​Nurses have an obligation to provide safe, competent and ethical care to their clients, in accordance with BCCNM’s Standards of Practice and relevant legislation.

Practice Standard

• Duty to Provide Care

Case studies

• Balancing work fatigue and client safety
• How do I know if I have a conscientious objection?
• Is it safe to provide care?
• Volunteering as a nurse: what's your accountability?

Resources

• Defining client abandonment
• Working with limited resources

F​AQs​

I am a nurse practitioner leaving my practice. What do I need to consider?

You are responsible and accountable for ending relationships in a way that considers the clients needs and ensures continuity of care. Avoid actions that could be seen as abandonment of care.  

• Where possible communicate your decision to your clients in person. You may also end the relationship  with a letter, secure email or by telephone. A minimum of three months is generally considered reasonable time to allow clients to make alternate care arrangements. And  if you are in an employment situation, notify your employer as soon as possible to give them sufficient time to replace you.
• Document the reason for ending the relationship in the client record, including a copy of any communications you have with the client.
• Ensure there is a process for all outstanding reports or test results to be reviewed and acted upon.
• Be aware that if you convert to non-practicing or do not renew your registration, all written unfilled prescriptions, including refills, are void. Plan accordingly.
• Contact BCCNM to return your duplicate prescription pads.
• Make a reasonable effort to transfer the care of clients you are actively caring for to another care provider. Agree upon when and how the alternate provider will assume responsibility for the clients’ care.  If an alternate provider is not found to take over care, clients must be advised of contingency plans. Document these plans in the client record.
• Arrange for client records to be stored or transferred – provide the college a written summary of the steps you have taken to dispose of those records as per section 357 of the BCCNM bylaws. (s. 187 BCCNM Bylaws September 1, 2020) Advise clients how they can access copies of their medical records.
• Advise other health care providers and support staff that you will no longer be providing services.
• Notify relevant organizations involved in the management of clients -  such as BCCNM, MSP, WorkSafeBC, ICBC, CNPS, BCCA, providers you regularly refer and/or receive referrals,  diagnostic facilities (laboratory and imaging,) private labs -  of your departure date and change in practice address.
• Seek legal advice from the Canadian Nurses Protective Society.

The Duty to Provide Care practice standard provides more information and guidance about your legal and professional obligations to clients.

I am an NP employed in an HA elder care program. I gave 4 months’ notice I was leaving, but they can’t recruit a new NP before I go. What are my pr​ofessional obligations to my patients? After I leave, can I follow-up on the diagnostic tests I’ve ordered?

Once you have given reasonable notice, you are responsible and accountable for working with the Health Authority to facilitate continuity and transfer of client care. For example, notifying clients and giving them information about how their health care needs will be met; prioritizing high-risk clients for appointments; ensuring the clinic is aware of pending diagnostic test or lab results. You may also have other obligations to the Health Authority based on your employment contract with them.

The clinic is responsible for addressing client-care needs while they recruit your replacement.

You cannot access client health records, including diagnostic test results, when you are no longer employed at the clinic. You can only remain involved in the care of these clients if you are retained by the Health Authority in some other way

(e.g., contract), to provide health services to these clients.

Thank you to the College of Nurses of Ontario for allowing us to adapt this Q & A from their NP Practice Q & A tab.

As an NP what should I consider related to ending my contract in a primary care network?

NPs are independent contractors, not Health Authority employees when contracted to provide health services in primary care networks. You are responsible and accountable for ending relationships in a way that considers the clients’ needs, ensures continuity of care, and meets your obligations to the Health Authority based on your employment contract with them.

Recommendations:

• Notify the appropriate contract manager within the Health Authority as soon as possible and as per your contract obligations.
• Notify clients and give them information about how their health care needs will be met, prioritizing high-risk clients for appointments. Ensure the clinic is aware of pending diagnostic test or lab results, prescription refills.
• Clients may wish to follow you if you intend to maintain an ongoing attachment relationship with them. If you do not intend to maintain an ongoing attachment relationship with your clients, work with the PCN, the Health Authority you contracted with and any other appropriate health system partners to collaboratively maintain primary care access for the clients and re-attach them to another primary care practice where possible. The Duty to Provide Care practice standard provides more information and guidance about your legal and professional obligations to clients.
• Complete and submit all reports as set out in your contract.
• Be aware that you may be considered a custodian of personal health information for the purposes of FIPPA and PIPA. Contact the contract manager or health authority privacy office regarding your obligations.
  
  Please refer to the next FAQ in this section “What are some key considerations related to client records for NPs in primary care networks?” for additional information.
• If appropriate, contact BCCNP to return your duplicate prescription pads.
• Notify relevant organizations involved in the management of clients—such as MSP, WorkSafeBC, ICBC or BCAA, providers you regularly refer and/or receive referrals, diagnostic facilities (laboratory and imaging,) private labs—of your departure date and change in practice address.
• Seek legal advice from the Canadian Nurses Protective Society.

As a family nurse practitioner, when do I have to transfer care of a pregnant client to a physician or midwife?

You can transfer care for a pregnant client to a physician or midwife at any agreed upon time during the pregnancy and before delivery. This is a decision influenced by factors such as maternal/fetal complexity and risk, your individual competence providing prenatal care, and care provider preference.

Make sure you inform your prenatal client early on that another provider will be involved in their care, including performing the delivery. You’ll need to consult with the midwife or physician at an appropriate time to determine the best approach for your client’s care. Possibilities include:

• You assume primary responsibility for prenatal care until an agreed upon gestation, then transfer care to the physician/midwife, or
• You and physician/midwife agree to share care. Clarify with the physician/midwife who will assume responsibility for various aspects of prenatal care, or
• You immediately transfer care to the physician /midwife.

If the client does not have a physician or midwife, discuss with the client and refer to an appropriate physician/midwife.

See the Consultation and referral standards in the Scope of Practice for NPs.

Can I end an NP-Client relationship when it becomes non-therapeutic?

NPs have a Duty to Provide Care and should avoid any actions that could be seen as abandonment of care. However, NPs may be required to discontinue their professional relationship with clients when the NP-client relationship is eroded to the point where NPs can no longer meet their professional obligations toward the client. Ending the professional relationship when a client has not requested it and still requires care, is generally a measure of last resort.

If the NP-client relationship no longer seems therapeutic, you may need to discontinue that relationship.  When this occurs, consider the following:

• Work with the client and others to develop and implement strategies to resolve issues impacting the NP-client relationship wherever feasible. Make reasonable attempts to resolve the situation first as this decision may have negative consequences for the client, such as limiting their access to medical care. 
• Do not allow personal judgments about a client or the client’s lifestyle to compromise the client’s care by withdrawing or refusing to provide care.
• Do not base your decisions on reasons that are discriminatory under the BC Human Rights Code, including:  race, colour, ancestry, place of origin, religion, marital status, family status, physical or mental disability, sex, sexual orientation, gender identity or expression, and age.
• Document the reasons for the decision to discontinue services in the client’s medical record, including a description of actions taken to resolve issues prior to ending the relationship, and accommodations made to ensure continuity of care.
• Where possible, assist the client to find an alternate provider or allow the client a reasonable amount of time to find an alternate provider.
• Continue to provide essential health care services such as renewing prescription medication and arranging for appropriate follow-up on any diagnostic tests ordered whenever feasible until another provider has been identified .
• Seek legal/risk management advice from the Canadian Nurses Protective Society.

Provide your client with:

• written notification of the decision to discontinue care and discuss the reason for this decision, unless meeting with the client is a safety risk.
• a copy of their medical record, or transfer the client’s medical record to another NP, physician or clinic in a timely manner.
• a time frame to find another NP, physician, or clinic. This varies depending on the circumstances of the situation, including the client’s medical condition.

While you are not obligated to continue to care for a client indefinitely, you must not abandon a client in an emergency where harm may be imminent.  In the event of a complaint to BCCNP, abrupt discontinuation of necessary medical care and treatment may constitute unprofessional conduct.
The following are examples of situations where ending the NP-client relationship may be appropriate:

• client exhibits threatening or abusive behaviour towards the NP and/or staff, including behaviour or comments of a sexualized nature
• client makes a declaration of non-confidence in the NP
• client’s behaviour is such that the primary care practice is not being utilized as the primary medical home by the client (e.g. attending other clinics unnecessarily)

The following are examples where ending the NP-client relationship is not appropriate:

• prohibited by the BC Human Rights Code
• client’s objectionable behaviour is reasonably attributable to cognitive impairment, unless it is determined that the client poses a significant safety risk to the NP and/or staff
• client respectfully declines to follow the NP’s advice
• client seeks treatment to which the NP objects based on scientific, conscience or religious beliefs

Review CNPS information on ending the NP client relationship.

Thank you to the College of Physicians and Surgeons of BC for permission to adapt their content.

Sometimes I’m concerned about my safety when my practice takes me into certain environments. What can I do to keep myself safe?

If you think providing care would put you at risk, you may withdraw from providing care or refuse to provide care. Think about your legal, professional, and contractual responsibilities and use an ethical decision-making process to help you make the decision.  The Duty to Provide Care practice standard provides more information and guidance about your legal and professional obligations to clients.

It's important to work with the client, co-workers, and your employer to develop a plan that allows for client care and for your safety.  

For example:

• Make sure the environment is safe by having the client remove any offending material or persons before your visit.
• Negotiate a treatment plan with the client that states the terms under which care will be provided.
• Arrange for another nurse to partner with you when doing home visits.
• Make sure you have a way to call for help in an emergency (i.e. cell phone)​.
• Have the client come to the clinic for treatment. ​

My client rarely keeps his appointments. When he does he is rude and verbally abusive to staff and other clients. Do we have a duty to provide care to this client?

Nurses have a professional and legal duty to provide clients with safe, competent and ethical care, and the client has a right to receive care. Do not allow your personal judgments about a client, or the client's lifestyle, to compromise the client's care by withdrawing care or refusing to provide care.

While you cannot abandon your clients, do not put yourself or clients in situations where giving care might be a danger to personal safety - violence; communicable disease; physical, verbal, or sexual abuse.

When we have to work over census or short-staffed, I’m concerned that client care may be compromised. What should I do?

Situations where the need for health care is greater than the available resources require your professional judgment and ethical decision making. You are responsible for providing safe, appropriate and ethical care to the best of your ability.

The following strategies may help you:

• Work with the care team to assess client needs, staff capacity and available resources. Be sure to consider environment safety needs such as oxygen, suction, and access to call bells.
• Set priorities, adjust client plans of care and care delivery as needed. This may include moving clients to ensure appropriate access to equipment or monitoring.
• Identify and communicate any immediate safety concerns to the appropriate person, such as your supervisor or manager.
• Explore whether discharging or transferring clients is an option. Include physicians in the discussion when appropriate.
• Check in with the care team regularly throughout the shift to reassess and adjust care plans as needed.
• Document the situation and communicate any concerns to your manager.

Working with limited resources and 10 tips may provide further information and guidance for these situations.  For further assistance contact practice@bccnm.ca

When we work short-staffed, we’re not always able to meet all our clients’ care needs. Can we be reported for not meeting standards?

In this type of situation it is very unlikely that you would be reported to BCCNM. For BCCNM to become involved, a formal written complaint must be received, describing how a nurse’s unethical, impaired or incompetent practice puts clients’ at risk.

 

It’s important to remember that even in situations where you cannot provide optimal client care, you can still meet the Professional Standards. These situations are usually beyond your individual control and often require a systems approach for resolution. You are responsible for providing the best care possible under the circumstances. In these situations:

• Start by assessing client needs, available staff and mix.
• Communicate any immediate safety concerns to your manager or supervisor.
• Work with the care team, set priorities, and adjust client plans of care and care delivery as needed.
• Check in with the care team frequently during the shift. Reassess and adjust client plans of care as appropriate.
• At the end of your workday, document the situation and your concerns and share with your manager.

By following these steps, you are likely meeting your Professional Standards and your obligation to provide clients with safe, competent, ethical care.

You’ll find more information and guidance in in the resource Working with limited resources.

For further assistance contact practice@bccnm.ca.

I’m expected to work in an unfamiliar practice area. Can I refuse?

Your employer has a right to reassign you to another area. You were likely hired by an agency or health authority and cannot refuse to be reassigned.

Consider what care you can safely provide, while practicing within your level of competence. Clearly communicate this to the most appropriate person such as your immediate supervisor and discuss any concerns about your reassignment.  Refusing a reassignment is generally justified only when the risk of harm to clients is greater if you accept than if you refuse. If you don’t have the competence to work in the assigned area, collaborate with others to determine the best option and follow up in writing.

Working in an unfamiliar practice area can be challenging and anxiety provoking. Using these strategies may help:

• Ask for an orientation to the clients, environment and resources.
• Review your assignment with the charge nurse and discuss the care requirements for your assigned clients.
• Outline your competencies as they relate to the client care required, indicating what care you can safely provide and what you cannot.
• Communicate regularly with the charge nurse/team leader about changes to your clients and their plan of care.
•  Ask for nurse to be assigned as your resource person.

Working with limited resources may provide further information and guidance for these situations.  For further assistance contact practice@bccnm.ca​​​​​​​