Researchers from the University of Pennsylvania School of Medicine asked 393 hospital-based registered nurses to track their working hours along with the number of errors or near errors they made on each shift. The results of that work, partially funded by the Robert Wood Johnson Foundation, were published in the July/August 2004 issue of Health Affairs. Rogers was the lead author.
Q: You say that this study, which explored the link between the hours nurses work and patient safety issues, is one of the first of its kind. Why has no one looked at this before?
A: Probably because, and this is just conjecture, most people think of nurses working eight-hour shifts, from 7 a.m. to 3 p.m., then getting off at the end of the shift. Unfortunately, that's not the case. Many nurses are now working 12-hour shifts and very few get off at the end of the shift.
Q: Why are they working longer shifts?
A: That came about in the '80s and '90s as a response to the nursing shortage. Hospitals were looking at different schedules to attract and retain nurses. Nurses, like many other workers, like more days off. So if you work 12 hours straight, you get more days off. It's very attractive. So that's probably part of the why. You only need two nurses to staff 24 hours instead of three.
Q: But why are nurses working beyond the end of their shift?
A: We don't know for sure. It appears they simply cannot get everything done in the time allotted. Some nurses in our study did say their overtime was needed because of high patient acuity and not enough staff. I notice the American Association of Critical-Care Nurses conducted a poll and found nurses were finishing charting and other work-related tasks. Our study found that nurses were able to leave work at the scheduled time in only 19 percent of shifts.
Q: Why aren't there any state or federal regulations governing the amount of time nurses can work?
A: I wish I knew. I guess it's not perceived as something that's been an issue in nursing. Legislators perhaps didn't know there were safety issues or didn't know that nurses were working this long. This is not a political climate that would necessarily lend itself to regulations.
Q: You note that some states have passed bans on mandatory overtime. Does that help?
A: A number of states have, but what we found was that only about 7 percent of the shifts nurses reported working overtime were mandated. Only 3 percent said they were coerced into working. The rest probably just stayed beyond their scheduled shift because they knew the work had to be done. They're responsible, and they know if they don't cover the extra shifts no one will. Some of the hospitals, we know from talking with other nurses, pay time-and-half plus maybe an extra $25 an hour, so they put a nice financial incentive into working overtime.
Q: How much of this need for overtime is driven by the nursing shortage and how much is driven by other aspects, such as sicker patients?
A: I'm not sure. I do know the nursing shortage is contributing to it. If you don't have enough nurses, someone needs to do the work. My area of concern is if the nursing shortage gets worse, what are we going to expect the staff to do? They're already working hours our data suggests are risky for patient care. There may have to be some other solutions. The Institute of Medicine report, "Keeping Patients Safe: Transforming the Work Environment of Nurses," suggests that nurses should not provide direct care more than 12 hours a day or 60 hours a week.
Q: What were some of the more interesting or surprising results from your survey?
A: We were surprised at how many nurses were actually working 12-hour shifts, because that hadn't been well documented. We were also surprised at the strong association of hours worked with errors made. Also, that it made no difference whether the overtime was voluntary or mandated. It still had an adverse effect.
Q: Do the hospitals notice that there are more errors when they require their nurses to work more hours?
A: Possibly not because there's evidence that nurses and other health care professionals report only about 5 percent of errors and they report only the most significant ones. So many things the nurses reported to us as errors are never going to be reported, so the hospital wouldn't notice the link. Also, errors are, fortunately, rare events, so if you're just looking at one hospital or one unit you're not going to get a large enough sample to find if there's a relationship.
Q: How did you define "error?"
A: We didn't define it. The nurses did. But when we looked at what they said were errors, they were clear deviations from accepted practice. For example, nurses reported that they gave a medication at the wrong time, to the wrong patient or in the wrong amount. They also reported procedural errors—that they made charting errors or transcribed orders incorrectly. What they told us clearly fell into things that are not an appropriate practice.
Q: They sound like the kind of errors you make simply because you're tired.
A: Some of them. And some of them were system-related, but our study wasn't designed to sort that out.
Q: Your article mentions previous studies in which two epidemics of staph infection were linked to nurses' hours.
A: Those were hospital-wide epidemics and I believe the researchers said there was a nurse shortage and the nurses were working longer hours. Because the nurses were tired and in a hurry, investigators believed that the nurses skipped important steps when changing dressings and ended up spreading the infection from one patient to another. When we're tired, no matter who we are, we skip details. We just focus on getting done. We say, "well, that's not important," when in reality that small change or step in the procedure might be very important.
Q: You call the use of mandatory overtime a "controversial and potentially dangerous practice." Can you expound on that?
A: There's a lot of controversy right now on this topic. Is mandatory overtime appropriate? Is it not appropriate? When can you use it, when can't you use it? There's a lot of legislative action over this and managers and nurses have different viewpoints on it. It's potentially dangerous, just as working overtime is potentially dangerous. Even though working overtime, whether voluntary or mandatory, increases the risk of making an error, legislative action has been focused on curtailing mandatory overtime.
Q: What message does this study send to policy-makers, hospital administrators and nurses?
A: That there are risks associated with nurses working long hours and that we probably need to look at ways to decrease their hours.