Forced Overtime - Say What?
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I have been following the debate about “forced overtime” for nurses. After working a full and demanding shift is it safe to work another shift? Is patient care or safety being compromised?
Medical trainees, myself included, have lived through times of long hours of service leading to concerns for compromised patient safety due to “worker fatigue”. In MB there are maximum hours for in-house work/call for medical residents/fellows and they get the next day off (i.e. post-call day) to rest.
Discussions on forced overtime for nurses have generally focused on hiring practices (e.g. insufficient number of nurses hired) and impact on workers, including burnout and retention. More attention needs to be paid to patient care and safety.
Rogers et al. surveyed American nurses and concluded:
The risks of making an error were significantly increased when work shifts were longer than twelve hours, when nurses worked overtime, or when they worked more than forty hours per week.
These “errors" included: medication (most common), charting, procedure and transcription. The risk of an error, or “near-error”, increased with the duration of overtime and ranged, when compared to a standard shift, from two to three times more likely when working an extra 8 hour or 12 hours, respectively.
Lobo et al. (McMaster University) surveyed Canadian critical care nurses and concluded:
Nursing managers and institutions need to be accountable for staffing practices they institute, and nurses themselves may require further education regarding healthy work-life balance. There are both negative and positive consequences of nursing overtime for nurses and patients, but nurses at large valued the option to work it.
They discussed balancing financial incentives versus fatigue, family time, patient care and patient safety. Their study focused on voluntary overtime.
Based on media reports it appears that forced overtime frequencies have increased and some feel that we are in a crisis (Manitoba Nurses Union: Mandatory overtime crisis continues at St. Boniface Hospital in Winnipeg June/19: source https://nursesunions.ca/manitoba-nurses-union-mandatory-overtime-crisis-continues-at-st-boniface-hospital-in-winnipeg/).
Forced, or mandatory overtime, should be contemplated only in emergency situations such as an unexpected spike in demand due to unforeseen external factors such as a mass casualty event or an epidemic. It should not be used for routine coverage when someone calls in sick. Adequate staffing to cover expected staff shortages (e.g. holidays, sick calls, other forms of leave), casual call pools to provide additional urgent coverage and, as a last resort, a call for volunteers to provide coverage when all else fails, should be the status quo. Even with voluntary overtime there should be limits on maximum overall shift times to enhance patient safety.
Establishing a sufficient and reliable work force to manage the expected ebbs and flows of health care delivery systems is the responsibility of health care leaders who, in turn, rely on government to provide adequate resources and enabling policy to do so.
It is interesting to note that a Quebec administrative labour tribunal recently ruled that forced overtime can be instituted "only in the event of an emergency." (CBC, Montreal April 5/19, source).
When I first heard that nurses could be “forced” to work overtime I shocked. People have lives, family care responsibilities and other commitments. Patient care and safety needs to be the priority. To me “Forced overtime” is a Draconian concept that conjures up images of the Industrial Revolution and less than ideal labour standards.
Such practices do not belong in the 21st century.
Dr. Sandor Demeter is an Associate Prof at the U of M, Faculty of Health Sciences
Rogers AE et al. Health Affairs. 2004;23(4):202-212. https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.23.4.202
Lobo et al. Critical care nurses' perceptions of the outcomes of working overtime in Canada. Nurs Outlook. 2017 Jul - Aug;65(4):400-410. Epub 2017 Jan 7)