NURSE / PATIENT MANAGEMENT
CONTEMPORARY
ISSUES OF
OVERTIME
REGULATIONS AND NURSE
/
PATIENT OUTCOMES
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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
3.4
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 overtime 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, policies 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
The
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 such 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 their 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 Patient 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 equipment. 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).
Sleep
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
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 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.
3.3
Deciding when to work overtime
Hospital
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 for 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 other 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 work
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
REFERENCES
Alberta Association of Registered Nurses. (2006, September). Working extra hours. Alberta RN,
62(7), 8-9.
Berney, B., Needleman, J., & Kovner, C.(2005). Factors influencing the use of registered nurse
overtime in hospitals, 1995-2000.
Journal of Nursing Scholarship, 37(2), 165-172.
Borges, F.N., &
Fischer F.M. (2003). Twelve-hour night shifts of healthcare workers: A risk to
the
patients? Chronobiology international, 20(2), 351-360.
Buerhaus, P., & Staiger, D. (1996). Managed care and the nurse labor market. Journal of the
American Medical Association, 276(18), 1487-1493.
de Castro, A.B., Fujishiro, K., Rue, T., Tagalog, E.A., Samaco-Paquiz, L.P., & Gee, G.C. (2010).
Associations between work schedule characteristics and occupational injury and illness.
International Nursing Review, 57(2), 188-194.
Dawson D, McCulloch K. Managing fatigue: it's about sleep. Sleep Med Rev. 2005
Oct;9(5):365–80.
Institute of Medicine (IOM). (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academies Press.
LeMoal, L. (1999, January). Forced overtime reveals deepening nursing shortage. SUN Spots,
25(1), 1-2. Retrieved from http://www.sun-nurses.sk.ca/SS/1999/January99SS.pdf
Olds, D.M., & Clarke, S.P. (2010). The effect of
work hours on adverse events and errors in health care. Journal of Safety Research, 41(2), 153-162.
Rosa, R. R. (1995). Extended work shifts and excessive fatigue. Journal
of Sleep Research,
4(S2), 51-56.
Rogers, A.E.,
Hwang, W.T., Scott,
L.D., Aiken, L.H., & Dinges, D.F. (2004). The working hours of hospital staff nurses and patient safety. Health Affairs, 23(4), 202-212.
Trinkoff, A., Geiger-Brown, J., Brady, B., Lipscomb, J., & Muntaner, C. (2006). How long and how
much are nurses now working? American Journal
of Nursing, 106(4), 60-71.
Trinkoff, A.M., Johantgen, M., Storr, C.L.,Gurses, A.P., Liang, Y.,
& Han, K. (2011). Nurses’
work schedule charac-teristics, nurse staffing, and patient mortality. Nursing Research,
60(1), 18.
Trinkoff, A.M., Le, R., Geiger-Brown, J., & Lipscomb, J. (2007). Work schedule, needle use, and needlestick injuries among registered nurses. Infection Control & Hospital Epidemiology, 28(2), 156-164.
Trinkoff, A.M., Le, R., Geiger-Brown, J., Lipscomb, J., & Lang, G. (2006). Longitudinal relationship of work hours, mandatory overtime, and on-call to musculoskeletal problems
in
nurses. American Journal
of Industrial Medicine, 49(11), 964-971
U.S. Department of Health and Human Services. (2010). The registered nurse population: Findings from the 2008 national sample survey of
registered nurses. Retrieved from:
Wieck, K. L., Prydun, M., & Walsh, T. (2002). What The Emerging Workforce Wants In Its
Leaders. Journal of Nursing Scholarship, 34(3), 283-288.
