Nursing Work and Life

Nurses’ extended work hours: Patient, nurse and organizational outcomes W. Kunaviktikul1 RN, PhD, O. Wichaikhum4 RN, PhD, A. Nantsupawat4 RN, PhD, R. Nantsupawat2 RN, PhD, R. Chontawan2 RN, PhD, A. Klunklin1 RN, PhD, S. Roongruangsri3 MNS, RN, P. Nantachaipan3 RN, PhD, T. Supamanee4 RN, PhD, B. Chitpakdee4 RN, PhD, T. Akkadechanunt3 RN, PhD, & S. Sirakamon3 RN, PhD 1 Professor, 2 Associate Professor, 3 Assistant Professor, 4 Lecturer, Faculty of Nursing, Chiang Mai University, Thailand

KUNAVIKTIKUL W., et al. (2015) Nurses’ extended work hours: patient, nurse, and organizational outcomes. International Nursing Review 62, 386–393 Background: Nursing shortages have been associated with increased nurse workloads that may result in work errors, thus impacting patient, nurse and organizational outcomes. Aim: To examine for the first time in Thailand nurses’ extended work hours (working more than 40 h per week) and its relationship to patient, nurse and organizational outcomes. Methods: Using multistage sampling, 1524 registered nurses working in 90 hospitals across Thailand completed demographic forms: the Nurses’ Extended Work Hours Form; the Patient, Nurse, Organizational Outcomes Form; the Organizational Productivity Questionnaire and the Maslach Burnout Inventory. The data were analysed using descriptive statistics, Spearman’s rank correlation and logistic regression. Results: The average extended work hour of respondents was 18.82 h per week. About 80% worked two consecutive shifts. The extended work hours had a positive correlation with patient outcomes, such as patient identification errors, pressure ulcers, communication errors and patient complaints and with nurse outcomes of emotional exhaustion and depersonalization. Furthermore, we found a negative correlation between extended work hours and job satisfaction as a whole, intent to stay and organizational productivity. Nurses who had extended work hours of >16 h per week were significantly more likely to perceive all four adverse patient outcomes than participants working an extended ≤8 h per week. Limitations: Patient outcomes were measured by respondents’ self-reports. This may not always reflect the real occurrence of adverse events. Conclusions: Associations between extended work hours and outcomes for patients, nurses and the organization were found. The findings demonstrate that working two shifts (16 h) more than the regular work hours lead to negative outcomes for patients, nurses and the organization.

Correspondence address: Dr Wipada Kunaviktikul, Chiang Mai University, Faculty of Nursing, 110 Intavaroros Road, Chiang Mai 50200, Thailand; Tel: 66-53-945-011; Fax: 66-53-289231; E-mail: [email protected]; [email protected].

Funding This study was funded by the Nursing Policy and Outcome Center, Faculty of Nursing, Chiang Mai University, Thailand, and supported by the China Medical Board. Conflict of interest No conflict of interest has been declared by the authors.

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Implications for nursing and health policy: Our findings add to increasing international evidence that nurses’ poor working conditions result in negative outcomes for professionals, patients and health systems. Policymakers need to be aware of the issues regarding nurses’ extended work hours, which has been found to contribute to burnout. Urgently, nurse and health administrators need to develop and implement appropriate nursing overtime policies and strategies to help reduce this phenomenon, including measures to overcome the nursing shortage. Keywords: Emotional Exhaustion, Extended Work Hours, Intent to Stay, Nurse Outcomes, Nursing, Nursing Burnout, Organizational Outcomes, Overtime, Patient Outcomes, Thailand

Introduction Nursing shortages are a great concern globally and this phenomenon has its impact in terms of the quality of health care nurses provide, as well as the nurses themselves. The genesis of these shortages is complex and results in part from a high demand for nurses as many from the 55–65 age group are retiring. High nurse attrition results from poor working conditions, low demand to work in hospitals, increased work choices for women allowing them to change jobs more easily as well as nurse migration. Thailand has not been immune to the burdens of the nursing shortage, a heavy workload and the imbalance between the available healthcare workforce and the number of patients (International Council of Nurses 2014). There are increasing efforts around the world to try to improve both conditions for nurses and the health and safety of patients. Much effort has been invested in solving the nursing shortage internationally. For instance, in Hong Kong, rest breaks are taken during the shift and nurses who worked night duty are offered 24 h off before their next shift (International Council of Nurses 2014). Thailand has addressed the nursing shortage by increasing production of nurses to 7000–8500 nurses/year, an increase from 6000 nurses/year, from both public and private nursing educational institutes (Srisuphan & Sawangdee 2012). In addition, nurses are required to extend their work hours to ensure that patients receive continuous care for all 24 h. There are numerous studies that have focused on the effects of extended work hours (EWH) on patients, nurses and organizations. EWH refers to working more than 40 h per week, including both mandatory and non-mandatory overtime, paid work shifts (Rogers et al. 2004), as well as overtime work, longer work hours and working two consecutive shifts. For the purposes of this study, EWH is interpreted to mean paid work shifts that nurses are required to work above 40 h a week. Studies have shown that a high workload and working overtime results in high levels of burnout, particularly emotional exhaustion (Aiken et al. 2002; Garrett 2008; Nantsupawat et al. 2011;

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Stimpfel et al. 2012). In a study based in Thai regional hospitals, nurses have reported occurrences of work errors and near misses (Nantsupawat et al. 2010). Overtime work and working longer hours may be linked to adverse events and result in negative organizational outcomes, not to mention negative outcomes for nurses themselves. EWH may have a real and direct effect on patient safety and quality of care, making this issue the direct responsibility of the nurse manager to ensure that sufficient staff is available to provide safe and effective care for patients in their service departments. In this paper, we report on the first Thai study on extended work hours and present nurses’ perspectives on the relationship between EWH and outcomes for patients, nurses and the organization.

Literature review Studies indicated that nurses in healthcare facilities tend to work longer hours (Olds & Clarke 2010; Rogers et al. 2004). In New York State, the average overtime work (per week) accounted for 4.5% of total hours (Berney et al. 2005). Bae (2013) found that 15.6% of hospital nurses in two American states worked more than 40 h per week. Regulations in Thailand allow employers to assign nurses aged under 40 years to work a maximum of 54 h per week as well as 16 h (two consecutive work shifts) per day (Thailand Nursing and Midwifery Council 2012). Of great concern is the reality of some Thai nurses working 10–12 shifts more per month than is normal. This high workload puts Thai nurses at risk for work errors, near errors and the provision of unsafe care. EWH may affect quality of care and patient safety as the impact of longer work hours negatively affects the health of healthcare personnel and their rate of error (McDonald 2008). Nurses who work longer hours can potentially threaten patient safety. Aiken et al. (2014) demonstrated that a one patient increase in the nurses’ workload caused an increase of 7% in the chance of patient mortality within 30 days of admission.


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Additionally, another study documented the relationships between nurse staffing and mortality rate, hospital-acquired pneumonia and respiratory failure (Kane et al. 2007). Furthermore, working more than 40 h per week was associated with medication errors (Olds & Clarke 2010). Importantly, the risk of error significantly increased when nurses work more than 12 h per shift or more than 40 h per week (Rogers et al. 2004). Therefore, it can be concluded that longer work hours do have an effect on outcomes of care. Nurses who worked longer than scheduled had decreased vigilance (Scott et al. 2013). Nurse who worked long work hours and rotating shifts resulted in nurse fatigue or exhaustion making it impossible for them to relax. Healthcare staff with long working hours suffered increased oxidative stress (Buyukhatipoglu et al. 2010). Yoder’s (2010) study found that 15% of nurses had fatigue or were at risk of fatigue and fatigue scores were significantly different between nurses who worked 8- and 12-h shifts. Both Asian and Western studies have shown that longer work hours contributed to burnout and emotional exhaustion (Aiken et al. 2002; Garrett 2008; Nantsupawat et al. 2011; Stimpfel et al. 2012). Lipscomb et al. (2002) demonstrated that working full time, working more than 8 h per day and working a shift other than the day shift were significantly related to musculoskeletal disorders. De Castro et al. (2010) discovered that shift length of nurses in the Philippines was correlated with work-related injury and workrelated illness and the frequency of working mandatory overtime was correlated with work-related injury and work-related illness. It was found that the performance of fatigued nurses deteriorates and as a result, they experience increased stress in situations that undermine the quality of care provided. Nurses also encounter mental strain with high patient loads and work longer hours in comparison with other professions (Ede’ll-Gustafsson et al. 2002). Extended work hours may affect organization outcomes as well. When nurses work longer hours, they may develop bad attitudes towards work and feel dissatisfied with their jobs and may be absent from work (Zboril-Benson 2002), reduce productivity (Keller 2009) and organizational commitment (Kovner et al. 2009). These studies show that extended work hours impact patients, nurses and the organization as a whole. However, no research has been published in Thailand regarding the relationship between EWH and patient, nurse and organizational outcomes. Therefore, the aims of this study were to explore EWH and to predict EWH and patient, nurse and organizational outcomes. From this study, five papers have been planned in Thai language to report findings according to region; two have been published and three are under development.

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Methodology Design

This was a descriptive predictive study of nurses working in different healthcare facilities in Thailand. Sample and setting

A multistage sampling method was used to select participants. The sample population was 58 356 nurses working in Thai hospitals overseen by the Ministry of Public Health and the Ministry of Education. Yamane’s (1973) formula was used to calculate the sample size of 1492 which included a 5% sampling error. Considering the likely loss of participants during the study duration, the sample size was expanded by 20%. The final sample size was estimated to be 1791 nurses. The sample was drawn from registered nurses who worked in 51 community, 30 provincial, 5 regional and 4 university hospitals. Inclusion criteria included staff nurses who worked >40 h per week of both non-mandatory and mandatory paid shifts, including working two consecutive shifts. Nurse administrators were excluded from this study. Instruments

The questionnaire consisted of five instruments. Instruments 1–4 were developed by researchers. 1. The Demographic Form sought information on gender, age, marital status, education level, continuing education, number of family members, working years, hospital type, working department, sick leave and work absence, health status, sleep adequacy, balance of work and life, drowsiness while driving, commitment, and intent to leave and job satisfaction. 2. The Nurses’ Extended Work Hour Form included six items: the number of extended work shifts and EWH and the number of times working two continuous shifts per month. The characteristics of EWH were also assessed. 3. The Patient, Nurse, and Organizational Outcomes Form had 18 items measuring frequency of incidents involving patients (such as patient identification errors and patient falls) and incidents involving nurses (such as needlestick injuries and musculoskeletal disorders) on a 4-point rating scale ranging from 0 (never) to 3 (frequently) during the past year. 4. The Organizational Productivity Questionnaire (OPQ) had four items measuring perceptions of the effect of EWH on organizational productivity. The OPQ used a 5-point rating scale ranging from 1 (no effect) to 5 (strong effect). Reliability of the OPQ was 0.81–0.97. The research instruments described earlier were validated by six experts, including nursing instructors and nurses from both

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educational and nursing service institutes, to ensure the content validity of these instruments. These instruments were pilot tested with nurses from all types of hospitals prior to data collection. The Maslach Burnout Inventory (MBI), Thai version, comprised part five of the questionnaire. This 22-item survey uses a 7-point scale for answers ranging from ‘never’ to ‘every day’. This instrument measures burnout in terms of emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA). Score interpretation for the medical subgroup, in this case nurses, is: EE; low (≤18), moderate (19–26) and high (≥27), DP; low (≤5), moderate (6–9) and high (≥10), PA; low (≥40) moderate (39–34), and high (≤33) (Maslach et al. 1996). The reliability for the MBI of this study was 0.79–0.94 for EE, 0.36–0.76 for DP and 0.65–0.84 for PA. Data collection

After the Institutional Review Board (IRB) approval, a research package containing a cover letter, consent form and all research instruments was sent to the research coordinators at each hospital. Respondents who met the criteria were selected and were asked to complete the questionnaires and then to return their questionnaires directly to the researchers using the preaddressed postage-paid envelopes provided. Research instruments were distributed to 1791 nurses working in community, provincial, regional and university hospitals in all four regions of Thailand. A total of 1524 questionnaires (85.09%) were fully completed and used for the analysis. Data analysis

The data were analysed using descriptive statistics, Spearman’s rank correlation, and logistic regression. Logistic regression was used to examine the relationship between numbers of extended work hours and patient outcomes. Ethical considerations

Approval was obtained from the IRB of the Faculty of Nursing, Chiang Mai University, as well as from all hospitals involved. In the research package, participants received informed consent statements describing all aspects of the study and describing their rights regarding voluntary participation, study withdrawal at any time and their rights to privacy and confidentiality. The consent statement asked participants to sign the consent form to show their willingness to participate in the study. Participants were able to withhold consent or to omit answers from the questionnaire if they did not want to openly refuse involvement.

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Results Most participants were female (96.64%) and had a mean age of 34.73 years. Only slightly more than half were married (50.96%) as opposed to single (44.37%). An overwhelming majority had a bachelor degree (92%) and 73.38% did not have additional continuing higher education. Only 18.53% had taken part in the 4-month short training programmes which were operated after work hours such as nursing administration or nurse practitioner programmes. Participants had an average of 3.34 family members and worked on average of 11.85 years in nursing and midwifery. Specific characteristics of EWH

The majority (79.34%) reported that a typical work shift was 8 h long, but they worked on average 58.82 h per week. The majority of participants (80.33%) worked two consecutive shifts and 81.06% of participants rotated between the day and evening shifts. Of the nurses who responded, 77.04% reported that their overtime work was scheduled in advance. Impact of EWH on patients, nurses and organizational outcomes (Tables 1–3) Patient outcomes

Most nurses perceived that work errors or near misses caused by EWH never occurred or rarely occurred. In contrast, they perceived that communication errors, patient identification errors, patient complaints, patient pressure ulcers occurring while a under the hospital’s care, and errors in medication administration occasionally occurred at rates of 33.86%, 25.00%, 24.21%, 22.32% and 21.73%, respectively. About 13.74% believed that pressure ulcers frequently occurred. EWH was positively correlated with patient identification errors, development of a pressure ulcer while under the hospital’s care, communication errors and patient complaints (Table 2). Nurses who had EWH >16 h or two extra shifts per week were significantly more likely to perceive communication [odds ratio (OR) = 1.38, 95% confidence interval (95%CI) = 1.00– 1.92, P ≤ 0.05], patient identification errors (OR = 1.76, 95%CI = 1.24–2.49, P ≤ 0.001) and patient complaints (OR = 1.68, 95%CI = 1.18–2.38, P ≤ 0.05) than nurses working ≤8 h per week (Table 3) when controlling for age, sex and education. Participants working 33–40 h per week were the exception for patient complaints. Participants with EWH >24 h per week were significantly more likely to perceive the occurrence of pressure ulcers (OR = 1.51, 95%CI = 1.03–2.21, P ≤ 0.05) than participants working ≤8 h per week. Furthermore, nurses who had EWH >16 h per week were significantly more likely to perceive


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Table 1 Frequency and percentage of nurse outcomes affected from extended work hours (n = 1524) Nurse outcomes



Fairly good



Health status during first year of work Health status after 1 year of work Current health status compared with coworkers

533 (35.04%) 407 (26.74%) 300 (19.69%)

169 (11.11%) 258 (16.95%) 576 (37.80%)

37 (2.43%) 94 (6.18%) 229 (15.03%)

206 (13.54%) 323 (21.22%) 276 (18.11%)

575 (37.80%) 432 (23.38%) 140 (9.19%)






163 (10.72%) 25 (1.64%) 34 (2.23%) 87 (5.71%) 140 (9.19%)

421 (27.68%) 235 (15.42%) 325 (21.33%) 501 (32.87%) 391 (25.66%)

258 (16.96%) 829 (54.40%) 774 (50.79%) 632 (41.47%) 653 (42.85%)

499 (32.81%) 395 (25.92%) 341 (22.38%) 275 (18.04%) 258 (16.93%)

179 (11.77%) 37 (2.43%) 47 (3.08%) 26 (1.71%) 81 (5.31%)

Frequently occurred

Occasionally occurred

Rarely occurred

Never occurred

Not driving

126 (8.27%)

314 (20.60%)

654 (42.91%)

219 (14.37%)

209 (13.71%)

Job satisfaction as a whole Sleeping adequacy Balance between work and lives Organizational commitment Intent to stay

Drowsy or sleepy while driving

Table 2 Spearman’s correlation coefficient between extended working hours per week and outcomes (n = 1524) Outcomes

Patients Patient identification errors Pressure ulcers Communication errors Patient complaints Nurses Job satisfaction as a whole Intent to stay Emotional exhaustion Depersonalization Organization Organizational productivity

Correlation coefficient

P value

0.083 0.073 0.068 0.072

0.001 0.004 0.008 0.005

−0.084 −0.052 0.085 0.080

0.001 0.042 0.001 0.002



with other health professions. Interestingly, 32.81% of nurses rated their satisfaction with their overall work as low, 54.40% had moderate level of adequate sleep and 50.79% reported a moderate level of balance between work and life. About 28.87% reported occasional or frequent lapses of attention and drowsiness when driving (Table 1). Most nurses (73.34%) did not recognize needlestick injury as related to working longer hours, while over a quarter of the sample (26.66%) did believe that needlestick injuries were due to EWH. Moreover, more than 60% of them were selfdiagnosed or medically diagnosed as having knee pain, leg pain and varicose veins. More than 50% of the sample had selfdiagnosed or medically diagnosed neck pain. In addition, there was a negative correlation between EWH and job satisfaction and intent to stay. There was positive correlation between EWH and emotional exhaustion and depersonalization (Table 2). Organizational outcomes

all adverse patient outcomes, including all four patient outcomes than participants working ≤8 h per week (Table 3). Nurse outcomes

During their first year of work, about an equal number of participants perceived their health to be either poor (37.80%) or excellent (35.04%). However, after the first year, only 26.74% of nurses perceived their health as excellent. Moreover, only 37.80% considered their health status as good when compared

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About 35.63% perceived that EWH had a high negative effect on hospital service quality. Additionally, EWH was considered to have a moderate effect on the achievement of their hospital’s established objectives, such as achievement of deadline and the efficient use of resources for hospital services. Moreover, nurses reported a moderate level of organizational commitment (41.47%) and a moderate level of intent to stay (42.85%). The average days of official leave taken, such as sick leave or personal leave, was 2.03 days per year and absence from work, 0.18 days per year. Emotional exhaustion and depersonalization were at

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Table 3 Prevalence of perceived patient outcomes and its association with extended work hours (n = 1524) Patient outcomes Extended work hours per week

Communication errors OR (95%CI)

Patient identification errors OR (95%CI)

Patient complaints OR (95%CI)

Pressure ulcer OR (95%CI)

All four patient outcomes OR (95%CI)

≤8 h 9–16 h 17–24 h 25–32 h 33–40 h

1 1.03 (0.78–1.38) 1.38 (1.00–1.92)** 1.53 (1.04–2.23)** 1.45 (1.01–2.08)**

1 1.00 (0.72–1.38) 1.76 (1.24–2.49)* 1.76 (1.18–2.63)** 1.50 (1.02–2.21)**

1 1.25 (0.91–1.72) 1.68 (1.18–2.38)** 2.33 (1.57–3.46)* 1.38 (0.94–2.05)

1 0.96 (0.71–1.29) 1.13 (0.81–1.58) 1.51 (1.03–2.21)** 1.77 (1.23–2.54)**

1 1.15 (0.86–1.53) 1.72 (1.23–2.41)* 1.85 (1.24–2.77)** 1.61 (1.11–2.34)**

Note: Controlling for age, sex and education. CI, confidence interval; OR, odds ratio. *P ≤ 0.001; **P ≤ 0.05.

high (x = 30.94) and moderate levels (x = 9.89). Personal accomplishment was at a low level (x = 45.15). It was also found that EWH was negatively correlated with organizational productivity (Table 2).

sions such as engineering or medicine that are able to earn extra income through freelance or independent practice. This leads the researcher to believe that some nurses want to work overtime in order to earn extra income.


EWH and patient, nurse and organizational outcomes

Characteristics of EWH

While an 8-h shift was reported as the norm, the average nurse worked an extra 18.82 h per week, which amounted to a 58.82 h per week. This supports other studies in Thailand which have documented that nurses in public or general hospitals have to work 32 shifts per month or 54 h per week on average and that 30% of nurses were required to work 16 h per day (Thailand Nursing and Midwifery Council 2012). These results are also consistent with a previous study that found that staff nurses worked longer daily than scheduled and generally worked more than 40 h per week (Rogers et al. 2004). The issue of nursing shortage has escalated in Thailand (Srisuphan & Sawangdee 2012). To deal with the professional nursing shortage, working overtime or exceeding the 40-h workweek has become an inadequate solution to ensuring continuous patient care. It has become common for nurses to work consecutive day and evening shifts that is working 16 h straight, instead of the regular 8 h. This was true for 80.33% of the sample who worked two consecutive shifts and 81.06% often rotated between the day and evening shifts. The large number of nurses who reported advanced scheduled overtime raises an important issue. Even though working overtime is not mandatory in Thailand, it was observed that nurses have difficulty refusing extra hours due to the nursing shortage. Refusing to work overtime may affect their employment and chances for a promotion. Thai nurses do not have high salaries compared with other profes-

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The results of this study suggested that nurses’ EWH were associated with patient, nurse and organizational outcomes. Most of the sample perceived that the errors or near errors resulting from EWH never occurred or rarely occurred. However, some participants perceived that communication errors, patient identification errors, patient complaints, the occurrence of pressure ulcers while under the hospital’s care, and medication errors occasionally occurred due to EWH. Interestingly, about 13.74 % perceived that pressure ulcer development while under the hospital’s care frequently occurred due to EWH. A previous study in Thailand found similar results with this study (Nantsupawat et al. 2010). A positive correlation between EWH and patient identification error, the occurrence of pressure ulcer while under the hospital’s care, communication errors and patient complaints were found. Apparently, long working hours is a contributing factor for physical fatigue. On average, nurses worked almost 60 h per week which resulted in fatigue. The extra working hours decreased work performance due to their decreased ability to provide patient care services. Fatigued nurses may not be as likely to detect changes in patient conditions and may fail to respond appropriately to these changes. Fatigue could be a likely explanation for the positive correlation between EWH and patient outcomes such as communication errors, patient identification errors, patient complaints, the occurrence of pressure ulcers while under the hospital’s care and medication errors. Hence, long working hours can affect quality of care and


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patient safety. Similarly, previous studies found that reports of errors in care and patient safety were associated with long working hours (Olds & Clarke 2010; Rogers et al. 2004; Trinkoff et al. 2011). The nurses in this study were not doing well and this might be attributed to their long working hours. About 30% had low satisfaction with their overall work. Only half of the sample received adequate sleep and felt a true balance existed between work and their personal life. About 28.87% reported occasional or frequent lapse of drowsiness while driving. More than 50% of the sample perceived the symptoms of musculoskeletal disorders. The negative correlation between EWH and work satisfaction as well as the positive correlation between EWH and emotional exhaustion and depersonalization support this. These findings support previous studies connecting longer working hours with increased fatigue and decreased alertness (Scott et al. 2013; Yoder 2010). EWH may increase risk of physical injuries as nurses lack concentration or vigilance. Moreover, inadequate sleep may also contribute to medical errors which is also consistent with previous studies that have found a correlation between long working hours and work-related injuries and illness (De Castro et al. 2010). This is also consistent with a study performed in Taiwan that found that 57% of nurses who are working in shift have poor quality of sleep and EWH was associated with muscle and bone injury as well as needlestick injury (Shao et al. 2010). About 35% of participants perceived that EWH had a major effect on hospital service quality. Moreover, the sample’s organizational commitment and intent to stay was only moderate. Emotional exhaustion and depersonalization were moderate to high, while feelings of personal accomplishment were low. These factors could explain why EWH was negatively correlated with organizational productivity, which supports a previous study documenting that working beyond 8 h decreases alertness and productivity (Keller 2009). Working longer hours may lead to fatigue and stress and may increase burnout among nurses. A previous study found that mandatory overtime is associated with organizational commitment (Kovner et al. 2009).

Conclusions and implications for nursing and health policy Thus, the practice of nurses working extended hours is associated with patient, nurse and organizational outcomes. The results of this study can provide nurse leaders as well as policymakers with the evidence to propose more equitable nurse staffing and to revise mandatory overtime policies. Nurses are expected to provide good nursing care to the patients. Nurses have to be competent and qualified. The researchers also suggest further investigation be made as to the relationship

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between nurses’ low salaries and overtime work, as well as the relationship between nurses’ sense of obligation to work overtime and overtime work. Overtime allowance as well as shift work allowances should be increased (Srisuphan & Sawangdee 2012), so that nurses would not need to work extra time to maintain their quality of life, as longer work hours affect patients as well as nurse outcomes. Responsible organizations, such as the Thailand Nursing and Midwifery Council, the Ministry of Public Health and public and private institutions should propose a new mandatory overtime policy stating that nurses should not work more than 16 h in addition to the 40 h per week as working too many extra shifts or hours may have adverse patient outcomes. Furthermore, given the nursing shortage, there should be action taken to create a better balance between the number of patients and nurses. Finally, nurses should have a choice whether they would like to work overtime or not. To ensure sufficient staffing, more nurses may need to be recruited into hospitals, reducing the need for nurses to work overtime. Adequate break time should be given both during and between shifts to prevent fatigue. In contemplating overtime work, nurses themselves need to be aware of their ethical obligation to provide good quality and safe nursing care. If their overtime work is resulting in fatigue, they should refuse to work overtime.

Study limitations A limitation of this study was that patient outcomes were measured by respondent self-reports. This may not be an accurate reflection to the occurrence of adverse events. Further studies should focus on documenting occurrence of adverse events and their connection to EWH.

Acknowledgement The authors would like to thank the nurses who generously shared their time in this research project and the Nursing Policy at the Faculty of Nursing Chiang Mai University supported by the China Medical Board for the research grant.

Author contributions Study design: WK, AK, OW, RC, PN. Data collection and analysis: WK, RN, OW, SR, PN, TS, BC, TA, SS, AN. Drafting the manuscript: WK, OW, AN. content: WK, OW, AN.

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Nurses' extended work hours: Patient, nurse and organizational outcomes.

Nursing shortages have been associated with increased nurse workloads that may result in work errors, thus impacting patient, nurse and organizational...
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