How Nurse Leaders Create Effective and Fair Nurse Scheduling

For most nurses, no two work shifts are alike. All shifts require healthy recovery time, but some situations call for more rest between shifts than others. That’s just one of the challenges nursing managers face in crafting schedules flexible enough to meet the needs of staff while ensuring an adequate level of patient care.

Scheduling problems contribute to nurse burnout and lower job satisfaction. In particular, mandatory overtime has been associated with increased levels of nurse burnout. This highlights the importance to nurse leaders of crafting schedules that meet staffing needs without endangering the health and well-being of nurses and patients.

The negative impacts of nurse scheduling problems and creative approaches to effective and equitable nurse schedules are examined in this guide. Resources are presented for workload management and other problems that arise when devising efficient and fair nurse schedules.

What Is a Typical Nurse Schedule?

A study reported in the Journal of Advanced Nursing (JAN) determined a typical nurse schedule for newly licensed registered nurses averages 39.4 hours per week. It also found:

• New nurses prefer to work 12-hour shifts rather than eight-hour shifts.
• Most nurses choose a day shift over working evenings or nights.
• Nearly half of new nurses (45.6%) work voluntary overtime, averaging three hours per week.

In addition, 13% of the nurses participating in the study have a second paid job.

Avoiding Unhealthy Shift Patterns

The JAN study found 12% of new nurses work mandatory overtime, which averaged less than one hour per week. Nurse leaders face a quandary when planning nurse schedules: They are often required by federal and state regulations to maintain minimum nursing staff levels, yet the dire nursing shortage makes it difficult to meet these staffing levels.

The nursing shortage contributes to unhealthy shift patterns. American Nurse describes the types of shifts and schedules having a negative impact on nurses’ health:

• Being assigned more than three consecutive 12-hour shifts, four consecutive 10-hour shifts, or five consecutive eight-hour shifts
• Rotating from days to nights or nights to days in a single 24-hour period
• Working two shifts with less than the equivalent of two standard shifts of rest in between (except for 12-hour shifts), such as working two eight-hour shifts in a single 24-hour period
• Working more than 12 consecutive hours, such as a 16-hour double shift
• Working overtime

Limiting the Number of Consecutive Shifts

One of the ways nurse managers can combat burnout and ensure nurses function at their peak is to provide sufficient time between shifts for nurses to rest and recuperate. Becker’s Hospital Review described strategies for reducing consecutive nurse shifts:

• Keep tabs on the number of shifts that flip between day and night.
• Create a work environment allowing nurses to comfortably decline to work overtime.
• Encourage nurses to learn about sleep hygiene and the symptoms of shift work sleep disorder.
• Promote effective collaboration in health care teams as a vital element of patient safety.

Avoiding Double Shifts and Excessive Consecutive Hours

The Fair Labor Standards Act doesn’t limit the length of a work shift, in part because emergencies sometimes require nurses and other essential workers to stay on the job for extended periods. However, several states have enacted limits on the length of nurse shifts and mandatory overtime.

When nurses work double shifts or too many hours in a row, patient care suffers. For example, a study reported in the European Review for Medical and Pharmacological Sciences identified the primary causes of errors in administering medication. They include stress, fatigue, increased workload, working nights, nurse staffing ratio and workflow interruptions. The researchers concluded working more than 12 consecutive hours or more than 40 to 50 hours per week increased the frequency of nurse medication errors.

Importance of Including Nurses in the Scheduling Process

The key to establishing a healthy work environment for nursing staff is to collaborate with all team members about shift patterns, shift lengths and overtime work. An analysis of the National Database of Nursing Quality Indicators (NDNQI) survey of RNs found nursing teams with low levels of collaboration recorded higher levels of overtime.

Sharing the Workload of Schedule Creation

When nurses were involved in the scheduling process, their job satisfaction levels increased. Additional management functions correlated to increases in nurse job satisfaction include planning, organizing, staffing, actuating (via motivation and communication), and controlling.

Building Flexibility into Nursing Schedules

Similarly, providing nurses with more flexibility in their work schedule relates directly to increased job satisfaction. However, creating a balanced work schedule allowing nurses to meet their familial and other obligations outside of work requires strong, mutually beneficial communication between nurses and health care organizations.

Ensuring Equal Opportunity for Career Advancement

One of the best ways to recruit and retain talented nurses is to offer nurses ample opportunity to advance their careers. Nurses seeking promotion to nurse manager positions benefit from experience in such management skills as accountability, team building, and problem-solving, along with their nursing skills and experience.

Resources for Tips on Effective Nurse Scheduling

• Trusted, “Navigating Nursing Shifts” — Learn about the pros and cons of 12-hour, 10-hour and eight-hour nursing shifts.
• Passports and Preemies, “How to Prepare for 12 Hour Shift Schedules as a Nurse” — Discover tips that help nurses adjust smoothly to working longer shifts.
• ProQuest, “Capacity Planning and Scheduling of a Nursing Resource Team (NRT)” — Read about a new model proposed to improve the efficiency of scheduling a team of nurses that provides on-demand support for understaffed nursing units.

Mandatory Overtime in Nursing

The ongoing shortage of RNs has required some health care providers to implement mandatory overtime for nursing staff. However, many states now limit mandatory overtime for nurses and other health care workers. Ohio is one of the latest states to consider restricting mandatory overtime for nurses. Mandatory overtime restrictions have been enacted by 17 states, including California, Texas, New York, and Massachusetts.

Why Is There Mandatory Overtime in Nursing?

Health care organizations are required to meet minimum staffing requirements for nurses, yet they are challenged to find qualified RNs and other nursing professionals to meet those minimum staffing levels. As a result, they require nurses to work hours beyond their standard shift. Mandatory overtime has become a point of contention in disputes between nursing associations and health care providers.

Regulations Mandate Minimum Nurse Staffing Levels

Federal regulations require hospitals certified to treat Medicare patients have adequate numbers of licensed registered nurses and other nursing professionals. In addition, more than two dozen states have enacted laws stipulating minimum nurse staffing levels. The state regulations fall into one of three general categories:

• Laws mandating the creation of nurse-driven staffing committees to devise staffing plans
• Legislatures setting specific nurse-to-patient ratios themselves
• Laws requiring health care facilities to publish their nurse-to-patient ratios or report them to a regulatory body

Impact of Nursing Shortage on Mandatory Overtime

The COVID-19 pandemic has exacerbated the critical shortage of qualified nurses. While elements of the Coronavirus Aid, Relief, and Economic Security Act (CARES) funds nursing education and training in areas of greatest need, health care providers will continue to impose mandatory overtime requirements on nurses in states that haven’t restricted the practice.

Impact of Mandatory Overtime on Patient Care

Highlights of the dangers of mandatory overtime in nursing:

• Patient health is at greater risk because nurses working long hours are more prone to mistakes and inattention.
• Nurses who haven’t had adequate rest are more likely to lose focus when instructing or treating patients, and they react more slowly in triage situations.

Overworked Nurses Are More Likely to Make Mistakes

A study found nurses whose workload was above optimal levels, as established by the RAFAELA patient classification system for measuring nurse workloads, were 10% to 30% more likely to be involved in a patient safety incident and 40% more likely to experience patient mortality. Conversely, nurses whose workloads were lighter than the levels established by the RAFAELA system were 25% less likely to encounter a patient safety or patient mortality issue.

Sleep Deprivation Causes Diminished Cognitive Functioning

Sleep deprivation’s negative impact on cognitive function is shown in the effect of a lack of sleep on a person’s working memory. Working memory is the state between short- and long-term memory; it’s critical to voice understanding, learning, and reasoning. Sleep deprivation reduces the speed of the brain’s information processing, which limits the amount of information a person can process in a given period.

Impact of Mandatory Overtime on Nursing Morale

A survey estimates the average cost of replacing a bedside RN at around $40,000 in a range from $28,400 to $51,700. A primary reason nurses look for a new job is low morale, and the nursing shortage that causes health care providers to impose mandatory overtime is a primary source of low morale among nurses.

Nurses Hesitate to Complain About Mandatory Overtime

Nurses may feel pressure from peers and co-workers to acquiesce to mandatory overtime even when they believe the extra work hours are impairing their ability to do their job. Many of the state laws prohibiting or otherwise regulating mandatory overtime for nurses include provisions mandating a mechanism by which nurses can submit complaints about the practice.

Overworked Nurses Are More Prone to Injure Themselves

The U.S. Occupational Safety and Health Administration (OSHA) reported the health care and social assistance industry has the highest rate of work-related injuries and illnesses of all industries. To address the high rate of on-the-job injuries among nurses and other health care workers, OSHA promotes a culture of safety to identify injury causes. One of the main ways to prevent these injuries is by ensuring workers are alert, attentive, and well rested.

Overworked Nurses Experience Higher Levels of Stress

A study determined the source of stress most often cited by nurses is inadequate staff to handle the workload, followed by performing procedures causing patients great pain, and lack of required equipment and supplies. The stress induced by excessive workloads is made worse by lack of nurse participation in decision-making, lack of organizational communication, and failure to create a family-friendly work environment.

How Voluntary Overtime Can Improve Nurse Work Environments

Nurses respond more positively to working extra hours when they can decide for themselves when to accept overtime and the number of extra hours they work. The Texas Nurses Association outlines the steps nurses and nursing managers can take to prepare for the added workloads resulting from the COVID-19 pandemic in light of mandatory overtime restrictions:

• At work, take plenty of breaks for rest and nourishment whenever possible. Support and celebrate co-workers.
• At home, maintain as regular a rest, eating and exercise schedule as possible. Find time to engage in rewarding activities, and keep tabs on stress and mental health status.

Resources for Mandatory Overtime in Nursing

• S. Department of Labor, “Fact Sheet #17N: Nurses and the Part 541 Exemptions Under the Fair Labor Standards Act (FLSA)” — Learn about the federal regulations stipulating overtime pay for nurses in specific situations.
• American Nurses Association, “Nurse Staffing Crisis” — Find out the steps the ANA is taking to address the chronic and increasing shortages in nurse staffing.

What Are the Greatest Scheduling Problems in Nursing?

The nurse scheduling problem is a critical balancing act that weighs the health care organization’s need to ensure the facility is staffed sufficiently to provide quality care versus budgetary constraints and the health and well-being of nursing staff. To address the conflicting demands present in health care environments, nurse leaders must devise schedules providing all employees with sufficient time off, including scheduled days off, while maintaining a productive work environment and promoting positive patient outcomes.

Hard Constraints vs. Soft Constraints on Nurse Scheduling

The first step in creating a fair and efficient nurse schedule is to set priorities in two categories:

• Scheduling needs required for the facility to function (hard constraints)
• Scheduling the department’s nonessential needs for operation (soft constraints)

For example, meeting minimum nursing staff levels is a hard constraint, while granting a nurse’s request for a specific day off is a soft constraint.

Hard Constraints

Most hard constraints affecting nurse schedules relate to emergencies and government regulations.

• Minimum staffing: In the absence of specific minimum staffing requirements from the federal government, more than a dozen states have enacted their own rules related to nurse staffing. The ANA emphasizes the importance of involving nurses in establishing staff levels based on the specific needs of various nursing units.
• Number of hours per shift: Research found nurses working a single 12-hour shift experience a range of fatigue-based impairments, including an 8% reduction in reaction time. In addition, working three shifts longer than 12 hours with a 12-hour break between shifts cuts a nurse’s reaction time by 17%. The study determined nurses working 12-hour shifts also had more attention lapses and reduced muscle function. The researchers recommend nurse managers implement fatigue-management strategies to ensure patients receive optimal nursing care.
• Number of shifts per week: A study found a hospital’s scores for patient-safety competencies declined as the number of hours nurses worked each week increased. Regardless of the length of each shift, adverse nurse outcomes were significantly higher when nurses worked 50 hours or more in a week than when they worked 40 hours or fewer.

Soft Constraints

While not considered as critical as hard constraints, soft constraints to nurse scheduling have a direct impact on nurses’ physical and mental well-being. By allowing them to participate in setting their schedules, managers help promote a positive work environment and combat nurse burnout.

• Requests for days off: The key to meeting nurses’ needs for off time is to start planning early. Set deadlines for summer vacation requests, encourage nurses to swap shifts, and provide incentives for working shifts many staff members have asked to take off.
• Avoiding mandatory overtime: There are a number of steps employers must take before requiring nurses and other health care employees to work overtime. For example, employers must first seek volunteers to work the shifts and attempt to fill the shift with qualified per diem staff or temporary employees.
• Having less than a full staff of nurses on a shift: Failure to anticipate staffing needs may be due to underestimating employee availability, misunderstanding the organization’s scheduling policies, or failing to accommodate the various roles played by members of the nursing staff.

Poor Communication of Coverage Needs

There are several benefits to effective communication between nurses and managers when planning work schedules.

• Online message boards allow nurses and managers to collaborate more effectively when making schedule changes, approving overtime, and sending floating schedule alerts.
• Online scheduling applications save nurse managers time and effort by letting nurses preset their schedule preferences and limitations, such as their availability to work overtime or specific shifts.
• Nurses can view shift changes and updates at any time via a computer or mobile device.
• Scheduling software presents nurse managers with a single comprehensive view of nursing staff members’ hours worked, scheduled time off, and future availability.

Shortcomings of Online Calendars

Online scheduling is not a perfect system. For example, some requests for time off come up at the last minute, but online calendars may not indicate who is available to take the worker’s place. Online scheduling requires clear communication channels between all nursing team members via mobile apps and other tools. Here are eight common online work-scheduling problems and ways to address them.

Ensuring Schedule Changes Are Timely and Communicated Accurately

While shift swapping is generally encouraged when nurses find they need to adjust their work schedules, nurse managers and others on the team must be aware of the changes in time for them to respond as necessary. Nurse leaders must also monitor late changes in work schedules to ensure no one is violating policies about working too many hours without adequate rest between shifts, for example.

Resources on the Nurse Scheduling Problem

• Alexandria Engineering Journal, “A New Formulation and Solution for the Nurse Scheduling Problem: A Case Study in Egypt” — Researchers present a mathematical model that minimizes hospital costs and maximizes nurses’ preferences.
• Optimization Online, “The Nurse Rostering Problem in COVID-19 Emergency Scenario” — This mathematical model allows nurse managers to schedule nurse shifts in emergencies.

What Is Nurse Burnout?

Nurse burnout isn’t new, but the problem has taken on a new dimension in light of the strains placed on the profession by the response to the COVID-19 pandemic. Yet the nature of burnout among nurses and other health care workers has varied over time and in different circumstances. This makes combating the problem more difficult.

What Are the Causes of Nurse Burnout?

In the earliest studies of the impact of work-related stress on nurses, four sources were targeted: patient care, decision-making, responsibilities, and change. Societal stresses are now acknowledged as a primary source of nurse burnout as well. These are among the areas that nurse managers can address to prevent nurses from experiencing burnout.

12-Hour Shifts vs. Eight-Hour Shifts

The trend in the nursing profession is toward more 12-hour shifts and away from conventional eight-hour shifts. This is especially so for new nurses, but regardless of experience level, 12-hour shifts tend to increase work-related stress in large part because of the need for adequate rest between shifts. However, a study found nurses working in a critical care unit were able to switch from eight-hour shifts to 12-hour shifts with no increase in burnout symptoms.

Nurses’ Duties Continue to Expand

The sharp increase in telehealth services in response to the COVID-19 pandemic is only one example of the expanding role of nurses in the front lines of patient care. Nurses now have a higher profile in their communities as they interact with patients via videoconferencing and other technologies. However, these technologies also increase nurses’ patient load and add new skills and responsibilities to their job descriptions.

Work Group Conflict and Tension

The more interactions nurses have during a workday, the more likely they’ll encounter some conflict as a result. Following are several factors leading to conflicts involving health care workers:

• Personnel issues
• Physical work environment
• Power struggles
• Differences in value systems
• Personality conflicts
• Leadership styles
• Organizational structure

Addressing these and other areas of conflict and tension requires nurse leaders to have strong communication, motivation, and team-building skills.

What Are the Effects of Nurse Burnout?

Burnout can impact all aspects of a nurse’s personal and professional life. It also has a detrimental effect on nurse work groups and health care institutions. Some of the effects of nurse burnout:

• Nurses may feel a sense of dread about their work.
• Nurses experiencing burnout often feel physically or mentally exhausted.
• Nurses may have problems falling or staying asleep.
• Burnout makes nurses more prone to depression.
• Nurses may experience compassion fatigue and thus feel disengaged from their patients.

High Stress Levels Lead to Mistakes, Lower Motivation

Burnout among health care professionals has a direct negative impact on patient care because nurses and other professionals may lose motivation and suffer cognitive impairment that increases the likelihood of mistakes.

Nurse Burnout Reduces Patient Satisfaction

As health care environments grow more complex, it becomes increasingly difficult for patients and their families to avoid feeling overwhelmed. When nurses feel burned out, they are unable to offer patients and their families the support they need in very trying times. The Joint Commission has devised a program to improve resilience in nurses and other health care professionals as a way to address and prevent nurse burnout.

Lower Job Satisfaction Contributes to the Critical Shortage of Nurses

The connection between low nurse job satisfaction and the continuing shortage of nurses is shown in studies that found higher nurse satisfaction correlates to lower nurse turnover. More-satisfied nurses also are associated with higher patient satisfaction and fewer adverse events.

Resources for Information on Nurse Burnout

• International Journal of Environmental Research and Public Health, “Impact of Job Demands and Resources on Nurses’ Burnout and Occupational Turnover Intention Towards an Age-Moderated Mediation Model for the Nursing Profession” — The model described is designed to help nurse managers anticipate and respond to nurse burnout before it leads to nurse turnover.
• Guideway Care, “6 Strategies for Decreasing Nurse Burnout” — Among the approaches presented for decreasing nurse burnout are tips for reducing nurse-to-patient ratios and addressing other policy matters.

How to Create a Nurse Schedule

The steps entailed in creating a nurse schedule are part of a nurse staffing plan that considers a range of staffing and patient needs. Elements include:

• The number and type of patients
• The number of health care professionals required to meet the needs of the patients
• The nurses and other employees necessary to comply with government regulations

Nurse managers are responsible for the important and difficult task of meshing the guidelines stated in the staffing plan with the unpredictable reality of managing schedules in a way that ensures nurses are well rested and have their time-off needs met. The schedule must also ensure patients receive the care they need, the facility complies with staffing regulations and the department runs as efficiently as possible.

Limit Voluntary Overtime and the Number of Consecutive Shifts

Any health care facility that cares for patients around the clock, seven days a week, will require RNs on duty to care for the patients. Whether nurses will be expected to be available for overtime or to work extra shifts depends on several factors:

• The level of demand for RNs in the area
• Unique scheduling needs of the facility
• Short-term or seasonal staffing needs
• Restrictions on work hours that have been negotiated as part of an employment contract

Nurse managers should make every effort to adhere to the standard 40-hour or 36-hour workweek for full-time employment. They may also need to schedule at least eight hours of rest between consecutive work shifts, as is required by law after 12 consecutive hours of work in Washington and other states.

Schedule Rotating Shifts in a Forward Pattern

People who work rotating shifts generally get more sleep when their shifts rotate in a forward pattern moving from days to afternoons to nights:

1. Day shift (two or more consecutive)
2. Afternoon shift (two or more consecutive)
3. Night shift (two or more consecutive)
4. Days off (two or more consecutive)

Backward, or counterclockwise, shift rotation was associated with lower quantity and quality of sleep and diminished alertness at work.

Ensure Adequate Rest Periods Between Shifts

While at least eight hours between eight-hour work shifts is considered the minimum requirement to ensure nurses are adequately alert, certain work situations require much longer rest periods for nurses to maintain peak performance. For example, a study found nurses who worked two consecutive 12-hour night shifts required at least three days to recuperate sufficiently.

Make Sure Staff Are Comfortable Turning Down Overtime Requests

The guidelines published by the U.S. Centers for Disease Control and Prevention (CDC) for preventing workplace fatigue during COVID-19 call for health care managers to be mindful of the negative effect of fatigue on nurses’ health and on the quality of care patients receive. The agency recommends employers create a culture of safety in which nurses are trained to recognize when they are fatigued and can safely communicate this to their manager.

Promote “Sleep Hygiene” and Other Shift-Related Health Habits

Nurses need to apply self-care to ensure they get enough sleep to stay alert during their work shifts. Sleep-promoting techniques include establishing a wind-down period before bedtime that tones down the gadgets, and adopting the practice of journaling before going to bed, which helps quiet the negative thoughts making it difficult to fall asleep.

Make Room for Continuing Education Opportunities

The challenges of daily nurse scheduling can cause nurse managers to neglect the career development of their nursing staff. For individual nurses, however, the ability to pursue an advanced education is a major part of their career growth. By offering chances for advancement, nurse managers promote morale in the work group and benefit the organization by broadening the talents of its workforce.

Monitor Shift Trading to Prevent Overwork

Nurses may sometimes be overzealous in their quest for extra shifts when they become available. While the practice of shift trading benefits nurses and employers alike, nurse managers must be sure the trading doesn’t present a risk to patient care or the well-being of the nursing staff.

Be Flexible Enough to Accommodate “High-Acuity” Patients

One study reported caring for high-acuity patients in a neonatal intensive care unit created a high level of stress for nurses for which standard scheduling methods failed to account. The nurses’ subjective workload caused them to miss essential care practices that jeopardized their patients’ health.

Resources for Creating Nurse Schedules

• PayPro, “The Complete Guide to Writing a Nurses’ Self Scheduling Policy” — Read about the pros and cons of allowing nurses to create their own schedules.
• American Nurse, “The Imperative for an Electronic Nurse Scheduling System. Case Study: West Hospital VCU Health” — Find out how one hospital improved staff morale and staffing efficiency by adopting an electronic nurse scheduling system.

How to Be a Great Nurse Leader

What makes a great nurse leader? The ANA Leadership Competency Model consists of 10 standards of professional performance:

• Collaboration
• Communication
• Education
• Environmental health
• Ethics
• Evidence-based practice and research
• Leadership
• Professional practice evaluation
• Quality of practice
• Resource utilization

Why Nurse Scheduling Is an Important Nurse-Leadership Issue

Effective nurse scheduling taps all 10 of the ANA leadership model’s standards, especially in building collaborative relationships, managing change, exerting influence, problem-solving, decision-making, and systems thinking. However, in ensuring nurse schedules meet the needs of patients, staff and administrators, nurse leaders must also demonstrate these specific leadership characteristics:

• Adaptability and openness to be influenced by others
• Initiative in the form of self-motivation
• Integrity in building and maintaining relationships
• Learning capacity to gain knowledge about the profession and the health care industry
• Self-awareness to know one’s strengths and weaknesses and own up to mistakes

Healthy Scheduling Is Nurse Leadership in Action

Few tasks faced by nurse managers are as daunting or as important as devising effective and fair nurse schedules. The skills required to meet the scheduling needs of patients, nurses and administrators encompass all the tools, knowledge and expertise a nurse leader requires. Effective nurse scheduling serves as the foundation for establishing mutually beneficial relationships with nursing staff, improving patient outcomes and ensuring efficient provision of health care services.

Infographic Sources:

Becker’s Hospital Review, “Nurse Scheduling, Staffing Issues Continue to Afflict Hospitals: 8 Key Statistics”

HealthLeaders, “Top 5 Nurse Leadership Issues for 2020”

U.S. Bureau of Labor Statistics, Registered Nurses