N U R S I N G A N D H E A L T H C A R E M A N A G E M E N T I .docx

N U R S I N G A N D H E A L T H C A R E M A N A G E M E
N T I S S U E S
Time management strategies in nursing practice
Susan Waterworth MSc RGN RNT
Senior Lecturer, School of Nursing, Faculty of Medical and
Health Sciences, University of Auckland, Auckland,
New Zealand
Submitted for publication 24 July 2002
Accepted for publication 20 April 2003
Correspondence:
Susan Waterworth,
School of Nursing,
Faculty of Medical and Health Sciences,
University of Auckland,
Private Bag 92019,
85 Park Road,
Grafton,

Auckland,
New Zealand.
E-mail: [email protected]
W A T E R W O R T H S . ( 2 0 0 3 )W A T E R W O R T H S .
( 2 0 0 3 ) Journal of Advanced Nursing 43(5), 432–440
Time management strategies in nursing practice
Background. With the increasing emphasis on efficiency and
effectiveness in health
care, how a nurse manages her time is an important
consideration. Whilst time
management is recognized as an important component of work
performance and
professional nursing practice, the reality of this process in
nursing practice has been
subject to scant empirical investigation.
Aim. To explore how nurses organize and manage their time.
Methods. A qualitative study was carried out, incorporating
narratives (22 nurses),
focus groups (24 nurses) and semi-structured interviews (22
nurses). In my role as
practitioner researcher I undertook observation and had
informal conversations,
which provided further data. Study sites were five health care

organizations in the
United Kingdom during 1995–1999.
Findings. Time management is complex, with nurses using a
range of time man-
agement strategies and a repertoire of actions. Two of these
strategies, namely
routinization and prioritizing, are discussed, including their
implications for
understanding time management by nurses in clinical practice.
Conclusions. Ignoring the influence of ‘others’, the team and
the organization
perpetuates a rather individualistic and self-critical perspective
of time management.
This may lead to a failure to address problems in the organizing
of work, and the
co-ordinating of care involving other health care workers.
Keywords: efficiency, prioritizing, routinization, time
management, time strategies,
work organization, nursing
Introduction
Individuals do not invent the concept of time, but learn about
it, both as a concept and a social institution, from childhood

onwards (Elias 1992). In the Western world, time has been
constructed around devices of measurement, such as clocks,
calendars and schedules, and these are a representation of
particular symbolism (Elias 1992).
Time budget studies are one of the oldest approaches for
investigating time (Adam 1990). From a nursing perspective,
empirical investigation into nurses’ time management has
been overshadowed by this reductionist perspective, typified
by task analysis (Waterworth et al. 1999). There is value in
this research, as it illustrates the range of tasks and time
taken, but the perspectives of nurses themselves have been
ignored. This is particularly important when there is an
increasing trend to emphasize the ‘invisible’ dimensions
(Davies 1995) of nursing work.
A previous study (Waterworth 1995), exploring the value
of nursing practice from the viewpoint of practitioners, has
identified that time with patients is important, but raises the
question of how nurses manage their time.

432 � 2003 Blackwell Publishing Ltd
Time management
Literature on time management in nursing is mainly
anecdotal, providing a number of tips on ‘how to’ manage
time, along with descriptions of processes or strategies. The
order for thinking about the process varies, ranging from
setting objectives as the first step (Brown & Wilson 1987,
Noreiko 1996) to working out how time is being used with
the aid of time logs (McFarlane 1991). Giving information
to patients about the routine is the starting point for DeBaca
(1987), while using written contracts negotiated with
superiors is the advice of Jones (1988). Determining the
importance of tasks or priorities is part of the process,
although the stage at which this should occur varies between
authors.
An overarching theme in this literature is the need for
nurses to think about their own time management, with the

main ‘message’ that individuals can manage their time. This is
an individualistic view of time management.
Thus, time management in professional nursing discourse
is presented as an externally-defined set of practices. How-
ever, the reality of this process in nursing practice has been
subject to scant empirical investigation, although studies on
nurses’ work organization (Bowers et al. 2001) have found
time management problematic, with nurses compensating for
lack of time by developing strategies in an attempt to
complete their work.
The study
Aim
The aim of this qualitative study was to explore how nurses
organize and manage their time.
Methods
A range of different data collection methods, namely narra-
tives, focus groups and semi-structured interviews, was used.
All data were audio-taped to ensure accurate records of

participants’ accounts. I was in the role of practitioner
researcher (Reed & Procter 1995), and used observation and
informal conversations as further sources of data. I recorded
these in field note diaries, as a form of professional
journalling (Manias & Street 2000).
Each data collection method has strengths and limitations
and use of diverse methods was an attempt not only to
enhance the trustworthiness of the study, but also to
minimize the difficulties associated with individuals thinking
and talking about time. As time is so deeply embedded and
taken for granted within our tacit knowledge base, it is
difficult to think past the superficial and beyond common
associations with clocks and timetables (Adam 1995).
Sample
The sample of qualified nurses came from five different health
care organizations in the United Kingdom (UK) and a range
of clinical areas (Table 1). Access to the health care
organizations was gained by making use of ‘friendly gate-

keepers’ (Reed et al. 1996). I was reliant on senior nurse
managers providing the names of staff who might participate
in the study. When contacting the nurses to discuss the study
and elicit informed consent, their genuine interest in parti-
cipating and their potential contribution to the sample could
be determined. These initial background data were used to
determine suitability, so that sampling could be purposive
(Patton 1990), and achieve diversity in relation to organiza-
tion, clinical area, roles and gender.
Focus groups
Focus groups can generate group interaction and insight
(Morgan 1997). Group discussions enabled nurses to talk
about how nurses managed their time. Initial questions on
time were broad, such as ‘How does time influence nurses’
work?’ Kitzinger (2000) identifies another strength of focus
groups: the ability to study ‘forms of communication’ that
participants use, allowing observation of interactions and
emotions generated. Four focus groups were held, with

24 participants overall. On completion of each group,
I reflected on the group process to evaluate my facilitation
of the discussion. The skill of the researcher as a group
facilitator is critical in achieving maximum interaction and
adequate data (Morgan 1997).
Table 1 Numbers of nurses participating in the study by clinical
area
Clinical area Number of nurses
Acute assessment 1
Coronary care 3
Gastroenterology 3
Haematology 11
Intensive care 1
Intermediate care 2
Medical 10
Oncology 3
Orthopaedic 3
Palliative care 7

Rehabilitation 5
Surgery 19
Nursing and health care management issues Time management
strategies in nursing practice
� 2003 Blackwell Publishing Ltd, Journal of Advanced
Nursing, 43(5), 432–440 433
Semi-structured interviews
Interviews were conducted with 22 participants who had not
been involved with focus groups or narratives. The aim of the
interviews was to understand further the themes that had
been identified from analysis of focus group data (Figure 1).
They provided an opportunity for more in-depth interaction
with participants on an individual level and minimized any
possible influence of a group effect.
Narratives
Narratives are a means of representing experience of social
reality (Geist & Hardesty 1990). In this study, a narrative
was used as a story (McCance et al. 2001). Twenty-

two narratives had been obtained in a previous study
(Waterworth 1995). It was during this research that the
issue of time had been identified as important and worthy of
further study. I made the decision to return to this data set
when nearing completion of the main study, as a means of
testing out the usefulness of the conceptual framework in
providing more understanding about the taken for granted
and invisible meanings of time in nursing practice. Thus,
secondary analysis of this narrative data was a means of
making comparisons and confirming or challenging the
ability of the emerging conceptual framework of time
management to reveal how complex time is and how it is
embedded in nursing practice in myriad ways.
Data analysis
Data were managed using the qualitative data analysis
software package Atlas.ti (Scientific Software Developments,
Berlin, Germany) Prior to transcription all data were anon-
ymized. The approach was inductive, using line by line

analysis (Strauss & Corbin 1998) to derive codes and,
highlight words, sentences or paragraphs that reflected a
meaning of time. Case analysis meetings (Miles & Huberman
1994) took place with research supervisors. Peer review by
colleagues was used to check the analysis and interpretation
of a sample of transcripts, and this confirmed but also
challenged my coding and categorization of themes, which
was modified accordingly.
Findings
The findings demonstrate that time management is complex,
with nurses using a range of time management strategies.
In accounting for time management as described and
discussed by nurses in this study, six time strategies (Table 2)
have been identified. There are also repertories of actions and
interactions (Table 3), suggesting that a nurse may need to
use a combination of actions and interactions in order to
decide on a strategy. In effect, nurses have to define the
meaning of a situation in order to determine an appropriate

strategy. Situations can be extremely complex, and nurses
may have to pursue several strategies at the same time to
control overall performance. Time strategies also involve
engaging in actions and interactions that enable management
of tensions produced by time pressure. Strategies may involve
not only the individual but also the team and organization.
Some of the performance strategies and actions identified
can be classed as representing an acceptable face of time
management. This means that they are not only expected, but
are also promoted as a means of managing time, for example,
setting priorities. Strategies may be viewed as indirect or
direct. An indirect strategy may resolve an immediate time
problem the nurse is encountering. A direct strategy may
prevent the time problem from arising in the future. As an
example, a charge nurse reflects on the problems he is
encountering:
Sickness – people phone up sick. You can say ‘Right, I will
stick eight
on the off duty this morning.’ You need eight this morning and

you
Time with patients Time effects
Controlling time Frames of temporal reference
Figure 1 Initial themes from focus groups.
Table 2 Time strategies identified
Prioritizing
Routinization
Concealment
Catch up
Juggling
Extending temporal boundaries
Table 3 Repertoire of actions
Controlling interactions
Focusing
Avoidance
Selective attention
Short cutting
Saying no

Making compromises
Delegation
Synchronizing
S. Waterworth
434 � 2003 Blackwell Publishing Ltd, Journal of Advanced
Nursing, 43(5), 432–440
can bet your bottom dollar the next morning there will be five
there.
And what you planned to do with Mrs X and Y and see relatives
–
you are ringing up cancelling, saying ‘I am very sorry we
cannot see
you this morning.’ And it all boils down to crisis on the day.
There is
very little planning we can do.
This nurse is attempting to manage his time by shifting
priorities for that day. This will deal with the immediate
problem and is an indirect strategy, but does not resolve the
underlying problem of sickness and absence in the team
which, if resolved, would be a direct strategy.

Emotion is produced by temporal demands (Fine 1996),
and nurses may have to manage the emotion engendered.
Complexity is added when noting the assertion that an
individual can ‘engage in time work to either promote or
suppress a particular kind of temporal experience’ (Flaherty
(1999, p. 153).
Time is not autonomous (Fine 1996) and there are
connections between time strategies, repertoire of actions
and other skills and knowledge that nurses possess. When
learning a skill such as taking a blood pressure measurement
competence develops over a period of time. This competence
involves accuracy in determining the measurement of blood
pressure and ability to perform the measurement at a certain
speed. As Benner (1984) found, expert nurses can respond
rapidly to situations, whereas a novice’s pace would be
slower. Competence of nurses in completing skills will affect
the other building blocks of the temporal organization of
work. These building blocks comprise the speed of the

worker, duration, synchronicity or timing and sequence (Fine
1996). The following staff nurse’s account illustrates the
problems she had with speed:
When I was first qualified I would not have had much
experience
or had much confidence. So I would have probably taken a lot
longer over tasks and different things and probably would not
have
been confident about talking to doctors or talking to other
people
and pushing other people, so that would have slowed everything
down.
Workers can put pressure on each other to keep up the speed
of work (Novek et al. 1990), and nurses in this study made
frequent reference to the speed of their work. Faster skill
performance may reduce time pressures, especially when this
is part of the speed of the team itself; therefore, the nurse does
not feel she is delaying the overall team performance.
Routinization

Nurses in this study had a routine, which was their temporal
plan of work and brought with it a sense of order. Routines
are habituated ways of responding to occurrences in everyday
life (Strauss & Corbin 1998), and are part of our normative
experience. As such, they are taken for granted unless they
are disrupted in some way. Understanding routines is import-
ant, because they demonstrate actions that have previously
been worked out to maintain order (Strauss et al. 1998).
In complex organizations, the synchronization of people’s
routines is important for overall continuity (Zerubavel
1979). Routines can provide a form of time supervision,
not only for individual nurses but also for the team and
organization. Systems such as critical care paths, which
provide a plan of the routine management of a specific
diagnostic group of patients within a time frame, function in
a similar manner.
Routines bring with them a set of expectations and, for
nurses in my study, the time slots for activities that they

needed to complete. Routines can decrease the thinking time
needed in time management. Thinking about activities that
need to be completed and the sequence of these is a time-
consuming activity. Having a routine can reduce the time
pressure nurses’ experience, and may be one of the reasons
that they attempt to protect their routines from changes in
practice. This is despite the arguments for them to reduce
their routines to promote individualized care (Audit
Commission 1992).
Others’ routines
Nurses may have their own routines but this is influenced by
others’ time. Routines exist at different levels, as a staff nurse
explains in the following extract:
You do sort of have your routines. It is just organizing your
time.
If the physio starts at 9 a.m. you have to have some sort of
routine.
As a component of nurses’ routine, there is a need to
complete activities within certain time frames. A sense of

timing about the duration of activities and sequence of when
these need to occur is required to synchronize an individual
routine with others, so other people’s time management can
influence time and routine. Routine is not just about what
activities need to be completed, but incorporates sequencing,
timing, and speed. The ability to synchronize one routine
with others is important. This is in order to be efficient, not
only as an individual performer, but in working with others
involved in the overall provision of care. A staff nurse
illustrates the difficulties encountered by other’s routines as
follows:
Someone else is asking ‘Can you take a patient down and then
collect
him from Gastro?’ Somebody else needs collecting from theatre.
Nursing, 43(5), 432–440 435

If this is likely to be problematic, altering a routine by making
shifts in the tempo, duration and timing of work may be
needed. Nurses may use other strategies and actions in
situations in which the timing within routines becomes
problematic. In learning time management, other people’s
routines are incorporated and become accepted as a new
routine. This then becomes taken for granted as a way of
managing time. In a focus group, discussion took place about
how nurses’ practice had changed:
There was an incident the other day. We had an elderly
gentleman
who became very confused and the doctor suggested that we
should
give him thioridine. Now it is ages since that situation happened
here.
In the old ward, it was quite often given to patients because
they were
not quiet or because they were rambling or wandering.
Routines can often be invisible (Bowers et al. 2001), unless
they are exposed or attempts are made to change them.

Zerubavel (1981) states that routine is essentially antithet-
ical to spontaneity, but nurses’ routines can be responsive to
the contingencies inherent in clinical practice as a ward sister
explains:
There are all these people talking about time management, but
they
are usually people who work in an office nine to five. They are
not
dealing with all the unpredictable things that can happen.
Nonetheless, routine, which brings about a sense of predict-
ability, sense of time control and familiarity, is relevant to
time management. A routine not only comprises a sequence
of activities or tasks that need to be completed, but also the
duration of these activities and the speed with which these are
carried out. A routine has a pace that can be altered as the
situation demands.
Some events or activities are amenable to temporal
relocation, others cannot be easily extracted (Hassard
1996). Possibility of disruption to others’ routines is a

reflection of the connections between power and time
management. Some health care workers’ status means that
it is their routine that will be established as the priority
routine. On one of the study wards, despite there being set
times for ward rounds, one consultant in particular would
change the time or even the day, giving minimal notice to the
ward team.
There is reliance on patients playing their part in support-
ing nurses’ performance of time management. Goffman
(1959) refers to protective measures that are used by the
audience and others to assist the performers. For example, it
is important for the maintenance of routine and time
performance that patients take their medication at the times
allocated. Patients who disrupt this may be labelled as
‘difficult’ (Stockwell 1972).
Prioritizing
Time is one of the principles that can best allow people to
establish and organize priority in their lives, as well as

to display it symbolically (Zerubavel 1981). The ability to
prioritize is a prerequisite for effective work performance and
is an expected strategy. The assumption is that priorities can
be determined, and decisions made as to what is most
important, and that this can be followed by appropriate
nursing actions.
Prioritizing provides a structure for the temporal ordering
of work. In this study, prioritizing forms a complex picture,
unlike the rational process evident in the literature. Priorit-
izing has paths of connectivity (Strauss et al. 1998) to
different levels of routine. Priorities may be determined by
those of the organization and the resultant organizational
routine. A staff nurse relates the problems encountered as
follows:
It is all dictated by outpatients. Five outpatients come in an
ambulance, so put back the patients on the ward. The patients
on
the ward at the moment are sometimes being treated at 10
o’clock at

night, so they could be treated at 8 o’clock one night, 10
o’clock the
following morning and so it is very difficult. When you ask
them for a
schedule, they say it is not possible to give you one. So
basically you
get what you are given as far as time. Even talking to a patient
and
then they are taken away and what they were going to tell you
or
what you were trying to establish is either broken off because
they
have gone for treatment.
The team may determine priorities and, as such, there is an
expected team routine, as a ward sister explains in relation to
changing a routine:
We used to do an MST (morphine slow-release tablets) round 10
[o’clock] and 10 [o’clock] but we found that, because there are
only
two trained night staff and an auxiliary, by the time they finish
the
ordinary drug round and settle the patients who desperately
need

commodes and whatever, quite often it was nearly 12 o’clock
before
the MSTs were done. And then lights were going off very late.
So it
makes the night very short for the patients. So I thought about it
and
said to the staff what about if we do the MSTs at 9 and 9. There
is a
problem in the morning with our patients because they are going
off
for treatment. So, when you come to do their MSTs at 10, half
of the
patients were missing, because they had gone for treatment or
you
found half the drug sheets in pharmacy. Quite often it became
11
before you had finished. If you are doing something in a
morning you
have to concentrate and think ‘Has anybody done the MSTs?’.
There is evidence of tension between the ward routine and
other departments’ routines. If nurses are not ‘on time’, that
is they have not got their timing of medications right and

S. Waterworth
Nursing, 43(5), 432–440
synchronized this process, patients may have left the ward or
there may be delays in patients’ transfer to other depart-
ments.
Patients are admitted to wards with their own time frames,
their routines incorporating the times to take their medica-
tion. Individual patients’ medication times and routines may
have to adapt to the ward routine. Decisions about priorities
may be taken with reference to the ward routine, rather than
individual patient needs (Procter 1989). Meeting individual
needs not only requires knowledge of the patient, but an
acknowledgement that this is a responsibility, a commitment
and a priority. The delegated authority and responsibility
associated with work organization systems, such as primary
nursing, may allow the priorities of the individual to co-exist
with some of the priorities of the team and organization.

However, this creates tensions for nurses because the needs of
one patient compete with those of another in terms of
urgency. This is reflected in one staff nurse’s account:
When you have taken your report the most important thing is to
assess which one out of your team requires that ultimate care –
the
most in need of your ‘hands on care’ first. I like to go along and
say
‘hello’ to everyone and then I go to them all and if I can’t offer
them
any assistance with hygiene or care I will explain why –
because I
have got somebody else who is poorly at the moment and needs
my
attention. But if there is anything I can do for them first, if not I
will
be back as soon as possible. So I go and say ‘hello’ and check
whether
there is anything vital within that first 15 minutes. If not, I
explain
would they like to wait and I go and see to the poorly ones and
they

usually say ‘fine’ and I say for them to buzz in the meantime
should
they need us.
Prioritizing is part of this nurse’s routine, entailing the
sequencing of her work and its duration. This is about the
need to spend time with specific patients. With the exception
of high dependency areas such as intensive and coronary care
units were the nurse–patient ratios usually are 1:1 or 1:2,
nurses, like the staff nurse quoted above, have several patients
that they need to spend time with. It is notable that she gives
other patients permission to interrupt her if necessary.
Prioritizing becomes an integral part of a nurse’s routine.
The latter is comprised of other routines, such as the ward
routine. In effect, nurses are dealing with different priority
systems:
There are some things that are priorities that always have to be
done,
like medications. There are priorities to you and to the patient.
So if it
was a priority to the patient and they wanted something, I would

see
that as a priority.
There is complexity in this, as what patients might perceive as
a priority may not always be recognized as such by nurses.
For some specialist nurses, contact with patients may only
arise because others’ involved have identified this as as a
priority. Tensions can arise if there have been differences in
determining whether contacting a specialist nurse is a priority
or not. Specialist nurses will also make judgements as to
whether particular situations should be a priority for them.
Differences in priority systems and time agendas exist. Nurses
have to have local knowledge of whose priority systems, in
fact, take priority and the way in which these can be
influenced.
Interruptions to nurses’ work can be accepted and taken
for granted (Waterworth et al. 1999). However, this can be
more complex, because team members, supporting team
priority systems can function to provide time protection for

other team members, as a ward sister’s account reveals:
It is very difficult because, if people need you specifically and
they
need you there and then, if I did not want to be interrupted –
say I
was talking to a patient or relative – I would say to S ‘Look, I
do not
want to be disturbed unless it is very urgent’. So then, S would
try to
answer anything that would come my way. She would only get
me if
she could not cope with or someone specifically wanted me. So
you
sort of rely on your other colleagues to try and take the burden
off
you.
Provision of cover by other nurses can provide some degree of
protection against interruptions, but for the team members
involved, this will bring extra work and impact on their own
time management. Providing support for the protected time
needed with a patient or relative has to be viewed as
important within the team’s priority system. If team support

is not available, nurses have to work around the situation and
use other strategies to manage their time. Working as part of
a team means getting to know the priority systems, what may
be urgent and, therefore, when it may be appropriate to
interrupt a co-worker. In order to maintain the team
performance of time management, judgements are made
about individual team members. If the time a team member
spends with patients is viewed as excessive, this can create
tension and disrupt team performance, as a staff nurse
illustrates:
I don’t mind X spending time with patients, but there are his
other
patients to think of and we are doing his work. He has to learn
that
there is a limit to the amount of time he can spend with one
patient
like that. It is annoying the others, as they have to do his work,
answer the call bells and then they have to catch up on some of
their
own work.

Nurses need to be able to sequence their work according to
priorities and deal with conflicting priorities. Being able to
compromise is an accepted part of prioritizing, and involves
Nursing, 43(5), 432–440 437
understanding the need to compromise and the feelings
associated with it. A charge nurse relates compromising and
prioritizing to patient safety in the following extract:
Ultimately, compromises are made along the way. As I said
before,
setting priorities [is necessary], but the patient needs to be safe.
Hopefully, with working with experienced staff other staff learn
and
are educated as to what are the priorities.
In determining priorities, decisions are made as to what work
should be completed and what work other workers could do,
and integral to this process is delegation. Being able to

delegate work to others can be problematic for nurses
(Hansten & Washburn 1996). In some instances, there is
no one to whom one can delegate, as illustrated by the
following extract:
You have to do it. If the ward clerk is off sick, within 48 hours
you
will have a pile of case notes that is taller than me. If you do
not do it,
you will not be able to find anything on that ward again.
Student nurses were valued in a number of ways, and this
was, in part, because work could be delegated to them.
Duplication of workers’ skills has become more promin-
ent in health care. This is relevant to nurses and their
expanding portfolio of skill development. Delegation is
reliant on workers having certain skills that enable them to
complete the delegated work. Walby et al. (1994), assert
that nurses do not have the right to impose their priorities
on junior doctors. The expanding portfolio and the devel-
opment of advanced nursing practice roles, means that

nurses will have to delegate work to medical staff. Although
the language of ‘sharing work’ may be used in order to
minimize some of the tensions between the professions,
conflict may be anticipated and attempts to avoid this may
cause nurses to complete the work themselves, as a staff
nurse explains:
It would be easier to get someone to wash and dress a patient
and
make a bed than it would be to come and take bloods and make
up
antibiotics. Well, it is more accessible to get a care assistant
and help
wash a patient and make sure a patient is comfortable in a bed
or if
you can get some care assistant or student to do the
observations.
Whereas it can be harder to get a doctor to come and help you
do the
antibiotics or come and take bloods, because they are always
too
busy doing something else.

Allen (1997) argues that nurses undertake medical work,
because it is less time consuming than trying to get a doctor to
do it. In the study reported in this paper, the idea of ‘time
consuming’ was also present in the effort required to delegate
work to others. This involves determining whose representa-
tion of busyness takes priority.
Discussion
Whilst having time to spend with patients has been perceived
as important to nurses (Waterworth 1995), how time is
managed is not only highly problematic but reveals how time
itself has become so deeply embedded in issues relating to
care. Therefore, attempting to understand how nurses man-
age their time reveals not only the complexity of what is
involved but also some of the invisible dimensions.
An ability to manage time in an acceptable way is an
important performance standard and reflects competency in
organizing work on an individual basis. The emphasis is on
individual performance. As Nicholson states:

If you find yourself saying I just don’t have enough time, then
it is
probably your own fault (Nicholson 1992, p. 52).
A powerful image of personal inadequacy can be associated
with the idea of time management.
My paper has focused on two time management strategies
that, on the surface at least, present as an acceptable face of
time management. The evidence suggests that one of these,
prioritizing, is an expected time management strategy and
that other actions such as delegation are given professional
approval and considered important skills for effective man-
agement of patient care. As is evident from the analysis in my
study, it is important to examine what lies beneath strategies
(Hochshild 1997), what they reveal about the temporal
demands on nurses as they attempt to organize their work,
and the influence of the team and organizational routines and
priorities. In my study, the importance of routine, which
represented the nurse’s temporal plan, was evident. The way
in which nurses’ routines have to take into consideration

others’ routines and the impact of this are also clear. Some of
the strategies maintain a dysfunctional image, supporting
management rhetoric that time can, in fact, be managed. The
strategies used to manage time can also have adverse
consequences for patients, as well as fail to address some of
the underlying problems nurses face in attempting to organize
their work in shifting health care systems. This is particularly
so when the strategies are indirect and may perpetuate less
effective care or at least limit its effectiveness.
With the increasing emphasis on efficiencies in health care,
management of time becomes central. Shifts in organizational
temporal frameworks, such as rapid throughputs and
decreased lengths of stay in hospitals, are increasing and
there is an expectation that people will work harder.
Warhurst and Thompson state:
The combination of increased competitive pressures for cost
reduc-
tion in public and private organizations, with expanded means
for

S. Waterworth
Nursing, 43(5), 432–440
reducing and recording ‘idle time’, are leading to substantial
work
intensification (Warhurst & Thompson 1998, p. 9).
In my study, work intensification was experienced as time
pressure.
Whether time management has become more problematic
for nurses because of the concern with improving efficiency
and productivity, is largely unknown. Few studies to date,
with the exception of mine and that of Bowers et al. (2001),
concerning long-term care, have focused specifically on time
management. The changing temporal structure in health care
affects, in a negative way, how nurses perceive their work
when standards cannot not be achieved. Time pressure can
also have a negative effect on decision-making (Hunt &
Joslyn 2000), impacting on its quality, because reflection and

consideration of alternatives can be perceived as time wasting
processes, as nurses attempt to work quicker.
In this era of the specialist knowledge worker, there is more
need for horizontal co-ordination (Warhurst & Thompson
1998). In health care, the increasing division of labour means
that more specialists can be involved in a patient’s manage-
ment. The co-ordination function, largely viewed as a nursing
responsibility, becomes crucial but also problematic. This is
particularly so when there are different interpretations, result-
ing from a number of influences, as to whose time is a priority.
This creates more tension, not only for nurses attempting to
manage their own time, but in relation to attempts to influence
the time management of other health care workers.
Conclusion
Examining the two time management strategies of routiniza-
tion and prioritizing exposes the contradictions that nurses
face in their attempts to organize work within temporal
boundaries. The taken for granted notion of time manage-

ment has been challenged, revealing the influence of ‘others’,
the team and the organization. Ignoring these perpetuates a
rather individualistic and self-critical perspective of time
management, and may lead to failure to address some of the
problems in organizing nursing work and co-ordinating care
involving other health care workers.
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D e v e l o p i n g a n I n t e g r a t e d P r i m a r y C a r e P r a
c t i c e :
S t r a t e g i e s , T e c h n i q u e s , a n d a C a s e I l l u s t r a
t i o n
m
Barbara B. Walker
Indiana University

m
Charlotte A. Collins
Geisinger Medical Center
Numerous studies have now demonstrated that integrating
behavioral
health and medical care can reduce medical costs, improve
patient
and provider satisfaction, and enhance clinical outcomes. Given
this,
one might expect that behavioral health programs would be
fully
integrated into primary care clinics across the country, but in
fact
integrated primary care programs remain quite rare. One reason
for
this discrepancy is that implementing such programs has proven
to be
extraordinarily challenging. Most of the integrated programs
that are
currently operating successfully are in settings where
professionals
are all members of the same health care system (e.g., HMOs, the
Veterans Administration, Departments of Family Practice, etc.).
Many

providers, however, are in communities where various services
are
provided in different locations from different organizations that
have
very different clinical, administrative, and financial structures.
In these
situations, the challenges are even greater. The authors describe
a set
of strategies and techniques providers can use to move their
health
care system toward a higher level of integration and illustrate
how
they applied these steps to develop and assess the impact of an
integrated primary care program in the state of Rhode Island. &
2009
Wiley Periodicals, Inc. J Clin Psychol 65:268–280, 2009.
Keywords: integrated care; collaborative care; primary health
care;
integrated services; delivery of health care; mental health
services
Correspondence concerning this article should be addressed to:
Barbara B. Walker, Indiana University,
Department of Psychological and Brain Sciences, 1101 E. 10th
Street, Bloomington, IN 47405; e-mail:

[email protected]
JOURNAL OF CLINICAL PSYCHOLOGY, Vo l . 6 5 ( 3 ) , 2 6
8 – 2 8 0 ( 2 0 0 9 ) & 2009 Wiley Periodicals, Inc.
Published online in Wiley InterScience
(www.interscience.wiley.com). D O I : 1 0 . 1 0 0 2 / j c l p . 2
0 5 5 2
Introduction
In the early 1960s, physicians at Kaiser Permanente Health Plan
noticed that the
majority of primary care visits were from patients who were
found to have no
organic pathology. Results of their 20-year longitudinal study
(Cummings &
VandenBos, 1981) revealed that 60% of visits were from
patients who had no
physical disease, and the vast majority of these patients suffered
from depression,
anxiety, stress, and unhealthy lifestyles that negatively
impacted their physical
health. In response, this Health Maintenance Organization
(HMO) began to apply
the biopsychosocial approach (Engel, 1977, 1980) by
integrating behavioral health
1
and medical services in their primary care clinics. A series of
subsequent studies
found that savings in medical utilization exceeded the costs of
providing behavioral
health treatment (Cummings & Follette, 1968; Follette &
Cummings, 1967).

More recently, integrated primary care programs have been
developed in other
systems as well. The Veterans Administration (Druss,
Rohrbaugh, Levinson, &
Rosenheck, 2001; Elhai, Richardson, & Pedlar, 2007; Hedrick et
al., 2003), the Air
Force (Runyan, Fonseca, Meyer, Oordt & Talcott, 2003) and
other branches of the
military have all been investing heavily in developing
integrated care programs.
Taking all the evidence together, Blount (2003) recently
concluded that in certain
populations with certain types of patients and problems,
integrating behavioral
health and medical care can reduce medical costs, improve
patient and provider
satisfaction, and enhance clinical outcomes.
Given these findings, one might expect that behavioral health
programs would be
fully integrated into primary care clinics across the country.
Unfortunately, this is
not the case; integrated care programs remain extremely rare.
One reason for this
situation is that the health care system in the United States is
not designed to foster
the development, implementation, and/or maintenance of
integrated services. Our
largely fee-for-service structure provides strong incentives for
performing medical
procedures and doing diagnostic tests but few, if any, for
focusing on prevention,
communicating with other providers, and/or coordinating care.
In addition,
behavioral health and mental health have not yet achieved parity

with ‘‘physical’’
health despite significant efforts to bring about this change. As
a result, behavioral
and mental health factors are often ignored clinically and
‘‘carved out’’ financially,
resulting in fragmented, poor-quality, more-expensive care.
This, combined with the
misaligned financial incentives, often leads to insurmountable
barriers for those
attempting to develop any type of integrated care program.
Given this structure, it is not surprising that most integrated
programs to date
have developed in settings where professionals all take care of a
given population
within the same health care system. Examples include HMOs,
Departments of
Family Medicine, the Air Force and other branches of the
military, and the Veterans
Administration. Many communities across the United States,
however, have few (if
any) such unified systems, making integration even more
challenging. Given the
challenges that occur even when all providers work within one
system (Blount, 1998),
how can care be integrated in communities where primary care
teams, psychiatry,
psychology, behavioral medicine, and training programs all

operate within different
systems in different locations with completely separate
administrative and financial
structures?
1
In this article, we use the broad term behavioral health to
include both mental health and behavioral
medicine services.
269Developing an Integrated Primary Care Practice
Journal of Clinical Psychology DOI: 10.1002/jclp
In this article, we present a more detailed rationale for
integrated primary care,
and then describe four specific steps that can be taken to move
one’s health care
system toward a higher level of integration. We then illustrate
how we applied these
four steps to develop an integrated primary care program that
linked several separate
systems together in the state of Rhode Island: a Department of
Behavioral Medicine,
a clinical psychology training program, and a private fee-for-
service primary care
office. Finally, we present some data assessing the impact of the
program.
Why Integrate Care?

According to Selden (1997), most health care plans spend only
about 4–6% of their
annual budget on behavioral health care, suggesting that it may
not be worth
expending much effort in this area because it is inconsequential.
This figure is
misleading, however, because most behavioral health care is
actually carried out in
the medical sector. The majority of people seeking help for
psychological problems
are seen by their primary care physician (PCP) and not by a
mental health specialist
(Regier et al., 1993). Not surprisingly, the primary care sector
is now often referred
to as the ‘‘de facto mental health system’’ (Regier et al., 1993).
Patients with chronic medical disorders are more likely to suffer
from
psychological disorders than those without any medical
conditions (Wells, Golding,
& Burnam, 1988). The most prevalent disorders among this
population were found
to be depression, anxiety and panic, somatization disorder, and
alcohol abuse.
Compared to the general community, patients with medical
disorders are two to
three times more likely to suffer from major depression (Regier
et al., 1993). Panic
disorder and somatization disorders are 10–20 times more
frequent in primary care
settings (Katon & Roy-Burne, 1989), and substance abuse
disorders are three to five
times more common in a primary care practice than in the
general community
(Regier et al., 1993).
Patients with comorbid physical and psychological disorders are

extremely costly
for the health care system. Studies at the University of
Washington in Seattle found
that a relatively small percentage of patients (10%) accounted
for 29% of all primary
care visits, 52% of specialty visits, 40% of in-patient stays, and
26% of all
prescriptions. Among these high utilizers, 50% were
psychologically distressed
(Katon et al., 1990). Other studies have demonstrated
significant costs associated
with each of these types of patients. For example, patients with
somatization
disorder were found to use nine times more overall health care
services than other
patients (Smith, 1994), and depressed patients were found to use
three times more
services (Katon & Schulberg, 1992). Also, patients with anxiety
and panic disorder
have 10 times more visits to the emergency room than those
without anxiety, and
70% of these patients actually see 10 or more physicians before
they are accurately
diagnosed with anxiety (Katon & Roy-Burne, 1989). Health care
costs for families
with an alcoholic member are twice that of families without
alcoholism (Holder &
Blose, 1986).
Why be concerned with behavioral healthcare in a primary care
setting? One
reason is that patients typically present to primary care
providers with all their
problems, and these problems are not purely medical; they
usually include biological,

psychological, and social components. In a classic study,
Kroenke and Mangelsdorff
(1989) found that less than 30% of symptoms seen in primary
care were classified as
having an identifiable organic cause after one year. There
remains little doubt that
psychosocial and lifestyle factors play a significant role in
chronic illnesses and
270 Journal of Clinical Psychology, March 2009
somatic complaints. Ignoring these factors is costly to the
system and leads to
inefficient and ineffective patient care. Although PCPs are
inundated with patients
who require behavioral health care, behavioral health providers
have developed cost-
effective treatments that reach only a small fraction of those
who could benefit. The
challenge is to find ways to provide quality, integrated care to
improve the current
system.
Changing any system is challenging, but changing the way
health care is delivered
is particularly challenging given our current health care system.
Not only are
incentives misaligned, they are misaligned in different ways in
each state, region, and
community. As a result, integrated programs developed in one
community may not
necessarily succeed in another. There are no simple formulae

for developing or
maintaining integrated care programs. Local and regional
differences significantly
impact the configuration of service delivery, and understanding
these differences and
targeting an intervention to a particular area and specific setting
is critical.
Fortunately, there is a positive side to this challenging
situation. Valuable lessons
have been learned from both successes and failures in many
different types of
systems in different regions across the country, and many of
these have now been
published (see Kessler & Stafford, 2008 for an excellent
example). Through these
efforts and those of professional organizations dedicated to
fostering integrated care
(e.g., Collaborative Family Healthcare Association and Society
of Teachers of
Family Medicine), it has become clear that the process of
developing integrated
programs is critical, and it is now possible to identify some
general strategies that
have been successful. Below we propose four specific steps to
guide the process of
developing an integrated care program. In many ways, these
steps parallel the
clinical process used to help individual patients change: (a)
analyze the situation and
forge trusting relationships; (b) collaboratively set realistic
goals; (c) identify and find
ways to overcome the barriers to change; and (d) implement a
plan, test the outcome,
and revise the plan.

Four Steps Toward Integrated Care
Step 1: Analyze your health care system, identify potential
collaborators, forge,
and strengthen alliances.
A helpful first step is to begin analyzing your health care
system by generating a list
of all potential collaborators in the community. When compiling
the list, it is
important to think broadly and consider all those who refer
patients to you, all those
to whom you refer patients, your colleagues, and the many
different types of
institutions in your community (e.g., hospitals, HMOs,
university training programs,
medical schools, etc.). After developing the list, it may help to
draw a detailed
diagram delineating exactly how all the various individuals and
groups currently
interact. Give careful thought to which people and/or groups
might be motivated to
develop a closer partnership.
The importance of personal relationships in this process cannot
be over-
emphasized. Every conversation with another health care
provider provides an
opportunity to begin forging alliances in an effort to move
toward a higher level of
integration. It is particularly important to collect information
about what difficulties
potential collaborators encounter on a daily basis. For instance,
asking, ‘‘What
clinical problems frustrate you most in your practice?’’ can lead
to a fruitful

discussion of how an integrated care model might improve the
situation. Many
PCPs, for example, describe having great difficulty managing
patients with problems
such as somatoform disorders, mood disorders, chronic pain,
substance abuse, and
obesity. An integrated care program could better manage these
issues and benefit
everyone involved.
Despite the fact that clinicians typically prefer to focus only on
clinical issues, the
clinical, financial, and administrative spheres all need to be
considered when
developing integrated care networks. Failure in any one of these
spheres will lead to
overall failure of an integrated program (Patterson, Peek,
Heinrich, Bischoff, &
Scherger, 2002; Peek & Heinrich, 1995). As such, in addition to
working on
relationships with other clinicians, it is equally important to
develop good working
relationships with nurses, technicians, billing personnel, office
managers, and anyone
else involved with patient issues. Without support from
everyone involved, change is
very difficult to achieve. Within the potential collaborators
identified, consider
which individuals might serve as ‘‘champions’’ for the cause.

Individuals who see
the merit of enhanced collaboration are likely to have greater
success convincing
others within their own ‘‘system’’ of its worth than would an
individual who is
outside their system.
Step 2: Assess where you are now on the continuum of
integrated care and set
realistic goals for change.
It is important to assess exactly where you fall on the
continuum of integrated
care before making any changes. As Blount (2003) has pointed
out, a continuum of
care exists with regard to both location and the nature of the
relationship between
providers. At one end of the continuum are situations where
behavioral health
providers work in different locations than the primary care
providers, have
completely separate treatment plans, and do not communicate
with one another.
At the other end of the continuum are providers who
communicate regularly and
share the same office, the same administrative staff, the same
billing system, the same
charts, and the same treatment plans. A worksheet illustrating
this continuum is
Figure 1. A worksheet illustrating the continuum of care that
exists with regard to both location and the
nature of the relationship between providers.

shown in Figure 1. The worksheet is designed to help those
developing programs
identify where they are on the continuum.
After identifying where one is in terms of both location and
relationships, it is
helpful to formulate appropriate, realistic, short- and long-term
goals. For example,
if you are currently in separate locations with completely
separate treatment plans
and little communication (A1 on the worksheet), the most
realistic short-term goal
might be to increase communication (A2–A4). Once
relationships are better
established, it might be reasonable to consider taking steps
toward co-location,
and ultimately, full integration (B4–C4). Although it is
certainly possible to skip
steps, it is often worthwhile to proceed slowly through the
various steps so that
problems can be identified and solved as a group at each step.
This allows time for
trusting relationships to develop that is crucial to the process.
These relationships
can then serve as the foundation for a more fully integrated
system of care in the
future.
Step 3: Identify the driving forces and the barriers to change,
enlist others to help
tip the balance toward change.

Working toward cultural change in an organization can be time-
consuming,
difficult, slow, and frustrating. There are significant forces that
drive people toward
change and significant barriers that drive people to resist
change. When the barriers
and resistance to change are greater than the driving forces,
change is unlikely to
occur. On the other hand, when the driving forces outweigh the
barriers and
resistance is lowered, the opportunity exists for change to
occur. In this third step, it
is important to examine the driving forces and the barriers to
change for each
stakeholder. Once ‘‘champions’’ emerge, the task becomes to
help those individuals
enlist others to decrease the barriers and point out the enhanced
benefits of
integrated care.
Step 4: Collaboratively implement a ‘‘pilot program,’’ evaluate
it, redesign it, and
test it again.
Even when the balance begins to tip toward change, there may
still be a significant
amount of resistance. Under these circumstances, it may be
worth suggesting a ‘‘pilot
program.’’ Stakeholders often see this as less of a risk because
it is seen as a
temporary arrangement. Nevertheless, respect for everyone
involved in the change
(e.g., clinicians, students, secretaries, nurses, office staff,
business managers, etc.) is
absolutely critical at this stage. If the entire group designs the
‘‘pilot program,’’

participants can agree to convene regularly to evaluate and
make changes to the
program. In this way, clinical, financial, and administrative
aspects of the program
are all treated as equally important, each person’s opinions and
thoughts matter, and
each person can play an important role in helping to identify
and solve problems that
arise. Again, the stage is thus set for trusting relationships to
develop, and that is
essential to the process.
In the next section, we illustrate how we used these steps to
develop an integrated
primary care program in Rhode Island.
Case Illustration: Linking Systems in Rhode Island
When members of the Department of Behavioral Medicine at
The Miriam Hospital
(an academic medical center affiliated with Brown University in
Providence, Rhode
Island) began to track referrals, they discovered that a large
percentage of patients
who were referred by their physicians never called to schedule
an appointment.
Informal discussions with patients revealed that they resented
being referred for any
services they perceived as ‘‘mental health,’’ and they preferred

to talk to their
‘‘doctor’’ about their mental/behavioral health needs. Informal
discussions with the
physicians revealed that they were frustrated because they had
neither the time nor
the skills to help patients with all their mental/behavioral
problems. Concurrently,
the clinical psychology internship program in behavioral
medicine at the hospital
began to face new challenges. Due to changes in insurance
requirements, psychology
interns could see only uninsured patients, thereby diminishing
the breadth of their
training experience. Clinicians in behavioral medicine, referring
physicians, and the
Director of the Training Program were all interested in
exploring new models of
working together that would benefit patients, providers, and
students. As described
earlier in Step 1, formal and informal meetings occurred to
forge relationships with
organizations that wanted to be involved in change, and to
identify ‘‘champions’’
within the various organizations. Very few individuals within
the different groups
knew anything about integrated care, so education was a key
component of the
process. Each time a patient was shared between a clinician in
behavioral medicine, a
trainee, and/or a primary care provider, it was viewed as an
opportunity to discuss
the merits of integrated care and explore the driving forces and
the barriers to
integration.
As a second step, we analyzed where we were on the continuum
and tried to agree

on short-term and long-term goals. At the beginning of this
process, primary care
offices and behavioral medicine offices were housed in different
buildings several
miles from each other, occasionally exchanged information, and
had completely
separate treatment plans (corresponding to A2 in Figure 1). The
training program
was located in The Department of Behavioral Medicine, but had
no connection to
the physician group. We set a specific goal of trying to move
each group toward
more regular exchange of information and coordination of
treatment plans (A4).
This allowed time for more trusting relationships to develop,
which proved to be
critical in the process. During this phase, more and more levels
of health care
providers were involved including nurses, technicians, office
managers, and billing
staffs of the different organizations. As Peek and his colleagues
have emphasized
(Patterson et al., 2002; Peek & Heinrich, 1995), programs that
do not give ample and
equal attention to the clinical, financial, and administrative
spheres are doomed
to fail.
As described in Step 3 earlier, we identified several driving
forces that provided the
impetus for the development of an integrated primary care
program in Rhode Island.
Because of financial changes in the health care system, primary
care practices that
were once housed within the hospital moved out into the

community. Resources that
were previously easily accessed within the same building and
the same system became
difficult to access. In addition, PCPs increasingly became the
‘‘gatekeepers’’ for the
vast majority of their patients, requiring more time and effort.
Concurrently, the
average time of a medical office visit was declining due to
pressures related to
insurance reimbursement. To complicate matters further,
psychology interns could
no longer be reimbursed for treating individual patients.
These changes in the health care system created a variety of
problems for both
medical and behavioral health providers. Evidence had
accumulated showing that
behavioral health interventions can be effective, reduce health
care costs, and
improve patient care (Blount, 2003), but accessing such
programs was a challenge,
and reimbursement was an even greater challenge. The new
system created a
situation where physicians had an overwhelming number of
patients who needed
behavioral health treatment they could not provide, and
qualified behavioral health
professionals were unable to provide treatments that had been
shown to be clinically

beneficial and cost-effective.
Although there was interest in integrating behavioral health,
trainees, and primary
care, there was also a significant number of barriers. First, even
finding time to
discuss development of an integrated care program was an
enormous challenge in
itself. Discussions often occurred sporadically in hallways and
cafeterias with ideas
and plans written out on napkins in restaurants. Second, once
barriers were
identified, they seemed overwhelming and included a significant
number of
administrative, clinical, and financial issues. Administrative
issues related primarily
to staffing demands and space problems. As is true in most PCP
offices, the
secretarial staff was working at maximum capacity and reluctant
to take on any
additional administrative tasks. There was little office space
available for the
behavioral health providers to see patients at the primary care
site. Clinical issues
centered on confidentiality and record keeping. It was unclear if
behavioral health
visits should be documented in the medical chart, and, if so,
how they should be
documented. Who should have access to which sections of the
chart and under what
circumstances should certain sections be released to others?
How would the
behavioral health specialist(s) be paid? How could patients be
charged without
incurring additional administrative costs? How could students
be utilized more

effectively?
At times, these issues seemed insurmountable, and it took
almost 2 years of formal
and informal discussions before we were ready to launch a pilot
program. The
collaborators initially had very different views on how each of
these issues should be
handled, but in time, the group agreed on how to resolve the
administrative and
clinical barriers. As is commonly the case, the most difficult
issues to resolve were
financial. In the past, the primary care practitioners had rented
space to other health
care professionals, so they suggested renting space to the
Department of Behavioral
Medicine. The Department of Behavioral Medicine, however,
could not afford to
pay rent given the low rates of reimbursement for
psychologists’ services. The
Department of Behavioral Medicine’s view was that the PCPs
should consider
paying Behavioral Medicine to deliver co-located services
because their providers
would have to spend time traveling, behavioral health services
would serve to
leverage physician time, and integrating behavioral health
services would increase
patient satisfaction in their practice.
What served as the ‘‘tipping point’’ to get us to Step 4 allowing
us to launch a pilot
program? It was clear from the start that financial barriers were
the primary
obstacles. The tipping point came when it was decided that
during the pilot phase, no

money would be exchanged between the Department of
Behavioral Medicine and the
PCPs, and that this arrangement would be reevaluated in 6
months. The behavioral
health specialists did not pay to rent space in the PCP office,
and the PCPs did not
pay to have the behavioral health specialists see patients in their
offices. It was
agreed that the behavioral health providers and PCPs would
both continue billing
exactly as they had done before; the only difference was that the
behavioral health
specialists evaluated and treated a certain percentage of patients
in the PCPs office
rather than in their own office.
The group was well aware that it was unrealistic (clinically,
financially, and
administratively) to achieve full integration from the start (e.g.,
to have a full-time
behavioral health specialist in the PCP office). As a result, the
short-term goal
became to improve communication, develop a pilot program of
integrated care on a
small scale (that could grow over time), and increase the
number of patients who
followed up for behavioral health treatment after being referred.
Increasing overall
access to behavioral health care was a goal for the entire group.

As mentioned earlier, finding time for communication and
planning is
always a tremendous challenge when developing and
implementing new
programs. It requires that those involved be personally
committed because
providers are rarely if ever reimbursed for spending time talking
with one
another. Thinking creatively while building on the strengths of
the system that were
already in place helped. In our case, communication often
occurred in hallways,
restaurants, and hospital cafeterias, through notes placed in
charts or on chairs and
desks, and through phone calls and e-mail. We all learned
quickly that keeping
communication brief and targeted reduced the burden of time
that is in short supply
for all providers.
In our specific pilot program, a trainee and his or her supervisor
arrived at the
PCP office once each week during the lunch break to allow time
for communication
with the staff. Conversations usually occurred informally
around the lunch table and
focused on both shared patients and ‘‘problem’’ patients in the
office. Patients were
then seen by the behavioral health consultant for approximately
30 minutes each.
After each visit, the behavioral health consultant provided
verbal feedback to the
PCP (if available) and wrote a brief ‘‘Behavioral Health
Consultation Note.’’
Patients signed a written consent to have these notes contained

within the
correspondence section of their medical chart. This section was
chosen to ensure
that the note would not be released unless a separate Release of
Information form
was signed by the patient.
Results of the Pilot Program
This pilot program began with three general questions:
* Would PCPs refer their patients for behavioral health
services, and, if so, would
patients come? What types of problems would trigger referrals?
* What types of interventions would most commonly be
implemented? How
successful would the interventions be?
* Would the service prove to be financially viable?
Which Patients Were Referred and Why?
We began by scheduling only two patients each week. Primary
care physicians did
not think that two patient slots would be ample; and they
encouraged us to allocate
more slots. Our goal, however, was to start small and build very
slowly as we
developed trusting relationships with the physicians, nurses, and
office staff.
Interestingly, it surprised everyone to find that patient slots
were often empty the
first month of the program. When meetings were held to discuss
possible reasons, the
PCPs indicated that they routinely ‘‘just forgot’’ to make such

referrals. Some
informal meetings were held to discuss these two areas of
concern, and one of the
nurses suggested putting a sign in each exam room informing
patients of the
available behavioral health services. This sign encouraged
patients to talk with their
doctor if they wanted help with problems such as weight, sleep,
stress, anxiety, pain,
depression, alcohol/drug use, or smoking. When patients
mentioned it to their PCPs,
the PCPs made the appropriate referral. After the signs went up
in exam rooms,
empty appointment slots were extremely rare, and we slowly
increased the number of
appointment slots as needed.
We explored the characteristics of the first 68 patients to
receive integrated
services, and found that they were seen for a total of 89 visits.
Figure 2 illustrates the
percentage of patients seen for each type of problem. As shown
in the figure, the
most common problem was stress and anxiety, followed by
depression, pain and
headache, and lifestyle factors.
What Types of Interventions Were Implemented and How
Successful Were the

Interventions?
The first session with the behavioral health specialist focused
specifically on the
issue(s) identified in the referral from the PCP. Primary goals
of the first interview
were as follows:
* To assess the problem from the patient’s perspective.
* To assess readiness to change.
* To educate the patient regarding the nature of the problem,
the types of treatment
available, and what each type of treatment would entail.
* To triage the patient (if appropriate) to a behavioral or mental
health specialist in
the community matched to the patient’s needs as well as their
insurance coverage
and/or arrange a follow-up visit at the PCP office.
* To provide useful feedback to the PCP and follow-up with the
PCP regarding
patient progress.
Most of the patients seen (78%) were seen for only one visit in
the PCP office. Of the
patients seen more than once in the PCP office, almost all had
been referred for either
stress/anxiety or a chronic pain problem. Of the 68 patients
seen, 34 (50%) were
referred to mental and/or behavioral health programs within our
health care system,
and 8 (12%) were referred to programs outside of our health
care system. Interventions
for patients who were not referred to specialized programs

consisted most often of
motivational interviewing, education, and brief, cognitive–
behavioral interventions.
A major goal of the program was to increase the probability that
patients
would receive appropriate care for behavioral health problems.
Given this, it
was of interest to explore the likelihood that patients actually
followed through with
Figure 2. The percentage of patients seen for each type of
problem addressed. The most common
problem was stress and anxiety, followed by depression, pain
and headache, and lifestyle factors.
referral suggestions. Of the 50% of patients referred to
programs within our own
health care system, 85% scheduled and attended their first
appointment. Most of
these patients were referred for treatment of depression or
anxiety. Patients referred
for smoking cessation were the least likely to follow through
with suggestions. Of the
five patients referred for help with smoking, none showed up
for their next
appointment.
How successful were the interventions? Most patients began
behavioral health

consultations with statements such as: ‘‘I’ve never talked to
anyone like you before—
I wouldn’t have come but my doctor really thought I should. I
hope you don’t think
I am crazy.’’ Clearly, these were not patients ready to accept a
referral to a ‘‘mental
health’’ provider on the other side of the city. Meetings held in
the PCP office
provided an opportunity to use the biopsychosocial model to
explore problems with
patients in a way they could grasp it, at a time they were ready
to hear it. These visits
served as a bridge to help patients link their physical and
mental health, and their
doctors were readily available to reinforce that message.
For the PCPs, having behavioral health specialists in their
office helped them (and
their staff) become more efficient. When they (or their patients)
had behavioral
health questions, they knew where to go for help. For the
behavioral health
specialists, working closely with PCPs meant better care for
patients with medical
problems because the care was integrated. The physician and the
behavioral health
specialist were working toward the same goals and could
coordinate their treatment
plans. This approach proved particularly important for pain
patients and other
patients on multiple medications that included psychotropics.
Finally, for the
trainees involved, the experience offered them a chance to
evaluate and treat a wide
variety of problems in a busy medical office, and, equally
important, the opportunity

to learn how to interact with nurses and physicians as
colleagues. This opportunity
seems particularly valuable given the vast cultural differences
that exist between
these groups and the ever-increasing likelihood that students
will be working in
integrated care settings in the future.
Was the Program Financially Viable?
When all providers are employed by one system such as an
HMO, studies have
shown that integrated care can at times be financially viable
because of a medical
cost offset. When all the providers are in different systems,
however, and these
systems are based on a fee-for-service model, can integrated
care be financially
viable?
In the pilot program, the behavioral health specialist (who was,
in this case, a
psychologist) visited the PCP office each week with the trainee,
resulting in lost
income due to travel time. The psychologist billed for services
provided in the PCPs
office and collected the same revenue that would have been
collected had these
patients been seen in her own office. We know that 50–90% of
patients referred for
mental health treatment do not follow through (Bloch, 1993;
Glenn, 1987); and
about one third of patients who make appointments do not show
for their first
appointments. Of the 34 patients seen in the PCP office who
were referred for

treatment within our own system, 29 (85%) showed up for their
first visit. Given this,
it seems reasonable to assume that the revenues generated
amounted to more than
the investment involved in traveling to the PCP office. This
does not account for
other factors that also impacted revenues including the increase
in direct referrals
from the PCP office which resulted from our collaborative
efforts.
Integrating Behavioral Health and Primary Care: Is It Worth the
Effort?
Integrating behavioral health and primary care presents
extraordinary challenges as
well as extraordinary opportunities for those in primary care
and behavioral health.
The purpose of this article is to add to the growing body of
evidence showing that
the important question is no longer whether to integrate care,
but how to integrate
care. With dedication, commitment, hard work, and creativity,
systems can be linked
together to form networks that ultimately provide better patient
care. It is our hope
that the strategies and program described here will prove
helpful to others
attempting to build programs of integrated care.

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Introduction
This article represents the second of two (see

Frankish et al., 2006) articles that present a concep-
tual framework of health promotion in primary
health care (HP in PHC) settings. The framework
has five domains (values, structures, strategies,
processes and outcomes). Frankish et al. (2006)
present the foundational values and structures that
serve to create a supportive environment for health
promotion. The latter three domains are the focus
of the present article.
We argue that health promotion deserves greater
attention in primary health care settings. Treatment
alone is unlikely to have marked effects on health
inequities that underlie many health conditions.
Many jurisdictions and health professionals now
recognize that a reduction in health inequalities and
a closing of the gap in health status requires greater
integration of HP in PHC (Keleher, 2001; Ministry
of Health, New Zealand, 2003).
Health promotion research in primary health care
often focuses on only one or two of many compon-
ents. This further contributes to the maintenance
of diverse and fragmented perspectives. It is critical
to identify/define the terms/concepts underpinning
Primary Health Care Research and Development 2006; 7: 269–
277
© 2006 Edward Arnold (Publishers) Ltd
10.1191/1463423606pc286oa
Building on a foundation: strategies, processes
and outcomes of health promotion in primary
health care settings

Glen Moulton Institute of Health Promotion Research,
University of British Columbia, Vancouver, BC, Canada,
James Frankish Institute of Health Promotion Research, Faculty
of Graduate Studies, Department of Health Care
and Epidemiology, Faculty of Medicine, University of British
Columbia, Vancouver, BC, Canada, Irving Rootman
Faculty of Human and Social Development, University of
Victoria, Victoria, BC, Canada, Carol Cole and Diane Gray
Institute of Health Promotion Research, University of British
Columbia, Vancouver, BC, Canada
Jurisdictions around the world have articulated the need for the
development of an inte-
grated health care system with an increased emphasis on
primary health care that incorp-
orates the principles/practices of health promotion. Over the
past century, the medical
model has been the default model of care in many countries, and
yet treatment alone is
unlikely to have marked effects on health inequities or health
status. This article presents
and discusses three fundamental dimensions (strategies,
processes and outcomes) of
health promotion in primary health care (HP in PHC) settings.
We argue that the three
dimensions are founded on the values and structures of health
promotion (Frankish
et al., 2006). Our work is based on a comprehensive literature
review, validation by key
informants and a national survey of Canadian primary health
care settings. We suggest
that the strategies (types of interventions), processes (client and
community centred
care), and desired health promotion outcomes (intended or
unintended results) need to
be better articulated and understood. Identification and

discussion of the domains of HP
in PHC settings is a crucial first step. It is a step toward the
subsequent identification of
related indicators and measures of health promotion that can be
used for planning,
implementation and evaluation of important health promotion
initiatives.
Key words: health care reform; health inequities; health
promotion; indicators; popu-
lation health; primary health care; standards
Received: May 2004; accepted: December 2005
Address for correspondence: Glen Moulton, Institute of
Health Promotion Research, University of British Columbia,
Room 411, LPC Building, 2206 East Mall, Vancouver, BC,
Canada V6T 1Z3. Email: [email protected]
PC286oa-11.qxd 1/7/06 12:15 Page 269
270 Glen Moulton et al.
277
HP in PHC. We do so by differentiating it from the
more predominant disease focused model. By oper-
ationalizing the breadth, depth and diversity of HP
in PHC, settings may be able to develop and sustain
it. This change requires a philosophical paradigm
shift and practical implementation. For definitions
of primary health care and health promotion, read-
ers are referred to Frankish et al. (2006).

Research design
This research project consulted broadly, using quali-
tative and quantitative methods, to construct a con-
ceptual framework for HP in PHC that distils the
most salient characteristics from dozens of possi-
bilities. It included an extensive review of the pub-
lished literature in scholarly journals, and grey
literature, including policy documents and reports.
We employed a Delphi technique by convening
experts to seek input on relevant characteristics of
HP in PHC.We also sought input from focus groups
held in four Canadian cities. Finally, we undertook
a national survey of primary health care settings to
examine the perceived level of importance and
reported activity that professionals and adminis-
trators attributed to the characteristics of our con-
ceptual framework. Our conceptual framework was
refined with each successive research phase. The
characteristics within the five domains (values,
structures, strategies, processes, and outcomes) were
modified until no other aspects of health promotion
could be identified for inclusion. Complete details
on our research design is provided in Frankish
et al. (2006).
Key domains and characteristics
of HP in PHC
Health promotion comprises multiple, intercon-
nected concepts that can be incorporated into the
practice of primary health care settings.
Frankish et al. (2006) describes the philosoph-
ical values that provide the foundation for health
promotion. They also highlight how these values

should manifest in structures that create a support-
ive environment for health promotion. Our focus
is to build on Frankish et al. (2006) by presenting
the remaining three domains (strategies, processes,
outcomes).
The strategies (types of interventions) and pro-
cesses (client and community centred care) are
important to the outcomes that health promotion
initiatives may achieve in primary health care set-
tings. Strategies are specific types of interventions.
Processes describes aspects of providing client-
centred care through interpersonal relationships.
Finally, outcomes are the intended or unintended
results of the strategies, processes and structures.
The synergy between the first four components
leads to desired health promotion outcomes.
None of the dimensions within the five domains
are unique to health promotion per se. Health pro-
motion is unique precisely because it is an amalgam
of values and practices that enhance health. The
information provided exemplifies the breadth of
the subject area. Practitioners and decision makers
may require additional information to acquire suf-
ficient depth of knowledge.
This article builds on these values and structures.
Below, we outline the strategies, processes and out-
comes that may be expected to arise out of these
foundational values and structures.
Strategies
Multifactoral causes of illness and disease
necessitate a multifactoral approach to health pro-

motion. We see three complimentary approaches
to health promotion (Birse, 1998). The first is the
medical or preventive medicine approach that is
directed at improving physiological risk factors.
Next, the behavioural or lifestyle approach is
directed at improving behavioural risk factors, such
as smoking and physical inactivity. Finally, the socio-
environmental approach is concerned with the
totality of health experiences and the factors that
help to maintain or improve health (including risk
conditions and psychological risk factors). This
approach targets the determinants of health in one’s
physical and social environment.
These approaches differ in how health is viewed,
how health problems are defined, what interven-
tions are implemented, and how effectiveness is
measured. They are most effective in terms of long-
term outcomes when a combination of such strat-
egies is used concurrently, and at several levels
within a setting and with external partners (Swaby
and Biesot, 2001).
Despite the apparent widespread acceptance
of a socio-environmental (eg, population health)
PC286oa-11.qxd 1/7/06 12:15 Page 270
perspective held by many working in health pro-
motion, most health promotion activity continues
to be preventive and lifestyle oriented through the
provision of health information/education, screen-
ing and early intervention. These are valid strat-
egies. But, they are insufficient and ineffective on

their own and they do not harness the full potential
of health promotion to positively affect individual
and community health.
A health promotion approach seeks to expand
the focus of attention beyond the individual. Clients
of primary health care may be individuals, families,
groups, communities and populations. Health pro-
motion is more than a specific programme (add-on
to existing health services) or a single strategy or
aggregate of individual strategies. It demands a
multifaceted reorientation and incorporation of a
range of services and intervention strategies that
meet people’s immediate needs and also address
social and economic conditions. Group and com-
munity strategies are fundamental to health
promotion.
Empowerment is a fundamental value of health
promotion and in keeping with health promotion’s
focus of enabling individuals. If the strategies
employed are not enabling or empowering to indi-
viduals and communities, then it is not health
promotion. Community empowerment involves
individuals acting collectively to gain greater influ-
ence and control over the determinants of health
and the quality of life in their community. Health
professionals generally have more power (status,
legitimacy, access to or control over resources) than
their clients (Labonte, 1994). It is important that
health professionals do not remain the locus of con-
trol, but rather are an enabling agent. Empowering
individuals or groups requires access to decision
making, skills and knowledge to effect change.
People cannot achieve their fullest health potential
unless they are able to take control of those things

that determine their health.
Individual strategies
The individual level of care is fundamental to
our health system. Primary care interventions are
generally episodic and brief. They occur between
an individual and a health care provider, typically
a physician, and health promotion strategies are
consequently short term, such as giving advice for
smoking cessation or distributing health education
pamphlets. Some practitioners see this as the full
extent of health promotion (Swaby and Biesot,
2001). The individual is targeted for change rather
than the social or environmental conditions that
underlie the illness or disease. Individual focused
strategies are not unique to health promotion. A
health promotion approach, however, focuses on
the individual in the context of their community,
such as vaccinations targeted towards hard to reach
populations, and includes the provision of ancillary
services. Individual oriented health promotion
strategies include personal life skills, psychological
counseling, health education (and information),
self care, referrals, home visits, and preventive inter-
ventions (eg, screening), individual risk assess-
ments (for body weight, diet, activity levels), and
immunizations (for tetanus, measles, polio and
influenza).
Individual oriented strategies have not been
successful in meeting the needs of the most vulner-
able in society. Health promotion seeks to redress
inequalities in health status. Need and demand for
primary care are clearly divergent, with those in

greatest need of an intervention being the least
likely to receive it. The inequality of provision has
led to inequity of uptake, and should be remedied
by appropriate targeting and tailoring of pro-
grammes (Davis et al., 1996).
Group strategies
Group strategies typically refer to groups small
in number, generally fewer than 20 participants.
These groups generally focus on life conditions of
their members. They are where people begin to
forge new identities in supportive relationships.
Group strategies include group counseling, cap-
acity building, outreach, self-help/mutual aid, and
social support. Issues addressed may include drug
and alcohol dependency, adolescent health, or men-
tal health.
Community strategies
Community strategies are those that will affect
the broad community and population (whether or
not they directly participate) through social and
environmental change. The groups that benefit
the most from community level strategies are the
ones at greatest risk of ill health, and often, the most
difficult to reach through conventional approaches.
Community strategies include community develop-
ment/community economic development, healthy
public policy (eg, economic and regulatory activities
Strategies, processes and outcomes of health promotion in
primary health care 271

277
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272 Glen Moulton et al.
277
involving financial and legislative incentives or dis-
incentives focusing on price, availability, restrictions
and enforcement, such as modifying consumption of
tobacco and alcohol through increased taxation, and
restrictions on advertising), health communication
(eg, health fairs, social marketing, mass media strat-
egies), coalition building, advocacy (eg, direct pol-
itical lobbying, media advocacy), and supportive
environments.
Organizational strategies
Organizational strategies are targeted at the
health setting itself, and its practitioners (see struc-
ture section).
The range and content of the various strategies
is vast. It can include any combination of medical
conditions, determinants of health, lifestyle/behav-
ioural issues and/or population groups (eg, age,
gender, ethnicity). Strategies implemented in a
primary health care setting will differ based on the
needs of the population. In an inner city area, the
strategies for community members may address
poverty, homelessness, addictions problems, while

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