Introduction
Low nurse retention is a challenge accounting for staff shortages at ABH. The purpose of this capstone project was to implement self-scheduling to reduce turnover. Its scope is limited to ABH’s orthopedic unit and the nursing staff. The turnover rate is high, at 20%, hence, an urgent issue (Wright et al., 2017). Complaints about heavy workloads, burnout, and growing job stress due to working longer shifts to cover surging COVID-19 patients are rising. Notably, shift scheduling is centralized, which excludes staff input and affects autonomy. It causes poor work-life balance, leading to a high turnover rate.
Description of Filled Gap
The gap addressed by this capstone project was ABH’s inflexible scheduling that impacts job satisfaction, leading to a high turnover intent. The self-scheduling protocol supports greater shift flexibility that is associated with improved morale and autonomy (Wright et al., 2017). Thus, it will address the root cause of low nurse retention – perceived loss of control over work hours. Additionally, self-schedules empower the nursing staff to achieve appropriate work-life balance. Nurses can perform their professional role optimally and meet their family or social obligations.
The practice gap (inflexible scheduling) will be bridged once ABH is ready to receive the solution. The self-scheduling protocol has not yet been implemented, as the COVID-19 situation limited access to stakeholders. However, best practices were identified through a review of current evidence. Small units without complex acuity challenges are an ideal setting for a pilot project (Wynendaele et al., 2020). Nurses must follow pre-established guidelines for sign-up order, vacation approval, and shift requests without affecting staffing needs. Further, communication training can help staff negotiate shift exchanges effectively.
Developing & Launching Process
In developing the proposal for the capstone project, I followed the steps outline in the rubric. First, I completed and returned research approval forms to the school before starting the clinical experience. Periodic meetings with my preceptor helped develop and plan the project activities. I then identified a practice problem that needed change or improvement in my clinical setting. Based on unit-level reports and personal observations, nurse retention was a challenge at the orthopedic unit. ABH also considered it an area of concern due to the cost implications of a high turnover.
The root cause of the high turnover problem at ABH was identified as inflexible scheduling. Relevant peer-reviewed evidence was reviewed to support the link between inflexible shift schedules on poor nursing outcomes, including burnout, inability to meet social engagements, and low satisfaction (Rizany et al., 2019). Given the physical and mental demands of clinical tasks, nurses need breaks in between shifts to recover from exhaustion. However, inflexible schedules limit this recovery and contribute to poor work-life balance due to long or consecutive shifts (Wynendaele et al., 2020). The outcome is low satisfaction and increased intent to leave the organization.
The next step involved identifying key stakeholders for the project at ABH. The director of nursing (DON), orthopedic unit manager, and staff nurses were considered people critical to the success of this practice change. Their respective roles and responsibilities in the capstone project were described. In brief, the DON is responsible for allocating funds and lobbying for buy-in from ABH’s management. The unit manager’s role is to teach nurses self-scheduling and enforce compliance. Nurses are the users of the self-scheduling protocol; they will input desired shifts, vacation days, and off-days based on the tool. Additionally, 30 peer-reviewed articles were reviewed to support the solution.
A plan of action or timeline for implementing the project was developed, with details of each planned activity. Subsequently, key resources required were identified; they included a budget for a 3-day workshop (user training), the personnel to train the nursing staff (unit manager and nurse educator), IT systems supporting Google calendar and Facebook, and personal smartphones or tablets running these applications. The PDSA theory was chosen to underpin the implementation of self-scheduling at the unit. Key implementation barriers were identified and described, and the plan was shared with the preceptor for a review.
Most Successful Aspects
Although there were some challenges, the capstone project had notable successes. First, it provided me an opportunity to apply theory into clinical practice. Second, I developed a solution (a self-scheduling protocol) to a problem – low nurse retention at ABH’s orthopedic unit. Third, I focused my project to a single issue that required change rather than being global. Personal observations and reports helped identify the root cause of the retention problem. A search and analysis of current evidence helped establish a causal relationship between inflexible schedules and low nurse retention.
Another notable success was identifying, summarizing, and synthesizing 30 sources supporting self-scheduling as a solution to the nurse turnover problem. This aspect ensured that the practice change proposed was evidence-based. A critical appraisal of peer-reviewed nursing articles was completed, including the evidence strength of each source. Effective collaboration in a clinical setting was another successful aspect of the capstone process. I was able to work collaboratively with my preceptor to complete an alternative clinical activity as required. Additionally, the final report was written and a multimedia presentation prepared to meet the capstone project requirements.
Successes Informing Future Projects
The capstone process is an opportunity to integrate knowledge in a clinical setting. The skills of inquiry can help develop and implement change that would result in improved patient care. Identifying and contextualizing a problem can be applied in any future project addressing an area that needs improvement or change. Gaps in practice can be identified through working with other professionals in one’s setting. Once the problem has been established, the next activity is reviewing relevant articles to define root causes and develop a solution consistent with the recommended practice change in the literature.
The key learning area of comprehensive literature review also applies to any practice change or quality improvement initiative. Current sources published in peer-reviewed nursing journals are analyzed to generate evidence supporting the project. Best practices identified from recommendations in the literature are incorporated into the practice change. Another aspect with implications for future projects is collaboration with the preceptor and other professionals in the clinical setting. Writing a report of the findings and making a presentation in a conference are key activities applicable in future projects.
Aspects that Did Not Go as Well
The self-scheduling protocol was intended to be implemented in ABH’s orthopedic unit. However, unforeseen circumstances related to the COVID-19 pandemic impeded this plan. Regulations introduced to curb infections discouraged in-person meetings, which made it difficult to access the stakeholders (the DON, unit manager, and staff nurses) for this project. Additionally, the planned pre-implementation training could not take place due to these restrictions. Nurses’ daily workloads multiplied during the pandemic; hence, ABH was not ready to adopt self-scheduling under these circumstances. As a result, an alternative clinical activity was completed with the preceptor.
Contrary to the initial plan, the metrics for evaluating the project’s success were not used. The pandemic affected access to baseline turnover data from the human resources department. Additionally, staffing changes were effected at the orthopedic unit, moving nurses to COVID-19 critical care wards. As a result, the project could not be implemented in this setting. Another unforeseen drawback was the lack of resources for training, as the facility had prioritized its pandemic response. Implementation timelines were altered to reflect the new clinical reality. Staff satisfaction surveys at baseline and after the project were not conducted for the same reasons.
Understanding to Inform Future Projects
Movement restrictions and banning of in-person meetings during a pandemic present an opportunity for future capstone projects to include a virtual component. This aspect will ensure that implementation is not disrupted or abandoned. Further, capstone projects seeking to reduce turnover should prioritize reducing workloads that impact morale and job satisfaction (Wynendaele et al., 2020). Flexible schedules are particularly appropriate in pandemic times to curb burnout among nurses. Piloting self-scheduling under situations of strained staffing will help promote compliance with shift selection guidelines. Future capstone projects should include an alternative clinical experience because certain risks may necessitate the abandoning of the initial plan.
In future projects, the constraint of accessing turnover data from the HR department can be overcome by providing the information in the hospital’s website. The attrition rate is a useful indicator of job satisfaction at baseline and after the project. A convenient sampling approach is ideal since staffing changes may affect the number of nurses accessible for the project. Before implementing the project, securing a budget for activities, such as staff training, is a priority. The entire capstone plan, including implementation timelines, should be adaptable to change. Web-based surveys as a part of project evaluation can help overcome the risks that limit in-person interactions.
Organization’s Plan
Before moving to project maintenance, ABH must first receive the self-scheduling protocol since it has not been implemented yet. The solution is designed for implementation in a clinical setting without complex acuity challenges, such as the orthopedic unit. The evaluation of its success will be based on increases in the post-implementation retention rate and job satisfaction from the baseline. Subsequently, self-scheduling will be implemented in all ABH’s departments and units.
The short-term plan for project maintenance after implementation centers on dissemination. The outcomes of the practice change (self-scheduling) at the orthopedic unit will be presented to stakeholders for action. An improvement in nurse retention and job satisfaction from the baseline will make a compelling business case for the wider adoption of self-scheduling at ABH. The results will be shared with the staff to communicate the need to act consistent with the PDSA model. Any concerns or misgivings will be addressed at this stage to avert resistance.
The long-term maintenance of the project will require additional support from the organization. Allocating funds for training nurses will enhance compliance and efficient use of the system. Additionally, developing and communicating a self-scheduling policy across all departments will accelerate cultural change. Flexible scheduling guidelines will be required to ensure fair and impartial distribution of shift hours, off-days, weekends, and holidays. Perceived unfairness would affect adherence and protocol utilization levels by nurses. Other key components needed for long-term maintenance of the plan are a web-scheduler that tracks compliance and a payroll/time feature to compensate RNs for overtime work.
Resources Needed
Adequate post-implementation support will be needed to ensure long-term viability of the project. Among the key resources needed are the personnel to operate the system. The staff nurses will be required to use the protocol to select preferred shifts and off-days. The unit manager is a key person involved in designing the shift selection policy and guidelines for overtime claims. On the other hand, the IT team will handle technical issues related to the system and educate staff on how to use the web-scheduler. A network support will be needed for on-site and off-site access to the tool to select or exchange shift hours.
A wider adoption of the protocol will need structural support resources. For example, a procedural guideline for fair self-scheduling should be adopted across all units. It should specify sign-up order, the procedure for vacation approval by the unit manager, and shift hour, day-off, and holiday selection. Another key resource is a staffing model that ensures the right skills mix at all times in individual units. Outcome measurement tools, such as survey instruments, will also be needed to assess user experience and job satisfaction.
Some resources needed in the initial phase of this project will still be useful in post-implementation support. For example, a budget for a 3-day training of nurses, including new ones, will be required to enhance staff capacity to use the protocol. Meeting rooms fitted with a projector will be needed to conduct the training. Regarding personnel, nurse educators and the IT team will train nurses how to use the system. Additional requirements include applications (Google Calendar & Facebook) for self-scheduling and interaction and tablets or smartphones running these apps.
MSN Outcomes
One MSN program outcome that was integrated into the capstone project is developing innovative nursing practices that impact quality outcomes. A creative, evidence-based solution (self-scheduling) to the problem of low nurse retention at ABH’s orthopedic unit was designed. It involved a change in the current practice of inflexible schedules that affect work-life balance, leading to burnout and low morale among nurses (Wynendaele et al., 2020). A dissatisfied nursing workforce is likely to leave a facility or quit the profession altogether. Self-scheduling enhances autonomy and can ameliorate the impact of heavy workloads on patient safety.
A second MSN program outcome integrated into the project is the assembly of scientific findings from nursing science to inform a practice change. In this respect, 30 articles published in peer-reviewed journals were appraised to identify support for the solution and relevant best practices. For example, self-scheduling must entail guidelines for fair or impartial shift and holiday selection (Al-Hinai et al., 2018). Further, a schedule manager is needed to address issues related to shift exchanges and maintain optimal staffing based on predicted acuity needs.
Conclusion
The problem addressed by this capstone project was the low nurse retention at ABH. A root cause identified for this issue included inflexible schedules that limit staff autonomy and increase workloads, leading to low morale and turnover intent. A self-scheduling protocol was designed to enhance the nurses’ control over their work time and increase work-life balance. It presented an evidence-based solution to the turnover problem at the facility.
References
Al-Hinai, N., Al-Yazidy, N., Al-Hooti, A., & Al-Shereiqi, E. (2018). A goal programming model for nurse scheduling at emergency department. Proceedings of the International Conference on Industrial Engineering and Operations Management, 99-103. Web.
Rizany, I., Hariyati, T. S., Afifah, E., & Rusdiyansyah, P. (2019). The impact of nurse scheduling management on nurses’ job satisfaction in army hospital: A cross-sectional research. SAGE Open, 9(2), 1-9. Web.
Wright, C., McCartt, P., Raines, D., & Oermann, M. H. (2017). Implementation and evaluation of self-scheduling in a hospital system. Journal for Nurses in Professional Development, 31(1), 19-24. Web.
Wynendaele, H., Gemmel, P., Pattyn, E., Myny, D., & Trybou, J. (2020). Systematic review: What is the impact of self-scheduling on the patient, nurse and organization?Journal of Advanced Nursing, 77(1), 47-82. Web.