CONTEMPORARY ISSUES OF OVERTIME REGULATIONS AND NURSE

/ PATIENT OUTCOMES

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NURSING CONTEMPORARY ISSUES

TABLE OF CONTENT

1.0 INTRODUCTION 3

2.0 WHY IS THERE OVERTIME?

2.1 Trends in Overtime 5

2.2 Risks and effects associated with overtime

6

3.0 COUNTERMEASURES AND RECOMMENDED

PRACTICES

3.1 Breaking the cycle 8

3.2 Strategic planning 8

3.3 Deciding when to work overtime

9

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NURSING CONTEMPORARY ISSUES3.4 Safe-Staffing Ratios 9

3.5 Nursing Shortage 10

4.0 CONCLUSION 11

REFERENCES

1.0 INTRODUCTION

To provide the best care to patients, the physical well-ness of

nursing staff is essential. Long work hours can lead to fatigue,

restlessness, inadequate sleep, pain, and deficits in performance

and reaction time as a result of increased expo-sure to physical

demands and insufficient recovery time (Borges & Fischer, 2003;

Geiger-Brown, Trinkoff, & Rogers, 2011; Trinkoff, Geiger-Brown,

Brady, Lipscomb, & Muntaner, 2006). Reduced rest and recovery

time leads to physiologic depletion or exhaustion that continues

into the next workday (Rosa, 1995). The Institute of Medicine

(IOM) recommended nurses work no more than 12 hours in a 24-hour

period and no more than 60 hours in a 7-day period to avoid

error-producing fatigue (IOM, 2004). In order to provide the best

care possible to patients, the physical and mental well-being of

the nurse is essential. Evidence has shown that working long or

extensive hours, or beyond a scheduled shift can lead to negative

patient and nurse outcomes. Studies have also shown that nurse

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NURSING CONTEMPORARY ISSUESovertime has been used as a solution to treat chronic

understaffing and variations in patient census.

Most hospital staff nurses’ work schedules extend beyond the

typical9:00 a.m. to 5:00 p.m., Monday through Friday work day, to

provide continuous nursing care to patients (Trinkoff et

al.,2011). Simultaneously, most hospitals in the United States

exclusively use 12-hour shifts (Geiger-Brown & Trinkoff, 2010).

Thus, staff nurses who work overtime may work more than 12 hour

within a 24-hour period and return to work quickly without

sufficient rest and sleep. Nurses' fatigue may continue following

work regardless of regular or overtime shifts. Working overtime

among nurses is a prevalent practice used to control chronic

under-staffing and a common method used to handle normal

variations in the patient census (Berney, Needleman, & Kovner,

2005). According to the 2004 National Sample Survey of Registered

Nurses (NSSRN), more than 40% of U.S. registered nurses (RNs)

worked more than 40 hours per week (Bae & Brewer, 2010). Fifty-

four percent of the respondents to the 2008 NSSRN worked more

than 39 hours per week in their principal nursing position (U.S.

Department of Health and Human Services, 2010).

2.0 WHY IS THERE OVERTIME?

Overtime is defined as the time a person works beyond regular

working hours as outlined by contract, collective agreement,

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NURSING CONTEMPORARY ISSUESpolicies and/or scheduling practices. In 1999 LeMoal stated “a

vicious cycle is now unfolding as overworked nurses walk away

from nursing leaving units that are dangerously short-staffed

because of the nursing shortage”. This article cites the

following staffing practices that are contributing to this

problem. These include “denying leaves, paying out vacation pay

without granting vacation, refusing to replace nurses on sick

leave, failing to post vacant part-time positions because casual

nurses might apply, requiring full-time nurses to routinely work

days off, and begging nurses to work even if they are sick.”

LeMoal and the SUN believe that “forced overtime is the most

desperate, short sighted and destructive strategy ever employed

by health districts to force fewer and fewer nurses to work

harder and harder.”

In addition to the nursing shortage, other factors contribute to

overtime that include weather conditions or other unmanageable

event that may prevent the typical change of shifts. During an

ongoing procedure, professional ethics also prevent nurses from

leaving their regularly scheduled hours of work. Overtime hours

allow nurses to complete vitals documentation tasks that usually

occur at the end of a shift. As well, hospital administrators

find it difficult to employ enough full-time nurses so overtime

is used to fill in the gaps.

2.1 Trends in Overtime

6

NURSING CONTEMPORARY ISSUESThe issue of nurses having to work overtime is far from being

resolved. A report released from the Alberta Association of

Registered Nurses in 1999 estimated that in Canada, overtime for

registered nurses had increased by 58% between 1997and 2005, but

the average number of overtime hours remained the same at 6.4

hours per week. Meaning that the amount of overtime worked by

each nurse remained approximately the same but more nurses worked

overtime hours. It was also reported that nursing supervisors and

registered nurses in direct care provider roles were more likely

to work overtime than nurses in other roles. Studies show that

there are increasing requests and requirements for registered

nurses to work extra hours. For this reason there are many

factors that nurses need to consider when accepting to work these

extra hours. A nurse must feel that he or she can practice

competently and not put the safety of the patient, coworkers or

themselves at risk. If a nurse feels that they are not meeting

these standards, it is their responsibility to refuse these

additional work hours.

2.2 Risks and effects associated with overtime

Nurses’ poor quality of sleep and fatigue are associated with

working long hours, their quick return to work, and also shift

work (Geiger-Brown, Trink off, & Rogers, 2011). Sleep deprivation

from working overtime often results in fatigue, which is

associated with difficulties in neuron behavioral functioning

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NURSING CONTEMPORARY ISSUESsuch as reduced or impaired vigilance, reaction time, and

decision making ability (Trinkoff et al., 2011). Previous

research has demonstrated long work hours have adversely affected

nurse and patient out-comes. Excessive use of overtime can

increase the incidence of nurses’ needle stick injuries and

musculoskeletal problems (Clarke, Rockett,Sloane, & Aiken, 2002;

Trinkoff, Le,Geiger-Brown, & Lipscomb, 2007; Trinkoff, Le,

Geiger-Brown, Lipscomb, & Lang, 2006).

Working mandatory or unplanned overtime was also associated with

the occurrence of work-related injuries and work-related

illnesses (de Castro et al., 2010). The risk of making medical

errors was three times higher when nurses worked shifts lasting

up to 12.5 hours or more (Rogers, Hwang, Scott, Aiken, & Dinges

2004). The most recent studies found long work hours during

nurses’ typical work schedule for the past 6months on average

were significantly related to patient mortality in the hospitals

they worked after controlling for staffing levels and hospital

characteristics (Trinkoff et al., 2011), and that working more

than 40 hours per week was related to nurse’s perception

regarding the occurrence of medication errors, falls with

injuries, and nosocomial infections (Olds & Clarke, 2010). The

underlining mechanism of the relationship of nurse overtime to

nurse injuries and adverse patient events is that when nurses

work overtime or long hours, it contributes to nurses’ fatigue

and sleep so their alertness and vigilance are impaired in both

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NURSING CONTEMPORARY ISSUEStheir regular shift and overtime shift. It influences patient

quality of care that fatigued nurses deliver.

Although the exact amount of sleep needed by healthy adults has

not been determined, the effects of insufficient sleep have been

well documented. A review of the relevant literature over the

past 15 years reveals that insufficient sleep (or partial sleep

deprivation) has a variety of adverse effects. Despite the wide

range of research methodologies (e.g., qualitative studies,

surveys and clinical trials, instruments) and settings (e.g.,

field studies, and time-isolation laboratories, and sample

sizes), the results are quite similar: insufficient sleep has

been associated with cognitive problems, mood alterations,

reduced job performance, reduced motivation, increased safety

risks, and physiological changes. Results from laboratory studies

of total sleep deprivation (one or more nights without sleep)

were not included in this review, since the focus of this section

is on insufficient sleep (partial sleep deprivation) and not on

total sleep deprivation.

Although some people are less impaired by insufficient sleep than

others, 34 several studies have shown that failure to obtain

adequate sleep is an important contributor to medical error.

Although most studies have focused on measuring the effects of

sleep deprivation on the performance of interns and resident

physicians, sleep deprivation also has adverse effects on the

performance of hospital staff nurses. Using data from the first

sample of nurses who participated in the Staff Nurse Fatigue and

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NURSING CONTEMPORARY ISSUESPatient Safety Study, Dawson and his colleagues (Dawson, personal

communication, 2005) found a significant relationship between

sleep in the prior 24 hours and the risk of making an error.

Nurses who reported an error or near miss obtained significantly

less sleep than nurses who did not report an error or near miss.

Using techniques described in one of their papers, researchers

determined that there was a 3.4 percent chance of an error when

nurses obtained 6 or fewer hours of sleep in the prior 24 hours

and 12 or fewer hours of sleep in the prior 48 hours (Dawson,

personal communication, 2005). Although a 3.4 percent risk of an

error or near miss sounds insignificant, it would translate to a

probability of 34 events per day in an average teaching hospital

with 1,000 nursing shifts per day.

In addition to jeopardizing patient safety, nurses who fail to

obtain adequate amounts of sleep are also risking their own

health and safety. According to the National Center for Sleep

Disorders Research and the National Highway Transportation Safety

Administration Expert Panel on Driver Fatigue and Sleepiness,

sleep loss is the leading cause of drowsy driving and sleep-

related vehicle crashes. Drowsy drivers have slower reaction

times, reduced vigilance, and information processing deficits,

which make it difficult to detect hazards and respond quickly and

appropriately. Laboratory studies have shown that moderate levels

of prolonged wakefulness can produce performance impairments

equivalent to or greater than levels of intoxication deemed

unacceptable for driving, working, and/or operating dangerous

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NURSING CONTEMPORARY ISSUESequipment. Dawson and his colleagues were the first to report

that prolonged periods of wakefulness (i.e., 20 to 25 hours

without sleep) can produce performance decrements equivalent to a

blood alcohol concentration of 0.01 percent, and numerous other

studies have confirmed that prolonged wakefulness significantly

impairs speed and accuracy, hand-eye coordination, decision

making, and memory. Although numerous studies have shown that

night shift workers report very high rates of drowsy driving and

motor vehicle accidents when driving home after work, the

majority of research on drowsy driving among health care

providers has focused on the dangers of resident physicians

driving home after a night of being on-call.

There is also a growing body of evidence that sleep duration is

linked to metabolism and the regulation of appetite, and

decreased sleep times may be a contributing factor to the growing

epidemic of obesity in this country. Several large-scale studies

have shown dose-dependent relationships between sleep duration

and obesity, with greater sleep deprivation associated with a

higher risk of obesity. Glucose tolerance is altered by short-

term sleep restriction, and habitually short sleep durations have

been shown to significantly increase the risk of developing

diabetes in women. Tightly controlled laboratory studies have

also shown those short sleep durations, e.g., 4 hours per night,

can result in alterations of hormones involved in the regulation

of appetite (e.g., leptin, cortisol, and thyrotropin).

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NURSING CONTEMPORARY ISSUESSleep is also believed to play a role in regulating immune

function. Both human and animal studies have shown those

immunological challenges such as vaccinations and both

experimentally induced and spontaneous infections tend to

increase sleep duration, often increasing the duration and

intensity of slow-wave sleep (deep sleep) and decreasing REM

sleep (rapid eye movement sleep or dream sleep). Even though

studies evaluating the effects of sleep deprivation on immunity

have shown a variety of effects, no study has been able to link

these changes in immune function with increased rates of

infection or other adverse effects on health.

Other than that based on my working experience overtime also

sometimes can caused few inconvenience factors to medical

assistant. As example when working overtime in Malaysia sometime

medical assistant are not eligible for work hour’s claim. Even

though they are clearly needed at the hospital at the time, no

specific provision for overtime claims. To be worst they

sometimes need to replace medical officers that are clearly not

bound to any overtime requests.

This is not only brought an emotional impact on medical assistant

but they are also burdened by the financial factors which are

required when working overtime. This burden grows as they had

worked on the early shift the next day.

3.0 COUNTERMEASURES AND RECOMMENDED PRACTICES

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NURSING CONTEMPORARY ISSUES

3.1 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

decides whether to accept or decline a request to work overtime?

Research on long work hours and its impact on patient care

haven’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. 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).

3.2 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

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NURSING CONTEMPORARY ISSUESthrough 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.

3.3 Deciding when to work overtime

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NURSING CONTEMPORARY ISSUESHospital management should encourage individual nurses to make

informed decisions about when to work overtime and avoid work

related injuries.

i. The nurse’s primary commitment is to the patient, whether an

individual, family, group, or community.

ii. The nurse promotes, advocates for, and strives to protect

the health, safety, and rights of the patient.

iii. The nurse is responsible and accountable for individual

nursing practice and determines the appropriate delegation

of tasks consistent with the nurse’s obligation to provide

optimum patient care.

iv. The nurse participates in establishing, maintaining, and

improving health care environments and conditions of

employment conducive to the provision of quality health care

and consistent with the values of the profession through

individual and collective action.

3.4 Safe-Staffing Ratios

Nurses have an integral role in the health care system. State-

mandated safe-staffing ratios are necessary to ensure the safety

of patients and nurses. Adequate nurse staffing is key to patient

care and nurse retention, while inadequate staffing endangers

patients and drives nurses from their profession. Staffing

problems will only intensify as baby boomers age and the demand

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NURSING CONTEMPORARY ISSUESfor health care services grows, making safe-staffing ratios an

ever-pressing concern.

3.5 Nursing Shortage

In an effort to draw more people into nursing, nursing

educational programs will become more flexible, affordable, and

accessible. According to Wieck (2004), "nursing education is

probably the most inflexible 'one size fits all' environment that

exists today" (p. 6). This will have to change if nursing is to

have any hope of luring the twenty something generation into

professional nursing careers. As the American society becomes

more diverse, so too will the nursing workforce. More campaigns

such as Johnson and Johnson's Campaign for Nursing's Future and

the Oregon Center for Nursing's campaign, Are You Man Enough to

be a Nurse, will need to be launched to bring more men and

minorities into the profession. Other recruitment trends will be

lower educational costs, greater access to federal loans and

grants, and new educational methods including shortening the time

required to become a registered nurse (Buerhaus, Staiger, &

Auerbach, 2001).

Imaginative research and development strategies will help secure

greater numbers of graduate students choosing nursing educator

careers and more federally funded scholarships and grants will

enable them to affordably complete their education. The programs

of study may also reflect innovative changes already pursued in

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NURSING CONTEMPORARY ISSUESother programs. According to Matthews (2003), "educator

preparation should be a core competency for nursing graduate

students regardless of specialty" (. Greater access to masters

and doctoral programs and the elevation of faculty salaries and

benefits will enhance recruitment into nurse educator programs of

study (Matthews, 2003). Unless these challenges facing the

shortage of nurse educators are addressed, the pattern of more

graduate students choosing more lucrative career options such as

certified registered nurse anesthetist, nurse midwife, nurse

practitioner, and clinical nurse specialist will continue.

CONLUSIONS

This paper attempts to strike a balance between the needs of both

nurse and hospital management. It recognizes that nurse’s demand

for better working hours may fluctuate from day to day and week

to week. Unexpected nurse’s shortages may arise due to an

increase in business activity, sick leave, or other unexpected

circumstances and nurses surely need to have some discretion to

vary employees’ hours. On the other hand, under this paper,

hospital management cannot place or shift the entire burden on

burses when labor shortages arise. For example, an employer

should no longer be permitted to require an employee to work an

entire second shift without some reasonable minimum advance

notice before the first shift is finished. Further, employers who

face continuous labor shortages should be induced to hire and

train additional employees rather than require current employees

to put in more hours. In the meantime, employees who refuse to

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NURSING CONTEMPORARY ISSUESwork long hours should be able to exercise their decision as a

basic right of employment without fear of reprisal or loss of

their jobs. For workers and the community at large, this right

will mean greater control overworking hours, ability of working

families to balance the conflicting demands of work and family,

and access to the highest possible quality of work and care in

services.

3043 Words

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