I was a Second Lieutenant in the Air Force Nurse Corps when I began working on a medical oncology floor.  Still a novice, I had moments of feeling overwhelmed by my responsibilities, but I was  proud of my progress, enthusiastic about learning, and constantly seeking out ways to improve my practice.     

During one particularly busy shift, I suspected one of my patients developed an acute upper gastrointestinal bleed.   After completing my assessment, I called the physician to report my findings and suspicions.  

People with upper GI bleeds may have black, tarry stools; bloody emesis; alterations in their vital signs; and cool, clammy, pale skin.  They typically require intravenous fluid and insertion of a tube through the nose and into the stomach.  In this case, the patient required lavage, or irrigattion of the contents of the stomach; the administration of blood products; preparation for an upper GI endoscopy; and transfer to the Medical Intensive Care Unit for closer observation.

Working calmly, but hurriedly, I inserted the nasogastric tube and began lavage while another nurse prepared to start a second intravenous line on the patient.   I explained to the patient what we were doing and attempted to reassure him as best I could.  Together with the physician, we were ultimately able to stabilize the patient and transfer him to the ICU. 

Once the crisis had passed, I quickly rounded on my other patients and sat down to catch up on my charting.  Standing at the other side of the nurses’ station, the physician said, “You know, you really should have gone to medical school.”  

Initially, I took this as a compliment.  I respected this physician, and reasoned that he must think I’m smart if he thinks I should have gone to medical school, right?  It was only later, as I became more confident in my role as a nurse, and developed a more sophisticated understanding about the difference between nursing and medicine, that I wished I had questioned him on his choice of words. 

Today, I would not be complimented by the implication that being smart and competent are not essential attributes for nursing practice.  If I could replay that scene, I would take the opportunity to explain to the physician that my actions during the management of our patient were not extraordinary, but typical of ordinary, qualified nurses. I would politely point out that without skilled and knowledgeable nurses at the bedside, our patient’s outcome could have been dramatically different.  

I would make clear that, despite shared characteristics, nursing is a unique and distinct discipline from medicine—one that respects and works in concert with other health care professionals—but that offers a unique perspective to patient care.  I would explain that I was interested in focusing on the human response to illness, on spending time with patients and advocating for them, and helping them achieve the best possible state of health or a peaceful death. I didn’t want to be acknowledged for my potential as a medical student; I wanted to be acknowledged for my capabilities and value as a nurse.

Although flexibility is an often touted advantage of being nurse in an acute care setting, the around-the-clock nature of patient care demands around-the-clock coverage.  Your scheduling preferences may vary widely depending on your particular situation.  I loathed evening shifts (3 pm to 11 pm) in my 20s because of the impact it had on my social life, whereas a former colleague favored them because she was able to surf every day, weather permitting, before coming to work.  

Your scheduling preferences also may be dynamic, changing based on changing life circumstances.  To avoid the need for outside childcare, a nurse I once worked with opted to work twelve hour weekend shifts once she had children, another worked 11pm-7am night shifts, whereas I opted to work part time and–later–per diem. 

A recent article in Nursing Economics* suggests that one of the predictors to a registered nurse remaining in nursing is scheduling. In their survey, researchers asked over 8000 nurses to quantify the weekly number of hours they were hired to work, the number of hours they actually work, the number of hours they would ideally like to work, and the number of hours they work providing direct care to patients.  They compared this data to the nurses’ plans to continue working as nurses.   Not surprisingly, the researchers found that when the schedules and hours were in harmony with the nurses’ expectations, retention of the nurses was more likely. 

This didn’t strike me as unusual—scheduling logically influences job satisfaction and quality of life.  What I had not considered was the tangible ways in which we, as nurses or future nurses, can do to enhance our job satisfaction so that we remain in nursing.   The researchers identified specific strategies nurse managers, individual nurses, and nurse educators can employ to improve job satisfaction relative to scheduling:

Management should find ways to meet nurses’ requests for schedule changes whenever possible. 

Many hospitals now offer flexible or alternative scheduling for their nurses, including offering shifts that range from four to twelve hours, having the option to stagger shift start times, allowing nurses to self-schedule, and having access to additional staffing through hospital float pools or outside staffing agencies. 

Nurses should clearly understand the expectations the employer has regarding scheduling.

Prior to accepting a position, we have a responsibility to ask questions to ensure we understand what our obligations are.  We need to have ongoing conversations with our managers to ensure that our expectations are reasonable and to facilitate a process for requesting changes.  

When I was hired to work the aforementioned evening shifts, it was explicitly stated and written into the job offer that I would be switched to twelve hour rotating shifts as soon as such a position became available.  Although there was no guarantee as to how long this might take, my manager kept me informed as to the anticipated timeline, and my request was granted within a few months. 

Nurse educators can be instrumental in developing student nurses who have a realistic expectation about scheduling. 

Nursing education must include exposure to the rigors of the shift work involved in staff nursing, not only by discussing the issues, but when possible by facilitating clinical rotations on off-shifts and weekends.   The more realistic the students’ expectations are, the more likely their transition to nursing will be. 

*Kirschling, J.M., Colgan, C., & Andrews, B.  (2011).  Predictors of registered nurses’ willingness to remain in nursing.  Nursing Economics, 29:3, 111-117.