Statement of the New York State Nurses Association, submitted to the New York State Assembly Committee on Health and Committee on Labor, May 18, 2006, New York, NY.
Good afternoon Assemblywoman John, Assemblyman Gottfried and Members of the Assembly Labor and Health Committees. My name is Windelina Tirona. I am a registered nurse and I work in the intensive care unit at Cabrini Medical Center in Manhattan. I have been a member of the New York State Nurses Association for nearly 20 years. Joining me today is Shaun Flynn, Associate Director for Governmental Affairs of the New York State Nurses Association. NYSNA is the largest professional association and union for registered nurses in New York State. It represents the interests of 34,000 RN members and the patients we serve in a wide range of settings including hospitals, nursing homes, home care, schools and public health.
Registered nurses are the most numerous healthcare providers in New York State. We are professionals, licensed by the state, who must renew our registration every three years. According to the State Education Department and the Nursing Code of Ethics, RNs are individually responsible and professionally accountable for the nursing care we provide to our patients.
When nurses are forced to work beyond our regularly scheduled shifts, to the point of physical and mental exhaustion, we are no longer able to provide competent care. We are caught in a dilemma. If we stay on the unit, we are violating our ethical code, putting patients at risk, and putting ourselves at risk for legal action if an untoward event occurs. If we refuse to work overtime, our employers can charge us with patient abandonment.
Although the State Education Department has issued a memo stating that it is inappropriate for nurses to be coerced into working extra hours with threats of patient abandonment charges, it continues to happen and many nurses continue to feel threatened.
Mandatory overtime is a relatively frequent event. Nearly half of the New York RNs surveyed by the SED in 2002 said that they always or sometimes worked mandatory OT. A study published in 2004 by Health Affairs described work schedules of hospital staff nurses as unpredictably prolonged; noting that, on average, registered nurses work an extra hour per day. Almost one sixth of the nurses involved in that study said they had worked 16 or more consecutive hours within the past month. This is supported by a study published last month by the American Journal of Nursing, which found that more than a quarter of registered nurses regularly work more than 12 hours a day and a third regularly work more than 40 hours a week.
The trend is so prevalent that NYSNA has developed a form that nurses can use to document a “protest of assignment” or POA. POAs notify supervisory staff that nurses have accepted assignments under protest based on professional judgment that the assignments are unsafe and place patients at risk.
What is the effect on patients? Mandatory overtime leads to nurse fatigue, which can triple the rates of errors and near-errors, more than half involving medication administration, according to the Health Affairs study. In at least two documented cases, nurse fatigue and stress due to overtime and high patient caseloads contributed to hospital-wide staph infections among patients.
Mandatory overtime is not employed only in unexpected emergencies. According to hospitals surveyed by the Greater New York Hospital Association, 95% of respondents reported using overtime as a supplemental nurse staffing strategy.
Overtime is frequently used as a solution to foreseeable staff shortages due to scheduled breaks and vacations, in addition to unplanned events such as sick calls. Overtime may be mandated explicitly or implicitly. Nurses are told they may only leave work once they have determined among them who will “volunteer” for extra hours. That’s probably why over 60% of RNs who responded to a survey by the American Nurses Association reported being “forced to work voluntary overtime.”
What is the effect of mandatory OT on nurses? Research has shown that employees who routinely work overtime run a much higher risk of injury and illness. They also are less satisfied with their jobs. The SED survey found that two thirds of New York nurses who were looking for another job had been forced to work overtime.
This indicates that mandatory overtime can be both a cause and an effect of the nursing shortage. Facilities that try to compensate for staffing shortages by mandating overtime are actually exacerbating shortages by driving nurses away from the bedside. When nurses leave the profession, they say they are tired of being forced to choose between their patients and their families. Many opt for early retirement because they are physically, emotionally, and psychologically worn out.
For the sake of nurses, our patients, and the future of healthcare facilities themselves, the state must take action to ensure adequate staffing without reliance on mandatory overtime. The state legislature of New Jersey successfully implemented a mandatory overtime ban in 2002. A mandatory overtime ban before the Massachusetts legislature is supported by the Massachusetts Hospital Association.
On behalf of the New York State Nurses Association and all RNs in New York State, I urge you to pass A.1199, which would make it illegal for employers to mandate overtime for nurses, except in specific emergency situations. This measure would not prevent nurses from exercising our professional judgment to volunteer for overtime. NYSNA believes this legislation could be implemented immediately, as some hospitals in New York State are already adhering to the terms of collective bargaining agreements that prohibit mandatory overtime.
Banning mandatory overtime is an important first step. But the overall level of nurse staffing is also an important issue that must be resolved in order to promote safe patient care. Research has demonstrated a direct relationship between low nurse staffing and adverse patient outcomes. Where nurse staffing rates are lower, there are higher rates of patients with urinary tract infections, upper gastrointestinal bleeding, cardiac arrest, and shock.
It’s a chilling statistic that patients are 7% more likely to die within 30 days of hospitalization when patient-to-RN ratios are 8 to 1 rather than 4 to 1. It’s even more horrifying when you see it happen.
Insufficient staffing actually results in higher costs to healthcare facilities due to staff turnover, workers’ compensation claims, and increased patient care costs related to treatment of complications and extended stays.
NYSNA urges the Assembly to pass legislation that would establish staffing ratios in healthcare facilities. NYSNA is collaborating with other healthcare unions to propose language that incorporates optimal nurse-to-patient ratios and related protections, such as specified in current Assembly bills A.4094, A.3263, A.5495, and A.7768. In light of the failure of New York State’s healthcare industry to maintain safe staffing levels, it is the moral obligation of the New York State government to enact ratios to improve patient safety.
In conclusion, NYSNA urges the New York State Assembly to enact legislation that bans mandatory overtime for nurses. When nurses can exercise our professional judgment to accept or decline work beyond our regularly schedule hours, we are more likely to provide safe patient care and remain in the nursing profession. NYSNA also urges the New York State Assembly to enact legislation that establishes safe staffing ratios. Adequate nurse staffing improves patient outcomes and promotes workplace conditions that are safer and more satisfying, thus reducing the impetus for nurses to leave the profession. Please take action now to address patient safety and the nursing shortage in New York State. Thank you for the opportunity to address this important issue.
Aiken, L.H., Clarke, S.P., Sloane, D.M. et al. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288(16), 1987-93.
Dembe, A.E., Erickson, J.B., Delbos, R.G., Banks, S.M. (2005). The impact of overtime and long work hours on occupational injuries and illnesses: New evidence from the United States. Occupational and Environmental Medicine, 62, 588-597.
New York State Education Department. (2003). 2002 survey of New York State registered nurses. Albany, NY: Author.
Rogers, A., Hwang, W., Scott, L., Aiken, L., Dinges, D. (2004). The working hours of hospital staff nurses and patient safety. Health Affairs, 23(4), 202-212.
Trinkoff, A., Geiger-Brown, J., Brady, B., Lipscomb, J., Muntaner, C., (2006). How long and how much are nurses now working? American Journal of Nursing, 106(4), 60-71.
For more information, contact Governmental Affairs at 518.782.9400, ext. 283 or by e-mail.