Use scheduling rules to promote nurse health.

Takeaways:

• An organization’s scheduling practices are one of the most important factors in promoting nurse health.
• Standardizing and monitoring scheduling practices are essential for making improvements and preventing unhealthy patterns.

By Alvin D. Jeffery, PhD, RN; Cindy Borum, MSN, RN; and Jane Englebright, PhD, RN

Fatigue is common among shift-work nurses, and longer shifts and overtime are associated with increased patient errors and undesirable nurse health outcomes. Consistent with the American Nurses Association’s 2017 focus on the healthy nurse, one of the best ways for a workplace to promote nurse health is with its scheduling practices.

If we look to the aviation industry (as healthcare frequently does) to explore its scheduling practices, we find several regulations, including shift length limits based on when a shift begins in an attempt to be mindful of humans’ circadian rhythms. At our organization, we’ve created and implemented several rules and metrics to guide our scheduling practices. Our goal is to achieve a healthy schedule that ensures safe patient care and promotes nurse health.

Metrics and rules

When creating schedules, our organization focuses on three important factors:

1. unhealthy shift patterns
2. weekend assignments
3. employee preferences.

The frequency of an unhealthy scheduling practice is converted to a metric so we can review the healthiness of a given schedule. These metrics are translated to dashboards for comparison between units and over time. Each facility also can treat these as hard rules that don’t permit a particular scheduling configuration.

Unhealthy shift patterns

In our organization, we avoid these five scheduling practices that can lead to unnecessary fatigue:

1. working more than three consecutive 12-hour shifts, four consecutive 10-hour shifts, or five consecutive 8-hour shifts
2. rotating shifts (from days to nights or vice versa) within the same 24-hour period
3. with the exception of 12-hour shifts, rotating shifts with less than twice the number of hours of a standard shift in between (for example, working an 8-hour evening shift, resting for 8 hours overnight, and returning for an 8-hour day shift is considered unhealthy)
4. excessive consecutive hours (for example, a 16-hour double shift)
5. overtime.

Weekend assignments

This scheduling rule aligns with unit and organizational policies for weekend requirements. The goal is to prevent any employee from working fewer weekend shifts than other employees, which might lead to perceptions of unfair scheduling.

Employee preferences

Because we assume employee satisfaction is associated with scheduling requests and preferences, we assess the proportion of employee requests and preferences that are honored in a given schedule. Converting this metric into a rule and permitting all employees’ requests to be honored and still meet patient needs would be challenging. However, measuring the degree to which employee preferences aren’t being honored helps us understand how well a schedule meets employee needs.

Employee participation in scheduling

Using the objective criteria described above and accompanying mathematical formulas (which can be modified to meet any organization’s needs) allows for easy adoption into computerized scheduling programs that can be used in either manager-scheduled or self-scheduled frameworks.

Employee engagement in scheduling promotes structural empowerment and is an indicator of a healthy practice environment. In addition, sharing the workload of schedule creation with employees or scheduling centers can lead to healthier nurse managers. Delegating this time-consuming task may leave more time for managers to be present on the units.

Regardless of the degree to which managers and employees contribute to a unit’s schedule, rules offer structured guidance that ensure the healthiest possible schedule is developed.

The present and future of scheduling

Moving toward a rule-based system that keeps nurses healthy may help enhance work-life balance, improve quality of care, and decrease fatigue and accompanying errors. Workforce researchers should consider exploring the influence of both scheduling rules and total work demands (for example, nurses working in multiple organizations) on empirical changes in nurse and patient outcomes. Studying these associations is essential to developing policies and regulations that keep our nation’s nurses as healthy as possible.

Eliminating the negative effects of fatigue will require additional interventions, such as providing education to prevent fatigue, detecting fatigue, and creating systems that are fatigue-proof, but these may be significantly more challenging to implement and enforce. As the healthcare profession develops these holistic approaches to fatigue management, improved scheduling practices can be implemented immediately, making them the first step toward reducing patient errors and improving nurse health.

The authors work in the clinical services group at Hospital Corporation of America in Nashville, Tennessee. Alvin D. Jeffery is a nurse scientist, Cindy Borum is assistant vice president, and Jane Englebright is senior vice president and chief nurse executive.

Selected references

Agency for Healthcare Research and Quality. Fatigue, sleep deprivation, and patient safety. September 2016.

Bae SH, Fabry D. Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: Systematic literature review. Nurs Outlook. 2014;62(2):138-56.

Clavelle JT, O’Grady TP, Drenkard K. Structural empowerment and the nursing practice environment in Magnet® organizations. J Nurs Adm. 2013;43(11):566-73.

Gander PH. Evolving regulatory approaches for managing fatigue risk in transport operations. Rev Human Factors Ergon. 2015;10(1):253-71.

Gardner LA, Dubeck D. Health care worker fatigue. Am J Nurs. 2016; 116(8):58-62.

Tarpey RJ, Nelson MF. Schedule quality assessment metrics. Health Care Manag (Frederick). 2009;28(2):145-58.