Abstract
The problem requiring a practice change was the low nurse retention at my clinical setting, the Abbott MidWestern Hospital. RNs at the orthopedic unit were overwhelmed with clinical responsibilities given that the facility serves patients with critical care needs, including those with COVID-19 symptoms. As a result, they were prone to exhaustion from working longer, demanding shifts, leading to a high turnover problem. A self-scheduling protocol was developed to improve autonomy, morale, and satisfaction by supporting a better work-life balance. Following the steps of the rubric, filled research approval forms were submitted before starting the project. The topic was narrowed down to improving nurse retention through a practice change in shift scheduling after consulting my preceptor. Key stakeholders with critical roles in the project were identified as the DON, orthopedic unit manager, and nurses. A comprehensive analysis of 30 sources identified through a literature search produced scientific evidence supporting the use of flexible scheduling by nurses. Best practices for implementing self-scheduling noted from the scientific findings included establishing a scheduling guideline or policy for work hour selection, vacation days, and shift exchanges to ensure fairness and meet unit-level acuity needs. However, due to the unique circumstances of the COVID-19 pandemic, accessing stakeholders was a problem. Therefore, an alternative clinical activity was done with the preceptor who reviewed the plan and provided support throughout the project. The project allowed for the integration of two MSN program outcomes: designing innovative nursing practices that impact quality and assembling scientific findings to inform practice. Introduction
Background
Nurse retention is a priority to Abbott NorthWestern Hospital 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 NorthWestern 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 for the Practice Change, Quality Improvement, or Innovation
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.
Review of the Literature
Credible Sources
The solution proposed to the nurse retention problem at ABH was implementing a self-scheduling protocol. This practice change had to be supported by relevant research evidence. Therefore, 30 sources from peer-reviewed sources were appraised and presented in a table (Appendix A). The articles supported the use of self-scheduling to improve morale and job satisfaction among nurses. Best practices in this area were also identified from the review of these sources.
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 retention (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.
Recommended Practice Change, Quality Improvement, or Innovation
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.
Implementation
Description of Steps
To develop a proposal for this research project, I followed the steps of the rubric. First, research approval forms were completed and returned to the school before commencing the project. Subsequently, periodic meetings with my preceptor helped develop and refine the change protocol to implement. The third step was identifying and describing a problem in my practice setting that needs to be addressed to improve patient care. I selected ABH’s high nurse turnover, as it was an area of concern for the facility. The background or cause identified for this problem was that perceived physical and mental demands of inflexible schedules impacted the nurses’ work-life balance, leading to high attrition.
The fourth step entailed identifying key stakeholders for the project that will collaborate in a shared governance model. The DON, orthopedic unit manager, and staff nurses and their respective roles in the project were described. Then, the proposed solution (a self-scheduling tool) to the high turnover problem was developed and explained. A comprehensive literature search of databases yielded 30 peer-reviewed articles that were reviewed to support this evidence-based intervention. Subsequently, the plan of action or timeline for project implementation was developed and presented in a table. Resources, including the personnel required to implement a self-scheduling system at the orthopedic unit, were identified. A change theory (PDSA) was then selected as an appropriate model to underpin the implementation of this solution. Key implementation barriers that must be addressed to promote change were recognized and described. Finally, the plan was shared with the preceptor for review and constructive feedback.
Discussion of Changes
No major changes were made to the original plan except the addition of a table of credible sources that was missing in the initial proposal submitted.
Discussion of Barriers
The main barrier to this project was COVID 19 because it was not possible to reach the stakeholders. Without a seamless access to the DON, orthopedic unit manager, and staff nurses to hold regular, in-person meetings, it was deemed difficult to maintain collaborative teamwork and dynamic communication. The unique circumstances of this pandemic demanded a shift from in-person activity to remote engagement. However, making the transition would not have been easy during the project, as it required in-person interactions with the stakeholders rather than videoconferencing.
Another barrier was the lack of preparedness to move the cross-functional team (stakeholders) to working remotely. All stakeholders needed to have competence in using virtual communication tools to complete this work. Additionally, cultural change, new norms, values were necessary to achieve effective collaboration under the COVID-19 health crisis. The high number of chronic care patients overstretched the health care resources, presenting a barrier to the implementation of a self-scheduling protocol. Scheduling changes were implemented at the unit, requiring nurses to work longer shifts to handle the surge in new infections.
Explanation of overcoming barriers
Given the unique circumstances of the current pandemic, it became necessary to adjust the proposed project in order to work through the crisis. The barriers above were overcame by doing an alternative clinical activity with my preceptor. This approach eliminated the need for in-person interactions with all stakeholders. Similarly, the challenge of limited virtual communication tools and overstretched health care resources were overcome through an alternative clinical activity. Guidance from the preceptor helped augment the clinical experience expected in this project.
Identification of Interprofessional Relationships
The relationships were not formed because I was in an alternative clinical experience with the preceptor. The stakeholders for this project (the DON, orthopedic unit manager, and staff nurses) could have helped foster effective interprofessional collaboration practices. A successful implementation of self-scheduling needed the active involvement of this team. Interprofessional relationships were critical to achieving the key outcomes of this project: improved retention, quality, and staff needs (manageable workloads, flexibility, and work-life balance).
Discussion of relationships. As mentioned above, for my capstone project, I completed a clinical activity supervised by the preceptor. Our personal and professional relationship evolved over the project period. Professionally, my preceptor became responsive to my identified learning needs. Working collaboratively, we set learning goals, which were crucial for me to achieve progress in clinical practice. She tailored her teaching to my learning objectives, ensuring that the content delivered was not overwhelming. On a daily basis, she provided clear, helpful feedback on assigned clinical tasks, helping me improve my abilities and grow in confidence and reflective thinking. She helped me overcome early difficulty, confusion, and uncertainty when I began the capstone project by being encouraging and empathetic.
Her mentorship and approach to teaching was foundational to the supportive relationship. She was welcoming, friendly, and viewed me positively during the training. As we developed more trust in each other, I could confide in her about clinical tasks that I found challenging and needed more help. We had conversations about my struggles in mastering each new skill and she advised me to change my attitude to obtain a good result. She was supportive during emotionally draining clinical experiences, which strengthened our relationship.
Post Capstone Project Considerations
Discussion of Successes
In spite of the barriers mentioned above, the capstone process had many successes. It provided a great opportunity for me to apply the knowledge I learnt in class to a practical project. I was able to develop a solution (a self-scheduling protocol) to a compelling problem of low nurse retention in ABH’s orthopedic unit. A notable success was refining and narrowing my topic to a specific idea rather than being global. Analyzing a broad issue would have it difficult to develop a solution to the problem that was clearly defined.
Another key success was identifying, summarizing, and synthesizing sources supporting my proposed solution. A capstone project usually seeks to implement a practice change or quality improvement intervention, and thus, it must be evidence-based. I applied the steps of translating research into clinical practice in searching and synthesizing scientific evidence. A critical appraisal of peer-reviewed articles (credible sources) was completed in a table to support self-scheduling and identify best practices. The analysis of 30 sources graded according to the quality or strength of evidence yielded objective findings supporting the intervention.
Another success was the effective collaboration with an external professional in a clinical setting. Working with the preceptor in the development and implementation of the project helped me acquire competency in interprofessional communication that is critical to promoting patient safety. A key milestone in the capstone process was the development of the final project report. It helped me learn the essentials of scientific writing, including defining a clinical issue clearly and substantiating claims using evidence.
How successes will inform future projects
I will use the same capstone process again to develop and implement clinical changes or quality improvement initiatives in practice. The key steps of identifying and contextualizing a problem, proposing a solution, and searching and synthesizing multiple sources of evidence to identify best practices can be applied in future evidence-based change projects. Collaboration with a preceptor will be crucial to the development and implementation of nursing interventions and effective interprofessional communication for improved outcomes.
Aspects that Did Not Go Well
Some aspects of the project did not go as well as anticipated. The COVID-19 regulations banning in-person meetings made it difficult to access the stakeholders of this project. As a result, an alternative clinical activity was completed with the preceptor. Had it not been for the pandemic, it would have been easier to reach staff and implement self-scheduling in the orthopedic unit. Another limitation was that no data on turnover rate were obtained from the HR department. As such, it was not possible to assess if the self-scheduling protocol could increase retention at the unit or not. In the initial plan, reduced turnover rate was to be used as a measure of the project’s success.
The COVID-19 pandemic led to a surge in patients requiring emergency care at the facility. The hospital’s capacity was stretched, which made it difficult to implement self-scheduling, which was targeting nurses involved in routine care. The result was high levels of fatigue after a highly demanding shift. Additionally, staffing changes that prioritized emergency care for COVID-19 patients during the health crisis hampered the implementation of the project as envisioned. Further, more evidence from health care organizations implementing self-scheduling, including turnover rates, should have been analyzed to support this project.
Understanding what did not go well
Some lessons learnt from the negative aspects or drawbacks encountered in the capstone project will inform future change initiatives. A web scheduler was an appropriate tool for enhancing the predictability and flexibility of shifts, even under unfavorable conditions such as the COVID-19 pandemic. It should have been piloted to assess its efficacy in improving autonomy and retention, assuming that all nurses at the unit followed the rules of self-scheduling. Further, the analysis of evidence from hospitals or networks that have implemented flexible schedules can help support effective implementation of future self-scheduling projects.
Explanation of How Gap was Bridged
The practice gap addressed through this project is the inappropriate staffing and scheduling at ABH’s orthopedic unit that results in a high turnover rate. Since the proposed self-scheduling protocol was not implemented, the gap will be bridged once ABH is ready to receive the developed solution, presumably after the COVID-19 pandemic has been controlled. Best practices identified from current evidence will help guide the implementation of this solution to improve nurse retention at the unit.
A successful self-scheduling protocol must consider unit-level demand and fluctuating staffing needs at different times. Thus, small units without complex acuity challenges at ABH are an ideal setting for implementing self-schedules before expanding to more busy settings. Further, nurses must follow rules or guidelines that promote fairness and justice to achieve success. The self-scheduling system adopted must be seen to be fair and impartial – workdays, off-days, and vacations should be distributed objectively based on need and acuity changes. A training can equip nurses with effective communication skills to negotiate shift exchanges and workdays. For ABH, the movement to self-scheduling must be based on the unit needs, workload, and available staff in each unit.
Supporting the Plan
The scope of this project was to implement an evidence-based solution (self-scheduling) to the problem of low retention at ABH’s orthopedic unit. It was a pilot phase to move all departments to a flexible scheduling system, with the additional services of shift exchanges and acuity adjustments. However, the project will need to be supported in the subsequent phases after a successful piloting at the orthopedic unit following the PDSA theory. In the short term, the plan will be presented to the organization and project stakeholders. The goal is to prepare them and obtain buy-in that will be needed to implement the project once the facility is ready to receive it.
Additional support and training will be needed for the long-term maintenance of the protocol. Further, for the self-scheduling tool to work or be maintained in the organization, a policy to be followed must be developed and communicated. This supportive guideline will ensure fair and impartial distribution of shifts, weekends, and holiday offs. If self-scheduling is going to be adopted in the entire organization, self-scheduling software or web scheduler will be needed to track compliance and ensure that RNs work their required hours weekly. Additionally, the system should include a payroll/time clock feature to determine the appropriate compensation for overtime work. The unit manager will promptly handle issues related to the rotation schedules, initial hour selection, and shift adjustments.
Resources for Post-Implementation
After the self-scheduling system is installed, nurses will be responsible for the initial hour selection and shift trading among themselves. The posting of schedules and scheduling requirements, including hours for each nurse, the staff needed per shift, and overtime policy will be the role of the unit manager. Any issues outside the routine use of the scheduling system will be directed to the IT team that includes database administrator. The individual can contact the developer for additional expertise and support to align the tool with the organization’s needs. Thus, additional network support will be needed after implementing self-scheduling in all departments.
Further, all units will require key resources to implement self-scheduling. A procedural guideline for scheduling will help managers achieve fair unit-specific schedules that do not compromise acuity needs. It will stipulate sign-up order, the procedure for approving vacations, and off-day requests. A staffing model developed using a shared governance model is another critical resource that will ensure units are adequately staffed at all times. The outcome measurement tools will also be required to determine user experience and utilization levels. Examples include a staff satisfaction survey to measure the nurses’ perception and support for the project.
Some resources required in the initial phase of this project will still be needed to sustain it. A budget for a 3-day mandatory training on the self-scheduling system for all nurses, including new hires, will be necessary to equip users with key skills to use the tool properly. Meeting rooms fitted with a projector and public address system will be required to conduct the workshop. Nurse educators and IT experts will deliver the education on using the system to participants. Additional resources required are applications such as Google Calendar and Facebook to support shift exchange interactions. Nurses will also need tablets or smartphones running these apps for offsite shift selection and hour trading and requests.
Reflection
Integration of MSN Program Outcomes
Among the most important lessons I learned from this capstone project is how to develop an evidence-based solution to a nursing problem within a practice setting. I was able to search and synthesize findings from 30 articles supporting self-scheduling as a practice change that improves nurse retention. Although the COVID-19 situation hampered the implementation of this proposal, the alternative clinical activity with my preceptor involved collaborative learning experiences that allowed for the integration of key WGU MSN program outcomes into practice.
Innovative nursing practices that impact quality outcomes
The project developed a creative solution to the nurse turnover problem in a clinical setting – the orthopedic unit. Current practices involve inflexible shift schedules that limit nurses from meeting their family or social obligations. As a result, they experience burnout, low morale, and job satisfaction, increasing their intention to leave the facility. An evidence-based practice change was developed to increase retention at the unit. A self-scheduling protocol, which has been shown to enhance autonomy and satisfaction, can reduce turnover intention and associated financial costs (Wynendaele et al., 2020). Additionally, the schedule flexibility achieved using this tool ameliorates the negative effect of workload and burnout, leading to safe, quality patient care.
Scientific findings assembled from nursing sciences
The project implemented an evidence-based practice change (self-scheduling) to improve nurse retention. A key part of the capstone process was assembling and synthesizing scientific findings from nursing journals to support the solution. Evidence from 30 current peer-reviewed sources was analyzed to identify best practices in self-scheduling. Thus, the analysis of relevant scientific findings can be used to inform a practice change or future nurse-led quality improvement initiatives.
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