Nursing Overtime and Patient Safety

With the concern of work-related injuries associated with mandatory overtime, many research studies have been piloted to examine the impact of overtime on nursing. A particular study conducted with 655 registered nurses in the Philippines reveals significant results in regards to the effects of nurses working mandated overtime. Results show 65% of nurses involved in the study report working over 40 hours per week. Also, 83% report working mandatory or unexpected overtime at least once a month and 15% state working overtime more than seven times each month. Furthermore, 37% of the nurses have suffered an occupational injury and 41% acquired an occupational related illness within a year span (de Castro, Fujishiro, Rue, Taglog, Samaco-Paquiz, & Glee, 2010). Mandatory overtime increases staffing absences.

For over a decade researchers have been performing studies examining the effects patient-to-nurse ratios have on adverse outcomes, mortality rates, and failure-to-rescue rates of patients and on job dissatisfaction and burnout experiences of nurses. Aiken, Sloane, Sochalski, and Silber (2002) performed a study which showed that each additional patient per nurse increased patient mortality within 30 days of admission by 7% and increased failure-to-rescue by 7% as well. This same study also showed that each additional patient per nurse resulted in a 23% increase in nurse burnout and a 15% increase in job dissatisfaction. Additionally, Rafferty et al. (2007) performed a study in which the results showed that patients in hospitals with higher patient-to-nurse ratios had a 26% higher mortality rate and nurses were twice as likely to have job dissatisfaction and experience burnout. Blegen, Goode, Spetz, Vaughn, and Park (2011) performed a study where results showed that more staffing hours for nurses resulted in lower rates of congestive heart failure morality, infection, and prolonged hospital stays. The same study also showed that increased nursing care from registered nurses resulted in lower infection and failure to rescue rates and fewer cases of sepsis.

ANA rejects the adoption of overtime as a staffing solution and joints the Congress to establish national legislation to approach concerns about safe staffing and prohibition of mandatory overtime. ANA concludes that overtime is not a reasonable answer and has driven to various matters such as reduce patient satisfaction, an increase in adverse patient events, preventable medication, and medical errors and increased patient mortality. Besides, mandatory overtime reflects on job satisfaction, on nurse recruitment and retention, nurse fatigue and deficits in nurse’s work

Reasons for mandatory overtime varies from natural disaster to lack of staff. Many companies, organizations, and hospitals require mandatory overtime because of staffing issues. “Increasingly, however, nurses are reporting that mandatory overtime has become standard operating procedure instead of a last resort to short staffing. In fact, in some hospitals, mandatory overtime is routinely used in an effort to keep fewer people on the payroll, as well as to alleviate immediate shortage needs.” (Huston,

A major issue in the medical career field is the demand for nurses and this, of course, means that these nurses will be working strenuous hours to meet the high demands. While this may satisfy some issues it also creates others. Longer hours results in exhausted nurses and this leads to negative patient outcomes.

Significance: Because nursing is the largest health care profession and nurses provide most of the patient care, and as an acute nurse, I can relate to how unsafe nurse staffing/low nurse-to-patient ratios can have negative impact on patient satisfaction and outcome, can lead to medical and/or medication errors and nurse burnout. It can also bring about anxiety and frustration, which can also clouds the nurses’ critical thinking. Most patients might not know the work load on a particular nurse and can assume that her nurse is just not efficient. Doctors also can become very impatient with their nurses because orders are not being followed through that can delay treatments to their patients. There is also delays in attending to call lights resulting in very unhappy patients who needed help.

I am very fortunate to be serving as a Registered Nurse (RN) in our community for the past 17 years. For years, my RN colleagues here in Michigan have expressed frustration and concern when working chronically understaffed shifts and the when using mandated overtime to cover staffing shortages. Safe staffing levels

Inconsistent nurse-patient ratios are a concern in hospitals across the nation because they limit nurse’s ability to provide safe patient care. Healthcare professionals such as nurses and physicians agree that current nurse staffing systems are inadequate and unreliable and not only affect patient health outcomes, but also create job dissatisfaction among medical staff (Avalere Health, 2015). A 2002 study led by RN and PhD Linda Aiken suggests that "forty percent of hospitals nurses have burnout levels that exceed the norms for healthcare workers" (Aiken, Clarke, Sloane, Sochalski & Silber, 2002). These data represents the constant struggle of nurses when trying to provide high quality care in a hospital setting.

For some nurses, mandatory overtime can be an advantage due to financial instability but mostly mandatory overtime can cause fatigue, burnout, injuries, errors, inadequate sleep and deficits in performance. According to research working long hours which consists more than 40 hours a week or over 12 hours a day leads to an increased medication errors and patient mortality. The probability of making medication errors increases tremendously when nurses work longer than 12.5 hours a day. During surveys regarding reasons of overtime, 60 % of nurses stated that overtime was obligatory as part of their job, 29 % of nurses stated that they volunteered and 41% of nurses stated that they were “on call hours” (Bae, 2012)

Nurse staffing have an effect on a variety of areas within nursing. Quality of care is usually affected. Hospitals with low staffing tend to have higher incidence of poor patient outcomes. Martin, (2015) wrote an article on how insufficient nursing staff increases workload and job dissatisfaction, which in effect decreases total patient care over all. When nurse staffing is inadequate, the ability to practice ethically becomes questionable. Time worked, overtime, and total hours per week have significant effect on errors. When nurses works long hours, the more likely errors will be made. He also argued that inadequate staffing not only affects their patients but also their loved ones, future and current nursing staff, and the hospitals in which they are employed. An unrealistic workload may result in chronic fatigue, poor sleep patterns, and absenteeism thus affecting the patients they take care of.

Mandatory overtime in the field of nursing is described as forced overtime to maintain an adequate amount of staff present to meet the needs of the hospital. With a normal work schedule, a nurse usually works 12-hour shifts, usually three times a week. With the obligatory hours that are extended with overtime due to the continuation of nursing shortages, a nurse’s shift can be continued ranging from 12 to 16 hours, with very short notice. This mandatory action is related to putting not only nurses, but also patient’s health at risk. The advantages that accompany mandatory overtime are overshadowed by the disadvantages that surpass the benefits of working extended hours, therefore, mandatory overtime should not be allowed in the nursing work place.

In recent years, the healthcare industry has seen a significant decline in the quality of patient care it provides. This has been the result of reduced staffing levels, overworked nurses, and an extremely high nurse to patient ratio. The importance of nurse staffing in hospital settings is an issue of great controversy. Too much staff results in costs that are too great for the facility to bear, but too little staffing results in patient care that is greatly hindered. Moreover, the shaky economy has led to widespread budget cuts; this, combined with the financial pressures associated with Medicare and private insurance companies have forced facilities to make due with fewer

Mandatory overtime has become an increasing problem for nurses who work in many hospital settings. Mandatory overtime is defined as additional hours added to a nurse’s current shift, making the nurse feel as if it’s a threat of being fired or disciplinary action will be taken in some form if they refuse to stay and work. Extensive overtime studies have established and confirmed that there are serious dangers to both the nurse and the patient being cared for in all types of healthcare settings.

Barry Hill (2017) performed studies related to the quality of care that patients receive and what factors are associated with those perceptions. One area that was noted to be of importance and directly related to quality of care provided to patients is staff dissatisfaction and burnout. This study also found that longer shifts contributed to increased amounts of emotional exhaustion leading to decreased quality of care for patients. Addressing staffing needs early and intervening can decrease the amount of nurse burnout and dissatisfaction that is often seen. This study has shown that hiring additional competent nurses reduces medication errors, falls, infections, wounds, and decreases hospital litigation costs, while improving staff morale, patient experience and care, and cost-effectiveness for the hospital.

To provide high-quality care for the patient it is essential for the nursing staff to have enough time for recovery from long hours of demanding work. Eight-hour shifts for hospital nurses have become a standard of the past. Nowadays, 12-hour shifts for three days a week have become typical in most hospitals as recommended by the Institute of Medicine (IOM) (Stimpfel, Sloane & Aiken, 2012). The length of the shifts and the working days; however, are often unpredictable due to increased demand for patient care and high census episodes. Nursing shortages, along with a weak economy, have left hospital nurses with no choice, then to work extended hours and overtime. Long hour shifts, as well as mandatory overtime, has become an increasing