A Statement from The American Association of Critical-Care Nurses (AACN)
Mandatory overtime is identified as a workplace issue and a patient safety issue.
Mandatory overtime is the practice of hospitals and health care institutions to
maintain adequate numbers of staff nurses through forced overtime, usually with
a total of twelve to sixteen hours worked, with as little as one hour's notice.
With mandatory overtime nurses are unable to refuse the required extra hours due
to 1) fatigue, or 2) feeling that she/he would be unable to deliver adequate, safe
patient care. This does not include overtime mandated in an unforeseen emergency,
such as a mass casualty situation, or a sudden snowstorm. "On call" time is not
included in this definition, unless the nurse's on call time is immediately before
or after a scheduled shift, and it would force him or her to work a double shift.
The dramatic changes in the health care environment that have impacted nursing practice
in recent years have come as managed care programs grew in dominance and federal
Medicare and Medicaid reimbursements declined (Berens, M.J.). With the nursing shortage
continuing, the growing trend is for hospitals to use mandatory overtime as a common
staffing practice (ANA, June 2000).
Mandatory overtime may cause or lead to increased stress on the job, less patient
comfort and mental and physical fatigue that can contribute to errors and "near-misses"
with medications and case-related procedures. This is occurring as patient acuity
has increased. The practice of mandatory overtime ignores the responsibilities nurses
may have at home with children, other family members, or other obligations. Being
forced into excessive overtime can cause an exhausted RN to practice unsafe patient
care, jeopardizing her nursing licensure status. Impact is felt at the level of
the bedside nurse in three major areas identified through current literature: medication
errors, quality patient care, and nurses' legal liability.
- The Institute of Medicine's report To Err is Human: Building a Safer Health System
(IOM, 12/1999) states the deaths from medication errors that take place both in
and out of hospitals, more than 7000 annually, exceed those from workplace injuries.
In a separate report, investigation by the Chicago-Tribune states that since 1995,
at least 1,720 hospital patients have died and 9,548 others have been injured because
of mistakes made by RN's across the country (Associated Press, 9/10/2000).
Quality Patient Care
- As the nurse-to-patient ratio worsens, and as patient acuity increases, hospital
management is free to demand that nurses work mandatory sixteen-hour shifts, with
one-hour notice (MNA, 4/3/2000). In a 1989 article published in the Journal of Occupational
Health and Safety, the author stated, "Once a shift exceeds twelve consecutive hours,
acute fatigue sets in. A worker may still be able to perform routine tasks, but
his brain waves exhibit a pattern of stage one alpha sleep. Errors made in this
stage are frequently major, since the worker tends to perform the opposite of the
- Nurses practice under each state's Nurse Practice Act, which govern nursing practice.
Most nurse practice acts state that nurses are held accountable for the safety of
their patients. Thus, if a nurse accepts a patient assignment and something untoward
happens to that patient, the nurse is liable under her license. Once a nurse accepts
an assignment, her license can be in jeopardy if she is unable to deliver safe patient
Implications of Change
- If mandatory overtime is legally banned in all states, hospitals and health care
institutions will have to look at real remedies for understaffed facilities such
- Hiring more RN's
- Utilizing strategies to recruit and retain more nurses.
ANA's recent study, Nurse Staffing and Patient Outcomes in the Inpatient Hospital
Setting (3/2000), tracks five adverse outcomes measures that can be mitigated
if adequate patient staffing is provided: hospital length of stay, nosocomial pneumonia,
postoperative infections, pressure ulcers, and nosocomial urinary tract infections.
With sufficient nurse staffing, time is available for more thorough patient assessment
and interventions to improve outcomes.
The American Academy of Nursing (AAN) conducted research in the 80's, which has
had several follow-up studies since, which reinforce the original findings of researcher
Linda Aiken. Her research affirmed that specific organizational variables create
a milieu that not only attracts nurses, but also create practice environments that
provide better outcomes for patients. "Magnet facilities" have higher nurse-staffing
levels, and lower mortality and morbidity rates, shorter length of stay, and lower
utilization of ICU days. In the 1999 follow-up research, a lower incidence of needlestick
injuries among nurses was also noted. If mandatory overtime is allowed to continue,
one could easily project:
- Increase in medication errors
- Decrease in safe, quality patient care
- Decrease in patient satisfaction
- Increase in hospital length of stay
- Increase in mortality and morbidity
- Decrease in recruitment of new nurses
- Decrease in retention of nurses
- Increase in legal liability issues against nurses
February 12, 2003 - Senator Edward M Kennedy re-introduced
S. 373, the "Safe Nursing and Patient Care Act of 2003",
which amends title XVIII of 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.
A companion bill, H.R. 745 was again re-introduced in the House by Representative
Pete Stark. The bills are currently in committee.
November 14, 2001- Senator Edward M Kennedy, introduced S.
1686, the "Safe Nursing and Patient Care Act of 2001",
which was referred to the Committee on Finance. The bill would amend title XVIII
of 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. and referred
to the House Committee on Education and the Workforce and to the Subcommittee on
September 15, 2000- H.R. 5179 "The Registered Nurses and Patients
Protection Act" was introduced into the U.S. House of Representatives
by Rep.Tom Lantos (D-Calif.). The bill would amend the Fair Labor Standards Act
so that no RN would be required to work beyond eight hours in any workday or 80
hours in any 14-day work period. This legislation was not acted on in the 106th
Congress and Lantos reintroduced the bill (H.R. 1289) in the 107th
Congress where it was referred to the House Committee on Education and the Workforce
and to the Subcommittee on Workforce Protections.
AACN believes that mandatory overtime is not an acceptable means of staffing a hospital,
because it may place nurses and their patients at increased risk of being involved
in medical errors. Instead, nurses should be able to decide whether working overtime
will affect their ability to care safely and effectively for patients. They should
have the option of refusing overtime assignments and not be forced into working
beyond their capacity to provide optimal care. AACN supports this legislation and
will continue to work to educate the public on the negative impact that mandatory
overtime can have on patient safety.
What You Can Do
Work with the administrators in your facility to develop systems that support the
delivery of quality care and a safe work environment.
Let your legislators know that this bill has strong support of nurses. Discuss with
him or her:
Your concern that mandatory overtime is not an acceptable means of staffing a hospital
because it can place nurses and their patients at increased risk for making errors.
The fact that studies have shown that when a worker (especially a health care worker)
exceeds 12 hours of work, and is fatigued, the likelihood of their making an error
increases. The IOM report on medication errors substantiates these findings, where
the experts who compiled the report specifically recommended that safe staffing
and limits on mandatory overtime are a component to preventing medication errors.
Explain RN accountability for the delivery of safe care and that nurses should not
be forced into working beyond his or her capacity to provide optimal care without
the right to refuse that assignment.