Scheduling

The shift, or typical pattern of time worked, is an important factor in scheduling. Some areas of care use multiple types of shifts, whereas others have only one type. Typical shifts are 8, 10, and 12 hours in length. More and more hospitals are using 12-hour shifts, and some schools of nursing are using 12-hour clinical rotations for students. Staff members often prefer the 12-hour shift because it allows for more days off (40 hours can add up quickly). However, there has been concern about 12-hour shifts and the resulting fatigue level that may lead to more errors and staff stress (ANA, 2023b); Bell et al., 2023; Battle & Temblett, 2018; Dempsey, 2016; Trinkoff et al., 2011; Geiger-Brown & Trinkoff, 2010; Montgomery & Geiger-Brown, 2010; IOM, 2004).

Trinkoff and colleagues (2011) examined the independent effect of work schedules on patient care outcomes. Their study examined patient mortality when staffing levels and hospital characteristics were controlled. Other concerns are increased risk of infections among staff who are fatigued and ergonomic stressors, accidents that result from driving home tired, and responsibilities at home that further increase nurses' fatigue (Geiger-Brown & Trinkoff, 2010). More research needs to be done to determine the impact of shifts on fatigue and errors and methods to reduce these problems.

Split shifts are used to provide more staff at busy times of the day (such as 7:00-11:00 a.m. or later in the day). Part-time staff usually fill in during split shifts, and this has implications for consistency of care and quality with increased risk of errors.

The staffing issues such as the following can cause problems for staff. Because staff usually do not get off on time, longer shifts can compound the problems associated with 12-hour shifts. For example, when staff work 10- or 12-hour shifts instead of eight-hour shifts, staying one hour past the end of their shifts can be very difficult. This is a frequent occurrence because some staff may be arriving late or not coming at all, and temporary coverage is needed until additional staff coverage is found. This makes a 10- or 12-hour shift much longer. In some HCOs, staff are required to rotate shifts so that they may switch back and forth from the day shift to the night shift. This can be hard for many nurses, although some like to work the night shift.

Scheduling is not easy and may cause conflict among staff. Nurses invariably want more say about scheduling. Some organizations use computerized request systems so that staff can input their special staffing requests, and others do this in writing or orally. When the staffing schedule is announced/shared is also of concern because staff need to make their personal plans. The procedures for schedule changes need to be known by all staff. The trend is for HCOs to develop staffing schedules centrally, although some may do it unit by unit. In addition, a non-nurse scheduler may actually develop the schedule. This model has disadvantages because it may leave out or limit important input from nurse managers. Staff can get very frustrated with issues around the schedule. Scheduling must consider patient needs; staff competencies; individual staff issues such as days off, vacation time, sick leave, and so on; organization needs; legislative and regulation requirements; union requirements; shortage concerns; use of external sources for staff (for example, agencies); standards; and rising labor costs.

Patient classification systems may be used to assist in determining staffing levels. These computerized systems are used to identify and quantify patient needs, which can then be matched with staffing level and mix. It is thought that these systems are more objective because data related to patients and their needs are used to determine the number and type of staff required per shift.

Some HCO or patient care/clinical units use self-scheduling. With this system, guidelines are developed for the schedule. Staff members are then given a certain amount of time to fill in the schedule based on the guidelines. Individual staff members need to consider the schedules that other staff members have already posted. When the designated time period is completed, the nurse manager (or a staff member who is responsible for completing the schedule) reviews it and makes any required changes or additions to ensure that staffing is adequate. This type of scheduling allows staff to feel more in control of the staffing and to work with one another to come up with the most effective arrangement. It also reduces the time that the nurse manager or another scheduler might spend on staffing. More staff input and control over staffing usually results in greater staff satisfaction and less absenteeism, which leads to greater staff empowerment.

The schedule inevitably has holes-positions on the schedule for which there is no staff member assigned. What does the HCO do? One method HCOs use to fill staff needs in the schedule is to develop a float pool. This is a group of staff (RNs, LPNs, or APs) who may be moved from unit to unit based on need. These staff members need to be competent in the relevant area of care, flexible, and able to quickly adjust to new environments. Float pool staff are HCO employees who are not assigned to a specific unit. Staff members who float need orientation and training related to the types of care that they are expected to provide.

When nursing shortages become a serious problem, hospitals increase the number of staff who are not permanent employees of the HCO but, rather, temporary employees. Agency nurses are nurses hired by a nursing agency; the agency then contracts with an HCO for specific types of staff to meet schedule requirements. Some hospitals contract with one supplemental staffing agency, whereas others contract with multiple agencies to meet their staffing needs and pay the agency for their services. An agency nurse is paid by the agency (typically more than regular HCO staff), must be licensed, and should meet employee competency qualifications or any other criteria required by the HCO. Work assignments can be for one shift, for several days, or for weeks or months.

Another method for responding to incomplete schedules or lack of staff to fill all positions needed is the use of travelers. Travelers are nurses who work for an staffing agency but not a local agency. The HCO contracts and pays this agency to find nurses to meet their needs. The nurses are hired by the agency and then assigned to work at an HCO for a block of time (more than a few days and often several months or longer). The nurse may come from anywhere in the United States. The agency pays the nurse's salary, which is usually at a high level, and benefits, and often moving, travel, and housing expenses are covered by the HCOs that use the travelers. Nurses can decline a specific assignment, and moving is required. Nurses might even be assigned a management position. Nurses who are employees of the HCO are often concerned about the pay difference; traveling nurses, as well as regular agency nurses, typically earn much more than the full-time employees, which can cause conflict. Travelers must meet the requirements to practice in the state and the HCO requirements.

All of these nurses need orientation and should not be expected to just “get to work.” It is not easy to change from one HCO to another because HCOs are not all the same. The nurse must learn quickly to work with a new team. More experienced nurses are better at making this transition, and most of the traveling nurse agencies hire only experienced nurses. Although the fluctuations in the nursing shortage have decreased in some areas, shortages go up and down, for example, when more nurses retire, there will be greater need again to use alternative staffing strategies. This was also experienced during the COVID-19 pandemic with staff leaving positions, staff illness, patients requiring more staff time, and so on.