JAN

THEORETICAL PAPER

A concept analysis of routine: relevance to nursing

Anna Zisberg1, Heather M. Young2, Karen Schepp3 & Leehu Zysberg4
Accepted for publication 6 September 2006

Anna Zisberg PhD RN

Assistant Professor
Department of Nursing, University of Haifa,
Haifa, Israel
2

Heather M. Young PhD GNP FAAN

Endowed Professor
School of Nursing, Oregon Health and
Sciences University, Ashland, Oregon, USA
3

Karen Schepp PhD RN

Associate Professor
School of Nursing, University of Washington,
Seattle, Washington, USA
4

Leehu Zysberg PhD

Associate Professor
Department of Psychology,
Tel Hai Academic College, Tel Hai, Israel
Correspondence to Anna Zisberg:
e-mail: azisberg@univ.haifa.co.il

Z I S B E R G A . , Y O U N G H . M . , S C H E P P K . & Z Y S B E R G L . ( 2 0 0 7 ) A concept analysis of routine: relevance to nursing. Journal of Advanced Nursing 57(4), 442453
doi: 10.1111/j.1365-2648.2006.04103.x

Abstract
Title. 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 adaptation 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 published 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 patterns (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

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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 interchangeably 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 implications 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 effectiveness 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

A concept analysis of routine

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 interventions. 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 ecologicalcultural principles to account for the formation as well as the
main function of routine. Swartz (2002) reviewed the collective-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 inconsistent 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.

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A. Zisberg et al.

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 conducted 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 routinization. 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 attributes, antecedents, consequences, surrogate and related concepts. 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 occupational therapy (42%), followed by nursing (24%) and
psychology (12%). The overwhelming majority were descriptive-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 populations. 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
Occupational therapy
Nursing
Psychology
Public health
Medicine/psychiatry
Other*
Total

16
10

2
28

Descriptive
2
2
1
4
1
10

Correlational

Experimental/
quasi-experimental
4
2

4
1
1
1
7

4
1
11

Theoretical review
and book chapters

Opinion

6
2
2

2
2

1
11

1
5

Case
study
2

Total
32
18
7
5
5
7
74

*Geography, Gerontology, Social Work and Criminology.

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A concept analysis of routine

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 terminology used in the various definitions, some coherent converging 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 of
activities.
Routines coordinate various activities within the axes of
time, space, and interpersonal interaction.
Routines are by definition repetitive within a given timeframe (e.g. day, week etc.).
Routines occur in context with both social and physical
spatial characteristics.

Table 2 Definitions of routine a representative sample from the literature 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)
Regular behaviours that comprise a [persons] typical day

Family
routines

Psychology

Personal
routines
General*

Psychology and
anthropology
Occupational
therapy

Wagner & Ryan (2004)

Kielhofner (2002)

Clark (2000)

Ludwig (1998a)
Dyck (2002)
Segal (2004)
Christiansen & Baum (1998)
Baum (1995)
Rowles (2000)

Greenberger (1998)

Lepola & Vanhanen (1997)

Denham (2000)
Hawdon (1996)

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 cyclical
routinesthat create an overall patternof occupations (p. 68)
Routinesare a type of higher-order habit that involves sequencing and
combining processes, procedures, steps and occupations. Routines
specify what a person will do and in what order (p. 128S)
Routine is definedas the orchestration of specific consistent
occupations into a fixed sequence in linear time (p. 214)
Daily routines are material practices through which body, subjectivity,
and environment become one, mediating and constituting each other
Routines an orderly structured activities
Occupations with established sequences
Routine continued engagement in occupation such as instrumental,
leisure, and social activities
Routine is observed as complex social and spatial repeating patterns of
interaction between a person and the environment or other persons
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
Daily routine type, place, others presence and level of involvement
in activities
Observable, repetitive patternswhich occur with predictable regularity
in the ongoing life of the family (p. 194)
Routines are social involvement patterns that include the following
dimensions: visibility, and instrumentality

General

Personal
routines
General
General
General
Personal
routines
General

Personal
routines

Personal
routines
Family
routines
Social
routines

Occupational
therapy and
Gerontology
Gerontology

Nursing

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.
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A. Zisberg et al.

Routines involve automation of activities and thus serve as

resource 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 individuals
world, 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 organization. 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 achieving given outcomes and an orderly life (Clark 2000, p. 128S).
In some instances, participation in occupations and routine 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
446

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 routinized 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 routines 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 organization 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 environment (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 constraints changed life routines related to parenthood.

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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, Wheatley 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, behavioural 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 association 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,

A concept analysis of routine

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 depression, psychological distress, anxiety, neuroticism, physical
symptoms, hopelessness and anomie. These findings were
supported by additional studies (Brown et al. 1996, Leiferman 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

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A. Zisberg et al.

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 achievements 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/unpredicted;
economize memory allowing performance of functions
without 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
Antecedents

Individual characteristics
Personality, background,
age, family status

Environmental factors
Culture and society
Change in Environment
(transition, hospitalization,
institutionalization)

Level of Health & Function

Illness, disability, functional and
cognitive limitation

448

Attributes
Observables
behaviour patterns
Organizes the
timing, duration
and order of
activities
Repetitive within a
time-frame
Coordinates
activities within the
axes of time, space,
interpersonal
interaction
Occurs in context
Involves automation
and conserve
resources
Applicable to an
individual, a social
group or a
community
Comprises the
individuals world,
lifestyle and even
identity

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 mechanism 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 adjustment. 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 conditions and major life changes that disrupt routines, may
Consequences

Personal: Emotional
Mood, purpose in life, selfesteem, optimism, well
-being, life satisfaction,
sense of control

Personal: Physical/Healthrelated
Maintenance of functional
status, lower disruptive
behaviour, perceived health,
adherence to medication
Efficiency of function
Families
Parental competence,
parent-child harmony,
child health, academic

Community
Adverse habits,
deviant behaviour

Figure 1 Attributes, antecedents and

consequences of routine.

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JAN: THEORETICAL PAPER

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 situational 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 individuals 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 professional 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

A concept analysis of routine

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 analysis 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.

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449

A. Zisberg et al.

What is already known about this topic

Sporadic publications, from different fields of research
and practice, suggest that life routines may be important
in understanding well-being.
Routine as a research construct has predominantly been
associated with various outcomes in families with children and compliance with medication in special populations.
Routine is defined differently in different settings, and
often used interchangeably with other concepts and
terms, such as habits and social rhythms.

What this paper adds

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.
Personal routine maintenance may offer a promising
conceptual and therapeutic direction for the preservation of functional status when facing major situational
or life changes.
Understanding the routine patterns of individuals,
communities and families could help raise the effectiveness of diverse healthcare interventions, such as
medication adherence, supporting informal caregivers,
and health promotion.

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 promising 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
450

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 consistency, 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 attempting 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 administrative support. AZ, KS and LZ provided statistical expertise.

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JAN: THEORETICAL PAPER

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

provided methodological contributions.

References
Abegg C., Croucher R., Marcenes W.S. & Sheiham A. (2000) How
do routines of daily activities and flexibility of daily activities affect
tooth-cleaning behavior? Journal of Public Health Dentistry 60(3),
154158.
Andrew T. (2004) Hospital routine adaptation, not vice versa.
Nursing Standard 18(39), 6.
Bargh J.A. & Chartand T.L. (1999) The unbearable automaticity of
being. American Psychologist 54, 462479.
Baum C.M. (1995) The contribution of occupation to function in
persons with Alzheimers disease. Journal of Occupational Science:
Australia 2, 5966.
Bond M.G. & Feather N.T. (1988) Some correlates of structure and
purpose in the use of time. Journal and Personality and Social
Psychology 55(2), 321329.
Borell L., Gustavsson A., Sandman P. & Kielhofner G. (1994)
Occupational programming in a day hospital for patients with
dementia. The Occupational Therapy Journal of Research 14,
219237.
Bouisson J. & Swendsen J. (2003) Routinization and emotional wellbeing: an experience sampling investigation in an elderly French
sample. Journals of Gerontology. Series B, Psychology Sciences
and Social Science 58(5), P280P282.
Brown L.F., Reynolds C.F. III, Monk T.H., Prigerson H.G., Dew
M.A., Houck P.R., Mazumdar S., Buysse D.J., Hoch C.C. &
Kupfer D.J. (1996) Social rhythm stability following a late life
spousal bereavement: associations with depression and sleep
impairment. Psychiatry Research 62(2), 161169.
Bytheway B. (2001) Responsibility and routines: how older people
manage their long-term medication. Journal of Occupational
Science 8(3), 513.
Christiansen C.H. (1996) Three perspectives on balance in occupation. In Occupational Science the Evolving Discipline (Zemke R.
& Clark F., eds), F. A. Davis Co., Philadelphia, PA, pp. 431448.
Christiansen C. & Baum C. (1998) Understanding occupation: definition and concept. In Occupational Therapy: Enabled Function
and Wellbeing (Chrisitansen C. & Baum C., eds), Slack Inc.,
Thorofare, NJ.
Clark F.A. (2000) The concepts of habit and routine: a preliminary
theoretical synthesis. The Occupational Therapy Journal of Research 20, 123S127S.
Clark F., Azen S.P., Zemke R., Jackson J., Carlson M., Mandel D.,
Hay J., Josephson K., Cherry B., Hessel C., Palmer J. & Lipson L.
(1997) Occupational therapy for independent-living older adults. A
randomized controlled trial. Journal of American Medical Association 278, 13211326.
Clark F., Azen S.P., Carlson M., Mandel D., LaBree L., Hay J.,
Zemke R., Jackson J. & Lipson L. (2001) Embedding health-promoting changes into the daily lives of independent-living older
adults: long-term follow-up of occupational therapy intervention.
The Journals of Gerontology. Series B, Psychology Sciences and
Social Science 56, P60P63.
Cronin A.F. (2004) Mothering a child with hidden impairments.
American Journal of Occupational Therapy 58(1), 8392.

A concept analysis of routine

Denham S.A. (1995) Family routines: a construct for considering
family health. Holistic Nursing Practice 9(4), 1123.
Denham S.A. (2000) Family routines: a structural perspective for
viewing family health. ANS Advanced Nursing Science 24(4), 60
74.
Denham S.A. (2003) Relationships between family rituals, family
routines, and health. Journal of Family Nursing 9(3), 305330.
Dunn W.W. (2000) Habit: Whats the brain got to do with it? The
Occupational Therapy Journal of Research 20, 6S19S.
Dyck I. (1992) The daily routines of mothers with young children
using a sociopolitical model in research. The Occupational Therapy Journal of Research 12(1), 1634.
Dyck I. (2002) Beyond the clinic: restructuring the environment in
chronic illness experience. The Occupational Therapy Journal of
Research 22, 52S60S.
Fiese B.H., Tomcho T.J., Douglas M., Josephs K., Poltrock S. &
Baker T. (2002) A review of 50 years of research on naturally
occurring family routines and rituals: cause for celebration? Journal of Family Psychology 16(4), 381390.
Flores G., Tomany-Korman S.C. & Olson L. (2005) Does disadvantage start at home? Racial and ethnic disparities in healthrelated early childhood home routines. Archive of Pediatric Adolescence Medicine 158, 158165.
Foldvari M., Clark M., Laviolette L.C., Bernstein M.A., Kaliton D.,
Castaneda C., Pu C.T., Hausdorff J.M., Fielding R.A. & Singh
M.A. (2000) Association of muscle power with functional status in
community-dwelling elderly women. Journal of Gerontology, A
Biology Science and Medicine Science 55, M192M199.
Francis-Connolly E. (2002) The unpredictability of habits and routines for mothers of preschool-age children Proceedings of
Habits 2 Conference. Occupational Therapy Journal of Research
22, 94S95S.
Gallimore R. & Lopez E.M. (2002) Everyday routines, human
agency, and ecocaltural context: Construction and maintenance of
individual habits. The Occupational Therapy Journal of Research
22, 70S77S.
Greenberger D. (1998) This form of decline is of the charts.
Contemporary Long Term Care 21(3), 103.
Hawdon J.E. (1996) Deviant lifestyles: the social control of daily
routines. Youth and Society 28(2), 162188.
Hawdon J.E. (1999) Daily routine and crime: using routine activities
as a measure of Hirchis involvement. Youth and Society 30(4),
395415.
Hebert R., Brayne C. & Spiegenhalter D. (1999) Factors associated
with functional decline and improvement in a very elderly community-dwelling population. American Journal of Epidemiology
150, 501510.
Henriksson C.M. (1995) Living with continuous muscular pain
patient perspectives. Part I: encounters and consequences. Scandinavian Journal of Caring Sciences 9, 6776.
Holm M.B., Rogers J.C. & Stone R.G. (1998) Person-task-environment interventions: a decision making guide. In Chapter 21:
Treatment of performance contexts. In Occupational Therapy, 9th
edn (Neistadt M.E. & Crepeau E.B., eds), Lippincott, New York,
NY, pp. 471516.
Howe G.W. (2002) Integrating family routines and rituals with
other family research paradigms: comment on the special section.
Journal of Family Psychology 16(4), 437440.

 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd

451

A. Zisberg et al.
Johnson J.E. (1991) A comparative study of the bedtime routines and
sleep of older adults. Journal of Community Health Nursing 8(3),
129136.
Kielhofner G. (2002) A Model of Human Occupation, 3rd edn.
Lippincott Williams, Baltimore, MD.
Larson E.A. & Zemke R. (2003) Shaping the temporal patterns
of our lives: the social coordination of occupation. Journal of
Occupational Science 10(2), 8089.
Law M. (2002) Participation in the occupations of everyday life.
American Journal of Occupational Therapy 56, 640649.
LeClerc C.M., Wells D.L., Craig D. & Wilson J.L. (2002) Falling
short of the mark: tales of life after hospital discharge. Clinical
Nursing Research 11(3), 242263.
Leiferman J.A., Ollendick T.H., Kunkel D. & Christie I.C. (2005)
Mothers mental distress and parenting practices with infants
and toddlers. Archives of Womens Mental Health 8(4), 243
247.
Leishman J.L. (2006) Culturally sensitive mental health care: a
module for 21st century education and practice. The International
Journal of Psychiatric Nursing Research 11(3), 13101321.
Lepola I. & Vanhanen L. (1997) The patients daily activities in acute
psychiatric care. Journal of Psychiatric and Mental Health Nursing
4(1), 2936.
Liukkonen A. (1995) Life in a nursing home for the frail elderly: daily
routines. Clinical Nursing Research 4(4), 358370.
Lopez E.M. (2002) Every day habitual behaviors of Latino high
school students. The Occupational Therapy Journal of Research
22, 86S88S.
Loveys B.J. & Klaich K. (1991) Breast cancer: demands of illness.
Oncology Nursing Forum 18(1), 7580.
Ludwig F.M. (1998a) How routine facilitates wellbeing in older
women. Occupational Therapy International 4(3), 213228.
Ludwig F.M. (1998b) The unpacking of routine in older women. The
American journal of Occupational Therapy 52(3), 168175.
Mallett S., Rosenthal D., Myers P., Milburn N. & Rotheram-Borus
M.J. (2004) Practicing homelessness: a typology approach to
young people daily routines. Journal of Adolescence 27, 337349.
Markson S. & Fiese B.H. (2000) Family rituals as a protective factor
for children with asthma. Journal of Pediatric Psychology 25(7),
471479.
Meyer A. (1922) The philosophy of occupational worker. Archive of
Occupational Therapy 1, 111.
Monk T.H., Flaherty J.F., Frank E., Hoskinson K. & Kupfer D.J.
(1990) The Social Rhythm Metric. An instrument to quantify the
daily rhythms of life. Journal of Nervous and Mental Disease 178,
120126.
Monk T.H., Kupfer D.J., Frank E. & Ritenour A.M. (1991) The
Social Rhythm Metric (SRM): measuring daily social rhythms over
12 weeks. Psychiatry Research 36, 195207.
Ndiwane A., Miller K.H., Bonner A., Imperio K., Matzo M., McNeal
G. & Amertil N. & Feldman Z. (2004) Enhancing cultural
competencies of advanced practice nurses: health care challenges in
the twenty-first century. Journal of Cultural Diversity 11(3), 118
1121.
Oakley D., Yu M.Y., Zhang Y.M., Zhu X.L., Chen W.H. & Yao L.
(1999) Combining qualitative with quantitative approaches to
study contraceptive pill use. Journal of Womens Health 8(2), 249
257.

452

Olson K., Tom B., Hewitt J., Whittingham J., Buchanan L. & Ganton
G. (2002) Evolving routines: preventing fatigue associated with
lung and colorectal cancer. Qualitative Health Research 12(5),
65570.
Poole J.L. (2000) Habits in women with chronic disease: a pilot
study. The Occupational Therapy Journal of Research 20, S112
S118.
Quigley M.C. (1995) Impact of spinal cord injury on the life roles
of women. American Journal of Occupational Therapy 49(8),
780789.
Redfern S., Norman I., Briggs K. & Askham J. (2002) Care at home
for people with dementia: routines, control and care goals. Quality
in Ageing 3(4), 1223.
Reich J.W. & Williams W. (2003) Exploring the properties of habits
and routines in daily life. Occupational Therapy Journal of
Research 23(2), 4858
Reich J.W. & Zautra A.J. (1991) Analyzing the trait of routinization
in older adults. The International Journal of Aging and Human
Development 32(3), 161180.
Rodgers B.L. (1989) Concept analysis, and the development of nursing knowledge: the evolutionary cycle. Journal of Advanced
Nursing 14, 330335.
Rodgers B.L. (2000) Concept analysis: an evolutionary view. In
Concept Development in Nursing, 2nd edn (Rodgers B.L. & Knafl
K.A., eds), W.B. Sanders Co., Philadelphia, PA, pp. 77102.
Rogers J.C. & Holm M.B. (1991) Teaching older adults with
depression. Topics in Geriatric Rehabilitation 6, 2744.
Rogers J.C., Holm M.B., Burgio L.D., Granieri E., Hsu C., Hardin
J.M. & McDowell B.J. (1999) Improving morning care routines of
nursing home residents with dementia. Journal of American
Geriatric Society 47, 10491057.
Rowles G.D. (2000) Habituation and being in place. The Occupational Therapy Journal of Research 20, 52S67S.
Roy K.M., Tubbs C.Y. & Burton L.M. (2004) Dont have no time:
daily rhythms and the organization of time for low-income families. Family Relations 53, 168178.
Sanden I. & Hyden L. (2002) Howe everyday life is affected: an
interview study of relatives of men suffering from testicular cancer.
Journal of Psychosocial Oncology 20(2), 2744.
Schultz-Krohn W. (2004) The meaning of family routines in a
homeless shelter. American Journal of Occupational Therapy
58(5), 53142.
Segal R. (2004) Family routines and rituals: a context for occupational therapy interventions. American Journal of Occupational
Therapy 58(5), 499508.
Segal R. & Frank G. (1998) The extraordinary construction of ordinary experience: scheduling daily life in families with children
with attention deficit hyperactivity disorder. Scandinavian Journal
of Occupational Therapy 5(3), 141147.
Swartz D.L. (2002) The sociology of habit: the perspective of Pierre
Bourdieu. The Occupational Therapy Journal of Research 22, 61S
68S.
Takahashi L.M., Wiebe D. & Rodriguez R. (2001) Navigating the
timespace context of HIV and AIDS: daily routines and access to
care. Social Science and Medicine 53, 845863.
Trainor A. & Ezer H. (2000) Rebuilding life: the experience of living
with AIDS after facing imminent death. Qualitative Health
Research 10(5), 646660

 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd

JAN: THEORETICAL PAPER

Wagner G.J. & Ryan G.W. (2004) Relationship between routinization of daily behaviors and medication adherence in HIV-positive
drug users. AIDS Patient Care STDS 18(7), 385393.
Westfall U.E. (1992) Nursing chronotherapeutics: a conceptual
framework. Image Journal of Nursing Scholarship 24(4), 307
312.
Wheatley F. (2001) Strict patients routines can be abusive. Nursing
Time 97, 19.

A concept analysis of routine

Wiles J. (2003) Daily geographies of caregivers: mobility, routine,
scale. Social Science and Medicine 57(7), 13071325.
Wolf Z.R. (1988) Nurses Work: The Sacred and the Profane.
Pennsylvania Press, Philadelphia, PA.
Zisberg A. (2005) Influence of routine on functional status in elderly:
development and validation of an instrument to measure routine.
Unpublished PhD Dissertation, University of Washington, Seattle,
WA.

 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd

453