Nurse Mandatory Overtime Harms Patients and Nurses Alike

By Jason Fisher posted 30 days ago

Nurse Mandatory Overtime Harms Patients and Nurses Alike

Jason J. Fisher, MSN(c), RN-BC

April 18, 2019

Mandatory nurse overtime has a strong association with adverse patient outcomes including healthcare-associated infections, falls, and pressure ulcers. Nurses are more likely to make errors and experience illness, injury, burnout, and job dissatisfaction. Patients are more likely to be dissatisfied, and healthcare organizations requiring mandatory overtime face the prospect of diminished revenue from value-based programs along with the increased cost and operational disruption of increased turnover. Perceived cost savings from onboarding and fringe benefits rather than a nursing shortage are the likely explanation for the persistence of mandatory overtime. While indeed staffing is complex, this should not be an excuse wielded by healthcare organizations for failing to protect patients and nurses.


  • According to Trinkoff, Le, Geiger-Brown, Lipscomb, and Lang (2006), many nursing positions require extended work schedules that include on-call activities, working while sick, and mandatory overtime. Mandatory nursing overtime is highly prevalent. Of the 60 percent of surveyed US nurses reporting working overtime, 18 percent reported mandatory overtime and 37 percent reported mandatory on-call shifts in addition to their scheduled work time (Wheatley, 2017). Nearly half worked more than 12 hours of overtime per week, and of these a shocking 97 percent reported this as either mandatory overtime or on-call requirements (Wheatley, 2017).

  • Meanwhile, nurses are already at a high risk for musculoskeletal disorders. A longitudinal study found that this risk increases with mandatory overtime (Trinkoff et al., 2006). The association of mandatory overtime and risk of injury is not unique to nursing, but rather the risk of injury increases as work hours increase in many other industry sectors as well (Trinkoff et al., 2006). Perhaps more specific to nursing though is the illness and needle-stick injuries that are also associated with overtime (Wheatley, 2017).

  • Not only are nurses negatively impacted by mandatory and other unhealthy scheduling requirements, but so are patients. Rogers, Hwang, Scott, Aiken and Dinges (2004) found that as nurse shifts exceed 12 hours, there are significant increases in the risk of making an error. The most common overtime-associated error are medication errors (Wheatley, 2017). There is also a relationship between overtime and patient falls, healthcare-associated infections, and pressure ulcers (Wheatley, 2017). Quick turnarounds in shifts were also related to increased hypoglycemic events and pneumonia deaths. Sloane, Smith, McHugh, and Aiken (2018) found not only that fewer adverse patient outcomes are associated with lower nurse-patient ratios and work environments that support effective nursing care, but also that the relationship is so strong that as hospital dynamics shift over time, so do patient outcomes.

  • Stimpfel, Sloane, and Aiken (2012) have also found that as the proportion of nurses working more than 13 hours increased, patients' dissatisfaction with care increased.

  • Nurses working shifts of ten hours or more were more than twice as likely to experience burnout, job dissatisfaction, and intention to leave their jobs, suggesting that nurses be able to refuse to work overtime without retribution (Stimpfel et al., 2012).

  • High-risk industries such as aviation, commercial vehicle transit, and public safety all have work hour regulations due to the negative effects of fatigue on performance (Wheatley, 2017). Overtime remains largely unregulated in healthcare at the federal and state levels, however this is changing as 18 states have passed legislation prohibiting mandatory overtime for nurses (Wheatley, 2017). Seven states passed legislation that permits the right of refusal of overtime without retaliation (Wheatley, 2017).

  • Mandatory overtime persists likely due to understaffing for the perceived cost savings attributed to onboarding and fringe benefits for the required additional nursing hires (Wheatley, 2017). The national nursing shortage has generally resolved with the addition of approximately 1 million registered nurses from 2000 to 2015 (Buerhause, Skinner, Auerbach, & Staiger, 2018). Some regional variation, likely in the Pacific and New England regions, is expected (Buerhause et al., 2018). This suggests that a nursing labor shortage is not a valid explanation or rationale for mandatory overtime in Ohio.

  • Indeed, nurse staffing is a complex challenge. Substantial evidence supports that variables including nursing experience, education, and staffing mix have strong relationships with patient outcomes. Staffing forecasts work well except for times of unexpected demand. However, with the high prevalence and persistence of mandatory overtime, complexity should not be an excuse for failing to protect patients and nurses.

Practice Implications

  • There is substantial evidence in the literature that supports the urgent implications of mandatory overtime for patient and nurse safety, diminished patient outcomes, reduced patient satisfaction, nursing burnout, and nursing turnover.

  • Mandatory overtime is a lose-lose-lose proposition for patients, nurses, and healthcare organizations when considering these factors and the cost of turnover.

  • Nurses’ commitment is to the patient first and nurses are ethically responsible and accountable for advocating, protecting, and promoting the rights, health, and safety of our patients (American Nurses Association [ANA], 2015).

  • Similarly, nurses have a corresponding ethical obligation to themselves and others (ANA, 2015).

  • Individually and collectively, nurses are ethically bound to improve the work setting and conditions of employment so that they are conducive to healthcare that is safe and of high quality (ANA, 2015). 

Advocacy Opportunities

  • Avenues for advocacy at the organizational level include working for policy change through a shared governance program, involvement in one’s union chapter, and working collaboratively with nursing and organizational leadership.

  • Within the local community, consider seeking mentorship from nurse leaders within healthcare organizations, academic institutions, and your ONA chapter as you grow as an advocate beyond the bedside.

  • At the state level, advocacy opportunities include supporting the Ohio Nurses Association legislative efforts, including the current Ohio House Bill 144 (2019) that would “prohibit a hospital from requiring a registered nurse or licensed practical nurse to work overtime as a condition of continued employment” (HB 144, 2019). State Representative Don Manning offered sponsor testimony on this legislation just over a week ago on April 10th.  Find your state representative at or state senator at and ask them to support HB144. Share your story and experience with mandatory overtime as well as the evidence of its impact on patients and nurses. Don’t forget to also visit, click on the Ohio Nurses’ Action Center, and join the ONA Advocacy Network.

Share Your Questions, Feedback, and Resources
Any questions or feedback that you may have are appreciated. If you know of any resources that would be helpful for our nurse colleagues in working to end mandatory nurse overtime, I encourage you to share them. Thank you!

About the Author
Jason J. Fisher, MSN(c), RN-BC is a graduate student at Kent State University in the nursing and healthcare management concentration graduating on May 10, 2019. With over a decade of both business and clinical experience, he is passionate about improving healthcare safety, quality, access, and clinician experience. Jason believes that strong nursing leadership will be a powerful force in shaping the future of healthcare. Residing in District 10 in Dayton, he tweets primarily about health policy, practice, and tech topics at @jasonjfisher.


American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MA: American Nurses Association.

Buerhaus, P.I., Skinner, L.E., Auerbach, D.I., & Staiger, D.O. Four challenges facing the nursing workforce in the United States. Journal of Nursing Regulation, 8(2), 40-46. doi:10.1016/S2155-8256(17)30097-2

Rogers, A.E., Hwang, W.T., Scott, L.D., Aiken, L.H., & Dinges, D.F. (2004). The working hours of hospital staff nurses and patient safety. Health Affairs, 23(4), 202-212. doi:10.1377/hlthaff.23.4.202

Ohio 133rd General Assembly. (2019). House Bill 144. Retrieved from:

Sloane, D.M., Smith, H.L., McHugh, M.D., & Aiken, L.H. (2018). Effect of changes in hospital nursing resources on improvements in patient safety and quality of care: A panel study. Medical Care, 56(12), 1001-1008. doi:10.1097/MLR.0000000000001002

Stimpfel, A.W., Sloane, D.M., & Aiken, L.H. (2012). The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Affairs, 31(11), 2501-2509. doi:10.1377/hlthaff.2011.1377

Trinkoff, A.M., Le, R. Geiger-Brown, J., Lipscomb, J., & Lang, G. (2006). Longitudinal relationship of work hours, mandatory overtime, and on-call to musculoskeletal problems in nurses. American Journal of Industrial Medicine, 49, 964-971. doi:10.1002/ajim.20330

Wheatley, C. (2017). Nursing overtime: Should it be regulated? Nursing Economic$, 45(4), 213-217.