Presence of Nurse Mandatory Overtime Regulations and Nurse and Patient Outcomes

Sung-Heui Bae, PhD, MPH, RN


Nurs Econ. 2013;31(2):59-68. 

In This Article


Most hospital staff nurses' work schedules extend beyond the typical 9:00 a.m. to 5:00 p.m., Monday through Friday work day, to provide continuous nursing care to patients (Trinkoff et al., 2011). Simultaneously, most hospitals in the United States exclusively use 12-hour shifts (Geiger-Brown & Trinkoff, 2010). Thus, staff nurses who work overtime may work more than 12 hours within a 24-hour period and return to work quickly without sufficient rest and sleep. Nurses' fatigue may continue following work regardless of regular or overtime shifts. Working overtime among nurses is a prevalent practice used to control chronic understaffing and a common method used to handle normal variations in the patient census (Berney, Needleman, & Kovner, 2005). According to the 2004 National Sample Survey of Registered Nurses (NSSRN), more than 40% of U.S. registered nurses (RNs) worked more than 40 hours per week (Bae & Brewer, 2010). Fifty-four percent of the respondents to the 2008 NSSRN worked more than 39 hours per week in their principal nursing position (U.S. Department of Health and Human Services, 2010).

Nurses' poor quality of sleep and fatigue are associated with working long hours, their quick return to work, and also shift work (Geiger-Brown, Trinkoff, & Rogers, 2011). Sleep deprivation from working overtime often results in fatigue, which is associated with dif ficulties in neurobehavioral func tioning such as reduced or im pair ed vigilance, reaction time, and de cision-making ability (Trinkoff et al., 2011). Previous research has demon strated long work hours have adversely affected nurse and patient outcomes. Excessive use of overtime can increase the incidence of nurses' needlestick in juries and musculoskeletal problems (Clarke, Rockett, Sloane, & Aiken, 2002; Trinkoff, Le, Geiger-Brown, & Lipscomb, 2007; Trinkoff, Le, Geiger-Brown, Lipscomb, & Lang, 2006). Working mandatory or unplanned overtime was also associated with the occurrence of work-related injuries and workrelated illnesses (de Castro et al., 2010). The risk of making medical errors was three times higher when RNs worked shifts lasting 12.5 hours or more (Rogers, Hwang, Scott, Aiken, & Dinges, 2004). The most recent studies found long work hours during nurses' typical work schedule for the past 6 months on average were significantly related to patient mortality in the hospitals they worked after controlling for staffing levels and hospital characteristics (Trinkoff et al., 2011), and that working more than 40 hours per week was related to nurse's perception regarding the occurrence of medication errors, falls with injuries, and nosocomial infections (Olds & Clarke, 2010). The underlining mechanism of the relationship of nurse overtime to nurse injuries and adverse patient events is that when nurses work overtime or long hours, it contributes to nurses' fatigue and sleep so their alertness and vigilance are impaired in both their regular shift and overtime shift. It influences patient quality of care that fatigued nurses deliver. From previous studies, there is strong evidence fatigue associated with long work hours among nurses is related to adverse events and errors in both patients and nurses.

In an effort to minimize the use of nurse overtime, as well as to decrease non-scheduled work hours, since year 2000 more states have regulated the use of mandatory nurse overtime. As of 2011, 16 states have placed restrictions on the use of mandatory overtime worked by nurses (American Nurses Association [ANA], 2011). Mandatory overtime laws regulate either nurse mandatory overtime or total work hours. To ban nurse mandatory overtime, state law allows employees to refuse the request of overtime by health care facilities such as working more than their regularly scheduled hours, except during a health care disaster, which requires increased need for health care personnel unexpectedly. To limit total work hours, regulations limit the number of hours worked by nurses in a specific time period (e.g., not allowing to work more than 12 hours a day) (ANA, 2011). The ultimate goal of implementing mandatory overtime regulations is to provide better working conditions for nurses, as well as improve quality of patient care (Washington State Department of Labor and Industries, 2002).

The impact of mandatory nurse overtime regulations on nurse and patient outcomes has not been researched previously. To determine the relationship between the mandatory overtime regulations and nurse and patient outcomes, nurse overtime can be used as a mediator in that relationship. As mentioned earlier, the regulations utilize two ways in an effort to control nurse overtime; either banning mandatory overtime or limiting the total number of hours worked. When regulations limit the total number of hours nurses are allowed to work, we would expect a decrease in the total number of hours worked. Likewise, when regulations ban mandatory overtime, mandatory overtime hours should decrease or become zero hours. However, regulations do not directly limit the number of hours a nurse may voluntarily work overtime. Therefore, it is possible health care facilities may rely upon voluntary overtime to handle fluctuations in the patient census. Also staff nurses could volunteer to work overtime because of monetary rewards or other non-monetary reasons (Workplace Employee Relations Survey, 1998). All of these research questions have not been examined yet. There is limited understanding as to whether or not mandatory overtime regulations for nurses are effective in preventing mandatory nurse overtime and long work hours as well as advocating nurses' well-being and providing better quality of patient health care. Whether the outcomes for nurses and patient quality indicators are improved when the regulations are implemented is vital to understand the impact of regulation on this issue.