In the US, the predominant shift length is 12 hours in acute care settings.¹² Full-time staff nurses typically work three 12-hour shifts per week, with some nurses hired into roles with schedules that include rotating shifts.¹³ Nursing management is responsible for scheduling staff nurses with staffing targets estimated by patient demand.¹⁴ Staff preferences are often at least part of the scheduling decision-making process; however, this is not always the case.^15,16

In practice, nurse scheduling is managed in several ways. First, some follow systems of pen-and-paper scheduling or use homemade spreadsheets for scheduling requests. This may be done for several weeks or months at a time.¹⁶ Second, scheduling practices and policies may follow explicit hierarchies (i.e., experienced staff choose which holidays they work; less experienced or newer staff work more night shifts). However, some hierarchies may be implicit, such as preferential scheduling based on friendships or other personal reasons, which may lack transparency to staff. Some units have volunteer-based staff nurses or staffing committees who assist in developing schedules or soliciting requests for vacation, holiday, or personal time off. However, the nurse manager has the fiduciary duty associated with adhering to the staffing budget and typically holds the final authority on schedules. Managing scheduling, including switches, call outs, and overtime in this way is often an ineffective use of a nurse manager’s clinical experience and time, resulting in staff dissatisfaction.^5,16,17

Nurses have cited poor schedules and increased workloads as reasons for job dissatisfaction.^1,18 Scheduling practices may impact overall job satisfaction in multiple ways. First, nursing has historically had little scheduling flexibility. Flexible scheduling provides opportunities for better work-life interface, and reduced work-family conflict is an important factor in attracting and retaining nurses, especially as a primarily female occupation.^19–21 Nurses with social and family obligations outside of work have cited flexible scheduling, particularly in part-time roles, as influencing their decision to continue with direct-care nursing positions.²² Second, nurse scheduling practices are dynamically linked to nurse-to-patient staffing ratios and the ability of workplaces to ensure appropriate match between patient needs, available nurses, and nurse competencies.^1,23 The mismatch between staff competency and patient acuity is a source of stress and contributor to dissatisfaction. For example, among surveyed critical care nurses in 2021, only about 1 in 4 nurses (24%) perceived an appropriate match between patient needs and available nursing skill more than 75% of the time at work.²³

A deep body of research has identified job satisfaction as a predictor of retention among nurses.^24,25 Retention of staff nurses in acute care settings is critical to ensure adequate nurse-to-patient ratios and to provide high-quality patient care.²⁶ Lack of staffing has a cascading effect on patients and nursing staff.^26–28 Poorer staffing is associated with poor quality and patient safety outcomes, including increased risk of mortality.^27,29,30 Further, turnover impacts morale and stress for the remaining nursing staff, which can reduce health, well-being, and productivity.³¹ Nurses are on average less healthy than the general population in the US in terms of weight, sleep, and stress.³² Surveys of nurses have identified health challenges such as high levels of stress including workplace violence, lack of adequate breaks, and lack of appropriate nutrition and exercise as contributing to poor overall nurse health.³² Finally, scheduling practices that include overtime, multiple consecutive shifts, and/or quick returns (ie., <11 hours off between consecutive shifts) hamper nurses’ ability to care for their own health and sleep needs.³³

Although nurse job satisfaction, scheduling satisfaction, and associated outcomes have been well documented,^3,24,34,35 gaps remain in understanding the dynamic interface of overall job satisfaction as influenced by scheduling satisfaction in a post-COVID-19 pandemic environment. Furthermore, researchers have not captured perspectives on what prevents or supports satisfaction in scheduling from direct care nurses and the nurse managers who are responsible for the scheduling process.³⁶ Previous research on nurses’ job satisfaction is abundant and mostly quantitative but very few studies have a priori combined concurrent data collection from nurses and managers from the same institution to understand the phenomena of interest through a qualitative methodology. The aim of this research was to describe barriers and facilitators of job and scheduling satisfaction among staff nurses and nurse managers.

This study is guided by Harvard’s Center for Work, Health and Wellbeing’s conceptual model for integrated approaches to protecting and promoting worker health, which was updated by Sorensen et al. to reflect the future of research on work, safety, health, and well-being.³⁷ This framework identifies pathways through which working conditions may influence health and safety processes, behaviors, and outcomes. As shown in our adapted conceptual model in Figure 1, organizational policies, programs, and practices, such as scheduling practices, are situated in this conceptual model as potential points for intervention that influence working conditions and worker safety and well-being outcomes. Through this intervention point, enterprise outcomes can be improved. For our study, we focused on enterprise-level organizational outcomes of job satisfaction, scheduling satisfaction, and turnover intention. Using this conceptual model helped to inform the structure of the interview guide (see Supplemental content for interview guide) and overall understanding of key domains associated with scheduling satisfaction.

This study used a qualitative descriptive design. In qualitative descriptive studies, common to healthcare research,³⁸ the researchers seek to describe experiences using everyday terms and typically use semi-structured interviews or focus groups followed by content analysis.

Our sampling frame included staff nurses and nurse managers employed at a large, urban academic medical center. After approval by the Institutional Review Board (IRB), participants were recruited using multiple approaches including targeted emails, infographics, and snowballing. We employed maximum variation sampling to recruit across unit type, shift, work experience, and sociodemographic characteristics.

Potential participants were directed to a REDCap link where they were screened for eligibility and completed informed consent. Next, participants completed a sociodemographic and work characteristics survey and then self-scheduled their interview using the Calendly electronic scheduling software (Calendly, Atlanta, GA). Reminder emails were sent prior to interviews, and re-scheduling was completed using Calendly. Participants completed interviews between August 2023 and February 2024 with the PI or research assistants who were nurses with experience in qualitative research. None of the participants were known to the interviewers. Before starting the interview, the purpose of the study and brief introduction to the interviewer were presented to the participants. We used audio-only recorded interviews on Zoom (Zoom Video Communications, San Jose, CA). No repeat interviews were conducted. Participants were entered into a raffle for one of ten $50 e-gift cards.

Sociodemographic data included age, education, partnership status, and dependent/caregiving status. Work characteristics included questions regarding primary job, second job status, work setting, years of experience as a nurse, work hours per week, primary work schedule, shift length, and average unit staffing. We have used these questions in previous studies, and they are based on the National Sample Survey of Registered Nurses (NSSRN) by the United States Health Resources and Services Administration (HRSA).²¹

Two similar but distinct semi-structured interview guides were used for the staff nurses and nurse managers, undergirded by the conceptual model.³⁷ The interview guide was also informed by prior work on nurses across care settings describing their work experiences and nurse outcomes.^8,39 The interview guides consisted of open-ended questions and probes to elicit thick, rich data. Example questions included, “Tell me about some of the benefits of your current scheduling process?” and “How does your schedule impact your health and quality of life?” Interviews lasted 35–50 min, and we reached data saturation after 16 interviews. Data saturation is identified as the stage at which additional data from participant interviews does not yield new insights related to the research questions.⁴⁰

All audio-recorded interviews were downloaded from Zoom and transcribed. All transcripts were checked for accuracy and coded using ATLAS.ti (ATLAS.ti GmbH, Berlin, Germany), a software package for the qualitative analysis of textual data, by the PI (PhD prepared nurse) and research assistants (nursing PhD candidates). Data were analyzed using conventional content analysis,⁴¹ a flexible approach that seeks to describe the phenomena of interest allowing researchers to be immersed in the data.⁴¹ Data management and analysis entailed the following: first, processing the data, including careful review of transcripts, second, analyzing data to identify the experiences of staff nurses and nurse managers across scheduling practices; and finally, identifying themes to understand connections across work scheduling factors that impact overall job and scheduling satisfaction. The preliminary analysis of the data included review of transcripts yielding clusters of data that were labeled into brief headings. Then codes were categorized based on lineages and relationships. Lastly, themes within and across coding categories were identified. At each point in the data analysis, team meetings were held to discuss the codes, categories, and themes. During the discussions, any disagreements that occurred were resolved by consensus of the team.

Qualitative rigor followed Lincoln and Guba’s criteria (credibility, transferability, dependability, and confirmability) as a guide.⁴² Credibility was achieved by comprehensiveness in data collection and analysis. Using analyst triangulation, multiple team members (PI, Co-I, research assistants), with different perspectives and clinical backgrounds, participated in data analysis. Transferability was achieved by describing the research context and using direct quotes to illustrate the results. Dependability was attained by including an audit trail in coding notes/memos and meeting notes. Finally, confirmability was completed by sharing findings with an outside expert in both occupational health nursing and qualitative methods to reduce risk of researcher bias.

The overarching theme of this study was “Scheduling is everything,” reflecting the importance of scheduling for the participants’ job satisfaction and personal satisfaction. Participants described the interconnectedness between their schedule and their physical and mental health, overall job satisfaction, and career intention. One participant described, “The schedule is number one. It really dictates your quality of life, your well-being, what you’re able to give to work, your attitude when you show up, your attitude when you leave. . .schedule is everything.” Participants described building their lives around their work schedule, which determined their ability to see their family and friends, to travel, and ultimately to enjoy their jobs. Another staff nurse described her belief that, “. . .if people are able to have a schedule that works for them, that that makes everyone happy, and keeps everyone enjoying their job.” Aligned with the conceptual model, barriers and facilitators of scheduling satisfaction emerged in participant interviews in worker, enterprise, and employment and labor domains. Subthemes related to barriers and facilitators of scheduling satisfaction are detailed in the following sections.

Across the interviews, participants identified common facilitators of scheduling satisfaction, which were endorsed by nurse managers’ perceptions. Subthemes included scheduling flexibility, scheduling autonomy, and scheduling equity. Additionally, participants demonstrated creativity and innovation by offering many ideas for improving scheduling processes both on their units and at the enterprise level. Exemplar quotes are found in Table 3.

Limitations of this study are recognized. This study was based upon in-depth interviews with nurses and managers working at a single institution, with a study design not based on achieving generalizability. While many of the findings may be site-specific, some of the findings may inform points of reflection for other institutions as well. In terms of positionality, the researchers’ backgrounds were primarily as bedside staff nurses, not managers. This limitation was addressed through in-depth discussion and reflection throughout the study along with one researcher (Co-I) with significant management expertise. Finally, selection bias may have played a role in the recruitment of participants, who were either highly satisfied or dissatisfied with their schedule.