LEADERSHIP ASSIGNMENT PART 2

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T HE HEALTHCARE industry faces ongoing challenges with cost containment, workforce shortages, and

a growing chronically ill patient population. These challenges are driven by reimbursement con- straints and expanding unfunded care; a global shortage of nurses and other providers; and the aging Baby Boomer generation’s consumption of services and

longer life expectancy (Garrett, 2008). To maintain economic viability, hospitals must provide services to as many patients as possible to leverage overhead, maximize revenue, and meet federal and state man- dates for provision of services. Key strategies employed by the healthcare industry to provide appropriate nurse staffing levels include the use of contracted labor, flexible unbenefited positions, and both mandatory and voluntary overtime (Lobo, Fisher, Peachey, Ploeg, & Akhtar-Danesh, 2015).

Concerns have arisen about the negative impact of overtime on both nurses and patients due to nurse fatigue from long work hours, inadequate sleep, and inadequate recovery time between shifts (Bae, 2012; Garrett, 2008). Nursing overtime, regulations govern- ing overtime, and the effects of those regulations are reviewed, and a call to action is posed.

Definitions of Overtime A fundamental challenge in assessing the preva-

lence and consequences of nursing overtime is the lack of a consistent definition. Lobo, Fisher, Ploeg, Peachy, and Akhtar-Danesh (2013) found the term

Nursing Overtime: Should It Be Regulated?

CATHLEEN WHEATLEY, MS, RN, CENP, is Chief Nurse Executive and Vice President of Clinical Operations, Wake Forest Baptist Health, Winston Salem, NC.

Cathleen Wheatley

Cathleen Wheatley

overtime was poorly defined and indiscriminately used. Definitions included mandatory, voluntary, coerced, and extended work hours; working an off day; having on-call hours; having unpaid versus paid overtime; and varied quantifications of hours per week and hours per extended shift. They noted lack of agreement on the definition has led to disparate research methodologies, limiting the validity of find- ings and the ability to compare results or develop appropriate intervention strategies. Similar inconsis- tencies were found in the author’s review (see Table 1), and in an integrative review of nursing overtime by Lobo and colleagues (2015). Discussions of the overtime concept have addressed antecedents that are societal, organizational, and individual; attributes of perception of control or reward, relative value to off- duty; and the stress associated with inability to pre- pare; and consequences that both benefit and impose risk for key stakeholders, including nurses, patients, and organizations (Lobo et al., 2013) highlighting the complexity of nursing overtime as a phenomenon of interest to the profession, industry, and society.

Overtime Prevalence Nursing overtime is prevalent in the United

States and in Europe. Bae (2012) found 60% of U.S. nurses surveyed worked at least one type of overtime, with only 10% reporting unpaid overtime. Of nurses who reported working overtime, 54% worked less than 12 hours a week of overtime and 46% worked 12 hours or more per week. For those working less than 12 hours, 62% reported voluntary overtime, 18% mandatory, and 37% on call. For those working 12 hours or more per week of overtime, 35% reported mandatory and 72% on call. Of the total sample, approximately 17% reported working more than 40 hours per week as the norm. Most nurses reported working overtime to make money and/or to not let their co-workers down. Nurses who worked unpaid overtime reported doing so to finish their work. Approximately half of the sample reported chronic nursing shortages on their unit.

Berney, Needleman, and Kovner (2005) found similar high usage in a retrospective study of nursing overtime in New York hospitals between 1995 and 2000, with an average of 4.5% of total worked hours as overtime in all hospitals. Hospital characteristics associated with higher overtime usage were for-profit status, unionization, lower nurse-to-patient ratios, and higher wages for registered nurses.

Excellence & Evidence in Nurse Staffing

EXECUTIVE SUMMARY Nursing overtime is common in health care to accommodate staffing needs despite evidence that it increases the incidence of patient and nurse adverse events. Some states have been successful in implementing overtime regulation; however, attempts at the federal level remain unsuccessful.

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In European countries, Griffiths and colleagues (2014) found 27% of nurses reported working over- time, but there was wide variation between hospitals and countries. Approximately half of all nurses (working both 8 and 12-hour shifts) reported working some overtime, but nurses who worked shifts longer than 13 hours reported the most end-of-shift overtime (60%).

Overtime Effects Researchers exploring the effects of nursing over-

time have identified relationships between overtime and practice errors, nurse fatigue and injuries, and adverse patient outcomes (Bae & Fabry, 2014; Beckers et al., 2008; Lobo et al., 2015; Olds & Clarke, 2010; Rogers, Hwang, Scott, Aiken, & Dinges, 2004). Medication administration errors were the most fre- quently reported practice error. Olds and Clarke (2010) found nurses working overtime of any type reported an increased occurrence of wrong-dose med- ication error, and Lobo and coauthors (2015) identi- fied similar findings after 4 hours of overtime, regard- less of shift length. Nurse fatigue and low work satis-

faction have been associated with involuntary over- time (Beckers et al., 2008; Garrett, 2008), and an increased odds ratio (OR) of inadequate sleep (OR 1.36) was found in nurses working mandatory over- time or being on call more than once per month and for quick turnarounds (Geiger-Brown, Trinkoff, & Rogers, 2011). A greater occurrence of inadequate sleep was found for nurses working 9-11 hours per day versus 8 or fewer, and for those reporting week- end shift work compared to those working no week- ends (Geiger-Brown et al., 2011). In addition to safety risks, the fatigue associated with overtime negatively impacts nurse morale and increases turnover intent, with associated increased organizational costs due to vacancies and voluntary turnover (Garrett, 2008; Reed, 2013).

An association between overtime and nurse out- comes such as needlestick and musculoskeletal injuries, fatigue, illness, absenteeism, burnout, job dissatisfaction, and turnover intent was reported in studies reviewed by Bae and Fabry (2014). They found a statistically significant relationship between overtime and falls, pressure ulcers, and nosocomial

Table 1. Overview of Published Literature on Nurse Overtime: Study Definitions and Methodologies

Source Overtime Definition Methodology Bae, 2012 Paid and unpaid mandatory, paid and unpaid voluntary, paid

and unpaid on call, an excess of 40 hours per week in principal position

Cross-sectional survey

Bae, 2013 Paid and unpaid mandatory, paid and unpaid voluntary, paid and unpaid on call, an excess of 40 hours per week in principal position

Cross-sectional survey

Bae & Brewer, 2010 Mandatory/unscheduled overtime, voluntary overtime, paid on call, hours per week of 41-60 and ≥61

Secondary analysis of cross- sectional survey data

Bae & Yoon, 2014 In excess of 40 hours hours worked per week and in excess of 60 hours in principal position

Quasi-experimental

Beckers et al., 2008 Hours per week in excess of regularly scheduled/contracted hours

Questionnaire

Berney et al., 2005 Hours per week in excess of 40 hours Secondary analysis of institutional cost reports

Geiger-Brown et al., 2011 Hours per day in excess of 9-11 and ≥12; hours per week of 41-49 and ≥50

Longitudinal survey with random selection

Griffiths et al., 2014 Shift length of 8.1-10, 10.1-11.9, 12-13, >13 hours Cross-sectional survey Olds & Clarke, 2010 Mandatory overtime, paid overtime, and unpaid overtime Secondary analysis of anonymous

questionnaire, random selection Rogers et al., 2004 Hours worked that exceeded scheduled hours, scheduled

overtime hours Prospective survey

Stimpfel et al., 2015 Shift length of 8, 10, 12, or “other” hours; mandatory and voluntary overtime hours (not quantified) worked per week in principal position

Secondary analysis of cross- sectional survey data

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infections. Significant relationships were also found between quick turnarounds and hypoglycemic events and pneumonia deaths.

An increased risk of needlestick injury was reported by Stimpfel, Brewer, and Kovner (2015) in newly licensed nurses who worked 12-hour shifts, over 40 hours per week, and weekly overtime greater than 8 hours per week, with significance (incidence rate ratio 1.25) at more than 8 hours of weekly over- time. When comparing nurses working more than 8 hours of overtime per week with those who did not work overtime, they found a 32% increased risk (inci- dence rate ratio 1.32) for the overtime group. An increased risk of musculoskeletal injuries such as neck and back strain has been similarly associated with overtime and extended shift length (Bae & Fabry, 2014; Lobo et al., 2015; Olds & Clarke, 2010; Stimpfel et al., 2015).

Olds and Clarke (2010) found a statistically signif- icant increased risk for patient falls with injury (p<0.05) and for nosocomial infections (p<0.01) for nurses working over 40 hours in the average week. Lobo and associates (2015) found significant relation- ships between overtime and catheter-associated uri- nary tract infections (OR 4.72) and pressure ulcers (OR 1.91). Bae (2013) found similar trends for falls (OR 3.36) and for pressure ulcers (OR 3.50).

Despite the negative effects of nursing overtime, select stakeholders receive advantages. Healthcare facilities can manage nursing shortages and high cen- sus peaks without hiring additional permanent per- sonnel with the associated costs for benefits (Berney et al., 2005; Griffiths et al., 2014), and nurses are able to “make money” (Bae, 2012, p. 69) and eliminate the negative financial impact of flexing down during low- census periods (Nelson & Kennedy, 2008). Mandatory overtime restrictions also benefit certain groups: trav- el nurses and their employers have the potential to benefit from the opportunities created when hospitals turn to this contracted labor pool to manage staffing needs without breaching overtime restrictions (Sederstrom, 2013).

Current Regulations The negative effect of fatigue on performance has

been demonstrated in other high-risk industries such as aviation, commercial vehicle transit, and public safety (Lindsay, 2007; Olds & Clarke, 2010). While these industries have work hour regulations, the healthcare sector has been slow to adopt similar reg- ulations (Berney et al., 2005; Lindsay, 2007). Except for work hour restrictions for medical residents insti- tuted by the Accreditation Council for Graduate Medical Education in the early 2000s and several state regulations on nursing overtime or extended shift regulation, overtime in the healthcare industry remains largely unregulated at both the federal and state levels (Berney et al., 2005; Brooke, 2011).

Many state-based nursing associations have been pursuing nursing mandatory overtime regulation since the early 2000s (Schildmeier, 2012). In general, regulations prohibit hospitals and other healthcare institutions such as nursing homes from forcing nurs- es to work more than their regularly scheduled hours (Bae & Brewer, 2010). As of 2017, 18 states have passed legislation restricting nurses’ mandatory over- time (J. Haebler, personal communication, January 30, 2017). As shown in Table 2, some states have regula- tion addressing mandatory overtime only, while oth- ers include restrictions on shift length and required respite periods. All states exempt these regulatory requirements during emergency or disaster situations, and some states, such as Massachusetts, have defined emergency situations that qualify for the mandatory overtime exemption (“Nursing Practice Alert,” 2013).

Attempts to regulate nursing mandatory overtime at the federal level occurred in 2005 with the intro- duction of the Safe Nursing and Patient Care Act (H.R. 791). This bill would have prohibited Medicare-par- ticipating healthcare facilities from mandating nurses to work more than 12 hours in a 24-hour period or more than 80 hours in a 2-week period except during emergencies or disasters (Gonzalez, 2005). The bill did not progress further through the legislative process and has not been reintroduced to subsequent congressional sessions.

Current attempts to address safe nursing staffing have been approached in two related acts, neither of which specifically restricts nurses’ mandatory over- time or shifts. The first, the Registered Nurse Safe Staffing Act of 2015 (H.R. 2083/S.1132), was intro- duced in 2007 and reintroduced in 2010, 2011, 2013, and 2015 (Civic Impulse, 2017a). This bipartisan bill would amend Title XVIII (Medicare) of the Social Security Act and stipulates that Medicare-participat- ing hospitals establish a nurse staffing committee comprising a minimum of 55% direct-care nurses and develop staffing plans specific to each unit to provide safe levels of nursing care based on patient popula- tion and nurse proficiency (Civic Impulse, 2017a). H.R. 2083 also includes whistle-blower protections and requires public reporting of staffing information, including nursing overtime usage. The second, the Nurse Staffing Standards for Patient Safety and Quality of Care Act of 2015 (H.R. 1602), was intro- duced in 2004 and reintroduced in 2005, 2007, 2009, 2011, 2013, and 2015 (Civic Impulse, 2017b). This bipartisan bill would amend the Public Health Service Act and require hospitals to establish mini- mum direct-care registered nurse-to-patient staffing ratios. The bill would allow nurses to refuse any assignment they believe breaches minimum ratios or for which they do not feel prepared, by education or experience, to perform the assignment without com- promising patient safety or their own license. The bill would prohibit retaliation or discriminatory treat-

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ment by the hospital to the nurse for refusing such an assignment. Neither bill progressed through the leg- islative process in the 114th Congress.

Impact of Regulation Bae and Brewer (2010) analyzed total nursing

hours worked, regular and overtime, including both mandatory and voluntary, in states with and without overtime regulations. Regulations included restric- tions on total hours worked per day or per week, ban- ning of mandatory overtime, and nurse right to over-

time refusal. Findings indicated states that restricted total hours worked showed more mandatory overtime usage than states that did not, indicating a possible permissive effect for mandatory overtime within capped limits. Voluntary overtime was not similarly affected. Conversely, in a later study, Bae and Yoon (2014) found states with regulations limiting manda- tory overtime and consecutive work hours reduced mandatory overtime hours by 3.9 percentage points and the incidence of working more than 40 hours per week by 11.5 percentage points, concluding that both

Table 2. Overview of State Nursing Overtime Regulations (as of 2015)*

State Mandatory Overtime Shift Length and Respite Requirements Year

Passed Alaska Illegal 14 consecutive hours 2010 California Illegal, right to refusal without retaliation 12 hours in any 24-hour period 2001

Connecticut Illegal Extension required beyond scheduled shift length prohibited except for emergency or completion of procedures

2004

Illinois Illegal Shift extension capped at 4 hours even for emergencies, 8-hour required rest following any 12-hour shift

2005

Maine Illegal, right to refusal without retaliation 10 consecutive rest hours after working any overtime 2001

Maryland Illegal Require extension beyond scheduled shift in a predetermined schedule prohibited unless emergency or critical skill needed

2002

Massachusetts Illegal 12 consecutive hours in any 24-hour period 2012 Minnesota Illegal, right to refusal without retaliation 12 consecutive hours 2002 Missouri Illegal for licensed practical nurses only None 2006 New Hampshire Illegal, right to refusal without retaliation 12 consecutive hours 2008 New Jersey Illegal Hours per week cannot exceed 40 2002 New York Illegal None 2008 Oregon Illegal 12 consecutive hours, hours per week cannot

exceed 48, shift extension capped at 4 hours even for emergencies

2001

Pennsylvania Illegal Extension beyond scheduled shift prohibitedexcept for emergency 2008

Rhode Island Illegal 12 consecutive hours 2008 Texas Illegal, right to refusal without retaliation None 2007 Washington Illegal, right to refusal without retaliation None 2002 West Virginia Illegal, right to refusal without retaliation 16 consecutive hours, 8 consecutive hours rest

required after any 12-hour shift 2004

* Emergency situation exceptions apply.

SOURCE: Adapted from J. Haebler, American Nurses Association, personal communication, July 13, 2016.

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mandatory overtime and consecutive work hour reg- ulations effectively reduced nurse hours worked. In the analysis of the association between mandatory overtime regulation and outcomes, no effect was shown for nurse injuries, but the regulation of manda- tory overtime was associated with statistically signif- icant higher odds of nurse-reported adverse patient events, inferring the same permissive effect in capped-hour states (Bae, 2013).

Conclusion Nursing overtime, both mandatory and voluntary,

is prevalent in the healthcare industry as a solution for managing staff shortages and high census episodes. There is sufficient evidence of the negative impact of this practice on nurse personal wellness and risk for workplace injury, patient outcomes, and nursing turnover to warrant the continued attention of policy- makers. Current evidence demonstrating the impact of regulation is limited by the lack of a consistent defini- tion for nursing overtime and by disparate research methodologies. Nurse researchers need to continue to study this topic to advance the body of knowledge and support the development and promotion of effective regulation. Although several states have been success- ful in regulating nursing overtime and extended shifts, attempts at the federal level have not been successful. Two bills proposed to the 114th Congress had the potential to address the problem through staffing requirements and transparency, but they lacked spe- cific language related to overtime, extended shifts, or respite periods. Neither bill was enacted; either those bills or new bills will need to be introduced to the 115th Congress for further progression. Continued efforts by individual nurses, professional nursing asso- ciations, and other vested stakeholders should focus on influencing policymakers through direct personal contact, lobbying, expert testimony, political action committees, policy drafts, alignment with other stake- holder special interest groups, as well as exercising the power of the ballot. $

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