Factors Contributing to Time-Wasting Activities among Palestinian Nurses: A Cross-Sectional Study

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Introduction
Nurses face ongoing challenges as they try to handle a growing number of complex tasks and demanding work conditions within the constraints of limited time [1].In a mixed-methods study conducted in Palestine, [2], a nurse captured the challenges they encounter while endeavoring to address the requirements of all their patients: "You cannot give quality when you are overwhelmed with quantity.When I have 15 patients on a ward to take care of on a night shift, I barely have time to distribute the medications, leaving little time to care for patients" other needs."According to Saintsing et al. [3], nurses indicated that time limitations constrained their capacity to conduct thorough patient assessments.Around 80% of entry-level nurses acknowledged making errors due to time pressure.Managing time efciently and avoiding time-wasting activities are therefore essential in the nursing work environment.Te lack of time management and organizational skills was also related to inequities in health service provision and distribution [4].
Causes of time-wasting behaviors among nurses include a lack of efective time management skills.Tis includes not setting short-and long-term goals, failing to organize tasks, engaging in activities that waste time, and lacking knowledge and experience in setting priorities [5,6].
Consequences of time-wasting behaviors include inefective work performance, decreased productivity, and the potential for missing essential nursing care tasks [5].Nurses who wasted their time and energy on social media and lowpriority tasks were found to signifcantly lower their work performance [7].Not knowing how to set priorities by giving equal attention to major and minor problems can have dire consequences on patients' health and overall nursing outcomes [8].
Numerous studies have consistently demonstrated a detrimental impact of inefective time management on job performance [9,10].Tang and Vandenberghe [11] explained that demands that exceed an individual's available resources contribute to a decline in overall work performance and well-being.Others found that work overload negatively afects performance through increasing stress [10].A crosssectional study from Brazil revealed that work-related stresses had the greatest negative impact on job performance while social networks and job autonomy had the greatest positive impact [12].
A study by Knezevic et al. [13] investigated the efects of time management skills on job satisfaction for nurses.Te study found that poor time management skills were signifcantly associated with lower job satisfaction levels among nurses.In a related study, Ozkan & Timbil [14] found that nurses with poor time management skills made more medication errors and missed nursing care activities more frequently than those with good time management skills.Te authors recommended that time management training should be included in nursing education to improve patient safety and quality of care.
Similarly, a study by Cleland Woods et al. [15] found that poor time management skills were associated with higher levels of job-related stress among nurses.Te authors recommended incorporating time management training into workplace wellness programs to help nurses manage their time more efectively and reduce job-related stress.In conclusion, poor time management skills can have negative efects on nurses' capacity to provide optimal patient care.It is, therefore, essential that time management skills are included as a critical component of nursing education and workplace wellness programs.
Numerous studies, including those conducted by Hamzehkola and Naderi [16], Higazee et al. [17], Ebrahim et al. [18], and Elsabahy et al. [19], have presented sound evidence that time management interventions can enhance the organizational skills of nurses, mitigate work-related stress levels, and ultimately elevate the overall quality of their work.A time management educational program for head nurses in Iran assessed improvements in fve essential time management skills (setting goals, setting priorities, time mechanics, time control, and organizing time).Te results showed dramatic improvements in these basic skills after the educational intervention [20].
Another quasi-experimental experiment of 60 nurses from all hospital wards in Tehran examined the psychological and social impacts of a one-day educational workshop on strategies to improve time management and avoid wasting nursing time [16].A pretest was followed by a posttest one month after the workshop.Results showed signifcant improvements in psychological well-being and trust among staf.
Setting priorities has been defned as the action of assigning precedence in rank with regard to the importance or time for some activities over others [8].In addition to delaying activities of less importance, prioritization can also eliminate unnecessary tasks which allow nurses to allocate more precious time for patients [16].Tese fndings underscore the importance of time management skills for nurses.Prioritizing tasks and activities are crucial aspects of time management skills.
It has been noted that new nurses struggle with managing their time and that their abilities to prioritize tasks and minimize time-wasting activities improve with experience [21].
Te degree to which this relationship is a function of experience, age, education, or other variables that evolve with time has not been extensively investigated in previous research [22].Many studies show that time-wasting activities decrease with age, education, experience, and attending time-management courses.Most of the previous research, however, did not adjust for confounding efects in multivariate analyses [23].Te current study aims at exploring the relationships between these background variables and time-wasting behaviors in multivariate models to distinguish the most important factors contributing to time-wasting behaviors.
1.1.Principles of Setting Priorities.Te fundamental question is how can nurses determine the priority, importance, and urgency of the multitude of tasks they are tasked with?Several time management theories and models can help nurses in managing their time and minimizing time-wasting activities.Te items used in the time-wasting scale of this study such as appreciating planning, distinguishing important tasks, and understanding time-wasting activities refect those principles.Tose principles include (1) Te Pareto 80/20 rule notes that 80% of outcomes result from 20% of eforts [24].Tis principle calls for identifying and focusing on the most impactful tasks, i.e., the ones that yield the highest returns.Te 80/20 rule therefore prioritizes the 20% of tasks that produce the best results.(2) Te two-minute rule recommends completing small tasks (e.g., those requiring 2 minutes or less) frst before embarking on tasks that are complicated or require long durations [25].Tis rule helps minimize the accumulation of small tasks and fosters a sense of progress.(3) Te efort impact matrix, also known as the PICK Chart, prioritizes tasks based on impact and efort [26].Te impact can be assessed based on fnancial gain, patient satisfaction, or health improvement.Te impact or yield of a task ranges from low to high.(4) Te ABC method involves categorizing tasks based on their priority and then completing the highest priority tasks while less urgent tasks can be delayed or delegated [27].(5) Eisenhower matrix categorizes tasks based on their urgency and importance into four quadrants: (a) urgent and important, (b) important but not urgent, (c) urgent but not important, and (d) not urgent and not important.Te model helps prioritize tasks and focus on the most critical ones.
Nursing time management skills are essential for delivering efcient and efective patient care.Poor time management skills can lead to decreased patient satisfaction, inefcient use of resources, and ultimately compromised patient care [14].Terefore, this study aimed to investigate sociodemographic and institution-level factors associated with time-wasting behaviors among nurses in Palestine.Specifcally, the research questions were whether time-wasting behaviors vary by nurses' age, gender, place of residence, and educational levels.Of interest were the efects of institutional-level factors such as type of healthcare institution (public versus private), facility size (hospital versus clinic), and teaching status (teaching versus nonteaching institutions) on time-wasting activities.Te impact of attending a time-management course on time-wasting behaviors was also investigated.

Methods
Te surveys were collected in the period between March and August 2019 from 714 nurses working in 17 hospitals and multiple primary health care clinics in the North of the West Bank of Palestine.Approval was obtained from the Palestinian Ministry of Health.Te researcher contacted the nursing directors of each hospital and primary healthcare center, inquiring about the number of nurses employed within their respective organizations.Subsequently, the researcher prepared questionnaires based on the gathered information, met with each nursing director in person, delivered the questionnaires, and explained the data collection process, including its content, objectives, and the process of obtaining consent.
Te nursing directors were then tasked with distributing the questionnaires to all nurses in their organizations and collecting the completed questionnaires within a week.Te researcher personally collected the completed questionnaires from the nursing directors.All nurses completed the questionnaires except those who were sick or on leave.
Inclusion criteria: all male and female staf and practical nurses who were available at the time of the data collection.Exclusion criteria: nurses who were on a sabbatical leave, a sick leave, nurse volunteers, and internship student nurses.Te entire process was completed within a span of six months, and the researcher, along with the assistance of two experienced data entry personnel, entered the data into SPSS version 25.Te collected data were analyzed using t-tests and ANOVA.To account for confounding efects, multivariate linear regression was employed.

Study Instrument.
Te study examined various sociodemographic variables including gender, age, residence, educational level, and years of experience.Time-wasting behaviors were evaluated using an 11-item scale developed based on prior research [28].Tis scale measures diferent aspects of time-wasting behaviors, such as excessive grooming, poor planning, failing to distinguish between important and unimportant tasks, underestimating task completion time, excessive use of social media, and excessive socialization.Responses were recorded on a 5-point scale ranging from "never � 1" to "always � 5" and a summative score was computed.Scores could range from a minimum of 11 to a maximum of 55, with higher scores indicating more frequent engagement in time-wasting activities.
Te face and content validity of the study were ensured through consultations with 10 experts in nursing and time management.Tese experts were briefed on the study's objectives and the construct of the scale.Tey were then asked to assess whether the items clearly and efectively measured their intended concepts (face validity).Additionally, the experts provided feedback on the relevance of the items and their representation of the content domains within the intended construct.
Te author carefully analyzed the feedback received from the experts and made necessary adjustments to the wording and number of items.Subsequently, the revised questionnaire was pilot-tested with a group of 5 staf nurses.Construct validity was evaluated through factor analysis, and reliability was assessed using Cronbach's alpha.

Results
Cronbach's alpha of the entire sample was 0.862, indicating good internal consistency.Factor analysis identifed three distinct factors, as detailed in Table 1.Te Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.845, indicating strong partial correlations among the variables and justifying the use of factor analysis.Bartlett's test of sphericity returned a p value of less than 0.001, which rejects the null hypothesis that the variables are unrelated.Tis indicates that the correlation matrix is not an identity matrix, afrming the appropriateness of factor analysis.None of the items had a commonality value above 0.4, indicating the appropriateness of factor analysis for exploring the data.Overall, the threefactor structure accounted for a substantial 76.77% of the variance in the nursing time management scale.
Te divergent validity of the scale was assessed by correlating it with another scale which is theoretically intended to measure good time management behaviors among nurses.Te time nursing wasting scale correlated negatively with the nursing time managements scale (NTMS), correlation coefcient � −0.162, p < 0.001.Te NTMS is a scale that measures positive time management skills among nurses such as planning, goal setting, and coordination of activity (Table 1).
Te factor loadings, means, and standard deviations for each item within the time-wasting scale are displayed in Table 2. Higher mean values indicate more frequent engagement in time-wasting behaviors among the participants.Among the various behaviors, grooming appeared to be the least time-consuming activity, with a mean score of 2.14.In contrast, work interruptions, such as being overly accessible, ranked as the most signifcant time-wasting factor, with a mean score of 3.15.Following closely were behaviors like not having specifc time to respond to emails and phone calls (mean of 3.03) and continuously checking emails and other communication media (mean of 2.83).
Te factor analysis unveiled a three-factor model, categorizing time-wasting behaviors into three dimensions: (1) Inability to plan and organize tasks (2) Improper use of technology and social media (3) Excessive socialization Table 3 shows the frequencies and means of the timewasting scores by background variables.Of the 714  Regarding workplace, the table shows that the mean time-wasting score was signifcantly higher for participants working in a hospital (28.53) compared to those working in a patient community clinic (25.17) (P < 0.001).For this type of organization, the mean time-wasting score was signifcantly higher for participants working in a private organization (31.53) compared to those working in a government organization (26.31) (P < 0.001).
Regarding the current job position, the table shows that 631 participants (88.3%) were nurses, while 82 participants (11.5%) were nurse supervisors.Te mean time-wasting score was similar across the two job positions, with no statistically signifcant diference (P � 0.342).Participants who worked in teaching hospitals/clinics had a lower mean time-wasting score (26.59) than those who did not work in teaching hospitals/clinics (28.88), and those who attended a time management course had a slightly lower mean timewasting score (27.00) than those who did not attend a time management course (28.44).
Te multivariate linear regression in Table 4 shows no signifcant relationship between time wasting and gender, age, place of residence, educational level, and job experience.On the other hand, place of work emerged as a signifcant predictor of the time-wasting score when other background variables were considered.Individuals working in community clinics have lower time-wasting average scores compared to those working in hospitals (B � −3.2, p < 0.001).
Te type of organization was also a signifcant predictor of time management skills.Individuals working in private organizations engaged in more time-wasting activities compared to those working in government organizations (B � 4.09, p < 0.001).
Nurses in nonteaching hospitals are more likely to engage in time-wasting activities than nurses in teaching hospitals (B � 2.63, p < 0.001).Nurses who had not attended a time management course obtained a higher score on the time-wasting scale compared to nurses who had attended a time management course (B � 3.11, p < 0.01).

Discussion
Tis research sought to examine the predictors of timewasting behaviors among nurses.Te results indicate that time-wasting behaviors are infuenced by individual-level and organizational-level factors.Te fnding that attending a time management course is efective in reducing timewasting activities and improving time management skills corroborates numerous previous studies that have provided evidence for the positive impact of time management training [19,22,[29][30][31].
Prior studies have demonstrated that time-wasting activities decrease with age [22].In the current study, older age was associated with lower time-wasting scores in the bivariate analysis, but this association did not hold in the multivariate analysis, most likely due to adjustments for confounding variables such as seniority or job experience.Similarly, job experience was associated with lower timewasting scores in the bivariate analysis, but this relationship did not persist in the multivariate analysis.Tis fnding contradicts previous research, which found signifcant correlations between years of experience and improved time management skills [23].Educational level, however, was not associated with time-wasting behavior in this study.Tis result aligns with fndings from a study in Bangladesh that failed to establish a relationship between educational level and time management skills [32].In contrast, a study in Iran found signifcant positive correlations between time management skills and age, education, job experience, and managerial experience, probably because this study did not adjust for potential confounding efects [16].
Organizational types, such as hospital vs. community clinic or government vs. private, were strongly statistically related to time-wasting scores in this study.Tis suggests that organizational-level factors could infuence timemanagement behaviors.Elsayed et al. [23] reported that organizational factors, such as understafng, work overload due to a large number of visitors, and the absence of clear management plans, strongly infuence employees' time management behaviors.Others have found that poor organizational and policy factors, such as frequent staf meetings, inefcient and unclear communications, and excessive administrative work, such as writing attendance records or tasks unrelated to their specialty, can result in signifcant time wastage among employees [33].
Time-wasting activities, as reported by nurses in this and previous studies, include spending too much time on lowpriority tasks; treating everything as urgent; inability to say "no" to extra work; and excessive interruptions by people and colleagues [34].Meetings that are inefective, with no clear purpose, agenda, or follow-ups are a waste of time as well as arriving at meetings late.Other time-wasters include excessive socializing, phone calls, and phone interruptions; inefcient and unclear communications with patients and colleagues; insufciently detailed policies and procedures; reluctance to delegate tasks; and an overload of paperwork [34].
Not knowing how to prioritize, plan, and handle interruptions can lead to increased errors and work inefciencies [35,36].Te fndings from this study concur with previous research, which shows the inability of nurses to say "no" as one of the most important factors negatively infuencing nurses' workfow [19,35].It is known that in Arab culture, saying "no" or "I do not know" is not commonly used, probably because such terms are thought of as impolite.Nevertheless, nurses should learn to refuse additional tasks that they cannot perform or tasks that interrupt their workfow.Other major time-wasters mentioned in previous research include not knowing how to delegate.Figure 1 illustrates a theoretical framework of the types, causes, and consequences of time wasting in the nursing profession.Te fgure summarizes the fndings from this article and previous studies.

4.1.
Limitations.While this study was carried out on a representative sample within the northern regions of Palestine, it is important to note that generalizing the fndings to other contexts may not be fully established.To strengthen the generalizability of the fndings, it is necessary to conduct further research in various other contexts.Although having the nursing directors distribute and collect the surveys has increased response rates and motivation to complete the questionnaires with precision, it cannot be ruled out that some respondents may have been unduly infuenced to participate despite the fact that it was explained to them that participation is voluntary.

Conclusions
According to the results of this research, providing time management courses to nurses can be an efective strategy to reduce time waste and improve work quality.However, in addition to providing time management courses, hospitals and clinics should also consider implementing organizational policies and strategies to reduce time-wasting activities.
5.1.Recommendations.Hospitals and clinics should conduct regular time management courses for their employees, with an emphasis on providing practical instructions and exercises on how to avoid and eliminate time-wasting activities such as interruptions, distractions, and procrastinations.In addition, organizations should design policies that minimize time-wasting activities, such as requiring excessive reporting, vague communications, and unnecessary meetings.Such policies should be clearly communicated to all employees.
In addition to time management courses, organizations should also provide their employees with the necessary tools and resources to manage their time efectively, such as timetracking software or prioritization frameworks.By following these recommendations, hospitals and clinics can create a more productive work environment and improve the quality of care they provide to their patients.

Table 1 :
Correlation between the time-wasting scale and NTMS.

Table 2 :
Factor loading, means, and SD for each question in the time-wasting scale.

Table 3 :
Time-wasting scores by background variables, N � 714.8% were male and 65.0% were female.Te mean time-wasting score for male participants was 28.02, and for female participants, it was 27.38, p � 0.223.Te average time-wasting score of nurses over the age of 35 is higher than younger age groups, p < 0.001.Te mean timewasting score was highest for participants living in the camp (29.25) and lowest for those living in the city (27.00).

Table 4 :
Multivariate linear regression of time-wasting score by background variables, N � 714.Figure 1: A theoretical framework of types, causes, and consequences of time-wasting behaviors.6Journal of Nursing Management Moreover, as a cross-sectional study, causal inferences are constrained.Nevertheless, one strength of this study lies in its high sample size, addressing the constraints associated with smaller sample sizes in earlier research.