1
Q
The consideration of ethical issues is an essential component of providing care within the therapeutic nurse-client relationship. Nurses may encounter ethical situations in their everyday practice. HOW AS A NURSE WOULD YOU ACHIEVE THIS?
A
Understanding and communicating the clients’ beliefs and values, as well as their own, helps nurses recognize ethical conflicts and work through them if they do occur.
2
Q
- Are strongly held personal beliefs - ideals we strive to uphold
- Are enduring beliefs or attitudes about the worth of a person, object, idea, or action
- Are both consciously and unconsciously acquired
- Are revealed in our behaviour – verbal and non verbal communication
- Repeated patterns of behaviour tell as a lot about what a person values
- Whether or not we realize it, our values influence our behaviour, the choices we make, how we see an issue and how we respond
A
VALUES
3
Q
• Are formed from an early age and are learned.
• Influencing factors:
•
o Family, friends, educators
o The socio-cultural environment a person lives in
o Life experiences
o Religion
o Mass media
o
social media: facebook, twitter, instagram
A
VALUE FORMATION
4
Q
• Personal and professional values can be transmitted
•
o eg. you learn personal values from family, friends, peers, life experiences
o eg. you learn professional nursing values from clinical and classroom experiences, teachers, nurses
A
Values Transmission
5
Q
- Results in greater self-awareness and personal growth
- Requires conscious, deliberate examination of one’s values
- Is the process by which a person reflects on, identifies, names, and develops his or her own individual values
- Helps a person understand why he or she behaves a certain way
A
Values Clarification
6
Q
involves deliberate examination of one’s thoughts, beliefs, feelings, physical and emotional responses to others and situations.
A
Reflection
7
Q
• Reflection involves deliberate examination of one’s thoughts, beliefs, feelings, physical and emotional responses to others and situations.
• It requires honesty with self:
• What are my core values and beliefs and how did I get them?
• What are my biases about others and how did I get them?
• Does my behaviour – physical and emotional responses - express what I truly believe? If not, how can I change this?
Dialogue with others is helpful. It helps you:
• Articulate your point of view
• Hear and understand others’ points of view and gain a sense of their values
• Realize there are different ways of understanding the same thing
A
Values Clarification
8
Q
- Requires honest, open communication and discussion, and mutual respect
- Requires active listening and a willingness to try to understand the other person’s perspective
A
Effective dialogue
9
Q
Values clarification helps you?
A
- Freely choose to keep, discard or adopt new values
- Know why you prize and cherish your values and beliefs - and explain this to others
- Act on your beliefs and values in a consistent pattern. You walk your talk
10
Q
• Ethical relationships require us to be fully aware of our own values and beliefs
• Every person has their own understanding of a situation. We need:
•
o To know why we react and feel the way we do in a given situation
o To know what “pushes our buttons” and why
o To be open to other people’s ways of understanding the same thing
A
Self-Awareness
11
Q
- Reflect the core beliefs that guide the behaviour and decision making of members of the professional group
- Determine how members of the professional group frame and address problems
- Are reflected in the professional group’s mission and vision statements, and code of ethics
- Inform others about the type and quality of service or interactions they can expect when interacting with members of the profession.
- Usually reflect societal values, thus, change over time in response to changes in societal values
A
Professional Values
12
Q
- In Ontario, the College of Nurses Ethics Practice Standard identifies core values that all nurses who are licensed in the province are expected to abide by.
- When the CNO assesses a member’s behaviour, it considers how well the nurse adhered to and embodied the CNO’s professional values.
- Professional nursing associations (e.g. the RPNAO) also develop codes of ethics outlining the values that are important to them.
A
Professional Values
13
Q
- Workplaces also have their own set of values
- Values may be overt – e.g. vision and mission statements
- Values may be covert – e.g. not recognized or known unless a person is employed or a patient/family member
- When you accept employment, there is an assumption that you are willing and ready to commit to the values of the agency/institution.
- Having a clear understanding of your personal values and nursing’s professional values will enable you to confidently assess whether a potential employer is right for you.
A
Institutional Values
14
Q
- Professional values build on and expand personal values.
- Your socialization into the nursing profession exposes you to nursing’s professional values.
- Your personal values may compliment nursing’s professional values or conflict with them.
- Nurses are part of a team consisting of our clients, other health professionals, and the public.
- Every person has their own unique combination of values that influence beliefs about how a situation should evolve or how others should behave.
- When team members have conflicting values and beliefs about an issue, it can be challenging.
A
Marrying Personal and Professional Values
15
Q
- Best addressed if we have clarified our values as discussed previously
- Requires mutual respect, honesty, active listening, and open communication among all involved parties
- If a patient is involved, his or her right to choose must be respected – some exceptions may apply
A
Values Conflict
16
Q
- We all have our own unique sets of values and nurses need to know how clients value health as they define it
- Nurses may need to help clients identify what their values are
- We need to be able to help clients learn how personal values affect their understanding and responses to the health issues they face
- Nurses must take care not to impose their own values and beliefs on the client
- Refer to Chapter 4 of your Burkhardt et al. text (2010) for information on clarifying values with patients
A
Helping Clients Clarify Values
17
Q
. The CNO has identified 7 values as being most important in providing nursing care in Ontario, LIST THE SEVEN VALUES
A
CLIENT WELL-BEING CLIENT CHOICE PRIVACY & CONFIDENTIALLY RESPECT FOR LIFE MAINTAINING COMMITMENTS TRUTHFULLNESS FAIRNESS
18
Q
health and welfare, and preventing or removing harm.
eg. keeping the bed low and call bell in reach
eg. keeping pain under control
Eg. health teaching
eg. putting slippers on client’s feet to prevent slipping
A
o client well-being
19
Q
right to the information necessary to make choices, and right to consent and right to refuse care
eg. right to know diagnosis to choose course of treatment
eg. respecting a client’s right to choose lifestyle choices, such as diet, smoking, or substance abuse
A
o client choice
20
Q
limited access to a person, the person’s body, conversations, bodily functions or objects immediately associated with the person.
important aspects of privacy need to be identified by individual clients
eg. all things said within client interview should be kept between physician, nurse and client
eg. closing the curtains
eg. not talking about someone in the halls
A
o privacy and confidentiality
21
Q
human life is precious and needs to be respected, protected and treated with consideration
considerations of the quality of life
eg. pain control
eg. respecting dnr
eg. providing comfort measures for palliative patients
A
o respect for life
22
Q
obligation to maintain the commitments they assumed as regulated health professionals.
maintaining commitments means keeping promises, being honest and meeting implicit or explicit obligations toward their clients, themselves, each other, the nursing profession, other members of the health care team and quality practice settings.
eg. providing pain medication on a regular schedule, or whenever client is in pain and able to receive more medication
A
o maintaining commitments
23
Q
speaking or acting without intending to deceive.
also refers to providing enough information to ensure the client is informed.
omissions are as untruthful as false information
eg. not giving false information or false promises
A
o truthfulness
24
Q
allocating health care resources on the basis of objective health-related factors
eg. not playing favourites
A
o fairness
25
• concerned with right and wrong behaviour
• analyzes what we “ought” to do in a specific situation
•
o what our obligations to others are
o what kinds of behaviour we should expect from others
ETHICS
26
WHAT ARE THREE INFLUENCES OF ETHICS
o conscience
o beliefs
o law
27
* based on the moral theories
* serve as rules to guide moral conduct.
* Help us be consistent in our approach on particular issues.
* Assume we have genuine regard and respect for the value and uniqueness of every person
Ethical Principles
28
Why Study Ethics?
• to be able to practice safely for the client
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* Are sets of principles accepted by all members of a profession
* Do not provide a step-by-step formula for professional behaviour
* Do not stipulate how values should be prioritized or balanced in practice
* Serve as guidelines for professional conduct
Professional Codes of Ethics
30
WHAT DOES THE CNO REQUIRE FROM ALL NURSES WHO ARE REGISTERED IN ONTARIO?
to practice in accordance with its Ethics practice standard
31
WHO DOES THE CNO ENCOURAGE nurses to consult with?
colleagues and others with expertise in ethics, to take courses and attend conferences on ethics
32
Why do nurses have a good understanding of ethics?
TEST QUESTION
Tort:
Because someone can be harmed by someone else's action - intentional or unintentional
Unintentional - when an act or omission causes unintended injury or harm to another person
33
If a physician makes an error; such as, abuse. You must contact WHO?
TEST QUESTION
If a physician makes an error; such as, abuse. You must contact the physician college
34
When a nurse is deciding to refuse an assignment or discontinue care the primary concern is?
client safety and well being
35
What are the 3 out of the 13 controlled acts nurses can perform?
* Performing a prescribed procedure below the dermis or mucus membrane
* admin a substance by injection or inhalation, *putting an instrument, hand or beyond the ear, anal, vagina, ect
36
Distinguish between ethical distress and residue.
Moral Distress
• occurs when someone faces a moral problem that seem to have a clear solution, yet cannot follow moral beliefs due to institutional or other restraints
• typically there are no moral claims
• the right action is clear, yet nearly impossible to pursue
• eg. nurses in the hurried atmosphere of hospital same-day surgery report that they are expected to have sedated patient sign connect forms, recognizing that the physicians have often neglected to explain the procedure fully. Nurse knows this practice does not respect patients right's to be in formed, but feel that they have neither the personal authority nor access to decision-making channels; and therefore, feel powerless to making changes
Moral Residue
• the tendency for moral distress to linger
• long-lasting and powerfully integrated into one's thoughts and views of the self
• can be damaging to the self and one's career, particularly when morally distressing episodes repeat over time
37
When you’re going on the CNO website the professional standards provide a link to?
Professional standards provide a link to other documents
38
• Are broad ethical theories that outline accepted moral judgments and help determine correct moral action
Ethical Frameworks
39
* a form of teleology
* forward-looking theory based on the perspective of how you look at it
* the right action is that which has the greatest utility or usefulness
utilitarianism:
40
* obligation to tell the truth.
| * not lying, deceiving, or withholding information.
Veracity
41
Means "self-governing"
Autonomy
42
•Presumes that an autonomous person:
o Is respected by others
o Is able to determine personal goals
o Has the capacity to make decisions
o Has the freedom to act upon choices
43
Threats to patient autonomy
* knowledge and authority of health care providers provides them with more power than the patient (challenged by patient knowledge via internet, etc.)
* patient role is often dependent and patients are expected to comply with tx
* health care routines are institution and care provider centred - not client centred
44
* associated with the Latin maximum primum non nocere “above all (or first) do no harm”.
* obligation to not deliberately inflict harm or injury (physical or emotional)
Non-maleficence
45
• Sets a higher standard than non-maleficence
• it requires you to take steps to help others, to do or promote good
•
o Eg. the CNO requires us to act in ways that benefit patients
• Lays the groundwork for the trust society places in nurses and in the health care system.
• Involves proactive interventions to:
•
o Do or promote good
o Prevent or refrain from harmful acts
o Remove evil or harm
Beneficence
46
a “father knows best” attitude, often associated with the principle of beneficence.
• Paternalism
47
the intentional overriding of a person’s wishes, to protect them from the harmful consequences of their choices.
•
o eg. The person overriding another’s wishes usually justifies the action by claiming he/she is acting in the person’s best interests by preventing or removing harm.
• Paternalism
48
established and maintained by the nurse through the nurse’s use of professional nursing knowledge, skill, and caring attitudes and behaviours to provide nursing services that contribute to the client’s health and well-being.
The therapeutic relationship
49
• The relationship is based on trust, respect and intimacy and requires the appropriate use of the power inherent in the care provider’s role
The therapeutic relationship
50
• This ethical framework is designed to provide nurses with?
direction in identifying and resolving ethical situations.
51
• Continuing education about ethical issues and conflicts will help nurses and other health care professionals
understand and resolve new ethical situations
52
• Ongoing self-reflection and further discussion with peers about these issues will contribute to?
The nurses’ ability to resolve ethical situations in their practice
53
• Consideration of ethical issues is an essential component of ?
providing care within the therapeutic nurse-client relationship.
54
•Nurses encounter _______ ______, __________ and in their everyday practice
ethical conflict, uncertainty and distress
55
•Continuous changes in the health care system, in areas such as___________ and in ________, contribute to these ______ _______.
technology, values contribute to these ethical dilemmas
56
________________and ____________beliefs and values helps nurses to prevent ethical conflicts and to work through them when they do occur.
Understanding and communicating
57
What are some types of ethical concern?
* When two or more ethical values apply to a situation, but these values support diverging courses of action, an ethical conflict or dilemma exists.
* Nurses may experience ethical uncertainty when faced with a situation in which they are unsure of what values apply or even where the moral problem is.
* They may also experience ethical distress when they know the “right” thing to do, but various constraints make doing the “right” thing difficult
58
Resolving ethical conflict by?
* Working through and understanding ethical situations is an ongoing part of care.
* It is not always possible to find a resolution to a conflict that satisfies everyone. At these times, the best possible outcome is identified in consultation with the client, and the health care team works to achieve that outcome.
59
Ethical Decision Making Guide
* Gather data and identify conflicting moral claims
* Identify key players
* Determine different perspectives
* Determine desired outcomes
* Identify options
* Choose a course of action and act on it
* Evaluate the outcome
60
Ethical decision making requires?
careful, thoughtful deliberation.
61
• As nurses, we must always remember that?
our client is the main priority
62
Meeting your client’s _______ must always be your main consideration when making ethical decisions.
Needs
63
* occurs when there are conflicting moral claims
| * picking the lesser of 2 evils
Moral/Ethical Dilemma
64
Moral/Ethical Dilemma is present in at least 2 ways
o conflict can be experienced when there is evidence to indicate that a certain act is morally right and evidence to indicate that the act is morally wrong, but no evidence is conclusive
o
eg. terminally ill patient, whether it is morally right to preserve life to morally wrong to prolong suffering
o may also occur when the agent believes that one or more moral norms exist to support one course of action, and one or more moral norms exist to support another course of action, and the 2 norms are morally exclusive
o
eg. deciding who gets the critical care bed relative to who is most deserving, who got their first, who is youngest, who has best chance of survival
65
* wrong or injury that a person suffers because of someone else's action, either intentional or unintentional
* torts are part of civil law
* unintentional torts occur when an act or omission causes unintended injury or harm to another person
* To be liable in a tort, the defendant must owe a duty of care to the plaintiff.
Tort Law
66
As nurses, you owe a ______ ___ _____ to your patients to act in a competent and diligent manner as per your professional standards of practice, in accordance with the actions of any reasonably competent nurse. This includes maintaining competence through ongoing education.
duty of care
67
* the omission to do something a reasonable person, guided by those ordinary considerate which ordinarily regulate human affairs, would do
* or doing something which a reasonable or prudent person would not do
* used interchangeably with "malpractice"
Negligence
68
What is the role of CNO?
The College of Nurses is responsible for regulating the approximately 160,000 nurses in Ontario. Its mission is regulating nursing in the public interest.
69
The College fulfils its role by:
* establishing requirements for entry to practice
* articulating and promoting practice standards
* administering its Quality Assurance program
* enforcing standards of practice and conduct
70
The College also supports the regulation of nursing in the public interest by:
* participating in the legislative process
| * sharing statistical information about Ontario’s nurses
71
What are the CNO Practice Standards?
The College creates practice standards to support nurses in providing safe and ethical care to the public. The documents apply to all nurses, and nurses are accountable for practising in accordance with these standards.
72
What do the CNO Practice Standards provide?
The College provides a variety of services and resources to members who wish to enhance their understanding of nursing practice:
* complete all tasks related to maintaining College membership, such as renewing their membership annually and updating personal information
* access resources and information about the QA Program
* download all College documents and publications, including The Standard and all practice standards and guidelines
* access a variety of educational tools designed to assess and update nurses’ knowledge of practice documents
* submit questions about nursing to a College Practice Consultant or Outreach Consultant
* learn about opportunities to volunteer for College projects, apply for a committee or run for Council.
73
* provides an overall framework for the practice of nursing and a link with other standards, guidelines and competencies developed by the College of Nurses of Ontario (CNO).
* It describes in broad terms the professional expectations of nurses and applies to all nurses, in every area of practice.
Professional Practice Standards Revised 2002
74
• Professional Standards includes 7 broad standard statements, a description of each statement and indicators that illustrate how the standard may be demonstrated.
* accountability
* continuing competence
* ethics
* knowledge
* knowledge of application
* leadership
* relationships
Professional Practice Standards Revised 2002
75
WHICH PROFESSIONAL PRACTICE STANDARD?
Each nurse is accountable to the public and responsible for ensuring that her/his practice and conduct meets legislative requirements and the standards of the profession.
Accountability
76
WHICH PROFESSIONAL PRACTICE STANDARD?
Each nurse maintains and continually improves her/his competence by participating in the College of Nurses of Ontario’s Quality Assurance (QA) Program.
Continuing competence:
77
WHICH PROFESSIONAL PRACTICE STANDARD?
| Each nurse understands, upholds and promotes the values and beliefs described in CNO’s Ethics practice standard.
o Ethics:
78
WHICH PROFESSIONAL PRACTICE STANDARD?
Each nurse possesses, through basic education and continuing learning, knowledge relevant to her/ his professional practice.
o Knowledge:
79
WHICH PROFESSIONAL PRACTICE STANDARD? Each nurse continually improves the application of professional knowledge.
o Knowledge application:
80
WHICH PROFESSIONAL PRACTICE STANDARD?
Each nurse demonstrates her/his leadership by providing, facilitating and promoting the best possible care/service to the public.
o Leadership:
81
WHICH PROFESSIONAL PRACTICE STANDARD?
| Each nurse establishes and maintains respectful, collaborative, therapeutic and professional relationships.
relationships
82
: The client’s needs are the focus of the relationship, which is based on trust, respect, intimacy and the appropriate use of power. Nurses demonstrate empathy and caring in all relationships with clients, families and significant others. It is the responsibility of the nurse to establish and maintain the therapeutic relationship.
Therapeutic nurse-client relationships
83
Professional relationships are based on trust and respect, and result in improved client care.
Professional relationships:
84
What is the purpose of Mandatory reporting?
* Mandatory reporting ensures that the College is alerted if there is a concern that a nurse is not practising safely.
* It allows the College to take action to protect the public and use innovative approaches to help rehabilitate the nurse when necessary.
85
What does the CNO do when they receive a report?
* The College’s Executive Director reviews the report along with any information about the nurse that the College may have previously received.
* The Executive Director assesses the level of risk posed to the public and determines an appropriate regulatory response.
86
Who is required to report?
* Facility operators
* Employers
* Nurses
87
What must be reported?
* Sexual abuse
* Incompetence
* Incapacity
* Charged with an offence
* Guilty of offence
* Finding of professional negligence or malpractice
* Proceeding in any jurisdiction
* Finding in any jurisdiction
88
What are the 5 components of the nurse-client relationship?
1. trust
2. respect
3. professional intimacy
4. empathy
5. power
89
________ is critical in the nurse-client relationship because the client is in a vulnerable position. Initially, ________ in a relationship is fragile, so it’s especially important that a nurse keep promises to a client. If _______ is breached, it becomes difficult to re-establish.
trust
90
_______ is the recognition of the inherent dignity, worth and uniqueness of every individual, regardless of socio-economic status, personal attributes and the nature of the health problem.
• Respect
91
________________ __________ is inherent in the type of care and services that nurses provide. It may relate to the physical activities, such as bathing, that nurses perform for, and with, the client that create closeness. Professional intimacy can also involve psychological, spiritual and social elements that are identified in the plan of care. Access to the client’s personal information, within the meaning of the Freedom of Information and Protection of Privacy Act, also contributes to professional intimacy.
• Professional intimacy
92
_________ is the expression of understanding, validating and resonating with the meaning that the health care experience holds for the client. In nursing, ___________ includes appropriate emotional distance from the client to ensure objectivity and an appropriate professional response
EMPATHY
93
• The nurse-client relationship is one of unequal _____. Although the nurse may not immediately perceive it, the nurse has more ___________ than the client. The nurse has more authority and influence in the health care system, specialized knowledge, access to privileged information, and the ability to advocate for the client and the client’s significant others. The appropriate use of power, in a caring manner, enables the nurse to partner with the client to meet the client’s needs. A misuse of power is considered abuse.
POWER
94
What is professional misconduct?
* Acts that constitute a breach or abuse of the nurse- client relationship are considered professional misconduct, as is conduct that demonstrates a lack of integrity.
* In other words, a nurse’s conduct that is harmful in any way, or that undermines or detracts from the professional caring relationship with and for the client, is not consistent with expected professional standards.
95
How does the CNO deal with professional misconduct?
* Acts of professional misconduct may result in an investigation by the College, followed by disciplinary proceedings.
* As set out in the legislation, the College investigates all complaints about nurses.
* The College also receives mandatory reports of termination of nurses from employers.
* When the information reported discloses reasonable and probable grounds to believe that the nurse has committed an act of professional misconduct or is incompetent, the executive director may initiate an investigation.
96
* Refusing to work an extra shift or overtime is not the type of situation that was intended by the inclusion of clause 1 (5) (discontinuation of services) in the Nursing Act as a definition of professional misconduct; therefore, it is not considered abandonment.
* However, depending on the context and facts of a particular situation, nurses can be found guilty of professional misconduct under one of the other clauses.
REFUSING ASSIGNMENTS
97
______________ occurs when a nurse has accepted an assignment and discontinues care without:
o getting the client’s permission;
o arranging a suitable alternative or replacement service; or
o allowing a reasonable opportunity for alternative or replacement services to be provided.
A nurse who discontinues services without meeting the above conditions could be found guilty of professional misconduct.
• Abandonment
98
RHPA
REGULATED HEALTH PROFESSIONS ACT
99
WHAT IS THE RHPAs PURPOSE?
* regulatory model in Ontario
* establishes the relevant authority of the act
* a scope of practice statement that describes in a general way what the profession does and the methods that it uses
100
In what Canadian jurisdictions does the RHPA apply
ONTARIO
101
What role does the RHPA play in nursing practice?
CLARIFIES SCOPE
102
Do you know of any other professions are regulated by the RHPA? If so, can you give some examples of the differences in regulation between the various health professions?
* dieticians
* pharmacists
* dental hygienists
* audiologists
* chiropractor
* medical lab tech
* midwives
* opticians
* physio
* physicians
* psychiatrists
103
PURPOSE OF THE NURSING ACT
* determines how the nursing profession is regulated in the province of Ontario.
* contains a procedural code applicable to all of Ontario’s self-regulated health professions
* contains a scope of practice statement, as well as provisions and regulations specific to the nursing profession
104
In what Canadian jurisdictions does the NURSING Act apply?
• in the province of Ontario
105
How does the NURSING Act impact nursing practice?
* The Nursing Act contains a scope of practice statement, as well as provisions and regulations specific to the nursing profession
* categorizes registrations and classes of nurses
* clarifies entry-to-practice
* introduces title protection
106
What is a controlled act?
• activities that are considered to be potentially harmful if performed by unqualified persons.
107
• RNs and RPNs are authorized to perform three of the 13 controlled acts. They are:
1. Performing a prescribed procedure below the dermis or a mucous membrane.
2. Administering a substance by injection or inhalation.
3. Putting an instrument, hand or finger
i. beyond the external ear canal,
ii. beyond the point in the nasal passages where they normally narrow,
iii. beyond the larynx,
iv. beyond the opening of the urethra,
v. beyond the labia majora,
vi. beyond the anal verge, or
vii. into an artificial opening into the body.
108
A Registered Nurse (RN) or Registered Practical Nurse (RPN) may perform a procedure within the controlled acts authorized to nursing:
o if it is ordered by a physician, dentist, chiropodist, midwife or Nurse Practitioner (NP); or
o if it is initiated by an RN or RPN in accordance with conditions identified in regulation.
109
Consent is _________ if, before giving it:
• the person received the information about the treatment that a reasonable person in the same circumstances would require to make a decision; and
• the person received responses to his/her requests for additional information about the treatment.
informed
110
Must informed consent always be written?
Informed consent does not always need to be written, but can be oral or implied.
111
How old do you have to be to give consent in Ontario?
There is no minimum age for giving consent. Health care practitioners and evaluators should use professional judgment, taking into account the circumstances and the client’s condition, to determine whether the young client has the capacity to understand and appreciate the information relevant to making the decision.
112
According to College of Nurses of Ontario (CNO) standards, nurses are accountable for obtaining consent whether the intervention or service relates to a ___________ (as defined in the HCCA or as required in common law), __________ to a facility, or the provision of a personal _________ service.
treatment
admission
assistance
113
Consent is required for any ________ except ___________ provided in certain emergency situations. The consent must:
• relate to the _________ being proposed;
• be informed;
• be voluntary; and
• not have been obtained through misrepresentation or fraud.
The health care practitioner who proposes the _________ is responsible for taking reasonable steps to ensure that ___________ is not administered without consent.
treatment
114
If consent to ____________ to a care facility is required by law (e.g., under the Nursing Homes Act), then consent is needed in all cases except in a crisis situation.
admission
115
The HCCA does not specify that consent to a personal __________ service is required. It does, however, provide that if an evaluator finds a recipient of a personal assistance service incapable of giving consent, and the person providing the service wants to obtain consent, it may be obtained from a substitute decision-maker using the hierarchy set out in the Act.
assistance
116
A client is ____________ when he or she can understand the information that is relevant to making a decision about treatment, and appreciate the reasonably predictable consequences of a decision or lack of decision.
capable
117
Under the HCCA, the health care practitioner who proposes the treatment is ___________ for determining capacity for consent to treatment
responsible
118
Under what circumstances might a health care professional make treatment decisions for a client or have a client admitted to a health care facility without consent?
According to the Health Care Consent Act, 1996, an emergency occurs when the person for whom the treatment is proposed is apparently experiencing severe suffering or is at risk of sustaining serious bodily harm if the treatment is not administered promptly. In an emergency situation, treatment can be given without consent.
119
What is a public guardian and trustee?
PGT is the substitute decision-maker of last resort for a mentally incapable person. The court will not appoint the PGT as guardian of property or guardian of the person unless there is no other suitable person available and willing to be appointed.
120
What is a substitute decision maker?
• The person who is authorized to give or refuse consent on behalf of an incapable client. The substitute decision-maker may be a relative or a specially appointed person, such as someone with power of attorney for personal care.
121
How is a substitute decision maker determined?
• The HCCA provides a hierarchy to determine who is eligible to be a substitute decision-maker. The substitute decision-maker is usually a spouse, partner or relative. A power of attorney for personal care is not necessarily required to act as a substitute decision-maker.
122
What rights does the substitute decision maker have?
Substitute decision-maker decides in the client’s best interests, taking into account:
o the client’s values and beliefs;
o the impact of the treatment on the client’s condition or well-being;
o whether the benefit outweighs the risk of harm;
o whether a different treatment would be as beneficial.
123
Nurses are professionally accountable for ensuring that clients are capable of giving consent. What are some of the ways that nurses can effectively advocate for their clients where consent is concerned?
1. If the nurse proposing a treatment or evaluating capacity to make an admission or personal assistance service decision determines the client is incapable of making the decision, then the nurse informs the client that a substitute decision-maker will be asked to make the final decision. This is communicated in a way that takes into account the particular circumstances of the client’s condition and the nurse-client relationship.
2. If there is an indication that the client is uncomfortable with this information, then the nurse explores and clarifies the nature of the client’s discomfort. If it relates to the finding of incapacity, or to the choice of substitute decision-maker, then the nurse informs the client of his/her options to apply to the CCB for a review of the finding of incapacity, and/ or for the appointment of a representative of the client’s choice.
3. If there is an indication that the client is uncomfortable with the finding of incapacity when the finding was made by another health care practitioner, then the nurse explores and clarifies the nature of the client’s discomfort. If it relates to the finding of incapacity, or to the choice of substitute decision-maker, then the nurse informs the health care practitioner who made the finding of incapacity and discusses appropriate follow-up.
4. The nurse uses professional judgment and common sense to determine whether the client is able to understand the information. For example, a young child or a client suffering advanced dementia is not likely to understand the information. It would not be reasonable in these circumstances for the nurse to inform the client that a substitute decision-maker will be asked to make a decision on his/her behalf.
5. The nurse uses professional judgment to determine the scope of advocacy services to assist the client in exercising his/her options. The nurse documents her/his actions according to CNO’s Documentation, Revised 2008 practice standard and agency policy.
124
What is an advance directive?
The means used to document and communicate to a substitute decision-maker a client’s preferences regarding treatment in the event that the client becomes incapable of expressing those wishes.
125
According to Ontario law, how must advance directives be communicated (orally, in writing, other)?
A client may provide an advance directive for decisions s`uch as organ donation and resuscitation. Nurses should be familiar with legislation and their organization’s policies about the use of advance directives.
126
When the client’s need for CPR has been anticipated, what actions should the nurse take?
* assessing whether the client has sufficient and relevant information to make an informed decision about treatment and end-of-life care, including resuscitation;
* providing an opportunity to discuss, identify and review the client’s end-of-life care wishes;
* identifying the client’s wishes about preferred treatment and/or end-of-life care as early as possible, while considering the client’s condition and the degree to which the therapeutic nurse- client relationship has been established;
127
Your client told you he did not want to have any heroic measures taken, including CPR, if his heart stopped beating. The doctor will not write a DNR order. If this client arrests, must you do CPR? Why?
No. Because the client said they did not want CPR.
128
What does a DNR order mean in terms of the level and kind of care the client should receive?
It means do not resuscitate. Clients at this level should receive palliative care:
• Care that aims to relieve client suffering and improve the quality of living and dying. It strives to help clients and families address physical, psychological, social, spiritual and practical issues, and their associated expectations, needs, hopes and fears. Palliative care prepares the client and others for managing self-determined life closure and the dying process. Palliative care is appropriate for any client and/or family living with, or at risk of developing, a life-threatening illness due to any diagnosis, with any prognosis, and whenever they have unmet expectations and/or needs and are prepared to accept care, regardless of age.
129
A client was transferred from the Golden Manor to TDH. Her transfer form indicates she has a written DNR order at the Manor. The lady arrests shortly after arrival on the medical floor. Should you perform CPR? Why?
No. Because she had a writ`ten DNR.
130
If the client changes his/her mind about a DNR or advance directive at a later date, how must they communicate this? What does the law in Ontario say about this?
• Under the Health Care Consent Act, 1996, resuscitation is considered to be a treatment. There is no legal requirement to obtain a physician’s written, telephone or verbal DNR order
• Under the Health Care Consent Act, 1996, a client’s wishes about treatment may be expressed in:
o a power of attorney for personal care;
o any written form;
o a verbal form; or
o any other manner (such as sign language). In addition, a client’s wishes about treatment:
o can be changed at any time (nurses must respect the most current wishes and ensure the client has given informed consent for the treatment choice); and
o are to be interpreted by the client’s substitute decision-maker if the client is found to be incapable; and the wishes do not constitute consent or refusal of consent.
131
Nurses are accountable for their own _________ & ___________. Accountability comes with registration with the College of Nurses of Ontario (CNO), and remains an obligation whether an individual holds single or dual registration or is working as an unregulated care provider (UCP)
conduct and practice.
132
Nurses do not always need to possess dual ____________ to work in other positions. For example, an RN does not need to be registered with CNO as an RPN to work in an RPN role, but without registration cannot use the title RPN. However, a nurse is still accountable as an RN while employed in an RPN role
registration
133
When an RN accepts a position as an RPN, or when an RN or RPN accepts a position as a UCP, the nurse is expected to fulfil only the requirements of the _________’s job description
position
134
When the client’s health status appears predictable, a nurse working as a UCP is accountable for:
* knowing and performing within the limits of the UCP role; and
* recognizing when the client’s condition deviates from the norm
135
In the event that symptoms present that are beyond the expectations of a UCP role, a nurse working as a UCP is accountable for:
* stepping out of the UCP role to identify and assess the problem as a nurse;
* ensuring the client receives appropriate care — whether by communicating the information to a nurse or by practising as an RN or RPN if another nurse is unavailable within an appropriate period of time;
* practising as an RN or RPN until a member practising at the RN or RPN level is available; and
* assessing why she/he has stepped out of the UCP role.
136
In the event of an emergency situation, the nurse working as a UCP will immediately function at the RN, NP or RPN level. The member is accountable for:
* stepping out of the UCP role to identify, assess and respond to the emergency at the level of her/his RN, NP or RPN preparation;
* practising at the RN, NP or RPN level until a member practising at the RN, NP or RPN level is available; and
* assessing why she/he has stepped out of the UCP role.
137
The four standards of procedures and authority?
On test!
1. Appropriate health care provider
Nurses must consider each situation to determine if the performance of the procedure promotes safe client care, and if it is appropriate for a nurse to perform the procedure.
2. Authority
Nurses ensure that they have the appropriate authority before performing procedures.
3. Competence
Nurses ensure that they are competent in both the cognitive and technical aspects of a procedure prior to performing it.
4. Managing outcomes
Prior to performing procedures, nurses ensure that they are able to identify the potential outcomes of procedures, have the authority and competence to manage the outcomes, or have the resources available to manage those outcomes.
138
Refusing assignments & discontinuing nursing services document:
What are nurses accountable for?
Providing safe, effective, and ethical care to their clients.
139
Refusing assignments and discontinuing services doc:
| What is the nurses number one priority?
.?
140
What does CNO expect any prudent nurse to. Do when faced with making ethical decisions in the workplace that could have an impact on the client?
Nurses are expected to demonstrate leadership and accountability when weighing their professional and personal obligations, and to make decisions in the best interest of the public.
141
Name two legislative acts that nurses can use to support them when seeking improved workplace conditions?
The Employment Standards Act (2000)
| Occupational Health and safety act (1990)
142
Name three instance when a nurse can be Charged for abandoning a client:
Abandonment occurs when a nurse has accepted an assignment and discontinues care without:
■ getting the client’s permission;
■ arranging a suitable alternative or replacement
service; or
■ allowing a reasonable opportunity for alternative
or replacement services to be provided.
143
Name five principles every nurse should use to guide them when determining whether to refuse an assignment or discontinue services:
The safety and well-being of the client is of primary concern.
Nurses are not required to work extra shifts or overtime for which they are not contracted.
Nurses are accountable for their own actions and decisions and do not act solely on the direction of others.
■ Nurses have the right to refuse assignments that they believe will subject them or their clients to an unacceptable level of risk
Persons whose safety requires ongoing or emergency nursing care are entitled to have these needs satisfied throughout any job action
144
Name key expectations the CNO expects ever nurse to do when choosing the appropriate course of action
Carefully identify situations in which a conflict
with her/his own values interferes with the
care of clients (College of Nurses of Ontario, 2004b, p. 10) before accepting an assignment or employment.
■ Identify concerns that affect her/his ability to provide safe, effective care.
■ Communicate effectively to resolve workplace issues.
■ Become familiar with the collective agreement or employment contract relevant to her/his settings and take this into account when making decisions.
■ Learn about other legislation relevant to her/his practice setting.
■ Give enough notice to employers so that client safety is not compromised.
■ Provide essential services in the event of a strike.
■ Inform the union local and employer in writing of her/his ongoing professional responsibility to
provide care, which will continue in the event of any job action (for example, strike or lockout).
145
If the CNO receives a complaint about a nurse what is it obligated to do?
The College is required to investigate all formal complaints in which a nurse and the complainant are clearly identified.
146
Review scenarios 2&5 in doc refusing assignment in....
Shelly said to do this In class when we didn't go
147
An RPN also a PSW certificate, he is called into work as a PSW.
Is he accountable as an RPN or PSW? Why?
He/She is accountable for all duties he / she is competent in as an RPN.
148
What is teleology
Believes whatever comes out of our actions determines whether it's good or bad.
149
What deontology?
The rightness or wrongness or an act, depends on the nature of the act rather then the consequence
150
What is pragmatism
Do what works!
PROFESSIONAL GROWTH 2
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