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A concept analysis of routine: relevance to nursing

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A concept analysis of routine: relevance to nursing
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  A concept analysis of routine: relevance to nursing Anna Zisberg 1 , Heather M. Young 2 , Karen Schepp 3 & Leehu Zysberg 4 Accepted for publication 6 September 2006 1 Anna Zisberg PhD RN Assistant Professor Department of Nursing, University of Haifa,Haifa, Israel 2 Heather M. Young PhD GNP FAAN Endowed Professor School of Nursing, Oregon Health andSciences University, Ashland, Oregon, USA 3 Karen Schepp PhD RN Associate Professor School of Nursing, University of Washington,Seattle, Washington, USA 4 Leehu Zysberg PhD Associate Professor Department of Psychology,Tel Hai Academic College, Tel Hai, IsraelCorrespondence to Anna Zisberg:e-mail: azisberg@univ.haifa.co.il ZISBERG A., YOUNG H.M., SCHEPP K. & ZYSBERG L. (2007)ZISBERG A., YOUNG H.M., SCHEPP K. & ZYSBERG L. (2007)  A concept ana-lysis of routine: relevance to nursing.  Journal of Advanced Nursing   57 (4), 442–453 doi: 10.1111/j.1365-2648.2006.04103.x Abstract Title. A concept analysis of routine: relevance to nursingAim.  This paper reports a concept analysis identifying the attributes, antecedentsand consequences of the concept of routine and examining the implications andapplications of this concept in the field of nursing. Background.  Routine may be a pivotal concept in understanding functional adap-tation and wellbeing. Nurses in institutional settings work according to scheduledroutines, patient care is largely orchestrated in routines set by organizations andregulations, and persons receiving care have their own life routines determiningidentity, capacities and frame of reference. However, to date, nursing has paid littleattention to the relevance of routine and the role it may play in patient care. Method.  A concept analysis was conducted using Rodgers’ guidelines. The literaturesearch was based on the following databases: PsycInfo, CINAHL, MedLine, SocialServices, and Social Work abstracts. To be included in the analysis, papers had torelate directly and essentially to the concept of routine. Seventy-four papers pub-lished from 1977 to 2005 were included in the final stage of the analysis. Theanalysis included target populations, disciplinary perspectives, type of manuscript,themes and definitions, theoretical models, antecedents and consequences, as well asrelated terms. Results.  Routine is a concept pertaining to strategically designed behavioural pat-terns (conscious and subconscious) and is used to organize and coordinate activitiesalong different axes of time, duration, social and physical contexts, sequence andorder. It emerges from the literature as a strategy that serves adaptation, in general,especially in the face of change and stressful situations. The conceptual structure,relations with other concepts, antecedents and consequences are described. Conclusion.  The concept of routine is ill-defined and seldom used in the field of nursing, despite the promise it may hold for a better understanding of a wide rangeof health-related issues. This concept analysis offers an integrative view of routineand suggests directions for future research and practice. Keywords:  concept analysis, daily routines, functional status, nursing, Rodgers’evolutionary method, routine THEORETICAL PAPER  JAN 442    2007 The Authors. Journal compilation    2007 Blackwell Publishing Ltd  Introduction ‘Routine’ is a term often used in research and practicecontexts with varying meanings and connotations: from anegative portrayal of routines as rigid, maladaptive patternsof behaviour to a positive view of routines as key to normalfunctioning and stability (Reich & Zautra 1991, Abegg  et al. 2000, Olson  et al.  2002, Bouisson & Swendsen 2003). Toadd complexity, the term ‘routine’ is often used interchange-ably with other terms, such as ‘habits’, ‘rituals’ and ‘rhythms’(Clark 2000, Denham 2003). At the same time, there is asomewhat disorganized, fluid, but consistently growing bodyof work pointing to the importance of routine as a key factorin understanding human adaptation and behaviours in suchcontexts as development of skills among young children(Markson & Fiese 2000, Denham 2003), adherence tomedication regimens among patients in various settings(Wagner & Ryan 2004), and cognitive and physical functionin older adults (Johnson 1991, Wiles 2003). Background Routine is a reality in which nurses are constantly immersed:nurses work by scheduled routines, patient care is largelyorchestrated in routines set by organizations and regulations(Wolf 1988), yet each and every person receiving care hastheir own life routines that plays a role in determiningidentity, capacity and frame of reference (Greenberger 1998,Wheatley 2001, Gallimore & Lopez 2002). However, todate, nursing has paid little attention to the possible relevanceof routine and the role it may play in various aspects of patient care. From the years 1970 to 2005, only 19manuscripts pertaining to the subject of routine werepublished in major academic journals by nursing scholars.Moreover, in most of these manuscripts the reference toroutine was not intentional, but rather an emergent conceptor theme raised mostly in qualitative research.A limited number of theoretical models relating to routineare in existence today. The theoretical frameworks vary intheir discipline of srcin, and their nature and purpose fromattempts to understand the srcins and reasons for routineformation to attempts to clarify the components and impli-cations of routine.Dunn (2000) explored the biological basis of routineformation. The main supposition of this theory was that brainactivities aimed at energy conservation and perceptual effect-iveness encourage the formation of routines. This process wasrelatedespeciallytotheprinciplesofthresholds,modulationof information and seeking to maintain homeostasis. Anotherattempt to understand the mechanisms of routine formationlinkedpersonalitystructuresandroutineformation.ReichandWilliams (2003) suggested that the tendency to seek or avoidstructure and repetition in one’s life is personality driven.Therefore, routine is the product of an interaction betweenpersonality predispositions and social, physical and culturalcontexts. On a somewhat similar note, Westfall (1992)delineatedtheconceptof‘chronotherapeutics’suggestingthatpeoplehavetheirownrhythmsintheirmanagementofhumanbiological, sensory and social functions. Those rhythmsdetermine the level of energy, and tendency to maintainstructure or change. She further asserted that the rhythms of human existence constitute one of the individual’s centralcharacteristics when it comes to planning care and interven-tions.LarsonandZemke(2003),inanattempttoputtogethersociological, psychological and occupational principles,coined the term ‘temporality’. According to thismodel, ‘socialinteractions are shaped within temporal streams that arepatterned by biological, familial and cultural influence. Theorchestration and synchronization of daily activities are anexceedingly complex anddynamicprocess for social groupsinwork and home context’ (p. 88). The model offered a glimpseinto the complexity of the concept of human rhythms of occupation, but offered minimal means of applying it inresearch or practice. Additional models followed a similarpath, integrating personal, psychological and ecological-cultural principles to account for the formation as well as themain function of routine. Swartz (2002) reviewed the collec-tive-social roots of habit formation and the implications andfunctions of routine within social and cultural contexts.Gallimore and Lopez (2002) offered an even broader pointof view of routines as a socio-cultural product determinedlargely by the rules, norms and practical constraints of livingwithin a given socio-economic stratum.The theories reviewed above offer sporadic and inconsis-tent insights into the nature of the concept of routine. In thefollowing concept analysis, we clarify and delineate the scopeand boundaries of the concept of routine to facilitate wideruse by nursing scholars in research and practice. Aims The aims of this concept analysis were to identify theattributes, antecedents and consequences of the concept of routine and examine the implications and applications of thisconcept in the field of nursing. Method The process of concept analysis was performed using thesteps outlined in Rodgers’ (1989, 2000) evolutionary method.  JAN: THEORETICAL PAPER  A concept analysis of routine   2007 The Authors. Journal compilation    2007 Blackwell Publishing Ltd  443  The first step was to identify the interdisciplinary scope of sources appropriate for data collection. Then, the attributesof the concept, as well as surrogate and related concepts, andantecedents and consequences were delineated. Finally,implications for further development were generated. Toallow for methodological replication of the process conduc-ted here, the distribution of sources by discipline and targetpopulation are presented.The literature review conducted for this study includedmanuscripts from the following databases: PsycInfo,CINAHL, MedLine, Social Services and Social Workabstracts. The following keywords and free text were usedfor the search: ‘routine’, ‘routines’, ‘daily routine/s’, ‘weeklyroutine/s’, ‘personal’/‘individual routine/s’, and ‘routiniza-tion’. It was found that the use of the term ‘routine’ alone wasmisleading since the word also serves as an adjective (e.g.‘routine procedures in the emergency room’), especially in theMedLine and CINAHL databases. Therefore, the other termsand keywords were used as combinations. There were nolimits on year of publication (in order to be as inclusive aspossible), but only English language publications wereincluded.A total of 2818 manuscripts was identified in thedatabase review. These were screened at the title level forpotential relevance to the concept or its application, andthose screened in were then reviewed at the abstractlevel. A total of 550 papers met the preliminary inclusioncriteria and were further screened at the abstract level, andwhen required at the whole manuscript level. To beincluded in the final concept analysis, papers had to meetat least one of the following conditions: (1) the concept of routine was at the centre of the theoretical discussion inthe manuscript; (2) routine was discussed as one of theoutcomes of the study; and (3) routine was measured in thestudy. Using these criteria, the final concept analysisincluded 74 papers and book chapters published from1977 to 2005. Data analysis The 74 papers were categorized according to discipline,definition of routine, whether routine was referred to as anantecedent, a consequence or an intervening factor, the targetpopulation on which the concept was examined, relatedterms and concepts and type of paper [e.g. qualitative study,opinion paper, randomized control trial (RCT), etc.]. Theinformation provided in the manuscripts was sorted into thefollowing categories: theoretical background, concept attrib-utes, antecedents, consequences, surrogate and related con-cepts. Within each category, literature was analysed toidentify common themes and trends. Findings Manuscript type Table 1 shows the distribution of papers reviewed by content(discipline) and type of publication. Originally, 10 differentdisciplines were identified and subsequently grouped into sixcategories.The table shows that the majority of manuscripts dealingwith the concept of routine were from the field of occupa-tional therapy (42%), followed by nursing (24%) andpsychology (12%). The overwhelming majority were des-criptive-qualitative small-scale studies (40%), followed bycorrelational studies (14 Æ 7%). RCTs and other experimentaldesigns constituted a small percentage (5 Æ 8%) only. Target populations Routine was described in a few well-defined target popula-tions. The leading population was older adults and theircaregivers (in 34% of papers), followed by families andchildren (23 Æ 5%). Other target populations were teenagersand specific patient populations (e.g. cancer, HIV, etc.). Table 1  Distribution of manuscripts across categoriesQualitative Descriptive CorrelationalExperimental/ quasi-experimentalTheoretical reviewand book chapters OpinionCasestudy TotalOccupational therapy 16 2 4 6 2 2 32Nursing 10 2 2 2 2 18Psychology 1 4 2 7Public health 4 1 5Medicine/psychiatry 1 4 5Other* 2 1 1 1 1 1 7Total 28 10 7 11 11 5 2 74*Geography, Gerontology, Social Work and Criminology. A. Zisberg   et al. 444    2007 The Authors. Journal compilation    2007 Blackwell Publishing Ltd  Definitions of routine The literature review yielded a wide range of definitions,often varying across disciplines. Table 2 gives a representativesample of the definitions retrieved in the process of conceptanalysis.Despite the marked differences in perspectives and termin-ology used in the various definitions, some coherent conver-ging themes can be extracted from the literature, and thesebegin to delineate the attributes of routine: •  Routines consist of behavioural (or occupational) patterns,in most cases overt and observable. •  Routines organize the timing, duration and order of activities. •  Routines coordinate various activities within the axes of time, space, and interpersonal interaction. •  Routines are by definition repetitive within a given time-frame (e.g. day, week etc.). •  Routines occur in context – with both social and physical–spatial characteristics. Table 2  Definitions of routine – a representative sample from the literature reviewAuthors Definition Context DisciplineHowe (2002) ‘ … interactions that recur frequently and do so on a daily to weekly basis.They are considered episodic, having a relatively clear beginning andend. They may be cyclic with a regular period of recurrence, althoughthis is probably more characteristic of routines that are involved in andentrained by circadian rhythms such as hunger or sleep/wake cycles … ’(p. 437)FamilyroutinesPsychologyWagner & Ryan (2004) Regular behaviours that comprise a [person’s] typical day PersonalroutinesPsychology andanthropologyKielhofner (2002) Cycles of activities embedded in time and place. Support the fulfilmentof psychological, social and physical needs. Provide a degree of structureand predictability in life. The consistency of routines depends on one’senvironment. ‘ … everyday life is designed and shaped by cyclicalroutines … that create an overall pattern … of occupations’ (p. 68)General* OccupationaltherapyClark (2000) ‘Routines … are a type of higher-order habit that involves sequencing andcombining processes, procedures, steps and occupations. Routinesspecify what a person will do and in what order … ’ (p. 128S)GeneralLudwig (1998a) ‘Routine is defined … as the orchestration of specific consistentoccupations into a fixed sequence in linear time … ’ (p. 214)PersonalroutinesDyck (2002) Daily routines are material practices through which body, subjectivity,and environment become one, mediating and constituting each otherGeneralSegal (2004) Routines an orderly structured activities GeneralChristiansen & Baum (1998) Occupations with established sequences GeneralBaum (1995) Routine – continued engagement in occupation such as instrumental,leisure, and social activitiesPersonalroutinesRowles (2000) Routine is observed as complex social and spatial repeating patterns of interaction between a person and the environment or other personsGeneral Occupationaltherapy andGerontologyGreenberger (1998) Daily routines are hundreds of personal indicators that we pay littleattention to because they are not so much the content of our life as aframework we live in. Routines are our ‘reference points’ (p. 103) thatanchor usPersonalroutinesGerontologyLepola & Vanhanen (1997) Daily routine – type, place, others presence and level of involvementin activitiesPersonalroutinesNursingDenham (2000) ‘Observable, repetitive patterns … which occur with predictable regularityin the ongoing life of the family’ (p. 194)FamilyroutinesHawdon (1996) Routines are social involvement patterns that include the followingdimensions: visibility, and instrumentalitySocialroutinesCriminology Definition : Quoted or extracted from the srcinal text. Context  : The type or the applied context in which the concept is discussed or studied. Discipline : Based on the manuscript or authors’ main field of study/scholarship.*An attempt to provide a broad definition as part of a theoretical inquiry.  JAN: THEORETICAL PAPER  A concept analysis of routine   2007 The Authors. Journal compilation    2007 Blackwell Publishing Ltd  445  •  Routines involve automation of activities and thus serve asresource conserving strategies on both the physical andcognitive levels. •  Routines may apply to an individual, a social group (e.g.families or clubs) or a community. •  Routines may in the long run comprise the individual’sworld, lifestyle and even identity.Based on this summary of attributes, we suggest a workingdefinition of routine: Routine is a concept pertaining tostrategically designed behavioural patterns (conscious andsubconscious) used to organize and coordinate activitiesalong the axes of time, duration, social and physical contexts,sequence and order. Related concepts To further clarify the concept of routine, related terms andconcepts were examined. In early family studies, the terms‘routines’ and ‘rituals’ were both used. Fiese  et al.  (2002)separated these concepts, claiming that rituals were related toroutines but were not a surrogate concept because they weremore symbolic and psychological, while routines were moreinstrumental. In occupational therapy, the terms ‘habits’ and‘routine’ are used interchangeably. Clark (2000) claimedthat routines were ‘a kind of a habit’ (p. 127S), implying thatroutines may be ahigher-order structure of function organiza-tion. Although routines have ahabitual element, not all habitsare routines. Habits are defined as automatic sequences of thought or actions (Clark 2000). Some investigators suggestthat habits could be so automatic as to be completely out of awarenessandthusnotconsciouslyconsideredbythepersoninhisorherdailyroutine(Bargh&Chartand1999).Othersclaimthat routines are defined as higher order habits ‘that involvesequencing and combining processes, procedures, steps oroccupations. Routines specify what a person will do and inwhat order, and therefore constitute a mechanism for achiev-ing given outcomes and an orderly life (Clark 2000, p. 128S)’.In some instances, ‘participation in occupations’ and ‘rout-ine’ were used interchangeably. Following a differentialanalysis of the two, Law (2002) claimed that participationhas numerous dimensions, including personal preferences,interests, level of enjoyment and satisfaction. Participationmaythereforebeahigher-levelconceptdescribingphenomenathat are beyond and above the scope of routines. Segal andFrank(1998)mentionedtheterm‘schedules’whilereferringtowhat seemed to be routines. They defined ‘schedules’ asmechanisms that regulate the duration, frequency, pace andsequences of daily occupations in families, and in this sensecouldalsoberegardedastheorchestrationofoccupations.Wesuggest that in light of the definitions reviewed here, schedulesmay not necessarily include the repetitive characteristic of routine,andthereforemayrelatemoreaccuratelytotemporarypatterns of behaviour rather than fixed ones.Monk  et al.  (1990, 1991) proposed the term ‘socialrhythms’, referring to a structure organizing activities into a24-hour cycle. These authors determined norms for routi-nized or ‘deviating’ patterns of activity and also showed thatregularity and activity level were positively correlated, with a60% overlap. This was especially evident for chronically illpatients. This finding, although not directly measuring andpertaining to routine in the sense explored here, supports theconceptual link of timing and level of activity as twocomponents of the concept of routine.‘Routinization’ was defined by Reich and Zautra (1991) asthe personality trait responsible for the extent to whichindividuals have structure in their lives, and at the same timethe extent to which they reject order and structure. Althoughroutinization has been used in some studies as a proxy of theconcept of routine, there is a marked difference in thatroutinization is a tendency that may predict the amount of routine found in a person’s life. Antecedents Our analysis of the literature reviewed for this papersuggested that major life changes have been identified asthe main factor leading to the formation, maintenance (inthe sense of the lack of change), and disruption of routines.Francis-Connolly (2002) showed that having children in thefamily created unpredictability that threatened daily rou-tines of family units. Huddleston  et al.  (1991) demonstratedthe change in daily routine as a result of separation anddivorce. Berger (2001) reviewed the challenges of olderadulthood, including the need for adjustment to retirementfrom work, the importance of maintaining a social circleand coping with the loss of spouses. Environmental andecological factors have been suggested as supporting ordisrupting routine on the personal and collective levels.Rowles (2000) examined how the environment and organ-ization in time created and disrupted the routines of a smallrural community in which the majority were elders. Thestudy showed a ‘snowball’ effect of changes in the environ-ment (e.g. blocking a road for repair work, the illness of oneof the members of the community) that affected the routinesand activities of numerous members of that community. Theauthor stressed the importance of time sequencing and theinterdependence of the routines of different individuals.Schultz  et al.  (2004), in a descriptive study of homelessparents, showed that shelter rules and related time con-straints changed life routines related to parenthood. A. Zisberg   et al. 446    2007 The Authors. Journal compilation    2007 Blackwell Publishing Ltd
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