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Is it safe to provide care?

Case study about personal safety and ethical decision making

 

Marcie is currently employed in a Home Health office, delivering home care nursing services to clients in the community.

A new client, Ray, has been referred to the home care program for complex wound care. Ray lives in a two-bedroom apartment on the second floor of a rundown building, in a neighbourhood that has a lot of street crime. He has two roommates who he met while in an addiction treatment program. Ray has been in recovery from a substance use disorder for the past six months.

Marcie is confident she has the skills to carry out the wound care Ray needs. However, she wonders if his home is a safe place to provide care. 

Concerned by recent staff reports of aggression towards the home health staff, Marcie has recently completed employer-provided education in violence prevention related to personal safety. She applies this knowledge when reviewing Ray’s information, taking note of factors that could present a risk to the client, herself and others. These risk factors may affect how and where this client’s care will be delivered.

 Marcie makes note of:
Client factors
  • While in the hospital, Ray had multiple recorded incidents of confusion. During these episodes, he would become physically aggressive, and throw items at staff who attempted to deliver care
  • He has a history of substance misuse
  • His injury is related to a police incident that occurred while he was fleeing the scene of a crime
Environmental factors
  • ​Ray’s roommates both have a history of substance misuse 
  • Ray lives in an area known for high rates of street crime
  • The elevator in his building has a history of frequently breaking down
  • There have been several documented  incidences of violence against care providers in this community
​Marcie is aware that the current client situation presents a number of risks factors. She also knows she has a duty to provide quality care to Ray, while keeping herself and others safe.

 What steps could Marcie take?
Perform a pre-visit risk assessment

​Interview the client by phone, using her organization's risk assessment tool.

  • Assess the client's mental status
  • Ask about the neighbourhood and the safest time to visit
  • Discuss the possibility of not having the roommates at home when she comes
  • Review current medication and substance use
  • Ask about his support system, including family and friends
Implement, evaluate and amend the care plan as needed
  • ​Reflect on decisions made and the outcomes.
  • Continue to communicate and consult with others as necessary to update the plan.
  • If any incidents occur related to personal safety, report them to your employer verbally and in writing.
Consult available experts and resources

​In making the decision on how to provide care to Ray, Marcie may want to:

Develop, document and communicate a plan of care

The plan of care addresses risk and include mitigating strategies, while meeting both the client’s care needs and ensuring staff safety. Both the client and care team should be involved in planning for the care. Consider:

  • Developing a contract with the client, significant others, and/or family outlining the circumstances under which care will be delivered
  • Setting expectation that physical, mental and emotionally abusive behaviors will not be tolerated, and that a breach of these expectation could result in the withdrawal of care
  • Exploring alternate care locations, such as clinic settings, or consider two-nurse visits or training Ray’s friends or family to deliver care

​Nurses have a professional and legal obligation to provide their clients with safe, competent and ethical care; however, they are not obligated to put themselves in danger. Marcie needs to balance her duty to provide care with her personal safety and the safety others.

Marcie's decision

After careful thought and preparation, Marcie decides that she feels safe providing care in Ray’s home when his roommates aren’t home. She speaks to Ray and they agree the best time for this care is early afternoon.

This case study originally appeared on our website in 2012. It was updated in June 2016 to better reflect some of the challenges facing nurses. We thank everyone who contributed.

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