From three routine shifts, TTSH now offers six additional variable shifts for nurses
9 MAY 2024
The nature of nursing work often involves irregular hours, long shifts and unexpected demands which have been hindering hospitals’ ability to attract and retain nurses. Having to adhere to routine work schedules can be challenging for nurses, especially as general society trends towards flexible working arrangements such as working from home and flexible hours. Yet, this structure of routine work shifts has enabled the hospital to provide care for patients around the clock.
In October 2023, TTSH piloted its Liquid Nursing initiative in one ward. Today, the hospital has rolled it out to three other wards and will progressively scale to more inpatient areas. The initiative not only accords a good level of flexible shift options and hence work-life balance for nurses, but it also strengthens the way the ward nurses deliver care as a team.
The journey towards greater flexibility
Nursing work is location- and time-specific. It is carried out onsite, during day or night shifts. Any requests for flexible work arrangements would have to be studied carefully by the ward team to assess the impact on operational staffing levels, and the entire team of nurses would typically have to readjust their schedules to accommodate the request. It has been challenging to accommodate flexi-work arrangements in nursing.
Focus group discussions were conducted with nurses, which uncovered:
- Lack of flexibility in shift start and end times, and duration of shifts, resulting in challenges in juggling personal commitments
- Lack of adequate break time due to workload and manpower requirements
- Nurses leaving work later than official shift end time, due to activities such as handover sessions that typically take much time on each shift
A time-motion study was conducted in ward 11C – TTSH’s SMART ward for advancing workforce innovations, to capture what ward nurses do in the three shifts over a 24-hour workday. The study shed light on the peak time periods where patient care needs are the highest and nursing time is most needed. Hence, care activities can be modularised and reassigned to nurses working flexible shift hours.
The nurses then started working on Liquid Nursing to deliver on the better future of care envisioned. This initiative is now transforming the nature of TTSH nursing.
Introducing Liquid Nursing, the flexible nursing schedule with more options
Under the new initiative, ward nursing is redesigned to two broad roles – Principal Nurses (ie. Nurses on routine shifts with full duty of care) and Flexi-Nurses (ie. Nurses on flexible shifts with modularised roles and specific duty of care).
More Shift Diversity
Full-time TTSH nurses can now have a mix of routine and flexible shifts each month. They have six flexible shifts with variable start and finish times, as well as durations, to apply for. These new shifts are much welcomed by the nurses as they can better plan their personal and family responsibilities around work.
| Routine Shift Schedule (Principal Nurses) Shift Duration | Shift Duration |
|---|
| AM | 7 am to 3 pm | 8 hours |
| PM | 1 pm to 9 pm | 8 hours |
| Night | 8 pm to 8 am | 12 hours |
| Flexible Shift Schedules (Flexi-Nurses) Shift Duration | Shift Duration |
|---|
1
| 8 am to 4.30 pm
| 8.5 hours |
| 2 | 10 am to 7 pm | 9 hours |
| 3 | 12 pm to 7 pm | 7 hours |
| 4 | 2 pm to 8 pm | 6 hours |
| 5 | 7 am to 7 pm | 12 hours
|
| 6 | 4-hour shift (flexible timing) | 4 hours |
More role diversity
Flexi-Nurses support the Principal Nurses by assisting with complex bedside procedures such as wound dressings, and providing auxiliary support such as caregiver training, and transporting patients to and from their venues of treatment. Meanwhile, Principal Nurses focus on their clinical core roles, such as participating in doctor’s rounds, nursing assessment and documentation, communication with family, care coordination and shift handovers.
The role of "Procedural Nurse" was also trialed, where a group of surgically trained nurses supported hospital-wide requests for assistance with lengthy bedside procedures. Procedural Nurses provided quality patient care and lightened the Principal Nurses’ workload.
The hospital is also expanding beyond the Procedural Nurse role towards the hybrid model, including taking on various Nurse specialty roles such as Wound Nurse, Nurse Innovator, Nurse Researcher to enhance staff learning experiences and patients’ care outcomes.
The role redesign is complemented by a revised shift handover process. With digitisation, nurses now save 2.5 hours per shift by efficiently retrieving and relaying important information required for continuing care across shifts. The time saved is now directed towards enhancing patient interaction, allowing nurses more time for direct care. Additionally, nurses benefit from well-deserved breaks and the ability to finish their shifts on time.
Boosting morale and efficiency in the hospital wards
The Liquid Nursing initiative has saved some 30 to 90 minutes of a Principal Nurse’s daily time, allowing them to have greater focus on their key tasks, and to have sufficient break times during the shift.
After the two-month-long trial, a post-implementation survey was conducted in November 2023 with the participating nurses to measure its effectiveness.
- More than 60% described their new work arrangements as "flexible" [prior to pilot: less than 35%]
- 70% recorded that they were able to leave work on time for most or all of their shifts [prior to pilot: less than 30%]
- Almost 100% of nurses reported that they were able to rest adequately during a shift [prior to pilot: 54%]
"It is encouraging to see our nurses respond positively to this initiative, with a visibly renewed drive and sense of excitement. The heightened collaboration and esprit-de-corps among the nurses have resulted in greater efficiency in the ward, while still upholding the high standard of care that they have always taken pride in," shared Ms Sui Huangbo, Project Advisor and Deputy Director of Nursing at TTSH. "With the new arrangement, most of the nurses on shift have sufficient breaks, and are taking significantly less time for our handovers. As a flexi-nurse, it gives me great satisfaction to know that I am able to assist the principal nurses in several medical procedures, which can be unpredictable and time-consuming. This has contributed to an overall positive and efficient environment in the ward," shared Tan Jia Hui, Senior Staff Nurse, TTSH. "With this initiative, it feels good to be able to leave on time, allowing me to spend more quality time with my family, and have much more flexibility in managing my personal duties around my work hours," shared Manjares Melody Biag, Senior Staff Nurse, TTSH.
The initiative will be extended to more inpatient wards in TTSH. The team is developing an artificial intelligence-supported software which allows the generation of full shifts and rosters.
"The nursing sector has always grappled with manpower strains. There is a need to strengthen the attractiveness of the nursing profession in a holistic approach that includes incentives such as flexibility at work, aside from the monetary incentives provided by the ministry. The Liquid Nursing initiative will give our nurses the option and autonomy to align with their life stages, commitments, and professional aspirations. Our nurses aspire to go beyond to care for patients and it is important that this aspiration is always nurtured, starting from being supportive and flexible in the way they work, develop, and grow," shared Dr Hoi Shu Yin, Chief Nurse at TTSH.