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Mandatory Overtime and Patient Safety

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    Introduction

                A shortage of nurses in hospitals was caused by restructuring efforts through replacement of unlicensed assistant personnel for registered nurses. Instead of hiring more licensed nurses some employers opted to use overtime as a staffing strategy and cost cutting measure. Nurses are forced to work extra hours thus, they are overworked and exhausted. They are pushed beyond their limits, therefore, the safety and quality of care they provide to the patients is compromised. Fatigued nurses are less alert and are most likely to make errors. The working conditions have also had an impact on staff recruitment and retention. Job dissatisfaction has pushed out many nurses; they have opted to leave that sector to work elsewhere. Others are discouraged from joining the profession. Regulation of working hours and overtime is necessary in the effort to provide quality health care to all citizens. Registration needs to be enacted that regulate overtime for nurses and others in the health care sector. Mandatory overtime should not be imposed on nurses. They should be allowed to work overtime on voluntary basis (Aiken, 2001, p. 112).

    Mandatory overtime and patient safety

                It is a common practice for nurses to work mandatory over time. Overtime is used when there is a shortage of nurse due to vacations or sick offs or when there is an emergency. However, the trend has changed. Overtime is no longer and option due to unpredictable events or emergencies. Instead, it is a substitute for understaffing.  As a quality assurance strategy, unlicensed hospital assistant personnel were downsized and replaced with registered nurses. The available registered nurses were forced to work extra hours in order to provide a solution for the shortage of nurses. A survey by the Health Affairs in 2004 revealed that registered nurses have unpredictable work schedules characterized by long working hours. Each nurse worked approximately one extra hour daily.  About a sixth of the nurses surveyed worked over 16 hours consecutively that month. A survey by the American Journal of Nursing provided similar information on the issue. A quarter of the nurses they surveyed worked over 12 hours daily while a third often put in not less than 40 hours each week. A study by the Great New York Hospital Association found out that employers use mandatory overtime as a staffing strategy. Health care workers who are worn out are likely to compromise their patients’ safety. Generally, flexible and regular shifts are safer for all the parties involved; employers, health care providers and patients.

                Nurses become physically and mentally exhausted when they are forced to work extra hours. Hence they are not able to provide competent care to patients thus compromising the safety of the patients. Chances of an error during treatment increase significantly when the nurse is fatigued. According to a study by the Health Affairs errors caused by fatigue mostly involve administration of medication. There are documented cases of spread of infections in a hospital due to the nurses’ fatigue associated with overtime and excess workload; too many patients. Working through the overtime shift is unethical for the nurses. This is because it compromises the quality of health care that they give to citizens.

                When nurses are forced to work over time they do not derive satisfaction from their work. Moreover, it interferes with their person life. The main reason why nurses decide to change their career or employer is forced mandatory extra shifts. Some nurses change their careers because they feel that they constantly have to choose between their family and career. Early retirement offers a way out for other nurses who may feel drained emotionally, physically and psychologically by their work. As a result the forced overtime is partly responsible for the shortage of nurses. A survey indicated that approximately one-half million licensed nurses have opted to work in other sectors. Unless the mandatory overtime and staffing conditions are resolved, more nurses will continue to leave the profession (Clarke, 2002, p. 67)

                Nurses also risk facing legal charges in case any thing goes wrong when they are attending to patients during the mandatory overtime. Employers often threaten to charge nurses with abandonment of patients or neglect if they refuse to work the extra hours. In spite efforts by the state to discourage harassment of nurses who turn down the overtime, nurses are still threatened. A statement to the New York State Assembly Committee on Health and Committee on Labor by the Nurses Association testified to the harassment of nurses by employers. Overtime acted as a solution for employers in their attempt to cut down cost. Administrators believed that limiting recruitment and utilizing the available staff maximal would reduce benefits they pay out. However, research has proven that this approach is the worst error made in the staffing of hospitals. In the long run overtime and understaffing of nurses leads to the increase in health care cost. This is reflected in longer hospital stays by patients, lower levels of productivity and high rates of treatment due to errors.

                Unless legislators pass law to regulate overtime for nurses then nurses will continue to be over worked and their patients’ will still be at risk. In the past, health care providers have down their tools in protest of the mandatory overtime. Various states have proposed the banning of mandatory overtime. In 2002, several states enacted laws against mandatory overtime. New Jersey, Washington, Maryland and Minnesota banned mandatory overtime while Texas passed a regulation on the mandatory overtime. The state of California in earlier years had also enacted laws to regulate mandatory overtime. Other states that had banned mandatory overtime are Maine and Oregon (Allan, 1998, p. 23).

    The State Nurses Associations advocated for enactment of laws that regulate mandatory overtime by the legislators and regulatory bodies. The nurses also campaigned for the enactment of the federal mandatory overtime legislation: The Safe Nursing and Patient Care Act (2005). The aim of the bill is to protect the quality of health care that patients received and to retain experienced nurses in the profession. The legislation regulates mandatory overtime for nurses. The law would be enforced through Medicare’s provider agreement that was amended to ban mandatory overtime. The Secretary of Health and Human Services was charged with the responsibility of investigating claims of violation of the act. The act also prohibits discrimination, penalizing or revenge on nurses who decide to use the act for their protection.

                Banning forced extra shifts is a step in the right direction. However, more should be done to address the issue. The staffing of nurses also influences the quality of health care they provide as well as patients’ safety. When nurses are understaffed they are easily overworked and errors may occur. Research showed that cardiac arrest, shock, urinary tract infections and upper gastrointestinal bleeding cases are higher when the number of nurses attending to patients is low. According to statistics the number of patients who die within 30 days of admission when the ratio of patients to registered nurses is 8 to 1 instead of the recommended 4 to 1 increases by 7%.

    The issues of staffing and mandatory overtime for nurses need to be resolved. Banning of overtime improves the quality of health care provided to patients. Nurses will also be retained in the profession because they will derive satisfaction from their work and also attend to their families. Nurses should be allowed to volunteer themselves for overtime when need be; they should not be coerced into accepting extra shifts. They have the right to use their own discretion or goodwill (Sloane, 2003, p. 69).

    Conclusion

                In the past mandatory overtime was used in case of emergencies or unavoidable circumstances. However, it has become a staffing option for employers. Hospitals have less staff force the nurses to work extra shifts; eight hours back-to-back or twelve-hour shifts and four extra hours. According to a poll conducted by Feldman Group registered nurses work an average of 6 and a half overtime hours weekly and 8 and a half weeks of overtime each year. Due to the long working hours, nurses are often exhausted. Thus errors in treatment or administration of medication can occur. A report by the Institute of Medicine revealed that medical errors account for between 44,000 to 98,000 deaths yearly, in national hospitals. Overworked nurses and other health care givers are not as alert as those working regular shifts. Regulation of overtime in health care is essential in order to prevent medical errors related to fatigue. It will also ensure retention of nurses in the profession as well as attract others into the profession. (Harvard School of Public Health, 2001)

    Summary

                Mandatory overtime has posed a great risk to the safety of patients and the quality of health care. Staff shortage in hospitals is partly responsible for the long working hours that are imposed on nurses. Employers force nurses to work overtime as a measure to cut down cost. However, research has revealed that the opposite occurs. Cost increases due to prolonged hospital stays, treatment due to errors and lower turn over. Various surveys have been conducted such a; the surveys by the American Journal of Nursing, Great New York Hospital Association, Health Affairs and the study by Feldman Group. They all pointed out that mandatory overtime contributed to medical errors, influenced recruitment and retention of staff in the health care sector. Nurses opposed the mandatory overtime and urged the legislators to enact laws that regulate mandatory overtime. The states had a positive response, regulations were enacted or mandatory overtime was banned altogether. The landmark however, was the enactment of The Safe Nursing and Patient Care Act (2005).

    Reference:

    Aiken, C. (2001). Care and outcome in hospital: adverse effects of recruitment. Journal of         Health and Human Services Administration.

    Clarke, T. (2002).staffing of nurses in hospitals, burnout, job dissatisfaction and mortality rate. Journal of the American Medical Association; 288, 16.

    Allan, B. P. (1998). Health Care financing.  New York: Hill crest.

    Sloane, S.  (2003). Staffing and Patients in Hospitals. New York: Russel Sage Foundation.

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    Frequently Asked Questions

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    Can overtime work impact the quality of work that nurses do?
    Reduce Errors: In a study of nearly 400 hospital nurses, researchers found that the risk of making an error increased when nurses worked overtime or extended shifts (those longer than 12 hours). During the study's 28-day data-gathering period, 199 errors and 293 near-errors were reported.
    How does mandatory overtime affect patient care?
    Nurses who work longer than 12-hour shifts on a regular basis or without enough time off between shifts become fatigued, which can lead to mistakes. They also may feel resentful or dejected, which can lead to subpar patient care.
    Why do nurses work so much overtime?
    There is a shortage of nurses which means that hospitals and other clinical settings have to make use of the staff a lot more than committed. This means that they have to ask their staff on a routine basis to work overtime.
    Why nurses should not work overtime?
    As a result, nurses often must put in unplanned overtime beyond the scheduled shift length. When long shifts are combined with overtime, shifts that rotate between day and night duty, and consecutive shifts, nurses are at risk for fatigue and burnout, which may compromise patient care.

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