Setting limits that could save lives

It's no secret that healthcare workers are taking care of more patients, but not many people know that they are also working longer hours. And sometimes, those longer hours have serious consequences.

Last year, two nurses faced jail time for incidents that occurred after each worked too many hours.

Laura Ann Brockhaus, a registered nurse at the Veterans Affairs Medical Center in Minneapolis, was charged in January with careless driving, a misdemeanor, in the death of an 18-year-old high school student.

In the summer of 2006, Brockhaus had been returning home after working overnight, when her car veered off the road and struck and killed Jacquelyn Devney.

Brockhaus told police that she must have fallen asleep. She had worked overnight shifts from 7:30 p.m. to 8 a.m. for three days in a row. In that time, she had slept only five to six hours one day and three hours the next.

That same summer, a registered nurse at St. Mary's Hospital in Madison, Wis., made a fatal mistake that cost a patient her life. Julie Thao provided epidural medication for 16-year-old Jasmine Gant, who was pregnant, instead of penicillin. Gant died but her baby survived. Thao had worked two eight-hour shifts back to back, stayed in the hospital overnight and was near the end of her next shift when the mistake occurred.

Thao was charged with felony neglect, but the charges were later reduced under pressure from nurses, doctors and hospitals, all of whom said unintentional mistakes should not be considered criminal offenses. She ultimately was sentenced to three years of probation for two misdemeanors of illegally administering prescription medication, and was barred from critical care nursing during that time.

Thao's fatal mistake has prompted discussion, particularly in Wisconsin, about whether work hours for health professionals should be limited. Nurse organizations have been calling for an end to mandatory overtime for years, but some say it is time for the profession to consider putting a limit on all hours a nurse can work-mirroring work-hour restrictions placed on industries such as air transportation and trucking.

"There is no question we need to outlaw mandatory overtime, but the real question is, do we need to look at all hours?" asks Candice Owley, chair of AFT Healthcare's program and policy council and an AFT vice president.

Limiting overtime

Like any 24-hour operation, extended work schedules (which include more than 12 hours in a 24-hour period and more than 40 hours in a seven-day period) are common in healthcare, especially in nursing. Because of this, overtime often means a 14 to 16 hour workday. Fatigue and sleep deprivation are also common among healthcare workers. Several studies have shown that long hours and sleep deprivation have an adverse effect on the performance of healthcare workers.

In a 2004 report, "Keeping Patients Safe: Transforming the Work Environment of Nurses," the Institute of Medicine makes this recommendation: To reduce error-producing fatigue, nursing staff should be prohibited from providing patient care in any combination of scheduled shifts, mandatory overtime or voluntary overtime, in excess of 12 hours in any given 24-hour period or in excess of 60 hours in any given seven-day period.

Ann E. Rogers, a sleep researcher at the University of Pennsylvania School of Nursing, says 12-hour shifts in hospitals should be limited, and overtime—especially that associated with 12-hour shifts—should be eliminated.

Rogers' research reveals that work duration, overtime and number of hours worked per week have a significant effect on errors. In fact, both errors and near errors are more likely to occur when nurses work 12 or more hours.

With the shortage of nurses, "most nurses work beyond their scheduled shift to catch up on the things they couldn't do [during scheduled time]," says Rogers. "When you are understaffed, you don't have time to chart or take breaks."

Still, Rogers doesn't expect to see any limitations on overtime-mandated or voluntary-established anytime soon.

"Not in this anti-regulatory climate," says Rogers. And, she notes, there is likely to be resistance from the industry and healthcare workers.

"Hospitals need nurses to work-whether they are mandated or they volunteer—and nurses are often paid overtime or offered nice inducements to stay on the job longer than they should," says Rogers. She acknowledges that some nurses are pressured to take shifts. "That is the culture," she says.

"Hospitals don't hire enough staff to operate without the use of overtime," says Owley. In Thao's case, she had volunteered to work, but the hospital depended on her to do that, she notes.

"As professionals, we are responsible and we monitor our practice and would not work beyond our limits," says Bernie Gerard, vice president of Health Professionals and Allied Employees in New Jersey. "When an individual volunteers to work overtime they plan accordingly, when they are mandated they don't have that planning time."

Because hospital management often demand that nurses work overtime, hospitals should bear some responsibility for scheduling workers for shifts, says Gerard. New Jersey, along with Connecticut, Maryland, and Oregon, has a ban against mandatory overtime. In each of these states, AFT Healthcare members lobbied their state lawmakers aggressively until a ban, which prohibits hospitals from imposing mandatory overtime on nurses, was in place.

"The wholesale mandating of healthcare workers has stopped," because of the ban, says Gerard. "Clearly there is a need for a national ban on mandatory overtime," says Gerard. But until there is one, "It is incumbent upon everyone—hospitals and healthcare workers—to figure out how to deal with the issue."

Nurse can do their part to ensure patient safety, says Rogers. To prevent errors, the best thing workers can do is get their proper rest," Rogers advises. "I know that's hard, but it's the one thing that will protect them from making mistakes. Most people don't know how tired they really are and so they don't see it as an issue," she says. Unfortunately, sleep is not a priority for most time-crunched Americans, says Rogers. "Most of us are not getting adequate amounts of sleep. Sleep is viewed as expendable."

Unionized facilities are in a unique position to negotiate contracts that limit mandatory overtime as well as the amount of overtime worked voluntarily, says Rogers. In her studies, Rogers found error rates were less pronounced when the extra work time was voluntary rather than mandatory, but she notes that even nurses who worked overtime voluntarily were still at high risk for making an error.

Incidents like the ones in Minnesota and Wisconsin serve to enlighten others , says Rogers. "Nurses need to be made more aware of the chances that they could make a mistake."

"There is a lot of discussion and education that needs to happen around this issue," says Owley, who would like to see more of an effort to raise awareness among workers and employers about the effects of excessive overtime on the ability to deliver quality care. And, she points out, "Salaries must be sufficient to attract the best and the brightest and not have nurses depend on overtime, bonuses and extra shifts."

Change is coming

The healthcare workers at Kaiser Sunnyside Hospital in Clackamas, Ore., who are represented by the Oregon Federation of Nurses and Health Professionals, are working with Kaiser Permanente to educate their members on the issue of fatigue.

The national contract between Kaiser and its unionized workers has a provision that calls for the development of an education program on fatigue and safety to be implemented in all seven-day-a-week units.

Bruce Corkum, an RN contract specialist for OFNHP, believes it's only a matter of time before work-hour limits are established in healthcare.

"It's coming. Healthcare workers need to get behind this effort to limit hours. If it's the right thing to do for other industries, why wouldn't we say it's the right thing to do for healthcare workers?"

Corkum, a former step-down nurse, has been working to the get the education program up and running. He is hoping to use research to educate nurses and the public, and to move forward on implementing a policy to address the issue.

"I don't think our members truly think about the increased risk of errors associated with extended hours," says Corkum. Educating the public will put pressure on hospitals to hire more staff so nurses won't have to work extra hours.

Right now staffing shortages are a reality and hospital management is asking our members to work many extra hours. They (management) would be shooting themselves in the foot if they implemented a policy limiting voluntary overtime, says Corkum. However, he notes, it might force management to go out and hire more staff.

Corkum expects a lot of push-back from healthcare workers who take on additional shifts and work on-call. Many are concerned that regulations could limit the flexible work schedules they prefer and do not believe to be dangerous.

"The culture shift will be tough but the change will mean much safer outcomes for patients," says Corkum.

Kaiser Sunnyside is one of a number of AFT Healthcare locals that have taken steps to limit overtime—mandatory and voluntary—in their contracts.

In Wisconsin, the members of the Dynacare chapter, WFNHP Local 5001, have agreed to restrict hours for cytotechs to no more than two hours of overtime per day (10-hour maximum shift per day) and no more than six days in row. The nurses at Fletcher Allen Health Care, represented by the Vermont Federation of Nurses and Health Professionals, have language in their most recent contract that addresses maximum and minimum consecutive shifts. Members cannot be scheduled to work more than 16 hours in a row.

Of course, mandates to limit nurses' working hours will not guarantee patient safety if adequate staffing levels are not also ensured. "Unsafe staffing and mandated hours go hand in hand," says Owley. The bottom line is that "legislation must be passed to outlaw dangerous overtime practices and support safe staffing ratios and any other methods that will create a safe environment for patients," says Owley.

Read what our members are saying:
Should there be a limit on all hours worked
by healthcare workers?