Archives for June 2013

Problems Caused by Mandatory Overtime for Nurses in Arizona

Mandatory Overtime for NursesThe phrase “hit and run” nursing comes from Peter Kilborn’s 1998 The New York Times article concerning cost-efficiency tactics in health care systems, and specifically addresses the type of fast-pace patient care that can lead to “mistakes, abuses and oversights.” Peter Kilborn, “Nurse Put on Fast Forward in Rush for Cost Efficiency,” N.Y. Times, at 24 (Apr. 9, 1998). His piece explores the intersection of nurses and their employers and how they differ with respect to workload, patient care and other aspects of managed care. It highlights what Thomas E. Bender and Christina M. Hanna discuss in the Health L. Handbook: the effects of understaffing and mandatory overtime on nurses and the nursing profession overall. 2005 Health L. Handbook § 11:6. This can be a particularly troubling aspect of employment for Arizona nurses in that “an RN’s refusal to work overtime may lead to charges of patient abandonment, which could lead to an eventual loss of their license.” Id. It is therefore important for RNs (and other similar medical professionals such as LPNs) to understand the risks associated with understaffing and mandatory overtime.

The Joint Commission, through advice from the Patient Safety Advisory Group, issued an alert at the end of 2011 concerning health care worker fatigue and patient safety, the highlights of which should be read and understood by anyone providing medical care or assistance under a board-issued license in Arizona (and nationally, for that matter). The Joint Commission, “Health care worker fatigue and patient safety,” The Joint Commission Sentinel Event Alert, Issue 48, December 14, 2011. Fatigue has a broad range of potential risks, including the increased possibility of adverse events and compromised personal and patient safety and well-being. The primary culprits in these cases are insufficient duration of sleep and poor sleep quality for an extended period of time. When a nurse is fatigued there is a greater likelihood of a number of potential problems, including (1) lapses in attention and/or memory, (2) lack of focus, (3) the inability to problem solve effectively, (4) confusion, irritability and diminished reaction time, (5) impaired ability to communicate, (6) feelings of indifference and/or loss of empathy for patients, and/or (7) slowed ability to process information and to make sound judgments. A number of studies have shown that ultimately the longer a shift length is the greater the risk of errors, close calls and injuries to nurses themselves because of decreased vigilance. Rogers AE, et al: The working hours of hospital staff nurses and patient safety. Health Affairs, 2004; 23(4):202-212. For more information about empirical studies concerning residents working on recurrent 24-hour shifts, see the footnotes section of the Joint Commission’s Alert.

Based in part on studies conducted by NASA about sleep deprivation, the Joint Commission makes several recommendations for employers to reduce problems associated with nurse fatigue, and nurses themselves should be aware of specific scientific strategies they can adopt that might conform to the other rules of employment as best they can. Such a “fatigue management plan” may include engaging in conversations with others (not just listening and nodding), doing something that involves physical actin (even if it’s just stretching), making use of strategic caffeine consumption, and taking short naps lasting less than 45 minutes in duration and only if permitted by the employer. Rosekind, MR, et al: Crew Factors in Flight Operations XIV: Alertness Management in Regional Flight Operations Education Module. National Aeronautics and Space Administration, February 2002,  (accessed June 10, 2013). Ultimately, however, the only way to effectively counteract severe sleep deprivation is to sleep. Rosekind, MR, et al: Fatigue Countermeasures: Alertness Management in Flight Operations. National Aeronautics and Space Administration, Southern California Safety Institute Proceedings, Long Beach, Calif., 1994, (accessed June 10, 2013).
One final resource of quality information available to nurses is “Patient Safety and Quality: An Evidence-Based Handbook for Nurses.