International Journal of Emergency Mental Health and Human Resilience
Open Access

With increased technology and development in the field of medicine, people are living significantly longer than ever before in human history. With increased age, comes increased disease factors which also places a higher demand on the need for healthcare workers at an exponential rate. The need for registered nurses and Licensed Practical Nurses (LPNs) is expected to grow by 15% and 12% respectively from 2016 to 2026; however, it is estimated that 33% of new nurses are leaving the nursing career field within the first two years of employment . Unfortunately, the incredibly high turnover rates for the career field make the rapid increase of licensed nurses inconsequential in the struggle to keep up with demands (Cho E, 2016).

We must analyze the problem to find a solution. One of the key factors for the exodus from nursing is burnout due to poor working environments to include a lack of break time, being short-staffed, and not having the proper equipment to do the necessary tasks. Nursing is physically and emotionally exhausting and due to the many shortages around the world, nurses are required to work a significant amount of overtime without the underlying issues of understaffing being addressed. Over time, nurses experience a “progressive psychological response to chronic work stress” called burnout. Burnout is characterized by emotional exhaustion, depersonalization (also called compassion fatigue), and a decline in the perceived ability to perform well. Without addressing this phenomenon, the deficit of nursing professionals will continue to rise (DSa V, 2018).

EVIDENCE SUMMARY: According to Bae, 60% of U.S. nurses work overtime which has been linked to an increase in errors, fatigue, injuries, and adverse patient outcomes. There is also a relationship between overtime and sick time used by nurses an increase of 3.3 hours used for every 10 hours of overtime worked) which creates a vicious cycle of needing to replace the sick nurse with another nurse who is likely now on overtime as well. Nurses who work overtime regularly experience higher injury rates, decreased immune function, hypertension, insomnia, and even increased mortality rates. According to the study by Wu et al., each hour of overtime worked raised the prevalence of nursereported injuries by 20-30% on average. One study also links increased burnout to the worker’s perception of working overtime. If the nurse feels the overtime is required due to a lack of resources and autonomy, the nurse is more likely to experience burnout. In several studies, the perception of the nurses surveyed indicated a severe dissatisfaction with the work environment. Wu et al. state that staffing and resources were scored lowest amongst surveyed nurses as the least satisfactory aspect of their work environment observed that over 65% of respondents rated the quality of care as poor.

Not only are nurses adversely affected, but patient care is affected as well. Working overtime has been linked to an increase in patient falls, pressure ulcers, rescue failures, unplanned estuations, and urinary tract infections. Medication errors are the most frequently reported consequence of nursing fatigue. Multiple studies have linked as little as 4 hours of overtime regardless of the length of shift with a higher incidence of wrong-dose medication errors (Rabenu E, 2017).

EVIDENCE-BASED PRACTICE RECOMMENDATION: While the needs of patients are at the forefront of the healthcare worker’s priorities, studies have found a strong correlation between working more than eight-hour days with being harmful and working more than a 12-hour limit to be exceedingly dangerous. It is therefore recommended that staffing allows nurses to leave immediately when the 12-hour shift has been completed regardless of what work was not accomplished. The nurse must also have enough recovery time between shifts for sleep. “A greater occurrence of inadequate sleep was found for nurses working 9-11 hours per day versus 8 or fewer”. On a weekly basis, working over 80 hours per week is highly discouraged due to a higher prevalence of burnout according to Martine recommend working not more than 60 hours per week and suggest that the institution should take on accountability for hours nurses are working . The recommendation for any facility is to adopt a schedule with a maximum of 48 hours per week and no mandatory overtime.

KEY STAKEHOLDERS: Identifying key stakeholders is extremely important for implementing change. It allows the discussion of proposed changes and decreases misunderstandings at an early stage in the implementation process. Reducing overtime hours worked by individual staff nurses would have a huge effect on any organization. Of course, this would directly affect the nurses who are required to reduce their work hours which will either be perceived as a positive effect or a negative effect depending on the nurse’s reasons for working overtime. Nurses would need to embrace the change, recognizing the need for a true work and life balance. A team of administrators such as the Chief Financial Officer and Human Resources Officer would need to evaluate and help implement this change because the result of reducing the hours indicates a need for more employees. The financial officer would need to evaluate the cost of hiring new employees and there may need to increase salaries for nurses who depend on the overtime. Managers would also be key stakeholders because they would need to oversee the amount of overtime worked by nursing staff and would be responsible for hiring nurses to fill in the gaps in staffing that were previously filled by nurses working overtime (Wu Y, 2018).

POTENTIAL BARRIERS: Several barriers can affect the implementation of this change. The facility may not want to hire more full-time or part-time nurses to cover shortages due to the increased cost. Some nurses may need the additional income that overtime provides and would therefore likely find work elsewhere if they were required to reduce their hours. It may be possible to retain some of these nurses with an increase in salary. Emergent situations and procedures do not consider shift change times and can cause some nurses to work more than their 12-hour shift. Another potential barrier is the lack of nurses available to hire. Many organizations are teaming up with nursing schools in order to give incentives for new nurses to work in their facilities which could combat the lack of nurses available to hire for this facility.

PRACTICE CHANGE MODEL: The best way to implement change is to have a detailed plan in place. By using proven change models such as Kotter and Cohen’s Model of Change, a plan is more easily brought to fruition. Kotter and Cohen have defined eight steps for successful change. The first step is to create a sense of urgency for the change. Then, a team is selected to implement the change and they create a vision and strategy that they communicate to employees. The next step requires the removal of barriers to empower individuals to change their behaviors. The last three steps monitor and drive the success of the change. Step six requires individuals to see short-term wins to create motivation to continue the change and then the change must be driven forward constantly to make the vision a reality. Next, to create long-term change, the change must be nourished. The change must become the new normal and the expectation.

The facility and the individual staff members must agree that excessive overtime makes nurses sick, causes medications errors, causes injuries, and over time creates burnout. By acknowledging this problem, the sense of urgency to change is created. The team to implement the change should consist of the key stakeholders - a financial officer, nurse managers, nursing staff representatives and human resources representatives. This team will create a vision to implement a safer environment for nurses and patients while also encouraging a better work-life balance for staff. It will be up to this team to also identify and remove the barriers to the change. Because it takes time to recruit, hire and train new employees, the team may implement a plan to bring in per diem nurses to fill in the staffing shortages in order to see short term wins. Once hired and trained, the improved working environment should encourage nurses to stay working at the facility long-term.

ETHICAL CONSIDERATIONS: When implementing any change to nursing practice, it is important to evaluate the ethical aspects of the change. The American Nurses Association outlines nine provisions in its code of ethics which are the standard for ethics in nursing. These standards include the responsibility of the nurse to promote, advocate for, protect the rights, health, and safety of the patient . Provision four of the code of ethics describes the nurse’s accountability and responsibility for nursing practice. It states that nurses are always accountable for their actions, but that the institution may be equally responsible in some circumstances. Administrative nurses also share responsibility for the care of the patients provided by whom they supervise. By acknowledging the detrimental effects of excessive overtime on patient safety as stated in the various studies and creating the change required to reduce the possibility of errors, the individual nurse, nurse manager, and facility are being ethically responsible according to the code of ethics.

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