Nurse retention is a priority to most hospitals in light of the persistent problem of nursing shortages. The goal is to retain sufficient staffing levels to deliver quality and safe patient care and avoid overstraining current RNs with work that may increase their intent to leave the organization. On the economic front, the turnover costs can hurt the fiscal health of a facility; loss of experienced bedside nurses can interrupt service delivery and affect quality. Thus, low staff retention is a major concern for healthcare practitioners.
Among the root causes of turnover is job dissatisfaction due to multiple environmental factors. The work environment itself can affect nurse retention, especially in conditions of overloads or inflexible shift schedules that deter RNs from attending to family or social engagements (Rizany et al., 2019). Additionally, mandatory overtime hours and long shifts may lead to burnout and the inability to achieve a work-life balance. RNs are working on a 12-hour shift, 40 hours weekly, are likely to become dissatisfied with their role and quit (Wynendaele et al., 2020). Therefore, reasonable workloads are a crucial consideration in nurse retention.
Limited empowerment is another critical factor affecting satisfaction among practicing nurses. Excluding RNs from key decisions about workloads is likely to elicit feelings of unfair treatment and low morale. On the contrary, including RNs in shared governance groups or policy committees can lead to a perception of support by the leadership, increasing their job satisfaction (Rizany et al., 2019). Limited control over working hours may have adverse effects on morale and retention. Flexible schedules may moderate the undesirable impact of shifts on work-life balance and general wellbeing. The implementation of a self-scheduling protocol may foster empowerment and greater involvement of RNs and create a better work-life balance that would reduce job dissatisfaction underlying low nurse retention at Abbott MidWestern Hospital (ABH).
Problem Statement
The issue requiring a practice change is nurse retention at ABH orthopedic unit. A new evidence-based self-scheduling protocol is developed to support greater autonomy in creating work schedules without affecting the acuity needs of the unit. ABH’s turnover rate is relatively high, at about 20%, making nurse retention an urgent issue (Wright et al., 2017). Maintaining work-life balance is challenging due to expectations of 24-hour service and long undesired shifts. At ABH, nurses intimate that they are sometimes overwhelmed with responsibilities that are demanding both physically and mentally. As the major acute care facility in Minneapolis, ABH attends to diverse patient populations with critical care needs, including those with COVID-19 symptoms. Therefore, the units are overstretched, and nurses are prone to burnout and job stress due to long shifts – a scenario that may account for the low retention rate.
Inappropriate staffing and scheduling that does not consider workloads are bound to affect staff morale and impact the quality of care. Inflexible schedules, work pressure, long shifts, and undesired shifts cause job dissatisfaction with significant ramifications for the organization’s financial health (Wynendaele et al., 2020). Increasing staff to ease workload pressure is a gradual process and may not be feasible given the nursing shortages. As a result, RNs at busy units, such as orthopedics, are forced to work harder (resulting in burnout) or reduce the time spent caring for a patient, which leads to a decline in quality.
The existing model in most ABH units is centralized scheduling; the nurse manager prepares and communicates weekly shifts to RNs. Staff input and shift preferences are rarely considered in this process. Additionally, the work hours are fixed, limiting the exchange of shifts between nurses based on need. As Son and Ham (2018) note, inflexible scheduling is a key predictor of low staff morale and job satisfaction. Thus, the failure to address RN’s need for flexibility and work-life balance is a significant factor contributing to low nurse retention at the facility.
Practice Change, Quality Improvement, or Innovation
The practice change proposed entails implementing self-scheduling to address job dissatisfaction and low morale among nurses at ABH’s orthopedic unit in order to reduce their intent to leave the facility. The unit manager will send a blank list (a self-scheduling software or web scheduler) to staff nurses and request each individual to sign up for preferred shift dates at least a month in advance. He or she will then review the draft schedule to ensure fairness and consistency with pre-established guidelines about weekends, holidays, and evening/night rotations.
Before implementation, a unit meeting will be held to explain the scheduling rules and prepare nurses for the transition. Flexibility will help accommodate changing acuity needs of the unit. The system will be linked to the Google calendar app to enable nurses to receive reminders or update the schedule after shift exchanges. The web scheduler will allow staff to view and post requests for a shift change. Any agreement to exchange work hours by staff nurses must be followed by notifying the unit manager to ensure a balanced daily schedule. RNs will be free to work overtime depending on patient acuity needs. An additional component is a Facebook page that will allow nurses to post requests and contact a colleague individually before trading shifts. This aspect will also promote professional communication and interaction among RNs. The self-scheduling protocol is intended to eliminate undesired shifts and reduce workloads that impact staff morale, increasing turnover intent.
Rationale
The self-scheduling concept is not new; hospitals have successfully implemented flexible work arrangements before to boost morale and reduce turnover. Schedule flexibility, which gives nurses autonomy over work hours, can ameliorate the negative impact of workload on work-life balance and burnout (Wynendaele et al., 2020). Therefore, the project will address the structural root causes of job dissatisfaction that account for low nurse retention: limited empowerment, perceived loss of control over personal and professional life, and inflexible schedules.
The project aims to address the strain on RNs by implementing a self-scheduling protocol to cater for flexibility in work hours and achieve greater autonomy and satisfaction. Under this model, RNs can exchange shifts on a voluntary basis provided that they notify the unit manager about the changes for him/her to reorganize the schedules. This project is intended to address this gap so that both unit and coworker needs are accommodated. The nursing staff will feel empowered by introducing an element of flexibility. This scenario is likely to lead to a satisfied workforce because of perceived control over work time, contributing to nursing retention.
Best Practices
Based on the literature review, if implemented correctly, self-scheduling can increase job satisfaction, which is a key factor in improving nurse retention. Various strategies for self-scheduling exist that maximize RNs’ shift, a day off, and vacation preferences without compromising unit acuity needs and patient volume fluctuations. In general, the process is organized into distinct phases completed manually or with the help of IT tools. First, scheduling guidelines are established for staff to use when inputting preferred shift dates, day-offs, and vacation days (Wynendaele et al., 2020). In this stage, other RNs cannot see a colleague’s schedule; hence, a nurse is free to consider individual choices. Second, individual schedules sent to the unit manager are integrated to determine shortages or surpluses and balance workloads based on projected staffing needs (Mischek & Musliu, 2019). A core component of this process is the negotiation between coworkers in exchanging shifts. If there is no consensus, a shared governance committee can sit and make adjustments (Rizany et al., 2019). The unit manager who acts as the facilitator in self-scheduling then approves the final schedule for use.
Evidence Summary
The studies reviewed to emphasize the link between self-scheduling and job satisfaction – a positive staff-related outcome (Rizany et al., 2019; Wynendaele et al., 2020). Thus, self-scheduling could be an effective intervention for retaining nurses. It ameliorates the effects of heavy workloads on work-life balance, nurse wellbeing, and stress (Lee & Kang, 2018). Self-scheduling also facilitates flexibility, greater control over work hours, and autonomy, aspects that are associated with increased job satisfaction and low turnover intent (Gifkins et al., 2017). The process also enhances a nurse’s influence on shift duration and date, which may not be possible under fixed scheduling (Son & Ham, 2018). Self-scheduling also fosters recovery from fatigue before it can become acute and increases access to exercise and family support that ameliorate work-related stress (Giftkins et al., 2020). All these aspects suggest that implementing self-scheduling could improve retention because of its effect on satisfaction and wellbeing. However, to achieve these benefits, shift, holiday, and day off preferences must be balanced manually or using algorithms to promote fair assignment (Rerkjirattikal et al., 2020). The approach will also ensure that unit needs are accommodated in the plans without overwhelming current staff.
Recommendation
A successful implementation of self-scheduling is dependent on unit-level demand or staffing needs, which is often difficult to predict. Therefore, the protocol should be implemented in small wards that do not involve complex acuity challenges. Additionally, fairness or justice must be achieved through adjustments to the schedules submitted by nurses to balance between highly demanded and less popular shift days. The system must be perceived as fair and impartial; therefore, equal distribution of work hours, off-days, and vacations is recommended for this project. A training to build communication skills is also suggested to help RNs negotiate shift exchanges and understand the scheduling problem. The self-scheduling guidelines should also be made available, and a shared governance committee involved in implementation to manage staff attitudes. An assessment of unit needs and workload is also recommended before transitioning into self-scheduling to cater to acuity needs.
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