salaries by working extra hours or shifts. The effects on patient care, however, are unknown.

The use of overtime, whether mandatory or voluntary, to cope with staffing shortages is quite common in hospital and nursing home settings. Interviews with staff members who worked at 17 nursing homes studied by Louwe and Kramer (2001) revealed that in 13 of the 17 facilities, at least one nursing staff member, and usually more, had worked between one and three double (16-hour) shifts during the previous 7 days. In 5 of the facilities, at least one staff member had worked four to seven double shifts in the last seven days. And in one facility, more than one-third of the nursing staff had worked between eight and eleven double shifts in the past 14 days. Although all direct-care nursing staff (RNs, licensed practical nurses [LPNs]/ licensed vocational nurses [LVNs] and nursing assistants) worked extra hours, the majority of double shifts were worked by nursing assistants.

Anecdotal evidence suggests that hospital nurses are also working large amounts of overtime because of short staffing. Nurses continue to report working over 13 hours with only a 20-minute break (Northcott, 1995), and working “four eight hour shifts in two days—32 hours during a 40-hour stretch, leaving the hospital only once for an eight-hour break” (CNA, 2001a). A recent poll conducted by the American Association of Critical Care Nurses (AACCN) indicated that the use of mandatory overtime is also quite common in the United States (AACCN, 2001). Only 40 percent of 2,125 respondents had never been required to work mandatory overtime. Approximately one-third (31 percent) reported working mandatory overtime at least once a month, another 22 percent at least once every 2 weeks, and 7 percent (n = 149) at least once a week. Another poll conducted by the American Nurses Association showed similar results: approximately 60 percent of respondents (n = 4,258) reported being forced to work voluntary overtime (ANA, 2001).

Decisions about mandatory overtime are usually made at the last minute, and nurses may receive less than 60 minutes’ notice that they will not be allowed to go home at the end of their scheduled shift (author’s unpublished data). No special accommodations are made for nurses working an extra shift; they are simply assigned a group of patients and expected to provide high-quality care with no additional breaks or a chance to take a short nap between shifts (author’s unpublished data). This practice is particularly dangerous when nurses are required to work extra hours at night. Under such conditions, the nurse may have been awake up to 24 hours, working 16 of those hours and often having only a 30- or 60-minute break.

The potential dangers posed by such overtime hours have been clearly documented. For example, the extensive use of overtime has been identified as a contributor to two separate outbreaks of Staphylococcus aureus (Arnow et al., 1982; Russell, et al., 1983). At the time, both hospitals were

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