Insurance Dilemma in Health Care Term Paper

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Insurance for Nurses

Most of us probably see the issues of overtime and insurance as being entirely separate from each other. But for nurses, there is a clear connection between the two - one that is becoming clearer all of the time. Nurses have throughout the past decades found themselves working more and more hours, often being forced to take overtime shifts. This has resulted in a decreased quality of life for the nurses themselves and often results in poorer care for patients. One of the roles that nurses have always provided is the kind of extended personal care that patients need and that doctors cannot economically provide. This is being compromised by ever-increasing patient loads and by nurses who themselves are increasingly stressed.

So what has the issue of mandatory overtime to do with insurance? Quite a lot, actually. Nurses are being used more and more often to perform work once done by doctors, even as LVNs and technicians are being pushed more and more to perform work once done by RNs. This displacement of labor down the organizational hierarchy results in savings in health care (since each task is performed by the person who can be paid the least to do it) - or at least savings for insurance companies and HMOs. These savings are paid for in terms of lowered patient healthcare and decreased job satisfaction.

However, some nurses have in the past several years begun to flex their muscle to demand that savings for insurance companies not interfere with patient care to the extent that nurses are working too many hours and seeing too many patients.


Nearly anyone who has ever been in the workforce has been faced at one time or another with the issue of mandatory overtime - that is, being asked to work more than eight hours in a day or forty hours in a week. This situation is sometimes perfectly acceptable to the employee. For example, an accountant might reasonably be expected to be called upon to work more than 40 hours in the weeks leading up to April 15. Assuming that she is being paid for the hours worked, she is more than likely to agree that such a "request" on the part of her employer is a reasonable one.

However, sometimes required overtime is not so reasonable, as is the case taken up in this paper. When workers are not compensated for overtime (either not paid at all or paid only at their regular rates) or when they are required to work such long hours that their own safety or those of others is endangered, then the employee is rightly concerned about the issue.

The issue of mandatory overtime is one that has in the past decade become of increasing concern to nurses. This is due to a number of causes, including the fact that many fewer women now choose to go into nursing for the simple reason that they have more prestigious and better-paying options now open to them, something that was not true for previous generations. This is coupled with a growing need for nurses as the baby boom generation ages and requires more medical care along with the fact that managed health care facilities are often all too eager to cut nursing staff as a way to save money, as noted above.

But while an accountant who is overtired may make mistakes that can cost someone tax penalties, a nurse who is tired may make mistakes that can cost someone her life. This fact is behind the impetus for new laws and labor agreements that will limit the number of hours that nurses are required to work.

Many nurses - both in the United States and in other industrialized nations - have for a number of years been forced to work mandatory overtime. Often, such action can endanger the safety and health of both nurses and patients. (For example, a tired nurse is far more likely to stick herself accidentally, increasing her chance of contracting AIDS, hepatitis, and a number of other diseases). Nurses do not simply have the option of declining to work these longer hours, which is why the practice has been designated as mandatory overtime: Nurses who refuse the overtime often are threatened with losing their jobs and their licenses, which has prompted a number of nursing unions and advocacy groups to call for contracts that end mandatory overtime. The Maryland Nurses Association is one group that has been particularly vocal and articulate on this issue.

One bill recently considered and passed by the Maryland General Assembly exemplifies this trend in capping the number of hours that nurses may be forced to work. HB 889 prohibits an employer from requiring a nurse to work more than 8 hours in a workday or 40 hours in a workweek while authorizing an employer to require a nurse to work up to 10 hours in a day or part or all of a succeeding work shift in limited circumstances. Among these circumstances are the provision that a nurse "may not be considered responsible for the care of a patient beyond the nurse's prescribed work period if the nurse notifies another nurse and transfers his or her responsibility for a patient's care to a properly designated individual."

Literature Review

The state legislative analyst's summary of the bill further clarifies its potential impact on the medical workforce: In a workweek based on four ten-hour days, a nurse may not be required to work more than ten hours in a day. However, an employer may require a nurse to work part or all of the next succeeding work shift if:

the work is a consequence of an emergency situation that could not have been reasonably anticipated; (2) the emergency is nonrecurring and is not caused by or contributed to by the employer's inattention or lack of reasonable contingency plans; (3) the employer has exhausted all good faith reasonable attempts to obtain voluntary workers during the succeeding shifts; (4) the nurse has critical skills and expertise that are required for the work; and (5) the employer has informed the nurse of the basis for the employer's direction.

There are particular issues involved when health-care workers are required to work long shifts (and of course doctors as well as other health workers often work very long hours in addition to nurses); however, this argument against mandatory overtime for nurses must be seen in a larger context in which all workers are protected against unreasonable demands from their employers, especially when those demands are made to increase the profits of another entity - in this case, the insurance companies.

American workers in general are protected by the Fair Labor Standards Act, which is also more commonly called the Wages And Hours Act. This was in fact the first act passed in the United States that required the federal government to regulate wages and hours. Passed in law in 1938, the law applied to all industries engaged in interstate commerce and established a minimum wage of 25 cents per hour for the first year - which was to be increased to 40 cents within seven years. No worker could be obligated to work more than 44 hours (declining to 40 after two years) unless that person was paid overtime. This is a fundamental part of labor law and practice in this country, and it demonstrates the power of insurance companies that they have in many ways been able to undermine such an importance piece of legislation when it comes to nurses.

Such legal restrictions on overtime work are the primary reason that the average number of hours performed by workers has declined substantially greatly since the middle of the 19th century. Workers in advanced industrial countries in the 21st spend far fewer hours per year in every field than they did in comparable fields125 or 100 years ago.


The movement for shorter hours was an important part of the first unionization efforts in this country - and was always met with employer resistance since employers - like insurance companies - want the most labor for the least amount of pay from workers. Part of the reason that employers initially resisted shorter days also had to do with the fact that, at the beginning of industrialization, capital equipment was both scarce and expensive relative to the cost of labor. While this is no longer true in many fields, it does in fact remain true in some fields of work today, including medicine. We see in medicine that nurses' labor is relatively cheaper than capital investments as well as relatively cheaper than the work of other health-care professionals such as doctors.

Both traditionally male and female professions have been affected by required overtime:

Mandatory overtime is an increasingly contentious issue in contract negotiations for employees who feel they've been pushed to the limit, including those in telecommunications, nursing, transportation, steel, mining, and the auto industry...Nurses have been particularly hard hit by forced…[continue]

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