29 Jun 2019



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1.0     INTRODUCTION                                                                      3

2.1 Trends in Overtime                                                                  5
2.2 Risks and effects associated with overtime                          6

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
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).

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.


3.1      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.
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.

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