News & Events

Realities of mandatory overtime on the patient and the nurse

From the Massachusetts Nurse Newsletter
April 2011 Edition

By Joe Twarog
Associate Director, Labor Education & Training

A regularly scheduled day-shift nurse is rotated to work the evening shift. Towards the end of that evening shift she is then mandated to work the full night shift for a total of 16 hours straight.

A nurse is mandated to work a full eight-hour shift following her regular eight-hour evening shift. Following report and driving home, she gets home and sleeps for no longer than 6 hours and has to return to the hospital for her next regular evening shift.

When confronted with blatant incidents of mandated overtime involving exhausted and sick nurses, the hospital’s human resource director responds, “It is better to have an ill or fatigued nurse at the bedside than no nurse at all.”

These are all actual events that have recently occurred at some Massachusetts hospitals. This reflects the unfortunate reality and sad state of hospitals these days. Most of these situations are due to chronic short staffing, or “lean management”—where the idea is to push the envelope on staffing patterns until just before the whole system breaks down. Think lean production methods and Toyota.

It is common for the hospital to post schedules with holes in them, meaning that not all of the shifts are covered and they are short on nurses from the start. The crisis is predictable and inevitable. These crises are not unforeseen or emergency situations, but rather ones that are planned, systemic and programmed for failure. They are not due to “call-ins” that the hospitals like to cite. Even so, there is absolutely no leeway for the event when a nurse does call in sick. And nurses do get sick!

Some hospitals have become creative with what they call “mandatory overtime.” The words themselves seem offensive even to the management bosses so that some have begun to sanitize the “mandated” part by referring to it as “continuation of care.”

Impact of long work hours, extensive OT

Study after study establish and confirm that there are serious dangers associated with excessive use of overtime—in virtually all types of work settings. The dangers are well documented as seen in these studies.

Alex Kerin of Circadian Technologies has found that, “Companies with high amounts of overtime are having more accidents than ones with low overtime, and also those accidents are more severe,” and that, “Excessive overtime ultimately results in lower productivity, more fatigue-related accidents and injuries, costly increases in absenteeism and turnover, and higher employer medical costs. It also increases the chances of a mistake or accident that could severely damage brand image and financial performance.”

“Studies by both trade associations and the government clearly document that overtime typically reduces productivity. Accidents, absenteeism and mistakes increase. The problem of fatigue is directly proportional to the amount of overtime worked. These studies have found that … fatigue reduces productivity. Studies have also shown that the fatigue produced by overtime work affects work done on regular time as well.” (Effects of Extended Work Time on Productivity by George Hague)

“Inadequate sleep is a major factor in human error, at least as important as drugs, alcohol, and equipment failure,” writes David Dinges, author of Sleep to Survive: How to Manage Sleep Deprivation.

The Canadian Centre for Occupational Health and Safety has identified the effects of fatigue to the work being performed. These include:

  • Reduced decision making ability
  • Reduced ability to do complex planning
  • Reduced communication skills
  • Reduced productivity/performance
  • Reduced attention and vigilance
  • Reduced ability to handle stress on the job
  • Reduced reaction time, both in speed and thought (a few studies have shown this effect as similar to being legally drunk)
  • Loss of memory or the ability to recall details
  • Failure to respond to changes in surroundings or information provided
  • Unable to stay awake (e.g., falling asleep while operating machinery or driving a vehicle)
  • Increased tendency for risk-taking
  • Increased forgetfulness• Increased errors in judgment
  • Increased sick time, absenteeism and turnover
  • Increased medical costs
  • Increased accident rates

Research done by Tony Rieck of T.R. Consulting Inc. has found that, “The consistent conclusion of studies has been that sleep deprivation results in loss of concentration, forgetfulness, inattentiveness, reduced cognitive ability, increased reaction time and diminished alertness. When an individual’s level of alertness decreases, the individual is no longer as capable of making good decisions, performing tasks or responding quickly to emergencies. It is easy to see that fatigue is an important factor in workplace safety.”

The ground crews at the Kennedy Space Center work extensive overtime in preparation for a shuttle launch. The Challenger disaster occurred on Jan. 28, 1986. But an earlier scrubbed launch on January 6 was also in danger of catastrophic failure due to a misinterpretation of system error messages. The Report of the Presidential Commission on the Space Shuttle Challenger Accident cites operator fatigue as one of the major factors contributing to this incident. The operators had been on duty at the console for eleven hours during the third day of working 12-hour night (8 p.m. to 8 a.m.) shifts.

And finally, “Understaffing of nurses at hospitals means that nurses sometimes are forced to work a second shift after their first shift ends. High patient load and fatigue from long hours can result in inadequate compliance with procedures and less monitoring of patients. As a result, overtime can compromise patients’ health or safety.” (Lonnie Golden & Helene Jorgensen, Time After Time: Mandatory Overtime in the U.S. Economy.)

Other industry work hour limits

According to the National Institute for Occupational Safety and Health (NIOSH) employees in the U.S. work the highest number of hours per year compared to the rest of the world—about 70 more hours per year than workers in Japan, and 350 hours more than in Europe . Americans work longer work weeks and have fewer weeks of vacation. Also, overtime and second jobs add to the regular work week.

Yet the Federal Fair Labor Standards Act (FLSA) does not restrict the number of daily or weekly work hours that employers may schedule for adult workers. But certain industries do in fact have strict limits on the number of hours of work in one stretch. Here is a sampling.

Truck drivers

The US Department of Transportation has established an 11-hour driving limit for property carrying drivers after 10 consecutive hours off duty and passenger-carrying drivers have a 10-hour driving limit and may drive the maximum only after eight consecutive hours off duty.

Rail transportation

The U.S. Department of Transportation’s hours of service regulations governs the on-duty time of railroad engineers, conductors, dispatchers, and employees that maintain and manage signal systems. This act requires that engineers and conductors get at least eight consecutive hours of off-duty time in a 24-hour period. In addition, when employees work 12 consecutive hours, they must have at least 10 consecutive hours of off-duty time.

Maritime traffic

The International Maritime Organization requires a minimum 10-hour rest period during any 24-hour period.


FAA regulations address flight time limitations and required rest periods. For domestic flights pilots are generally limited to eight hours of flight time during a 24-hour period. This limit may be extended provided the pilot receives additional rest at the end of the flight.

Hospitals and mandatory overtime

Yet despite all of this overwhelming and compelling evidence of the dangers of overtime, many hospitals persist in using mandatory overtime as a way to staff their facilities. Mandatory overtime is linked to short staffing. A recent issue of the New England Journal of Medicine (March 17, 2011) once again establishes the link between patient outcome and nurse staffing. But evidence shows that hospitals seem to be more interested in “patient satisfaction surveys” and the bottom line.

The union’s consistent response to short staffing and mandatory overtime has been to challenge such practices as harmful to patient care and to the nurse, as well as short-sighted, dangerous and not cost effective. Staffing incident reports are regularly filed by MNA nurses placed in these unsafe and unacceptable situations. Grievances are filed, and arbitrations are heard. But the hospitals continue.

Nurses who are mandated following the completion of their regular shift are often ill-equipped to continue working. They have not planned for that situation with: proper advance rest; arrangements for child responsibilities and family obligations; and even preparing personal meals for their extended hours of work. There is a total loss of control over one’s work life when one is mandated, resulting—in addition to all of the challenges cited above—to resentment, anger and poor morale.

Contractual language

The MNA has been successful in negotiating contract language to limit or totally ban the practice of mandatory overtime. Here are some examples.

  • During the term of the Agreement the Hospital shall not mandate RNs to work overtime unless the Disaster Plan has been implemented.
    —Cooley Dickinson Hospital
  • “…the Hospital may require a nurse to perform a reasonable amount of overtime work, provided that no nurse shall be mandated to work more than four (4) hours past their regularly scheduled shift.”
    —Mercy Medical Center
  • No nurse shall be mandated to work overtime more than sixteen (16) hours in a calendar year.
    —Baystate Franklin Medical Center
  • One contract has a procedure to follow:
    “The mandated nurse will be granted a day off to be taken within six (6) months of the mandated shift worked. This day cannot be cashed in as earned time and must be scheduled between the nurse and the supervisor according to the standard practice of planned time off.

    “If the nurse mandated to work overtime is scheduled to work a shift during the following 24 hours of the overtime shift, the nurse will have one of the following options: A. be absent for the regular shift, but will accrue earned time at the regular rate for the mandated shift; B. work the regular shift as scheduled; and C. use ETP for the regular shift.”
    —Quincy Medical Center

  • “Mandatory overtime shall not be the established practice for staffing the Hospital (i.e., mandatory overtime will be the exception, not the rule). The Hospital will exercise good faith and reasonable efforts in filling committed RN positions, thereby recognizing its goal to keep mandatory overtime to a minimum.”
    —North Adams Regional Hospital

Early in the 19th century there was a worldwide movement to establish the eight-hour workday. A slogan of the Eight-hour Day Movement from the 1880’s was “Eight hours for work, eight hours for rest and eight hours for what you will.” It looks like we will have to resurrect that adage for hospitals that refuse to recognize the universal negative impacts of mandatory overtime.