1. Nelson, Roxanne BSN, RN
  2. Kennedy, Maureen Shawn MA, RN, editorial director


'Flexing down' means nurses are losing money and patience.


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Some nurses refer to it as "health care's dirty little secret," and it goes by a variety of names: "flexing down," "management requested time off," "hospital convenience days," or "staff adjustments." But regardless of what it's called, the outcome is the same. When the patient census decreases and the unit is then overstaffed, nurses' scheduled shifts are routinely cancelled. They will not be paid unless they use vacation time to make up the lost wages and maintain their benefits. As a result, some nurses may be left without any vacation time. Nurses may also be sent home once they have arrived at work or at any time during the shift if there is a change in patient census and the unit is declared to be overstaffed. In response to a letter we received from a nurse complaining about her institution's policy of cancelling RNs' shifts when the census is low, AJN asked readers to send information about their experiences with this practice. We were astonished to receive more than 50 responses.


"At my facility, nurses are cancelled before and during a shift when [the patient] census drops below a prescribed number," wrote Pam Bethke, BS, RN, CHPN, in a letter to AJN. "Additionally, we are expected to remain available should the census increase. No compensation is provided."

Figure. M. Mikki Gre... - Click to enlarge in new windowFigure. M. Mikki Gremp, RN, left one hospital because a number of policies, including its practice of 'flexing down,' left her feeling that nurses weren't valued. Now employed at Porter Memorial Hospital in Valparaiso, Indiana, she says the care provided 'is the kind of nursing I want to be a part of. There are options in place for times of low census and the nurses are well respected and have a voice in how patients are cared for.' She adds, 'Staffing is managed so that there are very few times when someone is told not to come in.'

The specifics vary; some hospitals require nurses to be on call if their shift is cancelled. Some nurses whose shifts are cancelled are required to call in every four hours to see if they are needed, reported a nurse in Kansas. (Some RNs would only share their stories if we didn't use their names.) They must remain available until the end of the shift, because they are still considered scheduled to work.


"My husband and I are both RNs and being sent home or staying home with no pay for low census seems to be standard in our area," wrote M. Mikki Gremp, RN, of her former employer in her letter to AJN. "The policy states that the nurse must be notified of low designation 90 minutes before the start of a shift. If the nurse doesn't receive the required notification and shows up at work, she or he is compensated with two hours of pay."


Generally, per diem nurses' shifts are cancelled first, followed by regular staff. Some hospitals will cancel staff shifts by seniority. Others cancel on a rotating basis, so that lost time is more evenly distributed. A nurse in Southern California reported that travel nurses at her facility have contracts that prohibit their shifts from being cancelled because of a low patient census, so they will work while full-time staff are sent home without pay.


While there are no formal statistics on the practice, it occurs in every type of facility, including Magnet-designated hospitals. Downsizing nurse staffing to meet patient-census demands appears to have been instituted at least 25 to 30 years ago, and nurses report that it contributes to low morale and high turnover rates. It has also made many nurses rethink their career choice or their hospital-based job.


"Back in the late 1990s, I had a nonnursing colleague ask why nurses seemed to have no loyalty to their hospitals anymore," said Bethke. "I asked her why we should be loyal to an employer who hires us for 40 hours a week and then, to save a little money, cuts our income whenever they want to. What other professional is expected to give 100% during the busy times, yet is sent home without pay during the slower times?"


Making headway. Although the practice remains widespread, some progress has been made toward reducing its impact on nurses' income and morale, or in eliminating it completely. As part of its program to make it the most "nurse-friendly" organization in health care, Kaiser Permanente in Northern California has instituted a no-cancellation policy in all of its facilities in that region. This program is the only one of its kind in California, and it is expected to improve morale, decrease reliance on agency nurses, and improve patient care.


When there is a low patient-census day, nurses have a number of options, according to Kaiser spokesperson Gerri Ginsberg. "Options include completing mandatory annual competency training, taking educational programs, or working on projects on their unit, such as quality audits."


Flexing down has been addressed by unions, including the United American Nurses, AFL-CIO (UAN) and the Service Employees International Union (SEIU). Most of the hospitals with UAN representation require schedules to be posted well in advance, and after a schedule is posted, there are often restrictions on how the employer can alter it. At the University of Michigan Medical Center in Ann Arbor, for example, a schedule must be posted two weeks in advance, and unless there is mutual agreement, part of a shift can't be cancelled in exchange for hours elsewhere in the schedule.


"The UAN contracts address this practice by restricting how and when an employer can alter a nurse's schedule and requiring minimum pay if a nurse is sent home due to low [patient] census," commented former UAN president Cheryl L. Johnson, RN, in an interview with AJN in early November. (Johnson died shortly after the interview.) "Staff nurses, just like other workers, need to be able to count on a fair and consistent paycheck from their employers, and our union contracts help us achieve that."


Chris Barton, RN, currently secretary-treasurer of SEIU District 1199 NW, made this an issue in 1989 while working labor and delivery at a Group Health Cooperative facility in Washington State. Since patient census in that specialty continually fluctuates, Barton said, that it was a "feast or famine" issue.


"We would jump from doing overtime one day, to being called off the next, and then being begged by administration to come in on our day off," said Barton. "We felt like we had no schedule at all."


The facility had unionized six years earlier with 1199 NW, and in 1989, 1,200 nurses went on strike for six weeks over the issue of cancelled shifts. The nurses won the strike and negotiated for the creation of a "low census fund."


"We did research and came up with a dollar amount that the hospital puts into the fund, and nurses are paid through this fund to work on other projects when the [patient] census is down," said Barton.


The SEIU negotiated setting up this type of fund in other hospitals in Washington State, and many have adopted it in various forms, including large facilities such as the Swedish Medical Center in Seattle.


Julia Weinberg, RN, a nurse from Bow, Washington, wrote to AJN that she believes that changing the working environment is the key to solving the nursing shortage. "Employers need to pay nurses well and pay them for the time that they are contracted, and nurses should be working as scheduled," she said. Weinberg believes that if nothing changes and employers continue the same detrimental practices, all of the recruiting, educating, training, and placing of new staff will be to no avail.


Roxanne Nelson, BSN, RN


Maureen Shawn Kennedy, MA, RN


editorial director