Assessment of Potential Nursing Conflicts

From an administrative perspective, there are several areas of potential conflict for the nurses if this plan were to be implemented. The conflicts could include exploitation of the nurses or coercion to participate, potential harm to the hospital if nurses provide Ms Mason's care, damage to the nurses' peer relationship, nurse fatigue, and the response to Ms Mason if she were to be readmitted to the hospital and specifically to the same unit. All of these conflicts could create long-term effects on Ms Mason, the nurses, and the hospital.

Discussion of the Conflicts

Exploitation and/or Coercion to Participate

To implement the home hospice coverage for Ms Mason everyday around the clock, a sufficient number of nurses would need to agree to participate. If an adequate number of nurses do not volunteer, the environment may become coercive because the plan cannot be implemented without sufficient nurses to cover all shifts. The coercion may be financially motivated by the need of some nurses to earn extra money. By offering double the normal wages, the pressure to participate could become intense. The coercion could also be motivated by the devotion to Ms Mason as a long-standing nurse-patient relationship has already been established.

As the nurses spend more time with Ms Mason, the arrangement may transform beyond the nursing role, and the nurses may be considered as surrogate family members and may be expected to take on additional responsibilities. This situation can provide the opportunity for additional exploitation by Ms Mason. It will then be difficult for the nurses to separate professional decisions from those based upon the friendship or surrogate role. According to Provision 2.4 of the Code of Ethics for Nurses,1 professional boundaries need to be maintained especially in long-term relationships. When the boundaries become jeopardized, nurses should make attempts to remove themselves from the situation.

In addition, participation would also need to be distributed equally to dispel the appearance of favoritism. This may be difficult based upon the other responsibilities of the nurses. Those with families will not have the opportunity to work as many shifts as those without similar responsibilities. If the nurses without additional responsibilities work more hours than the others do, there may be the appearance of favoritism and additional financial benefit. This situation could not only harm the relationship between the nurses and Ms Mason but can also harm the peer relationship between the nurses.

Potential to Harm the Hospital

When nurses are employed by a hospital, they enter a type of contract that infers that their primary obligation is to the employer. If the nurses who are already employed by the hospital enter into an arrangement with Ms Mason, they may have difficulty being loyal to both employers. Some nurses may choose loyalty to the employer who is paying them more for their services, in this case, that would be Ms Mason. These nurses face a conflict of interest between their professional integrity and potential economic self-interest. Nurses are responsible for ensuring that their roles do not create a conflict between patient care obligations and personal gain.1^{(Provision 2.2)}

The following is an example of the type of conflict that could occur. Nurse A is ill and cancels her shift with Ms Mason. Nurse B decides to work a double shift to cover but subsequently calls off her hospital shift to do so. Now the hospitalized patients are placed at risk for unsafe care if another nurse cannot be found to replace nurse B. Nurse A is now tired of working at both jobs and begins to cancel more shifts with Ms Mason. The remaining nurses working for Ms Mason must cover the extra shifts, which in turn may increase their absence at the hospital because Ms Mason pays double the nurses' salary. This situation places an additional burden on the nurses working for Ms Mason. The situation also places added burdens on the hospital nurses, and the peer relationship between the nurses becomes strained and damaged. Once the care responsibilities for Ms Mason are ended, the nurses peer relationship may be irreparably damaged, causing disharmony on the nursing unit.

Nurses' Fatigue and Potential Errors

The oncology unit nurses who participate in the care of Ms Mason, in addition to working their assigned hospital shifts, may become fatigued from the extra hours being worked. In addition, the oncology unit nurses may be working extra shifts to cover the absence of the nurses caring for Ms Mason, also leading to fatigue. Fatigue has been documented as a factor contributing to hospital errors. According to the Institute of Medicine Committee on Work Environment for Nurses and Patient Safety, fatigue leads to errors of omission, compromised problem solving, inattention to detail, and slower reaction times.2 Nurses are responsible to protect the health, safety, and rights of the patient.1^{(Provision 3.4)} In addition, nurses are accountable and responsible for their individual nursing practice.1^{(Provision 4.1)} The fatigued nurses are at an increased risk of making a serious error in care or judgment with Ms Mason or with the hospitalized oncology patients.

Ms Mason Returns to the Hospital

A final factor that could create a conflict would be the rehospitalization of Ms Mason on the oncology unit. The conflict and the strain on the nurses' peer relationships may be enhanced with Ms Mason's return as a patient. Ms Mason may request certain nurses to provide care because she is familiar with those nurses. This situation could be viewed as favoritism, and the nurses who did not participate in her home hospice program may become demoralized by the situation. There could also be the perception that the nurses providing her care are continuing to receive additional payment while Ms Mason is hospitalized. Professional boundaries could become blurred, and incidental breaches of confidentiality could occur. Only information that is essential to the care and treatment should be shared,1^{(Provision 5.4)} but many of the nurses involved in the hospice care may inadvertently reveal information gained in the home setting, thus breaching Ms Mason's right to privacy and confidentiality.

The nurses in this situation are being asked to participate in a role that not only threatens their integrity but also directly violates the Code of Ethics for Nurses, and the nurses are justified in refusing to participate in the situation.1^{(Provision 5.4)} In addition, nurses are responsible to practice in a manner that fulfills their ethical obligations to patients and employers.1^{(Provision 6.2)} The option of caring for Ms Mason in her home would lead to a variety of ethical, nursing, and hospital conflicts, and it may not allow the nurses the opportunity to practice with integrity and fulfill their ethical obligation to all parties.

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