INTERNSHIP FINAL PROJECT REPORT

Analysis of the Cyclical Nature of Nurse Scheduling

And Possible Solutions

Johnny White

Western Kentucky University

Abstract

Throughout my internship experience, the one particular area that I took most interest in was nursing. I had no idea how difficult and how many elements these nurses face on a daily basis which help to contribute to nurse burnout and turnover. One of the biggest issues I heard over and over again was the issue of scheduling and how this has a detrimental effect on the overall work force moral, leading to unnecessary turnover and loss of valuable employees. My goal of this paper is to investigate certain rostering methods that can be applied, not just specifically to XYZ Hospital, but to a nation who is experiencing a workforce of nurses who are experiencing greater job dissatisfaction and the issues that are associated with these problems. Several models are discussed and settle upon one certain model which I feel has the ability to help alleviate some of these problems, if not fix them for good. My experience here at XYZ Hospital has been amazing, and through my research I hope to present a valuable project which can be considered to help the staff here and maybe make the relevant leadership at least look into what I have discovered.

Analysis of the Cyclical Nature of Nurse Scheduling

And Possible Solutions

Nurse staffing has presented many challenges for healthcare executives today and has contributed to a list of major issues and problems. With an increasing population of elderly individuals the current outlook on nurse census is high. So high in fact that there is a concern that the growth in nurse workforce will not be able to keep up with the predicted growth in patient needs (Garrett, 2008). It is estimated that there is going to be at least a 40% increase in the demand for medical services with an aging Baby Boomer population, while the total nursing workforce continues to grow at a steady rate of 6% (Seago, Williamson, & Atwood, 2006). With these statistics it is clear to see that there is going to be a need for an efficient staffing method which can help to overcome such drastic numbers.

Introduction and Summary

Today there is a strong need to help solve many of the issues associated with being a nurse such as; nurse burnout, high turnover rates, nurse retention issues, and more. Many of these issues stem from the scheduling and issuance of work hours which may not be ideal for each and every nurse. Staffing in a healthcare environment presents many challenges because there is no clear way to interpret what each and every daily census is going to be (Smith & Wiggins, 2007). What this means is that each day is entirely different in terms of patient needs and patient severity that you cannot simply come up with a model that easily solves this problem. What this has led to is a system that allows for undue overtime and exhausted nurses who experience severe burnout and fatigue (Garrett, 2008). These two factors alone can have dramatic influences on the patient experience and the overall patient care outcome which are affected in a negative way.

Throughout this paper I am going to describe the cyclical nature of nurse staffing according to various census’ and how understaffing during a specific season can have serious consequences for the health provider and their teams in the long term. There are several models that I will discuss in which individuals have tested and studied and suggestions as which models work best and which don’t. Many of the issues being discussed throughout this paper can cost health organizations enormous amounts of money; however, with proper guidance, thought, and action can solve many of the issues and hopefully save the organization a lot of money.

Literature Review

In healthcare there is a huge initiative and concern when it comes to employee satisfaction and employee retention. One of the reasons suggested through research on why employee retention, particularly nurse retention, may be a problem is associated with fatigue and a general feeling of being over worked and under slept (Seago, Williamson, & Atwood, 2006). There is no area where this is a greater threat than in the nursing area. There is evidence to suggest that nurse fatigue is a major issue and can have drastic problems when it comes to the overall care of patients and meeting their every need. Nurse fatigue can be a huge contributor to medical errors and patient dissatisfaction, which in our new day in age with the Affordable Care Act and an increase focus on quality healthcare, can have further negative implications on the reimbursement rates that hospitals receive for their services that they provide (Rogers, Hwang, Scott, Aiken, & Dinges, 2004).

There has been an increase focus on the use of managed care throughout the healthcare world, particularly in the United States, where managers and administrators are encouraged to save money throughout the organization. One of the ways this is being done is by cutting down on the number of nurses who are employed by the hospital. This leads to a greater number of nurses who are subjected to undue overtime and the issues that are associated with long hours of work with no rest, such as fatigue and the problems that it can carry for the patient. For example, in 2006 there was a report of nurse who was working in hospital setting in Wisconsin.

It is stated that the nurse worked two 8 hour shifts back to back with only a minor period designated for rest time. During her two shifts she accidentally gave a patient under her care the wrong medication which, unfortunately, resulted in the death of the patient. This brought about a number of lawsuits which cost the hospital money and a three year suspension of the nurse on all critical care units. The reason for the mishap is reportedly attributed to a general fatigue of the nurse involved (Garrett, 2008). So as you can see it is very important for administrators to properly and adequately staff their wards to avoid such problems.

Due to financial reasons and in the interest of cutting costs for the hospital, administrators have taken a cyclical approach to solving the staffing issues of nurses. Throughout the course of the year there are times where the census historically is low and nurse ratios can be decreased in order to save money. However, as previously stated, there is no sure way to really forecast just how much staff you are going to need on any particular day. This cyclical nature of nurse staffing has led many healthcare leaders to really question the overall model of nurse staffing. There are several methods that try and overcome this scenario and below I am going to outline several proposed ideas, including the cyclical staffing model, which attempt to alleviate many of the issues experienced with nurse staffing and the problems that it carries with it.

Cyclical Staffing

Cyclical staffing is a method that many healthcare environments, particularly in the healthcare environment have chosen as the best method of cost savings. In essence what happens is that there is a certain census for every part of the year where nursing ratios can remain lower than normal due to the forecasted projection that there is going to be fewer instances of patients checking into an inpatient setting (Smith & Wiggins, 2007). These months primarily coincide with warmer months of spring and summer where there are historically lower amounts of individuals who become infected with viral diseases such as the flu and pneumonia. The problem with this though, as stated previously, is that there is simply no sure fire way to know exactly what a census of nursing needs is going to be on a particular day.

Throughout my internship experience and in discussions with the hospital’s CNO there seems to be a similar trend that is occurring throughout the nation in various medical settings. During the lower census months there is a perceived need for a fewer amount of nurses than in months that are associated with higher sickness months, such as winter months. These nurses are not scheduled as heavily and the process of hiring new nurses for those that have elected to move on is often times in the back of people minds and not really given much concern. The winter months then come around and the hospital finds that they are in need of more nurses and the census is up. The problem here is that now that a hospital is in these busier months there is obviously a lot more attention that is going to be paid to the patient and there is a lack of staff which is able to train and monitor the new hires. These nurses who have been on staff the entire time are left to deal with their own patients as well train the newly hired nurses.

These nurses who are now responsible for patient care as well as training new hires can experience a severe burden and a feeling of being overworked (Cheang, Li, & Lim, 2003). This in turn leads to a lower job satisfaction, fatigue, and therefore in some cases the nurse will look for a job elsewhere increasing the turnover rate as well as increasing the need to hire an additional nurse to fill the void left by an experienced, valued nurse. This is a vicious cycle and has become the unfortunate norm for most health care facilities. An area, or a model, which has tried to combat these issues is based on the cyclical scheduling model which attempts to set a schedule in stone over a period of time, and can be extended out for as long as possible. What this model attempts to portray is a sense of normalcy and a reliable schedule that is not changing on a weekly or bi-weekly basis (Brusco & Showalter, 1993).

In nursing where work weeks generally consist of 3 to 4 days of work with the remainder of week days off, it is a popular request to have weekends off of two or more consecutive days off in a row. What the cyclical model does is rotates the staff in a set schedule where each individual nurse gets these desired weekends or blocks of days off in a row throughout the cycle of the schedule (Bard & Purnomo, 2007). Of course, there are always times where personal issues arise and therefore a nurse must request off work for personal days, these issues are handled like they generally are where the nurse on call has to come in and pick up for them, earning overtime. But again the problem arises because there is no way of predicting long term what a certain census is going to be which always presents challenges for the managers and staff members charged with the duties of setting schedules.

This method is a simple concept and attempts to solve the issue of nurse staffing, however, I feel that there are better ways to combat these issues through the use of several models and the combination of two or models could present itself to be the most convenient method to account for every individual nurse’s needs. And because of this, cyclical nurse scheduling can be effective more covering the needs of the hospital, but is highly ineffective in accounting for the personal issues that so often arise in nurse staffing.

Self-Scheduling

Self-scheduling is discussed throughout the research as one of the most desired approaches to nurse scheduling. This is due to the fact that it allows the most leniencies for the nurses to really decide and cooperate among themselves. This model is said to provide the nursing staff with the greatest benefit because they can come together and decide amongst them and negotiate which shifts they want and which ones they want to give away (Berrada, Ferland, & Michelon, 1996). However, as stated previously there are always going to be shifts that no one particularly likes or wants and can have an effect on the overall effectiveness of the schedule itself.

The nurses need to come together and decide for themselves which shifts they want to work and the schedule must then be looked over by their supervisor or director. The director then from there looks at the needs of the hospital and will make changes accordingly. This method allows for employee empowerment and therefore in turn leads to a greater satisfaction with their job. This is a very important aspect in health care today as employees need to feel like they have the power to make certain decisions, and although this is a minor decision, it has to ability to make all the difference. This in turn will lead to a lower nurse turnover rate and greater ability to do the necessary duties associated with the patient’s care they are responsible for (Rogers, Hwang, Scott, Aiken, & Dinges, 2004).

Self-scheduling in nursing environment is not new to the healthcare world, there have been countless studies on the effects of nurse staffing and how it can affect the cyclical nature of nurse turnover and retention. As stated above there are many reasons to engage in a self-scheduling program. What was interesting about a study done by MIT department of health was the finding that this method of self-scheduling gave the nursing staff a perceived perception that they were getting more quality time to spend with their families and friends outside of work, and attributed it to the fact that they were engaged in actively setting their own schedules. This in turn led to a greater quality in life for many of the nurses which meant that they have a greater job satisfaction.

As healthcare and healthcare companies are moving more towards Value Based Purchasing models where patients are beginning to become more like customers, where they have a choice, having nurses who enjoy their jobs and can appreciate their time off, will in turn have a greater satisfaction in terms of job life. This has all types of positive ramifications which can lead to greater patient care and therefore, lead to greater reimbursement rates in terms of Value Based Purchasing.

Self-scheduling also gave the nurses in the study a greater sense of empowerment and a greater sense of teamwork amongst themselves. In an environment where nurses typically work the same floors and usually do not float around to different departments, team work usually forms which in turn has a huge positive effect on the patient care element. Self-scheduling enables the use of team work and cooperation to further this process and work together more closely on a personal level (Bard & Purnomo, 2007). Nurses will begin to get involved in each-others personal lives in requesting to work and not work on certain days for certain matters which will drive the personal element of a team to new levels.

Another interesting discovery during the study was the fact that nurse request for days off decreased dramatically within the first two months. Simply decreasing the amounts of requested days off may seem like a simple and irrelevant statistic but simply having a smoother schedule where department directors do not have to worry about filling certain shifts and covering nurse’s shifts for specific requests off allows for a smoother work environment. Again, all of these staffing issues are based around the fact they improve patient care, and in today’s world of healthcare there is no place for patient care that does not live up to the standards that the patients have come to expect.

Team Scheduling

Team scheduling is the last method that is going to be explored and again presents its own challenges and benefits, just like the other methods mentioned in terms of nurse scheduling and staffing. The idea of team scheduling has been explored through various studies and has come back with mixed reviews. What this model attempts to do is to solve many of the problems faced by the cyclical scheduling model and the self-scheduling model by addressing the two main issues of each model. Team scheduling assigns nurses of say ten to certain team and each week, or however long the leader is determined to be a leader, holds the responsibility of collaborating with the nurses on their specific team and setting the roster based on the feedback from their team members (Rogers, Hwang, Scott, Aiken, & Dinges, 2004). The team leader then schedules the nurses accordingly. What this method attempts to dissuade is the impersonal nature of the cyclical staffing model where any small personal matter can cause the need for a request or cause an unhappy nurse if they do not get their requested day off.

Through communicating with their team members the team leader can accurately get a picture of the nurses in their team’s personal needs and preferences and create a more cohesive environment for the nurses to work in. However, just like directors experience in the cyclical model, team leaders can be exposed to a sense of bias amongst their team members. However, because of the nature of the team leader model, where the leader is only the scheduler for a certain amount of time, can help to alleviate the feeling of bias towards certain members of the team in terms of getting their requested days off.

Giving a team leader the authority to make the schedule according to how they see fit, they avoid the issues associated with the self-scheduling model where certain shifts will remain uncovered. This can cause some of the inflexible issues that come with the cyclical model, but there is a sense of teamwork associated with this team leader model that encourages the nurses to overcome their issues with certain shifts, knowing that eventually they will be the team leader and given the authority to schedule at a certain point in time (Bard & Purnomo, 2007). Overall, this method allows for the greatest flexibility among the nurses and still creates an environment of teamwork while simultaneously covering the schedule in an appropriate manner.

Discussion

Throughout my time here at XYZ Hospital I have heard numerous times the issues that are associated with nurse scheduling and how this issue can have a huge impact on nurse turnover and nurse retention which has a major effect on the hospitals bottom line. Through my research on this issue and the interest that this fostered in my, I hope to expose various nurse scheduling process that can help to alleviate some of the problems experienced, not just by nurses in this specific hospital, but nurses across the nation. There is no substitute for a quality nurse who has gained experience with a single entity through strong dedication and loyalty. Through the use of a combined structure which takes a team scheduling model, I feel many of the issues I have come into contact with in speaking with the nurses can be reduced if not completely wiped out, making a much happier nursing staff.

Nurse satisfaction plays a major role on the overall outcome and patient satisfaction. In healthcare, with a reimbursement model that is continuing to favor a quality experience where patient satisfaction is one of the biggest measures in calculating reimbursement, it cannot be expressed enough how important it is to have a happy staff, particularly a happy nursing staff. There are several ways in which we have explored on how to do this, and each one has its own benefits and drawbacks. Nurse scheduling has been pinpointed by many as the root cause of nurse burnout and in turn creates a vicious work environment which allows for many nurse errors to occur which could be severely detrimental to the overall outcome and safety of the patients under their care.

Coming up with an efficient manner in which to schedule your nurses has been a focus for many years in terms of trying to retain quality nurses while simultaneously improving the patient experience. Because of this nature of burnout and unacceptable work conditions, where nurses sometimes work double shifts back to back and experience severe fatigue, leading to high a turnover rate which is not easily combatted. Models have been developed through research and several have been discussed in this paper. It would appear that there are two models that are more efficient than the one, that one being cyclical model. The cyclical model is ideal, however it doesn’t account for the personal side of staff and their team. There are many drawbacks in terms of accounting for unexpected days off and personal issues that may arise.

The self-scheduling and team leader scheduling models can account for the personal nature of a work-life routine, with the team leader model exhibiting the greatest potential for covering all issues that may be associated with a nurse staffing model. This allows for the greatest empowerment among the team leaders, who collaborate with their team members and come up with a schedule that attempts to tailor the various needs of every member of the staff. Self-scheduling attempts to accomplish the same goals, however, leaves variations when it comes to unfavorable shifts and acquiring the proper personnel to cover those unfavorable shifts. What was interesting though was the amount of team works that self-scheduling promoted and how that could lead to greater patient turnouts in the long run.

Conclusion

As we have learned through this paper and through my research, acquiring and maintaining a happy and satisfied staff can pay off hugely in term of patient satisfaction and patient turnout. Not only does this affect the hospitals reimbursement rates in terms of Value Based Purchasing, it also increases your employee retention rate which ultimately saves the hospital millions of dollars in training and orienting the staff properly to make up for the lost staff. There is no measurable amount to account for retaining quality staff and resolving nursing scheduling is one step in that direction.

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