Longer hours and overtime are taking a toll on nurses and patients alike

Study examined hours, errors, and near misses

Hospital staff nurses who cover shifts during a shortage often find themselves working overtime, too. This combination, a new study concludes, has adverse effects not only on the nurses, but also on their patients.

Occupational health nurses working in hospital employee health departments may not themselves be subject to the extreme work hours their staff colleagues face, but they can see the effects in the toll it takes on shift nurses, says Jean Randolph, RN, COHN-S, of the American Association of Occupational Health Nurses in Atlanta.

The study, released by Grand Valley State University in Allendale, MI, and the University of Pennsylvania in Philadelphia, mirrors findings included in a report released last year by the Institute of Medicine (IOM). The IOM report ("Keeping Patients Safe: Transforming the Work Environment of Nurses," www.nap.edu) stated that long work hours pose one of the most serious threats to patient safety, because fatigue slows reaction time, decreases energy, diminishes attention to detail, and otherwise contributes to errors.

While most nurses typically work eight- to 12-hour shifts, some work even longer hours. At the same time, patients admitted to hospitals typically are more acutely ill and require technologically more complicated care than in the past.

University of Pennsylvania nursing professor Ann Rogers, PhD, RN, FAAN, co-authored the more recent study, published in July, that studied the work habits of 393 hospital staff nurses. Nurses were asked to keep logs for 28 days, and recording their work hours, overtime hours, sleep habits, caffeine intake, mood, errors, near-errors, and days off. Nurses were randomly selected from across the country, and no data were collected about where they worked — just about how they worked and factors that influenced their work.

"We were looking to see if there’s a relationship between the hours the staff nurses were working and errors," says Rogers. "In other [occupational fields], some things show up and others they don’t. For example, in industrial jobs and truck driving, more accidents occur after nine hours on the job. We thought it would be likely that nurses would have increased problems, but there were no data prior to this study."

Rogers says her team’s study found that nurses working more than 12.5 consecutive hours were three times more likely to be at an elevated risk of making an error than nurses working shorter hours. Working overtime at the end of a shift also increased the risk of error.

12+ hours typical

Rogers says the study results are important because of the number of nurses represented. "The majority of nurses working today are not scheduled for eight-hour shifts," she reports. "At least 60% of the nurses in this sample were scheduled to work 12-hour shifts, and 80% worked overtime. That means they get out on time only one shift out of four."

Of nurses in the survey who work eight-hour shifts, 85% stayed on for overtime after their shifts ended; of those on 12-hour shifts, 78% stayed on for overtime.

Rogers’ team found that most hospital nurses no longer work eight-hour day, evening, or night shifts. Instead, they may be scheduled for 12-, 16-, or even 20- shifts. Even when working extended shifts (more than 12.5 hours), they rarely were able to leave the hospital at the end of their scheduled shift. All participants reported working overtime at least once during the data-gathering period, and one-third of the nurses reported working overtime every day they worked.

Randolph says the longer shifts are the result of an evolution in nursing, from shorter shifts worked more days per week, to longer shifts and shorter workweeks. "Our nursing force has an average age of over 40, and some of those people are finding that those 12-hour shifts are rigorous and, of course, it’s never just 12 hours," she says. "But there are many nurses who work three 12-hour days and have four days off, and that suits their needs."

Randolph says that while fatigue is a problem if overtime is abused, she finds that for most nurses, working extended schedules satisfies’ nurses’ needs without cost to the nurse or the patients in terms of injury. "You have older nurses who have worked the longer shifts for 10 years, saying they’re ready to not work those long shifts anymore, but then you have younger nurses who maybe are having their first children, and for them, the schedule fits their needs."

Overtime can be unavoidable on occasion, she says, such as during a temporary staffing shortage or during busy periods, such as last winter’s flu season. "In our system, we had lots of people working very long shifts and overtime during the flu season, but I didn’t see any [negative effects], and that’s probably for a couple of reasons," Randolph recalls. "We got a boost from outside staff, who gave our staff the support they needed, and because the bell curve for the flu is about seven weeks, we knew there was an endpoint and that they weren’t going to be working those hours for long."

While the schedule of three days on, four off might accommodate family schedules, Rogers’ team found that the longer working hours can put both nurses’ well-being and patient safety at higher risk.

Participants reported 199 errors and 213 near errors during the data-gathering period. More than half of the errors (58%) involved medication administration; other errors included procedural errors (18%), charting errors (12%), and transcription errors (7%).

Rogers said the study did not examine patient outcomes, and acknowledges that many of the errors were fairly trivial. Most medication errors involved patients receiving their medications late, rather than receiving wrong medications or incorrect dosages.

"Both the use of extended shifts and overtime documented in this study pose significant threats to patient safety," Rogers said. "In fact, the routine use of 12-hour shifts should be curtailed, and overtime — especially overtime associated with 12-hour shifts — should be eliminated."

The IOM report calls for changes in how nurse staffing levels are established and mandatory limits on nurses’ work hours as part of a comprehensive plan to reduce problems that threaten patient safety by strengthening the work environment in four areas: management, work-force deployment, work design, and organizational culture.

Additionally, legislation has been introduced to address the problem. HR 745, the Safe Nursing and Patient Care Act, legislation sponsored by U.S. Reps. Pete Stark (D-CA) and Steven C. LaTourette (R-OH), was introduced last year and seeks to limit mandatory overtime and increase patient safety while curbing the nation’s nursing shortage crisis. The bill would strictly prohibit nurses from working more than 12 hours in a 24-hour period or 80 hours in a consecutive 14-day period unless there is a declared state of emergency. If enacted, this legislation would allow nurses to volunteer for overtime if and when they feel they can continue to provide safe, quality care.

Hospitals have widely discontinued mandatory overtime for their nurses, seeing it as a deterrent to patient safety and nurse recruitment.

"No one or two actions by themselves can keep patients safe," says Donald M. Steinwachs, PhD, chair of the committee that wrote the report, and chairman of the department of health policy and management, Bloomberg School of Public Health, Johns Hopkins University in Baltimore. "Rather, creating work environments that reduce errors and increase patient safety will require fundamental changes in how nurses work, how they are deployed, and how the very culture of the organization understands and acts on safety. We present a comprehensive plan to address all these areas."

The IOM report pointed out a potential for losing the safety net nurses provide against medical error — the report cites studies by two hospitals that found nurses intercept 86% of medication errors before they reach patients — and questions whether nurses stressed by overtime and long shifts can retain the mental acuity necessary to catch errors at that rate.

Rogers is hoping the IOM report coupled with her team’s findings might prompt change in the way some hospitals schedule their nursing shifts. "We’re hoping hospital administrators will look at why their nurses are always having to stay later," she says.

Working conditions affect how well hospitals can attract new nurses, and in the climate of a nursing shortage, work schedules can be an important factor, Rogers notes. "Hopefully, people will pay attention. Nurses are the largest group of health care providers in the United States, and the more nurses you have caring for patients, the better the outcome," she points out.

For more information, contact:

Jean Randolph, RN, COHN-S, American Association of Occupational Health Nurses. Phone: (404) 732-5711.

Ann Rogers, PhD, RN, FAAN, assistant professor, University of Pennsylvania School of Nursing, 420 Guardian Drive, Philadelphia, PA 19106. Phone: (215) 573-7512. E-mail: aerogers@nursing.upenn.edu.

Donald M. Steinwachs, PhD, professor and chair, Johns Hopkins University, Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore. E-mail: dsteinwa@jhsph.edu.