Thank you to the College of Registered Nurses of British Columbia for permission to adapt their case study.
Mia logged off the computer and sighed. It had been a long, busy day in the step down unit and she was tired. They'd worked one RN short again and everyone felt the extra pressure.
She glanced at the clock and then at her list of things to do before the end of her shift. As she turned to get started, the nurse in charge stopped her. “We’ve had a sick call for nights again,” she reported, her frustration evident. “I’m looking for a volunteer to stay until I can find someone to come in. We need everyone tonight ― we’re swamped.”
Mia took a deep breath and replied, “I’m not sure I can do that. I’m pretty exhausted. Give me a few minutes to think about it.”
“Could you let me know as soon as possible?” the nurse in charge wearily asked. “Everyone's tired but we need someone to stay until we find a replacement,” she said walking away.
Mia considers the situation as she walks down the hall. The unit is having difficulty finding staff. She’d heard rumblings from others about being short-staffed and working overtime. Everyone is stressed. She’d half-expected to be asked today, but that didn’t make the decision any easier.
Mia ducks into the nurses' lounge for a minute and tries to sort out what is important. Her patients’ safety and well-being is her primary concern. As a professional, she is accountable for her decisions and actions, including determining whether she can continue to practise safely. She has to decide if working extra hours would put her or her clients at risk. Could she stay and safely provide some care? Could she stay for a few hours? Mia recognizes there is no ideal solution to the dilemma. What is her best option?
Mia heads out of the lounge and finds the nurse in charge at the nursing station. "I can stay for three hours," she says. "I think it's safest if I help out as part of a team rather than taking an assignment."
Together, Mia and the nurse in charge work out a plan for the first part of the next shift. As she leaves the unit for home a few hours later, Mia thinks through her decision again. She's glad she’d been clear about her limits and how long she could stay. "Tonight," she said to herself, "staying for a few hours was the best choice."
Mia heads out of the lounge and finds the nurse in charge at the nursing station. "I can't stay,” she tells the charge nurse. "I don’t feel I can safely make decisions or respond to a crisis. I have a couple of suggestions that might help for nights though."
As she leaves the unit to go home, Mia thinks through her decision again. She knows her limit and she had reached it. "Tonight,” she said to herself, "leaving was the best choice."
Mia must balance her duty to provide care with a duty to ensure her own fitness to practise (Practice Standard 5.9). If her fitness to practise is compromised by fatigue or other factors, she has the right and a duty to decline to work extra hours (Working Extra Hours Guidelines for Regulated Members on Fitness to Practise and the Provision of Safe, Competent, Ethical Nursing Care (September 2011)).
In this situation, either option would be appropriate.
On her next shift, Mia discussed the situation with her manager and shared some ideas for dealing with similar situations. Reflecting back, Mia felt she had been professionally accountable, using an ethical decision-making process and considering the circumstances to decide the best option.