Practice Spotlight: Protecting Yourself is Not Abandonment

One of the fundamental principles guiding nursing practice is the “duty to provide care”. This obligation requires nurses to continue providing care to clients once they have accepted them into their care. For more information about the duty to provide care, please review this document.

But what happens when that care presents unreasonable personal risk to the nurse? This practice spotlight explores the limits of the duty to provide care and offers guidance, about how to navigate challenging situations that may require you to withdraw from caring for physically or verbally aggressive, combative, or violent clients.

Understanding the Limits of Your Duty to Provide Care

Nurses are committed to delivering high-quality care, but it is essential to recognize that the duty to provide care has limits. When doing so will put the registrant at unreasonable personal risk, continuing to provide care is not an expectation. There are steps a registrant can take, to ensure they are meeting their practice expectations, when they make the decision to withdraw from care, to protect their own safety.

Making the Decision to Withdraw from Care

When faced with a potentially unsafe situation, the decision to withdraw from care should be thoroughly considered. Here are some suggestions, which may assist registrants with this consideration:

Involve Others: Engage colleagues, managers, and team members in the decision-making process. Involving others in decision-making will assist registrants to identify any blind spots and bias, consider the situation more objectively, and brainstorm potential solutions.
Articulate and Evaluate the Risks: Clearly identify what is unsafe or potentially unsafe about the provision of care. What specifically are your concerns? Evaluating the likelihood and potential outcome of continuing to engage in care can help you to assess the risk.
Assess Safe Care Options: Explore whether there are aspects of care that can be delivered safely. Can certain treatments or interactions be adjusted to minimize risk? Can you provide crucial parts of the required care now and provide the rest later, when it is safer?
Consider Possible Solutions: Consider practical steps to improve the safety, such as:

- Making efforts to understand the client’s actual or perceived unmet needs.

- Making efforts to understand and treat any medical or psychiatric explanation for the aggressive or violent behaviour.

- Using a different approach to communicate with the client.

- Considering if it would be helpful to have another clinician lead or provide the needed care.

- Involving additional personnel.

- Utilizing appropriate protective equipment that is available in the practice environment.

- Allocating extra time to provide the needed care.

- Waiting to provide care until later.

- Administering medication, if applicable and appropriate.

- Changing the care setting as needed.

Once the Decision Is Made

After careful consideration, if the decision is to withdraw from providing care, consider the following suggestions:

Provide what care you can, under the circumstances: Deliver care without compromising your safety. If there are steps you can reasonably take to keep the client safe, take them.
Communicate with the client compassionately and transparently: If it is safe and appropriate, explain to the client the nature of the care you intend to provide, why it is necessary, and what needs to happen to continue safely. As always, be thoughtful and intentional with verbal and non-verbal messages.
Collaborate to improve safety: Work with your employer and team to implement plans to monitor the client or improve the safety of the situation.
Monitor the client: Take reasonable and safe steps to monitor the client’s condition, ensuring they are stable and secure. If it becomes safe to provide care, take steps to reengage cautiously.

Follow-Up Responsibilities

Nurses must be accountable for their decisions and actions. Proper documentation is crucial and should include:

Details of the nursing care provided.

Any efforts made to improve safety, whether successful or not.

Information about the decision to withdraw from providing care, including who was consulted.

Any plans to monitor the client’s health and safety.

It is also crucially important that nurses report safety concerns and participate in quality improvement initiatives in their practice environment. This may involve:

Reporting safety concerns using the processes available in the practice environment (occurrence reports, for example).

Participating in care planning sessions or incident reviews, as appropriate.

Identifying any reflections or lessons learned during the process and suggesting improvements in the care plan or practice setting.

Consider if there were resources or processes in the practice environment which could have been utilized.

Finally, remember that a registrant’s personal well-being impacts the registrant and their clients. Following situations when registrants have needed to manage or respond to aggressive or violent behaviour, they should take the necessary actions to assess and attend to their physical and mental wellness and ensure they are fit to practice before going back to work. For more information about Fitness to Practice, see this document.

Conclusion

Navigating the complexities of care, especially in challenging situations, can be daunting. By understanding your responsibilities and recognizing the limits of your duty to provide care, you can make informed decisions that prioritize both your safety and the quality of care you deliver. Remember, withdrawing from care to protect oneself from the actions of a violent, aggressive, or combative client is not abandonment; it is a necessary step to ensure that the client receives safe and effective care.

For additional reading on this subject, please review the following resources: