NUR 300 Module 2 Milestone One example

Mandatory Overtime as a Professional Practice Issue in Hospital Nursing

[Student Name]

Southern New Hampshire University

NUR 300: Scholarly Inquiry

Final Project Milestone One

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Mandatory Overtime as a Professional Practice Issue in Hospital Nursing

Mandatory overtime is the practice of requiring a nurse to stay beyond a scheduled shift, usually because the oncoming shift is short, under the threat of discipline or a report of patient abandonment. On the composite 28-bed orthopedic and general surgery unit used as the setting for this paper, day nurses work 12-hour shifts from 7:00 a.m. to 7:30 p.m. During one recent quarter, nurses on the unit were held over on 41 of 91 days, and in 17 of those cases the extension ran four hours or longer, which turned a 12-hour shift into a 16-hour one. Most of these holdovers followed sick calls on the night shift that the staffing office could not fill. Staff describe a pattern that begins around 6:45 p.m., when the charge nurse learns how many night nurses have called out, and ends with one or two day nurses told they cannot leave. Nurses with children at home or a second job report the most distress, because they learn only at the end of a long shift that it will run four hours longer.

This paper identifies mandatory overtime as the professional practice issue for the final project and explains why it matters to patients, to nurses, and to the profession. It summarizes what published research shows about long work hours, names the people who have a stake in the issue, and closes with the question the final paper will pursue.

Why This Is a Professional Practice Issue

Mandatory overtime is often discussed as a scheduling or budget problem, but it is also a practice problem, for three reasons. First, it affects the nurse's ability to meet the standard of care. A nurse in the fourteenth or fifteenth hour of a shift still carries full responsibility for assessment, medication administration and surveillance, yet the conditions for safe judgment have worsened. Second, it places the nurse in an ethical conflict. The nurse who refuses to stay may be accused of abandoning patients, while the nurse who stays while exhausted may knowingly accept a higher risk of error. Third, it affects the profession's ability to keep its members. Nurses who are repeatedly held over report exhaustion and consider leaving, and each departure increases the shortages that caused the overtime in the first place.

Professional organizations have treated fatigue as a shared responsibility of nurses and employers rather than a personal failing (American Nurses Association [ANA], 2014), which places the issue squarely inside professional practice. Registered nurses are expected to recognize when fatigue affects their ability to practice safely, and employers are expected to build schedules that do not require them to work beyond safe limits.

What the Evidence Shows

Research on nurse work hours points in one direction. Rogers et al. (2004) asked 393 hospital staff nurses to record every shift they worked for four weeks, along with any errors or near errors, and then compared error rates by shift length. Errors became more likely as shifts grew longer, and on shifts that ran 12.5 hours or more the odds of an error were roughly three times those of a standard eight-hour shift. Working overtime raised the risk even when the extra hours were short. Because the data were logged shift by shift rather than recalled months later, this study speaks directly to the situation on a unit where nurses are held over at the end of a 12-hour day.

A national expert panel reached a similar judgment well before the current staffing crisis. In its report on the work environment of nurses, the Institute of Medicine recommended that nurses not work more than 12 hours in any 24-hour period or more than 60 hours in any seven-day period, and that state regulators monitor and restrict mandatory overtime (Institute of Medicine, 2004). A 16-hour holdover on the unit described above breaks the first of those limits outright.

A systematic review of the literature on nurse work hours and overtime by Bae and Fabry (2014) found that most studies connected long hours and overtime with adverse nurse outcomes, such as fatigue and injury, and that several also connected them with adverse patient outcomes, although findings for patient outcomes were less consistent. The review shows that the concern rests on a body of research rather than a single study, while also showing where that research is still uneven. Finally, work on state regulation suggests that policy can shift practice, since nurses in states that restricted mandatory overtime were less likely to report working it (Bae & Brewer, 2010). Whether those rules reduce total hours, or simply move the extra hours into voluntary overtime, is a question the literature review in Milestone Two will need to examine.

Stakeholders

Several groups are affected by mandatory overtime or hold power over it. Patients are the first group, because their safety depends on the alertness of the nurse caring for them. Staff nurses are the second, since they absorb the physical and emotional cost of extended shifts and carry the professional risk of errors made while fatigued. Nurse managers and staffing coordinators decide whether to hold nurses over when a shift is short, and hospital leaders decide whether to fund float pools, incentive shifts or agency staff that would reduce the need to do so. State boards of nursing and legislatures set the legal limits in many states, and professional organizations shape the standards and positions that inform those limits. Each of these groups will appear again in the final paper, because any solution will require at least some of them to act.

Direction for the Final Paper

The evidence already reviewed shows that long hours and overtime carry risks for nurses and patients. The final paper will therefore not ask whether mandatory overtime is harmful. It will ask a narrower question: which staffing strategies allow a hospital unit to stop relying on mandatory overtime without leaving shifts unsafely short? Milestone Two will review the literature on those strategies, including internal float pools, self-scheduling and state regulation, and Milestone Three will recommend an approach for a unit like the one described here. The answer matters beyond one unit. If a unit can staff safely without holding nurses over, the same approach may help other units in the hospital that face the same night-shift gaps, and it would give nurse leaders evidence to bring to budget discussions instead of anecdotes.

References

American Nurses Association. (2014). Addressing nurse fatigue to promote safety and health: Joint responsibilities of registered nurses and employers to reduce risks [Position statement]. https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/

Bae, S.-H., & Brewer, C. (2010). Mandatory overtime regulations and nurse overtime. Policy, Politics, & Nursing Practice, 11(2), 99-107. https://doi.org/10.1177/1527154410382300

Bae, S.-H., & Fabry, D. (2014). Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: Systematic literature review. Nursing Outlook, 62(2), 138-156. https://doi.org/10.1016/j.outlook.2013.10.009

Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. The National Academies Press. https://doi.org/10.17226/10851

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. https://doi.org/10.1377/hlthaff.23.4.202