Patient Safety / Quality

Stopping the vicious cycle of mandatory overtime

All hospitals have occasional nursing shortages stemming from unexpected census peaks, unfilled nursing vacancies, personal time off, or leaves of absence. As a short-term solution to this problem, they commonly have staff nurses work overtime. And many nurses are glad to do this occasionally, or even regularly, because it lets them earn more money.
But chronic use of overtime can jeopardize the quality and safety of patient care. Under pressure from chronic staffing shortages, hospital administrators may implement a policy of mandatory overtime. One study found that more than half of hospital staff nurses work more than 12 hours per day and 17% work mandatory overtime. Some hospitals go so far as to terminate nurses who refuse overtime work; others report them to the state licensing board for patient abandonment.

Instigating the cycle
Chronic overtime can lead to a vicious cycle: Excessive work hours reduce staff morale, which in turn contributes to job burnout. Job burnout reduces staff retention and creates more nursing vacancies, forcing the remaining nurses to work more overtime. Thus, mandatory overtime increases nurse dissatisfaction and burnout, ultimately worsening the staffing shortage.
Frequent shift rotation, poor relationships with physicians, and lack of nursing autonomy can contribute to reduced morale and job dissatisfaction, perpetuating the vicious cycle. The same goes for fatigue caused by consistently long work hours.

Getting to the root of nurse dissatisfaction
Nurses leave their jobs for various reasons, some of which aren’t related to job dissatisfaction. Hospitals constantly recruit nurses to replace those who leave, but they should try to minimize resignations stemming from job dissatisfaction. Without exploring the cause of nurses’ dissatisfaction and taking corrective steps, hospitals may continue to suffer high nurse turnover, high recruiting expenses, and inadequate staffing on many shifts.

The risks of working fatigued
The vicious cycle of mandatory overtime can become perpetual and imperil the quality and safety of patient care. Forcing a nurse who may already be fatigued to work beyond her scheduled shift increases the likelihood of patient harm. A fatigued nurse is more apt to make errors; the risk of errors triples when nurses work more than 12½ consecutive hours. Shift work and prolonged work hours resulting in fatigue are strongly linked to poor performance, including reduced focus and attention and potentially harmful errors. Recognizing the correlation between inadequate staffing and patient harm, the Institute of Medicine has recommended public reporting of hospital staffing and turnover data.

Breaking the cycle
Voluntary overtime is one alternative to mandatory overtime. Most nurses know when they’re too fatigued to perform their jobs safely and effectively, so why not let the individual nurse decide whether to accept or decline a request to work overtime? Research on long work hours and its impact on patient care hasn’t distinguished between mandatory and voluntary overtime; long hours alone increase the risk of patient harm. But if nurses carefully gauge their fatigue level before accepting voluntary overtime, this could prove (at least in theory) to be a safer mechanism for staff coverage.
Breaking the vicious cycle of mandatory overtime won’t be easy. Some states have enacted laws to curb mandatory overtime—but this is just one step. (See Mandatory overtime laws: An update in PDF format by clicking the download now button.) Multiple interventions are needed. Maintaining adequate staffing requires aggressive retention efforts, effective recruiting of new staff, and use of float pools and temporary staffing agencies (assuming voluntary overtime won’t completely fill the void left by eliminating mandatory overtime).

Strategic planning
But even if mandatory overtime were prohibited nationwide, that wouldn’t be the complete solution. Optimally, healthcare facilities should strive to eliminate the need for overtime by having enough nursing staff available. They can do this only through strategic staffing planning based on a thorough understanding of their goals and objectives—in conjunction with dedicating resources to long-term solutions, such as new nurse graduate programs, internal training programs for specialty units, foreign nurse recruitment, and appropriate use of temporary staff.
Strategic planning doesn’t necessarily mean eliminating all overtime. Voluntary overtime can promote continuity of care while giving nurses the option of working longer hours and earning more money. But because longer shifts from any cause can contribute to burnout, voluntary overtime should be limited.
Overtime isn’t the only issue that can influence the quality of the work environment and patient care. To improve the work environment and promote better recruitment, retention, and patient care, hospitals should determine the root cause of each factor that affects nursing staff levels. One study found that nurses who weren’t dissatisfied or burned out were more likely to stay on the job. Reducing overtime and eliminating mandatory overtime can decrease a primary cause of nurse attrition. It’s the first step toward creating a better environment for both nurses and patients.


Selected references
American Nurses Association (2007). Mandatory overtime. www.nursingworld.org/MainMenuCategories/ANAPoliticalPower/State/State
LegislativeAgenda/MandatoryOvertime.aspx. Accessed October 20, 2008.
Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. The working hours of hospital staff nurses and patient safety. Health Affairs. 2004;23(4):202-212.
Trinkoff A, Geiger-Brown J, Brady B, Lipscomb J, Muntaner C. How long and how much are nurses now working? Am J Nurs. 2006;106(4):60-71.
Visit www.AmericanNurseToday.com/journal for a complete list of selected references.

Marcia Faller is Chief Nursing Officer and Executive Vice President of Operations at AMN Healthcare in San Diego, California.

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