My professional journey as a nurse was shaped by the unexpected. When I entered practice and was asked a standard interview question, "Where do you see yourself in five years?" I confidently answered, "as an ICU nurse."
When I first started practicing as a nurse, my plan was to work on a step-down unit to gain experience and then move to the ICU. Plans changed six months into my practice when I became a charge nurse. The new role sparked my interest to learn how hospital systems worked (or didn’t work) together. Five years later, I became a nurse manager of the 27-bed step-down unit, fresh with my newly earned master’s degree in hand. This was the same unit where I started my practice as a new grad.
Management was new territory, and I was excited and scared at the same time. As I learned the role, one area consumed my thoughts: nurse staffing and scheduling. I spent hours building a schedule, and yet, even with all my efforts, the outcomes seemed futile. I was taught “this is how it has been,” often scheduling to midnight census or to hours per patient days (HPPD). Using these models, my unit experienced frustrating over- or under-staffing. Still hungry for professional growth, I found a position that allowed me to explore alternative approaches to staffing. I moved to become a system leader for eight hospitals tasked with transforming staffing and scheduling operations, paired with technology implementation.
Once again, I was simultaneously terrified and inspired. I stepped forward into the unknown and ultimately developed my passion and life's work. During this career change, I also started my doctoral journey and focused my project on innovative solutions for nurse staffing and scheduling. I discovered there was a significant gap, with research-based analytical models rarely making it into practice. After learning about optimization models, linear regression and predictive techniques, I built a predictive model for nurse scheduling to be used by nurse managers. Testing the model in practice demonstrated successful outcomes. Currently, I am leading and designing staffing and scheduling transformation for an even larger health system, seeking to challenge the status quo and fiercely holding to the mantra that nothing is impossible.
Following is a description of how we implemented new staffing and scheduling technology, operational models and policies at the two health systems where I have worked as a nurse leader.
Legacy Health System: Leveraging Technology to Redesign Staffing and Scheduling
Legacy Health System is an integrated health system spanning two states, with eight hospitals and 4,200 nurses. In 2015, we kicked off a new initiative: the redesign of nurse staffing and scheduling with new technology implementation. The system CNO held a four-day Lean 3P (production, preparation and process) event in which 75 people re-envisioned the work. The event set the tone for the project, particularly the involvement of front-line leaders and staff. After the event, staff engagement was involved every step of the way. Key elements included:
- A 30-member work group (including front-line nurses) to select the technology
- A system-wide shared governance model
- A Rapid Process Improvement event with 45 leaders and front-line nurses to build new system staffing and scheduling policies
- A dedicated pilot phase with a communication and feedback loop
The project was implemented with a wave approach, with four waves to allow for training, discoveries, build and rollout support. The central team was nimble and worked to adapt to each wave of feedback. In total, 126 inpatient nursing units and 5,000 team members were moved to a new staffing and scheduling system, along with an “open shift” text message platform.
The initiative required engagement and dedication from the nurse leadership team at every level. The change also required a shift in mindsets for front-line leaders as they engaged with the new technology, policies and central model for recruitment and scheduling. Centralized recruitment was a game-changer.
New technology allowed for the central staffing team to recruit for open shifts and reach a broad group with one text message. This feature integrated with the schedule – replacing single phone calls, one-off emails and blind group text messages. Key accomplishments and achievements from the initiative included building a healthy work environment through improved staffing resources and the reduction of staffing agency spend.
What I was most proud of in this work was the change we saw in front-line nurses’ perceptions of staffing in their work environments. Nurses rated staffing as more adequate in 2018, with 74% of the units using the new system’s ratings above the national average. That was a significant achievement, considering 2017 was the year of implementation and there were many changes to adjust to. Additionally, the system experienced a year-over-year reduction of agency spending from 2017 to 2019, another successful outcome in stabilizing and creating a healthy work environment.
Bon Secours Mercy Health: A Centralized Model to Support Nurse Leaders
Bon Secours Mercy Health is an integrated health system spanning seven states with 60,000 employees. There are a total of 10 operating markets that vary in size and number of hospitals. In 2019, a new vision and direction for nursing led to a central resource management model that supports inpatient nurse staffing and scheduling on a 24/7 basis. The new vision included:
- The Resource Optimization Center (ROC). A new centralized operating model for staffing, scheduling and timekeeping of inpatient nursing, women's services, and an emergency department (ED) on a 24/7 basis. The model, which incorporated patient throughput, float pool deployment and agency management, was built with both remote and on-site operations.
- New enterprise staffing, scheduling and timekeeping technology
- Organizational redesign: new nursing leadership roles and new non-nurse centralized staffing, scheduling and timekeeping roles
- New system staffing, scheduling and incentive policies
- System standard operating procedures for the ROCs
The ROCs were deployed across 10 markets, coinciding with the rollout of new staffing and scheduling technology from summer 2020 to fall 2021. In total, the model was implemented for 34 hospitals, 11 freestanding EDs and 388 inpatient nursing units supporting 15,000 employees. The ROC was implemented to create operational efficiencies through a scalable approach. It allows for local market and system views of resources, flexibility for the nurses, transparent pricing and proactive incentive offerings.
A crucial element is that the model was designed and implemented to support the work and role of the front-line nurse manager. Typically, a nurse manager spends 60% of their day on scheduling and staffing activities, precious time that could be spent on other work such as team development, coaching individual staff members, patient and team rounding or implementing evidence-based projects and research studies. The new operating model enhances the role of the nurse manager by providing a team to do staffing and scheduling so the nurse manager can work at the top of their licensure as a leader.
Implementing and sustaining the new model has not been an easy journey. Aside from the pandemic, a transformation of this magnitude is difficult for front-line nurses, including charge nurses, supervisors and nurse managers. The transformation requires the adoption of new practices such as moving from paper processes to scheduling and embracing a system approach for nurse recruitment. Some nurse leaders struggle to give up scheduling and staffing – unsure of how to lean into the support of a new central team. In some cases, this struggle comes from a fear that the new process will lead their staff to quit.
For example, I explored barriers to implementation at both health systems and learned that many unit leaders feel they need to call an employee to pick up an extra shift rather than use new mobile-first text messaging that can reach the whole team and other qualified staff. I was told their staff like it better, or staff don't trust the new technology. I’ve found that fears like these are often the biggest hurdles to overcome.
Key Learnings From These Two Experiences
- Technology can be leveraged to improve nurse staffing and scheduling when nurses have a voice in developing those solutions and commit to using the technology.
- A learning mindset – knowing that we were going to try new approaches and adjust based on the outcome – was essential to my team’s success.
- Nurses are aptly suited to lead and design transformation in nurse staffing and scheduling processes.
- Challenge the status quo – if the current system isn’t working well, then the benefit of trying a new approach is greater than the risk.
There is no magic bullet that will solve all the challenges of nurse staffing and scheduling; success comes from a compilation of efforts and approaches. Some of those efforts will fail, some will need revision, and others just need time to take effect. Ultimately, this is a journey, not a final destination. A continuous cycle of improvement, progress and innovation can be achieved if the nursing profession dares to hold fearlessly to the mantra that nothing is impossible, and no mindset is off-limits.
What new and different approaches have you taken to improve scheduling and flexibility? Please share your solutions – large or small – that could benefit your fellow nurses.
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