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Cap on Mandatory Overtime, the Right Rx for Nursing Care

Study by Robert Wood Johnson Foundation finds state laws effective in reducing nurses' hours.

Hospital nurses -- and their patients -- are benefitting from laws capping mandatory overtime, according to a new report that found laws in 16 states, including New Jersey, effective.

"Nurses routinely work long shifts, often as long as 12 hours straight. These laws were intended to prevent hospitals from piling mandatory overtime on top of such shifts," said Carol Brewer professor at the School of Nursing, University at Buffalo, and one of the study's authors.

Nurse overtime is a critical issue, according to the study, which cites research finding fatigue caused by long hours adversely affecting patient care.

"You have to stay sharp," said Virginia Treacy, executive director of the nurses' union JNESO. "While nursing does have manual labor attached to it, it also requires a sharp intellect, and the ability to analyze and respond appropriately in a rapid fashion."

The study comes from the RN Work Project, a 10-year longitudinal study of newly licensed registered nurses that began in 2006 and is funded by the Robert Wood Johnson Foundation.

The study follows nurses who graduated from nursing school between July 2004 and August 2005. The data for the mandatory overtime survey was gathered in 2006, at the height of the nursing shortage.

"Employers, especially hospitals, didn't have enough people to cover their shifts, and the fallback position was mandating overtime," Brewer said. States responded to complaints from nurses and beginning in 2000 began passing laws capping mandatory overtime. New Jersey's law took effect in 2005.

The study includes data about nurses in 34 states, and found that 11.6 percent of nurses said they worked mandatory overtime in a typical work week, averaging 6.1 hours of mandatory overtime.

"In the operating room and the intensive care units, there still may be challenges, because you can't just pull nurses from anywhere and plug them in," said Patricia Barnett, chief executive of the New Jersey State Nurses Association.

The study found that nurses are 59 percent less likely to work mandatory overtime in states with laws that regulate the number of hours they are required to work.

"Just because you have a mandatory overtime law doesn't mean overtime goes away," Barnett said. "Things happen: A nurse is getting ready to come into work" but instead must care for a sick child. "Or the census in the ICU is normally 10 and all of sudden there's a big traffic accident and you have 15."

Nurses rarely invoke the overtime law because most feel "very obligated not to leave before there is proper relief, said Treacy, the head of the nurses' union. "If you're an OR nurse and you're in the middle of a case, and nobody comes to relieve you, there is no way for you to leave. So there are still instances where people are required to stay past their shift."

Most nurses are not unionized and "probably don't even know the law exists, let alone how to use it," Treacy said. "If it's 11 at night and no one comes to relieve you, you are not leaving."

Strategies hospitals use to avoid mandatory overtime include "shift bidding systems" in which nurses who want more hours can request overtime, Brewer said.

Hospitals have also created "float pools" in which "nurses are guaranteed a certain number of hours but they float to different areas. So they are given preparation for the clinical area they might be expected to work in and then they are scheduled a certain number of hours." Hospitals also contract with outside nurse agencies to fill staff shortages.

Nurses often work voluntary overtime, and the study found that hospitals that create a good working environment are more likely to find nurses volunteering to fill in when they are needed.

Researchers anticipated that caps on mandatory overtime might lead to increased voluntary overtime. While the data demonstrated no relationship between mandatory and voluntary overtime hours, more than half the nurses reported working voluntary overtime in a typical work week.

The study also looked and the level of the nurses' commitment to their organization and found that nurses with a higher organization commitment were more likely to work voluntary overtime, Brewer said. "That told us that if you work with your nurses so they become committed to your organization, you are less likely to have a problem [with mandatory overtime] in the first place because the nurses are more likely to work voluntary overtime."

That's been the experience at the Robert Wood Johnson University Hospital in Rahway. "Here we do a lot of things to empower our nursing staff," said Lynn Kearney, chief nursing officer. "They are offered opportunities to be on committees, such as the nurse practice committee, where they actually write and revise nursing policies and procedures. They are included in making those changes. It gives them the opportunity to be proactive."

Brewer said improved nurse engagement is the goal of the magnet hospital program of the American Nurses Credentialing Center of the American Nurses Association.

The hallmark of a magnet hospital is "a work environment that is conducive to work satisfaction and organization commitment," Brewer said. "There is a whole constellation of things that employers can do to retain the loyalty and increase the satisfaction of their employees, and if they systematically develop that they are going to have fewer problems. The message is that employers really need to think carefully about what they do to develop their employee commitment and satisfaction."

Magnets include the Robert Wood Johnson University Hospital in New Brunswick. "We are really focused on our level of nurse engagement," said Kathy Easter, assistant director for the magnet program. "We believe if our nurses are satisfied, our patient outcomes improve."

There is no mandatory overtime at the hospital, and on many nursing units, the nurses do self-scheduling, working together to make sure the staffing needs are covered, Easter said. "By not mandating overtime, nurses are better rested, they can think more clearly and patient outcomes improve as a result. Patient outcomes are really linked to nurse satisfaction."

Bernard Gerard, vice president of the Health Professionals and Allied Employees union, which represents nurses, said the work environment in hospitals was improved by the state's mandatory overtime law.

The law limits the situations where mandatory overtime can be imposed and requires that nurses have an hour's notice "so they can arrange childcare, or do what is necessary so that they can stay," Gerard said. "The law came about because nurses were being mandated to work overtime, and it was really a case of poor management."

Sixteen states now have rules restricting mandatory overtime hours for nurses, New Jersey, Arkansas, California, Connecticut, Illinois, Maryland, Minnesota, Missouri, New Hampshire, New York, Oregon, Pennsylvania, Rhode Island, Texas, Washington and West Virginia.

"We are now in a different landscape in terms of the issue of shortages," Brewer said. "Most areas are not experiencing nursing shortages right now. So the incentive for employers to mandate overtime shouldn't be nearly as strong, and this is a good time for employers to think about what kind of systems do they need in place to prevent [mandatory overtime] from happening if a shortage reoccurs."

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