Guest editorial

A REFLECTION ON NURSING TIME

On the sight of a Clock

How fruitlesse our designes would prove, if we

Should be possest with so much vanitie,

As with our fraile endeavours, to assay

To stop the winged houres in their way?

Or fondly seek to chaine up Time, and try

To make him with our wild desires comply,

Since leaden plummets hung upon his feet,

Not clog we see, but make his pace more ¯eet.

Thomas PhilipottPhilipott (1646)(1646) (Cited by Martin 1950 p. 2)

Time is an illusion¼ lunchtime doubly so.

From The Hitchhikers Guide to the Galaxy (Adams 1992 p. 29)

That time dominates our lives is I think without question.

Whether it is in literature or real life, we cannot escape it.

For a serious consideration of the concept of time,

Coveney and High®eld (1991) provide insight for the

mental gymnast. For a more offbeat consideration of the

paradoxes that time throws up, Rucker's (1988) The

Fourth Dimension and How to Get There is entertainingly

thought provoking. On a more practical level there are

many publications which deal with the better manage-

ment of time. A good example is the `magic hour'

technique described by Black (1987). I would heartily

recommend this technique, as it sounds both feasible and

likely to be successful¼ though to be honest I've never

found the time actually to try it.

It is a little known fact that the scienti®c name for the

smallest unit of time is actually the `jiffy'. This is the time

it would take a beam of light to travel one million-billion-

billion-billionth of a centimetre (Davies 1988). For prac-

tical purposes, a jiffy is what you say you'll be back in

when a patient asks for a bedpan or to be assisted in

putting in their dentures, and can be anything from 5

minutes to in®nity.

Like many nurses I always had dif®culty in making time

available to study, and spent many pre-exam nights

cramming several months of study time into a few tense

hours. Reading is something which I still struggle to make

time for, only to succumb to the likes of Robert Rankin's

(1991) They Came and Ate Us (a classic time travel

novel¼ honestly) rather than the latest research-based

answers to nursing's perennial problems.

Patients' perceptions of time can be very different to the

perceptions of relatives and nurses simply because the

demands on them are so different. Patients in intensive

care can lose days from their lives, but for the relatives

waiting anxiously by the bedside time will have been

slowed to the point where each minute seems to last

forever. They all require some of our time.

Giving freely of their time can be the most dif®cult of all

the demands made on nurses. They juggle complex

technical skills with busy ward management, research

awareness with still having to complete tasks in the

allotted time. Often patients just want nurses to sit with

them and give them some of their time. That can be the

most dif®cult thing of all to do. It is the most basic of

nursing skills, and yet the most dif®cult to justify in the

great battle of determining health-care priorities.

When a nurse stands at the foot of a bed and asks of a

patient `Is your pain all right?', what is often really being

said is `Look, sorry, but I'm too busy at the moment, so I

hope to goodness you're okay'. Patients detect the nature

of the question and are not slow to pick up on the nuances.

Patients may wish to please and will often under-report

their pain or give the answer they think nurses would like

to hear simply because they don't want to be thought a

burden on their valuable time.

Pain relief is about more than just being `nice' to people (it

is also a therapeutic necessity). The nurse who utilizes time

well and understands that would move to the patient's side

and ask how they were really feeling; check if they can take

a deep breath and cough, or change their position in the bed.

This small investment of nursing time increases the nurse's

awareness of the patient's true condition, and from that

point the nurse is duty bound to respond appropriately. It

also lets the patient feel cared for by creating the impression

that nurses really are wanting to know how they are feeling

and intend to do something about it.

Sitting and talking with patients is the most basic of

nursing skills, which student nurses often display in

abundance; that is, before the weight of the `system' irons it

out of them. The clinical nurse specialist for pain man-

agement or palliative care does not necessarily draw upon

advanced clinical nursing skills or a sound knowledge of

evidence-based practice, when she or he makes time for a

patient in this way. It is simply following a conviction that

if you give patients some time they will tell you everything

you need to know. Specialist nurses, however, have to be

careful not to antagonise their colleagues. It is not uncom-

mon for a hospital patient to tell other staff consistently

that they have no pain, yet tell the specialist pain nurse

that they have been in agony all day.

An important message

Fordham and Dunn (1994), describe how the act of `being

alongside' the patient fosters a feeling of comfort, of being

Journal of Advanced Nursing, 1998, 28(4), 693±694

Ó 1998 Blackwell Science Ltd 693

cared for, and this in itself has the potential to boost a

patient's coping strategies and break the cycle of help-

lessness and hopelessness which can spiral ever down-

wards. This is an important point for nursing managers to

appreciate. They should not consider personal, interactive

clinical time spent with the patient to be either an

unproductive luxury, or even a fashionable quality-

enhancing concept. It is simply the essence of good

nursing care and as such must be actively supported.

Koh and Thomas (1994) have shown that patient con-

trolled analgesia (PCA) systems reduce staff time spent in

drawing up and administering opioid analgesia. They

emphasize that any time saved should be used to increase

patient±nurse contact; PCA is not a device for reducing

nursing staff. Its purpose is simply to allow an individu-

alized analgesic dose regime based on the patient's eval-

uation of its ef®cacy. If patients are to get the best out of

PCA, safely and effectively, time must be spent monitor-

ing and providing support for them, pre- and postopera-

tively.

In his book Zen and the Art of Motorcycle Maintenance

Prisig (1989) recounts the tale of having garage mechanics

damage his machine. The radio was loudly playing in the

background, and the mechanics attentions were elsewhere;

they never consulted the manual to check that what they

were doing was correct. The resulting damage was frus-

trating for the author, and he blames the whole episode on

the mechanics functioning as `spectators', i.e. not actively

taking part in their lives or the work in hand. How many

times have nurses got through a busy shift and felt that the

day has passed them by without being empowered to play

a meaningful part in it? This is something to guard against,

as nursing is not a spectator sport. To achieve anything at

all requires time spent on planning, implementing and

evaluating every aspect of one's work.

The concept of having time to care is not new. Indeed it

possibly pre-dates the evolution of the species Homo

sapiens. Around 1.7 million years ago, an adult female

Homo erectus (numbered as KNM-ER 1808) died. This

skeletal specimen was found to have suffered from hyper-

vitaminosis A (an excess of vitamin A which leads to

deformity of the bone and death). She had lived for some

time with this painful condition in which the periosteum

splits from the bone, as the associated blood clots had

ossi®ed. Someone must have taken care of her or she

would not have lasted long in the African bush. Someone

must have provided her with shelter, food and water. In

other words time was spent caring for her basic needs

(Walker & Shipman 1996 p. 134).

Her bones are poignant testimony to the beginnings of sociality, of

strong ties among individuals that came to exceed the bonding

and friendship we see among baboons or chimps or other non-

human primates.

The hominid line was established over four million

years ago, with modern humans thought to have become

distinct around 100 000 years ago. The bulk of this

`human' time was spent in small, closely related, hunter-

gatherer groups. Only very recently in evolutionary terms

have we seen the rise of large communities, where it is

impossible to know every person in the group, their

relation to you, their history of friendships and allegiances.

Perhaps that is in part why we ®nd it dif®cult to make

time for so many strangers, and treat them as we would

kin. It is no small task to remind ourselves of this. Next

time nurses walk hurriedly past the bed of a pale,

withdrawn individual, they should ask, were this their

brother, aunt, grandparent or neighbour, would they make

the time to be sure that they were really all right?

Time is many things to many people whether the

physicist, poet or patient. The realm of nursing is with the

patient. Therefore it is the nurse's travels in time with

patients that deserve the nurse's deepest meditations.

Ramon Pediani

RGN BSc(Hons)

Clinical Nurse Specialist for Acute Pain

Blackpool Victoria Hospital

Blackpool FY3 8NR, England

References

Adams D. (1992) The Hitch Hiker's Guide to the Galaxy Ð A

trilogy in four parts. BCA, London.

Black R. (1987) Getting Things Done. Duncan Petersen Publishing

Ltd, London.

Coveney P. & High®eld R. (1991) The Arrow of Time. Flamingo-

HarperCollins, London.

Davies P. (1988) Other Worlds. Space, Superspace and the

Quantum Universe. Penguin Books, London

Fordham M. & Dunn. V. (1994) Alongside the Person in Pain.

BaillieÂre Tindall, London.

Koh P. & Thomas VJ. (1994) Patient Controlled Analgesia (PCA):

does time saved by PCA improve patient satisfaction with

nursing care? Journal of Advanced Nursing 20, 61±70.

Martin L.C. (1950) Poems (1646) by Thomas Philipott. University

Press, Liverpool.

Prisig M. (1989) Zen and the Art of Motorcycle Maintenance.

Black Swan, London.

Rankin R. (1991) They came and ate us: Armageddon II: The B

Movie. Bloomsbury Publishing Ltd, London.

Rucker R. (1988) The Fourth Dimension and How to Get There.

Penguin Books, London.

Walker A. & Shipman P. (1996) The wisdom of bones Ð in search

of human origins. Weidenfeld and Nicolson, London.

Guest editorial

694 Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 693±694