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How Will The Change Be Measured?

What can be the biggest challenges to facilitate the program?

How the message will be communicated to the stakeholders?

My Employment

In the profession of nursing, long shift hours or extended shifts are not an uncommon thing. Due to the high amount of stress on healthcare professionals to address the healthcare needs of the patients and also due to frequent inadequacies in the number of skilled and experienced nurses, extending the shift timings to assist more patients or other healthcare professionals, nurses often have to work 10 to 12 hours at a stretch (Caruso 2014). This causes significant fatigue and stress among the nurses and also adversely affects their productivity and competency (Kivimäki et al., 2015).

The aim of this study is to develop a project aimed to reduce stress and fatigue among nurses due to long shift hours. For this purpose, the Wadula workbook is used in order to develop an idea or initiative from its conceptual stage to a point where it can be proposed to others and engage them in the development of the idea or concept in a cooperated fashion. The workbook involves the following important steps: step 1: identifying the puzzle, step 2: clarifying the purpose, Step 3: Looking at the evidence, Step 4: Engagement of people, Step 5: Identifying contexts, Step 6: Evaluation of the outcomes, Step 7: Facilitation of the implementation process and Step 8: Implementing the project (Uche et al. 2017). These steps helps to develop a logical flow between the conception and development of the idea to address a particular situation or challenge, identify strategies to address those challenge, identify how these strategies can address the challenges or context, how to evaluate its success and how these strategies can be used and implemented in an effective manner to ensure it addresses the challenges.

I am currently employed in emergency nursing department where I have to treat patients in the emergency ward. Every day several new patients are admitted to this department, all in need of significant care and often require nurses to extend their shift timings to compensate for staff shortage or to provide comprehensive care for the patient. Previously I also worked in the critical care unit, which was also a very stressful job.

I am working in a public hospital in Australia.

My main responsibilities in the emergency department is to assist the doctors to treat the patient, administration of medications as prescribed by doctors, cleaning of wounds, setting intravenous channels. I am also responsible to develop a therapeutic relation with the patient and their family or caregivers and help in the early recovery of the patient. Additionally, I have the responsibility of preparing care plan for the patients, and providing them instructions for their recovery and long term care.

Name of Agency where I am employment

Identifying the puzzle: The initiative that I want to implement is to support the nurses to manage their stress caused due to extended shift timing. The idea is to help them overcome this stress in order to prevent a loss of productivity or incidences of clinical errors due to fatigue and provide support to the nurses to prevent the necessity for extending their shift timings and overcome stress and fatigue at work. The puzzle question is “how can we help the nurses to overcome or prevent fatigue and stress at work due to their long working hours?” This provides a Generative opportunity to identify strategies through which stress and fatigue can be avoided or prevented and improve the productivity and clinical competency of the nurses. This helps to identify more than one possible solution and select the most appropriate solution or combination of solutions to address the problem (Phillips and Miltner 2015).

The purpose of the proposal is to identify strategies that can be used to help the nurses to overcome the effects of long shift hours and maintain their productivity and performance. The significance of these strategies is implied through the impact of long shift hours on the health, wellbeing, productivity and efficiency of the nurses in healthcare. In healthcare organizations, nurses often have to work on extended shift timings in order to compensate for a lack of skilled and experienced workforce or due to increases in patient admissions. Also a lack of effective clinical governance can lead to nurses working for long shift hours as the nurses get unequal share of workload which they have to manage themselves and inadequate support to help them properly take care of their responsibilities. According to Han et al. (2015) these long shift timings, the nurses often experience fatigue, which adversely affects their performance as well their health, and lead to dissatisfaction in patients due to poor care delivery (Liu et al., 2016).

What would be better for the nurses? Our services can help the nurses to manage their stress and fatigue between work to overcome the effects of extended working hours, provide support to the nurses to manage their time in a more effective manner, helping them identify the early warning signs of burnout, support healthy lifestyle and adequate sleep and also propose the need for additional staffing to address the need for extra workforce (van der Riet et al. 2015; Delaney et al. 2016).

Main focus of my job role

Evidence that suggests that change is needed: Studies show that working in long shift timing can cause fatigue among the nurses which can increase the risks of clinical errors. Such as aspect has been supported by other studies that show most of the clinical errors are caused mostly due to fatigue (Caruso 2014; Hayes et al. 2015). The long shift and its associated stress and fatigue also results in burnout syndrome, which can affect the job satisfaction of the nurses. Burnout and the resultant clinical errors can also cause dissatisfaction among the patients. Fatigue can also adversely affect the health of the nurses as it can lead to loss of sleep, sleepiness during work, decision regret as well as negative cognitive emotions. These studies suggest that the long shift hours can have overall negative impact on both the healthcare professionals as well as the service users (Interests 2015; Bae and Fabry 2014).

What is happening now? Currently due to a shortage of skilled and experienced nurses, the experienced nurses often have to take up multiple responsibilities such as mentoring new nurses, supervising and collaborating the duties of other nurses and from time to time cover for other nurses who did not show up for work. Also, there is an uneven distribution of work across the various departments, due to which some nurse ends up having more work to tend to compared with other nurses. Due to this many nurse have to work more than 10 or 12 hours in a single day, with every experienced and skilled nurse doing more than 20 hours of extra work every week in average (Caruso 2014).

Evidences that support a need for change: Recently the rate of clinical errors has increased even from experienced and skilled nurses, and complaints of fatigue, burnout and reduction in productivity have been made by the healthcare professionals. Almost 73% of the nurses complained that they work more than 10 hours every day since the last 2 years, and the rate of clinical errors have increased by more than 57% in this time. 89% of these nurses have stated that fatigue was the main reason for the clinical errors, while 34.5% of the nurses were diagnosed of burnout syndrome and compassion fatigue. 43.6% of the nurses also complained that they do not get adequate sleep or do not get enough time to spend with their family, friends or relaxing (Caruso 2014; Wickwire et al. 2017; Conway et al. 2017).

What I want to change

Where these evidences can be sourced: These evidences can be sourced to the clinical management and clinical governance teams to support my proposal.

Evidences that can support the proposal: In order to support my proposal adequately and persuasively, information related to the increase in clinical errors, amount of additional shift timing the nurses have to work for, shortage of staffing, diagnosis of fatigue and burnout syndromes among nurses, reduced job satisfaction of nurses, patient dissatisfaction, poor staff retention rates and nurses not getting enough rest and sleep (Caruso 2014; Acton et al. 2017).

Strength of the evidence: All the evidences are empirical and quantitative in nature and are therefore very strong and convincing

Thoughts about the evidence can support the given problem: These evidences can help to understand the relation between long shift hours and fatigue of the nurses and its effect on the performance and job satisfaction (Clinton 2017).

Key partners I need to work with directly as a part of the engagement process: Nurses, Nursing supervisors, doctors/physicians, hospital administration, psychologists, lifestyle consultants and occupational safety advisors.

Individuals who needs to be engaged in consultation process: Lifestyle consultant, occupational advisors, doctors and physicians and hospital administration and governance.

Individuals who need to be kept informed and communicated with: Nurses, Nursing supervisors, doctors/physicians, hospital administration, psychologists, lifestyle consultants and occupational safety advisors (Clinton 2017).

Any exclusions and reasons for exclusion: None

People who might be supportive to the proposal: Nurses, nursing supervisors, doctors/physicians, patients, and advisors.

People who might react negatively to the proposal: Hospital administration.

Who will be interested in the puzzle?  All the stakeholders

Will the parties approach the engagement with the intention to succeed? The involved parties are most likely to approach being engaged in the project with the intention to succeed in it and allow the nurses to overcome stress and fatigue due to long working hours.

Any precondition for engagement: The project won’t be supported if additional resources and expenses are needed for the solution. The nurses would also expect that the program can help them to alleviate stress and fatigue at work.

Do I have a solution in mind? The main solutions I have in my mind are: stress management activities, time management, getting adequate sleep, breaks and relaxation between work, provisions for vacations, improve lifestyle and eating habits, helping nurses to balance work and personal life, involving meaningful activities in the spare time and develop positive thinking (Caruso 2014; Acton et al. 2017; Clinton 2017).

Purpose Behind the proposal

Whether I already tried to engage around this problem or similar issues? I have previously tried to address the issue related to the understaffing of the nurse which caused increase in the stress on the healthcare professionals, causing them to work extra hours.

Other questions that might be related to engagement? Questions related to the engagement includes, “how time management can help to prevent long shift hours”, “how improving staffing can prevent long shift hours” and ‘how adequate breaks can help the nurses to relax between work” (Clinton 2017)

Positive and negative aspects: The positive aspects of this program are that it can prevent fatigue and burnout in nurses working in long shift hours. The negative aspect of the program is that it can be challenging for the administration to ensure effective management of the care delivery while avoiding the nurses having to extend their shift timing (Lacy and Chan 2018).

Readiness for change: There is an adequate readiness for change among the nurses, as they realise how the long shift timing is affecting their productivity and health.

Time and energy that needs to be contributed or devoted for the process: The nurses need to take at least one hour from their work schedule to participate in the program. The administrators also have to give an equivalent amount of time every day.

Do the involved people have the emotional and cultural competency to cope up with the problem? No, the nurses are unable to cope up with problem on their own; they need additional support from administration and consultants. However they are emotionally and culturally competent to participate in the program.

Will the evidence/proposal be considered applicable to the context? The evidences are all applicable to the context and the proposals are also applicable to address the problems.

  • Feasibility: The identified strategies are feasible to be implemented in the given environment.
  • Acceptability: The nurses are acceptable to the proposal if adequate support is given from the administration.
  • Meaningfulness: The proposed resolutions are all meaningful to the given context and can help the nurses to overcome stress and fatigue.
  • Effectiveness: The solutions can be very effective to address the problem.

Other questions related to current context: Can the relaxation strategies help to reduce fatigue and improve clinical performance? Can reducing fatigue prevent clinical errors? Can the long working hours be avoided by hiring new nursing staff?

(Hayes et al. 2015)

How to identify the impact of the change/ Potential Outcomes:

  • On Patients: Impact on patients can be seen in the form of improved patient satisfaction, better therapeutic relations with healthcare providers and prevention of adverse health effects due to clinical errors.
  • On Staff: Impact on the healthcare staff can be identified through better productivity, lesser clinical errors, improved job satisfaction, reduced diagnosis of burnout syndrome and an improved well being of the healthcare professionals as well as improvement in competency.
  • On Service: Better accuracy, reliability, quality, compassion, timeliness and appropriateness of care delivery and healthcare service. Better customer centricity of care.

(Caruso 2014; Acton et al. 2017; Clinton 2017)

Data that is needs to be collected to evaluate these outcomes: To evaluate the potential outcomes identified above the following data are needed: patient satisfaction scores, incidence of adverse health incidents due to clinical errors, staff productivity, number of clinical errors, job satisfaction scales of the nurses, number of nurses diagnosed of burnout syndromes, staff retention rates, the qualifications, skills and competencies of the nurses and accuracy of care (Rhéaume and Mullen 2018).

Justification or Rationale

Where these data can be collected: The data can be collected from the hospital administration and management as well as from reports of external audits (Duarte and Pinto-Gouveia 2017).

What data is already being collected: Currently I am already collecting information related to the rate and number of clinical errors, diagnosis of burnout syndrome, the job satisfaction of the nurses and the extra shift hours the nurses have to work for.

Any new information that might be identified: There is a possibility to identify a relation between the knowledge, experience and skills of the nurses with the rate of clinical errors.

Additional question related to the evaluation process: Additional questions that might be relevant to the context include: Are the errors due to lack of expertise of the nurses? Can staffing increase really address the problem of fatigue and clinical errors? (Rhéaume and Mullen 2018)

Mobilising cooperation instead of resistance: It is important to attract cooperation from the stakeholders to ensure their participation in the program.

How to facilitate the engagement process: The engagement of the nurses in the program can be encouraged through the focus on improvement of their health and well being through stress and fatigue reduction strategies, and also the possible improvement in their performance and reduction in clinical errors. The program can be facilitated through the involvement of the nursing supervisors, administration and independent advisors.

How my team can respond to the proposed change? My team would be very receptive of the change as it can support an overall improvement in the wellbeing of the nurses as well as patients (Duarte and Pinto-Gouveia 2017).

Need for advice and whom to seek advice from: Advice can be very crucial for the success of the program. Advice can be sought from the independent advisors on healthy lifestyle and occupational health as well as sleep therapists, psychologists and physicians.

Best strategy to communicate the puzzle to others to mobilise support: The best strategy to communicate the puzzle with the key stakeholders is to focus on how the problem of long shift timing and fatigue is affecting the performance of the nurses, increasing clinical errors and also adversely affecting the health and wellbeing of both the healthcare professionals as well as the patients. The focus can be made on the benefaction of the healthcare professionals through the program (Rhéaume and Mullen 2018).

Any other thoughts or questions related to the facilitation process: and would the program hamper the productivity of the nurses?

What is happening now

Timeline: The program will be conducted for one month, where the nurses will undergo one hour sessions every alternative day (3 days a week)

Consultation: For the development of the program consultation from occupational health advisors, sleep pathologist or therapist, psychologists, physicians and lifestyle consultants can be involved. Also consultation from the hospital administration, nursing supervisors and physicians in charge can be very useful for the success of the program.

Reporting: All the collected data will be shared with the administration and the researcher team. Analysis if the data will also be shared with everyone at the end of the data analysis of the process in a seminar. Progress of the program will also be reported to the administration as well as the nurses.

Reference Groups: Studies on other hospitals can be used as reference to the study to understand if the given context of puzzle is a common theme and identify strategies or insights from those studies. Studies on other healthcare professionals showing the relation between shift timing and stress with clinical errors can also be important reference points in the study.

Inter Professional Involvement: The program would require involvement from different healthcare professionals such as psychologists, physicians, sleep therapist and lifestyle therapists.

(Han et al. 2015; Liu et al. 2016; Delaney et al. 2016)

Actions that will give the best chances of success with the puzzle: The actions that can be used to ensure best chances of success with the puzzle includes conducting seminars and workshops with the nurses to educate them regarding strategies to manage their stress and fatigue, helping them to take break from work to relax during their shift timings, educating them about adequate sleep and proper diet, educating on strategies to get optimal sleep and rest, educating them about time management strategies and helping them to engage in meaningful activities in their spare time (Delaney et al. 2016).

Specific actions that can need to be acted upon: Actions such as relaxation techniques, time management techniques, sleep therapies; anxiety management and positive thinking development sessions can be useful.

People or services with which relations need to be developed before launching the puzzle, and the actions needed to do that: Before launching the puzzle, it is important to develop relations with the nurses, nursing supervisors, hospital administrators and physicians. Involving them in open discussion regarding the problem or puzzle and understanding their views on how they can be addressed can help to develop an effective channel of communication (Hayes et al. 2015).

Evidence that suggests that change is needed

Specific actions related to the environment and resource before taking the puzzle out: It is vital to set up the ideal venue for conducting the seminar and workshops with the nurses. Training materials needs to be developed with support from the advisors, nursing supervisors, administrators and physicians as well as from the patient surveys. Support needs to be given to the nurses to allow them to take out the extra 1 hour for the session (Phillips and Miltner 2015; Neville et al. 2017).

Message for the key partners: “Let us work together to overcome the stress and anxiety in the midst of the strenuous work, and prevent any more clinical errors and job dissatisfactions/burnouts”

“We would like to discuss with you how we may work together around the proposal to reduce stress and anxiety due to long shift hours with the view of achieving better clinical performance and lesser clinical errors and prevent burnout or job dissatisfaction among nurses. The main reason for undertaking the proposal is the increase in the number of clinical errors and long shift hours nurses have to work for everyday, and we hope that by working together we may be able to generate a solution which is beneficial to us all and the clients for whom we care”

All the nurses are invited to participate in the program which can help to overcome stress and fatigue due to long shift hours and prevent burnout. The program would require active involvement where strategies taught during the program can be implemented by the nurses in their professional and personal life to overcome or avoid stress, fatigue and burnout and prevent its adverse effect on professional and personal life. The advisors, nursing supervisors and hospital administration will have passive involvement, as they will be kept informed about the progress of the program and its final outcomes (Johnson et al. 2017;

We are proposing to engage around the puzzle of ‘how can we reduce the incidence of clinical errors due to fatigue among nurses. The purpose of engaging around the puzzle is to reduce the number of clinical errors that has been identified in this hospitals, most of which has been caused due to fatigue and stress. We hope that by funding solutions for this puzzle, our patients, staff and service would benefit in the following ways: improvement in patient satisfaction levels, better therapeutic relations, avoiding adverse health outcomes due to clinical errors, improved job satisfaction, reduced clinical errors, improved clinical competency, better mental and physical wellbeing of healthcare professionals, improvement in clinical competency due to reduced errors, better safety and accuracy of service and improved customer centricity of the service. The evidence that we have to support our belief that this puzzle is important is based on the clinical details and statistics of the hospital administration showing an increase in the number of clinical errors over the last 2 years, along with the increase in healthcare professionals working for long hours (more than 10 or 12 hours). The evidence that we still need to collect includes patient satisfaction scores, number of adverse health events due to clinical errors, job satisfaction scales of the nurses, diagnosis of burnout syndrome of the nurses, staff retention rates over the last two years and the skill and competency levels of the nurses. The people or services that we have identified as the most important to this puzzle are the nurses, patients, hospital advisors and supervisors, and we think that we will still need more to engage directly with the nurses, supervisors and administrators to seek solution for this puzzle. We have identified the following features of the current context as being important for supporting the puzzle such as relaxation techniques, time management, adequate sleep, healthy diet, work-life balance, engaging in meaningful activities in spare time and stress management strategies. We propose evaluating any changes generated through the process by analysing any change in the number of clinical errors, report of fatigue, stress and burnout and satisfaction levels of the patient. In order to facilitate the initial engagement of key stakeholders with the puzzle, we will communicate the puzzle by seminars, meetings and discussions (Myers et al. 2018).

Evidences that support a need for change

This project can help to understand the effect of stress on healthcare professionals. Findings of the study can be implemented on other healthcare professionals apart from nursing.


Long working hours are a common thing for many healthcare professionals, and this has resulted in the professionals being stressed at work. Due this fatigue, clinical errors can occur and affect the performance of the professionals. It is vital therefore that strategies be devised that can reduce the anxiety and stress among the professionals and support them with ways to overcome the stress related to work. Considering that in a healthcare profession extra work might not be avoidable, it is important that the providers are aware of strategies they can use to overcome the effect of fatigue and stress and prevent burnout at work. This also can help to maintain the safety and quality of healthcare and support the overall health and wellbeing of the healthcare professional as well as the patients.


Acton, J., Tucker, P.E., Bulsara, M.K. and Cohen, P.A., 2017. Working hours of obstetrics and gynaecology trainees in Australia and New Zealand. Australian and New Zealand Journal of Obstetrics and Gynaecology, 57(5), pp.508-513.

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