Hospitals that rely on nurses working overtime have an increased risk of patients developing pressure ulcers, according to a study published this month by researchers at the Milken Institute School of Public Health.
The study, led by Patricia Pittman, a professor of health policy and management, found a positive correlation between hospitals’ reliance on nurses working overtime and the rate of the hospital’s patients experiencing pressure ulcers, a soft-tissue injury caused by prolonged pressure. Pittman said the study’s identification of a high pressure ulcer rate, which is often caused by caretaker negligence — like failing to turn patients in bedrest to alleviate pressure — indicates that hospitals must rethink their current approach to overtime for nurses.
“So the question was, where is that cut-off point?” Pittman said. “At what point should we start being worried about excessive use of overtime and excessive use of agency nurses, if at all?”
Researchers examined daily reports on hospital operations and data from biweekly payroll-based reports from 70 hospitals participating in the study between January 2019 and December 2022. For every 10 percent increase in overtime worked by registered or licensed practical nurses in hospitals, there was a corresponding 0.73 percent increase in the risk of patients developing pressure ulcers, according to the study.
The COVID-19 pandemic led to a significant increase in nurses working overtime due to the widespread shortage of medical personnel and influx of patients. Short term and localized nursing shortages — like those during the 2017-18 influenza epidemic — have given rise to higher overtime rates in the past, but Pittman said the COVID-19 pandemic and resulting persistent nursing shortage led to hospitals having a “structural dependence” on overtime.
“There was a shortage of nurses during COVID or at least of nurses willing to work during COVID,” Pittman said. “And so the reliance, particularly on agency nurses but also on overtime really skyrocketed.”
Annually, there are 2.5 million cases of pressure ulcers, causing 60,000 deaths per year in the United States, according to the International Wound Journal. Pressure ulcers, which disproportionately affect elderly or physically limited patients, often occur when caretakers fail to take adequate precautions against restricted blood flow, like repositioning functionally impaired patients to alleviate pressure on the body.
Pittman said financial considerations have also contributed to increased overtime rates because nurses are considered a part of hospitals’ operational costs, rather than revenue-generating professionals, like doctors and surgeons. Unlike physicians, whose procedures and services are directly billable, nurses’ labor is bundled into costs, like room and board. She said because of this, hospitals are financially encouraged to not hire sufficient nursing staff.
“They’re literally included in the room and board section of the billing, and so they don’t lose any revenue offensively by reducing or keeping to the minimum the nurse staff,” Pittman said.
Pittman said to reduce the risk posed by enforcing overtime on nurses, hospitals should create work schedules and make hiring decisions based on their assessment of nurses’ health and well-being rather than relying on “financial algorithms” to decide.
“When hospitals themselves and health systems are thinking about sort of the decision, you know how much to inform their decisions, about how much to rely on agency nurses and overtime, it’s really important for them to do their own analysis disaggregating these types of nurses,” Pittman said.
Amy Witkoski, an assistant professor at New York University’s Rory Meyers College of Nursing, said extending overtime hours on nurses may lead to diminished performance because of increased risk to mental health, like burnout, which contributes to a lower quality of care and heightens patient risk.
“Overtime hours, on top of nurses’ typical 12-hour shifts, can add to myriad deleterious outcomes to their health and well-being as well as patient care,” Witkoski said in an email.
Hospitals should address these risks by hiring more nurses to limit overtime and ensure longer breaks between shifts, Witkoski said. She said adopting more flexible work schedules — like more shift rotations for nurses — would help sustain nurses’ health and performance.
“Reducing overtime hours, limiting quick returns, frequent changes in shift rotation and following good sleep hygiene can help nurses to limit some risk for poor outcomes,” Witkoski said.
