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Duty to Provide Care

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

Practice Standards set out requirements related to specific aspects of nurses' practice. They link with other standards, policies and bylaws of the College of Registered Nurses of British Columbia (CRNBC) and with all legislation relevant to nurses' practice.

Nurses1 have an obligation to provide safe, competent and ethical care to their clients, in accordance with CRNBC's Standards of Practice and relevant legislation. There are, however, some circumstances in which it is acceptable for a nurse to withdraw from care provision or refuse to provide care.

Employers are responsible for providing the necessary resources and support to help nurses meet the Standards of Practice.

Principles

1.

Nurses have both a professional and legal obligation to provide their clients with safe, competent and ethical care.

2.

Nurses do not allow their personal judgments about a client, or the client’s lifestyle, to compromise the client’s care by withdrawing or refusing to provide care.​​​​

3.

Nurses do not abandon their clients. Abandonment occurs when the nurse has engaged with the client or has accepted an assignment and then discontinues care without:

  a.

negotiating a mutually acceptable withdrawal of service with the client, or

  b.

arranging for suitable alternative or replacement services, or

  c.

allowing the employer a reasonable opportunity to provide for alternative or replacement services

4.

Nurses who have a conscientious objection to a client’s request for a particular treatment or procedure:

  a.

listen carefully, respectfully, and explore the client’s reason for the request and their understanding of options that could meet their needs. 

  b.

do not attempt to influence or change a person’s decision based on the nurse’s conscientious objection

  c.

do not allow his or her beliefs or values to alter or interfere with a client receiving high quality safe, ethical and competent care

  d.

ensure that the most appropriate person within their organization is informed of the conscientious objection well before a client is to receive the requested treatment or procedure

  e.

work with their organization to ensure uninterrupted continuity of care including reporting the client’s request  and, if needed,  safe transfer of the client’s care to a replacement provider

  f.

despite their conscientious objection, provide safe care to a client in situations involving imminent risk of death or serious harm that arise unexpectedly and require urgent action for the client’s safety

5.

Nurses may withdraw from care provision or refuse to provide care if they believe that providing care would place them or their clients at an unacceptable level of risk. In these situations, nurses use an ethical decision-making process and consider these factors:

  a.

the specific circumstances of the situation

  b.

their legal and professional obligations

  c.

their contractual obligations

6. Nurses do not provide care that is outside the scope of practice except: 
  a.

In situations involving imminent risk of death or serious harm that arise unexpectedly and require urgent action,2 or

  b. Where a restricted activity has been formally delegated. In emergencies, nurses are ethically obligated to provide the best care they can, given the circumstances and their level of competence. In carrying out restricted activities through delegation, nurses comply with CRNBC standards for delegation3

7.

Nurses recognize that informed, capable clients have the right to be independent, live at risk and direct their own care. Regardless of this right, nurses do not comply with client wishes when doing so would require action contrary to the law or CRNBC’s Standards of Practice

Applying the principles to practice

The client’s right to safe, competent and ethical care is of paramount importance. In some situations, however, your individual rights and values may conflict with the client’s right to receive care.

Use an ethical decision-making process to determine the most appropriate course of action:

1.

Determine the facts and identify the issue or concern by:

  • gathering  information significant to the concern from all relevant sources;
  • identifying situations in which your judgments, beliefs, or values conflict with the client’s right to receive safe, ethical and competent care;
  • identifying the people (e.g. client, family, health care team) involved; and
  • articulating the issue of concern

2.

Clarify the issue of concern by:

  • consulting various sources of information (e.g., Standards of Practice, Code of Ethics for Registered Nurses, relevant legislation, and your collective agreement or employment contract); and
  • discussing it with other knowledgeable people (e.g., colleagues, employers, educators, CRNBC nursing practice consultants or others with an expertise in ethics)

3.

Identify your options and develop a plan.

4.

Implement the plan, evaluate the outcomes of your decision and amend it if necessary.

Nurses may experience difficulties in meeting their obligations to provide care when they are faced with one or more of the following:

  • an unreasonable burden
  • a personal danger
  • concerns about individual competence
  • conscientious objection

Unreasonable Burden: An unreasonable burden exists when your ability to provide safe care and meet the Standards of Practice is compromised by unreasonable expectations, lack of resources, or ongoing threats to personal well-being.

  • When an unreasonable burden exists: Do your best to meet the Standards while making your concerns known to your employer and, if appropriate, your union and CRNBC.
  • When you are asked to cope with an unreasonable burden: First assess your fitness to practise. If you decide that you do not have the necessary physical, psychological or emotional well-being to provide safe and competent care, you may withdraw from care provision or refuse to engage in care once you have given notice to your employer and allowed a reasonable opportunity4 for alternative or replacement services to be arranged. If you are self-employed, give reasonable notice to your client and take reasonable action to ensure that alternative or replacement services are in place. In all likelihood, you will need to document situations involving unreasonable burden.

Personal Danger: While you are not entitled to abandon your clients, you are not obligated to place yourself in situations where care delivery would entail unreasonable danger to your personal safety. This includes situations involving:

  • violence
  • communicable diseases
  • physical or sexual abuse

Under the Workers Compensation Act, employers are obliged to provide a safe work environment, which includes providing a comprehensive program to eliminate or manage the risk for abuse or injury in the workplace. Work with your employer to develop strategies that make the work environment a safe place to practise.

In recent years, there has been a growing awareness of the importance of planning for pandemics and other disasters. If such plans are being developed in your area, consider how you could contribute to the process.

Individual Competence: You are obligated to practise competently and to continually acquire new knowledge and skills in your areas of practice. You are not obligated, however, to provide care beyond your level of competence.
If you are asked to provide care beyond your competence:

  • Provide the care you are competent to give.
  • Consider whether providing a part of the required care (i.e., that part you are competent to give) is more appropriate than not providing care at all.
  • Inform your employer verbally and, if necessary, in writing that you do not have the competence to work in the specific situation.

Conscientious Objection: When a specific type of care, treatment or procedure, conflicts with your moral or religious beliefs and values, you may arrange with your employer to refrain from providing the care. Personal biases or judgments against the client or client’s lifestyle are not grounds for conscientious objection. Make the conscientious objection known to your employer well before a client would require care.

If you have a conscientious objection you are responsible for ensuring that your conscientious objection does not impact the continuity of care or compromise the ability of the client to receive high quality, safe, ethical and competent care.

Applying the principles in specific nursing roles

  • If you are a nurse practitioner, understand your obligations as a primary care provider (e.g., leaving your practice or taking call).
  • If you are a nurse administrator, educator or researcher, consider how to apply the principles to your work
  • Regardless of your role, participate in developing a workplace environment that supports staff safety and well-being and enables nurses to meet their professional responsibility to provide safe, competent and ethical care.

Glossary

Abandonment: A situation where the nurse has engaged with the client or has accepted an assignment and then discontinues care without negotiating a mutually acceptable withdrawal of service with the client, or without arranging for suitable alternative or replacement services, or without allowing the employer a reasonable opportunity for alternative or replacement services to be provided.

Competence: The integration and application of knowledge, skills and judgment required for safe and appropriate performance in an individual’s practice.

Fitness to practice: All the qualities and capabilities of an individual relevant to his or her capacity to practise as a nurse, including, but not limited to, any cognitive, physical, psychological or emotional condition, or a dependence on alcohol or drugs, that impairs his or her ability to practice nursing.

For more information​

Stan​dards of Practice

CRNBC's Standards of Practice (Professional Standards, Practice Standards, Scope of Practice Standards) set out requirements for nurses' practice. They are all available from the Nursing Standards​ section.

  •  Communicable Diseases: Preventing Nurse-to-Client Transmission Practice Standard (pub 442)
  • Boundaries in the Nurse-Client Relationship Practice Standard (pub. 432)
  • Professional Standards for Registered Nurses and Nurse Practitioners (pub. 128)
  • Scope of Practice for Registered Nurses: Standards, Limits, Conditions (pub. 433)
  • Scope of Practice for Nurse Practitioners: Standards, Limits, Conditions (pub. 688)

Other CRNBC​ resources

  • Fitness to Practice: The challenge to maintain physical, mental and emotional health (pub. 329)
  • Legislation Relevant to Nurses’ Practice (pub. 328)

Other resources

  • Canadian Nurses Association (CNA) Code of Ethics for Registered Nurses available at www.cna-aiic.ca

For more information on the duty to provide care or any other practice issue, contact CRNBC's Practice Support Service at practice@crnbc.ca or 604.736.7331 ext. 332 or toll-free 1.800.565.6505.

Footnotes

1

"Nurse" refers to the following CRNBC registrants: registered nurses, nurse practitioners and licensed graduate nurses.

2

Employers and nurses should not rely on the emergency exemption when an activity is considered an expectation of practice in a particular setting.

3

For information about delegation, see CRNBC's Scope of Practice for Registered Nurses: Standards, Limits, Conditions, Part 4.

4

What is reasonable in one context may not be reasonable in another. Reasonableness will vary depending on the specific circumstances of the situation and is established through discussion and consultation.

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 Need help?

For further information on the Standards of Practice or professional practice matters, contact us:

  • Telephone 604.736.7331 ext. 332
  • Toll-free in Canada 1.800.565.6505
  • Email practice@crnbc.ca
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