, , , ,

I’ve spent the last two days observing a hearing in the Fair Work Commission – the ANF (Vic. branch) vs a hospital wanting to introduce changes without, ANF believes, following the process required in our Agreement.

The details of the case aren’t relevent for the purposes of this piece (though I found the experience useful and interesting). What was particularly illuminating, though, was the realisation that hospitals collect statistics on claimed overtime and missed meal breaks.

I knew we kept statistics on medication errors, falls, urinary tract infections, emergency calls and arrests, rates of hospital acquired pneumonia and deep vein thromboses (or clots), skin tears, pressure sores, intravenous access site infections, episodes of assault and aggression, and staff injures, among others. Many of these are requirements for funding, and many of these fall into the category of “nurse sensitive outcomes,” which I’ll write about tomorrow.

If I’d given it some thought I may have concluded that double shifts were tracked, though I must admit I’d never considered the idea. I certainly didn’t know that every time a staff member stays back to finish work, every time s/he is too busy to take a break, it’s logged and noted and collated and analysed.

Only it’s not.

Because nurses (and, I imagine, midwives) donate hundreds of hours to the public health system every week.

It’s not just an issue here – a 2012 snapshot study found 62.5% of surveyed nurses worked overtime, 10% for more than an hour, yet only one in thirteen was paid for it.

This type of overtime stems directly from the healthcare workers’ concern for patients. If they left immediately when their contracted hours finished, patient care could be put at risk. Employers are aware of this necessity as well. Refusing to pay overtime for such a commonplace and practical occurrence is placing the employee in a distinctly unfair position. If they stay they will work for free and if they leave they may be putting someone’s life at risk. [source]

And unpaid overtime’s not a new problem – in 1999, Victoria’s nurses contributed the effective full-time equivalent of 450 positions every week through their unpaid overtime and untaken meal breaks.

What I want to focus on is two reports a little more contemporary, and local. The informative report “Stable, but critical” – The working conditions of Victorian public sector nurses in 2003 found that almost 2/3 of nurses (62.9%) were regularly working overtime, including 41.7$ of respondents who indicated working overtime most weeks – yet only 15% of them were consistently paid or compensated with time in lieu , while just under 22% were never or rarely paid/compensated.

Why were the nurses working overtime, often knowing it would be unpaid? In 56.1% of cases it was to deliver or maintain a basic standard of patient care.

As the authors note “There appears to be a system-wide reliance on the high level of commitment (and a significant degree of good will) from the nursing labour force at the present time.” (p. 16)

In the 2003 study most nurses (over 2/3) took their breaks most of the time. By 2006 (“Undermining the ratios: nurses under pressure in Victoria in 2006“) that had changed: 33% of nurses rarely took a meal break and 40% never did – and only 14% of those who had no break, or an abbreviated break claimed for the time.

Additionally, the amount of overtime performed had increased to 67% of surveyed nurses and midwives, with unpaid overtime being more common than paid or compensated overtime – including 8% of those who worked ten hours or more. Once again, the most common reason for working extra hours was to ensure safe care was given to their patients.

What was most interesting to me about this survey is the response to the question why participants weren’t paid, and which I’ll address in full shortly. In 8% of cases overtime compensation was refused by the employer; 12% of respondents worked a shorter period of time than their employer compensated for (a fifteen or twenty-minute overtime threshold); for 19% the overtime hasn’t been pre-approved; and in 22% of cases the culture was that of unpaid overtime.

That culture is a killer. One of the wards at my hospital has an unspoken but highly enforced no-break culture – nurses may eat at the stations outside their patients rooms, on what passes for a quiet shift, but handing patients over to another nurse and going to the tea room (let alone leaving the floor) is frowned upon. On my old ward nurses took breaks overnight most of the time, but always took their pagers into the tea room, and would leave to answer buzzers – the one nurse who regularly handed over his patients was viewed as painful, selfish and not a team player.

Many employers have a policy, often cited but (in my first- and second-hand experience) rarely documented, that overtime compensation doesn’t kick in until a threshold has been reached – usually 15 or 20 minutes. Fifteen mintes isn’t very long in the scheme of things, and it’s a little petty to want to be paid overtime just because Mrs Brown was incontinent just as you were starting your notes, or Mr Green wanted pain relief when you were supposed to go to tea. Besides, goes the rationale, this time balances out with shifts where staff can leave a little early. And, once upon a time, that was the case, particularly on weekend AM shifts.

Not any more. Rare indeed is the day where any of the staff get out early, and the overwhelming majority of the time none of the staff get out on time. If every nurse on each shift works just 15 minutes of unpaid overtime each day, that’s an hour and a quarter each week for every effective full-time (EFT) position – and that’s 65 hours a year right there. Per nursing EFT.

On my current ward, with five nurses on each morning and afternoon shift, plus two overnight, that’s three hours a day – and that’s two eight-hour shifts and almost a six-hour shift right there. Multiple it across one hospital and you’re looking at hundreds of hours a month.

In 27% of cases overtime wasn’t approved, or pre-approved. Many wards have a requirement that nurses inform the nurse in charge in advance that they won’t be able to leave on time, usually at least two hours before the end of the shift. In theory this allows the nurse in charge to facilitate additional support (directly or through delegation) to allow the nurse’s work to be done in a timely manner. In practice this is often unworkable – a myriad of small events can escalate, and the later in the shift they occur the harder it is to catch up. Many are the shifts here I was sailing smoothly at seven, knee-deep by eight, and leaving after ten.

That said, asking nurses to project forward, flag a problem (or potential problem), and redistribute work is reasonable, provided there’s an understanding that the nature of the work means it won’t always be possible. When management’s reasonable this kind of approach allows for team work and reduces overtime – but I’ve known nurses who were refused overtime because it wasn’t pre-approved two hours before shift end, even though their patient had a cardiac arrest twenty minutes before the incoming shift arrived.

The 8% incidence of refused overtime is also interesting. No further detail is given in the report, but I can guess the reason in many cases: had your time management been better you could have completed your work within the shift. If the situation is one nurse (or sub-set of nurses) who consistently claim overtime every shift, regardless of workload or acuity, then I’d agree there may be a need for improved practice and time management. When it’s the case that most nurses, on most shifts, are staying back late then the problem may be systemic, not individual.

Of course, there’s no way to know if only some nurses are reporting missed breaks and overtime. If a few nurses and midwives claim for working through meal and tea breaks, if only some of us document the overtime many of us have come to expect as part of the job, then there’s no way for management to respond to a ward, department or even hospital-wide crisis.

Many of my colleagues have a belief, rarely articulated, that we owe it to the good of our patients, our colleagues, our manager, our ward, or our hospital, to make sacrifices. If that means missing a break here or there, staying back every other night, or working through lunch well, that’s the nature of our work. Most of the time the doctors don’t get any breaks, after all – we should be grateful we get anything, really.

It’s true that doctors, especially junior ones, work ridiculous hours and often miss breaks. And I fully support any action taken by my medical colleagues to remedy this – I’d love to see the AMA get behind its youngest and most vulnerable members.

That doesn’t negate the importance of our hours, though. We don’t have breaks because management likes us – we have them because those who went before us fought for them, because they’re a legal entitlement, because they allow us the opportunity to recuperate and return to work fresher, because they reduce the incidence of errors and injury, because they make us more resistant to burn out and illness, because they reduce fatigue and thus accidents driving home, and because all of this allows us to be better colleagues and to give better, more compassionate, more attentive care to our patients.

They’re also all pretty good reasons why overtime should be an exception, rather than the rule – and why there should be recognition and compensation if work demands mean everything can’t be done in the time allowed.

Today I learned that hospitals track overtime and missed or partial tea breaks – but only if they’re claimed for. Without that data even the most nurse-focused organisation can’t act. So next time you’re unable to take a break, are called back from a break, or need to stay back late, claim the time. It’s the best way to help your management help you. And if your hospital or centre uses electronic records that you can’t amend, take heart – it’s almost as quick and easy to email your manager as it is to make a note on a paper time sheet. If, for some reason, your overtime or missed break isn’t paid, or you’re refused time off in lieu, that record may come in handy when you discuss it with your Industrial Officer…