New nurses work overtime, long shifts, and sometimes a second job, research shows

Overtime in particular has been negatively associated with patient care, and a good proportion of nurses are required to work extra hours.

New nurses are predominantly working 12-hour shifts and nearly half work overtime, trends that have remained relatively stable over the past decade, finds a new study by researchers at NYU Rory Meyers College of Nursing. And 13 percent hold a second job.

Changes in health policy in recent years — from the passage of the Affordable Care Act and increased access to healthcare, to the recession — which delayed some nurses’ retirements — have had implications for nurses and the hours they work, while overtime has been linked to patient safety and nurse well-being.


The research team analyzed surveys from more than 4,500 newly licensed nurses in 13 states and Washington D.C., collecting information on nurse demographics, education, work attributes and attitudes. Specifically, nurses were asked about their work schedule, daily shift length, weekly work hours, overtime, and whether they worked a second job.

In addition to the 12-hour shifts and second jobs, it was found that new nurses prefer working the day shift and 12 hours is the preferred shift length.

Twelve percent of nurses report working mandatory overtime (an average of less than an hour in a typical week), and nearly half, 45.6 percent, work voluntary overtime (an average of three hours in a typical week).

There were nuanced changes in overtime hours during the decade studied: There was a decline in both mandatory and voluntary overtime during the economic recession by about an hour per week, but overtime hours rose in the most recent cohort.

There’s good news and bad news in the results. The good news is that new nurses seem to be working a similar proportion of 12-hour shifts as more experienced nurses, and most are working the shift and schedule they prefer. There also weren’t statistically significant increases in weekly work hours or overtime hours.

But the findings on overtime were troubling given that previous research has established associations between working overtime and patient outcomes (such as medication errors), occupational injury among nurses, and factors like burnout and job dissatisfaction.

While voluntarily working overtime can be a welcome source of income for some nurses, mandatory overtime — which is restricted by law in 18 states — was found to be a practice norm, occurring for 12 percent of new nurses.


Nurses operate within a highly competitive job market, and as is the case in other high-stress fields, there’s a fatigue starting to set in. Burnout is a very real danger, and much like physicians, nurses are prone to leaving when they’ve finally had enough — and that turnover can have detrimental effects on everything from a hospital’s financial strength to the quality of patient care.

A recession is coming: What it could mean for healthcare

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More than half of 147 CFOs surveyed by Deloitte believe the U.S. will be in a recession by the end of 2020.

Eighty-eight percent of CFOs rated the North American economy “good” in the fourth quarter of 2018, but just 28 percent expected conditions to improve in 2020. Larry Summers, former U.S. Treasury Secretary, has also warned of recession twice in the past three months, Fortune reports.

What would a recession mean for healthcare? We looked back to the effects of the 2008-09 recession:

1. A recession could temporarily alleviate or delay workforce shortages. A 2011 report from The Washington Post indicated the 2008-09 recession partially addressed nurse shortages at Washington, D.C., hospitals because some retired nurses rejoined the workforce, some delayed retirement and some part-time nurses sought full-time work.

2. Underemployment and unemployment can lead to significant declines in hospital admissions and elective surgeries for commercially insured patients. A 2013 report from PwC indicated the 2008 financial collapse drove many patients to delay elective procedures, negatively affecting hospital earnings for years after the fact. In fact, the decline in commercially insured patients due to underemployment and unemployment caused the average 300-bed hospital to lose $3.7 million from 2009-11 due to declining admissions, according to a 2012 infographic from Objective Health.

3. A slowdown in healthcare spending could continue to push the industry toward outpatient care. The 2013 PwC report indicated the slow growth rate of healthcare spending post-recession continued to push care to the outpatient setting, which is more consumer-friendly and less expensive.

4. Pediatric care could be recession-proof. A 2014 report from the Health Care Cost Institute found spending on children’s healthcare services under employer-based plans grew an average of 5.5 percent from 2009-12.

5. Healthcare fundraising could decline. In 2011, an Association for Healthcare Philanthropy report indicated fundraising was starting to improve after the recession, but 71 percent of healthcare fundraisers said the recession was still having negative effects.



Outlook is negative for nonprofit hospital sector, Moody’s says

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Moody’s Investors Service has issued a negative outlook on the nonprofit healthcare and hospital sector for 2019. The outlook reflects Moody’s expectation that operating cash flow in the sector will be flat or decline and bad debt will rise next year.

Moody’s said operating cash flow will either remain flat or decline by up to 1 percent in 2019. Performance will largely depend on how well hospitals manage expense growth, according to the credit rating agency.

Moody’s expects cost-cutting measures and lower increases in drug prices to cause expense growth to slow next year. However, the credit rating agency said expenses will still outpace revenues due to several factors, including the ongoing need for temporary nurses and continued recruitment of employed physicians.

Hospital bad debt is expected to grow 8 to 9 percent next year as health plans place greater financial burden on patients. An aging population will increase hospital reliance on Medicare, which will also constrain revenue growth, Moody’s said.


Hospital Operating Income Falls for Two-Thirds of Health Systems

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Hospital expenses are rising faster than revenue growth for health systems, resulting in declining operating income.

Health system operating income is deteriorating as hospital expenses continue to grow, according to a recent Navigant analysis.

In the three-year analysis of the financial disclosures for 104 prominent health systems that operate almost one-half of US hospitals, the healthcare consulting firm found that two-thirds of the organization saw operating income fall from FY 2015 to FY 2017. Twenty-two of these health systems had three-year operating income reductions of over $100 million each.

Furthermore, 27 percent of the health systems analyzes lost revenue on operations in at least one of the three years analyzed and 11 percent reported negative margins all three years.

In total, health systems facing operating earnings reductions lost $6.8 billion during the period, representing a 44 percent reduction.

Rapidly growing hospital expenses as the primary driver of declining operating margins, Navigant reported. Hospital expenses increased three percentage points faster hospital revenue from 2015 to 2017. Top-line operating revenue growth decreased from seven percent in 2015 to 5.5 percent by 2017.

Hospital revenue growth slowed during the period because demand went down for key hospital services, like surgery and inpatient admissions, Navigant explained.

Many of the revenue-generating services hospitals rely on are under the microscope. Policymakers and healthcare leaders are particularly looking to decrease the number of hospital admissions and safely shift inpatient surgeries to less expensive outpatient settings.

In exchange, Medicare and other leading payers are reimbursing hospitals for decreasing admissions or readmissions and their performance on other value-based metrics.

The shift to value-based reimbursement, however, is slow and steady, with just over one-third of healthcare payments currently linked to an alternative payment model. Hospitals and health systems are still learning to navigate the new payment landscape while keeping their revenue growing.

Value-based contracts also failed to deliver sufficient patient volume to counteract the discounts given to payers, Navigant added.

According to the firm, other factors contributing to a slowdown in hospital revenue growth included a decline in collection rates for private accounts and reductions in Medicare reimbursement updates because of the Affordable Care Act and the 2012 federal budget sequester.

“Because of reductions in Medicare updates from ACA and the sequester, hospital losses in treating Medicare patients rose from $20.1 billion in 2010 to $48.8 billion in 2016, according to American Hospital Association analyses,” the report stated. “The sharp $7.2 billion deterioration in Medicare margins that occurred from 2015 to 2016 surely contributed to the reduction in hospital operating margins in the same year of this analysis.”

While hospital revenue growth slowed, hospital expenses sharply rose as healthcare organizations invested in new technologies. Value-based reimbursement, federal requirements, and other components of the Affordable Care Act prompted hospitals to make strategic investments in EHRs, physicians, and population health management, causing expenses to increase, Navigant stated.

Key strategic investments made by hospitals and health systems included:

  • Compliance with the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which requires certified EHR implementation in hospitals and affiliated physician practices
  • Compliance with Medicare payment reform initiatives, such as accountable care organizations (ACOs) or pay-for-performance programs
  • Participation in new value-based contracts with payers
  • Establishment of employed physician groups or clinically integrated networks to develop the capabilities needed for compliance with performance- or value-based initiatives

“In addition to these strategic investments, other factors drove up routine patient care expenses, including a nursing shortage that increased nursing wages and agency expenses; specialty drug costs, particularly for chemotherapeutic agents; and, for some systems, recalibration of retirement fund costs,” the report stated.

The shift to value-based reimbursement and all of its accompanying policies will be the “new normal,” and hospitals should expect the low rate of revenue growth to persist, Navigant stated.

But hospitals and health systems can withstand the economic downturn by achieving strategic discipline and operational excellence, the firm advised.

“Systems must be disciplined to invest their growth capital in areas of actual reachable demand; that is, matched to the growth potential in the specific local markets the system serves,” the report stated. For example, creating a Kaiser-like closed panel capitated health offering in markets where there is no employer or health plan interest in buying such a product is a waste of scarce capital and management bandwidth.”

In line with strategic discipline, organizations will need to “prune” their owned assets portfolio by improving the utilization of their clinical capacity and growing patient throughput. Health systems can achieve this by focusing on scheduling and staffing, ensuring adherence to clinical pathways, streamlining discharges and care transitions, and adjusting physical capacity to actual demand.

The tools used to succeed in value-based contracts should also be applied to Medicare lines of business to reduce Medicare operating losses.

Additionally, vertical alignment will be key to weathering falling operating earnings, Navigant explained.

“Revenue growth is more likely to occur around the edges of the hospital’s core services — inpatient care, surgery, and imaging — rather than from those services themselves,” the report stated. “Creatively repackaging services like care management that is presently imbedded in every aspect of clinical operations, and finding retail demand for services presently bundled as part of the hospital’s traditional service offerings, represent such edge opportunities.”

Reducing patient leakage in multi-specialty groups and systems through improved referral patterns, scheduling, or care coordination will help to grow revenue and keep it within the system.

“To achieve better performance, health system management and boards must take a fresh look at their strategy considering local market realities. They need to look closely at the markets they serve, and size and target their offerings to actual market demand,” the report concluded. “They must re-examine and rationalize their portfolio of assets and demand marked improvements in efficiency and effectiveness, and measurable value creation for those who pay for care, particularly their patients. Since much of this should have been done five years ago, time is of the essence.”

Should Hospitals Limit the Number of Patients Nurses Can Help?

A male nurse with an elderly patient.


The medical community is divided over a November ballot measure that would make Massachusetts only the second state with such staffing requirements.

Voters this fall could make Massachusetts only the second state in the country to limit the number of patients that hospital nurses can help at one time.

Question 1 would create legal ratios based on the type of patients that nurses are dealing with. Nurses aiding women during birth and up to two hours after, for instance, would be limited to one patient. If they’re working with children, they could see four patients at once. In the psychiatric ward, nurses could help up to five patients.

While nurses unions and progressive political groups back the ballot measure, most medical groups — including the Massachusetts chapter of the American Nurses Association and the state’s Health and Hospital Association — oppose it.

The ballot measure’s supporters argue that not regulating this negatively impacts patient care and overall health outcomes.

“There is overwhelming evidence when you look at studies and talk to nurses that when there are limits, there are better health outcomes,” says Kate Norton, campaign spokewoman for the Committee to Ensure Safe Patient Care, which is the official campaign for the ballot measure.

2011 study in the journal Health Affairs found that nurse-patient ratios in California resulted in decreased mortality rates after surgery and an additional half-hour of care for patients overall.

Seven states have laws that require hospitals to have committees that address staffing issues, but California is the only state with a cap on the number of patients a nurse can see during one shift. Advocates have struggled to gain support for ratio laws elsewhere, in part because the hospital industry doesn’t believe there’s enough evidence to support them.

California’s regulations were drafted by the state’s department of health and have been in effect since 2004. There was some fear at the time that hospitals would be forced to hire more nurses with less education in order to comply with the ratios. But according to the 2011 study, that didn’t happen.

Opponents of Massachusetts’ measure also worry that it would force hospitals “to make deep cuts to critical programs, such as opioid treatment and mental health services. Many community hospitals will not be able to absorb the added cost and will be forced to close.”

In California’s experience, those fears are likely overblown.

Research by the California Healthcare Foundation in 2009 shows that while “leaders reported difficulties in absorbing the costs of the ratios, and many had to reduce budgets, reduce services or employ other cost-saving measures,” the impact of the ratios was not discernible on hospital finances.

Research further shows that hiring levels only increased slightly after the mandate. But California is expected to have a nursing shortage of more than 44,000 by 2030. It’s not clear how big a role, if any, the staffing ratios play in this shortage.

In Massachusetts, opponents of the measure argue that it would worsen the existing nurse shortage there. Right now the vacancy rate for registered nurses in Massachusetts hospitals is 6.4 percent.

“If it passes, the estimates are that hospitals will have to hire 6,000 more nurses [according to a study led by the opposition camp]. Where will they get them?” says Jake Krilovich, director of policy and public affairs for the Home Care Alliance of Massachusetts, which opposes the measure.

But according to data from the U.S. Department of Health and Human Services, the state is projected to have a surplus of nurses by 2030.

Although well-financed organizations like the Massachusetts Business Roundtable, Massachusetts Health and Hospital Association and 11 local chamber of commerces oppose the measure, the supporting campaign has much more cash on hand: $1 million to just over $11,000 in the opposition camp.

There hasn’t been any formal polling done on the measure.


Experienced Bedside Nurses: An Endangered Species?

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“The trend toward our hospitals being primarily populated with nurses with less than two years’ experience is worrisome.”

At least three colleagues who’ve recently been patients in hospitals or had family members who were have remarked on the youthful nurses they encountered—and on their lack of experience. In two of the conversations, my colleagues cited instances in which this lack of experience was detrimental to care, one of them dangerous. That “sixth sense,” that level of awareness that comes with lived experience and becomes part of expert clinical knowledge, is important for safe, quality patient care.

In the February editorial, I report on the answers I received when I queried our editorial board members about new nurses’ inclination to work in acute care for only two years to gain experience and then leave to pursue NP careers. Many of the board members have seen a similar trend, one reflected by research on nurse retention, some of it published in AJN (most recently, see Christine Kovner’s February 2014 study on the work patterns of newly licensed RNs, free until February 6).

As one board member noted:

“The narrative must be shifted to embrace the full range of roles and contributions of all nurses. Our health care system depends upon a well-trained, experienced workforce. The trend toward our hospitals being primarily populated with nurses with less than two years’ experience is worrisome.”

It’s a complex issue, and no one is faulting new RNs for the career paths they pursue. But as this trend accelerates, what can be done to ensure that there are enough experienced nurses at the bedside to protect patient safety? Let us know your thoughts.


Moody’s: Nursing shortage will pressure hospital margins for years

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U.S. nonprofit hospital margins will be negatively affected by an extreme nursing shortage for at least the next three to four years, according to a new report from Moody’s Investors Service.

To attract and retain nursing talent, many hospitals are increasing compensation and offering sign-on bonuses and attractive fringe benefits. However, these incentives are putting expense pressure on hospitals.

“Labor is the largest hospital expense and is increasing faster than total expense growth while outpacing revenue growth,” Safat Hannan, a Moody’s analyst, said. “The lack of qualified nurses will compound these expense pressures and negatively affect hospital margins.”

The nursing shortage is most prevalent in Florida, Georgia, Texas, California, Louisiana, Mississippi, Alabama and West Virginia, according to the report.