Duty to provide care is a professional responsibility requiring NPs to provide reasonable care to those under their care. This resource will cover some common topics about which we often receive questions.
What will I learn?
Standards
The
Duty to Provide Care practice standard is comprehensive and includes various aspects of nursing practice. NPs are expected to follow standards to ensure the delivery of safe, competent, and ethical care to their clients.
Duty to provide care is a nurse's ethical, legal, and professional responsibility and applies to all aspects of nursing practice. The duty continues until the accountability for care has been transferred to another appropriate care provider.
Failing to meet the duty to provide care standard, inappropriately discontinuing the NP-client relationship, or failing to properly transfer the accountability for ongoing care to an appropriate care provider could be seen as abandonment.
Leaving NP practice
Leaving your NP practice, regardless of the setting you work in, is a decision that requires careful consideration. The
Duty to Provide Care practice standard lays out your legal and professional obligations.
Other factors to consider:
- Notice period
-
Giving enough notice is professional and ensures a smooth transition for your clients and colleagues. If you are working under a contract, review it to find out how much notice you need to give. If you are a self-employed NP, provide adequate notice unless there are extenuating circumstances, for example, unable to contact the client.
Once you have given notice, work with your employer or contractor to facilitate continuity and transfer of client care. For example, prioritize high-risk clients for appointments, and ensure the workplace is aware of pending diagnostic tests or lab results. If you are self-employed, take steps to ensure client's care needs are addressed or transferred.
As you will not be able to access client health records or diagnostic test results once your employment contract ends, ensure there is a process for all outstanding reports or test results to be reviewed and acted upon.
Where possible, end the NP–client relationship in person. You may also end the relationship with a letter, secure email, or by telephone/web conference. Do not end an NP–client relationship with a text message. Document all communications with the client, the outcome, and the plan in the client's record.
- Client care
-
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 new provider will assume responsibility for client care. If another provider is not found, tell clients of contingency plans including how they can access copies of their health records. Document these plans in the client record.
If you are converting to non-practising status or you do not renew your registration, all unfilled prescriptions, including refills, are void. Plan accordingly.
Let other health-care providers and support staff know that you will no longer be providing services. Notify relevant organizations involved in client care (e.g., MSP, WorkSafeBC, ICBC, BCCA, providers you regularly refer and/or receive referrals, diagnostic facilities, private labs) of your departure date or change in practice address, if moving to a new practice.
- Legal considerations
-
Consult with the Canadian Nurses Protective Society to ensure you are fulfilling legal requirements around client care, employment contracts, and non-compete agreements.
- Client records
-
Arrange for client records to be stored or transferred. Provide the college with a written summary of the steps you have taken to dispose of those records as per section 187 of the BCCNM bylaws. You may be considered a custodian of personal health information for the purposes of FIPPA and PIPA. Contact your contract manager or health authority privacy office regarding your obligations.
Ending the NP–client relationship
Withdrawal from care requires careful and deliberate decision-making and thoughtful consideration of many factors. Ending an NP–client relationship can be challenging. Make reasonable attempts to resolve issues as ending the relationship may negatively impact the client, such as by limiting their access to medical care.
Ending the professional relationship when a client has not requested it and still requires care is generally a last resort. Avoid any actions that could be seen as abandonment of care. While you are not obligated to care for a client indefinitely, you must not abandon a client in an emergency where harm may be imminent. Abrupt discontinuation of necessary medical care and treatment may be seen as unprofessional conduct.
Examples of appropriate and inappropriate reasons to end the NP–client relationship:
Appropriate
Not appropriate
- Reason is prohibited by the BC Human Rights Code (for example, discrimination based on race, colour, sex).
- Client's objectionable behaviour is reasonably attributable to cognitive impairment unless the client poses a safety risk to the NP and/or staff.
- Client declines to follow the NP's advice.
- Communicate with empathy
-
Be empathetic when communicating with clients. Acknowledge that ending the relationship may be difficult for them and offer your support and understanding throughout the transition process.
- Help in transitioning care
-
Where possible, help your client transition their care to a new provider. Recommend other nurse practitioners or physicians and transfer client records, prescribe medication refills, and/or follow-up on any diagnostic testing where feasible until the client has another provider.
- Give advance notice
-
Give your clients written advanced notice by sending out a letter or email. Give clients adequate notice so they have ample time to find a new provider and let them know how their health-care needs will be met during the transition. Prioritize high-risk clients for appointments. Ensure you (if self-employed)or your workplace are aware of pending diagnostic test or lab results and prescription refills.
Document the reasons for the decision to end the relationship in the client's record, including actions to resolve issues and ensure continuity of care.
- Provide a summary of care
-
Provide your clients with a summary of their care history, including diagnoses, medications, and treatment plans. This can help ensure continuity of care with their new provider. Follow workplace policies.
- Maintain professionalism
-
Maintain a professional demeanor during the transition process. Avoid discussing your reasons for leaving in detail, and do not make negative comments about your employer or colleagues.
- Follow legal and ethical guidelines
-
Ensure that you follow legal and ethical guidelines in ending the relationship. This includes maintaining client confidentiality, fulfilling any legal or contractual obligations, and avoiding any conflicts of interest.
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.
In summary, ending an NP–client relationship requires professionalism, empathy, and adherence to legal and ethical guidelines. By providing advance notice, offering assistance in transitioning care, and maintaining a professional demeanor, you can ensure a smooth and ethical transition for both you and your clients.
After-hours coverage (on-call)
BCCNM does not have a standard on after-hours coverage as there are many variables in a practice setting that need to be considered. NPs ensure continuity of care by having processes to facilitate continuity and access to care after hours.
Depending on the work setting (hospital, primary care, self-employment), when deciding about after-hours care, NPs are expected to follow:
Case studies
FAQs
-
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 (i.e., 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:
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:
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:
Working with limited resources may provide further information and guidance for these situations. For further assistance, contact
practice@bccnm.ca.
Resources
BCCNM resources
External resources