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Balancing work fatigue and client safety

Case study about ethical decision making

​​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 shift coordinator stopped her. “We’ve had a sick call for nights again” she reported, her frustration evident. “I haven't found anyone to come in yet, so I’m looking for a volunteer to stay until I can find someone. 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 shift coordinator 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’s dilemma

Mia ducks into the nurses' lounge for a minute, and tries to sort out what is important. Her clients' 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.

Would working extra hours put her clients at risk? Could it put her 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?

She thinks about what she must consider: 

  • the clients, care needed and its complexity
  • where was she in her stretch of shifts
  • how many hours had she been awake already and her level of alertness now 
  • whether she'd had appropriate breaks and nutrition over her shift 
  • her commute home

If you were Mia, what would you do?

Stay and work extra hours

Mia takes stock. She’d slept well last night and is  off tomorrow.  She’d managed to take breaks to eat lunch and dinner. She feels alert right now and her drive home is short. Mia heads out of the lounge and finds the shift coordinator at the nursing station. "I’m off tomorrow and feel reasonable  right now. 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 shift coordinator 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."

Leave at the end of the shift

Mia takes stock. It was her first of four and she’d barely slept the night before. She hadn’t had dinner yet and was feeling exhausted. She was already having problems calculating her ins and outs and still had to drive home.  Mia heads out of the lounge and finds the unit coordinator at the nursing station. "I can't stay,” she tells the shift coordinator. "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."

What do the Standards say?

Mia must balance her duty to provide care with a duty to ensure her own fitness to practice (Professional Standard 1.6). If her fitness to practice is compromised by fatigue or other factors, she has the right and a duty to decline to work extra hours. Her desire to help out her coworkers must be balanced against the safety of her clients.

In this situation, either option would be appropriate.

Mia’s next steps

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.​

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