Michigan mental health nurses say OT hurts patient care

LANSING — The well-being of some 700 patients in state psychiatric hospitals is in the hands of nurses who say they're overworked, overtired and overstressed because of excessively mandated double shifts.

Sometimes several days a week, nurses in Michigan's five state-run hospitals end their regular eight-hour shifts only to be ordered to cover staffing shortages by working another eight hours. Against the recommendations of nursing groups and one of the state's own task forces, several current and former nurses at the Michigan Department of Health & Human Services told the State Journal they're worked to the point of exhaustion and ragged nerves, more prone to errors or poor judgment as they deal with unpredictable, sometimes violent patients.

Employees who refuse overtime mandates can be disciplined and "patient abandonment" could get them stripped of their licenses.

State hospitals are "mandating their staff to death, truly to death," said Eliza Marroni, a 41-year-old Plymouth nurse who said she left her job at the state's Hawthorn Center in August because of the stress.

State auditors have blamed at least one patient death on poor oversight by nurses and resident care aides at DHHS hospitals, though audits don't mention overtime or fatigue. Nationwide, some estimates peg medical errors as the third-leading cause of death, and advocacy group the American Nurses Association says mistakes and fatigue go hand-in-hand.

But DHHS officials said overtime is not as prevalent as nurses claim. They also said aides — who are less likely to be mandated because there are more of them — have the most direct contact with patients.

"We appreciate and understand the demands of the mandatory overtime on staff, and we're doing everything we can to reduce it," said Joe Collins, DHHS human resources director. "But we don't see it as impinging on patient care."

Data provided by the department — a snapshot of overtime for registered nurse managers from mid-June to mid-September — shows nurses were occasionally mandated to take an extra shift three or more days in a row — at the Kalamazoo Psychiatric Hospital, for example, some employees logged 32 hours of required overtime on some biweekly paychecks. But the logs show the most overworked nurses averaged only about three hours of mandatory overtime per week this summer.

Yet nurses said that, with the care of others in their hands, even that can be problematic.

"We're taking care of patients and you want to be your most alert and using your problem-solving skills," said Cassandra Craig, a 52-year-old nurse at the Kalamazoo hospital. "For anybody that's working an additional shift ... you're not going to be as alert, even if it's just one time."

Hospitals mandate extra shifts when no one volunteers and there aren't enough nurses — because of turnover, employees calling in sick or off with injuries, special patient demands, or other issues — to meet patient needs. The logs show nurses volunteered for overtime almost twice as much they were mandated.

DHHS officials said they struggle to recruit and keep nurses. But nurses said the problem is cyclical: nurses call in, quit and are injured because they're exhausted by mandatory overtime, but their absence causes more mandates.

The only solution, according to the Michigan Nurses Association, a union unaffiliated with the ANA, is for Michigan to join a dozen other states in limiting mandatory overtime through statute. They're backing a bill state Sen. Rebekah Warren plans to introduce this month.

"It is a universal problem," said Dawn Kettinger, the union's director of advocacy and outreach. "Nurses are being burned out in all sectors."

'My family didn't want to be around me'

Fred Spes, a 49-year-old registered nurse manager at the state's Caro Center, celebrated his 20th anniversary at the Thumb Region hospital last month. He said mandatory overtime is the worst he's seen it.

Every day, the Unionville man is up by 4 a.m. to get out the door in time for his half-hour drive to a 6 a.m. shift. If he's mandated — as happened to him a handful of times over the last three months — he may not leave work until 10:30 p.m. and won't get home until 11. He's lucky to fall asleep by midnight and then it's back up at 4 to start all over again.

On those days, "you're tired. You're dealing with the mentally ill, who can be aggressive at any moment," he said. "You're just not functioning as well."

The ANA says hospitals should not use mandatory overtime — 12 hours a day, 40 hours a week is the ceiling, ANA President Pam Cipriano said —because fatigued nurses can compromise patient care. It's a warning DHHS has heard before: In 2012, a state-commissioned task force said the department should "support a workplace culture change that eliminates extended work periods" because fatigued nurses might miss mistakes.

At state hospitals, nurses said they typically don't find out they're mandated until they come to work. They must work an entire additional shift unless they find a colleague willing to relieve them.

"It's hard to find any takers," Spes said. "I've paid a hundred bucks to someone to take my mandate."

Problems at home pile on.

Marroni, the former Hawthorn nurse, is married with a 13-year-old son. She said she's missed her son's hockey tournaments and family dinners. During a particularly bad three- or four-week stretch earlier this year, she said she was mandated at least three times a week. It took its toll.

"I gained a ton of weight. I wasn't eating well. I certainly wasn't exercising," she said. "I was crabby. My family didn't want to be around me too much."

After about three years with DHHS, she quit and took a job as a school nurse.

'Then we're stuck'

Nurses burn out — some quicker than others, said Cindy Kelly, director of DHHS's Bureau of State Hospitals. Community health has one of the highest turnover rates in state government, according to the Michigan Civil Service Commission.

Sometimes DHHS invests in finding, hiring and training nurses who then "get on the floor and decide they just don't want to work there," Kelly said. "Then we're stuck."

At one hospital, the department was recently blindsided by four simultaneous exits.

"It's a demanding area to work in," she said. "We're trying to fill the positions as quickly as we can, to get the most competent people that we can."

The ANA's Cipriano said mandatory overtime ebbs and flows with nurse shortages, and she agreed psychiatric hospitals are "a tougher area to recruit to."

In years past, state government's pensions, valuable health insurance and competitive pay made it worthwhile, said John DeTizio, labor relations director for the Michigan Association of Governmental Employees. But he said the calculus has changed with public sector benefit cuts in recent years.

"These are dangerous patients," DeTizio said. "And then (nurses) compare the pay and say, 'Why the heck should I stay here?' "

$8,800 per employee

DeTizio said he'll ask the state to give nurses a special salary bump to help with recruitment and retention, which should alleviate mandatory overtime. DHHS' registered nurses make between $22 and $41 an hour, according to state Civil Service Commission. In public and private facilities, the average registered nurse in Michigan makes $32 an hour.

Kelly said she's been unable to convince the Legislature she needs more money. Lawmakers cut $178,000 from state hospitals for the budget year that began Oct. 1.

Meanwhile, overtime costs taxpayers.

Across all departments, Michigan spent $105.5 million between October and July compensating state employees for both voluntary and mandatory overtime, the State Budget Office said. That works out to a rate of nearly $2,300 per employee.

The state spent $8,800 per nurse on mandatory and voluntary overtime.

The Department of Corrections, state government's top overtime spender, is in the midst of a hiring spree and expects toemploy 1,000 new recruits before year's end. The State Police, the second-highest spender, will run an 88-trooper recruit school this year, but much of that department's overtime is spent on emergencies, court appearances, and special enforcement initiatives, spokeswoman Shanon Banner said, and federal grants and dedicated funds cover about a third of the cost.

Community health, where about two-thirds of employees work at state hospitals, is the third-highest spender on overtime.

An unacceptable tradeoff

Warren, a Democratic Senator from Ann Arbor, said the bill she plans to introduce this month — establishing staff-to-patient ratios at both public and private facilities and prohibiting mandatory overtime except for emergencies — would help.

The sister and daughter of nurses, Warren introduced similar legislation in 2013, but her bill stalled in committee. This time, Warren said she'll tweak the bill to reflect lessons learned from states with existing overtime prohibitions. And she'll come with data showing the regulations can work, despite some of her colleagues' concerns that there aren't enough nurses to meet her stipulations.

A 2010 University of Pennsylvania study found California, which limits nurse overtime, had less nurse "burnout" and more satisfied nurses than states without such limits. California also grew its nursing workforce.

"It actually makes nursing more desirable as a profession and we get folks who go into it and stay into it," she said.

Collins and Kelly said an overtime prohibition would make it more difficult to adequately staff state hospitals. The U.S. Department of Health & Human Services said last year that Michigan will actually have a surplus of registered nurses by 2025. But today, "there's still a nursing shortage," Collins said.

In Texas, which has a statutory prohibition on mandatory overtime, state hospitals incentivize voluntary overtime and have switched to 12-hour shifts at some facilities to cover needs without requiring additional shifts, Texas Department of State Health Services spokeswoman Carrie Williams said.

Warren said it would be up to DHHS to request any additional funding necessary to prevent overtime, but she called it a public health issue that should be a priority for the Legislature.

"We don't let people fly airplanes after so many hours on the job. We don't let people drive trucks when they've had too many hours on the job," she said. "And yet, in nursing, the most hands-on public safety occupation there is, we have people who are working exhausted."

A dozen states already regulate nurse overtime through statute, and lawmakers in at least another eight states have tried, according to the National Conference of State Legislatures.

Cipriano, of the ANA, said overtime bans are successful because, at the very least, "it puts some guardrails in place" and forces staff and management to work together toward a solution.

"I would not for an instant say it's easy to solve these staffing challenges," she said. "But tiring out your staff and making it unsafe for them is not an acceptable tradeoff."

Contact Justin A. Hinkley at 517-377-1195 or jhinkley@lsj.com. Follow him on Twitter @JustinHinkley.

MANDATORY OVERTIME

Though nurses were sometimes ordered to work mandatory overtime three shifts in a row, the Michigan Department of Health & Human Services says the overall burden on each nurse was relatively low, as this Lansing State Journal analysis of department data shows. And nurses were more likely to work voluntary overtime than mandatory. The figures below show the total per-employee average overtime worked throughout the data range, and the average weekly per-employee overtime during that time. Figures for all hospitals are for June 21 to Sept. 12, except for the Caro Center, which provided data through Sept. 30.

Note: A per-employee breakdown at the state's Center for Forensic Psychiatry wasn't available, but the department said nurses worked only 52.1 total mandatory overtime hours from June 1 through Sept. 18.

Source: LSJ analysis of DHHS

OVERTIME PER EMPLOYEE

Between Oct. 11, 2014 and July 18, 2015, Michigan state government spent $105.5 million compensating its employees for overtime. Based on each department's average employee count as of July 18, that works out to nearly $2,300 per employee. That is a rate, and not an actual measurement of how much overtime pay each worker received. Here's a department-by-department breakdown:

Sources: State Budget Office, Michigan Civil Service Commission