Overtime and On-the-Job Injuries

Sometimes it seems a nurse’s job is never-ending. Some of that has to do with overtime, be it voluntary or mandatory. Nurses may relish the extra income those hours bring in, but could they do themselves a disservice when they work more than a certain number of hours in a given pay period? Some studies have shown injury rates and hours worked are connected, making it imperative for hospitals to reassess their staffing practices.

Karlene Kerfoot, PhD, chief clinical integration officer, API Healthcare, admitted, “Overtime is a difficult issue for hospitals to solve.” At times, hospitals are not thoughtful with scheduling and don’t rely on past trends to proactively determine the adequate number of staff. They then rely on overtime to fill those slots. She explained, “Nationally many systems are striving to hold overtime scheduling to 2-4 % of the total staffing hours worked.” At many institutions, that is not the case.

Even though, as Matthew F. Powers, MS, BSN, RN, MICP, CEN, president, Emergency Nurses Association, said, “Hospitals are 24 hours” and nurses can theoretically work whenever they want, some states have begun restricting mandatory overtime. 17 states have laws detailing nurses can’t be required to work more than 12 hours in a 24-hour period. 1

Preventable Injuries

That could be a step in the right direction, as a correlation has been shown between shift length and nurse injury rate. Sung-Heui Bae, PhD, MPH, RN, assistant professor, The University of Texas at Austin, School of Nursing, who studied adverse nursing effects, found working more than eight hours per shift increased the chances of a nurse suffering a needle stick, sprain or other health complaint on the job. 2

Yet it is not simply mandatory overtime that leads to adverse nurse incidences. Bae said, “In terms of a relationship between nurse work hours and nurse outcomes, there is a strong one.” She added, “Nurses who work 12 hour shifts had more needle stick injuries then nurses who work eight hour shifts.” A Joint commission study found that nurses who work longer than 12 hours at a stretch were three times as likely to involve themselves in preventable adverse events. 1

And it’s not just shift length that has an impact on nurses hurting themselves on the job. According to Bae and her colleagues’ research, nurses have an increased risk of both needle stick and muscular skeletal injuries when they work over 40 hours in a week.

Impaired Judgment

Indeed, many nurse injuries are connected to fatigue. “Nurses must understand how working long hours can be hurtful,” Bae explained. Kerfoot noted, “If you’re working more. You’re trying to get the work done, but fatigue causes you to lose focus, which puts you at greater risk for injury.” Some of those awareness efforts need to come from a nurse’s colleagues. Powers encourages nurses to speak up when they notice someone is tired, especially in the crowded, fast-paced emergency department.

Adequate rest is crucial for nurses working in all settings. Bae explained, “When nurses work long hours, they have a short time period to rest.” Less rest means impaired reaction time. When nurses don’t have enough time in between shifts to recover and overcome fatigue, they are less alert. Bae noted that fatigue can affect vigilance, and reaction time, sometimes leading to a higher risk of needle stick injuries.

Culture of Overtime

A hospital’s culture is a large factor in the prevalence of overtime, explained Powers. “The hospital needs to encourage nurses to make decisions on what is safe for them,” he said. He agrees with Kerfoot, that a lot of overtime is caused by inefficient staffing, especially in the emergency department where the number of patients can increase dramatically in a short time span.

Powers said, “It needs to be a collaborative effort of the working emergency nurse, nurse manager and administration” to communicate best needs of nurses and appropriate staffing levels. As Kerfoot put it, “If you’re always surprised every day, the chaos is not good for healthcare. It is critical that you use smart scheduling to maintain order.”

What is good for healthcare-both for nurses and their employees-is safer staffing practices. “There is a lot of financial risk for paying for injuries and the loss of productivity when nurses are not on the floor working,” said Powers. To lower the need for overtime, the hospital needs to have support from all levels of the organization.

Safer Work Environments

Although more research is needed on work hours and injury rates, the preliminary findings show that by working either more than 12 hours at a stretch and/or more than 40 hours in a week can negatively impact nurses’ well-being. Bae wrote, “Hospital leaders need to be aware of such empirical evidence and develop overtime guidelines and restrictions at the individual health care organizational level to promote a healthy and safe workplace environment”. 3

Decreasing work hours can then, theoretically, lower injury rates, making for happier, more productive nurses.


1. Emergency Nurses Association. “Nurse Fatigue.” August 2013. Online. http://www.ena.org/practice-research/research/Documents/NurseFatigueWhitePaper2013.pdf Accessibility verified 4/8/15.

2. Bae, Sung-Heui. “Presence of Nurse Mandatory Overtime Regulations and Nurse and Patient Outcomes.” NURSING ECONOMIC$. March-April 2013. p. 59-69. https://www.nursingeconomics.net/ce/2015/article31025989.pdf. Accessibility verified 4/8/15.

3. Bae, Sung-Heui and Fabry, Donna. “Assessing the relationships between nurse work hours/ overtime and nurse and patient outcomes: Systematic literature review. Nursing Outlook, 62(2),138-156. http://dx.doi.org/10.1016/j.outlook.2013.10.009. Accessibility verified 4/8/15.

Danielle Bullen is on staff at ADVANCE. Contact: [email protected]

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