Many states banning mandatory RN overtime

But is that enough to combat fatigue?

As concern grows about fatigue and its impact on patient safety, 17 states have enacted laws or regulations to restrict mandatory overtime. But that alone may not reduce nurses’ work hours — or even end the use of mandatory overtime.

Bans on mandatory overtime have produced some improvements in work hours, nursing research shows, but it’s still not clear how much impact the new laws are having, says Sung-Heui Bae, PhD, MPH, RN, assistant professor at the University at Buffalo (NY) School of Nursing. “Having a policy in place doesn’t guarantee the implementation of a policy,” she says.

Meanwhile, nursing unions are reporting continued use of mandatory overtime, despite state laws.

“Even though the language may be in the law, some nurses are still fearful that if they report a violation of the law they’ll be retaliated against,” says Janet Haebler, RN, MSN, associate director for state government affairs at the American Nurses Association in Silver Spring, MD.

In 2004, an Institute of Medicine report said nurses should not work more than 12 hours in a 24-hour period or more than 60 hours in seven days.1 Yet financial and staffing difficulties weigh heavily on hospitals and lead to excessively long shifts, nursing experts say.

“I think the hospitals would suggest that it’s the bottom line, that they can’t afford to fill more [nursing] slots,” says Haebler. “I would suggest that shouldn’t be the case. They clearly should recognize that RN staffing is critical to patient outcomes and [reduced] length of stay. RN staffing saves money.”

Half of RNs work voluntary overtime

Hospitals were put on notice about the risks of extended work days and long work hours when The Joint Commission accrediting agency issued a Sentinel Event Alert in 2011. The Joint Commission didn’t recommend specific limits on shifts or work hours, but advised hospitals to assess fatigue-related risks and give staff input in work schedules.

Yet long work hours remain commonplace for nurses. About one in three (31%) newly licensed nurses work more than 40 hours per week (or more than three 12-hour shifts), Bae and her colleagues found.2 In earlier research, they found that 41% of nurses worked more than 40 hours per week and almost one in 10 (9%) worked 61 hours or more.3

Newly licensed nurses who worked in states with mandatory overtime rules were 59% less likely to work forced overtime than nurses in states without regulations, an indication that the restrictions are working. But Bae cautioned that more research is needed on the effectiveness. She has found that total work hours can be actually higher in states that restricted mandatory overtime compared with those without regulations.

Overtime rules are often regulated by the state’s department of labor rather than the department of health, and enforcement may be lax, she says. Nurses may have more on-call hours, or may be asked to work voluntary overtime, she says.

“Although it’s voluntary overtime, they may feel like they have to work,” she says.

About half of all nurses (52%) worked voluntary overtime, averaging an extra seven hours per week, the study found. There was no significant link between voluntary overtime and mandatory overtime restrictions.

The study was based on survey data from 34 states and was part of the RN Project, a longitudinal study sponsored by the Robert Wood Johnson Foundation to investigate nurses’ career patterns.

Mandatory overtime and nursing work hours can impact turnover, but they also have broader implications, says Bae. “The nurses with better working conditions can provide better patient care,” she says. “That’s why working hours or mandatory overtime are not only about nurses’ wellbeing and health, [but] ultimately it has impact on patient care and patient safety.”

RNs must monitor fatigue

The bottom line: Reducing nurses’ work hours is a complex issue. And it’s one that requires collaboration between employers and employees, says Bae.

Fatigue can set in with repeated shifts of 12 hours or more that leave too little time for sleep between shifts, regardless of the reason for the schedule, says Alison Trinkoff, ScD, MPH, BSN, RN, FAAN, professor at the University of Maryland School of Nursing in Baltimore and a leading research of the impact of working conditions in health care.

“It really doesn’t matter whether someone makes you do it or you volunteer to do it, it’s not a good idea to work a lot of very long shifts,” she says. “There’s enough data to show that people who are working successive 12 hour shifts get fatigued.”

In a 2006 study, Trinkoff and colleagues found that 17% of nurses worked mandatory overtime, most often with less than two hours notice.4 Some 14% of the nurses worked 50 or more hours a week, and about one in four (29%) reported working six or seven consecutive days at least once in the past month. Overall, 17% of the nurses in the sample of 2,273 nurses in the Nurses Worklife and Health Study reported exceeding the limits suggested by the Institute of Medicine panel.

Nurses who are 50 or older were less likely to work shifts of 12 hours or longer. “Anecdotally, nurses have said regretfully that they are so tired and they really wonder if they can keep it up or provide their best care,” says Trinkoff.

The ANA also seeks to educate nurses about fatigue and its risks, says Haebler. “We worry greatly about nurse fatigue,” she says. “Our position is that regardless of the number of hours worked, each RN has an ethical responsibility to consider his or her fatigue level when deciding whether to accept an assignment.”


  1. Committee on the Work Environment for Nurses and Patient Safety. “Executive Summary.” Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press, 2004.
  2. Bae, S.-H., Brewer, C. S., & Kovner, C. T. State mandatory overtime regulations and newly licensed nurses’ mandatory and voluntary overtime and total work hours. Nursing Outlook 2012; 60:60-71.
  3. Bae S.-H and Brewer C. Mandatory overtime regulations and nurse overtime. Policy Politics Nursing Practice 2010; 11:99-107.
  4. Trinkoff A, Geiger-Brown J, Brady B, et al. How long and how much are nurses now working? Amer Jrl Nurs 2006; 106:60-71.