At Trusted, we’re on a mission to deliver care to people everywhere. That can only become a reality when the nursing workforce is experienced, engaged and able to sustain a clinical career. Yet, nurses continue to exit the workforce in alarming numbers and even more signal an intent to. In 2022, nurse turnover was 22.5% and the number of nurses ages 35 and older dropped significantly. Additionally, 52% of nurses reported anintention to leave their position. These trends, coupled with a younger nurse workforce, are greatly concerning. As highlighted in our most recent annual Nurse MentalHealth & Well-being Survey, it’s become clear: Many nurses do not see their profession as compatible with mental health.

But what if poor mental health outcomes are symptomsof broken fundamentals of a clinical career? While some of the challenges inherent to the profession are perhaps nearly impossible to change, we must shine light on other factors that are within leadership’s control to redesign — ultimately to make nursing a more attractive and sustainable career choice. Leaders’ efforts here pose opportunities for alignment with key groups like the American Nurses Association’s Nurse Staffing Task Force,which released imperatives for hospitals that includecreating and sustaining flexible staffing programs to foster psychological well-being for staff.

For the purposes of this survey, we specifically narrowed in on a concept we continue to hear about repeatedly from front-line nurses: flexibility in work arrangements.

A cross-sectional study of registered nurses in Swiss hospitals found that “higher work schedule flexibility is associated with lower emotional exhaustion among registered nurses.”. Despite this knowledge, there continues to be a lack of clarity around different definitions for flexibility and workers, specifically healthcare gig workers.

The aim of this study was to better understand nurses’career preferences, and more specifically, how nursesdefine and perceive flexibility in various aspects ofwork arrangements, such as scheduling, shift types andlengths, as well as employment options.

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Methodology & demographics

The data in this study was gathered from more than 500 nurses (RN, APRN, LVN/LPN) — 96% of whom are RNs, across more than 11 different specialties — via an online survey conducted in August 2023. Forty-five percent of respondents were younger than 34, nearly 32% were between ages 35-44 and 20% were between ages 45-54. The ages represented are particularly important as it relates to current trends of nurses older than 35 exiting the profession, leaving the profession about 30 years earlier than other generations. If health systems make changes now, there is an opportunity to retain young nurses in the workforce and combat the anticipate dexodus of 800,000 nurses by 2027.

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Key findings

When it comes to optimizing for flexibility, self-scheduling continues to be the preferred choice for nurses. More than 87% of nurses ranked self-scheduling first (64%) or second (23.8%) among avariety of choices, including part-time work with hour requirements; hybrid shift lengths; hybrid roles; gig work without hour requirements; and full-time role swith the opportunity to work additional, flexible hours according to their preferences (location, time, duration).

These findings reflect nurse scheduling preferences and changes recently advocated for by the American Nurses Association.

Seventy-three percent of nurses defined self-scheduling as choosing which days and shift times they work, within FTE and employment requirements, without those shifts being moved or swapped.

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The second-most-preferred flexible option was part-timework with a weekly hour requirement of 24 hours. Gig work without hour requirements was ranked first or second by only 26% of respondents, aligning with trends in health systems’ declining contract labor costs.

A lack of control over when nurses work is a key barrier to sustaining a clinical nursing career. Perceived flexibility is correlated with control — giving nurses more control over when they work and how they plan. The top reported barrier (33%) was not having more control over whic hdays nurses schedule/are scheduled, followed by having to schedule their lives 4-6 weeks at a time (24%), a lack of control and flexibility with PTO (20%) and processes for having to find coverage when personal schedules change (19%). Only 5% of survey respondents cited 12-hour shift requirements as a barrier to sustaining a clinical nursing career. More than 62% would prefer to know their schedule at least six weeks in advance, with half of those preferring eight weeks or more in advance.

Health system internal travel or rotational programs might not provide enough flexibility and variety. More than half of nurses would prefer to pursue external travel opportunities rather than an internal travel program — a key consideration as major systems in recent years have invested more heavily in their internal programs. Thirty-four percent indicated it would be an ideal option for their lifestyle, while 14% see it as an option for career progression.

Partial shift offerings and variety are essential for nurses to work extra hours. More than 65% of nurses indicated that partial shift offerings (shifts between 4-8 hours) would make them more likely to work additional hours. While 23% indicated no interest in working beyond their committed FTE (underscoring a widespread desire among nurses for greater work-life balance), other options that would increase nurses’ likelihood of working additional hours are work opportunities somewhere other than their home unit or at an alternate healthcare employer altogether.

Nurses plan to continue pursuing travel opportunities. More than 77% of respondents indicated they expec ttravel opportunities will play a role in their employment, with 33% working travel/contract opportunities only, 31% working travel/contract opportunities while maintaining a per-diem position and 12% working travel/contract with secondary gig work. Only 8% of respondents plan to work a permanent, full-time (.9-1.0 FTE) opportunity.

Nurses prefer not to schedule too far in advance. According to the survey findings, 38% of nurses prefer scheduling 4-6 weeks in advance, followed by 27% preferring to schedule 6-8 weeks out.

Two Core Recommendations

1. Give nurses more control and optionality with self-scheduling, part-time work, extra-shiftofferings and reconsidering internal travel programs.

Capitalize on and optimize your ability to offer self-scheduling.

• Now more than ever, nurses crave flexibility and autonomy when it comes to work and the role workplays in their personal lives. Self-scheduling gives them the opportunity to make personal plans and incorporate their work into their lives.
• In a profession that already requires employees tobe flexible with weekends, holidays, nights, etc., self-scheduling is an opportunity to give nurses some autonomy and predictability. It enables easy scheduling of overtime shifts at the nurse’s leisure, benefiting nurses and managers.
• Self-scheduling in practice must truly allow for choice and freedom. Ensure nurses have sufficient time for scheduling but also sufficient options. Even if a schedule is not made for them, true autonomy and flexibility require some degree of choice in days, hours and shift types.
• It’s critical for self-scheduling practices to be accessible and staff friendly. Requiring staff to be on a computer at 0600 or 0000 limits their ability to easily schedule ina way that aligns with their lives and schedules outside of work. Eliminate all paper processes so staff can access and modify schedules remotely.
• Giving nurses autonomy to self-schedule can result in reduced sick calls that create last-minute shift gaps.

Translating into practice

To achieve true schedule flexibility and protect nurses’ mental health, leaders must balance service demands against the needs of their available nursing staff. They must:

1. Define and align on what “self-scheduling” means and become familiar with differences from collaborative scheduling (where scheduling staff develop and the schedule and unit staff representatives adjust it to meetpatient care and staff needs).
2. Review and adjust scheduling policies to align with definitions and the ideal state.
3. Ensure the right technology is in place to enable efficient self-scheduling.
4. Optimize technology so the right staff can schedule accordingly.
5. Eliminate paper and manual processes. Review any scheduling practices, including vacation and call-outs, that require staff to be in-person or rely on someone else to schedule.
6. Enable auto-approvals for trades/swaps not only for self-scheduling but autonomous schedule management as well.
7. Provide training and resources for staffing and scheduling teams, as well as front-line staff.

Rethink how you offer PTO. Nurses’ personal lives, and the people and events within them, often aren’t planned to align with how nurses are expected to request their PTO. To add flexibility for nurses, you may consider offering a 12-month rolling PTO request period. This allows nurses to plan up to a year in advance for vacations without having to wait until the last minute for vacation requests and approvals.

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2. Ensure what is offered aligns with nurses’ needs and preferences.

Reconsider attempts to optimize for full-time. While .9-1.0 FTE is preferred by most health systems, nurses are indicating these options don’t meet their needs for flexibility. Offering nurses an opportunity to work clinically and maintain a position within your health system at a reduced weekly/hour requirement may bea critical factor in increasing nurse engagement. It’s important to recognize these work options allow nurses to maintain their clinical skills during different life transitions and stages, rather than having to step away from front-linecare entirely. It is also an avenue to re-engage nurses who left because there previously weren’t employment options that aligned with their lifestyle needs.

While part-time options may not be the first choice for health systems, being more flexible in offering them can be a win-win, as it gives nurses a way to work that aligns with their lifestyle needs while enabling your health system to have a more robust and dynamic workforce. Leaders may consider:

• Part-time can range from 16 to 32 hours per week (or 32 to 64 hours per pay period) equaling a 0.4 to 0.8 FTE.
• Per diem is meant to be one of the most flexible optionsfor nurses — reassess your per-diem requirements, as well as eligibility for reducing employment to per diem. These options are often inaccessible to younger or less-tenured staff. Consider flexibility in dropping staff down to per diem, in cases where staff members may otherwise leave to pursue other opportunities, such as travel or advanced degrees.
• Build a gig layer: Gig nurses are contracted employees of a hospital or healthcare facility and pick up open shifts at their contracted facility. Gig work truly enables nurses to work in a way that aligns with their lifestyle, enabling them to maintain clinical contribution and skills for longer and through different seasons of their lives.

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Offer partial shifts or hybrid shift lengths. If nurses are willing to cover for 4-8 hours, be flexible with what you’re willing to accept. Partial coverage, or coverage split between 2-3 nurses, can still bring much-needed resourcing and relief to staff and improve patient outcomes. It also gives nurses more autonomy in how clinicians work, with the technology platform Works designed specifically to enable flexibility - allowing clinicians to work at shift lengths that they prefer.

Don’t rely on your nurses to work more hours at their home units. In fact, it may only exacerbate burnout. Ensure nurses can view and pick up shifts outside of their home units. Focus proactive and just-in-time open-shift recruitment efforts on nurses from other units and areasto increase variety, exposure and upskilling. Doing so will also identify opportunity areas for upskilling and sharing of resources.

Enable extra hours on their terms. While off-shift, it’s necessary for nurses to be able to disconnect from work and the notification fatigue that comes with it. Avoid calling, texting or notifying nurses on their days off about needing extra help. By employing technology like Works that integrates with your schedule, you give your nurses the ability to set notification preferences, indicate their availability and access and claim all the open shifts they qualify for that match their preferences with pay and workdetails — on their own time.

Consider how you can support nurses through variety and flexibility. Internal travel programs can save on premium spend and give health systems greater control while providing staffing coverage, but it may be more advantageous to health systems and still not satisfy nurses’ needs.

WORKS drives clinical cost savings and bolsters nurse retention through flexibility and workforce optimization - clinicians moving across units and hospitals to fill shifts with your own labor resources.

Learn more at www.works.ai