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Issues Update

American Journal of Nursing - May, 2001 - Volume 101, Issue 5

Mandatory Overtime
New developments in the campaign

Katherine Kany, RN

Probably the most significant and risky byproduct of insufficient staffing is the routine and widespread use of overtime to fill gaps in scheduling. In the midst of an aggressive national initiative to reduce adverse events such as medical error, and at a time when consumers are horrified at the thought of fatigued pilots, railroad engineers, or drivers endangering public safety, fatigued nurses and other providers are routinely allowed—even forced—to run up and down the hallways of health care facilities. Without limits on work hours or prohibitions on involuntary overtime, nurses have been essentially powerless to stop this practice, and have even been threatened with charges of "patient abandonment" when they refuse to work extended hours.

As a result of these threats, boards of nursing in several states, including Michigan, Alabama, California, Oregon, and Ohio, have developed clear statements differentiating patient abandonment and employment abandonment. These statements define employment abandonment as nurses leaving their places of work to avoid injury to patients or to themselves. The ANA's 2000 House of Delegates also made clear the nursing profession's position on the matter when it passed a resolution opposing mandatory overtime and stating that refusal to accept additional hours does not constitute patient abandonment.

The science of overtime's impact

To date, research on the effects of "overtime" has been largely limited to studies of those working scheduled 12-hour shifts. Nurses routinely report working far more than 12 hours when overtime is involved and also report working erratic schedules that result in disrupted sleep patterns and fatigue.

These factors further complicate the issue and beg more in-depth analysis. A study conducted in Australia by Dawson and Reid and published in the July 17, 1997, issue of Nature , demonstrated that, while both alcohol and fatigue affect performance, fatigue has a greater impact . Their data show that a full day of being awake impairs performance in a manner equal to that of a person with a blood alcohol level of 0.1%, a level generally equated with intoxication.

Currently, there is little empirical evidence to help in setting appropriate limits on continuous hours of work in order to protect both patients and nurses. For now, The ANA's approach is simply to oppose all involuntary overtime, in keeping with the directive from the 2000 House of Delegates.

Opposing mandatory overtime through legislation

Opposition to mandatory overtime is a priority at the ANA and is strongly tied to four of the organization's five core issues: patient safety and advocacy, workplace rights, workplace health and safety, and appropriate staffing.

At a federal level, the ANA is lobbying for legislation that would reaffirm the professional rights and responsibilities of individual nurses to determine their own fitness for duty, and would also protect those individuals from any recriminations for their decisions. This right is detailed in the ANA Code for Nurses which states: "If the nurse concludes that he or she lacks competence or is inadequately prepared to carry out a specific function, the nurse has the responsibility to refuse that work and to seek alternative sources of care based on concern for the client's welfare."

While only one bill on this issue was introduced in the last Congress (H.R. 5179, the Registered Nurses and Patients Protection Act), growing concern and public pressure to address the issue of "medical error" has raised the interest level on Capitol Hill. The ANA is advocating for more legislation to be introduced this year.

At the state level, one of the priorities identified for 2001 by many of the ANA constituent member associations is to develop a focused and coordinated effort across the country to address major issues related to staffing and patient safety. The ANA's nationwide state legislative campaign, which was launched in February, includes mandatory overtime among its priorities. So far this year, mandatory overtime legislation is in varying stages of development in 12 states: Connecticut, Hawaii, Illinois, Maine, Maryland, Nevada, New York, Ohio, Oregon, Rhode Island, Washington, and West Virginia. With some variation, these bills and preliminary efforts would limit the employers' ability to dictate overtime and protect individuals from recrimination if they refuse additional hours of work.

While efforts on the legislative front are unrelenting, the realities of navigating the legislative process can be frustrating. Anne Tan Piazza, assistant director of government and media relations with the Washington State Nurses Association (WSNA), reports that WSNA's results have been mixed thus far, so their work will continue into next year's legislative session. Washington nurses have gained good press coverage for their views and have very good support among key Democrats and some Republicans, Piazza says. All the same, WSNA has met with resistance from within the Republican ranks and the state hospital association, with the result that their bill was not scheduled for a hearing during the 2001 legislative session.

Piazza says, "We are adamant that nurses will determine their own capability to work overtime." She notes that legislators have responded most strongly to personal impact statements from nurses. In one extreme example, "a day care provider threatened to report one of our members to child protection services for failure to pick up her child in a timely fashion. She was accused of bad parenting solely because her employer imposed long hours that kept her away from family and home responsibilities."

For nurses, eliminating mandatory overtime is a priority and a struggle that has resulted in strikes in California, Massachusetts, New York, and Washington, DC, during the past year.

Gaining protections through contracts

In addition to addressing overtime concerns through legislative initiatives, nurses in Ohio, Minnesota, the District of Columbia, and many other states have also negotiated contract provisions that address involuntary overtime. Language in some contracts prohibits mandatory overtime altogether, and in others gives nurses the right to make their own judgement calls.

In Illinois, RNs who are state employees are now in a strong position regarding mandatory overtime. Their state bargaining unit negotiated a contract provision stating that after three episodes of voluntary overtime and three occasions of mandatory overtime per calendar quarter, nurses will be paid double-time for additional hours worked. "Overtime demands for nurses have really gone down," says Debbie Reed, chair of the Illinois Nurses Association RC23, the state employees' bargaining unit. "We have the first language of this kind anywhere in our state."

In Washington, DC, nurses at the Washington Hospital Center went out on strike for six weeks last fall before they reached an agreement with management that limits mandatory overtime. The nurses won the right to refuse overtime due to fatigue, illness, and extenuating circumstances.

At Long Island College Hospital in Brooklyn, New York, RNs won a three-year contract last year that grants them the right to a day off following a day of required overtime. Also in New York last year, RNs at North Shore University Hospital in Plainview ended a 41-day strike with several gains, including a voice in setting staffing levels.

"These kinds of gains for nurses are absolutely crucial," says United American Nurses Chair Cheryl Johnson, RN. "Mandatory overtime is an unacceptable way to run a business and it jeopardizes patient safety. It's a key part of the working conditions that are driving people away from the nursing profession."

The ANA has been working with health services researchers and with various funding agencies to further study the impact of overtime on patient safety and on the incidence of work-related injuries. The goal is to make certain that the studies are informed by the priorities and experiences of direct care staff across the country. The ANA also will continue to raise awareness of the ramifications of overtime abuse, as it has through publication of its Nurse Staffing Survey and the substantial nationwide media coverage of the survey, especially in the weeks following its release. Efforts to shape policy through ANA testimony before Congress and visits with legislators continue; initiatives like Staffing Crisis Lobby Day, coming up on June 26 in Washington, DC, are great opportunities to impress legislators that nurse staffing issues greatly affect nurses and their patients nationwide. (For information on Staffing Crisis Lobby Day, contact Vickie Spence at (202) 651-7225.) These ANA activities on the research and lobbying fronts, combined with ongoing discussions with government regulators, all aim at the goal of exposing and eliminating the unsafe and unethical practice of mandatory overtime.

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