Running head: MANDATORY OVERTIME
Mandatory Overtime
Jennifer Dixon & Ann Swanson-Hill
Washburn University
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MANDATORY OVERTIME
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Mandatory Overtime
Problem Identification
Nurses already work long hours, and many work even longer hours due to concerns about
job loss if they are not compliant with mandatory overtime. It is widely known that there is a
direct correlation between nurses working overtime and patient safety (Michigan Nurses
Association, MNA). Unfortunately, the associated result is a reduction in patient safety. The
International Council of Nurses (ICN) acknowledges that nurses around the world are
increasingly working overtime and "the increasing amount of overtime threatens nurses' ability
to provide safe and individualized care for patients."(ICN, n.d.) The Joint Commission on the
Accreditation of Healthcare Organizations (JCAHO) reported to the Senate Committee on Health
Education, Labor and Pensions, "that almost one-quarter of sentinel events that were analyzed
under their guidance were related to nurse staffing issues, including fatigue."(Michigan Nurses
Association, MNA, p. 1-11)
For many nurses, hours spent at work have increased, but there has not been a decrease in
responsibilities at home. Mandatory overtime presents a challenge to working families.
Especially when a health care worker is encouraged to work overtime, leaving children without
care or burdening family members to assist at the last minute. Overtime often decreases the
amount of sleep an individual receives. When nurses cut back on sleep, their work performance
suffers. Also, frequent overtime can be a cause of stress and chronic fatigue that can lead to
burnout or long term health complications. "The financial impacts of fatigue and nursing staff
burnout tend to be associated with increased patient-care errors and medical errors, liability
concerns, and increased absenteeism and turnover." Each of these is associated with increased
costs to health care organizations. (Michigan Nurses Association, MNA, p. 6)
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Since overtime can have damaging effects on nurses and their families, nurses should not
be forced to work overtime. Due to public health considerations, mandatory overtime should
have federally mandated limits for all health care workers.
Social Background
Working mandatory overtime can affect a variety of different aspects of one's social life.
There is more dissatisfaction in nursing and burnout is more frequent in relation to the number of
hours worked (Golden and Jorgenson, 2002). When workers spend more time at work, they
continue to have the same amount of responsibilities at home, thus taking away valuable family
time. Working overtime can make it difficult for a parent to attend their child's school and
sporting activities. Providing childcare can be difficult when nurses are unexpectedly required to
work overtime. Working overtime makes it more difficult for nurses to attend school to improve
their education. In addition, nurses are left without enough time for leisure activities and rest.
There can be negative effects to the community as a whole when nurses work mandatory
overtime. There is an increase in car accidents when someone is tired from working an extended
shift. This is dangerous to the nurse as well as the community. Dawson and Reed (1997) equate
impairment levels of fatigue to being intoxicated.
Economic Background
The effects of working mandatory overtime can be costly to hospitals and health care
organizations.
More errors occur when workers are fatigued (Easton and Rossin, 1997) Some
medical errors result in insurance claims or litigation for a hospital, which can be quite costly.
The consulting firm Circadian Technologies, Inc. that specializes in risk assessment with regard
to human fatigue," there has been an increase recently in malpractice lawsuits claiming that
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medical error was caused by nurse or physician fatigue due to working long hours"(MNA, 2004).
In 1999, at a conference on medical liability, Dr. Lucian Leape reported, "as many as 1 million
medical errors occur each year and 120,000 of these errors result in death" (MNA, 2004). The
projected cost of these deaths was $69 million dollars. Employees that frequently work
overtime consistently report their jobs as highly stressful. According to Donatelle and Hawkins
(1989)" job stress is estimated to cost $150 billion per year in absenteeism, health insurance
premiums, diminished productivity, compensation claims and direct medical costs. "
Ethical Background
Often time’s nurses are put in an ethical dilemma when required by their employer to
work overtime. Nurses are aware of the fact that they are not giving their best patient care and
that they are jeopardizing their patients well being by working excessive hours. Nurses will
violate their own professional nursing code of ethics due to fear of loss of employment. The
Code of Ethics for Nurses is the professional ethical standard for nurses and by being required to
work mandatory overtime nurses may be forced to act in a way that is inconsistent with these
values and ethics of the profession. Provision 3.4 in the Code of Ethics for Nurses with
interpretive statements notes that “nurses should promote, advocate and strive to protect the
safety of patients by addressing both environmental and system factors and human factors that
present risk to patients” (American Nurses Association [ANA], 2001). Provision 5.4 addresses
the responsibility of the nurse to insure the integrity and safety of the patient and object to
activities or expectations that jeopardize the patient or nurses wellbeing (ANA, 2001). Nurses
are directed in the Code of Ethics not to accept unsafe or inappropriate practices and that “nurses
should not remain employed in facilities that routinely violate patient rights or require nurses to
severely and repeatedly compromise standards of practice or personal morality” (ANA, 2001).
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Growing evidence shows that nurse fatigue due to mandatory overtime places both the patient
and the nurse at risk and is a violation of the Code of Ethics for Nurses. The ANA has taken the
position that “regardless of the number of hours worked, each registered nurse has an ethical
responsibility to carefully consider his/her level of fatigue when deciding to accept any
assignment extending beyond the regularly scheduled work day or week, including mandatory or
voluntary overtime assignments” (American Nurses Association [ANA], 2011)
Legal Background
The Fair Labor Standards Act of 1938 (FLSA), which regulates overtime, does not
address limits on overtime hours but merely requires that hourly employees be paid an overtime
rate of time and a half for each hour worked over 40 during a work week (Golden & Jorgensen,
2002, p. 2). Although the FLSA does not cover the practice of mandatory overtime, sixteen
states currently regulate or restrict this practice in the nursing field. In 2001, Maine became the
first state to pass an overtime law that would “prevent nurses from being disciplined for refusing
to work more than 12 consecutive hours except in certain circumstances and must be given 10
consecutive hours off following overtime” (ANA, 2011). As of 2010, there are a total of sixteen
states with restrictions on the use of mandatory overtime for nurses; Alaska, Connecticut,
Illinois, Maryland, Minnesota, New Jersey, New Hampshire, New York, Oregon, Pennsylvania,
Rhode Island, Texas, Washington, West Virginia, California and Missouri (ANA, 2011). States
that have introduced restrictions or provisions during 2011-2012 include Florida, Illinois,
Massachusetts, New York, Pennsylvania, and Vermont (ANA, 2011).
Political Background
Concerns that mandatory overtime affects patient safety has prompted legislation at the
federal level to restrict the amount of overtime hours that nurses are allowed to work. The Safe
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Nursing and Patient Care Act have been introduced in the United States Congress several times
but the bill has never become a law ("Safe Nursing," 2007). The Safe Nursing and Patient Care
Act is “a bill to amend the social security act to provide for patient protection by limiting the
number of mandatory overtime hours a nurse may be required to work in certain providers of
services to which payments are made under the Medicare program” ("Safe Nursing," 2007).
Under the Registered Nurses and Patient Protection Act, “licensed health care professionals
could not be required to work more than eight hours in a day or 80 hours within a two-week
period, unless a written agreement between the employer and the employee specifies otherwise”
(Golden & Jorgensen, 2002, p. 10). So far, these legislative proposals have not caused House
leaders to take action against such a potentially dangerous practice.
Issue Statement
Mandatory overtime is not an acceptable means of staffing a hospital, patient
safety is decreased and nurses are at increased risk for making errors. There is also an increase
in legal liability issues against nurses and health care organizations.
Stakeholders
Stakeholders are defined as “those directly impacted by specific policy decisions and tend
to be highly involved in the policymaking process” (Mason, Leavitt, & Chaffee, 2012, p. 50). In
regards to mandatory overtime, we identified the following three stakeholders: patients, nurses,
and health care organizations.
Patients are the first and most important stakeholders in this policy issue as it can directly
affect their safety and wellbeing. Nurses working long hours present a serious threat to the
safety of patients. The International Council of Nurses acknowledges that nurses throughout the
world are increasingly working long hours, and “the increasing amount of overtime threatens
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nurses’ ability to provide safe and individualized care for patients” (Public Policy Associates,
Incorporated, 2004, p. 2). Some threats to patient safety may include; nurses being less alert and
may not notice changes in a patients’ condition, nurses reaction times are slower, medication
errors occur more frequently, clinical judgment errors by the nurse, and an increase in
nosocomial infections in hospitalized patients (Public Policy Associates, Incorporated, 2004, p.
2). Studies have shown that prolonged periods of wakefulness can produce effects that are
similar to the effects produced by alcohol intoxication which decreases a persons reaction time
and speed of mental processes (Public Policy Associates, Incorporated, 2004, p. 3). Fatigued
nurses working overtime would most likely fall into this category of prolonged wakefulness thus
posing a serious threat to patient safety.
Nurses and the professional organizations that support nurses are the next stakeholders
that hold a valued interest in mandatory overtime. The American Nurses Association and the
American Academy of Nursing (ANA) have concerns with how the effects of mandatory
overtime impacts the public, but also the impact it has on nurses and the practice of nursing. "It
is the position of the ANA that all employers of registered nurses should ensure sufficient system
resources to provide the individual registered nurse in all roles and settings with 1) a work
schedule that provides adequate rest and recuperation between scheduled work; and 2) sufficient
compensation and appropriate staffing systems that foster a safe and healthful environment that
the registered nurse does not feel compelled to seek supplemental income through overtime,
extra shifts, and other practices that contribute to worker fatigue." (American Nurses Association
[ANA], 2006, para. 5).
Nurses are directly impacted by hospital policies in regards to mandatory overtime. Many
states have passed some form of legislation regulating mandatory overtime for registered nurses.
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Nurses still may find themselves in a situation that requires them to work longer hours than their
scheduled shift. The risk of making an error increases significantly when, working longer than
twelve hours, greater than forty hours in a pay period or working overtime. (Rogers, Hwang,
Scott, Aiken, & Dinges, 2004, p. 202) Research has shown that "Excessive overtime ultimately
results in lower productivity, more fatigue-related accidents and injuries, costly increases in
absenteeism and turnover, and higher employer medical costs." (Twarog, 2011, p. 10) It is for
the aforementioned reasons that nurses hold great concern in regards to the safety of mandatory
overtime.
Overtime work by nurses has a significant effect on the finances of hospitals and other
health care organizations. Some of the consequences of long shifts, increased workload and
overtime contribute to fatigue and nurse burnout which, in turn, leads to several costly
consequences for health care organizations when they have to constantly hire and train new
nurses (Public Policy Associates, Incorporated, 2004, p. 6). As mentioned above, longer work
hours by the nurse are associated with an increase in patient-care or medical errors, including
medication errors that pose a serious threat to patient safety. All patient-care errors are serious,
but it is recognized that approximately 5% of significant errors are potentially life threatening for
the patient (Public Policy Associates, Incorporated, 2004, p. 6). Direct costs to the health care
organization may include any remedial action that must be taken to rectify the situation, such as
additional hospital stay for the patient, recording of the error, and internal hospital review and
analysis of the error (Public Policy Associates, Incorporated, 2004, p. 7). The cost of
identifying, addressing and rectifying these errors are not usually reimbursable. Some of the
indirect costs to health care organizations as a result of nurse fatigue include; heightened riskmanagement activities, increased internal-review and remediation efforts, public relation issues,
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and even threats to accreditation and licensure (Public Policy Associates, Incorporated, 2004, p.
7). An increase in errors that are made known to the public can ruin a hospitals reputation
leading to decrease in revenue for that health care organization.
Policy Objectives
The goal of decreasing or eliminating mandatory overtime is to ensure safe patient care,
support nurses professional practice and enhance community well being. Policy objectives
include the following:
1. In order to reduce errors related to fatigue, states should eliminate mandatory overtime
in excess of twelve hours in any twenty-four hour period and/or sixty hours per week.
2. Nurses should not suffer punitive discipline for refusing to work overtime.
3. Hospitals should be required to provide adequate nurse staffing in order to prevent the
use of mandatory overtime.
4. Job satisfaction of nurses will be improved as indicated by a decrease in nursing
turnover and decrease in absenteeism at the workplace.
Policy Alternatives
Policy alternatives for resolving the issue of mandatory overtime include the following:
1. Do Nothing Option: Continue mandatory overtime as in current practice.
2. Incremental Change Option: Enact legislation to regulate mandatory overtime.
3. Major Change Option: Enact legislation to eliminate mandatory overtime.
Evaluation Criteria
1. Decrease in medication errors
2. Increase in nurse retention
3. Decrease in legal liability issues
MANDATORY OVERTIME
Analysis of Option 1
Criterion 1: Decrease in medication errors
Pro: There are no advantages to the Do Nothing Option.
Con: Patient safety continues to be jeopardized, as medication errors will continue to be made
with the current policy in practice.
Criterion 2: Increase in Nurse Retention
Pro: There are no advantages to the Do Nothing Option.
Con: Nursing staff turnover continues due to decrease in job satisfaction which in turn is an
added expense to health care organizations as they hire and train new employees.
Criterion 3: Decrease in Legal Liability Issues
Pro: There are no advantages to the Do Nothing Option.
Con: The cost of legal liability issues continues to rise for health care organizations as their
reputation is potentially ruined leading to a loss in profits.
Analysis of Option 2
Criterion 1: Decrease in medication errors
Pro: Patient safety will be increased due to less medication errors being made by overworked
nurses.
Con: The time and expense of implementing a policy change may be a disadvantage.
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Criterion 2: Increase in Nurse Retention
Pro: The cost of hiring and training new staff will be decreased for health care organizations and
nurses are retained.
Con: The increased benefits and salary of a long-term employee is an increased cost to health
care organizations.
Criterion 3: Decrease in Legal Liability Issues
Pro: Decrease in cost of legal litigation for health care organizations. Increase in health care
organization’s reputation as legal liability issues are decreased.
Con: There are no disadvantages for the Incremental Change Option.
Analysis of Option 3
Criterion 1: Decrease in Medication Errors
Pro: The increase in patient safety due to less medication errors is potentially life saving for
many patients.
Con: The time and expense of changing a law may be a downfall.
Criterion 2: Increase in Nurse Retention
Pro: With an increase in nurse retention due to increased job satisfaction, the cost of hiring and
training new staff will be decreased for health care organizations.
Con: The increased benefits and salary of a long-term employee is an increased cost to health
care organizations.
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Criterion 3: Decrease in Legal Liability Issues
Pro: The decrease in legal liability issues will be cost saving for health care organization. With
a decrease in legal liability issues, the health care organizations reputation is sure to improve thus
increasing profit.
Con: There are no disadvantages to the Major Change Option.
Comparison of Policy Alternatives
Analysis and comparison of the three policy alternatives on the criteria for evaluation and
alternatives matrix (refer to Appendix A), reveal a tie score between alternatives two,
(regulations to mandatory overtime) and alternative three (law change, mandatory overtime no
longer allowed.) The regulation of mandatory overtime and change in law to eliminate
mandatory overtime both score positively on each of the three criteria.
Option one fails on each of the criteria of decreasing medication errors; increasing
retention of nurse and a decreasing legal/liability issues- we do not consider this a viable option.
Options two and three reveal a tie; both of these options offer positive changes to the mandatory
overtime dilemma. It is difficult to determine which option is the absolute best. The scorecard
results do indicate that change is necessary.
Summary
The relationship between mandatory overtime for nurses and a reduction in patient safety,
particularly an increase in medication errors, has been demonstrated by many studies. In
addition to a decrease in patient safety, mandatory overtime decreases job satisfaction for nurses
resulting in costly staff turnover. Legal liability also increases as mandatory overtime increases
the number of patient-care/medication errors made by overworked nurses. In order to preserve
patient safety and enhance community well being mandatory overtime needs to be regulated if
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not eliminated completely. In order to reduce errors related to nurse fatigue, states should
eliminate mandatory overtime in excess of twelve hours in any twenty-four hour period and/or
sixty hours per work week. Nurses should not be punished for refusing to work unscheduled
overtime. Hospitals will be required to provide adequate nurse staffing in order to eliminate the
need for mandatory overtime. These changes need to be made in order to preserve patient safety
and potentially save lives by reducing avoidable and costly mistakes.
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References
American Nurses Association. (December 8, 2006). Assuring patient safety: The employers’ role
in promoting healthy nursing work hours for registered nurses in all roles and settings
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American Nurses Association. (2011). Mandatory Overtime. Retrieved from
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Center for American Nurses. (2006). Opposition to Mandatory Overtime. Retrieved from
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Leape, L. L. (1996). Out of darkness: Hospitals begin to take errors seriously. Health Systems
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Mason, D. J., Leavitt, J. K., & Chaffee, M. W. (2012). The Policy Process. In M. Iannuzzi (Ed.),
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Public Policy Associates, Incorporated. (2004, August). The Costs of Mandatory Overtime for
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Rogers, A. E., Hwang, W., Scott, L. D., Aiken, L. H., & Dinges, D. F. (2004, July/August). The
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Appendix A