost
every day. If I compare, I used to belong to those who
preferred to work many days and then have more time
off. Like Friday to Sunday or Saturday to Monday. But
for my part I feel better doing this, working shorter
days, because when I worked many days I was very
tired once I had the days off. (registered nurse, G:
169–179)
Similarly, another participant explained that working
five day shifts in a row previously would have made her
exhausted, but that it would not feel as exhausting today
because of the shorter shifts.
If I see one, a week in front of me, where I am working
from 7:00–16:00 five days in a row, then I know that I
would be a zombie on the Friday. But now, a
five-day week, even if it would mean starting 7:00
every morning, although it rarely happens that I have
a week with only day-shifts, but if it did happen, it
would not feel as burdensome, because I know I get to
leave early. (assistant nurse, F: 257–270)
Several participants experienced that their sleep was

improved because they had less stress and ache in the
body and were able to sleep without needing to set
an alarm.
I don’t have this back pain, either, like I had
previously. It means that my sleep is better. (registered
nurse, D: 319–320)
I sleep in every day [laugh]. I don’t set the alarm. I go
to bed, and I sleep eight to nine hours every night, and
it is wonderful. So it feels like I am regaining the sleep
that I lost when I was working nights, because at that
time it was a constant nagging on the sleep. It just
happens. So now, I am rested in a way that I have not
felt in many years. (registered nurse, E: 135–142)
The time off between the shifts increased, which
meant an increased possibility for recovery outside work.
A consequence of this was being able to let go of work-
related thoughts.
If I work Monday and finish at 13:00 and then start,
perhaps I don’t start until 15:30 on the Tuesday or
12:30, and it is quite a long time in between where I
have time to rest and let go of thoughts about work.
(assistant nurse, F: 231–235)
Improved work climate
The workplace climate had improved, according to par-
ticipants. They also experienced more stability within
the group, as there were fewer people leaving or plan-
ning to leave the department. This was experienced as a
big change compared to previously.
I have been here for quite a long time, and there has
almost always been someone that has resigned,

sometimes several people… But now, and since the
summer, I don’t know anybody that has left because
they have resigned. I have always known that there are
people who are leaving, and this is the first time in a
very, very long time, I think, when this isn’t the case.
There has always been a big turnover rate. A
(registered nurse, A:444–459)
There was a better climate among the colleagues and
more joy and laughter at work, and the participants de-
scribed how they felt more of a group feeling.
I think we influenced each other as well, that
everybody was in such high spirits. A feeling of
euphoria in the whole group. (registered nurse, C:
555–558)
“Yes, I think there is more laugher, that people are
happier. It is a good atmosphere, for most of the time.
It is not always paradise, of course; there are many
individuals and there are conflicts here as well, of
course. But it feels like there is a happier atmosphere.
(registered nurse, E: 547–554)
If we get to keep this, and become a unified group, that
we… that is very pleasing. We had an after-work a
while ago and then one of the guys said that we are a
great gang now! Now it is cool, now it is stable! And of
course, I become happier when I feel that WE, we are
a large group of personnel, and we all work, we strive
after the same thing. This is fun. (assistant nurse, J:
605–614)
Some participants described that there was more col-
laboration within the department following the reduc-
tion of work hours, something that improved the quality
of the work.

I am working at a ward, and everybody works six
hours there, and you become a tight team that
particular day. So I do think we have become better at
collaborating, I do actually think so. When we have to
be more focused on what we do. (registered nurse, B:
62–65)
Effects of having no lunch breaks
The participants expressed that the value of having a
six-hour workday was higher than the loss of the
breaks. However, the lack of lunch breaks was defin-
itely a negative effect of the new work situation, par-
ticularly because of hunger. There were differences
among the participants regarding their ability to deal
with having to go longer without eating. Some got
used to it, while others found ways of eating during
the shifts.
[I]t is the only thing that can feel a little hard. And I
think it was hard in the beginning, because I am one
of those hungry persons (laughter). Here you can take
a break when it fits with the work. For example, on
the prosthesis side we should avoid opening the doors
too much. So we have coffee break very early, and then
I am very hungry. So this is something that I have got
used to… but is it the only thing that I have felt as
being a cost. But it is also worth it. I feel that it is
worth it. To know that I can go home at 13:00 and eat
then. (registered nurse, G: 216–228)

And it sounded heavy at first – omigod, is there no
lunch? – but it is so worth it. I get a little hungrier just
before lunchtime, but on the other hand I get to come
home straight after. Instead of sitting there and having
45-minutes’ unpaid break and going back to work
when the alternative is so much more appealing. I can
take it. (assistant nurse, F: 334–339)
We don’t have any break, but we have to be able to
eat. And that has also been a problem, because the
doctors have thought – have been a bit annoyed
because it is six hours, and when we say that we will
eat, they say that we should not eat. Such a miss in
communication. Of course we have to eat during six
hours, but we don’t have a break, and that is
something different. (assistant nurse, H: 340–346)
A negative aspect of removing the lunch breaks was
that the social contact at work was reduced. The par-
ticipants reported that they rarely got the chance to
meet colleagues in the same profession. And some
described how they missed talking to colleagues dur-
ing the lunch break.
Previously, it could be nice to have time to go to the
lunch room and sit down and talk to my colleagues.
So that is possibly a negative aspect, that this
particular time is gone. But it is so worth it. (registered
nurse, E: 194–198)
I think it is a little bit of a shame, this with the
social aspect. Eh… I think that some people stay
after they have finished, if they finish at 13:00, and
kind of stay on and eat lunch afterwards. So you
get a small part of it, but we rarely see each other,
anyway; as an operating nurse you are on your
own. You are the only operating nurse in the

operating theatre all the time, so you rarely meet
and get to speak with the other operating nurses.
(registered nurse, C: 299–314)
Working without taking breaks could make the work
appear more intense. Some participants described the
days as feeling much shorter than expected.
When you work six hours you got to keep going all the
time (snaps their fingers) until you go home…You do
something all the time, and I love it! Time flies. And it
never happens that I look at my watch to see what
time it is…but suddenly we get relieved and it is over.
(assistant nurse, J: 447–455)
So when we started with this six-hour day in November I
experienced that they days went fast. Time just disap-
peared, and six hours passed very quickly. Despite the fact
that we didn’t have any breaks we thought that the work
hours passed very quickly. (registered nurse, B: 20–24)
Improved work–life balance
The participants expressed that after the reduced work
hours were introduced they had a better balance
between work and leisure time, which meant more time
and energy for leisure activities and for non-work-
related everyday tasks. Moreover, the stress of everyday
life was easier to handle, and some experienced an
increased level of control in their lives, as they had more
control over what shift to choose. Finally, a few partici-
pants expressed that they now lived a more ideal life
compared to previously.
Energy for life outside work
Many expressed that there was more energy for life out-
side of work. Some expressed that work used to con-
sume all their energy and that there used to be no

energy left after work, whereas now there was energy for
both work and leisure time.
So I cannot see any disadvantage of working six
hours. I can only see advantages with it. I can work
full-time, I don’t wear down my body, I get a good
balance. I think that as a human you only have the
energy to work a certain part of the day…
Previously, all the energy went to work and there
was nothing left. Now there is a better balance, I
have the right amount of tiredness when I go to
work. (registered nurse, D: 480–492)
Several participants described having more time and
energy to spend time with family and friends.
I can say that I have more energy and desire to
meet people during the weekends when I am off.
Previously (before reduced work hours), I could feel
that I didn’t have the energy, you know. (registered
nurse, I: 178–182)
I do have the energy to call friends and spend time
with them. I still have the desire to do things – as
you do when you are not too tired. (registered
nurse; K, 148–151)
Shorter working hours meant more time and energy,
which some of the participants spent doing physical
exercise.
I am not physically tired, because I work six hours. I

still have energy in my body and can go to the gym
afterwards. (registered nurse, D: 85–86)
We work such short days, so we have time to do many
other things as well, I have time to do a lot of other
physical activity. I think that … my body is stronger
now, after a year, compared to when we started with
this. So… I have time to take care of my body. So I
don’t have massive pain in my shoulders and lower
back anymore. (registered nurse, B: 171–178).
Some used the extra spare time to relax on the beach.
[I]f I start at 15:30, then I cycle out to the sea and lay
there until 14:00, and then cycle to work. I get – it
feels like I have two days in one. I have the time to
have a whole lot of spare time and a whole lot of
work. (assistant nurse, J: 120–125)
Spending less time at work meant having more time to
do other things that needed to be done during the day,
such as dentist appointments and domestic chores. To
have the morning or the afternoon to deal with these
things appeared to create more flexibility, which made
everyday life easier and less stressful.
…I think I have a good balance. It feels like everyone
else says that they just work, that life is all about
work, but I don’t feel that way, anymore. Or, it is like
this: I have two parts, I have work and leisure time
every day… It is very nice actually. Today I will have
time to go to the shops, prepare for Christmas, and
clean, and then I will still have my two hours on the
couch. (assistant nurse, J: 621–630)
I have the time, and therefore I can plan these things,
talks with teachers, visits to the dentist. Normally, I

need to take time off… but if I start at noon, then I
have four hours before lunch… Even if I start at twelve
I am home at 19:00. So I am still at home in time to
eat dinner with my family and help at bedtime. So
from a family point of view this is great. (registered
nurse, C: 71–79)
Some participants related that they had previously ex-
perienced domestic stress relating to everything that
needed to be done outside of work, and that this stress
now was gone.
I feel that there is less stress… It is only positive,
there is nothing negative at all… I think that is the
greatest gain. Because to come home after four o
clock and start cooking food, and then there is
homework and stuff, suddenly the time is way too
much, and I should have managed to do a little
more… Time just flies. And it is not like that now.
(registered nurse, I: 509–521)
Another aspect of the reduced work hours was that
the participants who had previously worked part-time, in
order to manage everyday life, were now able to work
full-time. This had a positive effect on their pay and
pension benefits.
If I had worked here and it was eight hour shifts, I
would have worked part-time. Then I would have
worked 80% – I would not have managed to work
100%, eight hours – I would not have managed that.
Because then my daughter would be at nursery for a
very long time and it would have been… difficult. It is
tiring I have worked 100% as a nurse before I had my
child, at that was ok. But since then I have worked

part-time… Now I can work full-time with all that it
entails regarding pension and salary and so on, but
still have the advantages of reduced work hours. (regis-
tered nurse, F: 64–74)
Living life, not just surviving
All participants expressed that their life situation
had improved and that there was more time to do
what they really wanted. They appeared to be living
life in a manner that was closer to an ideal way of
living.
I feel that it must be a little bit more like this that
one is supposed to live. Instead of working all day,
going home and picking up tired children and what
not. No, I, because I feel that I have another form
of energy, I come home and it is afternoon and I
have time to be in the sun and take care of things.
And socialise, and spend time with the family.
(registered nurse, G: 602–612)
You get a life. I can say as much. You do get it,
actually – it is unbelievable what a big difference
these two hours make. (registered nurse, B: 460–465)
A consequence of gaining a better balance was the
experience of living a fuller life.
Everything is about work, and it is your life… Work is
a big part, but you still have to have the energy to live!
That is the primary thing, and if you have the energy
to live and feel that you have the energy to manage

things, then you are happy. And, of course, when you
feel good, that will have an influence on work.
(registered nurse, K: 61–167)
Consequences of being part of a project
The reduction of work hours within this department is a
time-limited project that was planned to run for two
years. It will be evaluated and possibly become a
permanent change. Because of this situation, the partici-
pants described uncertainty over the future of their
employment and the department. However, their
descriptions of the project were full of enthusiasm for
reduced work hours, and it was seen as a privilege that
they were willing to make sacrifices for.
Uncertainty over the future
Because the project is time limited, many participants
expressed that there was a feeling of uncertainty among
the staff. Many were worried about what would happen
in the future and predicted a high risk of staff leaving
the workplace if the reduced work hours were to be
discontinued.
If they stop this and decide that we will not continue
to get it (reduced work hours), anymore, then people
will flee this place… Because it is orthopaedic surgery
we are working with and many think it is demanding
work… so these six hours make up for that. (registered
nurse, D: 687–693)
I think things could turn out really bad for this
workplace if that were to happen (that reduced work
hours would be discontinued)… Because, as I have
said, this (reduced work hours) has raised the place so
much… I am not sure, but I think that many would
quit. (registered nurse, G: 322–327)

The main determinant of whether the project
would be continued was the cost-effectiveness of the
programme, according to the participants. Cost-
effectiveness in this context meant producing more
care to compensate for the increased costs linked to
reduced work hours. The participants believed that
the well-being of the personnel was not enough to
compensate for the increased costs.
It is not enough that we, the personnel, are satisfied, it
is not enough. Instead, it has to be shown, that we
have a high production, that it is worth it, to take care
of all people, so nobody should have to wait, and
nobody should have to be sent to other hospitals,
which costs money… That we can be cost-effective.
And that through this we can see that this is worth it.
(registered nurse, K: 43–49)
We have produced a lot more, but it is still money in
the end, and, yes, they have to do their estimations,
and so, I don’t know, nothing is certain. (registered
nurse, G: 316–320)
The belief that the economy was the most important
factor appeared to create an expectation of increased ef-
fectiveness and productivity, something that could lead
to feelings of stress.
[T]his is a project, and we are not sure that we get to
keep it. So I am on my toes, for sure, I don’t want to
laze around. I wouldn’t do that normally, either, but
do I hurry up. (assistant nurse, J: 414–419)
Now, there is a goal that we should become more
effective, we shall work, do more, because everyone
wants to keep the six hours… so then I do shape up

(assistant nurse, H: 134–137)
I know some that think that the pace is much higher,
that they feel more stress. That is not my experience…
Organisational change can be stressful, but here it has
been so positive. (assistant nurse, F: 535–538)
Privilege
A pervading theme in the participants’ accounts was the
expression of elation and enthusiasm for the reduced
work hours project. They described a feeling of being
chosen and having been given a privilege that they
wanted to make the best of.
I think we have a great situation… We say that
several times to each other, God, we got it so good!
Now we are going home at 1 p.m. Great! (assistant
nurse, F: 35–38)
Because it is still a sign of trust, a gift that we have
received, a possibility. That one wants to make the
best of. (registered nurse, K: 356–357)
Some of the participants stated that the new work
hours were such a positive change that it would be diffi-
cult to consider working anywhere else if the shortened
work hours became permanent.
A negative aspect was that – haa, now I can’t work
anywhere else, if I should ever have those thoughts,
because this is too damn good… I guess I get to stay
here (laughs), because it is difficult to give this up, as

it is fantastic. (registered nurse, E: 533–539)
I feel a little worried about whether I will ever dare to
leave this place if we get to keep the six hours… Will I
hold on to this and not dare (laugh), dare to move and
try something else? (registered nurse, I: 589–593)
A common theme in the interviews was that the
reduced work hours had meant so many positive things
in the participants’ lives that they preferred to endure
the negative aspects and problems linked to the reduced
hours rather than going back to normal working hours.
To go back and work nine hours … with a lunch, it is
not an option for me, if I get to choose this. Despite
nights and a non-existent management. Despite a lot
of different things, such as severely ill patients and
other things. (registered nurse, C: 334–337)
Personally, I think it is fantastic to work six hours. It is
intense and you don’t get a break, but that does not
bother me at all. So I think that in life this suits me
really well. (assistant nurse, H: 36–41)
There are a lot of great things with this… Some people
you don’t see for weeks, sometimes. But still I have to
say that I would not swap this for anything in the
world. I really hope it will be continued. (registered
nurse, B: 677–685)
Many of the participants experienced the reduced
work hours as something very positive, and they believed
that more people should have the opportunity to try it.
The more you look at it, the more you realise that this
is something that everybody should have… I think… I
do actually think that everybody experiences positive

effects from it. (registered nurse, D: 784–789)
I hope that it will be continued and that there will be
more that dare to try it. (registered nurse, G: 595)
Personnel and recruitment
The participants described how the reduced work hours
had involved hiring more staff to fill out the new shift
schedules. Previously, the department had had problems
recruiting and had needed to hire temporary staff from
staffing agencies. Several of the participants reported
that the reduced work hours were a big reason they
started working at the department. Another aspect that
was highlighted in the interviews was the possibility of
attracting new staff through reduced work hours rather
than with salaries.
It was actually this project that attracted me, to have
the opportunity to be part of it, to work six hours and
try that… So that was the crucial … that I applied
here. Mm, so I was here from the beginning when it
started. (registered nurse, K: 13–18).
To compete with the salary is not done that
much… rather it is, oh, how can we get the staff?
And it is so difficult within certain areas within
health care. It really is. And this is a fantastic way
of recruiting personnel. It is a big gain. (registered
nurse, K: 567–573)
Previously, they have not been able to recruit
people. They have had many, especially operating
nurses – there have been so many temporary
nurses from staffing agencies. And it must have
been expensive having them all. Now suddenly…
now they start to work, recently graduated,
though, but they are really great, those girls and

boys. They started recently five or six, and this
attracts people, it really does. (registered nurse, D:
677–685)
The participants described how the newly recruited
staff have had a positive effect on the atmosphere in the
department.
And it is people that have been attracted to this place
because of this… We, the people that have started are
bringing in an amazing energy and positive
atmosphere… that I believe has had a positive effect
on the whole department. And it is not only the case
that they can attract people – they can attract very
good people. (registered nurse K: 575–582)
Improved quality of care
All throughout the interviews the participants described
that there was an improvement in the quality of care
due to the new shifts that were introduced together with
the reduced work hours.
Several factors led to this improvement, including an
improved performance of the staff and better use of
available resources such as operating theatres.
Improved work performance
Some participants reported that they had improved
their work performance following the reduced work
hours. For example, they described being focused on
doing a good job during the operations.
You have one or two operations. And you got to
finish those. And you can do it really great. I do
think that I am doing a qualitatively better job now
compared to previously. I have always aimed to do

a good job, but I think that my work is even better
now, actually. I do actually believe this… because I
know that ‘This is the operation that I shall do,
then do it well.’(registered nurse, B: 277–283)
Some participants reported that the staff had more
energy following the reduced work hours and were
therefore able to engage more with the patients com-
pared to previously, when they were more tired.
I think that people were more exhausted and found
it more difficult to motivate themselves to do a
good job, compared to now. Now I believe that
several feel that they have the energy to engage with
the patients and do the job we are supposed to do.
(registered nurse, C: 641–643)
Several of the participants said that the new shifts
have meant fewer door openings during the opera-
tions, which decreases the risk for infection. In
addition, a further benefit of having fewer changes
of staff during the operations was the reduced risk
of misunderstandings and mistakes.
The fewer changes you have, the fewer times the door
is open, the fewer people that are involved, the less risk
of misunderstandings or something being forgotten or
misunderstandings. In fact, the more people that are
involved in something, the more potential mistakes.
(registered nurse, B: 116–121)
Effective use of available resources

The new shifts allowed the department to use the oper-
ating theatres during a larger part of the day, according
to the participants. Previously, the work had to be
wrapped up early in the afternoon, because the staff
were finishing work in the afternoon. The participants
proudly described how the department had increased its
activity and how the rooms were now better used.
[T]hen we had to… start wrapping up early at
several operating theatres so that we were done by
three o’clock, because people finished work at four
o’clock. And then you can’t start the next operation,
because it would take too long. So the operating
theatres were not effectively utilised, and that is
also a big cost… having them stand empty cost a
lot. (registered nurse, E: 320–330)
[T]he six-hour workday and the increased number of
staff has meant that we can open another operating
theatre… which means that our activity has increased.
(registered nurse, E: 390–392)
In addition, the participants experienced that the time
they spent at work was used more efficiently compared
to previously. The time they called ‘wasted’ had been re-
duced, and the elimination of breaks meant that they no
longer needed to replace each other during lunch breaks,
something that used to take a lot of time.
I was going to replace her (during a surgical
procedure)… And then I had to get into the work and
all the equipment that is needed for the operation, and
then she comes back forty-five minutes later… and
then I would go out again and report to her what has
happened during the hour. No it was not good. This
way is much better. Now I replace her and she goes

home, and I stay until it is finished. (registered nurse,
D: 246–257)
In my experience we are more effective than when we
worked eight hours. Because it was a lot of looking at
the watches: ‘Oh, soon there is lunch,’ a little bit like
that. (registered nurse, B: 74–77)
Discussion
The current qualitative study investigated the experi-
ences of reduced work hours and no lunch breaks
among nurses and assistant nurses at an orthopaedic
surgery department in Sweden. Four main themes with a
number of subthemes were found in the interview data.
The main themes were A more sustainable working situ-
ation, Improved work–life balance, Consequences of
being part of a project, and Improved quality of care. All
participants in the study appeared to view the reduced
work hours as a positive change at work.
‘A more sustainable working situation’ consisted of a
number of subthemes, including ‘Improved recovery’.
According to the participants, working shorter days im-
proved recovery in several ways. Work consumed less
energy because the participants spent less time at work,
and there was more time for recovery before and after
the work shifts. Thus, the workdays were shorter and
the periods outside work were longer, which created
good opportunities for continuous recovery from work.
Indeed, previous research has found that daily recovery
is more important for health than longer vacations. The
positive effects of a vacation quickly disappear [16].
However, in the present study the lunch breaks were
eliminated, and shorter breaks/pauses were not guaran-
teed. In the subtheme ‘Effects of having no lunch breaks’
the participants reported that the reduced work hours
compensated for the lack of breaks. The lack of breaks

was not described as a big problem for the staff. A rea-
son for this could be that the staff had been involved in
the planning of the new work hours and shifts, which
meant that they had a certain level of control over the
work situation. The lack of breaks most likely involved
intensifying work, which can have negative health ef-
fects. In a study with driving instructors it was found
that removing shorter breaks and intensifying the work
had negative effects on sleep and cognitive performance
[12]. However, the work hours were not reduced in that
study. In addition, a study with social workers found that
reduced work hours had a positive effect on restorative
sleep, sleep quality (on weekends), stress, sleepiness, and
fatigue and exhaustion (both on workdays and weekends).
Moreover, instrumental manager support was also affected
positively, which is somewhat in accordance with the
present study, which found an improved work climate [6].
In the main theme ‘Improved work–life balance’ the
participants described an improved balance between
work and leisure time. Improved balance between work
and life involved several aspects, such as more energy to
do things during leisure, time including increased social
activity and exercise. Indeed, a previous study on the ef-
fects of the six-hour workday, for female health care and
day care personnel, found that the biggest effect was in-
creased time for social activity [8]. However, the same
study did not find an increase in exercise. The partici-
pants in the current study also reported that it was eas-
ier to handle the everyday stress with children and
family commitments following the reduced work hours

and that they experienced an increased control over
working hours. The previously mentioned study found
that reduced work hours had a positive effect on work
intrusion on private life [6]. Previous research has shown
that a poor work–life balance, regardless of gender, is re-
lated to having more health problems compared to em-
ployees with a good work–life balance [18].
‘Consequences of being part of a project’ was a main
theme related to the fact that the reduced work hours pro-
ject was introduced on a temporary basis with no definite
end date. The participants reported experiencing uncer-
tainty and worry over what would happen in the future
expressed a strong wish for the project to continue. The
uncertainty and lack of control regarding what would hap-
pen with the working situation in the future appeared to
lead to worry among the participants. Indeed, control is
an important factor in well-being at work, and lack of
control can have negative effects on health [19].
The final main theme was ‘Improved quality of care’,
which described how the participants reported that they
had improved their performance and that the depart-
ment’s resources were used more effectively following
the reduced work hours. Indeed, increased production
and employee health do not need to be the only mea-
sures of the effects of reduced work hours. Quality of
care could also be a relevant outcome measure. The pre-
liminary results in the evaluation of a six-hour workday
at a nursing home for the elderly in Gothenburg munici-
pality found that the assistant nurses experienced that
they were providing better care [10]. Another study that
evaluated reduced work hours compared to physical
activity at work found that the group that had reduced
work hours had improved their productivity more than
the group that did physical activity [9].

There are several limitations with this study, one being
the low response rate, with only 10% of the members of
staff agreeing to take part in the study. It could be the
case that the participants who agreed to take part were
the members of staff that were particularly positive or
negative towards the project. It is also possible that the
participants wished to portray the project in a good light
during the interviews for fear of a negative evaluation of
the project. These risks need to be considered, but the
interviewers were very aware of these possibilities and
asked about both positive and negative aspects of the
participants’ experiences. In, addition a structured inter-
view questionnaire could have assisted the data analysis.
Transferability is important to consider in qualitative
studies. Issues such as the sample and number of groups
and interviews need to be considered. The sample con-
sisted of individuals who worked as nurses or assistant
nurses with reduced work hours at a particular depart-
ment. Only a small proportion of the staff at the depart-
ment took part in the study, so it is not possible to say
that the findings represent all individuals. However, this
is in accordance with the method of IPA, where studies
are conducted with small sample sizes, and through pur-
posive sampling a group of participants is found for
whom the research question is significant [17]. Regard-
ing generalisability, it could be said that if the study has
identified an experience, it could be similar for many
others. For the current study it is also important to re-
late the finding to previous studies (see above) and
thereby add to the accumulation of results regarding the
experience and effects of reduced work hours [20].
Possible implications of these findings are that the re-

duced work hours could help to create a more
sustainable working situation for nurses and assistant
nurses. There may be positive long-term effects on both
physical and psychological health that is not yet evident.
Reduced work hours increase the possibility for suffi-
cient recovery between the shifts. However, some
participants found it difficult to work a whole shift with-
out a break (although they still thought it was worth it),
and for future studies it could be important to consider
the issue of recovery or lack of recovery while working
for six hours without a break. Perhaps a formal system
for food intake during the shifts could be useful. There
have been difficulties recruiting nurses within this par-
ticular region, and another implication could be that
implementing reduced work hours is a way to create
an attractive place of work for nurses that would
make the recruitment process easier. This particular
hospital could not compete for staff with higher
salaries than other departments, so offering reduced
working hours could be one effective way to attract
skilled personnel. Furthermore, the participants
expressed that they were now able to provide better
care for their patients, and this could also be a pos-
sible effect of reduced work hours.
Implications for nursing practice research is that
future studies should evaluate short- and long-term
individual and organisational effects of reduced work
hours including quality of care. Considering this is a
qualitative study, that cannot be generalised to the same
extent as larger quantitative studies, further studies are
needed to draw firm conclusions regarding the effects of

reduced work hours and to make suggestions for nursing
practice research.
Conclusions
The present study explored the experiences of a number
of nurses and assistant nurses who had reduced work
hours. Four main themes were found: A more sustain-
able working situation, Improved work–life balance,
Consequences of being part of a project, and Improved
quality of care. Overall, reduced work hours appeared to
have many, mainly positive, effects, in both work and
home life.
Acknowledgements
The authors wish to thank all the participants who contributed
to this study.
Funding
This research received no specific grant from any funding
agency in the
public, commercial, or not-for-profit sectors.
Availability of data and materials
The data from this article may be requested at no cost from the
first author.
Authors’ contributions
KG designed and planned the study. GA and HM conducted the
interviews.
All authors analysed the data. KG wrote the manuscript drafts.
All authors
reviewed manuscript drafts and approved the final version.
Competing interests
The authors declare that they have no competing interests.

Consent for publication
Informed consent to participate in the study was obtained from
all participants.
Consent for publication was obtained from all participants.
Ethics approval and consent to participate
The study was approved by the Regional Ethical Board in
Gothenburg
(Regionala Etiksprövningsnämnden i Göteborg) diarienummer
698–15.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional
claims in
published maps and institutional affiliations.
Author details
1Department of Occupational and Environmental Medicine,
University of
Gotenburg and Sahlgrenska University Hospital, Gothenburg,
Sweden.
2Department of Psychology, University of Gotenburg,
Gothenburg, Sweden.
Received: 27 September 2016 Accepted: 23 March 2017
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AbstractBackgroundMethodsResultsConclusionsBackgroundMet
hodBackgroundParticipantsProcedureData analysisResultsA
more sustainable working situationEnergy for workImproved
recoveryImproved work climateEffects of having no lunch
breaksImproved work–life balanceEnergy for life outside

workLiving life, not just survivingConsequences of being part
of a projectUncertainty over the futurePrivilegePersonnel and
recruitmentImproved quality of careImproved work
performanceEffective use of available
resourcesDiscussionConclusionsAcknowledgementsFundingAva
ilability of data and materialsAuthors’ contributionsCompeting
interestsConsent for publicationEthics approval and consent to
participatePublisher’s NoteAuthor detailsReferences
Municipal Night Nurses’
Experience of the Meaning
of Caring
Christine Gustafsson, Margareta Asp and Ingegerd Fagerberg
Key words: care of older people; caring in nursing;
gerontological care; night nursing;
phenomenological hermeneutics
The aim of this study was to elucidate municipal night
registered nurses’ (RNs) experi-
ences of the meaning of caring in nursing. The research context
involved all night duty
RNs working in municipal care of older people in a medium-
sized municipality located
in central Sweden. The meaning of caring in nursing was
experienced as: caring for by
advocacy, superior responsibility in caring, and consultative
nursing service. The muni-
cipal night RNs’ experience of caring is interpreted as meanings
in paradoxes: ‘being close
at distance’, the condition of ‘being responsible with
insignificant control’, and ‘being
interdependently independent’. The RNs’ experience of the

meaning of caring involves
focusing on the care recipient by advocating their perspectives.
The meaning of caring
in this context is an endeavour to grasp an overall caring
responsibility by responding to
vocational and personal demands regarding the issue of being a
RN, in guaranteeing
ethical, qualitative and competent care for older people.
Introduction
Older peoples’ need for care is expected to increase in line with
changes in life ex-
pectancy and variation in the patterns of diseases over the next
50 years.1–3 There is an
increasing prevalence of age-related morbidity and disability in
the European popu-
lation.4 Older people experiencing multiple functional decline
combined with a need
for medical care require a mix of services from multiple
providers.5 Key contributors
to Swedish municipal care are night nurses who provide nursing
care and medical ser-
vices during the night to large groups of older people in
community facilities. Nursing
has changed significantly in recent decades, which will continue
in the future, with
nurses taking on different roles, especially in the long-term care
of older people.6 In
many western countries care for older people is being
transformed from a health care
model towards a social care model.7 This study concerns
municipal night nurses’
experiences of the meaning of caring in nursing.
Address for correspondence: Christine Gustafsson, Mälardalen
University, School of Health

Care and Social Welfare, Mälardalen University Eskilstuna, PO
Box 325, SE-631 05 Eskilstuna,
Sweden. Tel: +46 16 15 3469; Fax: +46 16 15 3740; E-mail:
[email protected]
Nursing Ethics 2009 16 (5) © The Author(s), 2009.
10.1177/0969733009106652
Reprints and permissions:
http://www.sagepub.co.uk/journalsPermissions.nav
600 C Gustafsson et al.
Nursing Ethics 2009 16 (5)
Caring in nursing
The concept of ‘caring in nursing’8 encompasses the caring
dimension in municipal
nursing practice during the night. Caring is accepted as a central
concept in nursing
practice.9–11 Van Hooft8 conceptualizes caring in nursing as a
virtue. This includes the
dynamics between a ‘caring perspective’ and a ‘justice
perspective’ that relate to the
ethical life of nursing. The caring perspective is an emotional
concept that stresses feel-
ings of concern and relationships between nurses and care
recipients that inspire and
motivate caring practice. The justice perspective focuses on the
effective performance
of professional nursing practice, whether or not motivated by
feelings of sympathy or
compassion. The dispute between these perspectives is
accommodated in moral theory
by virtue ethics.12

Care of older people from an international perspective
The municipal nursing of older people in Sweden comprises
care in special forms
of housing, nursing homes and other community-based settings
or home care.13–15
Registered nurses’ (RNs) care of older people includes
characteristics of both long-
term16 and palliative17 care around the clock and is defined as
gerontological nursing18
and community nursing.16 RNs’ night care is different from
day-time care.19 Today’s
RNs’ night-time care of older people often entails administering
treatments and under-
taking activities also associated with day-time care.13,18 In
Sweden, the role of RNs who
work in the social care context appears different when compared
with the hospital
context.
Swedish municipal care for older people
Swedish municipal care for older people is regulated by two
separate laws. The Social
Services Act20 governs care mangers, residential home mangers
and care staff (en-
rolled nurses and nurses’ aides). The Health and Medical
Act21,22 regulates RNs and
physicians. RNs may delegate care staff23 to carry out nursing
care.21 Care staff are, by
definition, on the same organizational level as RNs. This means
that RNs do not have
any authority regarding the provision of social care, nor are
they staff leaders.24,25 In
2006, 4.7% (12 200) of staff working in the municipal care of
older and disabled people
were RNs.26 No data are available for exclusively night-duty
RNs.

To ensure appropriate care, RNs are employed in municipal
social care21 and also act
as supervisors for care staff.27 These RNs have responsibility
for large groups of older
people, especially during the evening and at weekends,27,28
and for even larger groups
during the night. Care staff provide overnight care while RNs
rarely provide bedside
care. Unlike night RNs caring for older people in the UK15 and
the USA,29 Swedish
RNs have a telephone consultation function. Every area of the
municipal social care
of older people is covered by day/evening duty RNs who are
responsible for different
caring units. These RNs call the night duty RNs to report any
care recipients who will
need nursing care or a visit during the night. The night duty
RNs work in pairs, and
for about 15 minutes they will receive telephone reports from
their different areas of
nursing responsibility. They then prepare summaries and a
schedule for their planned
visits. When an RN is required in a central residential home the
two nurses normally
Municipal night nurses’ experience of the meaning of caring
601
go together. When a unit on the outskirts of the town requires a
RN visit, they split
up because they must arrive at any calling unit within 30

minutes. The RNs can have
approximately 30–50 telephone consultations during one night
and a total of about 15
nursing visits (two or three of these may be visits to care
recipients who are at the end
of life).
The RNs’ working conditions are described in terms of being on
call to support and
direct care staff and, on request, to arrive at a calling unit
within 30 minutes. Tasks of
planned advanced medical care and contact visits to persons
being cared for at the end
of their life are also included. For support, the RNs can contact
the district physician on
call. The RNs can also make referals to the hospital emergency
department.
The RNs’ nursing responsibility includes all outpatients
enrolled in home care and
supporting care staff in assisting old people with alarms. They
are also accessible for
both planned advanced medical treatments and unplanned
nursing needs in the muni-
cipal catchment area. Two RNs have nursing responsibility for
the night-time care
needs of approximately 2700 people.
Rationale
Little research has focused on nursing provided at night.30–32
Existing studies have
mainly described RNs’ work in hospital settings32 rather than
in the municipal, social
care context. An expected increase in the need for RNs to care
for older people in
special forms of housing, nursing homes and other community-

based settings or home
care suggest the importance of investigating nurses’ caring at
night. This is particu-
larly important when there is nursing responsibility for large
groups of older care reci-
pients. When conceptualizing caring as ‘the ethical life of
nursing’,8 questions about the
meaning of caring in nursing are justified: What is caring in
municipal night nursing?
How do night RNs who provide nursing and medical services to
large groups in the
community experience caring? The aim of the present study was
to elucidate municipal
night RNs’ experiences of the meaning of caring in nursing.
Method
Understanding the meaning of people’s lived experiences in new
and different ways
and explaining them in a better way may open up opportunities
for people to live better
lives. According to the French philosopher Paul Ricoeur,33
lived experience remains
personal but its meaning can be transmitted through the
interpretation of narratives.
The aim of the interpretation is to reveal the meaning in a text,
that is, to interpret the
world that is opened in a text. Its meaning is not created by our
interpretation; it is
already in the world. Through the interpretation of texts we can,
however, learn more
about world phenomena.
A phenomenological-hermeneutic method, inspired by
Ricoeur33,34 and developed
by Lindseth and Norberg,35 was used for the text analysis. The
aim of this method is to

interpret (i.e. to elucidate and understand) the meaning of a
phenomenon as it emerges
from the text.34 The scientific openness of Gadamer’s
philosophical hermeneutics,36 as
well as Ricoeur’s33 distancing, questioning and critical
approach, influences the inter-
pretive process.
Setting and participants
The research context involved all seven night duty nurses
working in the municipal
care of older people in a medium-sized municipality (90 000
inhabitants) located in
central Sweden. All-night RNs in this district also participated
in a larger project ex-
ploring municipal night nursing. The RNs were all women who
were experienced in
the profession, having worked for 6–35 years in various nursing
contexts. At the time
of the data collection for the present study, two participants
withdrew owing to illness
or termination of employment.
In January 2006, the participants had nursing responsibility for
21 units for older
people in sheltered housing. They also had nursing
responsibility for 25 special hous-
ing units for disabled persons. During collection of the data
(January–May 2007) the
RNs reported increased nursing responsibility that included all

outpatients enrolled in
home care, support for care staff assisting older people with
alarms, and having to be
accessible for unplanned nursing needs in the municipal
catchment area.
Data collection
The first author (CG) conducted open, tape-recorded interviews
with the participants.
Follow-up questions varied between the interviewees,
depending on the individual
narratives.37 The interviews lasted for between 55 and 120
minutes and were conducted
in privacy at the local university. The questions were chosen to
cover relevant aspects
of the participants’ experience of caring in nursing by asking
the following opening
questions: What does caring mean in municipal night nursing?
How do you experience
caring in your work?
Ethical considerations
Permission for the study was obtained from the staff manager
responsible for the RNs
in the municipal organization. The study was approved by the
Regional Ethics Board
in Uppsala (ref. 2004-Ö-437).38 Participating RNs were
guaranteed confidentiality and
were offered supportive guidance, but none requested this.
The general rules for good research practice concerning
honesty, openness, con-
sideration of research value and impartiality were
respected.39,40 More specifically, the
study was also considered appropriate to satisfy the research
criteria of risk–benefit

assessment,40,41 importance and quality, and protection of
individual participants.39,42
Interpretation process and results
The process of interpretation of the transcribed interviews was
guided by a phenomen-
ological-hermeneutic analysis using three phases: naive reading,
structural analysis
and comprehensive understanding.35 Each interview transcript
was read several times
in order to grasp its meaning as a whole (naive understanding).
A structural analysis
was performed and, in a process carried out by the first and
second authors, related to
the naive understanding in order to elucidate the different parts
of the text. Initially the
text was split into meaning units defined as a piece of text of
any length that expressed
a meaning of caring in nursing. The meaning units were
condensed and reflected upon
to identify similarities, variations and differences, and then
used to create subthemes.
603
These subthemes were then grouped into themes by reflection
and abstraction35 (Table 1).
During this process of structural analysis, the naive
understanding was reconsidered
and revised.

Table 1 Examples from the structural analysis
Meaning unit Condensed meaning
unit
Subtheme Theme
When you enter an old person’s room
at a unit, you do not just rush into the
room, turn on the light and speak loudly,
deliver the injection and then leave. You
have to be careful, knock on the door,
try to speak to the person in the bed, and
ask how he or she is experiencing the
problem. I also always take my jacket off
before I enter the room.
In caring for the care
recipient the nurse is
deliberately careful
and aware of the care
recipient’s well-being
and comfort.
The nurse does not just
enter a room, turn on the
light, do her nursing task
and then leave.
Considering
care
recipients’
perspective
Caring
for by

advocacy
You kind of try to have your eyes open,
to see the person behind the disease,
but also to see relatives and the care
staff ... to see wider and observe more
than just the task you are there for ...
to see the whole situation ... it is to see
relatives, the care staff ... in this case,
they had not succeeded in checking the
blood glucose, they did not understand
the blood glucose machine ... and this
was something I discussed with them
afterwards ... I mean it was correct of
them to give the man sugar cubes, they
understood he had hypoglycemia, they
were not sure, but anyway they gave
him sugar, and that was good! I mean
it is better to do that than to do nothing
... anyway they did handle the situation
and it is about giving support and
paying tribute to their actions.
It is a nursing process to
be open, observant of the
whole situation, to see
the person behind the
disease.
Not to ignore the
complex situation.
To observe the care
recipient’s comfort,
the relative’s situation
and care staff’s caring.

Trying to figure out the
needs for all involved
in preparing a caring
situation.
Considering
situations
in wider
perspectives
If I observe, for example, medicine that
does not work, or if it is care staff who
do not understand how to care or, in
some way I tell them how I want it to be,
or how I think the care recipient would
like to be cared for ... that is what I do
... In some way I think I more and more
have to stand up for the care recipients to
protect them from relatives’ ideas of how
the care should be ... actually, nowadays,
some relatives have many strange
ideas and like to consider themselves
as the ones knowing what is best care
... and somewhere there you have to be
courageous and tell them that ... NO ...
The care recipient’s well-
being, needs and comfort
are prioritized ahead of
relatives’ or care staff’s
requests.
Caring with
a prioritized
care
recipient

focus
Meaning unit Condensed meaning
unit
Subtheme Theme
In my work the most important thing
is to make sure that the care recipients
are given proper care, that I am doing
my best every time I make a nursing
contribution and that I have courage to
act when I observe something wrong or
insufficient care.
The main function in
nursing is to guarantee
care, the recipient’s
well-being and doing
one’s very best every
time when caring for
someone.
To have courage to take
charge when observing
insufficient caring.
Protecting
and
guarding

care
recipients’
rights
Table 1 (Continued)
Each interview text was then read again as a whole and related
to the naive under-
standing and the findings from the structural analysis. It was
then reflected upon in
discussions with all three authors, resulting in an interpretation
of possible meanings
of caring in nursing. From the interpretations a comprehensive
understanding was
formulated, which took into account the authors’ pre-
understanding (see ‘Critical
considerations’ section).
Naive understanding
A naive understanding was formulated linked to the structural
analysis, as follows.
Caring is a fundamental stance exercised in nursing activities by
RNs, meaning caring
advocacy of care recipients in encounters, nursing actions and
nursing service. A caring
stance means that the care recipients’ rights are considered and
given priority ahead
of the requests of others. Prioritization in nursing exists in an
implicit hierarchy giving
caring precedence in the following order: care recipients,
relatives and care staff.
Caring in night duty nursing is initiated by other staff or
relatives’ cell phone com-
munication in informing and consulting the RN. ‘Caring for’

means mediated caring in
a triad with care staff (or relatives), that is, this type of caring
in nursing means remote
caring, being on alert and supporting backup care staff (or
relatives) in caring for care
recipients. These RNs’ remote caring dimension with superior
caring responsibility
makes the process of emphasizing and expressing the care
recipients’ perspectives
easier by advocacy in guarding their needs, well-being and
dignity ahead of those
of care staff (or relatives). ‘Caring about’ has a preventive
dimension in developing
confident relationships with care staff and relatives, and caring
service mainly implies
RNs’ medical services.
Structural analysis
In the following sections the meaning of caring is described
according to the three
themes: caring for by advocacy; superior responsibility in
caring about; and con-
sultative nursing service (Table 2).
605
Caring for by advocacy
Caring for care recipients, relatives and care staff means
attending to persons in need of
a RN consultation. This includes both direct caring encounter

situations and telephone
consultations mediated by care staff or relatives. The primary
persons cared for are the
care recipients, which means that their perspective is constantly
taken into account,
although care staff’s or relatives’ problems may be the reason
for the consultation.
Caring for by advocacy means prioritizing care recipients’
perspective, and caring
encounters being achieved in a hierarchical fashion. This
hierarchy means that care reci-
pients’ needs are given precedence, followed by those of
relatives. Finally, care staff’s
problems and needs must be considered.
Caring for by advocacy is related to respecting care recipients’
basic human rights
such as dignity, integrity and autonomy. It also means reflection
on care recipients’
problems using a broader perspective (their life situation).
Assessments in caring
situations imply caring while endeavouring to see the person
behind the disease/con-
dition. Here, caring means understanding the situation by
stopping and reflecting, and
using nursing experience to consider the problem combined with
the RN’s own life
experiences:
... you kind of try to have your eyes open, to see the relatives
too; I think you have more ...
I believe it is a process of maturing, looking more broadly than
just at the problem.
Having concern for the care recipient can often mean leaving

direct caring actions to
the care staff who are familiar to the care recipient. Experience
and knowledge facilitate
understanding of care recipients’, relatives’ and care staff’s
situations.
Table 2 Subthemes and themes describing municipal night RNs’
experiences of the
meaning of caring in nursing
Subtheme Theme
Caring with a prioritized care recipient focus
Protecting and guarding care recipients’ rights
Considering care recipients’ perspective
Considering situations in wider perspectives
Caring for by advocacy
Caring at a distance
Co-operating and collaborating with care staff
Adopting a superior caring responsibility
Prioritizing problems requiring a nurse
Being accountable for care staff’s caring
Supporting and supervising care staff‘s and relatives’ caring
Advising care staff and relatives by confidence and courage
guidance
Superior responsibility
in caring about
Caring during brief encounters
Assessing needs and problems
Caring with extensive nursing experience
Caring with a range of problems
Giving service in advanced medical treatments

Giving medical service in advanced medical treatments
Consultative nursing
service
Caring during life’s final stages means contact visits to
guarantee care recipients’
well-being, signify accessibility, and offer further contact
between relatives and care
staff. Caring for aggressive and anxious people with dementia
means allowing flexi-
bility with the care recipient and striving to attain the best
possible treatment for the
condition while giving support to care staff in a difficult
situation.
Superior responsibility in caring about
Caring about care recipients, relatives and care staff by superior
responsibility means
adopting vocational accountability by virtue of being a RN.
Caring about implies a
more remote and distanced caring, excluding direct care and
caring encounters. Caring
about concerns situations in which RNs’ caring is negotiated,
which are triadic with
care staff as mediators.
Caring in the current context means responsibility in preparing
propitious conditions

for night caring by co-operation, collaboration, and supporting
and supervising care
staff or relatives.
... that you are explicit in terms, they should know that you are
there for them, there is a
nurse with superior responsibility. If there are any questions or
something they would like
to discuss they should turn to me through the care staff, because
I am seldom at the unit ...
Collaborating with care staff also means managing staff, and
sometimes directing
how caring is to be employed. In RNs’ adoption of a superior
caring responsibility,
car ing about may be seen to benefit from RNs rarely
participating in bedside care. This
facilitates supervision by RNs and sometimes involves care
staff in discussions of how
to care for care recipients. A superior caring responsibility also
includes estimating
care staff’s competence in dealing with delegation and
instructions.
The focus on care recipients requires, in some cases, teaching
care staff to provide
competent care. A superior caring responsibility also means
having a mandate from
care staff concerning decisions, instructions and actions to
solve problems that have
been raised. Superior accountability and requiring a mandate
imply that RNs need
confidence and courage in the nursing profession. The authority
function also means
adopting an overall caring obligation entailing removing
responsibility from care staff

or relatives by taking charge of a particular problem:
I must be explicit, to inform relatives about the situation, this is
what we can offer and
what we will do, and there is a kind of response reflecting their
understanding about the
expected course of events ... in some way I give them a part of
me as a professional nurse
... to be there at hand, and in my view, approach to care for the
care recipient, and also to
care for the staff ...
Caring about also includes a prioritizing dimension, signifying
assessment and
prioritization of when a face-to-face RN consultation is needed.
This is enabled
by support from other caring team professionals’ and the
organizations’ models of
prioritization. Caring about by superior caring responsibility
means striving for caring
advocacy in facilitating quality and competent night care for
older people.
Consultative nursing service
Providing a night nursing service to care recipients, relatives,
care staff and clients
of a municipal organization means that RNs must be on the alert
to respond to acute
607

problems and needs requiring RNs’ skills, competence and
authority. The nursing
service mainly has the characteristics of medical services, also
including planned
activities ordered by clients of municipal social care.
... it can be various treatments in private homes, for example,
parenteral nutrition via a
port-a-cath [a subcutaneous central venous catheter], peritoneal
dialysis, or vacuum
pumps for leg ulcers.
These nursing tasks mainly involve advanced medical technical
treatments neces-
sitating the contribution of a RN.
The on-call dimension entails nursing consultations during brief
encounters con-
cerning the assessment of problems and needs, the use of
advanced medical equip-
ment, and planning approaches to a broad range of difficulties.
These consultations are
initiated by care staff observing a problem, leading to arranging
a telephone consulta-
tion and RNs often giving a prescription and instructions and/or
delegation to the
care staff in how they are to deal with the situation. When night
RNs’ consultations
mean encountering a care recipient, relatives or care staff, this
consists of intense brief
assessments during which the whole situation is taken into
consideration.
... I have more demands on me when I enter a caring situation
where I do not know

anybody ... I have to do my assessment in 10 minutes and give
the impression of not being
stressed, of having a genuine interest in how they are (relatives
and care staff) and the
care recipient’s condition. Rapidly, I have to create a picture,
give some kind of sense of
community, make them feel confident ... it starts when I enter
the door. I have a nurse’s
role in encountering relatives, you always have two paths or ...
more ... you have to sense
which to choose ...
A consultative nursing service implies a requirement for
confident RNs with
extensive nursing experience. Basically, night nursing care is an
interdependent
phenomenon. The initial stage is observation of a problem by
care staff leading to a RN
consultation and the RN’s assessment and decisions concerning
confidence in care staff
to take further action.
... you have to trust the care staff because you do not have time
... you cannot be
everywhere.
In this way, caring in nursing means a state of contradiction,
existing in an inter-
dependent independency, including both RNs’ and care staff’s
independence in caring
actions as well as dependency on communication, competence
and attention to an
identified problem.
Comprehensive understanding and reflection
Comprehensive understanding is based on the naive reading, the

themes and sub-
themes, the authors’ pre-understanding, reflections related to
the context of the study,
the research question and the literature.
Municipal night RNs’ experiences of caring in nursing are
interpreted as paradoxes:
‘being close at a distance’ and the conditions of ‘being
responsible with insignificant
control’ and ‘being interdependently independent’. The themes
emerging from the
structural analysis seem to be connected and intertwined with
each other, illustrating
the complexity of the phenomenon under study.
It could be suggested that caring may be considered to comprise
RNs’ all-nursing
activities. On the other hand, the participant RNs experience
caring as a fundamental
and basic stance in night nursing. Conversely, caring is often
associated with and
described in terms of relationships and encountering the care
recipient.10,43–45 However,
that these RNs seldom physically meet care recipients does not
mean a lack of caring.
The philosopher Marcel46 discusses the concept of being co-
present. Marcel explains
that encounters can also occur at thought level. An encounter is
not merely to cross

someone’s path, it is also to be near to or with them. Municipal
RNs’ night caring may
also occur at thought level. This means thought while near to or
with the care reci-
pient. Consequently, the caring stance is important despite the
lack of a meeting that
could be discussed in terms of nursing ethics. The caring stance
can also be viewed
in relation to the work of Marcel,46,47 who examined ‘being’
and ‘having’ in a variety
of contexts. When applied in the study context, the RNs’ caring
stance means caring
is more important than having a caring attitude. The RNs
thereby think and narrate
caring with the care recipient as a natural focus taking
precedence over the problems
of both relatives and care staff. This means that, in caring, the
RNs strive ‘to be close at
distance’ because by their actions they deliberately advocate the
care recipients’ needs,
well-being and dignity. The needs, well-being and dignity of
relatives and care staff,
are considered at a subordinate level. This deliberate focus on
care recipients emerges
as caring advocacy.
Advocacy is a central concept in nursing ethics48 and also in
gerontological nurs-
ing.13,18 Caring advocacy is also in line with a caring science
approach, which emphasizes
the patient’s perspective.10,43,44 In the present study, caring
advocacy was stated to be
a feature for protecting care recipients’ dignity, well-being and
caring needs, as also
noted in the literature.48,49 If their condition seldom permits
care recipients to consult

RNs this is mitigated by the triad formed by care staff (or
relatives) being mediators in
the communication process between RNs and care recipients.
This means that despite
the night duty RNs’ distance from the care recipients, it is easy
to advocate for this
group, in spite of the fact that they are mainly frail older people
not capable of involve-
ment. Similar situations have been discussed50 when studying
telecare, which also has
emphasis on the importance of having experienced care staff as
intermediaries in the
communication process.
Van Hooft8 considers the concept of caring in nursing
connected to moral theory by
virtue ethics, which is neither merely an interpersonal emotion
nor just a professional
practice; it is the ethical foundation of nursing. A RN who
demonstrates phronesis (an
Aristotelian concept meaning ‘practical wisdom’) will feel
caringly, think caringly and
thereby act virtuously.8 In the results presented in this article
RNs deal with medi-
ated care carried out by care staff, which seems to call for a
nursing quality of clinical
wisdom43,51,52 or phronesis.53 The concept of clinical wisdom
is complex, being related to
advocacy in preserving care recipients’ dignity. There is also a
stated need for skills of
sensitivity, patience, trust, compassion, ethical discernment and
clinical competence in
the care of older people.43,52,54,55
Night RNs are consequently dependent on care staff and
relatives to guarantee

good nursing care for older people; that is, they are responsible
but have insignificant
control. They want to give, and are responsible for, good quality
care21,56 that they do
609
not administer themselves and over which they have
insignificant control. This leads
to a high risk of work-related stress28,57 and can be a reason
for moving away from
caring for older people.58,59
The difference between caring for and caring about stands out
in the findings.
Caring for means a care recipient focus despite the RNs’ remote
function. This can
be considered as an individual characteristic founded in self-
knowledge by a process
of vocational maturity and incorporated into these RNs’ being
and their meaning of
caring. Ricoeur33,60 acknowledges that the self is not a simple
subjective entity. It is in
some part a social construct, and an important source of such a
construction of the self
is the role we occupy in society. This van Hooft12 exemplifies
as especially clear in the
case of the nursing profession. For the RNs, caring is not just a
matter of doing the job
effectively by looking after sick people, it is also a matter of
having a compassionate and

benevolent attitude towards them. The care recipients and the
RNs are, in many ways,
dependent on the care staff (or relatives) owing to decisions that
have to be made about
if and when RNs are to be consulted. This is the situation of
being interdependently
independent. The RNs are independent in the execution of their
professional practice,
making their own self-governing assessments and decisions. At
the same time they are
dependent on the skills of care staff and/or relatives to observe
problems and also to
perform the RNs’ instructions and delegated care. It is also
illustrated in the findings
that the night duty RNs seldom participate in bedside nursing,
which is instead exer-
cised by relatives or care staff. The RNs’ caring thus often
means also caring for relatives
and care staff. This has been brought about by Swedish national
and political reforms
in the care of older people.61
One perspective on caring in night nursing revealed in this
study relates caring
to an organization that mainly requires RNs’ medical services.
Conversely, caring in
nursing means striving to grasp an overall caring responsibility
by responding to the
vocational and personal demands of being a RN,8 and in
guaranteeing quality, ethical
and competent night-time care for older people.
Critical considerations
This was a small study undertaken in Sweden. The intention was
to obtain a better
under standing of the meaning of caring in municipal night

nursing. The interpretation
process was an ongoing dialectical movement between the
whole and parts of the text,
between nearness to and distance from the text, with the
purpose of validating what
the text is revealing. This was completed by all the authors
being involved in different
parts of the analysis. The parallel reading made it possible to
approach the relational
uniqueness that is always there in everyday (night) nursing
practice. Ricoeur33 argues
that there is always more than one way of understanding a text,
but this does not mean
that all interpretations are equal. The results of these analyses
should be judged taking
into account the authors’ pre-understandings. None of the
authors have experience
of municipal night care for older people, however, all three are
experienced RNs and
educators, and have knowledge and interest in caring. To these
authors, the results
represent a most useful and credible understanding of these
RNs’ experiences of the
meaning of caring in night nursing.
There has been emphasis on describing the interpretation
procedure in a way that
provides possibilities for the reader to follow the interpretation
from the raw material

to the comprehensive understanding. Transferring the findings
to other contexts there-
fore presupposes a recontextualization of the results to the
actual context.35,62 Results
obtained using this method may be considered credible if RNs
recognize descriptions
or interpretations comparable with their own.35,62 This allows
results to be transferred
to other comparable situations.
Conclusion and applications
This study was an exploration of caring in nursing by municipal
night RNs that reveals
both ethical dimensions and problems. Although the
organization mainly requires RNs’
medical services, the RNs experience that caring in nursing
means striving to grasp an
overall caring responsibility connected to the RN profession.
This involves striving
to offer quality, ethical and sufficient caring to older people
during the night. This
entails understanding that caring is the ethical foundation of
nursing. In considering
the context, it is important to understand that the care recipients
are older people and
some times their relatives and also care staff, which is
necessary for preparing propitious
conditions for the care of these older people. This indicates the
presence of dimensions
of family nursing.63,64 The findings consequently point to the
necessity to implement
further studies observing municipal night RNs caring for
relatives and care staff in
addition to the elderly people in their care. The results of this
study can be applied to
increase understanding of RNs’ ethical reasoning when having

RESEARCH ARTICLE Open AccessExperiences of reduced work ho.docx

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