zisberg, young, schepp y zysberg. 2007.a concept analysis of routine relevance to nursing

A concept analysis of routine: relevance to nursing

Anna Zisberg1, Heather M. Young2, Karen Schepp3 & Leehu Zysberg4

Accepted for publication 6 September 2006

1Anna Zisberg PhD RN

Assistant Professor

Department of Nursing, University of Haifa,

Haifa, Israel

2Heather M. Young PhD GNP FAAN

Endowed Professor

School of Nursing, Oregon Health and

Sciences University, Ashland, Oregon, USA

3Karen Schepp PhD RN

Associate Professor

School of Nursing, University of Washington,

Seattle, Washington, USA

4Leehu Zysberg PhD

Associate Professor

Department of Psychology,

Tel Hai Academic College, Tel Hai, Israel

Correspondence to Anna Zisberg:

e-mail: [email protected]

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), 442453

doi: 10.1111/j.1365-2648.2006.04103.x

AbstractTitle. A concept analysis of routine: relevance to nursing

Aim. This paper reports a concept analysis identifying the attributes, antecedents

and consequences of the concept of routine and examining the implications and

applications 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 scheduled

routines, patient care is largely orchestrated in routines set by organizations and

regulations, and persons receiving care have their own life routines determining

identity, capacities and frame of reference. However, to date, nursing has paid little

attention to the relevance of routine and the role it may play in patient care.

Method. A concept analysis was conducted using Rodgers guidelines. The literature

search was based on the following databases: PsycInfo, CINAHL, MedLine, Social

Services, and Social Work abstracts. To be included in the analysis, papers had to

relate 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. The

analysis included target populations, disciplinary perspectives, type of manuscript,

themes and definitions, theoretical models, antecedents and consequences, as well as

related terms.

Results. Routine is a concept pertaining to strategically designed behavioural pat-

terns (conscious and subconscious) and is used to organize and coordinate activities

along different axes of time, duration, social and physical contexts, sequence and

order. 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 range

of health-related issues. This concept analysis offers an integrative view of routine

and suggests directions for future research and practice.

Keywords: concept analysis, daily routines, functional status, nursing, Rodgers

evolutionary method, routine

THEORETICAL PAPERJAN

442 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd

Introduction

Routine is a term often used in research and practice

contexts with varying meanings and connotations: from a

negative portrayal of routines as rigid, maladaptive patterns

of behaviour to a positive view of routines as key to normal

functioning and stability (Reich & Zautra 1991, Abegg et al.

2000, Olson et al. 2002, Bouisson & Swendsen 2003). To

add 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 a

somewhat disorganized, fluid, but consistently growing body

of work pointing to the importance of routine as a key factor

in understanding human adaptation and behaviours in such

contexts as development of skills among young children

(Markson & Fiese 2000, Denham 2003), adherence to

medication regimens among patients in various settings

(Wagner & Ryan 2004), and cognitive and physical function

in 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 largely

orchestrated in routines set by organizations and regulations

(Wolf 1988), yet each and every person receiving care has

their own life routines that plays a role in determining

identity, capacity and frame of reference (Greenberger 1998,

Wheatley 2001, Gallimore & Lopez 2002). However, to

date, nursing has paid little attention to the possible relevance

of routine and the role it may play in various aspects of

patient care. From the years 1970 to 2005, only 19

manuscripts pertaining to the subject of routine were

published in major academic journals by nursing scholars.

Moreover, in most of these manuscripts the reference to

routine was not intentional, but rather an emergent concept

or theme raised mostly in qualitative research.

A limited number of theoretical models relating to routine

are in existence today. The theoretical frameworks vary in

their discipline of origin, and their nature and purpose from

attempts to understand the origins and reasons for routine

formation to attempts to clarify the components and impli-

cations of routine.

Dunn (2000) explored the biological basis of routine

formation. The main supposition of this theory was that brain

activities aimed at energy conservation and perceptual effect-

iveness encourage the formation of routines. This process was

related especially to the principles of thresholds, modulation of

information and seeking to maintain homeostasis. Another

attempt to understand the mechanisms of routine formation

linked personality structures and routine formation. Reich and

Williams (2003) suggested that the tendency to seek or avoid

structure and repetition in ones life is personality driven.

Therefore, routine is the product of an interaction between

personality predispositions and social, physical and cultural

contexts. On a somewhat similar note, Westfall (1992)

delineated the concept of chrono therapeutics suggesting that

people have their own rhythms in their management of human

biological, sensory and social functions. Those rhythms

determine the level of energy, and tendency to maintain

structure or change. She further asserted that the rhythms of

human existence constitute one of the individuals central

characteristics when it comes to planning care and interven-

tions. Larson and Zemke (2003), in an attempt to put together

sociological, psychological and occupational principles,

coined the term temporality. According to this model, social

interactions are shaped within temporal streams that are

patterned by biological, familial and cultural influence. The

orchestration and synchronization of daily activities are an

exceedingly complex and dynamic process for social groups in

work and home context (p. 88). The model offered a glimpse

into the complexity of the concept of human rhythms of

occupation, but offered minimal means of applying it in

research or practice. Additional models followed a similar

path, integrating personal, psychological and ecological-

cultural principles to account for the formation as well as the

main function of routine. Swartz (2002) reviewed the collec-

tive-social roots of habit formation and the implications and

functions of routine within social and cultural contexts.

Gallimore and Lopez (2002) offered an even broader point

of view of routines as a socio-cultural product determined

largely by the rules, norms and practical constraints of living

within a given socio-economic stratum.

The theories reviewed above offer sporadic and inconsis-

tent insights into the nature of the concept of routine. In the

following concept analysis, we clarify and delineate the scope

and boundaries of the concept of routine to facilitate wider

use by nursing scholars in research and practice.

Aims

The aims of this concept analysis were to identify the

attributes, antecedents and consequences of the concept of

routine and examine the implications and applications of this

concept in the field of nursing.

Method

The process of concept analysis was performed using the

steps 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 attributes

of the concept, as well as surrogate and related concepts, and

antecedents and consequences were delineated. Finally,

implications for further development were generated. To

allow for methodological replication of the process conduc-

ted here, the distribution of sources by discipline and target

population are presented.

The literature review conducted for this study included

manuscripts from the following databases: PsycInfo,

CINAHL, MedLine, Social Services and Social Work

abstracts. The following keywords and free text were used

for the search: routine, routines, daily routine/s, weekly

routine/s, personal/individual routine/s, and routiniza-

tion. It was found that the use of the term routine alone was

misleading since the word also serves as an adjective (e.g.

routine procedures in the emergency room), especially in the

MedLine and CINAHL databases. Therefore, the other terms

and keywords were used as combinations. There were no

limits on year of publication (in order to be as inclusive as

possible), but only English language publications were

included.

A total of 2818 manuscripts was identified in the

database review. These were screened at the title level for

potential relevance to the concept or its application, and

those screened in were then reviewed at the abstract

level. A total of 550 papers met the preliminary inclusion

criteria and were further screened at the abstract level, and

when required at the whole manuscript level. To be

included in the final concept analysis, papers had to meet

at least one of the following conditions: (1) the concept of

routine was at the centre of the theoretical discussion in

the manuscript; (2) routine was discussed as one of the

outcomes of the study; and (3) routine was measured in the

study. Using these criteria, the final concept analysis

included 74 papers and book chapters published from

1977 to 2005.

Data analysis

The 74 papers were categorized according to discipline,

definition of routine, whether routine was referred to as an

antecedent, a consequence or an intervening factor, the target

population on which the concept was examined, related

terms and concepts and type of paper [e.g. qualitative study,

opinion paper, randomized control trial (RCT), etc.]. The

information provided in the manuscripts was sorted into the

following categories: theoretical background, concept attrib-

utes, antecedents, consequences, surrogate and related con-

cepts. Within each category, literature was analysed to

identify common themes and trends.

Findings

Manuscript type

Table 1 shows the distribution of papers reviewed by content

(discipline) and type of publication. Originally, 10 different

disciplines were identified and subsequently grouped into six

categories.

The table shows that the majority of manuscripts dealing

with the concept of routine were from the field of occupa-

tional therapy (42%), followed by nursing (24%) and

psychology (12%). The overwhelming majority were des-

criptive-qualitative small-scale studies (40%), followed by

correlational studies (147%). RCTs and other experimental

designs constituted a small percentage (58%) only.

Target populations

Routine was described in a few well-defined target popula-

tions. The leading population was older adults and their

caregivers (in 34% of papers), followed by families and

children (235%). Other target populations were teenagers

and specific patient populations (e.g. cancer, HIV, etc.).

Table 1 Distribution of manuscripts across categories

Qualitative Descriptive Correlational

Experimental/

quasi-experimental

Theoretical review

and book chapters Opinion

Case

study Total

Occupational therapy 16 2 4 6 2 2 32

Nursing 10 2 2 2 2 18

Psychology 1 4 2 7

Public health 4 1 5

Medicine/psychiatry 1 4 5

Other* 2 1 1 1 1 1 7

Total 28 10 7 11 11 5 2 74

*Geography, Gerontology, Social Work and Criminology.

A. Zisberg et al.


Definitions of routine

The literature review yielded a wide range of definitions,

often varying across disciplines. Table 2 gives a representative

sample of the definitions retrieved in the process of concept

analysis.

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 these

begin 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 ofactivities.

Routines coordinate various activities within the axes oftime, 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 physicalspatial characteristics.

Table 2 Definitions of routine a representative sample from the literature review

Authors Definition Context Discipline

Howe (2002) interactions that recur frequently and do so on a daily to weekly basis.They are considered episodic, having a relatively clear beginning and

end. They may be cyclic with a regular period of recurrence, although

this is probably more characteristic of routines that are involved in and

entrained by circadian rhythms such as hunger or sleep/wake cycles(p. 437)

Family

routines

Psychology

Wagner & Ryan (2004) Regular behaviours that comprise a [persons] typical day Personal

routines

Psychology and

anthropology

Kielhofner (2002) Cycles of activities embedded in time and place. Support the fulfilment

of psychological, social and physical needs. Provide a degree of structure

and predictability in life. The consistency of routines depends on ones

environment. everyday life is designed and shaped by cyclicalroutinesthat create an overall patternof occupations (p. 68)

General* Occupational

therapy

Clark (2000) Routinesare a type of higher-order habit that involves sequencing andcombining processes, procedures, steps and occupations. Routines

specify what a person will do and in what order (p. 128S)

General

Ludwig (1998a) Routine is definedas the orchestration of specific consistentoccupations into a fixed sequence in linear time (p. 214)

Personal

routines

Dyck (2002) Daily routines are material practices through which body, subjectivity,

and environment become one, mediating and constituting each other

General

Segal (2004) Routines an orderly structured activities General

Christiansen & Baum (1998) Occupations with established sequences General

Baum (1995) Routine continued engagement in occupation such as instrumental,

leisure, and social activities

Personal

routines

Rowles (2000) Routine is observed as complex social and spatial repeating patterns of

interaction between a person and the environment or other persons

General Occupational

therapy and

Gerontology

Greenberger (1998) Daily routines are hundreds of personal indicators that we pay little

attention to because they are not so much the content of our life as a

framework we live in. Routines are our reference points (p. 103) that

anchor us

Personal

routines

Gerontology

Lepola & Vanhanen (1997) Daily routine type, place, others presence and level of involvement

in activities

Personal

routines

Nursing

Denham (2000) Observable, repetitive patternswhich occur with predictable regularityin the ongoing life of the family (p. 194)

Family

routines

Hawdon (1996) Routines are social involvement patterns that include the following

dimensions: visibility, and instrumentality

Social

routines

Criminology

Definition: Quoted or extracted from the original 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.



Routines involve automation of activities and thus serve asresource conserving strategies on both the physical and

cognitive 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 individualsworld, lifestyle and even identity.

Based on this summary of attributes, we suggest a working

definition of routine: Routine is a concept pertaining to

strategically designed behavioural patterns (conscious and

subconscious) used to organize and coordinate activities

along the axes of time, duration, social and physical contexts,

sequence and order.

Related concepts

To further clarify the concept of routine, related terms and

concepts 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 to

routines but were not a surrogate concept because they were

more symbolic and psychological, while routines were more

instrumental. In occupational therapy, the terms habits and

routine are used interchangeably. Clark (2000) claimed

that routines were a kind of a habit (p. 127S), implying that

routines may be a higher-order structure of function organiza-

tion. Although routines have a habitual element, not all habits

are routines. Habits are defined as automatic sequences of

thought or actions (Clark 2000). Some investigators suggest

that habits could be so automatic as to be completely out of

awareness and thus not consciously considered by the person in

his or her daily routine (Bargh & Chartand 1999). Others claim

that routines are defined as higher order habits that involve

sequencing and combining processes, procedures, steps or

occupations. Routines specify what a person will do and in

what 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 differential

analysis of the two, Law (2002) claimed that participation

has numerous dimensions, including personal preferences,

interests, level of enjoyment and satisfaction. Participation

may therefore be a higher-level concept describing phenomena

that are beyond and above the scope of routines. Segal and

Frank (1998) mentioned the term schedules while referring to

what seemed to be routines. They defined schedules as

mechanisms that regulate the duration, frequency, pace and

sequences of daily occupations in families, and in this sense

could also be regarded as the orchestration of occupations. We

suggest that in light of the definitions reviewed here, schedules

may not necessarily include the repetitive characteristic of

routine, and therefore may relate more accurately to temporary

patterns of behaviour rather than fixed ones.

Monk et al. (1990, 1991) proposed the term social

rhythms, referring to a structure organizing activities into a

24-hour cycle. These authors determined norms for routi-

nized or deviating patterns of activity and also showed that

regularity and activity level were positively correlated, with a

60% overlap. This was especially evident for chronically ill

patients. This finding, although not directly measuring and

pertaining to routine in the sense explored here, supports the

conceptual link of timing and level of activity as two

components of the concept of routine.

Routinization was defined by Reich and Zautra (1991) as

the personality trait responsible for the extent to which

individuals have structure in their lives, and at the same time

the extent to which they reject order and structure. Although

routinization has been used in some studies as a proxy of the

concept of routine, there is a marked difference in that

routinization is a tendency that may predict the amount of

routine found in a persons life.

Antecedents

Our analysis of the literature reviewed for this paper

suggested that major life changes have been identified as

the main factor leading to the formation, maintenance (in

the sense of the lack of change), and disruption of routines.

Francis-Connolly (2002) showed that having children in the

family created unpredictability that threatened daily rou-

tines of family units. Huddleston et al. (1991) demonstrated

the change in daily routine as a result of separation and

divorce. Berger (2001) reviewed the challenges of older

adulthood, including the need for adjustment to retirement

from work, the importance of maintaining a social circle

and coping with the loss of spouses. Environmental and

ecological factors have been suggested as supporting or

disrupting 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 small

rural community in which the majority were elders. The

study showed a snowball effect of changes in the environ-

ment (e.g. blocking a road for repair work, the illness of one

of the members of the community) that affected the routines

and activities of numerous members of that community. The

author stressed the importance of time sequencing and the

interdependence of the routines of different individuals.

Schultz et al. (2004), in a descriptive study of homeless

parents, showed that shelter rules and related time con-

straints changed life routines related to parenthood.

A. Zisberg et al.


Hospitals and other institutional settings limit patients

ability to practise personal routines, and instead establish

new passive, inactive activity patterns that later do not serve

patients in their readjustment to the home environment

(Westfall 1992, Liukkonen 1995, Greenberger 1998, Wheat-

ley 2001, LeClerc et al. 2002, Andrew 2004). This notion is

based on observational studies. For example, Borell et al.

(1994) found that in hospital units for people with dementia,

in which one of the main goals was enabling return to home,

staff actually limited patients activity levels rather than

stimulating ongoing participation. Analyses showed that the

approaches used were mainly aimed at facilitating staff

members work rather than optimal function for patients.

Research in occupational therapy discussed routinization

as a personality trait. This trait reflected the extent to which

individuals were motivated to maintain the daily events of

their lives in an unchanging, relatively orderly, pattern of

regularity (Reich & Zautra 1991). In other words, beha-

vioural tendencies anchored in personality factors may

influence how much individuals need and seek routine.

Another relevant aspect was related to disease and disability

and their effects on routines. Poole (2000) showed that physical

illness that has a functional impact (e.g. rheumatoid arthritis)

altered routine activities of women when compared with a

control group of patients with a less physically impairing illness

(e.g. diabetes). In other studies, changes in daily routines

reflected the adjustment of cancer patients to their illnesses as

well as patients suffering from advanced functional limitations

like paraplegia or severe illness like AIDS (Loveys & Klaich

1991, Quigley 1995, Trainor & Ezer 2000, Olson et al. 2002,

Sanden & Hyden 2002). The disruption of daily routine was

also one of the major findings in women with fibromyalgia

(Henriksson 1995). Routines changed at the most basic levels:

the order in which people bathed/washed, the way they set the

table for lunch, etc. More generalized routine patterns may also

change (e.g. sleeping times and hours, work or studies, time

dedicated to social engagements). Jones et al. (1996) analysed

the quality of life of older adults with learning disabilities living

in assisted living environments. They found a positive associ-

ation between older age, lower self-help skills, having more

problems with incontinence and mobility, and higher levels of

routine in daily living. The effects of illness and disability on

routine were potentially twofold; on the one hand, illness and

disability challenged existing routines and, on the other hand,

they invoked a higher need for routine in daily life.

Consequences

In the literature, both adverse and positive consequences of

routines were identified. Routines were related to boredom,

burnout, as well as to adverse habits, fostering detrimental

behaviours and making behavioural change harder (e.g.

tobacco consumption, eating patterns and nutrition) (Holm

et al. 1998, Clark 2000). Another adverse aspect identified was

the inflexibility of routine the inability to change and adapt

routines to varying circumstances (Rogers & Holm 1991).

Theoretically, the advantages of habitual routine behaviour

are also noteworthy: Meyer (1922) developed a theory that

one of the major reasons for mental illnesses was habit

disorganization and absence of routine. He also asserted that

human beings derive meaning and maintain well-being

through the organization of time (p. 6). He identified sleep,

work, rest and play as daily activities that determine the

overall adaptation of a person to life (Christiansen 1996).

Bond and Feather (1988) reviewed studies that linked a

measure of psychological routine with various outcomes, and

noted links between the maintenance of routine and a sense

of purpose in life, self-esteem, reported health, optimism

about the future, type A behaviour, and more efficient study

habits. Routine was also negatively correlated with depres-

sion, psychological distress, anxiety, neuroticism, physical

symptoms, hopelessness and anomie. These findings were

supported by additional studies (Brown et al. 1996, Leifer-

man et al. 2005). Some work has focused on the role of

routine in the lives of older adults. Rogers et al. (1999)

demonstrated a statistically significant improvement among a

group of 84 nursing home residents with Alzheimers disease

in independence in performing ADLs after 3 weeks of a habit

training intervention. Clark et al. (1997, 2001) tested the

effectiveness of occupational therapy interventions, with a

central theme of enhancing regularly performed activities

(such as grooming, exercise and shopping). The results

showed improvement in functional mental and health status,

life satisfaction, social functioning, body pain, emotional

problems and role limitations attributed to health problems

in the routine activity enhancement group. There was

additional evidence stemming from cross-sectional and

observational, studies suggesting that routine maintenance

was associated with lower disruptive behaviour and higher

functional status in patients with Alzheimers disease (Baum

1995, Redfern et al. 2002). In community-dwelling older

adults, Ludwig (1998a, 1998b) reported that daily routine

facilitated well-being in older patients by helping to maintain

a sense of control, perception of health, steady level of

activity and by providing balance and continuity.

Habitual physical activity level was found to be one of the

two major predictors of self-reported functional status in

community-dwelling older women (Foldvari et al. 2000). In a

longitudinal study of a representative sample of 504 people

aged 75 and older, the most important predictor of functional



decline was the number of days off regular activity (Hebert

et al. 1999).

Additional evidence has supported the importance of

routine in other fields of human functioning. A body of

studies identified a consistent link between regular life

routines and adherence to medication plans as well as access

to care (Oakley et al. 1999, Bytheway 2001, Takahashi et al.

2001, Wagner & Ryan 2004). Numerous studies have

examined the outcomes of social and family related routines

and found them to be associated with parental competence,

child health, parentchild harmony and academic achieve-

ments and better resource management (Dyck 1992, Denham

1995, 2000, Fiese et al. 2002, Howe 2002, Cronin 2004, Roy

et al. 2004).

Young (1988) suggested four functional advantages of

routines and habits. These may shed light on the common

beneficial outcomes of routines because they

increase the skill with which actions are performed; diminish fatigue (serve an energy conserving function); spare attention and resources for the unexpected/unpre-

dicted;

economize memory allowing performance of functionswithout having to recall the specific elements.

Indeed, some of the existing evidence and theoretical

development on the role of routine suggest that routines serve

as adjustment strategies both for the individual (e.g. cancer

patients adopt routines that will facilitate their coping with

varying health conditions, diminished energy levels and so

on) (Loveys & Klaich 1991) and the organization (e.g.

hospital routines that facilitate treatment but may interrupt

personal lifestyle) (Wheatley 2001). On a larger scale, some

evidence from the field of criminology has suggested a link

between social routines and consequences of socially deviant

behaviour (e.g. drug abuse). In these studies emphasis was

put on aspects of social routines as predictors of social

behaviour (Hawdon 1996, 1999, Mallett et al. 2004).

Despite a wide range of diverse definitions and theoretical

views of routine, a few key factors re-emerge in almost any

attempt to capture the notion of routine: routine is a means of

coping and a tool for adjustment, especially in a limited

resources system. In other words, it is an adaptation mechan-

ism serving individuals by allowing a more efficient allocation

of resources, automation of activities and organization of the

environment into units that can be handled efficiently.

Routine creates order and uniformity and facilitates adjust-

ment. Figure 1 presents an integrative summary of routines

antecedents, attributes and consequences.

Implications for nursing research

Routine can be seen as a mechanism for adjustment to the

environment, especially for those with limited health-relevant

resources. However, routines, almost by definition, are rigid

and difficult to change. Therefore, extreme changes in the

environment, such as hospitalization, various health condi-

tions and major life changes that disrupt routines, may

Antecedents

Individual characteristicsPersonality, background,

age, family status

Environmental factorsCulture and society

Change in Environment(transition, hospitalization,

institutionalization)

Level of Health & FunctionIllness, disability, functional and

cognitive limitation

Consequences

Personal: EmotionalMood, purpose in life, self-

esteem, optimism, well-being, life satisfaction,

sense of control

FamiliesParental competence,parent-child harmony,child health, academic

Observablesbehaviour patternsOrganizes the timing, duration and order of activities Repetitive within a time-frame Coordinatesactivities within the axes of time, space, interpersonal interaction Occurs in context Involves automation and conserve resourcesApplicable to an individual, a social group or a communityComprises the individuals world, lifestyle and even identity

Attributes

CommunityAdverse habits,

deviant behaviour

Personal: Physical/Health-related

Maintenance of functionalstatus, lower disruptive

behaviour, perceived health,adherence to medication

Efficiency of function

Figure 1 Attributes, antecedents and

consequences of routine.

A. Zisberg et al.


challenge the person in a more drastic way than currently

assumed in the literature. As a result, a greater impact on

health and function may occur. To ameliorate the negative

implications of environmental change, nursing care could be

designed to incorporate or consider aspects of routine

maintenance. Personal routine maintenance may offer a

promising conceptual and therapeutic direction for the

preservation of functional status when facing major situa-

tional or life changes. Further studies should focus on the link

between routine maintenance and functional outcomes in

older age during times of transition, coping with loss (e.g. of a

family member), examine the contribution of life routines to

family and individual well-being, and explicate the links

between personal and family routines. Other populations of

interest may be children and social groups or communities

under situational stress. An additional perspective on this

issue might involve an investigation of specific aspects of

routine and their predictive values. Such an investigation

might allow the determination of which categories and

aspects of routine are most predictive of health outcomes.

Another avenue for future research might be a focus on

routines as mirrors of cultural and societal values and

structures (Gallimore & Lopez 2002). Since culture

provides a context for adaptation to the environment, it

probably directs and shapes individual routines. The current

nursing literature stresses the importance of culturally

sensitive care (Ndiwane et al. 2004, Leishman 2006),

which may be even more important with vulnerable

populations with limited emotional, physical and social

resources. Assessing routine may be a means of planning

and delivering culturally sensitive interventions for individ-

uals and groups.

Implications for nursing practice

In current nursing care settings, routine plays a central role.

Most care settings, such as hospitals, nursing homes, and

assisted living arrangements have strict routines for activities,

meals, treatments, assessment and sleep. Routines at times

facilitate actions and often become symbolic of the profes-

sional mandate of the nursing profession (Wolf 1988). It is

often not acknowledged, however, that the main function of

these routines is to serve the needs of the healthcare staff

rather than the patients (Borell et al. 1994, Palmer et al.

1998). Findings that are slowly accumulating from studies

such as those described here suggest that routines play a

major role in the preservation or loss of function and health.

Nurses serve as patient advocates in most of the above

settings. It is the nurses responsibility then to lead change in

the systems approach and consideration of patients routines

as a vital aspect of their functional status and health. Once

further empirical work is completed, a number of possible

directions could be of interest.

First, routine maintenance could be useful as an outcome

measure to assess how quickly and at what point after

hospitalization patients are able to resume their previous

routines. Secondly, it could be used to assess how much illness/

hospitalization disrupts patients routines. The main goal

could be to create interventions allowing the maintenance of

routines or at least minimizing the impact on functional decline

while in hospital or any healthcare setting.

Understanding individuals routine patterns, as well as

those that are typical of communities and families, could help

raise compliance rates and the effectiveness of diverse health

interventions, such as supporting patients with HIV in

adhering to their medication plans, supporting caregivers of

people with chronic illness, assisting with smoking cessation,

or educating families about healthy nutrition.

Study limitations

The concept analysis described here may shed new light on a

potentially important concept for research and practice.

However, the analysis, as well as the specific context in which

it was applied, have their limitations. First, since there has

been limited empirical work to date, the literature review

(though exhaustive) was based on a relatively small number

of papers. Second, this review included only a representative

sample of papers using related concepts. A more exhaustive

review of studies on related terms and concepts might have

added more information. We intentionally limited the ana-

lysis to the concept of routine at this preliminary stage.

Future conceptual work may examine views of routine vis-a`-

vis other related concepts in a more systematic manner. Last,

we acknowledge the limitations of the process itself. Concept

analyses help to integrate knowledge, propose solutions to

conceptual disagreements and point toward possible ways of

promoting more research and practice in the field of choice.

They do not, however, produce new knowledge, as empirical

research may offer.

We did not carry out a systematic analysis of the

relationship between the concept of routine and concepts in

nursing theories. Therefore, we are not ready to suggest a

theoretical structure, or a locus within nursing theory, at this

point of the work on routine. We merely tried to establish a

sense of clarity about the inter-relations between routine and

other concepts that are often used interchangeably with it.

We did not, therefore, construct a middle-range theory at this

time; however, future work may allow a suggested theory of

routine.



Conclusion

Routine was defined here as a concept pertaining to

strategically designed behavioural patterns (conscious and

subconscious) used to organize and coordinate activities

along different axes of time, duration, social and physical

contexts, sequence and order. Routine emerges as a prom-

ising concept that may fulfil a role in better understanding

individual and group adjustment to environmental demands

and changes. From the little research in existence, routine is

portrayed as a key factor in understanding lifestyles,

identity, self-esteem, sense of control, activity levels and

continuity, energy and resource management, and coping

with major life changes and other types of environmental

press.

At this point, most of these directions are still theoretical

assumptions or emerging directions from qualitative and

descriptive efforts. Too little empirical evidence is in

existence to provide support to any of the above mentioned

consequences of routine. No one discipline has undertaken

the responsibility of further exploring this concept in a

systematic, continuous manner. As a result there are

inconsistent uses of terms, methods and models in the

literature on routine and its nature. Definitions lack consis-

tency, and methods and measures vary to the extent that

they are incomparable to each other. This seemingly

promising concept, therefore, remains outside the centre of

academic attention. In this paper, we propose a working

definition of the concept of routine, exploring and attempt-

ing to define its core attributes, based on a systematic

literature review. This is a necessary step providing the

infrastructure upon which further studies and eventually

new nursing interventions incorporating aspects of routine

may take place.

Nursing has much to gain from better understanding and

implementing this concept in both research and practice.

Using the concept of routine in conceptualizing models of

health and function in various settings may be of benefit to

both nurses and patients. To achieve this goal, instruments

should be designed, combining quantitative and qualitative

aspects to allow for effective measurement of routine in

nursing-relevant settings. Promising work has begun to

capture routine as a whole (Zisberg 2005), measure parts of

it (Abegg et al. 2000, Lopez 2002, Wagner & Ryan 2004),

or assess it through a proxy measure (Clark et al. 1997,

Flores et al. 2005). These measures remain to be widely

tested. Second, empirical evidence needs to be gathered to

shed more light on the nature of routine and the potential

roles it may play in managing and promoting health, and in

providing rehabilitation and general care. These all revolve

around individual behaviour and function. The concept of

routine holds promise for advancing our understanding of

individual and group behaviour and function in various life

situations.

Acknowledgements

We would like to thank the Center of Absorption for

scientists in Israel, The Fulbright foundation of the United

States of America (USA), and the Spencer foundation of Israel

for supporting the work leading to this manuscript.

Author contributions

AZ, HY and KS were responsible for the study conception

and design and AZ and LZ were responsible for the drafting

of the manuscript. AZ performed the data collection and AZ,

HY, KS and LZ performed the data analysis. AZ and HY

obtained funding and AZ, HY and KS provided administra-

tive support. AZ, KS and LZ provided statistical expertise.

What is already known about this topic

Sporadic publications, from different fields of researchand practice, suggest that life routines may be important

in understanding well-being.

Routine as a research construct has predominantly beenassociated with various outcomes in families with chil-

dren and compliance with medication in special popu-

lations.

Routine is defined differently in different settings, andoften used interchangeably with other concepts and

terms, such as habits and social rhythms.

What this paper adds

Routine is a concept pertaining to strategically designedbehavioural patterns (conscious and subconscious) used

to organize and coordinate activities along the axes of

time, duration, social and physical contexts, sequence

and order.

Personal routine maintenance may offer a promisingconceptual and therapeutic direction for the preserva-

tion of functional status when facing major situational

or life changes.

Understanding the routine patterns of individuals,communities and families could help raise the effect-

iveness of diverse healthcare interventions, such as

medication adherence, supporting informal caregivers,

and health promotion.

A. Zisberg et al.


AZ, HY, KS and LZ made critical revisions to the paper. LZ

provided methodological contributions.

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