1 Running head: NEGATIVE IMPACT OF MANDATORY OVERTIME IN NURSING

Negative Impact of Mandatory Overtime in Nursing Saeedeh Jawad Seyyed George Mason University Nursing 334 December 3rd, 2011

Negative Impact of Mandatory Overtime in Nursing

Abstract The paper discusses how mandatory overtime is a pressing issue nurses face in the healthcare industry in the United States. Current literature supports the fact that the risk for errors doubles when nurses work for 12.5 or more hours consecutively. Nurses who work overtime are more prone to making errors or near errors which can negatively impact healthcare in the three major areas of medication errors, quality patient care and nurses' legal liability. Keywords: mandatory overtime, healthcare, errors, patient safety

Negative Impact of Mandatory Overtime in Nursing

Negative Impact of Mandatory Overtime in Nursing Several studies have found that long working hours have an adverse effect on the performance of health-care providers. The worsening hospital nurse shortage is linked to an unrealistic nursing workload which leads to nurse fatigue, burnout and job dissatisfaction. Overworked nurses have a negative impact on patient safety, and hospital nurse staffing levels are inadequate to provide safe and effective care. Mandatory overtime is identified as a patient safety issue. Mandatory overtime is the use of forced overtime used by hospitals and health care institutions to maintain adequate numbers of staff nurses, usually with shift lengths of a total of twelve to sixteen hours worked, with as little as one hour's notice (ANA,2011). Nurses working mandatory overtime are unable to refuse the required extra hours when feeling fatigued or feeling they will be unable to provide safe patient care. With the nursing shortage continuing, the growing trend is for hospitals to use mandatory overtime as a common staffing practice (ANA, June 2000). Approximately 60 percent of the participants in the American Nurses Association Staffing Survey reported being "forced to work voluntary overtime" (ANA, 2006). Impact is felt at the level of the bedside nurse in three major areas identified through current literature: medication errors, quality patient care, and nurses' legal liability (AACN, June 2000). Discussion Longer hours are associated with a variety of patient-care or medical errors, including medication errors, and the longer the hours worked, the greater the likelihood of making an error. A nurse working over the recommended hours is at a greater risk to commit a medication error due to lack of alertness. Medication errors include the wrong patient, the wrong medication, the wrong dosage, the wrong means of administration, the wrong time, and failure to administer the medication at all. The Institute of Medicine (IOM) published a report titled To Err Is Human (1999), which estimates that 98,000 Americans die each year as a result of errors in their medical care. All patient-care or

Negative Impact of Mandatory Overtime in Nursing

medical errors are serious, but some are more serious than others, and it is generally recognized that approximately 5.0% of significant errors are potentially life threatening (Leape, 1996). The statistically significant findings of the current literature conclude that longer work durations increase the likelihood for errors and near errors among nurses, therefore affecting quality patient care. Aiken and colleagues conducted a survey (2006) which discovered extended work shifts significantly decreased levels of alertness, and the risk for making an error doubled when nurses worked 12.5 or more consecutive hours. The findings conclude the minimizing of 12 hour shifts to no more than 12 consecutive hours during a 24 hour period would reduce the number of errors or near errors occurring while on the job. The study finds that due to the hospital nurse shortage, the safety of the patients is negatively impacted since not only are the nurses overworked, but they also have more patients per nurse than recommended for optimal performance. A previous study by Aiken and colleagues (2004) indicates that nurses in the hospital with the highest patient-to nurse ratio are twice as likely to experience job related burnout and commit errors on the job. With a high patient to nurse ratio the nurse is unable to completely assess a patient or provide quality care, and on top of that a nurse working overtime is fatigued and not alert enough to tend to the needs of each patient. Due to this many important patient issues which may need immediate attention can go unnoticed. The Journal of Occupational Health and Safety (1989) states Once a shift exceeds twelve consecutive hours, acute fatigue sets in. A worker may still be able to perform routine tasks, but his brain waves exhibit a pattern of stage one alpha sleep. Errors made in this stage are frequently major, since the worker tends to perform the opposite of the correct action." Nurse Staffing and Patient Outcomes in the Hospital Study (ANA, 2000) tracks five adverse outcomes measures that can be mitigated if adequate patient staffing is provided: hospital length of stay, nosocomial pneumonia, postoperative infections, pressure ulcers, and nosocomial urinary tract infections. By working only

Negative Impact of Mandatory Overtime in Nursing

during the times required, the nurse can remain fresh and motivated to continue to provide quality care to the patients. When the brain is acutely fatigued the nurse tends to disregard issues of hygiene and safety. It becomes difficult for the nurse to remember when the patient was last turned over to prevent pressure ulcers, or to critically think about the care needed to be given to a post-operative patient. Adequate care provided to each client can help formulate a discharge plan leading to a shorter stay at the hospital, however if a patient is not completely assessed many key elements that might need to be addressed will be overlooked and the patient will not recover to full health as early as potentially possible. Nurses practice under each state's Nurse Practice Act, which govern nursing practice. Most nurse practice acts state that nurses are held accountable for the safety of their patients. Not only does mandatory overtime cause job burnout, but it greatly increases the risk of unsafe patient care ultimately jeopardizing the nurses license. Although not actually threatened with job loss or disciplinary proceedings, many nurses also report feeling that there will be repercussions if they refuse to work extra hours or that overtime "is voluntary but feels like it is required" (Steinbrook, 2002). Once a nurse accepts an assignment, her license can be in jeopardy if she is unable to deliver safe patient care. A fatigued nurse does not have the motivation or energy to take care of a patient to their full capacity increasing the risk of errors and jeopardizing their license. Mandatory overtime may cause or lead to increased stress on the job, less patient comfort and mental and physical fatigue that can contribute to errors and "near-misses" with medications and caserelated procedures (AACN, June 2000). The practice of mandatory overtime ignores the fact that nurses have other responsibilities outside their scope of practice such as obligations to their family. The nurses in return become de-motivated; and the practice of mandatory overtime leads to absenteeism in the

Negative Impact of Mandatory Overtime in Nursing

workplace. The vicious cycle continues as the remaining nurses on the unit have an increased patient to nurse ratio, will mostly likely be forced to stay overtime, and will ultimately burnout as well. Conclusion The negative impact of mandatory overtime is affecting the three major areas of medication errors, quality patient care and a nurses' legal liability. To reduce or eliminate this effect, steps must be taken to ban the practice of mandatory overtime. The Institute of Medicine in its report on working conditions for nurses and patient safety stated that to reduce error-producing fatigue, state regulatory bodies should prohibit nursing staff from providing patient care in any combination of scheduled shifts, mandatory overtime, or voluntary overtime in excess of 12 hours in any given 24-hour period and in excess of 60 hours per 7-day period. (Page, 2004, p. 13) If mandatory overtime is legally banned in all states, hospitals and health care institutions will have to hire more RN's to reduce the nurse to patient ratio, and focus on strategies to recruit and retain more nurses (AACN, 2000). With sufficient nurse staffing, time is available for more thorough patient assessment and interventions to improve outcomes. Out of 2.7 million nurses only 2.2 million were employed in 2003 (Polaneczky, 2003). This means that there isnt a nurse shortage as much as there is a shortage of nurses who are willing to work mandatory overtime at understaffed hospitals. For every patient added to a nurses workload, the chance of a patient dying goes up by 7%, for nurses that are already tired, the climb is even steeper (Polaneczky, 2003). Incentives should be given to the healthcare industry to increase the supply of nurses to overcome the nursing shortage the nation faces. This would help in ensuring that a nurse does not exceed a 12 hour shift in a 24 hour period. If hospitals invest in registered nursing staff, it would lead to fewer errors lowering mortality rates and nurse burnout. The number of patients per nurse also needs to be limited to a safe level to ensure adequate safety and care for the patient. A law needs to be passed for

Negative Impact of Mandatory Overtime in Nursing

elimination of extended work shifts for the benefit of both the nurse and patient safety. Further studies should be conducted to study the negative impact of mandatory overtime in the areas of medication errors, quality patient care, and nurses' legal liability in states where mandatory overtime has been banned for further evidence on the negative effect of mandatory overtime. This will further strengthen the argument to ban mandatory overtime and will assist in making a nationwide change.

Negative Impact of Mandatory Overtime in Nursing

Reference List Aiken, L. H., Dinges, D. F., Hwang W., Rogers, A. E., & Scott, L. D. (2004). The working hours of hospital staff nurses and patient safety. Health Affairs, 23 (4), 202-212. Aiken, L. H., Hwang W., Rogers, A. E., & Zhang, Y. (2006). Effects of critical care nurses' work hours on vigilance and patients safety. American Journal of Critical Care, 15, 30-37. American Association of Critical Care Nurses. (2003). Mandatory overtime. Retrieved from http://www.aacn.org/wd/practice/content/publicpolicy/mandatoryovertime.pcms? menu=practice. Accessed October 20,2011. American Nurses Association. (2011). Mandatory overtime. Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAPoliticalPower/State/State LegislativeAgenda/MandatoryOvertime.aspx. Accessed September 30,2011. Bhambhani, D. (2000, October 30). At Inova, nurses opt for talks, not strike. The Washington Times, p. D3. Faller, M. (2008). Stopping the vicious cycle of mandatory overtime. American Nurse Today, 3 (12), 12-14. Institute of Medicine. (1999, November) To err is human: building a safer health system. Retrieved from http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment for nurses. Washington, DC: The National Academic Press. New York State Nurses Association. (2008, September 8). Nurses working overtime in New York. [Audio podcast]. Retrieved from http://www.nysna.org/podcasts/podcastCtr.htm.

Negative Impact of Mandatory Overtime in Nursing

Polaneczky, R. (2003, November 25). Nurses are ready to work, but want fair staffing. Philadelphia Daily News. Retrieved September 30,2011, from http://www.truthaboutnursing.org/news/2003/nov/daily_news_11-25-2003.html. Steinbrook, R. (2002, May 30). Nursing in the crossfire. New England Journal of Medicine, 346, 1757-1766.