[Article] Overtime: The Unintended Consequences

Overtime has become a necessary “evil” in healthcare staffing. Managers struggling to fill vacant positions or to cover unexpected absences or higher acuity will turn first to overtime shifts. Loyal team members and those looking to supplement their income will pick up the shifts.

However, overtime is not always welcomed by the staff and pressure from management to fill shifts has led to many states implementing mandatory overtime laws. The financial cost of overtime traditionally creates an over-budget state as leaders struggle to juggle the demands of patient care needs and cost.


In the 2018 Medscape RN/ LPN Compensation Report, 58% of nurses surveyed stated that they routinely worked overtime. Of these, 60%, worked 1 to 5 hours, 26% worked 6 to 10 hours and 15% worked greater than 10 hours per week. Overtime does solve the immediate staffing problem, but what are the non-financial implications and unintended consequences of this practice?

For the past three decades, researchers have documented the effects of nurse staffing on patient quality of care. The landmark research, published by Linda H. Aiken and colleagues, provided the baseline knowledge and background for numerous subsequent follow-up and validation studies. This research continues to add to the science of nurse staffing.

Most recently, Eunhee Cho and associates reported findings of a nurse perception study conducted in 65 hospitals in South Korea and published in the International Journal of Nursing Studies (2016). Over
one third of nurses who responded to this study reported that they routinely worked more than the scheduled twelve hour shift. Findings indicate that RN’s working overtime reported an 88% increase in failing or poor patient safety, a 45% increase in fair or poor quality of nursing care, and an 86% increase in care left undone as compared to those who did not work overtime.

Interestingly, a recent study published in the Journal of Nursing Administration (JONA) in May 2018 found that nurse-healthcare provider and nurse-physician collaboration suffered in nursing units with
longer overtime shifts and more nurses working overtime.

How does overtime affect the nurse or employee? A downstream effect of working overtime is chronic fatigue. Fatigue manifests as a state of impairment that reduces attention and reaction time, and leads to slower decision making and short term memory loss, which can then lead to error. Although the National Sleep Foundation recommends that adults sleep 7 to 9 hours per night, the effect of
working incidental overtime on the heels of a 12-hour shift will often result in an average of 5 to 6 hours of sleep between shifts. This loss of sleep can create significant sleep debt or chronic fatigue over time.

In addition to patient safety concerns, fatigue contributes to personal health risk for the individual and may lead to weight gain and obesity, type 2 diabetes, high blood pressure, digestive disorders and
heart disease.

A study published in the American Journal of Industrial Medicine in 2014 cited that working 61 to 70 hours per week increased the risk of coronary heart disease by 42% and working 71 to 80 hours led to a 63% increased risk. Other recent health-related studies found psychological distress in the form of depression, anxiety and not enough time to unwind to promote positive sleep patterns, higher
risk of stroke, and type 2 diabetes in women. Chronic levels of stress, coupled with a less-than-desirable work environment, promotes burnout, creating a vicious cycle of turnover and yet more opportunity for overtime.

The research continues. Each new study confirms the reality that overtime, as a first step, “go-to” scheduling solution has many side effects. Awareness of these unintended consequences and ongoing, strategic schedule management will minimize these outcomes.

RightSourcing Chief Clinical Officer, Terry McGoldrick has 40-plus years of experience in nursing, including over 30 years in nursing administration. Her tenure as CNO includes urban hospital, academic medical center, and for-profit national health system experience. Terry provides clinical consultation for staffing, scheduling, union contract compliance, IT implementations and budgeting projects.

For more information on how your healthcare system would benefit from RightSourcing’s expertise, request a free workforce analysis or contact us at 800-660-9544.