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Most nurses work beyond their hours, often unpaid, but relying on their goodwill to cover staff shortages is damaging for retention, well-being and care quality
Nurses working longer than their set hours is not a problem for a minority – it is the norm.
Nursing Standard. 37, 7, 19-21. doi: 10.7748/ns.37.7.19.s12
Published: 06 July 2022
According to the RCN’s 2021 employment survey, three quarters of nurses (74%) regularly work beyond their hours once a week; for almost one in five (17%) it is every shift.
More than one in ten (12%) work between seven and ten hours extra a week, and the same amount (12%) work more than ten hours extra every week, it found. The majority of this work is unpaid, highlighting the reliance on the commitment and goodwill of staff to cover nursing shortages, the RCN says.
The impact of overworking on staff was debated at RCN congress in Glasgow in June. Nurses at the event told of their experiences of overworking, not taking lunch breaks and never finishing a shift on time. Delegates backed a resolution calling on RCN council to investigate the impact on the health and well-being of nursing staff of working beyond their contracted hours.
The additional pressure of overworking has a worrying effect on individual nurses, the RCN employment survey suggests. Only four out of ten said they feel they have a good work-life balance.
While just over half (53%) told the RCN that the extra work they did was unpaid, 21% said they receive time off in lieu. Yet some of those entitled to time off in lieu said they had no time to actually take it, as that would only exacerbate work pressures.
Rates of overwork are highest in the community, where 45% work over their hours several times a week, and 21% every day, the survey found.
London South Bank University chair of healthcare and workforce modelling Alison Leary says: ‘Every available study and evaluation says nurses are doing unpaid overtime.
For the average clinical nurse specialist, it is 6.5 hours extra a week, for a district nurse it is an average of ten hours.’
One matron at an NHS hospital in Scotland told the RCN survey: ‘I cannot remember the last time I worked less than 50 hours a week, in charge of 300-plus staff during the worst staffing crisis I’ve ever known. You cannot work 37.5 hours and support staff properly. Absolutely no work-life balance and strain on personal life too. Definitely not worth the salary.’
Major staff shortages – put at 40,000 nurses in England alone – are exacerbating this difficult problem.
According to the UK Working Time Regulations (1998), most workers should not work more than 48 hours a week. There should be 11 hours rest between shifts and breaks are mandatory.
Everyone is also entitled to an uninterrupted rest period of at least 24 hours in each seven-day reference period.
The regulations stipulate:
» All staff are entitled to take a break of at least 20 minutes when the working day is longer than six hours.
» Rest breaks should be taken during the period of work, not at the start or the end of a shift.
» Employees should be able to take rest breaks away from their workstation.
Healthcare professionals need to be vigilant about the impact of fatigue on their professional practice. The RCN says long hours, fatigue and lack of rest breaks or time to recuperate between shifts are associated with an increased risk of errors. Nurses should consider their obligations under the Nursing and Midwifery Council code.
Inability to take scheduled breaks, insufficient rest periods between shifts and pressure to do excessive overtime, are legitimate issues on which to raise professional concerns.
The RCN’s Raising Concerns toolkit can help. If concerns are not addressed by the manager, the RCN recommends members contact the union.
Adapted from: Working time and breaks (RCN) tinyurl.com/work-and-breaks
Professor Leary says one study she was involved in found that when a team was given 20 hours of administrative support, the nurses were able to start working proactively with patients, leading to a drop in patient bed days.
But working for free has now just become part of nursing and nurses can be ‘gaslit’ into thinking this is normal, she says.
‘Unpaid overtime has been normalised,’ she says. ‘There can also be an element of emotional blackmail, a sense of “if you don’t do it, then who will?” And someone who does leave on time is seen as a bit of a slacker.
‘The culture of healthcare is to put the issue on the front-line worker rather than the system. We have a system that is inadequately resourced, and the front-line health worker not only has to bear the physical burden but also the cognitive and emotional burden of the labour, and that is just normalised. It is very unhealthy.’
Research suggests that overworking and overtime has an effect on a person’s mental and physical health.
A global review by the World Health Organization and the International Labour Organization published in 2021 found that three quarters of a million people in the general population are dying from ischaemic heart disease and stroke due to working long hours of more than 55 a week.
A US review in 2004, looking at 52 papers, found overtime was associated with poorer perceived general health, increased injury rates, more illnesses and increased mortality.
It was also associated in some studies with unhealthy weight gain, increased alcohol use and smoking, according to the report from the US Department of Health and Human Sciences.
74% of nurses regularly work beyond their set hours once a week
Source: RCN Employment Survey 2021 tinyurl.com/employment-survey-RCN
1 in 5 nurses work beyond their set hours every shift
Source: RCN Employment Survey 2021
11 hours is the minimum rest required by law between when a night shift ends and the next shift starts
A study in Ontario, Canada, found that for every ten hours of nursing overtime in critical care units, there was a 3.3-hour increase in sick leave among staff for those taking part in the study.
Researchers in a 2018 study said: ‘Because of the potential cost and patient care ramifications, hospitals and nurse managers are encouraged to track collective and individual paid and unpaid hours to impose appropriate limits and ensure accountability.’
Long shifts are already a divisive issue in nursing, with research suggesting negative effects for both patients and staff, despite their popularity with some nurses.
Peter Griffiths, chair of health services research at the University of Southampton, says research suggests that fatigue increases as someone works longer, leading to higher levels of burnout, sickness absence and lower quality of care.
But the outcomes appear to be even worse for someone who ends up working a long shift by doing overtime, compared with someone who knew they would be doing that many hours.
One study looking at nurses working overtime in 12 European countries found it was linked to poor or failing patient safety, lower quality of care and more care left undone.
Professor Griffiths says: ‘There are a number of studies that show that working overtime on a given shift is independently linked to worse outcomes.
‘This has not been so well studied but it seems likely that at least some of this is the pressure of work that is associated with the need to do those extended hours and the lack of control.’
Managers need to be aware of how much overtime their staff are doing and consider it a red flag issue if it is high, he says.
‘While a flexible workforce that is able and willing to go the extra mile on occasion is important and should be valued, if you are calling on them to go that extra mile all the time you are exploiting your workforce, reducing resilience and ultimately exploiting unpaid labour to meet routine demands,’ says Professor Griffiths.
‘It seems obvious that the time should be paid but also routine use of overtime, paid or unpaid, should serve as a red flag that something is wrong.’
Jane Roberts, a staff community nurse in a district nursing team in the north west of England, says she and her colleagues work extra hours every week as it is impossible to fit the job into their contracted time.
Ms Roberts is contracted to work 22.5 hours spread over three days, but says she works about six hours extra every week. Completing paperwork from visits, which there is no time for during the day, has to be done in the evening and she works two to three evenings to catch up.
While she and her team are paid for overtime, they do not want to work every evening as it leaves them tired and with a poor work-life balance. ‘We have to do our documentation in the evening, and that has become the routine,’ Ms Roberts says. ‘My team are on their knees. We have quite a few single mums on the team and the last thing they want to do is come home, get the children sorted and then open up their laptop.’
Damaging recruitment and retention
She said pressures have become unsustainable in the community, with an expectation that they will always accept referrals. Pressure on hospitals and social services leads to more, often inappropriate, referrals to their service.
She and colleagues regularly have 13-14 visits each to complete in a 7.5-hour shift. The unrelenting pressure is driving away experienced and much-needed staff.
‘It is affecting recruitment and retention,’ she says. ‘I will go above and beyond to enhance things for my colleagues or patients but there are times when I think I don’t want to do this now. We are struggling to see what will help, or when there will be an end to this culture of expectation.’
Colleagues have left, and others talk about looking for other roles or leaving the profession. ‘These are nurses who are amazing at their job. But if we can’t foster that love for nursing and keep people who have been doing the job for a long time, what are we going to do in the future?’
The reality for many nurses is that it can be incredibly difficult to say no, but they must consider their own needs, nursing experts say.
Mandy Day-Calder, formerly a nurse and now director of healthcare training company Charles Bloe Training, says: ‘Nurses must think about the needs of their whole life, as opposed to just the needs of the ward. If constantly staying late is draining energy and causing friction at home they have to find a better balance without feeling guilty.’
However, Ms Day-Calder says she recognises how difficult it is for nurses, who do not want to leave patient care undone or colleagues with even more work.
‘It’s not easy, given the pressures nurses are working in, but running themselves low every single shift can’t be the answer,’ she says.
‘If a nurse can’t stay late it’s about staying calm and letting their manager know in a professional manner.’
Using the time available during your shift well is also essential, she adds.
‘Unpaid overtime has been normalised. There can be an element of emotional blackmail, a sense of “if you don’t do it, then who will?”’
Alison Leary, pictured, chair of healthcare and workforce modelling at London South Bank University
‘Don’t leave notes till the last minute,’ she says. ‘If you run out of time due to other pressures, simply do what you can and hand over to the next shift.’
RCN: Raising concerns toolkit tinyurl.com/toolkit-concerns-RCN
RCN: Working time and breaks tinyurl.com/work-and-breaks
WHO (2021) Long working hours increasing deaths from heart disease and stroke tinyurl.com/who-stroke-deaths