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In Montreal’s Maisonneuve Rosemont Hospital nursing shortage has led nurses to work 18 hour shifts (CBC news, 2010).  While there is no disputing the fact that health care services should never be stopped, there does need to be careful consideration of using methods such as - mandatory overtime, to ensure continuation of health care services When patients and their families entrust their care into the hands of a nurse, they trust that the nurse wants to be present there, and is prepared to handle the responsibilities. But at the same time research has shown that mandatory overtime leads to fatigue due to working long hours, increasing the likelihood of errors i.e. medication errors, jeopardizing patient safety. In 2008, the provincial health minister of Quebec, Yves Bolduc, commented on the issue of mandatory overtime by saying, “If it’s a choice between rupture of service (to patients) and mandatory overtime, I’ll choose not to have a rupture of service” (Canada.com, 2008).      Whatever the logic be, the scenario is that the nurses too exhausted to work are mandated to work hours. It certainly is an unethical and unfair practice, and takes away nurses’ autonomy, patient safety, and the quality of practice setting.

Description of Mandatory Overtime         

Mandatory Overtime means nurses are authoritatively ordered to work overtime hours or else be fired, be subjected to disciplinary proceedings, or lose their nursing licence if they refused (Rogers et al., 2004).  When institutions face problems such as - decreased government funding, nursing shortage, heavy workloads, and increased patient acuity levels, mandatory overtime is used to keep up the nursing services (Rogers et al, 2004). In 2005, registered nurses (RNs) worked an estimate of 349, 800 hours per week, which equalled to 10,054 full time hours (CNFU, 2009). 

Overtime hours are hours that are greater than the ones that are predetermined by contract or established in work scheduling practices and policies (Colorado Nurses Association, 2003).  As per the College of Nurses of Ontario (CNO) practice guideline on refusing assignment and discontinuing services, there are some collective agreements that include mandatory overtime clauses, so nurses need to be aware of their employment agreement, while also keeping their professional accountability to provide safe care in mind (CNO, 2009). 

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Issues surrounding Mandatory Overtime

Mandatory Overtime is definitely risky for the nurses, patients, and the institution as well.  It places the nurses at an increased risk of fatigue potentially leading to accidental errors.  An institution that relies on mandatory overtime as a fix for staff shortage needs to weigh the risk of having a fatigued nurse stay longer versus the risk of having increased workload on the nurses that are working a shift short staffed (College of Registered Nurses of Manitoba, 2004).

Effects of Mandatory Overtime on the Nurse

Nursing is a high stress job, and nurses are often exhausted at the end of their 8 hour or 12 hour shifts.  It is not safe for the nurses to be forced to work overtime, when they are exhausted from just having completed their regular shift.  It could not be safe for the patients to receive care from nurses who are fighting a battle with themselves to function properly.

Because of the mandatory overtime many of the older nurses may decide to take early retirement or leave the hospital or province in search for better working condition, which will only put more pressure on the remaining nurses to work extra hours.  

Effect of Mandatory Overtime on the patient

Mandatory Overtime may decrease the quality and safety of patient care, decrease patient satisfaction, and increase the length of hospital stay. If nurses are exhausted from working long hours, working in a poor, unsupportive environment, then they are less likely to be alert and make more case related errors (Rogers et al, 2004).  If the nurses are too worried about their problems, to concentrate on the patients, then that affects not the nurse-client therapeutic relationship, but also the emotional support the clients and their families may require.

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Effect of Mandatory Overtime on the Institution

Mandatory Overtime may have negative impact on the institutions.  Institutions may find it harder to keep experienced nurses, increased likelihood of absenteeism, low workplace morale, limited flexibility, and increased liability for patients and staff members, decreased patient safety, increased costs, and be endangering trust relationship with employees. Absenteeism due to fatigue may be more likely leading to increased costs required to cover the extra personnel. The more employees are pressured into mandatory overtime, the greater likelihood of older nurses being motivated to seek early retirement or seek employment in other institutions.  Mandatory overtime may also impact the nurse/employer relationship because institutions are being unethical by choosing mandatory overtime over hiring more staff to limit payroll expenses, and it gives the impression that they do not respect the nurses enough to support them. Overtime is shown to be a negative indicator to quality of workplace and reflects staff shortage and absenteeism (CNFU, 2009).  

Effect of Mandatory Overtime on the Health Care System

Mandatory Overtime is an issue that stems from underfunding and nursing shortage. However in an attempt to control costs, only more pressure is being put on the system due to increased risk patients and nurses are being placed at, increasing occupational health concerns, and increased legal liabilities from medical errors e.g. Medication errors.   It is the responsibility of the government to ensure that they create policies ensuring the safety of the people.  The people includes not only the patients, but also health care professional e.g. the nurses.  The continuum of mandatory overtime is a reflection of poor policies and it may be indicative of government not recognizing the importance of role nurses play in the health care system.

Values broken by Mandatory Overtime

When a nurse is mandated to work overtime, there is an impact on the values they hold that drives the reason as to why they do not appreciate the mandate.  These values are – Respect, Autonomy, and Accountability, and fairness.  Respect is broken when the employers pressure the nurses to working extra time especially by threat of dismissal or legal action.  It shows that the employers do not value the nurses enough to take measures to promote employee well-being, that they do not respect the fact that what the nurses may be feelings, the amount of stress they may be under from not only being given extra workload, but also dealing with the stress of adjusting their personal life to accommodate their job. Pressuring Nurses to work Mandatory Overtime also affects the principle of Autonomy too.  Mandating overtime is also imposing on the nurses’ autonomy leaving them feeling powerless as opposed to the nurses volunteering to work the extra overtime on their own will, giving them the control and choice over their work.   However regardless of whether they are exhausted in the end they are liable for their errors.  If nurses are aware that they do not have the capacity to provide such care then they may decline to engage in care, but being mandated to work takes away their option to consider their best interests because of the institutions paternalistic approach.

Ethical issues with Mandatory Overtime

According to the CNO practice standard of ethics, maintaining commitment does not only imply maintaining commitment to client, but also to oneself, to the nursing profession, and to quality practice settings (CNO).  Being mandated, also impacts nurses’ ability to maintain commitment to themselves because, even though they may recognize their physical and mental limitations, they are placed in a situation where they have to continue despite their feelings.  The nurses are maintaining their commitment to the nursing profession, the same level of commitment or consideration is not being reciprocated to support the nurses’swell-being, and this unbalance leads to the notion of fairness.  The health care institutions support for the policy of mandatory overtime speaks of the degree of fairness they allocated to the division of health care resources.  While it is true that the nurses prime responsibility is to the patient, putting the nurses’ in a situation that does not afford them any choice is not fair.

Professional Standards

Nurses are accountable for their actions, which is regardless of whether they have been mandated to work overtime or not.  Under the CNO practice standard for refusing assignments and discontinuing nursing services, nurses can refuse to work overtime for which they are not contracted, and they can refuse assignments that they believe will put themselves or their client to an unacceptable level of risk (CNO, 2009).  Mandating nurses to overtime does not allow them the full degree of control over the provision of safe, competent, and ethical care.

Nurses are regulated under the Nursing Act, which defines professional misconduct as an act or omission that breaks ethical and professional conduct of practice (Nursing Act, Fact Sheet).  However, once a nurse is mandated to work overtime, and the nurse accepts the overtime, even though they are aware they are not able to work in full capacity, they cannot abandon their client since doing so would be seen as an act of professional misconduct, they have to either arrange a replacement or wait until a replacement can be arranged for them (CNO, 2009).  Regardless of whether they have been mandated, nurses are responsible for taking action in situations where client care could be compromised,  putting their practice and their licence to practice on the line.

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Personal Position     

Mandatory Overtime lean brings to mind the notion of unethicality and unfairness.  For a Health Care institution that works to restore the physical and emotional health wellbeing of individuals, to support mandatory overtime and overlook the adverse impact it may have on nurses is hypocritical.  For an institution to support mandatory overtime instead of taking steps to avoid the practice by hiring more workers is not very respectful.  It is an employer’s responsibility to support their employees, to provide them with working conditions that will allow their employees to excel in their work, and allow for best patient care possible.  It is an employer’s responsibility to allocate health care resources appropriately. Nurses should have the option of refusing overtime work, because it is their licence and career that is at stake.

If there was to be an issue of mandatory overtime in the health care institution in personal workplace, it would be the responsibility of the nursing staff to let the nurse managers and the administrators know the impact such a policy is having on the nursing staff, the effects of a low-quality work setting, discuss with them the literature that shows that mandatory overtime increases the likelihood of errors  In Ontario, the nurses would have the backing of the CNO – which clearly states that nurses are not required to work overtime for the hours they are not contracted.  As long as a nurse is able to voluntarily accept overtime hours, being fully aware of their health status, then nurses can refuse the overtime with knowledge that they cannot be pressured into accepting overtime assignments.

Mandatory Overtime is a practice that is not only unethical and unfair but it also takes away from the nurses the autonomy to make their own decisions.  Nurses are highly accountable for their actions, and they should not be forced into situations which increases their risk in erring.  Literature shows that mandatory overtime, puts nurses at increased risk for fatigue as a result of the working long hours, and may cause them to make errors i.e. medication error, putting patient safety on the line.  Health Care Institutions need to overcome the need for a desperate policy such as mandatory overtime by hiring more nurses.  Only to compensate the cost factor the policy of mandatory overtime must not be encouraged. By recruiting the necessary staff both the patients and nurses can be saved from their misery.

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