By Debra Wood, RN, contributor
August 12, 2010 - The evidence is in about the risks of nurses working overtime, but many hospitals continue to rely on nurses who have already worked a full week to fill in gaps in the schedule. However, some innovative nursing leaders have decreased their reliance on overtime.
“We’re trying to reduce overtime,” said Marilyn Margolis, MN, RN, director of nursing operations at Emory University Hospital in Atlanta. “It is not an effective way financially. It’s not effective for the caregiver, and it may not be effective care for the patient.”
Emory limits overtime to less than 3 percent of its schedule. It does not let nurses who want overtime money to work more than 60 hours a week. It never mandates nurses work overtime and does not count on overtime hours to staff the schedule.
Ann Rogers, Ph.D., RN, FAAN, conducted pioneering research that showed an association between longer work hours and errors.
The hospital has added as-needed nurses and created incentives to fill difficult shifts. Emory has established a Central Staffing Resource Center, with nurses who are willing to travel to any of Emory’s four hospitals to work in any unit. Those nurses receive additional training, a mentor on the new unit and differential pay.
The risks of working overtime
Overtime can lead to fatigue and contributes to errors and injury.
“We’re physiologically not designed to work long hours,” said Ann Rogers, Ph.D., RN, FAAN, an Emory University Nell Hodgson Woodruff School of Nursing faculty member. “We can’t maintain concentration. When we work that long, we don’t get enough sleep. We have our limits.”
While at the University of Pennsylvania School of Nursing, Rogers completed the groundbreaking investigation in 2004 that found an association between longer work hours and errors, with shifts lasting 12.5 or more hours raising the risk three fold.
“There was no difference between mandatory and voluntary overtime,” Rogers said. “The nurses working voluntary overtime didn’t get any more sleep and didn’t make any fewer errors.”
Nurses often aren’t aware of the risks, and they feel pressured not to let coworkers work short-staffed or leave patients without care, she said.
“As nurses we are socialized to put the patient first, even if that means coming in on your day off, and overtime money is good,” Rogers said.
In a more recent study led by Danielle Olds, MSN, MPH, a pre-doctoral fellow at the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing in Philadelphia, researchers found medication errors and needlestick injuries increased when nurses worked more than 40 hours in an average week.
Matthew D. McHugh, Ph.D., JD, MPH, CRNP, RN, expressed concern that overtime can lead to nurse burnout and nurses leaving the field.
“We see the use of overtime as having implications for patient outcomes and nurse outcomes,” said Matthew D. McHugh, Ph.D., JD, MPH, CRNP, RN, assistant professor of the Center for Health Outcomes and Policy Research at the Penn School of Nursing. “As nurses increase the use of overtime, they have a higher risk of adverse patient events and medical errors as nurses become more fatigued. They also become more burned out and dissatisfied.”
These factors can lead to higher turnover, which also can negatively affect patient outcomes, McHugh adds.
A study led by Jeanne Geiger-Brown, Ph.D., RN, associate professor at the University of Maryland School of Nursing in Baltimore, found nurses’ neurobehavioral functioning declined as nurses work additional 12-hour shifts.
Australians Drew Dawson and Kathryn Reid studied wakefulness and performance and determined that after 17 hours of wakefulness, people performed about the same as when they had a blood alcohol concentration of 0.05 percent.
Research by Jeanne Geiger-Brown, Ph.D., RN, found that nurses’ neurobehavioral functioning declined as nurses work additional 12-hour shifts.
Overtime also can affect nurses’ health, according to a study released in June from the University of Washington School of Nursing in Seattle. Researchers found an association between frequency of mandatory overtime and work-related injury and work-related illness.
Continuing to rely on overtime
“Hospitals are using overtime instead of hiring,” said Karen Higgins, RN, co-president of National Nurses United in Massachusetts, explaining that facilities rely on existing staff to work extra hours rather than hiring new graduates. “It’s able to keep the budget more controlled, but it’s a bad practice.”
Higgins reported some hospitals still mandate nurses work additional hours or shifts, but voluntary overtime has increased, with some hospitals calling nurses nearly every day on their days off to come in. Nurses often like the extra money of an occasional extra shift.
Diana Blackmon, administrator of 34-bed Kindred South Hospital in Oklahoma City and chairperson of the Oklahoma City University Kramer School of Nursing executive advisory committee, feels that many hospitals, including her facility, prefer asking nurses to work overtime than to bring in extra personnel.
“There’s still a shortage,” Blackmon said. “If you are running a higher than normal census, you are already short. You can have someone work overtime, work overtime and get a premium pay, or you can have contract from a nursing agency.”
Blackmon said Kindred is too small to start a per diem pool. Kindred offers premium pay differential for working additional shifts, beyond time-and-a half. Blackmon acknowledges the quality issues associated with working too many hours. Some nurses will only sign up for two days in a row. However, others will work 60 hours a week.
Matt Fenwick, spokesman for the American Hospital Association and American Organization of Nurse Executives in Chicago added that the nursing shortage, temporarily eased by the recession, will return and contribute to the use of overtime.
“Although used only as a last resort, one way hospitals cope with the RN shortage is to ask staff to remain voluntarily on patient care units after the completion of a scheduled shift until replacement staff can be found,” Fenwick said. “The AHA and AONE are committed to working with all stakeholders to identify strategies, resources and policies that support our caregivers and keep America's caring workforce strong.”
The fight to limit mandatory overtime
Nursing organizations have organized campaigns to educate legislators about the risks of nurse overtime and convince them to prohibit the practice. According to the American Nurses Association, 14 states have taken legislative action, two have issued regulations to limit it and one has authorized a study.
“Clearly some facilities do not respect nurses when they say I’m not capable of working additional hours,” said Janet Haebler, MSN, RN, associate director of ANA’s state government affairs. “It’s the excessive and recurrent use of overtime, sometimes as a staffing strategy, that make it necessary for states to pursue prohibition.”
Haebler said those requirements have decreased reliance on mandatory overtime. She expects state requirements that hospitals form staffing committees and staff to levels appropriate to patients’ needs will further decrease the use of mandatory overtime.
Deb Bonn, RN, director of the SEIU Nurse Alliance of Pennsylvania, worked to convince Pennsylvania legislators to pass stringent mandatory overtime restrictions for health care workers in multiple settings. She indicated the preponderance of evidence on the effect of overtime on nurses’ injuries and illnesses and risks to patients convinced lawmakers to take action.
“The nurses are thrilled, but it’s still a struggle,” Bonn said. The law offers provisions to use mandatory overtime in emergency situations, so nurses are sometimes still required to work extra hours. But the work environment has improved.
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