I n January 2001 the nursing shortage had already hit the radar screen of many nursing and healthcare organizations. Several reports came out from the Tri-Council Members of Nursing (National League for Nursing, American Nurses Association, and American Association of Colleges of Nursing), the United States Government Accounting Office (GAO, report GAO 01 944), and the Nursing Institute at the University of Illinois College of Nursing as well as other industry organizations forecasting a national deficit of qualified nurses in the coming years. Since that period the United States healthcare industry has been weathering a serious short fall of qualified nurses. Current data is expecting the shortage to continue to grow unless abated, with some 500,000 nursing positions expected to be left unfilled by the year 2025 unless industry leaders can shift the current tide in nursing.
Several conditions were initially identified as causative factors for the nursing shortage that was beginning to unfold in the late 1990s and early portion of 2001. Factors attributing to the shortage included: aging of the current nursing work force, low accession rates for new nurses, poor working conditions which included inadequate staffing of patient care areas, heavy workloads, increased use of overtime, insufficient support staff, and poor compensation. Many of these same issues are still present today. More recently issues relating to lateral violence between healthcare workers have provided the basis for many new nurses to end their careers early and seek employment in other career fields. Furthermore academic institutions are experiencing a concurrent deficit of qualified nursing professors to teach nursing students thus compounding the shortage. Several media sources over the last few years have reported that nursing schools are turning away prospective candidates due to instructor shortfalls. Additionally and more recently most healthcare organizations are in the midst of financial hardships from private and federal third party reimbursement changes that have negatively affected most hospital's bottom line. Many healthcare organizations do not have the fiscal capacity to increase their payroll expenditures by hiring or attracting more nurses. The end result is that healthcare organizations are minimally staffed so that there is little to no flexibility within the organization to absorb staffing fluctuations. To that end many healthcare facilities have employed the use of mandatory overtime to meet staffing needs. Mandatory overtime simply is forcing a staff member (nurse) to stay at work caring for patients up to eight additional hours past their current work day. In many cases this means nurses are at work for sixteen hours and in some cases deprived of sleep for more than twenty-four hours if they have to work the overnight shift.
There are three separate parties involved in this issue. The first and foremost because of the influential impact it has on the other two parties is the hospital leadership. The leadership of any hospital is highly complex and in some cases extremely politically charged. Key members of this group as it pertains to the issue include Nurse Managers, Nursing Supervisors, Nurse Directors, Directors of Nursing, Chief Operations Officers (COO), and Chief Executive Officers (CEO). Nurse Managers and Supervisors typically represent the middle management portion of the organization and are responsible for day to day operations of their specific areas – Intensive Care Unit, Emergency Department and so on. The other three entities (COO, CEO and mid-level directors) are typically involved with establishing policy, developing strategic plans, and overseeing macro issues that affect the organization. It is at this executive medical level that organizational policy is decided upon which is a key factor with this issue.
The other two parties in this issue are the patients and the nurses. Patients are cared for at the hospital either in an outpatient setting such as the emergency department or an inpatient setting such as a medical-surgical area. The outpatient settings are typically short stay areas where limited care is provided whereas inpatient settings offer more comprehensive care that requires several days. The staff nurse is the organizational entity who provides most of the care for the patient and is responsible for ensuring patient safety. The patient may be represented by any age group or gender. The most significant issue with respect to the patient in this discussion is their level of wellness while in the care of the hospital staff. Typically more acutely ill patients will be more vulnerable to the staffing fluctuations in the facility and the potential negative aspects of mandatory overtime than less acutely ill patients. Simply put more acutely ill patients require more attention from the staff nurse than do less ill patients. The staff nurse’s level of vulnerability is directly related to their level of fatigue, their years of experience in nursing, and their ability to work long hours. Clearly higher levels of fatigue will increase the risk of patient injury, harm, or medical error in the case of mandatory overtime.
All healthcare facilities must provide a standard of care that is recognized and accepted by several regulatory agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Additionally healthcare facilities must work within the boundaries of what they are licensed for by the individual state they resided in. Not all hospitals are licensed to provide all services. Typically each State’s Department of Health provides the licensing for each hospital which includes the type of services offered and number of patient beds permitted. The process is highly complex and based on the needs of the surrounding community and the State. To add to this, some states such as California require minimal staffing on all patient care areas by nurses. This means that the healthcare facility must provide a predetermined minimal number of nurses on each patient area of the hospital twenty-four hours a day. Penalties for disregarding this typically are financially punitive.
It should be noted that not all states have minimal staffing laws for hospitals. Those that don’t are not obligated to staff a patient care area in any particular manner. Hospitals that operate with lean staffing models which typically offer no flexibility often resort to the use of mandatory overtime to mitigate staffing short falls that come up suddenly, which is what happens when a nurse calls out from work ill. If a nurse calls out sick the nurse manager or nursing supervisor who is responsible for staffing a patient care area will attempt to find a replacement nurse to complete the schedule. In the event that they are not successful they may enforce mandatory overtime for one of the nurses that are already on duty and require them to stay at work which fills in the schedule short fall. Staff nurses that are “mandated” to stay at work can be forced to stay on duty for up to sixteen hours. If a nurse is working an eight our day shift from 7:00 am to 3:00 pm they would be mandated to stay at work until 11:00 pm that evening before being able to return home. The nurse who normally works in the evening from 3:00 pm to 11:00 pm would be mandated to stay at work until 7:00 am the next morning. Finally the nurse that normally works at night from 11:00 pm to 7:00 am would be mandated to work until 3:00 pm the following afternoon. Nurses that typically work twelve hour shifts would only be able to be mandated for an additional four hours. The total time any one nurse can be at work is sixteen hours.
It is easy to see how several factors such as fatigue can play an integral role in the delivery of safe patient care. The staff nurse that works in the evening is typically awake during the day prior to going to work at 3:00 pm. Once at work they are normally leaving at 11:00 pm unless they get mandated to stay. If they have to stay until the next morning they are staying awake in many cases up to and in excess of twenty-four hours. Clearly this is cannot be considered safe for the delivery of care to ill patients.
The establishment of mandatory overtime is purely a function of the executive medicine level where mid-level directors, COO, and CEO members function. In order for such a policy to be put in place the leadership of the healthcare facility must make a value judgment regarding the use of mandatory overtime and increasing payroll expenditures to allow for flexibility in the hospital’s staffing plan. At the end of the day it is less expensive to pay a nurse over time periodically when staffing short falls exist through the use of mandatory overtime than have an inflated work force all the time. The use of mandatory overtime is a decision based on financial factors where patient safety and the management of risk and liability are placed in a lesser role by organizational leadership. When a healthcare organization consciously chooses to establish a mandatory overtime program over increasing their employee base to add flexibility to staffing patterns the decision to do so clearly increases liability for patients, staff members, and the organization and demonstrates a poor ethical choice.
The dichotomy at issue here is between providing a safe environment for both patients and staff and exercising fiscal restraint. While the organization will clearly reap the benefits of having less payroll expenditures by employing fewer nurses, the amount of risk that the organization incurs with the use of mandatory overtime cannot and should not be overlooked.
The other ethical aspect buried in this issue revolves around the individual nurse that is being forced to work additional hours past their scheduled period. The nurse must make a judgment regarding what they feel is safe for them in terms of their level of fatigue and their ability to provide safe care to patients. The choice to refuse to stay at work due to fatigue will clear the nurse of any risk, but in doing so they increase the workload for the remaining nursing staff if they leave and this again puts patient care and safety at substandard levels. Often the nurse desiring to leave will be made to feel guilty if the leave and peer pressure will be brought to bear on the nurse and they will typically succumb to the mandatory overtime rule.
At the end of the day it is clear that healthcare organizations that employ the use of mandatory overtime have clearly determined that saving money out ways the importance of providing safe patient care and minimizing liability for the organization and their staff members and seems to contradict the Joint Commission Patient Safety Goals. With respect to the staff nurse that is placed in the predicament of making a judgment to stay additional hours at work to cover a staffing shortfall it is very much an individual choice. Both the staff nurse and the organization must way the issues of patient safety and professional liability.