Luc Bonneville, Ph.D. Associate Professor Department of Communication University of Ottawa Affiliate scientist Research Institute Montfort Hospital (Ottawa) luc.bonneville@uottawa.ca

Sylvie Grosjean, Ph.D. Associate Professor Department of Communication – University of Ottawa Affiliate scientist Research Institute of Montfort Hospital (Ottawa) sylvie.grosjean@uottawa.ca

 

Abstract

In the past few years, the media has frequently reported cases of psychological distress among nurses. Cases of unease, fatigue, chronic stress, and so on have not stopped making headlines, which highlight and put into perspective work conditions that are increasingly becoming generators of stress and suffering. This phenomenon is not specific to nurses but it is generally known that the nurses’ work is associated with a high degree of difficulty, particularly in “heavy” places such as hospitals. The demands on nurses continue to increase, prompting nurses to work with urgency, and be continually reactive and always on the lookout for changes or crises. Information-communication technologies (ICTs) most notably play an important role in this dynamic. Although ICTs may not always be the cause for increased problems of overwork among workers in a general sense, they are often seen, when used daily, as vehicles that possess the potential to cause excessive demands on nurses. This is precisely the issue that we wish to discuss in this paper, by presenting the results of an exploratory research study carried out in a major hospital in Eastern Ontario, Canada, with hyper-connected nurses.

Acknowledgement

Thanks to the Social Sciences and Humanities Research Council (SSHRC) for their financial support.

Keywords

Information-Communication Technologies; Smartphone; Nursing; Work overload; Critical Theory; Complex Organizations.

Introduction

In the past few years, the media has frequently reported cases of psychological distress among healthcare professionals (physicians, nurses, healthcare managers, etc.). Cases of unease, fatigue, chronic stress, and so on have not stopped making headlines, which highlight and put into perspective work conditions that are increasingly becoming generators of stress and suffering. As Jourdan et al. noted, “according to the results of various studies, stress at work has intensified, producing specific pathologies now known as overload pathologies” (2010, p. 26, translated by the authors). The organization of work has become an issue, in a more global context characterized by measures of rationalization that considerably intensify daily work. This phenomenon is not specific to healthcare professionals, although one assertion can be made: their work is associated with a high degree of difficulty, particularly in “heavy” places such as hospitals The demands on nurses continue to increase, prompting nurses to work with urgency, and be continually reactive and always on the lookout for sudden changes or complex crises. Information-communication technologies (ICTs) most notably play an important role in this dynamic, and can be considered to be a “double-edged sword”: “on the one hand, they allow us to save time, to liberate ourselves from physical constraints, to live according to the rhythm of immediate desire in an illusion of abolished time. On the other hand, they create a new constraint: that of obligation imposed on oneself to respond and to be connected instantaneously, falling into a permanent type of pressure without any chance to temper the relationship” (Aubert, 2003, p. 64, translated by authors).

Although ICTs may not always be the cause for increased problems of overwork among workers when used daily, they can be viewed as vehicles that possess the potential to cause excessive demands and pressure.  For that reason, there is a need to better understand the ways ICT’s are used not only at work but also outside of it.  Since “workers in different fields bring their devices to work with them, we need to take a broader approach to understanding the diverse ways they are used throughout the workday” (Ticona, 2015, p. 510).  This is precisely the issue we wish to discuss in this paper, by presenting the results of an exploratory research carried out in a major hospital in Eastern Ontario, Canada, in collaboration with nurse-managers who use a smartphone on a day-to-day basis.

Context and research problem

Increasingly Demanding Work Environments in “greedy organizations”

Firstly, it must be specified that a “voracious” (greedy) organization is a metaphor. This particular metaphor evokes the notion of organizations that are very demanding of its employees. As Burchielli explained, “The concept of the greedy organization provides a useful metaphor to understand the management innovations that result in the extraction of surplus value from employees. This concept has been borrowed from greedy institutions theory, and has previously been extended in the literature to include other organizations (Franzway, 2001)” (Burchielli, 2008, p. 112). As Burchielli highlights with reference to Coser, one of the first to conceive the concept of “greedy organizations” (1974), “voracious” organizations are those that often demand total loyalty and the highest possible level of engagement from their members. Here, one thinks of the army, of certain religious organizations, etc. These organizations, by their structures and their way of functioning, are distinct from other organizations in that their members are often under tension and subject to multiple demands which overwork them. We think here, for example, of the need to respond in a quasi-instantaneous manner to multiple solicitations on a daily basis.

So, if both private and public organizations seem to be increasingly more “voracious”, this is no doubt because they adhere to a cult of excellence and performance which several scholars describe in their work as a result of the emergence of a so-called “hypermodern” society. According to Aubert, hypermodernity is “the fruit of economic globalization and the general flexibility which it facilitates, with its demands of performance, adaptability and reactivity that must always be greater, inducing a profound modification to our behaviour” (2008, p. 24, translated by authors). Thus, “hyper is a notion that describes too much, an excess, over and above the norm or tradition. It possesses a connotation of constantly surpassing oneself, of maximum, of reaching the limit” (Aubert, 2006, p. 7, translated by authors).

This phenomenon first began to be observed in certain multinational organizations (private sector), as Pagès et al. illustrated in their study published in 1979 (L’Emprise de l’Organisation [The Influence of the Organization, in English]). These researchers demonstrated how certain organizations came to develop new managerial strategies in an effort to enhance collaboration and participation by employees. A transition from a management of “bodies” (to reference Foucault [1975]), to a “psychological” form of management—that is to say, a shift from the “classic contract” of work to a “narcissistic contract” between the employee and his/her organization for which he/she develops loyalty, pride, and devotion developed (Aubert and De Gaulejac, 1991, translated by authors). As Aubert highlighted, “it is from these last decades of the 20^th century that it appears, in all the spheres of existence, this idea that one must surpass and do better than others. From now on, one must always go farther, be faster, be stronger, and work without respite to be ‘the best’” (2008, p. 422, translated by authors).  It is not surprising that experts are writing about “increasing work strain” amongst workers (Green, 2004, p. 709).

Emerging values that promoted the need to surpass oneself also originated from these new styles of management that have been progressively implemented since the 1970s. The rise of competition between enterprises, the reduction of public budget, a global change in methods of production, and so on quickly led organizations to restructure by rationalizing (intensifying) the organization of work in its existing form. Demands that work must be “better” (more), done “otherwise” and with “less”, as was implied (and as is still implied). In official discourse, the repetitive push for necessary modernization in organizations was evoked, in order to increase “profitability”, “performance”, “efficiency”, “optimization” and so on – all terms that, today, are part of the daily vocabulary of a manager. While the private sector was the initial target, the public sector no longer remains untouched (Osborne & Gabler, 1992; Beach, 2010). Consequently, what was then called “New Public Management” (NPM) is now an integral part of all managerial approaches structuring public and para-public organizations. The NPM derives from the laboratories of neo-liberal ideas of the 1970s (Merrien, 1990). NPM challenges traditional bureaucratic organizations, and is best characterized by the transposition of qualities that prevail in the private sector into the public sector (Hood, 1995).

Naturally, in order to make these organizational changes possible, one must have rapidly grasped the opportunities and benefits facilitated by ICTs at the turn of the 1980s. These new mechanisms came to both support changes and establish new ways to be more productive. In the management literature, this led to topical discussions of “reengineering”. As Hammer and Champy described in 1993, “the real power of technologies was not found in improving old processes, but in allowing organizations to break old rules in order to create new ways of working—that is to say, reconfiguring” (p. 104, translated by authors). One can also reference previous studies that focused on how ICTs were conceived, implanted, and deployed in different healthcare organizations, and how these were initially invested in a manner which was meant for healthcare professionals to do more, better, and with fewer resources (publication manuscript by authors in progress, hereafter referred to as Anonymous Reference). ICTs allow workers to better circulate information, complete more tasks in a shorter amount of time, work with more files in more compressed periods, and so on. But, ICTs are also responsible “for a high proportion of the overload effect” (Bawden and Robinson, 2009, p. 5).  Information overload refers to the difficulties that individuals face when dealing with a significant volume of information, especially when they have to locate, retrieve, verify, understand, and react to its content. Eppler and Mengis (2004) discussed information overload as tense situations that individuals face when working with a large volume of information with shorter and shorter time delays. Thus, the notion of information overload is heavily related to the phenomenon of urgency. Consequently, the literature on the pressures of organizations heavily relates the concept of urgency to that of information overload, which is itself a phenomenon largely attributed to the introduction of ICTs (Assadi and Denis, 2005; Eppler and Mengis, 2004; Edmunds and Morris, 2000).

In fact, as Reinke and Chamorro-Premuzical recently noted about email, “Email communication has become an essential part of organizational life. In fact, it was found that about 28% of an average work week is spent on reading and responding to emails (Chiu et al., 2012). Although emails were originally thought to enable quick communication and increase productivity (Derks & Bakker, 2010), there is a rising concern that for some employees, the use of email gets out of control. This perception of an individual as unable to find, cope with or process his/her emails effectively was defined as a feeling of “email overload” (Dabbish & Kraut, 2006; Sevinc & D’Ambra, 2010). Email overload may in turn have negative effects on well-being and performance by increasing stress levels and impeding productivity (Dabbish & Kraut, 2006; Mark, Voida & Cardello, 2012). Therefore, it appears to be a highly relevant phenomenon for organizations” (2014, p. 502). This is precisely the issue at hand: even though ICTs appear to facilitate work (which is actually the case in certain situations), they also often cause a considerable amount of tension for workers. The heavy workloads of nurses with a myriad of work demands is serious, especially when coupled with the use of computers (or smartphones) on a daily basis.

Another concern is that ICTs sometimes become popular instruments for the creation of work tension in organizations that strive to augment their productivity. In fact, as Sullivan recently indicated, “The greatest enabler of greediness, however, is one that Coser probably could not anticipate. Continuous connectivity allows employers to reach into the after-hours of their employees’ lives, extending the workday beyond its traditional limits. And globalization, which extends a firm’s reach across many time zones, requires more workers to be alert and responsive for more hours of the day. Smart phones and other technologies that emerged over the last couple of decades have played a particularly insidious role for greedy institutions. The technology has enabled employers to get greedier—often while appearing to do just the opposite. For example, an employer can appear to be generous to employees by issuing company-funded smart phones, but those smart phones become tethers that keep the employees attached to their work and their super- visors 24/7.  And in many cases, the worker is expected to provide both the cell phone connectivity and the on-call availability” (2014, p. 4).

The Difficulties that are facing Nurses and related jobs

The transformations that took place in advanced capitalist economies over the past few decades facilitated organizations to transform in significant ways. The different economies and enterprises being “at war” with one another, to borrow from the vernacular of De Gaulejac (2005, p. 10), organizations had to find different ways in which their profitability could be raised to the highest possible point by rationalizing and augmenting the productivity of work itself. Hence a characteristic “urgency” was attributed to various reforms in practically all sectors of social and human activity, and in the implementation processes of the ICTs that accompanied them. The healthcare sector evidently did not escape this, as we have already illustrated (Anonymous Reference). Healthcare organizations now promote values like high performance, surpassing oneself, reactivity, and so on which has quickly led workers to “abuse” time by completing the greatest number of tasks possible in an increasingly shorter and shorter amount of time (Aubert, 2008). This was done with the goal of becoming as productive as possible, and to act in perfect accordance with the demands of one’s organization. But this relentless pursuit of productivity is also the source of an increased sense of time pressure, pressure that causess a sense of urgency (Coeugnet et al., 2011). Time pressures result from “an unfavourable ratio between the amount of time available and the amount of time necessary to complete a task” (Rastegary & Landy, 1993; cited by Coeugnet and al., 2011, p. 160, translated by authors). Thus, “a person is under time pressure when an anomaly appears between what this person wishes to do or feels as they should do, and what they can realistically accomplish before the deadline” (Svenson & Benson, 1993, p. 133). This deadline could be a due date that marks a delay (for example, the moment a report must be submitted or the time of a meeting) or could even correspond to the fastest possible completion of the current task” (Coeugnet and al., 2011, p. 160).

In the healthcare sector as in others, this time pressure has become omnipresent in the daily work of employees who must respond to multiple, ever increasing demands. The increase in cases of work overload amongst nurses and other health professionals continues to rise, which is correlated with an increase in chronic stress. “Workload has emerged as one of the most consistent stressors occurring in nurses, including acute care nurses, surgical nurses and general hospital nurses.  Work overload is a significant predictor of negative mental health outcomes in nurses, less job satisfaction and burnout” (Greenglass, 2001, p. 211). Wall (2010) also highlighted this phenomenon, extracting multiple causes of mental and physical health problems in nurses from statistical studies conducted in Canada, including “job stress, job strain, low support, low autonomy, low respect and poor nurse-physician relationships” (p. 147).  Zeytinoglu et al. (2007) also discussed a number of concerns about the deterioration of working conditions for nurses.

According to Cazabat et al., “the causes of an alarming increase of stress in the professional workplace are certainly attributable to evolutions in work, evolutions which can be characterized by the growth and spread of flexibility (Brangier, Lancry & Louche, 2004, translated by authors): job flexibility, the work contract, flexibility of spaces at work, just-in-time, flexibility in working times and hours” (2008, p. 1). Even if their analysis concentrated primarily on France, it applies to all industrialized countries where one notes very clearly that, “reduction in working hours has paradoxically facilitated the increase of production rhythms, a decrease in “down time”, overflowing schedules, a fragmentation of work, and as many factors that compete to considerably increase the time constraints that are imposed on employees (Quéinnec, Barthe & Verdier, 2000, translated by authors in Cazabat et al., 2008, p. 1).

All of these different problems lead one to question the impact of recent restructuring movements in the healthcare system. Back in 2002, Tyson, Pongruengphant & Aggarwal summarized the restructuring of healthcare facilities in Canada as: “In many cases, organizational change means hospital closure, job loss, reduced employee status, and higher levels of workload…. Lack of organizational support and involvement was the major source of stress reported by our sample of hospital nurses in Ontario. Nurses perceived that management did not understand the real medical needs of their hospital ward and that changes were being imposed on them without their involvement” (p. 457). As stated by Leiter and Maslach, “the shortage of nurses in post-industrial countries has been a major problem in recent years, and finding solutions has become an increasingly urgent priority” (2009, p. 331).  This becomes even more of a priority when we consider that young (or new) nurses are at a higher risk of developing severe stress symptoms from workplace conditions (Lavoie-Tremblay et al., 2008).

In short, the daily work of nurses is becoming increasingly more demanding. It is marked (as we have observed by examining important literature on the subject) by constraints which are more and more serious and workloads that are heavier. “Nurses, being the largest workforce in hospitals, have historically absorbed a disproportionate burden of the job cuts resulting from fiscal constraints and healthcare restructuring” (Alameddine et al., 2009, p. 1045).  In the field, as we will see, this particular context obligates organizations to develop various strategies to “let go” (decompress, disconnect, re-appropriate the time). These strategies are sometimes spontaneous, sometimes organized. But, as shown by Moen et al., “resisting time pressures at work requires considerable effort” (2013, p. 96). Whatever the strategies may be, they force us to view them as creative, revelatory accomplishments for the type of society in which we live.  In that context, questions must be asked: “How do nurses, working in a stressful environment, “deal” with the multiple pressures and constraints they face?” and “How do they use ICT’s (in this case a smartphone) in such a context?”

Methodology

We wanted to better understand how people at work manage the multiple pressures and constraints they face.  In this case, we were interested in a specific team composed of hyper-connected nurses in a position of authority (“nurse-managers”) relative to other nurses. We wished to study the daily strategies of decompression/disconnecting—or the ways in which these nurse-managers are able to get “their heads above water” in a work environment where time pressures are enormous.

Our research was exploratory since we wanted to focus on a specific group (nurse-managers who use a smartphone on a day-to-day basis) for which no previous or very little study have been conducted.  As it was explained by Stebbins (2001), researchers explore when they have little or no scientific knowledge about the group, process, activity, or situation they want to examine but nevertheless have reason to believe it contains elements worth discovering.

We conducted eight semi-directed interviews of 45 to 75 minutes in length.  These interviews were conducted with nurse-managers in a hospital in Eastern Ontario, Canada. Women from the following three interconnected groups were interviewed: specialized clinical nurses, clinical managers and clinical nursing educators. These professionals were largely recruited by their hospital based on their previous work experience as “basic” nurses and are recognized for their respective leadership in their field. The particularity of their work is such that these three categories of nurses assume intermediary roles; that is to say, their roles are below upper management roles but above the general nursing personnel. The nurse-managers need to be always (or most of the time) “connected” (by email or by phone) to their workplace.  That is one of the main reasons why they use a smartphone.  They are constantly connected to their smartphone, which makes them susceptible to responding essentially all the time (whether this be during regular work hours or after hours). In the frame of their daily work, they have to support the nurses in the service environment who are taking care of patients. They also have the responsibility of developing training initiatives, guides and brochures for patients (cancer, diabetes, chronic illnesses, etc.) and creating demonstration materials and teaching tools. Moreover, they regularly conduct an enormous amount of coordination between nurses, doctors, and sometimes surgeons. They must also coordinate training to respond to the specific needs of their teams like providing training on new materials or equipment. Thus they juggle multiple tasks and must unrelentingly listen (and respond) to the needs of their teams.

The selection criteria for the recruitment of nurses for this study were the following. We elected to meet with nurses who:

1. worked in a heavily technologized environment (the use of a smartphone, pager, information system, email, etc., on a regular basis)

2. work in a stressful environment, sometimes under pressure

3. are sometimes on call outside their normal working hours (i.e. need to address different requests when at home [evening, overnight, weekends)

4. work in an environment where interruptions, unforeseen and unexpected, are frequent.

The interviews were recorded and then transcribed before a thematic analysis was done.

Key Testimonies

Presented below are a select number of key testimonies from interviewed nurses to explain the nature of their professional roles and the daily pressures they are confronted with. We emphasized the challenges raised by these multiple pressures from the point of view of their practice, focusing our attention on the ways in which they can (or cannot) escape these pressures. Note: The following testimonies have been translated from French to English.

The “Physical requirements”

In a recent publication (Anonymous Reference), we illustrated the extent to which the nurse-managers we encountered were “connected” to their various technological devices (particularly their mobile phone, a Blackberry). They used them mainly for exchanging information (files, requests, follow-ups, etc.) but also to communicate with their colleagues in an effort to improve coordination of tasks within the hospital. Thus, it is nurse-managers who experience multiple role specific demands within the organization in which they work. This also requires them to check their emails frequently outside of the hospital (weeknights or weekends, thus even when they are “theoretically” on break or off shift). They specified to us that their work required that they remain vigilant, reactive, and always ready to intervene in situations such as those where they must address unforeseen circumstances related to their patients or other nurses for whom they are responsible. Of course, in such a context, marked very regularly by overwork, nurses are forced to work in “multi-tasking” mode. This explains the fact that they are often selected, upstream, depending on a number of key skills and competencies that they must have. This is particularly true for the nurse-managers with whom we met. Firstly, as one indicated, “you must be in good health” [Nurse # 7]. Next, as another nurse indicated, you must be capable of adapting to situations that change rapidly:

“You must be capable of adapting to change, to rapid management, to critical management.” [Nurse # 1].

Indeed, in the daily work of nurse-managers whom we met with, everything goes very quickly and one must be able to adapt to the spontaneities of everyday life. This tends to force them to multi-task, as emphasized above:

“I’m good at multi-tasking.” [Nurse # 5].

“To do my job, which is not for everyone, you must be able to multi-task. You must be able to take things to heart. But you must also like doing it.”
[Nurse # 7].  

Thus, a priori, the nurse-managers surveyed believe that you must be made for the job that they call their own:

“I think that it’s a vocation, yes. If you’re not made for it, despite all good intentions, that your mother wanted you to become a nurse, if you’re not made for it you can’t do it. If you’re not in good physical condition you can’t do it, if you don’t have a good sense of humour and take everything too seriously then you can’t do it because you’ll be attacked on several fronts.” [Nurse # 2].

For another nurse-manager, the fact that they constantly interact with several other nurses for whom they are responsible necessitates many key relational competencies:

“You have to have a bachelor’s in psychology to be a manager [laughs], not just in nursing. We really need a bachelor’s in human resources and in psychology to have meetings with employees.” [Nurse # 6].

For this type of work, it seems that nurse-managers must also contend with multiple distractions that make up the working environment. Learning on the job, honing one’s patience, “taking in” any potential criticisms —these are the competencies that are the “physical requirements”.

“One of the skills [that you need to acquire] is “learning on the fly”. Another competency is that you have to be really “focused”, because you have many distractions and because there are 2-3 difficulties to address at the same time. […] So you have to always, always produce autosuggestions to be able to mitigate this. Am I making the right decision? what’s the impact on the patients? etc. […] It takes someone who has a lot of patience. It’s a skill, patience. To enjoy working with people, because some people complain all the time. I myself have a personality that makes it so that I complain only rarely. I always look at things in a positive way. Sometimes I’m stressed but not the majority of the time.” [Nurse # 7].

Overload: An Integral Part of the Everyday Life

If the nurse-managers we interviewed were first and foremost selected on the basis of a certain number of key competencies, it is because the demands that weigh on their shoulders are numerous and sometimes difficult to manage. As we have already mentioned (Anonymous Reference), the nurse-managers interviewed work a great deal and are regularly requested to work overtime:

“I’m always here at 8:00a.m., because in any case we never know at what time we’ll be leaving […].  Time isn’t calculated, not in this profession.” [Nurse # 1].

“I work a lot of overtime.” [Nurse # 2].

“My workdays are never less than 10 hours, and I work at home too. […] I usually arrive around 7:30-8:00a.m., and I leave roughly around 5:00p.m., and with my bag [I bring the work home].” [Nurse # 5].

Working “overtime” is an integral part of the everyday, so much so that it could be considered the “norm” for a growing number of healthcare professionals—among which, of course, are nurses. The phenomenon of overtime can be explained by a chronic lack of resources and a consequent increase of workload in general. In the background, the administrative expectations of nurses appear to be greater and greater, and obligate them to work daily under constraint.

As it is explained by several of the nurses interviewed:

“The demands come a bit from everywhere and not from the same one… […] If you want your department to fare well, you have to respond to their request. […] We are solicited for all sorts of projects all the time. […] The more experience you have, the more you are solicited.” [Nurse # 1].

“I’ve learned that everything is obligatory, everything is a priority, everything is urgent. We’re told that if we’re overloaded we shouldn’t attend meetings, but if we miss meetings we’re called in at the last minute, and we’re told then that no one came to the last meeting ! […] The manager [clinical manager] is caught between directives from above, between his team, the pressure to cut here, to buy there, and you’re sandwiched, between a rock and a hard place, who do you listen to?” [Nurse # 6].

This last nurse-managers (# 6) offered us earlier an extremely intriguing testimony with respect to the description she made of her daily work. Being very critical of even the organization of work that seems to prevail in her hospital, she specified that nurse managers are all out of breath:

“Physically there are limits. […] The managers are all out of breath, I’m not the only one; we’re all out of breath.” [Nurse # 6].

She explains that the members of the team she supervises are all overwhelmed and that everyone is exhausted:

“The team is overwhelmed, they’re exhausted, and more is placed on them, always more, always more, at any given time ugh, […] it never ends. I’m overwhelmed, I have difficulty concentrating, and sometimes I send an email to the wrong person…” [Nurse # 6].

It is evident that this highly acute rhythm of work requires nurse-managers to constantly be on the lookout for what is going on around them. And to be on the lookout implies that most of the time one has to “negotiate” between multiple demands that they must address:

“You have 97 employees who work every day. It’s certain that something will happen and that you have to be made aware of it. You have to plan, for example if employees are absent (sick). […] We’re solicited all the time for all sorts of projects, because it’s us who’s experienced them. They want to have our opinion, they want us to sit on a committee, etc. The more experience you have, the more you are solicited.” [Nurse # 1].

“There was a day where I came in the morning and I didn’t move from my chair for two hours [in my office]. All I did was make calls and follow-ups on complaints. I had 12 voicemail messages. It was Monday morning. Everything that went badly at the en d of the week was communicated to me, by 3-4 employees. Lack of personnel. All I did was make calls for two hours, without stopping. One telephone call after another and it didn’t stop, it didn’t make sense…” [Nurse # 6].

Naturally, in this context, ICTs occupy a preeminent role as was mentioned above. If they can effectively be seen help nurse-managers manage time and tasks, they can be viewed as an important vehicle for over-solicitations and demands (Anonymous Reference). The situation is evidently worse when someone has to leave for vacation, in the sense that their respective email inboxes congest themselves to a degree that is proportional to the length of their “absence”.  In this way, nurse-managers must juggle with what constitutes a veritable information overload.  As we have come to observe, this concept thus refers to the idea that an individual would be under pressure from the moment he or she experiences a certain inability to respond (treat, manage, negotiate, etc.) to the different information that comes his or her way. In order to tame this “infobesity” when they are about to go on holiday or when they return, the nurses felt they needed to implement “locks” to “buy time” on a daily basis:

“It’s stressful coming back [from vacation], so much so that in returning I’ll take at least a day [before going back to work], to have an idea of my schedule, to get into the habit. I’m not able to come back Monday morning and not know what happened [while I was away on vacation], I’m not able to [laughs].” [Nurse # 5].

“The day before, when I know I’m going back to work, I take it [the Blackberry] and I say to myself OK… […] I prepare myself psychologically, and I say to myself OK this is what occurred. And that prepares me to better manage things, by being less surprised. I understand a bit at that moment the difficulties and I’ll be able to establish good judgment and good decisions. […] Usually if I come back on Monday after two weeks of vacation, I’ll see what’s happened Sunday afternoon or Sunday night. There, there’s a set of emails and you know who has sent them to you.” [Nurse # 7].

This feeling of needing to treat information, requests, and solicitations of all sorts in an efficient way is linked to the fact that email composes an integral part of the everyday and that it is at the heart, in every situation for the team of nurses we interviewed, of different exchanges and relations:

“Technology is very rapid now, because everyone has email and everyone expects a rapid response. There are many more requests because they’re easy to create, everyone has an email and everyone uses it.” [Nurse # 1].

For this reason, certain nurse-managers believe that it is practically impossible to switch off or even to disconnect:

“As a manager I think it’s impossible to switch off. It’s seriously impossible. I don’t know how others do it. Really, because I listen to them and they as well look at their emails over the weekend. It’s not because I’ve been here [in this position] for 6 months. They don’t want it to accumulate [so they regularly check their emails].” [Nurse # 6].

We have seen that the nurse-managers interviewed are equipped with a smartphone, pager, computer with email, etc. All of these communications tools add to one another as different layers of a heavy tome (Kalika, 2007). Kalika postulated that the technologies that have been developed these past few decades do not substitute for older modes of communication, but rather, add to them. For example, email has not replaced the telephone and videoconferencing has not dethroned physical meetings. Each mode of communication possesses its own qualities and disadvantages that are unique to it, and thus renders it appropriate or not for a particular situation. But what has been noted is that this superposition of communications media creates a feeling of urgency and time pressures, as is illustrated by the interview extracts from the nurse-managers we interviewed.  One could say that the phenomena of information and cognitive overload literally exhausts those who experience it continually, bringing them to a very destabilizing perception of a loss of control and meaning in work activities. Moreover, nurse-managers who are less experienced feel more stressed than more experienced managers and claim they have not yet sufficiently developed strategies to face these feelings and to avoid feeling overwhelmed. They seem to believe that if they do not succeed in doing so, it is because they have not developed the expected competencies for this type of position. Some will even feel guilty for not having taken this pressure in stride.

Manage the Impossible Disconnection or How to Retake Control?

As we have come to see, the nurse-managers we interviewed experience extremely demanding workloads. The nature of the work is just as “taxing” emotionally as it is physically. Working overtime becomes the “norm”, and often requires nurses to be “creative” to either avoid or tame it. What can be observed is the multiplication of work intensification practices that are characterized by completing as many tasks as possible in a certain period of time and to complete what one did not have time to do outside of official work hours.  However, as shown by Dean and Webb, there are also perils of multitasking: “We tend to believe that by doing several things at the same time we can better handle the information rushing toward us and get more done.  What’s more, multitasking—interrupting one task with another—can sometimes be fun. Each vibration of our favorite high-tech e-mail device carries the promise of potential rewards. Checking it may provide a welcome distraction from more difficult and challenging tasks. It helps us feel, at least briefly, that we’ve accomplished something— even if only pruning our e-mail in-boxes. Unfortunately, current research indicates the opposite: multitasking unequivocally damages productivity” (2011, p. 3).  The nurse-managers we interviewed know this, first hand.  The solution, for them, is to become proficient at “taming” the “overwork”. Thus, when faced with situations at work where time pressures are omnipresent, nurse-managers develop an assortment of strategies and tactics to re-appropriate time. It is precisely this phenomenon that was exemplified in a text published in 2015 in which an emphasis was placed on various forms of “decompression” (Anonymous Reference). But beyond these decompression strategies, where the objective is to resume control over one’s “breath” in an environment where the constraints are very heavy, several nurse-managers explained to us how they also developed a capacity to adapt to unforeseen circumstances, events, and multiple solicitations that compose their daily work. Thus, added to the forms of decompression that were described in our previous text (Anonymous Reference) are diverse strategies where nurses not only re-appropriate time but instrumentalize it to their own ends. While it certainly is a way to decompress, the testimonies collected also demonstrate that hyper-connected nurses tend to make time “malleable” and “docile”. This is done in three different ways: making optimal use of “downtime”, in negotiating the urgent nature of work demands, and managing their information environment in order to reduce any possible information and cognitive overload.

Firstly, one of the common practices consists of optimizing downtime and preventing any free time from going unutilized, as this nurse-manager explains:

“The Blackberry was an asset for me, yes it’s demanding, but it’s an asset, because when we’re in a meeting, you could say that they always start 10 minutes late, so it’s time that I can take to send a few emails, they’re empty slots of time that I can now fill to help me complete my work.” [Nurse # 1].

On the other hand, the nurse-managers explained how they had, over time, developed certain “strategic” practices for the use of email aimed to support the process of putting their activities “in order”:

“A typical day for me starts with the unit, listening to my voicemail messages (which can vary from 2 to 12 messages), every day (healthcare coordinators, complaints from employees, resources to add, messages about illnesses, etc.), so this is my morning routine… ugh- after doing that I look at my agenda for the day and I try to situate myself to see how I’m going to align my day.” [Nurse # 6].

“A lot of emails are pointless, they’re full of information only, like for example emails from other departments, they CC me but I don’t really need to respond, but at any given point in time you look at everything you have and look at the priorities and you know the people who you work with, and at the end of three months if that person hasn’t followed up with you or asked any questions, I erase the email, delete…” [Nurse # 7].

As we have already illustrated (Anonymous Reference), the nurse-managers have come to prioritize urgencies by managing the solicitations that confront them:

“We prioritize, you have to prioritize, it’s certain that we won’t be able to complete everything we planned to in the morning, we proceed with the priorities and the urgent tasks, it’s not bad because now, in this way, in the end we are able to manage the volume that we have, with priorities (…) you have to speak with your colleagues, your director, to establish priorities.” [Nurse # 1].

“The prioritization of urgencies. It depends on who sent the message. I look at my plan for the day and I question myself. I’ll probably prioritize the action that I was trying to accomplish with an employee on the floor or a patient returning to my office to respond. I take my phone and at that point I exchange information in order to make my decision.” [Nurse # 4].

Thus, we understand that prioritizing certain tasks reveals learning that is acquired gradually from experience and represents a conscientious acknowledgement of the time constraints that nurse-managers are confronted with on a daily basis.

In a strictly technical sense, several nurse-managers will attempt to control or enslave (“informationally and physically jigging the environment”) their information environment (Kirsh, 1995) in order to avoid succumbing to the whirlwind of emails that eventually become invasive. Thus some of these nurses will arrange their email inboxes in a specific manner:

“I’ve come to prioritize, or often I’ll see [the emails] and close them by labeling them a color, by coding them, by telling myself that this or that email can wait.” [Nurse # 1].

“I never manage to empty my inbox of messages, of email, and so I have categories, when I see something and I want to save it I’ll store it in archives, and the others that I don’t have time to move, because I want to keep them, so then I color-code them, for follow-ups, for urgent messages, I make priorities, along the way.” [Nurse # 5].

By structuring their email inboxes (I have categories) and making use of aids (I color-code them), nurse-managers guide the email response process. The goal is to reduce information and cognitive overload, to attract attention to particular elements, and to progressively put in order a chronology of actions to undertake. Finally, in arranging their email space, they gradually control or enslave the volume, and the categories and color codes used become indicators in the environment to then support activity. Through this form of intelligent use of email space (Kirsh, 1995), they endeavour to resume control and thus limit cognitive and information overload.

We understand here why enslaving (“informationally and physically jigging”) the information environment is crucial, in an environment where everything is urgent. As Aubert emphasized, urgency constrains individuals “to always do more things in always less time, [which] obligates one to sacrifice meaning and a desire to produce good work and strays them too often in a confusion between what is urgent and what is important, which prevents them from taking the necessary break needed to legitimately establish a hierarchy of priorities” (2006, p. 4, translated by us). So should we have to stop, and then, as we have just come to note, establish priorities. As this other nurse-manager implies, establishing priorities is first and foremost “slowing down” cadence:

“[…] I go into my office and I shut the door, and I say to myself OK, this is problem 1, this is problem 2 and problem 3, and then in my head I say focus, focus, what do I have to do, what’s the next step, what’s the most important, so you always always have to produce autosuggestions to be able to mitigate this. Am I making the right decision, what’s the impact on the patients, euh.” [Nurse # 7].

So the nurse-managers we met with take the time to establish their priorities in order to tackle ICTs that – we repeat – contribute to the densification of their everyday. As Rivière had previously highlighted in 2002, “the permanence of technological and social connection multiplies equally the strategies of joinability of actors in terms of accessibility choices and anticipation of his or her own and others’ availability” (p. 141, translated by authors). Hence the necessity to coordinate one’s own communications, coordination which requires an “intelligent” utilization of email to regain control and thus limit information and cognitive overload (Cicourel, 2002; Eppler & Mengis, 2004; Helmersen et al., 2001). However, oftentimes the “task” is not easy, as has been illuminated by the selection of testimonies we have reviewed. In effect, we have been able to question nurse-managers about what they do with their emails when they, among other things, return from vacation. All the nurse-managers interviewed explained how extensive email messages in their inboxes could accumulate if they don’t intercept them for a few days, or even a few weeks (when they are away on holidays). For one of the nurses surveyed, a first “coordination” consists of not opening all emails received by reasoning that if the messages were so important, those who sent them would find another way to reach her:

“I’ll be honest with you. When I come back from vacation I can have 1300 unopened email messages and I won’t open them, by telling myself that the senders can remind me, come back, can prompt me. Because you can’t open every email.” [Nurse # 1].

In other words, the nurse-managers we interviewed felt that you need to disconnect if you want to survive or even cope.  As explained by Dean and Webb, there is a “responsibility to hit the reset button” (2011, p. 7).

Conclusion

The results of our analyses demonstrate that the nurse-managers we interviewed have developed a capacity to adapt to unforeseen circumstances, events, and multiple solicitations coming from the work environment. To do this, they put in place a multitude of micro-strategies that are reflected in the thematic data. Choosing to turn off their mobile, to leave their smartphone turned off in their bag or on the table – to disconnect in other words, has added new possibilities to the arbitrations that nurse-managers conduct in order to regain control over their environment. For example, by using “downtime” to respond to solicitations or by enslaving their information environment to reduce cognitive and information overload.  As Cicourel (2002, 2004) showed in his work on hospitals, the perception of “cognitive overcharge” can conceivably affect problem-solving, or even certain work routines. In the context of this research, we very quickly noted that the nurses we surveyed expressed this perception of cognitive overcharge and overload. We also see it in the cited interview extracts where nurse-managers describe multi-tasking and their work universe composed of constant interruptions and multiple solicitations.

The nurse-managers also described ritual practices for the use of email to support the process of getting activities “in order”. They describe consultation rituals for their email inboxes that contribute to an order that develops progressively. They explained to us how they organize their work time, their workday and the prioritizing of urgencies, most notably by putting them to the side and leaving them to be addressed – especially after vacation or holidays. This attitude permits them to proceed in a form of natural selection for urgencies; one nurse even explained to us that if one individual does not contact her again for a situation deemed urgent, she deletes the message from her computer. Furthermore, the nurse-managers described on several occasions a form of dialogue, of negotiating the urgent character of a situation. It is often from whom the call has been made that determines how best to categorize the urgency. This ability rests on a thorough knowledge of their personnel and their teams, but also on the connection of confidence they’ve created with the members of their team to be able to act this way.

Even if the analyses conducted on the collective of nurse-managers permitted us to reveal the micro-strategies that they put into place in order to regain control of their environment, we hope to conclude by specifying that another way these nurse-managers regain control over their environment is by developing an ability to anticipate events. They often explained to us that in their work, they must learn to be attentive to what is said and what is done to have a solid understanding of the state of the situation, and to follow the actions of others in order to be able to anticipate problems. They must cobble together solutions with the resources at their disposal. In fact, they must improvise daily. It could be pertinent to deepen this line of inquiry and to better understand the anticipation and improvisation strategies they implement to regain control of their environment.

Thus, we have come to examine the manner in which nurse-managers operate in an ultramodern and greedy organization like the hospital we investigated for this exploratory study. However, as we explained earlier, one must not necessarily be hyper-connected to be overwhelmed and to experience what we consider to be a systematic temporal pressure. Indeed, as we have established from the beginning, the transformations of organizations over the past three to four decades have had important structural repercussions on healthcare itself. The system continues to demand more of healthcare professionals who must adapt to situations and environments which are increasingly more constrained. More and more is demanded of various healthcare personnel despite budget and time constraints. Certainly, the technology and the efforts of coordination between professionals have without a doubt helped increase efficiency and time. However, as De Gaulejac accentuates, “what workers have gained in work time, they seem to have paid in terms of intensity” (2012, p. 14, translated by authors). Additionally, as Jauréguiberry asserts, it seems “after fifteen years of ideologizing communications technologies (assimilating them into something intrinsically good, the bad being materially that of silence, a black screen and disconnection), the injunction to “communicate more” and the pressure to be constantly connected, came the time to reflect on what appears to be sustainable in terms of psychological capabilities and desirable from a social and organizational perspective” (2010, p. 119, translated by authors).

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