Introduction

“Are you going to keep working eighty hours a week?

_Oh no I won’t, I won’t! Well, no, it would be the death of me.

_So, you are going to refuse the overtime? Is your employer going to accept this?

_Yeah, well, there are strategies to do. I could play on the strings that: I can, or I can’t. You know? But you know, it’s not everyone who has strong enough balls to refuse.

_To refuse overtime?

_Yeah. Because they’re giving disciplinary measures to those who don’t stay. Then it becomes a fight.”

Overtime work in the nursing profession has been a hot issue for the past decade in North America. Recently, the province of Quebec in Canada has seen much debate around mandatory overtime for nurses and its use by hospital managers (Lévesque, 2022), with reports of nurses being forced to work 16-h shifts (Jonas, 2021). The Covid-19 pandemic has further amplified the overtime issue by increasing healthcare professionals’ working hours, in Canada (Carrière et al., 2020) and elsewhere (Ayar et al., 2022). A provincial survey indicated that the means of weekly overtime work in Quebec rose from 6.2 h in May 2019 to 16.9 h in May 2020, constituting the highest rise and means of overtime amongst all Canadian provinces (Carrière et al., 2020). While nurses are the backbone of the healthcare system (Gordon, 2012), there are alarming reports of a global nurse shortage (Murphy et al., 2012). Practitioners and scholars observe that the “staffing crisis” in nursing (Jonas, 2021) leads to heavier workloads for the remaining nurses, resulting in increased levels of work-family conflict and more people leaving the profession. As put by Varma and colleagues, “the current nurse shortage has created a cycle in which increased workload and other factors, such as increased overtime, has led to decreased job satisfaction and increased work-life conflict, causing some nurses to resign” (Varma et al., 2016, p. 59). Likewise, it appears that several potential nurses never enter the profession in their anticipation of time-based work-family conflict (World Health Organization, 2001). Therefore, nurses’ working times are a central matter in the question of attracting and retaining nurses in the profession. As put by Berney and colleagues, “if undesirable working conditions contribute to the nurse shortage, overtime is certainly part of the problem” (2005, p.165).

Indeed, overtime work is not without negative consequences for nurses’ health and well-being. It has been linked to work-related injuries and illness (de Castro et al., 2010). A study about Turkish nurses indicated that increased work hours during the pandemic “negatively affected their family life, their roles, and responsibilities in the family” (Ayar et al., 2022, p.648). In Belgium, overtime was found to increase work-family conflict (Lembrecht et al., 2015). A Japanese study showed that involuntary overtime had a direct negative effect on work-nonwork balance satisfaction (Watanabe & Yamauchi, 2016). Another study showed that longer shift length and weekly hours negatively affected nurses’ physical and mental health (Bae & Fabry, 2014). Yet, there are indications that nurses may desire to work overtime, as a personal preference to make extra income for instance. There are even nurses who “work more overtime for the fun of work” (Watanabe and colleagues, 2018, p.686). Still, it seems that the distinction between voluntary and involuntary overtime is not always clear. Despite being called “voluntary”, nurses may feel that overtime is required or necessary and, in that sense, poses the question of what really constitutes a personal choice for the nurse. A qualitative study amongst Canadian nurses revealed that, aside from the financial gain, overtime was experienced by nurses as detrimental in terms of physical effects, impact on patient care, balancing family and work, and safety, leading to a global sense of resentment (Lobo et al., 2017). In some cases, employers may even be “exempt” from paying shift workers’ overtime hours (Sullivan, 2014). There is therefore a tension between hospital management agendas and nurses’ desire to work a certain number of hours. However, it is not clear how often nurses are obliged to working overtime, nor how much they do it; neither are the circumstances in which they are “forced” to do so. In this way, it seems to us that research is so far lacking a clear view about nurses’ subjective experiences of overtime.

In this light, the aim of this study is to describe the perceptions held by nurses concerning their experience of overtime. There have been calls for more research about nurses’ perceptions of overtime (Varma et al., 2016). This is especially important since the pandemic context, where nurses’ work hours have been considerably increased (Jonas, 2021). While quantitative research has revealed disruptions in nurses’ work-life balance because of increased work hours (Ayar et al., 2022), there is a need for an in-depth exploration of the subtleties in which mandatory overtime and other hospital management strategies may impact nurses.

Theoretical Background

The work-family interface literature regroups several theoretical strands. Role theory considers the interaction between the various roles that individuals play in different spheres of their lives. Greenhaus and Beutell (1985) explain that work-family conflict occurs when the requirements associated with one role make it difficult to meet the demands required in the other role. In particular, such conflict may be time-based, where “multiple roles conflict for a person’s time” (Greenhaus & Beutell, 1985), particularly as it relates to excessive work time and schedule conflict dimensions (Pleck et al., 1980). Conversely, work-life balance refers to “satisfaction and good functioning at work and at home, with a minimum of role conflict” (Clark, 2000, p. 751).

The work-life interface can also be understood in terms of borders and boundaries (Allen et al., 2014). Border theory recalls that individuals are proactive in shaping the work-life border, rather than reactive to external factors (Clark, 2000). In other words, employees tend to be proactive in “crafting” their own work-life balance (Sturges, 2012), that is using strategies to achieve satisfaction in reconciling their work and non-work roles. According to Kossek (2012), individuals with high boundary control are able to establish boundaries that best suit them. For instance, an individual with personal influence will be able to negotiate preferred boundaries and be better adjusted at work and at home. However, organizational policies and practices often constrain individuals as concerns managing boundaries (Olson-Buchanan & Boswell, 2006). Indeed, “organizational culture and human resource management practices can impede or enable boundary work” (Desrochers & Sargent, 2004, p. 43). This echoes the concept of “greedy institutions” coined by Coser, (1974), which describes how institutions (eg. workplace, family) compete to make the most of the committed individual’s resources in time and energy. Some institutions will make unreasonable demands and “use non-physical mechanisms” as well as “cultivate voluntary compliance as a means of encompassing their members.” (Sullivan, 2014, p. 3).

Hobfoll’s (1989) Conservation of resource theory (COR) further helps understand how nurses may experience overtime. The COR posits that “people strive to retain, protect, and build resources and that what is threatening to them is the potential or actual loss of these valued resources.” (Hobfoll, 1989, p. 513). Resources include personal traits and skills that aid resilience. Energies such as time and money, are also important resources which can be determined by an individual’s external conditions, such as one’s position within an organization. In this model, stress occurs when individuals lose valued resources. The Job demands-resources theory further developed by Bakker and colleagues (2001) builds on the COR to propose a model of burnout. In this model, excessive job demands (ie. aspects of the job requiring sustained physical mental effort) will influence employees through a health pathway leading to emotional exhaustion, while insufficient job resources (ie. health protecting aspects of the job) influence employees through a motivational pathway leading to disengagement (ie. job burnout, Maslach, 2005).

These elements of theory will enable a more thorough understanding of our findings.

Methods

Participants and Procedure

This paper stems from a research project seeking to assess factors contributing to nurse attraction and retention in the profession, by paying attention to aspects including organizational changes, work-life balance, well-being and psychosocial safety at work. This project was done in collaboration with the provincial Ordre des infirmiers et infirmières du Québec (Order of Quebec nurses), who gave us access to a list of nursing professionals who were first invited to fill out an online questionnaire. In this survey, participants were asked if they would like to participate in a semi-directed interview for the qualitative part of this research. An invitation was forwarded by e-mail to the participants who volunteered. The semi-directive interviews were led by one of the authors. Ethical and confidentiality matters were carefully explained at the beginning of each interview, which happened by phone or videoconference between April 2020 and March 2021. We met 42 nurses, who all agreed to being recorded and signed a consent form. The average length of the recorded interviews is of 63 min. Interviews were then transcribed manually into verbatims and pseudonyms were attributed to participants.

Interview Guide

Qualitative research has the “aim to describe and understand the nature of reality through participants’ eyes with careful and on-going attention to context” (Milne & Oberle, 2005, p. 413). Interviews allow researchers “to obtain both retrospective and real-time accounts by those people experiencing the phenomenon of theoretical interest” (Gioia et al., 2012, p. 19). In that perspective, our interview guide was developed on the basis of our literature review and it starts with questions aiming to capture participants’ overall trajectory as a nurse.Footnote 1 Further questions were asked about the changes that had occurred throughout their career. These open questions welcomed their sharing experience related to any type of change, including schedule-related changes, thereby allowing to capture emerging data regarding overtime work. While leaving room for emerging data, precise questions regarding overtime were also asked: “Do you happen to work overtime hours? Is it by choice?”; “What do you think about your work schedule, the number of daily and weekly work hours? Is there any mandatory overtime?”; “Have you observed any changes regarding the intensification of work tasks, or working time? Explain how.” In the second part of our interview guide, open questions were asked about participants’ experiences with work-life balance and work stress, allowing to capture their perceptions on that matter.

Data Analysis

We used a conventional qualitative content analysis, which is appropriate to explore a phenomenon where theory or research literature is limited (Hsieh & Shannon, 2005). According to Hsieh and Shannon (2005), the main advantage of this method is to gain direct information from the participants without the imposition of preconceived categories, “allowing the categories and names for categories to flow from the data” (Hsieh & Shannon, 2005, p. 1279). We followed the process proposed by the authors: after reading the data as a whole, we then identified key thoughts and concepts relating to the subject of work schedule. The theme of mandatory overtime emerged as a puzzle to focus on (Grodal et al., 2021). After determining a certain number of codes, we then started to sort them into categories, showing how different codes are related and linked, with such emergent categories serving to “organize group codes into meaningful clusters” (Hsieh & Shannon, 2005, p. 1279). Throughout this process, some categories were merged, split, and dropped (Grodal et al., 2021). Overarching categories were determined after reaching a threshold where each unit of meaning could not be further reduced, and when each category contained enough codes to be considered relevant. Definitions for each category and subcategories were then developed (Hsieh & Shannon, 2005). Prolonged engagement with the data, member checks and a negative case analysis were performed to maximize the credibility of the findings (Manning, 1997). Once the code book established (Appendix 2), we engaged in pattern matching, that is “identifying the patterns in data, and then comparing this against one or more patterns that are proposed in the literature (Almutairi, Gardner, & McCarthy 2014). The transversal theme of choice consistently found throughout our data encouraged us to look into several theoretical strands pertaining to the work-life interface literature, as well as to the field of occupational health and psychology.

Findings

The main themes emerging from our data were regrouped in three overarching sections. The first section offers an overview of the diversity of situations found among nurses regarding the quantity and frequency of overtime hours that they do, also reporting on the contingent factors influencing these aspects. The second section presents an analysis of the reasons given by nurses as to why and how they found themselves engaging in undesired overtime. Finally, the third section reports on the negative consequences of mandatory overtime on nurses’ health, well-being and organizational behavior (see Appendix 2 for the full list of codes). The following paragraphs synthesize our findings for each category, with three tables presenting representative quotes for each code resulting from our qualitative content analysis. The characteristics of cited participants that are relevant regarding our findings (ie. position, workplace, employer) are presented in Appendix 1.

Varieties of Overtime

We found considerable variation in nurses’ reported experiences of overtime, ranging from a few hours that are freely chosen on occasion for personal interest to what appeared as enormous amounts of weekly unwanted, mandatory overtime, as reported in Table 1. Our negative case analysis revealed that a few participants never experienced overtime, or only a few hours occasionally that were not deemed as a problem. A few other participants reported working overtime hours on their own free will (eg. Participant #1). They were not experiencing constraining working hours and had a satisfying degree of control over their schedule. However, the majority of our participants experienced hardship regarding their working times. It was possible to identify throughout our participants’ accounts several factors influencing the ways in which overtime was going to be experienced.

Table 1 Varieties of overtime—Verbatims
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The workplace appeared determinant in the way nurses were going to encounter overtime. Participants consistently reported that working at a hospital, especially after the fusion of hospital centers into big regional administrations in 2015–2017, was a certain recipe to be subjected to mandatory overtime. Those that were not experiencing it were aware that it was the case in other departments (Participant #13). During the pandemic, many nurses were forced to go work in other departments or even go back to work at the hospital when they had managed to secure a position in a more favorable work environment, such as a clinic of family doctors (Participant #35). They lost a great deal of control over their schedule in the process, which highlights the gap between different workplaces when it comes to working times. Many participants had tried or were trying to move to departments where they would not be subjected to too much overtime, or that they would at least be able to compensate with a degree of control over their schedule (Participant #2).

Individual characteristics also appeared to play a role in whether nurses would be subjected to unwanted overtime or not. Table 1 offers an example of a nurse who feels comfortable setting their boundaries (Participant #1), while others struggle to do so (Participant #19). The capacity to organize oneself, which comes with experience was also sometimes cited as a reason why one would not do so much overtime (Participant #25), as well as organizing oneself with the colleagues. However, the workload was sometimes too important for this to be possible.

Reasons Behind Involuntary Overtime

While some participants, reported doing overtime on occasion by “professional conscience” (Participant #3), most nurses who worked in hospitals justified doing overtime out a sense of duty towards their colleagues and the patients. Our participants were aware of lacking human resources and expressed a willingness to do more hours in order to compensate for the absence of colleagues, in the sense that each does “their turn” for the team (Table 2, Participant #33). While all our participants found it normal from a deontological viewpoint to do some overtime hours on occasion, issues started arising when they found themselves working overtime in a systematic way. Most nurses who worked at a hospital, that is the majority of our participants, felt that the employer’s demands to work more hours had become unreasonable over the years, particularly since the political reform of hospital merging in Quebec. In that sense, nurses reported that the Covid-19 pandemic only accentuated already existing human resource problems. The expectation of doing regular overtime hours was perceived as problematic, with a sense that it had become a “management practice” and a new norm, as opposed to an option for making extra income or something that nurses may agree to do on occasion to accommodate the work team. One participant mentioned that he didn’t “know of any other profession that ha[d] this” (Participant #31).

Table 2 Reasons behind involuntary overtime – Verbatims
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On top of overusing mandatory overtime, several participants offered a detailed description of being pressured into accepting these overtime hours (Table 2). They reported how management had their way to influence and guilt nurses into coming to or staying at work at times when they had not planned to be working, very often at a few hours’ notice. Moreover, the arguments given by management to make them stay at work were not always perceived as justified. While nurses recognized the necessity of doing overtime on occasion for deontological reasons, they strongly felt that management resorted to using their deontology code as a pretense, even a threat, to make them stay to meet the current nurse-to-patient ratio. Several participants thus reported feeling forced into complying to those demands, yielding to the threat of being accused of failing their duty towards the patients. Such situations were excruciating for nurses already exhausted from a previous shift, constrained to stay extra hours at work to meet a given pre-established ratio, when in some cases the workload does not even require it (Participant #21). Here again, the presence of such tactics varied from one employer to the other, evident when comparing two cases: Participant #24, who worked in a dispensary as an employee of a Federal health agency, indicated that nothing was ever forced on her. On the opposite, Participant #7, working in a dispensary under the regional Integrated Center of Health and Social Services administration, described a situation of enormous amounts of overtime, some even unpaid, with extremely poor attitude and no support from her supervisors (Table 2). Several nurses from different establishments had encountered intimidation as a managerial practice during their career, and one participant had just quit the profession for this very reason, after experiencing harassment in the two workplaces she had been employed at over her short career as a nurse.

Consequences of Involuntary Overtime

The longer working hours and mandatory overtime conflicted with nurses’ responsibilities and plans outside their employment (Table 3). With children to tend to, even fifteen minutes of unplanned overtime create a lot of stress given the strict hours of daycare centers (Participant #11). As a result, nurses may be forced to leave the position or the hospital altogether to find another work environment (Participant #8). Mandatory overtime was particularly difficult for single mothers who could not rely on a partner to replace them in case of absence, one senior nurse reporting that she would have mothers crying on the phone to try and find solutions to care for their child overnight (Participant #15). During Covid, some nurses that were working part-time by choice were obliged to work full-time, with the imposition of twelve-hour shifts, which led to grave disturbances to their home life and cause burnout. Even outside the pandemic context, the lack of personnel forces nurses to continually go beyond their limits and exhaust themselves, which eventually ends up in a plethora of burnouts and nurses struggling to come back to work.

Table 3 Consequences of involuntary overtime – Verbatims
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Not only did the mandatory overtime add considerable stress to our participants’ home life and personal health, it was also described as an important risk for nurses who were obliged to stay at work while exhausted, making them more vulnerable to making mistakes. This could lead to serious consequences for a patient, and to the nurse who is held responsible no matter the circumstances of her being forced to stay at work by the employer Being aware of their reduced concentration levels, this situation created paradoxical situations and cognitive dissonance for nurses regarding their mission to treat patient safely (see Table 3, penal consequences).

Finally, our participants were conscious of the human resource crisis in healthcare and reflected on employers’ strategies to solve these staffing issues. Mandatory overtime was not perceived as an effective strategy and was seen as the cause of other human resource management problems, on top of making the working conditions unattractive for future generations of nurses. Several participants reported on a trend amongst nurses to work part-time in reaction to the recurring long hours and mandatory overtime, in order to reduce their overall amount of work hours and regain a little bit of control over their schedule (eg. Participant #31). Overall, most participants agreed that the present working conditions in hospitals were unattractive and unsustainable throughout one’s working life as a nurse, with mandatory overtime counting as a major reason.

Discussion

Summary of Findings

In this explorative research, we have sought to capture nurses’ perceptions about overtime, answering calls for more research on this topic (Oh & Choh, 2020; Varma et al., 2016) and considering recent political events around mandatory overtime in the province of Quebec (Lévesque, 2022). Our paper contributes to the literature by providing a clear representation of nurses’ various experiences of overtime. Our inductive approach allowed three salient themes to emerge from our data, allowing a useful classification of the important factors associated with overtime in the nursing profession. An inclusive figure was developed to offer a visual synthesis of our findings, emphasizing the most important aspects to consider when dealing with the question of overtime in the nursing profession according to our participants (Fig. 1). The figure also integrates relevant concepts pertaining to several theoretical strands that will be discussed below.

Fig. 1
figure 1

Overtime in the nursing profession in Quebec (2020–2021)

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Theoretical Contribution

Our inductive findings offer important contributions to the literature about overtime in the nursing profession. Our first inquiry was to shed light on how much and how often nurses experienced overtime. The important aspect that our paper points out in this respect is that there is a diversity of experiences when it comes to overtime in the nursing profession, which is determined by two main factors: the work environment, and personal abilities (Fig. 1). These factors, in turn, determine the amount and frequency of overtime done by nurses and most importantly, the degree to which it is actually chosen. A spectrum of experiences of overtime emerged from our findings, ranging from working a few extra hours on one’s own terms (i.e. high boundary control, Kossek, 2012), to being coerced into staying long hours at work against one’s will and without notice (i.e. low boundary control, Kossek, 2012). In the former case, no work-family conflict (Greenhaus and Beutell, 1985) and even satisfaction with work-life balance was reported, while serious issues were reported in the latter case regarding the reconciliation of work and non-work lives. Taking the viewpoint of the COR theory (Hobfoll, 1989), the more personal resources nurses have, especially in terms of interpersonal relationships to assert oneself with one’s management and colleagues, but also in terms of work experience and organization capabilities, the more likely they are to maintain a schedule that suits them. In that sense, overtime is partly within the locus of control of nurses. However, it is clear from our findings that the most determining factors regarding the presence of overtime pertain to the work environment itself, which will more or less encroach upon nurses’ non-work lives. For instance, a nurse working in a hemodialysis service at a hospital will be far more likely to experience excessive overtime than a nurse working at a family doctors’ clinic. A nurse working at a dispensary for a federal agency may receive much less pressure than a nurse working at a dispensary under a regional CISSS administration. Therefore, in our participants’ experience, most factors influencing overtime are beyond their control.

Our second inquiry was to examine under which circumstances nurses are led, or forced, to do overtime that is not wished for from a personal interest viewpoint. Two salient reasons emerged from our findings: a sense of duty, and employer pressure. It was clear that our participants were motivated by a strong solidarity towards their fellow coworkers. They were aware that not engaging in overtime meant that someone else would have to do it, and therefore were bound by this duty towards their team. While unwanted from the viewpoint of one’s own desire for work-life balance, coming to work in the spirit of helping the team constituted a motivation in itself which, according to the Job demands-resources theory (Bakker & Demerouti, 2007), is positive considering the motivational pathway through which demands and resources influence employee outcomes. In other words, offering one’s time to help out one’s colleagues and patients out of a strong identification to one’s role as a nurse can be experienced as a positive challenge, which would not result in negative outcomes. This is especially true considering that a collective of nurses who know each other are apt to judge who is the most in need for some time off and can therefore, according to the principle of social exchange (Emerson, 1976), expect to he helped out at another time. For these reasons, “duty” was included as a reason for desired, voluntary overtime (Fig. 1). However, negative outcomes were obvious when management intervened by using this sense of duty as a tactic to force nurses to do overtime (see Fig. 1), which is a completely different process than nurses arranging themselves together. By guilting nurses regarding their colleagues and patients, and even threatening them of professional misconduct, this authoritative and sometimes intimidating management style significantly added to the stress experienced by nurses. Our participants consistently reported a gap between recommendations by the Order of Nurses in terms of rest and what they were forced to do by their management to meet the established nurse-to-patient ratio, highlighting an opposition between two different rationales: one that is motivated by the well-being of patients and nurses, and another one that is focused on meeting ratios and budgets. Figure 1 illustrates how this notion of “duty” is at the core of the problem at hand and how hospital management exploits this grey zone to the detriment of nurses’ well-being, perpetuating absenteeism cycles. In that sense, it can be concluded that public hospitals stand out as greedy institutions according to the definition proposed by Coser in 1974.

Finally, our findings confirm previous studies regarding the negative outcomes of involuntary overtime for nurses in terms of work-life conflict (eg. Watanabe & Yamauchi, 2018) and for hospital human resources in terms of attraction and retention of nurses (Varma et al., 2016). Our findings also show how nurses are particularly vulnerable to job burnout, which occurs when employees are consistently subjected to stressors from the job and experience emotional exhaustion, cynicism and a sense of ineffectiveness (Maslach, 2005). It is obvious that hospital nurses tend to be subjected to a managerial logic which is far from the reality of the field and which can take meaning out of their work, such as when one is forced to stay for an extra shift while the current workload does not require it. Importantly, we add knowledge to the literature by showing how mandatory overtime constitutes a risk for patients and nurses by increasing the odds of making a mistake due to extreme fatigue. These findings press the need for a stronger protection of nurses from a perspective of occupational health and safety, but also to protect them against unfair legal repercussions.

Practical Implications

Our findings highlight the problematic case of mandatory overtime, raising the question of nurses’ right to refuse overtime. When faced with a request to stay at work for an extra shift, the Order of Nurses, which has authorship of the deontological Code, recalls that

After evaluating their capacity to work as well as the context in which they have been asked to do overtime, such as the complexity of care, the state of the patients, etc., the nurse may accept to stay at work. If they judge that they are not in a state to work, they then must withdraw from work and refuse to do overtime (Létourneau, Brisson and Maitre, 2018).Footnote 2

Therefore, mandatory overtime does not constitute a deontological obligation, and nurses are even expected to refuse overtime hours if they judge that they are not in a condition to provide safe care for the patients. Our findings showed that several participants found themselves in a situation where they could not refuse the overtime despite being exhausted and found themselves inapt to work. The Order of Nurses further recalls that “the employer must not use the deontological Code to manage a situation of lack of resources nor to exert pressure on nurses” and that “The use of mandatory overtime is a measure of last resort that should always be considered in the aim to provide quality care and services to the clients, in all safety.” (OIIQ, 2018). Our findings indicate that the reality is sometimes far from these expectations, with several nurses reporting to be pressurized, either by indirect, guilt-inducing remarks, or directly by threat of denunciation and accusation of professional misconduct. Furthermore, the Order of Nurses states that employers are “encouraged to search for other measures and to communicate to the nurses all the steps taken before imposing mandatory overtime, as well as encourage nurses to speak with their management to find satisfactory solutions.” While the Order seemingly expects a discussion between nurses and their management, our findings indicate that there is no such space for discussion. Nurses on mandatory overtime are warned at a few hours’ notice and very little time is left to find solutions. Moreover, these discussions often take the form of a confrontation.

Our results have shown the mechanisms through which hospitals act as greedy institutions (Coser, 1974) trying to make nurses devote more of their time and energy to the workplace, by using non-physical mechanisms and cultivating voluntary compliance (Sullivan, 2014). The Covid-19 pandemic accentuated these already existing problems (Ayar et al., 2022; Jonas, 2021). The fact that public health institutions are becoming increasingly “greedy” on nurses’ time and energy is alarming for the future of the public healthcare system as a whole, considering that nurses are the backbone of the healthcare system (Gordon, 2012). Nurses may leave for private agencies, leading to a privatization of care and thereby worsening societal inequities. The enormous amount of involuntary overtime to which many hospital nurses are subjected is a symptom of management issues on a larger scale. Many participants indicated a trend where the current generation of nurses will only spend a few years at the hospital and then leave to work elsewhere due to the unsustainable working conditions. In the meantime, nurses develop strategies to achieve work-life balance in spite of the highly constrained context. They may do so by choosing to work part-time, to gain more control over their schedule. However, part-time nurses do not suit hospital needs and employers may impose part-timers to work full-time, generating significant disturbances to their employee’s work-nonwork balance and leading to burnout, as showed within the Covid-19 context. Therefore, mandatory overtime clearly appears as an unsustainable solution from a human resource management point of view, at least in its apparent misuse by hospital managers.

Yet, previous research indicated a great variation of overtime use between hospitals, suggesting that other solutions can be found to meet staffing needs (Berney et al., 2005). Recently, a mobile application introduced in a Quebec CISSS, allowing nurses to manage their schedule, was reported to “soften” a management system highly marked by the use of mandatory overtime (Morissette-Beaulieu, 2022). This appropriation of new technologies by nurses themselves may help reinforce or reintroduce a collective organization between nurses, and move toward more satisfactory schedules for each team members. Such innovations may offer alternative solutions to mandatory overtime, which may prove less conflictual and more respectful of nurses’ lives.

Limitations and directions for future research

It would have been interesting to consolidate the validity of our results by resorting to data triangulation, either by contacting experts or interviewing hospital managers altogether. Future research should aim to analyze the subjective experience of managers and compare them to the experience of nurses to get more precise information regarding the way overtime is managed from both sides. Moreover, it would have been interesting to interview members of the union and Order of nurses to shed more light on the subject. Still, we believe that our method is valid and offers reliable findings, which adequately reflect the complexity characterizing the current issue of overtime in the nursing profession. Another limitation is that the data was collected in the early manifestations of the Covid-19 pandemic, which is known to have exacerbated feelings of exhaustion amongst nurses. It is possible that our participants held more negative views about their work environment because of this exceptionally difficult period. Still, they could clearly express problems that were specifically related to the previous minister’s political decision to regroup Quebec hospital centers under integrated administrations, and what happened for nurses in the wake of this reform. A longitudinal research design would help collect reliable quantitative data about the amount of overtime and nurses’ levels of exhaustion and attrition.

Conclusion

This paper answers calls for more research about overtime in the nursing profession. Our in-depth, qualitative exploration of nurses’ various experiences with overtime has allowed to map out key antecedents and consequences to voluntary and involuntary overtime. While doing overtime may result from a personal choice, our findings reveal cases of nurses pressured to do extra work shifts against their deontological duty to refuse overtime in a state of exhaustion. While some workplaces offer more attractive conditions regarding the choice of working times, public hospitals tended to make a systematic use of mandatory overtime and for this reason were identified as “greedy institutions” (Coser, 1974) competing for nurses’ time and energy, to the detriment of their health, the quality of patient care, and the retention and attraction of nurses in the profession.