Preoperative nutritional status and postoperative health outcomes in older adults undergoing spine surgery: Electronic health records analysis.

AIM: To examine whether a high nutritional risk status, assessed via the Geriatric Nutritional Risk Index (GNRI), is independently associated with postoperative health outcomes, including unplanned intensive care unit (ICU) admissions, infectious complications, and prolonged length of stay in older patients undergoing spine surgery. METHODS: We conducted a retrospective descriptive study analyzing electronic health records from a tertiary hospital, including data from 1,014 patients aged ≥70 undergoing elective spine surgery between February 2013 and March 2023. RESULTS: High nutritional risk patients had significantly higher odds of unplanned ICU admission, infectious complications, and prolonged length of stay compared to low-risk patients. For each one-point increase in GNRI, there was a significant 0.91- and 0.95-fold decrease in the odds of unplanned ICU admission and infectious complications, respectively. CONCLUSION: GNRI screening in older patients before spine surgery may have potential to identify those at elevated risk for postoperative adverse outcomes.

Nursing teamwork is essential in promoting patient-centered care: a cross-sectional study.

BACKGROUND: There has been little research regarding nursing teamwork, despite its important role in multidisciplinary teamwork in healthcare settings and its significance in ensuring high-quality nursing care. This study aimed to determine the teamwork levels of Korean nurses and examine the relationship between nursing teamwork and patient-centered care while controlling for other individual and work-related factors. METHODS: We conducted a cross-sectional analysis of online survey data. The study population consisted of 992 Korean registered nurses employed in hospitals who had a minimum of six months of clinical experience. We performed latent profile analysis to identify latent teamwork subgroups based on response patterns. We performed analysis of variance and Chi-square tests to examine differences in individual and work-related characteristics according to teamwork group. We used multiple linear regression to investigate how nursing teamwork could affect patient-centered care after controlling for covariates. RESULTS: We identified three nursing teamwork subgroups: low, mid, and high. Nurses with a higher level of teamwork in their units tended to work fewer hours with more adequate staffing (F = 5.88, p = 0.003 for working hours; F = 7.68, p < 0.001 for staffing adequacy). There was a significant positive association between nursing teamwork and patient-centered care after controlling for personal and work-related characteristics. Compared with low teamwork, mid and high teamwork increased patient-centered care scores by 0.32 (95% confidence interval [CI] = 0.23-0.40) and 0.57 (95% CI = 0.48-0.66), respectively. CONCLUSION: Our findings indicate that enhancing nursing teamwork can serve as an effective strategy for promoting patient-centered care. Providing nurse education and training to equip nurses with the necessary knowledge and skills for effective teamwork is a crucial step. Additionally, fostering management commitment to create a supportive working environment, including adequate staffing, can facilitate improved nursing teamwork and, subsequently, patient-centered care.

Mobile Internet Use and Life Satisfaction Among Older Adults: The Moderating Effect of Living Alone.

This study, informed by the principle of the Conservation of Resources (COR) theory, evaluated the relationships between mobile internet use frequency, living arrangement, and life satisfaction in older adults. We used data from the 2021 Digital Divide Survey in South Korea, conducting a secondary analysis on 2105 participants aged 65 or above who accessed the internet in the last month. Multiple linear regression models were performed. Compared to the older adults who lived with others, those living alone showed a stronger positive association between their use of the mobile internet for daily services, information production and sharing, social participation, and life satisfaction. These findings align with the principle of the COR theory, suggesting that older adults living alone due to a loss in resources are more likely to benefit from mobile internet use, indicating the potential effectiveness of promoting mobile internet use as a strategy to enhance their life satisfaction.

Nurses' Rest Breaks and Fatigue: The Roles of Psychological Detachment and Workload.

BACKGROUND: Rest breaks have been shown to reduce acute fatigue, yet not all nurses who take rest breaks report lower fatigue. Psychological detachment-letting go of work-related thoughts-during rest breaks and workload may be key factors in explaining this phenomenon. OBJECTIVE: To examine the mediating role of psychological detachment during rest breaks and determine how workload moderated that pathway to lower acute fatigue among hospital nurses. METHODS: In this cross-sectional study, data were collected from 1861 12-hour shift nurses who answered an online survey between July and September 2021. The survey included measures of occupational fatigue, psychological detachment from work, workload, and questions on breaks, work, health, and demographics. Structural equation modeling was used in Mplus 8.9 software to estimate the direct and indirect effects of rest breaks on acute fatigue at 3 levels of workload. RESULTS: Nurses, on average, reported high acute fatigue, rarely experienced psychological detachment during rest breaks, and reported heavy workloads. Around 60% were able to sit down for a break on their last shift but with patient-care responsibilities. The relationship between taking a rest break and acute fatigue was fully mediated by psychological detachment from work. However, this relationship only held in the context of manageable workloads. CONCLUSION: Our findings showed that within-shift recovery is possible when nurses can psychologically detach from work during rest breaks. However, this within-shift recovery mechanism was disrupted for nurses with heavy workloads.

Psychological safety, communication openness, nurse job outcomes, and patient safety in hospital nurses.

Promoting psychological safety in a workplace is known to contribute to improved job outcomes across a wide variety of industries. This study aimed to examine the relationships between psychological safety at work and job outcomes (i.e., job satisfaction and intention to leave), and patient safety among hospital nurses; and to determine the mediating effect of communication openness on these relationships. This cross-sectional study used survey data from 867 hospital nurses working in the United States. Multiple logistic regression models and Hayes' PROCESS macro in SPSS were used. Nurses who worked in an environment with higher psychological safety levels were more likely to be satisfied in their current job, less likely to intend to leave their current job within the next year, and more likely to report favorable patient safety ratings. Communication openness mediated these relationships. When nurses feel psychologically safe at work, they are more likely to engage in open communication, which in turn can lead to greater job satisfaction, decreased turnover intention, and improved patient safety. Nurse managers should strive to develop leadership strategies that promote psychological safety in the work environment and support open communication among nurses.

Hospital staff nurse perceptions of resources and resource needs during the COVID-19 pandemic.

BACKGROUND: There is a knowledge gap related to the resource needs of hospital nurses working during the Coronavirus disease 2019 (COVID-19) pandemic. PURPOSE: To investigate nurses' perceptions of organizational resources and support needs approximately 18 months after the COVID-19 pandemic began. METHOD: Cross-sectional survey of a convenience sample of 2,124 U.S. hospital nurses from July to September 2021 FINDINGS: There were some misalignments between what resources were provided to nurses and what was perceived as helpful to them. Nurses reported increased staffing, compensation, and management and leadership support most frequently as resources that could help them continue to provide safe and quality care during and after the pandemic. These were also the resources nurses most frequently reported that they wanted to be provided by their hospitals during the pandemic but were not. DISCUSSION: The findings offer valuable insights into how organizations can prepare to ensure workforce resilience during future crises.

The State of Rest Break Practices Among 12-Hour Shift Hospital Nurses in the United States.

OBJECTIVE: This cross-sectional study aimed to explore the characteristics, content, and context of rest breaks taken by hospital nurses. BACKGROUND: Nurses often miss, skip, or take interrupted breaks. To improve the quality of breaks and promote within-shift recovery, it is important to understand current rest break practices including break activities and contextual challenges around them. METHODS: Survey data from 806 nurses were collected between October and November 2021. RESULTS: Most nurses did not take regular breaks. Rest breaks were often interrupted, spent being worried about work, and rarely resulted in a relaxed state. Common break activities were having a meal or a snack, and browsing the Internet. Regardless of workload, nurses considered patient acuity, staffing, and unfinished nursing tasks when deciding to take breaks. CONCLUSION: Rest break practices are of poor quality. Nurses mainly consider workload-related factors when taking breaks, which warrants the attention of nursing administration.

Translations and psychometric validation of the Korean version of the Nursing Teamwork Survey.

Enhancing nursing teamwork benefits both patients and nurses. The Nursing Teamwork Survey is a reliable, valid tool to evaluate nursing teamwork. This study was conducted to translate and psychometrically validate the Nursing Teamwork Survey for nurses in Korea. In Phase 1, the Nursing Teamwork Survey was translated into Korean using forward and backward translations. Content and face validity were determined using expert review and pilot testing, respectively. In Phase 2, we evaluated construct and convergent validity and internal consistency, and test-retest reliability. We used survey data from 1119 hospital nursing staff; 98 of whom completed the Korean version of the Nursing Teamwork Survey after 2 weeks. Confirmatory factor analysis showed an acceptable fit (χ2 /df ratio = 3.96, root mean square error of approximation = 0.05, standardized root mean square residual = 0.05, comparative fit index = 0.91, and Tucker-Lewis index = 0.90) with good internal consistency (Cronbach's α = 0.76-93) and test-retest reliability (rs = 0.63-0.83). Convergent validity was supported by the correlation between the subscales of the Korean version of the Nursing Teamwork Survey and the Teamwork Within Units subscale of the Hospital Survey on Patient Safety Culture (rs = 0.45-0.69, ps < 0.01). These findings indicate that the Korean version of the Nursing Teamwork Survey is a reliable and valid measurement for assessing nursing teamwork. The Korean version of the Nursing Teamwork Survey can inform management strategies to promote nursing teamwork and improve patient safety and nurses' well-being.

Insomnia, fatigue and psychosocial well-being during COVID-19 pandemic: A cross-sectional survey of hospital nursing staff in the United States.

AIMS AND OBJECTIVES: To describe the levels of insomnia, fatigue and intershift recovery, and psychological well-being (burnout, post-traumatic stress and psychological distress), and to examine differences in these measures based on work-related characteristics among nursing staff during COVID-19 pandemic in the United States. BACKGROUND: The COVID-19 pandemic has created a major physical and psychological burden on nursing staff in the United States and worldwide. A better understanding of these conditions will lead to tailored support and resources for nursing staff during and after the pandemic. DESIGN: Cross-sectional study. METHODS: Hospital nurses and nursing assistants (N = 587) were recruited online between May-June 2020. The survey included measures on insomnia (Insomnia Severity Index) fatigue and intershift recovery (Occupational Fatigue and Exhaustion Recovery-15), burnout (Maslach Burnout Inventory-Human Services Survey), post-traumatic stress (Short Post-Traumatic Stress Disorder Rating Interview) and psychological distress (Patient Health Questionnaire-4), and questions on work and demographics. The STROBE checklist was followed for reporting. RESULTS: The sample had subthreshold insomnia, moderate-to-high chronic fatigue, high acute fatigue and low-to-moderate intershift recovery. The sample experienced increased emotional exhaustion and depersonalisation, increased personal accomplishment, moderate psychological distress and high post-traumatic stress. Nurses who cared for COVID-19 patients had significantly scored worse on almost all measures than their co-workers. Certain factors such as working hours per week and the frequency of 30-min breaks were significant. CONCLUSION: Nursing staff experienced poor sleep, fatigue and multiple psychological problems during the COVID-19 pandemic. Moreover, staff who were involved in the care of COVID-19 patients, worked more than 40 h per week and skipped 30-min breaks showed generally worse self-reported outcomes. RELEVANCE TO CLINICAL PRACTICE: Nursing administration is recommended to monitor for fatigue and distress on nursing units, re-visit current scheduling practices, reinforce rest breaks and provide access to mental health and sleep wellness resources with additional support for their front-line nursing groups.

Primary care nurses' perception of leadership and the influence of individual and work setting characteristics: A descriptive study.

AIMS: The aim of this study is to describe primary care nurses' perceptions of their formal leaders' leadership behaviours and outcomes and explore differences based upon nurses' individual and work setting characteristics. BACKGROUND: Formal nursing leadership is positively associated with patient, nurse workforce and organizational outcomes, yet no studies have examined primary care nurses' perception of formal leadership behaviours and outcomes in the United States. METHODS: Cross-sectional survey data from 335 primary care nurses were analysed to assess perceived leadership behaviours associated with transformational, transactional and passive-avoidant leadership styles, perceived leadership outcomes and individual and work setting characteristics. RESULTS: Positive leadership behaviours (transformational) were lower than those reported for other settings. There were significant differences in nurses' perceptions of their leaders' leadership behaviours and outcomes based upon individual and work setting characteristics. CONCLUSION: This study confirmed differences in perception of leadership and that individual and work setting characteristics influence nurses' perception of their leaders in primary care. IMPLICATIONS FOR NURSING MANAGEMENT: Leaders must be versatile and consider the unique needs of each staff member and the influence of clinic characteristics.

The insomnia, fatigue, and psychological well-being of hospital nurses 18 months after the COVID-19 pandemic began: A cross-sectional study.

BACKGROUND: Research has shown sleep problems, elevated fatigue, and high cases of burnout, as well as signs of post-traumatic stress and psychological distress among nurses during the COVID-19 pandemic. Many US hospitals attempted to minimise its impact on staff by providing basic resources, mental health services, and wellness programs. Therefore, it is critical to re-evaluate these well-being indices and guide future administrative efforts. PURPOSE: To determine the long-term impact of the COVID-19 pandemic after 18 months on hospital nurses' insomnia, fatigue, burnout, post-traumatic stress, and psychological distress. DESIGN: Cross-sectional. METHODS: Data were collected online mainly through state board and nursing association listservs between July-September 2021 (N = 2488). The survey had psychometrically tested instruments (Insomnia Severity Index, Occupational Fatigue Exhaustion Recovery Scale, Maslach Burnout Inventory, Short Post-Traumatic Stress Disorder, and Patient Health Questionnaire-4) and sections on demographics, health, and work. The STrengthening the Reporting of Observational studies in Epidemiology checklist was followed for reporting. RESULTS: Nurses had subthreshold insomnia, moderate-to-high chronic fatigue, high acute fatigue, and low-to-moderate intershift recovery. Regarding burnout, they experienced increased emotional exhaustion and personal accomplishment, and some depersonalisation. Nurses had mild psychological distress but scored high on post-traumatic stress. Nurses who frequently cared for patients with COVID-19 in the past months scored significantly worse in all measures than their co-workers. Factors such as nursing experience, shift length, and frequency of rest breaks were significantly related to all well-being indices. CONCLUSION: Nurses' experiences were similar to findings from the early pandemic but with minor improvements in psychological distress. Nurses who frequently provided COVID-19 patient care, worked ≥12 h per shift, and skipped rest breaks scored worse on almost all well-being indices. RELEVANCE TO CLINICAL PRACTICE: Administration can help nurses' recovery by providing psychological support, mental health services, and treatment options for insomnia, as well as re-structure current work schedules and ensure that rest breaks are taken.

Occupational fatigue, workload and nursing teamwork in hospital nurses.

AIMS: To evaluate the relationships between workload, nursing teamwork and nurse fatigue and the moderating effect of nursing teamwork on the relationship between workload and fatigue. DESIGN: This cross-sectional online survey study used data from 810 United States hospital nurses collected between March and April 2021. METHODS: Workload, nursing teamwork and fatigue were measured using the Quantitative Workload Inventory, the Nursing Teamwork Survey, and the Occupational Fatigue Exhaustion Recovery scale. Hierarchical multiple linear regression models were used. RESULTS: All the nursing teamwork subscales (i.e. trust, team orientation, backup, shared mental model, team leadership) were significantly negatively related to acute and chronic fatigue. Nursing teamwork components of team orientation, shared mental model and team leadership moderated the relationship between workload and chronic fatigue. The relationships between workload and chronic fatigue were stronger when these components of nursing teamwork were high. No moderating effects were found with acute fatigue. CONCLUSION: Efforts to increase nursing teamwork may be a promising strategy in managing nurse fatigue. It is equally important to monitor and modify high workload to protect nurses from elevated fatigue. IMPACT: WHAT PROBLEM DID THE STUDY ADDRESS?: Fatigue is negatively associated with the health and safety of hospital nurses and patients. Nursing teamwork has been shown to improve the nursing care of hospitalized patients; yet, it is rarely explored in relation to nurse fatigue. WHAT WERE THE MAIN FINDINGS?: Greater nursing teamwork is significantly associated with lower acute and chronic fatigue. The relationships between workload and chronic fatigue were stronger when nursing teamwork (i.e. team orientation, shared mental model and team leadership) was high than when nursing teamwork was low. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: Improving nursing teamwork, in addition to monitoring and modifying workloads, can be a promising approach for managing fatigue in healthcare organizations.

Occupational fatigue, individualized nursing care, and quality of nursing care among hospital nurses.

PURPOSE: This study aimed to evaluate the relationships among nurse fatigue, individualized nursing care, and nurse-reported quality of care. DESIGN: The study used a cross-sectional design. Data from 858 registered nurses providing bedside care in hospitals were collected between March and April 2021 in the United States. METHODS: Participants completed a self-administered online survey, including the Occupational Fatigue Exhaustion Recovery scale, the Individualized Care Scale-Nurse version, and a single item assessing nursing care quality. Relationships among the study variables were examined using multiple linear and logistic regression models. FINDINGS: Nurses' higher levels of acute fatigue were significantly associated with decreased perceptions of individualized nursing activities provided to patients on their last shifts, specifically related to personal life condition and decision-making control. Nurses' higher levels of chronic fatigue were significantly associated with decreased perception of individualized nursing activities provided to patients on their last shifts related to clinical condition, personal life condition, and decision-making control. Nurses with higher levels of acute or chronic fatigue, and who perceived their nursing care activities as less individualized were less likely to assess their quality of care as excellent. CONCLUSION: These findings suggest that addressing hospital nurses' acute and chronic fatigue may contribute to promoting the delivery of individualized nursing care and in improving patients' quality of care. CLINICAL RELEVANCE: Healthcare institutions are encouraged to regularly monitor and manage nurse fatigue to improve the delivery of individualized and quality nursing care to their patients.

Addressing Occupational Fatigue in Nurses: A User-Centered Design Approach for Fatigue Risk Management.

OBJECTIVE: To understand hospital nurses' current fatigue risk management (FRM), identify design goals and principles, and obtain feedback on FRM design concepts. BACKGROUND: FRM systems can address fatigue and associated risks, yet they are not widely implemented in hospital nursing. This may be due to a lack of contextually appropriate FRM tools. METHODS: A user-centered design approach was used, including interviews with 21 hospital nursing stakeholders. FINDINGS: Nurses described integrated fatigue monitoring and management activities to pursue balance between work demands and capacity to meet those demands as individual nurses, within the unit, across the hospital, and over time. Seven principles were identified and applied to 2 initial design concepts for tools to support FRM. Participants' feedback on designs was positive. CONCLUSIONS: This study advances the science and practice for FRM in nursing. The design principles and concepts from this study can be used to facilitate implementation of FRM systems in hospitals.

Unit work environment, psychological empowerment and support for patient activation among nurses.

AIMS: To investigate the relationship between the unit work environment and psychological empowerment of nurses and their perceptions of patient activation. BACKGROUND: Nurses' support for active patient roles in the care process is critical for better patient outcomes. The factors influencing nurses' support for patient activation should be thoroughly investigated. METHODS: This study was a cross-sectional secondary data analysis using the survey data of 1,042 nurses in 98 units at six hospitals in Korea. RESULTS: Nurses with perceptions that their work was valuable and autonomy in their work were more likely to work in units where managers had greater managerial and leadership skills and staffing and resources were sufficient. Those with confidence in their work were more likely to work in units with adequate staffing and resources. Nurses who worked with adequate staffing and resources and considered their work meaningful were more likely to perceive patient activation as more important. CONCLUSION: Favourable work environments at unit level and psychological empowerment at nurse level can strengthen nurses' support for patient activation. IMPLICATIONS FOR NURSING MANAGEMENT: To strengthen nurses' support for active patient roles, organisations should ensure optimal staffing and resources to each unit and help nurses find value in their work.

Changes in Fatigue Levels and Sleep Measures of Hospital Nurses During Two 12-Hour Work Shifts.

OBJECTIVE: The aims of this study were to explore nurses' fatigue levels and sleep measures during two 12-hour consecutive day shifts and examine the relationships between nurses' fatigue levels within shifts and their previous-night sleep characteristics. BACKGROUND: Monitoring changes in fatigue and sleep is important to enable effective fatigue management. METHODS: This was a descriptive, repeated-measures study. Data were collected using surveys and actigraphy 4 times during each consecutive shift (7:00 am-7:30 pm). RESULTS: General fatigue levels started trending up 4 hours after the start of work; highest levels were reported at 7:30 pm. Fatigue levels accumulated across consecutive shifts. Subjective sleep quality was higher the night before the 2nd shift than the night before the 1st shift. Nurses' poor sleep the night before a shift was related to increased fatigue levels during the next shift. CONCLUSION: It is important to consider when fatigue management interventions will be most effective and to consider previous-night's sleep when monitoring fatigue.

Nurse Fatigue and Nurse, Patient Safety, and Organizational Outcomes: A Systematic Review.

Hospital nurses are at high risk of fatigue due to stressful work environments with heavy workloads and non-standard work schedules. This systematic review examined the relationship between hospital nurse fatigue and outcomes. Full-text English language quantitative studies published between January 2000 and July 2020 were included. A total of 22 articles were reviewed and synthesized. The findings were synthesized into three major categories: nurse outcomes, nurse-reported patient outcomes, and organizational outcomes. Some of the most commonly studied outcomes include nursing performance (n=3), sickness absence (n=3), and intention to leave (n=4). Fatigue was consistently associated with mental health problems, decreased nursing performance, and sickness absence. Many studies confirmed that nurse fatigue is negatively associated with nurse, patient-safety, and organizational outcomes. However, our findings highlight gaps in current knowledge and the need for future research using a longitudinal design and measuring additional outcomes to better understand the consequences of nurse fatigue.

Hospital Nursing Staff Perceptions of Resources Provided by Their Organizations During the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has profoundly impacted the health and psychological well-being of hospital nursing staff. While additional support is needed to better cope with increased job stressors, little is known about what types of hospital resources have been provided and how nursing staff perceive them. This study addressed this gap by describing nursing staff perceptions of resources provided by hospitals during the COVID-19 pandemic in the United States. METHODS: Registered nurses and nursing assistants who were working in hospitals during the pandemic were recruited to an online survey via social media posts and emails between May and June 2020. A total of 360 free-text responses to an open-ended survey question were analyzed using content analysis. RESULTS: Over half of participants reported being provided with hospital resources. "Basic needs" resources that included food on-site, groceries, and childcare support were the most frequently reported compared with four other types of resources (personal health and safe practice, financial support, managerial support, communication). Four themes emerged related to staff perceptions of support: community support, unequal benefits, decreasing resources, and insufficient personal protective equipment. CONCLUSION: Our findings can assist organizational leaders in the planning and allocation of different types of resources that are meaningful to nursing staff and thus ensure sustainability, optimal performance, and worker well-being during crises.

Predicting nurse fatigue from measures of work demands.

Fatigue arising from excessive work demands is a known safety challenge in hospital nurses. This study aimed to determine which measures of work demands during nursing work are most predictive of hospital nurse fatigue levels at the end of the work shift. Measures of work demands of registered nurses from two hospital units in the United States were collected from organizational data sources, wearable sensors, and questionnaires. Fatigue levels were measured at the start and end of each shift using the Brief Fatigue Inventory. Multilevel linear regression analysis was used to predict end of shift fatigue based on work demand variables. The best fit model included multiple variables from organizational data sources and a physical activity variable measured by a wearable sensor. Organizational data can be used to create dynamic measures of work demands as they occur and predict end of shift fatigue levels in hospital nurses.

Work Schedule Characteristics, Missed Nursing Care, and Organizational Commitment Among Hospital Nurses in Korea.

PURPOSE: This study describes Korean nurses' work schedule characteristics and identifies their components to investigate associations of work schedule components with missed nursing care and organizational commitment. DESIGN: This cross-sectional secondary analysis used survey data of 1,057 nurses in 111 units at six hospitals in South Korea. Data were collected between April 2017 and March 2018. METHODS: A self-administered survey, including seven work schedule characteristic items, the Korean version of the MISSCARE Survey, and the Korean version of the Organizational Commitment Questionnaire, was employed. To construct independent components of work schedule characteristics, a principal component analysis was performed. The associations of work schedule components with missed nursing care and organizational commitment were analyzed using multiple linear regression models with generalized estimating equation methods. FINDINGS: The average number of daily work hours was 9.7. Nearly half of the study population worked while sick once or more per month. The two components of nurses' work schedule characteristics were "long work hours" and "lack of rest," and these components showed variations between units. Unhealthy work schedule components were linked to frequently missed nursing care and decreased organizational commitment. CONCLUSIONS: This study showed that proper work hours and adequate rest are important to reduce missed nursing care tasks and enhance organizational commitment, both of which are critical for better patient care and organizational outcomes. CLINICAL RELEVANCE: Healthcare organizations should provide adequate nursing staff and assign reasonable workloads. Furthermore, hospitals should periodically monitor the work schedule characteristics of nurses and actively intervene in cases of scheduling issues to resolve them.