Friday, October 26, 2007

Nurses and Overtime*

Nurses and Overtime*

Nurses are increasingly working overtime. Nurses' overtime (mandatory** or voluntary) has been used as a measure to reduce the impact of the critical shortage of nurses and/or the downsizing of nursing departments in both private and public health facilities. However, the increasing amount of overtime threatens nurses' ability to provide safe and individualised care for patients.
While in many countries federal regulations define the maximum hours that can be worked in sectors having a direct impact on public safety (e.g. aviation, transportation), nurses and other health care workers are rarely protected. A few examples have been selected to provide an overview of existing situations.

* Overtime is time worked in addition to the normal or regular contracted hours.

** Mandatory overtime is obligatory, compulsory or imposed by the employer leaving no choice to the employee.

1. USA - mandatory overtime

Promoted by hospital management as a way to staff effectively during an emergency, mandatory overtime has become instead a means to cover routine personnel shortages.
In a large number of hospitals nurses report the existence of a documented policy that imposes mandatory overtime. Overtime may be from 4 to 16 hours (or more) and nurses are included in a duty roster to perform the overtime after their regular shift. Depending on the state where the nurses are employed, they may be paid extra money (not always) but do not get any extra time off.
In January 2001 the "Registered Nurse and Protection Act" was introduced to the US Congress. It aims to limit the number of hours that licensed health care workers, including registered nurses (RNs), would be obliged to work. The bill will amend the Fair Labour Standards Act to bar mandatory overtime beyond 8 hours in a workday or 80 hours in any 14-day work period. Exceptions are accepted in cases of natural disasters or in the event of a state of emergency declared by the authorities. A licensed health care employee may however voluntarily work beyond 8 hours in any given workday.

2. Australia

Australian nurses report a significant increase in their workload over the past five years. A recent report shows an increasing amount of regularly worked overtime. On 23 June 2000, Australian Nursing Federation (ANF) ACT Branch members voted unanimously to outlaw the working of 16 and 18-hour shifts, and ban recall shifts when individual nurses considered them to be unsafe.

3. Europe

Nurses within the EU are protected by law from being forced to do overtime, but it is still common practice in almost all countries that nurses do work overtime. To date, the directive that exists has not been implemented in all European countries. According to the Working Time Regulations, work time must not average more than 48 hours per week over a standard averaging period of 17 weeks. It is possible however to extend this period to 26 weeks or a year if agreement is reached by employers and employees. Daily and weekly rest entitlements are also specified in the regulations:

Daily rest: Employees are entitled to a rest period of not less than 11 consecutive hours in each period of 24 hours during which the employee works for the employer.
Weekly rest period: Employees are entitled to an uninterrupted rest period of not less than 24 hours in each 7-day period. This is in addition to the daily rest period.
Breaks: Employees are entitled to a rest break when daily working time exceeds 6 hours.

United Kingdom: A national survey of registered nurses commissioned by the Royal College of Nursing (RCN) and carried out by the Institute for Employment Studies (IES) in 1999 showed that 59% of the respondents report that they work an average of 6.6 of excess hours per week. In 1998, the average was 5.8 hours/week. Twenty-eight percent of the nurses report undertaking paid work in addition to their main job. They work an average of 6.6 hours a week in these additional jobs. The increased income is the main reason given for taking on this secondary employment.

4. Japan

A 1997 survey by the Japanese Nursing Association showed that 4,636 nursing personnel reported working an average of 12 hours 36 minutes of overtime each month. More than 70% of hospital employees were required to work rotating night shifts (Japanese Nursing Association News, 1998).

It is common practice that individuals in certain positions (e.g. management) work overtime without specific compensation or benefits. Most often however this overtime is not mandatory and the risk to public safety is not present. Perceptions about the number of hours constituting long hours vary according to the type of work. However some employees work 100 hours per week or more. British employees are reported to work some of the longest hours in Europe.

Rationale for working long hours:

The main reasons for working long hours are:

  • Work pressure - arising from heavier workloads, increasing demand, fewer staff and tighter budgets.
  • Work organisation - in some cases lack of prioritisation or individual inefficiency can increase the workload
  • Long hours culture - generated by the example of managers working long hours, peer pressure, job insecurity, individuals feel their presence at work is critical for the realisation of the organisation's mission.
  • A strong commitment amongst individuals towards their work, colleagues, customers or clients.
  • A need to increase take-home pay

Some, if not all, of these reasons are relevant to nurses

Effect on health

When no limits are set on overtime work and no guidelines exist for the rest period following extended hours of work, the burden of these physical and mental demands will have a negative affect on patients as well as nurses. Extensive overtime (voluntarily or mandatory) may put patients and nurses at risk.


A limited number of studies demonstrate the relationship between extended shifts (more than eight hours) and fatigue as well as increased safety risks. The negative consequences are not limited to physical health, e.g. fatigue, headache, sleeplessness. Disruptions and stressed dynamics within the social and family life are also reported.


Extensive overtime puts patients at risk, due to:
- Nurses being less alert to changes in patients' condition.
- Nurses having slower reactions.
- Medication errors - adverse drug events (ADEs).
- Errors in clinical judgement.
- Increase in nosocomial infections.
- Increase in decubiti.

All the above potential consequences are likely to lead to deterioration in the quality of care provided.

What Nurses can do
  • A professional nurse is the best judge of her own capability. If she cannot provide safe care in a given situation, she must inform her supervisor.
  • Research on the subject of extended overtime and related health issues and the influence on medical errors should be undertaken so that more comprehensive data is available.
  • The public should be informed about the working conditions in health care settings - not to frighten them but to alert them about the actual situation and generate support for constructive change
  • National nurses' associations should work together with other health professional organisations to ensure appropriate regulation of overtime
  • National nurses' association should provide the ethical framework for nurses' overtime practices, especially in cases where nurses reject an assignment due to physical exhaustion or mental stress.
For further information please contact ICN at

Fact sheet/Nurses and Overtime

Considine G. and Buchanan J.: The hidden cost of understaffing: An analysis of contemporary nurses working conditions in Victoria, report for the ANF Vic Branch by the Australian Centre for Industrial Relations Research and Training, University of Sydney, 1999, p.2

Commission of the European Community: State of Implementation of Council Directive 93/104/EC of 23 November 1993, in force since October 1, 1998

On the Agenda: changing nurses careers in 1999, Robinson D, Buchan J, Hayday, IES Report 360, 1999. ISBN 1-85184-289

Breaking the long hours culture. , J Kodz, B Kersley, M T Strebler, S O'Regan. IES Report 352, 1998. ISBN 1-85184-281-0

Nursing around the world: Japan - preparing for the century of the elderly, Janet Primomo PhD, RN may 31,2000. Online Journal of issues in Nursing. Vol.5, No.2, Manuscript 1.

Harrington JM (2001). Health effects of shift work and extended hours of work. Occup. Environ med. 58: 68-72

Rosa, Roger R, (1995) Extended work shifts and excessive fatigue. Journal Sleep Research 4, Supll.2, 51-56

Spurgeon M, Cooper AJ, Cary L, (1997, June) Health and safety problems associated with long working hours. A review of the current position. Occupational and Environmental medicine, vol.54, no.6, 367-375.

Kohn L.T, Corrigan J.M, Donaldson M.S, eds. (1999)To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press

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