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Mandatory Overtime: The Threat to Patients
Beyond its impact on nurses, mandatory overtime also poses increased risk for the quality of patient care. The Institute of Medicine's landmark To Err Is Human study estimated that at least 44,000 Americans — and possibly as many as 98,000 — die each year as a result of hospital medical errors.254 Even using the lower figure, this makes medical errors the eighth leading cause of death in the United States, exceeding those caused by car accidents, breast cancer or AIDS.255 Errors in administering medication alone are estimated to cause 7,000 American deaths per year. On average, two out of every 100 patients admitted to a hospital can expect to suffer a preventable medication error. Significantly, medication errors also lead to unnecessary expenses in treating patients who suffer preventable hospital errors. One study estimates the costs of treating preventable medication errors at $2.8 million per year for a 700-bed hospital or approximately $2 billion for the country as a whole.256
The Institute of Medicine notes that human error in hospital treatment is not a random event but is linked to the level of stress and fatigue under which hospital staff are operating. The institute recommends clear-cut policies for avoiding this unnecessary toll in human life and hospital costs, specifically calling for the maintenance of "reasonable work schedules" and "well designed jobs" among the "preconditions for safe production processes."257 More specifically, the institute recommends the establishment of a national Center for Patient Safety. In setting a research agenda for the proposed center, the institute offers a tentative list of priority topics that begins with the need to "enhance understanding of the impact of various management practices (e.g., maximum work hours and overtime) on the likelihood of errors."258 The institute specifically recommends designing hospital jobs for safety, "bringing attention to ... work hours, workloads, [and] staffing ratios" and "anticipating harm that may accompany downsizing, staff turnover, and the use of part-time workers and 'floats' who may be unfamiliar with equipment and processes in a given patient care unit."259
The impact of mandatory overtime on nurses is intuitive. As one Maine legislator recalled,
In my former life as a millwright, I spent upwards of 32 [hours] straight on the ... clock. ... If you think you are coherent and you think you can work safely with that amount of hours ... try being a nurse or somebody that deals with health issues and want them to work on you after they have all those hours with no sleep.260
Similarly, another Maine legislator explained,
The right of a person who has worked to the point where they are too fatigued to do the job, to say they don't want to work anymore, I can't do it and to protect that person from being disciplined ... we need this protection so that people can use their professional judgment and say that they have worked too long and too hard to render quality care.261
Without such protection, patients may be left in the hands of workers who cannot guarantee the level of care we would all demand for our loved ones. Recently, the Chicago Tribune published the results of an investigation into the relationship between short-staffing of hospitals — including the use of mandatory overtime — and medical errors leading to patient deaths. The newspaper's staff found,
[S]ince 1995, at least 1,720 patients have been accidentally killed and 9,584 others injured from actions or inaction of registered nurses across the country, who have seen their daily routine radically altered by cuts in staff and other belt-tightening in U.S. hospitals. ... deteriorating, oppressive workplace conditions — from mandatory overtime to stagnant pay — have made hospital jobs less appealing. ... nurses sometimes [are] too overworked to adequately care for patients.262
Evidence from numerous industries suggests that accidents inevitably increase under the pressure of unwanted extended hours. The Economic Policy Institute recently undertook a comprehensive review of the impacts of mandatory overtime throughout the economy.263 The authors reviewed a number of studies documenting the relationship between overtime work and increased accident rates.264
For example, overtime has been found to contribute to incidents where safety is compromised at nuclear power plants,265 at manufacturing plants,266 and in hospitals among anesthetists.267 A study of autoworkers found that overtime resulted in decreased attention and impaired executive functions.268 Workers who work overtime therefore face a greater risk of injury and illness.269 One study found that accident rates began to rise after nine hours on the job, and by the 12th hour accident rates were twice as high as those of the first nine hours.270
A large body of literature attests to the detrimental effects of sleep deprivation, a likely effect of mandatory overtime. For industrial workers, overtime work has been shown to lead to more severe accidents with the likelihood of a severe accident increasing according to the amount of overtime worked and the number of consecutive overtime days worked.271
One literature review concluded that sleep-deprived subjects performed tasks significantly worse than those with normal sleep. Comparing sleep-deprived subjects to a control group, the authors found that an individual at the 50th percentile of the sleep-deprived group performed tasks equivalent to one at the ninth percentile of the control group. The impact was particularly acute on complex or extended tasks.272 In extreme cases, forcing nurses to endure unwanted and excessive schedules may result in patients being cared for by staff who are struggling against the equivalent of illegal alcohol intoxication. An Australian study found that employees working shifts of more than 16 hours may well be operating while functionally intoxicated. After 17 to 19 hours without sleep, the researcher found that subjects' "performance levels were low enough to be accepted in many countries as incompatible with safe driving."273
Excessive hours have also been directly linked to detrimental impacts for hospital staff. A New Zealand study found that when anesthetists worked more hours than their own self-defined safety limits, 86 percent reported fatigue-related errors, with 32 percent reporting such errors in the preceding six months.274 Among physicians, medical residents cited fatigue as a cause for 40 percent of serious errors,275 and physician overtime work has been linked to infection outbreaks.276 For nurses in particular, a 1992 study found that variable schedules (including mandatory overtime) were associated with "frequent lapses of attention and increased reaction time, leading to increased error rates on performance of tasks." 277
Thus, even without direct statistical studies measuring the specific impact of mandatory overtime, a wealth of evidence points to the dangers of this practice for both nurses and patients. As ANA President Mary Foley puts it, "In the end, any system that requires a nurse to work a 16-hour shift, while caring for too many critically ill patients, in a ward where he or she is not supported by adequate staff, is destined to failure."278
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