Longtime Sanford nurse says mandatory overtime may be putting employees, patients at risk

Nancy Buchl was tired when she left work at Sanford Hospital after being required to remain four hours past her 12-hour shift in the Family Birth Center.

So tired that she blames fatigue as the reason she ran a red light last fall on the drive home.

A fellow nurse, she said, wasn't so fortunate. After working a mandatory extended shift, that nurse was involved in an accident on her one-hour commute back home.

Buchl, who has worked at Sanford's (formerly MeritCare's) Family Birth Center for 10 years, said nurses throughout the hospital are commonly required to work extended shifts to provide patient coverage.

In fact, mandatory extended shifts are a problem that have occurred periodically in hospitals throughout the state over the years, according to Becky Graner, executive director of the North Dakota Nurses Association.

"There are other places in the state this is happening," Graner said, citing central North Dakota and the state's Oil Patch counties as recent examples. "Nurses are frustrated and tired."

She added, "North Dakota has no laws that prevent this from happening," although research has shown that patient care can suffer as a result. "It's just up to the judgment of the employers to keep it from happening."

Sanford Health's chief of nursing in Fargo said mandatory extra shifts are a last resort and supervisors strive to avoid them through incentives and scheduling options.

Studies have shown that nurses - as well as doctors and other professionals - are more prone to make mistakes when they become fatigued from working long shifts.

Although Buchl knows of no instances when patient care has suffered through errors or lapses by fatigued nurses, she believes the threat is real. That's why she decided to make her concerns public to The Forum.

"You shouldn't be forced to work," she said. "It's patient safety. Something bad is going to happen."

Subject to discipline

Mandatory extended shifts sometimes are necessary, although Sanford doesn't track their frequency, according to Carla Hansen, chief nursing executive at the Sanford Medical Center Fargo.

"It can be a problem if depended on for 'normal' staffing," although that is not the case, Hansen said.

Sanford has experienced increased patient volumes, including a 2.3 percent increase in hospital admissions in the past year, and expansion of programs that require more nurses.

"We need to continually be looking creatively at different strategies to assure our focus is on what is most important - the care of our patients," Hansen said.

When forced to extend their shifts, nurses face a dilemma, Buchl said.

Nurses can be subject to disciplinary charges of patient abandonment if they refuse to work an extra shift, which could mean the loss or suspension of their licenses.

"No one's ever refused to stay," Buchl said, adding that her nursing colleagues are dedicated. "They've stayed."

She added, "This is going on through the whole hospital. This is going on all the time."

Constance Kalanek, executive director of the North Dakota Board of Nursing, said she is unaware of any complaints involving patient safety from nurses having to work mandatory overtime.

"It hasn't been a problem that has been reported to us," she said. The board licenses nurses and has a mission of promoting patient safety.

Similarly, Kalanek said she could not recall an instance when a nurse was reported for patient abandonment.

Patient safety

Because of the risks to patient care and adverse effects on nurses' health, 16 states restrict the use of mandatory overtime for nurses, according to the American Nurses Association.

Minnesota law prohibits action against a nurse who refuses mandatory overtime because it would jeopardize patient safety. Minnesota also protects most nurses who work for the state from working more than 12 consecutive hours.

But the nursing staffs of many hospitals in Minnesota are represented by unions, Graner said. Many union contracts impose limits on mandatory overtime.

That isn't the case for nurses at private hospitals in North Dakota, which is a "right to work" state. Therefore, nurses do not have a unified voice through collective bargaining, she said.

Nurses who become frustrated by having to work too many mandatory extended shifts "put their voice in their feet," Graner said.

"That's when you see nurses leave and find another job," she added. "They have no other recourse."

Buchl believes turnover among the hospital nursing staff at Sanford Medical Center reflects nurses' growing frustration over mandatory extended shifts. In the Family Birth Center, which includes the neonatal unit, she estimates 10 to 15 nurses have left in the past year. Some, she added, took other nursing jobs at Sanford that do not involve possible mandatory extended shifts.

But Hansen said figures show nursing turnover at Sanford is down, although she did not provide a breakdown of turnover comparisons by department, such as the Family Birth Center.

Overall, the turnover rate among the nursing staff is running now at 10.3 percent and last year was almost 11.5 percent, she said.

"In previous years, it has been 12 to 14 percent or higher," Hansen added. "These are record lows for us."

To meet its increasing patient demands, Sanford continues to hire more nurses, she said. Last week, for instance, it had orientation for 22 new nurses, including replacements and those filling new positions.

"We are in a situation of rapid change," Hansen said. "We have to be creative and innovative, not only in our hiring but our scheduling to meet that demand."

Sanford nurses work normal shifts of eight or 12 hours, or combinations of eight- and 12-hour shifts, for a pay period of 72 hours over two weeks. If required to work overtime, they normally stay an extra four hours, with a break in between.

At Essentia Health, hospital nurses normally work three 12-hour shifts a week, or a total of 72 hours over two weeks. Nurses very rarely are asked to stay longer, said Ann Malberg, Essentia's vice president of inpatient services in Fargo. The need almost always is eliminated because nurses volunteer to step in, she said.

Research cited by the American Nurses Association has found that risks of making errors rise significantly when work shifts go longer than 12 hours, when nurses work overtime, or when they work more than 40 hours a week.

Ultimately, nursing staffs must cover the unpredictable needs of patients. Hospital admissions can fluctuate abruptly, as can the mix of case complexity, Hansen said.

"To me it is most important that we listen to the needs of our nurses as well as the needs of the patients," she said. "As leaders we have to be proactive in continuing to plan ahead."

But Buchl, who has 17 years of nursing experience, including her decade at Sanford, said the problem has persisted during her time there. She also encountered mandatory extended shifts at the former Dakota Heartland Hospital in Fargo.

"There's not an easy answer," Buchl said of nurse staffing challenges at hospitals. "It's a tough situation." But, she added, "There has to be a better solution than what they're doing."