The trap of the endless workday

"From 5:30 a.m. to 6:15 p.m. is my regular day. A three-day shift plus one mandatory overtime; they call it mandatory extra shift. We're short staffed and completely full, making beds, no lunch... management-created problems on staffing schedules... doctors who won't show up to release patients earlier so beds can be freed up. It takes 45 minutes to clean and turnover a room... and she said, 'let's get productive' and I said to her something to the effect that 'I need to get busy and take care of my patients' ... this was a director with long nails and high heels ... they're all business majors."

You could set those words to music and nurses across the country would know the tune. Call it "The Scared to Death I'm Going To Hurt My Patients Because I'm so Tired Blues." Or "The Mandatory Overtime Blues."

Actually this free-flowing riff on being overwhelmed by an endlessly growing patient load and a chronically understaffed department and being forced to deal with it by working longer and harder comes from a conversation with Nancy Roberts, a long-time RN at Menorah Hospital in Kansas City, Mo. This is a highly stressed Nancy Roberts, who has repeatedly told Menorah management that her busy department--a family birthing center--has been understaffed for almost two years, who has predicted a growing patient census, and who is about to go into Menorah Hospital herself for a surgical procedure. She's so afraid that she won't get a regular nurse to tend her that her husband will stay the night with her.

Roberts, who has been a nurse for 26 years, notes that the volunteer overtime among nurses on her unit has always been high "because we've always been understaffed." Now, because of the growing patient census that the nurses predicted and management reluctance to staff up, nurses are no longer volunteering, and overtime has become routine and required.

"We already work 12-hour shifts, which turn into 13-1/2 hour days," says Roberts. And then management tells the nurses "'on the next shift, you select another shift or you will be given one.'"

At Englewood Hospital in New Jersey, stories of mandatory overtime abound. Health Professionals and Allied Employees local president at Englewood, Stephanie Orrico, has the list:

"One nurse was mandated from 3:00 to 11:00 and then 11:00 to 7:00," recounts Orrico. "She said she had to get home because her husband leaves for work at 5:00 a.m., and the supervisor said, 'You're not abandoning your children, your husband is.'"

Other stories that Orrico has heard from nurses at Englewood:

• "There was a nurse in ER who voluntarily stayed for two hours but said she had to leave to pick up her child at 6:00. However, she was mandated for two more hours and couldn't pick up her child, who was then delivered to her. So then there was a two-year-old scampering around [the ER]."
• "Another nurse worked 32 hours in a 48-hour period, 16 were mandated. She also was a parent with two children at home."
• "Another nurse worked her regular five days and voluntarily worked an additional four shifts during that week and still other nurses were mandated."

Orrico says that, routinely, schedules are posted four to six weeks in advance with holes in them, meaning that management is planning on filling those holes by mandating overtime. "It's not unusual to get calls at 4:00 or 4:15 or even at 3:00 telling the day staff, 'Don't go home, you're mandated,'" says Orrico, who adds that she knows of at least one instance on a pediatric unit when there was no one on the schedule. "How do you put a schedule out and have nobody on that schedule? A former nurse on that unit, who's a manager now, worked that shift.

"How do you provide care that patients need if nurses aren't in place at quitting time?" Orrico wonders. "How are hospitals defining quality care if professionals are not in place to deliver that care?"

The reason mandatory overtime is used at Englewood Hospital, says Orrico, is because "they've chosen not to replace nurses who have left through attrition."

While other hospitals reorganized and downsized and even Englewood had plans to reduce their capacity to 183 beds, "we run through 260 to 300 beds," she explains. "The hospital was even cited by the department of health... for understaffing on a busy surgical floor. They listed mandatory overtime as a staffing tool!"

Tied to the phone

LuAnn Riddle, an RN at Lee's Summit Hospital in Lee's Summit, Mo., worked 23 hours straight recently, but she was so tired, she said, she can't remember much about it, except to say that "it was awful." Typically, Riddle's work "day" is an 18-hour shift. Mandatory overtime, which Lee's Summit has named "on call," has become a staffing method at the small hospital.

The post-anesthesia care unit (PACU) where Riddle works is a small department, which, until recently, did not have an evening or night shift. The way emergencies are staffed in both PACU and the operating room is through an on-call system, meaning a system of mandatory overtime.

One to two times a week plus one weekend a month, every PACU and OR nurse has to serve on-call time. What it means, says Riddle, is that "you don't have much of a life." Essentially, nurses are tied to their phones or beepers from the end of their shift until 7:00 the next morning and have to be within a 30-minute radius of the hospital so they can come in for an emergency. On the weekend, on-call time is from 7:00 a.m. Saturday to 7:00 a.m. Monday--48 hours.

Riddle says she has never attempted to ignore the phone or beeper. She figures that would be grounds for dismissal. "If you refuse to do an on-call, you don't work there, that's part of the job."

Under ordinary circumstances, a small hospital like Lee's Summit might not expect too many real emergencies that would bring nurses in after hours or on weekends. But lately, in an effort to increase productivity, says Riddle, the hospital has been allowing doctors to schedule cases anytime they want. Where procedures were typically scheduled in the mornings, now they're also being done in the afternoons and late afternoons, necessitating nurses to be called in to attend. So the nurses, who've already worked their regular shifts, wind up coming in for regularly scheduled elective cases. "In that sense, it's forced overtime."

Sacrificing your free time to on-call duty means "you don't have a whole lot of life with your family," says Riddle. "I'm fortunate in the fact that my children are grown, but I'd like to spend some time with my husband. For those with small children, it's very difficult. They have to have a baby sitter available on call or their husband or somebody who's available and if they get called in the middle of the night, hopefully they're married and the husband can watch the kids."

Riddle explains that on-call nurses can't even go shopping. "If you're in the checkout line with the frozen foods and you have to get to the hospital in 30 minutes, it means you have to leave your groceries."

The hospital pays only $1.25 an hour for this slavery. Recently, Lee's Summit did finally hire one nurse for the evening shift, so there's a little relief, notes Riddle. However, the ideal would be to have a cache of nurses whose only function is to be on call or, ideally, better staffing, better planning, better scheduling.

Put bluntly, mandatory overtime on an ongoing basis "screws up lives," says Wisconsin FNHP local leader Barb Janusiak. Mandatory overtime goes on "weekly, if not daily," at St. Francis Hospital in Milwaukee, where Janusiak works as an intensive care nurse.

One nurse Janusiak knows at another hospital in West Bend, Wis., said, "They just cancelled their days off and told them they had to come in." That nurse worked mandatory overtime for five days in a row to have time off, said Janusiak, "then they cancelled her days off. She felt so trapped by it she quit."

"We're in the throes of a nursing shortage, which is supposedly why they're using mandatory overtime. It's not working because nurses are leaving."

Nurses in other hospitals that Janusiak knows of are told they can't leave their regular shifts because, "they say, there's no one to replace you and it's your professional responsibility to stay. So they're deluded into staying," says Janusiak. "They try to fool the nurses into believing they're Florence Nightingales."

An ER nurse in West Allis, Wis., whom Janusiak knows, left her job in the ER for another floor when she couldn't get released from mandatory overtime in order to attend her son's school function.

"Of course, you can run but you can't hide," comments Janusiak. "No matter what floor she goes to."

A way out of the trap

None of these nurses is going to take it anymore. In Missouri, the nurses at both Lee's Summit and Menorah Hospitals have decided that forming a union is the key to helping them control their work environment so they can properly care for their patients. Nurses at Lee's Summit Hospital already won their election--choosing the FNHP as their collective bargaining representative--and nurses at Menorah recently filed for an election date (see p. 7). Nurses at both facilities and at many of the other facilities owned by Health Midwest are members of the Nurses United for Improved Patient Care, an organization that nurses started in the Kansas City, Mo., area to do something about the near-impossibility of providing decent care.

The union movement "is something I'm in for the future," says Nancy Roberts. "I feel that nurses need to have a voice in how decisions are made for patient care." If the understaffing, forced overtime and their debilitating effects continue, "if there's nothing that will attract and retain nurses to my profession, we are really in trouble as a nation," she adds.

At Lee's Summit Hospital, where the nurses are currently in negotiations for their first contract, Riddle said she spent time explaining to a management negotiator the details of her job as a post-anesthesia nurse--about the work it takes to keep tabs on the patients, to take their vital signs, see to their comfort and get them to the optimum point for being moved out onto the floor and then home. "I said, 'How would feel if you were my patient at the end of an 18-hour shift?'" said Riddle, "'or at the end of 23 hours?'"

FNHP members in the Kansas City area, as well as members throughout Wisconsin and New Jersey, have mounted campaigns to educate their members and the general public about the need for a ban on mandatory overtime. In Wisconsin, more than 3,700 cards have been signed by citizens calling on the State Legislature to introduce a bill that will end forced overtime. FNHP members in New Jersey, in conjunction with the support of its community alliance, Patients First, has already pushed for and seen passage of legislation that bans mandatory overtime in hospitals.

Nurses are going on strike over the issue of mandatory overtime and are winning the fight--as well as contract language--to limit the out-of-control practice.

FNHP members at Burlington Memorial Hospital in Wisconsin, at Staten Island University Hospital in New York City, and Virtua-Memorial Alliance in Mount Holly, N.J., have all won contract language limiting the use of mandatory overtime.

Under the contract for the Federation of Nurses/United Federation of Teachers nurses at Staten Island, hospital management agreed to hire two nurses immediately and to hire an extra nurse after every quarter year in which there are more than 300 mandatory overtime hours. The contract also created a labor-management committee to review the staffing situation floor by floor and shift by shift to alleviate as much mandatory overtime as possible.

At Virtua-Memorial Alliance, members of the Health Professionals and Allied Employees/FNHP won major limitations on the use of mandatory overtime, including a maximum of four hours of overtime; no more than two instances of mandatory overtime in a four-week period; one hour of notification before the end of shift if overtime is to be required; and the provision of time before the end of the shift for nurses to take care of family issues or day care.

At St. Vincent's Hospital in Worcester, Mass., where management tried to mandate 16-hour shifts, nurses who belong to the Massachusetts Nurses Association now have a contract that limits the amount of mandatory overtime assigned to no more than four hours and limits the number of times a nurse can be assigned overtime to eight times per year (twice each quarter). It also gives a nurse the right to refuse mandatory overtime if he or she feels too fatigued or ill to work safely.

Forced overtime simply has no place in any setting, much less the health care setting, says FNHP program and policy council chair and AFT vice president Candice Owley. "The emotional and physical cost to the employees is severe," says Owley. "For the patients, the situation is potentially grave. An overworked employee cannot provide the same safe level of care as someone who arrives fresh and ready to tackle the day's challenges."

While a great deal has been done over the past year in establishing contract protections that prevent or restrict the use of mandatory overtime, more must be done, says Owley. It is, she says, a battle that must be fought and won.