Despite paper airplanes flying around, Melanie Patterson was experiencing one of the lowest days of her career.
It was June 2022 when census was consistently high at Children’s Hospital of Orange County (CHOC), acuity levels were relentless, and nursing and respiratory leaders were exhausted.
Patterson, vice president of patient care services and chief nursing officer, asked 40 leaders to make a paper airplane, write something that was weighing them down, and then send it flying.
When she picked up the folded pieces of paper, her stomach dropped. Leaders anonymously expressed feeling unappreciated, lonely, and like they were running on fumes.
“This isn’t an individual challenge; it is a systematic crisis for all of us,” Patterson said. “It threatens the stability of our health care workforce and the quality of patient care. As a leader, I was devastated, and it was a call to action that couldn’t be ignored.”
In a bold step for the hospital, Patterson and Jennifer Hayakawa, director of nursing research and innovation, collaborated with Emma Sandhu, vice president and chief nursing officer at CHOC at Mission, to pilot a four-day workweek among nursing and respiratory leadership teams to address these issues.
The results: Leaders felt more engaged, productive, and satisfied with their work.
- Burnout fell from 61% to 4%
- Job satisfaction increased from 71% to 96%
- Joy in work rose from 34% to 86%
“There was a shift from the fear of missing out to the joy of missing out,” Patterson said. “Leaders began to embrace the joy of opting out of nonessential activities and instead prioritize self-care and meaningful engagement.”
Time for a change
Over 50% of nurse leaders in the U.S. plan to leave their positions within the next five years, many due to burnout and job dissatisfaction, further exacerbating the health care workforce shortage.
Patterson, Sandhu, and Hayakawa knew leaders were exhausted. They saw it in their eyes, heard it in their voices. Days are long, to-do lists are even longer, and they’re on call 24/7.
“Too often, we forget to ask the leaders how they’re doing and what their needs are, and yet they are the ones guiding teams through complex environments and making emotional decisions,” Hayakawa said.
During the four-month pilot, full-time, exempt leaders who were on a 24/7 unit transitioned from a traditional five-day, eight-hour workweek to four, ten-hour shifts per week. The change was guided by the Institute for Healthcare Improvement Joy in Work framework to explore factors such as maintaining work-life balance, managing high-stakes decisions, and navigating 24/7 accountability.
To evaluate the pilot’s effectiveness, the team gathered:
- Bi-weekly self-reported surveys to assess workload, time to complete work, and job-related stress.
- Organizational metrics to monitor hospital-acquired conditions and patient satisfaction scores.
- Focus groups to collect qualitative insights into participant experiences.
Fostering collective responsibility
Participants were invited to weekly meetings to share experiences and refine interventions. Key strategies that supported the change included implementing a buddy system to ensure coverage, establishing clear communication protocols, and redistributing workloads.
Maintaining 24/7 accountability required cross-coverage plans to prevent disruption on leaders’ days off. It was important for staff to designate a peer to take on work burdens when not on-site.
“The accountability partners play a vital role,” Patterson said. “Leaders were able to delegate more effectively, leverage team strengths, and foster collective responsibility. They consistently reported trust and confidence with their buddies, and that helped them have more control over their workload.”
Participants also worked with peers to establish clear and preferred communication methods with accountability partners. One day a week, all leaders were on campus to adjust schedules and maintain productivity. This was especially important, so leaders were not always absent on Monday or Friday, and so they could ensure coverage during holiday weeks.
“These conversations maintained consistency without compromising flexibility,” Patterson said. “This culture shift not only enhanced collaboration but also reinforced a sense of belonging.”
From pilot to permanent
While CHOC’s pilot had positive outcomes, the hospital also found opportunities for improvement.
Some newer leaders faced difficulties adapting to compressed schedules. They suggested a phased or hybrid approach to make it easier to adjust to the new schedule.
Implementation takes patience. It took nearly two months for participants to find creative ways to figure out responsibilities and ensure the pilot ran smoothly.
And it took six months to earn executive buy-in on the model. After emphasizing the need for and importance of work-life balance during multiple presentations, Patterson and Sandhu gained approval.
Transformative outcomes
Lessons learned from the pilot have been valuable as CHOC looks toward a broader adoption of a four-day model. The team would like to expand research to include diverse health care settings, such as those in low-resource environments. They are also exploring hybrid scheduling, combining compressed workweeks on campus with remote work.
One thing is clear: Flexible scheduling among health care leaders improved work-life balance, team morale, and personal well-being.
One participant described the ability to disconnect for one day as life-changing.
“The workload is the same, but the balance has shifted,” they noted. “It is amazing what a difference this one extra day has made.”
This article is based on a presentation at the Children’s Hospital Association’s 2025 Transforming Quality Conference.
