Approved by the AONE Board of Directors, December 2003
Statement of the Issue
In its groundbreaking publication, Perspectives on the Nursing Shortage: A Blueprint for Action (AONE, 2000), the American Organization of Nurse Executives (AONE) recognized early on the potential impacts of the nursing shortage. In the last three years, the nursing shortage has become more acute. Shortages have been documented in countless studies and have become a critical factor in the access to and the provision of timely patient care services. The Division of Nursing at the Health Resources and Services Administration projects the need for one million nurses by 2010. Barring aggressive intervention, the supply of nurses will fall by 29 percent below what is required by the year 2020.
A majority of the states have reported professional nurse vacancy rates from 12 to over 20 percent. To deal with the professional nurse shortages, health care institutions have closed beds, reduced the volume of elective surgeries, and placed emergency rooms on diversion to attempt to deal with rising nurse vacancies. In many cases, institutions have initiated mandatory overtime or asked staff to remain voluntarily on patient care units after the completion of a scheduled tour of duty. Surveys have indicated that the practice of using mandatory overtime is widespread; however, at times, the stories have been overblown. The use of mandatory overtime has contributed to a negative image of the nursing profession and the characterization of the hospital work environment as overly stressful and unsafe for patients.
Overtime has been defined as the hours worked in excess of an agreed-upon, predetermined, regularly scheduled full-time or part-time work schedule, as determined by contract, established work scheduling practices, policies or procedures. The Institute of Medicine report, Keeping Patients Safe: Transforming the Work Environment of Nurses (IOM, 2003), cautioned that long work hours of some nurses represented one of the most serious threats to patient safety. The Fair Labor Standards Act (FLSA) has defined mandatory overtime as hours worked over 40 per week or over 80 for a two-week period. Mandatory overtime does not include those overtime hours for which workers have volunteered, but the nurse manager must consider the total number of hours a nurse has worked and the effects of fatigue on human performance when making assignments.
In the view of AONE, declining a patient assignment after completion of a regularly scheduled shift will not be deemed as patient abandonment, be grounds for disciplinary action, or result in actions against the nurse. AONE does not consider mandatory overtime to include "staffing up" for unseen emergencies, such as mass causalities or snowstorms, or scheduled "on call" time when a nurse may be paged to come into work as defined in his or her job description.
It is the view of AONE that mandatory overtime is the staffing vehicle of last resort, limited to crisis situations that would put patients in danger of not receiving the basic requirements of the safe care that they require.
AONE believes that all health care delivery organizations, working in conjunction with the nurse executive and his or her nurse managers, are responsible for the monitoring of staffing as it relates to patient safety, actual or potential patient outcomes, and the quality of the work environment. Every effort must be made on the part of these organizations and the nurse management team to develop staffing plans based on the consideration of such factors as patient acuity and volume, the experience level of the nursing staff, the layout of the unit, the relationships and availability of physician staff and the needs of the patients and the nursing staff.
Ultimately, it is the individual nurse who must be accountable to assess his or her ability, within the parameters of one's physical, mental and emotional state, to either accept or decline extra hours as a competent and safe care provider at the patient side.
AONE is opposed to legislation prohibiting the use of mandatory overtime at both the state and federal level with regard to the registered professional nurse. It is the view of AONE that the issue is best addressed within the institutional setting. Mandatory overtime is but one aspect of the nursing shortage and its usage should be monitored and tracked.
American Organization of Nurse Executives. 2000. Perspectives on the Nursing Shortage: A Blueprint for Action. Chicago, IL: AONE.
Institute of Medicine. 2003. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press.