Planned and unplanned Emergency Department closures are frequent events within our healthcare system due to staff (physician and/or nurse) shortages. Some Emergency Departments do not have physician contact/coverage for the closure periods and are physically locked, and nurses are faced with the ethical dilemma of dealing with the public who arrive seeking treatment. Other departments remain physically open despite the lack of physician coverage, and nurses, potentially in conjunction with paramedics, continue to assess, triage and treat or transfer patients. The NSHA is seeking to standardize processes across the province.

Nurses have a professional obligation to provide clients with safe, competent and ethical care, a requirement defined by their College through Standards for Nursing Practice and the Code of Ethics, and through related legislation. These professional obligations can have limits as the duty to provide care may be constrained by several factors such as lack of physician services.

‘Duty of care’ is a legal term used to describe the obligation imposed on nurses requiring that they exercise a reasonable standard of care while providing nursing services. The moment a nurse engages in the provision of care with a client, a nurse-client relationship is established, and that nurse is held to that standard of care. Breach of the duty of care, if resulting in an injury, may subject a nurse to legal liability.

While there is an expectation that nurses will provide care to the sick, there should be no expectation that nurses will place themselves at unnecessary risk. Such risk may occur when a nurse’s ability to provide safe care and meet professional standards of practice is compromised by threats or potential threats to the nurse’s safety, or the safety of others. It could also occur by means of unreasonable expectations such as an expectation to provide care beyond scope, or without the appropriate resources. 

Employers are responsible to ensure mechanisms are in place to support safe and ethical practice and are accountable for providing:

• policies, procedures, and/or guidelines to assist employees in making decisions regarding the duty to provide care
• sufficient and appropriate staffing for safe, competent and ethical care

Note: In Canada, there is no legal duty that forces nurses to help someone in an emergency outside of the workplace setting. While a nurse may feel a moral or ethical duty to do so, a nurse cannot be held liable for failing to assist where there is no legal duty to do so. 

NSNU Position

During Emergency Department closure periods:

• Employers shall ensure that contingency policies and protocols are developed and circulated to all emergency department and other appropriate staff that experience closures.
• Employer protocols should clearly identify how nurses should transfer care to a more appropriate provider or setting when necessary.
• A team of nurses, or a nurse-paramedic team, may be expected to assess and treat patients, and/or transfer care to a more appropriate provider or setting, as the case warrants.
• If nurses believe they are being asked to provide care beyond scope, or beyond what is safe given the staff and resources at hand, the nurse should contact the employer and follow the Clinical Capacity Report process as outlined in section 17 of the collective agreement.
• Nurses will not triage, treat, register, or allow access to the department when they are alone, or when they believe their personal safety, or the safety of others may be at risk.
• When the public try to access a closed emergency department and a nurse is alone or otherwise not able to safely assess or provide care, the nurse will contact 911 for police and/or paramedic assistance.
• Nurses shall be informed prior to closures whether there will be physician coverage and shall be given clear direction regarding protocols for dealing with the public.
• The employer shall issue timely Public Service Announcements and public notices regarding closure and instructions for accessing treatment.
• The employer shall ensure there is signage at the emergency department entrance directing the public to alternate sites/services.
• If nurses are instructed by the employer to triage, treat or register patients while they are alone or otherwise feel unsafe, they should contact the NSNU. 
• Nurses, like all workers, have the right to refuse work that may threaten their personal safety, or the safety of any other person at the workplace. After other procedures are followed (e.g. calling 911 for the patient), nurses should inform their employer about a work refusal.
• If the event occurs after NSNU office hours, nurses shall follow the direction of the employer if, according to their professional judgment, there is not a significant safety risk justifying a refusal. Nurse shall complete a Clinical Capacity Report and contact the NSNU during office hours. Nurses may also contact their local union representative.